HomeMy WebLinkAboutContract 1574 I5
MEDICA SENIORCARE SECURE
MASTER GROUP CONTRACT
Employer Name: City of Columbia Heights
Employer Group #: 71113
Effective Date: February 1, 2001
Contract #: 13540
Amendment(s) #:
ARTICLE 1
INTRODUCTION
This Master Group Contract ( "Contract ") is entered into by and between Medica Health Plans
( "Medica ") and the employer group named above ( "Employer "), an employer under Minnesota
law and other applicable law. This Contract includes the Eligibility and 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 monthly 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.
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ARTICLE 2
TERM OF CONTRACT
Section 2.1 Term and Renewal. This Contract is effective from February 1, 2001 ( "Effective
Date ") to December 31, 2001 ( "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.
(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 due to material misrepresentation by Employer;
(c) Automatically on the date Employer ceases to do business pursuant to 11 U.S.C.
Chapter 7;
(d) 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 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 renewable basis.
Section 2.3 Notice of Termination.
Medica will notify Employer and Subscribers in writing if Medica terminates this Contract for any
reason. 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.
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ARTICLE 3
ENROLLMENT AND ELIGIBILITY
Section 3.1 Eligibility and Enrollment. The Eligibility and Enrollment Appendix to this
Contract governs who is eligible to enroll under this Contract as well as when eligible retirees or
spouses may enroll for Benefits under this Contract, including the Initial Enrollment Period, Open
Enrollment Period, and Off -Cycle Enrollment Periods. Employer shall conduct the Initial
Enrollment Period, Open Enrollment Period and Off -Cycle Enrollment Periods. The eligibility
conditions stated in the Eligibility and Enrollment Appendix are in addition to those specified in
the Certificate.
Section 3.2 Eligibility and Enrollment Decisions. Subject to applicable law and the terms of
this Contract, Employer has sole discretion to determine whether retirees or spouses are eligible
to enroll for Benefits. Medica shall rely upon Employer's determination regarding a Member's
eligibility to enroll for Benefits. Employer will be responsible for maintaining information verifying
its continuing eligibility and the continuing eligibility of its eligible Members. This information
shall be provided to Medica as reasonably requested by Medica. Employer shall also maintain
written documentation of a waiver of coverage by an eligible retiree or spouse and provide this
documentation to Medica upon reasonable request.
ARTICLE 4
PREMIUMS
Section 4.1 Monthly Premiums.
[Al The monthly Premiums for this Contract are:
Subscriber [Monthly
Classifications Premium Rate]
Retiree or Medicare $248.00
eligible spouse
A. Member will pay Premium directly to Medica. However, Employer will remain responsible for
payment of Premium to Medica. Member will have one of the following payment options:
1. The Automated Clearing House ( "ACH ") option. If Member has selected the ACH
option, he or she will need to contact Member Service to obtain the necessary
paperwork to automatically have the monthly Premium deducted from his or her
checking or savings account. Once this information is processed by Medica, Member
will receive written notification of the effective date of the automatic Premium
deductions;
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2. Direct billing option. If Member chooses the direct billing option, Medica will send
Member a monthly billing invoice stating the monthly Premium amount due and
payable to Medica by Member.
When Premiums are due:
1. For the ACH option, Premium deductions occur the fifth working day of every month.
2. For the direct billing option, the monthly Premium payment is due on the first day of
every month.
Member must continue to pay Medicare Part B premiums.
How to pay Premiums:
1. For the ACH option, once the appropriate paperwork has been processed, Member's
Premium deductions will occur automatically.
2. For the direct billing option, Member will:
a. send Premium and the appropriate payment form to Medica at P.O. Box 64847,
St. Paul, Minnesota 55164 -0847; or
b. deliver Premium to Medica at 5601 Smetana Drive, Minnetonka, Minnesota.'
In exchange for Premiums paid, Medica shall arrange for the provision of Benefits. In doing
so, Medica may enter into agreements with Providers of health care, one or more insurers,
and such other individuals and entities as may be necessary to enable Medica to fulfill its
obligations under the Contract.
Section 4.2 Grace Period and Reinstatement.
[Al Member has a grace period of 31 calendar days from the due date to pay each Premium.
