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HomeMy WebLinkAboutContract 1704 5601 Smetana Ditve Mailing Address Minnetonka, MN 55343 PO Box 9310 952 -992 -2900 Minneapolis, MN 55440 -9310 1 101 D LT — 2- 6 i 2 3 CC) F:17 \'‘ R _J I, R I�� DD ME CA �u :717Es 2 t 2003 0 Linda Magee City of Columbia Heights 590 40th Avenue NE Columbia Heights, MN 55421 Dear Linda Thank you for choosing Medica for your employees' group health coverage Enclosed are two copies of each medical Master Group Contract (MGC) binding Medica and City of Columbia Heights, Group Numbers 89944, 89945, 89946, and 89947, for the contract period commencing January 1, 2003 and expiring on December 31, 2003 The following steps should occur to ensure appropriate execution and continued performance under the MGCs • Ensure each MGC is signed and dated by an officer of the company or a person authorized to execute the terms of the MGC • Include the contract signer's title under the signature • Return one signed copy of each MGC to me within 30 days • Retain the other documents for your files The MGCs will be deemed to have been 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 us 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, I i f / . Cindy M Ramler /Janet M Litwin Account Service Representatives Enclosures cc Britt Osterhues @ Johnson McCann Benefits lvlcdtca teters to the 1 tin 1, of he ilth plan husmcsscs th it includes Mcchc, He ilth Plin, i ; Nledic t He ilth Plans o0 Wisconsin Medic i Instil untie Comp in, 1v1 iic 1 Selt Insured ind SclectCrte aeru� +;- Acctcdltcd b, tbe'N monil Committee toi Quihu Assm riot ^' 2C7) (D,321 An bqucd Opp°, Lmplosei 5601 Smetana Diive Mailing Address Minnetonka, MN 55343 PO Box 9310 952- 992 -2900 Minneapolis, MN 55440 -9310 000796 Februai y 26, 2003 MEDICA, tit �l M R #30550- DOL /Rce Linda Magee CITY OF COLUMBIA HEIGHTS 590 40th Ave NE Columbia Hgts, MN 55421 -3878 � — IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIlllllll Dear Group Administi ator Enclosed are two amendments updating your current Certificate of Coverage, which is a part of your Master Group Contract These amendments update language specific to federal Department of Labor regulations and state regulations We apologize for the delay in mailing this amendment and for any inconvenience this may have caused If you have any questions about your benefits, please call Medica Service Center at (952) 992 -2200 or 1- 800 - 936 -6880 One of our service representatives will be happy to assist you Medica Health Plans DOL REGS 2002 ME 02 REG ME Ic itc 1 1cteis to the 1Imtlt of he Ilth p1n husuicsses tint includes MCJIL 1 He dth P1 ins j , t Medic -111c 1lth Phns 11 Wisconsin Medic s Insul nice C omp ins 'Medic1 Belt Insured Ind SelectC AcctcdItcd ht the N tttonsil Committee lot Qunhtt Assn] nice 2007, 0/021 An Equal Oppal tunu, Emploscl w.tort)t r t t _ , 4 4 i ° 51C , ) ' r > MEDICA L 1 t i �, February 28, 2003 MN015- 2803- DOLREG «sub fname» «sub lname» «addr1 » «addr2» «city », « state »« zip» Dear Member Enclosed are two amendments updating your current Certificate of Coverage These amendments update language specific to federal Department of Labor regulations and state regulations We apologize for the delay in mailing this amendment and for any inconvenience this may have caused If you have any questions about your benefits, please call Medica Customer Service at (952) 945 -8000 or 1- 800 - 952 -3455 One of our service reps esentatives will be happy to assist you Medica Health Plans 1t 1 . 1 i i1lt .fli, !I, a +arr x t,t, to rr E, lhlrn It t t r 1 t + ' 1 vt 1 '^ 1 11 11 ,1 ',l& • DOL REGS 2002 ME t ,,1 , It 1 . ['tilt Ill r 11 1 r • 1 Ill, 02REG -ME ,1 rr; ,r • AMENDMENT TO THE CERTIFICATE OF COVERAGE This amendment modifies your Medica Health Plans ( "Medica ") Certificate of Coverage effective July 1, 2002. The second paragraph under the subsection titled " Medica's Prior Authorization Process ", in the Section titled Procedures for Obtaining Health Services is deleted and replaced with the following: Medica will review your request and provide a response to you and your attending provider within ten business days after the date your request was received, provided all information reasonably necessary to make a decision has been made available to Medica. Medica will inform both you and your provider of Medica's decision within 72 hours from the time of the initial request if your attending provider believes that an expedited review is warranted, or Medica concludes that a delay could seriously jeopardize your life, health, or ability to regain maximum function. If Medica does not approve your request for prior authorization, you have the right to appeal Medica's decision as described in the Section titled If You Have a Complaint. II. The Section titled How To Submit A Claim is deleted in its entirety and replaced with the following: This section describes the process for submitting a claim. Claims for benefits from network providers. If you receive a bill for any benefit from a network provider, you may submit the claim following the procedures described below, under Claims for benefits from non - network providers or call Customer Service at 1- 800 - 952 -3455 or (952) 945 -8000 (Mpls. /St. Paul metro area). The telephone