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Item 4DItem 4D CITY OF SOUTHLAK.E lI ll • : G l s l W TO: Shana Yelverton, City Manager FROM: Stacey Black, Director of Human Resources SUBJECT: Approve a contract renewal with Aetna to provide employee health insurance, dental insurance, and vision insurance benefits for Plan Year October 1, 2020 through September 30, 2021. Action Requested: Approve a contract renewal with Aetna to provide employee health insurance, dental insurance, and vision insurance benefits for the Plan Year October 1, 2020 to September 30, 2021. Background Information: Aetna became the City's health insurance provider on October 1, 2016 following a competitive bidding process. Aetna became the provider for dental and vision insurance on October 1, 2019. In late May, the City received its health, dental, and vision insurance renewals from Aetna. It is important to note that Section 112 of the Texas Property Tax Reform and Transparency Act of 2019, also known as Senate Bill 2, prevents a city from reducing the compensation of a first responder in the fiscal year beginning in 2020. For Southlake, this is Fiscal Year 2021. The Act defines "compensation" to include a salary, wage, insurance benefit, retirement benefit, or similar benefit an employee receives as a condition of employment. This includes maintaining employee insurance premiums and benefits at the current level for first responders. Health Insurance: Over the last 12 months, the City has experienced a 90% premium - to -claims ratio for medical and prescription claims. In March 2020 (the most recent data available) the claims ratio spiked to 134%. In addition, Aetna reported that the City is currently experiencing 18 large, ongoing claims. As a result of the high claims experience, Aetna's initial renewal offer proposed a 16.7% rate increase. Following negotiations, Aetna reduced its renewal offer to an 8% rate increase with no plan design changes. Based upon a review of the claims history, and the current and ongoing large claims, staff believes the final proposed renewal is fair. Shana Yelverton, City Manager July 29, 2020 Page 2 Item 4D The estimated cost of the original 16.7% premium increase is $265,000 for civilian personnel plus an estimated $325,000 for first responders. The estimated cost for first responders includes increasing the city's contribution to dependent premiums to maintain the current employee premium as mandated by S.B. 2. The estimated cost of the final proposal of an 8% premium increase is $130,000 for civilian personnel plus $160,000 for first responders. As part of the renewal, Aetna offered the City the opportunity to participate in a renewal incentive program that granted the City a 25% health insurance premium reduction for the August and September 2020 invoices. To qualify for the reduction the City was required to provide early notification of our intent to renew coverage with Aetna. Council was notified of this opportunity in the Daily Update on July 7, 2020 and the City confirmed with Aetna on July 10, 2020 its intention to renew. By participating in this program, the City will save approximately $190,000 in premium costs. The illustration below shows the estimated cost of the original proposal, the estimated cost of the final negotiated proposal, and the estimated savings from the renewal incentive. /J rAl 1�t t�5 }r+Snti� tN', Original Final Renewal Proposal Proposal Incentive EM Em 0 S►yi�sg�°I9t�;tl�t�C1 'Estimated impact of S.B. 2, which prohibits changes to first responder compensation. Dental Insurance: Aetna's dental plan renewal proposes a 4.8% rate increase for the PPO and no rate increase for the DMO plan. The PPO dental plan experienced high utilization with a premium -to -claims ratio of 92%. Based upon this experience, staff believes the renewal is fair. The estimated cost of the rate increase is for civilian personnel is $15,000 and the estimated cost increase for first responders is $25,000. Shana Yelverton, City Manager July 29, 2020 Page 3 Vision Insurance: Item 4D Aetna's renewal for vision insurance proposes no rate increase and no plan changes. Vision insurance is optional, and employees contribute 100% of the cost. The City's experience with Aetna has been favorable and very few service complaints have been received from employees. After a review of the claims data and given the favorable experience, Staff recommends City Council approve the proposed renewals for health, dental, and vision insurance. Financial Considerations: Coverage Estimated Estimated Estimated Total Annual Annual Annual First Estimated Total City Civilian Responder Annual Contribution Increase Increase Increase Health Insurance $4,247,150 $130,000 $160,000 $290,000 Dental Insurance $157,166 $15,000 $25,000 $40,000 Vision Insurance $0 $0 $0 $0 In addition, the City received a renewal incentive from Aetna that will save the city approximately $190,000 in premium costs. The proposed insurance plan costs will be included in the proposed budget for Fiscal Year 2021. Strategic Link: Performance Management and Service Delivery: attract, develop and retain a skilled workforce. Citizen Input/ Board Review: N/A Legal Review: NIA Alternatives: Deny contract with Aetna and seek alternative options. Supporting Documents: The following supporting documents are attached: • Aetna Health Renewal • Aetna Dental Proposal • Aetna Vision Proposal Shana Yelverton, City Manager July 29, 2020 Page 4 Item 4D Staff Recommendation: Approve a contract renewal with Aetna to provide employee health insurance, dental insurance, and vision insurance benefits for Plan Year October 1, 2020 through September 30, 2021. Alonzo Sanchez Sr Account Manager 2777 StemmomFreeway Dallas, TX75207 Phune:2I4-2OO-018I SanchezA@AET0Azom City OfSmuthlake Stacey Black 14OOMAIN ST,STE2GU South|mke,TX7GO92 This package provides information tohelp you develop the future benefits program for City OfSouth|ake. Aaweapproach the anniversary of our relationship in the journey to better health, we are pleased to present you with our renewal for the 2020 policy period. It's important to understand the full financial picture of your benefit plan. Therefore, the enclosed package provides the °Future Program Costs This section illustrates the cost projections tooperate your current benefit program txthe period 10/01/2020 through 09/30/2021. For the period 1O/O1/lO2Othrough OB/3O/2D2Ithe cost tooperate your current medical plans will increase O.OD96 compared tothe current rate. This renewal reflects both premium and the producer service fee. Caveats Our renewal offer is contingent upon the parameters outlined here. It is important to note that deviations from these assumptions may result in additional charges and/or adjustments on our medical quotations. Please review this section thoroughly. If there are no changes that impact the conditions of this renewal as outlined in our Caveatssection, the rates will remain in effect through September 3O,2D21. Please review the additional important information found atthe following URL 03.15.2o�� This information isincorporated |nand isapart ofthis proposal. This quote issubject toall the terms and conditions set forth in this URL. In the event that any information contained herein conflicts or is inconsistent with the information in the Underwriter Disclosure document, the information in your Package shall prevail. Ifyou would like tomake any plan changes, please contact mebySeptember O12O2Qmt214-2DO-8181. It's been apleasure working with you and | look forward tnour continued relationship. Sincerely, City Of SouthUake now We want to help you advocate for your workforce. We want to move away from a focus on products and programs —to focus on people. Health care can be overwhelming. 