RFP : GROUP HEALTH INSURANCE

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1 REQUEST FOR PROPOSAL INSTRUCTIONS SPECIFICATIONS BID SHEET(S) FOR RFP : GROUP HEALTH INSURANCE PER EAST TEXAS COUNCIL OF GOVERNMENTS SPECIFICATIONS AT EAST TEXAS COUNCIL OF GOVERNMENTS HUMAN RESOURCES DEPARTMENT OPENING DATE: TUESDAY, MARCH 24, :00 AM CST EAST TEXAS COUNCIL OF GOVERNMENTS HUMAN RESOURCES DEPARTMENT 3800 STONE ROAD KILGORE, TEXAS 75662

2 REQUEST FOR PROPOSAL Return Bid To: East Texas Council of Governments Human Resources Department 3800 Stone Road Kilgore, TX, The enclosed REQUEST FOR PROPOSAL and accompanying Specifications with Bid Sheets are for your convenience in bidding the enclosed referenced products and/or services for East Texas Council of Governments. Sealed bids shall be received no later than: 10:00 AM CST, MARCH 24, 2015, TUESDAY. Please reference RFP : GROUP HEALTH INSURANCE in all correspondence pertaining to this bid and affix this number to outside front of bid envelope for identification. All bids shall be to the attention of the Human Resources Department. East Texas Council of Governments appreciates your time and effort in preparing a bid. Please note that all bids must be received at the designated location by the deadline shown. Bids received after the deadline will be returned unopened and shall be considered void and unacceptable. Bid opening is scheduled to be held in the Human Resources Department, 3800 Stone Road, Kilgore, Texas. If Bidder desires not to bid at this time, but wishes to remain on the commodity bid list, please submit a "NO BID" response (same time/location). East Texas Council of Governments is always very conscious and extremely appreciative of the time and effort expended to submit a bid. However, on "NO BID" responses please communicate any bid requirement(s) which may have influenced your decision to "NO BID." If response is not received in the form of a "BID" or "NO BID" for three (3) consecutive REQUEST FOR PROPOSAL, Bidder shall be removed from said bid list. However, if you choose to "NO BID" at this time but desire to remain on the bid list for other commodities, please state the specific product/service for which your firm wishes to be classified. Awards should be made approximately three weeks following the bid opening date. To obtain results, or if you have any questions, please contact the Human Resources Department a: EAST TEXAS COUNCIL OF GOVERNMENTS HUMAN RESOURCES DEPARTMENT 3800 STONE ROAD KILGORE, TEXAS 75662

3 REQUEST FOR PROPOSAL INSTRUCTIONS/TERMS OF CONTRACT/GENERAL REQUIREMENTS RFP : GROUP HEALTH INSURANCE By order of East Texas Council of Governments, sealed bids will be received for: GROUP HEALTH INSURANCE TO PROVIDE for an annual Contract commencing after the date of the award and continuing for twelve month period. East Texas Council of Governments reserves the right to extend this contract for four (4) additional one-year periods as it deems to be in the best interest of the city. IT IS UNDERSTOOD that East Texas Council of Governments, reserves the right to reject any and/or all bids for any/or all products and/or services covered in this bid request and to waive informalities or defects in bids or to accept such bids as it shall deem to be in the best interests of East Texas Council of Governments. BIDS MUST BE submitted on the enclosed response. Each bid shall be placed in a separate sealed envelope, with each form manually signed by a person having the authority to bind the firm in a Contract, and marked clearly on the outside as shown below. FACSIMILE TRANSMITTALS SHALL NOT BE ACCEPTED! SUBMISSION OF BIDS: Sealed bids shall be submitted no later than 10:00 AM, MARCH 24, 2015, TUESDAY to the address as follows: East Texas Council of Governments Human Resources Department 3800 Stone Road Kilgore, TX, MARK ENVELOPE: "RFP GROUP HEALTH INSURANCE ALL BIDS MUST BE RECEIVED IN THE HUMAN RESOURCES DEPARTMENT BEFORE OPENING DATE AND TIME. EAST TEXAS COUNCIL OF GOVERNMENTS HUMAN RESOURCES DEPARTMENT 3800 STONE ROAD KILGORE, TEXAS 75662

4 RFP GROUP HEALTH INSURANCE BIDDERS PLEASE NOTE: TWO COPIES OF THE FOLLOWING BID SHEETS HAVE BEEN ENCLOSED FOR YOUR CONVENIENCE Bid Affidavit Form (required) Response Form (required) Conflict of Interest Form (required) Actual rates, terms & conditions of proposal (required) EAST TEXAS COUNCIL OF GOVERNMENTS HUMAN RESOURCES DEPARTMENT 3800 STONE ROAD KILGORE, TX, Page 4

5 RFP GROUP HEALTH INSURANCE PUBLIC NOTICE STATEMENT FOR ADA COMPLIANCE East Texas Council of Governments acknowledges its responsibility to comply with the Americans with Disabilities Act of Thus, in order to assist individuals with disabilities who require special services (i.e. sign interpretative services, alternative audio/visual devices, and amanuenses) for participation in or access to East Texas Council of Governments sponsored public programs, services and/or meetings, East Texas Council of Governments requests that individuals make request for these services forty-eight (48) hours ahead of the scheduled program, service and/or meeting. To make arrangements, contact Brandy Brannon, HR Director or other designated official at (903) EAST TEXAS COUNCIL OF GOVERNMENTS HUMAN RESOURCES DEPARTMENT 3800 STONE ROAD KILGORE, TX, Page 5

6 RFP GROUP HEALTH INSURANCE FUNDING: Funds for payment have been provided through East Texas Council of Governments budget approved by their Executive Committee for this fiscal year only. State of Texas statutes prohibit the obligation and expenditure of public funds beyond the fiscal year for which a budget has been approved. Therefore, anticipated orders or other obligations that may arise past the end of the current fiscal year shall be subject to budget approval. LATE BIDS: Bids received in East Texas Council of Governments Human Resources Department after submission deadline will be considered void and unacceptable. East Texas Council of Governments is not responsible for lateness or non-delivery of mail, carrier, etc., and the date/time stamp in the Human Resources Department shall be the official time of receipt. ALTERING BIDS: Bids can be negotiated, amended, and/or revised after the bid opening prior to contract placement provided any changes are in writing as indicated in the enclosed executed waiver by East Texas Council of Governments to House Bill 1466, Article of the Texas Insurance Code. Any interlineation, alteration, or erasure made before opening time must be initialed by the signer of the bid, guaranteeing authenticity. East Texas Council of Governments reserves the right to accept, negotiate, amend or reject any/all of the bid as it deems to be in the best interest of East Texas Council of Governments. WITHDRAWAL OF BID: A bid may not be withdrawn or canceled by the Bidder without the permission of East Texas Council of Governments for a period of ninety (90) days following the date designated for the receipt of bids, and Bidder so agrees upon submittal of their bid. SALES TAX: East Texas Council of Governments is exempt by law from payment of Texas State Sales Tax and Federal Excise Tax. Bidder shall include any sales taxes from concession sales of taxable items on East Texas Council of Governments property in the total price of the sale, and shall be responsible to report and pay such taxes in a timely manner. BID AWARD: East Texas Council of Governments reserves the right to award any combination of the three sections as is deemed in the best interest of East Texas Council of Governments. East Texas Council of Governments also reserves the right to not award one or none of the sections. CONTRACT: This bid, when properly accepted by East Texas Council of Governments, shall constitute a Contract equally binding between the successful Bidder and East Texas Council of Governments. No different or additional terms will become a part of this Contract with the exception of Change Orders. CHANGE ORDERS: No oral statement of any individual shall modify or otherwise change, or affect the terms, conditions or Specifications stated in the resulting Contract. All Change Orders EAST TEXAS COUNCIL OF GOVERNMENTS HUMAN RESOURCES DEPARTMENT 3800 STONE ROAD KILGORE, TX, Page 6

7 RFP GROUP HEALTH INSURANCE to the Contract will be made in writing by the East Texas Council of Governments Human Resources Director. IF DURING THE life of the Contract, the successful Bidder s net prices to other customers for items awarded herein are reduced below the Contracted price, it is understood and agreed that the benefits of such reduction shall be extended to East Texas Council of Governments. A PRICE redetermination may be considered by East Texas Council of Governments only at the anniversary date of the Contract and shall be substantiated in writing (i.e., Manufacturer s direct cost, postage rates, Railroad Commission rates, Wage/Labor rates, etc.). The Bidder s past history of honoring Contracts at the bid price will be an important consideration in the evaluation of the lowest and best bid. East Texas Council of Governments reserves the right to accept or reject any/all of the price redetermination as it deems to be in the best interest of the East Texas Council of Governments. DELIVERY: all delivery and freight charges (F.O.B. East Texas Council of Governments) are to be included in the bid price. DELIVERY TIME: Bids shall show number of days required to place goods ordered at the East Texas Council of Governments designated location. Failure to state delivery time may cause bid to be rejected. Successful Bidder shall notify the Human Resources Department immediately if delivery schedule cannot be met. If delay is foreseen, successful Bidder shall give written notice to the Human Resources Director. East Texas Council of Governments has the right to extend delivery time if reason appears valid. Successful Bidder must keep the Human Resources Department advised at all times of the status of the order. CONFLICT OF INTEREST: No public official shall have interest in this Contract, in accordance with Vernon's Texas Codes Annotated, Local Government Code Title 5. Subtitle C, Chapter 171. DISCLOSURE OF CERTAIN RELATIONSHIPS Effective January 1, 2008, Chapter 176 of the Texas Local Government Code requires that any vendor or person considering doing business with a local government entity disclose in the Questionnaire Form CIQ, the vendor or person s affiliation or business relationship that might cause a conflict of interest with a local government entity. By law, this questionnaire must be filed with the records administrator of East Texas Council of Governments not later than the 7 th business day after the date the person becomes aware of facts that require the statement to be filed. See Section , Local Government Code. A person commits an offense if the person violates Section , Local Government Code. An offense under this section is a Class C misdemeanor. EAST TEXAS COUNCIL OF GOVERNMENTS HUMAN RESOURCES DEPARTMENT 3800 STONE ROAD KILGORE, TX, Page 7

