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HomeMy WebLinkAboutContract 1869 PO Box 9310 Minneapolis, MN 55440-9310 952-992-2900 September 22, 2005 Linda Magee City of Columbia Heights 590 40th Ave NE Columbia Heights MN 55421-3835 Dear Linda Magee; Thank you for returning the Master Group Contracts. Enclosed please find your signed copy as well as the Evidence of Coverage for 2005 for your Medicare-eligible retirees of City of Columbia Heights for your files. Again, if there are any modifications required to amend the Master Group Contract as a result of the implementation of Medicare Part D, it will be communicated to you in writing. Thank you again for your time. Sincerely, ~CR~ Linda Straub Medica Center for Healthy Aging Group Account Specialist 952-992-3633 1-800-575-2330 Medica'" is a registered service mark of Medica Health Plans. "Ivledica" refers to the family of health plan businesses that includes 70531, 70561 43J18'7;a4!32j.t(r~lans" lvIedica Health Plans of Wisconsin, lvIedica Insurance Company', and lvIedica Self-Insured'. "Accredited by the f\jational Committee for Quality Assurance in the states of Mf\], f\jD, SO and WI. C01vl170Q.50405 An Equal Opportunity Employer lvIedica Commercial HIvIO/POS and Medicaid Plans MEDICA INSURANCE COMPANY MEDICA GROUP PRIME SOLUTION MASTEK GROUP CONTKACT GROUP BILLED Employer Name: City of Columbia Heights Employer Group #: 70531,70561 Effective Date: 1/1/2004 Contract #: 113708 ARTICLE 1 INTRODUCTION This Master Group Contract ("Contract") is entered into by and between Medica Insurance Company ("Medica") and the employer group named above ("Employer"), an employer under Minnesota law and other applicable law. This Contract includes the Evidence of Coverage and any Amendments. This Contract is delivered in the state of Minnesota. If this Contract is purchased by Employer to provide benefits under an employee welfare benefit plan governed by the Employee Retirement Income Security Act, 29 U.S.C. 1001, et seq. ("ERISA"), this Contract is governed by ERISA and, to the extent state law applies, the laws of the State of Minnesota. If this Contract is not governed by ERISA, it is governed by the laws of the State of Minnesota. In consideration of payment of the monthly Premiums by the Employer and payment of any applicable Deductible(s), Copayments, and Coinsurance by or for Members, Medica will provide coverage for the Benefits set forth in the Evidence of Coverage and any amendments, subject to all terms and conditions, including limitations and exclusions, in this Contract. This Contract replaces and supersedes any previous agreements between Employer and Medica relating to Benefits. Medica shall not be deemed or construed to be an employer for any purpose with respect to the administration or provision of benefits under Employer's welfare benefit plan. Medica shall not be responsible for fulfilling any duties or obligations of Employer with respect to Employer's benefit plan, including but not limited to required regulatory filings in accordance with Social Security Act (SSA). Employer is responsible for notifying eligible persons of all contractual changes relating to premiums and enrollment information, if applicable. Should Medica and Employer agree that Medica will be responsible for these notifications, administrative costs associated with the printing and mailing of these materials may be prorated to the Employer. RECEIVED MN-PRI-MGC-G-05-101-01 Page 1 ,", 'J DOh; .2 1_ .J MEDICA The terms used in this Contract have the same meanings given those terms defined in the Evidence of Coverage, unless otherwise specifically defined in this Contract. ARTICLE 2 TERM OF CONTRACT Section 2.1 Term and Renewal. The initial term of this Contract is effective from 1/1/2004 ("Effective Date") to 12/31/2005 ("Expiration Date"). All coverage under this Contract begins at 12:01 a.m. Central Time. This Contract may be renewed for an additional term of [one year] at the end of the initial term and at the end of each Contract renewal term. At least 30 days before the end of the initial term or Contract renewal term, Medica shall notify Employer of any modifications to this Contract, including Premiums and Benefits for the next one-year term of this Contract ("Renewal Terms"). If Employer accepts the Renewal Terms or if Employer and Medica agree on different Renewal Terms, this Contract is renewed for the additional Contract term, unless Medica terminates this Contract pursuant to Section 2.2. Section 2.2 Termination of This Contract. Employer may terminate this Contract after at least 30 days written notice to Medica. This Contract is guaranteed renewable and will not be terminated by Medica except for the reasons as stated