CIGNA IMPLEMENTATION GUIDE - LIST OF DOCUMENTS REQUIRING SIGNATURE CIGNA Implementation Guide
List of Documents Requiring Signature
There are a number of documents that are critical to the case implementation process.
Customer Acknowledge Form(CAF)
Discretionary Claim Authorization Form
HWPA Declaration Form
Hold Harmless Agreement for SPD Drafts
State Accept/Reject Forms
Summary Information Form_(SIF)
Without the proper documents and signatures,the case implementation process cannot be
completed. Timely receipt of these documents is essential to a successful implementation.
CUSTOMER ACKNOWLEDGMENT FORM
CIGNA
To be completed by Field Salesand Customer IfeubbCa,,
PART 1: Producer of Record Information Section;(Complete all)
Effective 1/1/2OQ9 . |xen*uxoc*nnw|odQe
GE0R|NG GROUP 100%
Producer(individual/Firm to Whom Compensation will be paid) (%share if other than 100%)
Producer(Individual/Firm to Whom Compensation will be paid) I share if other than 100%)
tphr designated the producer pf record for
CITY OFCLEARVVATER 3331468
Customer Name Account Number
PART 11: Funding Arrangement Information Section:(Check&Complete one)
Traditional Insured Cases:
4cmounmo,oupwumuar HMO Site(if applicable)
CITY OF CLEARVyATER /
Acct# 3331468
Cash Management Program<ci
Customer understands funding arrangement of the policies applied for will reduce the amount of premium paid directly to Connecticut General Life
Insurance Company. Customer hereby authorizes Connecticut General Life Insurance Company to act as transfer agent in paying compensation
to our designated producer of record based upon the premium paid to Connecticut General and the amounts funded by Customer through their
benefit payment occovnt(m under the funding arrangement elected.
Administrative Services Only(»SO}:
Customer recognizes this account is funded on an Administrative Services Only basis. We request Connecticut General Life Insurance Company
compensate our designated producer m record aafollows:
annual flat compensation per covered employee
Other(Please specify)
The compensation will be included ia Connecticut General's retention expenses.
PART III: Signature Requirements Section:(To be complet2d�y"C5STM"E"RI
Autborized Customer Signature Date
eo
Authorized Customer Name(Print)
Customer Street Address
Customer City,State and Zip Code
To comply with New York's four percent(4m)nmuv^compensation paid murc^eru"^HMO contracts,c/sw^x°"/mo=°win not pay more than four perc°'(4m)commissions""HMO,roe
formerly cn^).poa Open Access and HMO Open Access products for membership covered b'o/wwx Healthcare m New York,Inc.
1u4-ooms
DISCRETIONARY CLAIM AUTHORIZATION
PLEASE RETURN THIS SIGNED FORM
TO YOUR SALES REPRESENTATIVE
Plan Administrator: CIGNA HealthCare
Policy Number: 3331468
Policyholder: City of Clearwater
The Plan Administrator named above hereby delegates to the Claim Administrator the
discretionary authority to interpret and apply plan terms and to make a factual
determination in connection with its review of claims under the plan. Such discretionary
authority is intended to include, but is not limited to, the determination of the eligibility of
persons desiring to enroll in or claim benefits under the plan and the computation of any
and all benefit payments. The Plan Administrator also delegates to the Claim
Administrator the discretionary authority to perform a full and fair review, as required by
ERISA, of each claim denial which has been appealed by the claimant or his duly
authorized representative.
NAME
POSITION/TITLE
DATE 1113CI J,
If you sign this form, this language should be made part of your Summary Plan
Description. If the Summary Plan Description appears in your certificate, a rider for your
certificate will be issued adding the above statement to those pages in the certificate.
DISCLO1 04-18-98
CIGNA HEALTHCARE
c
HIPAA CERTIFICATION
CIGNA.
DECLARATO,N AGREEMENT
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that a proof of prior coverage
certificate (HIPAA Certificate)be issued to individuals who, for any reason, have lost their active or COBRA
medical plan coverage. For fully insured customers, CIGNA HealthCare will automatically generate individual
HIPAA Certificates for members and their dependents sinless the employer has declined this service by indicating
below (unless required by state law). For self-insured customers, CIGNA HealthCare will not provide this service
unless the customer elects this optional service by indicating below.
Please complete the following information and return this Declaration Agreement to:
CIGNA HealthCare 900 Cottage Grove Ind, GIMIG Bloomfield, CT 06152 Or fax: 860.22 .3 7
1. Account Dame: City of Clearwater
2. Contact Name: Allen Del Prete
Title: Human Resources Manager Phone: 727.562.4576
3. Contact Address: 100 S. Myrtle Avenue
City: Clearwater State: Fl, Zip: 33756
Account Number(s):: 3331468
Please select one of the following:
We do not elect to use CIGNA HealthCare Certification Services. We will have full responsibility to
comply with the issuance of HIPAA Certificates as required by federal law.
X We elect to have CIGNA HealthCare perform HIPAA Certification Services. We acknowledge that
CIGNA HealthCare's ability to provide HIPAA Certificates may be dependent on the quality of information
provided by us. We understand that CIGNA HealthCare is responsible only for coverage periods administered
by CIGNA HealthCare.
If you have elected CIGNA HealthCare to perform the services,please complete the following:
4. START DATE: For new accounts, the start date will be the account effective date. For existing accounts, please
indicate one of the following: ❑ At renewal / ] OR As of 01 / 01 j 2009
5. Type of Medical Coverage (Check all that apply):
Commercial HMO/POS x Indemnity/PPO/OAP Point-of-Service/PlexCare/Network Preferred Provider Access
6. Type of Funding Arrangement (check one box): X Insured ASO/Self-Funded Both
7. If you have elected the HIPAA certification services, CIGNA HealthCare will generate quarterly reports of HIPAA
Certificates that were generated for your account. Please indicate if you would like to receive this report:
,r
X Yes No
,Signature Date
Note: If you have elected to have CIGNA HealthCare perform the HIPAA certification service, YOU will receive a report upon
termination of your account. In accordance with HIPAA, no individual HIPAA Certificates will be issued. This report may be
used to provide prior coverage in fonration to a new administrator or carrier.
Version 04/01/08
AGREEMENT REGARDING ELECTRONIC DOCUMENTS
At the request of City of Clearwater ("Employer"), CIGNA Healthcare has agreed to provide Employer
the following documents ("Documents") in an electronic form for use by participants in a benefit plan
sponsored by Employer:
Medical SPI)s
in consideration for which Employer hereby agrees as follows:
1. Employer shall not alter the Documents and shall be responsible for promptly making any updates to
the Documents when such updates are provided by CIGNA Healthcare.
2. Employer shall prominently display the following notice so that it is visible to anyone accessing the
Documents electronically: THESE MATERIALS ARE MADE AVAILABLE ELECTRONICALLY
FOR YOUR CONVENIENCE BY YOUR EMPLOYER. CIGNA HEALTHCARE DOES NOT
CONTROL AND IS NOT RESPONSIBLE FOR THE CONTENT OF THESE MATERIALS AND
DOES NOT WARRANT THEIR ACCURACY.
3. Employer shall assume responsibility for compliance with applicable federal and state laws, including
Department of Labor's Rules for Disclosure Through Electronic Media [29 CFR 2520.104b-I and 29
CFR 2520.107-1].
