REQUEST FOR PROPOSAL INSTRUCTIONS ......final proposal as firm and final on or before August 15, 2020 (including any amendments and/or negotiations) and upon the conditions contained

EAST TEXAS COUNCIL OF GOVERNMENTS • 3800 STONE ROAD • KILGORE, TEXAS 75662

REQUEST FOR PROPOSAL

INSTRUCTIONS

SPECIFICATIONS

BID SHEET(S)

FOR

RFP 1001-2020: Group Health Insurance, Direct Provider Contracts, TPA &

Specific and Aggregate Stop Loss Re-Insurance

PER

EAST TEXAS COUNCIL OF GOVERNMENTS SPECIFICATIONS

AT

BRINSON BENEFITS ANALYTICS DEPARTMENT

OPENING DATE: WEDNESDAY, JULY 15, 2020

10:00 AM CST



Return Bid To: BRINSON BENEFITS c/o Carolyn Summy-Thompson 4851 LBJ Freeway Suite 900 Dallas, TX 75244 Email: [email protected]

The enclosed REQUEST FOR PROPOSAL and accompanying Specifications with Bid Sheets are for your convenience in bidding the enclosed referenced products and/or services for East Texas Council of Governments. Sealed bids shall be received no later than: 10:00 AM CST, JULY 15, 2020, WEDNESDAY.

Please reference “RFP 1001-2020: Group Health Insurance, Direct Provider Contracts, TPA & Specific and Aggregate Stop Loss Re-Insurance proposal and affix this number to the subject line of the email. All bids shall be to the attention of the BRINSON BENEFITS ANALYTICS DEPARTMENT. East Texas Council of Governments appreciates your time and effort in preparing a bid. Please note that all bids must be received at the designated location by the deadline shown. Bids received after the deadline will be returned unopened and shall be considered void and unacceptable. Bid opening is scheduled to be held in the BRINSON BENEFITS ANALYTICS DEPARTMENT. c/o Carolyn Summy-Thompson, [email protected].

If Bidder desires not to bid at this time, but wishes to remain on the commodity bid list, please submit a "NO BID" response (same time/location). East Texas Council of Governments is always very conscious and extremely appreciative of the time and effort expended to submit a bid. However, on "NO BID" responses please communicate any bid requirement(s) which may have influenced your decision to "NO BID."

If response is not received in the form of a "BID" or "NO BID" for three (3) consecutive REQUEST FOR PROPOSAL, Bidder shall be removed from said bid list. However, if you choose to "NO BID" at this time but desire to remain on the bid list for other commodities, please state the specific product/service for which your firm wishes to be classified. Awards should be made approximately three weeks following the bid opening date. To obtain results, or if you have any questions, please contact the HUMAN RESOURCES DEPARTMENT at 903-218-6400.

mailto:[email protected]



INSTRUCTIONS/TERMS OF CONTRACT/GENERAL REQUIREMENTS

RFP 1001-2020: Group Health Insurance, Direct Provider Contracts, TPA &

Specific and Aggregate Stop Loss Re-Insurance

By order of East Texas Council of Governments, sealed bids will be received for:

Group Health Insurance, Direct Provider Contracts, TPA & Specific and Aggregate

Stop Loss Re-Insurance

TO PROVIDE for an annual Contract commencing after the date of the award and continuing for

twelve month period. East Texas Council of Governments reserves the right to extend this

contract for four (4) additional one-year periods as it deems to be in the best interest of the city.

IT IS UNDERSTOOD that East Texas Council of Governments, reserves the right to reject any

and/or all bids for any/or all products and/or services covered in this bid request and to waive

informalities or defects in bids or to accept such bids as it shall deem to be in the best interests

of East Texas Council of Governments. BIDS MUST BE submitted on the pricing forms included for that purpose in this packet. Each Proposal shall be emailed to [email protected] each form manually signed by a person having the authority to bind the firm in a Contract, and marked clearly on the outside as shown below. FACSIMILE TRANSMITTALS SHALL NOT BE ACCEPTED!

SUBMISSION OF BIDS: Sealed bids shall be submitted no later than 10:00 AM, JULY

15, 2020, WEDNESDAY to the address as follows:

BRINSON BENEFITS c/o Carolyn Summy-Thompson 4851 LBJ Freeway Suite 900

Dallas, TX 75244 Email: [email protected]

RFP 1001-2020 Group Health Insurance, Direct Provider Contracts, TPA & Specific and Aggregate Stop Loss Re-Insurance

EAST TEXAS COUNCIL OF GOVERNMENTS • 3800 STONE ROAD • KILGORE, TX, 75662

MARK ENVELOPE: "RFP 1001-2020 Group Health Insurance, Direct Provider

Contracts, TPA & Specific and Aggregate Stop Loss Re-Insurance”

ALL BIDS MUST BE RECEIVED IN THE BRINSON BENEFITS ANALYTICS DEPARTMENT

BEFORE OPENING DATE AND TIME.

BIDDERS PLEASE NOTE: COPIES OF THE FOLLOWING BID SHEETS HAVE BEEN ENCLOSED FOR YOUR CONVENIENCE

• Bid Affidavit Form (required)

• Response Form (required)

• Conflict of Interest Form (required)

• Actual rates, terms & conditions of proposal (required)



PUBLIC NOTICE STATEMENT FOR ADA COMPLIANCE

East Texas Council of Governments acknowledges its responsibility to comply with the

Americans with Disabilities Act of 1990. Thus, in order to assist individuals with disabilities who

require special services (i.e. sign interpretative services, alternative audio/visual devices, and

amanuenses) for participation in or access to East Texas Council of Governments sponsored

public programs, services and/or meetings, East Texas Council of Governments requests that

individuals make request for these services forty-eight (48) hours ahead of the scheduled

program, service and/or meeting. To make arrangements, contact Brandy Brannon, Assistant

Executive Director or other designated official at (903) 218-6417.