numbers for hearing - impaired members with a TTY phone are 1- 800 - 841 -6753 or (952) 992 -3190 (Mpls. /St. Paul metro area). Network providers are required to submit claims within 120 days from when you receive a service. If your provider asks for your health care identification card and you do not identify yourself as a Medica member within 120 days of the date of service, you may be responsible for paying the cost of the service you received. Claims for benefits from non - network providers. Claim forms are provided in your enrollment materials. You may request additional claim forms by calling Customer Service at 1- 800 - 952 -3455 or (952) 945 -8000 (Mpls. /St. Paul metro area). The telephone numbers for hearing impaired members with a TTY phone are 1- 800 - 841 -6753 or (952) 992 -3190 (Mpls. /St. Paul metro area). If the claim forms are not sent to you within 15 days, you may submit an itemized statement without the claim form to Medica. You should retain copies of all claim forms and correspondence for your records. You must submit the claim in English along with a Medica claim form to Medica no later than 365 days after receiving benefits. Your Medica member number must be on the claim. Mail to: Medica Claims Route 2901 PO Box 659752 San Antonio, TX 78265 -9752 DOL REGS 2002 ME 1 7/2002 AMENDMENT TO THE CERTIFICATE OF COVERAGE Upon receipt of your claim for benefits from non - network providers, Medica will pay to you directly the non - network provider reimbursement amount. Medica will pay the provider of services if: 1. You or, in the case of a dependent or a child who is the subject of a qualified medical child support order (QMCSO), the custodial parent, ask Medica in writing to pay the provider directly; or 2. The non - network provider notifies Medica of your signature on file authorizing that payment be made directly to the provider. Medica will notify you of authorization or denial of the claim within 30 days of receipt of the claim. If your claim does not contain all the information Medica needs to make a determination, Medica may request additional information. Medica will notify you of its decision within 15 days of receipt of the additional information. If you do not respond to Medica's request within 45 days, your claim may be denied. Claims for services provided outside the United States Claims for services rendered in a foreign country will require the following additional documentation: • Claims submitted in English with the currency exchange rate for the date health services were received. • Itemization of the bill or claim. • The related medical records (submitted in English). • Proof of your payment of the claim. • A complete copy of your passport and airline ticket. • Such other documentation as Medica may request. For services rendered in a foreign country, Medica will pay you directly. Medica will not reimburse you for costs associated with translation of medical records or claims. Time limits If you have a complaint or disagree with a decision by Medica, you may follow the complaint procedure outlined in the Section titled If You Have A Complaint or you may initiate legal action at any point. However, you may not bring legal action more than six years after Medica has made a coverage determination regarding your claim. III. The Section titled If You Have A Complaint is deleted in its entirety and replaced with the following: This section describes what to do if you have a complaint or would like to appeal a decision made by Medica. You may call Customer Service at 1- 800 - 952 -3455 or (952) 945 -8000 (Mpls. /St. Paul metro area). The telephone numbers for hearing impaired members with a TTY phone are 1- 800 - 841 -6753 or (952) 992 -3190 (Mpls. /St. Paul metro area) or by writing to the address below in First level of review. You also may contact the Commissioner of Health, Minnesota Department of Health, at DOL REGS 2002 ME 2 7/2002 AMENDMENT TO THE CERTIFICATE OF COVERAGE (651) 282 -5600 or 1- 800 - 657 -3916, regarding complaints about in- network benefits, or the Commissioner of Commerce, Minnesota Department of Commerce, at (651) 296 -6789 or 1- 800 - 657 -3602, regarding complaints about out -of- network benefits. Complaint: Means any grievance against Medica, submitted by you or another person on your behalf, that is not the subject of litigation. Complaints may involve, but are not limited to, the scope of coverage for health care services; retrospective denials or limitations of payment for services; eligibility issues; denials, cancellations, or non - renewals of coverage; administrative operations; and the quality, timeliness, and appropriateness of health care services rendered. If the complaint is from an applicant, the complaint must relate to the application. If the complaint is from a former enrollee, the complaint must relate to services received during the time the individual was an enrollee. Medical Necessity Review: Means Medica's evaluation of the necessity, appropriateness, and efficacy of the use of health care services, procedures, and facilities, for the purpose of determining the medical necessity of the service or admission. 