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David Carey - Re: RFP# 7052 Benefits - Transplant Follow -Up
From:
David Carey
To:
Amy Sharkey
Date:
9/28/2009 2:42 PM
Subject:
Re: RFP# 7052 Benefits - Transplant Follow -Up
CC:
Gwen Feit; Jim O'Neill
Amy,
We will not use City's standard services agreement as contract since BCS documents previously used and are
still appropriate, but probably outdated. See attached file with information on past renewals from RFP#
P902. To proceed, seems like we would need similar letter from Segal to BCS Insurance and then obtain both
updated Rider to Group Contract (latest one Purchasing has a copy of was effective January 1, 2000) and
maybe Plan Sponsor's Request for Participation (originally signed June 1, 1997). Current and recent blanket PO's
for rate payments list BCS as the vendor. RFP award letter (file attached) has been sent to Linda Semmer at
Segal since response was from them and listed her as the contact.
So could Gwen review with Segal and request necessary updated documents since HR handles this program?
Please let me know.
Thanks,
David
>>> Gwen Feit 9/28/2009 11:47 AM >>>
Amy, I don't think we need to do anything special or change anything with Segal. I believe that Segal was the
purchasing agent thru the Western Cost Management Trust.. (some type of pooled group for a joint
purchases).. I can certainly find out more if needed... otherwise I would send the new contract to Cindy Zimmer
at Segal..
just let me know..
thanks!
Gwen K. Feit
Benefits Specialist
Human Resources
City of Fort Collins
970-221-6843
gfeit@fcgov.com
>>> Amy Sharkey 9/28/2009 11:26 AM >>>
Do you know the answer to David's question?
Thanks, Amy
>>> David Carey 9/25/2009 11:09 AM >>>
Amy,
Please refresh my memory if anything special needs to be done to create a new group contract with BCS
Insurance Company to continue to be a participant in the Western Cost Management Trust. Also, how does
Segal fit into the picture? As an agent for BCS? Thanks.
David
file://C:\Documents%20and%20Settings\dcarey\Local%20Settings\Temp\GW}00003.HTM 10/1/2009
Registered liver Candidate's death or the date of explant of the hepatic assist device, whichever
occurs first. Notwithstanding the provisions of this section, the hepatic assist device benefit period
will end effective on the date of termination of this Contract and no expenses incurred afterward
will be insured. An expense is considered incurred on the date a service is rendered or a supply is
delivered.
The section entitled "DEFINITIONS" is amended to include;
REGISTERED LIVER CANDIDATE - a patient who is a registered liver transplant candidate.
Verification of candidacy must be provided to the Company before any expenses will be
reimbursed.
CAUSE - a medical condition, disease, or physical condition which results in the need for a bone
marrow transplant.
The "MAXIMUM BENEFITS" subsection contained in the "SCHEDULE OF BENEFITS FOR HUMAN
ORGAN TRANSPLANTS AND BONE MARROW TRANSPLANTS" section is replaced with the
following:
MAXIMUM BENEFITS
I. 'Maximum Benefit Per -Lifetime* ....................................................42,000,000
II. Maximum Benefits for Procurement of Organ or Bone Marrow
Per Transplant Benefit Period"
A. _ Organ Procurement*"
1. LifeTrac Transplant Network Facility
a. If procurement is an included service
in the Contract Rate....................................No Maximum
Applicable
b. If procurement is not an included
service in the Contract Rate:
i. Cadaveric organ ........................:..... $35,000
li. Organ from living donor.... ..... 11 ......... $65,000
2. Other Transplant Facility
a. Cadaveric organ.........................................435,000
b. Organ from living donor ............................... $65,000
2
WCMT.812 (CO)
B. Bone Marrow Procurement"
1. LifeTrac Transplant Network Facility
a. If procurement is an included service
in the Contract Rate .................................... No Maximum
Applicable.
