Item 4D - MemoItem 4D
M E M O R A N D U M
July 25, 2023
TO: Shana Yelverton, City Manager
FROM: Stacey Black, Senior Director of Human Resources
SUBJECT: Approve a contract renewal with Cigna to provide employee health,
dental, and vision insurance benefits for Plan Year October 1, 2023
through September 30, 2024.
Action
Requested: Approve a contract with Cigna to provide employee health, dental, and
vision insurance benefits for Plan Year October 1, 2023 to September
30, 2024.
Background
Information: Full-time employees are offered health, dental and vision insurance as
part of the City's standard benefits package. Cigna is the City's current
provider and became the provider on October 1, 2021 following a
competitive bidding process. Cigna offers employees four medical plan
options, two dental plan options, and one vision plan. In early June, the
City received its health, dental, and vision insurance proposed renewals
from Cigna.
Health Insurance.
Since October 1, 2022, Cigna reports the City has experienced an
approximate 95% loss ratio for medical and prescription claims,
and in April 2023 the loss ratio spiked to 119%. In addition,
Cigna also reports the City is currently experiencing 22
large, ongoing claims.
In light of the high claims experience, Cigna's initial renewal offer
proposed a 14.9% rate increase. Following negotiations, Cigna
reduced its renewal offer to an average 6.9% rate increase. The rate
increase varies by plan option due to differences in usage for each
plan. The renewal includes plan modifications designed to
encourage the use of urgent care facilities when appropriate. As
such, the co-pay for urgent care will decrease from $75 to $50,
while the emergency room co-pay will increase from $300 to $500
on plans that utilize co-pay.
Shana Yelverton, City Manager Item 4D
July 25, 2023
Page 2
The estimated cost of the City's contribution towards health
insurance of the original 14.9% premium increase is $463,050;
however, the final negotiated 6.9% premium increase reduces the
estimated cost increase to $216,012.
The illustration below reflects the estimated annual cost of the
original proposal and the estimated annual cost of the final
negotiated proposal.
Based upon a review of the claims history and the ongoing large
claims, staff believes the final proposed renewal is fair.
Dental Insurance.
Since October 1, 2022, Cigna reports the City has experienced an
approximate 86% loss ratio for dental claims. As a result of the claims
experience and the increasing cost of dental procedures, Cigna's
dental renewal proposes a 5% rate increase for the PPO dental plan
and a 2.5% increase for the DMO dental plan. Both the City and
employees share the cost of dental insurance. The estimated annual
cost of the premium increase for the City's contribution is $7,227.
Vision Insurance.
Since October 1, 2022, Cigna reports the City has experienced an
approximate 80% loss ratio for vision claims. As a result of the claims
experience and the increasing cost of vision claims, Cigna's vision
renewal proposes a 4.5% rate increase. Vision insurance is optional,
and employees contribute 100% of the cost.
Shana Yelverton, City Manager Item 4D
July 25, 2023
Page 3
Staff believes the proposed health, dental, and vision insurance renewal
is financially favorable, given the City's ongoing claims experience. Staff
recommends City Council approve the proposed health, dental, and
vision insurance renewals.
Financial
Considerations:
The cost estimates reflected above assume current employee
enrollment and elections.
The proposed insurance plan costs will be included in the proposed
budget for FY 2024.
Strategic Link: Performance Management and Service Delivery and L3: attracting,
developing, and maintaining a talented and motivated workforce.
Citizen Input/
Board Review: N/A
Legal Review: N/A
Alternatives: Deny the contract with Cigna and seek alternative options.
Supporting
Documents: The following supporting documents are attached:
•Cigna Health Insurance Renewal
•Cigna Dental & Vision Renewal Rate Sheet
•Cigna Dental Insurance Proposal
•Cigna Vision Insurance Proposal
Staff
Recommendation: Approve a contract with Cigna to provide employee health insurance,
dental insurance, and vision insurance benefits for Plan Year October 1,
2023 through September 30, 2024.
COVERAGE ESTIMATED ANNUAL
TOTAL CITY
CONTRIBUTION
ESTIMATED ANNUAL
INCREASE
Health Insurance $5,144,223 $216,012
Dental Insurance $160,382 $7,227
Vision Insurance $0 $0
Note: The Quoted rates are subject to final Underwriting approval and, as noted below, are subject to change in the event
of changes in benefits selected or changes in the risk factors upon which the Quoted Rates are based. In addition, state
law may require regulatory approval of rates. If required regulatory approval has not been obtained on the proposed
effective date, the healthplan shall use rates that are consistent with its then currently approved rating methodology and
the quoted rates shall be effective immediately on the date for which they are approved for use. The Quoted Rates are
guaranteed while the Group Service Agreement remains in effect until the next anniversary date, unless enrollment
changes by 10% in which case Cigna HealthCare may change the Quoted Rate.
for
Cigna HealthCare
Medical Sold Renewal
City of Southlake Insurance Trust Fund
1400 Main St., Suite 210
Southlake, TX 76092-7645
Effective Date: October 01, 2023
SIC Code: 9111
Account Number: 3344509
Cigna Healthcare Financial Exhibit for:
City of Southlake Insurance Trust Fund
Effective Date: October 01, 2023
Q1P4 Opt. 1: +6.87%, $30k wellness (no-shop)
Cigna PLAN OFFERED
Open Access Plus
OAP Premium
Open Access Plus In- Network
OAPIN Buy Up
LocalPlus In-Network
LCPIN Mid
Plan Offering Quadruple Option Quadruple Option Quadruple Option
Plan Name OAP Premium Opt. 1 (17588877) OAPIN Buy Up Opt. 1 (17588879) LCPIN Mid Opt. 1 (17588880)
Medical Management Model Complete Care Complete Care Complete Care
Health Advocacy Excluded Excluded Excluded
Situs TX TX TX
Funding Fully Insured Fully Insured Fully Insured
Cigna MEDICAL BENEFITS*
Collective Deductible NO NO NO
Collective OOP NO NO NO
Combined Medical/Pharmacy Ded/OOP Combined OOP Only Combined OOP Only Combined OOP Only
Deductible/OOP Max Accumulator No Cross Accumulation NA NA
Variable Coinsurance Applies YES YES YES
Plan Deductible Order of Applicability Benefit Copay, Plan Deductible,
Coinsurance
Benefit Copay, Plan Deductible,
Coinsurance
Benefit Copay, Plan Deductible,
Coinsurance
In-Network:
Office Copay - PCP $25 $30 $30
Office Copay - SPC $50 $50 $50
Inpatient Deductible - Per Admit NA NA NA
