Carrier for Medicare Supplement or Medicare Advan

City of Meriden, Connecticut Purchasing Department Request For Proposal City of Meriden Carrier/TPA for Medicare Supplement Plan or Medicare Advantage Plan RFP023-05 Proposals Due: August 18, 2022 @ 11:00 AM Purchasing Department 142 East Main St. Room 210 Meriden, CT 06450 (203) 630-4115 LEGAL NOTICE The City of Meriden is accepting sealed proposals for: RFP023-05 Carrier for Medicare Supplement or Medicare Advantage Plan The City of Meriden, Human Resources Department, is seeking proposals from qualified insurance carriers or third-party administrators paying to administer its group Medicare Supplemental program for its Medicare- eligible retired employees and eligible spouses on either a fully insured or a self-funded basis. The anticipated effective date is January 1, 2023. Sealed RFPs, subject to the conditions contained herein, will be received by the City of Meriden Purchasing Department until 11:00 A.M. local , eastern standard time on August 18, 2022. Submissions, including

sealed fee proposals, shall be submitted in three (3) complete sets and one (1) flash drive, in the manner specified. Copies of the described RFP may be downloaded from the City of Meriden website (www.meridenct.gov). Additionally, copies of the RFP may also be downloaded from the State of Connecticut Department of Administrative Services website (https://portal.ct.gov/DAS/CTSource/BidBoard). Proposals will be accepted at the Purchasing Department, 142 East Main Street, Room 210, Meriden, Connecticut 06450 until 11:00 A.M. local, eastern standard time on August 18, 2022. The return envelope must be clearly marked with the Proposal Document RFP023-05 and addressed to the Meriden Purchasing Department, Room 210, and 142 East Main Street, Meriden, CT 06450. Any proposal received after the time and date specified shall not be considered. The successful firm shall have extensive, successful experience in providing such services The right is reserved to reject any or all proposals, in whole or in part, to award any item, group of items, or total proposal, and to waive informality or technical defects, if it is deemed to be in the best interest of the City of Meriden. No proposer may withdraw their submission within ninety (90) days of the date of the opening. The successful firm(s) shall ensure that any appropriate licenses or certifications required by the State of Connecticut are maintained for the duration of the project. The firm must meet all municipal, state and federal affirmative action and equal employment opportunity practices The City of Meriden is an Affirmative Action/Equal Opportunity Employer. Disadvantaged, minority, small, and women business enterprises are encouraged to respond. Adam B. Tulin Purchasing Officer City of Meriden, CT 06450-8022 Dated: July 26, 2022 http://www.meridenct.gov/ https://portal.ct.gov/DAS/CTSource/BidBoard INSTRUCTIONS TO PROPOSERS RFP023-05 Carrier/TPA for Medicare Supplement Plan or Medicare Advantage Plan 1. Receipt and Opening of Proposals: All Proposals shall be submitted in sealed opaque (non-see-through) envelopes clearly labeled with the Proposer’s name, address, and the name of the Project for which the proposal is submitted. The words “PROPOSAL DOCUMENT” must appear on the envelope and the time and the date the submittal is due. If mailed, the sealed envelope containing the proposal, marked as described above, shall be enclosed in another envelope properly addressed for mailing. No responsibility will be attached to any City Representative or employee for the premature opening of a proposal not properly addressed and identified. 2. Method of Proposal: Proposers shall be certified or licensed, if appropriate, by the State of Connecticut, or state of appropriate jurisdiction. The City may make such investigations as it deems necessary to determine the ability of the proposer to perform the service, and the proposer shall furnish to the city all such information and data for this purpose as the city may request. The City reserves the right to reject any proposal if the evidence submitted by, or investigation of such proposer fails to satisfy the city that such proposer is properly qualified to carry out the obligations of the contract and to complete the work contemplated therein. Conditional proposals will not be accepted. 3. Addenda and Interpretations: No interpretation of the meaning of the Request for Proposal will be made to any proposer orally. Every request for such interpretation should be in writing, e-mailed to meridenpurchasing@meridenct.gov and to be given consideration must be received at least seven (7) days prior to the date fixed for the opening of proposals. Any and all such interpretations and any supplementary instructions will be in the form of written addenda to the specifications which, if issued, will be posted on the City Website (www.meridenct.gov) not later than three (3) days prior to the date fixed for the opening of proposals unless it is to extend the proposal due date. Failure of any proposer to receive any such addenda or interpretation shall not relieve any proposer from any obligations under his bid as submitted. Proposers are prohibited from contacting any other City employee, officer or official concerning this RFP. A proposer’s failure to comply with this requirement may result in disqualification. 4. Subcontractors: The proposer is specifically advised that any person, firm or other party to whom it is to award a subcontract under this contract must be acceptable to the City and that approval of the proposed subcontract award cannot be given by the City unless and until the successful proposer submits all information and evidence to the City regarding the proposed subcontractor requested by the City. Although the proposer is not required to attach such information and evidence to the proposal, the proposer is hereby advised of this requirement so the appropriate action can be taken to prevent subsequent delay in subcontract awards. 5. Method of Award – Qualified Proposer: (a) The City reserves the right to reject any or all proposals and may waive any informality. (b) In the event that there is a discrepancy between price written in words and in figures, the price written in words shall govern. (c) The City reserves the right to increase or decrease the scope of each item proposed upon at the same proposal price stated in the proposal form. (d) The City reserves the right to correct any award erroneously made as a result of a clerical error. 6. Corrections: Erasures or other changes in the proposal shall be explained or noted over the signature of the proposer. mailto:meridenpurchasing@meridenct.gov http://www.meridenct.gov/ 7. Obligation of Proposer: (a) At the time of the opening of proposals, each proposer will be presumed to have read and to be thoroughly familiar with the specifications and other documents (including all addendum or addenda). The failure or omission of any proposer to receive or examine any form, instrument or documents which has been sent to the address given by such proposer, or the failure of the proposers to familiarize themselves with the conditions relating to the specifications shall in no way relieve any proposer from any obligation in respect to the proposal. (b) The proposer is responsible for submitting a proposal that will conform to all existing Federal, State of Connecticut, and City of Meriden statutes, ordinances, and regulations. Attention is called specifically to the state requirement relative to licensing of corporations and registrations of partnerships and fictitious names. (c) Duration of Proposal: By submitting a proposal to this RFP, Proposer agrees to honor the terms of its proposal for not less than 90 days from deadline for submission. 8. Patents: The proposer shall hold and save the City and its officers, agents, servants, and employees harmless from liability of any nature or kind, including cost and expenses for, or on account of, any patented or unpatented invention, process, article, or appliance manufactured or used in the performance of the contract, including its use by the City, unless otherwise specifically stipulated in the proposal documents. 9. Payments: a) The City will make such payments to the proposer not less than 30 days following the approval of an invoice submitted for service provided. b) Cash discounts offered must be for at least a period of 30 days to be considered in the awarding of contracts and discount periods shall be from the date of service, otherwise proposals should be net. c) The City of Meriden is exempt from the payment of the excise taxes imposed by the Federal Government, and the Sales and Use tax of the State of Connecticut, under State Statute 12-412, such taxes should not be included in the proposal price. 10. Contract: A contract will not be awarded to any corporation, firm, or individual who is in arrears to the City by debt or contract, or who is in default as security or otherwise by any obligation to the City. The City of Meriden reserves the right to reject any and all proposals or quotations, to waive any discrepancies in the proposals, quotations, or specifications, when deemed to be in the best interest of the City and also to purchase any part, all, or none of the service(s) specified. 11. Non-Collusive Proposal Statement: All proposers shall be required to provide a signed non-collusive statement with all the public proposals as follows: a) The proposal has been arrived at by the proposer independently and has been submitted without collusion with, and without any agreement, understanding. or planned common course of action with, any other vendor of materials, supplies, equipment or services described in the Legal Notice for Proposals, designed to limit independent proposals or competition, and: b) The contents of the proposal have not been communicated by the proposer or their employees or agents to any person not an employee or agent of the proposer or its surety on any bond furnished with the proposal, and will not be communicated to any such person prior to the official opening of the proposal. 12. City of Meriden Code of Ethics: The City of Meriden Code of Ethics, sections 21-1 through 21-15 of the City Code, are incorporated herein by reference and the terms of the Code of Ethics shall constitute a part of any contract or agreement entered into by the City as a result of this proposal as if those terms were set forth in such contract or agreement. Proposers are specifically advised that the Code of Ethics prohibits public officers or employees, their immediate families and business with which they are associated from participating in any transaction which is incompatible with the proper discharge of official duties or responsibilities. Proposers are also advised that the Code of Ethics contain provisions with respect to paid contractors and former employees and officials. PROPOSERS SHOULD NOTE THAT CONTRACTS, AGREEMENTS AND PROPOSALS ENTERED INTO OR AWARDED IN VIOLATION OF THE CODE OF ETHICS ARE VOIDABLE BY RESOLUTION OF THE CITY COUNCIL OF THE CITY OF MERIDEN. Copies of the Code of Ethics may be obtained from the office of the City Clerk. 13. Assignment of Contract: No contract may be assigned without the consent of the Purchasing Officer or his designee. 