94-50 Resolution No. 94-50
RESOLUTION
AUTHORIZING EXECUTION OF AN AGREEMENT WITH HMO ILLINOIS
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF ELGIN,
ILLINOIS, that Robert 0. Malm, Interim City Manager, be and is
hereby authorized and directed to execute a Benefit Program
Application on behalf of the City of Elgin with HMO Illinois
for an employee health insurance program, a copy of which is
attached hereto and made a part hereof by reference.
s/ Robert Gilliam
Robert Gilliam, Mayor Pro Tem
Presented: February 23, 1994
Adopted: February 23, 1994
Vote: Yeas 5 Nays 0
Attest:
s/ Dolonna Mecum
Dolonna Mecum, City Clerk
Blue Cross as HMO Illinois
Blue Shield C76)
• ti' A Blue Cross HMO
of Illinois a product of
ti ,q q, Health Care Service Corporation,
a Mutual Legal Reserve Company
(Blue Cross and Blue Shield of Illinois)
cvlOiv OFFIcL
Benefit Program Application
Group No.(s): H57023
Group Name: CITY OF ELGIN
(Specify the employer,the employee trust or the association applying tor coverage Names of subsidiary and affiliated companies must also be included
AN EMPLOYEE BENEFIT PLAN MAY NOT BE NAMED)
Address: 150 Dexter Court . Elgin , Tllinois 60120-5555
Group Administrator: Mr_ Fern i Po 1 ar i n Phone No.: ( 708 ) 931 -5670
Effective Date of Coverage:March 1 , 1994 Anniversary Date: March 1 , 1995
1. Eligible Person means a person who resides in the Service Area of a Participating IPA and is:
E a full-time employee of the Group.
El a member of(name of union or association)
k Elected Officials
2. Full-Time Employee means:
A person who is regularly scheduled to work a minimum of 40 hours per week and who is actively
at work and on the permanent payroll of the Group.
Li
3. Classifications of Eligible Persons:
E No classifications.
• See attached classifications.
4. Persons not Eligible are:
A person who does not meet the definition of Eligible Person stated above or a person who does meet
the definition of Eligible Person stated above but is affected by TEFRA-COBRA and has selected
Medicare as his Primary Coverage.
In the event a spouse of an Eligible Person, who is otherwise eligible for coverage under this Policy as a
Covered Person and who is affected by TEFRA-COBRA, selects Medicare as his/her primary coverage,
then, such spouse shall not be eligible for coverage under this Policy.
5. The Effective Date of Termination for a person who ceases to meet the definition of an Eligible Person:
❑ The date such person ceases to meet the definition of Eligible Person.
E The last day of the calendar month in which such person ceases to meet the definition of an Eligible
Person.
L-
6
. The limiting age for covered unmarried children is: 19 : 23 if full time student
❑ Coverage is terminated at the end of the month in which the limiting age is reached.
• Other(please specify):
7. Total number of employees in the Group: 490
(State the total number of employees,not enrollees.)
GA-16-1.1 HCSC Page 1
8. New Employee Waiting Period:
• ❑ the date of employment.
❑ the first day of the month following months or days of employment.
E the 1 s t day of the month following the date of employment.
❑ the day of employment.
• Free Ririe Billing Rule
❑ A full month's premium will be charged for the first month of coverage for those new employees whose
Coverage Dates fall between the first and sixteenth day of the Premium Period. No premium will be
charged for the first month of coverage for those new employees whose Coverage Dates fall between the
seventeenth day and the end of the Premium Period.
9. Extension of Benefits Due to Temporary Layoff or Leave of Absence: ❑ 30 days ❑ days
10. Type of Financial Arrangement:
N Premium Charge(complete 11 below)
E. Service Charge(complete 12 below)
11. Premium Information:
(a) Enrollee Contributions Required: ❑ Yes No
If Yes; Group contribution is:
100%of the Individual Coverage Premium and an amount equal to 100% of the Individual Coverage
Premium toward the Family Coverage Premium.
of the Individual Coverage Premium and % of the Family Coverage Premium.