1. First level of review You may direct any question or complaint to Customer Service by calling at 1- 800 - 952 -3455 or (952) 945 -8000 (Mpls. /St. Paul metro area). The telephone numbers for hearing impaired members with a TTY phone are 1- 800 - 841 -6753 or (952) 992 -3190 (Mpls. /St. Paul metro area) or by writing to the address listed below. You may have another person make a complaint on your behalf by telephone or in writing. Before releasing confidential information to a person filing a complaint on your behalf, Medica will require you to sign an authorization form. Filing a complaint may require that Medica review your medical records as needed to resolve your complaint. Upon request, Medica will assist you with completion and submission of your written complaint. Medica will also complete a complaint form on your behalf and mail it to you for your signature upon request. Complaints that do not involve a medical necessity review by Medica: a. For an oral complaint, if Medica does not communicate a decision within 10 business days from Medica's receipt of the complaint, or if you determine that Medica's decision is partially or wholly adverse to you, Medica will provide you with a complaint form to submit your complaint in writing. Mail the completed form to: Customer Service Route 0501 P.O. Box 9310 Minneapolis, MN 55440 -9310 Medica will provide written notice of its first level review decision to you within 30 days from the initial receipt of your complaint. b. For a written complaint, Medica will provide written notice of its first level review decision to you within 30 calendar days from initial receipt of your complaint. c. If Medica's first level review decision upholds the initial decision made by Medica, you have a right to request a second level review. The second level of review, as described in item 2 below, must be exhausted before you have the right to submit a request for external review. DOL REGS 2002 ME 3 7/2002 AMENDMENT TO THE CERTIFICATE OF COVERAGE Complaints that involve a medical necessity review by Medica: a. Your complaint must be made within one year following Medica's initial decision and may be made orally or in writing. b. Medics will provide written notice of its first level review decision to you and your attending provider, when applicable, within 30 calendar days from receipt of your complaint. c. When an initial decision by Medica, does not grant a prior authorization request made before or during an ongoing service, and your attending provider believes that Medica's decision warrants an expedited review, you or your attending provider will have the opportunity to request an expedited review by telephone. Alternatively, if Medica concludes that a delay could seriously jeopardize your life, health, or ability to regain maximum function, Medica will process your claim as an expedited review. In such cases, Medica will notify you and your attending provider by telephone of its decision no later than 72 hours after receiving the request. d. If Medica's first level review decision upholds the initial decision made by Medica, you have a right to request a second level review or submit a written request for external review, as described in items 2 and 3 below. The second level of review is optional and you may submit a request for external review without exhausting the second level of review. 2. Second level of review If you are not satisfied with Medica's first level review decision, you may request a second • level of review through either a written reconsideration or a hearing. a. Your request may be oral or in writing. It must be provided to Medica within one year following the date of Medica's first level review decision. If your request is in writing, it must be sent to: Customer Service Route 0501 PO Box 9310 Minneapolis, MN 55440 -9310 b. Regardless of the method chosen for review (hearing or a written reconsideration), testimony, explanation or other information provided by you, Medica staff, providers and others is reviewed. c. Medica will provide written notice of its second level review decision to you within: i. 30 calendar days from receipt of your request for second level review for required second level reviews; or ii. 45 calendar days from receipt of your request for second level review for optional second level reviews. 3. External review If you consider Medica's decision to be partially or wholly adverse to you, you have a right to submit a written request for external review to the Commissioner of Health for issues related to in- network benefits or the Commissioner of Commerce for issues related to out -of- network benefits. Please contact the Commissioner at: DOL BEGS 2002 ME 4 7/2002 AMENDMENT TO THE CERTIFICATE OF COVERAGE Minnesota Department of Health P.O. Box 64975 St. Paul, MN 55164 -0975 (651) 282-5600 or 1-800-657-3916 Minnesota Department of Commerce 85 7 Place East, Suite 500 St. Paul, MN 55101 -2198 (651) 296 -6789 or 1- 800 - 657 -3602. An independent entity contracted with the State Commissioner of Administration will review your request. The external review decision will not be binding on you but will be binding on Medica. Contact the Commissioner of Health or the Commissioner of Commerce for more information about the external review process. Complaints regarding fraudulent marketing practices or agent misrepresentation cannot be submitted for external review. 