P.O. Box Las Vegas, NV /14/2011

Transcription

1 02/14/2011 P.O. Box Las Vegas, NV GEORGE FOGELSON LA DEPT OF WATER&POWER ACTIVE&RETIREE NONRISK 111 N HOPE STREET, ROOM 564 LOS ANGELES CA Dear GEORGE FOGELSON: Enclosed is a renewal Amendment to the Group Enrollment Agreement between LA DEPT OF WATER&POWER ACTIVE&RETIREE NONRISK and Health Plan of Nevada, Inc. effective on 07/01/2011. It reflects the new rates and any plan change(s) that may have occurred at renewal. The renewal amendment should be attached to the GEA from the prior year. Please obtain the signature of a designated company representative and return the original fully executed renewal amendment to me at your earliest convenience for further processing. A postage paid envelope has been included for your convenience. Thank you in advance for your assistance. If you have any questions, please call T SHARRA WRIGHT at (702) Sincerely, Wayne Finch Assistant Vice President, Underwriting Services enc cc: T'SHARRA WRIGHT Agency: MERCER HEALTH & BENEFITS LLC

2 P.O. Box Las Vegas, NV Amendment to the Group Enrollment Agreement for the HPN Plan The Group Enrollment Agreement, Attachment A and Attachment B, dated 07/01/2010 and No. HPN-NV-GEA (July2006) by and between Health Plan of Nevada, Inc. ( HPN ) and LA DEPT OF WATER&POWER ACTIVE&RETIREE NONRISK ( Group ), Group number is hereby amended as follows: The above referenced Attachment A (Group Application) is hereby amended as follows and the above referenced Attachment B (Benefit Plans and Monthly Rates) is hereby replaced with a new Attachment B (Benefit Plans and Monthly Rates) as attached hereto. This Amendment is effective on 07/01/2011 and will remain in effect for a period of 12 consecutive months ending on 06/30/2012. EMPLOYER: LA DEPT OF WATER&POWER ACTIVE&RETIREE NONRISK # SEE ATTACHED Signed at on the day of 2011 By: (signature of company officer) Title: Printed name of authorized company officer: HEALTH PLAN OF NEVADA, INC. Wayne Finch/Assistant Vice President, Underwriting Services WF/cl 02/14/2011 Date Form No. HPN-NV GEA (July2006)

3 P.O. Box Las Vegas, NV HPN Group Enrollment Agreement LA DEPT OF WATER&POWER ACTIVE&RETIREE NONRISK (Company Name hereinafter called "Group") Company Number: Group Number: A002 Covered Affiliate(s): LA DEPT WATER & R001 POWER RISK RETIREES In consideration of the payment of premiums in accordance with the terms and provisions of this Group Enrollment Agreement, any Attachments (including, but not limited to, the Attachment A to the Group Enrollment Agreement ( GEA ) and Amendments hereto, and the Group Evidence of Coverage and any Attachments, Amendments, Endorsements, or Riders attached thereto and made a part hereof (hereinafter collectively referred to as the "Agreement"), Health Plan of Nevada, Inc. (hereinafter called "HPN"), and LA DEPT OF WATER&POWER ACTIVE&RETIREE NONRISK (hereinafter called "Group"), hereby agree as follows: that HPN shall arrange for the provision of professional and hospital services to such Eligible Employees of Group as are enrolled as Members of HPN in accordance with the terms and provisions of this Agreement. I. EFFECTIVE DATE AND TERM OF AGREEMENT This Agreement shall be effective on the first day of the Contract Period. The Contract Period will begin on 07/01/2011, at 12:01 a.m. Pacific Time. It will remain in effect for an initial period of 12 consecutive months, ending on 06/30/2012, unless terminated by either party pursuant to Section X herein. Thereafter, this Agreement shall automatically renew from year to year for additional 12 month periods. Renewal shall be subject to all terms and provisions of this Agreement (the initial and subsequent "Contract Periods", respectively), unless terminated by either party pursuant to Section X herein. II. PREMIUM DUE DATE AND PAYMENTS The first day of a calendar month of coverage hereunder is the Premium Due Date". The Group agrees to remit to HPN on or before the Premium Due Date the applicable Total Monthly Premium set forth in Attachment B, for each Eligible Employee, and Eligible Family Member enrolled as of such date as approved by HPN. If such premium payment is not made in full by Group on or prior

