HomeMy WebLinkAboutRFP - P832 BENEFITSCITY OF FORT COLLINS
REQUEST FOR PROPOSAL
PROPOSAL NO. P-832
BENEFITS
PROPOSAL DATE: 2:00 p.m. (our clock) APRIL 29, 2002
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TABLE OF CONTENTS
Section One: Request for Proposal 1
I. Background 1 1
II. Proposal Process Information and Requirements 2
III. Services To Be Provided 3
IV. Proposal Requirements 6
V. Proposal Checklist 8 VI. Plan
VII. Questionnaire 14
VIII. Performance Guarantees 19
IX. Financial Exhibits 20
APPENDICES:
Appendix A: Monthly Claims and Enrollment by Plan
Appendix B: Employee Census
Appendix C: Medical Plan SPDs
Appendix D: Stop Loss Report
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REQUEST FOR PROPOSAL
CITY OF FORT COLLINS
Proposal Number P-832
The City of Fort Collins is seeking proposals from firms reflecting fees for providing a Preferred
Provider Organization (PPO) network, Point-of Service (POS) network, Exclusive Provider
Organization (EPO) network, third party administration services, utilization review services, stop
loss insurance and prescription drug coverage.
Single service as well as multiple service providers are encourage to respond. Proposers may
be on one or multiple services.
The City currently provides all eligible employees and their dependents medical benefits on a
self-funded basis. Prescription drug coverage is provided to employees and their dependents
participating in the PPO options through a carve-out card program.
Proposals are being solicited by the City to obtain the most competitive benefits for its
employees and their eligible dependents. Current plan designs are to be replicated. Plan
documents are available upon request.
Written proposals, six (6) will be received at the City of Fort Collins' Purchasing Division, 215
North Mason St., 2nd floor, Fort Collins, Colorado 80524. Proposals will be received before
2:00 p.m. (our clock), April 29, 2992. Proposal No. P-832. If delivered, they are to be sent to
215 North Mason Street, 2nd Floor, Fort Collins, Colorado 80524. If mailed, the address is P.O.
Box 580, Fort Collins, 80522-0580.
Questions concerning the scope of the project should be directed to Vincent Pascale, Project
Manager, (970) 221-6828.
Questions regarding proposals submittal or process should be directed to Keith I. Ashby, CPPO,
Buyer, (970) 416-2191.
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 of Fort Collins 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 of Fort Collins reserves the right to reject any and all proposals and to waive any
irregularities or informalities.
Sincerely,
James B. O'Neill II, CPPO, FNIGP
Director of Purchasing & Risk Management
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I: Background
Background
The City of Fort Collins (“The City”) currently provides medical benefits to approximately 1,390
active employees and 50 retired employees.
The City offers its employees and retirees a choice between four medical plans, a Health
Maintenance Organization (“HMO”), a Point of Service (“POS”), and two preferred provider
(“PPO”) plans. The PPO plans’ prescription drug coverage is provided through a carve-out plan
administered by Express Scripts. Approximately 835 active employees are enrolled in the HMO
plan, 140 employees in the POS plan, and 415 employees in the two PPO plans.
All medical benefit plans, including HMO coverage, are provided on a self-insured basis.
PacifiCare administers the HMO and POS plans and National Health Systems (“NHS”)
administers the PPO plans with the PPO network provided by Sloans Lake Managed Care. All
medical plans have $120,000 specific stop-loss protection, which is currently underwritten by
Ulico. The PPO plans’ prescription drug benefits are “carved-out” and administered by Express
Scripts.
The City is requesting proposals to administer its current HMO, POS, and PPO plan designs, as
well as separate specific stop-loss proposals from independent stop-loss carriers. Based on the
proposals received, the City may select one administrator for all medical plans or a separate
administrator for the HMO/POS and PPO plans. The stop-loss coverage may or may not be
placed with an independent carrier.
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 view the selected vendor as an
active partner in assuring employee satisfaction.
Health Care Objectives and Proposal Evaluation Criteria
The City has adopted the following health care objectives as part of its health care strategy to
address medical care benefit needs:
The City strongly desires to provide employees access to managed care plans which
minimize disruptions to existing patient-physician relationships.
The City strives to provide employees with managed care options that offer a wide selection
of health care providers.
Managed care vendors will be selected that can provide an array of online administrative
services to the City including provider directories, billing and eligibility, claims reports and
claim status review, etc.
As a result of these objectives, The City has developed selection criteria to evaluate managed
care proposals. These objectives will be used heavily in the bidding process.
Parameter Main Criteria Weight
Access to Providers How does the network fit and
serve The City’s employees?
20%
Member and Customer Service How well does the plan service
its members and clients?
How satisfied are members
with the health care they receive?
20%
Care Management How well does the plan treat
sick members?
15%
Health Management How effective is the plan in 10%
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keeping members healthy?
Program Management How thorough is the managed care
plan in selecting providers and
managing health care programs?
15%
Cost / Financial Effectiveness How competitive are the managed
care plan’s costs and contracts
with area providers?
20%
William M. Mercer, Incorporated (“Mercer”) is assisting The City in evaluating its medical plans.
This Request for Proposal (RFP) is intended to assess which managed care organizations have
the ability to meet The City’s long-term goals and objectives as previously defined.
Together with Mercer, The City will evaluate competing proposals considering:
a) proposal adherence to the services requested and described in the RFP,
b) quality of care and customer service,
c) plan cost and rate guarantees, and
d) responses to the RFP's Questionnaire section.
Based on results of the initial evaluation, The City will select finalists for consideration. Any or
all proposals may be rejected by The City.
The 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 HMO, POS, and PPO
medical plans. Site visits may take place at the finalists' home offices and/or the claims and
administrative facility/facilities each finalist indicates will provide service to The City.
Please note that the selection of the claims administrator will not be based solely on cost
considerations. The City believes strongly in first assuring itself that the successful proposer
can provide the scope and intensity of services required. Once those issues are confirmed, The
City is prepared to pay a fair, competitive price for services rendered.
II. Proposal Process Information and Requirements
Proposal Process Information and Requirements
The intent of this RFP is to confirm key information about specific proposers, receive financial
proposals and 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 the
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 medical benefits payable to anyone in conjunction with this request.
Confidentiality
All data included in this RFP and accompanying appendices, 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.
Timetable
The following is a proposed timetable developed for this project. You will be notified of any
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significant changes which might occur:
The City releases RFP to vendors April 1, 2002
Intent To Propose due to The City April 5, 2002
Written questions due to The City April 10, 2002
Proposals due to The City April 29, 2002, 2:00 p.m. (our clock)
Finalist vendors notified May 28, 2002
Onsite evaluations of finalists (if
necessary)
By June 7, 2002
Finalist negotiations (completed) June 14, 2002
Selection of recommended vendors June 21, 2002
Plan effective date January 1, 2003
Response Format
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 April 29, 2002. 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, 2nd Floor
Reference RFP P-832
P.O. Box 580
Fort Collins, Colorado 80522-0580
Questions regarding this RFP are due to the City no later than April 10. A written response to
substantive questions will be provided to all proposers by the close of business on April 15,
2002. The City assumes no responsibility or liability for any costs you may incur in responding
to this RFP, including attending meetings, site visits or negotiations.
Deviations from RFP Specifications
All responses to the Request for Proposal 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 IV.
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 network administration. The City may, at its discretion, authorize Mercer to negotiate
with any proposer on its behalf. The City shall not be bound to accept the proposal with the
lowest price. The RFP may be amended or revoked at anytime prior to final execution of an
Agreement by The City.
Any deviations from this RFP must be clearly explained in your proposal. These deviations are
to be delineated as instructed in the Proposal Requirements as set forth in Section IV of this
RFP.
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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.
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 the 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. The City will use William M. Mercer (“Mercer”) to review the
proposals. Neither The City nor Mercer shall 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 and Mercer.
The City expects to enter into a written Agreement (the “Agreement”) with the chosen vendor
(“Chosen Vendor”) that shall incorporate this RFP and 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.
III. Services To Be Provided
Current Services
Overview
The City currently offers full-time and part-time active employees, and retirees a choice between
an HMO, POS, and two PPO medical benefit plans. The current HMO/POS administrator is
PacifiCare and the current PPO administrator is National Health Systems.
Funding/Stop Loss
All medical plans are self-funded. The plans have specific stop loss protection currently
provided by Ulico. The specific stop-loss deductible is $120,000. Please quote $120,000 and
$150,000 specific stop-loss protection. Stop-Loss coverage is to be quoted on a 15/12 or 24/12
basis in the first year and on a “paid” basis in subsequent years. Organ transplants will not be
covered under the stop-loss coverage since this coverage is “carved-out” of the plans.
Employee Contributions
The City provides employees with sufficient contributions to purchase PPO Plan 1 for
themselves and their dependents at no additional cost. If employees choose the HMO, POS, or
PPO Plan 2, they must contribute towards the cost of the medical coverage. Employee
contributions for these plan options currently range from 6.5% to 10% of the equivalent premium
cost over and above the employer contribution.
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Specific Requirements
The City has specific vendor requirements needed to support its day to day operations.
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
account service will not receive serious consideration;
Be extremely responsive;
Be comprised of individuals with specialized knowledge of the proposing company’s:
managed care networks,
claims and eligibility systems,
systems reporting capabilities,
claims adjudication policies and procedures,
administrative services contract wording,
standard and non-standard banking arrangements and
relationships with third parties;
Be thoroughly familiar with virtually all of the proposing company’s functions that relate
directly or indirectly to the account; and
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. The eligibility updates will be provided
electronically. The initial enrollment and updates will be 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 part of the claims management and adjudication process. A quarterly reconciliation between
payroll and eligibility will also be required of the selected vendor(s).
Fee Administration
All administrative fee statements will be self-billed by The City. The City will calculate the fees
payable on a monthly basis and will submit these fees directly to the selected vendor(s).
COBRA Administration
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; and
COBRA member service inquiries related to benefits and claims.
Customer Service
The selected vendor(s) must have, as its primary focus, efficient and effective processing of all
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inquiries. Satisfactory customer service will include prompt, courteous and accurate responses
to The City and employee inquiries regarding claim submissions, provider networks, utilization
review, plan design, 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, medical/utilization management files, 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 (either medical or stop-loss) for any employees.
Therefore, it is required that your proposal waives any “actively at work”, “dependent non-
confinement”, or any other rules that would prevent 100% continuity of coverage for any
employees or dependents who are currently covered under the plans.
IV. Proposal Requirements
Proposal Requirements
Your response should be organized into the following sections:
Section I Executive Summary
Section II Proposal compliance letter (A letter signed by an authorized officer of your
organization signifying your proposal’s complete compliance 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 Checklist
Section V Confirmation Section
Section VI Questionnaire Responses
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Section VII Performance Guarantees
Section VIII Financial Exhibits
Section IX 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)
Proposal Instructions
1. Please do not deviate from the requested formats. Your proposal should include the
financial exhibit from Section IX of the RFP. Please provide your proposed rates and
fees using the financial exhibits included in this RFP.
2. Assume an “incurred claims” basis (i.e., all claims incurred on or after 1/1/2003).
3. The City is seeking an initial premium/administration cost that runs for at least 24 months
(January 1, 2003 - December 31, 2004). Please confirm the time period applicable to your
proposed rate/fee guarantees.
4. Please quote all medical plans on a self-funded basis and stop-loss coverage on a fully-
insured, non-participating basis. If you are quoting stop-loss coverage only, please only
respond to the “Account Management” and “Stop-Loss” sections of the questionnaire.
6. Define specifically what services are included in the fees your company has quoted.
7. Please specify any charges for services that your company has not included in the fees
quoted above, including any start-up fees.
8. Please adhere to the instructions in this section when organizing your proposal.
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V. 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):
Yes No Description of Item
_____ _____ Intent to Propose
_____ _____ Signed Proposal Compliance letter
_____ _____ Signed Plan Design Confirmation
_____ _____ Completed and Signed Questionnaire
_____ _____ HMO Network Access Analysis
_____ _____ POS Network Access Analysis
_____ _____ PPO Network Access Analysis
_____ _____ A proposed Implementation timeline for The City
_____ _____ Audited financial statements and/or Department of
Insurance filings for the past two years
_____ _____ Provider “report cards” used to provide feedback
on clinical and non-clinical performance measures
_____ _____ A copy of your policy assuring member satisfaction
in receiving medical care
_____ _____ Your latest HEDIS report
_____ _____ A copy of your EOB for in-network and out-of-network
Services.
Samples of all standard & optional reports you are
proposing to provide on a health plan and account specific basis:
_____ _____ - Utilization and Claims reports
_____ _____ - Financial plan indicators
_____ _____ - Member Service/Performance Standard Reporting
_____ _____ - Member complaints/grievances reports
_____ _____ A copy of your banking services agreement
_____ _____ A copy of your member satisfaction survey
_____ _____ A copy of your Administrative Services Agreement
Signature of Authorized Representative:________________________________________
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VI. Plan Design Confirmation Checklist
The following pages describe The City’s current HMO, POS, and PPO plan designs. Please
quote your standard plans that most closely match the current plans. We realize there may be
differences between the current and your proposed plans. However, it is our goal to keep these
differences to a minimum. Please complete the column labeled “Your Plan” and “Differs
Because” only where your plan differs from the standard described. Your quoted rates and fees
should reflect your plan design as indicated in this checklist.
The key for completing the “Differs Because” column is as follows:
S - Systems limitations
C - Corporate Policy
L - Legal limitations
I - State Mandated Insured Benefit
O - Other (please describe)
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HMO
Your Plan
(Differences
Only)
Differs
Because
Eligible Employee
Participants
Active full time and part-time
employees and retirees.
Eligible Dependents Spouse; natural children, step-children,
adopted children (from date of
placement), legal guardianship, and
QMSCO to age 19 (25 if FT student)
In-Network Benefits Out-of- Network
Benefits
Annual deductible $0 N/A
Physician office visit $10 N/A
Inpatient Hospital
Copay
$100 N/A
Outpatient Hospital
Copay
$50 N/A
Emergency Room $50 N/A
Mental
Health/Substance
Abuse
Inpatient
Outpatient
$50/day; 45 days/
yr. MH; 21 days/yr.
SA
$0 visits 1-5, then
$10
N/A
Maternity $10 (pre-natal
visits)
N/A
Preventive Care
(periodic physical
exams, health
screenings,
immunizations, well
baby/child care)
$10 N/A
Prescription Drugs
Retail
Mail Order
$8/$15/$30
$16/$30/$60
N/A
Annual Out-of-
Pocket Limit
$2,500/$7,500 N/A
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POS
Your Plan
(Differences
Only)
Differs
Because
Eligible Employee
Participants
Active full time and part-time employees
and retirees.
Eligible Dependents Spouse; natural children, step-children,
adopted children (from date of
placement), legal guardianship, and
QMSCO to age 19 (25 if FT student)
In-Network Benefits Out-of- Network
Benefits
Annual deductible $0 $200/$400
Physician office
visit
$10 70% R&C after
deductible
Inpatient Hospital
Copay
$100 70% R&C after
deductible
Outpatient Hospital
Copay
$50 70% R&C after
deductible
Emergency Room $50 50% R&C after
deductible
Mental
Health/Substance
Abuse
Inpatient
Outpatient
$50/day; 45 days/
yr. MH; 21 days/yr.
SA
$0 visits 1-5, then
$10
50% R&C after
deductible; 45 days
per year
70% R&C after
deductible
Maternity $10 (pre-natal
visits)
70% R&C after
deductible
Preventive Care
(periodic physical
exams, health
screenings,
immunizations, well
baby/child care)
$10 70% R&C after
deductible
Prescription Drugs
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PPO Plan 1
Your Plan
(Differences
Only)
Differs
Because
Eligible Employee
Participants
Active full time and part-time employees
and retirees.
