HomeMy WebLinkAboutItem 06.fFebruary 1, 2012
Proposed Action
Staff recommends adoption of the following motion: Move to approve master group
contract with Medica Insurance Company.
Passage of this motion wiii finalize the contract between Medica insurance Company
and the City of Lakeville for 2012.
Overview
The City Council approved Medica Insurance Company as the new health plan provider
for the City of Lakeville effective January 1, 2012. The attached contract describes the
terms and rates that have already been discussed and implemented. City Attorney
Roger Knutson has reviewed and approved the language of the contract.
Primary Issues to Consider
6 None.
Supporting Information
® Master Group Contract.
Human Res roes Manager
Contract between Medica Insurance Company
and City of Lakeville
Item No.
Financial Impact: $ $0 Budgeted: N/A Source:
Related Documents (CIP, ERP, etc.):
Notes:
MASTER GROUP C;ONTRA.CT
BETWEEN
CITY OF LAKEVILLE
AND
MEDICIA .NSEIRANCE COMPANY
MEDICA INSURANCE COMPANY ( "MEDICA ")
MASTER GROUP CONTRACT
ARTICLE 1
INTRODUCTION
This Master Group Contract ( "Contract ") is entered into by and between Medica Insurance
Company ( "Medica ") and the employer group identified in Exhibit 1 ( "Employer "). This Contract
includes Exhibit 1, Exhibit 2, the Certificate of Coverage ( "Certificate "), and any Amendments.
This Contract includes the coverage option(s) set forth in Exhibit 2, offered by the Employer
under a single group health plan. This Contract is delivered in the state of Minnesota.
The capitalized terms used in this Contract have the same meanings given to those terms
defined in the Certificate, unless otherwise specifically defined in this Contract.
If this Contract is purchased by Employer to provide benefits under an employee welfare benefit
plan governed by the Employee Retirement Income Security Act, 29 U.S.C. 1001, et seq.
("ERISA"), this Contract is governed by ERISA and, to the extent state law applies, the laws of
the State of Minnesota. If this Contract is not governed by ERISA, it is governed by the laws of
the State of Minnesota. If this Contract is governed by ERISA, any legal action arising out of or
relating to this Contract shall be brought in the federal district court for the district of Minnesota.
If this Contract is not governed by ERISA, any legal action arising out of or relating to this
Contract shall be brought in state court in Hennepin County, Minnesota.
In consideration of payment of the Premiums by the Employer and payment of applicable
Deductibles, Copayments, and Coinsurance by or for Members, Medica will provide coverage
for the Benefits set forth in the Certificate and any amendments, subject to all terms and
conditions, including limitations and exclusions, in this Contract.
This Contract replaces and supersedes any previous agreements between Employer and
Medica relating to Benefits.
Medica shall not be deemed or construed to be an employer for any purpose with respect to the
administration or provision of benefits under Employer's welfare benefit plan. Medica shall not
be responsible for fulfilling any duties or obligations of Employer with respect to Employer's
benefit plan.
ARTICLE 2
TERM OF CONTRACT
Section 2.1 Tenn and Renewal. The initial Term of this Contract is set forth in Exhibit 1.
At least 30 days before each Expiration Date, as set forth in Exhibit 1, Medica shall notify
Employer of any modifications to this Contract, including Premiums and Benefits for the next
term of this Contract ( "Renewal Terms "). If Employer accepts the Renewal Terms or if
Employer and Medica agree on different Renewal Terms, this Contract is renewed for the
additional term, unless Medica terminates this Contract pursuant to Sect ion 2.2.
Section 2.2 Termination of This Contract. Employer may terminate this Contract after at
least 30 days written notice to Medica, This Contract is guaranteed renewable and will not be
terminated by Medica except for the following reasons and will be effective as stated below.
