HomeMy WebLinkAboutContract 1817
PO Box 9310
Minneapolis, MN 55440-9310
952-992-2900
February 07,2005
Linda Magee
590 40th Ave NE
Columbia Heights, MN 55421
S
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Dear Ms. Magee: df 1 ~
Thank you for choosing Medica!
The enclosed medical Mast r Group Co racts (MGCs) bind Medica and City of
Columbia Heights, group nu bers 899 ~ to 89947, for the contract period
commencing on January 1, 2 5, and xpiring on December 31,2005.
The following steps should occ to e sure appropriate execution and
continued performance under th M Cs.
. Ensure the MGCs are signed n dated by an officer of the company or a
Person authorized to execute t terms of the MGCs.
. Include the contract signer's titl under the signature
. Return one signed copy of each GC to me within 30 days
. Retain the other documents for ur files
The MGCs will be deemed to have b en accepted by City of Columbia Heights upon
the earlier of Medica's receipt of your first premium payment for this contract period
or City of Columbia Heights' execution of the MGCs. Please note that Medica will not
accept unilateral changes to the MGCs when they are returned to Medica.
Thank you for your prompt attention to this matter. If you have any questions,
please contact me at (952) 992-2455. I appreciate your business and look
forward to meeting the health care needs of City of Columbia Heights employees in
the upcoming contract year.
Sincerely,
9J~
Janet Litwin
Account Service Representative
Enclosures
Cc: Gayle McCann
COR 1709-50204
Medica' refers to the family of health plan businesses that includes
Medica Holding Company, *Medica Health Plans, Medica Health Plans of Wisconsin,
*Medica Insurance Company, *Medica Self-Insured, Medica Foundation, and Medica Affiliated Services.
*Accredited by the National Committee for Quality Assurance.
An Equal Opportunity Employer
Medica Choice Select
PLAN
MASTER GROUP CONTRACT
Employer Name:
Employer Group#:
Effective Date:
Contract#:
Amendments:
CITY OF COLUMBIA HEIGHTS
89944
January 01, 2005
MCS7, BPL Number: 56741
Amendments attached as applicable for benefit package log (BPL)
as listed above.
ARTICLE 1
INTRODUCTION
This Master Group Contract ("Contract") is entered into by and between Medica, together with its
affiliate Medica Insurance Company ("MIC"), and the employer group named above ("Employer"),
an employer under Minnesota law and other applicable law. This Contract includes the Eligibility
Appendix, the Enrollment Appendix, the Certificate of Coverage ("Certificate") 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 Premiums by the Employer and payment of Copayments and
Coinsurance by or for Members, Medica will provide coverage for the Benefits set forth in the
Certificate 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.
The terms used in this Contract have the same meanings given those terms defined in the
Certificate, unless otherwise specifically defined in this Contract.
Page 1
ARTICLE 2
TERM OF CONTRACT
Section 2.1 Term and Renewal. This Contract is effective from January 01,2005
("Effective Date") to December 31, 2005 ("Expiration Date"). All coverage under this Contract
begins at 12:01 a.m. Central Time.
At least 30 days before each Expiration Date, Medica shall notify Employer of any
modifications to this Contract, including Premiums and Benefits for the next 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 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 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) On the date specified by Medica due to Employer's violation of the participation or
contribution rules as determined by Medica;
(d) Automatically on the date Employer ceases to do business pursuant to 11 U.S.C.
Chapter 7;
(e) 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;
(f) On the date specified by Medica, after at least 180 days prior written notice to the
applicable state authority and Employer, that this Contract will be terminated because
Medica will no longer renew or issue any employer health benefit plan within the
applicable employer market;
(g) On the date specified by Medica when there is no longer any Member who resides or
works in Medica's approved service area;
(h) If this Contract is made available to Employer only through one or more bona fide
associations, on the date specified by Medica after Employer's membership in the
association ceases.
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(i) Any other reasons or grounds permitted by the licensing laws and regulations governing
Medica.
Notwithstanding the above, Medica may modify the Premium rate 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 or coverage shall not be
considered a failure of Medica to provide coverage on a guaranteed renewal basis.
Section 2.3 Notice of Termination.
Medica will notify:
(a) Employer in writing if Medica terminates this Contract for any reason;
(b) Subscribers in writing if Medica terminates this Contract pursuant to Section 2.2 (a), (d),
(e) or (t).
Employer will provide timely written notification to Subscribers in all circumstances for which
Medica does not provide written notification to Subscribers.
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; 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.
Page 3
ARTICLE 3
ENROLLMENT AND ELIGIBILITY
Section 3.1 Eligibility. The Eligibility Appendix to this Contract governs who is eligible to
enroll under this Contract. The eligibility conditions stated in the Eligibility Appendix are in
addition to those specified in the Certificate.
Section 3.2 Enrollment. The Enrollment Appendix to this Contract governs when eligible
employees and eligible dependents may enroll for Benefits under this Contract, including the
Initial Enrollment Period, Open Enrollment Period and any applicable Special Enrollment
Periods. Employer shall conduct the Initial Enrollment Period and Open Enrollment Period.
Employer shall cooperate with Medica in the event of a Special Enrollment Period.
Section 3.3. Qualified Medical Child Support Orders. Employer will establish, maintain and
enforce all written procedures for determining whether a child support order is a qualified
medical child support order as defined by ERISA. Employer will provide Medica with notice of
such determination and a copy of the order, along with an application for coverage, within the
greater of 30 days after issuance of the order or the time in which Employer provides notice of
its determination to the persons specified in the order.
When and if Employer receives notice that the child has designated a representative, or of the
existence of a legal guardian or custodial parent of the child, Employer shall promptly notify
Medica of such person(s).
Medica shall have no responsibility for:
(i) establishing, maintaining or enforcing the procedures described above;
(ii) determining whether a support order is qualified; or
(iii) providing required notices to the child or the designated representative.
Section 3.4. Eligibility and Enrollment Decisions. Subject to applicable law and the terms of
this Contract, Employer has sole discretion to determine whether employees and their
dependents are eligible to enroll for Benefits. Medica shall rely upon Employer's determination
regarding an employee's and/or dependent's eligibility to enroll for Benefits. The Employer will
be responsible for maintaining information verifying its continuing eligibility and the continuing
eligibility of its eligible Subscribers and eligible Dependents. This information shall be provided
to Medica as reasonably requested by Medica. The Employer shall also maintain written
documentation of a waiver of coverage by an eligible Subscriber or eligible Dependent and
provide this documentation to Medica upon reasonable request.
Page 4
ARTICLE 4
PREMIUMS
Section 4.1 Monthly Premiums.
The monthly Premiums for this Contract are:
Monthly Premium Rate
Monthly Employer
Contribution
Monthly Enrollee
Contribution
Class 1 $440.65
(Employee Only)
Class 4 $1,011.98
(Family)
Employer shall contribute a minimum of 50%
towards the single monthly premium rate.
The Premiums are due on the first day of each calendar month. Employer shall pay the Premiums to
Medica at the billing address stated in the Acceptance of Contract.
Employer shall notify Medica in writing:
(a) each month of any changes in the coverage classification of any Subscriber; and
(b) within 30 days after the effective date of enrollments, terminations or other changes regarding
Members.
Section 4.2 Grace Period and Reinstatement. Employer has a grace period of 10 days after
the due date stated in Section 4.1 to pay the monthly Premiums. If Employer fails to pay Premium,
the Contract will be terminated in accordance with Section 2.2(a). This Contract will be reinstated if
Employer pays all of the Premiums owed on or before the end of the grace period. In this event the
Contract is not reinstated pursuant to this Section, Medica will not be responsible for any Claims for
health services received by Members after the effective date of the termination.
Section 4.3 Premium Calculation. The monthly Premiums owed by Employer shall be
calculated by Medica using the number of Subscribers in each coverage classification
according to Medica's records at the time of the calculation. Employer may make adjustments
to its payment of Premiums for any additions or terminations of Members submitted by
Employer but not yet reflected in Medica's calculations.
A full calendar month's Premiums shall be charged for Members whose effective date falls on
or before the 15th day of that calendar month. No Premium shall be charged for Members
Page 5
whose effective date falls after the 15th of that calendar month. With the exception of
termination of coverage due to a Member's death, a Member's Benefits may be terminated only
at the end of a calendar month and a full Premium rate for that month will apply. In the case of
a Member's death, that Member's Benefits will be terminated on the date of the death.
Section 4.4 Retroactive Adjustments. In accordance with applicable law, retroactive
adjustments may be made for any additions, or terminations of Members or changes in
coverage classifications not reflected in Medica's records at the time the monthly Premiums
were calculated by Medica. However, no retroactive credit will be granted for any month in
which a Member received Benefits. No retroactive adjustments to enrollment or Premium
refund shall be granted for any change occurring more than 60 days prior to the date Medica
received notification of the change from Employer.
Regardless of the preceding, Employer shall pay a Premium for any month during which a
Member received Benefits.
Section 4.5 Premium Changes. Medica may change the 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 4.6 Employer Fees. Medica may charge Employer:
(a) a late payment charge in the form of a finance charge of 12% per annum for any
Premiums not received by the due date; and
(b) a service charge for any non-suffIcient-fund check received in payment of the Premiums.
ARTICLE 5
INDEMNIFICATION
Medica will hold harmless and indemnify Employer against any and all claims, liabilities,
damages or judgments asserted against, imposed upon or incurred by Employer, including
reasonable attorney fees and costs, that arise out of Medica's grossly negligent acts or
omissions in the discharge of its responsibilities to a Member.
Employer will hold harmless and indemnify Medica against any and all claims, liabilities,
damages or judgments asserted against, imposed upon or incurred by Medica, including
reasonable attorney fees and costs, that arise out of Employer's or Employer's employees',
agents', and representatives' grossly negligent acts or omissions in the discharge of its or their
responsibilities under this Contract.
Employer and Medica shall promptly notify the other of any potential or actual claim for which
the other party may be responsible under this Article 5.
Page 6
ARTICLE 6
ADMINISTRATIVE SERVICES
The services necessary to administer this Contract and the Benefits provided under it will be
provided in accordance with Medica's or its designee's standard administrative procedures. If
Employer requests such administrative services be provided in a manner other than in
accordance with these standard procedures, including requests for non-standard reports, and if
Medica agrees to provide such non-standard administrative services, Employer shall pay for
such services or reports at Medica's or its designee's then-current charges for such services or
reports.
ARTICLE 7
CLERICAL ERROR
A Member will not be deprived of coverage under the Contract because of a clerical error.
Furthermore, a Member will not be eligible for coverage beyond the scheduled termination date
because of a failure to record the termination.
ARTICLE 8
ERISA
When this Contract is entered into by Employer to provide benefits under an employee welfare
benefit plan governed by ERISA, Medica shall not be named as and shall not be the plan
administrator or the named fiduciary of the employee welfare benefit plan, as those terms are
used in ERISA.
The parties agree that Medica has sole, final, and exclusive discretion to:
(a) interpret and construe the Benefits under the Contract;
(b) interpret and construe the other terms, conditions, limitations and exclusions set out in the
Contract;
(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.
Page 7
ARTICLE 10
CONTINUATION OF COVERAGE
Medica shall provide Benefits under this Contract to those Members who are eligible to
continue coverage under federal or state law.
Medica will not provide any administrative duties with respect to Employer's compliance with
federal or state continuation of coverage laws. All duties of the Employer, including, but not
limited to, notifying Members regarding federal and state law continuation rights and Premium
billing and collection, remain Employer's sole responsibility.
ARTICLE 11
CERTIFICATION OF QUALIFYING COVERAGE FORMS
As required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA),
Medica will produce Certification of Qualifying Coverage forms for Members whose coverage
under this Contract terminates. The Certification of Qualifying Coverage forms will be based
on the eligibility and termination data Employer provides to Medica. Employer shall provide all
necessary eligibility and termination data to Medica in accordance with Medica's data
specifications. The Certification of Qualifying Coverage forms will only include periods of
coverage Medica administers under this Contract.
ARTICLE 12
AMENDMENTS AND ALTERATIONS
Section 12.1 Standard Amendments: Except as provided in Section 12.2, 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 12.2 Regulatory Amendment: Medica may amend this Contract to comply with
requirements of state 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 13
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 the inure
to the benefit of each party's successors and assigns.
Page 8
ARTICLE 14
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 14.
ARTICLE 15
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.
Page 9
ARTICLE 16
RELATIONSHIP BETWEEN PARTIES
The relationship between Employer and any Member is that of Employer and Subscriber,
Dependent or other coverage classification as defined in this Contract.
The relationship between Medica and Network Providers and the relationship between Medica
and Employer are solely contractual relationships between independent contractors. Network
Providers and Employer are not agents or employees of Medica. Medica and its employees
are not agents or employees of Network Providers or Employer.
The relationship between a Network Provider and any Member is that of provider and patient
and Network Provider is solely responsible for the services provided to any Member.
ARTICLE 17
EMPLOYER RECORDS
Employer shall furnish Medica with all information and proofs that Medica may reasonably
require with regard to any matters pertaining to this Contract. Employer will be responsible
for obtaining any necessary consent from Members which allows Medica to receive a
Member's protected health information (as defined in the federal privacy regulations
promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996
(HIPAA)). 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.
ARTICLE 18
MEMBER RECORDS
By accepting Benefits under this Contract, each Member, including Dependents, whether or
not such Dependents have signed the Subscriber's application, 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 it designees.
ARTICLE 19
NOTICE
Except as provided in Article 2, 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
Page 10
(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 20
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 terms and provisions
herein binding on Medica and the Employer.
IN WITNESS WHEREOF, MIC has caused this Contract to be executed on this February 7, 2005
to take effect on the Effective Date stated in the Contract.
