HomeMy WebLinkAboutCORRESPONDENCE - RFP - P985 BENEFITSChris Ewing
M[rZ-RCC ER
-� MARSH MERCER KROLL
LAr GUYCARPENTER OLIVERWYMAN
November 10, 2008
1225 17th Street, Suite 2200
Denver, CO 80202
303 375 5839 Fax 303 376 0087
ch ris.eMng@mercer.wrn
w .mercer.com
Amy Sharkey, CCP
Compensation and Benefits Manager
City of Fort Collins Human Resources
215 North Mason, 2nd Floor
P.O. Box 580
Ft. Collins, CO 80522-0580
Subject: Confirmation of Coverage PEN EWfi�
Dear Amy, (P 9 ?5
Enclosed please find signed copies of your Confirmation of Coverage forms for the City,of Fort... ;
Collins' Medical, Dental, Vision, Life Insurance and Disability renewals. Rates and benefits
have been outlined in these documents. Please let me know if you have any questions..
Sincerely
Chris Ewing
Copy: Wendy Stone, Kathy Dahlman, Mercer
Cceu!;iv g. Outsourcing. lnvestm en-s.
CONFIRMATION OF COVERAGE: 2009 Renewal
CARRIER/POLICY *
Client / Legal name:
ERISA Plan name:
Eligible employees:
Client /Insured Address:
Great West
City of Fort Collins
City of Fort Collins
1,400
215 North Mason Street, 2n° Floor
Fort Collins, CO 80522
This document will confirm renewal acceptance of the following coverage(s):
Medical -Administration (Core and Advantage plans)
Vision - Administration
Medical - Specific Stop Loss coverage with $175,000 deductible
Plan will be effective on: 1/1/2009
For a period of: 12 months
Rates / fees (including any subsequent period caps or guarantees) for the above -referenced coverage(s)
are:
Medical and Rx administration fee:
Per employee S38.45
Vision administration fee:
Peremployee $1.16
Specific Stop Loss rate ($175.000 deductible):
Per employee $61.64
Covers Medical Only
A description of benefits:
Core Plan
In Network
Deductible - $500 Individual/$1,000 Family
Coinsurance - 80%
Office Visit - S25 PCP/$40 Specialist
Out of Pocket - $4,500/$9,000
Inpatient Hospital - 80% after Ded
Outpatient Surgery - 80% after Ded
Emergency Room - 80% after Ded
Rx — $50 deductible per calendar year
Retail Generic: $8 copay or 10% (greater of), Preferred
Brand: $15 copay or 20% (greater of), Non -preferred
Brand: S30 copay or 30% (greater of)
Mail Generic: $16 copay, Preferred Brand: $30 copay,.
Non -preferred Brand: $60 copay
Out -of -Network
Deductible - $1,000 Individuall$2,000 Family
Coinsurance - 60%
Office Visit - 60% after deductible
Out of Pocket - $9,000/$18,000
Inpatient Hospital - 60% after Ded
Outpatient Surgery - 60% after Ded
Emergency Room - 60% after Ded
Rx — 50% of cost after Network copay and ded
MERCER
Advertises Plan
In Network_.
Rx d
". Out -of -Network - - ... .
Deductible - $250 Individual/$500 Family
Deductible - $500 Individual/$1,000 Family
Coinsurance - 90%
Coinsurance - 70% ..
Office Visit - $15 PCP/$30 Specialist
Office Visit - 70% after deductible
Out of Pocket - $2,250/$4,500
Out of Pocket - $4,500/$9,000
Inpatient Hospital - 90% after Ded
Inpatient Hospital - 70% after Ded -
Outpatient Surgery - 90% after Ded
Outpatient Surgery - 70% after Ded .-.
Emergency Room - $100 copay
R N 'bl
Emergency Room - $100 copay -
x — o separate de ucti a Rx - 50 /o of cost after In -Network copay "
Retail. Generic: $8 copay or 10% (greater of), Preferred _ _ -
., Brand: $15 copay or 20% (greater of). Non -preferred,
Brand: S30 copay or 30% (greater of)
Mail Generic: $16 copay, Preferred Brand: $30 copay; ,
Non -preferred Brand: $60 copay ,
.CHANGES TO PLANS FOR 111/09
PCP copay applies to chiropractic services.'
Ambulance services paid as in -network regardless of provider utilization. -... ,
Stop Loss -
Deductible -$175,000 -- - -
Contract Basis - "Paid'
Conditions of coverage(s):
As an authorized representative, I accept this confirmation of coverage. By signing below. I acknowledge
agreement with the rates and benefits described above and that subsequent contract(s) shall conform :to . .- .. .
this document unless otherwise agreed to in writing.
Authorized Representative:
I ImAky
Sward
Legal Name of Insurer/
Administrator
Gnaai_
iz-a
Signature:
Date:
/O/
This form must be signed and returned to Mercer H B prior to the effective date of coverage.
MERCER