Inpatient Deductible - Per Day NA NA NA
Outpatient Facility Copay None None None
Emergency Room Copay $500 $500 $500
Urgent Care Copay $50 $50 $50
Advanced Radiology Imaging Copay - Office None None None
Advanced Radiology Imaging Copay - Outpatient None None None
Deductible - Individual $1,500 $2,000 $1,500
Deductible - Family $3,000 $4,000 $3,000
Out-of-Pocket - Individual $3,500 $5,500 $5,000
Out-of-Pocket - Family $7,000 $11,000 $10,000
Out-of-Pocket - Family - Individual Amount $3,500 $5,500 $5,000
Out-of-Pocket Max Deductibles Ded Accumulates Ded Accumulates Ded Accumulates
Out-of-Pocket Max Copays All Copays Accumulate All Copays Accumulate All Copays Accumulate
Coinsurance Variable Variable Variable
PCP Office Visits 100% 100% 100%
Specialist Office Visits 100% 100% 100%
Inpatient Hospital Facility 80% 80% 80%
Outpatient Hospital Facility 80% 80% 80%
Inpatient Professional Services 80% 80% 80%
Outpatient Professional Services 80% 80% 80%
Emergency Room 80% 80% 80%
Urgent Care 100% 100% 100%
Laboratory Services at an Outpatient Facility 100% 100% 100%
Laboratory Services at an Independent Lab Facility 100% 100% 100%
Radiology Services at an Outpatient Facility 100% 100% 100%
Medical Specialty Drugs at an Outpatient Facility 80% 80% 80%
Medical Specialty Drugs at a Physician's Office 80% 80% 80%
Medical Specialty Drugs at Home Setting 80% 80% 80%
Out of Network:
Deductible - Individual $2,500 NA NA
Deductible - Family $7,500 NA NA
Out-of-Pocket - Individual $6,500 NA NA
Out-of-Pocket - Family $19,500 NA NA
Out-of-Pocket - Family - Individual Amount $6,500 NA NA
Out-of-Pocket Max Deductibles Ded Accumulates NA NA
Out-of-Pocket Max Copays All Copays Accumulate NA NA
Coinsurance Variable NA NA
PCP Office Visits 50% NA NA
Specialist Office Visits 50% NA NA
Inpatient Hospital Facility 50% NA NA
Outpatient Hospital Facility 50% NA NA
Inpatient Professional Services 50% NA NA
Outpatient Professional Services 50% NA NA
Emergency Room 80% NA NA
Urgent Care 100% NA NA
Laboratory Services at an Outpatient Facility 50% NA NA
Laboratory Services at an Independent Lab Facility 50% NA NA
Radiology Services at an Outpatient Facility 50% NA NA
Medical Specialty Drugs at an Outpatient Facility 50% NA NA
Medical Specialty Drugs at a Physician's Office 50% NA NA
Medical Specialty Drugs at Home Setting 50% NA NA
Maximum Reimbursable Charge Option 2 NA NA
Inpatient Deductible - Per Admit NA NA NA
Inpatient Deductible - Per Day NA NA NA
Outpatient Facility Deductible None NA NA
MRC Fee Schedule Percentage (Professional) 110% NA NA
MRC Fee Schedule Percentage (Facility/Ancillary) 110% NA NA
Mental Health/Substance Use Disorder (Yes/No)Yes Yes Yes
Vision Rider (Yes/No)No No No
*High level benefit summary. Please see your plan summary for a more
detailed benefit description. If this proposal includes Cigna Care Network,
the level of in-network benefits applicable may vary from what is shown
above.
Acct#:3344509/OP-5302612/Q1/3245456 Page 2 of 11 6/7/2023 10:41 AM
Cigna Healthcare Financial Exhibit for:
City of Southlake Insurance Trust Fund
Effective Date: October 01, 2023
Q1P4 Opt. 1: +6.87%, $30k wellness (no-shop)
Cigna PLAN OFFERED
Open Access Plus
OAP Premium
Open Access Plus In-
Network
LocalPlus In-Network
LCPIN Mid
Plan Offering Quadruple Option Quadruple Option Quadruple Option
Plan Name OAP Premium Opt. 1
(17588877)
OAPIN Buy Up Opt. 1
(17588879)
LCPIN Mid Opt. 1
(17588880)
Medical Management Model Complete Care Complete Care Complete Care
Health Advocacy Excluded Excluded Excluded
Situs TX TX TX
Funding Fully Insured Fully Insured Fully Insured
Pharmacy Benefits
Pharmacy Network Focused 90 - CVS Focused 90 - CVS Focused 90 - CVS
Formulary/Prescription Drug List Standard Standard Standard
Retail Generic Copay $10 $10 $10
Retail Pref Brand Copay $35 $35 $35
Retail Non Pref Brand Copay $70 $70 $70
Retail Specialty Copay $150 $150 $150
Retail Generic Copay (90 Days) $25 $25 $25
Retail Pref Brand Copay (90 Days) $88 $88 $88
Retail Non Pref Brand Copay (90 Days) $175 $175 $175
Home Delivery Generic Copay $25 $25 $25
Home Delivery Pref Brand Copay $88 $88 $88
Home Delivery Non Pref Brand Copay $175 $175 $175
Home Delivery Specialty Copay $375 $375 $375
Pharmacy Deductible - Individual None ($0) None ($0) None ($0)
Pharmacy OOP Maximum - Individual Combined With Medical Combined With
Medical
Combined With
Medical
Out-of-Pocket Adjuster Program Excluded Excluded Excluded
*High level benefit summary. Please see your plan
summary for a more detailed benefit description. If this
proposal includes Cigna Care Network, the level of in-
network benefits applicable may vary from what is
hb
Page 3 of 11 6/7/2023 10:41 AM
Cigna Healthcare Financial Exhibit for:
City of Southlake Insurance Trust Fund
Effective Date: October 01, 2023
Q1P4 Opt. 1: +6.87%, $30k wellness (no-shop)
Cigna PLAN OFFERED
CIGNA HealthCare - Choice Fund HSA Open Access Plus
HSA OAP Base
Plan Offering Quadruple Option
Plan Name HSA OAP Base Opt. 1 (17588878)
Medical Management Model Complete Care
Health Advocacy Excluded
Situs TX
Funding Fully Insured
Cigna MEDICAL BENEFITS*
Collective Deductible NO
Collective OOP NO
Combined Medical / Pharmacy Ded / OOP Combined Ded & OOP
Deductible/OOP Max Accumulator No Cross Accumulation
Variable Coinsurance Applies NO
Plan Deductible Order of Applicability Plan Deductible, Benefit Copay, Coinsurance
In-Network:
Office Copay - PCP None
Office Copay - SPC None
Deductible - Individual $3,000
Deductible - Family $6,000
Individual - In a Family Amount Deductible $3,000
Out-of-Pocket - Individual $6,000
Out-of-Pocket - Family $12,000
Out-of-Pocket - Family - Individual Amount $6,000
Out-of-Pocket Max Deductible Ded Accumulates
Out-of-Pocket Max Copays All Copays Accumulate
Coinsurance 90%
Adult Preventive Care 100%, No Ded
Out of Network:
Deductible - Individual $6,000
Deductible - Family $18,000
Individual - In a Family Amount Deductible $6,000
Out-of-Pocket - Individual $12,500
Out-of-Pocket - Family $37,500
Out-of-Pocket - Family - Individual Amount $12,500
Out-of-Pocket Max Deductibles Ded Accumulates
Out-of-Pocket Max Copays All Copays Accumulate
Coinsurance 50%
MRC Fee Schedule Percentage (Professional) 110%
MRC Fee Schedule Percentage (Facility/Ancillary) 110%
Mental Health/Substance Use Disorder (Yes/No)Yes
Vision Rider (Yes/No)No
Employer Fund Contribution
Fund Amount - Individual $0
Fund Amount - Family $0
Eligible Expense Included
*High level benefit summary. Please see your plan summary for a more
detailed benefit description. If this proposal includes Cigna Care Network,
the level of in-network benefits applicable may vary from what is shown
above.