b. If procurement is not an included service
in the Contract Rate .................................... $25,000
2. Other Transplant Facility ........................................ $25,000
Ill. Maximum Benefit For Transportation, Lodging, and
Meals Per Transplant Benefit Period*** ........ ............... $10,000
Maximum Daily Limit for Lodging and Meals* * * ............ I.- ........ .... $200
IV. Maximum Benefits For Private Nursing Care Per
Transplant Benefit Period............................................................. $10 000
V. Maximum Benefits for Circulatory Assist Device..............................No Maximum
Per Transplant Benefit Period Applicable
VI. Maximum Benefits for Hepatic Assist Device..................................No Maximum
Per Transplant Benefit Period Applicable
*Maximum Benefit Per Lifetime
The maximum benefit per lifetime of $2,000,000 is applied per type of organ transplant and per
Cause of bone marrow transplant. Benefits for subsequent retransplantations are combined with
previous benefits paid for the initial transplant and any other retransplantations in determining
whether the maximum benefit per type of organ transplant or per Cause of bone marrow transplant
per lifetime has been reached. Benefits for circulatory assist devices are combined with any
benefits paid for a heart transplant in determining whether the maximum benefit per heart
transplant per lifetime has been reached. Benefits for hepatic assist devices are combined with any
benefits paid for a liver transplant in determining whether the maximum benefit per liver transplant
per lifetime has been reached.
* *Procurement
With regard to the donation of a cadaveric organ, procurement expenses include surgical, storage,
and transportation costs incurred and directly related to the donation of an organ to be used in a
covered organ transplant procedure that is insured under this policy, including costs resulting from
complications of the donor's surgery. I
With regard to the donation of an organ by a living donor, procurement expenses include surgical,
storage, and transportation costs which are directly related to the donation of an organ to be used
in a covered organ transplant procedure that is insured under this policy, including costs resulting
from complications of the donor's surgery, and which are incurred on or within 120 days from the
date of the donor's surgery.
3
WCMT.812 (CO)
With regard to the donation of bone marrow and peripheral stem cells, procurement expenses
include the harvest and acquisition expenses outlined in (tern I.B, of the "COVERED PROCEDURES"
subsection contained in this "SCHEDULE OF BENEFITS FOR HUMAN ORGAN TRANSPLANTS AND
SOME MARROW TRANSPLANTS,
All procurement expenses will be reimbursed up to the maximum benefits listed above for each
covered transplant procedure completed.
* * *Transportation, Lodging, and Meals - Recipient
The following transportation, lodging, and meal expenses will be reimbursed up to the maximum
benefits for each covered transplant procedure completed:
If the recipient of the covered transplant procedure is an adult, costs of transportation to and from
the site of the covered transplant procedure for the recipient and one other individual will be
reimbursed. If the recipient of the covered transplant procedure is a minor, costs of transportation
to and from the site of the covered transplant procedure for the recipient and two other individuals
will be reimbursed. All reasonable and necessary lodging and meal expenses incurred, up to a daily
maximum of $200.00, by said individual(s) accompanying the recipient will be reimbursed. The
aggregate sum of all costs of transportation, lodging, and meals is subject to a maximum of
$10,000.00.
The "PROCEDURE SCHEDULED BUT NOT PERFORMED" subsection contained In the "SCHEDULE
OF BENEFITS FOR HUMAN ORGAN TRANSPLANTS AND BONE MARROW TRANSPLANTS" section
is amended to read as follows;
If a covered transplant procedure Is not done as scheduled due to the intended Eligible insured's
medical condition or death, benefits will be paid for charges incurred for procurement of a cadaveric
organ and bone marrow/peripheral stem cells and transportation, lodging, and meals: Benefits for
procurement of an organ from a living donor will be paid only if the -covered organ transplant
procedure was scheduled to occur within 24 hours of the donor's surgery.