MEDICA
EMPLOYER:
401 Carlson Parkway
Minnetonka, Minnesota 55305
(952)992-2200
CITY OF COLUMBIA HEIGHTS
Address:
Billing Address:
MN015-2838
P.O. Box 169063
Duluth, MN 55816
590 40th Ave. NE
Columbia Height, MN 55421
Mailing Address:
P.O. Box 9310
Minneapolis, MN 55440
Telephone: (763) 706-3609
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Title:
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Group Contact: Linda Magee
Date:
By:
Tom L. Henke
Title: Vice President, Commercial Sales and
Account Services
Page 11
ELIGIBILITY APPENDIX
Employer Name:
CITY OF COLUMBIA HEIGHTS
Employer Group#:
89944
Section 1 Eligibility to Enroll. A Subscriber, and his or her Dependents, as defined below,
who satisfies the eligibility conditions stated in this Contract are eligible to enroll for coverage
under this Contract. Any person who does not satisfy the definition of Subscriber or Dependent
is not eligible for coverage under this Contract.
A Subscriber and his or her Dependents must meet the eligibility requirements described below
and in the entire Contract. In no event may the number of Members residing outside the
Service Area exceed 10 percent of the total number of Members.
If there is a conflict between the Certificate and this Eligibility Appendix, this Eligibility Appendix
governs.
Section 2 Subscriber Definition.
The term "Subscriber" as used in the Contract will include the types of employees and
conditions identified below:
Classifications
Applicable Waiting Periods
and Effective Dates
1 . See comments
New Hires: Date of Hire
Return: Date of Return
Status Change: Date of Change
A Subscriber who is a child entitled to receive coverage through a qualified medical child support
order is not subject to any waiting periods, except to the extent that such waiting periods apply to
the employee who is ordered by the qualified medical support order to provide coverage.
Section 3 Dependent Definition. The term "Dependent" as used in this Contract includes the
following:
1. The Subscriber's spouse
2. The following Dependent children:
(a) Subscriber's unmarried natural or adopted child;
(b) an unmarried child Placed For Adoption with the Subscriber;
(c) a child for whom the Subscriber or the Subscriber's spouse has been appointed legal
guardian, however, upon request by Medica, the Subscriber must provide satisfactory
proof of dependency;
Page 12
(d) Subscriber's or Subscriber's spouse's unmarried grandchild who, from the date of
birth resides with and is dependent upon the Subscriber or Subscriber's spouse for
support and
(e) Subscriber's stepchild.
A Dependent child must be under 19 years of age if s/he is not a student and must be under 25
years of age if s/he is a student. A Dependent child is eligible as a student if s/he is enrolled full-
time in a recognized high school, college, university, trade or vocational school. If the student is
unable to a carry a full-time course load due to illness, injury, or a physical or mental disability, as
documented by a Physician, full-time student status will be granted if the student carries at least
60% of a full-time course load, as determined by the educational institution.
3. The Subscriber's handicapped Dependent. The handicapped Dependent must be:
(a) incapable of self-sustaining employment by reason of mental retardation, mental
illness, mental disorder or physical handicap; and
(b) chiefly dependent upon the Subscriber for support and maintenance.
The handicapped Dependent shall be eligible for coverage as long as he or she continues to
be handicapped and satisfies the requirements of (a) and (b) above, unless coverage
otherwise terminates under this Contract. Medica may require annual proof of handicap and
dependency. An illness will not be considered a physical handicap.
A child who is the subject of a qualified medical child support order is not a Dependent as
defined above and may not enroll Dependents for coverage. See Section 2.
Any person who does not satisfy the terms listed above will not be eligible for coverage under
the Contract.
Page 13
ENROLLMENT APPENDIX
Employer Name:
Employer Group#:
CITY OF COLUMBIA HEIGHTS
89944
INITIAL ENROLLMENT
"Initial Enrollment Period" is a 30 day time period starting with the date an eligible Subscriber
and his or her eligible Dependents are first eligible to enroll for coverage under this Contract.
An eligible Subscriber must apply within this period for coverage to begin the date he or she
was first eligible to enroll. (The 30 day time period does not apply to newborn Dependents; see
Special Enrollment, (item 4 ).) An eligible Subscriber who enrolls during the Initial Enrollment
Period is accepted without application of health screening or affiliation periods. An eligible
Subscriber and his/her Dependents who do not enroll during the Initial Enrollment Period may
enroll for coverage during the next Open Enrollment, any applicable Special Enrollment
Periods as described below.
A Subscriber who is a child entitled to receive coverage through a qualified medical child
support order is not subject to any Initial Enrollment Period restrictions, except as noted in the
Eligibility Appendix.
NOTIFICATION
Subscribers must notify Employer within 30 days of the effective date of any change of address
or name, addition or deletion of Dependents, or other facts identifying the Subscriber or the
Subscriber's Dependents.
The Employer must notify Medica within 30 days of the effective date of the Member's initial
enrollment application, changes to the Member's name or address, or changes to enrollment,
including if a Member is no longer eligible for coverage.
OPEN ENROLLMENT
"Open Enrollment" is a minimum 14 day period set by Employer and Medica each year during
which eligible Subscribers and his or her Dependents may enroll for coverage without
application of health screening or waiting periods.
SPECIAL ENROLLMENT
A. Special Enrollment Periods. The following "Special Enrollment Periods" are available in
addition to the Initial Enrollment Period and Open Enrollment Period.
A Special Enrollment period will apply to an eligible employee and Dependent if:
(1) the eligible employee or Dependent:
a. was covered under Qualifying Coverage at the time the eligible employee or
Dependent was first eligible to enroll under the Contract, and
b. declined coverage for that reason, and
c. presents to Medica either (i) evidence of the loss of prior coverage due to loss
of eligibility for that coverage, or (ii) evidence that employer contributions toward
the prior coverage have terminated, and
d. maintains Continuous Coverage, and
Page 14
e. requests enrollment in writing within 30 days of the date of the loss of coverage
or the date the employer's contribution toward that coverage terminates;
For purposes of this item:
a. prior coverage does not include continuation coverage required under federal law;
b. loss of eligibility includes loss of eligibility as a result of legal separation, divorce,
death, termination of employment, or reduction in the number of hours of
employment;
c. loss of eligibility does not include a loss due to failure of the eligible employee or
Dependent to pay Premiums on a timely basis or termination of coverage for
cause;
(2) the eligible employee or Dependent:
a. was covered under benefits available under (i) the Consolidated Omnibus
Budget Reconciliation Act of 1985 ("COBRA"), Public Law Number 99-272, as
amended, or (ii) any state continuation laws applicable to the employer or
Medica, and
b. declined coverage for that reason, and
c. the eligible employee or Dependent presents to Medica evidence that the
eligible employee or Dependent has exhausted such COBRA or state
continuation coverage and has not lost such coverage due to either failure of
the eligible employee or Dependent to pay Premiums on a timely basis or for
cause,and
d. maintains Continuous Coverage, and
e. requests enrollment in writing within 30 days of the loss of coverage;
(3) the Dependent is a new spouse of the Subscriber or eligible employee, provided that
the marriage is legal, enrollment is requested in writing within 30 days of the marriage,
and the eligible employee also enrolls during this Special Enrollment Period;
(4) the Dependent is a new Dependent child of the Subscriber or eligible employee,
provided that enrollment is requested in writing within 30 days of the Subscriber or
eligible employee acquiring the Dependent (the notification period is not limited to 30
days for newborn Dependents), and provided the eligible employee also enrolls during
this Special Enrollment Period;
(5) the Dependent is the spouse of the Subscriber or eligible employee through whom the
Dependent child described in item #4 above claims Dependent status and;
a. that spouse is eligible for coverage; and
b. is not already enrolled under the Contract; and
c. enrollment is requested in writing within 30 days of the Dependent child
becoming a Dependent, provided the eligible employee also enrolls during this
Special Enrollment Period.
Page 15
(6) the Dependents are eligible Dependent children of the Subscriber or eligible employee
and enrollment is requested in writing within 30 days of a Dependent, as described in
items #3 or #4 above, becoming eligible to enroll under the coverage, provided the
eligible employee also enrolls during this Special Enrollment Period.
Additionally, when Employer provides Medica with notice of a qualified medical child support
order and a copy of the order, Medica will provide such eligible dependent child with a Special
Enrollment Period. Employer will provide Medica with such notice, along with an application for
coverage, within the lesser of 30 days or the time in which Employer provides notice of its
determination to the persons specified in the order.
B. Effective Dates of Coverage. Coverage shall become effective:
(1) in the case of paragraphs (A)( 1) or (2) above, the day after the date the other
coverage ended;
(2) in the case of paragraph (A)(3) above, the date of the marriage;
(3) in the case of paragraph (A)(4) above, the date of birth, date of adoption, or date of
placement for adoption. In all other cases, the date the Subscriber acquires the
Dependent child.
(4) in the case of paragraph (A)(5) above, the date the Subscriber acquires the Dependent
Child; and
(5) in the case of (A)(6) above, the first day of the first calendar month beginning after the
date the completed request for enrollment is received by Medica.
(6) in the case of the qualified medical child support order, the first day of the first calendar
month beginning after the date the completed request for enrollment is received by
Medica.
Page 16
OFF-CYCLE ENROLLMENT -
NO OFF-CYCLE ENROLLMENT FOR LATE ENTRANTS WITHOUT CONTINUOUS
COVERAGE
An eligible Subscriber or an eligible Subscriber and his or her Dependents who do not enroll for
coverage offered through Employer during the Initial Enrollment Period, the Open Enrollment
Period or any applicable Special Enrollment Period will be considered Late Entrants.
(1) Late Entrants who have maintained Continuous Coverage may enroll and coverage will be
effective the first day of the month following date of approval by Medica. Continuous
Coverage will be determined to have been maintained if the Late Entrant requests
enrollment within 63 days after prior Qualifying Coverage ends.
(2) Late Entrants who have not maintained Continuous Coverage may not enroll off-cycle.
An eligible Subscriber or Dependent who:
(1) does not enroll during the Initial Enrollment Period, the Open Enrollment Period or any
applicable Special Enrollment period; and
(2) is an enrollee of the Minnesota Comprehensive Health Association ("MCHA") at the time
Medica offers or renews coverage with Employer, provided the eligible Subscriber or
Dependent maintains Continuous Coverage,
will not be considered a Late Entrant and will be allowed to enroll. Coverage will be effective as
determined by Medica.
Page 17
Medica Elect
PLAN
MASTER GROUP CONTRACT
Employer Name:
Employer Group#:
Effective Date:
Contract#:
Amendments:
CITY OF COLUMBIA HEIGHTS
89945
January 01, 2005
ME7, BPL Number: 68547
Amendments attached as applicable for benefit package log (BPL)
as listed above.
ARTICLE 1
INTRODUCTION
This Master Group Contract ("Contract") is entered into by and between Medica, together with its
affiliate Medica Insurance Company ("MIC"), and the employer group named above ("Employer"),
an employer under Minnesota law and other applicable law. This Contract includes the Eligibility
Appendix, the Enrollment Appendix, the Certificate of Coverage ("Certificate") 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 Premiums by the Employer and payment of Co payments and
Coinsurance by or for Members, Medica will provide coverage for the Benefits set forth in the
Certificate 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.
The terms used in this Contract have the same meanings given those terms defined in the
Certificate, unless otherwise specifically defined in this Contract.
Page 1
ARTICLE 2
TERM OF CONTRACT
Section 2.1 Term and Renewal. This Contract is effective from January 01,2005
("Effective Date") to December 31, 2005 ("Expiration Date"). All coverage under this Contract
begins at 12:01 a.m. Central Time.
At least 30 days before each Expiration Date, Medica shall notify Employer of any
modifications to this Contract, including Premiums and Benefits for the next 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 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 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) On the date specified by Medica due to Employer's violation of the participation or
contribution rules as determined by Medica;
(d) Automatically on the date Employer ceases to do business pursuant to 11 U.S.C.
Chapter 7;
(e) 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;
(f) On the date specified by Medica, after at least 180 days prior written notice to the
applicable state authority and Employer, that this Contract will be terminated because
Medica will no longer renew or issue any employer health benefit plan within the
applicable employer market;
(g) On the date specified by Medica when there is no longer any Member who resides or
works in Medica's approved service area;
(h) If this Contract is made available to Employer only through one or more bona fide
associations, on the date specified by Medica after Employer's membership in the
association ceases.
Page 2
(i) Any other reasons or grounds permitted by the licensing laws and regulations governing
Medica.
Notwithstanding the above, Medica may modify the Premium rate 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 or coverage shall not be
considered a failure of Medica to provide coverage on a guaranteed renewal basis.
Section 2.3 Notice of Termination.
Medica will notify:
(a) Employer in writing if Medica terminates this Contract for any reason;
(b) Subscribers in writing if Medica terminates this Contract pursuant to Section 2.2 (a), (d),
(e) or (f).
Employer will provide timely written notification to Subscribers in all circumstances for which
Medica does not provide written notification to Subscribers.
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; 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.
Page 3
ARTICLE 3
ENROLLMENT AND ELIGIBILITY
Section 3.1 Eligibility. The Eligibility Appendix to this Contract governs who is eligible to
enroll under this Contract. The eligibility conditions stated in the Eligibility Appendix are in
addition to those specified in the Certificate.
Section 3.2 Enrollment. The Enrollment Appendix to this Contract governs when eligible
employees and eligible dependents may enroll for Benefits under this Contract, including the
Initial Enrollment Period, Open Enrollment Period and any applicable Special Enrollment
Periods. Employer shall conduct the Initial Enrollment Period and Open Enrollment Period.
Employer shall cooperate with Medica in the event of a Special Enrollment Period.