4. Civil Action If you remain dissatisfied with Medica's determination after completing the required appeals process, you have the right to file a civil action under Section 502(a) of the Employee Retirement Income Security Act (ERISA). 5. In addition to directing complaints to Customer Service as described in this section, you may direct complaints at any time to the Commissioner of Health or the Commissioner of Commerce at the telephone numbers listed at the beginning of this section. All other terms and conditions of the Certificate remain in full force and effect. Medica Health Plans DOL BEGS 2002 ME 5 7/2002 AMENDMENT TO THE CERTIFICATE OF COVERAGE This amendment modifies your Medica Certificate of Coverage effective January 1, 2002 except as otherwise noted below. The following is added to the definition of "Network" as found in the Section titled Definitions: The Medica network provider directory will be furnished automatically, without charge. II. The definition of "Reconstructive" as found in the Section titled Definitions is deleted and replaced with the following: Reconstructive Surgery to rebuild or correct a: 1. Body part when such surgery is incidental to or following surgery resulting from injury, sickness or disease of the involved body part; or 2. Congenital disease or anomaly which has resulted in a functional defect as determined by your physician. In the case of mastectomy, surgery to reconstruct the breast on which the mastectomy was performed and surgery and reconstruction of the other breast to produce a symmetrical appearance shall be considered reconstructive. Surgery that is cosmetic is not reconstructive. III. The definition of "Standing referral" as found in the Section titled Definitions is deleted and replaced with the following: A referral issued by your primary care clinic for conditions that require ongoing services from a specialist provider. You may apply for, and if appropriate, receive a standing referral for: 1) a chronic health condition; 2) a life - threatening mental or physical illness; 3) pregnancy beyond the first trimester of pregnancy; 4) a degenerative disease or disability; or 5) any other condition or disease of sufficient seriousness and complexity to require treatment by a specialist provider. You may request an extension of a standing referral by contacting your primary care clinic. Standing referrals will only be authorized for the period of time appropriate to your medical condition. Standing referrals will not be issued to accommodate personal preferences, family convenience, or other non- medical reasons. Standing referrals will also not be issued for care that has already been provided. IV. The following is added to the Section titled Introduction: Continuity of Care In certain situations, you have a right to continuity of care. a. If Medica terminates its contract with your current primary care provider, specialist or hospital without cause, you may be eligible to continue care with that provider at the in- network benefit level. b. If you are a new Medica member as a result of your Employer changing health plans and your current primary care provider, specialist or hospital is not a network provider, you may be eligible to continue care with that provider at the in- network benefit level. This applies only if your provider agrees to comply with Medica's prior approval requirements, provide Medica with all necessary medical information related to your care, and accept as payment in full the lesser of Medica's network provider reimbursement or the provider's customary charge for the service. This does not apply when Medica terminates a provider's contract for cause. i. Upon request, Medica will authorize continuity of care for up to 120 days as described in a. and b. above for the following conditions: • an acute condition; • a life - threatening mental or physical illness; 02 REG -ME 1 02 REG -2 (10/02) AMENDMENT TO THE CERTIFICATE OF COVERAGE • pregnancy beyond the first trimester of pregnancy; • a physical or mental disability defined as an inability to engage in one or more major life activities, provided that the disability has lasted or can be expected to last for at least one year, or can be expected to result in death; or • a disabling or chronic condition that is in an acute phase. Authorization to continue to receive services from your current primary care provider, specialist or hospital may extend to the remainder of your life if a physician certifies that your life expectancy is 180 days or less. ii. Upon request, Medica will authorize continuity of care for up to 120 days as described in a. and b. above in the following situations: • if you are receiving culturally appropriate services and Medica does not have a network provider who has special expertise in the delivery of those culturally appropriate services within the time and • distance requirements defined in Minnesota law; or • if you do not speak English and Medica does not have a network provider who can communicate with you, either directly or through an interpreter, within the time and distance requirements defined in Minnesota law. Medica may require medical records or other supporting documentation from your provider to review your request, and will consider each request