Except as specified otherwise, terminations for the reasons stated below require at least 30
days written notice from Medica:
(a) Upon notice to an authorized representative of the Employer that Employer failed to pay the
required Premium when due, provided, however, that this Contract can be reinstated
Medica Large Group MGC 1 City of Lakeville
01/01/2012
pursuant to Section 5,2. If Employer fails to pay the required Premium within the grace
period described in Section 5.2, the Contract will be terminated, subject to a 30 -day advance
written notice of termination by Medica to Employer. The date of the termination shall be
retroactive to not more than 30 days prior to the effective date of the notice of termination;
(b) On the date specified by Medica because Employer committed fraud (through act, practice,
or omission) or intentionally provided Medica with false information material to the execution
of this Contract or to the provision of Benefits under this Contract. Medica has the right to
rescind this Contract back to the original effective date;
(c) On the date specified by Medica due to Employer's violation of the participation or
contribution rules as deter mined by Medica;
(d) Automatically on the date Employer ceases to do business pursuant to 11 U.S.C. Chapter 7;
(e) Automatically on the date Employer ceases to do business for any reason;
(f) On the date specified by Medica, after at least 90 days prior written notice to Employer, that
this Contract is terminated because Medica will no longer issue this particular type of group
health benefit plan within the applicable employer market;
On the date specified by Medica, after at least 180 days prior written notice to the applicable
state authority and Employer, that this Contract will be terminated because Medica will no
longer renew or issue any employer health benefit plan within the applicable employer
market;
(h) If this Contract is made available to Employer only through one or more bona fide
associations, on the date specified by Medica after Employer's membership in the
association ceases;
Automatically on the date that Employer fails to maintain any active employees who are
Subscribers;
(g)
(i)
(j) Any other reasons or grounds permitted by the licensing laws and regulations governing
Medica.
Notwithstanding the above, Medica may modify the Premium rate and/or the coverage at
renewal. Nonrenewal of coverage as a result of failure of Medica and the Employer to reach
agreement with respect to modifications in the Premium rate or coverage shall not be
considered a failure of Medica to provide coverage on a gu aranteed renewable basis.
Section 2.3 Notice of Termination.
Medica will notify Employer in writing if Medica terminates this Contract for any reason.
In accordance with applicable law, Medica will notify Subscribers in writing if Medica terminates
this Contract pursuant to Section 2,2(a), (b), (d), (f), or (g).
Employer will provide timely written notification to Subscribers in all circumstances for which
Medica does not provide w ritten notification to Subscribers.
Section 2.4 Effect of Termination. In the event of termination of this Contract:
(a) All Benefits under this Contract will end at 12:00 midnight Central Time on the effective date
of termination;
(b) Medica will not be responsible for any Claims for health services received by Members after
the effective date of the termination; and
(c) Employer shall be and shall remain liable to Medica for the payment of any and all
Premiums that are unpaid at the time of termination.
Medica Large Group MGC
2
City of Lakeville
01/01/2012
ARTICLE 3
ENROLLMENT AND ELIGIBILITY
Section 3.1 Eligibility. The Eligibility conditions stated in Exhibit 1 of this Contract govern who
is eligible to enroll under this Contract. The eligibility conditions stated in Exhibit 1 are in
addition to those specified in the Certificate.
Section 3.2 Enrollment. The Certificate governs when eligible employees and eligible
dependents may enroll for coverage under this Contract, including the Initial Enrollment Period,
Open Enrollment Period, and any applicable Special Enrollment Periods. Employer shall
conduct the Initial Enrollment Period and Open Enrollment Period. Employer shall cooperate
with Medica to ensure appropriate enrollment of Members under the Contract.
Section 3.3 Qualified Medical Child Support Orders. Employer will establish, maintain, and
enforce all written procedures for determining whether a child support order is a qualified
medical child support order as defined by ERISA. Employer will provide Medica with notice of
such determination and a copy of the order, along with an application for coverage, within the
greater of 30 days after issuance of the order or the time in which Employer provides notice of
its determination to the persons specified in the order.
When and if Employer receives notice that the child has designated a representative or of the
existence of a legal guardian or custodial parent of the child, Employer shall promptly notify
Medica of such person(s).
Medica shall have no responsibility for:
(1) establishing, maintaining, or enforcing the procedures described ab ove;
(11) determining whether a support order is qualified; or
(iii) providing required notices to the child or the designated representative.
Section 3.4 Eligibility and Enrollment Decisions. Subject to applicable law and the terms of
this Contract, Employer has discretion to determine whether employees and their dependents
are eligible to enroll for coverage under this Contract. Medica shall be entitled to rely upon
Employer's determination regarding an employee's and /or dependent's eligibility to enroll for
coverage under this Contract. The Employer will be responsible for maintaining information
verifying its continuing eligibility and the continuing eligibility of its eligible Subscribers and
eligible Dependents. This information shalt be provided to Medica as reasonably requested by
Medica. The Employer shall also maintain written documentation of a waiver of coverage by an
eligible Subscriber or eligible Dependent and provide this documentation to Medica upon
reasonable request.