Acct#:3344509/OP-5302612/Q1/3245456 Page 4 of 11 6/7/2023 10:41 AM
Cigna Healthcare Financial Exhibit for:
City of Southlake Insurance Trust Fund
Effective Date: October 01, 2023
Q1P4 Opt. 1: +6.87%, $30k wellness (no-shop)
Cigna PLAN OFFERED
CIGNA HealthCare - Choice Fund HSA Open Access Plus
HSA OAP Base
Plan Offering Quadruple Option
Plan Name HSA OAP Base Opt. 1 (17588878)
Medical Management Model Complete Care
Health Advocacy Excluded
Situs TX
Funding Fully Insured
Pharmacy Benefits
Pharmacy Network Focused 90 - CVS
Formulary/Prescription Drug List Standard
Retail Generic Copay $10
Retail Pref Brand Copay $35
Retail Non Pref Brand Copay $70
Retail Specialty Copay $150
Retail Generic Copay (90 Days) $25
Retail Pref Brand Copay (90 Days) $88
Retail Non Pref Brand Copay (90 Days) $175
Home Delivery Generic Copay $25
Home Delivery Pref Brand Copay $88
Home Delivery Non Pref Brand Copay $175
Home Delivery Specialty Copay $375
Pharmacy Deductible - Individual Combined With Medical
Pharmacy OOP Maximum - Individual Combined With Medical
Out-of-Pocket Adjuster Program Excluded
*High level benefit summary. Please see your plan summary for a more
detailed benefit description. If this proposal includes Cigna Care Network,
the level of in-network benefits applicable may vary from what is shown
above.
Page 5 of 11 6/7/2023 10:41 AM
Cigna Healthcare Financial Exhibit for:
City of Southlake Insurance Trust Fund
Effective Date: October 01, 2023
Q1P4 Opt. 1: +6.87%, $30k wellness (no-shop)
Cigna PLAN OFFERED
Plan Offering
Plan Name
Situs
Subscribers Members Current Rate Renewal Rate Monthly Billed
Amount
Change
Employee 25 $853.95 $907.67 $22,691.75 6.29%
Emp + Spouse 6 $1,904.31 $2,024.10 $12,144.60 6.29%
Emp + Child(ren)6 $1,682.29 $1,788.12 $10,728.72 6.29%
Emp + Family 6 $2,792.42 $2,968.09 $17,808.54 6.29%
Monthly Billed Amount 43 79 $63,373.61
Cigna PLAN OFFERED
Plan Offering
Plan Name
Situs
Subscribers Members Current Rate Renewal Rate Monthly Billed
Amount
Change
Employee 37 $673.81 $747.58 $27,660.46 10.95%
Emp + Spouse 5 $1,509.01 $1,674.21 $8,371.05 10.95%
Emp + Child(ren) 18 $1,332.46 $1,478.34 $26,610.12 10.95%
Emp + Family 16 $2,215.22 $2,457.74 $39,323.84 10.95%
Monthly Billed Amount 76 160 $101,965.47
Cigna PLAN OFFERED
Plan Offering
Plan Name
Situs
Subscribers Members Current Rate Renewal Rate Monthly Billed
Amount
Change
Employee 55 $782.49 $840.34 $46,218.70 7.39%
Emp + Spouse 8 $1,744.99 $1,873.99 $14,991.92 7.39%
Emp + Child(ren) 33 $1,541.54 $1,655.51 $54,631.83 7.39%
Emp + Family 22 $2,558.79 $2,747.96 $60,455.12 7.39%
Monthly Billed Amount 118 264 $176,297.57
Cigna PLAN OFFERED
Plan Offering
Plan Name
Situs
Subscribers Members Current Rate Renewal Rate Monthly Billed
Amount
Change
Employee 39 $819.93 $853.87 $33,300.93 4.14%
Emp + Spouse 8 $1,828.43 $1,904.11 $15,232.88 4.14%
Emp + Child(ren) 21 $1,615.25 $1,682.11 $35,324.31 4.14%
Emp + Family 28 $2,681.16 $2,792.13 $78,179.64 4.14%
Monthly Billed Amount 96 231 $162,037.76
Note: The fee associated with the administration of the HRA and/or HSA product and Incentive Program are excluded from the Rates.
Above rates do not reflect employer liability for fund contributions
Included in the proposed Monthly Billed Amount is the Benefit Advisor Fee which is not part of the monthly premium.
Open Access Plus
OAP Premium
Quadruple Option
OAP Premium Opt. 1
TX
OAP Premium (TXOAPD, TXOAPF, TXOAPN, TXOAPW, TXOAPX)
CIGNA HealthCare - Choice Fund HSA Open Access Plus
HSA OAP Base
Quadruple Option
HSA OAP Base Opt. 1
TX
HSA OAP Base (TXOAPD, TXOAPF, TXOAPN, TXOAPW, TXOAPX)
Open Access Plus In- Network
OAPIN Buy Up
Quadruple Option
TX
LCPIN Mid (TXLCPD, TXLCPF, TXLCPX)
OAPIN Buy Up Opt. 1
TX
OAPIN Buy Up (TXOAPD, TXOAPF, TXOAPN, TXOAPW, TXOAPX)
LocalPlus In-Network
LCPIN Mid
Quadruple Option
LCPIN Mid Opt. 1
Acct#:3344509/OP-5302612/Q1/3245456 Page 6 of 11 6/7/2023 10:41 AM
Cigna Healthcare Financial Exhibit for:
City of Southlake Insurance Trust
Fund
Effective Date: October 01, 2023
Program Administrative Fees
Fee Type Enrollment PEPM Fee
CIGNA HealthCare - Choice Fund HSA Open Access Plus HSA Administrative Fee 73 $4.50
Open Access Plus Incentive Program 36 $2.75
CIGNA HealthCare - Choice Fund HSA Open Access Plus Incentive Program 73 $2.75
Open Access Plus In- Network Incentive Program 120 $2.75
LocalPlus In-Network Incentive Program 104 $2.75
Total Program Administrative Monthly Fees $1,257.75
For Cigna Healthcare HSA products, the Fees above include the Cigna Healthcare Administrative Fee plus any Additional
Options selected.
For Cigna Healthcare products, the Fees above include the Incentive Program Fees.
Acct#:3344509/OP-5302612/Q1/3245456 Page 7 of 11 6/7/2023 10:41 AM
Cigna Healthcare Financial Exhibit for:
City of Southlake Insurance Trust Fund
Effective Date: October 01, 2023
PROPOSAL TERMS AND CONDITIONS for Proposal: Q1P4 Opt. 1: +6.87%, $30k wellness (no-shop)
A. General Terms of this Proposal
Cigna HealthCare is pleased to present this Proposal for a Fully Insured Non-Participating group medical and pharmacy benefit plan (the "Plan") sponsored by
City of Southlake Insurance Trust Fund. This proposal is valid for 60 days from its original date of release,05/22/2023. Any revisions or updates to this proposal
will not renew this valid timeframe unless expressly communicated by Cigna HealthCare.
Proposal Caveats
Cigna HealthCare may revise or withdraw this Proposal if:
1 there is a change to the effective date and/or duration of the period covered by the quote.
2 the policy period length is different than 12 months.
3 the policy will not be sitused in TX.
4 there is a change in any law, regulation, or required assessment or tax that changes Cigna HealthCare's costs in offering the plan.
5 the final enrollment deviates from the quoted enrollment such that it results in a needed change in premium rates. Rates are based on final enrollment factors,
including total number of enrollees, their age, sex, demographics, location and the distribution of enrollees by product or by customer tier.
6 enrollment in the Cigna HealthCare administered plan is less than 50% of the total eligible population identified as 374.
7 requires you to notify us within 30 days if any of the information upon which these rates or benefits were based (including Medical History Information) changes
or is inaccurate.
8 more than XX other insurers' plans are offered to City of Southlake Insurance Trust Fund's employees in the following worksites: "IDENTIFY"
9 Cigna HealthCare is not the exclusive provider of benefits and participation is below 50% based on the total eligible employee population identified as 374 that
must participate in one of the employer-sponsored medical plans. (NOT necessarily Cigna HealthCare's plan)
10 the employer contributes less than 50% toward the total cost of the coverage elected by each enrolled employee.