below and effective as stated below. Terminations for the reasons stated below require at least 30 days written notice from Medica: (a) Upon notice to an authorized representative of the Employer when Employer does not pay the required Premium when due, provided, however, that this Contract can be reinstated pursuant to Section 4.2; (b) On the date specified by Medica because Employer provided Medica with false information material to the execution of this Contract or to the provision of Benefits under this Contract. Medica has the right to rescind this Contract back to the Effective Date; (c) Automatically on the date Employer ceases to do business pursuant to 11 U.S.C. Chapter 7; (d) On the date specified by Medica, after at least 90 days prior written notice to Employer, that this Contract is terminated because Medica will no longer issue this particular type of group health benefit plan within the applicable employer market; (e) On the date specified by Medica, after at least 180 days prior written notice to the Employer and, if required, to the applicable state authority, that this Contract will be terminated because Medica will no longer renew or issue any employer health benefit plan within the applicable employer market; (f) On the date specified by Medica when there is no longer any Member who resides or works in Medica's approved service area; and (g) Any other reasons or grounds permitted by the licensing laws and regulations governing Medica. MN-PRI-MGC-G-05-101-01 Page 2 Notwithstanding the above, Medica may modify the Premium rate(s) and/or the coverage at renewal. Nonrenewal of coverage as a result of failure of Medica and the Employer to reach agreement with respect to modifications in the Premium rate(s) or coverage shall not be considered a failure of Medica to provide coverage on a guaranteed renewable basis. Section 2.3 Notice of Termination. Medica will notify: (a) Employer in writing if Medica terminates this Contract for any reason; (b) Members in writing if Medica terminates this Contract due to nonpayment of Premium. Employer will provide timely written notification to Members in all circumstances for which Medica does not provide written notification to Members. Section 2.4 Effect of Termination. In the event of termination of this Contract: (a) All Benefits under this Contract will end at 12:00 midnight Central Time on the effective date of termination; (b) Medica will not be responsible for any Claims for health services received by Members after the effective date of the termination, unless otherwise specified in the Evidence of Coverage; and (c) Employer shall be and shall remain liable to Medica for the payment of any and all Premiums that are unpaid at the time of termination. ARTICLE 3 ENROLLMENT AND ELIGIBILITY Section 3.1 Eligibility and Enrollment. Employer has sole discretion to determine whether a person is eligible to enroll for Benefits, subject to applicable laws, the terms of this Contract, and the following eligibility requirements: Eliqibilitv Requirements - to be eligible to enroll, an individual must: (a) be either (i) a Medicare eligible retiree of the Employer or (ii) a Medicare eligible spouse or Domestic Partner of a retiree of the Employer; (b) be enrolled in Medicare Parts A and B or enrolled in Medicare Part B only; (c) continue to pay his or her Medicare Part B premium; (d) reside permanently within the Medica Group Prime Solution service area; (e) not have End Stage Renal Disease (ESRD) unless the individual is enrolled in a Medica commercial plan at the time of enrollment for Medica Group Prime Solution, subject to Section 3.3 below; and (f) not be enrolled in a hospice program at the time of application. A person who does not satisfy the above requirements is not eligible to enroll for coverage under this Contract. If there is a conflict between the Evidence of Coverage and the eligibility requirements in this Section of the Contract, this Section of the Contract governs. MN-PRI-MGC-G-05-101-01 Page 3 2; JOOr:; .. - J MEDICA SALES Medica shall rely upon Employer's determination regarding a person's eligibility to enroll for Benefits. Employer will be responsible for maintaining information verifying its continuing eligibility and the continuing eligibility of its eligible Members. This information shall be provided to Medica as reasonably requested by Medica. Employer shall provide the following eligibility information when requested by Medica: full legal name of eligible person or Member, social security number, identification number, proposed effective date for coverage to begin, proposed termination date and reason for termination, date of birth, address, and phone number. Section 3.2 Initial/Open/Off-Cycle