4. Employer shall defend, indemnify and hold CIGNA Healthcare, its officers, employees and directors,
harmless from and against any and all losses, damages, expenses, casts (including attorneys' fees),
claims, causes of action, or obligations of any kind arising directly or indirectly from the provision by
CIGNA HealthCare of the Documents to Employer or the use of the Documents by any person or
entity.
CIGNA HealthCare
By:
Date:
City of Clearwater ("Employer")
By: ,
Date: "l c / o
CONNECTICUT GENERAL LIFE INSURANCE COMPANY
ALABAMA
STATE REQUIRED ACCEPTANCE/REJECTION FORMS
Connecticut General Life Insurance Company is required to offer to the group policyholder
the following benefits. The policyholder may choose to accept or reject the benefits and
understands that such coverage, if rejected,will not be provided at a later date unless
specifically requested.
Mental Health benefits must be offered to all Alabama residents regardless of contract
situs.
ACCEPT REJECT CITATION BENEFIT
ge 27-20A.1 Alcoholism: Coverage of inpatient, residential, and outpatient treatment of
through 4 alcoholism. May be limited to 30 days of inpatient care or its equivalent per
calendar year.
27-54-7 Mental Health: Coverage at the same terms and conditions as for physical
xillness. Must include inpatient, outpatient, and day treatment benefits. Can
limit to in-network benefits.
2004 SB ON/AFTER 81112004: Colorectal Cancer Screening*: Must offer coverage
403 for colorectal cancer screenings.
*This benefit is standardly covered under CGLIC plans and therefore does not have an impact on premium for those plans.
—City of Clearwater CG#3331468
Name of Policyholder
By Title A/unco &eSoL4e-C,0J MegetiZpv-
Name
Date Lo (f
CONNECTICUT GENERAL LIFE INSURANCE COMPANY
COLORADO
STATE REQUIRED ACCEPTANCE/REJECTION FORMS
Connecticut General Life Insurance Company is required to offer to the group policyholder
the following benefits. The policyholder may choose to accept or reject the benefits and
understands that such coverage, if rejected, will not be provided at a later date unless
specifically requested.
ACCEPT REJECT CITATION BENEFIT
10-16-104 Alcoholism*: Coverage for the inpatient and outpatient treatment of
(9) alcoholism for 45 days per calendar year for inpatient care and $500
per twelve-month period for outpatient care.
10-16- Home Health Care and Hospice Care: Coverage for up to 60 visits
104(8) per calendar year for Home Health Care services; coverage for
hospice care services, limited to $100 per day except for short term
inpatient care in a Hospice Facility or crisis care at home for a period
of 30 days and bereavement support services of up to $1,150 for the
family of the deceased for up to 12 months following death.
10-8-116; Reduction in Work Hours: Extension of coverage for employees
10-17-137 whose work hours are reduced due to economic conditions.
.*If this benefit is rejected,any level of alcoholism benefits, including no coverage, may be provided.
-City of Clearwater CG#3331468
Name of Policyholder
AP±r- Title &M60 'e'-
Name
Date
CONNECTICUT GENERAL LIFE INSURANCE COMPANY
FLORIDA
STATE REQUIRED ACCEPTANCEIREJECTION FORMS
Connecticut General Life Insurance Company is required to offer to the group policyholder
the following benefits. The policyholder may choose to accept or reject the benefits and
understands that such coverage, if rejected,will not be provided at a later date unless
specifically requested.
ACCEPT REJECT CITATION BENEFIT
627.669 Alcoholism and Drug Dependency: Coverage for inpatient and
outpatient treatment of alcoholism or drug dependency, up to 44
/X outpatient visits, with a lifetime limit of no less than $2,000.
Detoxification is covered only on an inpatient basis.
627.668(2) Mental Illness: Coverage for mental and nervous disorders at the
(b) same basis as any other illness, subject to an inpatient maximum of 30
days per benefit year. Mental illness coverage is not required, but if
provided, cannot be less than this benefit. (Rejection would only mean
that this particular set of benefits has been refused. A better benefit
may be provided, or no mental health benefits may be provided.)
627.42395 Nutritional Formulas*: Coverage for prescription and non-
prescription enteral formulas prescribed by a physician for inherited
1< diseases or malabsorption, up to $2,500 annually through the age of
24.
*This benefit is standardly covered under CGLIC plans and therefore does not have an impact on premium for those plans.
-City of Clearwater CG#3331468
Name of Policyholder
By Title
ov
- ae
Nm
Date
CONNECTICUT GENERAL LIFE INSURANCE COMPANY
GEORGIA
STATE REQUIRED ACCEPTANCE/REJECTION FORMS
Connecticut General Life Insurance Company is required to offer to the group policyholder
the following benefits. The policyholder may choose to accept or reject the benefits and
understands that such coverage, if rejected,will not be provided at a later date unless
specifically requested.
All Georgia laws are extraterritorial for METS, and this form must be signed by any MET
group covering Georgia residents.
ACCEPT REJECT CITATION BENEFIT
33-30-4.4 Bone Marrow Transplant: Coverage for bone marrow transplants for
the treatment of breast cancer and Hodgkin's disease. Must be
covered at the same level as provided for other types of physical
illness.
1< 33-30-4.1 Human Heart Transplant*: Coverage for human heart transplants at
same level as other types of physical illness.
31-15A-3 Bone Mass Measurement*: Coverage for bone density testing for
prevention, diagnosis, and treatment of osteoporosis.
33-24-29.1 Mental Illness: Coverage for treatment of mental disorders the same
as coverage for physical illnesses.
33-20A-9.1; Consumer Choice Option: Coverage from out-of-network Georgia
120-2-83 providers by nominating a provider. Additional premium charged to
employee for CCO option; choice to enroll at employee level.
This benefit is standardly covered under CGLIC plans and therefore does not have an impact on premium for
those plans.
City of Clearwater CG#3331468
Name of Policyholder
By &
I le& Title 4L�go 0 V/
,� Kevvt Ae,
Date 12--
CONNECTICUT GENERAL LIFE INSURANCE COMPANY
ILLINOIS
STATE REQUIRED ACCEPTANCE/REJECTION FORMS
Connecticut General Life Insurance Company is required to offer to the group policyholder
the following benefits. The policyholder may choose to accept or reject the benefits and
understands that such coverage, if rejected, will not be provided at a later date unless
specifically requested.
ACCEPT REJECT CITATION BENEFIT
51370c Mental, Emotional and Nervous Disorders; Coverage for the reasonable
and necessary treatment and services for mental, emotional or nervous
disorders or conditions up to the limits in the policy for other disorders and
conditions. Coinsurance may be limited to 50%,
215 ILLS TMJ: Coverage for the reasonable and necessary medical treatment of
51356q temporomandibular joint disorder(TMJ)and craniomandibular disorder subject
to the same limitations and cost sharing as for other disorders. The lifetime
maximum may be no less than$2,500.
City of Clearwater CG#3331468
Name of Policyholder
By Title 14(kA40
Name
Date
CONNECTICUT GENERAL LIFE INSURANCE COMPANY
KENTUCKY
STATE REQUIRED ACCEPTANCE/REJECTION FORMS
Connecticut General Life Insurance Company is required to offer to the group policyholder
the following benefits. The policyholder may choose to accept or reject the benefits and
understands that such coverage, if rejected,will not be provided at a later date unless
specifically requested.