FUNDING: Funds for payment have been provided through East Texas Council of Governments budget approved by their Executive Committee for this fiscal year only. State of Texas statutes prohibit the obligation and expenditure of public funds beyond the fiscal year for which a budget has been approved. Therefore, anticipated orders or other obligations that may arise past the end of the current fiscal year shall be subject to budget approval.

LATE BIDS: Bids received in East Texas Council of Governments BRINSON BENEFITS

ANALYTICS DEPARTMENT after submission deadline will be considered void and

unacceptable. East Texas Council of Governments is not responsible for lateness or non-

delivery of mail, carrier, etc., and the date/time stamp in the BRINSON BENEFITS ANALYTICS

DEPARTMENT shall be the official time of receipt.

ALTERING BIDS: Bids can be negotiated, amended, and/or revised after the bid opening prior

to contract placement provided any changes are in writing as indicated in the enclosed executed

waiver by East Texas Council of Governments to House Bill 1466, Article 21.49.16 of the Texas

Insurance Code. Any interlineation, alteration, or erasure made before opening time must be

initialed by the signer of the bid, guaranteeing authenticity. East Texas Council of Governments

reserves the right to accept, negotiate, amend or reject any/all of the bid as it deems to be in the

best interest of East Texas Council of Governments.

WITHDRAWAL OF BID: A bid may not be withdrawn or canceled by the Bidder without the

permission of East Texas Council of Governments for a period of ninety (90) days following the

date designated for the receipt of bids, and Bidder so agrees upon submittal of their bid.

SALES TAX: East Texas Council of Governments is exempt by law from payment of Texas

State Sales Tax and Federal Excise Tax. Bidder shall include any sales taxes from concession

sales of taxable items on East Texas Council of Governments property in the total price of the

sale, and shall be responsible to report and pay such taxes in a timely manner.

BID AWARD: East Texas Council of Governments reserves the right to award any combination

of the three sections as is deemed in the best interest of East Texas Council of Governments.

East Texas Council of Governments also reserves the right to not award one or none of the

sections.

CONTRACT: This bid, when properly accepted by East Texas Council of Governments, shall

constitute a Contract equally binding between the successful Bidder and East Texas Council of

Governments. No different or additional terms will become a part of this Contract with the

exception of Change Orders.

CHANGE ORDERS: No oral statement of any individual shall modify or otherwise change, or

affect the terms, conditions or Specifications stated in the resulting Contract. All Change Orders



to the Contract will be made in writing by the East Texas Council of Governments Assistant

Executive Director.

IF DURING THE life of the Contract, the successful Bidder’s net prices to other customers for

items awarded herein are reduced below the Contracted price, it is understood and agreed that

the benefits of such reduction shall be extended to East Texas Council of Governments.

A PRICE redetermination may be considered by East Texas Council of Governments only at the

anniversary date of the Contract and shall be substantiated in writing (i.e., Manufacturer’s direct

cost, postage rates, Railroad Commission rates, Wage/Labor rates, etc.). The Bidder’s past

history of honoring Contracts at the bid price will be an important consideration in the evaluation

of the lowest and best bid. East Texas Council of Governments reserves the right to accept or

reject any/all of the price redetermination as it deems to be in the best interest of the East Texas

Council of Governments.

DELIVERY: all delivery and freight charges (F.O.B. East Texas Council of Governments) are to

be included in the bid price.

DELIVERY TIME: Bids shall show number of days required to place goods ordered at the East

Texas Council of Governments designated location. Failure to state delivery time may cause

bid to be rejected. Successful Bidder shall notify the BRINSON BENEFITS ANALYTICS

DEPARTMENT immediately if delivery schedule cannot be met. If delay is foreseen, successful

Bidder shall give written notice to the Agent. East Texas Council of Governments has the right

to extend delivery time if reason appears valid. Successful Bidder must keep the BRINSON

BENEFITS ANALYTICS DEPARTMENT advised at all times of the status of the order.

CONFLICT OF INTEREST: No public official shall have interest in this Contract, in accordance

with Vernon's Texas Codes Annotated, Local Government Code Title 5. Subtitle C, Chapter

171.

DISCLOSURE OF CERTAIN RELATIONSHIPS Effective January 1, 2008, Chapter 176 of the

Texas Local Government Code requires that any vendor or person considering doing business

with a local government entity disclose in the Questionnaire Form CIQ, the vendor or person’s

affiliation or business relationship that might cause a conflict of interest with a local government

entity. By law, this questionnaire must be filed with the records administrator of East Texas

Council of Governments not later than the 7th business day after the date the person becomes

aware of facts that require the statement to be filed. See Section 176.006, Local Government

Code. A person commits an offense if the person violates Section 176.006, Local Government

Code. An offense under this section is a Class C misdemeanor.



ETHICS: The Bidder shall not offer or accept gifts of anything of value nor enter into any

business arrangement with any employee, official or agent of East Texas Council of

Governments.

