HomeMy WebLinkAboutC80-020 Blue Cross Blue Shield0
ENDORSEMENT NO. V
TO
GROUP MASTER CONTRACT NO. 78-00990200
BETWEEN
BLUE CROSS AND BLUE SHIELD OF COLORADO
AND
COUNTY OF EAGLE EMPLOYEES
"The Emp oyer
Effective date of this endorsement: January 1, 1981
The Contract identified above is hereby amended, pursuant to ARTICLE X., by
this endorsement which is issued to form a part of the Contract.
Schedule B. "COVERAGE AND DUES" is amended as follows:
Paragraphs 1. and 2. are deleted and the following is substituted therefor:
1. Dues - Dues under the Contract shall be as follows:
Maj or
Coverage Blue Cross Blue Shield AAB Medical Total
Comprehensive Blue Cross and
Preferred Service Blue Shield
Employee Only $20.88 $11.13 $.10 $ 7.00 $ 39.11
Employee and Dependents 58.26 31.05 .30 16.30 105.91
Medicare Complementary Coverage
Coverage Rate
Medicare Supplemental High Option PLUS $31.70
2. Rate effective date: January 1, 1981
Subject to "1" on Schedule B-1.
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ARTICLE V., "CATASTROPHIC MAJOR MEDICAL BENEFITS, LIMITATIONS AND EXCLUSIONS",
is amended as follows:
Section B. entitled "DEDUCTIBLE REQUIREMENTS", is deleted in its entirety, and
the following is substitute therefor:
B. DEDUCTIBLE REQUIREMENTS
1. Definition of "Deductible" - The deductible amount is the amount of
expense that the Member or combined family Members must incur within each
Member's Contract Year for expenses which are not covered under the basic or
Additional Accident Benefits coverages, but are covered under this
Catastrophic Major Medical coverage. The deductible amount is subtracted from
the total covered expenses, and payments are based on the remainder of such
covered expenses.
2. Deductible Amount - The deductible amount shall be applied as
follows:
a. Single Membership. Under a single membership, the deductible
amount is $100 for the Member for each Member's Contract Year.
b. Family Membership. Under a family membership, the deductible
amount is $200 per Mem er s Contract Year for the entire family and may be met
by a combination of Members enrolled under that family membership. However,
if one family member has individually satisfied one-half (or $100) of the
family deductible, then that family Member shall be entitled to benefits under
this Catastrophic Major Medical coverage. In this instance, the remaining
$100 family deductible amount may be satisfied by:
(1) one other individual family Member, or
(2) a combination of remaining family Members.
However, no more than $100 per individual family Member may be
applied toward the $707amily deductible per Member's Contract Year.
3. Carryover Provision - When no Catastrophic Major Medical benefits
have been payable during a ember's Contract Year because the deductible
requirement has not been met, then eligible charges that are incurred during
the last three months of the Member's Contract Year may be applied toward
satisfying the deductible requirement for the following Member's Contract Year.
ARTICLE XI., "TERMINATION PROVISIONS", is amended as follows:
Section B., "TERMINATION OF CONTRACT", Paragraphs 1. and 2. are deleted in
their entirety and the follow5g is substituted therefor:
1. The Employer may terminate the Contract at any time during its term
upon giving one month advance written notice of termination to Blue Cross and
Blue Shield of Colorado.
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2. Blue Cross and Blue Shield of Colorado may terminate the Contract at
any time during its term for (i) Employer's non-payment, or failure to make
timely payment of membership dues, (ii) any other breach of the Contract, or
(iii) upon giving one month advance written notice of termination to the
Employer.
Section C., "CONVERSION PRIVILEGE UPON TERMINATION", is amended as follows:
Paragraph 2. entitled "The Employee", subparagraph a., is deleted in its
entirety and the following is substituted therefor:
a. To avoid lapse in coverage, the Employee must:
(1) Transfer to non -group coverage within one month after the
termination date of the Employee's coverage under the contract; and,
(2) Pay the applicable non -group dues to Blue Cross and Blue
Shield of Colorado from the date of such termination of coverage.
Paragraph 3. is deleted in its entirety and the following is substituted
therefor:
3. The De endent(s) - If an Employee's coverage under the Contract is
terminated by i the Emp oyee's termination of employment, (ii) the
Employee's death, or (iii) termination of the Contract, except as defined in
-� Paragraph C.'F,of this Article XI., any Dependent of the Employee is entitled
to convert :_,.,=then available non -group coverage at then applicable non -group
rates and benefits; and, to avoid lapse in coverage, the converting Dependent
must:
a. Transfer to non -group coverage within one month after the
termination date; and,
b. Pay the applicable non -group dues to Blue Cross and Blue Shield
of Colorado from the date of such termination of coverage.
By their signatures below, the Employer and Blue Cross and Blue Shield of
Colorado approve this endorsement.
COUNTY OF EAGLE EMPLOYEES
ame of Employer)
By lU t , ��z
(Title) �t
(Date) p s,7
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BLUE CROSS AND BLUE SHIELD
OF COLOR
96 .
By g
4.
(Title) Vice -Pres dent, Sales
(Date) OCT 0 3 1980