This Rider is effective as of January 1, 2000. All provisions not amended remain in effect.
raunrxr
4
WCMT.812 (CO)
THE'SEGAL COMPANY
6300 S. Syracuse Way
Suite 750
Englewood, Colorado
80111-6722
303-714-9900
FAX:303-714-9990
FROM: De Anne Head
TO
as
Snj7y YEARS of PLAmAtma FOR 7NEfUWRE
MEMORANDUM
Plan/Fund Administrators
DATE: February 2000
Western Cost Management Trust — Organ and Tissue Transplant Program
Benefit Enhancement Rider
The Western Cost Management Trust enhanced benefit coverages, effective January 1, 2000.
These enhancements include:
• the addition of coverage for. Hepatic Assist Device Implants;
• the addition of a living donor procurement benefit of $65,000; and
• an increase in the cadaver donor procurement benefit from $25,000 to $35,000.
You will be receiving in the near future a supply of the BCS Insurance Company certificate
riders outlining these changes. Please distribute the rider to each Participant with instructions to
keep it with their other important health benefit plan information.
If you should have any questions, please feel free to contact our office.
DMH
cc
Benefit Consultant
107654/01945.001
Atlanta Boston Chicago Cleveland Denver Bdmnntnn Hartford Houston Los Angeles Minneapolis M G Mahle- kooal Group d Actuaries end Cmsultants: Amsterdam Antwerp
New Orleans New York Phoenix St. Louis San Francisco Seattle Toronto Washington D.C. West Palm Beach A G Barcelona Hamburg Lausanne London Melboume Mexico City Oslo Paris
The City of Fort Collins
(Plan Letterhead)
To: All Plan Participants
From: The Human Resources Department
The City of Fort Collins
l 4 1 17)
JUN jg '3S r
h6e,",V
June 1997
Re: Western Cost Management Trust -
Organ and Bone Marrow Transplant Benefits (O/BMT)
We are pleased to inform you that, effective June 1, 1997, a preferred provider organ and bone
marrow transplant benefit through the BCS Financial Western Cost Management Trust (WCMT),
which includes a centers of excellence network, is available to you and your eligible dependents.
Under the WCMT, a human organ and tissue transplant benefit will be provided as follows:
A. Persons Covered - the program will cover each eligible employee, retiree and dependents.
B. Covered Transplant Procedures - covered transplant procedures are limited to the following
human to human organ or tissue transplants: bone marrow (self and other donated); heart;
heart/lung; liver; lung; pancreas; pancreas/kidney; and small intestine. (Note: kidney and
cornea transplants are still covered by the City of Fort Collins Group Health Plan).
C. Covered Services - covered services include the following:
1. Organ and tissue procurement.
2. Transportation, lodging and meal costs for the recipient and a companion or two
companions if the recipient is a minor.
3. Hospital, room and board, and medical supplies.
4. Diagnosis, treatment, and surgical procedures performed by a doctor.
5. Private nursing care by an RN or LPN.
6. Rental of wheelchair, hospital -type beds, and respiratory therapy equipment.
7. Local ambulance services.
8. Medications.
9. X-rays and other diagnostic services, laboratory tests, and oxygen.
10. Rehabilitative therapeutic therapy, including speech therapy, audio therapy, visual
therapy, occupational therapy, and physiotherapy.
11. Surgical dressings and supplies.
Services Not Covered - benefits will not be payable if the service is for an injury or sickness
or for a related condition that existed within three months prior to the date the recipient
becomes insured. This limitation does not apply to expenses for these charges incurred after
the fist of the following dates:
1. The date after the person becomes insured when no charges were incurred or advice or
treatment received for the injury or sickness for three consecutive months;
2. In the case of an employee, the date at the end of six consecutive months in which the
employee was continuously insured under the WCMT or the policy it replaces and was
actively at work.
3. At the end of twelve consecutive months during which the person was continuously
insured under the Program.
Subject to approval by BCS Life Insurance Company, similar coverage under a prior plan
will be applied toward this pre-existing condition limitation period.