14. Insurance: The Proposer shall provide and maintain a Certificate of Insurance indicating proof of Professional Liability (and/or Errors and Omissions Coverage), Loss of Valuable Papers and other required insurance as noted below, and is hereby made a part of this Agreement. All insurance coverage shall be provided by the Proposer at no additional expense to the City. The scope and limits of insurance coverage specified are the minimum requirements and shall in no way limit or exclude the City from additional limits and coverage provided under the Proposer’s policies. The Proposer shall be responsible for maintaining the stated insurance coverage in force for the life of the contract with insurance carriers licensed and authorized to underwrite such insurance in the State of Connecticut. The type and limits of insurance coverage shall not be less than the type and limits designated herein, and the Proposer agrees that the coverage or the acceptance by the City of Certificates of Insurance indicating the type and limits of insurance shall in no way limit the liability of the Proposer to any such type and limits of insurance coverage. The insurance coverage hereinafter afforded by the Proposer shall be primary insurance, except when stated to apply in excess or contingent upon the absence of other insurance. The amount and type of insurance shall not be reduced by the existence of other insurance held by the City. The Proposer shall not commence work under the terms of this contract until he has obtained the liability insurance coverage required by this article and has filed Certificates of Insurance on same with the City, and the City has approved the Certificates of Insurance and the represented coverage. Each Certificate of Insurance shall include the following minimum pertinent information: * Name of Insurance Carrier writing policy * Name of Insured * Address of Named Insured * Description of coverage (Workers’ Compensation certificates should evidence the state(s) of operation including Connecticut) * Policy Periods (effective and expiration dates) * Limits of Liability * Brief description of operations performed and the property covered * Name and address of certificate holder * Authorized agents name and address * Date and signature of the issuing agent (original only) * All General Liability additional names insured endorsements * All General Liability cross liability endorsements * 30-day written notice provision * A deletion of any disclaimer wording relative to providing the holder with notice of cancellation - example: “endeavor to” provide notice or wording to the effect the Carrier will not be responsible should notice not be furnished. Each insurance policy (with the exception of Workers’ Compensation and Professional Liability) shall contain an endorsement including the City of Meriden as an Additional Insured, evidence of a Cross Liability endorsement so that each Insured’s interests are considered and treated separately in the case of claims between the insured, and an endorsement providing a 30-day Advance Notification to the City in the event of any material change, modification, cancellation, or non-renewal of insurance coverage. During the course of execution of the work, whenever there is a lapse in the insurance requirements as stated herein, through cancellation, expiration, failure to renew or any other cause, the City shall order the cessation of all proposer activities until such time as the insurance requirements are complied with. 15. Freedom of Information Act. All information submitted in a proposal or in response to a request for additional information is subject to disclosure under the Connecticut Freedom of Information. Proposers are encouraged not to include in their proposals any information which is proprietary, a trade secret or otherwise confidential. All materials associated with this procurement process are subject to the terms of state laws defining freedom of information and privacy, and all rules, regulations and interpretations resulting from those laws. 16. Proposer’s Costs in responding to this RFP: The City shall not be liable for any costs the Proposer incurs in preparation and submission of its proposal, in participating in the selection process or in anticipation of an award of contract. 17. Proposals become the property of the City: Any information or materials submitted as a response to this RFP shall become the property of the City of Meriden and will not be returned. 18. Conformance to RFP Specifications: In order to assure that all proposals are evaluated on a uniform basis, Proposers must conform to the RFP specifications as described in the Scope of Services. If a Proposer’s proposal does not so conform, the proposal must clearly indicate where differences exist. Proposer’s response is presumed to conform in every respect to the Scope of Service described herein except where Proposer has expressly set forth deviations from these specifications. As the RFP and the accepted proposal are automatically part of the contract between the Plan Sponsor and the Proposer such presumption will be contractually binding on the Proposer. CITY OF MERIDEN, CONNECTICUT RFP023-05 Carrier/TPA for Medicare Supplement Plan or Medicare Advantage Plan NON-COLLUSIVE PROPOSAL STATEMENT/AFFIDAVIT The undersigned proposer, having been duly sworn, does hereby depose and says: 1. The proposal has been arrived at by the proposer independently and has been submitted without collusion and without any agreement, understanding, or planned common course of action with any other vendor of materials, supplies, equipment, or services described in the Request for Qualifications/Proposal. 2. The contents of the proposal has not been communicated by the proposer or its employees or agents to any person not an employee or agent of the proposer or its surety on any bond furnished with the proposal, and will not be communicated to any such person prior to the official opening of the proposal. 3. The undersigned proposer is duly authorized to bind the business entity identified below. The undersigned proposer further certifies, under oath, that this statement is executed for the purposes of inducing the City of Meriden to consider the proposal and make an award in accordance therewith. ____________________________________ Signature of Proposer ____________________________________ Print Legal Name of Proposer ____________________________________ Relationship to Business Entity Below ______________________________________________________________________________ Business Entity Name, Address, Telephone Number, and Email Address STATE OF CONNECTICUT ) ) ss: COUNTY OF ) Duly sworn and subscribed to before me this __ day of _______, 2022. __________________________________ Notary Public My Commission Expires: Commissioner of the Superior Court STATEMENT OF PROPOSER'S QUALIFICATIONS This Statement of Proposer's Qualifications is to be submitted by the proposer at the time of the proposal. All questions must be answered and the data given must be clear and comprehensive. The proposer may submit any additional information he/she desires. It is understood that when the City has executed an Agreement, to which these General Conditions are a part, it is in part done upon the reliance of the answers provided herein by the proposer or the agent of the proposer. 1. Firm Name: _____________________________________________________________________________ 2. Permanent main office address: ______________________________________________________________ 3. Type of ownership: Minority Owned _____________ Yes ___________ No 4. Year Established? : _______________________________________________________________________ 5. If a corporation, where incorporated: __________________________________________________________ 6. How many years have you been engaged in business under your present firm name? ____________________ 7. Former firm name? :_______________________________________________________________________ 8. Personnel: Total________________________ Is any principal of your firm an employee or public official of the City of Meriden, or an immediate family member of an employee or public official of the City of Meriden? (Definition of immediate family includes: an individual’s spouse, fiancé or fiancée; the parent, brother or sister of such individual or spouse; and the child of such individual or the spouse of such child.) ______________ yes ________________ no 9. Have you ever failed to complete any contract awarded to you? If so, where and why? _____________________________________________________________________________________ _____________________________________________________________________________________ 10. List similar work performed within the past Five (5) Years, Including the Name and Address of each Contact Person and Telephone Number; and approximate cost of each project: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 11. The undersigned hereby authorizes and requests any person, firm or corporation to furnish any information requested by the City of Meriden, in verification of the recitals comprising this Statement of Proposer's Qualifications. Dated at _______________________ this ______________ day of _______________________, 2022 Name of Proposer: _____________________________________________ By: _________________________ Title: _________________________ PLEASE SUBMIT THIS FORM WITH PROPOSAL RFP023-05 City of Meriden, CT Carrier/TPA for Medicare Supplement Plan or Medicare Advantage Plan I. PURPOSE, GENERAL INFORMATION, BACKGROUND A. Purpose: The City of Meriden and Meriden Public Schools (hereinafter collectively referred to as the “City”) are seeking proposals from qualified insurance carriers or third-party administrators paying claims (hereinafter referred to as the “Proposer”) to administer its group Medicare Supplemental program for its Medicare-eligible retired employees and their eligible spouses or surviving spouses on either a fully insured or a self-funded basis. The anticipated effective date is January 1, 2023. B. Background 1. Since August 1, 2011, the City has provided a fully insured Medicare Supplement Plan through Cigna. There are currently 517 retirees and spouses on the plan. 2. Member contributions to the Plan are based on collective bargaining and in most cases, the City pays 100% for the retiree but the spouse pays 100% if participating in the plan. However, there are retirees under Police, Fire and Management that receive a 100% City paid benefit for themselves and their spouse at age 65. 3. The City currently has one plan in place and the plan pays secondary to Medicare. The current plan is equivalent to a Plan D (a federally standardized Medicare Supplement plan). The City is seeking proposals for both Medicare Supplement plans and Medicare Advantage plans, however, only one plan will be chosen to accommodate this entire post 65 retiree group. For additional information on this subject, refer to Section II (F) under Scope of Services. 4. For budgeting, billing, administrative and reporting purposes, the City retirees are divided into two distinct groups – City and Board of Education. 