Eligible Dependents Spouse; natural children, step-children,
adopted children (from date of placement),
legal guardianship, and QMSCO to age 19
(25 if FT student)
In-Network Benefits Out-of- Network
Benefits
Annual deductible $750 $1,500
Coinsurance 90% 70% R&C
Physician office
visit
90% after deductible 70% R&C after
deductible
Inpatient Hospital
Copay
90% after deductible 70% R&C after
deductible
Outpatient Hospital
Copay
90% after deductible 70% R&C after
deductible
Emergency Room 90% after deductible 70% R&C after
deductible
Mental
Health/Substance
Abuse
Inpatient
Outpatient
90% after deductible
90% after deductible
70% R&C after
deductible
70% R&C after
deductible
Maternity 90% after deductible 70% R&C after
deductible
Preventive Care 90% after deductible 70% R&C after
deductible
Prescription Drugs $50 deductible, then
greater of
$8/$15/$30 or
10%/20%/30%
(mail order – 2
copays for 90 day
supply)
N/A
Annual Out-of-
Pocket Limit
$1,150/$2,300 $2,300/$4,600
PPO annual out-of-pocket max requires 2 persons to each satisfy the individual max. Also, in
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PPO Plan 2
Your Plan (Differences
Only)
Differs Because
Eligible Employee
Participants
Active full time and part-time
employees and retirees.
Eligible Dependents Spouse; natural children, step-
children, adopted children (from
date of placement), legal
guardianship, and QMSCO to
age 19 (25 if FT student)
In-Network
Benefits
Out-of- Network
Benefits
Annual deductible $200 $500
Coinsurance 90% 70% R&C
Physician office
visit
90% after
deductible
70% R&C after
deductible
Inpatient Hospital
Copay
90% after
deductible
70% R&C after
deductible
Outpatient Hospital
Copay
90% after
deductible
70% R&C after
deductible
Emergency Room 90% after
deductible
70% R&C after
deductible
Mental
Health/Substance
Abuse
Inpatient
Outpatient
90% after
deductible
90% after
deductible
70% R&C after
deductible
70% R&C after
deductible
Maternity 90% after
deductible
70% R&C after
deductible
Preventive Care 90% after
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VII: Questionnaire
Instructions:
This section is to request additional information for evaluating which health care plans best
meets The City’s needs. All explanations should be labeled and tabbed in the response to the
RFP.
If you are unable to answer a question, please indicate why you cannot. If you are unwilling to
disclose particular information asked in a question, please indicate why you will not respond.
General
1. Who will be the Account Executive and Service Representative assigned to this account?
From what office will these individuals provide service?
2. What are the background and experience of the account team members? Please provide
name, address, phone number and current resume for each member.
3. Will you allow The City or its agent to perform clinical and/or financial audits of your plan(s)?
Will you provide online access to claims data?
4. Are you willing to protect, defend, indemnify and hold The City free and harmless from any
and all losses arising from clerical, professional or administrative decisions made by or on
behalf of your organization?
5. Please confirm that your company is and will continue to be compliant with both the DOL
claims regulations and HIPAA administrative simplification. Please provide a copy of your
compliance plans.
6. Will you agree to a contract provision requiring your organization to provide at least a 120-
day written notice to the City prior to the renewal dates of the contract of a change in rates?
7. Will you agree to the following contract provision for termination of agreement?
Termination of Agreement. This Agreement may be terminated at any time by mutual
consent of both parties. This Agreement may be terminated by either party at any time
upon sixty (60) days written notice to the other party.
8. It is required that proposals assume that all participants (including COBRA) presently
covered will be covered under a successor plan regardless of medical condition, disabled
status, or whether they are actively-at-work or on a no-loss no-gain basis for both the City
and the participant. Is your proposal written in accordance with this requirement?
9. In the event of termination of this contract, are you willing to provide utilization data,
including unique patient identifier, service codes, dates of service, and file format on
commonly used magnetic media?
10. Are directories available online? Are practices identified as “open” or “closed”? Can
employees make PCP elections online?
11. What services are available online for use by The City? Billing? Eligibility? Claim reports?
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12. Please provide a copy of your standard medical claims utilization reports package. How
often will these reports be provided to The City at no charge? What are your costs for ad
hoc reports?
13. Provide samples of your standard prescription drug reports which permit analysis of the
retail drug program and of the mail order drug program and which display the results of your
drug utilization review program. Is there a charge for your standard reports? Are ad hoc
reports available? Is there an extra fee?
14. Can you provide management reports that can isolate the components of cost increases in
the prescription drug benefit? For example, leading drugs dispensed, increases in
utilization, development of trends, physician outliers, high patient utilizers and/or possible
abusers? Is there an extra fee for any of them?
15. Will you agree to furnish monthly and year-to-date average enrollment, and total claims paid,
by line of coverage, showing the information separately for active, COBRA participants, and
retirees; and separately for employees and dependents?
16. Do you have physician and patient profiling/reporting capabilities? If so, please describe the
standard reports available and ad hoc capability. Provide sample reports.
Provider Access
17. Please attach a network access report, separately for HMO, POS, and PPO, using the
criteria outlined below and the census diskette included with this RFP. Please list the
number of employees not meeting these criteria, including the city and zip code within which
they reside.
a. Number of employees with two adult primary care physicians (Family Practice,
General Practice, Internists) within 10 miles of the employees’ zip code (open
practices only).
b. Number of employees with two obstetricians within 10 miles of the employee's
zip code.
c. Number of employees with two pediatricians within 10 miles of the employee's
zip code.
d. Number of employees with two specialists within 10 miles of the employee’s zip
code.
e. Number of employees with one hospital within 20 miles of an employee's zip
code.
18. Please complete the following for your proposed Fort Collins and Denver HMO and POS
networks (separately for HMO and POS and location):
Number
Hospitals
Number
PCPs
Number
Specialists
Number
Lab Facilities
Number
Pharmacies
19. How is the adequacy of a physician panel determined? What measures will be taken if the
physician network is weak in a given geographic area?
20. What ratio of physicians to participants do you maintain? What is the ratio currently in
Larimer County?
Provider Contracting
xvi
21. Do you screen the cost effectiveness of each HMO/POS/PPO network provider? How?
What actions are taken if a provider does not appear to be operating cost-effectively?
22. Do you measure the quality of care provided by your participating physicians? How often?
How is quality measured?
23. What criteria are used to select hospitals and other health care facilities? How are the
hospitals monitored for cost efficiency and quality of care on an ongoing basis? How often is
this review conducted? Have any hospitals been terminated or dropped from the managed
care program? Please describe circumstances.
24. May an employee nominate his or her physician for inclusion in the HMO/POS/PPO
networks? Please describe the process, including the anticipated timing to add a physician.
25. What percentage of HMO/POS plan physicians were terminated in the past year? Indicate
what percentages were terminated as a result of:
Percentage of total plan physicians
Quality of care problems
Over/under utilization
Customer complaints
Voluntary termination
Other (please list)
Total
26. Briefly describe any plans for changes to your HMO/POS/PPO physician or hospital financial
arrangements. Is it likely that these changes could result in smaller hospital or physician
networks or increased costs?
27. Are there any plans to increase or decrease your networks’ size over the next 12-18
months?
28. Do you subcontract any services (e.g., mental health) to another vendor or network? Please
describe.
29. If your reimbursement to a physician is based on a fee schedule, what is the basis for the
fee schedule? What is the target reimbursement level as a % of RBRVS for each managed
medical product?
Family Practice,
Internal Medicine,
Pediatrician,
OB/GYN,
Cardiologist,
Orthopedist,
Oncologist,
Neurosurgeon, and
Other Specialists.
Medical Management
30. If you were reviewed by an accrediting agency and did not receive full accreditation, please
summarize the key reasons.
31. Please describe at least two quality improvement activities initiated recently as a result of
member satisfaction surveys.
xvii
32. Please describe the disease management programs that you currently offer as part of your
medical benefit plans. Is the cost for these programs included in your premium rates and/or
administrative fees?
33. Does the managed care program have a formal procedure for addressing member
grievances? If so, please explain.
34. Please describe your prescription drug utilization review program separately for pharmacy
network and mail order claims. In addition to a description of the program and how it
functions, please advise how your drug utilization review program addresses the following
issues:
- quality and cost of patient's recommended therapy
- physician prescribing patterns
- pharmacy dispensing practices
- therapeutic and dosing regimes
- generic monitoring
- member education
35. Is utilization review performed on all prescriptions? If not, what criteria are used to select the
prescriptions reviewed?
36. Please provide a copy of your prescription drug formulary. Will you inform employees
directly regarding formulary changes that may impact them?
Member And Customer Service
37. What actions are you taking to improve average telephone responsiveness?
38. Are employee satisfaction surveys routinely performed? How often? Please provide a copy
of the survey and the results for the most recent two years.
39. What are the standard customer service unit operating hours for toll-free telephone access?
40. Please indicate below your average for the most recent twelve months, and specify the
reporting frequency you are proposing for The City. Also please provide copies of available
reports.
Tracked?
(Yes/No)
Monitoring
Frequency
Last 12 Month Average
# of members N/A N/A
# of calls
Call wait time
Abandonment rate
Complaint call log N/A
Administration
41. When were your current claims, eligibility, member services and data reporting systems last
updated? When are the next upgrades/ enhancements scheduled? Do you anticipate
changes in the claims system prior to January 1, 2003?
xviii
42. Do you have any plans to move, close, or consolidate your claims or member services
offices? If so, please describe.
43. Will you agree to furnish monthly and year-to-date average enrollment, and total claims paid,
by line of coverage, showing the information separately for active, COBRA participants, and
retirees; and separately for employees and dependents?
44. Are you able to administer on-line, electronic transfer, and tape-to-tape eligibility transfers?
How does this impact your cost proposal?
45. Do you agree to provide COBRA administration?
46. In addition to COBRA, describe your support services in complying with the issuance of
HIPAA certifications. Is there an additional charge for these services?
47. What was the employee turnover rate in the proposed claim payment office(s) in the past 36
months by year?
48. Please provide three current and two terminated references. Include name and phone
number of contacts.
49. Confirm that your system will accept named dependent eligibility data. Can your system
accept ongoing (after conversion) dependent eligibility? Please detail your audit process for
eligibility verification.
50. What percentage of your claims were adjudicated manually in the last 12 months? What
steps have you taken to reduce manual claims adjudication?
51. In the event of termination, what is your guaranteed fee to provide for payment of run-out
claims? Include all data processing charges.
52. How do you pay out of network claims? What percentage of R&C do you use? Which R&C
tables do you use?
53. Is there an aggregate annual or lifetime limit on your stop-loss liability for a given claimant?
54. Please confirm that you will not “laser” or exclude any employees or dependents at issue or
at renewal.
55. What special reports, if any, would you require from the current medical carrier for the stop-
loss coverage?
56. How soon after a claim is submitted to your company can reimbursement be expected by
the City?
57. How are discrepancies between your company's definition of a usual, customary and
reasonable charge and that of the claim administrator handled?
58. Please confirm that you will accept The City’s definition of “investigational” procedures as
defined in The City’s current contracts and SPDs, so that all claims approved for payment
under the medical plan will be eligible for stop-loss reimbursement. These definitions can be
found in the SPDs in Appendix D.
59. Does the proposed stop-loss coverage include any “inside” limits (e.g., mental health cap,
etc.)?
xix
60. Please provide a copy of your standard renewal disclosure form.
VIII: Performance Guarantees
The City expects its managed care partners to demonstrate an exemplary level of customer
service to The City. The attached performance standards are indicative of the levels of
customer service expected from The City’s managed care vendors. Please specify the current
performance of the office where The City’s claims will be processed and member services
provided next to the proposed standard. In the far right column please state your acceptance of
The City’s standard or your alternative proposed guarantees, as well as the amount you are
willing to put at risk. In total, we would expect 10%-15% of the ASO fee to be “at risk”.
EPO/POS/Catastrophi
c
The City Minimum
Standard
Actual Vendor
Performance – 2001
Vendor
Proposal
I.D. Card Mailing Mailed within 10 days
of receipt of complete
enrollment information
from The City
Network Directories Requested supply
delivered to The City
prior to open
enrollment
Employee Booklets Booklets will be printed
and mailed to
participants within 15
working days from
receipt of approval of
final draft
Financial Accuracy
Total paid dollars
errors divided by total
paid dollars
99% or higher
Coding Accuracy
Number of claims
without coding errors
divided by total number
of audited claims
98% or higher
Perfect Claims
Number of claims
without any errors
divided by number of
audited claims
97% or higher
Claims Turnaround
Time
90% within 14 calendar
days;
98% within 21 calendar
days
Telephone Response
Time
90% of all calls
answered within
30 seconds
xx
IX: Financial Exhibits
Please complete the following exhibits in full. If you are an incumbent, please complete both the
client specific and book of business exhibits. If you are not an incumbent, please return only the
book of business exhibits with your proposal.
Exhibit A: Self-Insured Administrative Fee And Fully-Insured Premium Rates
Exhibit B: Services Included In Self-Insured Administrative Fee
xxi
EXHIBIT A: SELF-INSURED ADMINISTRATIVE FEES AND FULLY-INSURED STOP-LOSS
RATES
Self-Insured Active HMO 2003 2004
Number of Employees - HMO
Number of Claims/EE - HMO
Monthly Costs per Employee
Network Access Fees
Utilization Management Fees
Claim Administration
Other Administration (specify)
Total Medical Administrative Fees
Expected Monthly Medical Paid Claims/EE
Self-Insured POS 2003 2004
Number of Employees - POS
Number of Claims/EE - POS
Monthly Costs per Employee
Network Access Fees
Utilization Management Fees
Claim Administration
Other Administration (specify)
Total Medical Administrative Fees
Expected Monthly Medical Paid Claims/EE
xxii
Self-Insured PPO Plan 1 2003 2004
Number of Employees - POS
Number of Claims/EE - POS
Monthly Costs per Employee
Network Access Fees
Utilization Management Fees
Claim Administration
Other Administration (specify)
Total Medical Administrative Fees
Expected Monthly Medical Paid Claims/EE
Self-Insured PPO Plan 2 2003 2004
Number of Employees - POS
Number of Claims/EE - POS
Monthly Costs per Employee
Network Access Fees
Utilization Management Fees
Claim Administration
Other Administration (specify)
Total Medical Administrative Fees
Expected Monthly Medical Paid Claims/EE
xxiii
EXHIBIT A: SELF-INSURED ADMINISTRATIVE FEES AND FULLY-INSURED STOP-LOSS
RATES
Stop-Loss Insurance (January 1, 2003 – December 31, 2003)
Specific Stop-Loss (Monthly Rate):
# of $120,000 $150,000
Employees Deductible Deductible
Employee (15/12) _______ $________ $_______
Employee (24/12) _______ $________ $_______
Employee (Paid*) _______ $________ $_______
*Paid rates are illustrative only.
xxiv
EXHIBIT B: PPO PRESCRIPTION DRUG FEE QUOTATION
Retail Only
Generic Dispensing Fee
Brand Dispensing Fee
Generic Discount Below AWP*
(AWP based on quantities of 30)
Brand Discount Below AWP**
(AWP based on quantities of 30)
Administration Fees
(per prescription)
Other Fees
Identification Cards
DUR Program
MAC Pricing
Other Fees (List in detail)
$___________/Rx
$___________/Rx
____________%
____________%
$__________/Rx
$__________/ee
$__________/ee
$__________/ee
$__________/ee
* If MAC, please indicate the average discount %.
** Indicate Source of AWP.
xxv
Mail Order Only
Generic Dispensing Fee
Brand Dispensing Fee
Generic Discount Below AWP*
(AWP based on quantities of 90)
Brand Discount Below AWP**
(AWP based on quantities of 90)
Administration Fees
(per prescription)
Other Fees
Identification Cards
DUR Program
MAC Pricing
Other Fees (List in detail)
$___________/Rx
$___________/Rx
____________%
____________%
$__________/Rx
$__________/ee
$__________/ee
$__________/ee
$__________/ee
* If MAC, please indicate the average discount %.
** Indicate Source of AWP.
xxvi
EXHIBIT B: SERVICES INCLUDED IN SELF-INSURED ADMINISTRATIVE FEE
Using the table below, specifically define the services included in your proposed fees. Please
specify any items included or excluded from your proposed fees that are not specifically listed in
the table in the “Other” section of the table.
