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MASTER GROUP CONTRACT
BETWEEN
CITY OF COLUMBIA HEIGHTS
AND
MEDICA INSURANCE COMPANY
MEDICA INSURANCE COMPANY ( "MEDICA ")
MASTER GROUP CONTRACT
ARTICLE 1
INTRODUCTION
This Master Group Contract ( "Contract ") is entered into by and between Medica Insurance
Company ( "Medica ") and the employer group identified in Exhibit 1 ( "Employer "). This Contract
includes Exhibit 1, Exhibit 2, the Group Application, Member enrollment forms, the Certificate of
Coverage ( "Certificate "), and any Amendments, all of which together shall constitute the entire
agreement between Medica and Employer concerning the health insurance coverage provided
under this Contract. This Contract includes the coverage option(s) set forth in Exhibit 2, offered
by the Employer under a single group health plan. This Contract is delivered in the state of
Minnesota.
The capitalized terms used in this Contract have the same meanings given to those terms
defined in the Certificate, unless otherwise specifically defined in this Contract.
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. If this Contract is governed by ERISA, any legal action arising out of or
relating to this Contract shall be brought in the federal district court for the district of Minnesota.
If this Contract is not governed by ERISA, any legal action arising out of or relating to this
Contract shall be brought in state court in Hennepin County, Minnesota.
In consideration of payment of the Premiums by the Employer and payment of applicable
Deductibles, Copayments, and Coinsurance by or for Members, Medica will provide coverage to
Members 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.
ARTICLE 2
TERM OF CONTRACT
Section 2.1 Term and Renewal. The initial Term of this Contract is set forth in Exhibit 1.
At least 30 days before each Expiration Date, as set forth in Exhibit 1, 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.
Medica Large Group MGC City of Columbia Heights
01/01/2018
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 following reasons, and such terminations will be effective
as stated below. Except as specified otherwise, 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 that Employer failed to pay the
required Premium when due, provided, however, that this Contract can be reinstated
pursuant to Section 5.2. If Employer fails to pay the required Premium within the grace
period described in Section 5.2, the Contract will be terminated, subject to a 30 -day advance
written notice of termination by Medica to Employer. The date of the termination shall be
retroactive to not more than 30 days prior to the effective date of the notice of termination;
(b) On the date specified by Medica because Employer committed fraud (through act, practice,
or omission) or intentionally 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 original 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) Automatically on the date Employer ceases to do business for any reason;
(f) 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 product within
the large employer market;
(g) 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 large employer market;
(h) On the date specified by Medica when there is no longer any Member who resides or works
in Medica's service area;
(i) Automatically on the date that Employer fails to maintain any active employees who are
Subscribers;
Q) 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 renewable basis.
Section 2.3 Notice of Termination.
Medica will notify Employer in writing if Medica terminates this Contract for any reason.
In accordance with applicable law, Medica will notify Subscribers in writing if Medica terminates
this Contract pursuant to Section 2.2(a), (b), (d), (f), or (g).
Employer will provide timely written notification to Subscribers in all circumstances for
which Medica does not provide written notification to Subscribers.
Medica Large Group MGC 2 City of Columbia Heights
01/01/2018
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.
ARTICLE 3
ENROLLMENT AND ELIGIBILITY
Section 3.1 Eligibility. The Eligibility conditions stated in Exhibit 1 of this Contract govern who
is eligible to enroll under this Contract. The eligibility conditions stated in Exhibit 1 are in
addition to those specified in the Certificate.
Section 3.2 Enrollment. The Certificate governs when eligible employees and eligible
dependents may enroll for coverage 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 to ensure appropriate enrollment of Members under the Contract.
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 discretion to determine whether employees and their dependents
are eligible to enroll for coverage under this Contract. Medica is entitled to rely upon Employer's
determination regarding an employee's and /or dependent's eligibility to enroll for coverage
under this Contract. 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.
Section 3.5 Notification. The Employer must notify Medica within 30 days of an individual's
initial enrollment application, changes to a Member's name or address, changes to a Member's
eligibility for coverage (including a loss of eligibility), or other changes to enrollment.