on a case -by -case basis. If Medica authorizes your request to continue care with your current provider, Medica will explain how continuity of care will be provided. After that time, your services or treatment will need to be transitioned to a network provider to continue to be eligible for in- network benefits. If your request is denied, Medica will explain the criteria used to make its decision. Coverage will not be provided for services or treatment that are not otherwise covered under this Certificate. If Medica terminates your current provider's contract for cause, Medica will inform you of the change and how your care will be transferred to another network provider. To request continuity of care or if you have questions about how this may apply to you, call Customer Service at the telephone numbers listed throughout this Certificate. V. The following is added to the Section titled Prescription Drugs and Pharmacy Services: If you have questions about the formulary, whether a specific prescription drug or supply is covered, or , would like to request a copy of the formulary at no charge, call Customer Service at the telephone numbers listed throughout this Certificate. VI. The following is added to the Section titled Prescription Drugs and Pharmacy Services: Your physician may request that Medics make an exception to allow the formulary copayment or coinsurance for a non - formulary prescription drug. Medica will work with your physician to determine if an exception is appropriate for your medical condition. Exceptions to the formulary can include antipsychotic drugs prescribed to treat emotional disturbance of mental illness, and certain drugs for diagnosed mental illness or emotional disturbance if removed from the formulary or you change health plans. If you would like to request a copy of Medica's formulary exception process, call Customer Service at the telephone numbers listed throughout this Certificate. VII. The following is added to the Section titled Mail Service Prescription Drug Program: If you have questions about the formulary, whether a specific prescription drug or supply is covered, or would like to request a copy of the formulary at no charge, call Customer Service at the telephone numbers listed throughout this Certificate. 02 REG -ME 2 02 REG - (10/02) AMENDMENT TO THE CERTIFICATE OF COVERAGE VIII. The following is added to Item 1. "Outpatient services include:" in the Section titled Mental Health effective July 1, 2001: h. Services, care or treatment ordered by a court on the basis of a behavioral health care evaluation performed by a physician or licensed psychologist and that includes an individual treatment plan. IX. The following is added to Item 2. "Inpatient services." in the Section titled Mental Health effective July 1, 2001: d. Services, care or treatment See items a, b, and c above See items a, b, and c above ordered by a court on the basis to determine your benefits. to determine your benefits. of a behavioral health care evaluation performed by a physician or licensed psychologist and that includes an individual treatment plan. X. Item 5 as found in the Section titled Mental Health, under the subsection `Services, supplies and associated expenses NOT covered:' is deleted and replaced with the following effective July 1, 2001: • 5. Services, care or treatment that is not medically necessary, unless ordered by a court as specifically described in this Section. XI. The following item is added to the Section titled Mental Health, under the subsection `Services, supplies and associated expenses NOT covered:' effective July 1, 2001: 9. Services, including room and board charges, provided by mental health providers who are not licensed to practice independently or substance abuse providers who are not certified, such as services received at a halfway house or therapeutic group home, except for outpatient mental health services that are specifically described in this Section. XII. The following is added to Item 1. "Outpatient services include:" in the Section titled Substance Abuse effective August 1, 2002: c. Services, care or treatment for a member that has been placed in the Minnesota Department of Corrections' custody following a conviction for a first - degree driving while impaired offense; to be eligible, such services, care or treatment must be required and provided by the Minnesota Department of Corrections. 02 REG -ME 3 02 REG -2 (10/02) AMENDMENT TO T E CERTIFICATE OF COVERAGE d. Services, care or treatment ordered by a court on the basis of a behavioral health care evaluation performed by a physician, licensed psychologist, licensed alcohol and drug dependency counselor or a certified chemical dependency assessor and that includes an individual treatment plan. XIII. The following is added to Item 2. "Inpatient services." in the Section titled Substance Abuse effective August 1, 2002: d. Services, care or treatment for See items a, b, and c above See items a, b, and c above a member that has been placed to determine your benefits. to determine your benefits. in the Minnesota Department of Corrections' custody following a conviction for a first -degree driving while impaired offense; to be eligible, such services, care or treatment must be required and provided by