Section 3.3. Qualified Medical Child Support Orders. Employer will establish, maintain and
enforce all written procedures for determining whether a child support order is a qualified
medical child support order as defined by ERISA. Employer will provide Medica with notice of
such determination and a copy of the order, along with an application for coverage, within the
greater of 30 days after issuance of the order or the time in which Employer provides notice of
its determination to the persons specified in the order.
When and if Employer receives notice that the child has designated a representative, or of the
existence of a legal guardian or custodial parent of the child, Employer shall promptly notify
Medica of such person(s).
Medica shall have no responsibility for:
(i) establishing, maintaining or enforcing the procedures described above;
(H) determining whether a support order is qualified; or
(Hi) providing required notices to the child or the designated representative.
Section 3.4. Eligibility and Enrollment Decisions. Subject to applicable law and the terms of
this Contract, Employer has sole discretion to determine whether employees and their
dependents are eligible to enroll for Benefits. Medica shall rely upon Employer's determination
regarding an employee's and/or dependent's eligibility to enroll for Benefits. The Employer will
be responsible for maintaining information verifying its continuing eligibility and the continuing
eligibility of its eligible Subscribers and eligible Dependents. This information shall be provided
to Medica as reasonably requested by Medica. The Employer shall also maintain written
documentation of a waiver of coverage by an eligible Subscriber or eligible Dependent and
provide this documentation to Medica upon reasonable request.
Page 4
ARTICLE 4
PREMIUMS
Section 4.1 Monthly Premiums.
The monthly Premiums for this Contract are:
Monthly Premium Rate
Monthly Employer
Contribution
Monthly Enrollee
Contribution
Class 1 $396.60
(Employee Only)
Class 4 $910.80
(Family)
Employer shall contribute a minimum of 50%
towards the single monthly premium rate.
The Premiums are due on the first day of each calendar month. Employer shall pay the Premiums to
Medica at the billing address stated in the Acceptance of Contract.
Employer shall notify Medica in writing:
(a) each month of any changes in the coverage classification of any Subscriber; and
(b) within 30 days after the effective date of enrollments, terminations or other changes regarding
Members.
Section 4.2 Grace Period and Reinstatement. Employer has a grace period of 10 days after
the due date stated in Section 4.1 to pay the monthly Premiums. If Employer fails to pay Premium,
the Contract will be terminated in accordance with Section 2.2(a). This Contract will be reinstated if
Employer pays all of the Premiums owed on or before the end of the grace period. In this event the
Contract is not reinstated pursuant to this Section, Medica will not be responsible for any Claims for
health services received by Members after the effective date of the termination.
Section 4.3 Premium Calculation. The monthly Premiums owed by Employer shall be
calculated by Medica using the number of Subscribers in each coverage classification
according to Medica's records at the time of the calculation. Employer may make adjustments
to its payment of Premiums for any additions or terminations of Members submitted by
Employer but not yet reflected in Medica's calculations.
A full calendar month's Premiums shall be charged for Members whose effective date falls on
or before the 15th day of that calendar month. No Premium shall be charged for Members
Page 5
whose effective date falls after the 15th of that calendar month. With the exception of
termination of coverage due to a Member's death, a Member's Benefits may be terminated only
at the end of a calendar month and a full Premium rate for that month will apply. In the case of
a Member's death, that Member's Benefits will be terminated on the date of the death.
Section 4.4 Retroactive Adjustments. In accordance with applicable law, retroactive
adjustments may be made for any additions, or terminations of Members or changes in
coverage classifications not reflected in Medica's records at the time the monthly Premiums
were calculated by Medica. However, no retroactive credit will be granted for any month in
which a Member received Benefits. No retroactive adjustments to enrollment or Premium
refund shall be granted for any change occurring more than 60 days prior to the date Medica
received notification of the change from Employer.
Regardless of the preceding, Employer shall pay a Premium for any month during which a
Member received Benefits.
Section 4.5 Premium Changes. Medica may change the 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 4.6 Employer Fees. Medica may charge Employer:
(a) a late payment charge in the form of a finance charge of 12% per annum for any
Premiums not received by the due date; and
(b) a service charge for any non-sufFicient-fund check received in payment of the Premiums.
ARTICLE 5
INDEMNIFICATION
Medica will hold harmless and indemnify Employer against any and all claims, liabilities,
damages or judgments asserted against, imposed upon or incurred by Employer, including
reasonable attorney fees and costs, that arise out of Medica's grossly negligent acts or
omissions in the discharge of its responsibilities to a Member.
Employer will hold harmless and indemnify Medica against any and all claims, liabilities,
damages or judgments asserted against, imposed upon or incurred by Medica, including
reasonable attorney fees and costs, that arise out of Employer's or Employer's employees',
agents', and representatives' grossly negligent acts or omissions in the discharge of its or their
responsibilities under this Contract.
Employer and Medica shall promptly notify the other of any potential or actual claim for which
the other party may be responsible under this Article 5.
Page 6
ARTICLE 6
ADMINISTRATIVE SERVICES
The services necessary to administer this Contract and the Benefits provided under it will be
provided in accordance with Medica's or its designee's standard administrative procedures. If
Employer requests such administrative services be provided in a manner other than in
accordance with these standard procedures, including requests for non-standard reports, and if
Medica agrees to provide such non-standard administrative services, Employer shall pay for
such services or reports at Medica's or its designee's then-current charges for such services or
reports.
ARTICLE 7
CLERICAL ERROR
A Member will not be deprived of coverage under the Contract because of a clerical error.
Furthermore, a Member will not be eligible for coverage beyond the scheduled termination date
because of a failure to record the termination.
ARTICLE 8
ERISA
When this Contract is entered into by Employer to provide benefits under an employee welfare
benefit plan governed by ERISA, Medica shall not be named as and shall not be the plan
administrator or the named fiduciary of the employee welfare benefit plan, as those terms are
used in ERISA.
The parties agree that Medica has sole, final, and exclusive discretion to:
(a) interpret and construe the Benefits under the Contract;
(b) interpret and construe the other terms, conditions, limitations and exclusions set out in the
Contract;
(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.
Page 7
ARTICLE 10
CONTINUATION OF COVERAGE
Medica shall provide Benefits under this Contract to those Members who are eligible to
continue coverage under federal or state law.
Medica will not provide any administrative duties with respect to Employer's compliance with
federal or state continuation of coverage laws. All duties of the Employer, including, but not
limited to, notifying Members regarding federal and state law continuation rights and Premium
billing and collection, remain Employer's sole responsibility.
ARTICLE 11
CERTIFICATION OF QUALIFYING COVERAGE FORMS
As required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA),
Medica will produce Certification of Qualifying Coverage forms for Members whose coverage
under this Contract terminates. The Certification of Qualifying Coverage forms will be based
on the eligibility and termination data Employer provides to Medica. Employer shall provide all
necessary eligibility and termination data to Medica in accordance with Medica's data
specifications. The Certification of Qualifying Coverage forms will only include periods of
coverage Medica administers under this Contract.
ARTICLE 12
AMENDMENTS AND ALTERATIONS
Section 12.1 Standard Amendments: Except as provided in Section 12.2, 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 12.2 Regulatory Amendment: Medica may amend this Contract to comply with
requirements of state 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 13
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 the inure
to the benefit of each party's successors and assigns.
Page 8
ARTICLE 14
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 14.
ARTICLE 15
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.
Page 9
ARTICLE 16
RELATIONSHIP BETWEEN PARTIES
The relationship between Employer and any Member is that of Employer and Subscriber,
Dependent or other coverage classification as defined in this Contract.
The relationship between Medica and Network Providers and the relationship between Medica
and Employer are solely contractual relationships between independent contractors. Network
Providers and Employer are not agents or employees of Medica. Medica and its employees
are not agents or employees of Network Providers or Employer.
The relationship between a Network Provider and any Member is that of provider and patient
and Network Provider is solely responsible for the services provided to any Member.
ARTICLE 17
EMPLOYER RECORDS
Employer shall furnish Medica with all information and proofs that Medica may reasonably
require with regard to any matters pertaining to this Contract. Employer will be responsible
for obtaining any necessary consent from Members which allows Medica to receive a
Member's protected health information (as defined in the federal privacy regulations
promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996
(HIPAA)). 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.
ARTICLE 18
MEMBER RECORDS
By accepting Benefits under this Contract, each Member, including Dependents, whether or
not such Dependents have signed the Subscriber's application, 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 it designees.
ARTICLE 19
NOTICE
Except as provided in Article 2, 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
Page 10
(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 20
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 terms and provisions
herein binding on Medica and the Employer.
IN WITNESS WHEREOF, MIC has caused this Contract to be executed on this February 7,2005
to take effect on the Effective Date stated in the Contract.
MEDICA
EMPLOYER:
401 Carlson Parkway
Minnetonka, Minnesota 55305
(952)992-2200
CITY OF COLUMBIA HEIGHTS
Address:
Billing Address:
MN015-2838
P.O. Box 169063
Duluth, MN 55816
590 40th Ave. NE
Columbia Height, MN 55421
Telephone: (763) 706-3609
Mailing Address:
P.O. Box 9310
Minneapolis, MN 55440
Contract
Signer:
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Date:
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Title:
By:
Tom L. Henke
Group Contact: Linda Magee
Title: Vice President, Commercial Sales and
Account Services
Page 11
ELIGIBILITY APPENDIX
Employer Name:
CITY OF COLUMBIA HEIGHTS
Employer Group#:
89945
Section 1 Eligibility to Enroll. A Subscriber, and his or her Dependents, as defined below,
who satisfies the eligibility conditions stated in this Contract are eligible to enroll for coverage
under this Contract. Any person who does not satisfy the definition of Subscriber or Dependent
is not eligible for coverage under this Contract.
A Subscriber and his or her Dependents must meet the eligibility requirements described below
and in the entire Contract. In no event may the number of Members residing outside the
Service Area exceed 10 percent of the total number of Members.
If there is a conflict between the Certificate and this Eligibility Appendix, this Eligibility Appendix
governs.
Section 2 Subscriber Definition.
The term "Subscriber" as used in the Contract will include the types of employees and
conditions identified below:
Classifications
Applicable Waiting Periods
and Effective Dates
1. See Comments
New Hires: Date of Hire
Return: Date of Return
Status Change: Date of Change
A Subscriber who is a child entitled to receive coverage through a qualified medical child support
order is not subject to any waiting periods, except to the extent that such waiting periods apply to
the employee who is ordered by the qualified medical support order to provide coverage.
Section 3 Dependent Definition. The term "Dependent" as used in this Contract includes the
following:
1. The Subscriber's spouse
2. The following Dependent children:
(a) Subscriber's unmarried natural or adopted child;
(b) an unmarried child Placed For Adoption with the Subscriber;
(c) a child for whom the Subscriber or the Subscriber's spouse has been appointed legal
guardian, however, upon request by Medica, the Subscriber must provide satisfactory
proof of dependency;
Page 12
(d) Subscriber's or Subscriber's spouse's unmarried grandchild who, from the date of
birth resides with and is dependent upon the Subscriber or Subscriber's spouse for
support and
(e) Subscriber's stepchild.
A Dependent child must be under 19 years of age if s/he is not a student and must be under 25
years of age if s/he is a student. A Dependent child is eligible as a student if s/he is enrolled full-
time in a recognized high school, college, university, trade or vocational school. If the student is
unable to a carry a full-time course load due to illness, injury, or a physical or mental disability, as
documented by a Physician, full-time student status will be granted if the student carries at least
60% of a full-time course load, as determined by the educational institution.
3. The Subscriber's handicapped Dependent. The handicapped Dependent must be:
(a) incapable of self-sustaining employment by reason of mental retardation, mental
illness, mental disorder or physical handicap; and
(b) chiefly dependent upon the Subscriber for support and maintenance.
The handicapped Dependent shall be eligible for coverage as long as he or she continues to
be handicapped and satisfies the requirements of (a) and (b) above, unless coverage
otherwise terminates under this Contract. Medica may require annual proof of handicap and
dependency. An illness will not be considered a physical handicap.
A child who is the subject of a qualified medical child support order is not a Dependent as
defined above and may not enroll Dependents for coverage. See Section 2.
Any person who does not satisfy the terms listed above will not be eligible for coverage under
the Contract.
Page 13
ENROLLMENT APPENDIX
Employer Name:
Employer Group#:
CITY OF COLUMBIA HEIGHTS
89945
INITIAL ENROLLMENT
"Initial Enrollment Period" is a 30 day time period starting with the date an eligible Subscriber
and his or her eligible Dependents are first eligible to enroll for coverage under this Contract.
An eligible Subscriber must apply within this period for coverage to begin the date he or she
was first eligible to enroll. (The 30 day time period does not apply to newborn Dependents; see
Special Enrollment, (item 4).) An eligible Subscriber who enrolls during the Initial Enrollment
Period is accepted without application of health screening or affiliation periods. An eligible
Subscriber and his/her Dependents who do not enroll during the Initial Enrollment Period may
enroll for coverage during the next Open Enrollment, any applicable Special Enrollment
Periods as described below.
A Subscriber who is a child entitled to receive coverage through a qualified medical child
support order is not subject to any Initial Enrollment Period restrictions, except as noted in the
Eligibility Appendix.
NOTIFICATION
Subscribers must notify Employer within 30 days of the effective date of any change of address
or name, addition or deletion of Dependents, or other facts identifying the Subscriber or the
Subscriber's Dependents.
The Employer must notify Medica within 30 days of the effective date of the Member's initial
enrollment application, changes to the Member's name or address, or changes to enrollment,
including if a Member is no longer eligible for coverage.