ACCEPT REJECT CITATION BENEFIT
304.17-312 Home Health Care: Coverage for home health care providing no less
304.18-037 than 60 home health care visits in a calendar year.
304.5-160 Elective Abortions: Coverage for elective abortions that are not life
_y threatening. Note: Policies that provide maternity benefits include
coverage for non-elective abortions.
304.17A- Bone Density Testing: Coverage for bone density testing for women
134 age 35 and over to obtain baseline data for purpose of early detection
of osteoporosis.*
304.17A- Endometriosis and Endometritis: When a plan provides coverage
134 for hysterectomies, coverage for the treatment of endometriosis and
endometritis must be offered and made available,**
*This benefit is standardly covered under certain CGLIC plans that include preventive care benefits for adults and
therefore does not have an impact on premium for those plans.
**This benefit is standardly covered under CGLIC plans and therefore does not have an impact on premium for
those plans. Rejection of this benefit is a non-standard choice which requires Screening Board approval,
For Plans offering Dependent Coverage:
Note: Kentucky's dependent age requirements may have tax implications.
Coverage for Dependent Age is automatically included as follows: Coverage to the nineteenth (19) birthday
and coverage to unmarried children from nineteen (19)to the twenty-fifth (25th) birthday who are full-time students
enrolled in and attending an accredited educational institution and who are primarily dependent on the policyholder
for maintenance and suppo t.
ACCEPT REJECT CITATION BENEFIT
304.17A Dependent Age: Coverage up until their twenty-fifth 25th birthday,
regardless of student status.
City of Clearwater CG#3331468
Name of Policyholder
Title X)All�iO q
By
Name
Date
CONNECTICUT GENERAL LIFE INSURANCE COMPANY
NORTH CAROLINA
STATE REQUIRED ACCEPTANCE/REJECTION FORM
Connecticut General Life Insurance Company is required to offer to the group policyholder
the following benefits. The policyholder may choose to accept or reject the benefits and
understands that such coverage, if rejected,will not be provided at a later date unless
specifically requested.
ACCEPT REJECT CITATION BENEFIT
58-51-50; Substance Abuse Benefits: Coverage for the necessary care and
58-67-70 treatment of substance abuse that is not less favorable than benefits
for physical illness generally.
City of Clearwater CG#3331468
Name of Policyholder
By �- Title J + ✓,�c�er
Name
Date / o
CONNECTICUT GENERAL LIFE INSURANCE COMPANY
NEW YORK
STATE REQUIRED ACCEPTANCE/REJECTION FORMS
Connecticut General Life Insurance Company is required to offer to the group policyholder
the following benefits. The policyholder may choose to accept or reject the benefits and
understands that such coverage, if rejected,will not be provided at a later date unless
specifically requested.
This form must be signed for any multiple employer trust or association group covering
residents of New York regardless of situs.
ACCEPT REJECT CITATION BENEFIT
3221(l)(10), *Hospice Care: Coverage for the reasonable and customary
4303(o) charges for Hospice Care Services for a terminally ill covered
individual and 5 bereavement counseling sessions for that
individual's family.
3221(l)(6); Inpatient Alcohol and Substance Abuse and Inpatient Detox
4303(k) Services: Coverage for 30 inpatient days and 7 inpatient detox
days for alcohol and/or substance abuse. (Note: 60 outpatient visits
for alcohol and/or substance are mandated by law and cannot be
rejected.)
3221(l)(2); *Nursing Home Care: Coverage provided in a nursing home or
4303(d); skilled nursing facility for a participant who has been in a hospital for
4406(4) at least three days immediately preceding admittance to the nursing
home or the skilled nursing facility and for whom further
hospitalization would otherwise be necessary.
3221(1)(3); *Outpatient Services/Ambulatory Care: Coverage for ambulatory
tl 4303(e) and care in an outpatient facility, including diagnostic x-rays, laboratory
(f) and pathological examinations, physical and occupational therapy,
radiation therapy, and nonexperimental cancer chemotherapy and
cancer hormone therapy.
3221(l)(9); *Registered Professional Nurse Services: Coverage for services
4303(m) rendered by a duly licensed registered professional nurse.
*This benefit is standardly covered under CGLIC plans and therefore does not have an impact on premium for
those plans.
City of Clearwater CG#3331468
Name of Policyholder
By OP if Title aJ)hVaA4 Afo VrC—ef 1J4qvqe-
Name
Date to
CONNECTICUT GENERAL LIFE INSURANCE COMPANY
SOUTH CAROLINA
STATE REQUIRED ACCEPTANCE/REJEC7[lONFORK80
Connecticut General Life Insurance Company is required to offer to the group policyholder
the following benefits. The policyholder may choose tm accept nr reject the benefits and
understands that such coverage, if rejected,will not be provided eta later date unless
specifically requested.
This law is extraterritorial and must be offered toaccounts covering South Carolina
residents regardless of situs.
ACCEPT REJECT CITA TION BENEFIT
38-71-737 Mental Illness, Alcoholism and Drug Abuse*: Coverage for mental
illness, alcoholism and drug abuse benefits subject to an annual
maximum of$2,000 and a lifetime maximum of$10,000.
38-71-1730 POS Offering to Employer: A point-of-service option must be offered
to employers of 50+ employees who are seeking closed panel
coverage. Acceptance of this law indicates the employer chooses to
/X offer a CIGNA POS plan. Rejection of this offer indicates that the
employer has been offered a CIGNA POS plan but chooses not to
provide that plan to employees.
Wental Illness benefits cannot be limited to an annual or lifetime dollar maximum unless the plan
is exempt from mental health parity legislation. Alcoholism and drug abuse may bolimited.
City of Clearwater CG#333140
Name ofPolicyholder
By Title
Name CV7
Date
CONNECTICUT GENERAL LIFE INSURANCE COMPANY
TENNESSEE
STATE REQUIRED ACC2PTANCE/REJECT0NFORK8S
Connecticut General Life Insurance Company is required to offer to the group policyholder the following
benefits. The policyholder may choose to accept or reject the benefits and understands that such
coverage,if rejected,will not be provided at a later date unless specifically requested.
Note: The offer of coverage required by 5,6-7-2601 (Mental Illness,Alcoholism and Drug Dependence) is
extraterritorial;therefore,this form must be completed even if the situs state of the plan is other than
Tennessee.
ACCEPT REJECT CITATION BENEFIT
56-7-2504 Bone Marrow Transplant*: Coverage for the treatment of cancer by close-
intensive chernothe rapy/auto logo us bone marrow transplants or stem cell
transplants to the same extent as any other illness under the plan
56-7-2363 Cancer Screenings -Colorectal: Coverage for colorectal cancer
examinations and laboratory tests for colorectal cancer screening of
asymptomatic individuals according to the guidelines of the American Cancer
Society or the U.S. Preventive Services Task Force. Benefits will be covered
at the same cost-sharing rate as other benefits under the plan.**
56-7-2606 Chlamydia Screening: Coverage for one annual Chlamyclia screening test in
conjunction with an annual pap smear for covered females who are not more
than 29 years old if the screening test is determined to be medically
56-7-2601 Mental Illness, Alcoholism and Drug Dependence: Coverage of mental
health benefits with the same lifetime and annual aggregate limits and cost-
sharing provisions as other illnesses. Substance abuse benefits do not need
to be covered at that level unless provided through Community Mental Health
Centers. Note: Pursuant to 56-7-2601(a)this required offer does not apply
to group plans with 25 or more employees which must provide minimum
coverage mandated by 56-7-2360.