Service Yes No Additional
Charge
Development of Plan Document and Amendments
Drafting and Printing of Employee Booklets
Other Communications (Please Specify)
Employee I.D. Cards
Preparation of Government Forms
Legal Services
Legislative Services
Establishment of Banking Arrangements and Banking Fees
Verification of Eligibility Assistance
Actuarial Services (determination of liabilities, estimate of cost
of benefit changes, and pricing for additional benefits)
Renewal Services (development of COBRA rates,
determination of reserve requirements, determination of total
plan costs)
Set Up Fees (Please specify the amount if not included)
Travel Expenses
Other (Please specify)
APPENDIX A
Monthly Claims and Enrollment
i
City of Fort Collins
Large Claimant
Report
January 1, 2001 thru
December Updated 31, as of 2001 3/20/02
City of Fort Collins
Large Claimant Report
January 1, 2001 thru
December 31, 2001
Updated as of 3/20/02
Product Diagnosis Prognosis Paid Amt
HMO Intertrohantic fracture Fair $ 44,295.71
POS Intestinal obstruction Good $ 38,843.10
HMO S/p laminectomy Good $ 45,063.53
POS Intestinal obstruction Good $ 64,419.84
HMO Malign. Neo/lymph,axillary Guarded $ 51,529.43
HMO Submucous leiomyoma Good $ 29,690.89
HMO Malign. Neo/orbit Fair $ 71,660.10
HMO Pre-term birth Good $ 47,113.95
HMO High risk pregnancy Good $ 25,237.40
POS Cellulitis/multiple personality Guarded $ 38,185.99
HMO MI/cardiac arrest Guarded $ 45,546.16
HMO Cervical disc displacement Good $ 75,939.51
POS Acute pancreatitis Fair $ 35,695.86
HMO C-section, respiratory distress Fair $ 35,141.66
HMO Post partum infection/HIV disease Guarded $ 38,579.60
HMO Obesity, cholelithiasis Fair $ 38,045.21
HMO Pulmonary embolism Fair $ 33,487.22
ii
City of Fort
Collins
Large Claimant
Report
January 1, 2002
thru February 28,
2002
Product Diagnosis Prognosis Paid Amt
POS Cellulitis/multiple
personality
Guarded $55,875.71
APPENDIX B
Employee Census (Active and Retired - on disk)
i
APPENDIX C
Medical Plan SPDs
i
CITY OF FORT COLLINS
PPO OPTIONS SPD
TABLE OF CONTENTS
SECTION PAGE
Schedule of Benefits 2
Introduction 3
Eligibility 4
Enrollment 5
COBRA Continuation of Benefits 7
Family and Medical Leave Act (FMLA) 9
Newborns’ and Mothers’ Health Protection Act 9
Women’s Rights and Cancer Health Act 9
Coverage during Leave for Military Service 10
Cost Containment Features 10
Benefit Provisions 11
Covered Expenses 13
Maximum Benefits 17
General Exclusions and Limitations 18
How to Claim Benefits 21
Appeals 26
Definitions 28
Other Important Information 30
ii
SCHEDULE OF BENEFITS
CITY OF FORT COLLINS GROUP HEALTH PLANS
PPO OPTIONS 1 AND 2
Plan Benefits are based on a calendar year, January 1 –
December 31.
Charges for Eligible Covered Services Option 1
Option 2
Deductible/person/year
Preferred Provider $ 750 $ 200
Non-Preferred Provider $1,500 $ 500
Coinsurance Paid by Plan
Preferred Provider 90% 90%
Non-Preferred Provider 70% R&C 70% R&C
Annual Individual Out-of-Pocket Maximum
Preferred Provider 2002: $1,150 2002: $ 600
2003: $1,350 2003: $ 800
2004: $1,750 2004: $1,200
Non-Preferred Provider 2002: $2,300 2002: $1,100
2003: $2,500 2003: $1,300
2004: $2,700 2004: $1,500
Family Out-of-Pocket Maximum is met when two covered persons each satisfy the individual Out-of-
Pocket Maximum.
Maximum Benefit per Participant $2,000,000
Annual Maximum Benefit per Medicare-Eligible
Retiree $100,000 (includes $5,000 for prescription
drugs)
Prescription Drugs: Benefits are paid according to a separate benefit formula. Amounts paid for
prescription drugs are not included in meeting deductible/coinsurance requirements for non-prescription
charges. The Plan uses a Formulary, or list, of medications to determine the level of benefit paid.
Deductible/person/year $50
Copayment for up to 30-day Supply
Generic on Formulary $ 8 or 10% of total charge, whichever is greater.
Brand on Formulary $15 or 20% of total charge, whichever is greater.
Generic or Brand not on Formulary $30 or 30% of total charge, whichever is greater.
iii
Copayment for 90-day Mail Order Supply
Generic on Formulary $16
Brand on Formulary $30
Generic or Brand not on Formulary $60
All eligible charges are subject to the Deductible requirement. The Plan Participant is
responsible for charges in excess of Reasonable and Customary (R&C) charges. This
schedule is for illustrative purposes only, and is not a substitute for the complete
Summary Plan Description (SPD) or Plan Document. No Participant shall accrue any
rights because of any statement in or omission from this Schedule. In the event of a
discrepancy between this schedule, the SPD and/or the Plan Document, the Plan
Document shall govern. Benefit provisions are subject to change.
INTRODUCTION
This Summary Plan Description (SPD) describes benefits in effect January 1, 2002. The City of Fort
Collins Health Plan (“Plan”) is self-funded, which means that the City of Fort Collins (“City”) provides
direct funding for claims payment and administrative costs. If a claim exceeds $120,000 (this amount is
subject to change), the excess charges are paid through a separate stop-loss insurance contract. Claims
processing and administration are provided by National Health Systems, Inc., a third party administrator.
Provider network, preauthorization, utilization review and case management services are provided by
Sloans Lake Managed Care. Prescription drug benefits are provided through Express Scripts, Inc., a
prescription benefit manager.
The Plan provides you and your enrolled dependents with coverage for a variety of eligible services.
Under this Plan, you have the option of enrolling in a high ($750) or low ($200) deductible option. The
Plan is a PPO (Preferred Provider Organization) Plan, which enables you to use Preferred or Non-
preferred Providers. Generally, claim payment is based solely on whether the provider is Preferred or
Non-preferred. Only under extraordinary circumstances, such as emergency situations, might charges
incurred through a Non-preferred Provider be paid on a Preferred Provider basis. Higher deductibles are
applied to services obtained from Non-preferred Providers: $1,500/person/year for Option 1 and
$500/person/year for Option 2.
Preferred Providers agree to provide services for reduced fees; therefore, you generally save money
when you use a Preferred Provider. Non-preferred Providers do not enter into such agreements;
therefore, your cost for using these providers may be higher. Nonetheless, the choice of provider is yours,
and you should verify with your provider whether he/she is a Preferred Provider. It is important to
remember that not all Medically Necessary services prescribed by a physician are covered services under
the Plan. The decision to seek medical attention should not be based solely on available Plan coverage.
It is your responsibility to enroll for the Plan that best meets your needs and to understand the
provisions of the Plan you select. Before a crisis situation arises, you and your enrolled dependents
should take time to read this Summary Plan Description (SPD) and become familiar with the terms,
conditions and limitations of the Plan in order to avoid benefit reductions. This SPD only summarizes the
Plan’s provisions, which are explained more fully in the formal Plan Document.
The Plan shall be administered in accordance with applicable governmental rules and regulations, and in
a nondiscriminatory manner. In the event of a discrepancy between the Plan, this SPD and any
applicable law, the applicable law shall govern. As Plan Sponsor, the City relies on guidance from the
Third Party Administrator (TPA), which handles the daily administration of Plan provisions. The City has
complete authority to establish standards of proof and to interpret the Plan as it pertains to any claim
dispute. The decisions of the City are final and binding with regard to claims disputes.
Funding The Plan is part of a cafeteria plan, as defined by Section 125 of the Internal Revenue Code.
Funding is provided by employer and employee contributions. Employee contributions are made on a
pre-tax basis, which reduces your taxable income. Such contribution amounts are subject to change.
Plan Amendment/Termination Although the City intends to maintain the Plan indefinitely, the City
reserves the right to amend or terminate the Plan in whole or in part at any time. This right of
amendment/termination shall apply to all participants, including retirees. Significant changes to Plan
provisions will be communicated usually during the annual Open Enrollment, and therefore may not
appear in this SPD. You should retain those announcements for future use in conjunction with this SPD.
Plan Document Shall Govern The information contained in this SPD is intended to be accurate and
complete. However, in the event of a discrepancy between this SPD and the actual Plan Document, the
Plan Document shall govern. The Plan Document is available for inspection at the Human Resources
Office. To review the Plan Document, please call 970-221-6535 and schedule an appointment.
ELIGIBILITY
Who is eligible for employee coverage?
Employees of the City of Fort Collins, the Poudre Fire Authority, the Downtown Development Authority,
the Fort Collins Housing Authority or the Northern Front Range Transportation Air Quality Planning
Council who regularly work 20 hours or more per week in the following categories are eligible for
coverage: unclassified management, classified employee, eligible contract employee and retiree.
An eligible contract employee is anyone whose specific employment contract states that he/she is eligible
for City-sponsored medical insurance. An eligible retiree is an employee who retires after completing ten
or more years of covered service with the City; at the time of retirement, the retiree is given the option to
elect COBRA coverage or retiree health insurance coverage. Except for disabled retirees, retirees who
elect COBRA upon retirement cannot enroll for retiree coverage after the COBRA benefit period expires.
Who is eligible to be enrolled for dependent coverage?
You may enroll eligible dependents in the same health care option under which you are covered. For
purposes of the Plan, eligible dependents include only the following:
your legal spouse (includes common law);
your unmarried, dependent children may be covered until the end of the month in which they
reach age 19, or age 25 if they are enrolled as full-time students in an accredited
institution of higher education or a technical school. Certification of student status is
required, and must be furnished upon request; otherwise, student coverage could be
terminated.
Your children include your natural children and stepchildren, children under your legal
guardianship, legally adopted children whom you claim as dependents on your income tax
return, and any other child for whom you or your spouse are legally responsible by court
order, including a Qualified Medical Child Support Order (QMCSO), for providing health care
coverage.
Children who are incapable of self-support due to mental or physical impairment are
eligible for coverage beyond age 19. However, the disability must have begun before the
child reached age 19, and the child must remain dependent upon you for support. There is
no age limit for covering handicapped children. However, you must send proof of the
disability to the claims administrator within 31 calendar days of the child’s 19th
birthday or
within 31 calendar days of the date on which coverage for the dependent child would
otherwise terminate. From time to time, you may be required to provide proof of continued
disability upon request from the claims administrator. Failure to provide this information
could result in loss of coverage.
When are you eligible for coverage?
You are eligible for coverage on the first day of the month following completion of 30 calendar days
continuous service as an eligible employee, unless your absence is due to a disability, illness or injury.
Special rules apply to married staff members.
If an employee and spouse are both eligible employees, each employee may enroll in the Plan option of
his/her choice, or each may enroll as an employee and as a dependent. Dependent children will be
enrolled primarily under the parent whose birthday falls earlier in the calendar year; however, they may be
enrolled under both parents. Benefits will be coordinated in accordance with the rules for Coordination of
Benefits on pages 22-24.
ENROLLMENT
When must enrollment be completed?
Enrollment must be completed within 31 calendar days of the date you become eligible for coverage.
What if you miss your enrollment deadline?
If you miss your enrollment deadline, you cannot enroll until the next following open enrollment period,
unless you experience an involuntary loss of other group coverage or qualify for “Special Enrollment” as
outlined in this section.
Enrollment of Newborn Children
Newborn children must be enrolled just like any other dependent if claims are to be paid. Within thirty-
one (31) calendar days from birth, call the Human Resources Department and provide the name, sex and
birth date of the newborn child. Newborns are covered automatically for the first thirty-one (31) calendar
days of life. If enrollment of the newborn will result in additional premium (for example, if you are
changing from employee + spouse to employee + family coverage), the newborn must be enrolled within
the first thirty-one (31) calendar days following birth for coverage to continue past the first thirty-one (31)
calendar days. If such enrollment is not completed as required, coverage will cease at the end of the
thirty-first day, and the newborn will not be able to be enrolled until the next Open Enrollment.
Involuntary loss of other group coverage can occur for a variety of reasons; for example, if: you were
covered under your spouse’s plan and that coverage ends due to your spouse’s termination of
employment, layoff or reduction in hours; you get divorced and are no longer eligible for coverage as your
spouse’s dependent; your spouse dies or your spouse’s employer terminates its plan. If you experience
an involuntary loss of other group coverage, you may enroll for coverage through the City during the first
31 days following the loss of coverage. Simply provide a statement from your former plan listing the
people who were covered and the date coverage ended. After expiration of the 31-day period, you may
not enroll until the next open enrollment.
Special enrollment is permitted for employees or dependents who originally declined coverage if they:
1. had other coverage, which they later lost because of separation/divorce, termination of
employment or reduction in the hours of the employee or of his/her spouse, death or the cessation of
contributions for their coverage by another employer (unless it was for cause or failure to pay
employee contributions on time), or
2. were on COBRA continuation of benefits coverage, but their COBRA eligibility has expired, or
3. did not initially enroll and later gains a new dependent as a result of marriage, birth, adoption or
placement for adoption, in which case the employee is entitled to special enrollment along with the
dependent(s), including the new child.
A person eligible for special enrollment has thirty-one (31) calendar days from the date of the occurrence
of the above listed events to enroll, and shall become a Participant on the first day of the month following
receipt of the properly completed enrollment form, except that in the event of special enrollment as the
result of birth, adoption or placement for adoption of a child, the person enrolling shall become a
Participant upon the date of birth or placement for adoption of the child.
How is enrollment completed?
At your benefits orientation, you received a packet of forms and information describing the available
benefit options. After you have reviewed the benefit information and you have determined which plans
are best suited to you and your family, complete the appropriate enrollment application, and return the
completed form to Human Resources. You should confirm your enrollment by referring to the entries on
your pay stub. If these entries do not appear on your pay stub on or after your enrollment date, you
should contact Human Resources immediately. Remember: enrollment must be completed within 31
calendar days of the date on which you first become eligible.
When does coverage begin?
For new eligible employees, coverage begins on the first day of the month following the completion of
thirty (30) consecutive days of service, unless your absence is due to a disability, illness or injury. Of
course, enrollment must be completed within thirty-one (31) days of the initial eligibility date. For
example, if your first day of employment is March 15 and you enroll for coverage during the initial
eligibility period, your coverage will go into effect on May 1.
Enrollment conducted during the annual open enrollment period is effective on the first day of the
following plan year, which begins January 1.
Dependent coverage begins the same day that your coverage begins. In the event that you acquire an
eligible dependent after you have already enrolled, those dependents must be enrolled within thirty-one
(31) days of their initial eligibility date. Newborns are eligible for coverage from date of birth; children
placed for adoption are eligible from date of placement; and children for whom you acquire the legal
responsibility to provide coverage are eligible from the date stipulated by court order.
Please Remember: Be sure to contact Human Resources whenever you acquire a new dependent you
wish to enroll for coverage. Otherwise, coverage could be delayed until the next Open Enrollment.
Changing Your Coverage
Generally, your group health plan choices must stay in effect from the date your elections take effect until
the end of the plan year on December 31. However, if you experience a qualifying change in status
during the year, you may add or drop coverage within 31 days from the date the event occurs. For
example, if you get married on June 13 and you wish to enroll your spouse for coverage, your spouse
is eligible for coverage on June 13, and must be enrolled within 31 days of your date of marriage.
If you have a child, the child must be enrolled within 31 days of birth.
If you do not register your change within the thirty-one (31) day period, you must wait until the next open
enrollment to make that change, except in the case of special enrollment (see page 3). If you enroll a
dependent after the initial thirty-one (31) day eligibility period, the dependent will be subject to the pre-
existing condition limitation (see page 11), except in the case of Special Enrollment (see page 3).
Qualifying changes in status include:
marriage, death or divorce of a spouse;
birth, adoption, death of a child, or obtaining legal guardianship of a child;
beginning or ending of your spouse’s employment;
switching from part-time to full-time employment, or vice versa;
you or your spouse beginning unpaid leave of absence;
dependents becoming ineligible for medical coverage;
involuntary loss of other group coverage;
significant changes to your spouse’s medical coverage attributable to your spouse’s employment; or
Special Enrollment criteria (see page 3).
It is important to remember that such qualifying changes do not automatically enable you to change your
enrollment option(s); rather, the change in status must cause you, your spouse or a dependent to lose or
gain coverage under this plan, or under the plan of your spouse’s or dependent’s employer. In addition,
your election must be on account of and correspond with the change in status. For example, if you get
married you may enroll your new spouse for coverage, but you may not change plans.