Failure to pay Premium within the grace period will result in Premium collection by Medica. If
Premium is not collected, Medica will formally notify Employer and Member of termination of
Member's coverage. If Member wishes to terminate coverage, non - payment of Premium
only does not constitute a termination notice; Member must notify Employer, who in turn will
notify Medica in writing to terminate coverage. See the section of the Certificate of
Coverage titled Ending Your Coverage for more information. To be eligible for coverage,
Member must continue to seek care from Medica Contracted Providers until Member
receives notice of termination from Medica.
Section 4.3 Premium Calculation. The monthly Premiums owed by Employer shall be
calculated by Medica using the number of Members in each coverage classification according to
Medica's records at the time of the calculation. Member's coverage for Benefits may be
terminated only at the end of a calendar month and a full Premium rate for that month will apply.
s Include only for groups that have chosen the "individually billed" option.
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Section 4.4 Retroactive Adjustments. In accordance with applicable law, retroactive
adjustments may be made for any additions of Members not reflected in Medica's records at the
time monthly Premiums were calculated by Medica. With respect to terminations of Member's
coverage, no retroactive credit will be granted for any month in which a Member received
Benefits. No retroactive Premium refund shall be granted for termination of Member's coverage
unless approved by HCFA.
Regardless of the preceding, Employer shall pay Premium for any month during which a
Member received Benefits.
Section 4.5 Premium Changes. Medica may change Premiums after 30 days prior written
notice to Employer on:
(a) the first anniversary of the effective date of this Contract;
(b) any monthly due date after the first anniversary of this Contract; or
(c) any date the provisions of this Contract are amended.
Section 4.6 Fees. Medica may charge Employer:
(a) a late payment charge in the form of a finance charge in the amount permitted under law
for any Premiums not received by the due date; and
(b) a service charge for any non - sufficient -fund check received in payment of Premiums.
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.
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
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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 discretion to interpret and construe the Benefits under the
Contract and the other terms, conditions, limitations and exclusions set out in the Contract. The
parties agree that Medica has sole, final, and exclusive discretion to change, modify, withdraw
or add Benefits without approval by Members and make factual determinations related to the
Contract and the Benefits. For purposes of overall cost savings or efficiency, Medica may, in its
sole discretion, provide services that would otherwise not be Benefits. The fact that Medica
does so in any particular case shall not in any way be deemed to require it to do so in other
similar cases. Medica may, from time to time, delegate discretionary authority to other persons
or entities providing services under this Contract.
ARTICLE 9
DATA OWNERSHIP AND USE
Information and data acquired, developed, generated, or maintained by Medica in the course of
performing under this Contract shall be Medica's sole property. Except as this Contract or
applicable law requires otherwise, Medica shall have no obligation to release such information
or data to Employer. Medica may, in its sole discretion, release such information or data to
Employer, but only to the extent permitted by law and subject to any restrictions determined by
Medica.
ARTICLE 10
AMENDMENTS AND ALTERATIONS
Section 10.1 Standard Amendments. Except as provided in Section 10.2, amendments to
this Contract are effective 30 days after Medica sends Employer a written amendment. Unless
regulatory authorities direct otherwise, Employer's signature will not be required. No Medica
agent or broker has authority to change this Contract or to waive any of its provisions.
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Section 10.2 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 11
ASSIGNMENT
Neither party shall have the right to assign any of its rights and responsibilities under the
Contract to any person, corporation or entity without the prior written consent of the other party;
provided, however, that Medica may, without the prior written consent of the Employer, assign
the Contract to any entity that controls Medica, is controlled by Medica, or is under common
control with Medica. In the event of assignment, the Contract shall be binding upon and inure to
the benefit of each party's successors and assigns.
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ARTICLE 12
DISPUTE RESOLUTION
Medica and Employer will work together in good faith to resolve any disputes under this
Contract. If they are unable to resolve the disputes within 30 days following the date one party
sent written notice of the dispute to the other party, and if either party wishes to pursue the
dispute, it shall be submitted to binding arbitration in accordance with the rules of the American
Arbitration Association ( "AAA "). In no event may arbitration be initiated more than one year
following the sending of written notice of the dispute.
The arbitrators shall apply Minnesota substantive law to the proceeding, except to the extent
federal substantive law, including ERISA, would apply to any claim. Any arbitration proceeding
under this Agreement shall be conducted in Hennepin County, Minnesota.