56-7-2602 Alcohol and Drug Dependency: Coverage for inpatient and outpatient care
and treatment of alcohol or other drug dependency subject to the same
durational limits,coinsurance,deductibles, and copayments,that are no less
favorable than for physical illness generally. Benefits so provided shall be
determined as if necessary care and treatment in an alcohol or other drug
dependency treatment center were care and treatment in a hospital,
56-32-228 Point of Service Option: No lock-in plan can be sold unless a point-of-service
plan is either offered through CG or through another carrier with the
employer's written representation that a point of service plan is available to
employees. Accepting this requirement means that CG will provide an
open network option as well as a lock-in Network plan, Rejecting this
option means that the employer will provide a point of service option
through another carrier. Indicate name of other carrier
This benefit is stand2rdly covered under a Connecticut General Life Insurance Company medical plan and
therefore does not have an impact on premium.
**This benefit is stand@rdly covered under certain CGLIC plans that include preventive care benefits for adults
and therefore does not have an impact on premium for those plans.
***This benefit is standardly covered under certain CGLIC plans that include preventive care benefits and
therefore does not have am impact on premium for those plans.
__.City of Clearwater CG#333140
Name mfPolicyholder
By_ctai/Je Title
Name
� ,/
Date
CONNECTICUT GENERAL LIFE INSURANCE COMPANY
WASHINGTON
STATE REQUIRED ACCEPTANCEIREJECTION FORMS
Connecticut General Life Insurance Company is required to offer to the group policyholder
the following benefits. The policyholder may choose to accept or reject the benefits and
understands that such coverage, if rejected,will not be provided at a later date unless
specifically requested.
ACCEPT REJECT CITATION BENEFIT
48.21.250 Continuation: Continued group medical coverage for terminated
employees and their insured dependents upon loss of group coverage
for a period of time and at a rate agreed upon by the group and
CGLIC.
Federal COBRA would still apply-
48.21.220 Home Health:
Home Health with a minimum of 130 visits per calendar year. A visit of
any duration by an employee of a home health agency, for the
purpose of providing services under the plan of treatment constitutes
one visit. May require that home health agencies have written
treatment plans approved by a licensed physician and may require
such treatment plans to be reviewed at designated intervals. The
coverage may contain provisions for utilization review.
CG's base medical plans include coverage for Home Health. If the
home health benefit noted above is rejected, CIGNA's base home
health coverage would be included in the contract.
48.21.220 Hospice:
No less than an initial coverage period of 6 months, authorized if
medically necessary.
CG's standard plan design includes hospice coverage, which may be
provided for 6 months or morefiess depending on the treating
physician's request and indications of medical necessity. If the
hospice benefit noted above is rejected, CIGNA's base hospice
coverage would be included in the contract.
48.21.240; Mental Illness: Coverage for mental health, subject to reasonable
48.46.290 deductibles or copayments, for treatment rendered by a licensed
physician, a licensed psychologist, a state hospital, or a licensed
community mental health agency. (Standard CG benefit plan designs
/X comply with this law. Rejection of this coverage would mean no
mental health benefits.)
48.21.320; TMJ: Coverage for temporomandibular joint disorders at the same
1 48.46.530; level as other musculoskeletal disorders, to a maximum of$1,000 per
284-96-020 calendar year and $5,000 per lifetime.
48.21.244 Maternity Congenital Testing: Coverage for prenatal screening to
diagnosis of congenital disorders of the fetus during pregnancy when
those services are determined to be medically necessary.
— Note, CIGNA currently covers medically necessary fetal screenings.
City of Clearwater CG#3331468
Name of Policyholder
By tu Title
Na�me- #
Date f l 0-e
th are
CIGNA HealthCare Group Benefits Proposal
City of Clearwater
100 South Myrtle Avenue
Clearwater, FL 33756
SIC Code : 9111
Group Contact : 3331468
Total Eligible Employees: participating Subscribers : ,
11'87q '3
Employer Contributions : Employee Contribution : 1 N
/001. 0/— sawn, OAPW Dependent Contribution:
Flo of- &-
src 0 A#OtlJ A 6 1P,
68c/ sic,.0 A ad —r �oero
r � a{
waing Period :
IS`of the month following date of hire
Eligibility Definition : Active Employees working at least 37 112 hrs, a week
Note: The Quoted rates are subject to final Underwriting approval and, as noted below, are subject to
change in the event of changes in benefits selected or changes in the risk factors upon which the Quoted
Rates are based. In addition, state law may require regulatory approval of rates. If required regulatory
approval has not been obtained on the proposed effective date, the healtbplan shall use rates that are
consistent with its then currently approved rating methodology and the quoted rates shall be effective
immediately on the date for which they are approved for use. The Quoted Rates are guaranteed while the
Group Service Agreement remains in effect until the next anniversary date, unless enrollment changes by
15% in which case the CIGNA Companies may change the Quoted bate.
S2-FXG1I71-SIF-1 Revisionl 1 of 23 10/29/08
City of Clearwater
CTGNA HealthCeixe
Proposed Benefits
Product: Open Access Plus loll- Network (Buy-lip)
Situs Mate: FL Effective Date: 01/01/2009
Benefits Summary
Category Description In Network
Medical Benefits
Modular Medical Management Program Benefit PHS+
Option
Office Visit Copay NA
Primary Care Copay $25
Specialty Care Copay—Tier 1 $35
Specialty Care Copay—Tier 2 $55
Coinsurance 100%
Hospital IP-Per Admit Copay $500
Hospital IP Copay Per Day NA
Collective Deductible/OOP Admin Option NO
Combined Medical/Pharmacy Deductible/OOP Admin NO
Option
Annual Individual Plan Deductible $0
Annual Family Plan Deductible $0
Deduct Accumulator Standard: One Way
Accumulation
OOP-Individual Maximum Amount 52,000
OOP-Family Maximum Amount 54,000
OOP Max-Accumulator Standard:One Way
Accumulation
OOP Max Ded NA
OOP Max Copays Includes Copays
Lifetime Maximurn Amount Unlimited
Lifetime Maximum-Annual Reinstatement Amount NA
Outpatient Facility Copay '$100
Emergency Room Copay $150
Urgent Care Copay $75
Other Health Care Facility IP Maximum Days 60
Lab/Radiology Standard Coverage Plan.Ded/Coins
MRI,CT PET Scans Copay 50
Lab/Radiology Mid-Point Coins Option Coinsurance NA
Home Health Care Maximum Days 60
Durable Medical Equipment Included
Durable Medical Equipment Maximum Amount Unlimited
External Prosthetic Appliances Included
External Prosthetic Appliances Deductible 5200
External Prosthetic Appliances Maximum Amount 51,000
Short Term Rehab and Chiro Combined Maximum 60
Days
Short Term Rehab Maximum Days NA
S2-FXG1171-SIF-1 Revisionl 2 of 23 10/29/08
City of Clearwater
CAIGNA HealthCare
Proposed Benefits
Product: Open Access Plus In- Network (Buy-Up)
Situs State: FL Effective Late: 01/01/2009
Benefits Summary (Cont.)
