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HomeMy WebLinkAboutC2021-240 - 7/27/2021 - Approved DocuSign Envelope ID:6A5E7A6E-C590-4DC9-B7C9-567814B64AD6 P PLICATION y . CARE PLAN • VS Attn:Sales 3333 Quality Drive,Rancho Cordova,CA 95670 800.852.7600 Complete all applicable questions accurately and in detail. INFORMATIONCLIENT 1 Full legal name of client as it should appear on the policy:City of Corpus Christi Address: 12011 Leopard St. city:Corpus Christi County: Nueces State:Texas ZIP:782401 Principal Contact: Ramon Henderson Title:Benefits Manager Grant online access?YES Phone:361.826.3878 Fax: E-mail:ramonh@cctexas.com Client is headquartered in state of Texas (if different state from section 1,provide physical address for client in this state) Address: City: County: State: ZIP: 2 Who should we contact with payment questions? Name:Ramon Henderson Title:Benefits Manager Grant online access?Yes Phone:361-826-3878 Fax:361- E-mail:ramonh@cctexas.com 3a Who should we contact with eligibility questions? Name:Jacinda Martinez Title:Sr. Benefits Analyst Grant online access?Yes Phone:361-826-3626 Fax: E-mail:jacindam@cctexas.com 3b Does your broker need access to view/manage/update your eligibility? ❑yes Eno Name: Titter Phone: Fax: E-mail: 4 Who is the Benefit Administrator responsible for the overall administration of the plan(if not principal contact)? Name:Ramon Henderson Title:Benefits Manager Grant online access?Yes Phone:361-826-3878 Fax: E-mail:ramonh@cctexas.com If multiple benefits administrators are at other locations,attach names,addresses,emoils,phone,and fax numbers,. 5 What is the nature/type of your business?Municipality What is the DUNS number? Standard Industry Code(SIC):J916 DivisiomPublic Administration Major Group:City or Local Government 6 Membership information will be sent to VSP via:®Electronic.Transfers (Online Eligibility Management Membership information will be reported using❑Member SSNs MUnique member IDs If electronic transfer reporting OR if a Third Party Administrator will handte your eligibility,please provide their information. Firm: Contact: Title: Grant online access? Version 06/2020 Client Application- Large Classification: Confidential page 1 of 5 DocuSign Envelope ID:6A5E7A6E-C590-4DC9-B7C9-567814B64AD6 Address: City: County: State: ZIP: Phone: Fax: E-mail: In conjunction with health plan industry practices when providing electronic eligibility,VSP requests clients to send dependent eligibility information to VSP.This would include providing the covered dependent's full name,date of birth,and'relationship to the employee/member. Dependents will be reported as a dependent under the employee's ID number. Will dependent information be sent to VSP for eligibility purposes?Myes Ono If no,please explain: Employers without Internet access for making membership updates will be contacted by VSP to review other options. 7 Is a COBRA division required?Myes Ono Names of additional divisions that require separate billing. Address of additional divisions if applicable.IMPORTANT:Separate divisions will be billed on separate invoices (if multiple divisions are needed,attach list of division names contact names,address,email,phone,and fox numbers): Billing address(if different than Client address):OptumHealth Financial Services,Ilnc City:Atlanta County: State:GA ZIP:30374-0221 Phone:952-202-2028 Fax: E-mail:meghan_robertson@uhc.com If Self-Funded Program,do claims billings and administrative fee billings go to the same person? Dyes Ono If no,please supply contact,title,address,email,phone,and fax number for each type of billing. S Number of employees eligible for benefits:2,999 Does this represent the total number of employees in the company?❑yes ®no total number:3,036 Do you have an employee population outside of the US?Oyes Mno If yes,what countries? number eligible? Do you provide benefits to your retiree population?®Yes ©no Dependents:Eligible dependents are the covered employee's spouse and®unmarried and/or❑married dependent children until the ❑date of birth OR Mend of the month OR F]end of the year that they reach their[26th]birthday(also includes a child if incapable of self-support because of physical or mental incapacity that commenced prior to reaching the above age),and full-time students until the ❑date of birth OR Mend of the month OR❑end of the year that they reach their[26th]birthday. 