In addition, an annual Open Enrollment period is held, usually during late October and early November.
During this time, you may change your coverage to another plan offered by the City or terminate your
coverage. Information is distributed to each department. Retired and COBRA participants may also
change coverage during the annual open enrollment; however, a retiree who elects Option 1 at retirement
may not switch coverage later to another option.
When does coverage end?
Coverage ends on the last day of the month in which you terminate employment or you elect to terminate
coverage due to a qualified change in family status. For a dependent, coverage ends on the last day of
the month in which the dependent ceases to be eligible for participation under the Plan. For example, if
a dependent child attains age 19 on March 15 and is not a full-time student at an accredited institution,
the child’s coverage ends March 31. Participants who cease to be eligible for coverage may be eligible
for COBRA continuation of benefits. See the COBRA section below.
Coverage for a divorced spouse ends on the last day of the month in which the divorce becomes final.
Unless stipulated in the divorce decree, divorced spouses are not eligible for coverage under the Plan,
and must be removed from coverage as soon as they become ineligible. No charges incurred by a
divorced spouse or other dependent after the coverage termination date will be reimbursed by the Plan,
and will be the responsibility of the employee. If benefits are paid improperly on behalf of an ineligible
dependent, the Plan retains the right to suspend benefits until those improperly paid benefits are
recovered.
Divorced spouses may be eligible for COBRA continuation of benefits coverage. Please see the next
section for more information about this continuation of benefits provision.
COBRA CONTINUATION OF BENEFITS
Depending on when you terminate employment with The City of Fort Collins, The City of Fort Collins
Group Health Plan may provide continued coverage for you and your family. You will be required to pay
the full premium cost of this continued coverage, plus a 2% administrative charge.
Your Legal Rights to Continuation Coverage under COBRA
Under a federal law called COBRA (Consolidated Omnibus Budget Reconciliation Act, 1985), The City of
Fort Collins is required to offer covered employees and their families the opportunity to extend coverage
temporarily at group rates after coverage under the Plan would otherwise cease. This extension is called
COBRA continuation coverage. Evidence of your good health is not required for this extension.
As an employee covered under The City of Fort Collins Group Health Plan, you have the right to elect
COBRA continuation if you lose coverage because:
1. your hours of employment are reduced; or
2. your employment is terminated for reasons other than gross misconduct.
Your spouse may elect continuation coverage, if he or she loses coverage under The City of Fort Collins
Group Health Plan because:
1. your hours of employment are reduced;
2. your employment is terminated for reasons other than gross misconduct;
3. you die;
4. you legally divorce; or
5. you become entitled to Medicare.
Your dependent child may elect continuation coverage, if he or she loses coverage under The City of Fort
Collins Group Health Plan because:
1. he or she loses dependent status under The City of Fort Collins Group Health Plan;
2. your hours of employment are released;
3. your employment is terminated for reasons other than gross misconduct;
4. you die
5. you and your spouse divorce; or
6. you become entitled to Medicare.
A child born to or placed for adoption with you during the continuation coverage period is also entitled to
elect COBRA continuation coverage.
Under COBRA, you (or your spouse or dependent child, if applicable) must notify The City of Fort Collins
Benefits Administrator within 60 days after
1. you and your spouse are divorced; or
2. one of your children loses dependent status under the Plan.
You (or your spouse or dependent child, if applicable) will then be notified of your right to elect
continuation coverage and the cost to do so. The deadline for electing continuation coverage is 60 days
after the date The City of Fort Collins Group Health Plan ceases to cover you or from the date you are
notified, whichever is later.
If you (or your spouse or dependent child, if applicable) do not elect continuation coverage, your coverage
will stop. If you (or your spouse or dependent child, if applicable) choose continuation coverage, The City
of Fort Collins Group Health Plan will provide coverage identical to that available to active employees.
However, you (or your spouse or dependent child, if applicable) must pay the full cost of this coverage,
plus a 2% administrative charge.
If the original qualifying event causing the loss of coverage was the death of the employee, divorce,
Medicare entitlement, or loss of “dependent status” of a dependent child under The City of Fort Collins
Group Health Plan, then each qualified beneficiary will have the opportunity to elect 36 months of
continuation coverage from the date of the qualifying event.
If you (or your spouse or dependent child, if applicable) lose coverage under The City of Fort Collins
Group Health Plan because your employment was terminated or your hours of employment were
reduced, then the maximum continuation period will be 18 months. If during those 18 months, another
qualifying event takes place that entitles you (or your spouse or dependent child, if applicable) to
continuation coverage, your continuation coverage (or your spouse’s or dependent child’s continuation
coverage, if applicable) may be extended by another 18 months. However, in no event will your
continuation coverage (or your spouse’s or dependent child’s continuation coverage, if applicable) extend
for more than a total of 36 months from the date of the initial event.
Disability is a special issue. If the Social Security Administration determines that you (or your spouse or
dependent child, if applicable) are disabled at the time of the qualifying event or at any time during the
first 60 days of the continuation coverage period, then your continuation coverage period as well as your
spouse’s and any dependent’s continuation coverage periods may be extended from 18 to 29 months.
To qualify, you (or your spouse or dependent child, if applicable) must notify The City of Fort Collins
Benefit Administrator) within 60 days of the date of the Social Security determination and during the initial
18-month continuation period. If the disabled qualified beneficiary continues coverage, premiums for
coverage during the disability period of the 19th
through the 29th
month shall be 150% of the normal
monthly premium rate. If only the non-disabled beneficiaries extend their coverage, the 102% premium
rate applies.
Your right to continuation coverage (or your spouse’s or dependent child’s right, if applicable) under
COBRA ends if:
1. The City of Fort Collins ceases to provide group health coverage to any of its employees;
2. You (or your spouse or dependent child, if applicable) fail to pay the premium within 30 days after
its monthly due date;
3. You (or your spouse or dependent child, if applicable) becomes covered, after the date of your
COBRA election, under another group health plan that does not contain any exclusion or
limitation with respect to any preexisting condition of such beneficiary (other than an exclusion or
limitation that may disregarded under the law);
4. You (or your spouse or dependent child, if applicable) becomes entitled to Medicare;
5. If you (or your spouse or dependent child, if applicable) have extended continuation coverage due
to a disability and then you (or your spouse or dependent child, if applicable) are determined by
the Social Security Administration to be no longer disabled.
FAMILY AND MEDICAL LEAVE ACT (FMLA)
If you are on a leave of absence that qualifies under the provisions of FMLA, you will remain eligible for
plan benefits during your leave of up to 12 weeks. However, during FMLA leave, you must continue to
pay the premiums you paid (if any) before your leave began.
If you are on a paid leave that runs concurrently with your FMLA leave, your premiums will continue to be
deducted from your paycheck. If you are on an unpaid FMLA leave, you need to make arrangements
with Human Resources for the payment of your required premium. Premium payment is due on the first
day of each month of coverage. If premiums are not paid within 30 days of the due date, coverage will be
terminated retroactively to the end of the month in which premiums were paid last. Coverage will be
reinstated upon your return from leave without a waiting period, but no coverage is provided for the period
you failed to pay required premiums.
If you elect not to return to work at the end of your FMLA leave, you must repay to the City the premiums
paid on your behalf during your leave, unless you cannot return due to circumstances beyond your
control.
If you elect not to return to work at the end of your FMLA leave, you may elect COBRA continuation of
benefits as described previously. Your benefit continuation period begins at the time you inform the City
of your decision not to return to work.
NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT
Under federal law, the Plan may not restrict benefits for any hospital length of stay in connection with
childbirth for the mother or newborn child to less than 48 hours following a normal vaginal delivery, or less
than 96 hours following a caesarian section. Also, the Plan may not require that a provider obtain
authorization from the Plan for prescribing a length of stay not in excess of the stipulated periods.
In addition, the Plan is prohibited under federal law from requiring a health care provider to obtain
authorization from the Plan in order to prescribe a length of stay not in excess of 48 hours (or 96 hours).
However, federal law does not prohibit the mother’s or newborn’s attending provider, after consulting with
the mother, from discharging the mother or her newborn child earlier than 48 hours (or 96 hours, if
applicable).
WOMEN’S RIGHTS AND CANCER HEALTH ACT
In accordance with this federal law, the Plan shall provide benefits for reconstructive surgery following a
mastectomy, surgery and reconstruction of the other breast to produce a symmetrical appearance, and
prostheses and physical complications of all stages of mastectomy, including lymphedemas.
COVERAGE DURING LEAVE FOR MILITARY SERVICE
If you enter the Uniformed Services as defined by the Uniformed Services Employment and
Reemployment Rights Act (USERRA) of 1994, your coverage under the Plan shall be continued for up to
30 days. If you enter service with the Uniformed Services for more than 30 days, coverage under the
Plan shall terminate, and you will be entitled to elect COBRA continuation of coverage.
When you are discharged from the Uniformed Services, your coverage under the Plan will be reinstated
immediately upon your return to work with the City, provided you return to work within certain time
periods. If your period of service was between thirty and 180 days, you must return to work with the City
within 14 days of your discharge in order for your coverage to be reinstated immediately upon return to
work. If your period of service was more than 180 days, you must return to work with the City within 90
days of your discharge in order for your coverage to be reinstated immediately upon your return to work.
If the former active Employee is hospitalized for or convalescing from any illness or injury caused by
active duty, the time limits to submit the application for reemployment are extended to the end of the
period necessary to recover and in no case beyond two (2) years.
COST CONTAINMENT FEATURES
To help maintain a cost-effective benefit program that provides value in exchange for our health care
dollars, the Plan uses several cost containment techniques. Failure to comply with the Plan’s cost
containment requirements could result in additional cost to you. These cost containment features include:
a preferred provider network
hospital pre-admission certification program
utilization review/case management
prescription benefit management
hospital self-audit program
The Preferred Provider Network enables the Plan to contract with certain providers for negotiated fees
that are generally lower than fees in the open market. If you select a provider who belongs to the
Preferred Provider network, the Plan’s savings are passed along to you in the form of lower coinsurance
costs. You are certainly free to use any provider you wish; however, your use of Non-preferred Providers
will require that you pay a larger portion of the cost for services. The Plan utilizes the Sloans Lake
Managed Care Network for Preferred Providers. Call your provider directly to determine whether he/she
is a Preferred Provider. The Sloans Lake Directory is always subject to change, and may not reflect the
most current information. You may also check the Sloans Lake website: www.sloanslake.com.
The Hospital Pre-Admission Certification Program requires each inpatient hospital stay (Preferred or
Non-preferred) to be precertified BEFORE you go to the hospital. This precertification program is
administered by Sloans Lake. If you do not precertify your inpatient hospital admission, your
inpatient hospital benefits will be reduced by $250.00.
Non-emergency Hospital Admissions When your physician recommends an inpatient hospital
stay, you must call Sloans Lake at 1-800-850-1899. Be prepared to identify yourself as a
participant in the City of Fort Collins Group Health Plan, and provide your name and Social
Security number. If the hospitalization is for a covered dependent, provide the dependent’s name
and date of birth. You also need to provide the name of your attending physician, the name of the
hospital, and the date and reason for the proposed hospitalization. Sloans Lake will discuss the
proposed hospitalization with your physician and, if possible, recommend appropriate cost-
effective alternatives, such as outpatient surgery.
Emergency Admissions In case of an emergency, obtain the care you need immediately. If you
are admitted overnight, call Sloans Lake within 48 hours (72 hours if you are admitted on a
weekend). If you are unable to make the call yourself, have a family member or friend call on
your behalf. Please familiarize your family members or a friend with this requirement so that you
can avoid the reduction in benefits.
Utilization Review seeks to provide the proper level of Medically Necessary care appropriate to a
patient’s condition; if warranted, adjustments to the treatment plan can be made. The Plan uses several
utilization review techniques:
Continued Stay Review If your hospital stay is expected to last longer than the approved period,
call Sloans Lake to request an extension. Sloans Lake in consultation with your physician may
authorize additional days that are necessary because of your condition.
Medical Case Management When Sloans Lake is notified of a hospital admission for a serious
illness or injury, they assign a medical case manager to monitor your treatment. The medical case
manager is usually a Registered Nurse. Case managers work with the physician and the patient’s
family to see that quality care and appropriate treatment are received. Case managers may also
recommend alternative forms of appropriate treatment. Please remember: Sloans Lake determines
only whether a service is appropriate, and not whether a service is actually covered by the Plan.
Please call National Health Systems, Inc. to verify whether a specific service is covered by the Plan.
Maternity Admissions and Care Remember to precertify with Sloans Lake your maternity
admission. Otherwise, your benefits will be reduced by $250.
Prescription Benefit Management To help contain the cost of prescription drugs, the Plan has entered
into an agreement with a Prescription Benefit Manager, Express Scripts, Inc.
One of the services Express Scripts provides is called “preferred drugs”; with this program, Express
Scripts suggests to physicians the use of lower cost medications that might be appropriate for your
treatment. This program suggests but does not require the use of lower cost medications.
When you purchase medications from a participating pharmacy, use your prescription drug plan
identification card for quick service.
For maintenance medications, a lower cost mail order prescription program is also available (see
page13). Questions about prescription drugs should be addressed to Express Scripts.
Hospital Self-Audit You can help the Plan contain health care
costs by participating in this program. If you receive a hospital bill
and you believe you are being charged for services or items you
did not receive, contact National Health Systems immediately and
let them know your concerns. Then, call Human Resources to
obtain a Hospital Self-Audit form. If an overpayment has been
prevented, you will receive 50% of the amount saved to a
maximum payment of $2,000.
BENEFIT PROVISIONS
The Plan offers you two benefit plan options from which to choose. Under either option of the Plan you
may use any hospital or physician you wish, including Non-preferred (Non-PPO) Providers; however, you
generally receive a greater level of benefit for some expenses when you use a Preferred (PPO) Provider
who has entered into a contractual fee agreement. The Plan contracts with Sloans Lake to provide a
Preferred Provider network. However, because the network directory is subject to change, you should
verify with your provider that he/she is a Preferred Provider before you obtain services.
Separate Accounting Preferred Provider and Non-Preferred Provider charges are accounted for
separately under the Plan; Preferred Provider charges are not applied toward Non-preferred Provider
deductibles and Out-of-Pocket Maximums and vice versa.
Benefit payments for charges rendered by out-of-network Non-preferred Providers are based on
Reasonable and Customary (R&C) charges that represent the prevailing rate in a geographic area.
Charges in excess of R&C limits are not covered by the Plan. In addition, you may refer yourself to a
specialist without a referral from your primary care physician. Amounts that you pay for deductible
charges or coinsurance payments may be reimbursable through the City’s Health Care Flexible Spending
Account; please see the separate brochure for information on this plan.
Deductible charges are paid on a calendar year basis, and apply to all covered expenses. There are
separate deductibles for Preferred Provider and Non-preferred Provider charges. Amounts paid for
Preferred Provider charges are not applied to the Non-preferred Provider deductible, and vice versa. If
you incur any deductible charges during the last three months of a plan year, those charges will also be
applied to your deductible requirement for the following plan year. If more than one covered family
member is injured during a common accident, only one deductible will need to be met for medical
expenses related to that accident. Amounts you pay for ineligible charges (including charges in excess of
R&C limits) are not applied toward meeting your deductible requirement or any out-of-pocket maximum.
The prescription drug deductible is separate, and is not included for purposes of this deductible.
Coinsurance is the percentage of covered charges you pay after satisfying your deductible. Coinsurance
payments for Preferred Provider services are different from payments for Non-preferred Provider
services. If you use a Preferred Provider, the Plan pays 90% of the provider’s contracted fee, and you
pay the remaining 10%. If you use a Non-preferred Provider, the Plan pays 70% of R&C charges and you
pay the remaining 30% of R&C charges, plus any charges in excess of R&C levels. Charges in excess of
R&C amounts are not covered by the Plan; therefore they are not applied toward your deductible or out-
of-pocket maximum amounts.
A Copayment is the fixed dollar amount you pay for prescription drugs, unless your cost of that drug is
subject to a percentage of the total cost.