Enrollment. As determined by Employer, enrollment may be limited to initial and open enrollment periods and off-cycle enrollment due to qualifying event] as follows: (a) "Initial Enrollment Period" is the 30-90 day period starting with the date the person is first eligible to enroll for coverage under this Contract. An eligible person must apply within this period for coverage to begin the first day of the month following Medica's receipt of the application and acceptance of enrollment by the Centers for Medicare and Medicaid Services (CMS). An eligible person who does not enroll during the Initial Enrollment Period may enroll for coverage during the next Open Enrollment Period or during an Off- Cycle Enrollment Due to Qualifying Event. (b) "Open Enrollment Period" is a minimum 14-30 day period set by the Employer and Medica each year during which eligible persons may enroll for coverage. [(c) "Off-Cycle Enrollment Due to Qualifying Event" is allowed if the eligible person was enrolled for health coverage under a spouse's or Domestic Partner's health benefit plan and such coverage ends due to one of the following qualifying events: (i) spouse's or Domestic Partner's involuntary termination or layoff from employment; (ii) death or permanent disability of the spouse or Domestic Partner; (iii) divorce; or (iv) any additional qualifying event as established by the Employer. Evidence of the qualifying event must be provided to Medica upon request. Section 3.3 Eligibility and Enrollment for ESRD. An employer group health plan must provide primary coverage with respect to Medicare for an individual with end stage renal disease (ESRD) during the coordination period. Medicare is the secondary payer during the coordination period. The coordination period is the first thirty (30) months after the individual becomes eligible for Medicare based on ESRD. These ESRD coverage rules apply regardless of the number of participants who are covered under the employer group health plan and without regard to the active or inactive status of the individual. ESRD coverage rules may vary in instances where an individual has dual entitlement to Medicare (a combination of age or disability, and ESRD). Section 3.4 Effective Date of Enrollment. Applications must be signed, dated and received by Medica by the last business day of the month in order to be effective the first day of the following month. However, the enrollment is not effective until Medica considers the application complete and it is accepted by CMS. Coverage begins at 12:01 a.m. on the Member's effective date. Applications may be submitted up to three months immediately prior to the person's entitlement to Medicare Part B. No retroactive enrollments shall be allowed except as approved by CMS. (' '1005 l1 L. MN-PRI-MGC-G-05-101-01 Page 4 MEDICA SALES Section 3.5 Effective Date of Request for Disenrollment. The disenrollment will be effective the last day of the month in which notification is received by Medica, unless a later date is requested. The requested disenrollment date cannot be effective more than three months after Medica's receipt of the request. The disenrollment request shall come from the Employer in writing. Additional disenrollment provisions are specified in the Evidence of Coverage. No retroactive disenrollments shall be allowed except as approved by CMS. ARTICLE 4 PREMIUMS Section 4.1 Monthly Premiums. The monthly Premiums for this Contract are: Member Classifications Monthlv Premium Rate 70531 70561 All Members 1-1-04 through 12-31-04 1-1-05 through 12-31-05 $258.00 $110.00 $253.95 $110.00 Invoices are generated on or about the 15th of the month for the month following. Premiums are due by the 1 st day of each calendar month. Member must continue to pay Medicare Part B premiums. How to pay Premiums: Employer shall pay Premiums to Medica at the billing address stated in the Acceptance of Contract. If Employer pays an amount different than the amount stated on the premium invoice, Employer will submit appropriate documentation in support of the premium variance. In exchange for Premiums paid, Medica shall arrange for the provision of Benefits. In doing so, Medica may enter into agreements with Providers of health care, one or more insurers, and such other individuals and entities as may be necessary to enable Medica to fulfill its obligations under the Contract. Section 4.2 Grace Period and Reinstatement. Employer has a grace period of 10 calendar days after the due date stated in Section 4.1 to pay the monthly Premium. Failure to pay premium, in whole or in part, within the grace period will result in Medica pursuing its collection process. If Employer fails to pay Premium, the Contract will be terminated in accordance