11 Cigna HealthCare is not the exclusive provider of benefits and the employer does not contribute the same percentage to the cost of each employer-sponsored
plan.
12 the benefits offered by Cigna HealthCare are at or above parity versus all other carriers, regardless of product type or funding.
13 the current waiting period is different than .
14 By way of illustration, such legislation or executive actions which impose controls or requirements that affect: our ability to determine rates; covered medical
expenses or service benefits; providers' delivery of care or the fees they charge; or our contracts with providers, may be deemed to so affect our contractual
obligations. Should this happen, Cigna HealthCare will make a good faith effort to work to reach a new agreement that equitably reflects the circumstances as
altered by government action.
15 there is any reimbursement arrangement ("gap" cards, etc.) that subsidizes or reduces the out-of-pocket obligation of covered persons under the policy.
16 benefit advisor fees/commissions are requested to be different than 4.20%.
17 Client confirmation of employee counts reveal the group to be a Small Employer,as defined under the Patient Protection and Affordable Care Act,and
accordingly Cigna HealthCare is not able to offer a PPACA compliant plan.
B. Scope and Application of this Proposal
Unless otherwise indicated, the coverage reflected in this Proposal:
1 supersedes and renders null and void any prior Cigna HealthCare offer or proposal with respect to the Plan.
2 or policy may be canceled as of any Premium Due Date if the number of insured Employees fails to meet the minimum required per group participation rules; or
for failure to comply with any other material plan provision relating to Employer contributions or group participation rules.
3 includes fixed charges for behavioral care services arranged by Evernorth Behavioral Health, Inc. or Evernorth Care Solutions, Inc. The fixed fee varies
depending on location and plan design and may not apply in certain states.
4 includes capitated charges for the provision of Hi-Tech Radiology services by eviCore (formerly known as MedSolutions, Inc.). Reimbursement methodology
varies by state.
5 includes charges made by either a specialty vendor or an affiliate, such as eviCore for care management programs to contain the cost of specific health
services/items and/or improve adherence to evidence-based guidelines to promote patient safety and efficient care (i.e., charges for management of diagnostic
cardiology, radiation therapy, musculoskeletal procedures, medical oncology, gastroenterology, sleep management and home health/DME/HIT and appropriate
setting of care/service) when applicable, and medical necessity review (i.e chiropractic services).
6 includes Cigna’s One Guide digital and customer guidance solution.
7 requires a separate benefit option due to state regulations, if you have purchased any product with Cigna Total Behavioral Health and you have customers
residing in CA or VI.
8 does not apply to part-time or seasonal employees for any plan.
9 Medicare eligible retirees are not included in this plan unless mandated by situs state legislation.
10 includes Cigna's Network Savings Program (NSP) and other Cost Containment programs designed to contain costs with respect to charges for out-of-network
health care services/supplies that are covered by the Plan and reduce the member’s balance billing exposure. For administering these programs, Cigna retains a
portion of the savings or recoveries generated.
11 excludes charges for converting a qualified customer of a group plan to an individual plan.
12 limits the allowable amount used in calculating benefits for out-of-network health care services/supplies to a Maximum Reimbursable Charge equal to 110% of a
fee schedule developed by Cigna based upon a methodology similar to that used by Medicare to determine the allowable fee for similar services in the
geographic market, OR, where that fee schedule does not provide a value, the 80th percentile of the usual and customary charges made by providers of such
service/supply or supply in the geographic area where the service/supply is received determined by reference to a third-party data base.
13 assumes all employees are located in the network area, and that all employees are only eligible for the Cigna HealthCare or any other affiliated company
product offerings specified.
14 may require regulatory approval of rates. If, as of their proposed effective date, regulatory approval is not obtained, the healthplan shall use rates consistent with
its then currently approved rates and the foregoing rates shall be effective automatically. If a product is new and has never had approved rates, the effective
date of coverage will be postponed until regulatory approval is received.
15 allows caveats and conditions set forth in this document to survive execution of any final contract and/or issuance by Cigna HealthCare of any policy and/or
Group Service Agreement.
16 assumes that Cigna HealthCare's standard insurance policy form approved for use in the applicable state by the state insurance regulator will be issued.
Because the insurance policy and certificate terms require regulatory approval, there is very little flexibility to change the provisions. The provisions of the
insurance policy and certificate will control in the event of a conflict with the terms of the request for proposal and the Proposal.
Acct#:3344509/OP-5302612/Q1/3245456 Page 8 of 11 6/7/2023 10:41 AM
Cigna Healthcare Financial Exhibit for:
City of Southlake Insurance Trust Fund
Effective Date: October 01, 2023
17 is a high-level summary of the proposed coverage. It does not identify all the categories of health care expenses that are covered or excluded.
18 may include state required continuation rates which will match the rates for the underlying plan. For Nebraska and New York Over Age Dependents the rates
will match the employee rate for the underlying plan.
19 includes fixed charges for Embarc Benefit Protection℠, a network solution for certain high-cost gene therapy drugs arranged by eviCore.
20 Cigna HealthCare assumes that the group health plan or health insurance coverage to which this proposal applies will not be a "grandfathered health plan" under
the Patient Protection and Affordable Care Act (the "Act") and that it will be subject to all requirements of the Act applicable to a group health plan or health
insurance coverage unless otherwise specified in writing.
21 includes applicable Patient Protection and Affordable Care Act fees and assessments imposed upon health insurers including the Comparative Effectiveness
Research Fee.
22 Assumes a non-Cigna HealthCare Pharmacy Benefit Manager administers oral or other self-administered anti-cancer prescription medication claims at a
copayment/coinsurance level that is no less favorable than that for intravenous or injected anti-cancer medication prescribed for the same purpose and covered
under employer’s Cigna HealthCare plan. This assumption is applicable only if: (a) employer has contracted with a PBM (not Cigna HealthCare); (b) employer’s
plan is either insured, or, if self-funded, not subject to ERISA (i.e., is a church, government or association plan); and (c) employer’s Cigna HealthCare plan is
sitused in IA, HI, NM, OR, NJ, NE, VA, MA, NV, FL, ME, GA or a state with similar chemotherapy coverage law, or covers one or more individuals residing in
CO, OK, VT, WA, TX, LA, MO or OH or in a state with similar extraterritorial chemotherapy coverage mandate.
23 establishes a Wellness/Health Improvement Fund (the "Fund") in the amount of $30000.00 for clinical/wellness/behavioral programs offered by Cigna
HealthCare. These funds shall be used to defray the cost of Cigna HealthCare designated and arranged health and wellness improvement programs for
employees (e.g., biometric screenings, flu shots, etc.) and to reward participation in these programs. The Fund may be accessed during the period from
10/01/2023 - 09/30/2024. The Fund may not be accessed following notice of termination of the Cigna HealthCare agreement. Unused funds cannot be rolled
over and Cigna HealthCare must pre-approve use of the Fund.
24 Important Notice Regarding Benefit Advisor Compensation - The premium for this guaranteed cost (i.e., non-Shared Returns) policy may not include
compensation payable to your benefit advisor. Check with your Cigna Sales representative to confirm whether this is the case. When that is the case, the
proposed billed amount includes both premium and benefit advisor fees, which are not part of the monthly premium and Cigna will include any benefit advisor
fees agreed to by the client and benefit advisor on client invoices and forward payments received to the benefit advisor if both the client and the benefit advisor
authorize Cigna to do so by signing Cigna’s Client and Benefit Advisor Acknowledgement Form. When required, this form must be signed before the date when
the new rates take effect. If the form is not signed, the benefit advisor will be responsible for billing the client directly for any benefit advisor fees.