Section 3.6 Multiple Benefit Package Options. Subscribers and enrolled Dependents may
only switch between Employer's health coverage options offered under the Contract during a
Medica Large Group MGC 3 City of Columbia Heights
01/01/2018
Special Enrollment Period, or the Open Enrollment Period, if applicable, as described in the
Certificate.
ARTICLE 4
ELECTRONIC DELIVERY OF INSURANCE DOCUMENTS
The Employer agrees to deliver, as Medica's agent, insurance documents required by law to be
furnished to Subscribers. These documents shall be furnished by Medica to the Employer for
delivery to Subscribers. The Employer shall not modify these documents in any way. The
Employer agrees to deliver such documents electronically to the extent permissible under Title I
of the Employee Retirement Income Security Act of 1974, Department of Labor Regulation
§ 2520.104b -1(c), if applicable, and Minn. Stat. § 72A.20, subd. 37. Such documents shall be
delivered electronically only to Subscribers who meet the following requirements: (a) has the
ability to access an electronic document effectively at any location where the Subscriber is
reasonably expected to perform his or her duties as an employee, and (b) with respect to whom
access to the plan sponsor's electronic information system is an integral part of those duties.
The Employer shall implement procedures that ensure actual receipt of these documents and
notify Subscribers of the significance of the materials at the time of delivery. In addition, the
Employer shall inform the recipient of his or her right to request a paper version of these
documents, and an expedient process for doing so. Upon such a request, Employer shall
furnish the recipient with paper copies supplied by Medica. Employer shall inform Medica of
individuals who do not qualify for electronic delivery because they do not meet the requirements
regarding access to a computer, or they are not in the workplace, including but not limited to
those on continuation coverage, on retiree coverage, or covered pursuant to a qualified medical
child support order. Employer shall provide the individual's mailing information to Medica so
that Medica can provide the documents.
ARTICLE 5
PREMIUMS
Section 5.1 Monthly Premiums.
The monthly Premium rates for this Contract are set forth in Exhibit 2.
The Premiums are due on the first day of each calendar month. Employer shall pay the
Premiums to Medica in accordance with the method set forth in the invoice.
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 5.2 Grace Period and Reinstatement. Employer has a grace period of 10 days after
the due date stated in Section 5.1 to pay the monthly Premiums. Coverage shall continue
during this grace period. If Employer fails to pay the Premium, the Contract will be terminated in
accordance with Section 2.2(a). If Employer wishes to apply for reinstatement of the Contract,
any such application must be in writing and in the form designated by Medica. If Employer
applies for reinstatement and Medica, in its sole discretion, approves the application, then this
Contract will be reinstated upon approval, or lacking such approval, upon the 45th day following
the date Medica conditionally received full premium payment, unless Medica has otherwise
notified Employer in writing that the application was not approved. Medica is not obligated to
accept premium payment after the end of the grace period. In the event this Contract is not
reinstated pursuant to this Section, Medica shall not be responsible for any Claims for health
services received by Members after the effective date of the termination.
Medica Large Group MGC 4 City of Columbia Heights
01/01/2018
Section 5.3 Premium Calculation. The monthly Premiums owed by Employer shall be
calculated by Medica in accordance with Exhibit 2 using the number of Subscribers in each
coverage classification according to Medica's records at the time of the calculation. Subject to
Section 5.4, 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 whose
effective date falls after the 15th day of that calendar month. With the exception of termination
of coverage due to a Member's death, a Member's coverage may be terminated only at the end
of a calendar month and a full Premium amount for that month will apply. In the case of a
Member's death, that Member's coverage will be terminated on the date of death.