EXCEPTIONS/SUBSTITUTIONS: All bids meeting the intent of this REQUEST FOR

PROPOSAL will be considered for award. Bidders taking exception to the Specifications, or

offering substitutions, shall state these exceptions in the section provided or by attachment as

part of the bid. In the absence of such, a list shall indicate that the Bidder has not taken

exceptions and shall hold the Bidder responsible to perform in strict accordance with the

Specifications of the Invitation. East Texas Council of Governments reserves the right to accept

any and all, or none, of the exception(s)/ substitution(s) deemed to be in the best interest of

East Texas Council of Governments.

ADDENDA: Any interpretations, corrections or changes to this REQUEST FOR PROPOSAL

and Specifications will be made by addenda. Sole issuing authority of addenda shall be

vested in East Texas Council of Governments Assistant Executive Director. Addenda will be

mailed to all who are known to have received a copy of this REQUEST FOR PROPOSAL.

Bidders shall acknowledge receipt of all addenda.

DESCRIPTIONS: Any reference to model and/or make/manufacturer used in bid Specifications

will be made by addenda. Sole issuing authority of addenda shall be vested in the East Texas

Council of Governments’ Assistant Executive Director. Addenda will be mailed to all who are

known to have received a copy of this REQUEST FOR PROPOSAL. Bidders shall

acknowledge receipt of all addenda.

BID MUST COMPLY with all federal, state, county, and local laws concerning these types of

service(s).

DESIGN, STRENGTH, QUALITY of materials must conform to the highest standards of

manufacturing and engineering practice.

All items supplied against credit must be new and unused, unless otherwise specified, in first-

class condition and of current manufacturer.

MINIMUM STANDARDS FOR RESPONSIBLE PROSPECTIVE BIDDERS: A prospective

Bidder must affirmatively demonstrate Bidder's responsibility. A prospective Bidder must meet

the following requirements: 1. Have adequate financial resources, or the ability to obtain such resources as

required;

2. be able to comply with the required or proposed delivery schedule;

3. have a satisfactory record of performance;



4. have a satisfactory record of integrity and ethics;

5. be otherwise qualified and eligible to receive an award. East Texas Council of Governments may request representation and other information sufficient

to determine Bidder's ability to meet these minimum standards listed above.

REFERENCES: Upon the selection of finalist, East Texas Council of Governments may request

Bidder to supply, with this REQUEST FOR PROPOSAL, a list of at least three (3) references

where like products and/or services have been supplied by their firm. Include name of firm,

address, telephone number and name of representative. The references should be provided

upon request.

BIDDER SHALL PROVIDE with this bid response, all documentation required by this

REQUEST FOR PROPOSAL. Failure to provide this information may result in rejection of bid.

SUCCESSFUL BIDDER SHALL defend, indemnify and save harmless East Texas Council of

Governments and all its officers, agents and employees from all suits, actions, or other claims of

any character, name and description brought for or on account of any injuries or damages

received or sustained by any person, persons, or property on account of any negligent act or

fault of the successful Bidder, or of any agent, employee, subcontractor or supplier in the

execution of, or performance under, any Contract which may result from bid award. Successful

Bidder indemnifies and will indemnify and save harmless East Texas Council of Governments

from liability, claim or demand on their part, agents, servants, customers, and/or employees

whether such liability, claim or demand arise from event or casualty happening or within the

occupied premises themselves or happening upon or in any of the halls, elevators, entrances,

stairways or approaches of or to the facilities within which the occupied premises are located.

Successful Bidder shall pay any judgment with costs which may be obtained against East Texas

Council of Governments growing out of such injury or damages. In addition, Contractor shall

obtain and file with East Texas Council of Governments, a Standard Certificate of Insurance and

applicable policy endorsement evidencing the required coverage and naming East Texas

Council of Governments as an additional insured on the required coverage.

WAGES: Successful Bidder shall pay or cause to be paid, without cost or expense to East

Texas Council of Governments, all Social Security, Unemployment and Federal Income

Withholding Taxes of all such employees and all such employees shall be paid wages and

benefits as required by Federal and/or State Law.

TERMINATION OF CONTRACT: This Contract shall remain in effect until Contract expires,

delivery and acceptance of products and/or performance of services ordered or terminated by

either party with a thirty (30) day written notice prior to any cancellation. The successful Bidder

must state therein the reasons for such cancellation. East Texas Council of Governments



reserves the right to award canceled Contract to best Bidder as it deems to be in the best

interest of East Texas Council of Governments.

TERMINATION FOR DEFAULT: East Texas Council of Governments reserves the right to

enforce the performance of this Contract in any manner prescribed by law or deemed to be in

the best interest of East Texas Council of Governments in the event of breach or default of this

Contract. East Texas Council of Governments reserves the right to terminate the Contract

immediately in the event the successful Bidder fails to:

1. Meet schedules;

2. defaults in the payment of any fees; or

3. otherwise perform in accordance with these Specifications.

Breach of Contract or default authorizes East Texas Council of Governments to exercise any or

all of the following rights:

1. East Texas Council of Governments may take possession of the assigned premises

and any fees accrued or becoming due to date;

2. East Texas Council of Governments may take possession of all goods, fixtures and

materials of successful Bidder therein and may foreclose its lien against such personal

property, applying the proceeds toward fees due or thereafter becoming due.

In the event the successful Bidder shall fail to perform, keep or observe any of the terms and

conditions to be performed, kept or observed, East Texas Council of Governments shall give the

successful Bidder written notice of such default; and in the event said default is not remedied to

the satisfaction and approval of East Texas Council of Governments within two (2) working days

of receipt of such notice by the successful Bidder, default will be declared and all the successful

Bidder's rights shall terminate.