Category Description In Network
Medical Benefits(Cont.) Chiropractic Care Maximum Amount NA
Chiropractic Care Maximum Days NA
Infertility Treatment Standard Coverage Not Covered
Infertility!Opt I -Diagnoses/Corrective procedure Excluded
Infertility Opt 2-Opt I plus invitro,GIFT,ZIFT Excluded
Infertility Opt 2-Lifetime Maximum Amount NA
Bariatric Services Excluded
Bariatric Surgery-Lifetime Maximum Amount NA
Preventive Care-Children thru Age 2 Included
Preventive Care Opt 2-Annual Physicals Age 3+ Included
Preventive Care Opt 2-Immunizations Included
Preventive Care Opt 2-Calendar Year Benefit Unlimited
Maximum Amount
Organ Transplant Included
Health Advisor Benefit Option Health Advisor
Corc/Non-CCF
Routine Foot Care Buy-up Excluded
Routine Foot Care-Cal Yr Buy-up Benefit Maximum NA
Amount
Non-Surgical TMJ Included
PCL Included
Medicare COB:Retirees>=65 Admin Option NA
Medicare COB Type None
Percent of Medicare Eligible NA.
Well Aware Program(Diabetes) Included
Well Aware Program(Cardiac) Included
We]I Aware Program(Asthma) Included
Well Aware Program(Low Back Pain) Included
Well Aware Program(COPD) Included
Well Aware Program(Weight Complications) Included
Well Aware Program(Targeted Conditions) Included
Well Aware Program(Depression Management) Included
Wellness Program(Healthy Steps to Weight Loss) Included
24HIL Included
Healthy Rewards Included
LifeSource Organ Transplant Network Transplant Included
Program
Language Line Included
S2-FXG1I71-SIF-1 Revisiortl 3 of 23 10/29108
City of Clearwater
CYGNA are
Proposed Benefits
Product: Open Access Plus In- Network (Buy-Up)
5itus State: FL Effective Date: 01/01/2009
Benefits ,Summary(Cont.)
Category Description In Network
Medical Benefits(Cont.) Transition of Care Included
Case Management Included
Provider Channeling Included
Away From home Care Included
Drugstore.Com Included
S2-FXG1171-SIF-1 Revision) 4 of 23 10/29/08
City of Clearwater
CTGNA ear
Proposed Benefits
Product: Open .Access Plus In- Network (Buy-Up)
Situs State: FL Effective Date: 01/01/2009
Benefits Summgy(Cont.)
Category Description In Network Out of Network
Pharmacy Benefits CIGNA PharmacyPlus 3-Tier Copay
Plan Buy Up Option Coinsurance NA
Retail-Generic Copay $15
Retail-Brand Copay $30
Retail-Non Preferred Copay $50
Mail Order-Generic Copay $30
Mail Order-Brand Copay $60
Mail Order Copay_Non-prefcrred $100
Retail-Individual Buy Up Option Deductible NA.
Retail-Family Buy Up Option Deductible NA
Retail-Individual Deductible Nip.
Retail-Family Deductible NA
COP-Individual Maximum NA NA
OOP-Family Maximum NA NA
Standard Preventive Drugs Excluded from Deductible NO
Ded&OOP Max Apply to MOD Do Not Apply to MOD
MOD Program No Mandatory
Maintenance Drug List NA
Oral Contraceptives/Devices Covered
Lifestyle Drugs Not Covered
Oral Fertility Drugs Not Covered
Self-Administered Injectables Covered
Optional Injectables Buy-Up Not Covered
Insulin Covered
Insulin Needles&Syringes Covered
Glucose Test Strips Covered
Lancets Covered
Prenatal Vitamins Covered
Step Therapy Program Included
Clinical Management Program Enhanced
Enh.-Benefit Exclusion Selected
Enh.-Intensive Appropriateness of Use Selected
Enh.-Utilization and Unit Cost Management Selected
Generic Push Included
Formulary Incentive
Prescriber Panel Open
S2-FXG1I71-SIF-1 Revision], 5 of 23 10/29/08
City of Clearwater
CIGNA are
Proposed Benefits
Product: Open Access Plus In- Network (Buy-Up)
Situs State: FL effective Tate: 01/01/2009
Benefits Summary(Cont.)
Category Description In Network
MH/SA Benefits OAPIN MHSA Combined
CIGNA Behavioral Health Benefit Option In&Outpatient Mgmt.
CAP
MH/SA Hospital IP Coinsurance 100%
MH/SA Hospital IP-Per Admit Copay '5500
MH/SA Hospital IT-Per Day Copay NA
MH/SA Hospital IP Combined Maximum Days 25
MH/SA Outpatient Copay S35
MH/SA Outpatient Coinsurance NA
MH/SA Intensive Outpatient Copay S50
MH/SA Intensive Outpatient Coinsurance 50°l
MH/SA OP&MH Group Therapy Combined 20
Maximum Visits
MH Grp Therapy Copay S35
MH Grp Therapy Coinsurance NA
MH/SA OP Tiered Copay Option Excluded
MH/SA OP Tier 1 Copay NA
MH/SA OP Tier I Visits(I to_)Maximum NA
MH/SA OP Tier 2 Copay NA
MH/SA OP Tier 2 Visits(Tier I Max to ) Maximum NA
MH/SA OP Tier 3 Copay NA
MH/SA OP Tier 3 Visits(Tier 2 Max to ) Maximum NA
Standard IP Review/Case Mgmt UR Program Included
OP Review/Case Mgmt Buy Up I UR Program Excluded
OP Review/Case Mgmt Buy Up 2 UR Program Excluded
Transition of Care(90 day period) Included
Vision Benefits None
S 2-F XG 1171-S1F-1 Revision 1 6 of 23 10/29/08
City of Clearwater
CIGNA Health Care
Proposed Medical and RX rates
Group Description All Employees Electing The OAPIN (Buy-Up)Medical Plan.
Tier Subscribers Premium Date Monthly
Premium
Employee 228 $508.99 $116,049.72
Emp+ 1 81 $875.47 $ 70,913.07
Emp+Family 67 $1,440.45 $ 96,510.15
Total 376 $283,472.94
52-FXG1I71-5IF-I Revisionl 7 of 23 10/29/08
City of Clearwater
CIGNA Health Care
Proposed Benefits
Product: Open Access Plus
Situs State: FL Effective Bate: 01/01/2009
Benefits Slimmary
Category Description In Network Out of Network
Medical Benefits
Modular Medical Management Program Benefit PHS+
Option
Office Visit Copay NA
Primary Care Copay S25
Specialty Care Copay®Tier 1 S35
Specialty Care Copay -Tier 2 $55
Coinsurance 100% 70%
Hospital IP-Per Admit Copay 5500
Hospital IP Deductible-Per Admit NA
Hospital IP Copay Per Day NA
Hospital IP Deductible-Per Day NA
Maximum Reimbursable Charge Benefit Option Option 2- 110%Inc[
NSP&Bill Negotiatio
Collective Deductible/OOP Admin Option NO NO
Combined Medical/Pharmacy Deductible/OOP Admin NO NO
Option
Annual Individual Plan Deductible 50 S500
Annual Family Plan Deductible SO 51,000
Deduct Accumulator Standard:One Way Standard: One Way
Accumulation. Accumulation
OOP-Individual Maximum Amount 52,000 S3,000
OOP-Family Maximum Amount 54,000 56,000
OOP Max-Accumulator Standard: One Way Standard: One Way
Accumulation Accumulation
OOP Max Ded NA Includes Ded
OOP Max.Copays Includes Copays Includes Copays
Lifetime Maximum Amount Unlimited
Lifetime Maximum-Annual Reinstatement Amount NA
Outpatient Facility Copay 5100
Outpatient Facility Deductible 5100
Emergency Room Copay S150
Emergency Room Deductible 5150
Urgent Care Copay S75
Urgent Care Deductible S75
Other Health Care Facility IP Maximum Days 60
Lab/Radiology Standard Coverage Plan Ded/Coins Plan Ded/Coins
MRI,CT PET Scans Copay SO 50
Lab/Radiology Mid-Point Coins Option Coinsurance NA NA
Home Health Care Maximum Days 60
Durable Medical Equipment Included Cvrd-Dcd/Coins
Durable Medical Equipment Maximum Amount Unlimited
External Prosthetic Appliances Included Cvrd-Ded/Coins
S2-FXG1171-SIF-1 Revision] S of 23 10/24/08
City of Clearwater
CIGNA Health Care
Proposed Benefits
Product: Open Access Plus
Situs State: FL Effective Date: 01/01/2009
Benefits Summ4a(Cont.)