The Annual Out-of-Pocket Maximum is the most you will pay for eligible charges during a Plan Year,
and is comprised of your deductible plus your coinsurance payments. Once you satisfy the out-of-pocket
maximum, the Plan will pay 100% of excess eligible charges for the balance of the Plan Year. There are
separate out-of-pocket maximums for Preferred Provider and Non-preferred Provider charges. Amounts
paid toward the Preferred Provider Out-of-Pocket Maximum are not applied to the Non-Preferred provider
Out-of-Pocket Maximum, and vice versa. The family Out-of-Pocket Maximum is satisfied when two family
members each satisfy the individual Out-of-Pocket Maximum. Amounts paid for prescription drugs are
not counted toward meeting this annual Out-of-Pocket Maximum. Amounts paid for any charges not
covered by the Plan or costs exceeding specific benefit maximums do not apply to the Out-of-Pocket
Maximum.
OPTION 1
Preferred Providers After you satisfy the calendar year deductible of $750 per person in eligible
Preferred Provider charges, the Plan pays 90% and you pay 10% coinsurance for additional covered
charges. After meeting your Out-of-Pocket Maximum, the Plan will pay 100% of eligible Preferred
Provider charges for the remainder of the calendar year. Individual maximum out-of-pocket cost per year
is:
2002: $1,150 ($750 deductible + $ 400 coinsurance)
2003: $1,350 ($750 deductible + $ 600 coinsurance)
2004: $1,750 ($750 deductible + $1,000 coinsurance)
Non-preferred Providers After satisfying a separate calendar year deductible of $1,500 per person in
eligible Non-preferred Provider charges, the Plan pays 70% of R&C charges and you pay 30% of R&C
charges, plus charges over R&C limits. After meeting your Out-of-Pocket Maximum, the Plan will pay
100% of eligible R&C charges for the remainder of the calendar year. Individual maximum out-of-pocket
cost per year is:
2002: $2,300 ($1,500 Deductible + $ 800 Coinsurance)
2003: $2,500 ($1,500 Deductible + $1,000 Coinsurance
2004: $2,700 ($1,500 Deductible + $1,200 Coinsurance)
OPTION 2
Preferred Providers After you satisfy the calendar year deductible of $200 per person in eligible
Preferred Provider charges, you pay 10% coinsurance for additional covered charges. After meeting your
Out-of-Pocket Maximum, the Plan will pay 100% of eligible R&C charges for the remainder of the
calendar year. Your maximum out-of-pocket cost per calendar year is:
2002: $ 600 ($200 Deductible + $ 400 Coinsurance)
2003: $ 800 ($200 Deductible + $ 600 Coinsurance)
2004: $1,200 ($200 Deductible + $1,000 Coinsurance)
Non-preferred Providers After satisfying a separate calendar year deductible of $500 per person in
eligible Non-preferred Provider charges, you pay 30% R&C coinsurance for additional covered charges.
After meeting your Out-of-Pocket Maximum, the Plan will pay 100% of eligible R&C charges for the
remainder of the calendar year. Your out-of-pocket cost per calendar year is:
2002: $1,100 ($500 Deductible + $ 600 Coinsurance)
2003: $1,300 ($500 Deductible + $ 800 Coinsurance)
2004: $1,500 ($500 Deductible + $1,000 Coinsurance)
Benefit Maximum For active Participants and retiree Participants not eligible for Medicare, the Plan will
pay up to $2,000,000 in covered charges for you and each of your eligible covered dependents. For
retired Participants eligible for Medicare, the Plan will pay up to $100,000 in covered charges per
calendar year, including $5,000 per year in prescription drug charges, up to the $2,000,000 maximum.
The benefit maximum applies to all periods of coverage under the Plan.
COVERED EXPENSES
The Plan covers a wide variety of Medically Necessary services that are prescribed by a physician.
However, not all services are covered even if they are determined Medically Necessary and prescribed
by your physician. Your decision to seek and obtain medical care should not be determined solely by the
availability of insurance coverage. In addition, the Plan reimburses only for eligible covered expenses.
Payment for Non-Preferred Provider services is limited by Reasonable and Customary (R&C) amounts;
charges over and above R&C limits are your responsibility. References to maximum benefits include
benefits received at any time of participation under Option 1 and/or Option 2.
Pre-existing Conditions are defined as conditions for which you have received medical treatment or
have incurred expenses within the three months immediately preceding your effective date of coverage
under the Plan. Generally, pre-existing conditions are not covered during the first six months of coverage
under the Plan; however, if no treatment is received for the pre-existing condition during the first three
months of participation under the Plan, the pre-existing condition shall be eligible for reimbursement
under the Plan. For purposes of the Plan, pregnancy is NOT considered a pre-existing condition.
The Health Insurance Portability and Accountability Act (HIPAA) places limits on pre-existing condition
limitations. If you and your eligible dependents had creditable coverage under another plan and did not
experience a break in coverage, that period of prior coverage is counted toward meeting the pre-existing
condition limitation. For HIPAA purposes, a break in coverage is defined as a period of 63 days or more
without health coverage.
To use creditable coverage toward meeting your pre-existing condition limitation, you must present a
Certificate of Creditable Coverage, which you obtain from your prior employer or health plan provider.
Work related illness or injury are not covered by the Plan and must be treated through the workers’
compensation program; otherwise, you could be held responsible for substantial charges. The Plan is not
authorized to pay for treatment related to work related conditions, and therefore will decline any such
claims. Questions about workers compensation should be addressed to the Risk Management
Department, at 221-6708.
The following services are covered by the Plan, subject to deductible and coinsurance requirements.
OUTPATIENT SERVICES
Physician Office Visits, including self-referral to specialists, for the diagnosis and treatment of covered
illness or injury.
Immunizations and Injections are covered for the treatment of illness or accidental bodily injury.
Routine Physical Exams are not covered, except to the extent provided under the guidelines for
mammography, pap smears, prostate screening and sigmoidoscopy (see below). Charges incurred for
routine laboratory and x-ray procedures are not covered.
Second/Third Surgical Opinions provided by a specialist or board certified surgeon
who acts only as a consultant. Second and third surgical opinions are not
covered for: cosmetic or dental surgery; minor surgery that may be performed in
a physician’s office; and Medicare-eligible participants who refuse to comply with
Medicare’s second surgical opinion program.
Outpatient Surgery for the treatment of illness or accidental bodily injury is
covered as an alternative to inpatient admission. Covered expenses include
eligible charges made by a Hospital or Outpatient Surgical Center for the use of
its outpatient facilities. Coverage of colonoscopy is based on Medical Necessity
and family history.
Maternity Care includes Physician Charges for Pre-natal, Delivery and Post-natal Care.
Nursery Fees for newborn children when Medically Necessary.
Well-child Care Routine Pediatric Visits, including immunizations. Benefits are paid up to $350 for
charges incurred before the covered child’s first birthday, and $175 for charges incurred on or after the
covered child’s first birthday but before the second birthday. Services must be received within the
timeframes specified. Delays in obtaining physician appointments do not warrant extensions.
Outpatient Diagnostic X-Ray and Laboratory: charges in addition to Physician office
visit charges for Medically Necessary X-ray and laboratory examinations for the
diagnosis and treatment of an illness or accidental bodily injury, including blood
tests, allergy tests, basal metabolism determination, electrocardiograms, thyroid
profiles, electroencephalograms. Routine X-ray and laboratory procedures are
not covered.
Routine Mammography: the following guidelines apply to mammography - participants age 35-39: one
baseline exam; participants age 40-49: one screening every two years; participants age 50 and over: one
screening each year; or any Medically Necessary screening due to family history, regardless of age.
Prostate Screening and Sigmoidoscopy: the following guidelines shall apply to prostate screening
(PSA): men age 40 and under: one screening; men age 41-49: one screening every two years; men age
50 and over: one screening each year. These same guidelines also apply to sigmoidoscopy for all
participants, including women. Any Medically Necessary prostate screening and sigmoidoscopy due to
family history is provided regardless of age or gender.
Pap Smears are provided annually for routine screening.
Hearing tests and audiograms for the purpose of diagnosing illness or accidental bodily injury.
Speech and Hearing Therapy (including diagnostic testing) to improve speech and
hearing ability or loss due to developmental disorders or deficiencies due to
illness or injury. Benefits in excess of $500 must be pre-approved by the Plan.
Benefits are payable up to an aggregate limit of $5,000 per participant; this
maximum includes any and all benefits received at any time from Preferred and
Non-Preferred Providers under Option 1 and Option 2 combined.
Short-Term Physical Therapy Performed on an Outpatient Basis is provided for up to
two consecutive months, when prescribed by a physician in whose judgement
significant improvement can be obtained. Additional benefits must be certified
by the attending physician as Medically Necessary. Occupational Therapy may
be performed by a properly accredited Occupational Therapist (OT) or a Certified
Occupational Therapy Assistant (COTA). Physical Therapy may be performed by
a Physician or a registered physical therapist.
Chiropractic Services are covered up to one visit per day to a maximum of thirty visits per Participant
per calendar year.
Acupuncture is covered when Medically Necessary and administered by a licensed medical doctor (MD).
Prescription Drugs are provided on an outpatient basis through a separate contract with Express
Scripts, Inc., and benefits are the same for Options 1 and 2. Questions about outpatient prescription drug
claims should be addressed to Express Scripts, Inc., and NOT to National Health Systems.
After satisfaction of a separate calendar year deductible of $50 per person, you pay only a copayment
for each prescription during the balance of that calendar year. One copayment is required for each thirty-
day supply of a prescription drug, to a maximum 100 tablets. You should remember that discounts are
available through participating pharmacies and through the mail order prescription drug program.
The Plan utilizes a prescription drug formulary, or list, to determine the amount you pay for your
medications. Your copayment is based on whether your medication is on the formulary list, and whether
your medication is a brand name or a generic medication. Greater savings are generally available by
using generic medications; consult with you physician to determine whether a generic medication would
be appropriate for your treatment. Under the “Preferred Drug” program, Express Scripts is required by
the Plan to suggest (but not to require) the use of lower cost alternative medications that might be
appropriate for your care. Only those medications prescribed for the treatment of a covered condition are
eligible for coverage.
Under our 3-tier formulary structure, your copayments are:
generic on formulary: you pay the greater of $8 or 10% of the total cost.
brand on formulary: you pay the greater of $15 or 20% of the total cost.
generic or brand not on formulary: you pay the greater of $30 or 30% of the total cost.
Mail Order Program: by utilizing the Express Scripts, Inc. prescription drug mail order program, you may
purchase a three-month supply of your maintenance medication for two copayments per medication. Mail
order prescriptions are not subject to deductible charges and are not subject to a percentage of the
medication’s cost. A maintenance medication is a prescription that is taken for at least 90 consecutive
days for the treatment of a chronic condition, e.g., blood pressure, cholesterol or birth control, etc.. Acute
care medications (e.g., antibiotics) are not eligible for the mail order program. Remember to place your
mail order prescription in time to avoid an interruption in the supply of your medication. Additional
information is available at the Human Resources Office. Mail order copayments per medication are:
generic on formulary: $16
brand on formulary: $30
generic or brand not on formulary: $60
Outpatient Mental Health care is provided, up to a maximum of thirty visits per person per calendar year.
Services are also available through the separate Employee Assistance Program (EAP). You may reach
the EAP at 1-800-284-1819.
Outpatient Substance Abuse Treatment is covered to a maximum of $2,000 per covered person per
calendar year; these benefits are included in the combined maximum benefit of $25,000 per participant
for inpatient plus outpatient substance abuse services. The aggregate benefit maximum shall include all
eligible charges incurred under any portion of the Plan, including charges incurred under Option 1 and/or
Option 2, and charges incurred with Preferred and/or Non-Preferred Providers. Services are also
available through the separate Employee Assistance Program (EAP). You may reach the EAP at 1-800-
284-1819.
INPATIENT/HOSPITAL SERVICES
Inpatient Hospital Admissions are covered for the Medically Necessary services prescribed by a
physician. Covered charges include: semi-private room and board (a private room is provided if Medically
Necessary); operating room, delivery room and recovery room charges; nursing and other professional
care charges; inpatient X-ray, laboratory, EKG, therapeutic and diagnostic services; the administration of
blood and blood plasma; medications; physical therapy, casts and dressings.
Newborn Nursery Charges are provided, subject to medical necessity.
Inpatient physician services are provided, including physicians’ and surgeons’ services, surgical
assistants and anesthesia. When Medically Necessary, coverage of assistant surgeon’s fees is provided
up to 20% of the surgeon’s fee; coverage of Medically Necessary physician assistant fees is provided up
to 10% of the surgeon’s fee.
Emergency Room Services are provided for the treatment of accidental injury or the sudden and
unexpected onset of a condition requiring immediate medical or surgical care. Without immediate
treatment, emergency situations could result in a more serious health condition or death. Emergency
Room services are not provided as a convenience. Conditions that do not require immediate attention
but could wait for treatment by your personal physician are not considered emergencies. The Plan is not
authorized to pay emergency benefits for non-emergency situations; therefore, the improper use of
emergency services could result in substantial charges for which you alone would be responsible.
Inpatient Mental Health Services are covered up to 100 days per participant.
Inpatient Treatment of Substance Abuse is covered up to $25,000 per participant. This benefit
maximum shall include also any payment for outpatient treatment of substance abuse. The aggregate
benefit maximum shall include all eligible charges incurred under any portion of the Plan, including
charges incurred under Option 1 and/or Option 2, and charges incurred with Preferred and/or Non-
preferred Providers.
OTHER SERVICES
Ambulance Service is provided when Medically Necessary for transportation to the hospital and to
transfer from one hospital to another for inpatient care.
Home Health Care is covered when prescribed by a physician, pre-certified by Sloans Lake Managed
Care and provided by health care professionals for care related to a condition for which you might
otherwise be hospitalized. The Plan provides coverage for Medically Necessary services and supplies
furnished on a visiting basis in a private residence by a certified home health care provider. Such
covered services and supplies include: professional nursing services, supervised home health aide
services, physical/occupational/speech/respiratory/ rehabilitation therapy, medical services and supplies
provided by or through a home health care agency, and nutrition counseling provided by or under the
supervision of a registered dietitian. One home health visit per day is provided, up to 100 visits per
calendar year.
Hospice Care is covered, if a physician certifies that you or one of your covered dependents is terminally
ill. For purposes of this section, a terminally ill patient is a patient who is expected to live 180 days or
less; this limitation may be recertified when Medically Necessary. Covered services include: inpatient
confinement in a hospice facility; physician services; physical/occupational/speech/hearing/respiratory/
inhalation therapy or a home health aide supervised by a registered nurse or specialized rehabilitative
therapist; professional services provided by (or under the supervision of) a registered nurse; prescription
drug therapy for pain control; eligible durable medical equipment and Medically Necessary supplies;
nutrition counseling by a nutritionist or dietitian; homemaker services; medical social services; emotional
support services; bereavement counseling by a licensed social worker or pastoral counselor (up to $250);
respite care to immediate family members on a short-term basis so that the terminally ill patient may
remain an outpatient.
Skilled Nursing Facility services following an inpatient hospitalization are provided for Medically
Necessary care prescribed by a physician; the physician must certify that these services are Medically
Necessary and provided in lieu of hospitalization. Services of a private duty nurse or physician are not
included. Plan benefits are payable for up to 60 days per confinement at 50% of the immediately
preceding Hospital’s semi-private room rate; if the Hospital does not have semi-private rooms, the limit is
45% of the daily charge for its lowest rate private room. Separate confinements due to the same or
related illness or injury are considered a single confinement, unless separated by complete recovery.
Durable Medical Equipment (DME) is designed for repeated use for a medical purpose, and is not
useful to a person in the absence of illness or injury. Purchase of DME is covered if rental is more
expensive. DME includes, but is not limited to, wheelchairs, hospital beds, respirators, glucose monitors
or other similar equipment. Replacement of DME must be Medically Necessary and pre-authorized by
National Health Systems. However, the following items are not covered: air conditioners, humidifiers,
dehumidifiers, air purifiers and other similar items; certain supplies may be available through Express
Scripts.
Appliances, Prosthetics and Supplies are covered when Medically Necessary and prescribed by a
physician. Such items include but are not limited to: original prosthetic devices and Medically Necessary
replacements; splints, trusses, braces, crutches; oxygen; and hearing aids. The maximum benefit paid for
hearing aids is $750 per participant every five years.