4 to the Premium Due Date, a thirty-one (31) day Grace Period shall be granted to Group for payment without interest accruing on the amount then due but unpaid. If the premium payment is not received by the expiration of the Grace Period, then this Agreement may be terminated by HPN pursuant to Section X. Premiums outstanding subsequent to the end of the Grace Period shall be subject to a late charge of 1.0% of the total premium amount due and unpaid. The late charge will be calculated for each thirty-one (31) day period, or the portion thereof, that the amount due and unpaid remains outstanding. The effective date of termination will be the last date of the premium period for which premiums were paid to, received and accepted by HPN. If this Agreement is terminated for any reason, Group shall continue to be held liable for all premium payments due and unpaid on the termination date. III. PREMIUM RATE CHANGES HPN may change the Premium Rate Schedule shown in Attachment B, at the end of the first Contract Period and any time thereafter by giving no less than sixty (60) days prior written notice to the Group. Further, as set forth in the Evidence of Coverage, in the case of a Small Group Member, when information provided to HPN by a Small Group Member in his Enrollment Form or Medical Questionnaire is determined to be untrue, inaccurate, or incomplete, in lieu of termination of coverage, HPN shall have the right to retroactively increase past premium payments to the maximum rate allowed that would have been billed if such untrue, inaccurate, or incomplete information had not been provided. If the revised premium rate is not received by HPN within thirty (30) days of the letter of notification, coverage will be terminated as of the paid-to-date. IV. GROUP CONTRIBUTION Group shall offer HPN coverage to all Eligible Employees of the Group. The terms of which offer shall be no less favorable with respect to the Group's contribution to the Total Monthly Premium than those applicable to such other health benefits coverage as may be available through the Group. Except as hereinafter provided, the Group's contribution shall not be changed during the term of this Agreement unless such change is agreed to in writing by HPN. If, however, the Group Contribution to such other coverage as may be available through the Group is increased during the term of this Agreement, Group agrees to increase its contribution to HPN coverage by an equivalent amount, effective the first Premium Due Date coinciding with or the next following increase. The Minimum Employer Contribution Percentage is set forth in the Attachment A to the GEA. V. ELIGIBILITY Eligible Employees of the Group and their Eligible Family Members shall be those persons who meet the criteria set forth in the Evidence of Coverage and such additional requirements as are set forth in this Agreement and the Attachment A to the GEA which is attached hereto. Eligibility requirements are considerations material to the execution of this Agreement. A misrepresentation regarding the eligibility of persons to enroll as Members of HPN is grounds to rescind this Agreement. During the term of this Agreement, no change in the eligibility requirements shall be permitted to affect eligibility or enrollment in any manner deemed adverse by HPN. The Group agrees that HPN has the right to check eligibility (including employment status) through review of any of the Group s records, including, but not limited to, its employment files and federal and state tax documents. HPN has the right to review eligibility at any time before, during or after the Contract Period. VI. EFFECTIVE DATES OF COVERAGE Coverage under this Agreement shall become effective as set forth in the Evidence of Coverage, subject to:

5 A. Group s payment and HPN s receipt and acceptance of the applicable monthly premiums; B. The receipt and acceptance of an Enrollment Form by HPN for each prospective Eligible Employee, and Eligible Family Member of the Eligible Employee, which must be received by HPN within thirty-one (31) days of the date such individual(s) first becomes eligible; and C. The other applicable provisions of this Agreement. VII. ENROLLMENT A. Initial Enrollment. During the thirty-one (31) days following his initial eligibility date, each Eligible Employee of the Group shall be entitled to make Application for himself, and his Eligible Family Members who must be listed on the Enrollment Form provided by HPN. B. Newly Eligible Employee. Each new Eligible Employee of the Group entering employment beginning affiliation with the Group after the Group's Initial Enrollment Period shall be permitted to apply for coverage for himself and his Eligible Family Members. Such application must be made to HPN within thirty-one (31) days of becoming eligible, subject to the enrollment regulations in effect with the Group. C. Newly Eligible Family Members. Any person attaining eligibility to become an Eligible Family Member may be enrolled by the Eligible Employee, by submitting to HPN a completed Enrollment Form within thirty-one (31) days of the Eligible Family Member becoming eligible. D. Special Enrollee. The definition of a Special Enrollee applicable to this Agreement is defined in the Evidence of Coverage. An Eligible Employee, and their Eligible Family Member will be enrolled if a completed Enrollment Form is submitted to HPN within thirty-one (31) days of the Special Enrollment Event. E. Special Enrollment Event. The definition of a Special Enrollment Event applicable to this Agreement is defined in the Evidence of Coverage. The Special Enrollment Event provision allows an Eligible Employee, and Eligible Family Member to enroll for coverage under this Agreement. F. Condition of Renewal. As a condition of the Group's renewal under this Agreement, HPN may require the Group to exclude an otherwise Eligible Employee, or his Eligible Family Member(s) who committed fraud upon HPN or misrepresented a material fact which affected his coverage under the Evidence of Coverage. VIII. OPEN ENROLLMENT PERIOD The definition of Open Enrollment Period applicable to this Agreement appears in the Evidence of Coverage and is defined therein. The Open Enrollment Period shall commence as stated in the Attachment A to the GEA, except as HPN and Group may otherwise agree in writing. IX. RESPONSIBILITIES OF GROUP Group agrees to: A. Offer HPN's coverage to Eligible Employees and their Eligible Family Members as described herein. It is understood that Eligible Employees of the Group shall be free to choose either HPN membership or such other coverage as may be available through the Group during both the Initial and subsequent Open Enrollment Periods. Every Eligible