with Section 2.2. This Contract will be reinstated if Employer pays all Premium owed within 60 days of the premium due date, unless the Employer has applied for reinstatement on two or more prior occasions. RECEIVED AUG I:' 1'1 MN-PRI-MGC-G-05-101-01 Page 5 MEDIC. In the event this Contract is not reinstated pursuant to this Section, Medica will not be responsible for any Claims for health services received by Members 30 days after the notice date as described in Section 2.2. Section 4.3 Premium Calculation. The monthly Premiums owed by Employer shall be calculated by Medica using the number of Members in each coverage classification according to Medica's records at the time of the calculation. Member's coverage for Benefits may be terminated only at the end of the calendar month in which Medica is notified and a full Premium rate for that month will apply. Section 4.4 Retroactive Premium Adjustments. In accordance with applicable law, retroactive adjustments may be made for any additions of Members not reflected in Medica's records at the time monthly Premiums were calculated by Medica. With respect to terminations of Member's coverage, no retroactive credit will be granted for any month in which a Member received Benefits. No retroactive Premium refund shall be granted for termination of Member's coverage unless approved by CMS. Regardless of the preceding, Employer shall pay Premium for any month during which a Member received Benefits. Section 4.5 Premium Reconciliation and Collection. Medica will complete a billing reconciliation for premium payments received. If there is a credit after Medica completes the billing reconciliation process, a letter will be sent to the Employer within 30 calendar days from the receipt date of the payment. A refund will be issued or the credit will be applied to the next billing, according to the Employer's instruction to Medica. If partial payment was received and there is a debit after the billing reconciliation process has been completed, a letter will be sent to the Employer within 30 calendar days from the receipt date of the payment, requesting additional payment or appropriate documentation from the Employer. If the entire Premium amount is past due, a letter will be sent to the Employer and Medica will initiate its collection process. Section 4.6 Premium Changes. Medica may change Premiums after 30 days prior written notice to Employer on: (a) the first anniversary of the effective date of this Contract; (b) any monthly due date after the first anniversary of this Contract; or (c) any date the provisions of this Contract are amended. Section 4.7 Fees. Medica may charge Employer: (a) a late payment charge in the amount permitted under law] for any Premiums not received by the due date; and (b) a service charge for any non-sufficient-fund check received in payment of Premiums. RECEIVED i~UG t'. 2 2005 MN-PRI-MGC-G-05-101-01 Page 6 MEDICA SALES (c) change, interpret, modify, withdraw or add Benefits without approval by Members; and (d) make factual determinations related to the Contract and the Benefits. For purposes of overall cost savings or efficiency, Medica may, in its sole discretion, provide services that would otherwise not be Benefits. The fact that Medica does so in any particular case shall not in any way be deemed to require it to do so in other similar cases. Medica may, from time to time, delegate discretionary authority to other persons or entities providing services under this Contract. ARTICLE 9 DATA OWNERSHIP AND USE Information and data acquired, developed, generated, or maintained by Medica in the course of performing under this Contract shall be Medica's sole property. Except as this Contract or applicable law requires otherwise, Medica shall have no obligation to release such information or data to Employer. Medica may, in its sole discretion, release such information or data to Employer, but only to the extent permitted by law and subject to any restrictions determined by Medica. ARTICLE 10 AMENDMENTS AND ALTERATIONS Section 10.1 Standard Amendments. Except as provided in Section 10.2, amendments to this Contract are effective 30 days after Medica sends Employer a written amendment. Unless regulatory authorities direct otherwise, Employer's signature will not be required. No Medica agent or broker has authority to change this Contract or to waive any of its provisions. Section 10.2 Regulatory Amendment. Medica may amend this Contract to comply with requirements of state law (for all states included in the Service Area) and federal law ("Regulatory Amendment") and shall issue to Employer such Regulatory Amendment and give Employer notice of its effective date. The Regulatory Amendment will not require