Section 3.5 Notification. The Employer must notify Medica within 30 days of an individual's
initial enrollment application, changes to a Member's name or address, changes to a Member's
eligibility for coverage (including a loss of eligibility), or other changes to enrollment.
Section 3.6 Multiple Benefit Package Options. Subscribers and enrolled Dependents may
only switch between Employer's health coverage options offered under the Contract during a
Special Enrollment Period, or the Open Enrollm ent Period, if applicable, as described in the
Certificate.
ARTICLE 4
ELECTRONIC DELIVERY OF INSURANCE DOCUMENTS
The Employer agrees to deliver, as Medica's agent, insurance documents required by law to be
furnished to Subscribers. These documents shall be furnished by Medica to the Employer for
delivery to Subscribers. The Employer shall not modify these documents in any way. The
Employer agrees to deliver such documents electronically to the extent permissible under Title I
Medica Large Group MGC 3 City of Lakeville
01/01/2012
of the Employee Retirement Income Security Act of 1974, Department of Labor Regulation
§ 2520.104b -1(c), if applicable, and Minn. Stat. § 72A,20, subd. 37. Such documents shall be
delivered electronically only to Subscribers who meet the following requirements: (a) has the
ability to access an electronic document effectively at any location where the Subscriber is
reasonably expected to perform his or her duties as an employee, and (b) with respect to whom
rr�c� t th plan sponsor's electronic information system is an integral part of those duties.
The Employer shall implement procedures that ensure actual receipt of these documents and
notify Subscribers of the significance of the materials at the time of delivery. In addition, the
Employer shall inform the recipient of his or her right to request a paper version of these
documents, and an expedient process for doing so. Upon such a request, Employer shall
furnish the recipient with paper copies supplied by Medica. Employer shall inform Medica of
individuals who do not qualify for electronic delivery because they do not meet the requirements
regarding access to a computer, or they are not in the workplace, including but not limited to
those on continuation coverage, on retiree coverage, or covered pursuant to a qualified medical
child support order. Employer shall provide the individual's mailing information to Medica so
that Medica can provide the docum ents.
ARTICLE 5
PREMIUMS
Section 5.1 Monthly Premiums.
The monthly Premiums for this Contract are: set forth in Exhibit 2.
The Premiums are due on the first day of each calendar month. Employer shall pay the
Premiums to Medica in accordance with the method set forth in the invoice.
Employer shall notify Medica in writing:
(a) each month of any changes in the coverage classification of any Subscriber; and
(b) within 30 days after the effective date of enrollments, terminations or other changes
regarding Members.
Section 5.2 Grace Period and Reinstatement. Employer has a grace period of 10 days after
the due date stated in Section 5.1 to pay the monthly Premiums. If Employer fails to pay the
Premium, the Contract will be terminated in accordance with Section 2.2(a). This Contract will
be reinstated if Employer pays all of the Premiums owed on or before the end of the grace
period. In the event this Contract is not reinstated pursuant to this Section, Medica shall not be
responsible for any Claims for health services received by Members after the effective date of
the termination.
Section 5.3 Premium Calculation. The monthly Premiums owed by Employer shall be
calculated by Medica using the number of Subscribers in each coverage classification according
to Medica's records at the time of the calculation. Subject to Section 5.4, Employer may make
adjustments to its payment of Premiums for any additions or terminations of Members submitted
by Employer but not yet reflected in Medica's calculations.
A full calendar month's Premiums shall be charged for Members whose effective date falls on or
before the 15th day of that calendar month. No Premium shall be charged for Members whose
effective date falls after the 15th day of that calendar month. With the exception of termination
of coverage due to a Member's death, a Member's coverage may be terminated only at the end
of a calendar month and a full Premium rate for that month will apply. In the case of a
Member's death, that Member's coverage will be terminated on the date of death.
Section 5.4 Retroactive Adjustments. In accordance with applicable law and this
Agreement, retroactive adjustments may be made for addition of Members, changes in
Medica Large Group MGC
4
City of Lakeville
01/01/2012
Members' coverage classifications, and certain terminations of Members not reflected in
Medica's records at the time the monthly Premiums were calculated by Medica. Employer
understands and acknowledges that federal law prohibits the retroactive termination of a
Member's coverage except in instances of fraud, intentional misrepresentation of material fact,
or failure to timely pay premiums or premium contributions. Employer agrees that it will not
request rptrnnntivea termination of any Member's coverage if s terminati is prohibited by
law. Notwithstanding the foregoing, no retroactive credit will be granted for any month in which
a Member received Benefits. No retroactive adjustments to enrollment or Premium refund shall
be granted for any change occurring more than 60 days prior to the date Medica received
notification of the change from Employer.