Outpatient casts, dressings and orthotics are covered when Medically Necessary and prescribed by a
physician. The maximum benefit for covered orthotics is $250 per participant.
Footcare services are provided for Medically Necessary non-surgical treatment of chronic foot conditions.
There is a maximum benefit of $500 per participant. A separate maximum of $250 per participant is
payable for orthotics prescribed by a physician
MAXIMUM BENEFITS
The following benefit maximums are in effect for covered Medically Necessary charges received from
either Preferred or Non-preferred providers combined. The aggregate benefit maximum per participant is
$2 million. Specific benefit maximums are listed below.
Benefit Maximums per Participant
1. 100 days for inpatient mental health treatment.
2. $25,000 per participant for inpatient and outpatient substance abuse treatment combined under all
portions of the Plan, including Options 1 and/or 2 and Preferred and/or Non-preferred Providers.
3. $5,000 per participant for speech and hearing therapy.
4. $250 per Participant who is an immediate family member for Hospice bereavement benefits.
5. $500 per Participant for Medically Necessary, non-surgical treatment of chronic foot conditions.
6. $250 per Participant for orthotics prescribed by a physician.
Calendar Year Benefit Maximums Per Participant
1. Thirty (30) visits for outpatient mental health disorders.
2. Thirty (30) visits per year for chiropractic treatment.
3. 100 home health care visits.
4. 180 days for hospice care.
5. $2,000 for outpatient substance abuse.
6. $100,000 in benefits paid for each Medicare-eligible retiree medical plan participant, including $5,000
per year for covered prescription medications.
GENERAL EXCLUSIONS AND LIMITATIONS
The following expenses are not covered by the Plan, even though they may be Medically Necessary and
prescribed by a physician.
1. Any charge not listed specifically as a covered expense.
2. Charges for medical expenses which are not prescribed by or provided by a physician or other
covered provider.
3. Expenses for which a participant is entitled or could have been entitled to any benefits provided by
any governmental agency.
4. Expenses a participant would not be obligated to pay, if the participant were not covered under this
plan.
5. Expenses for treatment that is not Medically Necessary, and amounts exceeding R&C levels.
6. Charges incurred before the participant’s effective date of coverage.
7. Services and supplies resulting from illness or injury arising out of and occurring in the course of
employment.
8. Eye examinations or refractions, eye glasses, contact lenses or fitting of eye glasses or contact
lenses.
9. Medical benefits for dental services and supplies, unless for treatment of accidental damage to sound
natural teeth and expenses are incurred within one year of the date of the accident.
10. Cosmetic, plastic or reconstructive surgery, unless needed after an injury you have sustained while
covered by the Plan or because of a congenital disease or anomaly of a dependent child covered
since birth which results in a functional defect or if needed for reconstructive surgery following a
mastectomy or other Medically Necessary treatment that results in disfigurement.
11. Custodial care, medical care or treatment and service or supply charges made by a nursing home,
rest home, convalescent home or similar establishment, except as specifically described herein.
12. Accidental injury or illness resulting from any act of war (declared or undeclared), except as required
by law.
13. Accidental injury or illness resulting from the release of nuclear energy, except when used for medical
treatment of a sickness or injury of a participant under direction and prescription of a physician.
14. Accidental injury or illness resulting from or occurring during the commission of a felony by a
participant.
15. Expenses for learning deficiencies and special education, whether or not related to a mental disorder.
16. Expenses for milieu therapy or recreational therapy.
17. Orthopedic shoes or supportive devices for the feet, or non-Medically Necessary orthotics, which do
not require a physician’s prescription, except as otherwise provided herein.
18. Services and supplies designed to facilitate conception, such as artificial insemination, in-vitro
fertilization and embryo transplantation; services for the treatment of sexual impotency; services for
the reversal of surgically induced infertility.
19. Humidifiers, air conditioners, exercise equipment, whirlpools, health spa or club memberships, or
swimming pools, whether or not prescribed by a physician.
20. Intentionally self-inflicted injury or illness, including overdose of medication, unless the participant is
under psychiatric care or immediately seeks psychiatric care.
21. Transsexual surgery.
22. Services that are provided by a person who ordinarily lives with the participant or is a member of the
participant’s immediate family, either by blood or through law.
23. Non-surgical treatment for the removal of corns or the trimming of callus or toenails, and strapping,
but not including Medically Necessary surgery and Medically Necessary treatment of the feet for
peripheral or vascular disease or diabetes, except as otherwise provided herein.
24. Weight loss, weight control programs, physical fitness programs or treatment for obesity, except
morbid obesity when pre-authorized.
25. Charges incurred for a pre-existing condition, except as described on page 11.
26. Charges for orthoptics or vision training.
27. Laetrile, enzymes and food supplements.
28. Treatment or services in connection with Premenstrual Syndrome (PMS).
29. Charges in connection with radial keratotomy, including all laser eye surgery and automated
keratoplasty.
30. Chelation therapy.
31. Experimental or investigative procedures as described in this SPD.
32. Insulin pumps, monitoring devices and other devices, other than pacemakers, that can be
permanently implanted.
33. Travel expenses for a participant or a physician.
34. Preparation of medical reports or itemized bills.
35. Telephone consultations.
36. Wigs and artificial hairpieces.
37. Personal convenience items, education materials, and classes.
38. Court ordered classes or treatments.
39. Lamaze classes.
40. Vocational rehabilitation.
41. Treatment or services not consistent with the diagnosis.
42. Treatment of growth hormone deficiency, except when determined Medically Necessary by medical
review.
43. Implantable and/or inflatable prosthesis and replacement of breast implants, except following a
mastectomy.
44. Smoking cessation substances, programs and devices.
45. Massage therapy rendered by a massage therapist, unless directly supervised by a licensed physical
therapist; self-help and stress management; and exercise stress testing.
46. Expenses for occupational therapy that retrains an individual for a job or career, physical therapy or
speech therapy except as outlined under the section of this booklet entitled “Covered Expenses.”
47. Replacement of durable medical equipment or prosthetic devices, unless Medically necessary.
48. Examinations or consultations for or in connection with cosmetic purposes.
49. Charges for hospital, surgical and related expenses incurred by a person for whom Medicare is
primary payer, when the person does not comply with Medicare’s mandatory Second Surgical Option
Program.
50. Elective abortions, except when necessary for the mother’s welfare or necessary due to severe
chromosomal abnormalities or malfunctions not compatible with life.
51. Treatment for functional defects of the jaw and TMJ.
52. Charges in connection with the alleviation of chronic pain in excess of the charges that would be
payable to a physician or hospital.
53. Charges in connection with biofeedback, unless prescribed by a licensed Medical Doctor (M.D.) and
performed by a covered provider for a covered diagnosis, or hypnotherapy.
54. Any charges incurred through Medicare private contracting arrangements.
55. Charges for human organ and/or tissue transplants, including but not limited to, donor screening,
acquisition and selection, organ or tissue removal, transportation, transplantation, post operative
services and drugs or medicines, and charges related to nonhuman (Xenografted) organ and/or
tissue transplants or implants, except heart valves; charges related to high dose chemotherapy with
autologous or allogenic bone marrow transplantation; except charges related to the transplantation of
the kidney or the cornea. This exclusion does not limit in any way the Organ and Bone Marrow
Transplant benefits which may be available through an insurance contract.
56. Acupuncture, unless performed by a licensed medical doctor (M.D.).
57. Certain outpatient prescription charges are not covered, including but not limited to: drugs or
medications that are procurable without a Physician’s written prescription; immunization agents,
biological sera, blood or blood plasma; Minoxidil (Rogaine) for the treatment of alopecia; infertility
medications; injectable allergy extracts; dietary supplements; anorectics for individuals over age
twenty-five (25); charges for the administration or injection of any drug; therapeutic devices, or
appliances, including needles, syringes, support garments, appliances, prosthetics, bandages, heat
lamps, braces, splints, and other non-drug items, regardless of intended use; smoking cessation aids;
medications used to treat impotence; drugs labeled “Caution – limited by federal law to investigational
use,” or experimental drugs, even though a charge is made to a participant. Charges excluded herein
may or may not be covered by Express Scripts, Inc. There are other outpatient medications which
also require prior authorization. This means a letter would need to be written by the prescribing
physician indicating a diagnosis and the name of the medication. This list includes but is not limited
to: growth hormones; drugs used to treat cosmetic indications; immunosuppressants and drugs used
for chemotherapy. For information on preauthorizations, call Express Scripts directly.
HOW TO CLAIM BENEFITS
Preferred Providers (PPO)
To claim Preferred Provider benefits under the PPO option, you must first select a provider who is a
member of the Sloans Lake provider network. Before services are obtained, verify with your provider
whether he/she is a Preferred Provider; otherwise, you may be responsible for additional charges.
Medical Claims (Physician Services). At the time you call a physician for an appointment, you should
confirm that he/she is a member of the network. When you arrive at the physician’s office, you must
follow certain specific steps to ensure that the office staff recognizes you as a PPO patient. Either
present your health plan identification card, or follow these two steps:
First, identify yourself (or your dependent) to the receptionist as a participant in the City of Fort Collins
Group Health Plan.
Second, you must specify that you are seeking benefits through the Plan’s PPO option. You should
inform the physician’s staff that the City of Fort Collins Group Health Plan participates with Sloans
Lake. This information is listed on your health plan identification card.
The physician’s office will file on your behalf the claim with the claims administrator, and payment will be
made directly to the physician. The physician may bill you for the deductible and coinsurance not paid by
the Plan. If a Preferred Provider requires full payment at the time of service, you should contact Sloans
Lake Customer Service at 1-800-850-2249.
Hospital Claims. PPO hospital admissions must be in a facility contracting with Sloans Lake. When
admitted on an inpatient or outpatient basis, present your plan identification card to the hospital admitting
office, identify yourself (or your dependent) as a participant in the City of Fort Collins Group Health Plan,
and inform the admitting office that you are seeking benefits through the Plan’s PPO option. Be certain to
complete all necessary forms presented to you. The hospital will send the claim directly to the claims
administrator for payment, and payment will be made directly to the hospital.
Remember: you are responsible for specifying that you seek benefits under the Plan’s PPO option. If
you do not, benefits may be paid on a non-PPO basis and you will be responsible for additional charges
that are not covered or paid by the Plan.
Non-preferred Providers
A claim for non-preferred provider hospital, medical and surgical expenses or questions relating to the
payment of a claim should be directed to the claims administrator. You will need to complete the required
claim form and obtain invoices from your providers. Upon receipt of this information, file the claim directly
with the claims administrator at the following address:
National Health Systems, Inc.
155 Inverness Drive West, Suite 300
Englewood, Colorado 80112
Phone: (303) 799-6882
1-800-253-0636
A claim for non-preferred provider prescription drug expenses or questions relating to the payment of a
prescription drug claim should be addressed to the Prescription Benefit Manager at:
Express Scripts, Inc.
PO Box 64022
Attn: Claims Department
Phoenix, AZ 85082
1-800-206-4005
To file a claim for non-preferred providers, follow these four simple steps:
First, obtain the proper claim form from the City’s Human Resources Department. Complete the form in
its entirety to avoid claim processing delays, and be sure to sign your form. A completed and signed form
is required for each person for whom a claim is submitted. Be sure to attach an itemized billing, and mail
the completed claim form to National Health Systems at the address shown above. Bills should include
the following information on the provider’s letterhead stationery:
name of the individual for whom expenses were incurred;
physician bills should show the date of service, the diagnosis and the charge for each
treatment;
nurse’s bills should show the date of service, the place and the hours of duty, the charge per
day and the nurse's signature;
bills for other medical expenses such as oxygen, blood and X-rays on the provider’s billing
letterhead, and should show the charges and the date the expense was incurred;
prescription drug bills should show the date of purchase and the name of the drug(s) for all
prescription drugs purchased at a participating pharmacy or a non-participating pharmacy.
Remember: prescription drug bills should be sent directly to Express Scripts, Inc. and
not to National Health Systems.
Second, if the claim information is complete as submitted and the claim is approved, payment will be
made to you or the providers, depending on whether you have assigned benefits. If you assign benefits
to the provider, payment will be made directly to the provider. If you have already paid the provider, do
not assign benefits and payment will be made directly to you.
Third, if your claim form is incomplete, National Health Systems will contact you or the provider for the
required information.
Fourth, you do not have to submit an additional claim form if your bills are for a continuing disability and
you have filed a claim within the past three calendar months. Mail to National Health Systems any further
itemized bills with diagnosis and breakdown of charges for any medical or hospital services covered by
the Plan as soon as you receive them. Be sure that your name, date of birth, social security number and
address appear on the bills.
Benefits will be paid by the Plan only if notice of claim is made within 90 days from the date on which
covered charges were first incurred. In no event shall benefits be allowed if notice of claim is made
beyond a fifteen month period immediately following the date on which expenses were incurred, unless
the City in its sole discretion determines that extenuating circumstances prevented timely filing of a claim.
All claims must be filed in writing by completing such procedures as required. Such procedures may
include the submission of documents and additional information.
Any hospital bills will usually contain all of the necessary information. However, physician bills are
sometimes incomplete. Claim payments may be expedited by having such bills prepared clearly and
correctly by the provider before they are submitted. Frequently, delays in claim payment are the result of
inaccurate or incomplete claims.
Proof of Claim
The Plan, at its own expense, shall have the right and opportunity to examine the person of any
participant when and so often as it may reasonably require during the pendency of any claim, and also
the right and opportunity to an autopsy in case of death where it is not forbidden by law. Proof of claim
forms, as well as other forms, and method of administration and procedure will be determined solely by
the Plan.
Explanation of Benefits
After your claim has been processed, you will receive in the mail from National Health Systems an
Explanation of Benefits (EOB), which notifies you of the manner in which your claim was handled. If
payment was made to a provider, the amount of the payment will be shown on the EOB, together with an
accounting of all the charges rendered. If no payment has been made, the EOB will provide you with the
reason payment has been reduced or denied. If you have any questions about information contained on
any EOB, please call National Health Systems. If an EOB shows a charge for a service you did not
receive, please notify National Health Systems immediately.
Reporting Changes by Participants
It is important that the claims administrator or the City’s Human Resources Department be notified
whenever a change in any of the following occurs:
a change in your address, so that records are kept up-to-date if you need to be contacted about any
matter concerning your benefit coverage; or
any change in your family status, such as marriage or divorce, birth of a child, the marriage of or the
loss of dependent student status by a dependent child, or the death of any dependent. Charges
incurred by any ineligible dependent will be your responsibility.
If You Need Assistance
Eligibility: if you have any questions about eligibility for coverage under the Plan, please do not hesitate
to contact the Human Resources Office at 221-6535.
Plan Provisions: if you have any questions about specific Plan provisions or claim payments, you should
contact National Health Systems at 1-800-253-0636. Questions about required preauthorization of
services or the preferred provider network should be directed to Sloans Lake Managed Care at 1-800-
850-2249. Questions about prescription drug benefits should be addressed to Express Scripts, Inc. at 1-
800-206-4005.
Coordination of Benefits
Coordination of Benefits applies to persons who are covered by more than one group health plan so that
each plan pays its proper share of benefits. If you or any of your dependents are covered by another
group insurance plan, you will need to provide information regarding other coverage when you file a
claim. If this Plan pays secondary to another plan of benefits, the benefits paid by this Plan are reduced
so that the benefits payable under all plans do not exceed 100% of the eligible charges incurred.
If you or any of your covered dependents are covered by a motor vehicle policy which provides for
coverage of medical expenses resulting from accidental injury, claims should be submitted first to those
other policies for payment. Benefits payable by the Plan shall be reduced by the benefits payable by
those other polices. Only after benefits have been determined by those other policies should claims be
submitted to the Plan. If benefits have been paid out by the Plan, the Plan shall have the right to recover
from you, the motor vehicle insurer the value of benefits that should have paid by those plans.
If there are two group plans providing coverage for you and your eligible dependents, a determination
must be made as to how the plans coordinate payment, and which plan pays first. These are the general
guidelines that are used to determine which plan pays first:
A. Employee/Dependent Rule
1. The plan which covers the participant as an employee pays first.
2. The plan which covers the participant as a dependent pays second.
B. Dependent Children of parents NOT separated or divorced
1. The plan which covers the parent whose birthday falls earlier in the year pays first; the
plan which covers the parent whose birthday falls later in the year pays second. The birthday
order is determined by month and day, and not by year of birth.