Bidder, in submitting this bid, agrees that East Texas Council of Governments shall not be liable

to prosecution for damages in the event that East Texas Council of Governments declares the

Bidder in default.

NOTICE: Any notice provided by this bid (or required by law) to be given to the successful

Bidder by East Texas Council of Governments shall conclusively deemed to have been given

and received on the next day after such written notice has been deposited in the mail to East

Texas Council of Governments, by Registered or Certified Mail with sufficient postage affixed

thereto, addressed to the successful Bidder at the address so provided; provided this shall not

prevent the giving of actual notice in any other manner.



PATENTS/COPYRIGHTS: The successful Bidder agrees to protect East Texas Council of

Governments from claims involving infringement of patents and/or copyrights.

CONTRACT ADMINISTRATOR: Under this Contract, East Texas Council of Governments may

appoint a Contract Administrator with designated responsibility to ensure compliance with

Contract requirements, such as but not limited to, acceptance, inspection and delivery. The

Contract Administrator will serve as liaison between East Texas Council of Governments

Human Resource Department (which has the overall Contract Administration responsibilities)

and the successful Bidder.

PURCHASE ORDER: A Purchase Order(s) shall be generated by East Texas Council of

Governments to the successful Bidder. The Purchase Order number must appear on all

itemized invoices and packing slips. East Texas Council of Governments will not be held

responsible for any orders placed/delivered without a valid current Purchase Order number.

PACKING SLIPS or other suitable shipping documents shall accompany each special order

shipment and shall show: (a) name and address of successful Bidder, (b) name and address of

receiving department and/or delivery location, (c) Purchase Order number, and (d) descriptive

information as to the item(s) delivered, including product code, item number, quantity, number of

containers, etc.

INVOICES shall show all information as stated above, shall be mailed directly to East Texas

Council of Governments, 3800 Stone Road, Kilgore, TX, 75662.

PAYMENT will be made upon receipt and acceptance by East Texas Council of Governments

for any item(s) ordered and receipt of a valid invoice, in accordance with the State of Texas

Prompt Payment Act, Article 601f V.T.C.S. Successful Bidder(s) required to pay subcontractors

within ten (10) days.

ITEMS supplied under this Contract shall be subject to East Texas Council of Governments

approval. Items found defective or not meeting Specifications shall be picked up and replaced

by the successful Bidder at the next service date at no expense to East Texas Council of

Governments. If item is not picked up within one (1) week after notification, the item will

become a donation to East Texas Council of Governments for disposition.

SAMPLES: When requested, samples shall be furnished free of expense to East Texas

Council of Governments.

WARRANTY: Successful Bidder shall warrant that all items/services shall conform to the

proposed Specifications and/or all warranties as stated in the Uniform Commercial Code and be

free from all defects in material, workmanship and title. A copy of the warranty for each item



being bid must be enclosed. Failure to comply with the above requirements for literature and

warranty information could cause bid to be rejected.

REMEDIES: The successful Bidder and East Texas Council of Governments agree that both

parties have all rights, duties and remedies available as stated in the Uniform Commercial

Code.

VENUE: This Agreement will be governed and construed according to the laws of the State of

Texas. This Agreement is performable in Kilgore, Texas.

ASSIGNMENT: The successful Bidder shall not sell, assign, transfer or convey this Contract, in

whole or in part, without prior written consent of East Texas Council of Governments.

SPECIFICATIONS and model numbers are for description only. Bidder may bid on description

only. Bidder may bid on alternate model but must clearly indicate alternate model being bid.

Bidder must enclose full descriptive literature on alternate item(s).

SILENCE OF SPECIFICATION: The apparent silence of these Specifications as to any detail

or to the apparent omission of a detailed description concerning any point, shall be regarded as

meaning that only the best commercial practices are to prevail. All interpretations of these

Specifications shall be made on the basis of this statement.

Each insurance policy to be furnished by successful Bidder shall include, by endorsement to the

policy, a statement that a notice shall be given to East Texas Council of Governments by

Certified Mail thirty (30) days prior to cancellation or upon any material change in coverage.

ANY QUESTIONS concerning this REQUEST FOR PROPOSAL and Specifications should be

directed to Carolyn Summy-Thompson, Brinson Benefits, Inc., 214.379.5172,

[email protected].



GENERAL REQUIREMENTS

1) The information contained in these specifications is confidential and is to be used only in connection with preparing a bid for all or part of the following employee benefit plans:

Group Medical Insurance

Direct Provider Contracts

TPA

Specific & Aggregate Stop Loss Re-Insurance

2) Currently all products are offered on a October 1 effective date. 3) All bid responses should be provided on the enclosed response forms with the signature of

your authorized representative. If attachments are necessary, please provide. DO NOT MODIFY RESPONSE FORMS. Proposals must include copies of the completed Bid Affidavit, Response Form, Conflict of Interest Form including actual rates, terms and conditions. Any additional information should be provided at the end of the response form. Contact EAST TEXAS COUNCIL OF GOVERNMENTS, Inc. for a copy of the response forms to be sent via email for your convenience.

4) East Texas Council of Governments has appointed Brinson Benefits as their Agent of

Record/Employee Benefit Consultant and is not selecting a new broker/consultant therefore; Medical Insurance should be submitted on a NET commission basis. If you are required to include commissions in your products, please note this clearly on your response form.