6 Employee of the Group: (1) shall be given a fair opportunity to elect one of such options over the other; and (2) shall not be penalized by the Group because of such a choice. B. Offer coverage only to persons that are Eligible Employees and their Eligible Family Members. C. Offer each new Eligible Employee the opportunity to elect HPN membership as an incident of membership in Group, employment when such person becomes an Eligible Employee, as provided in this Agreement and in the Evidence of Coverage. D. Give at least sixty (60) days notice to HPN of any intent to offer alternate coverage in addition to the coverage provided under this Agreement. E. Furnish to HPN on a monthly basis, on HPN approved forms, such information as may reasonably be required by HPN for the administration of HPN's Health Maintenance Organization ( HMO ) program and coverage provided hereunder. Such information shall include any change in a Member's eligibility status, as well as adequate documentation of any Eligible Employee, or Eligible Family Member status as defined by this Agreement and the Evidence of Coverage. In addition, HPN may, at reasonable times, examine Group's pertinent records with respect to eligibility and premium payments hereunder. F. Notify HPN upon a Member becoming ineligible. If Group fails to notify HPN of such Member's ineligibility and Group has made or continues to make the premium payments specified herein for such Member, such premium payment(s) will be credited by HPN to the Group; provided, however that: (1) the Group gives HPN notice of the ineligibility no later than sixty (60) days after the date eligibility ceased; and (2) HPN has not made benefit payments for or indemnified Covered Services for the Member other than provider prepayment amounts, rendered after the Member's eligibility ceased and before HPN received timely notice of ineligibility. In no event will premiums be refunded or credited to the Group for any period prior to sixty (60) days from the date HPN is notified that a Member is ineligible. G. Comply with all policies and procedures established by HPN (which will be provided to Group by HPN) in the Group s administration. H. Deliver to Members HPN's applicable Evidence of Coverage, notices, identification cards and other plan information when requested by HPN. I. Promptly furnish all membership change notifications to HPN on forms approved by HPN. X. TERMINATION A. This Agreement may be terminated for any reason by the Group upon sixty (60) days prior written notice to HPN, including but not limited to the following reasons. In such event, coverage hereunder shall terminate for all Members as of the Effective Date of termination: 1. Insolvency or bankruptcy of HPN; or 2. The revocation of HPN's Certificate of Authority; or 3. HPN's material breach of any other terms and provisions of this Agreement.