E. Benefit Period - the benefit period begins five days (30 days before for bone marrow) before
the date of the organ or tissue transplant and ends eighteen months after the transplant
procedure. Multiple transplant procedures will be covered under the same or separate benefit
periods as follows:
1. If they are due to related causes, they will be covered in the same benefit period.
2. If the transplants are due to unrelated causes, they will be covered under separate
benefit periods.
3. If they are due to related causes, they are covered under separate benefit periods if an
employee returns to active work before the second transplant, or if a dependent's
transplants are separated by at least three consecutive months.
F. Benefit Amounts Provided - the following benefit amounts are provided for covered
services:
1. Organ or tissue procurement: $25,000 for each transplant procedure.
2. Transportation costs and lodging and meals: $10,000 for each transplant procedure
(Lodging and meals expenses are covered to a maximum of $200 per day.)
3. Private nursing care: $10,000 for each transplant procedure.
4. All other services: 100% of char ems.
5. Maximum: the maximum benefit that will be paid during the lifetime of a recipient for
all organ or tissue transplant services is the amount of $2,000,000.
Transplant Network
The WCMT utilizes LifeTrac, a national network, for organ and bone marrow transplant services.
LifeTrac contracts with transplant facilities across the United States for favorable reimbursement
fees. It is a patient's choice whether or not to use a LifeTrac contracted facility; however,
reimbursement for a non-LifeTrac facility will be limited to what the LifeTrac facility would
have been paid. Please contact the Administrative Office for a listing of the current LifeTrac
facilities.
LifeTrac, the transplant network contracted by BCS Insurance Company, is managed by a group
of professionals who have a great deal of experience in working with the facilities that provide
these types of surgeries. Please note that you do not have to use the LifeTrac facilities for
a transplant, but if you use other facilities, your benefits may be limited.
HIPAA Business Associate Agreement Amendment
This Amendment is entered into this 17th day of February, 2010, between City of Fort Collins ("Employer"),
acting on behalf of Western Cost Management Trust (WCMT)-Organ and Bone Marrow Transplant
Benefits (the "Plan(s)"), and BCS Insurance Company ("Business Associate"). This Amendment is
incorporated into the RFP# 7052 Services Agreement between Employer and Business Associate, dated
January 1, 2010 (the "Agreement"). The parties intend to use the Agreement to satisfy the Business
Associate contract requirements in the regulations at 45 CFR 164.502(e), 164.504(e) and 164.314(a),
issued under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), as amended by
Title XIII, Subtitle D of the American Recovery and Reinvestment Act of 2009 (P.L. 111-5) and regulations
promulgated there under; and for further applicable HIPAA developments published after enactment of
P.L. 111-5, including statutes, case law, regulations and other agency guidance.
t. Effective as of February 17, 2010, the Agreement shall be amended by adding the following new
provision:
Enactment and Impact of ARRA Provisions. Business Associate acknowledges that enactment of
the American Recovery and Reinvestment Act of 2009 (P.L. 111-5, ARRA) amended certain
provisions of HIPAA in ways that now directly regulate, or will on future dates directly regulate,
Business Associate's obligations and activities under HIPAA's Privacy Rule and Security Rule.
Requirements applicable to Business Associate under Title XIII, Subtitle D of ARRA are hereby
incorporated by reference into the Agreement, including provisions that would govern the Plan's action
if the Business Associate undertakes that action on behalf of the Plan. Business Associate agrees to
comply, as of the applicable effective dates of each such HIPAA obligation relevant to Business
Associate, with the requirements imposed by ARRA, including monitoring federal guidance and
regulations published there under and timely compliance with such guidance and regulations.
In the event of a Breach of Unsecured Protected Health Information that Business Associate acquires,
accesses, uses, or discloses on behalf of the Employer, Business Associate assumes responsibility
for timely providing the notices required in Section 13402(e)(1) and (e)(2) of the HITECH Act, with
Employer having the right to review the content of any such notices before they are issued. Employer
shall provide Business Associate with the addresses and other information necessary for the Business
Associate to provide the notices.