25 This proposal made by Cigna HealthCare is contingent upon: Cigna HealthCare's receipt of the following information: -Completed medical history questionnaire
prior to the policy effective date.
26 assumes that any non-voluntary vision benefit that is included in the medical plan and not provided through a separate policy is subject to ACA requirements.
27 does not apply to individuals unless employed by the policyholder or an entity that participates in an association or trust that is the policyholder.
o ADDITIONAL GENERAL TERMS OF THIS PROPOSAL:
28 The information contained in this Proposal by Cigna HealthCare is proprietary and highly confidential. It is being provided with the understanding that it will not
be used by the employer, its representatives or consultants for any purpose other than the evaluation of the Proposal. Under no circumstances is any of the
information contained herein (including excerpts, summaries, extracts, and evaluations thereof) to be used, disseminated, disclosed or otherwise communicated
to any person or entity other than the employer, its representatives and consultants, and their respective employees who are directly involved in the evaluation
process.
C. Additional Representations & Disclosures
1 Each plan presented in this proposal has an actuarial value, determined by Cigna HealthCare, of 60% or greater. This determination was made using Cigna
HealthCare's manual rating application which may produce an actuarial value slightly different than the official HHS calculator. Although we would expect any
deviation to be small, you will have to consult with your actuarial consultant for a more precise determination of the plan's actuarial value. Cigna HealthCare
does not provide actuarial certifications.
2 In order to implement the requested benefit design, different funding arrangements (i.e., insured, self-insured and/or HMO) involving affiliated Cigna companies
may be required with respect to plan participants residing in certain states.
3 Cigna HealthCare may have an agreement with your benefit advisor, under which the benefit advisor may be paid for providing marketplace intelligence or for
the performance of administrative services. The qualification for and amount of this payment may be based upon overall business growth and/or retention levels.
Any such payment is funded through Cigna HealthCare’s general overhead.
4 The benefit advisor may qualify for incentive payment (monetary or non-monetary) from Cigna HealthCare. For example, the benefit advisor may receive
payment based upon new sales, new customer growth or retention. This incentive payment is funded from Cigna HealthCare’s general overhead.
5 Cigna HealthCare sponsors programs to inform benefit advisors about Cigna HealthCare’s plan coverage and services (including producer advisory councils).
The cost of these events is funded through Cigna HealthCare’s general overhead.
Acct#:3344509/OP-5302612/Q1/3245456 Page 9 of 11 6/7/2023 10:41 AM
Gap Fund Acknowledgement
If so, please let us know the details below. If not, please still confirm and sign below.
Do you offer any of these plans?
- Health Savings Account (HSA)
- How much is the employer funding amount? _______________________________
- Is there an annual rollover provision for the fund?
- Any changes in employer funding in the past year or future year?
- If YES, please provide details: _______________________________
Date: ___________________________
By: _____________________________
Title: ____________________________
`
- What is the reimbursement order? Does the HSA and/or HRA fund pay first, or something
else? _______________________________
Please notify Cigna HealthCare prior to implementing any "Gap Funding" program. Cigna
HealthCare will determine if we need to change the premium rates/charges both now and in the future
based on the information you provide.
Please affirm that the above information is true and complete. Thanks!
City of Southlake Insurance Trust Fund
Are your employees reimbursed for their co-payments, co-insurance cost, deductibles or out of
pocket expenses?
We assume NO subsidization or reimbursement for any portion of the employees’ cost-sharing
responsibilities. And that’s how we set the premium rates/charges for all benefit plans insured and/or
administered for you by Cigna HealthCare companies ("Cigna HealthCare, we, us").
Subsidization/reimbursement is also known as "Gap Funding". That is because employees receive
money to fund the gap between their cost-share responsibility and Cigna HealthCare's payments.
- Health Reimbursement Account (HRA)
- Other means to reimburse employees for health plan expenses
If YES, please confirm the following:
YES NOYESNO
YES NO
YES NO
Client Signature Date
Client Name Title
"Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are
provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Cigna Health and Life
Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental
Health, Inc.
I UNDERSTAND AND AGREE ON BEHALF OF CONTRACTHOLDER THAT CIGNA HEALTHCARE MAY,
NOTWITHSTANDING THE TERMS OF THE INSURANCE POLICY OR SERVICE AGREEMENT, REVISE
ANY PREMIUM RATES OR PREPAYMENTS FEES AT ANY TIME IF THE ENROLLMENT OR EMPLOYER
CONTRIBUTION LEVEL IS DIFFERENT THAN ASSUMED BY CIGNA HEALTHCARE IN UNDERWRITING
THE CONTRACT OR IF CIGNA HEALTHCARE IS (i) REQUIRED TO PAY ANY ASSESSMENT, OR (ii)
INCUR ADDITIONAL COSTS IN ADMINISTERING THE CONTRACT AS A RESULT OF THE PATIENT
PROTECTION AND AFFORDABLE CARE ACT AND THE REGULATIONS PROMULGATED THEREUNDER.
Underwriting Contingencies
For
City of Southlake Insurance Trust Fund
Cigna HealthCare reserves the right to change the Quoted Rates and/or Quoted Benefits or to decline to offer
coverage if any of the foregoing information is inaccurate or changes prior to the proposed Effective Date
indicated above, or if the quoted rates and/or fees are not agreed to within 60 days of receipt of this summary
information form. If any of the information identified above changes either prior to the proposed Effective Date
or while coverage is in effect, you agree to notify us promptly of such change.
The "Underwriting Contingencies" set forth above shall survive execution of any insurance policy, application,
etc., issued by Cigna HealthCare or any affiliated company, and shall further survive the effective date of any
such policies.
The benefits displayed in this summary are, for the most part, modular benefit packages used to
develop the rates. Please review the Benefit Summary and its attachments for information about the
benefits available in your sites.
Cigna Healthcare Financial Exhibit for:
City of Southlake Insurance Trust Fund
Effective Date: October 01, 2023
Dental Choice Plan Current Renewal
Cigna Rates
Choice Employee $40.99 $43.04
GC Dentacom Emp + Spouse $81.99 $86.09
Emp + Child(ren) $91.20 $95.76
Emp + Family $138.87 $145.81
Dental Care Plan Current Renewal
Cigna Rates
Dental Care Access Plus Employee $12.92 $13.24
K1-V9 Emp + Spouse $24.55 $25.16
Emp + Child(ren) $25.86 $26.50
Emp + Family $40.04 $41.03
Vision Plan Current Renewal
Cigna Rates
Vision PPO Employee $5.96 $6.23
Emp + Spouse $11.92 $12.46
Emp + Child(ren) $12.04 $12.58
Emp + Family $19.22 $20.09
Title:___________________________________________________________
DENTAL AND VISION RATE CONFIRMATION
Approved and Accepted this_______Day of_________________________2023
Signature________________________________________________________
Account #: 3344509 6/7/2023 11:07 AM
Date: May 12, 2023
0
Financial Proposal
for
City of Southlake Insurance Trust Fund
Effective Date: October 01, 2023
Cigna Dental is Your New Growth Plan.
•
•
•
•
•
•
•Making it easy and affordable to access care by bringing network dentists right to the workplace through Cigna Onsite DentalSM
•
•
•
Helping to increase productivity
Dental care is not just a cost of doing business. It's an investment in your future success. And dental benefits aren't "just dental." When provided by Cigna,
your dental program can help engage your workforce, increase productivity, improve health outcomes and manage healthcare costs. Cigna unlocks the full
potential of your dental program to deliver more value.
