Resolution No. 81441
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RESOLUTION NO. 8144
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
VERNON APPROVING AND RATIFYING THE EXECUTION OF A
UNIVERSAL CARE LARGE GROUP SUBSCRIBER AGREEMENT BY
AND BETWEEN THE CITY OF VERNON AND UNIVERSAL CARE
FOR THE HMO PREMIER 100 PLAN
WHEREAS, on March 20, 2002, the City Council of the City of
Vernon adopted Resolution No. 7929 approving Universal Care Large Group
Subscriber Agreement HMO Premier 100 Plan for the period January 1,
2002 through December 31, 2002; and
WHEREAS, on January 7, 2003, the Finance Committee
recommended that the City Council approve the recommendation of Bruce
V. Malkenhorst, Director of Finance, dated December 26, 2002, that the
renewal rates submitted by Universal Care for the HMO Premier 100 Plan
for the period January 1, 2003 through December 31, 2003 be approved
and the renewal agreement be executed when completed; and
WHEREAS, in order to meet the urgent need for the renewal of
the HMO Premier 100 Plan and to ensure the proper functioning and
continuity of the Plan, the City Administrator/City Clerk executed the
Large Group Subscriber Agreement with Universal Care on January 23,
2003, subject to ratification by the City Council; and
WHEREAS, by letter dated January 27, 2003, Bruce V.
Malkenhorst, City Administrator/City Clerk, recommended that the
agreement for the HMO Premier 100 Plan with Universal Care for the
period January 1, 2003 through December 31, 2003, be ratified; and
WHEREAS, the City Council desires to approve and ratify the
Large Group Subscriber Agreement, as executed by the City
Administrator/City Clerk, with Universal Care.
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NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE
CITY OF VERNON AS FOLLOWS:
SECTION 1: The City Council of the City of Vernon hereby
finds and determines that the recitals contained hereinabove are true
and correct.
SECTION 2: The City Council of the City of Vernon hereby
ratifies the execution of the Large Group Subscriber Agreement for HMO
Premier 100 Plan with Universal Care, a copy of which is attached
hereto as Exhibit "A" and made a part hereof.
SECTION 3: The City Clerk of the City of Vernon shall
certify to the passage of this resolution, and thereupon and
thereafter the same shall be in full force and effect.
APPROVED AND ADOPTED this 5th day of February, 2003.
(ATTEST:
BRUCE V. MALKENHORST, City Clerk
�LEMNIS C. MALB RG, Ma or
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STATE OF CALIFORNIA )
) ss
COUNTY OF LOS ANGELES )
I, BRUCE V. MALKENHORST, City Clerk of the City of Vernon, do
hereby certify that the foregoing Resolution, being Resolution No.
8144, was duly adopted by the City Council of the City of Vernon at a
regular meeting of the City Council duly held on Wednesday, February 5,
2003, and thereafter was duly signed by the Mayor of the City of
Vernon.
(SEAL)
Ll\V VI:.I V • 1-1�1L1\1J1V11 V1\4J1, V1l.Y V1\,.1 J1
- 3 -
UNIVERSAL CARE
LARGE GROUP SUBSCRIBER AGREEMENT
Group's Minimum Number of Eligible Employees is 51
THIS LARGE GROUP SUBSCRIBER AGREEMENT (the "Agreement") is
entered into between CITY OF VERNON (the "Group") and Universal Care, a California
corporation (hereinafter sometimes referred to as the "Health Plan" or "Universal Care Health
Plan") which operates a health care service plan licensed and regulated by the Department of
Managed Health Care of the State of California under the Knox -Keene Health Care Service Plan
Act of 1975, as amended.
To the extent herein limited and defined, this Agreement provides for
comprehensive health services provided through the Health Plan. Upon payment of Health Plan
Premiums (the amount paid by Group to Universal Care in consideration for the benefits
provided under the Health Plan) in the amount and manner provided for in this Agreement,
Universal Care HEREBY AGREES to furnish services and benefits as defined in this Agreement
to the eligible employees and their eligible Dependents of-
Group's Name: CITY OF VERNON
Group's Minimum Number of Eligible Employees is: 51.
Group's ID Number: 10010A*02
Group's Benefit Plan ID Code: Premier IOOM-RX4 (P100RX4)
Group's Effective Date: January 1, 2003
Documents Incorporated by Reference into this Group Subscriber Agreement:
1. Combined Evidence of Coverage and Disclosure Form for the Group's Benefit Plan
(includes Benefit Plan and Exclusions and Limitations)
2. Premium Rate Schedule
3. Available Riders (as applicable): Point of Service (POS); Dental; Vision; Chiropractic
IN WITNESS WHEREOF, the parties have caused this Agreement to be
executed at Signal Hill, California.
VERSAL CARE
By:
Jay B. s
Executive Vic President
Date: I I b
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Universal Care Large Group GSA (R9) DMHC Approval Pending
CITY OF VERNON
By: Zeo�
/0
Date:
Approved As To Form
EDUARDO OLIVO
CITY ATTORNEY
1. DOCUMENTS INCORPORATED BY REFERENCE
The application for the Group Subscriber Agreement, and any duly executed addenda,
amendments, applicable Combined Evidence of Coverage and Disclosure Form[s] and Schedules
are incorporated by this reference herein.
2. TERM AND TERMINATION OF AGREEMENT
This Agreement becomes effective on the Effective Date noted at the beginning of this
Group Subscriber Agreement at 12:01 a.m., Pacific Time, (the "Effective Date") and will remain
in effect for a term of twelve consecutive months, subject to amendments by Universal Care (see
section titled Amendments to Agreement) and the payment of Health Plan Premiums (see section
titled Health Plan Premiums and Copayments). This Agreement will automatically renew from
year to year on the anniversary of the Effective Date (the "Renewal Date"), unless terminated or
not renewed as set forth herein. This Agreement may be terminated by the Group with a 30-day
prior written notice to Universal Care. Universal Care may terminate or not renew this
Agreement for good cause as set forth in the Combined Evidence of Coverage and Disclosure
Form under the Section titled 'Ending Coverage (Termination of Benefits)." Termination of this
Agreement by Universal Care for good cause, other than for not paying Health Plan Premiums
(See section below titled "Health Plan Premiums and Copayments") shall become effective with
a 30-day prior written notice to the Group.
If this Agreement is terminated by either Universal Care or the Group, the Group shall
promptly mail or hand- deliver to each covered Subscriber, a notice of cancellation of this
Agreement. The group shall, upon request by Universal Care, provide Universal Care with a
copy of the notification, a written statement that the notice of cancellation was mailed or hand
delivered to each Subscriber, and the date of mailing or hand delivery.
Members who are hospitalized on the date coverage under this Agreement ends, may be
eligible for continuation of coverage. See Combined Evidence of Coverage and Disclosure Form
under the Section titled 'Extension of Benefits for Totally Disabled Members upon Termination
of Agreement Between Employer Group and Universal Care."
Universal Care shall give the group 30 days notice if the group does not meet the
Minimum Participation Requirements as stated on the signature page and in this Agreement.
Such notice period shall begin 30 days prior to the renewal date. If the group does not increase
its participation to the minimum requirements during the notice period, this Agreement may not
be renewed.
Universal Care shall give the. group 30 days notice if the group is not contributing a
minimum of 50% of the employee only premium cost. Such notice period shall begin 30 days
prior to the renewal date. If the group does not increase its contribution to the minimum
requirements during the notice period, this Agreement may not be renewed.
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Universal Care Large Group GSA (R4) DMHC Approval Pending
3. AMENDMENTS TO AGREEMENT
If the Plan proposes any amendment to this Agreement, including a change in the
prepayment fees (alternatively referred to as "premiums") or benefits or copayments, and gives
the Subscriber Group written notice of the amendment at least thirty (30) days in advance, the
amendment shall become effective on the date identified in the plan's thirty (30) day written
notice, unless the Subscriber terminates this Agreement in accord with its terms. If amendments
to this Agreement for premium increase[s] are the result of legislation or regulations imposed by
any regulatory body that has authority over the Plan and its Agreements, then the premiums may
be amended unilaterally by, and at the discretion of, the Plan at any time[s] during the contract
year. However, if premiums are to be amended for reasons other than legislation or regulations
imposed by any regulatory body that has authority over the Plan and its Agreements, then the
premiums may be amended unilaterally by, and at the discretion of, the Plan no more often than
once every twelve (12) months. With at least thirty (30) days notice, the Plan may also propose
amendments to this Agreement (including a change in the prepayment fees, premiums, benefits,
copayments, or the documents incorporated by reference into this Agreement) that result from
legislation or regulations imposed by any regulatory agency that has authority over the Plan and
its Agreements.