5) Retirees are not covered. Covered participants include: Full Time employees, Part Time

and COBRA participants. 6) No telephonic or fax bids will be accepted. Bids must be sealed and delivered to the

BRINSON BENEFITS ANALYTICS DEPARTMENT prior to the official bid opening time. East Texas Council of Governments will not be responsible for missing, lost or late proposals. Any bids received after the time set for opening will be returned to the sender.

7) The information contained herein is believed to be accurate and up-to-date, but is not

intended to be an express or implied warranty. 8) Bids are to be submitted on the basis of the specifications contained herein. Alternate bids

are encouraged and will be considered provided the alternatives enhance the current plan and are clearly explained. All deviations from the specifications must be clearly identified and explained.

9) East Texas Council of Governments reserves the right to negotiate, amend, accept or reject

all or any part of the bids, waive minor technicalities, and award the bid that best serves the interest of East Texas Council of Governments. East Texas Council of Governments also reserves the right to waive or dispense with any of the formalities contained herein.



10) Proposals must be submitted for coverage on all eligible full-time regular employees and their dependents. Full-time is defined as 40 or more hours per week. Dependent is defined as the employee's spouse and/or unmarried children from birth to age 26 and claimed as a dependent.

11) Waiting period: First of Month after Date of Hire 12) Contribution: Medical is 100% for the employee; EE + Spouse and Family coverage is 30%

and Employee + Child coverage is 30%. East Texas Council of Governments is aware of the time and effort you expend in preparing and submitting proposals to East Texas Council of Governments. Please let us know of any requirements in the RFP that are causing you difficulty in responding. We want to make this process as easy as possible so that all responsible vendors can compete for East Texas Council of Governments’ business.



East Texas Council of Governments Group Health Insurance, Direct Provider Contracts, TPA & Specific and Aggregate

Stop Loss Re-Insurance

1. Assumptions

a) East Texas Council of Governments offers a fully insured HMO, HSA and PPO

plan. See attached plan design. The bid is based on duplication of current benefits. Alternate plan designs are welcome.

b) Effective date is October 1, 2020. c) All participants enrolled in the plan as of September 30, 2020 are to be covered

on a “No loss/No gain” basis. “No loss/No gain” for participants is to include credit for accumulated deductible and coinsurance as applicable. The participant will provide documentation for this credit.

e) The selected insurance provider will provide enrollment and educational materials, as well as participant in East Texas Council of Governments annual open enrollment presentations.

f) East Texas Council of Governments must receive renewal rates by June 30th,

preceding the October 1st renewal date. Refer to the Bid Affidavit. g) See attached (Exhibit 1) for current summary of benefits. h) SIC Code is 9111. i) Writing Producer is: S. Dawn Brinson



2. TPA & Specific and Aggregate Stop Loss Re-Insurance GENERAL INFORMATION

Products Requested Stop Loss Specific & Aggregate Insurance

REQUESTED

STOP LOSS INSURANCE Network

HST RBP w/ Healthsmart physicians network

Specific Deductible

$40K, $50K, $60K

Lifetime Maximum Annual limit: Unlimited LTM: Unlimited

Contract Basis 12/12

Coverage Medical/Rx Aggregate

Attachment Corridor 125%

Contract Basis 12/12

Coverage Medical/Rx

2. Rates and History Buy-Up

MEDICAL PLAN YEAR NET OF COMMISSION

Employee Only

EE+ Spouse

EE+ Child(ren)

EE+ Family

RENEWAL October 1, 2020 – September 30, 2021

Pending Renewal

October 1, 2019 – September 30, 2020

$723.70 $1,664.52 $1,302.67 $2,243.48


$667.84 $1,536.02 $1,202.11 $2,070.29


$589.00 $1,295.80 $1,089.65 $1,884.80


$544.98 $1,198.96 $1,008.21 $1,743.94

June 1, 2015 – September 30, 2016

$539.00 $1,072.00 $803.00 $1,611.00



Core


Employee Only

EE+ Spouse

EE+ Child(ren)

EE+ Family


Pending Renewal


$565.58 $1,301.06 $1,018.23 $1,753.61


$489.27 $1,125.32 $880.63 $1,516.73


$486.10 $1,069.42 $899.28 $1,555.52


$456.12 $1,003.46 $843.82 $1,459.58

HMO


Employee Only

EE+ Spouse

EE+ Child(ren)

EE+ Family


Pending Renewal


$503.72 $1,158.54 $906.69 $1,561.52

Carrier History:

October 1, 2018 – September 30, 2020 BCBS

October 1, 2016 – September 30, 2018 United Healthcare

June 1, 2013 – September 30, 2016 Aetna



East Texas Council of Governments EMPLOYEE INSURANCE EXHIBITS

EXHIBIT I

Summary of Benefits – Medical (provided in .pdf)

EXHIBIT II Medical Census (provided in an excel spreadsheet)

EXHIBIT III

Medical Claim Experience Reports (provided in .pdf)

EXHIBIT IV Tx Ins Code Municipality Bid Waiver (provided in .pdf)

EXHIBIT V

Three Required Forms (provided below) -Bid Affidavit Form -Response Forms

-Conflict of Interest Form

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would sharethe cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is

only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visitwww.bcbstx.com/member/policy-forms/2019 or by calling 1-800-521-2227. For general definitions of common terms, such as allowed amount, balancebilling, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/UG-Glossary-508-MM.pdf or call 1-855-756-4448 to request a copy.

