Resolution No. 8653
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RESOLUTION NO. 8653
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
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WHEREAS, on July 14, 2004, the City Council of the City of
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Vernon adopted Resolution No. 8489 approving Universal Care Large Group
Subscriber Agreement HMO Premier 100 Plan for the period January 1,
2004 through December 31, 2004; and
WHEREAS, on January 5, 2005, the Finance Committee
considered the recommendation of Bruce V. Malkenhorst, Director of
Finance, dated December 22, 2004, that the renewal rates submitted by
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Universal Care for the HMO Premier 100 Plan for the period January l,
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2005 through December 31, 2005 be approved; and
WHEREAS, by letter dated January 18, 2005, Bruce V.
Malkenhorst, City Administrator/City Clerk, recommended that the Large
Group Subscriber Agreement for the HMO Premier 100 Plan with Universal
Care for the period January 1, 2005 through December 3l, 2005, be
approved and executed.
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
27 approves the Large Group Subscriber Agreement for HMO Premier lOO Plan
28 with Universal Care, a copy of which is attached hereto as Exhibit A
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1 and incorporated by reference.
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SECTION 3:
The City Council of the City of Vernon hereby
3 authorizes the Mayor to execute said Contract for, and on behalf of,
4 the City of Vernon and the City Clerk is hereby authorized to attest
5 thereto.
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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 English, Vice President of Sales
P.O. Box 93122
Long Beach, CA 90809-9871
(Reference: Premier lOOM-RX4 (PlOORX4) GRP 10010A*02)
SECTION 5:
The City Clerk of the City of Vernon shall
14 certify to the passage of this resolution, and thereupon and
15 thereafter the same shall be in full force and effect.
16 APPROVED AND ADOPTED this 2nd day of February, 2005.
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ATTEST:
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BRUCE V. MALKENHORST, City Clerk
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1 STATE OF CALIFORNIA
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COUNTY OF LOS ANGELES
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I, BRUCE V. MALKENHORST, City Clerk of the City of Vernon, do
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hereby certify that the foregoing Resolution, being Resolution No.
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8653, 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 2,
2005, and thereafter was duly signed by the Mayor of the City of
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Vernon.
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BRUCE V. MALKENHORST, City Clerk
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EXHIBIT
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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 ill Number: 10010A *02
Group's Benefit Plan ill Code: Premier 100M-RX4 (P100RX4)
Group's Effective Date: January 1, 2005
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.
B~ UNC&;~
Jay B. Davis
Executive Vice President
CITY OF VERNON
By:
Leonis C. Malburg, Mayor
Date: ~D 0
APPROVED AS TO ORM:
Date:
ATTEST:
Eric T. Fresch, City Attorney
Bruce V. Malkenhorst, City Clerk
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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 TERMI~ATION 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 3D-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 peri()d shall begin 30 days
prior to ~e 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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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 increaser 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 timer 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 timer 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 COP AYMENTS
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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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 timers] 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 increaser s]
shall be separated by a period oftime that is not less than twelve (12) months in duration if those
increaser 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 timer 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; (I)
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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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 ofthe 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 numb'ers 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 ofHeaIth 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.
(0 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 I, 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
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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 ofthose 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
Car~'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
3. Form or Content of Agreement
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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 seq. 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 ofthe 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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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
A TTN: 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 th~ 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 ano 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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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.
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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 incdrporated by reference herein.
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Universal Care Large Group GSA (R9) DMHC Approval Pending
. .
, ".
Description
Employee Only
Employee and Spouse
Employee and Child
Employee and Children
Employee and Family
'.
"
Premier lOOM-RX4 (PI00RX4)
Premium Rate Schedule
CityofVemon
1001 OA *02
Effective Date: January I, 2005
Premium Rate
$201.61
$423.39
$423.39
$645.16
$645.16
. .
universalca re@
HEALTHCARE YOU CAN FEEL GOOO ABOUT
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
,
. .
(FULL DOCUMENT DELIVERATELY OMITTED;~SEE ORIGINAL AGREEMENT FOR COMPLETE DOCUMENT)
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 inconsideration 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, 2005
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.
By: UN~A~
Jay B. Davis
Executive Vice President
CITY OF VERNON
By: .
,. Le is C. Mal g, Mayr
Date:~DO
APPROVE. D AS TO -ORM: ~
~/-:r ~
Eric T. Fresch, City Attorney
;c /t~/t1S'
ATTEST:
/-~~
Bruce V. Ma1kenhorst, City Clerk
Date:
1
Universal Care Large Group GSA (R9) DMHC Approval Pending