Section 5.4 Retroactive Adjustments. In accordance with applicable law and this Contract,
retroactive adjustments may be made for addition of Members, changes in Members' coverage
classifications, and certain terminations of Members not reflected in Medica's records at the
time the monthly Premiums were calculated by Medica. Employer understands and
acknowledges that federal law prohibits the retroactive termination of a Member's coverage
except in instances of fraud, intentional misrepresentation of material fact, or failure to timely
pay premiums or premium contributions. Employer agrees that it will not request retroactive
termination of any Member's coverage if such termination is prohibited by law. 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. In
accordance with the Certificate, retroactive terminations of coverage are effective at the end of a
calendar month. In the event Employer requests retroactive termination of a Member's
coverage, in accordance with applicable law and this Contract, any such termination will be
effective at the end of the month that includes the date that precedes the date Medica received
the request by 60 days.
Notwithstanding the foregoing, Employer shall pay a Premium for any month during which a
Member received Benefits (except as described in Section 5.3).
Section 5.5 Premium Changes. Medica may change the Premiums after 30 days prior written
notice to Employer.
Section 5.6 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;
and
(c) an administrative service fee of $250.00 at time of request for reinstatement.
Section 5.7 Premium Rebate Administration (When Applicable).
(a) General Obligation. In accordance with the Patient Protection and Affordable Care Act
( "PPACA "), Medica is obligated to provide a premium rebate to Employer if Medica's
medical loss ratio ( "MLR ") for the group market applicable to Employer's coverage does not
meet or exceed the minimum percentage required by PPACA for such group market.
PPACA requires Medica to make such determinations on a calendar year basis, regardless
of the Effective Date and Expiration Date of this Contract. For purposes of this Section 5.7,
"medical loss ratio" shall be defined in accordance with PPACA and the group market size
applicable to Employer's coverage shall be determined in accordance with PPACA's MLR
provisions and applicable state law and requirements.
Medica Large Group MGC 5 City of Columbia Heights
01/01/2018
(b) Rebate Determinations and Remittances. Medica agrees to determine whether such
rebates are owed under this Contract and, if applicable, remit such rebates to Employer
within the timeframe required by applicable law. Notwithstanding the foregoing, in the event
that Employer's group health plan has been terminated at the time rebate payment is due
and, despite reasonable efforts, Medica is unable to locate Employer, Medica will distribute
the entire rebate to Subscribers, in accordance with applicable law.
(c) Form of Rebates. Medica may, in its sole discretion, elect to provide any such rebates owed
in the form of a premium credit, a lump -sum check, or a lump -sum credit to the account used
to pay the premium.
(d) Employer's Responsibility Concerning Rebates. Employer agrees that it is Employer's
responsibility to determine how to treat any rebate funds remitted to Employer by Medica in
accordance with applicable law, including but not limited to 45 C.F.R. §158.242 and ERISA
requirements. Additionally, in no way limiting the foregoing, if Employer's group health plan
is not a governmental plan and is not subject to ERISA, Employer agrees that Employer
shall use the amount of any rebate that is proportionate to the total amount of premium paid
by all Subscribers for the coverage in a manner that benefits Subscribers and is specifically
provided in 45 C.F.R. §158.242(b)(1) and (2).
ARTICLE 6
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 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' 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 6.
ARTICLE 7
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 8
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 clerical error, such as a failure to record the termination.
Medica Large Group MGC a City of Columbia Heights
01/01/2018
ARTICLE 9
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 of the employee welfare benefit plan, as that term is used in ERISA. Medica shall
only be considered a named fiduciary for purposes of claims adjudication.
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 10
DATA OWNERSHIP AND USE
Information and data acquired, developed, generated, or maintained by Medica in the course of
performing under this Contract shall be Medica's sole property. Except as this Contract or
applicable law requires otherwise, Medica shall have no obligation to release such information
or data to Employer. Medica may, in its sole discretion, release such information or data to
Employer, but only to the extent permitted by law and subject to any restrictions determined by
Medica.