Why This Matters:AnswersImportant QuestionsGenerally, you must pay all of the costs from providers up to the deductible amount beforethis plan begins to pay. If you have other family members on the plan, each family member

In-Network - $6,650 Individual /$13,300 FamilyOut-of-Network - $13,300Individual / $26,600 Family

What is the overalldeductible?

must meet their own individual deductible until the total amount of deductible expenses paidby all family members meets the overall family deductible.This plan covers some items and services even if you haven’t yet met the deductible amount.But a copayment or coinsurance may apply. For example, this plan covers certain preventive

Yes. Preventive care services arecovered before you meet yourdeductible.

Are there services coveredbefore you meet yourdeductible? services without cost-sharing and before you meet your deductible. See a list of covered

preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.You don’t have to meet deductibles for specific services.No.Are there other

deductibles for specificservices?

The out-of-pocket limit is the most you could pay in a year for covered services. If you haveother family members in this plan, they have to meet their own out-of-pocket limits until theoverall family out-of-pocket limit has been met.

In-Network - $6,650 Individual /$13,300 FamilyOut-of-Network - UnlimitedIndividual / Unlimited Family

What is the out-of-pocketlimit for this plan?

Even though you pay these expenses, they don't count toward the out-of-pocket limit.Premiums, balanced-billedcharges, and health care this plandoesn't cover.

What is not included in theout-of-pocket limit?

This plan uses a provider network. You will pay less if you use a provider in the plan’s network.You will pay the most if you use an out-of-network provider, and you might receive a bill from

Yes. Seewww.bcbstx.com/go/bcppo orcall 1-800-810-2583 for a list ofNetwork Providers.

Will you pay less if you usea network provider?

a provider for the difference between the provider’s charge and what your plan pays (balancebilling). Be aware your network providermight use an out-of-network provider for some services(such as lab work). Check with your provider before you get services.You can see the specialist you choose without a referral.No.Do you need a referral to

see a specialist?

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association1 of 6

Summary of Benefits and Coverage:What this Plan Covers & What You Pay For Covered Services Coverage Period: 10/01/2019-09/30/2020

: MTBCPC1CH Blue Choice PPO HSASM C1CH Coverage for: Individual/Family Plan Type: PPO

EXHIBIT I - SUMMARY OF BENEFITS- MEDICAL

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Limitations, Exceptions, & Other ImportantInformation

What You Will PayServices You May NeedCommon

Medical Event Out-of-Network Provider(You will pay the most)

Network Provider (Youwill pay the least)

Virtual Visits are available. See your benefitbooklet* for details.

50% coinsuranceNo ChargePrimary care visit to treat aninjury or illness

If you visit a health careprovider’s office orclinic

None50% coinsuranceNo ChargeSpecialist visitYou may have to pay for services that aren'tpreventive. Ask your provider if the services

50% coinsuranceNo Charge; deductibledoes not apply

Preventive care/screening/immunization

needed are preventive. Then check what yourplan will pay for.

Preauthorization may be required; see yourbenefit booklet* for details.

50% coinsuranceNo ChargeDiagnostic test (x-ray, bloodwork)If you have a test

50% coinsuranceNo ChargeImaging (CT/PET scans, MRIs)Limited to a 30-day supply at retail (or a90-day supply at a network of select retail

No ChargeNo ChargePreferred generic drugsIf you need drugs totreat your illness orcondition

No ChargeNo ChargeNon-preferred generic drugspharmacies). Up to a 90-day supply at mailNo ChargeNo ChargePreferred brand drugsorder. Specialty drugs limited to a 30-day

More information aboutprescription drugcoverage is available athttps://www.bcbstx.com/member/prescription-drug-plan-information/drug-lists

No ChargeNo ChargeNon-preferred brand drugssupply. Payment of the difference betweenthe cost of a brand name drug and a genericmay also be required if a generic drug isavailable. All Out-of-Network prescriptionsare subject to a 50% additional charge afterthe applicable copay/coinsurance. Additionalcharge will not apply to any deductible orout-of-pocket amounts.

No ChargeNo ChargePreferred specialty drugsNo ChargeNo ChargeNon-Preferred specialty drugs

Preauthorization may be required. Abortionis not covered except in limitedcircumstances.For Outpatient Infusion Therapy, see yourbenefit booklet* for details.

50% coinsuranceNo ChargeFacility fee (e.g., ambulatorysurgery center)If you have outpatient

surgery 50% coinsuranceNo ChargePhysician/surgeon fees

None

No ChargeNo ChargeEmergency room careIf you need immediatemedical attention

No ChargeNo ChargeEmergency medicaltransportation

50% coinsuranceNo ChargeUrgent care*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2019.

2 of 6





Preauthorization required. Preauthorizationpenalty: $250 Out-of-Network. See yourbenefit booklet* for details.

50% coinsuranceNo ChargeFacility fee (e.g., hospitalroom)If you have a hospital

stay50% coinsuranceNo ChargePhysician/surgeon fees

Outpatient: Certain services must bepreauthorized, failure to preauthorize at least

50% coinsuranceNo ChargeOutpatient services

If you need mentalhealth, behavioralhealth, or substanceabuse services

50% coinsuranceNo ChargeInpatient servicestwo business days prior to service will resultin 50% reduction in benefits (not to exceed$500), refer to benefit booklet* for details.Inpatient: Preauthorization requiredOut-of-Network; failure to preauthorize at leasttwo business days prior to admission willresult in $250 reduction in benefits.Cost sharing does not apply to certainpreventive services. Depending on the type of

50% coinsuranceNo ChargeOffice visits

If you are pregnant50% coinsuranceNo ChargeChildbirth/delivery professional

services services, deductiblemay apply.Maternity caremay include tests and services describedelsewhere in the SBC (i.e. ultrasound).