Employer's consent and, unless regulatory authorities direct otherwise, Employer's signature will not be required. Any provision of this Contract that conflicts with the terms of applicable federal or state laws is deemed amended to conform to the minimum requirements of such laws. ARTICLE 11 ASSIGNMENT Neither party shall have the right to assign any of its rights and responsibilities under the Contract to any person, corporation or entity without the prior written consent of the other party; provided, however, that Medica may, without the prior written consent of the Employer, assign the Contract to any entity that controls Medica, is controlled by Medica, or is under common control with Medica. In the event of assignment, the Contract shall be binding upon and inure to the benefit of each party's successors and assigns. G i}."! ')(JO~ ,,,,,,f ("". ,,-,~ IvlEIiICA. ;)ALb:) MN-PRI-MGC-G-05-101-01 Page 8 ARTICLE 12 DISPUTE RESOLUTION Medica and Employer will work together in good faith to resolve any disputes under this Contract. If they are unable to resolve the disputes within 30 days following the date one party sent written notice of the dispute to the other party, and if either party wishes to pursue the dispute, it shall be submitted to binding arbitration in accordance with the rules of the American Arbitration Association ("AAA"). In no event may arbitration be initiated more than one year following the sending of written notice of the dispute. The arbitrators shall apply Minnesota substantive law to the proceeding, except to the extent federal substantive law, including ERISA, would apply to any claim. Any arbitration proceeding under this Agreement shall be conducted in Hennepin County, Minnesota. An award may be entered against a party who fails to appear at a duly noticed hearing. The arbitrators: (i) may construe or interpret, but shall not vary or ignore, the terms of this Agreement; (ii) shall have no authority to award any punitive or exemplary damages; and (iii) shall be bound by controlling law. A party may appeal an arbitration decision to a court of law only in accordance with applicable state arbitration laws or for de novo review of alleged errors of law or legal reasoning. The cost of arbitration shall be paid equally by the parties. In the event a third party initiates litigation involving Medica or Employer, and the party under this Contract who is involved in such third-party litigation desires to bring a claim against the other party under this Agreement for indemnity or contribution, the indemnity or contribution claim may be brought in the same venue as the third-party litigation, and shall not be subject to the terms of this Article 12. ARTICLE 13 TIME LIMIT ON CERTAIN DEFENSES No statement made by Employer, except a fraudulent statement, shall be used to void this Contract after it has been in force for a period of 2 years. ARTICLE 14 RELATIONSHIP BETWEEN PARTIES The relationship between Employer and any Member is that of Employer and Member as defined in this Contract. The relationships between Medica and Medica Contracted Providers and the relationship between Medica and Employer are solely contractual relationships between independent contractors. Medica Contracted Providers and Employer are not agents or employees!~Po1ElVED L\'IG' Z <1\ /0 at:; f".1. J .... .(., '_ J MN-PRI-MGC-G-05-101-01 Page 9 MEDICA SALES Medica. Medica and its employees are not agents or employees of Medica Contracted Providers or Employer. The relationship between a Medica Contracted Provider and any Member is that of provider and patient and the Medica Contracted Provider is solely responsible for the services provided to any Member. ARTICLE 15 EMPLOYER RECORDS Employer will be responsible for obtaining any consents from Members which allow Medica to receive a Member's protected health information. Medica may at any reasonable time inspect all documents furnished to Employer by an individual in connection with the Benefits, Employer's payroll records, and any other records pertinent to the Benefits under this Contract. The Employer agrees that it has amended its documents to reflect the restrictions on use and disclosure of protected health information ("PHI") as required by the Health Insurance Portability and Accountability Act of 1996 (UHIPAA") and that the Employer agrees to the required use and disclosure restrictions provided by HIPAA as follows: 1. The Employer will not use or further disclose such PHI other than as permitted or required by this Contract or as required by law (as defined in the HIPAA privacy standards ). 