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Resolution No. 84892 3 4 5 6 7 8 9 10 11 12 13 FXI! 15 16 17 18 19 20 21 22 23 24 25 26 27 28 RESOLUTION NO. 8489 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF VERNON APPROVING AND AUTHORIZING 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 February 5, 2003, the City Council of the City of Vernon adopted Resolution No. 8144 approving Universal Care Large Group Subscriber Agreement HMO Premier 100 Plan for the period January 1, 2003 through December 31, 2003; and WHEREAS, on December 16, 2003, the Finance Committee recommended that the City Council approve the recommendation of Bruce V. Malkenhorst, Director of Finance, dated December 11, 2003, that the renewal rates submitted by Universal Care for the HMO Premier 100 Plan for the period January 1, 2004 through December 31, 2004 be approved and the renewal agreement be executed when completed; and WHEREAS, on July 13, 2004, the Finance Committee recommended that the City Council approve the recommendation of Bruce V. Malkenhorst, Director of Finance, dated July 7, 2004 that the Large Group Subscriber Agreement for the HMO Premier 100 Plan with Universal Care for the period January 1, 2004 through December 31, 2004, be executed; and 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 a 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 approves the Large Group Subscriber Agreement for HMO Premier 100 Plan with Universal Care, a copy of which is attached hereto as Exhibit A and incorporated by reference. SECTION 3: The City Council of the City of Vernon hereby authorizes the Mayor and the City Clerk to execute said Agreement for, and on behalf of, the City of Vernon. SECTION 4: The City Council of the City of Vernon hereby directs the City Clerk, or his designee, to send one signature page of the Agreement to: Universal Care Attn: Jim K. Edmunds, Vice President Sales P.O. Box 93122 Long Beach, CA 90809-3122 (Reference: GRP 10010A*02) SECTION 5: 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 14th day of July, 2004. ATTEST: BRUCE V. MALKENHORST, City Clerk (LEONIS C. MALB RG, Ma or - 2 - 1 2 3 4 5 6 7 8' 91 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 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. 8489, was duly adopted by the City Council of the City of Vernon at an adjourned regular meeting of the City Council duly held on Wednesday, July 14, 2004, and thereafter was duly signed by the Mayor of the City of Vernon. (SEAL) BRUCE V. MALKENHORST, City Clerk - 3 - EXHIBIT 0 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 100M-RX4 (P100RX4) Group's Effective Date: January 1, 2004 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. UNTALCARE By: Jay B. Davis Executive Vice President Date: ' U 1 CITY OF VERNON Leonis C. Malburg, Mayor Date: ATTEST: By: Bruce V. Malkenhorst, City Clerk APPROVED AS TO FORM: Universal Care Large Group GSA (R9) DMHC Approval Pending Eric T. Fresch, 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. 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 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. 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 25`h 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 coopezate 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 5 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 6 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 parry, 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 7 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 8 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 SeMc .) 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. 9 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)." 10 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. 11 Universal Care Large Group GSA (R9) DMHC Approval Pending Premium Rate Schedule City of Vernon 10010A*02 amd 10010A*CO Premier 100 (P 100RX4) Effective Date: January 1, 2004 Description Employee Only Employee and Spouse Employee and Child Employee and Children Employee, Spouse and Child(ren) Premium Rate $191.55 $402.26 $402.26 $612.97 $612.97 Universal Care® Healthcare you can feel good about. Corporate Offices: 1600 East Hill Street Signal Hill, CA 90755-3682 Mailing Address: P.O. Box 93122 Long Beach, CA 90809-3122 562 424-6200 800 635-6668 SUPPORTING DOCUMENTS 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 10OM-RX4 (P100RX4) Group's Effective Date: January 1, 2004 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. .'F , UN SAL CARE CITY OF VERNON � J By: By: Jay B. Davis Ireeonis C . Malbu , Mayor Executive Vice President Date: Date: 267 5► ATTEST: By: Bruce V. Malkenhorst, City Clerk APPROV AST F 1 Universal Care Large Group GSA (R9) DMHC Approval Pending Eric re ch, City ney 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 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. 3 Universal Care Large Group GSA (119) 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 25th 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 5 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 6 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 562-424-6200. 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 7 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. TO. - 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 8 Universal Care Large Group GSA (119) 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 seq.) 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. 9 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)." 10 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. t„ 11 Universal Care Large Group GSA (R9) DMHC Approval Pending i r Universal Care® Healtbcare you can feel good about. Corporate Offices: 1600 East Hill Street Signal Hill, CA 90755-3682 Mailing Address: P.O. Box 93122 Long Beach, CA 90809-3122 562 424-6200 800 635-6668 Premium Rate Schedule City of Vernon 10010A*02 amd 10010A*CO Premier 100 (P l 00RX4) Effective Date: January 1, 2004 Description Employee Only Employee and Spouse Employee and Child Employee and Children Employee, Spouse and Child(ren) Premium Rate $191.55 $402.26 $402.26 $612.97 $612.9.7