Category Description In Network Out of Fretwork
Medical Benefits(Cont.) External Prosthetic Appliances Deductible $200
External Prosthetic Appliances Maximum Amount $1,000
Short Term Rehab and Chiro Combined Maximum 60
Lays
Short Term Rehab Maximum Days NA
Chiropractic Care Maximum Amount NA
Chiropractic Care Maximum Days NA
Infertility Treatment Standard Coverage Not Covered Not Covered
Infertility Opt 1 -Diagnoses/Corrective procedure Excluded Not Covered
Infertility Opt 2-Opt 1 plus Invitro,GIFT,ZIFT Excluded Not Covered
Infertility Opt 2-Lifetime Maximum Amount NA
Bariatric Services Excluded
Bariatric Surgery-Lifetime Maximum Amount NA
Preventive Care-Children thru Age 2 Included Not Covered
Preventive Care Opt 2-Annual Physicals Age 3+ Included Not Covered
Preventive Care Opt 2-Immunizations Included
Preventive Care Opt 2-Calendar Year Benefit Unlimited
Maximum Amount
Organ Transplant Included Not Covered
Health Advisor Benefit Option health Advisor
Core/Non-CCF
Routine hoot Care Buy-up Excluded Not Covered
Routine Foot Care Separate Buy-up Coinsurance NA.
Routine hoot Care-Cal Yr Buy-up Benefit Maximum NA NA
Amount
Non-Surgical TMJ Included Excluded
PCL Included Included
PAC/CSR-Standard IP Admit/Case Management UR Included
Program
PAC/CSR IP Non Compliance Penalty Amount 5750
PAC/CSR IP Non Compliance Penalty Percent 50%
Medicare COB:Retirees>�65 Admin Option NA
Medicare COB Type None
Percent of Medicare Eligible NA
Well Aware Program(Diabetes) Included
Well Aware Program(Cardiac) Included
Well Aware Program(Asthma) Included
S2-FXG1I71-SIF-I Revisionl 4 of 23 10/24/08
City of Clearwater
LIE
etr
Proposed Benefits
Product: Open. Access Plus
Situs State: FL Effective Date: 01/01/2009
Benefits Su>:nnr gaa Cont j
Category Description In Network Out of Network
Medical Benefits(Cont.) Well Aware Program(Low Back Pain) Included
Well Aware Program(COPD) Included
Well Aware Program(Weight Complications) Included
Well Aware Program(Targeted Conditions) Included
We]]Aware Program(Depression]management) Included
Wellness Program(Healthy Steps to Weight Lass) Included
24HIL Included
Healthy Rewards Included
LifeSource Organ Transplant Network Transplant Included
Program
Language Line Included
"Transition of Care Included
Case Management Included
Provider Channeling Included
Away From Horne Care Included
Drugstore.Com Included
S2-FXG1171-SIF-1 Revisionl 10 of 23 10/29/08
City of Clearwater
CAGNA HealthCaxe
Proposed Benefits
Product: Open Access Plus
Situs State: FL Effective Date: 01/01/2009
Benefits Summary(Cont.)
Category Description In Network Out of Network
Pharmacy Benefits CIGNA,PharmacyPlus 3-Tier Copay
Plan Buy Up Option Coinsurance NA
Retail-Generic Copay $15
Retail-Brand Copay $35
Retail-Non Preferred Copay $50
Mail Order-!Generic Copay S30
Mail Order-Brand Copay $70
Mail Order Copay-Non-preferred s l 00
Retail-Individual Buy Up Option Deductible NA
Retail-Family Buy Up Option Deductible NA
Retail-Individual Deductible NA
Retail-Family Deductible NA
OOP-Individual Maximum NA NA
OOP-Family Maximum NA NA
Standard Preventive Drugs Excluded from Deductible NO
Ded&OOP Max Apply to MOD Do Not Apply to MOD
;MOD Program No Mandatory
Maintenance Drug List NA
Oral Contraceptives/Devices Covered
Lifestyle Drugs Not Covered
Oral Fertility Drugs Not Covered
Self-Administered Injectables Covered
Optional Injectables Buy-Up Not Covered
Insulin Covered
Insulin Needles&Syringes Covered
Glucose Test Strips Covered
Lancets Covered
Prenatal Vitamins Covered
Step Therapy Program Included
Clinical Management Program Enhanced
Enh.-Benefit Exclusion Selected
Enh.-Intensive Appropriateness of Use Selected
Enh.-Utilization and Unit Cost Management Selected
Generic Push Included
Formulary Incentive
Prescriber Panel Open
S2-FXGlI71-SIF-1 Revision]. 11 of 23 10/29/08
City of Clearwater
LIE
CIGNA Health Care
Proposed Benefits
Product: Open Access Plus
Situs State: FL Effective Date: 01/01/2009
Benefits Summary(Cont.)
Category Description In Network Out of Network
MR/SA Benefits OA Plus MHSA Combined
CIGNA Behavioral Health Benefit Option In&Outpatient Mgmt.