OPEN ENROLLMENT
"Open Enrollment" is a minimum 14 day period set by Employer and Medica each year during
which eligible Subscribers and his or her Dependents may enroll for coverage without
application of health screening or waiting periods.
SPECIAL ENROLLMENT
A. Special Enrollment Periods. The following "Special Enrollment Periods" are available in
addition to the Initial Enrollment Period and Open Enrollment Period.
A Special Enrollment period will apply to an eligible employee and Dependent if:
(1) the eligible employee or Dependent:
a. was covered under Qualifying Coverage at the time the eligible employee or
Dependent was first eligible to enroll under the Contract, and
b. declined coverage for that reason, and
c. presents to Medica either (i) evidence of the loss of prior coverage due to loss
of eligibility for that coverage, or (ii) evidence that employer contributions toward
the prior coverage have terminated, and
d. maintains Continuous Coverage, and
Page 14
e. requests enrollment in writing within 30 days of the date of the loss of coverage
or the date the employer's contribution toward that coverage terminates;
For purposes of this item:
a. prior coverage does not include continuation coverage required under federal law;
b. loss of eligibility includes loss of eligibility as a result of legal separation, divorce,
death, termination of employment, or reduction in the number of hours of
employment;
c. loss of eligibility does not include a loss due to failure of the eligible employee or
Dependent to pay Premiums on a timely basis or termination of coverage for
cause;
(2) the eligible employee or Dependent:
a. was covered under benefits available under (i) the Consolidated Omnibus
Budget Reconciliation Act of 1985 ("COBRA"), Public Law Number 99-272, as
amended, or (ii) any state continuation laws applicable to the employer or
Medica, and
b. declined coverage for that reason, and
c. the eligible employee or Dependent presents to Medica evidence that the
eligible employee or Dependent has exhausted such COBRA or state
continuation coverage and has not lost such coverage due to either failure of
the eligible employee or Dependent to pay Premiums on a timely basis or for
cause,and
d. maintains Continuous Coverage, and
e. requests enrollment in writing within 30 days of the loss of coverage;
(3) the Dependent is a new spouse of the Subscriber or eligible employee, provided that
the marriage is legal, enrollment is requested in writing within 30 days of the marriage,
and the eligible employee also enrolls during this Special Enrollment Period;
(4) the Dependent is a new Dependent child of the Subscriber or eligible employee,
provided that enrollment is requested in writing within 30 days of the Subscriber or
eligible employee acquiring the Dependent (the notification period is not limited to 30
days for newborn Dependents), and provided the eligible employee also enrolls during
this Special Enrollment Period;
. (5) the Dependent is the spouse of the Subscriber or eligible employee through whom the
Dependent child described in item #4 above claims Dependent status and;
a. that spouse is eligible for coverage; and
b. is not already enrolled under the Contract; and
c. enrollment is requested in writing within 30 days of the Dependent child
becoming a Dependent, provided the eligible employee also enrolls during this
Special Enrollment Period.
Page 15
(6) the Dependents are eligible Dependent children of the Subscriber or eligible employee
and enrollment is requested in writing within 30 days of a Dependent, as described in
items #3 or #4 above, becoming eligible to enroll under the coverage, provided the
eligible employee also enrolls during this Special Enrollment Period.
Additionally, when Employer provides Medica with notice of a qualified medical child support
order and a copy of the order, Medica will provide such eligible dependent child with a Special
Enrollment Period. Employer will provide Medica with such notice, along with an application for
coverage, within the lesser of 30 days or the time in which Employer provides notice of its
determination to the persons specified in the order.
B. Effective Dates of Coverage. Coverage shall become effective:
(1) in the case of paragraphs (A)(1) or (2) above, the day after the date the other
coverage ended;
(2) in the case of paragraph (A)(3) above, the date of the marriage;
(3) in the case of paragraph (A)(4) above, the date of birth, date of adoption, or date of
placement for adoption. In all other cases, the date the Subscriber acquires the
Dependent child.
(4) in the case of paragraph (A)(5) above, the date the Subscriber acquires the Dependent
Child; and
(5) in the case of (A)(6) above, the first day of the first calendar month beginning after the
date the completed request for enrollment is received by Medica.
(6) in the case of the qualified medical child support order, the first day of the first calendar
month beginning after the date the completed request for enrollment is received by
Medica.
Page 16
OFF-CYCLE ENROLLMENT -
NO OFF-CYCLE ENROLLMENT FOR LATE ENTRANTS WITHOUT CONTINUOUS
COVERAGE
An eligible Subscriber or an eligible Subscriber and his or her Dependents who do not enroll for
coverage offered through Employer during the Initial Enrollment Period, the Open Enrollment
Period or any applicable Special Enrollment Period will be considered Late Entrants.
(1) Late Entrants who have maintained Continuous Coverage may enroll and coverage will be
effective the first day of the month following date of approval by Medica. Continuous
Coverage will be determined to have been maintained if the Late Entrant requests
enrollment within 63 days after prior Qualifying Coverage ends.
(2) Late Entrants who have not maintained Continuous Coverage may not enroll off-cycle.
An eligible Subscriber or Dependent who:
(1) does not enroll during the Initial Enrollment Period, the Open Enrollment Period or any
applicable Special Enrollment period; and
(2) is an enrollee of the Minnesota Comprehensive Health Association ("MCHA") at the time
Medica offers or renews coverage with Employer, provided the eligible Subscriber or
Dependent maintains Continuous Coverage,
will not be considered a Late Entrant and will be allowed to enroll. Coverage will be effective as
determined by Medica.
Page 17
Medica Elect $300 Oed.
PLAN
MASTER GROUP CONTRACT
Employer Name:
Employer Group#:
Effective Date:
Contract#:
Amendments:
City of Columbia Heights
89947
January 01, 2005
ME300-15, BPL Number: 68238
Amendments attached as applicable per benefit package log (BPL)
as listed above.
ARTICLE 1
INTRODUCTION
This Master Group Contract ("Contract") is entered into by and between Medica, together with its
affiliate Medica Insurance Company ("MIC"), and the employer group named above ("Employer"),
an employer under Minnesota law and other applicable law. This Contract includes the Eligibility
Appendix, the Enrollment Appendix, the Certificate of Coverage ("Certificate") 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 Premiums by the Employer and payment of Copayments and
Coinsurance by or for Members, Medica will provide coverage for the Benefits set forth in the
Certificate 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.
The terms used in this Contract have the same meanings given those terms defined in the
Certificate, unless otherwise specifically defined in this Contract.
Page 1
ARTICLE 2
TERM OF CONTRACT
Section 2.1 Term and Renewal. This Contract is effective from January 01, 2005
("Effective Date") to December 31, 2005 ("Expiration Date"). All coverage under this Contract
begins at 12:01 a.m. Central Time.
At least 30 days before each Expiration Date, Medica shall notify Employer of any
modifications to this Contract, including Premiums and Benefits for the next 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 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 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) On the date specified by Medica due to Employer's violation of the participation or
contribution rules as determined by Medica;
(d) Automatically on the date Employer ceases to do business pursuant to 11 U.S.C.
Chapter 7;
(e) 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;
(f) On the date specified by Medica, after at least 180 days prior written notice to the
applicable state authority and Employer, that this Contract will be terminated because
Medica will no longer renew or issue any employer health benefit plan within the
applicable employer market;
(g) On the date specified by Medica when there is no longer any Member who resides or
works in Medica's approved service area;
(h) If this Contract is made available to Employer only through one or more bona fide
associations, on the date specified by Medica after Employer's membership in the
association ceases.
Page 2
(i) Any other reasons or grounds permitted by the licensing laws and regulations governing
Medica.
Notwithstanding the above, Medica may modify the Premium rate 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 or coverage shall not be
considered a failure of Medica to provide coverage on a guaranteed renewal basis.
Section 2.3 Notice of Termination.
Medica will notify:
(a) Employer in writing if Medica terminates this Contract for any reason;
(b) Subscribers in writing if Medica terminates this Contract pursuant to Section 2.2 (a), (d),
(e) or (t).
Employer will provide timely written notification to Subscribers in all circumstances for which
Medica does not provide written notification to Subscribers.
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; 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.
Page 3
ARTICLE 3
ENROLLMENT AND ELIGIBILITY
Section 3.1 Eligibility. The Eligibility Appendix to this Contract governs who is eligible to
enroll under this Contract. The eligibility conditions stated in the Eligibility Appendix are in
addition to those specified in the Certificate.
Section 3.2 Enrollment. The Enrollment Appendix to this Contract governs when eligible
employees and eligible dependents may enroll for Benefits under this Contract, including the
Initial Enrollment Period, Open Enrollment Period and any applicable Special Enrollment
Periods. Employer shall conduct the Initial Enrollment Period and Open Enrollment Period.
Employer shall cooperate with Medica in the event of a Special Enrollment Period.
Section 3.3. Qualified Medical Child Support Orders. Employer will establish, maintain and
enforce all written procedures for determining whether a child support order is a qualified
medical child support order as defined by ERISA. Employer will provide Medica with notice of
such determination and a copy of the order, along with an application for coverage, within the
greater of 30 days after issuance of the order or the time in which Employer provides notice of
its determination to the persons specified in the order.
When and if Employer receives notice that the child has designated a representative, or of the
existence of a legal guardian or custodial parent of the child, Employer shall promptly notify
Medica of such person(s).
Medica shall have no responsibility for:
(i) establishing, maintaining or enforcing the procedures described above;
(ii) determining whether a support order is qualified; or
(iii) providing required notices to the child or the designated representative.
Section 3.4. Eligibility and Enrollment Decisions. Subject to applicable law and the terms of
this Contract, Employer has sole discretion to determine whether employees and their
dependents are eligible to enroll for Benefits. Medica shall rely upon Employer's determination
regarding an employee's and/or dependent's eligibility to enroll for Benefits. The Employer will
be responsible for maintaining information verifying its continuing eligibility and the continuing
eligibility of its eligible Subscribers and eligible Dependents. This information shall be provided
to Medica as reasonably requested by Medica. The Employer shall also maintain written
documentation of a waiver of coverage by an eligible Subscriber or eligible Dependent and
provide this documentation to Medica upon reasonable request.o
-Page 4
ARTICLE 4
PREMIUMS
Section 4.1 Monthly Premiums.
The monthly Premiums for this Contract are:
Monthly Premium Rate
Monthly Employer
Contribution
Monthly Enrollee
Contribution
Class 1
(Single)
Class 4
(Family)
$343.06
Employer shall contribute a minimum of 50%
towards the single monthly premium rate.
$787.84
The Premiums are due on the first day of each calendar month. Employer shall pay the Premiums to
Medica at the billing address stated in the Acceptance of Contract.
Employer shall notify Medica in writing:
(a) each month of any changes in the coverage classification of any Subscriber; and
(b) within 30 days after the effective date of enrollments, terminations or other changes regarding
Members.
Section 4.2 Grace Period and Reinstatement. Employer has a grace period of 10 days after
the due date stated in Section 4.1 to pay the monthly Premiums. If Employer fails to pay Premium,
the Contract will be terminated in accordance with Section 2.2(a). This Contract will be reinstated if
Employer pays all of the Premiums owed on or before the end of the grace period. In this event the
Contract is not reinstated pursuant to this Section, Medica will not be responsible for any Claims for
health services received by Members after the effective date of the termination.
Section 4.3 Premium Calculation. The monthly Premiums owed by Employer shall be
calculated by Medica using the number of Subscribers in each coverage classification
according to Medica's records at the time of the calculation. Employer may make adjustments
to its payment of Premiums for any additions or terminations of Members submitted by
Employer but not yet reflected in Medica's calculations.
A full calendar month's Premiums shall be charged for Members whose effective date falls on
or before the 15th day of that calendar month. No Premium shall be charged for Members
Page 5
whose effective date falls after the 15th of that calendar month. With the exception of
termination of coverage due to a Member's death, a Member's Benefits may be terminated only
aUhe end of a calendar month and a full Premium rate for that month will apply. In the case of
a Member's death, that Member's Benefits will be terminated on the date of the death.
Section 4.4 Retroactive Adjustments. In accordance with applicable law, retroactive
adjustments may be made for any additions, or terminations of Members or changes in
coverage classifications not reflected in Medica's records at the time the monthly Premiums
were calculated by Medica. However, no retroactive credit will be granted for any month in
which a Member received Benefits. No retroactive adjustments to enrollment or Premium
refund shall be granted for any change occurring more than 60 days prior to the date Medica
received notification of the change from Employer.
Regardless of the preceding, Employer shall pay a Premium for any month during which a
Member received Benefits.
Section 4.5 Premium Changes. Medica may change the 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 4.6 Employer Fees. Medica may charge Employer:
(a) a late payment charge in the form of a finance charge of 12% per annum for any
Premiums not received by the due date; and
(b) a service charge for any non-sufficient-fund check received in payment of the Premiums.
ARTICLE 5
INDEMNIFICATION
Medica will hold harmless and indemnify Employer against any and all claims, liabilities,
damages or judgments asserted against, imposed upon or incurred by Employer, including
reasonable attorney fees and costs, that arise out of Medica's grossly negligent acts or
omissions in the discharge of its responsibilities to a Member.
Employer will hold harmless and indemnify Medica against any and all claims, liabilities,
damages or judgments asserted against, imposed upon or incurred by Medica, including
reasonable attorney fees and costs, that arise out of Employer's or Employer's employees',
agents', and representatives' grossly negligent acts or omissions in the discharge of its or their
responsibilities under this Contract.
Employer and Medica shall promptly notify the other of any potential or actual claim for which
the other party may be responsible under this Article 5.