5. Beacon Retiree Benefits Group LLC, a duly licensed broker doing business in the State of Connecticut, provides enrollment, eligibility, member communications, claim resolution, call center functions and plan consulting to the City. Beacon is deemed the Agent-of-Record and the City’s Medicare Retiree Benefit Plans Administrator. It is the City’s intention that commissions or fees for Beacon’s services will be paid by the Proposer. C. General Information 1. Form of Agreement: The parties will use a contract created by the selected Proposer with mutually agreed upon modifications. Upon the acceptance of a proposal, the City will endeavor to negotiate a mutually satisfactory contract with the successful Proposer. In the event the successful Proposer fails, neglects or refuses to reach agreement with the City on contract language within thirty (30) days after the selection procedure has been approved by the Purchasing Department, the City may, at its option, terminate and cancel its action in awarding said contract, the City’s offer of a contract shall be withdrawn and the contract shall become null and void and of no effect, and the City may consider other proposals or solicit new proposals. 2. Who Can Respond: Proposals will only be accepted from Proposers licensed to sell, administer and adjudicate claims for self-funded and/or fully insured Group Medicare Supplement Plans and/or Group Medicare Advantage Plans for employers domiciled in the State of Connecticut with a retiree population residing in all fifty (50) states and U.S. territories. The City has an agreement with an Agent-of-Record to perform certain services relative to this contract. Intermediaries other than the Proposer as defined herein will not be compensated by the City for their services. 3. No Contact between Proposer and City or Beacon Retiree Benefits Group. Once this RFP is published, no Proposer may communicate with either the City or Beacon Retiree Benefits Group, on any substantive matter covered by this RFP, except through the Q and A process described in this document. Should administrative or logistical issues arise, the Proposer may contact the Purchasing Department at meridenpurchasing@meridenct.gov for guidance. Any unauthorized contact may be grounds for immediate rejection of a Proposer’s qualification and other remedies. II. SCOPE OF SERVICES. A. Term of contract: The term of this contract will commence on January 1, 2023 (Effective Date) and will end on December 31, 2023. The City shall have the option of three (3) one- year contract renewals. 120 days prior to expiration, the Healthcare provider should send the City a proposal for the upcoming year. Multi-year agreements are welcome and will be considered. B. Group Plan: This Plan will be a group Medicare supplement plan (retiree medical plan) and/or a group Medicare Advantage plan. Proposers able to provide responses for one or both should do so. The City is seeking both fully insured and self-funded proposals. Individual products will not be considered. The City will choose one option for the Medicare retiree population. mailto:purchasing@meridenct.gov mailto:purchasing@meridenct.gov mailto:purchasing@meridenct.gov C. Who the Plan Will Cover: Retired employees of the City and their spouses or surviving spouses who, at the sole discretion of the City, are deemed eligible to participate in the Plan and who are eligible for Medicare A and B by virtue of age or disability. D. Geographic range of coverage: United States and all U.S. territories E. Provisions pertaining to pre-existing conditions or waiting periods: There will be no exclusions, restrictions or benefit limitations for pre-existing conditions, nor will there be any waiting periods for coverage. F. Plan Designs: Current plan is equivalent to a Plan D. A Plan D, a federally standardized Medicare Supplement plan, picks up all deductibles and coinsurance charges for all Medicare covered services, secondary to Medicare, with the exception of the Part B deductible and any excess charge (charges above what Medicare allows). Proposer will provide proposals for a fully insured and self-funded alternative to the current Plan D with Cigna. Proposer will provide proposals for a Medicare Advantage plan option equivalent to the current Cigna Plan D. Medicare Advantage plan proposals should include PPO plans that allow members of the plan to access non-participating providers. Proposers unable to propose any of these options should specify so in their response. Enrollment and Billing: 1. Enrollment (initial eligibility, additions, terminations, changes) will be conducted through transmission of electronic eligibility files (in Excel) or via on-line capabilities. Proposer must have secure and HIPAA compliant data transmission capability. Proposer should specify capabilities relative to this benefit administration. 2. Proposer will provide initial eligibility file with member policy numbers or unique IDs to allow for electronic reconciliations. 3. Proposer will issue monthly electronic invoices (in Excel) for reconciliation purposes to both: a. City of Meriden b. Meriden Board of Education G. Claim Reporting Requirements: 1. For fully insured plans, carrier will provide claim data illustrating incurred and paid claims on a monthly basis and provided to the City on a quarterly basis and upon renewal. Reports will be provided in excel. 2. For self-funded plans, Proposer will provide claim data illustrating incurred and paid claims on the same schedule with claims invoices. Reports will be provided in excel. H. Claims Adjudication: Proposer will process claims with the speed and accuracy that is consistent with industry standards. I. Customer Service 1. Proposer will prepare and issue member ID cards, certificate booklets and summary of benefits to each member upon enrollment into the plan. 2. Proposer will work with and communicate directly with Beacon Retiree Benefits Group, the City’s Medicare Retiree Benefit Plans Administrator. A designated account representative will be assigned to the City’s groups to assist Beacon in the administration and servicing of the plan(s). J. Financials 1. For fully insured proposals, Proposer will provide a per-member-per-month premium quote for a period of not less than 12 months; for self-insured proposals, per-member- per-month administrative fee. Premiums or fees should be proposed net of commissions. 2. Proposer will specify desired funding process relative to the flow of funds for self- insured claims administration in self-funded proposals. 3. Premium rate or administrative fee increases may only take place at Contract renewal. 4. Proposer’s response includes all printing and postage costs for ID cards, booklets, certificates, SPDs and any other communications required by law. Proposer will illustrate online services available for members of their plan. III. MANDATORY SUBMISSION REQUIREMENTS: Each Proposer must submit its proposal addressing the items requested below. Requested information omitted by the Proposer is done at the Proposer’s peril. The City reserves the right to investigate all statements made by Proposer as to its qualifications and to request additional information it deems necessary. A. Provide a cover letter including the following items 1. Provide a statement of interest in providing this service. 2. Proposer’s name, address and contact information (telephone, fax, email and street address) for the representative for this proposal and the signature of the officer authorized to contract with the City for services proposed herein. 3. Company History and Capabilities: a. Provide an overview of the general nature of Proposer’s business, services rendered and clients served. b. Provide information relating to Proposer’s business structure and parent ownership, if applicable. c. Specify location of offices that will service this account. d. Describe business history including relevant experience in providing the services described in Section II, Scope of Services. e. Provide professional resumes for the staff who will service this contract. 4. License to Provide Insurance: Provide a statement that Proposer is licensed to sell and administer group Medicare Supplement Insurance plans and/or Medicare Advantage plans in all fifty (50) states and U.S. territories. 5. Financial Strength: Provide documentation from three recognized national rating agencies attesting to Proposer’s financial strength (if applicable to your organization). 6. Client References: Provide names, contact information, and dates of engagement for three organizations of comparable size and complexity to the City for which Proposer has performed services comparable to that described in the Scope of Services. In addition, list account(s), if any, that Proposer has lost in the past three years. If none, state, “None.” 7. Audited Financial Statement: Submit in a separate envelope or under separate cover. B. Scope of Services: Present proposal citing all items from the Scope of Services including 1. Term of Contract proposed 2. Plan design(s) 3. Enrollment, billing and payment procedures 4. Implementation: Specify steps and time periods required for a trouble-free implementation on the Effective Date. 5. Customer service commitments 6. Cost proposal a. For self-insured proposal state the administrative fee Proposer will charge on a per Member per month basis. b. For a fully insured plan proposal, state the premium Proposer proposes to charge on a per Member per month basis, exclusive of brokers’ commissions for each plan proposed. c. List and explain any other expenses Proposer plans to charge for its proposal. (i) Any charges not stated herein, may not be submitted at a later date. (ii) Quotations must be exclusive of taxes for which the City is not liable. Tax exemption certificates will be furnished upon request. C. Sample Contract: Provide a sample contract Proposer proposes to use for this service. D. Describe Value-added services and/or innovative programs not addressed elsewhere. IV. SUBMISSION OF PROPOSALS. A. Copies required, address and deadline for submission: Proposer will submit three (3) complete sets containing the items listed in Section III, Mandatory Submission Requirements, to the Purchasing Department, 142 East Main Street, Room 210, Meriden, CT 06450 by 11:00 AM on August 18, 2022. Respondents should also include one Flash Drive containing a PDF of the complete proposal. Note to Proposers: time is of the essence: late submissions, regardless of the reason, will not be accepted. B. Please mark your envelope: RFP for Carrier/TPA for Medicare Supplement Plan or Medicare Advantage Plan – RFP023-05. If your envelope is not marked accordingly, the City will not assume responsibility if your package is misdirected or its delivery delayed. V. AWARD CRITERIA & SELECTION The City reserves the right to correct, after proposer verification, any mistake in a proposal that is a clerical error, such as a price extension, decimal point error, etc. If any error exists in an extension of prices, the unit price shall prevail. The City reserves the right to accept all or any part of a proposal, reject all proposals, and waive any informalities or non-material deficiencies in a proposal. The City also reserves the right, if applicable, to award the purchase of individual items under this RFP to any combination of separate proposals or proposers. The City will accept the proposal that, all things considered, the City determines is in the best interests. Although price will be an important factor, it will not be the only basis for award. Due consideration may also be given to a proposer’s experience, references, service, ability to respond promptly to requests, past performance, and other criteria relevant to the City’s interests, including compliance with the procedural requirements stated in this RFP. Evaluation Criteria: The following specific criteria are expected to be among those utilized in the selection process. They are presented as a guide for the proposer in understanding the City’s requirements and expectation for this project and are not necessarily all inclusive or presented in order of importance. 