9 Dependents other than employee's spouse&children: ❑parents ®domestic partners{all] ❑domestic partners(same sex only) ®domestic partner's children r L I C Y D E T i The rates listed must support the plan design and benefit selected and must meet all eligibility requirements.Please refer to your VSP-provided rate sheet for details or contact your VSP Account Executive.Any discrepancies may preclude acceptance by VSP. 10 Benefit Year(select one): ❑Service Year(from last date of service) Calendar Year(IMPORTANT:Policy effective date and renewal date MUST be January 1) Plan Year(from effective date of contract) 11 Plan Type(select all that apply): ❑Signature Nan ❑Choice Plan Advantage ❑signature Exam Plus F]Choice Exam Plus ❑Advantage Exam Plus ❑Signature Exam Plus ❑Choice Exam Plus w/Allowances ❑Advantage Exam Plus w/Allowances w/Allowances ❑Choice Materials Only ❑Advantage Easyoptions ❑Signature Materials Only ❑Choice EasyOptions ❑Other: ❑Signature EasyOptions Versiorn 06/2020 Client Application-Large Classification: Confidential page 2 of DocuSign Envelope ID:6A5E7A6E-C590-4DC9-B7C9-567814B64AD6 12 Is vision benefit: ❑Core MVoluntary ❑Packaged with medical and/or dental If Voluntary(vision is included as a stand-alone menu item in a list of benefits to choose from.): Employer contribution percentage:for employee:0% for dependent:0% Voluntary Participation Structure:*A minimum number of enrolled employees may apply. [--]Exam w/Voluntary Materials* ❑Voluntary Pool 0-24%employer contribution* ❑Voluntary Pool 25%or more employer contribution* ❑Care'Employee/Voluntary Dependent.Coverage* If Core Plus Options(group provides a basic level of vision coverage to all employees with an option for the employee to buy up or enhance the benefit): Employer contribution percentage:for employee: % for dependent: % If Packaged{vision is tied to which of the following benefits:❑medical ❑dental 13 Frequency of Service(select one): ❑A(12/24/24)(IMPORTANT:.1.2/24/24 is not available on voluntary plans) EB(12/12/24) MC(12/1,2/12) ❑Materials Only(select ane): n(_112/12) ❑(_112/24) ❑ (,_,/24/24) ❑Other: Copayment(s)(select one): ❑None E]Total co-payment:$ (applies to exam and eyewear) OR 0 Split co-payment: $10 exam / $25 eyewear 14a Client has purchased Enhancements or Specialty Care: yes❑ no® Buy-up Plan: yesEl noz Description: ❑Anti-Reflective Coating ❑Covered Contact tenses ❑Preferred Laser VisionCare with$ copay or$ allowance ❑Scratch Coating ❑ProTec Safety ❑Photochromic ❑Second Pair of Glasses ❑Vision Therapy with$ copay or$ allowance ❑ Retinal Imaging ❑Computer VisionCare Progressives(all) Copay:$ ❑Primary EyeCare with$ copay or$ allowance ❑Suncare H Progressives(standard only) ❑Repair/Replace with$ copay or$ allowance ❑Other: 14b Elective Contact tens(Allowance): ❑$120 ®$130 ❑$140 ❑$150 ❑$180 ❑other:$ Frame(Retail Frame Aliowance): ❑$120 M$130 ❑$140 ❑$150 ❑$180 ❑other:$ 15 Requested effective date(The effective date should not precede the dote VSP receives this application.) This policy will become effective on the first day of[October](month)[2021](year),provided that all of the following has been completed prior to this effective date: A.VSP has received and accepted this Application. B.VSP has received and accepted Membership,including the required information of all employees that will be covered under this pokcy showung name,member ID,and number of dependents,if applicable. This agreement will continue in force[48]months from the effective date.Rates are based on the assumption that VSP will receive these amounts over the full plan term. 16 Schedule A Information: Fiscal Year[ ]through[ ]. Schedule A will be sent to the person named as the principal contact.A copy of the report may also be sent to your broker and/or your third party administrator. 17 Do you currently have coverage:Myes ❑no If yes,current vision plan carrier:Ameritas 4f current carrier is VSP,please provide Client Name.30028125 Version 05/2020 Client Application-Large: 0assification: Confidential page 3 of 5 DocuSign Envelope ID:6A5E7A6E-C590-4DC9-B7C9-567814B64AD6 18 For fully-insured programs(VSP will bill you for your first month's premium) Rates Employee-only or composite rate basis $5.20 Two-rate basis $9.46 Three-rate basis $14.48 Four-rate basis $ IMPORTANT:Sold rates are required 19 For self-insured programs,Administrative Fee: Fixed fee: or Percent of claims: % or Dollars per claims:$ If Administrative Fees are based on tiers,check box❑and indicate rates above in section 18. AGREEMENT The undersigned client hereby applies for vision care coverage through VSP.It is understood that: A. All future employees will be covered when they become eligible,or offered VSP coverage if voluntary. B. Member past service for clients previously covered by VSP will carry over and remain in force. C. Any non-VSP-created information outlining coverage or plan details must be reviewed by VSP prior to distribution to members. Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. This application signed this[101(day)of[August)(month)of[20211(year). Firm/Organization:City of Corpus Christi Name: Ramon Hendersons ' Title:Benefits Manager Signature: �4� Q 0&, . APPROVED AS TO LEGAL FORM: Doousignedby: Res. 032505 Authorized By 91MU_ 91661 ,--W 9/23/2021 07-27-2021 Assistant City Attorney Date Council Docu$Igned by: D$ 9/28/2021 r Josh Chronley Date Assistant Director, Contracts and Procurement ATTEST: o D ��sig�ea by, � � a Rebecca Huerta City Secretary Version 06/2020 Client Application-Large Classification: Confidential page 4 of 5 DocuSign Envelope ID:6A5E7A6E-C590-4DC9-B7C9-567814B64AD6 BROKER I CONSULTANT ®The broker/consultant indicated below is hereby designated Broker of Record by the above signed employer. Legal Firm Name:HUB International Address: 10000 North Central Iaxpressway 4700 City:Dallas County:Tarrant State:'rx ZIP:75231 Licensed Producer's Name:Brent Weegar Title: Phone:214.443.2400 Fax: E-mail:brent.oveegar c'x,hubinternational.corn Broker Assistant Name:Charlotte Starks Phone: E-mail: Taxpayer ILS:75-14731.93 Corporation❑ Independent❑ Commission Checks Payable to: ]Firm Name Contact Name Commission rate if paid: nNot Paid Name: Address: City: County: State: ZIP: This application signed this[ ](day) of[ ](month)of[ ](year). Print Name: Title: Signature of state-licensed agent: Please send a copy of agentfhroker license,if not currently on file with VSP. ADDITIONAL BR Please send a copy of agent/broker license,if not currently on file with VSP. Legal Firm Name: Address: City: County: State: ZIP: Licensed Producer's Name: Title: Phone, Fax,: E-mail: Broker Assistant Name: Phone: E-mail'. Taxpayer)D: Corporation[] Independent[] Commission Checks Payable to: Firm Name ❑Contact Name ❑Commission rate if paid: ❑Not Paid Name: Address: City: County: State: ZIP: This application signed this[ ](day) of[ ](month)of[ ](year). Print Name: Title: Signature of state-licensed agent: Version 06/2020 Client Application -Large Classification: Confidential pale 5 of 5 DocuSign Envelope ID:6A5E7A6E-C590-4DC9-B7C9-567814B64AD6 BROKER / CONSULTANT M The broker/consultant indicated below is hereby designated Broker of Record by the above signed employer. Legal Firm Name:HUB International Texas Address:10000 North Central Expressway Suite 1200 city:Dallas County:United States State:Texas ZIP:75231 Licensed Producer's Name:Brent`4Veel ar Title:Senior Vice President Phone:214-443-2429 Fax: E-mail:brent.weegar(c�.httbinternatiotial.corn Braker Assistant Name:Julian Fontana Phone:(469)391-902.2 E-mail: jutian.fontarta r hubitttentational.coiii Taxpayer ID:75-1473193 Corporation[A Independent❑ Commission Checks Payable to: Firm Name ❑Contact Name ❑Commission rate if paid: ❑Not Paid Name:Hub International Address: 10000 North central Expressway Suite 1200 City:Dallas County:United States State:gallas ZIP:75231 This application signed this[ 16](day)of[July](month)of[2021 ](year). Print Name:Brent Weegar Title:Senior Vice President Signature of state-licensed agent: 94, (rG/ Please send a copy of ogentfbroker license,if not currently on file with VSP. ADDITIONAL BROKER I CONSULT , Please send a copy of agentfbroker license,if not currently on file with VSP. Legal Firm Name: Address: City. County: State: ZIP: Licensed Producer's Name: Title: Phone: Fax: E-mail: Broker Assistant Name: Phone: E-mail: TaxpayeriD: Corporation[] Independent[] Commission Checks Payable to: E]Firm Name ❑Contact.Name Commission rate if paid: Not Paid Name: 6 +1OF"ip information will be sent to VSP via: (_f Electronic Transfers ElOnline Eligibility Management ey:embership information will be reported usnNtember 55Ns ❑iJnigreae member IDs State: ZIP: This application signed this[ j(day)of( ] (month)of[ ](year). Print Name: Title:. Signature of state licensed agent: Version 06/2020 Client Application Large Classification: Confidenbal page 1 of 5