The Plan may propose one or more amendments to this Agreement to go into effect no
sooner than thirty (30) days after the Plan has given written notice of the proposal to the
Subscriber Group. An amendment may include increases or other changes in prepayment fees
and copayments and reductions or other changes in benefits. Each such amendment shall go into
effect on the date specified in the notice unless the Subscriber Group gives the Plan at least thirty
(30) days written notice of its rejection of such amendment(s). If the Subscriber group rejects
any such amendments, this Agreement may not be renewed at the Renewal Date. Amendments
that result from legislation or regulations imposed by any regulatory body that has authority over
the Plan and its Agreements may be amended unilaterally by, and at the discretion of, the Plan at
any time[s] during the contract year. However, if amendments are made for reasons other than
legislation or regulations imposed by any regulatory body that has authority over the Plan and its
Agreements, then the premiums may be amended unilaterally by, and at the discretion of, the
Plan no more often than once every twelve (12) months.
No change in premium rates or changes in coverage shall become effective unless the
Plan has delivered in writing a notice indicating the change or changes at least 30 days prior to
the contract renewal effective date.
4. HEALTH PLAN PREMIUMS AND COPAYMENTS
The Group must pay Health Plan Premiums in exchange for coverage for the health care
benefits, services, and supplies. The Health Plan Premiums for the Health Plan's supplemental
benefits, if any, are set forth in the supplemental benefit rider(s) for those benefits.
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Universal Care Large Group GSA (R9) DMHC Approval Pending
The Health Plan Premiums for the first month of coverage must be paid to Universal Care
on or before the Effective Date of this Agreement. Subsequently, all Health Plan Premiums must
be received by Universal Care by the 25`" day of the month preceding the month for which the
Health Plan Premium fee applies.
Universal Care may unilaterally, at any time[s] during the term of this Agreement and
with thirty days written notice to the Group, increase all subsequent Health Plan Premiums that
are due from the Group to continue this Agreement in full force and effect. Any such increase[s]
shall be separated by a period of time that is not less than twelve (12) months in duration if those
increase[s] are not the result of legislation or regulations imposed by any regulatory agency that
has authority over the Plan and its Agreements. However, if premiums are to be increased as a
result of legislation or regulations imposed by any regulatory body that has authority over the
Plan and its Agreements, the premiums may amended unilaterally by, at the discretion of, the
Plan at any time[s] during the contract year. Payment of any portion of the increased Health Plan
Premium shall constitute acceptance of this modification.
a. Non-payment of Premiums
The Plan may terminate this Agreement if the Subscriber Group fails to pay the monthly
premium within fifteen (15) days after receiving notice of delinquency. The termination shall be
effective retroactively to the last day of the last month for which full payment has been made by
the Subscriber Group. Services obtained by Subscribers or Members during the retroactive
period will not be covered by Plan and the Subscriber Group shall assume financial responsibility
for payment of such services.
If this Agreement is terminated for any reason, the Group shall be liable for all Health
Plan Premiums for any time this Agreement is in force during a grace period and any notice
period. Only Members for whom the stipulated Health Plan Premium fee is actually received by
Universal Care shall be eligible for Covered Services under this Agreement and only for the
period covered by such payment.
b. Reinstatement
If, after giving notice of termination of this Agreement for non-payment of the
prepayment fees, the Plan receives full payment of those fees from the Subscriber Group before
the due date of the next month's prepayment fees, this Agreement shall be reinstated, unless; (1)
the Plan's notice of termination states that if payment is not received within fifteen (15) days after
issuance of the notice or such longer period as it may allow, the Plan will require a new
application and impose conditions on a new Agreement or reinstatement of this Agreement, or
(2) the payment is received more than fifteen (15) days after issuance of this notice and the Plan
refunds the payment within twenty (20) business days after receipt, or (3) the payment is received
more than fifteen (15) days after issuance and within twenty (20) business days of receipt the
Plan issues a new Agreement and a statement of the ways the new Agreement differs from this
Agreement. Individual Subscribers or other members have no right to renew or reinstate this
Agreement.
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Universal Care Large Group GSA (R9) DMHC Approval Pending
Any late payment, whether partial or full, which is received and accepted by Plan after
Plan serves a Notice of Termination upon Subscriber Group, shall accrue an interest penalty of
eighteen percent (18%) per annum, effective from the original due date of the payment. Plan
may, at its discretion upon acceptance of such payment, apply it, first, to such interest owed, and
then to the principle balance due.
C. Partial Payment
Plan may, at its sole discretion and without waiving its right to terminate this Agreement
or to assess an interest penalty, accept partial payment of any amount owed by Subscriber Group.
Plan may accept such partial payment and apply it, first, to interest owed thereon, and then; to the
principle balance due, but such acceptance of a partial payment shall not automatically operate as
a renewal or continuation of this Agreement. Plan shall have the sole authority to determine
whether a partial payment shall be sufficient to renew or continue this Agreement.
5. SOLICITATION AND ENROLLMENT
The Group shall cooperate with the Health Plan with respect to soliciting and enrolling
persons eligible to enroll hereunder and in obtaining authorized payroll withholdings from such
persons to the extent the applicable Health Plan Premiums exceed the Group's contribution on
their behalf. The Group shall, within thirty (30) calendar days of the date that the member[s]
is/are eligible to enroll with the Health Plan, send to the Health Plan copies of all signed
enrollment forms and enrollment change forms. The Health Plan may inspect the Group's
records pertinent to eligibility, enrollment and Health Plan Premiums hereunder, and make
copies thereof, at reasonable times upon reasonable prior notice to the Group.
The Health Plan Premiums will be calculated by Universal Care from current records as
to the number of Members enrolled. Within ten (10) days after the commencement of the term of
this Agreement, and on the first day of each month thereafter, the Group will deliver to Universal
Care an alphabetized list of the names and social security numbers of all persons who enroll
hereunder and whose enrollment has not terminated pursuant to the provisions hereof. Universal
Care may rely upon the latest information received from Group as correct without further
verification.
Retroactive payment adjustments will be made in subsequent billings for any additions or
terminations of Members not currently reflected in Universal Care's records at the time of
calculation of Health Plan Premiums. However, in no event will the effective date of an addition
or termination be more than sixty (60) days prior to the date of the receipt by Universal Care of
the written notice of the addition or termination from the Group, and Universal Care will not
refund any Health Plan Premiums to the Group paid for an ineligible Member if the request for
such refund is made later than sixty (60) days after the receipt of payment by Universal Care for
said ineligible Member.
When a Member is being retroactively terminated, the effective date of retroactive
termination cannot be prior to any date on which services or supplies were provided to the
Member under this Agreement. In such instances, the date of termination will be the first day of
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Universal Care Large Group GSA (R9) DMHC Approval Pending
-the calendar month following the month in which Covered Services were provided, and any
applicable credit of Health Plan Premiums will be calculated from that date.
, In addition to the Health Plan Premiums, each individual Member is required to pay
Copayments for some Covered Services provided. These Copayments are payable to the
Provider at the time the Covered Services are provided. The Copayments are specified in the
Benefit Schedule portion of the Combined Evidence of Coverage and Disclosure Form next to
the applicable Covered Services.
Pursuant to Section 1374.58 of the Knox -Keene Act, the Subscriber Group is hereby
notified of its right to purchase health care coverage for the qualified domestic partners of the
Subscriber Group's employees or subscribers who are eligible to receive health care coverage
under this Agreement. This available coverage is the same coverage as would be provided to a
dependent of the employee or subscriber and it is subject to the same terms and conditions.