the Minnesota Department of Corrections. e. Services, care or treatment See items a, b, and c above See items a, b, and c above ordered by a court on the basis to determine your benefits. to determine your benefits. of a behavioral health care evaluation performed by a physician, licensed psychologist, licensed alcohol and drug dependency counselor or a certified chemical dependency assessor and that includes an individual treatment plan. XIV. Item 5 as found in the Section titled Substance Abuse, under the subsection `Services, supplies and associated expenses NOT covered:' is deleted and replaced with the following: 5. Services, care or treatment that is not medically necessary, unless ordered by a court as specifically described in this Section. XV. The following item is added to the Section titled Substance Abuse, under the subsection `Services, supplies and associated expenses NOT covered:' effective August 1, 2002: 8. Services, including room and board charges, provided by mental health providers who are not licensed to practice independently or substance abuse providers who are not certified, such as services received at a halfway house or therapeutic group home, except for outpatient substance abuse services that are specifically described in this Section. 02 REG -ME 4 02 REG -2 (10/02) AMENDMENT TO THE CERTIFICATE OF COVERAGE XVI. Items 39 and 40 as found in the Section titled Exclusions are deleted and replaced with the following: 39. Exams, other evaluations or other services for employment, insurance or licensure, unless otherwise covered under this Certificate. 40. Exams, other evaluations or other services for judicial or administrative proceedings or research (except emergency examination of a child ordered by judicial authorities) unless otherwise covered under this Certificate. XVII. Item 1 as found in the section titled Your Right to Convert Coverage is,deleted and replaced with the following: 1. If other group coverage is not available, you are eligible to convert to an HMO individual conversion plan without proof of good health or waiting periods at the following times: XVIII. Item 4.c. as found in the section titled Your Right to Convert Coverage is deleted and replaced with the following:, c. You are eligible for other group coverage. All other terms and conditions of the Certificate remain in full force and effect. Medica Health Plans 02 REG -ME 5 02 REG -2 (10/02) Ot Medica Elect PLAN MASTER GROUP CONTRACT Employer Name: City of Columbia Heights Employer Group#: 89945 Effective Date: January 01, 2003 Contract#: ME7, BPL Number: 97425 Amendments: 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 t ARTICLE 2 TERM OF CONTRACT Section 2.11 Term and Renewal. This Contract is effective from January 01, 2003 ( "Effective Date ") to December 31, 2003 ( "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; (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 i ARTICLE 4 PREMIUMS Section 4.1 Monthly Premiums. The monthly Premiums for this Contract are: Monthly Premium Rate Monthly Employer Monthly Enrollee Contribution Contribution Class 1 $338.02 Employer shall contribute a minimum of 50% (Single) towards the single monthly premium rate. Class 4 $776.27 (Family) 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 f 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 ERRO 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. A :TBCLE 6 ERBSA 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, ®. % NERSHIP 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 1 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 ASSIGNME� 'T 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 RECOR S 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 fumished 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. A TOCLE 19 N•.TICE 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 Clikgri ; yCT 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 January 3, 2003 to take effect on the Effective Date stated in the Contract. MEDICA EMPLOYER: 5601 Smetana Drive City of Columbia Heights Minnetonka, MN 55343 (952)992 -2200 Address: Billing Address: 590 40th Ave. NE M N015 -2838 P.O. Box 169063 Columbia Height, MN 55421 Duluth, MN 55816 Telephone: (763) 706 -3609 Mailing Address: P.O. Box 9310 Contract Minneapolis, MN 55440 Signer: 0 Title: City Manager er g Date: 2 - 27 - 03 By: Tom L. Henke Group Contact: Linda Magee Title: Vice President, Commercial Sales and Account Services Assistant to the City Manager/ Human Resources Director 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: Applicable Waiting Periods Classifications and Effective Dates 1. Eligibility: Full -time employees working a New Hires: Eligible date of hire. minimum of 40 hours per week/Elected officials also. 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: City of Columbia Heights Employer Group#: 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 EN F, G LLMENT 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. Toss 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 Y 1 . 