8 RFP GROUP HEALTH INSURANCE ETHICS: The Bidder shall not offer or accept gifts of anything of value nor enter into any business arrangement with any employee, official or agent of East Texas Council of Governments. EXCEPTIONS/SUBSTITUTIONS: All bids meeting the intent of this REQUEST FOR PROPOSAL will be considered for award. Bidders taking exception to the Specifications, or offering substitutions, shall state these exceptions in the section provided or by attachment as part of the bid. In the absence of such, a list shall indicate that the Bidder has not taken exceptions and shall hold the Bidder responsible to perform in strict accordance with the Specifications of the Invitation. East Texas Council of Governments reserves the right to accept any and all, or none, of the exception(s)/ substitution(s) deemed to be in the best interest of East Texas Council of Governments. ADDENDA: Any interpretations, corrections or changes to this REQUEST FOR PROPOSAL and Specifications will be made by addenda. Sole issuing authority of addenda shall be vested in East Texas Council of Governments Human Resources Director. Addenda will be mailed to all who are known to have received a copy of this REQUEST FOR PROPOSAL. Bidders shall acknowledge receipt of all addenda. DESCRIPTIONS: Any reference to model and/or make/manufacturer used in bid Specifications will be made by addenda. Sole issuing authority of addenda shall be vested in the East Texas Council of Governments Human Resources Director. Addenda will be mailed to all who are known to have received a copy of this REQUEST FOR PROPOSAL. Bidders shall acknowledge receipt of all addenda. BID MUST COMPLY with all federal, state, county, and local laws concerning these types of service(s). DESIGN, STRENGTH, QUALITY of materials must conform to the highest standards of manufacturing and engineering practice. All items supplied against credit must be new and unused, unless otherwise specified, in firstclass condition and of current manufacturer. MINIMUM STANDARDS FOR RESPONSIBLE PROSPECTIVE BIDDERS: A prospective Bidder must affirmatively demonstrate Bidder's responsibility. A prospective Bidder must meet the following requirements: 1. Have adequate financial resources, or the ability to obtain such resources as required; 2. be able to comply with the required or proposed delivery schedule; 3. have a satisfactory record of performance; 4. have a satisfactory record of integrity and ethics; EAST TEXAS COUNCIL OF GOVERNMENTS HUMAN RESOURCES DEPARTMENT 3800 STONE ROAD KILGORE, TX, Page 8

9 RFP GROUP HEALTH INSURANCE 5. be otherwise qualified and eligible to receive an award. East Texas Council of Governments may request representation and other information sufficient to determine Bidder's ability to meet these minimum standards listed above. REFERENCES: Upon the selection of finalist, East Texas Council of Governments may request Bidder to supply, with this REQUEST FOR PROPOSAL, a list of at least three (3) references where like products and/or services have been supplied by their firm. Include name of firm, address, telephone number and name of representative. The references should be provided upon request. BIDDER SHALL PROVIDE with this bid response, all documentation required by this REQUEST FOR PROPOSAL. Failure to provide this information may result in rejection of bid. SUCCESSFUL BIDDER SHALL defend, indemnify and save harmless East Texas Council of Governments and all its officers, agents and employees from all suits, actions, or other claims of any character, name and description brought for or on account of any injuries or damages received or sustained by any person, persons, or property on account of any negligent act or fault of the successful Bidder, or of any agent, employee, subcontractor or supplier in the execution of, or performance under, any Contract which may result from bid award. Successful Bidder indemnifies and will indemnify and save harmless East Texas Council of Governments from liability, claim or demand on their part, agents, servants, customers, and/or employees whether such liability, claim or demand arise from event or casualty happening or within the occupied premises themselves or happening upon or in any of the halls, elevators, entrances, stairways or approaches of or to the facilities within which the occupied premises are located. Successful Bidder shall pay any judgment with costs which may be obtained against East Texas Council of Governments growing out of such injury or damages. In addition, Contractor shall obtain and file with East Texas Council of Governments, a Standard Certificate of Insurance and applicable policy endorsement evidencing the required coverage and naming East Texas Council of Governments as an additional insured on the required coverage. WAGES: Successful Bidder shall pay or cause to be paid, without cost or expense to East Texas Council of Governments, all Social Security, Unemployment and Federal Income Withholding Taxes of all such employees and all such employees shall be paid wages and benefits as required by Federal and/or State Law. TERMINATION OF CONTRACT: This Contract shall remain in effect until Contract expires, delivery and acceptance of products and/or performance of services ordered or terminated by either party with a thirty (30) day written notice prior to any cancellation. The successful Bidder must state therein the reasons for such cancellation. East Texas Council of Governments reserves the right to award canceled Contract to best Bidder as it deems to be in the best interest of East Texas Council of Governments. EAST TEXAS COUNCIL OF GOVERNMENTS HUMAN RESOURCES DEPARTMENT 3800 STONE ROAD KILGORE, TX, Page 9

10 RFP GROUP HEALTH INSURANCE TERMINATION FOR DEFAULT: East Texas Council of Governments reserves the right to enforce the performance of this Contract in any manner prescribed by law or deemed to be in the best interest of East Texas Council of Governments in the event of breach or default of this Contract. East Texas Council of Governments reserves the right to terminate the Contract immediately in the event the successful Bidder fails to: 1. Meet schedules; 2. defaults in the payment of any fees; or 3. otherwise perform in accordance with these Specifications. Breach of Contract or default authorizes East Texas Council of Governments to exercise any or all of the following rights: 1. East Texas Council of Governments may take possession of the assigned premises and any fees accrued or becoming due to date; 2. East Texas Council of Governments may take possession of all goods, fixtures and materials of successful Bidder therein and may foreclose its lien against such personal property, applying the proceeds toward fees due or thereafter becoming due. In the event the successful Bidder shall fail to perform, keep or observe any of the terms and conditions to be performed, kept or observed, East Texas Council of Governments shall give the successful Bidder written notice of such default; and in the event said default is not remedied to the satisfaction and approval of East Texas Council of Governments within two (2) working days of receipt of such notice by the successful Bidder, default will be declared and all the successful Bidder's rights shall terminate. Bidder, in submitting this bid, agrees that East Texas Council of Governments shall not be liable to prosecution for damages in the event that East Texas Council of Governments declares the Bidder in default. NOTICE: Any notice provided by this bid (or required by law) to be given to the successful Bidder by East Texas Council of Governments shall conclusively deemed to have been given and received on the next day after such written notice has been deposited in the mail to East Texas Council of Governments, by Registered or Certified Mail with sufficient postage affixed thereto, addressed to the successful Bidder at the address so provided; provided this shall not prevent the giving of actual notice in any other manner. PATENTS/COPYRIGHTS: The successful Bidder agrees to protect East Texas Council of Governments from claims involving infringement of patents and/or copyrights. EAST TEXAS COUNCIL OF GOVERNMENTS HUMAN RESOURCES DEPARTMENT 3800 STONE ROAD KILGORE, TX, Page 10

11 RFP GROUP HEALTH INSURANCE CONTRACT ADMINISTRATOR: Under this Contract, East Texas Council of Governments may appoint a Contract Administrator with designated responsibility to ensure compliance with Contract requirements, such as but not limited to, acceptance, inspection and delivery. The Contract Administrator will serve as liaison between East Texas Council of Governments Human Resources Department (which has the overall Contract Administration responsibilities) and the successful Bidder. PURCHASE ORDER: A Purchase Order(s) shall be generated by East Texas Council of Governments to the successful Bidder. The Purchase Order number must appear on all itemized invoices and packing slips. East Texas Council of Governments will not be held responsible for any orders placed/delivered without a valid current Purchase Order number. PACKING SLIPS or other suitable shipping documents shall accompany each special order shipment and shall show: (a) name and address of successful Bidder, (b) name and address of receiving department and/or delivery location, (c) Purchase Order number, and (d) descriptive information as to the item(s) delivered, including product code, item number, quantity, number of containers, etc. INVOICES shall show all information as stated above, shall be mailed directly to East Texas Council of Governments, 3800 Stone Road, Kilgore, TX, PAYMENT will be made upon receipt and acceptance by East Texas Council of Governments for any item(s) ordered and receipt of a valid invoice, in accordance with the State of Texas Prompt Payment Act, Article 601f V.T.C.S. Successful Bidder(s) required to pay subcontractors within ten (10) days. ITEMS supplied under this Contract shall be subject to East Texas Council of Governments approval. Items found defective or not meeting Specifications shall be picked up and replaced by the successful Bidder at the next service date at no expense to East Texas Council of Governments. If item is not picked up within one (1) week after notification, the item will become a donation to East Texas Council of Governments for disposition. SAMPLES: When requested, samples shall be furnished free of expense to East Texas Council of Governments. WARRANTY: Successful Bidder shall warrant that all items/services shall conform to the proposed Specifications and/or all warranties as stated in the Uniform Commercial Code and be free from all defects in material, workmanship and title. A copy of the warranty for each item being bid must be enclosed. Failure to comply with the above requirements for literature and warranty information could cause bid to be rejected. EAST TEXAS COUNCIL OF GOVERNMENTS HUMAN RESOURCES DEPARTMENT 3800 STONE ROAD KILGORE, TX, Page 11