1. The background experience, and strength of the Proposer in providing similar services elsewhere, including the level of experience in working with other Connecticut municipalities of similar size, and the quality of services performed, for other municipalities. 2. The Proposer’s responsiveness and compliance with the RFP requirements and conditions to provide the services requested. 3. A review of references provided with the Proposal, and administration of prior contracts. 4. Competitiveness of proposed fee. The City reserves the right to negotiate fees with the selected Proposer. The City will not award the proposal to any business that or person who is in arrears or in default to the City with regard to any tax, debt, contract, security or any other obligation. VI. QUESTIONS In order for Proposer’s proposal to be considered and accepted, Proposer must provide answers to the questions presented in this section. When answering the questions, please repeat the questions and provide answers numbered to correspond to the question as indicated in the RFP. All questions must be answered. Reference should not be made to a prior response, or to Proposer’s contract, unless the question involved specifically provides such an option. Refer to earlier sections of this RFP before responding to any of the questions in order to have a complete understanding of City’s requirements with respect to the bid. Please respond to all questions that relate to Proposer’s proposal. Questions that do not apply to Proposer’s proposal should be so noted. 1. Has your organization experienced a security breach whereby member PHI has been compromised at any point during the last ten years? If so, please describe what actions were taken as a result of that breach, how quickly the breach was identified, how many records were involved and what steps have been taken to avoid such breaches in the future. 2. Describe the rating methodology used to develop the proposed and future rates and fees (assumed claims, trend and target loss ratio). 3. If providing a fully insured premium proposal, will the City be pooled with other employers or rated on its own merit? 4. Please indicate if the risk is held entirely by Proposer’s organization or shared with a reinsurer or other risk bearing entities. 5. Please provide actual renewal percentage increases for comparable groups over the last 5 years and any other information that may provide a historical benchmark. 6. In the case of a proposed self-funded arrangement, please describe the Proposer’s typical process and timeline relative to the funding of claims. Describe the process in which the Proposer is reimbursed for claim dollars paid out on the City’s behalf. 7. In the case of a fully insured arrangement, please describe the Proposer’s typical billing process, when invoices are distributed, when premium payments are due and what grace periods apply. 8. Please provide the total number of existing enrolled members in Proposer’s Medicare Supplement plans and breakdown that membership between individual enrollees vs. group members. Please provide the same data pertaining to Proposer’s Medicare Advantage plans as well, if applicable. 9. Please provide the total number of employer groups or unions with 400 or more retirees enrolled in group plans with Proposer’s organization. Please indicate whether these employer groups are enrolled in self-funded programs or fully insured arrangements and in Medicare Supplement and/or Medicare Advantage plans. 10. Please provide a sample of Proposer’s master employer group application and any certificate, policy or schedule of benefits that would apply to the City under these proposed plans. 11. Please provide Proposer’s standard reporting templates or sample claim reports. 12. For retirees who enroll after the original effective date of the plan, approximately how long does it take from the date Proposer is notified to add them to the plan until their ID card and documents are mailed? 13. Does Proposer provide any on-line enrollment capabilities or offer any on-line administration? 14. City retirees and spouses are all enrolled as single participants. Please confirm that this is acceptable to Proposer’s organization. 15. Please describe your policy regarding retroactive enrollments and cancellations. 16. How do eligibility, member services and claims administration interface? 17. Will there be a dedicated service team for City retirees? 18. Where will the customer service representatives for City retirees be located? 19. What is Proposer’s current customer service staffing level per member? 20. Do customer service representatives have access to claims and eligibility? 21. What are the hours of operation for Proposer’s customer service unit? 22. Do members reach an automated system during the hours of operation? After hours? 23. If a retiree leaves a voicemail, how long before a call is returned? 24. Are calls recorded and tracked electronically? 25. Can retirees contact Proposer’s customer service team via email? 26. What is Proposer’s telephone call response times, average speed of answer and average hold time? 27. Please confirm Proposer is set up to receive electronic and automatic crossover of claims and eligibility from the Medicare intermediary or Medicare carrier. 28. Please provide current performance goals and actual results for: a. Claims processing turnaround time b. Payment accuracy c. Financial accuracy 29. Please provide the turnaround time distribution shown below using results from 2021 and 2022 YTD: a. Percentage of claims processed and paid within 5 working days b. Percentage of claims processed and paid within 10 working days c. Percentage of claims processed and paid within 20 working days d. Percentage of claims processed and paid within 20+ days 30. Describe fraud and abuse detection and prevention practices which will pertain to this contract, including practices to detect and avoid duplicate billing and payments? 31. What percentage of Proposer’s Medicare claims are processed manually? 32. Please provide a sample of Proposer’s standard Explanation of Benefits (EOB). 33. Does Proposer have the ability to customize EOBs or Certificates of Coverage? 34. Is Proposer able to provide retirees on-line access to their claims information? 35. What is the proposed staffing for this account, including brief biographies of key Personnel? 36. Please share any high-level performance guarantees Proposer will consider for implementation, member services, claims administration and eligibility processing. 37. If Proposer has TPA partner(s) that will be involved in providing services in the administration of the City’s plans, please provide the name(s) of those partners and services rendered. 38. Please provide an implementation schedule based on the proposed effective date. This should include details of specific activities, target dates, data requirements and responsibilities for completion. 39. What information does Proposer require from Beacon Retiree Benefits Group for implementation of its services? What data format is required? 40. Does Proposer use a third party to produce and distribute ID cards? If so, where are they located? 41. Please confirm that Proposer will assign a unique ID number for each member and that confirm what member identification number will appear on the ID card. 42. Please provide a sample ID card. VII. ATTACHMENTS Attachment A: Cigna Medicare Surround Plan D Attachment B: Census and Claims data Meriden City and Board of Education GROUP RETIREE MEDICAL BENEFITS EFFECTIVE DATE: January 1, 2022 CN005 3333413 This document printed in February, 2022 takes the place of any documents previously issued to you which described your benefits. Printed in U.S.A. THIS IS NOT A STANDARDIZED MEDICARE SUPPLEMENT PLAN HC-IMP75 10-10 V1 Table of Contents Certification ....................................................................................................................................5 Important Notices ..........................................................................................................................7 How to File Your Claim ......................................................................................................................................... 8 Eligibility - Effective Date .............................................................................................................8 Insurance for Eligible Persons ................................................................................................................................ 8 Insurance for Dependents ....................................................................................................................................... 9 Group Retiree Medical Benefits .................................................................................................10 The Schedule ........................................................................................................................................................ 10 Covered Expenses ................................................................................................................................................ 20 Exclusions .....................................................................................................................................21 Payment of Benefits .....................................................................................................................22 Termination of Insurance............................................................................................................22 Eligible Persons .................................................................................................................................................... 22 Dependents ........................................................................................................................................................... 22 Federal Requirements .................................................................................................................23 Qualified Medical Child Support Order (QMCSO) ............................................................................................. 23 Special Enrollment Rights Under the Health Insurance Portability & Accountability Act (HIPAA) .................. 23 Coverage for Maternity Hospital Stay .................................................................................................................. 24 Women’s Health and Cancer Rights Act (WHCRA) ........................................................................................... 25 Coordination with Medicare ................................................................................................................................. 25 Claim Determination Procedures .......................................................................................................................... 25 COBRA Continuation Rights Under Federal Law ............................................................................................... 26 Clinical Trials ....................................................................................................................................................... 