ARTICLE 11
CONTINUATION OF COVERAGE
Medica shall make available coverage under this Contract to those Members who are eligible to
continue coverage as required 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 12
SUMMARY OF BENEFITS AND COVERAGE
Medica will prepare a Summary of Benefits and Coverage ( "SBC "), as described under the
Patient Protection and Affordable Care Act ( "PPACA ") and related regulations, for each
coverage option set forth in Exhibit 2 and offered by Employer. Medica will provide applicable
SBCs to Employer. Employer will distribute such SBCs to individuals eligible for and covered
under Employer's group health plan in accordance with applicable federal regulations.
Medica Large Group MGC City of Columbia Heights
01/01/2018
ARTICLE 13
NONDISCRIMINATION AND EMPLOYER SHARED RESPONSIBILITY
To the extent, in accordance with the Patient Protection and Affordable Care Act ("PPACA"),
fully- insured group health plans other than grandfathered plans are subject to nondiscrimination
rules similar to those applicable to self- insured health plans under Section 105(h) of the Internal
Revenue Code. Medica assumes no responsibility for compliance with such rules. Employer,
as the sponsor of the insured employee benefit plan, shall be responsible for ensuring
compliance with any and all PPACA nondiscrimination requirements applicable to the insurance
coverage, including but not limited to payment of any and all governmental or regulatory taxes,
penalties, interest, or other charges resulting from noncompliance with applicable
nondiscrimination requirements. Employer, as the sponsor of the insured employee benefit
plan, is solely responsible (1) for determining whether, with respect to its employee workforce,
the aspects of a particular insurance contract are discriminatory under PPACA, and (2) for
appropriately addressing the situation if it is discriminatory under PPACA (including but not
limited to correcting, self- reporting, and payment of any penalties and interest related to the
discrimination).
PPACA added employer shared responsibility provisions as Section 4980H of the Internal
Revenue Code, under which an applicable large employer (as defined in Section 4980H) may
be subject to assessable payments in the event the employer fails to offer affordable coverage
providing minimum value to its full -time employees and their dependents and at least one full -
time employee is allowed a premium tax credit for coverage purchased through an insurance
exchange created pursuant to PPACA. PPACA also requires that applicable large employers
satisfy related information reporting requirements. The effective date of the employer shared
responsibility requirements and related information reporting requirements are as prescribed by
the federal government. Employer is solely responsible for ensuring compliance with PPACA's
employer shared responsibility provisions and related requirements, including but not limited to
(1) determining the full- time /part-time status of its employees; (2) communicating eligibility and
enrollment information to Medica, in accordance with Article 3 of this Contract; (3) determining
Employer and employee contributions to the payment of premium; (4) satisfying all information
reporting requirements applicable to applicable large employers; and (5) paying any and all
assessable payments, penalties, interest, or other charges resulting from noncompliance with
the employer shared responsibility provisions and related requirements.
ARTICLE 14
AMENDMENTS AND ALTERATIONS
Section 14.1 Standard Amendments. Except as provided in Section 14.2, 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 14.2 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.
Medica Large Group MGC 8 City of Columbia Heights
01/01/2018
ARTICLE 15
ASSIGNMENT
Neither party shall have the right to assign any of its rights and responsibilities under the
Contract to any person, corporation, or entity without the prior written consent of the other party;
provided, however, that Medica may, without the prior written consent of the Employer, assign
the Contract to any entity that controls Medica, is controlled by Medica, or is under common
control with Medica. In the event of assignment, the Contract shall be binding upon and inure to
the benefit of each party's successors and assigns.
ARTICLE 16
DISPUTE RESOLUTION
In the event that any dispute, claim, or controversy of any kind or nature relating to this Contract
arises between the parties, if acceptable to both parties, the parties will meet and make a good
faith effort to resolve the dispute. The party requesting the meeting will provide the other, in
advance of the meeting, with written notice of the claimed dispute. Upon receipt of the written
notice, representatives for each party will meet promptly to attempt to resolve the dispute. If a
mutually agreeable resolution is not reached within thirty (30) days following receipt of the
written notice, or if the parties do not agree to meet to attempt to resolve the dispute, either
party may pursue legal action in accordance with the terms of this Contract.