5oour approach focuses on each person tocreate a stronger individual. And with many stronger individuals comes a stronger workforce. When you have a stronger workforce, we can help you achieve your goals and get stronger results. Aswetransform the health care experience, we're honored 1oberecognized for our work. Click here to learn more about Aetna's awards apd recqgaW2n�i. "Aetna" is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. The Aetna companies include: Aetna Health Inc., Aetna Health of California Inc., Aetna Health of the Carolinas Inc., Aetna Health of Washington Inc., Aetna Health Insurance Company of Connecticut, Aetna Health Insurance Company of New York, Corporate Health Insurance Company; Aetna Life Insurance Company; Aetna Dental Inc.; and/or Aetna Dental of California Inc.; Aetna Health of Utah Inc. Certain dental plans are available only for groups of a certain size in accordance with underwriting guidelines. Managed care plans may not cover all health care expenses. Contracts should be read carefully to determine which health care services are covered. While this material is believed tobeaccurate asofthe print date, itissubject tochange. For more specific information about the coverage details, including limitations, exclusions, and other plan requirements, please contact an Aetna representative. Aetna has various programs for compensating producers (agents,brokers and consultarts). If you would like information regarding compensation programs for which your producer is eligible,payments (if any) which Aetna has made to your producer, or other material relationships your producer may have with Aetna, you may contact your producer or your Aetna account representative. Information regarding Aetna's program compensating producers is also available at: The information contained in this proposal is confidential and should not be shared with anyone other than your broker or benefit plan consultant. The problem with health care �-tr' :w -I I r, h c a, il-'nL, gr y l'kas I C -'t IC� " kS 'r I tit I, p! iy�'!' il, rv"ir- if a scia a I wrk,, it,, ' I I • t , It,, '"r -,I , I, j, 7p', F, C, 7 , I � v oL, i, A-r! U iey:' t li,e- kc is-, Vol w - A V'Afn1A ''Oir' "I *v i'V P, ":f I 'o 1 W:"dt .'nP PmV, (A,, - I Jig! v" I i"It t KIC1,110 I 'AF tsu e- Jt w t'&T 6k fl'yQve4 it i, ltanW" v e'W'w' it lCa" i ' C S a- m .:."!-Ik" But now, there's a solution with the Texas Health Aetna joint venture Personalized, connected care- available totally at an affordable price ch, 4i11 'j;)':4 at e -,-Ia 1,_-I�A Invd ke h"k, g"A n, icn-, -�c,,A iv ard' '-irAp -uc) Ukn m, ak"'Fl lyijuF ciu ok"J'K"tF 'jJfleve Owi' 5, Z"IF" e'rU le It; z "-'u E, r, v:' a'-'CL,S Co ca, C' Simple and seamless experience Convenient -to -access 1c;,,al Lof Affordabilitywo OCare that connects provi,- derst,.-U", I . Al" � llol, tal km c, -t�, Ar,F 1 c v�pw Cwc, r. ; To learn r-nore, visit texashealthaetna.com or contact your Texas Health Aetna sales rep today. %J 0 C' "'I D"- 101 V- q, ""D I texashealthaetna.coo @Texas Healtif aetna 111LIstrative City Of Southlake WWII! �111�1 W Account Manager Assumptions Contract State: Alonzo Sanchez 214-200-8181 Is Producer Service Fee: 4.20% Health Insurance Provider Fee%*: 0.65% Proposed Rates Effective Date: 10/1/2020 Total Amount Due Includes 4.20 % Producer Service Fee** Email: SanchezA@AETNA.com Lives: SIC Code: Mem/EE Ratio: Rx Formulary: 326 9111 111 Advanced Control Formulary Aetna Insured Illustrative City Of SouthUake Total Medical Lives: 326 Current Monthly Total Amount Due: $381,329.45 Proposed Monthly Total Amount Due: $411,836.37 Total % Change: 8.00% Proposed Total Contract Period Amount Due: $4,942,036.44 "The proposed rates includes our premium and Producer Service Fee as requested. Producer Service Fee will beremoved from Total Amount Due if Policyholder and/or Producer do not elect our company to serve as billing and collection agent. Total Amount Due will reflect executed Billing & Collection Agreement. *The Affordable Care Act imposed the health insurance provider fee effective January 1, 2014. This rate quote includes, where permitted, an estimate proportionate allocation of expenses associated with these fees. City Of Southlake • The components of your renewal rate change are detailed below. • The current Net Adjusted Incurred Claims ♦. Member Per Month (PMPM) are trended forward to the Renewal Rate Period. • 7.-se4 4,i,. cmst*mer sizs4y ex�ueiip&nck- ral8mg griW, clAms *ver a certAh tNre�skvW-, h*rM,?.k-Z the claims experience in order to minimize large yearly fluctuations. • A large claim adjustment is added to the Incurred Claims, and blended with Manual Claims, if applicable, to develop a blended expected claim. An adjustment for renewal benefit change is added if applicable. State taxes, commissions, and other adjustments are then added resulting in the final required premium. z This exhibit may include information from other carriers. Experience Grouping: Experience Group 1 Next Contract Period: 10/1/2020 - 9/30/2021 Claim Basis: Year Experience Period: Paid Through: Subscriber Member Months: Experience Period Average Members: 2/1/2019 3/31/2020 3,939 697 Incurred 1/31/2020 J 8,363 2/1/2018 3/31/2020 3,811 680 Incurred 1/31/2019 J 8,158 Current Subscribers: 326 Current Members: 689 1. Incurred Claims $324.21 $124.92 $449.13 $355.99 $110.66 $466.65 2. Deductible Suppression Factor 0.9997 0.9998 1.0000 1.0000 3. Incurred Claims x Deductible Suppression Factor $324.13 $124.92 $449.05 $356.01 $1.10.66 $466.66 4. Pooled Claims $2,36 $2.36 $4.93 $4.93 5. Pooling Charge a.Pooling Point $175,000 $175,000 $175,000 $175,000 b.Pooling Factor(non-capitated medical claims only) 10,23% 10.23% c.Pooling Charge $32.82 $32,82 $35.81 $35,81 6. Incurred Claims w/ Pooling (3 - 4 + 5c) $354.58 $124.92 $479.50 $386.89 $110.66 $497,55 7. Adjustment for Change in Network 0.9738 0.9923 0.9786 0.9463 0.9843 0.9548 & Adjustment for Change in Plan 0.9847 0.8948 0.9609 0.9598 0.8729 0.9399 9. Adjustment for Change in Demographics 0.9992 1.0190 1.0041 1.0172 1.0267 1.0192 10. Underwriting Adjustment 1.0000 1.0000 1.0000 1.0000 1.0000 1,0000 11. Adjusted Incurred Claims (6 x 7 x 8 x 9 x 10) $339.74 $113.02 $452.76 $357.43 $97.62 $455.05 12. Trend a. Annual Trend Factor 9.43% 10.60% 9.72% 9.65% 10,81% 9.90% b. # of Months of Trend 20.0 20.0 20.0 310 310 310 c. Projection Factor 1.1620 1.1829 1,1672 1,2785 1,3149 1,2863 13. Exp, Based Projected Claims (11 x 12c) $394.79 $133,69 $528.48 $456.97 $12835 $585.33 14, Experience Weighting 75.0% 75.0% 75,0% 25.0% 25.0% 25,0% 15. Experience Blended Projected Claims $410.34 $132.36 $542.69 16, Experience Credibility 100,0% 100,0% 100.0% 17. Manual (CRC) Projected Claims $397.01 $9933 $49634 18. Blended Projected Claims $410,34 $132.36 $542,69 19. Large Claim Adjustment $0.00 20, Retention Charges a, Administrative Component 11.26 % $69.66 b. Broker Commission Component 0,00% $0,00 c, Premium Tax Component 0.35% $2.16 d. Health Insurance Providers Fee 0.65% $A 02 e. Total Retention Charges (20a+20b+20c+20d) 12.26 % $75.84 21. Projected Premium $618.53 22, Multi Product Discount $0.00 23. Rate Adjustment ($44.64) 24. Proposed Premium $573.90 25. Producer Service Fee Component 4.20% $25,16 26. Total Amount Due $599.06 27. Estimated Current Premium $55145 28. Required Rate Change (excludes 22, 23) 167% 29. Proposed Rate Change ( 26/27 - 1) 8.2% City Of Southlake TX OAEPO Program Summary 200080% 80/50 111 1 N Rx3A AdvCtrl Im 0 WA—AdvCtrol "1 11 Designated Account Management Team