12 RFP GROUP HEALTH INSURANCE REMEDIES: The successful Bidder and East Texas Council of Governments agree that both parties have all rights, duties and remedies available as stated in the Uniform Commercial Code. VENUE: This Agreement will be governed and construed according to the laws of the State of Texas. This Agreement is performable in Kilgore, Texas. ASSIGNMENT: The successful Bidder shall not sell, assign, transfer or convey this Contract, in whole or in part, without prior written consent of East Texas Council of Governments. SPECIFICATIONS and model numbers are for description only. Bidder may bid on description only. Bidder may bid on alternate model but must clearly indicate alternate model being bid. Bidder must enclose full descriptive literature on alternate item(s). SILENCE OF SPECIFICATION: The apparent silence of these Specifications as to any detail or to the apparent omission of a detailed description concerning any point, shall be regarded as meaning that only the best commercial practices are to prevail. All interpretations of these Specifications shall be made on the basis of this statement. Each insurance policy to be furnished by successful Bidder shall include, by endorsement to the policy, a statement that a notice shall be given to East Texas Council of Governments by Certified Mail thirty (30) days prior to cancellation or upon any material change in coverage. ANY QUESTIONS concerning this REQUEST FOR PROPOSAL and Specifications should be directed to Carolyn Summy-Thompson, Brinson Benefits, Inc., , EAST TEXAS COUNCIL OF GOVERNMENTS HUMAN RESOURCES DEPARTMENT 3800 STONE ROAD KILGORE, TX, Page 12

13 RFP GROUP HEALTH INSURANCE GENERAL REQUIREMENTS 1) The information contained in these specifications is confidential and is to be used only in connection with preparing a bid for all or part of the following employee benefit plans: Group Medical Insurance 2) Currently all products are offered on a June 1 effective date. 3) All bid responses should be provided on the enclosed response forms with the signature of your authorized representative. If attachments are necessary, please provide. DO NOT MODIFY RESPONSE FORMS. Proposals must include two hard copies of the completed Bid Affidavit, Response Form, Conflict of Interest Form including actual rates, terms and conditions. Any additional information should be provided at the end of the response form. Contact Brinson Benefits, Inc. for a copy of the response forms to be sent via for your convenience. 4) East Texas Council of Governments has appointed Brinson Benefits as their Agent of Record/Employee Benefit Consultant and is not selecting a new broker/consultant therefore; Medical Insurance should be submitted on a NET commission basis. If you are required to include commissions in your products, please note this clearly on your response form. 5) Retirees are not covered. Covered participants include: Full Time employees and COBRA participants. The census does identify these participants. 6) No telephone, telephonic or fax bids will be accepted. Bids must be sealed and delivered to the Human Resources Department at East Texas Council of Governments prior to the official bid opening time. East Texas Council of Governments will not be responsible for missing, lost or late proposals. Any bids received after the time set for opening will be returned to the sender. 7) The information contained herein is believed to be accurate and up-to-date, but is not intended to be an express or implied warranty. 8) Bids are to be submitted on the basis of the specifications contained herein. Alternate bids are encouraged and will be considered provided the alternatives enhance the current plan and are clearly explained. All deviations from the specifications must be clearly identified and explained. 9) East Texas Council of Governments reserves the right to negotiate, amend, accept or reject all or any part of the bids, waive minor technicalities, and award the bid that best serves the interest of East Texas Council of Governments. East Texas Council of Governments also reserves the right to waive or dispense with any of the formalities contained herein. 10) Proposals must be submitted for coverage on all eligible full-time regular employees and their dependents. Full-time is defined as 40 or more hours per week. Dependent is defined as the employee's spouse and/or unmarried children from birth to age 26 and claimed as a dependent. 11) Waiting period: Newly hired employees and their dependents must complete 0 days of active employment before becoming eligible for coverage. EAST TEXAS COUNCIL OF GOVERNMENTS HUMAN RESOURCES DEPARTMENT 3800 STONE ROAD KILGORE, TX, Page 13

14 RFP GROUP HEALTH INSURANCE 12) Eligibility: All full-time employees and their dependents are eligible on the first day of hire. Terminated employees and all others currently covered under COBRA may continue coverage under COBRA. 13) Contribution: Medical is employer paid for employee only coverage and contributes 25% to dependent coverage. 14) Social Security: East Texas Council of Governments has opted out of social security at this time but has a voluntary life retirement plan. 15) Workers Compensation East Texas Council of Governments has State Workers Comp. East Texas Council of Governments is aware of the time and effort you expend in preparing and submitting proposals to East Texas Council of Governments. Please let us know of any requirements in the RFP that are causing you difficulty in responding. We want to make this process as easy as possible so that all responsible vendors can compete for East Texas Council of Governments business. EAST TEXAS COUNCIL OF GOVERNMENTS HUMAN RESOURCES DEPARTMENT 3800 STONE ROAD KILGORE, TX, Page 14

15 RFP GROUP HEALTH INSURANCE East Texas Council of Governments GROUP MEDICAL INSURANCE 1. Assumptions a) East Texas Council of Governments offers a fully insured core, buy-up and Louisiana PPO plan. See attached plan design. The bid is based on duplication of current benefits. Alternate plan designs are welcome. b) East Texas Council of Governments pays 100% employee costs and 25% dependent costs. Dependent contribution strategy may change. c) Bus Drivers are newly eligible as of 6/1/15. d) Census COVERAGE Core LA Buy-Up Employee Only Employee & Spouse Employee & Child(ren) Employee & Family COBRA 3 (included 0 above EE) 0 Waived e) Effective date is June 1, f) All participants enrolled in the plan as of May 31, 2015 are to be covered on a No loss/no gain basis. No loss/no gain for participants is to include credit for accumulated deductible and coinsurance as applicable. The participant will provide documentation for this credit. e) The selected insurance provider will provide enrollment and educational materials, as well as participant in East Texas Council of Governments annual open enrollment presentations. f) East Texas Council of Governments must receive renewal rates by February 28 th, preceding the June 1 st renewal date. Refer to the Bid Affidavit. g) A true open enrollment is required annually. h) COBRA/HIPAA will be administered by COBRA Charmers, Inc. This is not anticipated to change. i) See attached (Exhibit 1) for current summary of benefits. EAST TEXAS COUNCIL OF GOVERNMENTS HUMAN RESOURCES DEPARTMENT 3800 STONE ROAD KILGORE, TX, Page 15

16 RFP GROUP HEALTH INSURANCE 2. Rates and History Current Renewal Period Large Claim / Ongoing Medical Conditions Detail: See attached claims data from Aetna: East Texas Council of Governments has knowledge of the following relating to the large claims indicated by Aetna: ) $95,027- car accident; doing well 2) $20,097- receiving therapy 3) $35,735 no further information known PPO/Buy-Up PPO MEDICAL PLAN YEAR NET OF COMMISSION Employee Only EE+ Spouse EE+ Child(ren) EE+ Family RENEWAL June 1, 2015 May 31, 2016 $ $1, $1, $1, June 1, 2014 May 31, 2015 June 1, 2013 May 31, 2014 June 1, 2012 May 31, 2013 $ $1, $ $1, $ $ $ $1, $ $ $ $ June 1, 2011 May 31, 2012 $ $ $ $ June 1, 2010 May 31, 2011 $ $ $ $ June 1, 2009 May 31, 2010 $ $ $ $ June 1, 2008 May 31, 2009 $ $ $ $ PPO/Core PPO MEDICAL PLAN YEAR NET OF COMMISSION Employee Only EE+ Spouse EE+ Child(ren) EE+ Family RENEWAL June 1, 2015 May 31, 2016 $ $ $ $1, June 1, 2014 May 31, 2015 $ $ $ $1, EAST TEXAS COUNCIL OF GOVERNMENTS HUMAN RESOURCES DEPARTMENT 3800 STONE ROAD KILGORE, TX, Page 16