In consequence of the foregoing direct regulation of Business Associate by HIPAA laws and
regulations, notwithstanding any other provision of the Agreement, Business Associate further agrees
to monitor HIPAA Privacy and Security requirements imposed by future laws and regulations, and to
timely comply with such requirements when acting for or on behalf of the Plan in its capacity as a
Business Associate.
IN WITNESS WHEREOF, each of the parties has caused this Amendment to be signed on its behalf by a
duly authorized officer of such party as of the date written below.
City of Fort Collins, Colorado BCS Insurance Company, ("Business Associate")
"C By: _
/ Name:
Title: eyzc-c-7tx-� Title:
Date: t' 7-' Date:
-3 2-S/�
Financial Services
City ®f
Purchasing Division
215 North Mason Street
F6rt Collins
Floor
PO
PO Box 580
Fort Collins, CO 80522
970.221.6775
970.221.6707 - fax
fcgov. corn/purchasing
September 25, 2009
The Segal Company
Attn: Ms. Linda J. Semmer
5670 Greenwood Plaza Boulevard, Suite 425
Greenwood Village, CO 80111-2499
Re: 7052 Benefits -_Transplant
The City of Fort Collins Purchasing Division would like to thank you for your written proposal for
7052 Benefits - Transplant.
Your firm has been selected as the professional service provider for this project subject to
contract negotiations. Please contact the project manager Amy Sharkey (970) 416-2721 to
finalize the Scope of Work.
We appreciate the time you expended in preparing your proposal and look forward to working
with you.
Sincerely,
gctor
E_
s B. O'Neill II, CPPO, FNIGP
of � � Purchasing and Risk Management
JBO:jkb
w,
o•.
DIRECT DIALINij ISER
(303; 714•�3920
7� S E G A L EMAIL ADDRESS
sinunil3g ;segalco.co3n
THE SEGAL COMPANY
6300 S. Syracuse Way Suite 750 Englewood, CO 801 1 1.7302
T 303,714.9900 F 303.714.9990 www,segalco.com
January 19, 2005
Ms. Theresa O'Shea
Vice President
BCS Insurance Company
676 North St. Clair Street, Suite 1600
Chicago, IL 60611-2997
5001 0 z NVP
Re: City of Fort Collins ! R /9- ti ! Pi- 4A-J7
t9 AiL Ft i
Western Cost Management Trust
Dear Theresa:
We are writing to inform you that the referenced City has approved the proposed renewal for the
Organ Transplant Benefit program, effective January 1, 2005. The rate will be as follows:
Alternative I with Prescription Drug Rider: $9.65
(18-month benefit period)
By way of this letter, we are advising the Bank Trustee of the renewal acceptance. Should you
have any questions, please feel free to contact our office.
Sincerely,
Susan K. Imming
/mel
cc: - James B..O'Neill II
Vincent H. Pascale, Jr.
Laura Hamilton
Melissa Masek
139711/00386.001
Benefits, Compensation and IiR ConsUllin9 ATLANTA (3037ON CITICAGO CLEVELAND DENVER TIARTFORO HOUSTON LOS ANGELES MINNEAPOLIS I
NEW ORLEANS NEW Y0I111( PHILADELPHIA PHOENIX SAN FRANCISCO SEATTLE 'TORONTO WASHINGTON. L) 1
1
Mullinatlonn1 Group of Actuaries and COnsUllenls APASTF.RDAM RARCELONA GENEVA HAMBURG IOHANNF.SOURG LONDON MELROURNF
tAE%ICO CITY OSLO PARI,`'1 %
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.y.T SEGAL.
TH6 SEGAL COMPANY
6300 S. Symouse Way Suite 750
'1' 303,714.9900 F 303.714.9990
October 27, 2004
Vincent.H. Pascale, Jr.