Universal Care may require that the Subscriber Group verify the status of the domestic
partnership pursuant to the Domestic Partner Policy of Universal Care. The Subscriber Group
must also notify the plan upon the termination of the domestic partnership. Should the Group
purchase coverage for the qualified domestic partners of their eligible employees or subscribers,
that coverage would be subject to additional Health Plan Premiums, for each enrolled domestic
partner, in exchange for coverage for the healthcare benefits, services, and supplies.
6. BINDING ARBITRATION
(a) Except as provided in Subsection (c) below, any controversy or dispute between
any of the following interested parties -- the Subscriber Group; an agent, trustee, affiliate or
assignee of the Subscriber Group; a Subscriber; a Dependent; or an heir at law or personal
representative of a Subscriber or Dependent -- on the one hand, and any of the following parties -
- the Plan, its employees or agents, or its Contracting Providers or their agents or employees, --
on the other, whether involving a claim in tort, contract or otherwise, including disputes
pertaining to this Agreement or the care or other benefits rendered pursuant hereto or refused as
not covered hereunder, and including disputes which are not adequately resolved by the Plans
grievance procedures, shall be submitted to binding arbitration.
(b) Arbitration may be initiated by any interested party, but if the matter in dispute is
one which is subject to review under the Plan's grievance procedures, arbitration may not be
initiated until the completion of such procedures. The arbitration shall follow in accordance with
the applicable rules of the Judicial Arbitration and Mediation Services (JAMS). The arbitration
process may be initiated by calling the American Arbitration Association and requesting a form
used to demand arbitration. The demand for arbitration must be served personally or by
recognized messenger service or by certified mail, return receipt requested, on or before the last
date it would have to be filed in a court of law under the applicable statute of limitations.
(c) If a Subscriber, a Dependent, or an heir at law or personal representative of a
Subscriber or Dependent asserts an arbitration claim and the amount in dispute is less than
$200,000, the claimant and Universal Care shall agree to a single neutral person to render a
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Universal Care Large Group GSA (R9) DMHC Approval Pending
decision in arbitration. The single neutral arbitrator must be selected from the JAMS panel of
arbitrators and the arbitration will be conducted under the rules of the JAMS.
(d) In the event the claimant and Universal Care cannot agree on a single neutral
arbitrator, the JAMS shall appoint a default arbitrator according to its rules and procedures.
(e) Contracting Physicians, Contracting Hospitals and/or Contracting Providers may
bring legal actions to collect copayments for covered services or fee -for -service rates for non -
covered services. The Plan may seek declaratory relief regarding the interpretation of this
Agreement or seek judicial remedies to collect prepayment fees.
(f) The costs of the arbitration shall be borne equally by both parties; however, for
purposes of this Agreement, the costs of arbitration are limited to fees and expenses of the
arbitrators and charges for arbitrators' transcripts of the proceedings, and the room where the
arbitration is conducted. The arbitrator may require the submission of pleadings, briefs and other
memoranda and documents and may compel discovery from the parties, shall hold a hearing
within a reasonable time and shall set forth his decision in writing, with his reasons and authority
therefore. Any judgment or award rendered by the arbitrator may be entered into any court
having jurisdiction thereof. The arbitration procedure established by this Agreement is the sole
and exclusive means for the settlement of any such controversy or dispute.
(g) Beginning with arbitration claims served on or after August 1, 1997, extreme
hardship provisions will apply for Subscribers and Dependents or their heirs or personal
representatives seeking arbitration. Upon request, Universal Care will provide the Subscriber,
Dependent, heir or personal representative with either an application for relief from arbitration
costs or information on how to obtain such an application from JAMS. The approval or denial of
the application for hardship will be made by JAMS. Procedures established by JAMS for
handling such hardship requests will be followed. Information on how to file an application for
hardship relief may be obtained from Universal Care's Member Services Department by calling
800-635-6668 or 562424-6200.
7. INDEMNIFICATION OF PARTIES
The Parties agree to save, hold harmless, defend and indemnify each other from and
against all claims, demands, liabilities, actions or causes of action of any kind or nature which
may arise out of, in connection with, or related to any act, omission, negligence, malpractice or
lack of due care caused or alleged to have been caused by either party, any subcontractor of either
party, or any of their employees, Contracting Physicians, Contracting Hospitals, Contracting
Physicians, consulting doctors, agents or partners in the performance of the services, duties and
obligations under this Agreement, except as may result from a breach of either party's obligations
hereunder.
8. RELATIONSHIP BETWEEN PARTIES
The relationship between Plan and the physicians, hospitals and other health care
Providers who are its Contracting Physicians, Contracting Providers, Contracting Hospitals is
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Universal Care Large Group GSA (R9) DMHC Approval Pending
-that of an independent contractor relationship (except for the employees of Universal Care who
provide services at the medical offices owned and operated by Universal Care); they are not
agents or employees of Universal Care, and this Plan and its employees are not employees or
agents of those Contracting Providers.
Each physician, Hospital or other Provider of health care services is to maintain a direct
physician -patient, hospital -patient or other such relationship with Universal Care members to
whom it provides services, and is solely responsible for its decisions as to what health care
diagnostic, treatment or other services are required.
9. MODIFICATION OF AGREEMENT / HEALTH PLAN PREMIUMS
Universal Care may modify this Agreement at any time by providing a 30-day written
notice to the Group prior to the effective date of such modification. Universal Care may
unilaterally,'at any time[s] during the term of this Agreement and with thirty days written notice
to the Group, increase all subsequent Health Plan Premiums that are due from the Group to
continue this Agreement in full force and effect. If modifications to this agreement are for
premium increases that are the result of legislation or regulations imposed by any regulatory body
that has authority over the Plan and its Agreements, then those modifications may be made
unilaterally by the Plan, and at the discretion of the Plan, at any time[s] during the contract year.
However, if such modifications for premium increases are made for reasons other than legislation
or regulations imposed by any regulatory body that has authority over the Plan and its
Agreements, then the modifications for premium increases may be made unilaterally by the Plan,
and at the discretion of the Plan, no more often than once every twelve (12) months. Payment of
any portion of the increased Health Plan Premium shall constitute acceptance of this
modification.
If a government authority (a) imposes a tax or fee that is computed on Health Plan
Premiums or (b) requires a change in coverage or administrative practice that increases Universal
Care's costs. Universal Care may amend this Agreement and increase the Health Plan Premiums
sufficiently to cover the tax, fee, or costs. The effective date of such increase shall be the date set
forth in a written notice from Universal Care to the Group. The effective date shall not be earlier
than the date the tax, fee, or required change in coverage or administrative practice is imposed by
the governmental authority.
10. UNDERWRITING REQUIREMENTS
Underwriting requirements are incorporated by reference in the Large Group Health
Proposal which is created for each large group.
11. GENERAL PROVISIONS
a. Form or Content of Agreement
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Universal Care Large Group GSA (R9) DMHC Approval Pending
No agent or employee of Universal Care is authorized to change the form or content of
this Agreement. Any changes can be made only through a written amendment authorized and
signed by an officer of Universal Care.
b. Notice of Certain Events
Universal Care will give the Group written notice, within a reasonable time, of any
termination or breach of contract, or inability to perform services, by any Contracting Provider, if
the Group may be materially and adversely affected thereby.
C. Assignment
The Health Plan may assign this Agreement and its rights hereunder, and delegate its
duties hereunder, to any entity which is a licensed health care service plan into which it is merged
or which acquires substantially all of its assets, upon the approval of the Department of Managed
Health Care. The Group may not assign this contract without the prior written consent of the
Health Plan. Neither party may otherwise assign this Agreement unless such assignment is
required by law. Any purported assignment in violation hereof shall be void and unenforceable.
d. Applicable Law and Interpretation
This Agreement shall be construed and interpreted in accordance with the laws of the
State of California and so as to effectuate its purpose in accordance with the Medical Practice
Act, the ethics of the medical profession, the Knox -Keene Health Care Service Plan Act of 1975,
as amended ("Knox -Keene Act") and any other applicable laws and regulations. Any provision
required to be in this Agreement by the Knox -Keene Act (Health & Safety Code Section 1340 et
sM.) or regulations promulgated thereunder (Title 28, Section 1300.43 et M. of the California
Code of Regulations) shall bind the parties whether or not contained in this Agreement.
e. Acceptance of Contract
The Group may accept this Agreement either by execution of the face sheet or by making
the required Health Plan Premium payments to Universal Care, and such acceptance shall render
all terms and provisions hereof binding on the Health Plan and Group.
f. Contract Binding on Members
By this Agreement the Group makes the Health Plan coverage available to eligible
persons; however, this Agreement shall be subject to amendment or modification in accordance
with the provisions hereof or by mutual agreement between Universal Care and the Group
without the consent or concurrence of the Members.
g. Applications and Other Required Information
Members or those persons applying for membership shall' complete and submit to the
Health Plan such applications, forms or statements as the Health Plan may reasonably request.