29 Definitions .....................................................................................................................................30 Certificate Rider...........................................................................................................................33 Home Office: Bloomfield, Connecticut Mailing Address: Hartford, Connecticut 06152 CIGNA HEALTH AND LIFE INSURANCE COMPANY a Cigna company (hereinafter called Cigna) certifies that it insures certain Employees for the benefits provided by the following policy(s): POLICYHOLDER: Meriden City and Board of Education GROUP POLICY(S) — COVERAGE 3333413 - RBP GROUP RETIREE MEDICAL BENEFITS EFFECTIVE DATE: January 1, 2022 This certificate describes the main features of the insurance. It does not waive or alter any of the terms of the policy(s). If questions arise, the policy(s) will govern. This certificate takes the place of any other issued to you on a prior date which described the insu rance. HC-CER1 04-10 V1 Explanation of Terms You will find terms starting with capital letters throughout your certificate. To help you understand your benefits, most of these terms are defined in the Definitions section of your certificate. The Schedule The Schedule is a brief outline of your maximum benefits which may be payable under your insurance. For a full description of each benefit, refer to the appropriate section listed in the Table of Contents. myCigna.com 7 Important Notices Discrimination is Against the Law Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Cigna:  Provides free aids and services to people with disabilities to communicate effectively with us, such as:  Qualified sign language interpreters  Written information in other formats (large print, audio, accessible electronic formats, other formats)  Provides free language services to people whose primary language is not English, such as  Qualified interpreters  Information written in other languages If you need these services, contact customer service at the toll- free phone number shown on your ID card, and ask a Customer Service Associate for assistance. If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance by sending an email to ACAGrievance@cigna.com or by writing to the following address: Cigna Nondiscrimination Complaint Coordinator P.O. Box 188016 Chattanooga, TN 37422 If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to ACAGrievance@cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. HC-NOT96 07-17 Proficiency of Language Assistance Services English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711). Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711). Chinese – 注意:我們可為您免費提供語言協助服務。 對於 Cigna 的現有客戶,請致電您的 ID 卡背面的號碼。 其他客戶請致電 1.800.244.6224 (聽障專線:請撥 711)。 Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Dành cho khách hàng hiện tại của Cigna, vui lòng gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số 1.800.244.6224 (TTY: Quay số 711). Korean – 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 현재 Cigna 가입자님들께서는 ID 카드 뒷면에 있는 전화번호로 연락해주십시오. 기타 다른 경우에는 1.800.244.6224 (TTY: 다이얼 711)번으로 전화해주십시오. Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711). Russian – ВНИМАНИЕ: вам могут предоставить бесплатные услуги перевода. Если вы уже участвуете в плане Cigna, позвоните по номеру, указанному на обратной стороне вашей идентификационной карточки участника плана. Если вы не являетесь участником одного из наших планов, позвоните по номеру 1.800.244.6224 (TTY: 711). French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele nimewo ki myCigna.com 8 dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711). French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre carte d’identité. Sinon, veuillez appeler le numéro 1.800.244.6224 (ATS : composez le numéro 711). Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso contrário, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711). Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711). Japanese – 注意事項:日本語を話される場合、無料の言語支援サー ビスをご利用いただけます。現在のCignaの お客様は、IDカード裏面の電話番号まで、お電話にてご 連絡ください。その他の方は、1.800.244.6224(TTY: 711)まで、お電話にてご連絡ください。 Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali, chiamare il numero sul retro della tessera di identificazione. In caso contrario, chiamare il numero 1.800.244.6224 (utenti TTY: chiamare il numero 711). German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung. Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711). HC-NOT97 07-17 How to File Your Claim Upon enrollment, for smoother claim payment, you should provide Cigna with your Medicare Claim Number as it appears on your Medicare I.D. card. You can:  Enter it at myCigna.com or  Call Cigna Customer Service at the number on the back of your Cigna I.D. card. You must submit expenses covered by this plan to Medicare before they can be considered for payment under this plan. Hospitals, Skilled Nursing Facilities, home health agencies, and Physicians are required by law to file Medicare claims for covered services and supplies that you receive. If you visit your doctor or hospital, your doctor or hospital will send a claim directly to Medicare. Medicare will pay their part and will send the claim to Cigna. You will receive a Medicare Summary Notice (MSN) from Medicare. The Summary Notice will list your Medicare claims information including a note if the information was sent to your private insurer (Cigna) for additional benefits. For services not covered by Medicare but covered by this plan, you will need to send a claim form to Cigna. You may get the required claim forms from your Benefit Plan Administrator, by calling customer service or from our website at www.Cigna.com. All fully completed claim forms and bills should be mailed directly to the claim address that appears on the back of your Cigna ID card. CLAIM REMINDERS  BE SURE TO USE YOUR MEMBER ID AND ACCOUNT/GROUP NUMBER WHEN YOU FILE CIGNA’S CLAIM FORMS, OR WHEN YOU CALL CIGNA CUSTOMER SERVICE. YOUR MEMBER ID IS THE ID SHOWN ON YOUR CIGNA IDENTIFICATION CARD. YOUR CIGNA ACCOUNT/GROUP NUMBER IS THE 7- DIGIT POLICY NUMBER SHOWN ON YOUR CIGNA IDENTIFICATION CARD. PROVIDE YOUR MEDICARE CLAIM IDENTIFICATION NUMBER AS IT APPEARS ON YOUR MEDICARE ID CARD.  PROMPT FILING OF ANY REQUIRED CLAIM FORMS RESULTS IN FASTER PAYMENT OF YOUR CLAIMS. WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit is guilty of a crime and may be subject to fines and confinement in prison. HC-CLM33 10-10 V1 Eligibility - Effective Date Insurance for Eligible Persons This plan is offered to you as an Eligible Person. To be insured, you may have to pay part of the cost. myCigna.com 9 You will become eligible for insurance on the day you are in a Class of Eligible Persons. Classes of Eligible Persons Each Eligible Person as reported to the insurance company by your Employer. Effective Date of Your Insurance You will become insured on the date you elect the insurance by completing the application process, but no earlier than the date you become eligible. You will become insured on your first day of eligibility, following your election. Insurance for Dependents For your Dependents to be insured, you may have to pay part of the cost of Dependent Insurance. You will become eligible for Dependent insurance on the later of:  the day you become eligible for yourself; or  the day you acquire your first Dependent. Effective Date of Dependent Insurance Insurance for your Dependents will become effective on the date you elect it by completing the application process, but no earlier than the day you become eligible for Dependent Insurance. All of your Dependents as defined will be included. Eligibility Restrictions The Eligible Person must enroll for coverage under either this plan or a Related Plan in order to enroll for Dependent Insurance. HC-ELG38 10-10 V1 myCigna.com 10 Group Retiree Medical Benefits (Part A and Part B) The Schedule For You and Your Dependents Part A benefits cover the same benefits covered under Medicare Part A. Part B benefits cover the same benefits covered under Medicare Part B. Unless otherwise noted, the benefits covered under this plan are limited to expenses approved by Medicare but not paid by Medicare. To receive benefits, you and your Dependents must pay a portion of the Covered Expenses. That portion is the Deductible and Coinsurance. Coinsurance The term Coinsurance means the percentage of charges for Covered Expenses that an insured person is required to pay under the plan. Deductibles Deductibles are expenses to be paid by you or your Dependent. Deductible amounts are separate from and are in addition to any Coinsurance. Once the Deductible maximum in The Schedule has been reached, you and your family need not satisfy any further medical deductible for the rest of that year. Out-of-Pocket Expenses Out-of-Pocket Expenses are Covered Expenses incurred for charges that are not paid by the benefit plan because of any Part A or Part B expenses for:  Coinsurance  Deductible When the Out-of-Pocket Maximum shown in The Schedule is reached, Injury and Sickness benefits are payable at 100%. BENEFIT HIGHLIGHTS PART A EXPENSES PLAN PAYS PART B EXPENSES PLAN PAYS Lifetime Maximum Applies to Part A and B expenses Unlimited Coinsurance Levels Part A Coinsurance as shown below of the amount approved by Medicare but not paid by Medicare Not Applicable Part B Deductible Not Applicable Not Covered Remainder of expenses after the Part B Deductible Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Calendar Year Deductible (Applies to Part B expenses) Individual $233 per person . myCigna.com 11 BENEFIT HIGHLIGHTS PART A EXPENSES PLAN PAYS PART B EXPENSES PLAN PAYS Out-of-Pocket Maximum (Applies to Part A and Part B expenses) Individual Unlimited per person Family Maximum Unlimited per family . Family Maximum Calculation Individual Calculation: Family members meet only their individual Out-of-Pocket and then their claims will be covered at 100%; if the family Out-of-Pocket has been met prior to their individual Out-of- Pocket being met, their claims will be paid at 100%. Inpatient Hospital - Facility Services Semi-private room and board, general nursing and miscellaneous services and supplies. A new benefit period begins each time the member is out of the hospital more than 60 days Days 1 - 150 per benefit period (using 60 lifetime reserve days) 100% after plan deductible of the amount approved by Medicare but not paid by Medicare Not Applicable Once Lifetime Reserve days are used (or would have ended if used) additional 365 days of confinement per person per lifetime Days 1-365 100% after plan deductible of the amount approved by Medicare but not paid by Medicare Not Applicable Inpatient Services at Other Health Care Facilities Includes Skilled Nursing Facility, Rehabilitation Hospital and Sub- Acute Facilities First 20 days Medicare pays in full. Not Applicable 21st – 100th day 100% after plan deductible of the amount approved by Medicare but not paid by Medicare Not Applicable myCigna.com 12 BENEFIT HIGHLIGHTS PART A EXPENSES PLAN PAYS PART B EXPENSES PLAN PAYS Hospice/Inpatient Respite Care (includes Bereavement Counseling) 100% after plan deductible of the amount approved by Medicare but not paid by Medicare Not Applicable Physician’s Services Primary Care Physician’s Office Visit Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Specialty Care Physician’s Office Visit Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Surgery Performed In the Physician’s Office Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Second Opinion Consultations (provided on a voluntary basis) Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Allergy Treatment/Injections Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Preventive Care Routine