Engaging your workforce by empowering smarter dental coverage and care choices
We do this through data-driven and actionable insights, deep collaboration and strategic partners, offering the right coverage, care, and support, when and where employees need
it, and clinically driven programs that provide extra support for employees with certain risk factors.
myCigna.com gives employees 24/7/365 access to value-based network search tools and information that can help them find a dentist who meets their specific, unique needs. And
when employees utilize myCigna, 99.2% stay in-network and they save $117.10 more per member per year than those who don't.1
Cigna Dental Oral Health Integration Program® provides proactive, personalized support for customers with one of 14 medical conditions that can be impacted by oral health risks
like gum disease and cavities.
Enrollment campaigns help make choosing a dental plan simpler by providing personalized, relevant decision guide tools and information and help to increase enrollment into the
Cigna Dental Care DHMO plan by an average of 8%.2
Helping to improve health outcomes
Cigna Dental is an industry leader in engaging customers to use their preventive dental care benefits. And when customers get preventive care, the risk of developing periodontal
disease, experiencing potential medical complications or needing care in the emergency room or urgent care center is reduced.
Engaging customers to get important preventive dental care through proactive, automated outreach results in a 67% increase in visits.3
Moving the center of care to support better oral health routines with Cigna @Home Dental can help to reduce plaque by 77%.4
Reducing the risk of opioid addiction through our proprietary opioid dashboard and safe prescribing program has resulted in a 23% reduction in the number of prescriptions written
for children under 18, and a 9% reduction overall.5
1. Internal reporting as of November 2021 for DPPO customers who use myCigna and customers who do not use myCigna. Results may vary.
2. Internal reporting. Average increase in DHMO enrollment for clients who participate in a second-sale dual-enrollment campaign. Results may vary.
3. Internal reporting as of November 2021 for DPPO customers who received email for overdue preventive care and out-of-network claims. Results may vary.
4. Kay, E., Shou, L. A randomised controlled trial of a smartphone application for improving oral hygiene. Br Dent J 226, 508–511 (2019).
5. Internal report published in 2019, based on review and analysis of 2015-2018 Cigna pharmacy claims and Cigna dental membership data. Results may vary.
6. Kelekar, Uma, and Shillpa Naavaal. “Hours Lost to Planned and Unplanned Dental Visits Among US Adults.” Preventing chronic disease vol. 15 E04. 11 Jan. 2018, doi:10.5888/pcd15.170225. Accessed November 2021.
7. Internal reporting on average cost for ER claims submitted for dental-related concerns 2018-2019. 3. Internal reporting on Cigna Dental Virtual Care utilization for 2021.
8. “Preventive Dental Treatment Associated with Lower Medical Utilization and Costs.” Cigna national study, December 2020. Individual results may vary.
9. Cigna internal utilization data – average percentage of recommendations across network DPPO dentists by Cigna customers. As of October 2019.
Poor oral health directly impacts employers. Every year, $800M in productivity is lost due to health-related problems, and 320.8M hours of work/school are lost for dental care.6 92.4M
of those hours are lost for unplanned or emergency dental care.6 The Cigna Dental program can help reduce lost productivity by making it easy and affordable for employees to
access dental care, when, how and where employees need it most.
Cigna Dental Virtual Care eliminates the need for many dental-related emergency room visits by giving employees access to licensed dentists 24/7/365. In 2021, 73% of Cigna
Dental Virtual Care users avoided the emergency room.7
Helping to manage healthcare costs
Our dental program is designed to fit the lives of your employees, and we wrap them in the care and support they need to stay healthy. From the beginning of each customer's journey
with us, we are by their side. Enrollment support, oral health assessments, network search-ability, treatment cost estimators, 24/7/365 access to dentists through Cigna Dental Virtual
Care - our proactive and insightful solutions make getting dental care affordable and easy. And when employees get important dental care services, medical costs go down.
When customers get consecutive years of preventive dental care, there's an average savings of 4.4% per member, per year on medical costs. For customers with diabetes, the
savings are even higher - 12.2%. And for customers impacted by high social index and health equity factors, there's an additional savings of 37.3%.8
Our networks grow every year and give employees access to quality, high-value dentists. The search tools on myCigna help employees make informed decisions about their care,
specific to their needs. 95% of surveyed customers would recommend their network dentist to friends or family.9
Oppty #: OP-5064163 5/15/2023 10:10 AM
Cigna Healthcare Financial Exhibit for: City of Southlake Insurance Trust Fund
GC Dentacom
Effective Date: October 01, 2023
This is a summary of benefits for your dental plan.
All deductibles, plan maximums, and service specific maximums (dollar and occurrence) cross accumulate between in and out of network.
Your DPPO** plan allows you to see any licensed dentist, but using an in-network dentist may minimize your out-of-pocket expenses.
Plan Design
Calendar Year Maximum
(Class I, II, III, IX Expenses)$1750, Class I Applies $1750, Class I Applies
Calendar Year Deductible
Per Individual $50 $50
Per Family $150 $150
Class I Expenses - Preventive & Diagnostic Care
Oral Exams 100%, No Deductible 100%, No Deductible
Cleanings
Routine X-rays
Fluoride Application
Sealants
Space Maintainers (limited to non-orthodontic treatment)
Non-Routine X-rays
Emergency Care to Relieve Pain
Class II Expenses - Basic Restorative Care
Fillings 80%, After Deductible 80%, After Deductible
Oral Surgery - Simple Extractions
Oral Surgery - All Except Simple Extraction
Surgical Extraction of Impacted Teeth
Anesthetics
Minor Periodontics
Major Periodontics
Root Canal Therapy / Endodontics
Brush Biopsy
Class III Expenses - Major Restorative Care
Relines, Rebases, and Adjustments 50%, After Deductible 50%, After Deductible
Repairs - Bridges, Crowns, and Inlays
Repairs - Dentures
Crowns/Inlays/Onlays
Stainless Steel/Resin Crowns
Dentures
Bridges
Class IV Expenses - Orthodontia
Coverage for Eligible Children and Adults 50%, No Ortho Deductible 50%, No Ortho Deductible
Lifetime Maximum $1500 $1500
Class IX Expenses - Implants
50%, After Deductible
Plan Calendar Year Max $1750
Dental Plan Reimbursement Levels Based on Contracted Fees 90th Percentile of Allowed Charges***
None
Yes, the difference between the
member's dentist's billed charges and
the dental plan reimbursement level***
Student/Dependent Age 26/26
P0010 Network. Prepared by Underwriting.05/12/2023 11:47 AM
50%, After Deductible
$1750
Additional Member Responsibility in
excess of Coinsurance
Total Cigna DPPO Network**Out-of-Network
Cigna Healthcare Financial Exhibit for:
City of Southlake Insurance Trust Fund
GC Dentacom
Effective Date: October 01, 2023
Cigna Dental Choice / Indemnity Exclusions and Limitations:
Procedure Exclusions & Limitations
Exams Two per calendar year
Prophylaxis (cleanings)Two per calendar year
Fluoride 1 per calendar year for people under 19
X-Rays (routine)Bitewings: 2 per calendar year
X-Rays (non-routine)Full mouth: 1 every 3 calendar years. Panorex: 1 every 3 calendar years
Cone Beams Not covered
Model Payable only when in conjunction with Ortho workup
Minor Perio (non-surgical)Various limitations depending on the service
Perio Surgery Various limitations depending on the service
Crowns and Inlays Replacement every 5 years
Prosthesis over Implants 1 per 5 years if unserviceable and cannot be repaired. Benefits are based on the amount
payable for non-precious metals. No porcelain or white/tooth colored material on molar crowns or
bridges.