Page 6
ARTICLE 6
ADMINISTRATIVE SERVICES
The services necessary to administer this Contract and the Benefits provided under it will be
provided in accordance with Medica's or its designee's standard administrative procedures. If
Employer requests such administrative services be provided in a manner other than in
accordance with these standard procedures, including requests for non-standard reports, and if
Medica agrees to provide such non-standard administrative services, Employer shall pay for
such services or reports at Medica's or its designee's then-current charges for such services or
reports.
ARTICLE 7
CLERICAL ERROR
A Member will not be deprived of coverage under the Contract because of a clerical error.
Furthermore, a Member will not be eligible for coverage beyond the scheduled termination date
because of a failure to record the termination.
ARTICLE 8
ERISA
When this Contract is entered into by Employer to provide benefits under an employee welfare
benefit plan governed by ERISA, Medica shall not be named as and shall not be the plan
administrator or the named fiduciary of the employee welfare benefit plan, as those terms are
used in ERISA.
The parties agree that Medica has sole, final, and exclusive discretion to:
(a) interpret and construe the Benefits under the Contract;
(b) interpret and construe the other terms, conditions, limitations and exclusions set out in the
Contract;
(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.
Page 7
ARTICLE 10
CONTINUATION OF COVERAGE
Medica shall provide Benefits under this Contract to those Members who are eligible to
continue coverage under federal or state law.
Medica will not provide any administrative duties with respect to Employer's compliance with
federal or state continuation of coverage laws. All duties of the Employer, including, but not
limited to, notifying Members regarding federal and state law continuation rights and Premium
billing and collection, remain Employer's sole responsibility.
ARTICLE 11
CERTIFICATION OF QUALIFYING COVERAGE FORMS
As required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA),
Medica will produce Certification of Qualifying Coverage forms for Members whose coverage
under this Contract terminates. The Certification of Qualifying Coverage forms will be based
on the eligibility and termination data Employer provides to Medica. Employer shall provide all
necessary eligibility and termination data to Medica in accordance with Medica's data
specifications. The Certification of Qualifying Coverage forms will only include periods of
coverage Medica administers under this Contract.
ARTICLE 12
AMENDMENTS AND ALTERATIONS
Section 12.1 Standard Amendments: Except as provided in Section 12.2, 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 12.2 Regulatory Amendment: Medica may amend this Contract to comply with
requirements of state 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 13
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 the inure
to the benefit of each party's successors and assigns.
Page 8
ARTICLE 14
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 14.
ARTICLE 15
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.
Page 9
ARTICLE 16
RELATIONSHIP BETWEEN PARTIES
The relationship between Employer and any Member is that of Employer and Subscriber,
Dependent or other coverage classification as defined in this Contract.
The relationship between Medica and Network Providers and the relationship between Medica
and Employer are solely contractual relationships between independent contractors. Network
Providers and Employer are not agents or employees of Medica. Medica and its employees
are not agents or employees of Network Providers or Employer.
The relationship between a Network Provider and any Member is that of provider and patient
and Network Provider is solely responsible for the services provided to any Member.
ARTICLE 17
EMPLOYER RECORDS
Employer shall furnish Medica with all information and proofs that Medica may reasonably
require with regard to any matters pertaining to this Contract. Employer will be responsible
for obtaining any necessary consent from Members which allows Medica to receive a
Member's protected health information (as defined in the federal privacy regulations
promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996
(HIPAA)). 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.
ARTICLE 18
MEMBER RECORDS
By accepting Benefits under this Contract, each Member, including Dependents, whether or
not such Dependents have signed the Subscriber's application, 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 it designees.
ARTICLE 19
NOTICE
Except as provided in Article 2, 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
Page 10
(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 20
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 terms and provisions
herein binding on Medica and the Employer.
IN WITNESS WHEREOF, MIC has caused this Contract to be executed on this February 7, 2005
to take effect on the Effective Date stated in the Contract.
EMPLOYER:
MEDICA
401 Carlson Parkway
Minnetonka, Minnesota 55305
(952)992-2200
City of Columbia Heights
Address:
Billing Address:
MN015-2838
P.O. Box 169063
Duluth, MN 55816
590 40th Ave NE
Columbia Heights, MN 55421
Telephone: (763) 706-3609
Mailing Address:
P.O. Box 9310
Minneapolis, MN 55440
Contract
Signer:
~~
--~~~/~
Title:
C '/ +y m,O h'" 1er-
d-(ltfI05
Group Contact: Linda Magee
Date:
By:
Tom L. Henke
Title: Vice President, Commercial Sales and
Account Services
Page 11
ELIGIBILITY APPENDIX
Employer Name:
City of Columbia Heights
Employer Group#:
89947
Section 1 Eligibility to Enroll. A Subscriber, and his or her Dependents, as defined below,
who satisfies the eligibility conditions stated in this Contract are eligible to enroll for coverage
under this Contract. Any person who does not satisfy the definition of Subscriber or Dependent
is not eligible for coverage under this Contract.
A Subscriber and his or her Dependents must meet the eligibility requirements described below
and in the entire Contract. In no event may the number of Members residing outside the
Service Area exceed 10 percent of the total number of Members.
If there is a conflict between the Certificate and this Eligibility Appendix, this Eligibility Appendix
governs.
Section 2 Subscriber Definition.
The term "Subscriber" as used in the Contract will include the types of employees and
conditions identified below:
Classifications
Applicable Waiting Periods
and Effective Dates
1. See comments
New Hires: Date of hire
Return: Date of return
Status Change: Date of change
A Subscriber who is a child entitled to receive coverage through a qualified medical child support
order is not subject to any waiting periods, except to the extent that such waiting periods apply to
the employee who is ordered by the qualified medical support order to provide coverage.
Section 3 Dependent Definition. The term "Dependent" as used in this Contract includes the
following:
1. The Subscriber's spouse
2. The following Dependent children:
(a) Subscriber's unmarried natural or adopted child;
(b) an unmarried child Placed For Adoption with the Subscriber;
(c) a child for whom the Subscriber or the Subscriber's spouse has been appointed legal
guardian, however, upon request by Medica, the Subscriber must provide satisfactory
proof of dependency;
Page 12
(d) Subscriber's or Subscriber's spouse's unmarried grandchild who, from the date of
birth resides with and is dependent upon the Subscriber or Subscriber's spouse for
support and
(e) Subscriber's stepchild.
A Dependent child must be under 19 years of age if s/he is not a student and must be under 25
years of age if s/he is a student. A Dependent child is eligible as a student if s/he is enrolled full-
time in a recognized high school, college, university, trade or vocational school. If the student is
unable to a carry a full-time course load due to illness, injury, or a physical or mental disability, as
documented by a Physician, full-time student status will be granted if the student carries at least
60% of a full-time course load, as determined by the educational institution.
3. The Subscriber's handicapped Dependent. The handicapped Dependent must be:
(a) incapable of self-sustaining employment by reason of mental retardation, mental
illness, mental disorder or physical handicap; and
(b) chiefly dependent upon the Subscriber for support and maintenance.
The handicapped Dependent shall be eligible for coverage as long as he or she continues to
be handicapped and satisfies the requirements of (a) and (b) above, unless coverage
otherwise terminates under this Contract. Medica may require annual proof of handicap and
dependency. An illness will not be considered a physical handicap.
A child who is the subject of a qualified medical child support order is not a Dependent as
defined above and may not enroll Dependents for coverage. See Section 2.
Any person who does not satisfy the terms listed above will not be eligible for coverage under
the Contract.
Page 13
ENROLLMENT APPENDIX
Employer Name:
Employer Group#:
City of Columbia Heights
89947
INITIAL ENROLLMENT
"Initial Enrollment Period" is a 30 day time period starting with the date an eligible Subscriber
and his or her eligible Dependents are first eligible to enroll for coverage under this Contract.
An eligible Subscriber must apply within this period for coverage to begin the date he or she
was first eligible to enroll. (The 30 day time period does not apply to newborn Dependents; see
Special Enrollment, (item 4).) An eligible Subscriber who enrolls during the Initial Enrollment
Period is accepted without application of health screening or affiliation periods. An eligible
Subscriber and his/her Dependents who do not enroll during the Initial Enrollment Period may
enroll for coverage during the next Open Enrollment, any applicable Special Enrollment
Periods as described below.
A Subscriber who is a child entitled to receive coverage through a qualified medical child
support order is not subject to any Initial Enrollment Period restrictions, except as noted in the
Eligibility Appendix.
NOTIFICATION
Subscribers must notify Employer within 30 days of the effective date of any change of address
or name, addition or deletion of Dependents, or other facts identifying the Subscriber or the
Subscriber's Dependents.
The Employer must notify Medica within 30 days of the effective date of the Member's initial
enrollment application, changes to the Member's name or address, or changes to enrollment,
including if a Member is no longer eligible for coverage.
OPEN ENROLLMENT
"Open Enrollment" is a minimum 14 day period set by Employer and Medica each year during
which eligible Subscribers and his or her Dependents may enroll for coverage without
application of health screening or waiting periods.
SPECIAL ENROLLMENT
A. Special Enrollment Periods. The following "Special Enrollment Periods" are available in
addition to the Initial Enrollment Period and Open Enrollment Period.
A Special Enrollment period will apply to an eligible employee and Dependent if:
(1) the eligible employee or Dependent:
a. was covered under Qualifying Coverage at the time the eligible employee or
Dependent was first eligible to enroll under the Contract, and
b. declined coverage for that reason, and
c. presents to Medica either (i) evidence of the loss of prior coverage due to loss
of eligibility for that coverage, or (ii) evidence that employer contributions toward
the prior coverage have terminated, and
d. maintains Continuous Coverage, and
Page 14
e. requests enrollment in writing within 30 days of the date of the loss of coverage
or the date the employer's contribution toward that coverage terminates;
For purposes of this item:
a. prior coverage does not include continuation coverage required under federal law;
b. loss of eligibility includes loss of eligibility as a result of legal separation, divorce,
death, termination of employment, or reduction in the number of hours of
employment;
c. loss of eligibility does not include a loss due to failure of the eligible employee or
Dependent to pay Premiums on a timely basis or termination of coverage for
cause;
(2) the eligible employee or Dependent:
a. 'was covered under benefits available under (i) the Consolidated Omnibus
Budget Reconciliation Act of 1985 ("COBRA"), Public Law Number 99-272, as
amended, or (ii) any state continuation laws applicable to the employer or
Medica, and
b. declined coverage for that reason, and
c. the eligible employee or Dependent presents to Medica evidence that the
eligible employee or Dependent has exhausted such COBRA or state
continuation coverage and has not lost such coverage due to either failure of
the eligible employee or Dependent to pay Premiums on a timely basis or for
cause,and
d. maintains Continuous Coverage, and
e. requests enrollment in writing within 30 days of the loss of coverage;
(4 )
the Dependent is a new spouse of the Subscriber or eligible employee, provided that
the marriage is legal, enrollment is requested in writing within 30 days of the marriage,
and the eligible employee also enrolls during this Special Enrollment Period;
the Dependent is a new Dependent child of the Subscriber or eligible employee,
provided that enrollment is requested in writing within 30 days of the Subscriber or
eligible employee acquiring the Dependent (the notification period is not limited to 30
days for newborn Dependents), and provided the eligible employee also enrolls during
this Special Enrollment Period;
(3)
(5)
the Dependent is the spouse of the Subscriber or eligible employee through whom the
Dependent child described in item #4 above claims Dependent status and;
a. that spouse is eligible for coverage; and
b. is not already enrolled under the Contract; and
c. enrollment is requested in writing within 30 days of the Dependent child
becoming a Dependent, provided the eligible employee also enrolls during this
Special Enrollment Period.
Page 15
(6) the Dependents are eligible Dependent children of the Subscriber or eligible employee
and enrollment is requested in writing within 30 days of a Dependent, as described in
items #3 or #4 above, becoming eligible to enroll under the coverage, provided the
eligible employee also enrolls during this Special Enrollment Period.
Additionally, when Employer provides Medica with notice of a qualified medical child support
order and a copy of the order, Medica will provide such eligible dependent child with a Special
Enrollment Period. Employer will provide Medica with such notice, along with an application for
coverage, within the lesser of 30 days or the time in which Employer provides notice of its
determination to the persons specified in the order.
B. Effective Dates of Coverage. Coverage shall become effective:
(1) in the case of paragraphs (A)(1) or (2) above, the day after the date the other
coverage ended;
(2) in the case of paragraph (A)(3) above, the date of the marriage;
(3) in the case of paragraph (A)(4) above, the date of birth, date of adoption, or date of
placement for adoption. In all other cases, the date the Subscriber acquires the
Dependent child.
(4) in the case of paragraph (A)(5) above, the date the Subscriber acquires the Dependent
Child; and
(5) in the case of (A)(6) above, the first day of the first calendar month beginning after the
date the completed request for enrollment is received by Medica.
(6) in the case of the qualified medical child support order, the first day of the first calendar
month beginning after the date the completed request for enrollment is received by
Medica.
Page 16
OFF-CYCLE ENROLLMENT-
NO OFF-CYCLE ENROLLMENT FOR LATE ENTRANTS WITHOUT CONTINUOUS
COVERAGE
An eligible Subscriber or an eligible Subscriber and his or her Dependents who do not enroll for
coverage offered through Employer during the Initial Enrollment Period, the Open Enrollment
Period or any applicable Special Enrollment Period will be considered Late Entrants.
(1) Late Entrants who have maintained Continuous Coverage may enroll and coverage will be
effective the first day of the month following date of approval by Medica. Continuous
Coverage will be determined to have been maintained if the Late Entrant requests
enrollment within 63 days after prior Qualifying Coverage ends.
(2) Late Entrants who have not maintained Continuous Coverage may not enroll off-cycle.