Notwithstanding the foregoing, Employer shall pay a Premium for any month during which a
Member received Benefits (except as described in Section 5.3).
Section 5.5 Premium Changes. Medica may change the Premiums after 30 days prior written
notice to Employer.
Section 5,6 Employer Fees. Medica may charge Employer:
(a) a late payment charge in the form of a finance charge of 12% per annum for any Premiums
not received by the due date; and
(b) a service charge for any non - sufficient -fund check received in payment of the Premiums.
(c) an administrative service fee of $250.00 at time of request for reinstatement.
Section 5.7 Premium Rebate Administration (When Applicable).
General Obligation. In accordance with the Patient Protection and Affordable Care Act
( "PPACA "), Medica is obligated to provide a rebate to each Subscriber and group policy
holder (such as Employer) obtaining coverage in the large group market if the ratio of
Medica's premium revenue spent on claims expenses and health care quality improvement
activities for the large group market is less than eighty -five percent (85 %) of Medica's total
premium revenue (minus certain taxes and fees) for that group market. PPACA requires
Medica to make such determinations on a calendar year basis, regardless of the Effective
Date and Expiration Date of this Contract.
(b) Rebate Determinations and Remittances. Medica agrees to determine whether such
rebates are owed under this Contract and, if applicable, remit to Employer either: (i) the full
amount of such rebates (that is, the rebate amount owed based on the full Premium
payment ---- including both Employer -paid and Subscriber -paid portions of said payment); or,
at Medica's sole option, (ii) the Employer -paid portion of such rebates, only (in which case,
Medica would remit the Subscriber -paid portion of such rebates directly to Subscribers). If
Medica remits the full amount of such rebates to Employer (as described in (b)(i) above),
Medica shall remit such payment no later than July 1 of the calendar year following any
calendar year during which this Contract was in effect (for all or part of the year), and for
which a rebate is owed (for all or part of the year). In the event Medica elects to remit the
Subscriber -paid portion of such rebates directly to the applicable Subscribers (as described
in (b)(ii) above), Medica shall remit rebate payments no later than August 1 of the calendar
year following any calendar year during which this Contract was in effect (for all or part of
the year), and for which a rebate is owed (for all or part of the year).
Form of Rebates. Medica may, in its sole discretion, elect to provide any such rebates owed
in the form of a premium credit, a lump -sum check, or a lump -sum credit to the account used
to pay the premium.
(d) Rebate Distributions. Upon written request by Medica, Employer agrees to distribute to
Subscribers (including former Subscribers) that portion of any such rebate attributable to the
(a)
(c)
Medica Large Group MGC
5
City of Lakeville
01/01/2012
(e)
Subscriber -paid portion of the applicable Premium payment. Employer agrees to disburse
any unclaimed rebates attributable to the Subscriber -paid portion of such rebates in
accordance with applicable state law governing unclaimed property.
Information Required to Support Rebate Distributions. Under PPACA, Medica is required to
collect and retain (for audit by the federal Department of Health and Human Services) the
following information —which information Employer agrees to supply to Medica upon
Medica's written request: (i) the amount of Premium paid by each Subscriber; (ii) the
amount of Premium paid by Employer; (iii) the amount of rebate distributed to each
Subscriber; (iv) the amount of rebate retained by Employer; and (v) the amount of unclaimed
rebates and how and when they were distributed.
ARTICLE 6
INDEMNIFICATION
Medica will hold harmless and indemnify Employer against any and all claims, liabilities,
damages, or judgments asserted against, imposed upon or incurred by Employer, including
r.onable attorney feces and costs, that apse out of Medico's negligent acts or omissions in the
discharge of its responsibilities to a Member.
Employer will hold harmless and indemnify Medica against any and all claims, liabilities,
damages, or judgments asserted against, imposed upon, or incurred by Medica, including
reasonable attorney fees and costs, that arise out of Employer's or Employer's employees',
agents', and representatives' negligent acts or omissions in the discharge of its or their
responsibilities under this Contract.