Designated Service Center Open Enrollment Marketing Material Standard ID Cards Anytime -MD by Texas Health Aetna National Medical Excellence Program' Aetna Health Connections - Disease Management'" Aetna Maternity Program Enhanced Clinical Review MedQueryl with Member Messaging Regional Case Management Utilization Management 24/7 Call Services Member Website and Mobile Experience ..lam WIN, 16W 1111, Aetna Healthy Commitments" - Enhanced Biometric WIN1,1411 100,91-IN 11, ININ1111#11,111, IN, Utilization Management Reporting AbleTo Network subject to member cost share 111"IM11,111,111f 0`11, 11111,0111, 0111, 1141, 111 Applied Behavioral Analysis (ABA) Managed Behavioral Health Choose Generics w/ Dispense As Written Override 11114,04M. "01, Step Therapy 014,011 yt i 16W Annual Wellness Allowance 1111 11,01 IIIIFI 1 11 MI, WIN, 1111, City Of SouthKake Annual Wellness Allowance We are including a wellness allowance of up to $15,000 that may be used towards reasonable Included wellness services procured by the Plan Sponsor from third party vendors to pay for wellness -related expense such as wellness fairs, biometric screenings and on -site flu vaccinations incurred during the October 01, 2020 to September 3O,28Z1plan year. These funds will beavailable asnfthe effective date ofthe period. � Our preferred method of payment of well ness-related expenses is directly to the vendor. Payment will bemade once the expenses are incurred and invoice(s) are provided. Invoices must be submitted to us within 60 days following the close of the plan year. Expenses must befor we|ne related programs or activities that are designed to promote the health and well being of plan participants, or to educate the participants about healthy lifestyles and choices. Any expenses beyond the Wellness Allowance are the responsibility of the customer. Any balance of this allowance fund remaining at the end of the policy year will be forfeited. Any amounts ("Wellness allowance") paid by Aetna to a plan sponsor to offset or reimburse such plan sponsor for any expense or costs incurred as a result of contracting with Aetna for benefits plan administration services, shall be paid in accordance wi poplicable law. Plan sponsors are advised to cletermi !;ipro!2riate accountin- for these pw,iments with their own counsel or accountant. Any plan sponsor receiving a wellness allowance or other payments from us that offset or reimburse expenses that would otherwise be paid from plan assets, should consult with their ERISA counsel to determine if such allowance must be credited to plan assets, and for additional counsel regarding the accounting for reporting of such payments. We assume the funding of any wellness budget is either at the request of vour Plan Administrator actinein-thp-i-t�-ffd.iwiar\Lr-a-aacjtvjxLv-aLtr-Rla-n-oTJorlhp—p-,xcktsjvp—be-neft-o-f-vo-ucRUn— Citv Of Southlake below. Any of the information listed below, which has not been provided, may be required prior to final approval of a sale. We a I ' e on information from the Plan S onsor and its re resentatives in establishin the rates and terms of this ro osal. If Prospective Quoting The quoted insured medical rates are offered on a prospectively rated basis. No policy year accounting balance will be calculated for these coverages. Billing and Payment of Premium Amount due is payable on the first day of the month covered by the invoice. If the amount due is not paid in full within 30 days,we reserve the right tuterminate the contract and/or assess late premium payment charges. • The quote includes a Producer Service Fee of 4.20 % of the Total Amount Due as determined between the Plan Sponsor and Producer and memorialized inthe Billing and Collection Agreement. • The Producer Service Fee is negotiated directly between Plan Sponsor and Producer for services provided in connection with the Group Medical benefit plan. Producer Service Fee is not a component of the premium but is included in the Total Amount Due. ° The Producer Service Fee will be removed from the Total Amount Due if a Plan Sponsor and Producer do not agree on a service fee amount and sign aBilling and Collection Agreement. ° The Plan Sponsor is not required to use a Producer to purchase insurance and may purchase a policy directly from our company. • The Plan Sponsor selects, retains, and contracts with the Producer on its own accord. Producer Service Fees We do not administer Producer Service Fees for all fully insured business in the following states: Colorado, Kentucky, Louisiana, Maine, Missouri, Nebraska, New York, Washington and parts of Illinois. We do not offer Producer Service Fees for fully insured PRO products in California. If a Billing and Collection Agreement is currently in effect for this case in one of the states or products outlined above, it will be terminated upon renewal. Our rates assume compliance with our standard guidelines on employer contribution strategy. VVe$andardlyrequire that the employer contribute 75y6ofthe employee cost, or50%ofthe total emp|nyeeanddependentcns . Employer contributions may not favor other medical plans over that ofthe Aetna plans. Our plan will have neutral tufavorable employer contributions after adjusting for plan design, compared to other medical plans, including consumer directed plans (HRA and/or HSA models). In option situations, employer contributions must not disadvantage our offering. Eligibility - Active Employees/Retirees The quoted plans listed below are only for active employees and pre-65 retirees. It is assumed that retirees age 65 and over are not eligible for these plans. Participation For Full Replacement sales at least 75% of eligible employees excluding spousal and parental waivers must enroll in the plan, but not less than 50% of all eligible employees regardless of spousal and parental waivers. For Option Sales at least 75% of eligible employees excluding spousal and parental waivers must enroll in the employer's plans. Citv Of Southlake Financial Condition Plan Sponsor isalegitimate business and meets underwriting approval for acceptable financial strength. VVereserve the right to request additional supporting information in order to evaluate financial status. High Deductible Health Plan We reserve the right to change the quoted rating for coverage, or to decline to offer coverage if the Plan Sponsor funds the deductible inexcess ofSO%. Health Savings Account The Health Savings Account fee is billed from a separate billing system than the medical benefits. Account holders may incur additional charges for banking services. Mandates Benefit provisions are subject to state, local, and federal mandates. Future mandates will be incorporated in the plan(s) as of the date required bylaw and may require rate adjustments. Medicare -based Out of Network Reimbursement Please note your plan's out -of -network benefits. Your plan will cover out -of -network care based on what Medicare pays doctors and hospitals for a service. Typically the allowed amount is 90% of Medicare pays doctors and other health care providers. It is 90% of Medicare pays hospitals and other facilities. This helps to control rising health-care costs. Our Medicare -based payment generally is less than our previous payment for out -of -network services which was based on prevailing charges. This means members will pay more if they choose to go out -of -network. This applies to out -of -network doctors, behavioral health professionals, dentists, hospitals, ambulatory care centers, and other health care providers and facilities. This does not apply to emergency care. It also does not apply to services provided by out -of -network doctors