17 RFP GROUP HEALTH INSURANCE PPO/LA PPO MEDICAL PLAN YEAR NET OF COMMISSION Employee Only EE+ Spouse EE+ Child(ren) EE+ Family RENEWAL June 1, 2015 May 31, 2016 $ $1, $1, $1, June 1, 2014 May 31, 2015 $ $1, $ $1, Carrier History: June 1, 2013 May 31, 2015 June 1, 2008 May 31, 2013 PPO Medical Aetna TML TML Intergovernmental Employee Benefits Pool EAST TEXAS COUNCIL OF GOVERNMENTS HUMAN RESOURCES DEPARTMENT 3800 STONE ROAD KILGORE, TX, Page 17

18 East Texas Council of Governments EMPLOYEE INSURANCE EXHIBITS EXHIBIT I Summary of Benefits Medical (provided in.pdf) EXHIBIT II Medical Census (provided in.pdf) EXHIBIT III Medical Claim Experience Reports (provided in.pdf) EXHIBIT IV Tx Ins Code Municipality Bid Waiver (provided in.pdf) EXHIBIT V Medical Renewal Page (provided in.pdf) EXHIBIT VI Three Required Forms (provided in.pdf) -Bid Affidavit Form -Response Forms -Conflict of Interest Form EAST TEXAS COUNCIL OF GOVERNMENTS HUMAN RESOURCES DEPARTMENT 3800 STONE ROAD KILGORE, TEXAS 75662

19 LA PPO /70 OOS : EXHIBIT I Coverage Period: 06/01/ /31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall In-network: Individual $3,000 / Family You must pay all the costs up to the deductible amount before this plan deductible? $6,000; Out-of-network: Individual $6,000 / begins to pay for covered services you use. Check your policy or plan Family $12,000. Does not apply to in-network document to see when the deductible starts over (usually, but not always, office visits, emergency care, urgent care, January 1st). See the chart starting on page 2 for how much you pay for preventive care and prescription drugs. covered services after you meet the deductible. Are there other deductibles No. You don't have to meet deductibles for specific services, but see the chart for specific services? starting on page 2 for other costs for services this plan covers. Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn't cover? Yes. In-network: Individual $3,000 / Family $6,000; Out-of-network: Individual $6,000 / Family $12,000. Premiums, prescription drugs, balance-billed charges, penalties for failure to obtain pre-authorization for services and health care this plan doesn't cover. No. Yes. For a list of in-network providers, see or call No. Yes. Coverage for: Individual + Family Plan Type: PPO The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don't count toward the out-of pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn't cover are listed on page 5. See your policy or plan document for additional information about excluded services. Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 1 of 8

20 : LA PPO /70 OOS Coverage Period: 06/01/ /31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: PPO Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven't met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments, and coinsurance amounts. Common Medical Event If you visit a health care provider's office or clinic If you have a test Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-Of-Network Provider Limitations & Exceptions Primary care visit to treat an injury or $30 copay per visit, 30% coinsurance None illness deductible waived Specialist visit $60 copay per visit, 30% coinsurance None deductible waived Other practitioner office visit 0% coinsurance for 30% coinsurance for None chiropractic care chiropractic care Preventive care /screening /immunization No charge 30% coinsurance; deductible waived for immunizations to the age of 6 Age and frequency schedules may apply. Diagnostic test (x-ray, blood work) Lab: $30 copay per 30% coinsurance None visit, deductible waived; X-ray: $60 copay per visit, deductible waived Imaging (CT/PET scans, MRIs) 0% coinsurance 30% coinsurance Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification is not obtained. Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 2 of 8

21 : LA PPO /70 OOS Coverage Period: 06/01/ /31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Common Medical Event If you need drugs to treat your illness or condition More Information about prescription drug coverage is available at macy-insurance/individ uals-families If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Services You May Need Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs (e.g., self-injectable, infused and oral specialty drugs) Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fee Your Cost If You Use an In-Network Provider $10 copay (retail), $30 copay (mail order) $50 copay (retail), $150 copay (mail order) 50% coinsurance up to $500 max copay (retail); 50% coinsurance up to $1,500 max copay (mail order) 30% coinsurance up to $300 max copay for up to a 30 day supply 0% coinsurance 0% coinsurance $350 copay per visit, deductible waived 0% coinsurance $100 copay per visit, deductible waived 0% coinsurance 0% coinsurance Your Cost If You Use an Out-Of-Network Provider 50% coinsurance (retail) 50% coinsurance (retail) 50% coinsurance up to $500 max copay (retail) 50% coinsurance (retail) 30% coinsurance 30% coinsurance $350 copay per visit, deductible waived 0% coinsurance 30% coinsurance 30% coinsurance 30% coinsurance Coverage for: Individual + Family Plan Type: PPO Limitations & Exceptions Covers up to a 30-day supply (retail prescription); day supply (mail order prescription). No coverage for day supply out-of-network. Applicable cost share plus difference (brand minus generic cost) applies for brand when generic available. No charge for preferred generic FDA-approved women's contraceptives in-network. Precertification and step therapy required. None None None Copay waived if admitted. OON ER cost-share same as in-network. No coverage for non-emergency care. OON cost-share same as in-network. No coverage for non-urgent care. Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification is not obtained. None Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 3 of 8

22 : LA PPO /70 OOS Coverage Period: 06/01/ /31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Common Medical Event If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs Services You May Need Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services Your Cost If You Use an In-Network Provider $60 copay per visit, deductible waived 0% coinsurance $60 copay per visit, deductible waived 0% coinsurance Your Cost If You Use an Out-Of-Network Provider 30% coinsurance 30% coinsurance 30% coinsurance 30% coinsurance Coverage for: Individual + Family Plan Type: PPO Limitations & Exceptions None Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification is not obtained. None Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification is not obtained. Prenatal and postnatal care Prenatal: No charge; 30% coinsurance None Postnatal: 0% coinsurance Delivery and all inpatient services 0% coinsurance 30% coinsurance Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification is not obtained. Home health care 0% coinsurance 30% coinsurance Coverage is limited to 60 visits per calendar year. Rehabilitation services 0% coinsurance 30% coinsurance Coverage is limited to 60 visits for PT/OT/ST combined. Habilitation services Not covered Not covered Not covered. Skilled nursing care 0% coinsurance 30% coinsurance Coverage is limited to 60 days per calendar year. Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification is not obtained. Durable medical equipment 0% coinsurance 30% coinsurance None Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 4 of 8

23 : LA PPO /70 OOS Coverage Period: 06/01/ /31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Common Medical Event If your child needs dental or eye care Services You May Need Services Your Plan Does NOT Cover Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-Of-Network Provider Limitations & Exceptions Hospice service 0% coinsurance 30% coinsurance Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification is not obtained. Eye exam No charge 30% coinsurance Coverage is limited to 1 routine exam per 12 months. Glasses Not covered Not covered Not covered. Dental check-up Not covered Not covered Not covered. Excluded Services & Other Covered Services: Acupuncture Bariatric surgery Cosmetic surgery Dental care (Adult/Child) Habilitation services Other Covered Services Chiropractic care (This isn't a complete list. Check your policy or plan document for other excluded services.) Infertility treatment Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing Routine foot care Weight loss programs (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.) Hearing aids - limited to 1 hearing aid per ear every 36 months through the age of 17 Coverage for: Individual + Family Plan Type: PPO Routine eye care (Adult/Child) - limited to 1 routine exam per 12 months Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 5 of 8

24 : LA PPO /70 OOS Coverage Period: 06/01/ /31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type: PPO Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact us by calling the toll free number on your Medical ID Card. You may also contact the Department of Labor's Employee Benefits Security Administration at EBSA (3272) or You may also contact your State Department of Insurance at (225) , Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage". This plan or policy does provide minimum essential coverage. Does this Coverage Provide Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Para obtener asistencia en Español, llame al Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next page Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 6 of 8

25 : Coverage Examples LA PPO /70 OOS Coverage Period: 06/01/ /31/2015 Coverage for: Individual + Family Plan Type: PPO About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don't use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care also will be different. See the next page for important information about these examples. Amount owed to providers: $7,540 Plan pays: $4,390 Patient pays: $3,150 Sample care costs: Hospital charges (mother) Routine obstetric care Hospital charges (baby) Anesthesia Laboratory tests Prescriptions Radiology Vaccines, other preventive Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total Having a baby (normal delivery) $2,700 $2,100 $900 $900 $500 $200 $200 $40 $7,540 $3,000 $0 $0 $150 $3,150 Amount owed to providers: $5,400 Plan pays: $2,500 Patient pays: $2,900 Sample care costs: Prescriptions Medical equipment and Supplies Office Visits and Procedures Education Laboratory tests Vaccines, other preventive Total Patient pays: Managing type 2 diabetes (routine maintenance of a well-controlled condition) Deductibles Copays Coinsurance Limits or exclusions Total $2,900 $1,300 $700 $300 $100 $100 $5,400 $2,420 $400 $0 $80 $2,900 Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 7 of 8

26 : Coverage Examples LA PPO /70 OOS Coverage Period: 06/01/ /31/2015 Coverage for: Individual + Family Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don't include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren't specific to a particular geographic area or health plan. The patient's condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn't covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different, based on your doctor's advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can't use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you'll find the same Coverage Examples. When you compare plans, check the "Patient Pays" box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you'll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 8 of 8