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 PLAN MASTER GROUP CONTRACT Employer Name: City of Columbia Heights Employer Group#: 89944 Effective Date: January 01, 2003 Contract#: MCS7, BPL Number: 19570 Amendments: 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, 2003 ( "Effective Date ") to December 31, 2003 ( "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; (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 Monthly Enrollee Contribution Contribution Class 1 $375.56 Employer shall contribute a minimum of 50% (Single) towards the single monthly premium rate. Class 4 $862.50 (Family) 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 6 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 (0 WNERSHIP 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 117 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 IMedica'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. A� :TICLE 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 January 3, 2003 to take effect on the Effective Date stated in the Contract. MEDICA EMPLOYER: 5601 Smetana Drive City of Columbia Heights Minnetonka, MN 55343 (952)992 -2200 Address: Billing Address: 590 40th Ave. NE MN015 -2838 P.O. Box 169063 Columbia Height, MN 55421 Duluth, MN 55816 Telephone: (763) 706 -3609 Mailing Address: P.O. Box 9310 Contract Minneapolis, MN 55440 Signer: e Title: City Manager Date: 2/27/03 By: Tom L. Henke Group Contact: Linda Magee Title: Vice President, Commercial Sales and Account Services Assistant to the City Manager/ Human Resources Director 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: Applicable Waiting Periods Classifications and Effective Dates 1. Eligibility: Full -time employees working a New Hires: Eligible date of hire. minimum of 40 hours per week/Elected officials also. 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 Toad 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 Toad, 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: City of Columbia Heights Employer Group#: 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 Toss 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 Toss 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 Toss 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. 16. 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 4 • 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: City of Columbia Heights Employer Group#: 89947 Effective Date: January 01, 2003 Contract#: ME8, BPL Number: 97523 Amendments: 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 govemed 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, 2003 ( "Effective Date ") to December 31, 2003 ( "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; (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 Monthly Enrollee Contribution Contribution Class 1 $317.73 Employer shall contribute a minimum of 50% (Single) towards the single monthly premium rate. Class 4 $729.67 (Family) 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 6 EROS ?, 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 6 D,I TA ®W , J E ! SHIP 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 COVE ' ,2GE 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 SSIGNMENT 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 RECOR CIS 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 NciTICE 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 1 ' (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 CONT ',CT 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 January 3, 2003 to take effect on the Effective Date stated in the Contract. MEDICA EMPLOYER: 5601 Smetana Drive City of Columbia Heights Minnetonka, MN 55343 (952)992 -2200 Address: Billing Address: 590 40th Ave. NE M N015 -2838 P.O. Box 169063 Columbia Height, MN 55421 Duluth, MN 55816 Telephone: (763) 706 -3609 Mailing Address: P.O. Box 9310 Contract Minneapolis, MN 55440 Signer: . •/, V \- Title: City Manager Date: By: Tom L. Henke 9 / 9 7/n 1 Group Contact: Linda Magee Title: Vice President, Commercial Sales and Account Services Aggi atant to i City Manager/ Human Resources Director 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: Applicable Waiting Periods Classifications and Effective Dates 1. Eligibility: Full -time employees working a New Hires: Eligible date of hire. minimum of 40 hours per week/Elected officials also. 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. IC I Page 13 ENROLLMENT APPENDIX Employer Name: City of Columbia Heights Employer Group#: 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. SPECO L EN S OLLMENT 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 Toss 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. Toss 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 i (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 PLAN MASTER GROUP CONTRACT Employer Name: City of Columbia Heights Employer Group#: 89946 Effective Date: January 01, 2003 Contract#: MCS8, BPL Number: 18357 Amendments: Amendments attached as applicable for benefit package log (BPL) as listed above. ARTICLE 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 CONT CT Section 2.1 Term and RenewaO. This Contract is effective from January 01, 2003 ( "Effective Date ") to December 31, 2003 ( "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; (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 Monthly Enrollee Contribution Contribution Class 1 $353.03 Employer shall contribute a minimum of 50% (Single) towards the single monthly premium rate. Class 4 $810.95 (Family) 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. IA TICLE6 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 OV I ,IV,SHOP 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 COVE /- GE FORS. 