2. If both parents have the same month and day of birth, the plan which covered the
parent longer will pay first; the plan which covered the parent for a shorter period of
time pays second.
C. Dependent children of separated or divorced parents
1. The plan of the parent with custody of the child pays first.
2. The plan of the spouse of the parent with custody (i.e., the stepparent) pays second.
3. The plan of the parent not having custody of the child pays third.
4. The plan of the spouse of the parent not having custody pays fourth.
5. However, if there is a court decree which would otherwise establish financial responsibility for
medical or other health care expenses with respect to the child, the plan which covers the parent
with such financial responsibility shall be determined before the benefits of any other plan which
covers the child as a dependent.
D. Active/Inactive
1. The plan which covers the participant as an active employee or dependent of an active
employee pays first.
2. The plan which covers the participant as a retired or otherwise inactive employee or
dependent of a retired or otherwise inactive employee pays second.
E. Longer/Shorter
1. If the rules cited above cannot adequately determine the order of benefits, then the plan
which has covered the patient for a longer period of time will pay first.
In no event will benefits received from this Plan and all other plans combined exceed the total of eligible
charges incurred.
For purposes of coordination of benefits, the Plan may obtain claim information from any individual or
organization. In addition, any participant claiming benefits from the Plan shall furnish the Plan with any
information the Plan may require. If any overpayment is made by the Plan because of a participant’s
failure to report other coverage or any other reason, the Plan has the right to recover such excess
payment from any individual to whom or for whom overpayments were made.
Coordination of Benefits with Medicare
Benefits under the Plan are not designed to duplicate any benefit to which you are entitled under the
Social Security Act. If you and/or one of your covered dependents are covered by Medicare, special rules
about the order of payment apply, and benefits will be coordinated in compliance with current federal
regulation.
The Plan pays first and Medicare pays second when you are an active employee and you or your covered
dependent is enrolled for Medicare. When the Plan pays first, you receive the same benefits as all other
covered participants.
Medicare pays first and the Plan pays second when you are not an active employee and you or your
covered dependent are entitled to Medicare, regardless of whether you have actually enrolled in Medicare
Part A or Part B. Benefits are payable by the Plan without regard to entitlement to Medicare as an ESRD
beneficiary for the first 30 months of Medicare entitlement. Benefits are payable after Medicare benefits
whether or not you or your spouse is eligible for Medicare as an End Stage Renal Disease (ESRD)
beneficiary, or you or your spouse are disabled at any age.
If you have any questions about Medicare benefits, you should contact your local Social Security office.
HMO Coordination of Benefits
HMOs have special provisions for coordinating benefits. If you are an HMO participant, you should
contact the HMO regarding these provisions.
No Fault Insurance
The State of Colorado requires no fault automobile insurance, including medical coverage. The Plan
assumes that participants are covered for the required level of medical insurance under an automobile
policy, and will not pay any charges that should be covered by automobile insurance.
Subrogation (The Right to Third Party Payment)
If the Plan pays benefits to you or a covered dependent that are later determined to be the legal
responsibility of another person or company, the Plan has the right to recover these payments from you.
You will be asked to sign a subrogation form at the time of claim. You should know that the Plan will be
refunded for any payments you receive from the Plan which have also been paid to you by a third party.
This right of subrogation applies also to payments that are received through homeowners’ insurance.
Fraudulent Claims Plan participants are responsible for the accuracy of the claims
submitted for themselves and their eligible dependents. Anyone who knowingly
submits a fraudulent claim under the Plan will forfeit immediately coverage under the
Plan and will be subject to disciplinary action, up to and including termination of
employment. Submission of fraudulent claims may also result in criminal and/or civil
liability.
APPEALS
If you disagree with the manner in which a claim has been processed because you believe Plan
provisions have been misapplied, the Plan provides for a specific appeals procedure.
First, call National Health Systems, and ask them to explain the manner in which your claim was handled.
You should have your Explanation of Benefits with you for reference.
Second, if you still disagree with the result of your claim processing, contact the City’s Human Resources
Department to confirm the information provided by National Health Systems.
Third, if you still disagree with the outcome of your claim’s disposition, you may submit a written appeal
to the City’s Benefits Administrator. Be sure to include the specific reason why you believe the Plan’s
provisions were misapplied. Such an appeal must be made within sixty (60) days from the date shown on
the denial or reduction of benefits. In your written appeal, state the specific reasons for your
disagreement with the disposition of your claim. You will receive a written response to your appeal as
soon as possible, but not later than 120 days after receipt of your appeal by the Benefits Administrator.
The written response will include specific reference to Plan provisions applicable to your appeal. The
decision of the City or its designee with respect to your appeal will be final and binding on all parties.
DEFINITIONS
Accident means an unexpected event that could not have been foreseen and that causes physical injury
to the participant.
Claims Administrator means the organization responsible for calculating and preparing benefit
payments for the Plan.
Coinsurance means the amount, expressed as a percentage, of a covered expense that is paid by the
participant.
Copayment means the amount, expressed as a fixed-dollar figure, of a covered expense that is paid by
the participant.
Deductible means a specified amount of money that the participant is responsible for paying prior to
receiving reimbursement of a covered expense.
Dependent means the employee’s legal spouse and never-married natural children from birth, or never-
married legally adopted children, until the end of the month in which they attain age nineteen (twenty-five
if attending an accredited high school, college, university or vocational, technical or trade school on a full-
time basis); and
step children residing with the employee in a regular parent-child relationship; adopted
children (from date of placement); children for whom the employee has assumed legal
guardianship; and
any child incapable of self-sustaining employment by reason of mental or physical
impairment, who resides with the employee and who became incapable of self-support prior
to having attained age nineteen (notification of such impairment must be submitted to the
claims administrator within thirty-one days after the date the dependent child’s coverage
would otherwise terminate); and
or any child for whom the employee or spouse is responsible for medical or other health care
benefits under a Qualified Medical Child Support Order.
No other persons are eligible to be a dependent for purposes of coverage under the Plan. Proof of
dependency status may be requested from time to time by the Employer.
Durable Medical Equipment (DME) means medical equipment that is designed for repeated use, is used
primarily to serve a medical purpose, and is not useful to a person without an illness or injury. DME must
be prescribed by a physician and must be Medically Necessary. Examples of durable medical equipment
include wheelchairs, hospital beds, glucose monitors and respirators. Convenience items such as air
conditioners, humidifiers or air purifiers are not considered DME, even if prescribed by a physician as
Medically Necessary.
Emergency means the sudden and unexpected onset of a medical condition with acute symptoms of
such severity that the absence of immediate medical attention could: place the Participant’s health in
serious jeopardy; result in the serious impairment of bodily functions; or result in serious dysfunction of
any bodily organ or part.
Employee means all classified employees, unclassified management employees, contractual employees
whose specific employment contracts state that they are eligible for employer-sponsored medical
insurance as long as such employees are regularly scheduled to work at least 20 or more hours per
week.
Employer means the City of Fort Collins, Colorado; the Poudre Fire Authority; the Downtown
Development Authority; the Fort Collins Housing Authority and the Northern Front Range Air Quality and
Metropolitan Planning Council.
Experimental/Investigative means any treatment, procedure, facility, equipment, drug, device, or supply
not accepted as standard medical practice in Colorado. In addition, if a federal or other government
agency approval is required for use of any items and such approval was not granted at the time service
were administered, the service is Experimental. To be considered standard medical practice and not
Experimental or Investigative, treatment must meet all five of the following criteria:
A technology must have final approval from the appropriate regulatory government bodies.
The scientific evidence as published in peer-reviewed literature must permit conclusions concerning
the effect of the technology on health outcomes.
The technology must improve the net health outcome.
The technology must be as beneficial as any established alternatives.
The improvement must be attainable outside the Investigative settings.
Home Health Care means Medically Necessary services prescribed by a physician in lieu of inpatient
confinement in a hospital, convalescent nursing home, or a skilled nursing facility; such services must be
provided through an organization or agency which meets the requirements of Medicare.
Hospice Care means medical, health care and other services prescribed by a physician for terminally ill
patients to meet special physical and emotional needs so that the hospice patient may remain at home,
whenever possible. A hospice agency must be licensed by the state in which it is located and must meet
certification requirements, as required by Medicare.
Hospital means an institution primarily engaged in providing medical, diagnostic and surgical facilities for
the care and treatment of sick and injured persons on an inpatient basis, and which provides such
facilities under the supervision of a staff of physicians and with a 24-hour-a-day nursing service by
registered nurses. A hospital does not include any institution which is used principally as a rest facility,
nursing facility, convalescent facility or facility for the aged.
Intensive Care Unit means a section or wing within a hospital that is operated for critically ill patients and
provides special supplies, equipment and supervision and care by a registered nurse or other trained
hospital personnel.
Medically Necessary, Medical Necessity means tests, treatments, services or supplies provided by a
hospital, physician or other provider that the Plan determines to be:
appropriate for the symptoms or diagnosis and treatment of the participant’s condition, disease,
illness or injury;
provided for the diagnosis or the direct care and treatment of the participant’s condition, disease,
illness, or injury;
in accordance with standards of good medical practice within the medical community;
not primarily for the convenience of the participant, the participant’s family or the participant’s
provider;
the most appropriate level of services or supplies which can be provided safely.
Medicare means the program of health care for the aged, end-stage renal disease (ESRD) beneficiaries,
and Disabled established by Title XVIII of the Social Security Act of 1965, as amended.
Non-Preferred Provider means any provider who has not contracted with the Plan to provide covered
services to participants.
Occupational Therapy means the use of educational, vocational and rehabilitative techniques to improve
a patient’s functional ability to live independently.
Outpatient Surgical Center is a surgical facility, which is an appropriately licensed provider with an
organized staff of Physicians that meets all of the following criteria:
has permanent facilities and equipment for the primary purpose of performing surgical procedures on
an outpatient basis;
provides treatment by or under the supervision of Physicians and nursing services whenever the
patient is in the facility;
does not provide inpatient accommodations; and
is not a facility used primarily as an office or clinic for the private practice of a Physician or other
professional provider.
Participant means each eligible employee, retiree, dependent and qualified beneficiary who is enrolled to
receive benefits from the Plan.
Physical Therapy means the use of physical agents to treat a disability resulting from disease or injury.
Examples of such physical agents include heat, cold, electrical currents, ultrasound, ultraviolet radiation,
massage (other than massage therapy) and therapeutic exercise.
Physician means physician and surgeon (M.D. or D.O.) licensed to practice medicine in the state in
which he or she practices. The term physician may include a dentist, podiatrist, chiropractor, certified
nurse midwife, or nurse practitioner. Physician may also include licensed psychologists, licensed clinical
social workers or clinical specialist psychiatric registered nurses to the extent that they are rendering
services which they are legally qualified and licensed to perform, and licensed practitioners rendering
counseling and therapy services under the direction and supervision of a licensed psychologist or M.D.
Physician Assistant means an individual who is qualified to provide patient services under the
supervision and responsibility of a physician, and is currently certified by the state in which he or she
practices.
Plan means the City of Fort Collins Group Health Plan, as amended from time to time.
Plan Year means the fiscal period that begins January 1 and ends December 31 each year.
Preferred Provider means any Plan-recognized provider, corporation, organization or entity that has
contracted with the Plan to provide covered services to participants.
Reasonable and Customary (R&C) means those charges for Medically Necessary services, supplies
and treatment that do not exceed the general level of charges made by others of similar standing in the
locality where the charge is incurred. For both Preferred Providers and Non-Preferred Providers, the Plan
bases its R&C amounts on the Resource Based Relative Value Schedule (RBRVS) utilized by the claims
administrator.
Rehabilitation Facility means a facility that is recognized by the Plan and licensed or certified to perform
rehabilitative health care services by the state or jurisdiction where services are provided. Services of
such a facility must be among the covered services recognized by the Plan.
Resource Based Relative Value Schedule (RBRVS) means the description of medicine, x-ray and lab,
radiology, surgery and anesthesia procedures and services approved by the employer, as amended from
time to time. This schedule assigns geographic values to procedures and services based on Medicare
reimbursement levels, and pays charges based on a factor applied to Medicare reimbursement levels.
Respite Care means care that is furnished to a participant when confined as an inpatient so that the
family unit may have relief from the stress of the care of the participant.
Retiree means an Employee who has ten (10) or more years of eligible service completed with the
Employer in a classified position or an unclassified management position and who is eligible to file without
penalty for receipt of retirement benefits, or who is totally and permanently disabled and has ten (10) or
more years of eligible service completed with the Employer in a classified position or unclassified
management position and has exhausted his/her COBRA continuation period.
Skilled Nursing Facility means a lawfully operated institution for the care and treatment of persons
convalescing from an accidental bodily injury or illness which provides room and board and 24-hour
nursing service by licensed nurses and is under the full-time supervision of a legally qualified physician or
a registered nurse.
Spouse means a husband or wife, as recognized by Colorado state law.
Substance Abuse means intentional habitual and excessive misuse of alcohol or drugs resulting in the
need for medical treatment.
Surgery means the medical diagnosis and treatment of injury, deformity and disease by manual and
instrumental operations performed by a physician.
Terminally Ill Patient means a participant with a life expectancy of six months or less as certified in
writing by a physician.
OTHER IMPORTANT PLAN INFORMATION
Plan Sponsor: The City of Fort Collins is the sponsor of this self-funded health Plan. If you have
questions about eligibility or if you wish to appeal a claim decision made by the claims administrator, you
may address correspondence to:
Benefits Administrator
Human Resource Department
City of Fort Collins
PO Box 580
Fort Collins, CO 80522
Phone: (970) 221-6535
Claims Administrator: The Plan’s claims administration is conducted by National Health Systems, Inc., a
third-party administrator. If you have questions about a specific claim or Plan provisions, you may
contact:
National Health Systems, Inc.
155 Inverness Drive West, Suite 300
Englewood, CO 80112
Phone: (303) 799-6882 or 1-800-253-0636
Group Number: 17
Preferred Provider Network/Preauthorization/Utilization Review: these services are provided to the
Plan by Sloans Lake Managed Care. Questions should be directed to:
Sloans Lake Managed Care
1335 South Colorado Boulevard, Suite 902
Denver, CO 80222
Phone: 1-800- 850-2249
Group # 1641
Prescription Benefit Management services are provided to the Plan by Express Scripts, Inc. Do not call
National Health Systems for prescription questions. Questions should be directed to:
Express Scripts, Inc.
PO Box 52161
Phoenix, Arizona 85072-2161
Phone: 1-800-206-4005
Group Number: A5
APPENDIX D
Stop Loss Report
REPORT: CL851 GENERATED: 05 MAR 2002 09:04 RUN: THURSDAY
2002MAR21 09:10 PAGE 1
Group : 17 S T O P L O S S R E P O R T > $ 50000.00 BY DATE PAID
0.00
CITY OF FORT COLLINS 20010101 TO 20011231
Date paid span
INSURED SOC SEC # IX DEPENDENT REL DOB S AMOUNT
CH 19800425 F 68263.28
Diagnoses: 783.0, 307.1, 307.51, 783.2, 733.0, 263.9, 307.5
Prognosis: unknown/patient’s condition appears to be stable
at this time
SP 19490926 M 55332.38
Diagnoses: 453.2, 154.0, 154.8, V58.1, V58.61, 996.74, V66.2,
V15.3, 839.21, 728.85, 353.8, 453.8, 153.9, 786.2,
V58.81, 998.89, V15.82, 309.81, 239.2, 724.5, 296.32,
239.1, 782.2, 789.30, 607.84, 789.07
Prognosis: unknown
SB 19420906 M 82302.30
Diagnoses: 153.9, 199.1, 996.74, 592.1, 593.4, V58.1, 153.0,
154.1, V58.61, 284.8, 598.8, 153.8, 285.9,154.0, 789.0, 780.6,
789.06, 593.4, 788.0, 996.76, V10.05, V44.3, 195.3, 198.89, 719.45,
782.3, 733.19, 786.09, 153.0, 198.5, 808.8, 235.2, 307.9, 733.9
Prognosis: very poor-in hospice treatment
CH 19830104 F 55135.68
Diagnoses: 805.4, E849.4, 884.1, 724.5, E884.1, 722.83,
V67.09, V45.4
Prognosis: unknown
SP 19500720 F 75010.42
Diagnoses: 710.0,583.81, V58.69, 726.10, 719.45, 733.40, 583.81,
733.42, 719.45, 719.95, 039.8, 279.3, 486, 039.9, V12.5, V43.64,
786.5, 799.0, 786.05, 715.15, 583.81, V10
Prognosis: unknown
SP 19520411 F 82025.62
Diagnoses: 277.1, 784.0, V72.3, V76.12, 789.00
Prognosis: unknown
ND 20000209 M 51395.80
Diagnosis: 752.61, 765.10, 742.4, V65.9, V65, 382.9, 367.0,
520.7, 461.9, V20.2
Prognosis: unknown
CH 19800927 F 55241.58
Diagnosis: 735.0, 739.2, 739.1, 739.0, 724.1, 728.35, 737.1,
724.2, 564.1, 787.01, V72.3, 477.0, 795.0, 287.3,
719.45, 382.9, 784, 784.7
Prognosis: unknown/condition appears to be stable and she
has resumed normal activities
Aggregate Stop Loss is 2506893.55
CITY OF FORT COLLINS
ADDENDUM No. 1
April 2, 2002
Description of PROPOSAL NO. P-832, BENEFITS
OPENING DATE: 2:00 p.m. (our clock) April 29, 2002
To all prospective bidders under the specifications and contract documents described
above, the following changes are hereby made.