working at in -network facilities, such asradiologists, anesthesiologists and pathologists. Plan Design This Renewal is based on the current benefit plan designs, plus any noted deviations. Our standard provisions, contract wording and claim settlement practices will apply for items not specifically outlined. Prescription Drug Benefits Prescription drug benefits are included and will be provided through Aetna Pharmacy Management. Point of Service Rebates Thisproposa|mayindudepointofservicerebates("P0SRebates")favorab|eto,andsharedvvith,e|igib|esubscribersand dependents. However, Aetna reserves the right to make appropriate changes to the premium offered hereunder in the event POS Rebates are discontinued, in whole or in part, on account of any material changes made to (i) the laws, rules and/or regulations applicable to POS Rebates or (ii) any material drug manufacturer rebate contracts providing the source for POS Rebates. Run-in Claim Processing Expenses associated with run-in claims from any prior plan (claims incurred prior to the effective date of our plan) are excluded from the proposed rates. SPDkHodificatiom Our premium includes our standard Summary Plan Description language and any custornization may require an additional cost. Underlying Plan Our quoted rating assumes that there are no underlying plans in effect that will either partially or completely subsidize any member cost sharing including but not limited to co -pays, deductibles, and/or coinsurance balances. We reserve the right to change the quoted rating or decline coverage if we have not been notified of the existence of an underlying plan, Citv Of Southlake Network Re -Contracting In addition 10standard fee-for-servicesrates, contracted rates with network providers may also be based on case and/or per them rates and in some circumstances, include risk -adjustment calculations, quality incentives, pay -for -performance and other incentive and adjustment mechanisms, These mechanisms may include payments to organizations that may refer to themselves as accountable care organizations ("ACOs") and patient -centered medical homes ("PCMHs"), in the form of accountable care payments (ACP) and incentive arrangements based on clinical performance and cost-effectiveness. The ACP amount is based upon an assessment for each member who is already accessing providers in an ACO, and is assessed retrospectively on a quarterly basis and collected through established claim wire. Each ACO will have a different ACP based on the clinical efficiencies targeted and network negotiations. The ACPassists the A[Oinfunding transformation ofthe health care system toimprove quality, reduce costs and enhance the patient experience by: Identifying and engaging patients at risk for health crises sooner through more data -sharing Increasing patient engagement in best -in -class care management programs through doctor -driven outreach Member/Subscriber Ratio The enrolled member to subscriber ratio increases or decreases by more than 10% from the ratio assumed in this quote. Enrollment The actual enrollment in total or by plan changes by more than 10% compared with what was proposed. The plan sponsor offers coverage to employee previously not covered under the plan without prior notification. (Change in census is based on additions and subtractions --a 60 life group who adds 3 people and takes away 3 others has a 6 person change in census even though they stay utGDUves) HRAEnmol|ment More than 3D9Aofeligible lives enroll inthe Health Fund prmduct(d. Participation and Contribution Rules Under Affordable Care Act (ACA) and state insurance regulations, a group health insurance policy may be non -renewed for certain reasons. We reserve the right to non -renew for failure to comply with certain requirements such as participation and/or contribution rules. Contract Provisions The final benefit provisions, account structure, claim payment requirements or services change from those proposed. UnformationAccuracuyDeN1ogyaphics The information provided is inaccurate and/or the demographics of the quoted group change resulting in +/- 5% premium difference, 60 Day Provision A decision is not reached within 60 days from the time the quote is released. COBRA Enrollment If the total number of COBRA enrollees exceeds 10% of the total enrolled group or the total number of COBRA enrollees increases by more than 5 percentage points from what was assumed in this renewal, a rate change may be required. Retiree Enrollment There is a 5% increase in the percentage of employees or retirees over the age of 65 from that assumed or from any subsequently reset assumptions. We have assumed that 10% of the enrolled employees are over the age of 65� Industry The nature of business and/or SIC code 9111 changes compared with what was assumed in setting the rates. Quoted Benefits A material change in the plan of benefits offered, or a change in claim payment requirements or procedures, or a change in state premium taxes or assessments, or any other changes affecting the manner or cost of providing coverage that is required because of |eRis|ativeorreeu|aton/action. Citv Of Southlake This information is incorporated in and is a part of this proposal. This quote is subject to all the terms and conditions set forth in this URL. In the event that any information contained herein conflicts or is inconsistent with the information in the Underwriter Disclosure document, the information in your Package shall prevail. At the time of annual enrollment, your plan participants should be provided with the Medical Disclosure information related to their plan ofbenefits. GotuouroorporatewebsiteandenterthestatefoUowed6ythewmnd'Disdmsune^inthesearchfie|d.P|ease provide the applicable Medical Disclosure document and any required Addendum to your plan participants. If you have any questions, please contact your broker oraccount management team. The Affordable Care Act (ACA) imposed several fees/assessments, including the Health Insurance Providers Fee (HIF). e HIF is a recurring, annual, industry fee assessed based on each insurer's share of the fully insured market, as determined by the |R6. This rate quote includes, as applicable, an estimated proportionate allocation of expense associated with the HIF. We reserve the right to modify these rates, or otherwise recoup such fees, based on future regulatory guidance, subsequent state regulatory approval, orifestimates are materially insufficient. City Of SouthUake abuse services compared to medical and surgical services. The law allows outpatient benefits to be sub-ciassified between "office visits" and "all other" outpatient services. Beginning on 01/01/2018, or your next renewal date, we are changing your benefits separating Outpatient Mental health/Substance Abuse into two new benefit categories: BH Office Visit and BH All Other. • "BH Office Visit " includes services where members will interact with a provider in an office setting for treatment • "BH All other" includes services where members will have some other interaction with providers in obtaining care — such as technological intervention or where the service is traditionally delivered outside an office setting, like in the home 8eginning|anuaryDI,3Q18,thefoUow|ngBehavora|HealthsenviceswiUbedassifiedasbehaviore|hea|thoutpatient"aUother"for purposes ofFederal Mental Health Parity law: ° Partial hospitalization programs (PHP) ~ Intensive outpatient programs (|QP) • Applied behavior analysis (ABA) for the treatment of autism spectrum disorder = Home healthcare ° Tr nscrania|magnetic$dmu|adon ° Electroconvulsive therapy (ECU ° Vagusnerve stimulation (normally