Bridges Replacement every 5 years
Dentures and Partials Replacement every 5 years
Relines, Rebases Covered if more than 6 months after installation
Adjustments Covered if more than 6 months after installation
Repairs - Bridges Reviewed if more than once
Repairs - Dentures Reviewed if more than once
Sealants Limited to posterior tooth. One treatment per tooth every three years up to age 14
Space Maintainers Limited to non-Orthodontic treatment. No frequency limit for participants under age 19.
Alternate Benefit When more than one covered Dental Service could provide suitable treatment based on common dental
standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses
that will be included as Covered Expenses.
Missing Tooth Provision The amount payable is 50% of the amount otherwise payable until insured for a specified time period; thereafter, considered a Class III expense
Late Entrant Limit****50% coverage on Class III, IV (if applicable), and IX for 12 months
Pre-Treatment Review Available on a voluntary basis when extensive work in excess of $200 is proposed
Benefit Exclusions:
* Services performed primarily for cosmetic reasons
* Replacement of a lost or stolen appliance
* Replacement of a bridge or denture within five years following the date of its original installation
* Replacement of a bridge or denture which can be made useable according to accepted dental standards
* Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension,
diagnose or treat conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion
* Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars
* Bite registrations; precision or semi-precision attachments; splinting
* Instruction for plaque control, oral hygiene and diet
* Dental services that do not meet common dental standards
* Services that are deemed to be medical services
* Services and supplies received from a hospital
* Charges which the person is not legally required to pay
* Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition
connected to a military service
* Experimental or investigational procedures and treatments
* Any injury resulting from, or in the course of, any employment for wage or profit
* Any sickness covered under any workers' compensation or similar law
* Charges in excess of the reasonable and customary allowances
* To the extent that payment is unlawful where the person resides when the expenses are incurred;
* Procedures performed by a Dentist who is a member of the covered person's family (covered person's family is limited to a spouse,
siblings, parents, children, grandparents, and the spouse's siblings and parents);
* For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery;
* To the extent that you or any 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 benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to
comply with a "no-fault" insurance law or an uninsured motorist insurance law. Cigna HealthCare will take
into account any adjustment option chosen under such part by you or any one of your Dependents.
* In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental
Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored
or made available by your Employer.
** In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network.
***Charges are based upon an independent third party organization that is the industry standard. Percentile data is based upon the third party organization's aggregated industry-wide claims data
****Late Entrant coverage limitation does not apply to New Mexico Residents for Insured Dental Products.
This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of
coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description.
Benefits are insured and/or administered by Cigna HealthCare.
Cigna is a registered service mark, and the "Tree of Life" logo is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries.
All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance
Company, Cigna Health and Life Insurance Company, Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries.
Prepared by Underwriting.
Cigna DPPO Network (P0010)
Did you know that most of Cigna's dental plans include the Cigna Dental Oral Health Integration Program? This program was designed to address research that supports the association of oral
health to overall health and provides reimbursement of copays or coinsurance for customers with qualifying medical conditions for program eligible procedures. Additionally, registered program
members can access articles on behavioral conditions that impact oral health.
05/12/2023 11:47 AM
Cigna Healthcare Financial Exhibit for:
City of Southlake Insurance Trust Fund
Effective Date: October 01, 2023
Total Enrollment Current Renewal
Cigna Rates
Choice Employee 138 $40.99 $43.04
GC Dentacom Emp + Spouse 32 $81.99 $86.09
Emp + Child(ren)50 $91.20 $95.76
Emp + Family 68 $138.87 $145.81
Monthly Total $22,283.46 $23,397.63
5.00%
This quote assumes the proposed DPPO benefits will be administered on Dentacom.
Total Enrollment Current Renewal
Cigna Rates
Dental Care Access Plus Employee 20 $12.92 $13.24
K1-V9 Emp + Spouse 4 $24.55 $25.16
Emp + Child(ren)4 $25.86 $26.50
Emp + Family 9 $40.04 $41.03
Monthly Total $820.40 $840.71
2.48%
This quote assumes the proposed DHMO benefits will be administered on WEBSTER
Plan Cost Summary - Rates
Renewal Change
Renewal Change
Account #: 3344509 5/15/2023 10:10 AM
Cigna Healthcare Financial Exhibit for: City of Southlake Insurance Trust Fund
Effective Date: October 01, 2023
PROPOSAL TERMS AND CONDITIONS for Dental
A.General Terms of this Proposal
Cigna HealthCare is pleased to present this Proposal for a Fully Insured Non-Participating group Dental benefit plan (the ''Plan'') sponsored by City
of Southlake Insurance Trust Fund. This proposal is valid for 60 days from its original date of release, 05/12/2023. Any revisions or updates to this
proposal will not renew this valid timeframe unless expressly communicated by Cigna HealthCare.
The information contained in this Proposal by Cigna HealthCare is proprietary and highly confidential. It is being provided with the understanding
that it will not be used by the employer, its representatives or consultants for any purpose other than the evaluation of the Proposal. Under no
circumstances is any of the information contained herein (including excerpts, summaries, extracts, and evaluations thereof) to be used,
disseminated, disclosed or otherwise communicated to any person or entity other than the employer, its representatives and consultants, and their
respective employees who are directly involved in the evaluation process.
Proposal Caveats
Cigna HealthCare may revise or withdraw this Proposal if:
1 there is a change to the effective date of the quote.
2 the Plan benefits are different than shown or benefit modifications are requested.
3 participation is below 87%. This will be based on the total eligible employees, identified as 374.
4 enrollment increases or decreases by 10% or more, by product or for the total account, from the enrollment assumptions used in establishing the
rates and/or fees set forth herein.
5 it is not the exclusive provider of Dental for all of City of Southlake Insurance Trust Fund's employees in all worksites.
6 there is a change in law, regulation, tax rates, or the application of any of these that affects Cigna's costs
B. Scope and Application of this Proposal
Unless otherwise indicated, this Proposal:
1 assumes the quoted Dental rates are valid only when Dental is packaged and sold alongside Cigna Medical and/or CGI.
2 assumes employer contributions match the previous year's sold quote.
3 assumes the premium rates proposed by Cigna Healthcare are subject to final Underwriting approval and may be changed due to differences in
selection of benefits, changes in census data, or any other changes in risk determined by Cigna Healthcare.
4 includes rates which are subject to regulatory approval. If, as of their proposed effective date, regulatory approval is not obtained, Cigna shall use
rates consistent with its then currently approved rates and the foregoing rates shall be effective automatically upon approval.
5 assumes that Cigna HealthCare’s standard insurance policy form approved for use in the applicable state by the state insurance regulator will be
issued. Because the insurance policy and certificate terms require regulatory approval, there is very little flexibility to change the provisions. The
provisions of the insurance policy and certificate will supersede the Proposal in the event of a conflict.
6 includes Dental rates which are guaranteed for a period of 12 months while the contract remains inforce.
7 assumes the rates contain sufficient commission load for Dental of 10%.
8 assumes only a passive DPPO plan may be offered to TX or MS employees due to regulatory requirements.
9 assumes the plan will be implemented using Cigna's standard policy provisions, limitations, and contract language as reflected in Cigna's summary
plan description unless specific modifications have been approved and rated appropriately. These standards are summarized in the Underwriting
benefit summary. Any benefit modifications must be communicated in writing from Underwriting.
10 Cigna's Dental and/or Vision products are ''excepted benefits'' and not subject to Essential Health Benefit requirements.