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Universal Care Large Group GSA (R9) DMHC Approval Pending
-Members warrant that all material information contained in such applications, questionnaires,
forms or statements submitted to the administration hereof are true, correct and complete, and all
rights to benefits hereunder are subject to the condition that all such information is true, correct
and complete.
h. Notices
Any notice under this Agreement may be given personally, by a recognized messenger
service such as Federal Express or by United States mail, postage prepaid, addressed as follows:
To the Health Plan: Universal Care
ATTN: President
1600 E. Hill Street
Signal Hill, CA 90806
To the Member: To the latest address provided for the Member on the enrollment or
change of address forms actually delivered to Universal Care.
To the Group: To the latest address provided by the Group in connection with
Health Plan Premium payments.
Notice of material matter sent to the Group by Universal Care shall be disseminated to Members
by the Group in its regular communication to Members, but in no case later than thirty (30) days
after receipt of such notice.
i. Discrimination Prohibited
The Health Plan shall not cancel this Agreement, nor decline to renew or reinstate this
Agreement, nor shall the terms of this Agreement be modified and the benefits or coverage be
subject to any limitations, exceptions, exclusions, reductions, copayments, coinsurance,
deductibles, reservations, premiums, price change differentials or other modifications because of
the race, color, national origin, ancestry, religion, sex, marital status, sexual orientation or, age of
any Member or applicant for membership, except that Health Plan Premiums, price or charge
differentials because of the sex or, age of any such individual and based on objective, valid and
up-to-date statistical, underwriting or actuarial data shall not be prohibited.
The Health Plan will not deny or limit coverage or charge higher Health Plan Premiums
for an enrollee solely because of a physical or mental impairment, except when the refusal,
limitation or rate differential is based on sound actuarial or underwriting principles or practices.
However, if the Health Plan has requested a Member or applicant for membership to disclose a
physical or mental impairment in enrollment application materials and that person fails to
disclose or misrepresents such an impairment, the Health Plan may terminate that person's
enrollment as set forth in the Combined Evidence of Coverage and Disclosure Form under the
Section titled "Ending Coverage (Termination of Benefits)."
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Universal Care Large Group GSA (R9) DMHC Approval Pending
j. Entire Agreement
This Agreement, the application of the Group, and the individual applications of
employees shall constitute the entire Agreement between the parties.
k. Recordkeeping
The Group is responsible for keeping records relating to this Agreement. Universal Care
has the right to inspect and audit those records.
12. COBRA CONTINUATION COVERAGE
With regard to COBRA, Universal Care is committed.to the following:
A. Providing continuation coverage to Health Plan Members upon the request of a Group
when such requests are consistent with the Group's obligations under the law.
B. Sharing knowledge regarding COBRA with the Group as it experiences problems;
however, Universal Care will not give legal advice on these matters.
13. HEALTH PLAN BENEFITS AND COMBINED EVIDENCE OF COVERAGE
AND DISCLOSURE FORM
Universal Care will issue and deliver to each Member a Combined Evidence of Coverage
and Disclosure Form (including a Benefit Schedule) which will set forth a statement of services
and benefits to which Members are entitled, along with an Identification Card.
As noted above, the services and benefits of this Health Plan are set forth in the attached
Combined Evidence of Coverage and Disclosure Form and are incorporated by reference herein.
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Universal Care Large Group GSA (R9) DMHC Approval Pending
• •
Universal Care®
Healthcare you can feel good about.
Premium Rate Schedule
CITY OF VERNON
Group #:
10010A*02
Effective Date:
January 1, 2003
Premier 1 OOM-RX4 (P 1 OORX4)
Description Premium Rate
Employee Only 174.74
Employee and Spouse 366.95
Employee, Spouse, and Child(ren) 559.16
Employee and Child 366.95
Employee and Children 559.16
Corporate Offices:
1600 East Hill Street
Signal Hill, CA 90755-3682
Mailing Address:
P.O. Box 93122
Long Beach, CA 90809-9871
562 424-6200
800 635-6668
Run Date 01/14/2003
004JW25
Universal Care®
Corporate Offices:
i 600 East Hill Street
Signal Hill, CA go8o6-368z
562 424-6200
Boo 635-6668
SUBJECT: January 2003 Renewal
Dear JOAN FRANCONE:
Thank you for renewing your health benefit plan agreement with Universal Care. We
appreciate having the opportunity to meet you and your employee's health care needs.
Your updated Group Subscriber Agreement will be mailed to you shortly and it will
include the following terms:
Group Number:
Effective date of Renewal:
Open Enrollment:
Renewal rates:
Plan:
Account Service
10010A*CO
January 1, 2003
December 2002
Attached Premium Rate Schedule
P100MRX4
Evelyn Norcross, Extension 4041
For a complete explanation of your selected benefit, please refer to your enclosed
Evidence of Coverage and Disclosure Form.
Should you have any questions about this agreement, please contact your agent, or feel
free to contact our Employer Services Department at 562-424-6200, Ext. 4848, Monday
through Friday, 8:00 to 5:00 p.m.
Sincerely,
Mark Gunter
Director, Underwriting Services
Universal Care
CC: PETER H. COBO INS. AGENCY INC.
Enclosures
Large Group Renewals
Universal Care®
Corporate Offices:
1600 East Hill Street
Signal Hill, CA go8o6-3682
562 424-6200
Soo 635-6668
Premium Rate Schedule
CITY OF VERNON
10010A*CO
I atoll) ui :�!
Effective: January 1, 2003
Descri tion
Premium Rate
Employee Only
$174.74
Employee and Spouse
$366.95
Employee and Child
$366.95
Employee and Children
$559.16
Employee, Spouse, and Child(ren)
$559.16
Large Group Renewals
® •= 25
CITY COUNCIL
LEONIS C. MA%LBURG
Mayor
THOMAS A. YBARRA
Mayor Pro —Tern
WM. 'BILL" DAVIS
Councilman
H. "LARRY" GONZALES
Councilman
W. MICHAEL MCCORMICK
Councilman
BRUCE V. MALKENHORST
City Administrator/City Clerk
FAX (323) 826-1438
Finance Committee
City of Vernon
Honorable Members:
Pe�
n EDUARDO OLIVO
1(J� City Attorney
FAX: (562) 869-1883
CITY HALL
4305 SANTA FE AVENUE, VERNON, CALIFORNIA 90058
TELEPHONE (323) 583-8811
December 26, 2002
KEVIN WILSON
Director of Community Services & Water
FAX: (323) 826-1435
KENNETH J. DeDARIO
Director of Utilities
FAX: (323) 826-1425
STEVEN E. PARKER
Fire Chief
FAX: (323) 826-1407
BRUCE W. OLSON
Police Chief
FAX: (323) 826-1481
Universal Care, the City's current HMO Care provider, has submitted
renewal rates for the Premier 100 Plan for the period of January 1,
2003 through December 31, 2003, to which all terms and conditions will
remain the same. The current census report indicates an increase from
2002 at an annual rate of $1,021,550.44 to $1,114,058.28 for 2003 as
listed below:
2002 2003
Employee $161.78/mo. $174.74/mo.
Employee plus one $339.73/mo. $366.95/mo.
Employee plus two $517.69/mo. $559.16/mo.
or more
This has been reviewed by the Risk Manager and it is hereby
recommended that the new proposed renewal rates submitted from
Universal Care be approved and when completed the renewal agreement be
executed.