27 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall In-network: Individual $1,500 / Family You must pay all the costs up to the deductible amount before this plan $3,000; Out-of-network: Individual $3,000 / deductible? begins to pay for covered services you use. Check your policy or plan Family $6,000. Does not apply in-network for document to see when the deductible starts over (usually, but not always, certain office visits, urgent care, preventive January 1st). See the chart starting on page 2 for how much you pay for care and prescription drugs. covered services after you meet the deductible. Are there other deductibles for specific services? Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn't cover? TX OAMC /50 Basic No. Yes. In-network: Individual $6,350 / Family $12,700; Out-of-network: Individual $12,700 / Family $25,400. Premiums, prescription drugs, balance-billed charges, penalties for failure to obtain pre-authorization for services and health care this plan doesn't cover. No. Yes. For a list of in-network providers, see or call No. Yes. EXHIBIT I Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 06/01/ /31/2015 Coverage for: Individual + Family Plan Type: POS You don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don't count toward the out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn't cover are listed on page 5. See your policy or plan document for additional information about excluded services. Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 1 of 8

28 TX OAMC /50 Basic Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 06/01/ /31/2015 Coverage for: Individual + Family Plan Type: POS Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven't met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments, and coinsurance amounts. Common Medical Event If you visit a health care provider's office or clinic If you have a test Services You May Need Primary care visit to treat an injury or illness Your Cost If You Use an In-Network Provider $40 copay per visit, deductible waived for visits 1-3; thereafter 30% coinsurance Your Cost If You Use an Out-Of-Network Provider 50% coinsurance Limitations & Exceptions None Specialist visit $40 copay per visit, 50% coinsurance None deductible waived for visits 1-3; thereafter 30% coinsurance Other practitioner office visit 30% coinsurance for 50% coinsurance for Coverage is limited to 35 visits chiropractic care chiropractic care PT/OT/ST/Chiro combined. Benefit limits are shared between rehabilitation and non-autism habilitation services. Preventive care /screening /immunization No charge 50% coinsurance; No charge for immunizations to the age of 6 50% coinsurance 50% coinsurance Age and frequency schedules may apply. Diagnostic test (x-ray, blood work) 30% coinsurance None Imaging (CT/PET scans, MRIs) 30% coinsurance Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification not obtained. Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 2 of 8

29 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at macy-insurance/indi viduals-families If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs TX OAMC /50 Basic Summary of Benefits and Coverage: What this Plan Covers & What it Costs Services You May Need Preferred generic drugs Preferred brand drugs Non-preferred generic, brand and specialty drugs Preferred specialty drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fee Mental/Behavioral health outpatient services Your Cost If You Use an In-Network Provider $10 copay (retail), $30 copay (mail order) 50% coinsurance (retail/mail order) 50% coinsurance up to a max $500 copay (retail), 50% coinsurance up to a max $1,500 copay (mail order) 30% coinsurance up to a max $300 copay for up to a 30 day supply 30% coinsurance 30% coinsurance 30% coinsurance 30% coinsurance $100 copay per visit, deductible waived 30% coinsurance 30% coinsurance $40 copay per visit, deductible waived for visits 1-3; thereafter 30% coinsurance Your Cost If You Use an Out-Of-Network Provider 30% coinsurance after $10 copay (retail) 50% coinsurance (retail) 50% coinsurance (retail) 30% coinsurance for up to a 30 day supply 50% coinsurance 50% coinsurance 30% coinsurance 30% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance Coverage Period: 06/01/ /31/2015 Coverage for: Individual + Family Plan Type: POS Limitations & Exceptions Covers up to a 30-day supply (retail prescription); day supply (mail order prescription). No coverage for day supply out-of-network. Applicable cost share plus difference (brand minus generic cost) applies for brand when generic available. No charge for preferred generic FDA-approved women's contraceptives in-network. Precertification and step therapy required. None None None OON ER services cost-share same as in-network. No coverage for non-emergency care. OON cost-share same as in-network. No coverage for non-urgent care. Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification not obtained. None None Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 3 of 8

30 Common Medical Event If you are pregnant If you need help recovering or have other special health needs TX OAMC /50 Basic Summary of Benefits and Coverage: What this Plan Covers & What it Costs Services You May Need Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services Your Cost If You Use an In-Network Provider 30% coinsurance $40 copay per visit, deductible waived for visits 1-3; thereafter 30% coinsurance 30% coinsurance Your Cost If You Use an Out-Of-Network Provider 50% coinsurance 50% coinsurance 50% coinsurance Coverage Period: 06/01/ /31/2015 Coverage for: Individual + Family Plan Type: POS Limitations & Exceptions Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification not obtained. None Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification not obtained. Prenatal and postnatal care Prenatal: No charge; 50% coinsurance None Postnatal: 30% coinsurance Delivery and all inpatient services 30% coinsurance 50% coinsurance Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification not obtained. Home health care 30% coinsurance 50% coinsurance Coverage is limited to 60 visits. Rehabilitation services 30% coinsurance 50% coinsurance Coverage is limited to 35 visits PT/OT/ST/Chiro combined. Benefit limits are shared between rehabilitation and non-autism habilitation services. Habilitation services 30% coinsurance 50% coinsurance Coverage is limited for non-autism services to 35 visits PT/OT/ST/Chiro combined. Benefit limits are shared between rehabilitation and non-autism habilitation services. Skilled nursing care 30% coinsurance 50% coinsurance Coverage is limited to 25 days. Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification not obtained. Durable medical equipment 30% coinsurance 50% coinsurance None Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 4 of 8

31 Common Medical Event If your child needs dental or eye care Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-Of-Network Provider Limitations & Exceptions Hospice service 30% coinsurance 50% coinsurance Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification is not obtained. Eye exam No charge 50% coinsurance Coverage is limited to 1 routine exam per 12 months. Glasses Not covered Not covered Not covered. Dental check-up Not covered Not covered Not covered. Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.) Acupuncture Bariatric surgery Cosmetic surgery Dental care (Adult & Child) TX OAMC /50 Basic Summary of Benefits and Coverage: What this Plan Covers & What it Costs Infertility treatment Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing Routine foot care Weight loss programs Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.) Chiropractic care - limited to 35 visits combined with PT/OT/ST Hearing aids - limited to 1 hearing aid per ear every 36 months Coverage Period: 06/01/ /31/2015 Coverage for: Individual + Family Plan Type: POS Routine eye care (Adult) - limited to 1 routine exam per 12 months Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 5 of 8

32 TX OAMC /50 Basic Coverage Period: 06/01/ /31/2015 Coverage for: Individual + Family Plan Type: POS Summary of Benefits and Coverage: What this Plan Covers & What it Costs Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact us by calling the toll free number on your Medical ID Card. You may also contact the Department of Labor's Employee Benefits Security Administration at EBSA (3272) or You may also contact your State Department of Insurance at (800) , Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage". This plan or policy does provide minimum essential coverage. Does this Coverage Provide Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' Para obtener asistencia en Español, llame al To see examples of how this plan might cover costs for a sample medical situation, see the next page Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 6 of 8

33 Coverage Examples TX OAMC /50 Basic Coverage Period: 06/01/ /31/2015 Coverage for: Individual + Family Plan Type: POS About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don't use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care also will be different. See the next page for important information about these examples. Amount owed to providers: $7,540 Plan pays: $4,770 Patient pays: $2,770 Sample care costs: Hospital charges (mother) Routine obstetric care Hospital charges (baby) Anesthesia Laboratory tests Prescriptions Radiology Vaccines, other preventative Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total Having a baby (normal delivery) $2,700 $2,100 $900 $900 $500 $200 $200 $40 $7,540 $1,500 $20 $1,100 $150 $2,770 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays: $3,140 Patient pays: $2,260 Sample care costs: Prescriptions Medical equipment and Supplies Office Visits and Procedures Education Laboratory tests Vaccines, other preventative Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total $2,900 $1,300 $700 $300 $100 $100 $5,400 $1,500 $400 $280 $80 $2,260 Note: Your plan may have both copays and coinsurance for covered services; if so, these examples use copays only. Your costs may be higher. Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 7 of 8

34 Coverage Examples Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? TX OAMC /50 Basic Costs don't include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren't specific to a particular geographic area or health plan. The patient's condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn't covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different, based on your doctor's advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can't use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Coverage Period: 06/01/ /31/2015 Coverage for: Individual + Family Plan Type: POS Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you'll find the same Coverage Examples. When you compare plans, check the "Patient Pays" box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you'll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 8 of 8

35 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall In-network: Individual $2,000 / Family You must pay all the costs up to the deductible amount before this plan $4,000; Out-of-network: Individual $4,000 / deductible? begins to pay for covered services you use. Check your policy or plan Family $8,000. Does not apply in-network for document to see when the deductible starts over (usually, but not always, office visits, urgent care and preventive care. January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. Are there other deductibles No. You don't have to meet deductibles for specific services, but see the chart for specific services? starting on page 2 for other costs for services this plan covers. Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn't cover? TX OAMC /50 Yes. In-network: Individual $6,350 / Family $12,700; Out-of-network: Individual $12,700 / Family $25,400. Premiums, balance-billed charges, penalties for failure to obtain pre-authorization for services and health care this plan doesn't cover. No. Yes. For a list of in-network providers, see or call No. Yes. EXHIBIT I Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 06/01/ /31/2015 Coverage for: Individual + Family Plan Type: POS The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don't count toward the out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn't cover are listed on page 5. See your policy or plan document for additional information about excluded services. Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 1 of 8