enexcluded benefit) ° Outpatient monitoring ofinjectable therapy ° Psychological testing ° Neuropsycho|ogica|tesbng ° Medical treatment for withdrawal symptoms ~ Outpatient detoxification ° Ambulatory detoxification In an effort to comply with the new law, we are also revising several medical, mental health and substance use disorder benefits cost share. In order for your plan to pass the 'substantially all" and "predominate" cost share testing required by MHPAEA, the following medical benefits cost share may change with your renewal: ° Lab • X-ray noncomplex and X-ray complex ~ Outpatient Surgery Freestanding ~ Outpatient Surgery Hospital ° Medical Injection in an Office Visit ° Home Health City Of Somthlake Program Comparison Aproactive Aetna Resources For Living ' Employee Assistance Program (EAP) quote has been included with two options to meet the needs of your employee population. Unlimited telephonic consultation V/ V", Face-to-facecounseling, per issue, per year Uptu3 Uptp5 VVork|ifeyupport Vr` V/� myStrengthOonline emotional wellness portal V/�' w/'^ Financial resources Legal resources |DTheft V' V/'" K8emberwebsite V/�' */^ Member mobile opp Vr V~ Management referrals V/�` V/' Management consultation V/�' V~ FIR Consultation V/^' V!` Critical Incident Response V/ V�' Proactive Account Management V/''' V,` Flyers and wallet cards V, Vx Monthly email newsletter V/' V/' Semi-annual and Annual Utilization reports V/''' V/''^ Product Features Telephonic consultation Unlimited telephonic access to the EAP call center staff, available 24 hours per day, 7 days per week, Members have access to our EAP network providers for a pre -determined number of face-to-face clinical sessions, as elected by the customer. Each member is entitled, on a contract year, up to the number of counseling sessions per issue (e.g., up to three counseling sessions per member per problem under the 3-session EAP model). Face-to-face counseling sessions require prior authorization. The member contacts Aetna Resources For Living to receive referrals and an authorization to a contracted EAP network )trovider. We consider marital aad���,v sessions as one issue for the couple or family and do Some network providers also provide telephonic or televideo options where appropriate. Worklife support This service provides telephonic access to Worklife do all the legwork to meet members' everyday needs. They provide qualified referrals for child care, elder care and other isersonal. household and familN� issues. Financial resource Members may access financial forms and templates on-line aswell ayunlimited* telephonic consultation Legal resources Members have unlimited* telephonic consultation with legal professionals or an initial 30-minute face-to- face consultation with in -state legal professionals. If the member retains the legal professional, an additional ZS%discount isavailable. Member website Our member webshaincludes access toinformation and resources toassist with childcare, home health care, assisted living facilities, school, colleges, health clubs, pet services and more. *One session perbauewithun||mitednumberof issues. Management consultation We staff our Management Referral Unit with licensed Our account managers, management resources consultants and training consultants all stay abreast of knowledge to help formulate and update corporate Resources department — without the added expense. Critical Incident Response VVecustomize and design critical incident responses to meet your organizational and individual needs, 10 minimize damage and return people toprevious levels mf productivity assoon aspossible, Unlimited incidents included, upto ten hours per Proactive Account Management We have a seasoned account management team for any question, reports or feedback. I Theft Astaff certified Fraud Resolution telephonic specialist provides aconsultation upto6Dminutes for victims ofIdentity Theft. myStrengthm VVenow provide myStneng¢hw,aunique online emotional wellness portal. |1can help your employees with mild or moderate depression and anxiety. The program offers practical ways toimprove emotional and overall well-being through eLearningprograms, simple tools, trusted resources and daily motivation. Member mobile app Access Aetna Resources For Living onthe Amwith our mobile app. VVeprovide access toresources and content onyour schedule and track your mood or email aservice request. Terms and Conditions Pricing assumptions ° Prices assume no commissions orother fees payable to brokers or consultants. ° Quote does not apply toexisting full -service EAP customers. ° Billing process of single EAP bill at plan sponsor level from centralized EAP Operations. Any deviation from standard billing process will require EAP Operations approval. ° Prices are guaranteed for three years from the effective date. • Any deviation from the rate card will require a customer -specific quote from EAP Underwriting. • EAP services may be subject to regulation under the Knox Keene Act in the State of California Program documentation and procedures may beadjusted accordingly. EAP Terms/Conditions - Quote allows access for employees and immediate household members up to the selected number of sessions per issue, per year. * Quote assumes employee population will not increase ordecrease bymore than 20%. Bates may beadjusted if the population falls out ofthis range. * An unlimited number of Standard Critical Incident Response sessions are included in the EAP Session Model PE/PM Rate. Critical Incident Response Services are limited to lOhoue per incident. Immediate services and issues concerning downsizing, mergers, acquisition activities (i.e. Reductions in Force or RIFs), catastrophic natural disasters, and terrorism, or services beyond the 10 hour cap, are subject to the hourly rates below, ' Standard Services: On -site attendance response time ingreater than two hours: $2SOper hour plus travel. Immediate Services: On -site attendance response time in less than two hours: $35Oper hour plus travel. Reduction |nForce Services: $25Oper hour plus travel. Travel and preparation expenses reimbursed at a flat rate of $150 per location. Workplace Seminars/Brown Bag Training — General behavioral health and worklife training, including employee andsupemisororientaMonprovi6edin-persnn,te|ephonicaU\\orthnoughtheweb. $25Qper hour plus travel. Travel and preparation expenses reimbursed at a flat rate of $150 per location. If training is not scheduled consecutively or multiple topics are scheduled, additional travel and preparation costs may apply. For webinars with more than 25 participants, an additional charge of $50 applies for each additional 25 participants uptoamaximum of2OOparticipants, Department of Transportation (DOT) services are excluded from standard Training and Education services. Cancellation fees: Crisis Response orReductions inForce: Failure toprovide 24hour notice ofcancellation ofservices which are excluded from the unlimited provision listed above which are subject to the hourly rate will result in a charge of $375 per incident. Trainings: Failure to provide three business days' notice of cancellation of a previously scheduled training program will result inacharge of$375per hour. °Drug Free Workplace services: ' Substance Abuse Case Management byaSubstance Abuse Professional (5AP) and/or Department of Transportation regulation compliance. $75Oper case. Department ofTransportation (D0T)Training Please contact Aetna Behavioral Health for pricing. Aetna Resources For Livingsm is the brand name used for products and services offered through the Aetna group of subsidiary companies (Aetna). The EAP is administered by Aetna Behavioral Health, LLC. and in All EAP calls are confidential, except as required by law. This material is for informational purposes only. It contains only a partial, general description of programs and services and does not constitute a contract. EAP instructors, educators and network participating providers are independent contractors and are neither agents nor employees of Aetna. Aetna does not direct, manage, oversee or control the individual services provided by these persons and does not assume any responsibility or liability for the services they provide and, therefore, cannot guarantee any results or outcomes. The availability of any particular provider cannot be guaranteed and is subject to change. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to gJ20I7Aetna Inc. City Of Southlake Michelle Sunday 1400 Main St, Ste 260 REffluffiminymmmm Alonzo Sanchez 5rAccount Manager Z777StemmonsFreeway Dallas, TX752D7 Phone:214'2DO'8l81 SanchezA@AETNAzom As we approach the anniversary of our partnership in the journey to better health, we are pleased to present you with this renewal for your 2020 policy period. It's important to understand the full financial picture of your benefit plan. Therefore, the enclosed package provides the following important information about the cost of your current program and the value vvebring tuyou and your company. Rate Summary - This section illustrates the cost projections to operate your current benefit program for the period 10/1/2020 through 9/30/2021. This section contains the experience analysis and the development of the projected costs. As shown in this section, the cost to operate your current plan increase 4.50% for dental. This increase reflects both the Aetna premium and the commission. I Financial and Administrative Assumptions FI - Our renewal offer is contingent upon the parameters outlined here. It is important to note that deviations from these assumptions may result in additional charges and/or adjustments on our Dental quotations. Please review this section thoroughly. Ifthere are nuchanges that impact the conditions of this renewal as outlined in our Financial Assumptions section the rates will remain in effect through 09/30/2021, Sincerely, Alonzo Sanchez 8rAccount Manager WING Health Insurance Company of New York, Aetna Life Insurance Company (Aetna). In Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Health benefits and health insurance plans contain limitations and exclusions. O5/27/2O2O City Of Southlake The financial quotation presented is based on the financial and administrative assumptions outlined in this document. It is important to note that deviations from these assumptions may result in additional charges and/or adjustments to the renewal rates and/or site terminations. Aetna Medical/Dental Coverage The proposed medical and dental renewal rates are contingent upon both medical and dental lines of coverage renewing with Aetna. Funding Arrangement Insured dental renewal rates are on a prospectively rated basis. Plan eligibility Our rates assume that permanent full-time employees work a minimum of 25 hours per week on a regularly scheduled basis and that eligible dependents include an employee's spouse and unmarried children up to the limiting age of the plan. Our rates assume that temporary employees are not eligible for coverage. Contribution Strategy/ Participation Contributory plans: The employer pays at least 50% of the cost of employee only coverage (75% participation required) Open Enrollment The rates assume that there will be a predetermined annual enrollment period when all eligible employees have a choice of enrolling in any of the available plans. For voluntary plans, late entrant rules will be applied at annual enrollment (i.e., no true "open enrollment") as well as throughout the year. Enrollment Assumptions We have assumed that the plan of benefits will be extended to all groups included in our current eligibility files. Our renewal assumes that coverage will not be extended to any additional groups of employees without additional census and rate determination. A summary of assumed enrollment by plan option has been provided in the rate exhibit, Plan Design The renewal is based on the current plan design. Aetna's standard provisions, contract wording and claim settlement practices will apply for items not specifically outlined. Billing and Payment of Premium Amount due is payable on the first day of the month covered by the invoice, If the amount due is not paid in full within 30 days, Aetna reserves the right to terminate the contract and/or assess late premium payment charges. Dental Preferred Provider Organization (PPO) • Allows members to choose the dentist they want and pay deductibles and coinsurance up to an annual maximum. • Members generally save on dental costs when they see an in -network dentist, as coinsurance is applied to a negotiated rate. • Flexible claims system allows us to accommodate deductibles, coinsurance levels and plan maximums you choose. • Member cost sharing is based on negotiated provider fees. • Participating dentists will not balance bill members. • Offered on an active or passive basis with varying coinsurance, deductible and maximum levels. Aetna DentalO PPO If Network • This vendor -based network offers even greater access than our dental FPO plan by supplementing our traditional dental PPO network, • Rental providers located throughout the country offer discounts that are typically less than the discounts for PPO providers. • Increased access can lead to greater member satisfaction and less disruption. Dental Out of Network Savings Dental Out of Network Savings program is included for Indemnity and PPO dental plans that determine the Recognized Charge for out -of -network services based on FAIR Health data; it is not, however, available for dental benefits that are embedded with a medical plan. Aetna contracts with third -party network vendors that, in turn, have contracted with dentists who have agreed to charge discounted rates. Those dentists are still considered out -of -network providers, and the services they provide will be covered in accordance with your plan's benefits for out -of -network services. There is no additional charge to your per -employee -per -month (PERM) administrative services fee for adding this program. Aetna will retain 40% of the savings as a network access and servicing charge. Savings are calculated as the difference between your plan's Recognized Charge and the vendor's negotiated rates with providers participating in the Dental Out of Network Savings Program. May 2020 Proprietary vaetna, Page 2 City Of Southlake Dental Digital Tools We've improved our member website and added tools and content that empower AetnaDenta|*membeototakecortm|mf their oral health and maximize their benefits. = Find and compare dentists based onquality and price ° Read patient reviews and get detailed professional history for providers ° Evaluate aut-of-pnckctcosts for common services ° Track remaining balances, view claims and get treatment reminders ° Schedule appointments online ° Reduce out-of-pocket costs by providing increased price transparency and education about the value of staying in -network ~ Find the best in -network providers for them with better search capabilities, provider profiles, ratings and reviews " Better manage their family's oral health through easv-to-n avi Rate benefits dashboards Commission If commissions payable to a broker ka t Enrollment There isa1O%change inthe total numberofcmployeeyenmUedineachindkidua|Aetnaprnductorinaggregate,induding the impact ofnew ortenninat|nwlocations