50% coinsuranceNo ChargeChildbirth/delivery facilityservices

60 visits/year. Preauthorization required forOut-of-Network.

50% coinsuranceNo ChargeHome health care

If you need helprecovering or haveother special healthneeds

Preauthorization may be required. ForOutpatient, limited to combined 35 visits peryear, including Chiropractic.

50% coinsuranceNo ChargeRehabilitation services50% coinsuranceNo ChargeHabilitation services

25 day maximum per calendar year.Preauthorization required for Out-of-Network.

50% coinsuranceNo ChargeSkilled nursing care

None50% coinsuranceNo ChargeDurable medical equipmentPreauthorization required for Out-of-Network.50% coinsuranceNo ChargeHospice services

NoneNot CoveredNot CoveredChildren’s eye exam

If your child needsdental or eye care Not CoveredNot CoveredChildren’s glasses

Not CoveredNot CoveredChildren’s dental check-up

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2019.3 of 6

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)Private-duty nursingDental care (Adult)Abortion (Except for a pregnancy that, as certified

by a physician, places the woman in danger ofdeath or a serious risk of substantial impairmentof a major bodily function unless an abortion isperformed)

Routine eye care (Adult and Child)Long-term careNon-emergency care when traveling outside theU.S.

Weight loss programs

AcupunctureBariatric surgeryCosmetic surgery

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document)Routine foot care (Only covered in connectionwithdiabetes, circulatory disorders of the lowerextremities, peripheral vascular disease, peripheralneuropathy, or chronic arterial or venousinsufficiency)

Infertility treatment (Invitro and artificialinsemination are not covered unless shown inyour plan document)

Chiropractic care (Outpatient -Max. 35 visits/year)Hearing aids (Limited to two hearing aids everythree years)

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for thoseagencies is: the plan at 1-800-521-2227, U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, or Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 orwww.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health InsuranceMarketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint iscalled a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plandocuments also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights,this notice, or assistance, contact: Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com, or contact the U.S. Department of Labor'sEmployee Benefits Security Administration at 1-866-444-EBSA (3272) or visit www.dol.gov/ebsa/healthreform. Contact the Texas Department of Insuranceat 1-800-252-3439 or visit www.texashealthoptions.com.

Does this plan provide Minimum Essential Coverage? YesIf you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemptionfrom the requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? YesIf your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

4 of 6

Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-252-3439.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-252-3439.Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-252-3439.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-252-3439.

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

5 of 6

About These Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be differentdepending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs youmight pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby(9 months of in-network pre-natal care and a

hospital delivery)

The plan's overall deductible $6,650Specialist $0Hospital (facility) $0Other $0

This EXAMPLE event includes services like:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)

$12,800Total Example Cost

In this example, Peg would pay:Cost Sharing

$6,650Deductibles$0Copayments$0Coinsurance

What isn't covered$60Limits or exclusions

$6,710The total Peg would pay is

Managing Joe’s type 2 Diabetes(a year of routine in-network care of a

well-controlled condition)


This EXAMPLE event includes services like:Primary care physician office visits (includingdisease education)Diagnostic tests (blood work)Prescription drugsDurable medical equipment (glucose meter)


In this example, Joe would pay:Cost Sharing



$6,710The total Joe would pay is

Mia’s Simple Fracture(in-network emergency room visit and follow up

care)


This EXAMPLE event includes services like:Emergency room care (includingmedical supplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)


In this example, Mia would pay:Cost Sharing



$1,900The total Mia would pay is

The plan would be responsible for the other costs of these EXAMPLE covered services. 6 of 6

bcbstx.com

If you, or someone you are helping, have questions, you have the right to get help and information in your language at no cost. To speak to an interpreter, call the customer service number on the back of your member card. If you are not a member, or don’t have a card, call 855-710-6984.

العربیةArabic

فإن لم تكن عضوا، أو كنت . اتصل على رقم خدمة العمالء المذكور على ظھر بطاقة عضویتكللتحدث إلى مترجم فوري، . إن كان لدیك أو لدى شخص تساعده أسئلة، فلدیك الحق في الحصول على المساعدة والمعلومات الضروریة بلغتك من دون ایة تكلفة.6984-710-855 ال تملك بطاقة، فاتصل على

繁體中文 Chinese

如果您, 或您正在協助的對象, 對此有疑問, 您有權利免費以您的母語獲得幫助和訊息。洽詢一位翻譯員, 請致電印在您的會員卡背面的客戶服務電話號碼。如果您不是會員, 或沒有會員卡, 請致電 855-710-6984。

Français French

Si vous, ou quelqu'un que vous êtes en train d’aider, avez des questions, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, composez le numéro du service client indiqué au verso de votre carte de membre. Si vous n’êtes pas membre ou si vous n’avez pas de carte, veuillez composer le 855-710-6984.

Deutsch German

Falls Sie oder jemand, dem Sie helfen, Fragen haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Kundenservicenummer auf der Rückseite Ihrer Mitgliedskarte an. Falls Sie kein Mitglied sind oder keine Mitgliedskarte besitzen, rufen Sie bitte 855-710-6984 an.