36 TX OAMC /50 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 06/01/ /31/2015 Coverage for: Individual + Family Plan Type: POS Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven't met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments, and coinsurance amounts. Common Medical Event If you visit a health care provider's office or clinic If you have a test Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-Of-Network Provider Limitations & Exceptions Primary care visit to treat an injury or $30 copay per visit, 50% coinsurance None illness deductible waived Specialist visit $60 copay per visit, 50% coinsurance None deductible waived Other practitioner office visit 30% coinsurance for 50% coinsurance for Coverage is limited to 35 visits chiropractic care chiropractic care PT/OT/ST/Chiro combined. Benefit limits are shared between rehabilitation and non-autism habilitation services. Preventive care /screening /immunization No charge 50% coinsurance; No charge for immunizations to the age of 6 50% coinsurance Age and frequency schedules may apply. Diagnostic test (x-ray, blood work) Lab: $15 copay per None visit, deductible waived; X-ray: $30 copay per visit, deductible waived Imaging (CT/PET scans, MRIs) 30% coinsurance 50% coinsurance Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification not obtained. Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 2 of 8

37 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at macy-insurance/indi viduals-families If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs TX OAMC /50 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Services You May Need Preferred generic drugs Preferred brand drugs Non-preferred generic, brand and specialty drugs Preferred specialty drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fee Mental/Behavioral health outpatient services Your Cost If You Use an In-Network Provider $10 copay (retail), $30 copay (mail order), deductible waived 50% coinsurance (retail/mail order 50% coinsurance up to a max $500 copay (retail), 50% coinsurance up to a max $1,500 copay (mail order) 50% coinsurance up to a max $300 copay for up to a 30 day supply 30% coinsurance 30% coinsurance 30% coinsurance 30% coinsurance $125 copay per visit, deductible waived 30% coinsurance 30% coinsurance $60 copay per visit, deductible waived Your Cost If You Use an Out-Of-Network Provider 30% coinsurance after $10 copay (retail) 50% coinsurance (retail) 50% coinsurance (retail) 50% coinsurance for up to a 30 day supply 50% coinsurance 50% coinsurance 30% coinsurance 30% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance Coverage Period: 06/01/ /31/2015 Coverage for: Individual + Family Plan Type: POS Limitations & Exceptions Covers up to a 30-day supply (retail prescription); day supply (mail order prescription). No coverage for day supply out-of-network. Applicable cost share plus difference (brand minus generic cost) applies for brand when generic available. No charge for preferred generic FDA-approved women's contraceptives in-network. Precertification and step therapy required. None None None OON ER services cost-share same as In-Network. No coverage for non-emergency care. OON cost-share same as In-Network No coverage for non-urgent care. Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification not obtained. None None Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 3 of 8

38 Common Medical Event If you are pregnant If you need help recovering or have other special health needs TX OAMC /50 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Services You May Need Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services Your Cost If You Use an In-Network Provider 30% coinsurance $60 copay per visit, deductible waived 30% coinsurance Your Cost If You Use an Out-Of-Network Provider 50% coinsurance 50% coinsurance 50% coinsurance Coverage Period: 06/01/ /31/2015 Coverage for: Individual + Family Plan Type: POS Limitations & Exceptions Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification not obtained. None Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification not obtained. Prenatal and postnatal care Prenatal: No charge; 50% coinsurance None Postnatal: 30% coinsurance Delivery and all inpatient services 30% coinsurance 50% coinsurance Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification not obtained. Home health care 30% coinsurance 50% coinsurance Coverage is limited to 60 visits. Rehabilitation services 30% coinsurance 50% coinsurance Coverage is limited to 35 visits PT/OT/ST/Chiro combined. Benefit limits are shared between rehabilitation and non-autism habilitation services. Habilitation services 30% coinsurance 50% coinsurance Coverage is limited for non-autism services to 35 visits PT/OT/ST/Chiro combined. Benefit limits are shared between rehabilitation and non-autism habilitation services. Skilled nursing care 30% coinsurance 50% coinsurance Coverage is limited to 25 days. Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification not obtained. Durable medical equipment 30% coinsurance 50% coinsurance None Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 4 of 8

39 Common Medical Event If your child needs dental or eye care Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-Of-Network Provider Limitations & Exceptions Hospice service 30% coinsurance 50% coinsurance Precertification required for out-of-network care. Benefits will be reduced by $400 per occurrence if precertification is not obtained. Eye exam No charge 50% coinsurance Coverage is limited to 1 routine exam per 12 months. Glasses Not covered Not covered Not covered. Dental check-up Not covered Not covered Not covered. Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.) Acupuncture Bariatric surgery Cosmetic surgery Dental care (Adult & Child) TX OAMC /50 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Infertility treatment Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing Routine foot care Weight loss programs Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.) Chiropractic care - limited to 35 visits combined with PT/OT/ST Hearing aids - limited to 1 hearing aid per ear every 36 months Coverage Period: 06/01/ /31/2015 Coverage for: Individual + Family Plan Type: POS Routine eye care (Adult) - limited to 1 routine exam per 12 months Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 5 of 8

40 TX OAMC /50 Coverage Period: 06/01/ /31/2015 Coverage for: Individual + Family Plan Type: POS Summary of Benefits and Coverage: What this Plan Covers & What it Costs Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact us by calling the toll free number on your Medical ID Card. You may also contact the Department of Labor's Employee Benefits Security Administration at EBSA (3272) or You may also contact your State Department of Insurance at (800) , Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage". This plan or policy does provide minimum essential coverage. Does this Coverage Provide Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' Para obtener asistencia en Español, llame al To see examples of how this plan might cover costs for a sample medical situation, see the next page Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 6 of 8

41 Coverage Examples TX OAMC /50 Coverage Period: 06/01/ /31/2015 Coverage for: Individual + Family Plan Type: POS About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don't use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care also will be different. See the next page for important information about these examples. Amount owed to providers: $7,540 Plan pays: $4,420 Patient pays: $3,120 Sample care costs: Hospital charges (mother) Routine obstetric care Hospital charges (baby) Anesthesia Laboratory tests Prescriptions Radiology Vaccines, other preventative Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total Having a baby (normal delivery) $2,700 $2,100 $900 $900 $500 $200 $200 $40 $7,540 $2,000 $20 $950 $150 $3,120 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays: $2,790 Patient pays: $2,610 Sample care costs: Prescriptions Medical equipment and Supplies Office Visits and Procedures Education Laboratory tests Vaccines, other preventative Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total $2,900 $1,300 $700 $300 $100 $100 $5,400 $2,000 $430 $100 $80 $2,610 Note: Your plan may have both copays and coinsurance for covered services; if so, these examples use copays only. Your costs may be higher. Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 7 of 8

42 Coverage Examples Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? TX OAMC /50 Costs don't include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren't specific to a particular geographic area or health plan. The patient's condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn't covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different, based on your doctor's advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can't use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Coverage Period: 06/01/ /31/2015 Coverage for: Individual + Family Plan Type: POS Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you'll find the same Coverage Examples. When you compare plans, check the "Patient Pays" box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you'll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy Page 8 of 8

43 EAST TEXAS COUNCIL OF GOVERNMENTS 2015 EXHIBIT II Status: - Active - Waiting Period - Cobra / State - Retiree -Continuation -Part Time -Seasonal Gender Date of Birth Home Zip Code Date of Hire Title Medical Plan Selected Core / Buy- Up / LA Active Male 1/29/ /13/1987 WORKFORCE & ECONOMIC DEVELOPMENT TEAM LEADER Core EE Active Female 10/11/ /1/2005 PUBLIC SAFETY SPECIALIST Core EE Active Female 6/2/ /8/1997 WSIT SPECIALIST LEAD Core EE+CH Active Female 7/31/ /8/2005 FINANCIAL SERVICE SPECIALIST Core EE Active Male 7/18/ /1/2013 ETRDC MANAGER Core EE Active Female 9/24/ /16/2006 BENEFITS COUNSELOR Core EE+CH Active Female 9/12/ /1/2014 CALL CENTER SPECIALIST Core EE Active Female 9/18/ /10/1983 ACCOUNTING MANAGER Core EE Active Female 12/5/ /1/2014 CHILD DEVELOPMENT SPECIALIST Core WAIVE Active Female 9/4/ /31/2001 FINANCIAL SERVICE SPECIALIST Core EE Active Female 6/24/ /11/2008 DIRECTOR OF HUMAN RESOURCES Core EE+CH Active Female 9/29/ /21/2007 PUBLIC SAFETY MANAGER Core EE Active Female 12/20/ /1/2004 ASSOCIATE DIRECTOR AGING Core EE Active Female 3/30/ /16/2012 FISCAL MONITOR/DRAW COORDINATOR Core EE Active Male 3/22/ /1/2010 BUS OPERATOR Core EE Active Female 2/3/ /1/2000 ECONOMIC DEVELOPMENT LEAD Core EE+CH Active Male 7/24/ /4/2007 BUS OPERATOR Core EE Active Female 7/5/ /12/2015 PROGRAM CASE MANAGER Core EE Active Female 5/7/ /1/2011 GIS ANALYST Core EE+CH Active Female 3/1/ /4/2008 CONTRACT MANAGER ASSIST Core EE+CH Active Female 5/15/ /4/2007 BUS OPERATOR Buy up EE Active Male 8/21/ /14/2007 EXECUTIVE DIRECTOR Core EE+FAM Level of Medical Coverage EE EE+Sp EE+Ch EE+Fam waive - other coverage waive - due to cost