and/or jzmuns. Census We reserve the right to reallocate the premium ratios and/or the premium rates due to changes in composition of the censu Multiple Carriers In the event alternative carriers are to be offered. we reserve the rieht to reassess our rates immediately. Change in Plan Our guidelines allow for a change in plan on the renewal date only, unless initiated by legislative actions. If a material | chanize in the plan is initiated by and approved bv Aetna, an adiustment to the rates mav apply. Commissions Commissions - As requested, for dental we have included 3% commissions in our quoted rates. Medical - Dental ID Card (CmeCard) At Aetna, our goal is to make accessing care as simple as possible. To help our members access care when they need it, we provide a consolidated family medical and dental ID card (OneCard) as our standard offering, where applicable. Members only need to carry one ID card, regardless of their coverage, which they can also access on their smartphone through Aetna Employees in AZ, CA, GA, MA, MID, MCI, NC, NJ and TX must either live or work within the approved DM01 service area to be eligible to enroll in the DM01. Fees and Assessments Health Insurance Providers Fee (HIF) is a recurring, annual, industry fee assessed based on each insurer's share of the fully insured market, as determined by the IRS. The total assessment will increase each year thereafter at the rateof industry premium growth. Per the Omnibus Bill, signed on December 20\ 2019, HIP has been repealed for 2021 and beyond. This rate quote includes, as applicable, an estimated proportionate allocation of expense associated with the HIF. Aetna reserves the right to modify these rates, or otherwise recoup such fees, based on future regulatory guidance, or subsequent state regulatory approval. May202 HEMBSEEMM Policyholder Number - 0229323 Control Number - 0229323 This exhibit displays the historical experience used in the development of the rates. Claims displayed are incurred claims and have been adjusted and completed. Fully -insured DPPO or Indemnity Dental experience is provided with an average of 100 or more enrolled employees during the experience period where experience is used in the development of the renewal rates. Historical Experience (excludes DMO) Month Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 TOTALS Total Total Dental Adjusted Dental Employees Premium Claims Claims 263 $20,101 $19,374 $19,374 263 $19,866 $17,737 $17,737 263 $19,857 $14,916 $14,916 260 $19,592 $17,953 $17,953 253 $19,225 $20,596 $20,596 Net Incurred Claims 1,302 $98,641 $90,577 $90,577 $90,577 Net Adjusted Incurred Claims PEPM Premium Development 69.57 Current Employees Emp Only 118 Current Monthly Premium $18,936 Emp + Spouse 29 Current Subscribers 251 Emp + Child(ren) 38 Current Premium PEPM $75.44 Emp + Family 66 TOTAL 251 May 2020 Proprietary Page 4 NEMBSEEMM Policyholder Number - 0229323 Control Number - 0229323 The components of your renewal rate change are detailed below. The current Net Adjusted Incurred Claims Per Employee Per Month (PEPM) are trended forward to the Renewal Rate Period, Administration Expenses, state premium taxes, and commissions are then added resulting in the final required premium PEPM. Refer to the Dental Renewal Assumptions - Financial & Administrative page regarding an explanation of the Health Insurer Fee PEPM. PPO (excluding DMO) PPO Dental 1. Net Adjusted Incurred Claims PEPM $69.57 October 1, 2019 - March 1, 2020 2. Annual Trend 4.5% 3. Months to Trend Experience 15.5 Experience Period: October 1, 2019 - March 1, 2020 Midpoint--> 12/15/2019 Renewal Rate Period: October 1, 2020 - October 1, 2021 Midpoint--> 4/1/2021 4. Trended Experience Incurred Claims PEPM $73.64 5. Experience Credibility 66.0% 6. Manual Claims PEPM $52.00 7. Manual Weight (100% minus #5 above) 34.0% 8. Blended NET Expected Claims PEPM $66.28 9. Margin for Claim Fluctuation (only applies if retrospective) Not Applicable 10. Expenses (includes 3.00% commissions and 0.00% premium taxes) $12.79 11. Health Insurer Fee PEPM( 0.00%) $0.00 12. RENEWAL Premium PEPM (#8 + #9 + #10 + #11) $79.07 Current Employees 251 13. Current Premium PEPM $75.44 14. Calculated Rate Change (#12 / #13) -1 4.8% 15. Needed Premium PEPM (#13 x (1 + #14)) $79.07 May 2020 .Proprietary cwtnaoPage 5 Policyholder Number: 0229323 Control Number: 0229323 • Please refer to the Financial Assumptions for terms and conditions of this renewal. • Please refer to the Financial Assumptions regarding an explanation of the Health Insurer Fee PEPM. Current/Assumed ONSHOWN Coverage Categories Employees Current Rates Renewal Rates % Change Emp Only 30 $14.75 $14.75 0.0% Emp + Spouse 5 $28.03 $28.03 0.0% Emp + Child(ren) 9 $29.53 $29.53 0.0% Emp + Family 10 $45.72 $45.72 0.0% Monthly Total 54 $1,305.62 $1,305.62 0.0% Current/Assumed Coverage Categories Employees Current Rates Renewal Rates % Change Emp Only 118 $39.11 $40.99 4.8% Emp + Spouse 29 $78.23 $81.99 4.8% Emp + Child(ren) 38 $87.02 $91.20 4.8% Emp + Family 66 $132.51 $138.87 4.8% Monthly Total 251 $18,936.07 $19,845.55 4.8% Monthly Totals 1 305 1 $20,241.69 1 $21,151.17 1 4.5% "Aetna" is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. PPO/PDN is underwritten by Aetna Life Insurance Company. DMO is underwritten by Aetna Life Insurance Company, except as follows: Arizona, Georgia: Aetna Health Inc. California: Aetna Dental of California Inc. Maryland, Missouri, North Carolina, Texas: Aetna Dental Inc. New Jersey: Aetna Dental Inc. and Aetna Life Insurance Company. May 2020 Proprietary cwtnaPage 6 Use your Exam coverage once every rolling 12 months Routine/Comprehensive Eye Exam $30 Reimbursement Standard Contact Lens Fit/Follow-Up Not Covered Premium Contact Lens Fit/Follow-Up Not Covered Standard Plastic Lenticular Vision Lenses Premium Progressive Vision Lenses' Reimbursement Reimbursement Reimbursement $40 Reimbursement Standard Plastic Scratch Coating $15 Reimbursement Standard Polycarbonate Lenses - Adult Not Covered Standard Polycarbonate Lenses - Children To Age 19 $35 Reimbursement Standard Anti -Reflective Coating Not Covered Polarized And Other Lens Add Ons Not Covered Use your Lens coverage once every rolling 12 months to purchase either 1 pair of eyeglass lenses OR 1 order of contact lenses Conventional Contact Lenses $88 Reimbursement Disposable Contact Lenses $88 Reimbursement Medically Necessary Contact Lenses $200 Reimbursement Use your frame coverage once every rolling 24 months Any Frame available, including frames for prescription $65 Reimbursement sunglasses Employee Only $5.91 Employee + Spouse $11.24 Employee + Child(ren) $11.82 Employee + Family $17.38 Additional pairs of eyeglasses or prescription sunglasses' Up to a 40 % Discount Non -covered items31 20 % Discount Lasik Lasser vision correction or PRK from U.S. Laser I 15 % discount off retail or 5 % discount off the promotional price Network only. Call 1-800-422-6600 Retinal Imagings Member pays a discounted fee up to $39 version 04-15-20 aropDate Printed: 05-27-2020 We have made every effort to respond to your request in a manner that reflects existing and expected business practices for the effective date that you have chosen. Pricing and Underwriting Assumption Our proposal assumes that coverage will be extended to all eligible employees. This quotation is on a pretax basis and will be void for post -tax offerings. Policies and Claim Settlement Practices Our proposal assumes that our standard contract provisions and claim settlement practices will apply. If a material change is initiated by you due to legislative or regulatory action in the claim payment