ARTICLE 17
PROVISIONS ON CERTAIN DEFENSES
All statements made by Employer shall, in the absence of fraud, be deemed representations
and not warranties. No statement made by Employer shall be used in defense to a claim under
the Contract unless such statement is in writing.
No statement made by Employer, except a fraudulent statement, shall be used to void this
Contract after it has been in force for a period of 2 years.
ARTICLE 18
RELATIONSHIPS
The relationship between Employer and any Member is that of Employer and Subscriber,
Dependent, or other coverage classification as defined in this Contract.
The relationships 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 the Network Provider is solely responsible for the services provided to any Member.
ARTICLE 19
EMPLOYER RECORDS
Employer shall furnish Medica with all information and proofs that Medica may reasonably
require with regard to any matters pertaining to this Contract. Medica may at any reasonable
time inspect all documents furnished to Employer by an individual in connection with the
Benefits, Employer's payroll records, and any other records pertinent to the Benefits under this
Contract.
Unless Employer provides the appropriate written assurances required by 45 CFR 164.504,
Medica will only provide Employer with summary health information (for the purposes of
Medica Large Group MGC 9 City of Columbia Heights
01/01/2018
obtaining premium bids or for modifying, amending, or terminating the group health plan only)
and information on whether individuals are participating in the group health plan, or is enrolled in
or has disenrolled from the health plan as provided in 45 CFR 164.504 (f)(1) and the minimum
necessary information for purposes of auditing Medica's operations or services.
ARTICLE 20
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 below. All notices to Employer shall be
sent to the persons and addresses stated in the Group Application. All notices to Medica and
Employer shall be deemed delivered:
(a) if delivered in person, on the date delivered in person;
(b) if delivered by a courier, on the date stated by the courier;
(c) if delivered by an express mail service, on the date stated by the mail service vendor; or
(d) if delivered by United States mail, 3 business days after date of mailing.
A party can change its address for receiving notices by providing the other party a written notice
of the change.
ARTICLE 21
COMMON LAW
No language contained in the Contract constitutes a waiver of Medica's rights under common
law.
Medica Large Group MGC 10 City of Columbia Heights
01/01/2018
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, Medica has caused this Contract to be executed on January 5, 2018,
to take effect on the Effective Date stated in Exhibit 1 to this Contract.
MEDICA INSURANCE COMPANY
401 Carlson Parkway
Minnetonka, MN 55305
(952) 992 -2200
Billing Address:
NW 7958
P.O. Box 1450
Minneapolis, MN 55485 -7958
Mailing Address:
P.O. Box 9310
Minneapolis, MN 55440
By:
Paul R. Crowley
Senior Vice President and General Manager,
Commercial Markets
By:
James P. Jacobson
Senior Vice President and Secretary
Medica Large Group MGC 11
EMPLOYER
City of Columbia Heights
Address:
590 40th Avenue Northeast
Columbia Heights, MN 55421
By.
Title
Date
City of Columbia Heights
01/01/2018
EXHIBIT 1
1. Parties. The parties to this Master Group Contract ( "Contract ") are Medica Insurance
Company ( "Medica ") and the employer group City of Columbia Heights ( "Employer "), an
employer under Minnesota law and other applicable law.
2. Effective Date and Expiration Date of this Contract. This Contract is effective from
01/01/2018 ( "Effective Date ") to 12/31/2018 ( "Expiration Date "). All coverage under this
Contract begins at 12:01 a.m. Central Time.
3. Amendment(s) Number: Amendments attached as applicable for benefit package log
(BPL) as listed in Exhibit 2.
4. Eligibility. The following conditions are in addition to those specified in the Certificate:
4.1 Eligibility to Enroll.
A Subscriber and his or her Dependents who satisfy 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.