Very truly yours,
Bruce V. Malkenhorst ds
Director of Finance
BVM/gm
CITY COUNCIL
LEONIS C. MALBURG
Mayor
THOMAS A. YBARRA
Mayor Pro—Tem
WM. 'BILL" DAVIS
Councilman
H. "LARRY" GONZALES
Councilman
W. MICHAEL MCCORMICK
Councilman
BRUCE V. MALKENHORST
City Administrator/City Clerk
FAX (323) 826-1438
City Council
City of Vernon
Honorable Members:
CITY HALL
4305 SANTA FE AVENUE, VERNON, CALIFORNIA 90058
TELEPHONE (323) 583-8811
EDUARDO OLIVO
City Attorney
FAX: (562) 869-1883
KEVIN WILSON
Director of Community Services & Water
FAX: (323) 826-1435
KENNETH J. DeDARIO
Director of Utilities
FAX: (323) 826-1425
STEVEN E. PARKER
Fire Chief
FAX: (323) 826-1407
BRUCE W. OLSON
Police Chief
FAX: (323) 826-1481
January 27, 2003 \
O
On January 7, 2003, the Finance Committee recommended to City Council
that the proposed renewal rates submitted by Universal Care for the
HMO Premier 100 Plan for the period of January 1, 2003 through
December 31, 2003, be approved, and when completed the agreement be
executed.
This has been reviewed by the City's Risk Manager and it is hereby
recommended that the execution of the Agreement for the Premier 100
Plan for the period of January 1, 2003 through December 31, 2003, with
Universal Care be ratified.
Very truly yours,
,�
Bruce V. Malkenhorst
City Administrator/City Clerk
BVM/ gm
V mi , ,
w
.7am ni
Hia tc "Cos f
D"CTWkM of MHWIV
This summary of bewft'ts is not a ccnkr q. T$e ... t
be consulted for the exact terms and conditions of age, ` rirg any
pre-existing coadmon exclusion proms"
Q t _ . ..k» ---$0
p
time .». , . «.� .».. ».�. »None
Genera Nail Order MakwrAnce
rta�..». r►t
�5............................»...,».........�.�..,...,.,.,.....,�`!D nt per visit
Up to a threes month stiloply, as wailoble4l
..Brand Nune Mail Order Maintimance i .
!' SwVkw
Drug &
Periodic P exam » »$20t per visit
Up to a thr" as 4
bey cam;
p MAW Iocwwliii
Allergy ftsft and wewmwit_,_____$20 copWonentper visit
A i+eltVbiw .
screening throuP age 1$.,:..�._..,».w,«..:.�:.... per visit
,
ng thage i13....._..».........'$20 coperinerit per visit
I
Outpatient treatonent
@
and relet#t
by hissurCure
OuqmftK s►argery.._...............»..... - . .» ,.... --.No charge
_ initiol wmitatimby
er:
r1.» .. »«.« ...,. » .. « ..... ....» ......,..,.i copayonent
and outpotiewit mewmant jor'
,
,SpaschTherapyl .. 2# dement
Inpatient trawtnum for
.,;,...,,..
t talil►erapy� w $20 COp3yMent
T 20) tae nt for
went}' (
or crisis
i t Testa . .._ 0 copagrment
intervention in the BomekYesr (ems
of ton to My:.
Reaw and board in
(50) minutes in person or by telaphoine
psydwologist (PhZt) or lie
widw a
a sem' charge
X-r
.)1.....» ......F..�,.
i t p visit
mom and
and ces
Outpatient 2
dowsomoduXle ray scanning aatd
Inpatient d+etoa�taaan2..._........,�.....m....:...�.....,..::.:.3►
-
Su and charge
FaMW
I
Vaseca y (male
capsymem
SkMed ift Can
Tubal on) „........
... »... 1 et+t
Room board and general nursing K».„.„.., —t4* dwr up to 30 days
Birth control logtommtlion and instrtwolim.l
etdwr
in per benelit year
Interruption of WvrwW. meckaHy
t nt
smotracyif .� . .» .t....� . w..... $' ent per visit
Interov n of not i
} '�.- St ent nt
necessary ';. ina s
Infertility sta�dieala�eatment�
,149% of charges,
cy room or o or Hospital, Urvices.l
I
Man i C'ate+e
Prenatal and Postnatal Care
I
I
Approved ambulance service...,:..„.. , w .. ».�$50 copayment'
Inpatient._
Nracharge
whom brdemd or appeand In advionce by a "Universal Cann physician
O _ ................
"Went per,office visit
or in an emergency.
Delivery...,.. .». . «
» I . —,---No o 1
normala"
of
formulary Generic Drugs w $15 ccspaymentpnignancydad
is cwemd fmmt(**
dependwit 31 daps fiwn
so Jag w dAd h
Up to a orte month stf;opty Orodudes Wardt conato prestothortted by
a +aa wMM
Idaw,etb0h
UMvwvW,Cam for - 00 #4 fortatilary or gamic timp
not ort-tsse formulary but pneat by Carte,
Othwr
formulary ....»............ copayonent
Home s...r.,.„.....
t per visit
Up to a om mctntlr AWlY (ki6odes c ) weatothoriind byUrAWW,.
Care for on " Fomitibry whim no
gamic w or brxW name not on she Formtdary. brat
H i6W ____............
Courmft and an
.»» ... .
w0W of
preatothwirad by UnWasal Cue
such as prenaW ears,
dry D ___ . ..»$40 copayment
Up to a one mule aipply for cotain medically awasary brand
i Umitwom appok see a
or tx onsae
2 mm be wAar a f
3
by t bW Care. Not
-
rmd eras
by 1"wosaf Care,
emodond disawbMm of ciftwL
100 01.02 ,
EXHIBIT
0
SUPPORTING
DOCUMENTS
CITY COUNCIL
LEONIS C. MALBURG
Mayor
THOMAS A. YBARRA
Mayor Pro-Tem
WM. "BILL" DAVIS
Councilman
H. "LARRY" GONZALES
Councilman
W. MICHAEL MCCORMICK
Councilman
BRUCE V. MALKENHORST
City Administrator/City Clerk
FAX (323) 826-1438
Finance Committee
City of Vernon
Honorable Members:
,(� EDUARDO OLIVO
V, City Attorney
eo
FAX: (562) 869-1883
KEVIN WILSON
Director of Community Services & Water
FAX: (323) 826-1435
CITY HALL .
4305 SANTA FE AVENUE, VERNON, CALIFORNIA 90058
. TELEPHONE (323) 583-8811
December 26, 2002
KENNETH J. DeDARIO
Director of Utilities
FAX: (323) 826-1425
STEVEN E. PARKER
Fire Chief
FAX: (323) 826-1407
BRUCE W. OLSON
Police Chief
FAX: (323) 826-1481
,�o
Universal Care, the City's current HMO Care provider, has submitted
renewal rates for the Premier 100 Plan for the period of January 1,
2003 through December 31, 2003, to which all terms and conditions will
remain the same. The current census report indicates an increase from
2002 at an annual rate of $1,021,550.44 to $1,114,058.28 for 2003 as
listed below: -
2002 2003
Employee $161.78/mo. $174.74/mo.
Employee plus one $339.73/mo. $366.95/mo.
Employee plus two $517.69/mo. $559.16/mo.
or more
This has been reviewed by the Risk Manager and it is hereby
recommended that the new proposed renewal rates submitted from
Universal Care be approved and when completed the renewal agreement be
executed.
Very truly yours,
?dLe- V A&ff440
Bruce V. Malkenhorst
Director of Finance
BVM/gm
MEMORANDUM
TO: Bruce V. Malkenhorst, City Administrator
FROM: Joan Francone, Risk Manager/Personnel Assistant
DATE: December 3, 2002
SUBJECT: Universal Care HMO Premier 100 Plan - Renewal rates for 2003
Renewal rates for the policy year January 1, 2003 through December 31, 2003 have
been submitted by Universal Care. HMO and are as follows:
From To
Employee $161.78/mo. $174.74/mo.
Employee plus one $339.73/mo. $366.95/mo.
Employee plus two $517.69/mo. $559.16/mo.
or more
Using the current census report this indicates a monthly increase of $6885.54 or an
approximate annual 7% increase to $82,626.
Based on market trends the increase is below expectations.