requirements or procedures, account structure, or any changes materially affecting the manner or cost of paying benefits, we reserve the right to adjust our proposal accordingly. Participation requirements A minimum participation level of 10 enrolled subscribers is required. Plan Offering We have assumed that Aetna will be the sole Vision vendor offered. Rate Guarantee Our quoted rates are guaranteed for the first 3 years of the policy period and are valid as of the plan effective date. The quoted rates apply only to the benefit levels and conditions specified and any variations in benefit level or assumed conditions may require a rate change. We reserve the right to review and modify or terminate the guarantee arrangement if any of the following occur during the guarantee period: • Failure to make required premium payments in accordance with policy provisions. • A material change in the plan of benefits offered that is initiated by you or required because of legislative or regulatory action. Affordable Care Act— Fees and Assessments The Patient Protection and Affordable Care Act imposes a Health Insurer Fee ( the "Fee"). The Fee became effective on January 1, 2014. The Fee will be suspended for 2019, but reinstated starting in 2020. This rate quote includes, where permitted, the estimated proportionate allocation of the Fee for the years where the Fee is applicable. Plan Eligibility Our quoted rates assume that permanent full-time employees work a minimum of 25 hours per week on a regularly scheduled basis and that eligible dependents include an employee's spouse and unmarried children up to age 26. Run -Off Claim Processing Our quoted rates reflect an incurred (mature) claim base and take into account the expenses associated with the processing of run-off claims following cancellation, subject to the conditions of our financial guarantee. Fiduciary Aetna is claim fiduciary ID Cards Our quoted rates include the cost for standard ID cards. Each vision subscriber will receive two ID cards. The ID card includes a toll -free number for accessing member services. Commissions - 10 % commissions have been included in our rates. Compensation to Producers (Brokers, Agents and Consultants): Licensed and appointed producers may earn compensation in the form of a commission on the sale of this product. The amount of compensation varies depending on a number of factors, including customer segment and the product selected. Aetna offers additional bonus programs to its producers, which may also apply. Please consult your broker for additional information concerning their compensation for this sale, including commissions and any applicable bonus programs. The producer is prohibited by law from altering the amount of compensation received from Aetna based in whole or in part on the sale. Compensation to Salaried Aetna Employees: Salaried employees may earn compensation on the sale of Aetna products. The compensation varied depending on a number of factors, including customer segment and product selected. Combining all factors, compensation for each product quoted averages less than 8 % of the total first year annual premium. Aetna offers additional bonus programs, which may also apply. Neither Aetna nor the employee has material ownership interest in the other. The employee may not alter the amount of compensation received from Aetna. You may obtain additional information about the compensation expected to be received by eligible employees, based in whole or in part on the sale of an Aetna product, or alternative options presented, by contacting Aetna at www.aetna.com/about-us/forms/employee-compensation-disclosure.html. Exclusions and limitations for vision include: any charges in excess of the benefits, dollar or supply limits listed above; special vision procedures, such as orthoptics, vision therapy or vision training; vision services or supplies that do not meet professionally accepted standards; plane (non-prescription) lenses; non-prescription sunglasses; two pair of glasses in lieu of bifocals; medical and/or surgical treatment of the eyes; cosmetic services; lost or broken lenses, frames, glasses or contact lenses. Other exclusions and limitations may also apply. *You can choose to receive care outside the network. Simply pay for the services up front and then submit a claim form to receive an amount up to the out of network reimbursement amounts listed above. Reimbursement will not exceed the providers actual charge. Claim forms can be found at www.aetnavision.com or by calling customer service Mon -Sun @ 877-9-SEE-AETNA. Submit completed claim form with receipts to Aetna, PO Box 8504 Mason, OH 45040-7111. Enrolled members can access our secure member website once their plan becomes effective. Enrolled subscribers will receive a welcome packet with ID card mailed to their home within 15 business days after enrollment is processed. **Allowances are one-time use benefits. No remaining balances may be used. The plan does not provide a declining balance benefit. 'Premium progressives and premium anti -reflective Brand designations are subject to annual review and change based on market conditions. Ask your eye care provider for more information. 2Additional pair discount applies to purchases made after the plan allowances have been exhausted. Non covered discounts may not be available in all states. °Lasik or PRK from the US Laser Network, owned and operated by LCA Vision. 5Retinal Imaging available at participating locations. Contact your eyecare provider to verify if available. Vision insurance plans are underwritten by Aetna Life Insurance Company (Aetna). Certain claims administration services are provided by First American Administrators, Inc. and certain network administration services are provided through EyeMed Vision Care ("EyeMed"), LLC. Providers participating in the Aetna Vision network are contracted through EyeMed Vision Care, LLC. EyeMed and Aetna are independent contractors and not employees or agents of each other. Participating vision providers are credentialed by and subject to the credentialing requirements of EyeMed. Aetna does not provide medical/vision care or treatment and is not responsible for outcomes. Aetna does not guarantee access to vision care services or access to specific vision care providers and provider network composition is subject to change without notice. This quote is based on a contract situs of Texas. Extraterritorial state requirements may apply to members residing in specific States. If your plan covers members in other states, impacts to your plan of benefits and rates adjustments (if any) will be evaluated and communicated to you at the point of sale. Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability. Aetna provides free aids/services to people with disabilities and to people who need language assistance. If you need a qualified interpreter, written information in other formats, translation or other services, call 877-973-3238. If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with Civil Rights Coordinator by contacting: Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512, 1-800-648-7817, TTY: 711, Fax: 859-425-3379, CRCoordinator@aetna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https:Hocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD). Help for those who speak another language and for the hearing impaired For language assistance in your language call 877-973-3238. Para obtener asistencia linggistica an espanol, Ilame sin cargo al numero qua figure an su tarjeta de identificaci6n. Customer Signature: Date: NDEPENDENT PEARLE NETWORK VISION' version 04-15-20 Date Printed: 05-27-2020