CAP
MH/SA Hospital IP Coinsurance 100% 70%
MH/SA Hospital IP-Per Admit Copay 5500 $500
MH/SA Hospital IP-Per Day Copay NIA NA
MH/SA Hospital IP Combined Maximum Days 25
MH/SA Outpatient Copay S35
MH/SA Outpatient Coinsurance NA 70%n
MH/SA Intensive Outpatient Copay S50 S50
MH/SA Intensive Outpatient Coinsurance 50%Q 50%
MH/SA OP&MH Group Therapy Combined 20
Maximum Visits
MH Grp Therapy Copay $35
MH Grp Therapy Coinsurance NA 70%
MH/SA OP Tiered Copay Option Excluded
MH/SA OP Tier 1 Copay NA
MH/SA OP Tier 1 Visits(I to_)Maximum NA
MH/SA OP Tier 2 Copay NA
MH/SA OP Tier 2 Visits(Tier I Max to } Maximum NA
MH/SA OP Tier 3 Copay NA
MH/SA OP Tier 3 Visits(Tier 2 Max to_j Maximum NA
Standard IP Review/Case Mgmt UR Program Included
OP Review/Case Mgrnt Buy Up I UR Program Excluded
OP Review/Case Mgmt Buy Up 2 UR Program Excluded
Transition of Care(90 day period) Included
Vision.Benefits None
S2-FXG1171-SIF-1 Revisiortl 12 of 23 10/29/08
City of Clearwater
CIGNA HealthC-cue
Proposed Medical and RX rates
Group Description : All Employees Electing The Open Access Plus Medical Plan
'Pier Subscribers Medical Monthly
Premium Rate Premium
Employee 57 $544.43 $31,032.51
Ernp+ 1 20 $936.44 $18,728.80
Emp+Fan-Lily 17 $1,540.75 $26,192.75
Total 94 $75,954.06
S2-FXG11.71-S1F-1 R visionl 13 of 23 10/29/08
City of Clearwater
CIGNA Health Care
Proposed Benefits
Product: Open Access Plus In- Network (Basic)
Stus State: FE Effective Date: 01/01/2009
Benefits Sutrtrtlary
Category Description to Network
Medical Benefits
Modular Medical Management Program Benefit PHS+
Option
Office Visit Copay NA
Primary Care Copay S20
Specialty Care Copay—Tier I S40
Specialty Care Copay -Tier 2 S60
Coinsurance 80%
Hospital IP-Per Admit Copay NA
Hospital IP Copay Per Day NA
Collective Deductible/OOP Adrnin Option NO
Combined Medical/Pharmacy Deductible/OOP Admin NO
Option
Annual Individual Plan Deductible $750
Annual Family Plan Deductible $1,500
Deduct Accumulator Standard.One Way
Accumulation
OOP-Individual Maximum Amount $3,000
OOP-Family Maximum Amount 56,000
OOP Max-Accumulator Standard: One Way
Accumulation
OOP Max Ded Includes Ded
OOP Max Copays Includes Copays
Lifetime Maximum Amount Unlimited
Lifetime Maximum-Annual Reinstatement Amount NA
Outpatient Facility Copay NA
Emergency Room Copay 5200
Urgent Care Copay S I M
Other Health Care Facility IP Maximum Days 60
Lab/Radiology Standard Coverage 100%,No Ded.
MRI,CT PET Scans Copay S0
Lab/Radiology Mid-Point Coins Option Coinsurance NA
Home Health Care Maximum Days 60
Durable Medical Equipment included
Durable Medical Equipment Maximum Amount Unlimited
External Prosthetic Appliances Included
External Prosthetic Appliances Deductible S200
External Prosthetic Appliances Maximum Amount 51,000
Short Term Rehab and Chiro Combined Maximum 60
Days
Short Term Rehab Maximum Days NA
S2-FXG1I71-SIl~-1 Revision]. 14 of 23 10/29/08
City of Clearwater
Proposed .Benefits
Product: Open Access Plus In- Network (Basis)
Situs Mate: FL Effective Date: 01/01/2009
Benefits Summary(Cont.)
Category Description In Network
Medical Benefits(Cont.) Chiropractic Care Maximum Amount NA
Chiropractic Care Maximum Days NA
Infertility Treatment Standard Coverage Not Covered
Infertility Opt I -DiagnoseslCorrectivc procedure Excluded
Infertility Opt 2-Opt.I plus Invitro,GIFT,ZIFT Excluded
Infertility Opt 2-Lifetime Maximum Amount NA
Bariatric Services Excluded
Bariatric Surgery-Lifetime Maximum Amount NA
Preventive fare-Children thru Age 2 Included
Preventive Care Opt 2-Annual Physicals Age 3+ Included
Preventive Care Opt 2-Immunizations Included
Preventive Care Opt 2-Calendar Year Benefit Unlimited
Maximum Amount
Organ Transplant Included
Health Advisor Benefit Option Health Advisor
Cor"on-CCF
Routine Foot Care Buy-up Excluded
Routine Foot Care-Cal Yr Buy-up Benefit Maximum NA
Arnount
Non-Surgical TMJ Included
PCL Included
Medicare COB: Retirees65 Admin Option NA
Medicare COB Type None
Percent of Medicare Eligible NA
Wel I Aware Program(Diabetes) Included
Well Aware Program(Cardiac) Included
Well Aware Program(Asthma) Included
Well Aware Program(Low Back Pain) Included
Well Aware Program(COPD) Included
Well Aware Program(Weight Complications) Included
Well Aware Program(Targeted Conditions) Includedd
Well Aware Program(Depression Management) Included
Wellness Program(Healthy Steps to Weight Loss) Included
24HIL Included
Healthy Rewards Included
LifeSource Organ Transplant Network Transplant Included
Program
Language Line Included
S2-FXG1171-SIF-I Revisiorrl 15 of 23 10/29/08
City of Clearwater
CIGNA are
Proposed Benefits
Product: Open Access Plus In- Network (Basic)
Situs State: FL Effective Date: 01/01/2009
Benefits Summary(Cont.)
Category Description. In Network
Medical Benefits(Cont.) Transition of Care Included
Case Management Included
Provider Channeling Included
Away From Home Care Included
Drugstore.Com Included
S2-FXG1I71-SIF-1 Revision], 16 of 23 10/29/08
City of Clearwater
CIEGNA are
Proposed Benefits
Product: Open Access Plus In- Network (Basic)
Situs State: FL Effective Date: 01/01/2009
Benefits Summary(font,
Category Description In Network Out of Network
Pharmacy Benefits CIGNA PharmacyPlus 3-Tier Copay
Plan Buy Up Option Coinsurance NA
Retail-Generic Copay 520
Retail-Brand Copay 540
Retail-Non Preferred Copay S60
Mail Order-Generic Copay 540
Mail Order-Brand Copay S50
Mail Order Copay-Non-preferred 5120
Retail-Individual Buy Up Option Deductible NA
Retail-Family Buy Up Option Deductible NA
Retail - Individual Deductible NA
Retail -Family Deductible NA
OOP-Individual Maximum NA ILIA
OOP-Family Maximum NA NA
Standard Preventive Drugs Excluded from Deductible NO
Ded&OOP Max Apply to MOD Do Not Apply to MOD
MOD Program No Mandatory
Maintenance Drug List NA.
Oral Contraceptives/Devices Covered
Lifestyle Drugs Not Covered
Oral Fertility Drugs Not Covered
Self-Administered Injectables Covered
Optional Injectables Buy-Up Not Covered
Insulin Covered
Insulin Needles&Syringes Covered
Glucose Test Strips Covered
Lancets Covered
Prenatal Vitamins Covered
Step Therapy Program Included
Clinical Management Program Enhanced
Enh.-Benefit Exclusion Selected
Enh.-Intensive Appropriateness of Use Selected
Enh.-Utilization and Unit Cost Management Selected
Generic Push Included
Formulary Incentive
Prescriber Panel Open
S2-FXG1I71-SIF-1 Revisionl 17 of 23 10129/08
City of Clearwater
Proposed Benefits
Product: Open Access Plus In- Network (Basic)
Situs State: FL Effective Date: 01/01/2049
Benefits Summary Cont.)
Category= Description In Network
MH/SA Benefits OAPIN MESA Combined
CIGNA Behavioral Health.Benefit Option In&Outpatient Mgmt.