There are no amendments to plan provisions. All terms and condition of the Premier
100 Plan will remain the same as the policy year 2002.
JF/cc
{
From: Calzada, Cindy
Sent: Thursday, December 19, 2002 12:01 PM
To: Giron, Nelly
Subject: Universal Care HMO Annual Rates
The annual rates for 2002 and 2003 are as follows:
2002 $1,021,550.44
2003 $1,114,058.28 (based on December 2002 enrollment)
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00:A
RESOLUTION NO. 8144
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
VERNON APPROVING AND RATIFYING THE EXECUTION OF A
UNIVERSAL CARE LARGE GROUP SUBSCRIBER AGREEMENT BY
AND BETWEEN THE CITY OF VERNON AND UNIVERSAL CARE
FOR THE HMO PREMIER 100 PLAN
WHEREAS, on March 20, 2002, the City Council of the City of
Vernon adopted Resolution No. 7929 approving Universal Care Large Group
Subscriber Agreement HMO Premier 100 Plan for the period January 1,
2002 through December 31, 2002; and
WHEREAS, on January 7, 2003, the Finance Committee
recommended that the City Council approve the recommendation of Bruce
V. Malkenhorst, Director of Finance, dated December 26, 2002, that the
renewal rates submitted by Universal Care for the HMO Premier 100 Plan
for the period January 1, 2003 through December 31, 2003 be approved
and the renewal agreement be executed when completed; and
WHEREAS, in order to meet the urgent need for the renewal of
the HMO Premier 100 Plan and to ensure the proper functioning and
continuity of the Plan, the City Administrator/City Clerk executed the
Large Group Subscriber Agreement with Universal Care on January 23,
2003, subject to ratification by,the City Council; and
WHEREAS, by letter dated January 27, 2003, Bruce V.
Malkenhorst, City Administrator/City Clerk, recommended that the
agreement for the HMO Premier 100 Plan with Universal Care for the
period January 1, 2003 through December 31, 2003, be ratified; and
WHEREAS, the City Council desires to approve and ratify the
Large Group Subscriber Agreement, as executed by the City
Administrator/City Clerk, with Universal Care.
1 NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE
2 CITY OF VERNON AS FOLLOWS:
3 SECTION 1: The City Council of the City of Vernon hereby
4 finds and determines that the recitals contained hereinabove are true
5 and correct.
6 SECTION 2: The City Council of the City of Vernon hereby
7 ratifies the execution of the Large Group Subscriber Agreement for HMO
8 Premier 100 Plan with Universal Care, a copy of which is attached
9 hereto as Exhibit "A" and made a part hereof.
10 SECTION 3: The City Clerk of the City of Vernon shall
11 certify to the passage of this resolution, and thereupon and
12 thereafter the same shall be in full force and effect.
13 APPROVED AND ADOPTED this 5th day of February, 2003.
14
15
16 EONIS C. MALBU , MayJr
17 ATTEST:
18
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20 BRUCE V. MALKENHORST, City Cle
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2
1 STATE OF CALIFORNIA )
2 ) ss
COUNTY OF LOS ANGELES )
3
4 I, BRUCE V. MALKENHORST, City Clerk of the City of Vernon, do
5 hereby certify that the foregoing Resolution, being Resolution No.
6 8144, was duly adopted by the City Council of the City of Vernon at a
7 regular meeting of the City Council duly held on Wednesday, February 5,
8 2003, and thereafter was duly signed by the Mayor of the City of
9 Vernon.
10
11 ?/
BRUCE V. MALKENHORST, City Clerk
12
13 (SEAL)
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3 -
SUPPORTING
DOCUMENTS
EXHIBIT
0
UNIVERSAL CARE
n LARGE GROUP SUBSCRIBER AGREEMENT N
Group's Minimum Number of Eligible Employees is 51
THIS LARGE GROUP SUBSCRIBER AGREEMENT (the "Agreement") is
entered into between CITY OF VERNON (the "Group") and Universal Care, a California
corporation (hereinafter sometimes referred to as the "Health Plan" or "Universal Care Health
Plan") which operates a health care service plan licensed and regulated by the Department of
Managed Health Care of the State of California under the Knox -Keene Health Care Service Plan
Act of 1975, as amended.
To the extent herein limited and defined, this Agreement provides for
comprehensive health services provided through the Health Plan. Upon payment of Health Plan
Premiums (the amount paid by Group to Universal Care in consideration for the benefits
provided under the Health Plan) in the amount and manner provided for in this Agreement,
Universal Care HEREBY AGREES to furnish services and benefits as defined in this Agreement
to the eligible employees and their eligible Dependents of:
Group's Name: CITY OF VERNON
Group's Minimum Number of Eligible Employees is: 51.
Group's ID Number: 10010A*02
Group's Benefit Plan ID Code: Premier IOOM-RX4 (P100RX4)
Group's Effective Date: January 1, 2003
Documents Incorporated by Reference into this Group Subscriber Agreement:
1. Combined Evidence of Coverage and Disclosure Form for the Group's Benefit Plan
(includes Benefit Plan and Exclusions and Limitations)
2. Premium Rate Schedule
3. Available Riders (as applicable): Point of Service (POS); Dental; Vision; Chiropractic
IN WITNESS WHEREOF, the parties have caused this Agreement to be
executed at Signal Hill, California.
TRSAL CARE
By.
Jay B. Vis
Executive Vic President
Date:_
1
Universal Care Large Group GSA (R9) DMHC Approval Pending
CITY OF VERNON
B y: ��
Date:
Approved As To Form
L]DU REDO OLIVO
OI"FY ATTORNEY
1. DOCUMENTS INCORPORATED BY REFERENCE
The application for the Group Subscriber Agreement, and any duly executed addenda,
amendments, applicable Combined Evidence of Coverage and Disclosure Form[s] and Schedules
are incorporated by this reference herein.
2. TERM AND TERMINATION OF AGREEMENT
This Agreement becomes effective on the Effective Date noted at the beginning of this
Group Subscriber Agreement at 12:01 a.m., Pacific Time, (the "Effective Date") and will remain
in effect for a term of twelve consecutive months, subject to amendments by Universal Care (see
section titled Amendments to Agreement) and the payment of Health Plan Premiums (see section
titled Health Plan Premiums and Copayments). This Agreement will automatically renew from
year to year on the anniversary of the Effective Date (the "Renewal Date"), unless terminated or
not renewed as set forth herein. This Agreement may be terminated by the Group with a 30-day
prior written notice to Universal Care. Universal Care may terminate or not renew this
Agreement for good cause as set forth in the Combined Evidence of Coverage and Disclosure
Form under the Section titled "Ending Coverage (Termination of Benefits)." Termination of this
Agreement by Universal Care for good cause, other than for not paying Health Plan Premiums
(See section below titled "Health Plan Premiums and Copayments") shall become effective with
a 30-day prior written notice to the Group.
If this Agreement is terminated by either Universal Care or the Group, the Group shall
promptly mail or hand deliver to each covered Subscriber, a notice of cancellation of this
Agreement. The group shall, upon request by Universal Care, provide Universal Care with a
copy of the notification, a written statement that the notice of cancellation was mailed or hand
delivered to each Subscriber, and the date of mailing or hand delivery.
Members who are hospitalized on the date coverage under this Agreement ends, may be
eligible for continuation of coverage. See Combined Evidence of Coverage and Disclosure Form
under the Section titled "Extension of Benefits for Totally Disabled Members upon Termination
of Agreement Between Employer Group and Universal Care."
Universal Care shall give the group 30 days notice if the group does not meet the
Minimum Participation Requirements as stated on the signature page and in this Agreement.
Such notice period shall begin 30 days prior to the renewal date. If the group does not increase
its participation to the minimum requirements during the notice period, this Agreement may not
be renewed.
Universal Care shall give the group 30 days notice if the group is not contributing a
minimum of 50% of the employee only premium cost. Such notice period shall begin 30 days
prior to the renewal date. If the group does not increase its contribution to the minimum
requirements during the notice period, this Agreement may not be renewed.