'S 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. ACCE PV, NCE. OF COATS r,CT 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 January 3, 2003 to take effect on the Effective Date stated in the Contract. MEDICA EMPLOYER: 5601 Smetana Drive City of Columbia Heights Minnetonka, MN 55343 (952)992 -2200 Address: Billing Address: 590 40th Ave. NE MN015 -2838 P.O. Box 169063 Columbia Height, MN 55421 Duluth, MN 55816 Telephone: (763) 706 -3609 Mailing Address: P.O. Box 9310 Contract Minneapolis, MN 55440 Signer: „ L Titles City Manager Date: By: Tom L. Henke 2 -27 -03 Group Contact: Linda Magee Title: Vice President, Commercial Sales and Account Services Assistant to the City Manager/ Human Resources Director 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: Applicable Waiting Periods Classifications and Effective Dates 1. Eligibility: Full -time employees working a New Hires: Eligible date of hire. minimum of 40 hours per week/Elected officials also. 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; . I I 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: City of Columbia Heights Employer Group#: 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 1 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 5'601 Smetana Drive Mailing Address: Minnetonka, MN 55343 P.O. Box 9310 952- 992 -2900 Minneapolis, MN 55440 -9310 Important Information Regarding New Hearing Aid ����� Coverage for Medica Members Age 18 and Under MR80550 -HA 009305 Linda Magee City Of Columbia Heights 59040th Ave NE Columbia Hgts, MN 55421 -3878 �elelee�e�ee0eeleo�eleee��oe0�e0eeQo�ooe��oo�e�eDee00oeeDeele� September 19, 2003 Dear Linda Magee, Effective August 1, 2003, hearing aid coverage is available for Medica members 18 years of age or younger for hearing loss due to functional congenital malformation of the ears that is not correctable by other covered procedures. It is limited to one hearing aid per ear every three years. This added coverage is pursuant to 2003 Minnesota Statute, section 62Q.675. Please see the attached Amendment to your MGC for detailed information. What is functional congenital malformation? Functional congenital malformation is defined as born with a hearing loss due to a defect. What services are covered? Medici provides coverage for the office visit including testing, fitting, molds and the hearing aid. Batteries and repairs are covered when necessary due to normal wear and use. Appropriate deductibles and copayments or coinsurance apply. How can eligible members obtain hearing aids? Eligible members can obtain hearing aids from any Medica network hearing aid vendor. Medica's hearing aid vendors are network audiologists or network otolaryngologists (ENT) who are licensed to dispense hearing aids. Members need to coordinate care with their pediatrician or primary care physician. Members may obtain a list of hearing aid vendors by calling Medica or online at www.medica.com. • If you have questions, please contact the Medica Service Center at 952 - 992 -2200 or 1- 800 - 936 -6880. Sincerely, jea .4 Tom Henke Rich Sykora, Vice President & General Manager Vice President & General Manager Middle Market & Key Accounts Small Group & Administrators Medica Medica • (Amendment on back side) Medico refers to the family of health plan businesses that includes *Medici Health Plans, ' Medici Health Plans of Wisconsin, *Modica Insurance Company, *Medica Self - Insured and SelectCare. *Accredited by the National Committee for Quality Assurance. 20075 (5/02) An Equal Opportunity Employer AMENDMENT TO THE CERTIFICATE OF COVERAGE This amendment modifies your Medica Health Plans ( "Medica ") Certificate of Coverage ( "Certificate ") effective August 1, 2003. I. The following language is added in the subsection In- network benefits in the Sectio 1 titled Durable Medical Equipment And Prosthetics: In- network benefits also apply to hearing aids prescribed by a preferred network physician and received from a preferred network hearing aid vendor. II. The following item is added to the benefits table in the Section titled Durable Medical Equipment And Prosthetics: For Out -of- Network For In- Network Benefits After Benefits, Deductible, Benefits: You Pay: You Pay: 4. Hearing aids for members 18 years 20% coinsurance. No coverage. of age and younger for hearing loss Limited to one hearing aid due to functional congenital per ear every three years. malformation of the ears that is not Related services must be correctable by other covered prescribed by a physician procedures. and hearing aids must be received from a network hearing aid vendor. III. Item 5. in the Section titled Exclusions is deleted and replaced with the %Bowing: 5. Services provided by an audiologist when not under the direction of a physician, hearing aids and other devices to improve hearing, and their related fittings, except as stated in the Section titled Durable Medical Equipment And Prosthetics. All other terms and conditions of the Certificate shall remain in full force and effect. Medica Health Plans 03HearingME803 7/03