7 B. This Agreement may also be terminated by HPN at the times shown upon the occurrence of any one or more of the following reasons. In such event, coverage hereunder shall terminate for all Members as of the Effective Date of termination: 1. Upon written notice, if any premium payment required to be made by the Group is not received by the Premium Due Date, subject to a thirty-one (31) day Grace Period. Coverage will terminate effective on the last day of the period for which the required premium payment was received and accepted by HPN. Terminated Members will be held liable for the cost of any services received following the date of termination under this provision. 2. Upon written notice, if Group misrepresents any information regarding the Eligible Employees covered under the plan or other information regarding eligibility for coverage under the plan; 3. Upon written notice, if Group fails to comply with any underwriting requirements including, but not limited to, applicable participation and contribution requirements; 4. Upon written notice, if HPN discontinues transacting healthcare coverage in the geographical area of this state where the Group is located, provided HPN notifies the Commissioner and all affected Groups at least 180 days in advance of this discontinuance; 5. Upon written notice, if Group fails to cooperate or comply with reasonable requests of HPN. 6. No Members in connection with this Agreement reside or work in HPN s Service Area. 7. Membership of the Group in an association terminates. 8. Upon written notice, in the event of insolvency or bankruptcy of Group. 9. In the event of Group's material breach of any other terms and provisions of this Agreement, upon thirty-one (31) days prior written notice to Group. 10. Upon written notice, in the event that participation of those eligible falls below the Minimum Employee Participation Percentage as set forth in the Attachment A to the GEA of all Eligible Employees and Eligible Family Members for groups. XI. ENTIRE AGREEMENT The Evidence of Coverage, the Point-of-Service Rider, the Group Enrollment Agreement, the Attachment A to the Group Enrollment Agreement and any Endorsements, Riders, Amendments and any other Attachments thereto, the enrollment applications of the Eligible Employee, and Eligible Family Members, if any, constitute the entire contract between the parties. As of the Effective Date hereof, this Agreement supersedes all other Agreements between the parties. Any and all statements made to HPN by Group and any Eligible Employee, or Eligible Family Member thereof shall, in the absence of fraud, be deemed representations and not warranties. No such statement, unless it is contained in a written Application for coverage under this Agreement, shall be used in defense to a claim under this Agreement.

8 XII. AMENDMENTS AND WAIVERS Any amendments to this Agreement must be in writing and must be approved and executed by an officer of HPN. HPN specifically reserves the right to amend this Agreement upon thirty-one (31) days notice to Group. No agent of HPN has the authority to change this Agreement, waive any of its provisions or restrictions or extend the time for making any payment required hereunder. XIII. DELIVERY OF DOCUMENTS HPN will provide a copy of the Evidence of Coverage and applicable attachments to each Eligible Employee upon enrollment. XIV. APPLICABLE LAW This Agreement shall be governed by the laws of the State of Nevada. XV. WORKERS COMPENSATION This Agreement is not in lieu of and does not affect any requirement for Workers Compensation insurance coverage. XVI. OTHER PROVISIONS Open enrollment will commence on 07/01/2011 through 07/31/2011.

9 CERTIFICATION All statements are true and complete to the best of my knowledge, and I understand that Health Plan of Nevada, Inc. will rely upon these statements and the information provided as the basis for approving coverage under this Agreement. I further understand that no healthcare coverage will become effective without the approval of Health Plan of Nevada, Inc. Signed at on EMPLOYER: LA DEPT OF WATER & POWER ACTIVE & RETIREE NONRISK # By: Signature Print or Type Name/Official Title WITNESS I certify that I have witnessed the Employer's signature, and I have actively participated in the solicitation, negotiation, or placement of this healthcare coverage. Signature Title Date ACCEPTANCE EMPLOYER: LOS ANGELES DEPARTMENT OF WATER AND POWER By: Date: And: OF THE CITY OF LOS ANGELES BY BOARD OF WATER AND POWER COMMISSIONERS OF THE CITY OF LOS ANGELES Chief Executive Officer and General Manager Secretary The application for coverage set forth herein has been approved and accepted by HPN when signed below: HEALTH PLAN OF NEVADA, INC. Wayne Finch/Director of Underwriting WF/cl 2/14/2011 Date

10 Attachment B Benefits Plan and Monthly Rates HEALTH PROGRAM Plan Sold: MEDICAL: DENTAL: VISION: PRESCRIPTION: HCR GOLD V - SO. NEVADA (LAS VEGAS) & NO NV (RENO) + DOMESTIC PARNTER (DP0ADDEP) N/A N/A HPN $7G$15B/$40NP/GBSIO (1ST)- SO NEVADA PRODUCT CODES Medical Dental Vision RX HGLU003J (LAS VEGAS) & HGRU003J (RENO) N/A N/A PLV075B1 (LAS VEGAS) & PRN075B1 (RENO) Single (01) Subscriber & Spouse (02) Subscriber & Child (03) Subscriber & Dependents (04) Family (05) RETIREE CHOICE PLUS Total Senior Dimensions Risk Rate One with Senior Dimensions and Spouse without Senior Dimensions One with Senior Dimensions and Child without Senior Dimensions One with Senior Dimensions and Children without Senior Dimensions One with Senior Dimensions and Spouse without Senior Dimensions and Child/Children without Senior Dimensions Two with Senior Dimensions and Child/Children without Senior Dimensions Two with Senior Dimensions Only Does this Group have any other coverage with HPN, or any of its affiliates? If so, list: N/A There will be no monthly administration fee.

