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C97-077 Rocky Mountain Health Maintenance Organization
cc74ROCKYMOUNTAINHEALTHMAINTENANCEORGANIZATION,INC.GROUPSERVICEAGREEMENTGroupEagleCountyGovernmentAnnualRenewalDateSeptemberPlanH1O/1OGroupEffectiveDateSeptember1,1996ThisGroupServiceAgreementisenteredintobetweenRockyMountainHealthMaintenanceOrganization,Inc.(“RIvil-Th40”)andtheorganizationoremployerentitynamedbelow(“ContractingParty”),toprovidetheMembersoftheGroupelectingtoenrollhereunderwiththeBenefitsasspecifiedintheHealthBenefitsContractapplicabletotheHealthCarePlan(s)designatedinthisGroupServiceAgreement(“designatedHealthBenefitsContract”).ThisGroupServiceAgreementandsuchdesignatedHealthBenefitsContract,andamendmentsthereto,shallbereferredtohereinas“Agreement.”RMHMOandContractingPartyagreeasfollows:1.Definitions:ThedefmitionsoftermsinthedesignatedHealthBenefitsContractareincorporatedhereinbythisreference.2.Eligibility.InformationregardingeligibilityundertheAgreementissetforthonAttachmentI.3.EnrollmentandRates.InformationonenrollmentandratesundertheAgreementissetforthonAttachmentII.4.ApplicationForms.ChangeForms,andInspectionofRecords.ContractingPartyshallsubmitcompletedapplicationformsandchangeformsasnecessarytoassurecorrectinformationforpersonswhowillbecomeMembersforthepurposeofpremiumpaymentandbilling.RIvll{MOshallhavetherightatreasonabletimestoexamineContractingParty’srecordswithrespecttoeligibilityandmonthlypaymentsundertheAgreement.5.PaymentofPremiums.OnorbeforethefirstdayofeachmonthforwhichBenefitsarepayable,ContractingPartyshallpaytoRvil{MOallpremiumsdueundertheAgreementandshallprovidetoPJv1HvIOallsupportinginformationoneligibleMembers.IfContractingPartyfailstopaymonthlypremiumswhendue,RMHMOmayatitsoptionandinitsdiscretionnotifyeligibleMembersoftheGroupthatContractingPartyhasfailedtopaymonthlypremiumswhendueandthatBenefitswillbeprovidedonlythroughthedatepremiumshavebeenpaid(“Paid-Through-Date”). CC6.ConditionsofOfferingRMF{MOCoverage,andUnderwritingGuidelines.ContractingPartyshalloffercoverageundertheAgreementunderconditionsnolessfavorablethanthoseofanyotheralternatehealthcareplan(s)itmakesavailable.ContractingPartyshallnowandatalltimesduringthetermoftheAgreementcomplywiththeRMI4MOunderwritingguidelinesfortheRMEMOhealthcareplan(s)selectedbyContractingPartyunderthisAgreement.including,butnotlimitedto,maintainingminimumGroupsize,makingtheminimumcontributionrequiredbyRMHMOunderwritingguidelinesfortheemployeepremium,andmaintainingminimumparticipationratesasmayberequiredforeligibleemployees.7.OpenEnrollment.ThereshallbeanannualGroupopenenrollmentperiodduringwhichalleligibleSubscribersareofferedachoiceofenrollmentundertheAgreementoranyalternatehealthcareplanavailablethroughContractingParty.8.AlternateHealthCarePlansandChangingClassificationforEligibilityandParticipation.ContractingPartymayselectanalternateHealthCarePlanthroughRvll{MO,analternateopenenrollmentperiod,oralter,modif’,oramendtheclassificationsdeterminingeligibilityandparticipation,subjecttothirty(30)days’priorwrittennoticetoRtvfflMOandapprovalofRMHMO.ContractingPartymayselectanalternatehealthcareplanthroughanothercarrier,subjecttothirty(30)days’priorwrittennoticetoRMHMO.9.BenefitsNotinLieuofWorkers’Compensation.BenefitsthatareprovidedundertheHealthBenefitsContractarenotinlieuofworkers’compensationinsurance.ContractingPartyisrequiredtohaveineffectduringtheentiretermofthisAgreementworkers’compensationinsuranceasrequiredbyapplicablelawforallemployeeseligibletobecomeMembers.10.FamilyandMedicalLeaveAct.ThisparagraphonlyappliestoaContractingPartythatissubjecttotheFamilyandMedicalLeaveActof1993(FMLA).IfaMemberwhoisanemployeeofsuchaContractingPartytakesaleaveofabsenceoftwelve(12)workweeksorlesspursuanttotheFMLAanddiscontinueshealthcarecoveragethroughRMHMOduringsuchleaveofabsence,thenRtvffIMOwillnotimposeanynewqualificationrequirementsthattheMemberwouldhavetomeetbeforebecomingeligibleforhealthcarecoveragethroughRIvIIIMOwhensuchMemberreturnstowork.11.ColoradoContinuationofCoverageRegulationsandCOBRA.RMHMOprovidescontinuationofcoveragebenefitstoMemberseligibleforsuchbenefitsasrequiredbyapplicablelaw.RMHMOprovidesContractingPartiesthatareemployerswithsomeassistancetocomplywithapplicablecontinuationofcoveragelaws.ContractingPartyagreestoalltermsofRMHMOpoliciesregardingRMHMOprovidingsuchassistance,includinganychangestosuchpolicies.R’tHMOagreestoandshallholdContractingPartyharmlessforanyfailurebyRM}IMOtocomplywiththespecifiedadministrativeresponsibilitiesofR1v11Th40assetforthintheContinuationofCoverageInformationUnderCOBRA”sectionof2 C.atheEmployerManual.ContractingPartyisresponsiblefortheaccuracyofallinformationprovidedtoRIvIIIMO,whichinformationmaybeusedbyRIvINMOinassistingContractingPartyincomplyingwithcontinuationofcoveragelaws.ContractingPartyagreestoandshallholdRIvIHMOharmlessfromanycosts,expenses,penalties,forfeituresoranyotherclaimsordamagesresultingtoRMHMOasaresultofanyinaccuracyofinformationprovidedtoRMEMObyContractingParty,thefailuretogiveanynoticetoRIvflIMOregardinganemployee’seligibilityforcontinuationofcoverage,andfromanydisputearisingfromanyfailuretocomplywiththeprovisionsoftheColoradoContinuationofCoverageRequirementsandCOBRAortheemployer’sinterpretationoradministrationofthoselaws.Saidindemnityshallincludepenalties,courtcostsandattorneys’fees,andanyfinesimposedasaresultofanyfailuretocomplywiththeColoradoContinuationofCoverageRequirementsorCOBRA,orasotherwiseprovidedbylaw.12.TermandAmendments.TheAgreementshallcommenceontheGroupEffectiveDatesetforthaboveandautomaticallyrenewthereafteroneachAnnualRenewalDatesetforthaboveunlessearlierterminatedasprovidedintheAgreement.RenewaloftheAgreementshallmeanthecurrentAgreementterminatesandanewAgreementwiththesametermsasthecurrentAgreementasamendedbyRNI{MOhereundercommences,withoutanyrequirementforthepartiestore-executeorre-issueanycontractdocuments.Rtvll{MOmay,atanytime,amendtheAgreement:(a)toconformtotherequirementsofstateorfederallaw,statuteorregulation,effectiveuponthegivingofwrittennoticeoftheamendmenttoContractingParty;and(b)tochangeanyoralltermsoftheAgreement,includingtermsofcoverageandBenefitsbutnotrates,effectivethirty(30)daysfollowingthegivingofwrittennoticeoftheamendmenttoContractingParty.13.Termination.Exceptasotherwiseprovidedhereinorrequiredbyapplicablelaw,theAgreementmaybeterminatedasfollows:A.ContractingPartyandRMBMOshallbothhavetherighttoterminatetheAgreement,withorwithoutcause,onanypremiumduedatebygivingatleastsixty(60)days’priorwrittennoticeofterminationtotheotherparty.B.IfContractingPartyfailstopaymonthlypremiumswhendue,Rvil{MOmayterminatetheAgreementandanyandallBenefitsduetotheMembers,bygivingatleastfifteen(15)days’priorwrittennoticeofterminationtoContractingParty.BenefitswillbeprovidedtoMembersonlythroughthePaid-Through-Date.C.IntheeventthatR’fl{MOinitsdiscretiondeemsthatanychangesdescribedinparagraph8abovemayadverselyaffecttheGroup’scomposition,RMEVIOmay,bywrittennoticetoContractingParty,modifytheHealthCarePlanofferedbyRIVUIMO3 CC)totheGrouporterminatetheAgreement,effectivesixty(60)daysaftergivingwrittennoticetoContractingParty.D.IftheGroupnolongermeetsunderwritingrequirements,RIvllIMOmayterminatetheAgreementbygivingatleastsixty(60)days’priorwrittennoticeofterminationtoContractingPartypriortoanAnnualRenewalDateofthisGroupServiceAgreement.E.RIvll{MOandContractingPartymayterminatetheAgreementforcauseifeitherPartyfailstocomplywiththeterms,covenantsandconditionsoftheAgreement.Eitherpartyshallhavefifteen(15)daysfromthedatewrittennoticeofterminationisgiveninwhichtocure,correctorotherwiseresolvetothesatisfactionoftheotherpartythecauseoftermination.Intheeventthedefaultingpartyhasfailedtocure,correctorotherwiseresolvetothesatisfactionoftheotherpartythecauseoftennination,theAgreementshallterminateuponthedatesetforthinsuchnotice,providedthatsuchdateisatleastfifteen(15)daysfromthedatewrittennoticeofterminationisgiven.IntheeventofterminationoftheAgreementforanyreason,BenefitsunderthedesignatedHealthBenefitsContractshallceaseforallMembersonthedateofterminationoftheAgreementorthePaid-Through-Date,whicheveroccursfirst.IfthePaid-Through-Daterequiresaretroactivecancellation,R1Vil{MOwilldenyanyoutstandingMemberclaimsandwillnotifyboththeMemberandPlanProvidersthatpaymenthasbecometheMember’sresponsibility.14.RenewabilityforSmallGroupSicknessandAccidentInsurancePolicy.SmallGroupPlan.andSmallGroupPolicy.TotheextentthattheAgreementisa“smallgroupsicknessandaccidentinsurancepolicy,”a“smallgroupplan”ora“smallgrouppolicy”asdefinedbytheprovisionsofsection10-16-102(43)oftheColoradoRevisedStatutes,theAgreementshallberenewableastoallemployeesanddependentsattheoptionofthesmallemployer,exceptwherethereis:A.Nonpaymentofrequiredpremiums;B.Fraudormisrepresentationbythesmallemployerorwithrespecttocoverageofaninsuredindividual,fraudormisrepresentationbytheinsuredindividualortheindividual’srepresentative;C.Noncompliancewithplanprovisions;D.Aninsufficientnumberofindividualsundertheplantomeetthepercentagerequirementsoftheplan;orE.Thesmallemployerisnolongeractivelyengagedinthebusinessinwhichitwasengagedontheeffectivedateoftheplan.4 oC•ATTACHMENTIELIGIBILITYEagleCountyGovernmentEligibilitynotexpresslycoveredinthedesignatedHealthBenefitsContractisasfollows:(1)TobeeligibleformembershipinRMHMO,ContractingParty’seligibleemployeesmustmeetthegeneraleligibilityrequirementsofRMHMO’sHealthBenefitsContractandmustworkafull-time,regularworkweekof30hoursormore:SuchindividualshallbeeligibleformembershipinR4HMObeginningthefirstdayofthemonthfollowingthefirstdayofActiveEmployment.BoardofCountyCommissionersshallbeeligibleformembershiponthefirstdayofthemonthfollowingtheappointment.(2)Foreligibleemployeeswhoareworking30hoursormoreperweekandwhoseworkinghoursarereducedbelow30hoursperweek,ContractingPartymayelect,uponwrittennoticetoRIvlIThlO,tocontinueGroupmembershipforsuchemployeesandtheirdependentsunderthesameconditionsandforthesamepremium,ifthefollowingconditionsexist:(A)theemployeememberhasbeencontinuouslyemployedasanemployeeofContractingPartyworking30hoursperweekandhasbeeninsuredunderthedesignatedHealthBenefitsContract,orunderanygroupservicecontractprovidingsimilarbenefitswhichsaiddesignatedHealthBenefitsContractreplaces,foratleastsix(6)monthsimmediatelypriortosuchreductioninworkinghours;B)ContractingPartyhasimposedsuchreductioninworkinghoursduetoeconomicconditions;and(C)ContractingPartyintendstorestoretheemployeetoafull30hourperweekworkscheduleassoonaseconomicconditionsimprove. CCATTACHMENTIIENROLLMENTANDRATESEagleCountyGovernment1.OpenEnrollmentProvisions:ThemonthofDecemberannuallyforanJanuary1effectivedate.2.OtherProvisions:Employeesordependentswhomisstheiropportunitytoenrollmayapplyatotherthantheopenenrollmentperiodbutwillbesubjecttomedicalscreening.3.HealthCarePlan(s)selectedandapplicableMonthlyRateScheduleareasfollows:MonthlyRateSchedulePlanSingleTwoPartyFamilyOtherHl0/lO$154.00$308.00$331.10$462.00TheforegoingratesareeffectiveSeptember1,1996andshallremainineffectthroughAugust31,1997.TheratesnotedabovearesubjecttochangebyRIVIHMOgivingContractingPartynoticeofsuchchangeatleastthirty(30)dayspriortotheAnnualRenewalDate. C015.Notice.Whenevernoticeisrequiredhereunder,suchnoticeshallbedeemedeffectivelygivenifinwritinganduponmailing,postageprepaid,totheaddressofRM}IMOat2775CrossroadsBoulevard,PostOfficeBox10600,GrandJunction,Colorado81502-5500,ortotheaddressofContractingPartyassuchaddressappearsontherecordsofR1\il{MO.EitherRIvIHMOorContractingPartymaychangetheaddresstowhichnoticeisgivenhereunderbygivingnoticeofthechangeofaddressasdescribedinthisparagraph.16.Assignment.TherightsandprivilegesofContractingPartypursuanttotheAgreementmaynotbeassigned.RM}IMOshallhavetherighttàassigntheAgreementwithpriorwrittennoticetotheContractingParty.CONTRACTINGPARTY:ByDate:GSAI96OIROCKYMOUNTAiNHEALTHMAINTENANCEORGANIZATION,INC.ByTitle:DirectorofMarketingDate:November13.1996Title:/Y2/95