Employer and Medica shall promptly notify the other of any potential or actual claim for which
the other party may be responsible under this Article 6,
ARTICLE 7
ADMINISTRATIVE SERVICES
The services necessary to administer this Contract and the Benefits provided under it will be
provided in accordance with Medica's or its designee's standard administrative procedures. if
Employer requests such administrative services be provided in a manner other than in
accordance with these standard procedures, including requests for non - standard reports, and if
Medica agrees to provide such non - standard administrative services, Employer shall pay for
such services or reports at Medica's or its designee's then- current charges for such services or
reports.
ARTICLE 8
CLERICAL ERROR
A Member will not be deprived of coverage under the Contract because of a clerical error.
Furthermore, a Member will not be eligible for coverage beyond the scheduled termination date
because of a failure to record the termination.
ARTICLE 9
ERISA
When this Contract is entered into by Employer to provide benefits under an employee welfare
benefit plan governed by ERISA, Medica shall not be named as and shall not be the plan
administrator of the employee welfare benefit plan, as that term is used in ERISA. Medica shall
only be considered a named fiduciary for purposes of claims adjudication.
Medica Large Group MGC 6
City of Lakeville
01/01/2012
The parties agree that Medica has sole, final, and exclusive discretion to:
(a) interpret and construe the Benefits under the Contract;
(b) interpret and construe the other terms, conditions, limitations, and exclusions set out in the
Contract;
(c) change, interpret, modify, withdraw, or add Benefits without approval by Members; and
(d) make factual determinations related to the Contract and the Benefits.
For purposes of overall cost savings or efficiency, Medica may, in its sole discretion, provide
services that would otherwise not be Benefits. The fact that Medica does so in any particular
case shall not in any way be deemed to require it to do so in other sin filar cases.
Medica may, from time to time, delegate discretionary authority to other persons or entities
providing services under this Contract.
ARTICLE 10
DATA OWNERSHIP AND USE
Information and data acquired, developed, generated, or maintained by Medica in the course of
performing under this Contract shall be Medica's sole property. Except as this Contract or
applicable law requires otherwise, Medica shall have no obligation to release such information
or data to Employer. Medica may, in its sole discretion release such information or data to
Employer, but only to the extent permitted by law and subject to any restrictions determined by
Medica.
ARTICLE 11
CONTINUATION OF COVERAGE
Medica shall provide coverage under this Contract to those Members who are eligible to
continue coverage under federal or state law.
Medica will not provide any administrative duties with respect to Employer's compliance with
federal or state continuation of coverage laws. All duties of the Employer, including, but not
limited to, notifying Members regarding federal and state law continuation rights and Premium
billing and collection, remain Employer's sole responsibility.
ARTICLE 12
CERTIFICATION OF QUALIFYING COVERAGE FORMS
As required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Medica
will produce Certification of Qualifying Coverage forms for Members whose coverage under this
Contract terminates or upon request by Members. The Certification of Qualifying Coverage
forms will be based on the eligibility and termination data Employer provides to Medica.
Employer shall provide all necessary eligibility and termination data to Medica in accordance
with Medica's data specifications. The Certification of Qualifying Coverage forms will only
include periods of coverage Medica administers under this Contract.
ARTICLE 13
NONDISCRIMINATION
In accordance with the Patient Protection and Affordable Care Act ( "PPACA "), fully- insured
group health plans other than grandfathered plans are generally subject to nondiscrimination
rules similar to those applicable to self - insured health plans under Section 105(h) of the Internal
Revenue Code. Medica assumes no responsibility for compliance with such rules. Employer,
as the sponsor of the insured employee benefit plan, shall be responsible for ensuring
Medica Large Group MGC
7
City of Lakeville
01/01/2012
compliance with all PPACA nondiscrimination requirements applicable to the insurance
coverage, including but not limited to payment of any and all governmental or regulatory taxes,
penalties, interest, or other charges resulting from noncompliance with applicable
nondiscrimination requirements. Employer, as the sponsor of the insured employee benefit
plan, is solely responsible (1) for determining whether, with respect to its employee workforce,
the aspects of a particullar insurance contract are discriminatory under PPACA and (2) for
appropriately addressing the situation if it is discriminatory under PPACA (including but not
limited to correcting, self - reporting, and payment of any penalties and interest related to the
discrimination).
ARTICLE 14
AMENDMENTS AND ALTERATIONS
Section 14.1 Standard Amendments. Except as provided in Section 14.2, amendments to
this Contract are effective 30 days after Medica sends Employer a written amendment. Unless
regulatory authorities direct otherwise, Employer's signature will not be required. No Medica
agent or broker has authority to change this Contract or to waive any of its provisions.