11 Right to Audit The Contractor and the Contractor s subcontractors and suppliers shall be subject at any time, with 7 calendar days prior written notice, to audits by the Department or the Department s agents, collectively defined as "Authorized Auditors", relating to all billings and to verify compliance with all contract requirements relative to practices, methods, procedures, and documentation. The Authorized Auditors shall have access to all records and data relating to the contract. The audits will be performed using FAR, Part 30 and 31, et seq., generally accepted accounting practices and principles, and City Contractor Cost Guidelines, and any other applicable City, State and Federal government audit standards. The Contractor shall maintain and the Authorized Auditors will have the right to examine and audit all books, records, documents, accounting procedures and practices, and other evidence, regardless of form (e.g., machine readable media such as disk, tape, etc.) or type (e.g., databases, applications software, database management software, utilities, etc.), sufficient to properly reflect all costs claimed to have been incurred or anticipated to be incurred in performing the contract. Any information provided on machine-readable media shall be provided in a format accessible and readable by the Authorized Auditors. The Contractor shall not, however, be required to furnish the Authorized Auditors with commonly available software. If the Contractor, the Contractor s subcontractors and/or suppliers are required to submit cost or pricing data in connection with the contract and/or the Contract Amendment, the Authorized Auditors will have the right to examine all documents necessary to permit adequate evaluation of the cost or pricing data submitted, along with the computations and projections used. The Authorized Auditors will also have the right to reproduce, photocopy, download, transcribe, and the like any such records. The Contractor shall make said evidence or to the extent accepted by the Authorized Auditors, photographs, microphotographs, etc. or other authentic reproductions thereof available to the Authorized Auditors at the Contractor s offices at all reasonable times and without charge. The Contractor and the Contractor s subcontractors and suppliers shall keep and preserve all such records for a period of not less than 3 years from and after Final Payment or, if the contract is terminated in whole or in part, until 3 years after final contract closeout. The Contractor, the Contractor s subcontractors and suppliers shall account for and be responsible for unallowable costs and mutually agreed unallowable costs. The detail and depth of records required as backup support for proposals, billings, or claims shall be that which adequately establishes and maintains visibility of identified unallowable costs, costs directly associated to unallowable costs, and allowable costs. All changes are subject to audit. Changes with an absolute value of one hundred thousand ($100,000) dollars or more shall require an audit. The Department may waive the right to audit where there was adequate price competition, an established catalog or market prices for commercial items sold in substantial quantities to the public, and/or prices set by law or regulation. The Contractor shall maintain and segregate cost and pricing data, books, records, documents, and any other accounting evidence sufficient to properly reflect all direct and indirect costs of whatever nature claimed to have been incurred or anticipated to be incurred by a Contract Amendment, including a change order. For a period of 3 years from the date of Final Payment under the contract, and prior to the execution of any Contract Amendment that exceeds an absolute value of one hundred thousand dollars ($100,000), the Authorized Auditors will have the right to examine all books, records, documents, and any other applicable data or evidence that relate to the negotiation and/or performance of the contract and/or a Contract Amendment for the purpose of evaluating the accuracy and completeness of the cost or pricing data submitted by the Contractor. To the extent that the examination reveals inaccurate, incomplete, or non-current data, the data shall be considered defective; if the audit indicates the Contractor has been overpaid under a previous payment application, such overpayment, after 10 calendar days notice to the Contractor, shall be paid to the Department.

12 The Authorized Auditors may require that the Contractor supply appropriate documentation to support the costs or prices proposed for a Contract Amendment, including a change order, and will refuse to complete negotiations until satisfactory documentation is submitted. The Contractor s books, records, documents and any other applicable data or evidence that relate to the negotiations and/or performance of the Contract Amendment shall be subject to audit and inspection. Also subject to audit shall be the Contractor s records, books, documents and any other applicable data or evidence relating to those items on a billing that relates to: a. Work performed under the contract and/or a change order; b. Goods not yet incorporated into the work; c. Services or work performed under a contract amendment negotiated on an indefinite quantity basis; and d. Fixed-price change orders to validate the claimed percentage of completion on the payment application. Notwithstanding the foregoing, if the audit reveals that the overpayment is more than 5% of the billing, the Contractor shall pay all expenses and costs incurred by the Authorized Auditors arising out of or related to the audit.