Physical age 18 and over (including screenings and coverage for Preventive Breast Ultrasounds). Also covers one time per lifetime “Welcome to Medicare” exam. Not Applicable 100% of the amount approved by Medicare but not paid by Medicare Immunizations age 18 and over (includes flu shots, hepatitis B shots and Pneumococcal shots) Not Applicable 100% of the amount approved by Medicare but not paid by Medicare Early Cancer Detection Screenings Not Applicable 100% of the amount approved by Medicare but not paid by Medicare Outpatient Facility Services Operating Room, Recovery Room, Procedures Room and Treatment Room Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Inpatient Hospital Physician’s Visits/Consultations Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare myCigna.com 13 BENEFIT HIGHLIGHTS PART A EXPENSES PLAN PAYS PART B EXPENSES PLAN PAYS Inpatient Hospital Professional Services Surgeon/Assistant Surgeon Radiologist Pathologist Anesthesiologist Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Outpatient Professional Services Surgeon/Assistant Surgeon Radiologist Pathologist Anesthesiologist Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Emergency and Urgent Care Services Physician’s Office Visit Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Hospital Emergency Room Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Emergency Room Physician Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Urgent Care Facility or Outpatient Facility Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare X-ray and/or Lab performed at the Emergency Room/Urgent Care Facility (billed by the facility as part of the ER/UC visit) Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Independent x-ray and/or Lab Facility in conjunction with an ER visit Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Advanced Radiological Imaging (i.e. MRIs, MRAs, CAT Scans, PET Scans etc.) Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Ambulance Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare myCigna.com 14 BENEFIT HIGHLIGHTS PART A EXPENSES PLAN PAYS PART B EXPENSES PLAN PAYS Laboratory, Radiology Services and Advanced Radiological Imaging (includes diagnostic tests, pre- admission testing, MRIs, MRAs, CAT Scans and PET Scans) Physician’s Office Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Outpatient Hospital Facility Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Independent X-ray and/or Lab Facility Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Outpatient Short-Term Rehabilitative Therapy and Chiropractic Care Services Maximum: Unlimited up to Medicare limits Includes: Physical Therapy Speech Therapy Occupational Therapy Chiropractic Therapy (includes Chiropractors) Pulmonary Rehab Cognitive Therapy Cardiac Rehab Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Home Health Care Maximum: Unlimited Not covered by plan. Medicare pays in full. 80% after plan deductible of the amount approved by Medicare but not paid by Medicare myCigna.com 15 BENEFIT HIGHLIGHTS PART A EXPENSES PLAN PAYS PART B EXPENSES PLAN PAYS Maternity Care Services Initial Visit to Confirm Pregnancy Note: OB/GYNs are considered Specialists Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare All subsequent Prenatal Visits, Postnatal Visits and Physician’s Delivery Charges (i.e. global maternity fee) Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Office Visits in addition to the global maternity fee when performed by an OB/GYN or specialist Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Delivery - Facility (Inpatient Hospital) Same as plan’s Inpatient Hospital Facility benefit Not Applicable (Birthing Center) Not Applicable Same as plan’s Outpatient Surgical Facility benefit Abortion Includes non-elective procedures only Physician’s Office Visit Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Inpatient Facility Same as plan’s Inpatient Hospital Facility benefit Not Applicable Outpatient Facility Not Applicable Same as plan’s Outpatient Facility benefit Inpatient Physician’s Services Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Outpatient Physician’s Services Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare myCigna.com 16 BENEFIT HIGHLIGHTS PART A EXPENSES PLAN PAYS PART B EXPENSES PLAN PAYS Family Planning Services Surgical Sterilization Procedure for Vasectomy/Tubal Ligation Limited to Medicare covered services (excludes reversals) Physician’s Office Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Inpatient Facility Same as plan’s Inpatient Hospital Facility benefit Not Applicable Outpatient Facility Not Applicable Same as plan’s Outpatient Facility benefit Inpatient Physician’s Services Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Outpatient Physician’s Services Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Infertility Treatment Services Not Covered include:  Testing performed specifically to determine the cause of infertility.  Treatment and/or procedures performed specifically to restore fertility (e.g. procedures to correct an infertility condition).  Artificial means of becoming pregnant are (e.g. Artificial Insemination, In-vitro, GIFT, ZIFT, etc). Not Applicable Not Covered Note: Coverage will be provided for the treatment of an underlying medical condition up to the point an infertility condition is diagnosed. Services will be covered as any other illness. . myCigna.com 17 BENEFIT HIGHLIGHTS PART A EXPENSES PLAN PAYS PART B EXPENSES PLAN PAYS Organ Transplants Includes all medically appropriate, non-experimental transplants Inpatient Facility Same as plan’s Inpatient Hospital Facility benefit Not Applicable Inpatient Physician’s Services Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Outpatient Physician’s Services Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Travel Services Not Covered Not Covered Durable Medical Equipment Maximum: Unlimited Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare External Prosthetic Appliances Maximum: Unlimited Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Diabetic Supplies and Services Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Wigs Wigs prescribed for hair loss as a result of chemotherapy for cancer Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Clinical Trials Physician’s Office Visit Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Inpatient Facility Same as plan’s Inpatient Hospital Facility benefit Not Applicable Outpatient Facility Not Applicable Same as plan’s Outpatient Facility benefit Inpatient Physician’s Services Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Outpatient Physician’s Services Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare myCigna.com 18 BENEFIT HIGHLIGHTS PART A EXPENSES PLAN PAYS PART B EXPENSES PLAN PAYS Dental Care Limited to Medicare covered dental services Physician’s Office Visit Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Inpatient Facility Same as plan’s Inpatient Hospital Facility benefit Not Applicable Outpatient Surgical Facility Not Applicable Same as plan’s Outpatient Surgical Facility benefit Physician’s Services Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare TMJ Surgical and Non-surgical Not Covered Not Covered Habilitative Services Maximum: Unlimited Not Applicable 80% after plan deductible up to the Maximum Reimbursable Charge Routine Foot Disorders Includes only services associated with foot care for diabetes and peripheral vascular disease. Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Blood First 3 pints in a calendar year 100% of the amount approved by Medicare but not paid by Medicare 100% of the amount approved by Medicare but not paid by Medicare Additional amounts per calendar year 100% of the amount approved by Medicare but not paid by Medicare 100% of the amount approved by Medicare but not paid by Medicare Part B Covered Prescription Drugs Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare Smoking Cessation Counseling Not Applicable 100% of the amount approved by Medicare but not paid by Medicare Mental Health and Substance Abuse Inpatient Same as plan’s Inpatient Hospital Facility benefit Not Applicable Outpatient Not Applicable 80% after plan deductible of the amount approved by Medicare but not paid by Medicare myCigna.com 19 BENEFIT HIGHLIGHTS PART A EXPENSES PLAN PAYS PART B EXPENSES PLAN PAYS Foreign Travel Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA: Not Applicable 80% after foreign travel deductible Calendar Year Deductible: $250 Lifetime Maximum: $50,000 myCigna.com 20 Group Retiree Medical Benefits Covered Expenses The term Covered Expenses means expenses incurred by a person while covered under this plan for the charges listed below for:  Preventive Care Services , and  Services or supplies that are Medically Necessary for the care and treatment of an Injury or Sickness, as determined by Medicare or Cigna. As determined by Cigna, Covered Expenses may also include all charges made by an entity that has directly or indirectly contracted with Cigna to arrange, through contracts with providers of services and/or supplies, for the provision of any services and/or supplies listed below. Any applicable Deductibles or limits are show in The Schedule. Covered Expenses  charges made by a Hospital for Part A Medicare Eligible Expenses for a Hospital Confinement from the first day through the 150th day in any Medicare Benefit Period (includes 60 lifetime reserve days).  charges made by a Hospital for a Hospital Confinement for an additional 365 days per benefit period per person per lifetime once the lifetime reserve days are used (or would have ended if used).  charges made by a Skilled Nursing Facility, rehabilitation hospital and sub-acute facilities for Part A Medicare Eligible Expenses from the 21 st day through the 100 th day in any Medicare Benefit Period. A person must have been in the Hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the Hospital.  charges made for Hospice/Inpatient Respite Care for Part A Medicare Eligible Expenses which includes bereavement counseling for a terminally ill person.  charges made for the Medicare Approved Amounts remaining for Part B Medicare Eligible Expenses including but not limited to:  charges made for Inpatient and Outpatient Physicians services.  charges made for laboratory and radiology services.  charges for Medicare Eligible Expenses for preventive care for an annual routine physical and a one time "Welcome to Medicare" exam.  charges made for immunizations.  charges for the following Early Cancer Detection Screenings including but not limited to:  pap test and pelvic examination;  prostate cancer screening and digital exam;  mammogram screening;  colonoscopy;  sigmoidoscopy;  fecal blood test; and  barium enema.  charges made for the first 3 pints of blood in a calendar year or equivalent quantities of packed red blood cells as defined under federal regulations unless replaced in accordance with federal regulations.  charges made for additional amounts of blood after the first 3 pints in a calendar year.  charges made for outpatient short-term rehabilitative therapy.  charges made for home health care services.  charges made for maternity.  charges made for family planning surgical related services.  charges made for durable medical equipment and external prosthetic appliances.  charges made for diabetic supplies, including but not limited to: blood glucose test strips, blood glucose monitor, lancet devices and lancets, glucose control solutions for checking accuracy of test strips and monitors and therapeutic shoes or inserts.  