2
Universal Care Large Group GSA (R9) DMHC Approval Pending
3. AMENDMENTS TO AGREEMENT
If the Plan proposes any amendment to this Agreement, including a change in the
prepayment fees (alternatively referred to as "premiums") or benefits or copayments, and gives
the Subscriber Group written notice of the amendment at least thirty (30) days in advance, the
amendment shall become effective on the date identified in the plan's thirty (30) day written
notice, unless the Subscriber terminates this Agreement in accord with its terms. If amendments
to this Agreement for premium increase[s] are the result of legislation or regulations imposed by
any regulatory body that has authority over the Plan and its Agreements, then the premiums may
be amended unilaterally by, and at the discretion of, the Plan at any time[s] during the contract
year. However, if premiums are to be amended for reasons other than legislation or regulations
imposed by any regulatory body that has authority over the Plan and its Agreements, then the
premiums may be amended unilaterally by, and at the discretion of, the Plan no more often than
once every twelve (12) months. With at least thirty (30) days notice, the Plan may also propose
amendments to this Agreement (including a change in the prepayment fees, premiums, benefits,
copayments, or the documents incorporated by reference into this Agreement) that result from
legislation or regulations imposed by any regulatory agency that has authority over the Plan and
its Agreements.
The Plan may propose one or more amendments to this Agreement to go into effect no
sooner than thirty (30) days after the Plan has given written notice of the proposal to the
Subscriber Group. An amendment may include increases or other changes in prepayment fees
and copayments and reductions or other changes in benefits. Each such amendment shall go into
effect on the date specified in the notice unless the Subscriber Group gives the Plan at least thirty
(30) days written notice of its rejection of such amendment(s). If the Subscriber group rejects
any such amendments, this Agreement may not be renewed at the Renewal Date. Amendments
that result from legislation or regulations imposed by any regulatory body that has authority over
the Plan and its Agreements may be amended unilaterally by, and at the discretion of, the Plan at
any time[s] during the contract year. However, if amendments are made for reasons other than
legislation or regulations imposed by any regulatory body that has authority over the Plan and its
Agreements, then the premiums maybe amended unilaterally by, and at the discretion of, the
Plan no more often than once every twelve (12) months.
No change in premium rates or changes in coverage shall become effective unless the
Plan has delivered in writing a notice indicating the change or changes at least 30 days prior to
the contract renewal effective date.
4. HEALTH PLAN PREMIUMS AND COPAYMENTS
The Group must pay Health Plan Premiums in exchange for coverage for the health care
benefits, services, and supplies. The Health Plan Premiums for the Health Plan's supplemental
benefits, if any, are set forth in the supplemental benefit rider(s) for those benefits.
3
Universal Care Large Group GSA (R9) DMHC Approval Pending
The Health Plan Premiums for the first month of coverage must be paid to Universal Care
on or before the Effective Date of this Agreement. Subsequently, all Health Plan Premiums must
be received by Universal Care by the 251h day of the month preceding the month for which the
Health Plan Premium fee applies.
Universal Care may unilaterally, at any time[s] during the term of this Agreement and
with thirty days written notice to the Group, increase all subsequent Health Plan Premiums that
are due from the Group to continue this Agreement in full force and effect. Any such increase[s]
shall be separated by a period of time that is not less than twelve (12) months in duration if those
increase[s] are not the result of legislation or regulations imposed by any regulatory agency that
has authority over the Plan and its Agreements. However, if premiums are to be increased as a
result of legislation or regulations imposed by any regulatory body that has authority over the
Plan and its Agreements, the premiums may be amended unilaterally by, at the discretion of, the
Plan at any time[s] during the contract year. Payment of any portion of the increased Health Plan
Premium shall constitute acceptance of this modification.
a. Non-payment of Premiums
The Plan may terminate this Agreement if the Subscriber Group fails to pay the monthly
premium within fifteen (15) days after receiving notice of delinquency. The termination shall be
effective retroactively to the last day of the last month for which full payment has been made by
the Subscriber Group. Services obtained by Subscribers or Members during the retroactive
period will not be covered by Plan and the Subscriber Group shall assume financial responsibility
for payment of such services.
If this Agreement is terminated for any reason, the Group shall be liable for all Health
Plan Premiums for any time this Agreement is in force during a grace period and any notice
period. Only Members for whom the stipulated Health Plan Premium fee is actually received by
Universal Care shall be eligible for Covered Services under this Agreement and only for the
period covered by such payment.
b. Reinstatement
If, after giving notice of termination of this Agreement for non-payment of the
prepayment fees, the Plan receives full payment of those fees from the Subscriber Group before
the due date of the next month's prepayment fees, this Agreement shall be reinstated, unless; (1)
the Plan's notice of termination states that if payment is not received within fifteen (15) days after
issuance of the notice or such longer period as it may allow, the Plan will require a new
application and impose conditions on a new Agreement or reinstatement of this Agreement, or
(2) the payment is received more than fifteen (15) days after issuance of this notice and the Plan
refunds the payment within twenty (20) business days after receipt, or (3) the payment is received
more than fifteen (15) days after issuance and within twenty (20) business days of receipt the
Plan issues a new Agreement and a statement of the ways the new Agreement differs from this
Agreement. Individual Subscribers or other members have no right to renew or reinstate this
Agreement.
4
Universal Care Large Group GSA (R9) DMHC Approval Pending
Any late payment, whether partial or full, which is received and accepted by Plan after
Plan serves a Notice of Termination upon Subscriber Group, shall, accrue an interest penalty of
eighteen percent (18%) per annum, effective from the original due date of the payment. Plan
may, at its discretion upon acceptance of such payment, apply it, first, to such interest owed, and
then to the principle balance due.
C. Partial Payment
Plan may, at its sole discretion and without waiving its right to terminate this Agreement
or to assess an interest penalty, accept partial payment of any amount owed by Subscriber Group.
Plan may accept such partial payment and apply it, first, to interest owed thereon, and then to the
principle balance due, but such acceptance of a partial payment shall not automatically operate as
a renewal or continuation of this Agreement. Plan shall have the sole authority to determine
whether a partial payment shall be sufficient to renew or continue this Agreement.
5. SOLICITATION AND ENROLLMENT
The Group shall cooperate with the Health Plan with respect to soliciting and enrolling
persons eligible to enroll hereunder and in obtaining authorized payroll withholdings from such
persons to the extent the applicable Health Plan Premiums exceed the Group's contribution on
their behalf. The Group shall, within thirty (30) calendar days of the date that the member[s]
is/are eligible to enroll with the Health Plan, send to the Health Plan copies of all signed
enrollment forms and enrollment change forms. The Health Plan may inspect the Group's
records pertinent to eligibility, enrollment and Health Plan Premiums hereunder, and make
copies thereof, at reasonable times upon reasonable prior notice to the Group.
The Health Plan Premiums will be calculated by Universal Care from current records as
to the number of Members enrolled Within ten (10) days after the commencement of the term of
this Agreement, and on the first day of each month thereafter, the Group will deliver to Universal
Care an alphabetized list of the names and social security numbers of all persons who enroll
hereunder and whose enrollment has not terminated pursuant to the provisions hereof. Universal
Care may rely upon the latest information received from Group as correct without further
verification.
Retroactive payment adjustments will be made in subsequent billings for any additions or
terminations of Members not currently reflected in Universal Care's records at the time of
calculation of Health Plan Premiums. However, in no event will the effective date of an addition
or termination be more than sixty (60) days prior to the date of the receipt by Universal Care of
the written notice of the addition or termination from the Group, and Universal Care will not
refund any Health Plan Premiums to the Group paid for an ineligible Member if the request for
such refund is made later than sixty (60) days after the receipt of payment by Universal Care for
said ineligible Member.
When a Member is being retroactively terminated, the effective date of retroactive
termination cannot be prior to any date on which services or supplies were provided to the
Member under this Agreement. In such instances, the date of termination will be the first day of
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Universal Care Large Group GSA (R9) DMHC Approval Pending
the calendar month following the month in which Covered Services were provided, and any
applicable credit of Health Plan Premiums will be calculated from that date.
In addition to the Health Plan Premiums, each individual Member is required to pay
Copayments for some Covered Services provided: These Copayments are payable to the
Provider at the time the Covered Services are provided. The Copayments are specified in the
Benefit Schedule portion of the Combined Evidence of Coverage and Disclosure Form next to
the applicable Covered Services.
Pursuant to Section 1374.58 of the Knox -Keene Act, the Subscriber Group is hereby
notified of its right to purchase health care coverage for the qualified domestic partners of the
Subscriber Group's employees or subscribers who are eligible to receive health care coverage
under this Agreement. This available coverage is the same coverage as would be provided to a
dependent of the employee or subscriber and it is subject to the same terms and conditions.