(b) Premium Period:
The first day of each calendar month through the last day of each calendar month.
The day of each calendar month through the day of the next calendar month.
(c) Schedule of Monthly Premiums(by coverage):
HMOI PRE-DENT TOTAL
Enrollee only $ 164 . 55 $ $ 164 . 55
Enrollee with one dependent 4 0 0 .4 0 4 00. 4 0
Enrollee with two or more dependents 4 0 0 -4 n 4 00 .4 0
Medicare Eligible: Individual
Family
12. Service Charge Program: 1 New Group Existing Group
(a) Service Charge:
(b) Type of Service Charge Program:
I Advance Payment ❑ Transfer Payment Other
(c) Advance Payment Specifications
Amount of Advance Payment: $
Payment Period: Claim Settlement Period:
Monthly ❑ Monthly
❑ Quarterly ❑ Quarterly
❑
(d) Transfer Payment Specifications
Method of Transfer Payment: Payment Period:
❑ Wire Transfer ❑ Daily
• Draft ❑ Semi-Weekly
• Other ❑ Weekly
❑ Other
GA-16-1.1 HCSC Page 2
The undersigned person represents that he is authorized and responsible for purchasing coverage on behalf of the
Group, has provided the information requested in this Benefit Program Application(BPA)and on behalf of the Group
offers to purchase the benefit program as outlined in the Proposal document submitted to the Group by the Sales
Representative. Any changes to the Proposal are specified below. It is understood that the actual terms and condi-
tions of coverage are those contained in the Group Policy into which this BPA shall be incorporated and become a
part at the time of acceptance by Health Care Service Corporation,a Mutual Legal Reserve Company(HCSC). In the
event of any conflict between the Proposal and the Group Policy,the provisions of the Policy shall prevail. It is further
understood that this BPA is subject to acceptance by HCSC. Upon acceptance, HCSC shall issue a Policy to the
Group.The undersigned person hereby acknowledges that the Employee Retirement Income Security Act of 1974,
as amended(ERISA),establishes certain requirements for employee welfare benefit plans.As defined in Section 3 of
ERISA, the term "employee welfare benefit plan" includes any plan, fund or program which is established or main-
tained by an employer or by an employee organization,or by both,to the extent that such plan,fund or program was
established or is maintained for the purpose of providing for its participants or their beneficiaries, through the pur-
chase of insurance or otherwise,medical,surgical or hospital care or benefits,or benefits in the event of sickness,ac-
cident or disability.The undersigned person hereby acknowledges(i)that an employee welfare benefit plan must be
established and maintained through a separate plan document which may include the terms hereof or incorporate the
terms hereof by reference,and(ii)an employee welfare benefit plan document may provide for the allocation and del-
egation of responsibilities thereunder. However, notwithstanding anything contained in an employee welfare benefit
plan document of the Group(or any Group member, if the Group is an association),the undersigned agrees that no
allocation or delegation of any fiduciary or nonfiduciary responsibilities under the employee welfare benefit plan of the
Group(or any Group member, if the Group is an association)is effective with respect to or accepted by HCSC except
to the extent specifically provided and accepted in this BPA or the Policy or otherwise accepted in writing by HCSC.
ADDITIONAL PROVISIONS: $3/$8 Prescription Drug Plan
Elimination of Illinois Biodyne Extended Mental Health Network .
Sales Representativi Signa ure o Authonz Purchaser
HMO ILLINOIS ( 708 ) 691-9124 4.1. C
District Phone No Title
2001 Midwest Road , Suite 300 2.1 LC 4.4 4
Producer Representative Date
Oak Brook , Illinois 60521 t'644- ' t 1/4./1.." , / .C.4' ri-.
Producer Firm Witness
$ Amount Submitted
Producer Address
Tax I D Nc
Underwriting Only
Date BPA approved by Underwriting
Signature of Underwriter approving
Certificate Booklets: L Individual Mail
D. Ship to:
Attn:
No.:
Mail Policy to: Group District
GA-16-1.1 HCSC Page 3