Benefits Administration
City of Fort Collins
Human Resources Department
215 North Mason Street
P.C. Bux 580
Port Collins, CO 80522-0580
L nglowood, CO Rol 1 1-7309
www segalco.com
RE: Western Cost Management Trust (WCMT) Proposed Renewal
Dear Vincent:
DIRECT DIAL NUMBER
303-714-9920
WRITER'S EMAIL ADDRESS
simming 7'Segalco.com
We are pleased to advise that BCS Insurance Company is proposing a continuance of the current rates for
the organ and bone marrow transplant and drug rider coverages effective January 1, 2005.
Proposed Renewal
The renewal is based on BCS's analysis of WCMT''s recent favorable experience.
The Chronin,ed Drug Rider, whit!, is included in your coverage, will continue at the 2004 rate of $.52 per
eligible per month. The rider provides an additional 12 months of anti -rejection drug benefits following
expiration of the benefit period covered by WCMT's base coverage.
The current and proposed rates for the transplant and drug rider coverages for your plan are as follows:
Current prgposed % CW!me
Coverage
$9.65 $9.65 0%
Options
There are two coverage options available under the WCMT, one, for an 18-month benefit period (your
current coverage) and the other• for a 12-month benefit period. Both options otherwise provide exactly the
same benefits. Rates for the three alternative plans for both the 18-month and 12-month benefit periods
are shown below:
18-month
12-rnonHr
Alternative Plans
BLnef%t period
Bene1�od
Witleout ba•n Rider
Alternative I
$9.13
$8.71
Alternative 1I
7.35
7.01
Alternative III
3.32
3.17
With Drub Rider
....
Alternative 1
�$9.65
$9.23
Alternative 11
_.......
7.87
7.53
Alternative 11I
3.84
3.69
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Vincent 1-1. Pascale, Jr.
City of Port Collins
October 27, 2004
Page 2
Alternative I: Covers 100% of covered charges.
Alternative II: Covers 80% of covered charges and the participant or underlying plan covers
20% of covered charges.
Alternative III: Benefits are subject to a $100,000 deductible and payable at 100% thereafter.
Drug Ridei-: Extended drug and support services coverage for 12 montlis after expiration of
the I 8-month or 12-month benefit period.
SEGAL believes it is important: to consider the financial strength of insurance companies and managed
care organizations that are candidates for initial selection or renewal as insure!." or service providers to
employee benefit plans. Therefore, we regularly provide the most recent Standard & Poor's current
claims paying ability rating for the insurance company under consideration. We have selected Standard
& Poor's because of their excellent overall reputation as a rating service. In addition, they evaluate more
insurance companies than any of the other comparable rating services. You may wish to consult other
rating services (e.g., Fitch and Moody's) that also provide claims paying ability evaluations of insurance
companies and managed care organizations before making a decision regarding the initial selection o►-
renewal of an insurance company or managed care organization.
In this .instance, however, Standard & Poor's, which only rates carriers that specifically request the
service, has not published a rating for BCS Insurance, A.M. Hest, another rating service, rates BCS
insurance Company as "A — (Excellent)". SEGAL does not itself perform insurance company or
managed care organization credit quality evaluations and does not offer any warranty as to the scope or
reliability (e.g., with respect to an organization's ability to meet future obligations) of the insurance
company or managed care organization evaluations performed by A.M. Best or any other rating service.
Please let us know if you have any question regarding the proposed renewal. We will discuss this with
you in the near future.
Sincerely, f�
Susan K. Imming U
lzt
cc: Laurie Trujillo, RHU
138813101945,001
APR-14-2004 10:05 CEGHIw P.01
-T-SEGAL
THE SEGAL COMPANY
6300 S. SyraoQte Way, Suite 760 Englewood. 00 80111.7302
T 30,9.714,9900 F 303.714.9990 www.segalco.com
FAX TRANSMITTAL
FROM:u DATI✓: l y a
TO: 04a,"
FAX NO: 207
CC:
There trill be a Iola] of / , page(s) to follow.