2. The Employer will ensure that any agents, including a subcontractor, to whom the Employer or any party acting on behalf of the Employer provides PHI, agree to the same restrictions and conditions that apply to the Employer with respect to such PHI. 3. The Employer will not use or disclose PHI for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the Employer, except under an authorization which meets the requirements of the HIPAA privacy standards. 4. The Employer will report to Medica any PHI use or disclosure that is inconsistent with the uses or disclosures provided for of which the Employer becomes aware. 5. The Employer will make available PHI in accordance with a covered person's right of access under the HIPAA privacy standards. 6. The Employer will make available PHI for amendment and incorporate any amendments to PHI in accordance with the HIPAA privacy standards. 7. The Employer will make available the information required to provide an accounting of certain disclosures of PHI in accordance with the HIPAA privacy standards. 8. The Employer and any of its agents, including a subcontractor, will make its internal practices, books and records relating to the use and disclosure of PHI available to the Secretary of the U.S. Department of Health and Human Services for purposes of determining compliance by the Employer with the HIPAA privacy standards. 9. If feasible, the Employer and any of its agents, including a subcontractor, will return or destroy all PH I received from any party when the PH I is no longer needed for the purpose for which it was disclosed. If such return or destruction is not feasible, the Employer will impose all necessary protections to maintain the security of the PHI. I~UG l 9; ?OrV1 MN-PRI-MGC-G-05-101-01 Page 10 MEDICA 10. The Employer will ensure that PHI is only accessible to employees on an "as need to know basis." ARTICLE 16 MEMBER RECORDS By accepting Benefits under this Contract, each Member authorizes and directs any person or institution that has provided services to the Member to furnish Medica or any of Medica's designees at any reasonable time, upon its request, any and all information and records or copies of records relating to the Benefits provided to the Member. In accordance with applicable law, Medica and any of Medica's designees shall have the right to release any and all records concerning health care services: (i) as necessary to implement and administer the terms of this Contract; or (ii) for appropriate medical review or quality assessment. Such Member information and records shall be considered confidential medical records by Medica and its designees. ARTICLE 17 NOTICE Except as provided in Article 2 and required by applicable law, notice given by Medica to an authorized representative of Employer will be deemed notice to all Members. All notices to Medica shall be sent to the address stated in the Acceptance of Contract. All notices to Employer shall be sent to the persons and addresses stated in Employer's Application. All notices to Medica and Employer shall be deemed delivered: (a) if delivered in person, on the date delivered in person; (b) if delivered by a courier, on the date stated by the courier; (c) if delivered by an express mail service, on the date stated by the mail service vendor; or (d) if delivered by United States mail, 3 business days after date of mailing. A party can change its address for receiving notices by providing the other party a written notice of the change. ARTICLE 18 COMMON LAW No language contained in the Contract constitutes a waiver of Medica's rights under common law. ACCEPTANCE OF CONTRACT This Contract is deemed accepted by Employer upon the earlier of Medica's receipt of Employer's first payment of the Premium or upon Employer's execution of this Contract by its duly authorized representative. This Contract is deemed accepted by Medica upon Medica's deposit of Employer's first payment of the Premium. Such acceptance renders all term~ilED provisions herein binding on Medica and Employer. MN-PRI-MGC-G-05-101-01 Page 11 If! ZOOI; L, .J MEDICA SALES IN WITNESS WHEREOF, Medica has caused this Contract to be executed on August 11, 2005, to take effect on the Effective Date stated in the Contract. MEDICA INSURANCE COMPANY EMPLOYER City of Columbia Heights Corporate Office Address: 401 Carlson Parkway Minnetonka, MN 55305-5387 (952) 992-2362 1-800-575-2330 Address: 590 40th Ave NE Billing Address: P.O. Box 64847 St. Paul, MN 55164-0847 Columbia Heights, MN 55421-3835 Mailing Address: P.O. Box 9310 Mail Route CP320 Minneapolis, MN 55440 Telephone: (763 )706-3609 By: \'f\m\jL(1~ \ Nam: Mark Owen Title: Vice President By: ~ ~ ~","",~ .~ t:::/Il V' 50 C1"/ ,{ ! ., ( (Yl\...-rvG'?-1 e.r '-" Title: (ilL D I (e. C/fo ( Date: RECEIVED f\ l" I r,_,' ',P," n" {..\ ,; L! ,~' .4 MN-PRI-MGC-G-05-101-01 Page 12 MEDICA SALF'