Universal Care may require that the Subscriber Group verify the status of the domestic
partnership pursuant to the Domestic Partner Policy of Universal Care. The Subscriber Group
must also notify the plan upon the termination of the domestic partnership. Should the Group
purchase coverage for the qualified domestic partners of their eligible employees or subscribers,
that coverage would be subject to additional Health Plan Premiums, for each enrolled domestic
partner, in exchange for coverage for the health care benefits, services, and supplies.
6. BINDING ARBITRATION
(a) Except as provided in Subsection (c) below, any controversy or dispute between
any of the following interested parties -- the Subscriber Group; an agent, trustee, affiliate or
assignee of the Subscriber Group; a Subscriber; a Dependent; or an heir at law or personal
representative of a Subscriber or Dependent -- on the one hand, and any of the following parties -
- the Plan, its employees or agents, or its Contracting Providers or their agents or employees, --
on the other, whether involving a claim in tort, contract or otherwise, including disputes
pertaining to this Agreement or the care or other benefits rendered pursuant hereto or refused as
not covered hereunder, and including disputes which are not adequately resolved by the Plan's
grievance procedures, shall be submitted to binding arbitration.
(b) Arbitration may be initiated by any interested party, but if the matter in dispute is
one which is subject to review under the Plan's grievance procedures, arbitration may not be
initiated until the completion of such procedures. The arbitration shall follow in accordance with
the applicable rules of the Judicial Arbitration and Mediation Services (JAMS). The arbitration
process may be initiated by calling the American Arbitration Association and requesting a form
used to demand arbitration. The demand for arbitration must be served personally or by
recognized messenger service or by certified mail, return receipt requested, on or before the last
date it would have to be filed in a court of law under the applicable statute of limitations.
(c) If a Subscriber, a Dependent, or an heir at law or personal representative of a
Subscriber or Dependent asserts an arbitration claim and the amount in dispute is less than
$200,000, the claimant and Universal Care shall agree to a single neutral person to render a
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Universal Care Large Group GSA (R9) DMHC Approval Pending
decision in arbitration. The single neutral arbitrator must be selected from the JAMS panel of
arbitrators and the arbitration will be conducted under the rules of the JAMS.
(d) In the event the claimant and Universal Care cannot agree on a single neutral
arbitrator, the JAMS shall appoint a default arbitrator according to its rules and procedures.
(e) Contracting Physicians, Contracting Hospitals and/or Contracting Providers may
bring legal actions to collect copayments for covered services or fee -for -service rates for non -
covered services. The Plan may seek declaratory relief regarding the interpretation of this
Agreement or seek judicial remedies to collect prepayment fees.
(f) The costs of the arbitration shall be borne equally by both parties; however, for
purposes of this Agreement, the costs of arbitration are limited to fees and expenses of the
arbitrators and charges for arbitrators' transcripts of the proceedings, and the room where the
arbitration is conducted. The arbitrator may require the submission of pleadings, briefs and other
memoranda and documents and may compel discovery from the parties, shall hold a hearing
within a reasonable time and shall set forth his decision in writing, with his reasons and authority
therefore. Any judgment or award rendered by the arbitrator may be entered into any court
having jurisdiction thereof. The arbitration procedure established by this Agreement is the sole
and exclusive means for the settlement of any such controversy or dispute.
(g) Beginning with arbitration claims served on or after August 1, 1997, extreme
hardship provisions will apply for Subscribers and Dependents or their heirs or personal
representatives seeking arbitration. Upon request, Universal Care will provide the Subscriber,
Dependent, heir or personal representative with either an application for relief from arbitration
costs or information on how to obtain such an application from JAMS. The approval or denial of
the application for hardship will be made by JAMS. Procedures established by JAMS for
handling such hardship requests will be followed. Information on how to file an application for
hardship relief may be obtained from Universal Care's Member Services Department by calling
800-635-6668 or 562424-6200.
7. INDEMNIFICATION OF PARTIES
The Parties agree to save, hold harmless, defend and indemnify each other from and
against all claims, demands, liabilities, actions or causes of action of any kind or nature which
may arise out of, in connection with, or related to any act, omission, negligence, malpractice or
lack of due care caused or alleged to have been caused by either party, any subcontractor of either
party, or any of their employees, Contracting Physicians, Contracting Hospitals, Contracting
Physicians, consulting doctors, agents or partners in the performance of the services, duties and
obligations under this Agreement, except as may result from a breach of either party's obligations
hereunder.
8. RELATIONSHIP BETWEEN PARTIES
The relationship between Plan and the physicians, hospitals and other health care
Providers who are its Contracting Physicians, Contracting Providers, Contracting Hospitals is
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Universal Care Large Group GSA (R9) DMHC Approval Pending
that of an independent contractor relationship (except for the employees of Universal Care who
provide services at the medical offices owned and operated by Universal Care); they are not
agents or employees of Universal Care, and this Plan and its employees are not employees or
agents of those Contracting Providers.
Each physician, Hospital or other Provider of health care services is to maintain a direct
physician -patient, hospital -patient or other such relationship with Universal Care members to
whom it provides services, and is solely responsible for its decisions as to what health care
diagnostic, treatment or other services are required.
9. MODIFICATION OF AGREEMENT / HEALTH PLAN PREMIUMS
Universal Care may modify this Agreement at any time by providing a 30-day written
notice to the Group prior to the effective date of such modification. Universal Care may
unilaterally, at any time[s] during the term of this Agreement and with thirty days written notice
to the Group, increase all subsequent Health Plan Premiums that are due from the Group to
continue this Agreement in full force and effect. If modifications to this agreement are for
premium increases that are the result of legislation or regulations imposed by any regulatory body
that has authority over the Plan and its Agreements, then those modifications may be made
unilaterally by the Plan, and at the discretion of the Plan, at any time[s] during the contract year.
However, if such modifications for premium increases are made for reasons other than legislation
or regulations imposed by any regulatory body that has authority over the Plan and its
Agreements, then the modifications for premium increases may be made unilaterally by the Plan,
and at the discretion of the Plan, no more often than once every twelve (12) months. Payment of
any portion of the increased Health Plan Premium shall constitute acceptance of this
modification.
If a government authority (a) imposes a tax or fee that is computed on Health Plan
Premiums or (b) requires a change in coverage or administrative practice that increases Universal
Care's costs. Universal Care may amend this Agreement and increase the Health Plan Premiums
sufficiently to cover the tax, fee, or costs. The effective date of such increase shall be the date set
forth in a written notice from Universal Care to the Group. The effective date shall not be earlier
than the date the tax, fee, or required change in coverage or administrative practice is imposed by
the governmental authority.
10. UNDERWRITING REQUIREMENTS
Underwriting requirements are incorporated by reference in the Large Group Health
Proposal which is created for each large group.
11. GENERAL PROVISIONS
a. Form or Content of Agreement
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Universal Care Large Group GSA (119) DMHC Approval Pending
j. Entire Agreement
This Agreement, the application of the Group, and the individual applications of
employees shall constitute the entire Agreement between the parties.
k. Recordkeeping
The Group is responsible for keeping records relating to this Agreement. Universal Care
has the right to inspect and audit those records.
12. COBRA CONTINUATION COVERAGE
With regard to COBRA, Universal Care is committed to the following:
A. Providing continuation coverage to Health Plan Members upon the request of a Group
when such requests are consistent with the Group's obligations under the law.
B. Sharing knowledge regarding COBRA with the Group as it experiences problems;
however, Universal Care will not give legal advice on these matters.
13. HEALTH PLAN BENEFITS AND COMBINED EVIDENCE OF COVERAGE
AND DISCLOSURE FORM
Universal Care will issue and deliver to each Member a Combined Evidence of Coverage
and Disclosure Form (including a Benefit Schedule) which will set forth a statement of services
and benefits to which Members are entitled, along with an Identification Card.
As noted above, the services and benefits of this Health Plan are set forth in the attached
Combined Evidence of Coverage and Disclosure Form and are incorporated by reference herein.
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Universal Care Large Group GSA (R9) DMHC Approval Pending