44 Active Female 8/26/ /23/2014 PROGRAM CASE MANAGER Core EE Active Female 11/24/ /15/2013 TRANSPORTATION PLANNER/ANALYST Core EE+CH Active Female 8/21/ /4/2007 PROJECT COORDINATOR Core EE Active Male 2/28/ /1/2013 ICT SUPPORT SPECIALIST Core EE+SP Active Female 7/22/ /1/2013 BUS OPERATOR Core EE Active Female 1/8/ /18/2010 CALL CENTER SPECIALIST Core EE Active Male 10/4/ /4/2007 BUS OPERATOR Core EE Active Female 8/13/ /1/2013 HUMAN RESOURCES REPRESENTATIVE Core EE+CH Active Female 8/20/ /18/2010 EXECUTIVE ASSISTANT/TECHNOLOGY Core EE Active Female 2/12/ /1/2004 PROGRAM & FISCAL MANAGEMENT SPECIALIST Core EE+SP Active Female 8/25/ /4/2007 BUS OPERATOR Core EE Active Female 10/26/ /1/2013 FISCAL GRANT MANAGEMENT SPECIALIST Core EE Active Female 10/24/ /1/2004 FINANCIAL SERVICE SPECIALIST Core EE Active Female 4/13/ /1/2014 ECONOMIC DEVELOPMENT SPECIALIST Core EE+FAM Active Female 6/16/ /1/2010 BUS OPERATOR Core EE Active Female 4/19/ /9/1995 PROGRAM COORDINATOR Core EE Active Female 5/20/ /16/2012 FISCAL MANAGEMENT SUPPORT SPECIALIST Core EE Active Female 1/2/ /1/2008 WSIT SPECIALIST Core EE+CH Active Male 9/16/ /13/2009 DIRECTOR OF TRANSPORTATION Core EE+SP Active Female 10/4/ /15/2010 DIRECTOR OF PUBLIC SAFETY Core EE+CH Active Female 4/6/ /12/2001 FISCAL GRANT MANAGEMENT SPECIALIST Core EE Active Female 10/12/ /4/2008 PLANNING & COMMUNITY ENGAGEMENT Buy up EE Active Female 11/5/ /25/2011 BUILDING MAINTENANCE SPECIALIST Core EE Active Female 2/6/ /10/2014 DIRECTOR OF FINANCIAL OPERATIONS Core EE Active Male 6/18/ /3/1979 WSIT TEAM LEADER Buy up EE Active Female 7/16/ /9/2014 PURCHASING & FACILITIES TEAM LEADER Core EE Active Female 5/14/ /5/2014 BENEFITS COUNSELOR Core EE Active Female 12/12/ /1/2010 BUS OPERATOR Core EE Active Male 10/29/ /21/2013 ICT SUPPORT SPECIALIST Core EE+SP Active Female 11/30/ /29/1979 COMMUNITY CARE COORDINATOR Core EE Active Female 8/12/ /4/2010 BUS OPERATOR Core EE+CH

45 Active Female 6/20/ /8/1998 WSIT SPECIALIST Core EE Active Male 12/12/ /16/2010 BUS OPERATOR Buy up EE Active Female 11/5/ /1/2014 CALL CENTER SPECIALIST Core WAIVE Active Female 6/8/ /4/2007 FIELD OPERATIONS MANAGER & SAFETY OFFICER Core EE Active Female 4/25/ /11/2007 FINANCIAL SERVICE SPECIALIST Core EE Active Female 8/17/ /3/2007 BUS OPERATOR Buy up EE Active Female 1/19/ /16/2012 DIRECTOR OF AGING Core EE Active Female 8/6/ /1/2002 OPERATIONS MANAGER Core EE Active Male 1/31/ /20/2013 TRANSPORTATION MANAGER Core EE Active Female 9/18/ /20/2012 PUBLIC SAFETY SPECIALIST Core EE Active Female 9/7/ /29/2012 CASE MANAGER Core EE Active Female 7/3/ /4/2007 BUS OPERATOR Core EE+CH Active Female 7/5/ /16/2013 RECEPTIONIST Core EE+CH Active Female 9/17/ /16/2008 CALL CENTER AND TECHNOLOGY SUPERVISOR Core EE Active Male 1/24/ /11/2013 PROGRAM SPECIALIST Core EE Active Female 12/2/ /16/2012 WSIT SPECIALIST LEAD Core EE+FAM Active Female 6/11/ /4/2007 FISCAL MANAGEMENT SUPPORT SPECIALIST Core EE+CH Active Female 6/15/ /31/1994 DIVISION FOR WORKFORCE AND ECONOMIC DEVELOPMENT Core EE+CH Active Female 9/22/ /4/2007 BUS OPERATOR Core EE Active Female 6/27/ /4/2007 CALL CENTER SPECIALIST Buy up EE Active Female 3/2/ /14/2012 OMBUDSMAN Core EE+CH Active Female 1/25/ /7/2011 PUBLIC SAFETY SPECIALIST Core EE Active Female 9/4/ /7/2002 FISCAL GRANT MANAGEMENT SPECIALIST LA EE Active Male 1/17/ /1/2013 DIRECTOR OF WORKFORCE Core EE Active Female 11/12/ /2/2013 BENEFITS COUNSELOR Core EE+CH Active Female 9/4/ /1/2010 BUS OPERATOR Core EE+SP Active Female 2/8/ /16/2001 WSIT SPECIALIST LEAD Core EE+SP Active Male 6/2/ /18/2011 BUS OPERATOR Core EE Active Female 3/20/ /26/2013 TECHNOLOGY SUPPORT SPECIALIST Core EE+CH Active Female 8/18/ /15/2007 COMMUNICATIONS MANAGER Core EE+CH

46 Active Female 4/25/ /16/2013 OFFICE COORDINATOR Core EE+CH Active Female 10/26/ /13/1979 PLANNING & COMMUNITY ENGAGEMENT Core EE Active Female 8/30/ /1/2014 CHILD DEVELOPMENT SPECIALIST Core WAIVE Active Male 10/7/ /10/2011 FACILITIES SPECIALIST Core EE Active Female 6/11/ /5/ TECHNOLOGY COORDINA Core EE+CH Active Female 7/5/ /14/2011 BUS OPERATOR Core EE Active Female 12/7/ /1/2015 PURCHASING & FACILITIES ASSISTANT Core EE Part time Male 11/16/ /16/2013 BUS OPERATOR Eligible 6/1/2015 Part time Male 8/30/ /21/2013 BUS OPERATOR Eligible 6/1/2015 Part time Female 7/12/ /1/2010 BUS OPERATOR Eligible 6/1/2015 Part time Female 8/22/ /5/2000 FINANCIAL SERVICE SPECIALIST Not Eligible < 30 hour employee Part time Female 3/27/ /1/2013 BUS OPERATOR Eligible 6/1/2015 Part time Female 9/6/ /1/2010 BUS OPERATOR Eligible 6/1/2015 Part time Female 8/20/ /24/2014 BUS OPERATOR Eligible 6/1/2015 Part time Female 3/8/ /23/2013 OMBUDSMAN Not Eligible < 30 hour employee Part time Female 8/15/ /11/2012 OMBUDSMAN Not Eligible < 30 hour employee Part time Male 10/8/ /16/2012 BUS OPERATOR Eligible 6/1/2015 Part time Female 10/18/ /10/2012 BUS OPERATOR Eligible 6/1/2015 Part time Female 10/26/ /10/2012 BUS OPERATOR Eligible 6/1/2015 Part time Male 12/16/ /1/2014 WEB EOC ADMINISTRATOR Not Eligible < 30 hour employee Part time Female 8/14/ /1/2011 OMBUDSMAN Not Eligible < 30 hour employee Part time Female 3/12/ /18/2014 BUS OPERATOR Eligible 6/1/2015 Part time Female 12/4/ /21/2013 BUS OPERATOR Eligible 6/1/2015 Part time Female 6/9/ /16/2012 BUS OPERATOR Eligible 6/1/2015 Part time Female 7/17/ /4/2013 OMBUDSMAN Not Eligible < 30 hour employee Part time Male 4/27/ /16/2010 BUS OPERATOR Not Eligible < 30 hour employee Part time Female 8/27/ /7/2010 BUS OPERATOR Eligible 6/1/2015 Part time Female 3/2/ /1/1995 FINANCIAL SERVICE SPECIALIST Not Eligible < 30 hour employee Part time Male 5/22/ /1/2010 BUS OPERATOR Eligible 6/1/2015 Part time Male 3/25/ /1/2014 EMERGENCY MANAGEMENT PLANNER Not Eligible < 30 hour employee