An eligible Subscriber or Dependent who:
(1) does not enroll during the Initial Enrollment Period, the Open Enrollment Period or any
applicable Special Enrollment period; and
(2) is an enrollee of the Minnesota Comprehensive Health Association ("MCHA") at the time
Medica offers or renews coverage with Employer, provided the eligible Subscriber or
Dependent maintains Continuous Coverage,
will not be considered a Late Entrant and will be allowed to enroll. Coverage will be effective as
determined by Medica.
Page 17
Medica Choice Select $300 Ded
PLAN
MASTER GROUP CONTRACT
Employer Name:
Employer Group#:
Effective Date:
Contract#:
Amendments:
City of Columbia Heights
89946
January 01, 2005
MCS300-15, BPL Number: 68235
Amendments attached as applicable per benefit package log (BPL)
as listed above.
ARTICLE 1
INTRODUCTION
This Master Group Contract ("Contract") is entered into by and between Medica, together with its
affiliate Medica Insurance Company ("MIC"), and the employer group named above ("Employer"),
an employer under Minnesota law and other applicable law. This Contract includes the Eligibility
Appendix, the Enrollment Appendix, the Certificate of Coverage ("Certificate") 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 Premiums by the Employer and payment of Copayments and
Coinsurance by or for Members, Medica will provide coverage for the Benefits set forth in the
Certificate 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.
The terms used in this Contract have the same meanings given those terms defined in the
Certificate, unless otherwise specifically defined in this Contract.
Page 1
ARTICLE 2
TERM OF CONTRACT
Section 2.1 Term and Renewal. This Contract is effective from January 01, 2005
("Effective Date") to December 31 , 2005 ("Expiration Date"). All coverage under this Contract
begins at 12:01 a.m. Central Time.
At least 30 days before each Expiration Date, Medica shall notify Employer of any
modifications to this Contract, including Premiums and Benefits for the next 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 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 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) On the date specified by Medica due to Employer's violation of the participation or
contribution rules as determined by Medica;
(d) Automatically on the date Employer ceases to do business pursuant to 11 U.S.C.
Chapter 7;
(e) 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;
(f) On the date specified by Medica, after at least 180 days prior written notice to the
applicable state authority and Employer, that this Contract will be terminated because
Medica will no longer renew or issue any employer health benefit plan within the
applicable employer market;
(g) On the date specified by Medica when there is no longer any Member who resides or
works in Medica's approved service area;
(h) If this Contract is made available to Employer only through one or more bona fide
associations, on the date specified by Medica after Employer's membership in the
association ceases.
Page 2
(i) Any other reasons or grounds permitted by the licensing laws and regulations governing
Medica.
Notwithstanding the above, Medica may modify the Premium rate 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 or coverage shall not be
considered a failure of Medica to provide coverage on a guaranteed renewal basis.
Section 2.3 Notice of Termination.
Medica will notify:
(a) Employer in writing if Medica terminates this Contract for any reason;
(b) Subscribers in writing if Medica terminates this Contract pursuant to Section 2.2 (a), (d),
(e) or (t).
Employer will provide timely written notification to Subscribers in all circumstances for which
Medica does not provide written notification to Subscribers.
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; 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.
Page 3
ARTICLE 3
ENROLLMENT AND ELIGIBILITY
Section 3.1 Eligibility. The Eligibility Appendix to this Contract governs who is eligible to
enroll under this Contract. The eligibility conditions stated in the Eligibility Appendix are in
addition to those specified in the Certificate.
Section 3.2 Enrollment. The Enrollment Appendix to this Contract governs when eligible
employees and eligible dependents may enroll for Benefits under this Contract, including the
Initial Enrollment Period, Open Enrollment Period and any applicable Special Enrollment
Periods. Employer shall conduct the Initial Enrollment Period and Open Enrollment Period.
Employer shall cooperate with Medica in the event of a Special Enrollment Period.
Section 3.3. Qualified Medical Child Support Orders. Employer will establish, maintain and
enforce all written procedures for determining whether a child support order is a qualified
medical child support order as defined by ERISA. Employer will provide Medica with notice of
such determination and a copy of the order, along with an application for coverage, within the
greater of 30 days after issuance of the order or the time in which Employer provides notice of
its determination to the persons specified in the order.
When and if Employer receives notice that the child has designated a representative, or of the
existence of a legal guardian or custodial parent of the child, Employer shall promptly notify
Medica of such person(s).
Medica shall have no responsibility for:
(i) establishing, maintaining or enforcing the procedures described above;
(ii) determining whether a support order is qualified; or
(iii) providing required notices to the child or the designated representative.
Section 3.4. Eligibility and Enrollment Decisions. Subject to applicable law and the terms of
this Contract, Employer has sole discretion to determine whether employees and their
dependents are eligible to enroll for Benefits. Medica shall rely upon Employer's determination
regarding an employee's and/or dependent's eligibility to enroll for Benefits. The Employer will
be responsible for maintaining information verifying its continuing eligibility and the continuing
eligibility of its eligible Subscribers and eligible Dependents. This information shall be provided
to Medica as reasonably requested by Medica. The Employer shall also maintain written
documentation of a waiver of coverage by an eligible Subscriber or eligible Dependent and
provide this documentation to Medica upon reasonable request.
Page 4
ARTICLE 4
PREMIUMS
Section 4.1 Monthly Premiums.
The monthly Premiums for this Contract are:
Monthly Premium Rate
Monthly Employer
Contribution
Monthly Enrollee
Contribution
Class 1
(Single)
Class 4
(Family)
$381.16
Employer shall contribute a minimum of 50%
towards the single monthly premium rate.
$875.36
The Premiums are due on the first day of each calendar month. Employer shall pay the Premiums to
Medica at the billing address stated in the Acceptance of Contract.
Employer shall notify Medica in writing:
(a) each month of any changes in the coverage classification of any Subscriber; and
(b) within 30 days after the effective date of enrollments, terminations or other changes regarding
Members.
Section 4.2 Grace Period and Reinstatement. Employer has a grace period of 10 days after
the due date stated in Section 4.1 to pay the monthly Premiums. If Employer fails to pay Premium,
the Contract will be terminated in accordance with Section 2.2(a). This Contract will be reinstated if
Employer pays all of the Premiums owed on or before the end of the grace period. In this event the
Contract is not reinstated pursuant to this Section, Medica will not be responsible for any Claims for
health services received by Members after the effective date of the termination.
Section 4.3 Premium Calculation. The monthly Premiums owed by Employer shall be
calculated by Medica using the number of Subscribers in each coverage classification
according to Medica's records at the time of the calculation. Employer may make adjustments
to its payment of Premiums for any additions or terminations of Members submitted by
Employer but not yet reflected in Medica's calculations.
A full calendar month's Premiums shall be charged for Members whose effective date falls on
or before the 15th day of that calendar month. No Premium shall be charged for Members
Page 5
whose effective date falls after the 15th of that calendar month. With the exception of
termination of coverage due to a Member's death, a Member's Benefits may be terminated only
at the end of a calendar month and a full Premium rate for that month will apply. In the case of
a Member's death, that Member's Benefits will be terminated on the date of the death.
Section 4.4 Retroactive Adjustments. In accordance with applicable law, retroactive
adjustments may be made for any additions, or terminations of Members or changes in
coverage classifications not reflected in Medica's records at the time the monthly Premiums
were calculated by Medica. However, no retroactive credit will be granted for any month in
which a Member received Benefits. No retroactive adjustments to enrollment or Premium
refund shall be granted for any change occurring more than 60 days prior to the date Medica
received notification of the change from Employer.
Regardless of the preceding, Employer shall pay a Premium for any month during which a
Member received Benefits.
Section 4.5 Premium Changes. Medica may change the 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 4.6 Employer Fees. Medica may charge Employer:
(a) a late payment charge in the form of a finance charge of 12% per annum for any
Premiums not received by the due date; and
(b) a service charge for any non-sufficient-fund check received in payment of the Premiums.
ARTICLE 5
INDEMNIFICATION
Medica will hold harmless and indemnify Employer against any and all claims, liabilities,
damages or judgments asserted against, imposed upon or incurred by Employer, including
reasonable attorney fees and costs, that arise out of Medica's grossly negligent acts or
omissions in the discharge of its responsibilities to a Member.
Employer will hold harmless and indemnify Medica against any and all claims, liabilities,
damages or judgments asserted against, imposed upon or incurred by Medica, including
reasonable attorney fees and costs, that arise out of Employer's or Employer's employees',
agents', and representatives' grossly negligent acts or omissions in the discharge of its or their
responsibilities under this Contract.
Employer and Medica shall promptly notify the other of any potential or actual claim for which
the other party may be responsible under this Article 5.
Page 6
ARTICLE 6
ADMINISTRATIVE SERVICES
The services necessary to administer this Contract and the Benefits provided under it will be
provided in accordance with Medica's or its designee's standard administrative procedures. If
Employer requests such administrative services be provided in a manner other than in
accordance with these standard procedures, including requests for non-standard reports, and if
Medica agrees to provide such non-standard administrative services, Employer shall pay for
such services or reports at Medica's or its designee's then-current charges for such services or
reports.
ARTICLE 7
CLERICAL ERROR
A Member will not be deprived of coverage under the Contract because of a clerical error.
Furthermore, a Member will not be eligible for coverage beyond the scheduled termination date
because of a failure to record the termination.
ARTICLE 8
ERISA
When this Contract is entered into by Employer to provide benefits under an employee welfare
benefit plan governed by ERISA, Medica shall not be named as and shall not be the plan
administrator or the named fiduciary of the employee welfare benefit plan, as those terms are
used in ERISA.
The parties agree that Medica has sole, final, and exclusive discretion to:
(a) interpret and construe the Benefits under the Contract;
(b) interpret and construe the other terms, conditions, limitations and exclusions set out in the
Contract;
(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.
Page 7
ARTICLE 10
CONTINUATION OF COVERAGE
Medica shall provide Benefits under this Contract to those Members who are eligible to
continue coverage under federal or state law.
Medica will not provide any administrative duties with respect to Employer's compliance with
federal or state continuation of coverage laws. All duties of the Employer, including, but not
limited to, notifying Members regarding federal and state law continuation rights and Premium
billing and collection, remain Employer's sole responsibility.
ARTICLE 11
CERTIFICATION OF QUALIFYING COVERAGE FORMS
As required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA),
Medica will produce Certification of Qualifying Coverage forms for Members whose coverage
under this Contract terminates. The Certification of Qualifying Coverage forms will be based
on the eligibility and termination data Employer provides to Medica. Employer shall provide all
necessary eligibility and termination data to Medica in accordance with Medica's data
specifications. The Certification of Qualifying Coverage forms will only include periods of
coverage Medica administers under this Contract.
ARTICLE 12
AMENDMENTS AND ALTERATIONS
Section 12.1 Standard Amendments: Except as provided in Section 12.2, 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 12.2 Regulatory Amendment: Medica may amend this Contract to comply with
requirements of state 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 13
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 the inure
to the benefit of each party's successors and assigns.
Page 8
ARTICLE 14
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 I 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 ("MA"). 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 14.
ARTICLE 15
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.
Page 9
ARTICLE 16
RELATIONSHIP BETWEEN PARTIES
The relationship between Employer and any Member is that of Employer and Subscriber,
Dependent or other coverage classification as defined in this Contract.
The relationship between Medica and Network Providers and the relationship between Medica
and Employer are solely contractual relationships between independent contractors. Network
Providers and Employer are not agents or employees of Medica. Medica and its employees
are not agents or employees of Network Providers or Employer.
The relationship between a Network Provider and any Member is that of provider and patient
and Network Provider is solely responsible for the services provided to any Member.
ARTICLE 17
EMPLOYER RECORDS
Employer shall furnish Medica with all information and proofs that Medica may reasonably
require with regard to any matters pertaining to this Contract. Employer will be responsible
for obtaining any necessary consent from Members which allows Medica to receive a
Member's protected health information (as defined in the federal privacy regulations
promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996
(HIPAA)). 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.
ARTICLE 18
MEMBER RECORDS
By accepting Benefits under this Contract, each Member, including Dependents, whether or
not such Dependents have signed the Subscriber's application, 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 it designees.
ARTICLE 19
NOTICE
Except as provided in Article 2, 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
Page 10
(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 20
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 terms and provisions
herein binding on Medica and the Employer.
IN WITNESS WHEREOF, MIC has caused this Contract to be executed on this February 7, 2005
to take effect on the Effective Date stated in the Contract.
MEDICA
EMPLOYER:
401 Carlson Parkway
Minnetonka, Minnesota 55305
(952)992-2200
City of Columbia Heights
Address:
Billing Address:
MN015-2838
P.O. Box 169063
Duluth, MN 55.816
590 40th Avenue NE
Columbia Heights, MN 55421
Telephone: (763) 706-3609
Mailing Address:
P.O. Box 9310
Minneapolis, MN 55440
~~~t:~~t ;;$/4:;
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Date:
CI+'I ~a "'-/1 3'e.-
d-/J~ Or::;?
,
Linda Magee
Title:
By:
Tom L. Henke
Group Contact:
Title: Vice President, Commercial Sales and
Account Services
Page 11
ELIGIBILITY APPENDIX
Employer Name:
City of Columbia Heights
Employer Group#:
89946
Section 1 Eligibility to Enroll. A Subscriber, and his or her Dependents, as defined below,
who satisfies the eligibility conditions stated in this Contract are eligible to enroll for coverage
under this Contract. Any person who does not satisfy the definition of Subscriber or Dependent
is not eligible for coverage under this Contract.
A Subscriber and his or her Dependents must meet the eligibility requirements described below
and in the entire Contract. In no event may the number of Members residing outside the
Service Area exceed 10 percent of the total number of Members.
If there is a conflict between the Certificate and this Eligibility Appendix, this Eligibility Appendix
governs.