4.2 Subscriber Definition, Waiting Periods and Coverage Effective Dates
Employees. An employee eligible to enroll under the Contract as a Subscriber must be an
individual who:
(1) Satisfies either (a) or (b) below:
(a) Is employed on average for at least 40 hours per week by Employer. Employer
shall determine the average number of hours worked and Medica is entitled to
rely on Employer's representation in this regard;
(b) For Employers utilizing documented measurement and stability periods (as
described in federal law) to determine an employee's eligibility for coverage: Is
an employee who Employer determines eligible for coverage throughout the
applicable stability period; provided that such determination is consistent with
federal law applicable to such eligibility determinations and other applicable
provisions of this Contract; and
(2) Satisfies the Employer participation and eligibility requirements, including, but not
limited to, the satisfactory completion of any Waiting Period as described below.
Medica Large Group MGC Exhibit 1 City of Columbia Heights
Page 1 01/01/2018
Coverage for Subscribers will include the conditions identified below:
Classifications and Plan Design Waiting Period and Coverage Effective Date
Employees: , New Hires: Date of hire
Status Change: Date of status change
Return: Date of return from leave
Rehire: Date of rehire
In the event Employer imposes a Waiting Period on all otherwise eligible employees, such
Waiting Period shall be uniform and shall be as described herein. Any such Waiting Period
shall be calculated in compliance with the applicable provisions of PPACA and any and all
regulations and guidance issued pursuant to PPACA, including but not limited to 29 C.F.R.
§2590.715 -2708 and 45 C.F.R. §147.116, and shall in no event exceed 90 days. Employer
acknowledges that any desired change to applicable Waiting Periods or other provisions of
this Contract concerning employee eligibility require prior notice to Medica and a mutually
agreeable amendment to the Contract. Employer shall calculate the appropriate effective
date of coverage for each employee and inform Medica of such date. Medica is entitled to
rely on Employer's representation herein that the effective date of coverage does not violate
the applicable provisions of PPACA or any regulations or guidance issued pursuant to
PPACA.
Medica Large Group MGC Exhibit 1 City of Columbia Heights
Page 2 01/01/2018
EXHIBIT 2
Premiums
The monthly Premium rates for MIC PP MN 1500 -0% HSA, Passport, group number(s) 25520,
BPL #71594 are:
Single
$718.96
The monthly Premium rates for MIC PP MN 1500 -0% HSA, Passport, group number(s) 25628,
BPL #71595 are:
Family
$1,653.61
The monthly Premium rates for MIC ME /MES MN 1500 -0% HSA, Elect, group number(s)
25451, BPL #71596 are:
Single $668.63
The monthly Premium rates for MIC ME /MES MN 1500 -0% HSA, Essential, group number(s)
25454, BPL #71596 are:
l Single
1 $668.63
The monthly Premium rates for MIC ME /MES MN 1500 -0% HSA, Elect, group number(s)
25626, BPL #71597 are:
f Family $1,537.85
The monthly Premium rates for MIC ME /MES MN 1500 -0% HSA, Essential, group number(s)
25627, BPL #71597 are:
Family
$1, 537.85 1
The monthly Premium rates for MIC PP MN 2700 -0% HSA, Passport, group number(s) 25521,
BPL #71598 are:
Single $636.18
Family $1,463.21
The monthly Premium rates for MIC ME /MES MN 2700 -0% HSA, Elect, group number(s)
25452, BPL #71599 are:
Single -- $591.64
Family $11360.78
Medica Large Group MGC Exhibit 2 City of Columbia Heights
Page 1 01/01/2018
The monthly Premium rates for MIC ME /MES MN 2700 -0% HSA, Essential, group number(s)
25456, BPL #71599 are:
Single $591.64
Family $1,360.78
The monthly Premium rates for MIC PP MN 0 % -15, Passport, group number(s) 25519,
BPL #82440 are:
Single 1$815.49
Family 1 $1,875.63
The monthly Premium rates for MIC ME /MES MN 0 % -15, Elect, group number(s) 25450,
BPL #82441 are:
Single $758.41
Family $1,744.34
The monthly Premium rates for MIC ME /MES MN 0 % -15, Essential, group number(s) 25453,
BPL #82441 are:
Single $758.41
Family $1,744.34
Medica Large Group MGC Exhibit 2 City of Columbia Heights
Page 2 01/01/2018