Appendix A - Monthly Claims and Enrollment: Attachments on the proposal should be in Appendix D.
A new Appendix D is attached to this addendum in its entirety.
The corrected Appendix A is attached to this addendum.
Please replace Appendix A and D in your copy of the RFP.
RECEIPT OF THIS ADDENDUM MUST BE ACKNOWLEDGED BY A WRITTEN STATEMENT ENCLOSED WITH THE
BID/QUOTE STATING THAT THIS ADDENDUM HAS BEEN RECEIVED.
APPENDIX A
Monthly Claims and Enrollment
CITY OF FORT
COLLINS
Monthly Paid PPO/Rx Claims
Paid
Claims
Rx
Claims
EE Only EE + SP EE + CH EE + FAM
Jan-00 $211,969 $31,156 191 137 50 173
Feb-00 $210,183 $24,626 191 137 50 173
Mar-00 $325,725 $31,906 191 137 50 173
Apr-00 $237,299 $37,790 191 137 50 173
May-00 $247,501 $34,841 191 137 50 173
Jun-00 $224,584 $38,824 191 137 50 175
Jul-00 $215,760 $36,622 198 132 52 174
Aug-00 $184,811 $36,972 205 127 54 173
Sep-00 $152,605 $32,381 201 130 52 172
Oct-00 $173,178 $38,743 200 130 53 176
Nov-00 $155,357 $39,475 199 129 51 176
Dec-00 $146,561 $46,139 199 129 51 176
Total
2000
$2,485,532 $429,475
Paid
Claims
Rx
Claims
EE Only EE + SP EE + CH EE + FAM
Jan-01 $251,038 $28,937 187 138 49 157
Feb-01 $196,771 $32,386 188 136 47 156
Mar-01 $200,113 $30,438 189 136 47 157
Apr-01 $132,062 $39,060 189 136 46 158
May-01 $191,487 $35,715 190 138 45 159
Jun-01 $275,223 $35,597 186 138 46 158
Jul-01 $175,112 $40,410 187 138 47 157
Aug-01 $208,929 $39,007 185 137 46 160
Sep-01 $182,694 $41,635 186 135 44 163
Oct-01 $280,581 $3,745 184 134 42 165
Nov-01 $161,613 $44,864 179 134 42 167
Dec-01 $266,461 $52,287 172 132 41 168
Total
2000
$2,522,081 $424,081
Paid
Claims
Rx
Claims
EE Only EE + SP EE + CH EE + FAM
Jan-02 $198,702 $29,957 149 130 33 140
Feb-02 $111,132 $16,656 142 122 32 140
Mar-02
Apr-02
May-02
Jun-02
Jul-02
Aug-02
Sep-02
Oct-02
Nov-02
Dec-02
CITY OF FORT COLLINS
MONTHLY EXPERIENCE SUMMARY - HMO
Date Claims Pharmacy Capitatio
n
ASO
Fees
Total EE
Only
EE +
SP
EE +
CH
Family
Jan-00 $151,565 $36,514 $7,813 $27,657 $223,549 230 136 108 250
Feb-00 $135,098 $35,804 $6,883 $27,733 $205,518 230 132 107 257
Mar-00 $140,133 $32,767 $7,561 $27,810 $208,271 230 133 107 258
Apr-00 $220,333 $36,305 $648 $28,191 $285,477 229 135 109 265
May-00 $179,077 $30,403 $427 $28,306 $238,213 230 133 109 269
Jun-00 $139,319 $37,556 ($2,499) $28,420 $202,796 234 130 111 269
Jul-00 $158,551 $32,336 $2,426 $28,384 $221,697 235 129 109 270
Aug-00 $183,008 $34,866 $1,392 $28,688 $247,954 237 130 111 273
Sep-00 $141,464 $35,761 $2,485 $28,955 $208,665 238 134 110 276
Oct-00 $134,865 $38,184 $1,483 $29,109 $203,641 239 135 112 276
Nov-00 $134,337 $34,979 $2,949 $29,414 $201,679 240 137 114 279
Dec-00 $194,953 $38,193 $2,200 $29,644 $264,990 243 138 116 279
Total $1,912,70
3
$423,668 $33,768 $342,31
1
$2,712,45
0
2,81
5
1,60
2
1,32
3
3,221
Date Claims Pharmacy Capita
tion
ASO Fees Total EE
Only
EE +
SP
EE + CH Family
Jan-01 $166,386 $42,884 $3,136 $31,316 $243,722 246 136 119 278
Feb-01 $137,935 $37,064 $3,572 $31,316 $209,887 245 135 119 280
Mar-01 $332,013 $34,199 $2,793 $31,718 $400,723 248 139 121 281
Apr-01 $239,471 $40,775 $3,578 $31,838 $315,662 246 141 121 284
May-01 $191,738 $39,907 $3,626 $32,160 $267,431 252 141 123 284
Jun-01 $426,894 $41,698 $3,604 $32,522 $504,718 257 139 125 288
Jul-01 $186,219 $35,971 $291 $32,723 $255,204 259 141 127 287
Aug-01 $237,127 $39,401 $3,761 $32,160 $312,449 250 135 128 287
Sep-01 $297,825 $42,078 $3,561 $32,039 $375,503 248 140 119 290
Oct-01 $173,039 $43,831 $3,759 $32,281 $252,910 253 142 127 281
Nov-01 $148,821 $44,904 $3,598 $32,843 $230,166 254 144 129 290
Dec-01 $470,177 $43,858 $3,716 $33,085 $550,836 256 142 130 295
Total $3,007,64
5
$486,570 $38,995 $386,001 $3,919,21
1
3,014 1,675 1,488 3,425
Date Claims Pharmacy Capitatio
n
ASO Fees Total EE
Only
EE +
SP
EE +
CH
Family
Jan-02 $163,396 $50,992 $3,950 $39,758 $258,096 245 170 124 321
Feb-02 $254,235 $56,201 $4,163 $39,804 $354,403 243 172 124 322
Mar-02 $0
Apr-02 $0
May-02 $0
Jun-02 $0
Jul-02 $0
Aug-02 $0
Sep-02 $0
Oct-02 $0
Nov-02 $0
Dec-02 $0
Total $417,631 $107,193 $8,113 $79,562 $612,499 488 342 248 643
CITY OF FORT COLLINS
MONTHLY EXPERIENCE SUMMARY - POS
Date Claims Pharmacy Capitation ASO
Fees
Total EE
Only
EE +
SP
EE +
CH
Family
Jan-00 15,089 4,480 931 3,576 24,076 27 17 20 29
Feb-00 12,696 4,948 1,152 3,653 22,449 27 18 20 30
Mar-00 20,722 4,964 1,035 3,615 30,336 26 18 20 30
Apr-00 40,080 5,316 47 3,653 49,096 26 18 21 30
May-00 63,174 5,261 376 3,653 72,464 26 18 21 30
Jun-00 26,705 5,374 312 3,845 36,236 28 19 23 30
Jul-00 11,127 5,330 383 3,845 20,685 28 19 23 30
Aug-00 17,301 5,444 385 3,845 26,975 27 20 24 29
Sep-00 18,670 5,808 (45) 3,884 28,317 29 20 23 29
Oct-00 11,203 5,156 361 3,884 20,604 29 20 23 29
Nov-00 10,450 6,188 378 3,922 20,938 29 20 23 30
Dec-00 31,094 6,194 390 3,961 41,639 30 21 22 30
Total 278,311 64,463 5,705 45,336 393,815 332 228 263 356
Date Claims Pharmacy Capitation ASO
Fees
Total EE Only EE +
SP
EE +
CH
Famil
y
Jan-01 17,665 5,140 501 4,491 27,797 33 20 24 34
Feb-01 18,994 4,859 502 4,491 28,846 33 20 24 34
Mar-01 55,453 4,639 488 4,451 65,031 32 21 23 34
Apr-01 40,397 4,752 497 4,451 50,097 32 21 23 34
May-01 27,391 5,428 495 4,451 37,765 32 21 24 33
Jun-01 34,087 6,107 494 4,410 45,098 32 21 23 33
Jul-01 31,663 4,510 497 4,451 41,121 32 19 20 39
Aug-01 38,139 6,541 524 4,289 49,493 31 20 19 36
Sep-01 95,215 5,885 487 4,774 106,361 40 18 21 39
Oct-01 29,776 5,426 527 4,612 40,341 34 20 21 39
Nov-01 52,254 7,162 526 4,693 64,635 36 20 21 39
Dec-01 37,130 8,123 537 4,774 50,564 37 20 21 40
Total 478,164 68,572 6,075 54,338 607,149 404 241 264 434
Date Claims Pharmacy Capitation ASO
Fees
Total EE
Only
EE +
SP
EE +
CH
Famil
y
Jan-02 43,106 7,089 597 6,793 57,585 44 30 19 53
Feb-02 85,848 8,155 830 6,840 101,673 44 30 19 54
Mar-02 0
Apr-02 0
May-02 0
Jun-02 0
Jul-02 0
Aug-02 0
Sep-02 0
Oct-02 0
Nov-02 0
Dec-02 0
Total 128,954 15,244 1,427 13,63
3
159,258 88 60 38 107
APPENDIX D
Stop Loss Report
REPORT: CL851 GENERATED: 05 MAR 2002 09:04 RUN:
THURSDAY 2002MAR21 09:10 PAGE 1
Group : 17 S T O P L O S S R E P O R T > $ 50000.00 BY DATE
PAID 0.00
CITY OF FORT COLLINS 20010101 TO 20011231
Date paid span
INSURED SOC SEC # IX DEPENDENT REL DOB S
AMOUNT
CH 19800425 F
68263.28
Diagnoses: 783.0, 307.1, 307.51, 783.2, 733.0, 263.9, 307.5
Prognosis: unknown/patient’s condition appears to be stable
at this time
SP 19490926 M
55332.38
Diagnoses: 453.2, 154.0, 154.8, V58.1, V58.61, 996.74, V66.2,
V15.3, 839.21, 728.85, 353.8, 453.8, 153.9, 786.2,
V58.81, 998.89, V15.82, 309.81, 239.2, 724.5, 296.32,
239.1, 782.2, 789.30, 607.84, 789.07
Prognosis: unknown
SB 19420906 M
82302.30
Diagnoses: 153.9, 199.1, 996.74, 592.1, 593.4, V58.1, 153.0,
154.1, V58.61, 284.8, 598.8, 153.8, 285.9,154.0, 789.0, 780.6,
789.06, 593.4, 788.0, 996.76, V10.05, V44.3, 195.3, 198.89, 719.45,
782.3, 733.19, 786.09, 153.0, 198.5, 808.8, 235.2, 307.9, 733.9
Prognosis: very poor-in hospice treatment
CH 19830104 F
55135.68
Diagnoses: 805.4, E849.4, 884.1, 724.5, E884.1, 722.83,
V67.09, V45.4
Prognosis: unknown
SP 19500720 F
75010.42
Diagnoses: 710.0,583.81, V58.69, 726.10, 719.45, 733.40, 583.81,
733.42, 719.45, 719.95, 039.8, 279.3, 486, 039.9, V12.5, V43.64,
786.5, 799.0, 786.05, 715.15, 583.81, V10
Prognosis: unknown
SP 19520411 F
82025.62
Diagnoses: 277.1, 784.0, V72.3, V76.12, 789.00
Prognosis: unknown
ND 20000209 M
51395.80
Diagnosis: 752.61, 765.10, 742.4, V65.9, V65, 382.9, 367.0,
520.7, 461.9, V20.2
Prognosis: unknown
CH 19800927 F
55241.58
Diagnosis: 735.0, 739.2, 739.1, 739.0, 724.1, 728.35, 737.1,
724.2, 564.1, 787.01, V72.3, 477.0, 795.0, 287.3,
719.45, 382.9, 784, 784.7
Prognosis: unknown/condition appears to be stable and she
has resumed normal activities
Aggregate Stop Loss is 2506893.55
City of Fort Collins
Large Claimant
Report
January 1, 2001 thru
December Updated 31, as of 2001 3/20/02
Product Diagnosis Prognosis Paid Amt
HMO Intertrohantic fracture Fair $ 44,295.71
POS Intestinal obstruction Good $ 38,843.10
HMO S/p laminectomy Good $ 45,063.53
POS Intestinal obstruction Good $ 64,419.84
HMO Malign. Neo/lymph,axillary Guarded $ 51,529.43
HMO Submucous leiomyoma Good $ 29,690.89
HMO Malign. Neo/orbit Fair $ 71,660.10
HMO Pre-term birth Good $ 47,113.95
HMO High risk pregnancy Good $ 25,237.40
POS Cellulitis/multiple personality Guarded $ 38,185.99
HMO MI/cardiac arrest Guarded $ 45,546.16
HMO Cervical disc displacement Good $ 75,939.51
POS Acute pancreatitis Fair $ 35,695.86
HMO C-section, respiratory distress Fair $ 35,141.66
HMO Post partum infection/HIV disease Guarded $ 38,579.60
HMO Obesity, cholelithiasis Fair $ 38,045.21
HMO Pulmonary embolism Fair $ 33,487.22
City of Fort Collins
Large Claimant Report
January 1, 2002 thru February
28, 2002
Product Diagnosis Prognosis Paid Amt
POS Cellulitis/multiple personality Guarded $ 55,875.71
CITY OF FORT COLLINS
ADDENDUM No. 2
April 24, 2002
Description of PROPOSAL NO. P-832, BENEFITS
OPENING DATE: 2:00 p.m. (our clock) April 29, 2002
To all prospective bidders under the specifications and contract documents
described above, the following changes are hereby made.
Page 6, IV. Proposal Requirements - Your response should be organized into the following
sections:
Delete Section V - Confirmation Section
This is a duplication of Section IV - Plan Design Confirmation Checklist
RECEIPT OF THIS ADDENDUM MUST BE ACKNOWLEDGED BY A WRITTEN STATEMENT ENCLOSED
WITH THE BID/QUOTE STATING THAT THIS ADDENDUM HAS BEEN RECEIVED.
Total
2002
$309,834 $46,613
Time on Hold Average monthly hold
time will not exceed 20
seconds
Abandonment Rate Less than 2% of calls
abandoned
deductible
70% R&C after
deductible
Prescription Drugs $50
deductible,
then greater
of
$8/$15/$30
or
10%/20%/30
%
(mail order –
2 copays for
90 day
supply)
N/A
Annual Out-of-
Pocket Limit
$600/$1,200 $1,100/$2,200
PPO annual out-of-pocket max requires 2 persons to each satisfy the individual max. Also, in
and out of network out of pocket maximums do not cross apply and count towards the
satisfaction of each other.
The deductible is waived for mail order PPO RX.
and out of network out of pocket maximums do not cross apply and count towards the
satisfaction of each other.
The deductible is waived for mail order PPO RX.
Retail
Mail Order
$8/$15/$30
$16/$30/$60
In network copays
plus 30%
In network copays
plus 30%
Annual Out-of-
Pocket Limit
$2,500/$7,500 $2,500/$7,500