charges made for clinical trials.  charges made in an outpatient facility, emergency room or urgent care facility.  charges made for ambulance services.  charges made for routine foot disorders for diabetes and peripheral vascular disease when Medically Necessary.  charges made for prescription drugs including but not limited to: antigens, osteoporosis drugs, erythropoiesis, blood clotting factors, injectable drugs, immunosuppressive drugs, oral cancer drugs, and oral anti-nausea drugs.  charges for smoking cessation counseling.  charges made for mental health and substance abuse.  charges made for organ transplants.  charges made for dental care.  charges for a wig, if prescribed by a licensed oncologist for a patient who suffers hair loss as a result of chemotherapy.  charges made for any Foreign Travel Emergency Services deductible and for the charges remaining after any such deductible. Covered Expenses will include any Emergency myCigna.com 21 Services that begin within the first 60 days of travel outside the United States in a year. HC-COV880 10-19 Exclusions Additional coverage limitations determined by plan or provider type are shown in the Schedule. Payment for the following is specifically excluded from this plan:  any expense that is:  not a Medicare Eligible Expense; or  beyond the limits imposed by Medicare for such expense; or  excluded by name or specific description by Medicare; except as specifically provided under the “Covered Expenses” section or any other portion of this certificate including any riders attached.  any portion of a Covered Expense to the extent paid or payable by Medicare;  any benefits payable under one benefit of this plan to the extent payable under another benefit of this plan;  Covered Expenses incurred after coverage terminates. In addition, the following exclusions apply to any service that is a Covered Expense under this plan, but is not covered by Medicare:  care for health conditions that are required by state or local law to be treated in a public facility.  care required by state or federal law to be supplied by a public school system or school district.  care for military service disabilities treatable through governmental services if you are legally entitled to such treatment and facilities are reasonably available.  treatment of an Injury or Sickness which is due to war, declared, or undeclared.  charges which you are not obligated to pay or for which you are not billed or for which you would not have been billed except that they were covered under this plan.  for or in connection with experimental, investigational or unproven services. Experimental, investigational and unproven services are medical, surgical, diagnostic, psychiatric, substance abuse or other health care technologies, supplies, treatments, procedures, drug therapies or devices that are determined by the utilization review Physician to be:  not demonstrated, through existing peer-reviewed, evidence-based, scientific literature to be safe and effective for treating or diagnosing the condition or sickness for which its use is proposed;  not approved by the U.S. Food and Drug Administration (FDA) or other appropriate regulatory agency to be lawfully marketed for the proposed use;  the subject of review or approval by an Institutional Review Board for the proposed use except as provided in the “Clinical Trials” section(s) of this plan; or  the subject of an ongoing phase I, II or III clinical trial, except for routine patient care costs related to qualified clinical trials as provided in the “Clinical Trials” section(s) of this plan.  cosmetic surgery and therapies. Cosmetic surgery or therapy is defined as surgery or therapy performed to improve or alter appearance or self-esteem or to treat psychological symptomatology or psychosocial complaints related to one’s appearance.  unless otherwise covered in this plan, for reports, evaluations, physical examinations, or hospitalization not required for health reasons including, but not limited to, employment, insurance or government licenses, and court- ordered, forensic or custodial evaluations.  court-ordered treatment or hospitalization, unless such treatment is prescribed by a Physician and listed as covered in this plan.  private Hospital rooms and/or private duty nursing.  personal or comfort items such as personal care kits provided on admission to a Hospital, television, telephone, newborn infant photographs, complimentary meals, birth announcements, and other articles which are not for the specific treatment of an Injury or Sickness.  artificial aids including, but not limited to, corrective orthopedic shoes, arch supports, elastic stockings, garter belts, corsets, dentures and wigs (other than as described in Covered Expenses).  blood administration for the purpose of general improvement in physical condition.  for or in connection with an Injury or Sickness arising out of, or in the course of, any employment for wage or profit.  massage therapy. General Limitations  charges made by a Hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military-service-connected Injury or Sickness.  to the extent that you or any one of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid.  to the extent that payment is unlawful where the person resides when the expenses are incurred. myCigna.com 22  for charges which would not have been made if the person had no insurance.  to the extent that they are more than Maximum Reimbursable Charges.  expenses for supplies, care, treatment, or surgery that are not Medically Necessary.  charges made by any covered provider who is a member of your family or your Dependent’s family.  expenses incurred outside the United States other than expenses for medically necessary urgent or emergent care while temporarily traveling abroad. HC-EXC359 10-19 Payment of Benefits To Whom Payable Medical Benefits are assignable to the provider if the provider does not participate with Medicare. When you assign benefits to a provider, you have assigned the entire amount of the benefits due on that claim. If the provider is overpaid because of accepting a patient’s payment on the charge, it is the provider’s responsibility to reimburse the patient. All claims for providers that participate with Medicare will be assigned to the provider. Cigna may, at its option, make payment to you for the cost of any Covered Expenses from a Non-Participating Medicare Provider even if benefits have been assigned. When benefits are paid to you or your Dependents, you or your Dependents are responsible for reimbursing the provider. If any person to whom benefits are payable is a minor or, in the opinion of Cigna, is not able to give a valid receipt for any payment due him, such payment will be made to his legal guardian. If no request for payment has been made by his legal guardian, Cigna may, at its option, make payment to the person or institution appearing to have assumed his custody and support. When one of our participants passes away, Cigna may receive notice that an executor of the estate has been established. The executor has the same rights as our insured and benefit payments for unassigned claims should be made payable to the executor. Payment as described above will release Cigna from all liability to the extent of any payment made. Recovery of Overpayment When an overpayment has been made by Cigna, Cigna will have the right at any time to: recover that overpayment from the person to whom or on whose behalf it was made; or offset the amount of that overpayment from a future claim payment. Calculation of Covered Expenses Cigna, in its discretion, will calculate Covered Expenses following evaluation and validation of all provider billings in accordance with:  the methodologies in the most recent edition of the Current Procedural terminology.  the methodologies as reported by generally recognized professionals or publications. HC-POB31 10-10 Termination of Insurance Eligible Persons Your insurance will cease on the earliest date below:  the date you cease to be in a Class of Eligible Persons or cease to qualify for the insurance.  the last day for which you have made any required contribution for the insurance.  the date the policy is canceled. Dependents Your insurance for all of your Dependents will cease on the earliest date below:  the date your insurance ceases.  the date you cease to be eligible for Dependent Insurance.  the last day for which you have made any required contribution for the insurance.  the date Dependent Insurance is canceled. The insurance for any one of your Dependents will cease on the date that Dependent no longer qualifies as a Dependent. HC-TRM75 10-10 V1 myCigna.com 23 Federal Requirements The following pages explain your rights and responsibilities under federal laws and regulations. Some states may have similar requirements. If a similar provision appears elsewhere in this booklet, the provision which provides the better benefit will apply. All references in this section to "Employee" shall be deemed to mean "Eligible Person". HC-FED1 10-10 Qualified Medical Child Support Order (QMCSO) Eligibility for Coverage Under a QMCSO If a Qualified Medical Child Support Order (QMCSO) is issued for your child, that child will be eligible for coverage as required by the order, provided the child is otherwise eligible under this plan. You must notify your Employer and elect coverage for that child, and yourself if you are not already enrolled, within 31 days of the QMCSO being issued. Qualified Medical Child Support Order Defined A Qualified Medical Child Support Order is a judgment, decree or order (including approval of a settlement agreement) or administrative notice, which is issued pursuant to a state domestic relations law (including a community property law), or to an administrative process, which provides for child support or provides for health benefit coverage to such child and relates to benefits under the group health plan, and satisfies all of the following:  the order recognizes or creates a child’s right to receive group health benefits for which a participant or beneficiary is eligible;  the order specifies your name and last known address, and the child’s name and last known address, except that the name and address of an official of a state or political subdivision may be substituted for the child’s mailing address;  the order provides a description of the coverage to be provided, or the manner in which the type of coverage is to be determined;  the order states the period to which it applies; and  if the order is a National Medical Support Notice completed in accordance with the Child Support Performance and Incentive Act of 1998, such Notice meets the requirements above. The QMCSO may not require the health insurance policy to provide coverage for any type or form of benefit or option not otherwise provided under the policy, except that an order may require a plan to comply with State laws regarding health care coverage. Payment of Benefits Any payment of benefits in reimbursement for Covered Expenses paid by the child, or the child’s custodial parent or legal guardian, shall be made to the child, the child’s custodial parent or legal guardian, or a state official whose name and address have been substituted for the name and address of the child. HC-FED4 10-10 Special Enrollment Rights Under the Health Insurance Portability & Accountability Act (HIPAA) If you or your eligible Dependent(s) experience a special enrollment event as described below, you or your eligible Dependent(s) may be entitled to enroll in the Plan outside of a designated enrollment period upon the occurrence of one of the special enrollment events listed below. If you are already enrolled in the Plan, you may request enrollment for you and your eligible Dependent(s) under a different option offered by the Employer for which you are currently eligible. If you are not already enrolled in the Plan, you must request special enrollment for yourself in addition to your eligible Dependent(s). You and all of your eligible Dependent(s) must be covered under the same option. The special enrollment events include:  Acquiring a new Dependent. If you acquire a new Dependent(s) through marriage, birth, adoption or placement for adoption, you may request special enrollment for any of the following combinations of individuals if not already enrolled in the Plan: Employee only; spouse only; Employee and spouse; Dependent child(ren) only; Employee and Dependent child(ren); Employee, spouse and Dependent child(ren). Enrollment of Dependent children is limited to the adopted children or children who became Dependent children of the Employee due to marriage.  