Section 2 Subscriber Definition.
The term "Subscriber" as used in the Contract will include the types of employees and
conditions identified below:
Classifications
Applicable Waiting Periods
and Effective Dates
1. See comments
New Hires: Date of Hire
Return: Date of return
Status Change: Date of change
A Subscriber who is a child entitled to receive coverage through a qualified medical child support
order is not subject to any waiting periods, except to the extent that such waiting periods apply to
the employee who is ordered by the qualified medical support order to provide coverage.
Section 3 Dependent Definition. The term "Dependent" as used in this Contract includes the
following:
1. The Subscriber's spouse
2. The following Dependent children:
(a) Subscriber's unmarried natural or adopted child;
(b) an unmarried child Placed For Adoption with the Subscriber;
(c) a child for whom the Subscriber or the Subscriber's spouse has been appointed legal
guardian, however, upon request by Medica, the Subscriber must provide satisfactory
proof of dependency;
Page 12
(d) Subscriber's or Subscriber's spouse's unmarried grandchild who, from the date of
birth resides with and is dependent upon the Subscriber or Subscriber's spouse for
support and
(e) Subscriber's stepchild.
A Dependent child must be under 19 years of age if s/he is not a student and must be under 25
years of age if s/he is a student. A Dependent child is eligible as a student if s/he is enrolled full-
time in a recognized high school, college, university, trade or vocational school. If the student is
unable to a carry a full-time course load due to illness, injury, or a physical or mental disability, as
documented by a Physician, full-time student status will be granted if the student carries at least
60% of a full-time course load, as determined by the educational institution.
3. The Subscriber's handicapped Dependent. The handicapped Dependent must be:
(a) incapable of self-sustaining employment by reason of mental retardation, mental
illness, mental disorder or physical handicap; and
(b) chiefly dependent upon the Subscriber for support and maintenance.
The handicapped Dependent shall be eligible for coverage as long as he or she continues to
be handicapped and satisfies the requirements of (a) and (b) above, unless coverage
otherwise terminates under this Contract. Medica may require annual proof of handicap and
dependency. An illness will not be considered a physical handicap.
A child who is the subject of a qualified medical child support order is not a Dependent as
defined above and may not enroll Dependents for coverage. See Section 2.
Any person who does not satisfy the terms listed above will not be eligible for coverage under
the Contract.
Page 13
ENROLLMENT APPENDIX
Employer Name:
Employer Group#:
City of Columbia Heights
89946
INITIAL ENROLLMENT
"Initial Enrollment Period" is a 30 day time period starting with the date an eligible Subscriber
and his or her eligible Dependents are first eligible to enroll for coverage under this Contract.
An eligible Subscriber must apply within this period for coverage to begin the date he or she
was first eligible to enroll. (The 30 day time period does not apply to newborn Dependents; see
Special Enrollment, (item 4).) An eligible Subscriber who enrolls during the Initial Enrollment
Period is accepted without application of health screening or affiliation periods. An eligible
Subscriber and his/her Dependents who do not enroll during the Initial Enrollment Period may
enroll for coverage during the next Open Enrollment, any applicable Special Enrollment
Periods as described below.
A Subscriber who is a child entitled to receive coverage through a qualified medical child.
support order is not subject to any Initial Enrollment Period restrictions, except as noted in the
Eligibility Appendix.
NOTIFICATION
Subscribers must notify Employer within 30 days of the effective date of any change of address
or name, addition or deletion of Dependents, or other facts identifying the Subscriber or the
Subscriber's Dependents.
The Employer must notify Medica within 30 days of the effective date of the Member's initial
enrollment application, changes to the Member's name or address, or changes to enrollment,
including if a Member is no longer eligible for coverage.
OPEN ENROLLMENT
"Open Enrollment" is a minimum 14 day period set by Employer and Medica each year during
which eligible Subscribers and his or her Dependents may enroll for coverage without
application of health screening or waiting periods.
SPECIAL ENROLLMENT
A. Special Enrollment Periods. The following "Special Enrollment Periods" are available in
addition to the Initial Enrollment Period and Open Enrollment Period.
A Special Enrollment period will apply to an eligible employee and Dependent if:
(1) the eligible employee or Dependent:
a. was covered under Qualifying Coverage at the time the eligible employee or
Dependent was first eligible to enroll under the Contract, and
b. declined coverage for that reason, and
c. presents to Medica either (i) evidence of the loss of prior coverage due to loss
of eligibility for that coverage, or (ii) evidence that employer contributions toward
the prior coverage have terminated, and
d. maintains Continuous Coverage, and
Page 14
e. requests enrollment in writing within 30 days of the date of the loss of coverage
or the date the employer's contribution toward that coverage terminates;
For purposes of this item:
a. prior coverage does not include continuation coverage required under federal law;
b. loss of eligibility includes loss of eligibility as a result of legal separation, divorce,
death, termination of employment, or reduction in the number of hours of
employment;
c. loss of eligibility does not include a loss due to failure of the eligible employee or
Dependent to pay Premiums on a timely basis or termination of coverage for
cause;
(2) the eligible employee or Dependent:
a. was covered under benefits available under (i) the Consolidated Omnibus
Budget Reconciliation Act of 1985 ("COBRA"), Public Law Number 99-272, as
amended, or (ii) any state continuation laws applicable to the employer or
Medica, and
b. declined coverage for that reason, and
c. the eligible employee or Dependent presents to Medica evidence that the
eligible employee or Dependent has exhausted such COBRA or state
continuation coverage and has not lost such coverage due to either failure of
the eligible employee or Dependent to pay Premiums on a timely basis or for
cause,and
d. maintains Continuous Coverage, and
e. requests enrollment in writing within 30 days of the loss of coverage;
(3) the Dependent is a new spouse of the Subscriber or eligible employee, provided that
the marriage is legal, enrollment is requested in writing within 30 days of the marriage,
and the eligible employee also enrolls during this Special Enrollment Period;
(4) the Dependent is a new Dependent child of the Subscriber or eligible employee,
provided that enrollment is requested in writing within 30 days of the Subscriber or
eligible employee acquiring the Dependent (the notification period is not limited to 30
days for newborn Dependents), and provided the eligible employee also enrolls during
this Special Enrollment Period;
(5) the Dependent is the spouse of the Subscriber or eligible employee through whom the
Dependent child described in item #4 above claims Dependent status and;
a. that spouse is eligible for coverage; and
b. is not already enrolled under the Contract; and
c. enrollment is requested in writing within 30 days of the Dependent child
becoming a Dependent, provided the eligible employee also enrolls during this
Special Enrollment Period.
Page 15
(6) the Dependents are eligible Dependent children of the Subscriber or eligible employee
and enrollment is requested in writing within 30 days of a Dependent, as described in
items #3 or #4 above, becoming eligible to enroll under the coverage, provided the
eligible employee also enrolls during this Special Enrollment Period.
Additionally, when Employer provides Medica with notice of a qualified medical child support
order and a copy of the order, Medica will provide such eligible dependent child with a Special
Enrollment Period. Employer will provide Medica with such notice, along with an application for
coverage, within the lesser of 30 days or the time in which Employer provides notice of its
determination to the persons specified in the order.
B. Effective Dates of Coverage. Coverage shall become effective:
(1) in the case of paragraphs (A)( 1) or (2) above, the day after the date the other
coverage ended;
(2) in the case of paragraph (A)(3) above, the date of the marriage;
(3) in the case of paragraph (A)(4) above, the date of birth, date of adoption, or date of
placement for adoption. In all other cases, the date the Subscriber acquires the
Dependent child.
(4) in the case of paragraph (A)(5) above, the date the Subscriber acquires the Dependent
Child; and
(5) in the case of (A)(6) above, the first day of the first calendar month beginning after the
date the completed request for enrollment is received by Medica.
(6) in the case of the qualified medical child support order, the first day of the first calendar
month beginning after the date the completed request for enrollment is reeeived by
Medica.
Page 16
OFF-CYCLE ENROLLMENT -
NO OFF-CYCLE ENROLLMENT FOR LATE ENTRANTS WITHOUT CONTINUOUS
COVERAGE
An eligible Subscriber or an eligible Subscriber and his or her Dependents who do not enroll for
coverage offered through Employer during the Initial Enrollment Period, the Open Enrollment
Period or any applicable Special Enrollment Period will be considered Late Entrants.
(1) Late Entrants who have maintained Continuous Coverage may enroll and coverage will be
effective the first day of the month following date of approval by Medica. Continuous
Coverage will be determined to have been maintained if the Late Entrant requests
enrollment within 63 days after prior Qualifying Coverage ends.
(2) Late Entrants who have not maintained Continuous Coverage may not enroll off-cycle.
An eligible Subscriber or Dependent who:
(1) does not enroll during the Initial Enrollment Period, the Open Enrollment Period or any
applicable Special Enrollment period; and
(2) is an enrollee of the Minnesota Comprehensive Health Association ("MCHA") at the time
Medica offers or renews coverage with Employer, provided the eligible Subscriber or
Dependent maintains Continuous Coverage,
will not be considered a Late Entrant and will be allowed to enroll. Coverage will be effective as
determined by Medica.
Page 17
PO Box 9310
Minneapolis, MN 55440-9310
952-992-2900
-1
MEDICA@
Dear Client:
Enclosed are amendments which modify your current Medica Certificate of
Coverage, which is part of your Master Group Contract.
The first is an amendment providing clarification of language in the Continuation
section of the Certificate of Coverage.
e General disclosure information on COBRA.
e Updated language for Uniformed Services Employment and
Reemployment Right Act (USERRA).
The second amendment updates language in the Conversion section of the
Certificate of Coverage, providing further clarification regarding conversion rights.
If you have any questions or would like more information, please contact the
Medica Service Center at 800-936-6880 or 952-992-2200.
Medica
COM 1709-50405
MedicaiID is a registered service mark of Medica Health Plans. "Medica" refers to the family of health plan businesses that includes
Medica Health Plans*, Medica Health Plans of Wisconsin, Medica Insurance Company*, and Medica Self-Insured*.
*Accredited by the National Committee for Quality Assurance in the states of MN, ND, 5D and WI.
An Equal Opportunity Employer
Medica Commercial HMO/POS
and Medicaid Plans
AMENDMENT TO THE CERTIFICATE OF COVERAGE
This amendment modifies your Medica Health Plans ("Medica") Certificate of Coverage
("Certificate") effective December 1, 2005.
Subsection 2 of the section titled Continuation has been deleted and replaced with the
following:
2. Your right to continue coverage under federal
law
Notwithstanding the provisions regarding termination of
coverage described in Ending Coverage, you may be
entitled to extended or continued coverage as follows:
This plan is a group health plantor
purposes ofQOI3RA.
COBRA continuation coverage.
Continued coverage shall be provided as required
under the Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA), as amended (as
well as the Public Health Service Act (PHSA), as
amended). The employer shall, within the parameters
of federal law, establish uniform policies pursuant to
which such continuation coverage will be provided.
See General COBRA Information in this section.
USERRA continuation coverage.
Continued coverage shall be provided as required
under the Uniformed Services Employment and
Reemployment Rights Act of 1994 ("USERRA"), as
amended. The employer shall, within the parameters
of federal law, establish uniform policies pursuant to
which such continuation coverage will be provided.
See General USERRA Information in this section.
General COBRA Information.
COBRA requires employers with 20 or more
employees to offer subscribers and their families
(spouse and/or dependent children) the opportunity to
pay for a temporary extension of health coverage
(called continuation coverage) at group rates in certain
instances where health coverage under employer
sponsored group health plan(s) would otherwise end.
This section is intended to inform you, in summary
fashion, of your rights and obligations under the
continuation coverage provision of federal law. It is
intended that no greater rights be provided than those
required by federal law. Take time to read this section
carefully.
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05 MHP COBRA
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AMENDMENT TO THE CERTIFICATE OF COVERAGE
Qualified beneficiary
For purposes of this section, a qualified beneficiary is
defined as:
a. A covered employee (a current or former employee
who is actually covered under a group health plan
and not just eligible for coverage);
b. A covered spouse of a covered employee; or
c. A dependent child of a covered employee. (A child
placed for adoption with or born to an employee or
former employee receiving COBRA continuation
coverage is also a qualified beneficiary.)
Subscriber's loss
The subscriber has the right to elect continuation of
coverage if there is a loss of coverage under the
Contract because of termination of the subscriber's
employment (for any reason other than gross
misconduct), or the subscriber becomes ineligible to
participate under the terms of the Contract due to a
reduction in his or her hours of employment.
Subscriber's spouse's loss
The subscriber's covered spouse has the right to
choose continuation coverage if he or she loses
coverage under the Contract for any of the following
reasons:
a. Death of the subscriber;
b. A termination of the subscriber's employment (for
any reason other than gross misconduct) or
reduction in the subscriber's hours of employment
with the employer;
c. Divorce or legal separation from the subscriber; or
d. The subscriber's entitlement to (actual coverage
under) Medicare.
Subscriber's child's loss
The subscriber's dependent child has the right to
continuation coverage if coverage under the Contract is
lost for any of the following reasons:
a. Death of the subscriber if the subscriber is the
parent through whom the child receives coverage;
b. The subscriber's termination of employment (for any
reason other than gross misconduct) or reduction in
2
05 MHP COBRA
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05 MCS, ME-MES, MCC COBRA 12/1/05
AMENDMENT TO THE CERTIFICATE OF COVERAGE
the subscriber's hours of employment with the
employer;
c. The subscriber's divorce or legal separation from the
child's other parent;
d. The subscriber's entitlement to (actual coverage
under) Medicare if the subscriber is the parent
through whom the child receives coverage; or
e. The subscriber's child ceases to be a dependent
child under the terms of the Contract.