MESSAGE: ❑ For your information ❑ Per our conversation .
❑ Foryour action ❑ Per your request
❑ Original to follow by mail ❑ Please advise
Te]eeopy Operator:
THIS .MESSAGE IS .INT
WHICH IT •IS ADDRES.'.
CONFIDENTIAL AN,ia Z
intended,recipient or an
intended recipient, you an
communication is strictly
notify us immediately by tE
Banefks, Compensefion and MR Cor
f4CW ORWANS NEW YORH PHI6APElPH
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a4 r MU111n3110nal Group of AcWaries and
- APR-14-2004 10:05 SEC
APPENDIX -3-
PLAN SPONSOR'S REMST FOR PARTICIpA'ITON
IN THE BCS FINANCIAL.
WESTERN CUSP MANACIrNWNT TRUST
P.02
JUN 1 1 1997
The tuulcrstgned Plats Sponsor hereby Mquims that it be accept td as a pxTicipant in The BCS Financial Western
Cost a incur merit Trost elfeuivt upon approval by 8CS L ife Insurance Campatzy of tht: Plant Sponsor's application
for the insurance plan thcreuoder. if W=pmd as a Participant, the Plan Sponsor agrees to be bound by the terms
of the Trust as now in effect or amm ed in the fumm and agrees to maintain eligibility records and all other records
relattug TO its group health insurance program for its eligible individuals. The Plan Sponsor also agrees to
partietpate for a nsusinni period of 12 months.
A copy of the Trust AgreGuuat. Tun SCS Life Insurance Company Policy and the LifeTmu: Network agreement
issued in coonectioa (limwith arc held by BCS Ufp la surant;e Company. Copies of these documents shall be
pmvzded by 6CS Life insurance Company to any requesting participating Plan Sponsor.
Name of Orgmirauion:
1•fatling Address:
Telephone *lumber,
Name and. Title of Correspondent.
Numbcr of EnVloycr/MeWbers to be Insured:
Regorated Effective Date,
Plan selet eel (check one)
A. Insured
Pnmuy Plan t 100% coverage) X
Alterttattve I coverage)
The City of Fort Collins
200 West-40MXICain, Suyt:e A
tort: Collins, CO 80522-0580
9�Ct-z21�68zs
Laurie Harvey, Benefits Administrator
June 1, 1997
Ahct=ve it ($100,0W deductible)
Drug 9e370Rt (check 1) X Yrs, ___ no
B. Scheduled Trnnoplant or
Potential Tramplant (Check 1) X yea - Wormadon attached
n0
aceatnpanying this Request for Participation is check for the sum of 5 equal to the first rbonrh's
pre:tssasn under the policy as deposit toward the premium for coverage under rite Trust for which application is
herrby made phu sdditionai a4)ounts relating to contratsstotts and administrative fans payable by the Plan Sponsor.
rran
or insured argctttoars, it is understood that no ittstrtattea will take effect unless BCS Life fasumce Company,
as insurrr, VProvcs the aplrli =ion: and, if the applicaton is disapproved, the above deposit will be returned.
Date Sigrsed --5 1 lfG By `�C y
3
Ti0e C, 7Zll ~ �C�12 r_r1r> 1 Lo / .� /t'Il+h, �l,L✓. i14i!^
TI-ITQi P i-r;)
V
" SEGAL
THE SEGAL COMPANY
6300 S. Syracuse Way Suite 750 Englewood, Co 80111.7302
T 303.714,9900 F 303.714.9990 www,segalco.com
November 14, 2003
Ms. Theresa O'Shea
Vice President, Marketing Services
BCS Insurance Company
676 N. St. Clair Street, Suite 1600
Chicago, IL 6061 I-2997
Re: City of Tort Collins — Western Cost Man:
Dear Theresa:
If you tlavn any gU("stions abotd Shc alhu:lted, plcosc lcl me know.