CAP
MH/SA Hospital IP Coinsurance 80%
MH/SA Hospital IP-Per Admit Copay 51,000
MH/SA Hospital IP-Per Day Copay NA
MH/SA Hospital IP Combined Maximum Days 25
MH/SA Outpatient Copay S60
MH/SA Outpatient Coinsurance NA
MH/SA Intensive Outpatient Copay S50
MH/SA Intensive Outpatient Coinsurance 50%
MH/SA OP&MH Group Therapy Combined 20
Maximum Visits
MH Grp Therapy Copay $60
MH Grp Therapy Coinsurance NA
MH/SA OP Tiered Copay Option Excluded
MH/SA OP Tier I Copay NA
MH/SA OP Tier l Visits(I to )Maximum NA
MH/SA OP Tier 2 Copay NA
MH/SA OP Tier 2 Visits(Tier l Max to_) Maximum NA
MH/SA OP Tier 3 Copay NA
MH/SA OP Tier 3 Visits(Tier 2 Max to } Maximum NA
Standard IP Review/Case Mgmt UR Program Included
OP Review/Case Mgmt Buy Up I UR Program Excluded
OP Review/Case Mgmt Buy Up 2 UR Program Excluded
Transition of Care(90 day period) Included
Vision Benefits None
S2-FXGI171-SIF-I Revisiont 18 of 23 10/29/08
City of Clearwater
CIGNA t ,-.
Proposed Medical and M rates
Group Description : All Employees Electing The OAPIN(Basic)Medical Plan
Tier Subscribers Medical Monthly
Premium Rate Premium.
Employee 854 $425.05 $362,992.70
Emp+ 1 303 $731.07 $221,514.21
Emp+Family 252 $1,202.85 $303,118.20
Total 1,409 A $887,625.11
S2-FXG1I71-SIF-1 Revsionl 19 of 23 10/29/08
City of Clearwater
CIGNA HealthC-cue
Medical History Itxformatian
For
City of Clearwater
1. Have there been any claims over$10,000 in the last 12
months?
2. Has any employee missed more than 10 consecutive days in
the last 12 months date to illness or injury?
3. Are there any employees with ongoing disabilities?
4. Have any individuals been diagnosed,received treatment, or
are currently receiving treatment for any of the following
conditions in the past three years:Alcohol/Drug abuse, Cancer,
Diabetes,Heart Conditions, Immune System Disorders,Kidney
Ailments, Liver Diseases,Lung Conditions,Obesity,Organ
Transplants?
S2-FXG11 71-SIF-1 Revisioril 20 of 23 10/29/08
City of Clearwater
CIGNA HealthCcare
Underwriting Contingencies
For
City of Clearwater
CIGNA may revise or withdraw this Proposal if:
• there is a change to the effective date of the quote.
• the policy period length is different than 12 months.
• the policy will not be sitused in Florida.
• the current waiting period is different than 0 of the month following date of hire.
• the census or experience provided by the consultant or account is deemed inaccurate.
• there is a change in law,regulation, tax rates,or the application of any of these that affects CIGNA's
costs..
* enrollment increases or decreases by 10% or more,by product, from the enrollment assumptions used in
establishing the rates and/or fees set forth herein.
* the final enrollment deviates from the quoted enrollment such that it results in a needed change in the
premium rates. Rates are based on final enrollment factors,including total number of enrollees,their age,
sex, demographics, location and the distribution of enrollees by product or membership tier.
* participation is below 70%. This will be based on the total eligible employees, identified as Erruployees
working at least 37 1/2 hours per week.
* any of the informmation upon which these rates or benefits were based(including Medical History
Information)changes or is inaccurate.
* CIGNA is not the exclusive provider of Medical/Prescription Drugs or like products for all of the City
of Clearwater's employees in all worksites.
• the employer contributes less than 50%toward the total cost of the plan.
• the employer changes it's contribution to the plan rates(either the percentage or amount).
• either one or more of the quoted sites withdraws prior to the effective date or terminates during the
contract term, or at any time following enrollment.
Unless othenvise indicated, this Proposal:
• supercedes and renders null and void any prior CIGNA offer or proposal with respect to the Plan.
• or policy may be canceled as of any Premium Due Date if the number of hrsured Employees fails to
meet the minimum required per group participation rules;or for failure to comply with any other
material plan provision relating to employer contributions or group participation rules.
• reflects the claims and administrative savings realized by packaging the following specialty coverage
with medical: Pharmacy,Behavioral Advantage,Health Advocacy.
• requires a separate benefit option due to state regulations,if you have purchased OAP/PPO with
CIGNA Behavioral Advantage and you have members residing in NC or CA.
• does not apply to part-time or seasonal employees for any plan.
• does not apply to Medicare eligible retirees for any plan.
• includes Network Savings Program(NSP) and other bill negotiation.
• includes a maximum reiimbursable charge for out-of-network coverage equal to 110% of a fee schedule
developed by CIGNA based upon a methodology similar to that used by Medicare to determine the
allowable fee for similar services in the geographic market.
• assumes that all employees are located in the network area,and that all employees are only eligible for
the product offerings specified.
• requires you notify us within 30 days if any information set forth in this form changes at any time while
coverage is provided to you by CIGNA Healthcare Companies.
• does not provide administration of"run-out"claims incurred prior to the effective date.
S2-FXG1I71-5IF-1 Revisionl 21 of 23 10/29/08
City of Clcarwater
CIGNA are
• may require regulatory approval of rates. If,as of their proposed effective date,regulatory approval is
not obtained,the healthplan shall use rates consistant with it's then currently approved rates and the
foregoing rates shall be effective automatically. If a product is new and has never had approved rates,
the effective date of coverage will be postponed until regulatory approval is received.
• allows caveats and conditions set forth in this document to survive execution of any final contract
and/or issuance by CIGNA Healthcare of any policy and/or Group Service Agreement.
S2-FXG1I71-SIF-I Revisionl 22 of 23 10/299/08
City of Clearwater
0-9
CIGNA HealthCaxe
Underwriting Contingencies
For
City of Clearwater (cant)
The CIGNA Healthcare Companies reserve the right to change the Quoted Rates and/or Quoted Benefits or to
decline to offer coverage if any of the foregoing information is inaccurate or changes prior to the proposed
Effective Date indicated above,or if the quoted rates and/or fees are not agreed to within 60 days of receipt of
this suntinary information form. If any of the information identified above changes either prior to the proposed
Effective Date or while coverage is in effect,you agree to notify us promptly of such change.
The "Underwriting Contingencies"set forth above shall survive execution of any insurance policy, application,
etc., issued by Connecticut General Life Insurance Company or any other CIGNA Healthcare company, and,
shall further survive the effective date of any such policies.
The benefits displayed in this summary are,for the most part,modular benefit packages used to develop
the rates.Please review the Benefit Summary and its attachments for information about the benefits
available in your sites.
"CIGNA Healthcare"refers to various operating subsidiaries of CIGNA.Corporation.Products and services
are provided by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut
General Life Insurance Company,Tel-Drug, Inc. and its affiliates,CIGNA Behavioral Health, Inc.,Intracorp,
and HMG or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health,Inc.
Icep
Client Signature / Date
{j d: icv-
47
Client Name Title
S2-FXG1171-SIF-I Revisionl 23 of 23 10/29/08
City of Clearwater