Responsibility to inform
Under federal law, the subscriber and dependent have
the responsibility to inform the employer of a divorce,
legal separation, or a child losing dependent status
under the Contract within 60 days of the date of the
event, or the date on which coverage would be lost
because of the event.
Also, a subscriber and dependent who have been
determined to be disabled under the Social Security Act
as of the time of the subscriber's termination of
employment or reduction of hours or within 60 days of
the start of the continuation period must notify the
employer of that determination within 60 days of the
determination. If determined under the Social Security
Act to no longer be disabled, he or she must notify the
employer within 30 days of the determination.
Bankruptcy
Rights similar to those described above may apply to
retirees (and the spouses and dependents of those
retirees), if the subscriber's employer commences a
bankruptcy proceeding and these individuals lose
coverage.
Election rights
When notified that one of these events has happened,
the employer will notify the subscriber and dependents
of the right to choose continuation coverage.
Under federal law, the subscriber and dependents have
at least 60 days to elect continuation coverage,
measured from the later of:
a. The date coverage would be lost because of one of
the events described above, or
b. The date notice of election rights is received.
3
05 MHP COBRA
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Ifcontinuationcoverage is not
elected, your coverage under the
Contract will end.
05 MCS, ME-MES, MCC COBRA 12/1/05
AMENDMENT TO THE CERTIFICATE OF COVERAGE
If continuation coverage is elected within this period, the
coverage will be retroactive to the date coverage would
otherwise have been lost.
The subscriber and the subscriber's covered spouse
may elect continuation coverage on behalf of other
dependents entitled to continuation coverage.
However, each person entitled to continuation
coverage has an independent right to elect
continuation coverage. The subscriber's covered
spouse or dependent child may elect continuation
coverage even if the subscriber does not elect
continuation coverage.
Type of coverage and cost
If the subscriber and the subscriber's dependents elect
continuation coverage, the employer is required to
provide coverage that, as of the time coverage is being
provided, is identical to the coverage provided under the
Contract to similarly situated employees or employees'
dependents.
Under federal law, a person electing continuation
coverage may have to pay all or part of the premium for
continuation coverage. The amount charged cannot
exceed 102 percent of the cost of the coverage. The
amount may be increased to 150 percent of the
applicable premium for months after the 18th month of
continuation coverage when the additional months are
due to a disability under the Social Security Act.
There is a grace period of at least 30 days for the
regularly scheduled premium.
Duration of COBRA coverage
Federal law requires that you be allowed to maintain
continuation coverage for 36 months unless you lost
coverage under the Contract because of termination of
employment or reduction in hours. In that case, the
required continuation coverage period is 18 months.
The 18 months may be extended if a second event (e.g.,
divorce, legal separation or death) occurs during the
initial 18-month period. It also may be extended to 29
months in the case of an employee or employee's
dependent who is determined to be disabled under the
Social Security Act at the time of the employee's
termination of employment or reduction of hours, or
within 60 days of the start of the 18-month continuation
period.
4
05 MHP COBRA
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Underno circumstances is the total
continuation periodgreaterthan36
months from the datebfthe original
event that triggered the continuation
coverage,
05 MCS, ME-MES, MCC COBRA 12/1/05
AMENDMENT TO THE CERTIFICATE OF COVERAGE
If an employee or the employee's dependent is entitled
to 29 months of continuation coverage due to his or her
disability, the other family members' continuation period
is also extended to 29 months. If the subscriber
becomes entitled to (actually covered under) Medicare,
the continuation period for the subscriber's dependents
is 36 months measured from the date of the subscriber's
Medicare entitlement even if that entitlement does not
cause the subscriber to lose coverage.
Federal law provides that continuation coverage may
end earlier for any of the following reasons:
a. The subscriber's employer no longer provides group
health coverage to any of its employees;
b. The premium for continuation coverage is not paid
on time;
c. Coverage is obtained under another group health
plan (as an employee or otherwise) that does not
contain any exclusion or limitation with respect to
any applicable pre-existing condition; or
d. The subscriber becomes entitled to (actually
covered under) Medicare.
Continuation coverage may also end earlier for
reasons which would allow regular coverage to be
terminated, such as fraud.
General USERRA Information.
USERRA requires employers to offer employees and
their families (spouse and/or dependent children) the
opportunity to pay for a temporary extension of health
coverage (called continuation coverage) at group rates
in certain instances where health coverage under
employer sponsored group health plan(s) would
otherwise end.
This section is intended to inform you, in summary
fashion, of your rights and obligations under the
continuation coverage provision of federal law. It is
intended that no greater rights be provided than those
required by federal law. Take time to read this section
carefully.
Employee's loss
The employee has the right to elect continuation of
coverage if there is a loss of coverage under the
Contract because of absence from employment due to
service in the uniformed services, and the employee
was covered under the Contract at the time the absence
5
05 MHP COBRA
(6/05)
This plan is a group health plan for
purposes of USERRA.
05 MCS, ME-MES, MCC COBRA 12/1/05
AMENDMENT TO THE CERTIFICATE OF COVERAGE
began, and the employee, or an appropriate officer of
the uniformed services, provided the employer with
advance notice of the employee's absence from
employment (if it was possible to do so).
Service in the uniformed services means the
performance of duty on a voluntary or involuntary basis
in the uniformed services under competent authority,
including active duty, active duty for training, initial active
duty for training, inactive duty training, full-time National
Guard duty, and the time necessary for a person to be
absent from employment for an examination to
determine the fitness of the person to perform any of
these duties.
Uniformed services means the U.S. Armed Services,
including the Coast Guard, the Army National Guard
and the Air National Guard, when engaged in active
duty for training, inactive duty training, or full-time
National Guard duty, and the commissioned corps of the
Public Health Service.
Election rights
The employee or the employee's authorized
representative may elect to continue the employee's
coverage under the Contract by making an election on a
form provided by the employer. The employee has 60
days to elect continuation coverage measured from the
later of (1) the date coverage would be lost because of
the event described above, or (2) the date notice of
election rights is received. If continuation coverage is
elected within this period, the coverage will be
retroactive to the date coverage would otherwise have
been lost. The employee may elect continuation
coverage on behalf of other covered dependents,
however, there is no independent right of each covered
dependent to elect. If the employee does not elect, there
is no USERRA continuation available for the spouse or
dependent children. In addition, even if the employee
does not elect USERRA continuation, the employee has
the right to be reinstated under the Contract upon
reemployment, subject to the terms and conditions of
the Contract.
Type of coverage and cost
If the employee elects continuation coverage, the
employer is required to provide coverage that, as of the
time coverage is being provided, is identical to the
coverage provided under the Contract to similarly
situated employees. The amount charged cannot
6
05 MHP COBRA
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05 MCS, ME-MES, MCC COBRA 12/1/05
AMENDMENT TO THE CERTIFICATE OF COVERAGE
exceed 102 percent of the cost of the coverage unless
the employee's leave of absence is less than 31 days, in
which case the employee is not required to pay more
than the amount that they would have to pay as an
active employee for that coverage. There is a grace
period of at least 30 days for the regularly scheduled
premium.
Duration of USERRA coverage
When an employee takes a leave for service in the
uniformed services, coverage for the employee and
dependents for whom coverage is elected begins the
day after the employee would lose coverage under the
Contract. Coverage continues for up to 24 months,
unless the leave for service began prior to December,
10, 2004, in which case coverage continues for up to 18
months.
Federal law provides that continuation coverage may
end earlier for any of the following reasons:
a. The employer no longer provides group health
coverage to any of its employees;
b. The premium for continuation coverage is not paid
on time;
c. The employee loses their rights under USERRA as a
result of a dishonorable discharge or other
undesirable conduct;
d. The employee fails to return to work following the
completion of his or her service in the uniformed
services; or
e. The employee returns to work and is reinstated
under the Contract as an active employee.
Continuation coverage may also end earlier for reasons
which would allow regular coverage to be terminated,
such as fraud.
COBRA and USERRA coverage are concurrent
If the employer is subject to COBRA and USERRA, and
you elect COBRA continuation coverage in addition to
USERRA continuation coverage, these coverages run
concurrently.
7
05 MHP COBRA
(6/05)
05 MCS, ME-MES, MCC COBRA 12/1/05
AMENDMENT TO THE CERTIFICATE OF COVERAGE
All other terms and conditions of the Certificate remain in full force and effect.
Medica Health Plans
By:
~/~/-<.-.
Tom Henke
Senior Vice President
By:
1~tJ~
James P. Jacobson
Senior Vice President and Assistant Secretary
8
05 MHP COBRA
(6/05)
05 MCS, ME-MES, MCC COBRA 12/1/05
AMENDMENT TO THE CERTIFICATE OF COVERAGE
This amendment modifies your Medica Certificate of Coverage ("Certificate") effective December
1,2005.
The Conversion provision appearing in the Certificate of Coverage is deleted and replaced
with the following:
Conversion
Minnesota Residents: This section describes your right to convert to an individual conversion
plan if you are a resident of Minnesota on the day that you submit an enrollment form to Medica or
Medica's designated conversion vendor.
Overview
1. You may convert to an HMO individual conversion
plan through Medica or Medica's designated
conversion vendor without proof of good health or
waiting periods at the following times:
a. Your continuation coverage with Medica, as
described in Continuation, is exhausted.
See Definitions. These words have
specific meanings:
. Continuous coverage
. Dependent
. Premium
. Waiting period
b. Your coverage or continuation coverage ends
because the Contract is terminated and the
Contract is not replaced with other continuous
group coverage.
Your conversion plan coverage may
not provide the same coverage as your
previous group health plan. Benefits
and provider networks may be
different.
c. Your coverage ends under the Contract and
you do not have the right to continue coverage
as described in Continuation.
2. If you move from the service area you may convert
to an insurance conversion plan without proof of
good health or waiting periods.
a. When continuous coverage is not maintained;
or
If you are a Minnesota resident, you
may be eligipleto.obtain coverage
from 1) other private sources of health
coverage, or 2) the Minnesota
Comprehensive Health Association,
without a preexisting condition
limitation. Contact the Minnesota
Comprehensive Health Association for
further information:
3. Your conversion plan goes into effect the day
following the date your other coverage ends. You
may select a qualified 1, 2 or 3 conversion plan.
You must maintain continuous coverage when
applying for conversion coverage.
4. Conversion coverage is not available:
b. If your coverage terminates due to nonpayment
of premium; or
. For deductible plan options call 1-
866-894-8053 or TTY 1-800-841-
6753
c. If you have not exhausted your right to continue
coverage as described in Continuation; or
· For Medicare Supplement plan
options call 1-800-325-3540 or
TTY 1-800-234-8819
05 MHP MN CONVERSION (5/05)
1
MN MCC, MCS, ME/MES CONV 12/1/05
COM2561-11005
AMENDMENT TO THE CERTIFICATE OF COVERAGE
d. If your coverage or continuation coverage ends
because the Contract is terminated and the
Contract is not replaced with other continuous
group coverage; or
e. If you commit fraud or material
misrepresentation in applying for continuation
or conversion of coverage.
For purposes of numbers 3 and 4a. above, continuous
coverage will be determined to have been maintained if
you request enrollment for conversion within 63 days
after your coverage ends or within 31 days of the date
you were notified of the right to convert coverage,
whichever is later.
What you must do
1. For conversion coverage information, call Customer
Service at one of the telephone numbers listed
inside the front cover.
2. Pay premiums to Medica or Medica's designated
conversion vendor within 63 days after your
coverage ends or within 31 days of the date you
were notified of your right to convert coverage,
whichever is later. You will be required to include
your first month premium payment with your
enrollment form for conversion coverage.
3. Submit an enrollment form to Medica or Medica's
designated conversion vendor within 63 days after
your coverage ends or within 31 days of the date
you were notified of your right to convert, whichever
is later. You may include only those dependents
who were enrolled under the Contract at the time of
conversion.
What the employer must do
The employer is required to notify you of your right to
convert coverage.
Residents of a state other than Minnesota: This
section describes your right to convert to an individual
conversion plan if other group coverage is unavailable
and if you are a resident of a state other than
Minnesota on the day that you submit an enrollment
form to Medica or Medica's designated conversion
vendor.
05 MHP MN CONVERSION (5/05)
2
MN MCC, MCS, ME/MES CONV 12/1/05
AMENDMENT TO THE CERTIFICATE OF COVERAGE
Overview
You may convert to an individual conversion plan
through Medica or Medica's designated conversion
vendor without proof of good health or waiting periods,
in accordance with the laws of the state in which you
reside on the day that you submit an enrollment form to
Medica or Medica's designated conversion vendor.
What you must do
1. For conversion coverage information, call Customer
Service at one of the telephone numbers listed
inside the front cover.
2. Pay premiums to Medica or Medica's designated
conversion vendor within 31 days after your
coverage ends or such other period of time as
provided under applicable state law. You will be
required to include your first month premium
payment with your enrollment form for conversion
coverage.
3. Submit an enrollment form to Medica or Medica's
designated conversion vendor within 31 days after
your coverage ends or such other period of time as
provided under applicable state law. You may
include only those dependents who were enrolled
under the Contract at the time of conversion.
05 MHP MN CONVERSION (5/05)
3
MN MCC, MCS, ME/MES CONV 12/1/05
AMENDMENT TO THE CERTIFICATE OF COVERAGE
All other terms and conditions of the Certificate remain in full force and effect.
Medica Health Plans
By:
~x:~.c,
GG. Tom Henke
Senior Vice President
By:
'7~C;~
James P. Jacobson
Senior Vice President and Assistant Secretary
05 MHP MN CONVERSION (5/05)
4
MN MCC, MCS, ME/MES CONV 12/1/05