Susan It, trnminry
/� "/() y JAN 3 0 ZGO4.
SEGAL���„�
flit St -:GAL COMPANY
6300 S. Syr.'tcus(.',V:ry, Suilc 7;i0 EnlmVood. CO UOI 1 I.7302
T 303.7 14.9921) F J03.71 4.9c�,ry0
VIWIV a:(SgWcox
We are pleased to inform you that the City c t:lr
proposed renewal effective January I, 2004 tl-ro>~ , i lie
follows:
Alternative l with Prescription Drug Rider/Participant/Month
$9.65
By way of this letter, we are advising the Bank Trustee of the renewal acceptance. Should you
have any questions, please feel free to contact our office.
Sincerely,
Susan K. Imming U
czp
cc: James B. O'Neill
Vincent Pascale, Jr.
Laura Hamilton
Laurie Trujillo, RHU
Carolynn Pickett
134502/00386.001
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ir•@TlBfii�. Cc 7;.%r+.6:;E!Fi 7:+.': ^f t2 ;pn•_I;Irygy ATLANTA BOSTON CHICAGO CLEVELAND DENVER HARTFORD HOUSTON LOSANGELES MINNEAPOLIS
NEW ORLEANS NEW YORK PHILADELPHIA PHOENIX SAN FRANCISCO SEATTLE TORONTO WASHINGTON. DC
AI
Multinational G,oup of Actuaries and ConsultantS AMSTERDAM BARCELONA GENEVA HAMBURG IOHANNESOURG LONDON MELBOURNE
MEXICO CITY OSLO PARIS
BCS INSURANCE COMPANY
(the "Company")
676 N. Saint Clair Street
Chicago, Illinois 60611-2997
Rider to be attached to Group Contract No, OTBM-28985 and applicable to coverage provided
under the Contract to Participants of the Western Cost Management Trust (Group No. 050-0001).
This Rider is made a part of the above Group Contract and Certificates and supersedes any
provisions of the Group Contract in conflict with the Rider, This Rider may be cancelled by the
Company as of any date upon 30 days prior written notice.
The following is to be inserted after Item I„ C. of the "COVERED PROCEDURES" subsection
contained in the "SCHEDULE OF BENEFITS FOR HUMAN ORGAN TRANSPLANTS AND BONE
MARROW TRANSPLANTS" section:
D. Hepatic Assist Device Implants
All covered medical expenses incurred by Registered Liver Candidates during the hepatic
assist device benefit period that result from or are directly related to the implant of a
hepatic assist device, or that are related to the condition, illness, or disease that
necessitated the hepatic assist device implant, or complications resulting from the hepatic
assist device itself, will be reimbursed.
Item 11. of the "COVERED PROCEDURES" subsection contained in the "SCHEDULE OF BENEFITS
FOR HUMAN ORGAN TRANSPLANTS AND BONE MARROW TRANSPLANTS" section is replaced
with the following:
II: Procedures Performed at an Other Transplant Facility
Benefits will be paid for covered transplant procedures listed in I.A. and B., for circulatory
assist device implants set forth in I.C., and hepatic assist device implants set forth in I.D.
Benefits paid will •not exceed the Contract Rate that would have been charged had the
procedure been performed at the LifeTrac Transplant Network Facility nearest to the facility
in which the transplant is performed.
The following subsection is added after the "CIRCULATORY ASSIST DEVICE BENEFIT PERIOD"
subsection contained in the "SCHEDULE OF BENEFITS FOR HUMAN ORGAN TRANSPLANTS AND
BONE MARROW TRANSPLANTS" section:
HEPATIC ASSIST DEVICE BENEFIT PERIOD
The hepatic assist device benefit period begins 5 days before the hepatic assist device implant and
ends on the date of a covered liver transplant procedure. If a Registered Liver Candidate does not
receive a liver transplant, the hepatic assist device benefit period will end on the date of the
WCMT. 812 (CO)