An award may be entered against a party who fails to appear at a duly noticed hearing. The
arbitrators:
(i) may construe or interpret, but shall not vary or ignore, the terms of this Agreement;
(ii) shall have no authority to award any punitive or exemplary damages; and
(iii) shall be bound by controlling law.
A party may appeal an arbitration decision to a court of law only in accordance with applicable
state arbitration laws or for de novo review of alleged errors of law or legal reasoning. The cost
of arbitration shall be paid equally by the parties.
In the event a third party initiates litigation involving Medica or Employer, and the party under
this Contract who is involved in such third party litigation desires to bring a claim against the
other party under this Agreement for indemnity or contribution, the indemnity or contribution
claim may be brought in the same venue as the third party litigation, and shall not be subject to
the terms of this Article 12.
ARTICLE 13
TIME LIMIT ON CERTAIN DEFENSES
No statement made by Employer, except a fraudulent statement, shall be used to void this
Contract after it has been in force for a period of 2 years.
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ARTICLE 14
RELATIONSHIP BETWEEN PARTIES
The relationship between Employer and any Member is that of Employer and Member as
defined in this Contract.
The relationships between Medica and Medica Contracted Providers and the relationship
between Medica and Employer are solely contractual relationships between independent
contractors. Medica Contracted Providers and Employer are not agents or employees of
Medica. Medica and its employees are not agents or employees of Medica Contracted
Providers or Employer.
The relationship between a Medica Contracted Provider and any Member is that of provider and
patient and the Medica Contracted Provider is solely responsible for the services provided to
any Member.
ARTICLE 15
EMPLOYER RECORDS
Employer shall furnish Medica with all information and proofs that Medica may reasonably
require with regard to any matters pertaining to this Contract. 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 16
MEMBER RECORDS
By accepting Benefits under this Contract, each Member authorizes and directs any person or
institution that has provided services to the Member to furnish Medica or any of Medica's
designees at any reasonable time, upon its request, any and all information and records or
copies of records relating to the Benefits provided to the Member. In accordance with applicable
law, Medica and any of Medica's designees shall have the right to release any and all records
concerning health care services: (i) as necessary to implement and administer the terms of this
Contract; or (ii) for appropriate medical review or quality assessment. Such Member information
and records shall be considered confidential medical records by Medica and its designees.
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ARTICLE 17
NOTICE
Except as provided in Article 2 and required by applicable law, notice given by Medica to an
authorized representative of Employer will be deemed notice to all Members.
All notices to Medica shall be sent to the address stated in the Acceptance of Contract. All
notices to Employer shall be sent to the persons and addresses stated in Employer's
Application. All notices to Medica and Employer shall be deemed delivered:
(a) if delivered in person, on the date delivered in person;
(b) if delivered by a courier, on the date stated by the courier;
(c) if delivered by an express mail service, on the date stated by the mail service vendor; or
(d) if delivered by United States mail, 3 business days after date of mailing.
A party can change its address for receiving notices by providing the other party a written notice
of the change.
ARTICLE 18
COMMON LAW
No language contained in the Contract constitutes a waiver of Medica's rights under common
law.
ARTICLE 19
YEAR 2000 COMPLIANCE
Medica and Employer agree to use reasonable efforts to address Year 2000 information system
issues that may arise in the administration of this Contract. Each party will dedicate staff
resources as appropriate to carry out activities related to that party's Year 2000 readiness
program. Each party will implement tests to ascertain that party's ability to avoid Year 2000
problems in administering this Contract, and each party will develop and implement appropriate
Year 2000 contingency plans for that party's own organization. Upon request, each party
agrees to provide reasonable information regarding that party's Year 2000 readiness efforts.
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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 Employer.
IN WITNESS WHEREOF, Medica has caused this Contract to be executed on this March 6,
2001, to take effect on the Effective Date stated in the Contract.
MEDICA HEALTH PLANS EMPLOYER
5601 Smetana Drive City of Columbia Heights
Minnetonka, MN 55343 590 - 40th Ave NE
(952) 992 -2362 Columbia Heights, MN 55421
Telephone: (763) 7 0 6- 3 610
Billing Address:
/(e47
P.O. Box SDS 12 -0566 By:
Minneapolis, MN 55486 -1853 Walter R. Fe h s t
Title: City Manager
Employer Representative:
Mailing Address: Linda L. Magee
P.O. Box 9310
Minneapolis, MN 55440 Asst. to the City Manager/
Human R sources Director
Date:
By• i/// `i /ice
Lori A. Hart
Title:
Group Medicare
Account Service Specialist
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•
ELIGIBILITY and ENROLLMENT APPENDIX
Employer Name: City of Columbia Heights
Employer Group #: 71113
Section 1 Eligibility to Enroll.