47 Part time Female 3/10/ /1/2014 HOMELAND SECURITY PLANNER Not Eligible < 30 hour employee Temp Part time Female 12/29/ /16/2014 DWED Specialist Projects Not Eligible < 30 hour employee Part time Female 1/6/ /14/2011 BUS OPERATOR Eligible 6/1/2015 Part time Male 12/7/ /5/2013 BUS OPERATOR Eligible 6/1/2015 Temp Part time MALE 9/18/ /1/2014 FISCAL PROJECTS SPECIALIST Not Eligible < 30 hour employee Part time Male 9/25/ /20/2013 PROGRAM SPECIALIST Not Eligible < 30 hour employee Part time Male 7/16/ /11/2011 BUS OPERATOR Eligible 6/1/2015 Temp Part time Female 11/30/ /6/2014 BENEFIT COUNSELOR Not Eligible < 30 hour employee Temp Part time Female 2/25/ /1/2014 SPECIAL PROJECT MANAGER Not Eligible < 30 hour employee Part time Female 10/27/ /1/1999 WSIT SR PROGRAM FINANCIAL ANALYST Not Eligible < 30 hour employee Part time Male 6/15/ /2/2015 BUS OPERATOR Eligible 6/1/2015 Part time Female 8/24/ /1/2014 OMBUDSMAN Not Eligible < 30 hour employee Part time Female 6/22/ /17/2013 BUS OPERATOR Eligible 6/1/2015 Part time Male 12/8/ /5/2013 BUS OPERATOR Eligible 6/1/2015 Part time Female 6/8/ /28/2013 BUS OPERATOR Eligible 6/1/2015 Part time Male 10/6/ /1/2010 BUS OPERATOR Not Eligible < 30 hour employee COBRA eligible Female 11/13/ /4/2007 BUS OPERATOR Core EE COBRA eligible Female 4/5/ /18/2000 BUDGET MANAGER Core EE COBRA eligible Female 3/30/ /1/1996 HUMAN RESOURCE ASSISTANT Core EE

48 TML IEBP - HB 2015 Report East Texas COG - PEASTTE1 Claims Paid 6/1/2011 Through 5/31/2012 EXHIBIT III Group Name Dep Cd Start Date End Date Cov End Claimant Age Sex Status Rx Paid Medical Total Paid Diag 1 Diag 1 Desc Diag 1 Paid Diag 2 Diag 2 Desc Diag 2 Paid Diag 3 Diag 3 Desc Diag 3 Paid Diag 4 Diag 4 Desc Diag 4 Paid Diag 5 Diag 5 Desc Diag 5 Paid Oth Diag Paid Plan # Plan Desc East Texas COG East Texas COG s e 06/01/ /01/ /31/ /31/2012 MEMBER 01 MEMBER East Texas COG e 06/01/ /31/ MEMBER East Texas COG e 06/01/ /31/ MEMBER East Texas COG e 06/01/ /31/ MEMBER East Texas COG e 06/01/ /31/ MEMBER f Active $ $ $ ATRIAL FIBRILLATION $ ANAL & RECTAL POLYP $ INT HEMORRHOID W/O $ ABN FIND-STOOL CONTENTS $ CHRONIC DIASTOLIC HF $ $ CTbGO0F* Standard Plan 34 f Active $ $ $ CHR MAXILLARY SINUSITIS $ CHR ETHMOIDAL $ COMP CHR FRONTAL SINUSITIS $ ESOPHAGEAL REFLUX $ CHRONIC SINUSITIS NOS $ $ CTbGO0F* Standard Plan 64 m Active $ $ $ CLSD FX LAT MALLEOLUS $ SINUSITIS CL FX DISTAL RADIUS NEC $ DYSTHYMIC DISORDER $ COR AS-NATIVE VESSEL $ CLSD FX RAD W ULNA NOS $ $ CTbGO0F* Standard Plan 62 f Active $ $ $ HYPERTENSION NOS $ DM2/NOS UNCOMP NSU $ INCISIONAL HERNIA $ ASTHMA NOS $ CHF NOS $ $ CTbGO0F* Standard Plan 55 f Active $ $ $ URETERAL CALCULUS $ VOMITING ALONE $ RENAL COLIC $ HYPERTENSION NOS $ GB CALCULUS W CHOL NEC $ $ CTbGO0F* Standard Plan 61 f Active $ $ $ HYPERTENSION NOS $ RHEUMATOID ARTHRITIS $ LOC OA NOS-LOWER LEG $ V4962 OTH FINGER AMP STATUS $ LOC PRIMARY OA-LOWER LEG $ $ CTbGO0F* Standard Plan

49 TML IEBP - HB 2015 Report East Texas COG - PEASTTE1 Claims Paid 2/1/2012 Through 1/31/2013 EXHIBIT III Group Name Dep Cd Start Date End Date Cov End Claimant Age Sex Status Rx Paid Medical Total Paid Diag 1 Diag 1 Desc Diag 1 Paid Diag 2 Diag 2 Desc Diag 2 Paid Diag 3 East Texas COG e 02/01/ /31/2013 MEMBER f Active $ $ $ CERVICAL SPONDYLOSIS $ TOBACCO USE DISORDER $ East Texas COG 3 02/01/ /31/2013 MEMBER f Active $ $ $ JT DERANG NEC-SHOULDER $ JT DERANG NOS-SHOULDER $ East Texas COG e 02/01/ /31/2013 MEMBER f Active $ $ $ DM2/NOS UNCOMP NSU $ PNEUMONIA ORGANISM NOS $ East Texas COG e 02/01/ /31/2013 MEMBER f Active $ $ $ INFLAM BREAST DISEASE $ V145 HX NARCOTIC ALLERGY $

50 TML IEBP - HB 2015 Report East Texas COG - PEASTTE1 Claims Paid 2/1/2012 Through 1/31/2013 Diag 3 Desc Diag 3 Paid Diag 4 Diag 4 Desc Diag 4 Paid Diag 5 Diag 5 Desc Diag 5 Paid Oth Diag Paid Plan # Plan Desc HYPERTENSION NOS $ CARDIOMEGALY $ BRACHIAL NEURITIS NOS $ $ STbGO0F0 Standard Plan CLSD ANT DISLOC HUMERUS $ RECUR DISLOCAT-SHOULDER $ V571 PHYSICAL THERAPY NEC $ $ STbGO0F0 Standard Plan HYPERTENSION NOS $ HYPERLIPIDEMIA NEC & NOS $ OBSTRUCTIVE SLEEP APNEA $ $ STbGO0F0 Standard Plan BREAST HYPERTROPHY $ CERVICALGIA $ JOINT PAIN-SHOULDER $ $ STbGO0F0 Standard Plan

51 TML IEBP - HB 2015 Report East Texas COG - PEASTTE1 Claims Paid 2/1/2012 Through 1/31/2013 EXHIBIT III Enrollee Dependent Billed Paid Total Group Date Lives Lives Contributions Contributions Medical Claims Rx Copay Rx Mail Order Claims & RX Loss Ratio 02/ $41, $41, $6, $4, $0.00 $11, % 03/ $40, $40, $5, $4, $2, $11, % 04/ $41, $41, $9, $5, $ $15, % 05/ $41, $41, $9, $5, $ $15, % 06/ $39, $39, $13, $3, $ $17, % 07/ $41, $41, $21, $6, $ $28, % 08/ $41, $41, $35, $5, $ $40, % 09/ $40, $40, $15, $4, $ $20, % 10/ $40, $40, $6, $6, $ $13, % 11/ $42, $42, $9, $4, $ $13, % 12/ $40, $39, $10, $5, $ $16, % 01/ $38, $39, $42, $8, $0.00 $51, % Totals $486, $487, $184, $64, $6, $255, %

52 EXHIBIT III March 05, 2013 BRANDY BRANNON EAST TEXAS COUNCIL OF GOVERNMENTS 3800 STONE ROAD KILGORE TX Dear Ms. Brannon The TML Intergovernmental Employee Benefits Pool believes it is important to keep Members informed throughout the year of their group healthcare utilization as well as the healthcare utilization of the entire Pool. This information is important to decisions made regarding future contribution rates. The information outlined below shows your year-to-date experience. The Pool s administrative expenses are about 15%. Therefore, a loss ratio above 85% means that claims for your entity are exceeding contributions. Date Standard Plan Enrollee Lives Contributions Medical Claims Rx Copay Rx Mail Order Total Claims & RX Group Loss Ratio Pool Loss Ratio 06/ $39, $13, $3, $ $17, % % 07/ $41, $21, $6, $ $28, % % 08/ $41, $35, $5, $ $40, % % 09/ $40, $15, $4, $ $20, % % 10/ $40, $6, $6, $ $13, % % 11/ $42, $9, $4, $ $13, % % 12/ $40, $10, $5, $ $16, % % 01/ $38, $42, $8, $0.00 $51, % % 02/ $38, $10, $9, $0.00 $20, % % Totals 79 $361, $165, $53, $3, $222, % 1821 Rutherford Lane, Suite #300, Austin, TX (800) Service Team Fax: (512) or (512) Executive Fax: (512) PEASTTE1 Joe Sanchez

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