Section 14.2 Regulatory Amendment. Medica may amend this Contract to comply with
requirements of state and federal law ( "Regulatory Amendment ") and shall issue to Employer
such Regulatory Amendment and give Employer notice of its effective date. The Regulatory
Amendment will not require Employer's consent and, unless regulatory authorities direct
otherwise, Employer's signature will not be required. Any provision of this Contract that conflicts
with the terms of applicable federal or state laws is deemed amended to conform to the
minimum requirements of such laws.
ARTICLE 15
ASSIGNMENT
Neither party shall have the right to assign any of its rights and responsibilities under the
Contract to any person, corporation, or entity without the prior written consent of the other party;
provided, however, that Medica may, without the prior written consent of the Employer, assign
the Contract to any entity that controls Medica, is controlled by Medica, or is under common
control with Medica. In the event of assignment, the Contract shall be binding upon and inure to
the benefit of each party's successors and assigns.
ARTICLE 16
DISPUTE RESOLUTION
In the event that any dispute, claim, or controversy of any kind or nature relating to this Contract
arises between the parties, the parties agree to meet and make a good faith effort to resolve the
dispute. The party requesting the meeting shall provide the other, in advance of the meeting,
with written notice of the claimed dispute. Upon receipt of the written notice, representatives for
each party shall meet promptly to attempt to resolve the dispute. If a mutually agreeable
resolution is not reached within thirty (30) days following receipt of the written notice, either
party may pursue legal action in accordance with the terms of this Contract. The parties may
mutually agree to waive the informal dispute resolution process set forth herein. Any such
waiver must be in writing and executed by both parties.
ARTICLE 17
TIME LIMIT ON CERTAIN DEFENSES
No statement made by Employer, except a fraudulent statement, shall be used to void this
Contract after it has been in force for a period of 2 years.
Medica Large Group MGC 8 City of Lakeville
01/01/2012
ARTICLE 18
RELATIONSHIP BETWEEN PARTIES
The relationship between Employer and any Member is that of Employer and Subscriber,
Dependent, or other coverage classification as defined in this Contract.
The relation hetween Medica and Network Prnviriars and the relationship Between Medica
and Employer are solely contractual relationships between independent contractors. Network
Providers and Employer are not agents or employees of Medica. Medica and its employees are
not agents or employees of Network Providers or Employer.
The relationship between a Network Provider and any Member is that of provider and patient
and the Network Provider is solely responsible for the services provided to any Member.
ARTICLE 19
EMPLOYER RECORDS
Employer shall furnish Medica with all information and proofs that Medica may reasonably
require with regard to any matters pertaining to this Contract. Medica may at any reasonable
time inspect all documents furnished to Employer by an individual in connection with the
Benefits, Employer's payroll records, and any other records pertinent to the Benefits under this
Contract.
Unless Employer provides the appropriate written assurances required by 45 CFR 164.504,
Medica will only provide Employer with summary health information (for the purposes of
obtaining premium bids or for modifying, amending, or terminating the group health plan only)
and information on whether individuals are participating in the group health plan, or is enrolled
in or has disenrolled from the health plan as provided in 45 CFR 164.504 (f)(1) and the
minimum necessary information for purposes of auditing Medica's operations or services.
ARTICLE 20
NOTICE
Except as provided in Article 2, notice given by Medica to an authorized representative of
Employer will be deemed notice to all Members.
All notices to Medica shall be sent to the address stated in the Acceptance of Contract. All
notices to Employer shall be sent to the persons and addresses stated in the Group Application.
All notices to Medica and Employer shall be deemed delivered:
(a) if delivered in person, on the date delivered in person;
(b) if delivered by a courier, on the date stated by the courier;
(c) if delivered by an express mail service, on the date stated by the mail service vendor; or
(d) if delivered by United States mail, 3 business days after date of mailing.
A party can change its address for receiving notices by providing the other party a written notice
of the change.
ARTICLE 21
COMMON LAW
No language contai ned in the Contract constitutes a waiver of Medica's rights under common
law.