A Subscriber as defined below who satisfies the eligibility conditions stated in this Contract is eligible
to enroll for coverage under this Contract. Any person who does not satisfy the definition of
Subscriber is not eligible for coverage under this Contract.
A Subscriber must be entitled to Part A of Medicare and enrolled in Part B of Medicare and must meet
the eligibility requirements described below and in the entire Contract.
If there is a conflict between the Certificate and this Eligibility and Enrollment Appendix, this Eligibility
and Enrollment Appendix governs.
Section 4 Subscriber Definition.
The term "Subscriber" as used in the Contract will include the types of individuals and conditions
identified below:
Classifications Applicable Waiting Periods and Effective Dates
1. Retiree No waiting periods.
2. Medicare eligible spouse of No waiting periods.
retiree
Any person who does not satisfy the terms listed above will not be eligible for coverage under the
Contract.
Section 5 Initial Enrollment.
"Initial Enrollment Period" is a 31 day time period starting with the date the retiree or spouse is first
eligible to enroll for coverage under this Contract. An eligible retiree or spouse must apply within this
period for coverage to begin the date he or she was first eligible to enroll. An eligible retiree or spouse
who enrolls during the Initial Enrollment Period is accepted without application of health screening or
affiliation periods. An eligible retiree or spouse who does not enroll during the Initial Enrollment Period
may enroll for coverage during the next Open Enrollment or Off -Cycle Enrollment Period as described
below.
Section 6 Notification.
Members must notify Employer within 30 days of the effective date of any change of address or name
or other facts identifying the Member.
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Th'e Employer must notify Medica within 31 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.
Section 7 Open Enrollment.
"Open Enrollment" is a minimum 14 day period set by Employer and Medica each year during which
eligible retiree or spouse may enroll for coverage without application of health screening or waiting
periods.
Section 8 Off -Cycle Enrollment.
Medica will require retirees or spouses to provide evidence of insurability before enrollment will be
accepted at any time other than the Initial Enrollment Period, Open Enrollment Period or Hardship.
The following Off -Cycle Enrollment due to Hardship will be allowed without evidence of insurability:
An eligible retiree or spouse who did not previously elect coverage under the Contract may enroll
within 30 calendar days of a Hardship situation, which includes:
1. spouse's involuntary termination or layoff from employment;
2. death or permanent disability of the spouse;
3. divorce; and
4. other such circumstances as Medica may approve from time to time.
For the eligible retiree or spouse to enroll due to Hardship, he or she must have been enrolled for
health coverage under the spouse's health benefit plan. Evidence of Hardship must be provided to
Medica upon request.
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5601 Smetana Drive Mailing Address:
Minnetonka, MN 55343 P.O. Box 9310
612 -992 -2900 Minneapolis, MN 55440 -9310
*.
MED -CA,
March 6, 2001
C : ` •
0
Linda Magee " �
City of Columbia Heights \A�
590 - 40th Ave NE 5,
Columbia Heights, MN 55421
Jam
Dear Linda, .�
Thank you for giving Medica the opportunity to provide quality health care coverage to
your Medicare eligible retirees and dependents.
Your Group SeniorCare Secure contract is enclosed. Please have both copies of the
policy signed by the appropriate officer of your company. Retain one copy for your
records and mail the other copy to Medicp in the ostage paid envelope provided.
r 3 � a�' If you have any questions egarding this information, or if we can be of further assistance
to you, please feel free to call us at (952) 992 -2362 or (800) 906 -5432.
Sincerely,
Lori A. Hart
Group Medicare
Account Specialist
Medica refers to the family of health plan businesses Operating as subsidiaries of Allina Health System, and includes
*Medica Health Plans, *Medica Health Plans of Wisconsin, Medica Insurance Company, *Medica Self- Insured and SelectCare.
*Accredited by the National Committee for Quality Assurance. ---'
20075 (11/99)