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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. MGC [00) Page 1 03/06/01 Secure -co n t ra ct(I ). d oc d 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. MGC [00] Page 2 03/06/01 Secure - contract(I).doc 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; MGC [00] Page 3 03/06/01 Secure - contract(I).doc 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. MGC (00] Page 4 03/06/01 Secure - contract(I).doc 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 MGC (00] Page 5 03/06/01 Secure - contract (I ). d o c 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. MGC [00] Page 6 03/06/01 Secure - contract(I).doc 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. MGC [00] Page 7 03/06/01 Secure - contract(I).doc 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. MGC [00] Page 8 03/06/01 Secure - contract(I).doc 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. MGC [00] Page 9 03/06/01 Secure - contract(I).doc 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. MGC [00] Page 10 03/06/01 Secure - contract(I).doc 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 MGC [00] Page 11 03/06/01 Secure - contract(I).doc • 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. SCS EUENAPP(001 Page 1 03/06/01 Secure - eligibility.doc r 4 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. SCS EUENAPP[00] Page 2 03/06/01 Secure- eligibility.doc 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)