Medica Large Group MGC 9 City of Lakeville
01/01/2012
ACCEPTANCE OF CONTRACT
This Contract is deemed accepted by Employer upon the earlier of Medica's receipt of
Employer's first payment of the Premium or upon Employer's execution of this Contract by its
dul�� authorized representative, This Contract is deemed accepted by Medica upon 11/lerdica's
deposit of Employer's first payment of the Premium. Such acceptance renders all terms and
provisions herein binding on Medica and the Employer,
IN WITNESS WHEREOF, Medica has caused this Contract to be executed on this January 16,
2012, to take effect on the Effective Date stated in Exhibit 1 to this Contract.
MEDICA INSURANCE COMPANY EMPLOYER
401 Carlson Parkway
Minnetonka, MN 55305 City of Lakeville
(952) 992-2200 f
Address: 20195 Holy oke A
Lakeville, MN 55044
Billing Address:
NW 7958
PO Box 1450
Minneapolis, MN 55485 -7958
Mailing Address:
PO Box 9310
Minneapolis, MN 55440
By:
By:
John Naylor
Vice President and General M anager
Commercial Sales
4 /7
James P. Jacobson
Senior Vice President and Assistant Secretary
Medica Large Group MGC
10
By:
Title:
Employer Representative:
Cindi Joosten
Date:
City of Lakeville
01/01/2012
1. Parties. The parties to this Master Group Contract ( "Contract ") are Medica Insurance
Company ( "Medica ") and the employer group City of Lakeville ( "Employer "), an employer
under Minnesota law and other applicable law.
2. Effective Date and Expiration Date of this Contract. This Contract is effective from
01/01/2012 ( "Effective Date ") to 12/31/2012 ( "Expiration Date "). All coverage under this
Contract begins at 12:01 a.m. Central Time.
3. Amendment(s) Number: Amendments attached as applicable for benefit package log
(BPL) as listed in Exhibit 2.
4. Eligibility. The following conditions are in addition to those specif ied in the Certificate:
4.1 Eligibility to Enroll.
A Subscriber and his or her Dependents who satisfy the eligibility conditions stated in
this Contract are eligible to enroll for coverage under this Contract. Any person who
does not satisfy the definition of Subscriber or Dependent is not eligible for coverage
under this Contract.
A Subscriber and his or her Dependents must meet the eligibility requirements described
below and in the entire Contract.
4.2 Subscriber Definition.
An employee eligible to enroll under the Contract as a Subscriber must be an individual
who satisfies the Employer participation and eligibility requirements as defined below.
The term "Subscriber" as used in the Contract will include the types of employees and
conditions identified below:
Classifications Applicable Waiting Period or Effective Date
1. Employees: Employees working
a minimum of 30 hours /week
Medica Large Group MGC
EXHIBIT 1
Exhibit 1
Page 1
New Hires: First of the month following date of hire
Status Change: Date of change
Return: Date of return
Rehire: Date of rehire
City of Lakeville
01/01/2012
Single
$400.86
Employee + Spouse
$856.13
Employee + Child(ren)
$808.78
Family
$1,056.51
Single
$360.77
Employee + Spouse
$770.52
Employee + Child(ren)
$727.90
Family
$950.86
Single
$413.35
Employee + Spouse
$882.82
Employee + Child(ren)
$833.99
Family
$1,089.45
Single
$587.77
Employee + Spouse
$1,255.32
Employee + Child(ren)
$1 ,185.89
Family
$1,549.14
Single
$459.28
Employee + Spouse
$980.91
Employee + Child(ren)
$926.66
Family
$1,210.49
EXHIBIT 2
Premiums
The monthly Premiums for MIC PPMN 2000 - 100% HRA, group number(s) 80998, BPL #64185
are:
The monthly Premiums for MIC ME /MESMN 2000- 100% HRA, group number(s) 80999, 81799,
BPL #64186 are:
The monthly Premiums for MIC PPMN HSA 2400 - 100 %, group number(s) 81800, BPL #67551
are:
The monthly Premiums for MIC ME /MESMN HSA 2400 -100 %, group num ber(s) 81801, 81802,
BPL #67552 are:
The monthly Premiums for MIC PPMN 100 % -30, group numbers) 80995, BPL #84580 are:
Medica Large Group MGC
Exhibit 2
Page 1
City of Lakeville
01/01/2012
Single
$528.99
Employee + Spouse
$1,129.79
Employee + Child(ren)
$1 ,067.30
Family
$1,394.22
The monthly Premiums for MIC ME /MESMN 100 % -30, group number(s) 80996, 80997,
BPI_ #84581 are:
Medica Large Group MGC
Exhibit 2
Page 2
City of Lakeville
01/01/2012