Loss of eligibility for State Medicaid or Children’s Health Insurance Program (CHIP). If you and/or your Dependent(s) were covered under a state Medicaid or CHIP plan and the coverage is terminated due to a loss of eligibility, you may request special enrollment for yourself and any affected Dependent(s) who are not already enrolled in the Plan. You must request enrollment within 60 days after termination of Medicaid or CHIP coverage.  Loss of eligibility for other coverage (excluding continuation coverage). If coverage was declined under this Plan due to coverage under another plan, and eligibility myCigna.com 24 for the other coverage is lost, you and all of your eligible Dependent(s) may request special enrollment in this Plan. If required by the Plan, when enrollment in this Plan was previously declined, it must have been declined in writing with a statement that the reason for declining enrollment was due to other health coverage. This provision applies to loss of eligibility as a result of any of the following:  divorce or legal separation;  cessation of Dependent status (such as reaching the limiting age);  death of the Employee;  termination of employment;  reduction in work hours to below the minimum required for eligibility;  you or your Dependent(s) no longer reside, live or work in the other plan’s network service area and no other coverage is available under the other plan;  you or your Dependent(s) incur a claim which meets or exceeds the lifetime maximum limit that is applicable to all benefits offered under the other plan; or  the other plan no longer offers any benefits to a class of similarly situated individuals.  Termination of Employer contributions (excluding continuation coverage). If a current or former Employer ceases all contributions toward the Employee’s or Dependent’s other coverage, special enrollment may be requested in this Plan for you and all of your eligible Dependent(s).  Exhaustion of COBRA or other continuation coverage. Special enrollment may be requested in this Plan for you and all of your eligible Dependent(s) upon exhaustion of COBRA or other continuation coverage. If you or your Dependent(s) elect COBRA or other continuation coverage following loss of coverage under another plan, the COBRA or other continuation coverage must be exhausted before any special enrollment rights exist under this Plan. An individual is considered to have exhausted COBRA or other continuation coverage only if such coverage ceases: due to failure of the Employer or other responsible entity to remit premiums on a timely basis; when the person no longer resides or works in the other plan’s service area and there is no other COBRA or continuation coverage available under the plan; or when the individual incurs a claim that would meet or exceed a lifetime maximum limit on all benefits and there is no other COBRA or other continuation coverage available to the individual. This does not include termination of an Employer’s limited period of contributions toward COBRA or other continuation coverage as provided under any severance or other agreement.  Eligibility for employment assistance under State Medicaid or Children’s Health Insurance Program (CHIP). If you and/or your Dependent(s) become eligible for assistance with group health plan premium payments under a state Medicaid or CHIP plan, you may request special enrollment for yourself and any affected Dependent(s) who are not already enrolled in the Plan. You must request enrollment within 60 days after the date you are determined to be eligible for assistance. Except as stated above, special enrollment must be requested within 30 days after the occurrence of the special enrollment event. If the special enrollment event is the adoption of a Dependent child, coverage will be effective immediately on the date of adoption or placement for adoption. Coverage with regard to any other special enrollment event will be effective no later than the first day of the first calendar month following receipt of the request for special enrollment. Domestic Partners and their children (if not legal children of the Employee) are not eligible for special enrollment. HC-FED96 04-17 Coverage for Maternity Hospital Stay Under federal law, group health plans and health insurance issuers offering group health insurance coverage generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section. However, the plan or issuer may pay for a shorter stay if the attending provider (e.g., your physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier. Also, under federal law, plans and issuers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, a plan or issuer may not, under federal law, require that a physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain precertification. For information on precertification, contact your plan administrator. HC-FED10 10-10 myCigna.com 25 Women’s Health and Cancer Rights Act (WHCRA) Do you know that your plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema? Call Member Services at the toll free number listed on your ID card for more information. HC-FED12 10-10 Coordination with Medicare Benefits provided under this plan will not duplicate any benefits paid by Medicare. Determination of the amount payable under this plan will be based upon the difference between the amount paid by Medicare and the Medicare Approved Amount (for Part A) or the Maximum Reimbursable Charge (for Part B). Eligibility for Medicare This plan will assume the amount payable under Part A and/or Part B of Medicare for a person who is eligible for but is not currently enrolled in that Part(s), or Part B of Medicare for a person who has entered into a private contract with a provider, to be the amount he would receive in the absence of such private contract. A person is considered to be eligible for Medicare on the earliest date any coverage under Medicare could become effective for that person. HC-FED41 07-12 Claim Determination Procedures The following complies with federal law. Provisions of applicable laws of your state may supersede. Procedures Regarding Medical Necessity Determinations In general, health services and benefits must be Medically Necessary to be covered under the plan. The procedures for determining Medical Necessity vary, according to the type of service or benefit requested, and the type of health plan. Medical Necessity determinations are made on a preservice, concurrent, or postservice basis, as described below: Certain services require prior authorization in order to be covered. The Certificate describes who is responsible for obtaining this review. You or your authorized representative (typically, your health care professional) must request prior authorization according to the procedures described below, in the Certificate, and in your provider’s network participation documents as applicable. When services or benefits are determined to be not covered, you or your representative will receive a written description of the adverse determination, and may appeal the determination. Appeal procedures are described in the Certificate, in your provider’s network participation documents as applicable, and in the determination notices. Preservice Determinations When you or your representative requests a required prior authorization, Cigna will notify you or your representative of the determination within 15 days after receiving the request. However, if more time is needed due to matters beyond Cigna’s control, Cigna will notify you or your representative within 15 days after receiving your request. This notice will include the date a determination can be expected, which will be no more than 30 days after receipt of the request. If more time is needed because necessary information is missing from the request, the notice will also specify what information is needed, and you or your representative must provide the specified information to Cigna within 45 days after receiving the notice. The determination period will be suspended on the date Cigna sends such a notice of missing information, and the determination period will resume on the date you or your representative responds to the notice. If the determination periods above would seriously jeopardize your life or health, your ability to regain maximum function, or in the opinion of a health care professional with knowledge of your health condition, cause you severe pain which cannot be managed without the requested services, Cigna will make the preservice determination on an expedited basis. Cigna's reviewer, in consultation with the treating health care professional, will decide if an expedited determination is necessary. Cigna will notify you or your representative of an expedited determination within 72 hours after receiving the request. However, if necessary information is missing from the request, Cigna will notify you or your representative within 24 hours after receiving the request to specify what information is needed. You or your representative must provide the specified information to Cigna within 48 hours after receiving the notice. Cigna will notify you or your representative of the expedited benefit determination within 48 hours after you or your representative responds to the notice. Expedited determinations may be provided orally, followed within 3 days by written or electronic notification. If you or your representative fails to follow Cigna’s procedures for requesting a required preservice determination, Cigna will notify you or your representative of the failure and describe the proper procedures for filing within 5 days (or 24 hours, if an expedited determination is required, as described above) after receiving the request. This notice may be myCigna.com 26 provided orally, unless you or your representative requests written notification. Concurrent Determinations When an ongoing course of treatment has been approved for you and you wish to extend the approval, you or your representative must request a required concurrent coverage determination at least 24 hours prior to the expiration of the approved period of time or number of treatments. When you or your representative requests such a determination, Cigna will notify you or your representative of the determination within 24 hours after receiving the request. Postservice Determinations When you or your representative requests a coverag