11 Cigna HealthCare may have an agreement with your benefit advisor, under which the benefit advisor may be paid for providing marketplace
intelligence or for the performance of administrative services. The qualification for and amount of this payment may be based upon overall
business growth and/or retention levels. Any such payment is funded through Cigna HealthCare’s general overhead.
12 The benefit advisor may qualify for incentive payment (monetary or non-monetary) from Cigna HealthCare. For example, the benefit advisor may
receive payment based upon new sales, new customer growth or retention. This incentive payment is funded from Cigna HealthCare’s general
overhead.
13 Cigna HealthCare sponsors programs to inform benefit advisors about Cigna HealthCare’s plan coverage and services (including producer
advisory councils). The cost of these events is funded through Cigna HealthCare’s general overhead.
Account #: 3344509 5/15/2023 10:10 AM
Cigna Healthcare Financial Exhibit for: City of Southlake Insurance Trust Fund
Effective Date: October 01, 2023
PROPOSAL TERMS AND CONDITIONS for Cigna Dental Care
Rates contain sufficient load for a 10% flat commission.
Rates are guaranteed for 12 months.
The benefit advisor may qualify for incentive payment (monetary or non-monetary) from Cigna HealthCare. For example, the benefit advisor may receive
payment based upon new sales, new customer growth or retention. This incentive payment is funded from Cigna HealthCare's general overhead.
This quote assumes that Cigna HealthCare's standard insurance policy form approved for use in the applicable state by the state insurance regulator will
be issued. Because the insurance policy and certificate terms require regulatory approval, there is very little flexibility to change the provisions. The
provisions of the insurance policy and certificate will supersede the Proposal in the event of a conflict.
The information contained in this Proposal by Cigna HealthCare is proprietary and highly confidential. It is being provided with the understanding that it
will not be used by the employer, its representatives or consultants for any purpose other than the evaluation of the Proposal. Under no circumstances is
any of the information contained herein (including excerpts, summaries, extracts, and evaluations thereof) to be used, disseminated, disclosed or
otherwise communicated to any person or entity other than the employer, its representatives and consultants, and their respective employees who are
directly involved in the evaluation process.
This renewal information is being communicated in order to meet contractual requirements of changes to the rates/benefit schedules at least 60 days in
advance of the change.
This Cigna Dental Care (“DHMO”) proposal assumes covered services will be provided by the Cigna Dental Care Access Plus network of contracted
general and specialty dentists
The term DHMO is used to refer to product designs that may differ by state of residence of enrollee, including but not limited to, prepaid plans, managed
care plans, and plans with open access features. The Cigna DHMO is not available in the following states: AK, ME, MT, NH, NM, ND, PR, SD, VI, VT,
and WY.
The dental insurance coverage shall be provided under a standalone group insurance policy and is an "excepted benefit" as defined in Public Health
Service Act Section 2721(c) and (d).
Cigna HealthCare sponsors programs to inform benefit advisors about Cigna HealthCare's plan coverage and services (including producer advisory
councils). The cost of these events is funded through Cigna HealthCare's general overhead.
Cigna HealthCare may have an agreement with your benefit advisor, under which the benefit advisor may be paid for providing marketplace intelligence
or for the performance of administrative services. The qualification for and amount of this payment may be based upon overall business growth and/or
retention levels. Any such payment is funded through Cigna HealthCare's general overhead.
Account #: 3344509 5/15/2023 10:10 AM
Plan Code:
Effective Date :
Voluntary FI Quote (Per Employee Per Month)*15% Minimum Participation Required*
Enrolled EE's Current 10/01/2023 10/01/2024
Employee Only 129 $5.96 $6.23 $6.23
Employee + Spouse 31 $11.92 $12.46 $12.46
Employee + Child(ren)42 $12.04 $12.58 $12.58
Employee + Family 59 $19.22 $20.09 $20.09
Total EE's 261
*Broker commissions of 10.00% are included in this quote.
*Voluntary: Medical and/or dental subscribers can elect to not enroll in vision. Does not refer to contribution levels.
*Quote is valid for 90 days and includes claim processing, network access, customer service, policy
and certificate, and standard vision reporting.
*The fee does not include vision specific ID cards.
*Our Cigna Vision proposal is contingent upon selecting Cigna for your dental and/or medical coverage.
*This quote assumes the Cigna Vision will be administered on Cigna East platforms
*Rates are guaranteed for 2 years.
Cigna Vision Network serviced by EyeMed offers one of the largest national routine vision networks, with optometrists and
ophthalmologists at full service locations nationwide, including private practice and national and regional retail locations.
Please be aware that the Cigna Vision Network serviced by EyeMed is different from the Cigna medical networks.
In-Network Member
Cost***
Out-of-Network
Reimbursement
$10 Copay Up to $45 Allowance
Up to $39 Not Covered
$25 Copay Up to $40 Allowance
$25 Copay Up to $65 Allowance
$25 Copay Up to $75 Allowance
$25 Copay Up to $100 Allowance
$0 Not Covered
$0 Not Covered
$0 Not Covered
$0 $65
$15 Not Covered
$75 Not Covered
$15 Not Covered
$15 Not Covered
$45 Not Covered
20% off retail Not Covered
20% off retail
12 month
Balance over $110 Allowance Up to $98 Allowance
$0 Up to $210 Allowance
* Your Frequency Period begins on January 1 (Calendar year basis)
**coverage may vary at participating discount retail and membership club optical locations, please contact Customer Service for specific coverage information.
***Provider participation is 100% voluntary, please check with your Eye Care Professional for any offered discounts; stated Customer Cost, up to maximums, are subject to change without notice.
Benefits are underwritten or administered by Cigna. Read your plan carefully - this benefit summary provides a very brief description of the important features of your plans.
This is not the insurance contract. Your full rights and benefits are expressed in the actual plan documents that are available to you upon request. Network providers are
independent contractors solely responsible for your routine vision examination and products.
05/12/2023 14:21
Account Number: 3344509
18
Opportunity Number: OP-5302612 Delancy McKinley (Austin - 329)
Frame Retail Allowance
Frequency*: one per 12 month 100% up to $130 Retail Allowance 20% off balance over $130
Allowance Up to $71 Allowance
Contact Lenses Retail Allowance:
Frequency*: one pair or single purchase per
Elective 100% up to $110 Retail Allowance
Therapeutic 100%
Anti-Reflective (AR) Coating $0
Hi-Index Lenses $0
All other lens options, including Premium Tiers $0
Photochromic - Glass or Plastic $0
Standard Scratch Coating $0
Standard Ultraviolet (UV) Coating $0
Polycarbonate Lenses <19 years of age 100%
Progressives 100%
Plastic Dye Tints $0
Lens Enhancements / Options Oversize lenses 100%
Rose #1 and #2 Solid Tints 100%
Lined Bifocal 100%
Lined Trifocal 100%
Lenticular 100%
Standard Eyeglass Lenses Allowances:
Frequency*: once per 12 month
Lenses:Copay: $25
Single Vision 100%
Exam and Professional Services:
Frequency*: once per 12 month
Eye Exam 100% after $10 Copay
Retinal Screening $0
*Cigna Healthcare's vision products are “excepted benefits” and not subject to Essential Health Benefit requirements.
*The above quoted rates include Health Insurance Assessment fees (PPACA) for 2020 months, but not for 2021 and beyond. Cigna reserves the right to modify quoted rates, as necessary, should there be any changes in future
regulation or costs.
Vision Services and Frequency In-Network Plan Coverage**
Cigna Vision Solution for City of Southlake Insurance Trust Fund
10/01/2023
Renewal quote completed by Cigna Dental & Vision Underwriting on May 12, 2023