�જરાતીGujarati

જો તમન અથવા તમ મદદ કર� રહયા હોય એવી કોઈ બી� વય�કતન એસ.બી.એમ. �ભાિષયા સાથ વાત કરવા માટ�, તમારા સભયપદના કાડરની પાછળ આપલ ગરાહક સવા નબર પર કૉલ કરો. જો આપ સભયપદ ના ધરાવતા હોવ, અથવા આપની પાસ કાડર નથી તો 855-710-6984 નબર પર કૉલ કરો.

�हद� Hindi

य�द आपक, या आप िजसक� सहायता कर रह ह� उसक, परशन ह�, तो आपको अपनी भाषा म� �नःशलक सहायता और जानकार� परापत करन का अ�धकार ह। �कसी अनवादक स बात करन क �लए, अपन सदसय काडर क पीछ�दए गए गराहक सवा नबर पर कॉल कर�। य�द आप सदसय नह� ह�, या आपक पास काडर नह� ह, तो 855-710-6984 पर कॉल कर�।

日本語 Japanese

ご本人様、またはお客様の身の回りの方でも、ご質問がございましたら、ご希望の言語でサポートを受けたり、情報を入手したりすることができます。料金はかかりません。通訳とお話される場合、メンバーカードの裏のカスタマーサービス番号までお電話ください。メンバーでない場合またはカードをお持ちでない場合は 855-710-6984 までお電話ください。

한국어 Korean

만약 귀하 또는 귀하가 돕는 사람이 질문이 있다면 귀하는 무료로 그러한 도움과 정보를 귀하의 언어로 받을 수 있는 권리가 있습니다. 회원 카드 뒷면에 있는고객 서비스 번호로 전화하십시오. 회원이 아니시거나 카드가 없으시면 855-710-6984으로 전화주십시오.

ພາສາລາວ Laotian

ຖາທານ ຫ ຄນທ ທານກາລງໃຫການຊວຍເຫ ອມ ຄ າຖາມ, ທານມ ສ ດຂ ເອ າການຊວຍເຫ ອ ແລະ ຂ ມນເປນນພາສາຂອງທານໄດໂດຍບ ມ ຄາໃຊຈາຍ. ເພອລມກບນາຍແປພາສາ, ໃຫໂທຫາເບ ຝາຍບ ລການລກຄາທ ມ ຢດານຫງບດສະມາຊ ກຂອງທານ. ຖາທານບ ແມນສະມາຊ ກ, ຫ ບ ມ ບດ, ໃຫໂທຫາເບ 855-710-6984.

Diné Navajo

T’11 ni, 47 doodago [a’da b7k1 an1n7lwo’7g77, na’7d7[kidgo, ts’7d1 bee n1 ah00ti’i’ t’11 n77k’e n7k1 a’doolwo[. Ata’ halne’7 bich’8’ hadeesdzih n7n7zingo 47 kwe’4 da’7n7ishgi 1k1 an7daalwo’7g77 bich’8’ hod77lnih, bee n44h0zinii bine’d66’ bik11’. Koj7 atah naaltsoos n1 had7t’44g00 47 doodago bee n44h0zin7g77 1dingo koj8’ hod77lnih 855-710-6984.

فارسیPersian

کھ در پشت کارت عضویت شما شماره ایجھت گفتگو با یک مترجم شفاھی، با خدمات مشتری بھ . نمایید دریافت اطالعات کمک و رایگان طور بھ خود، زبان بھ کھ دارید را این باشید، حق سؤالی داشتھ مي کنید، کمک او بھ شما کھ کسی یا شما، اگر .تماس حاصل نمایید 6984-710-855یا کارت عضویت ندارید، با شمارهاگر عضو نیستید، . بگیرید درج شده است تماس

Русский Russian

Если у вас или человека, которому вы помогаете, возникли вопросы, у вас есть право на бесплатную помощь и информацию, предоставленную на вашем языке. Чтобы поговорить с переводчиком, позвоните в отдел обслуживания клиентов по телефону, указанному на обратной стороне вашей карточки участника. Если вы не являетесь участником или у вас нет карточки, позвоните по телефону 855-710-6984.

Español Spanish

Si usted o alguien a quien usted está ayudando tiene preguntas, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete comuníquese con el número del Servicio al Cliente que figura en el reverso de su tarjeta de miembro. Si usted no es miembro o no posee una tarjeta, llame al 855-710-6984.

Tagalog Tagalog

Kung ikaw, o ang isang taong iyong tinutulungan ay may mga tanong, may karapatan kang makakuha ng tulong at impormasyon sa iyong wika nang walang bayad. Upang makipag-usap sa isang tagasalin-wika, tumawag sa numero ng serbisyo para sa kustomer sa likod ng iyong kard ng miyembro. Kung ikaw ay hindi isang miyembro, o kaya ay walang kard, tumawag sa 855-710-6984.

اردوUrdu

جو آپ کے پر کال کریں کسڻمر سروس نمبر کا حق ہے۔ مترجم سے بات کرنے کے لیے، گر آپ کو، یا کسی ایسے فرد کو جس کی آپ مدد کررہے ہیں، کوئی سوال درپیش ہے تو، آپ کو اپنی زبان میں مفت مدد اور معلومات حاصل کرنے۔پر کال کریں 6984-710-855کارڈ کی پشت پر درج ہے۔ اگر آپ ممبر نہیں ہیں، یا آپ کے پاس کارڈ نہیں ہے تو،

Tiếng Việt Vietnamese

Nếu quý vị hoặc người mà quý vị giúp đỡ có bất kỳ câu hỏi nào, quý vị có quyền được hỗ trợ và nhận thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với thông dịch viên, gọi số dịch vụ khách

hàng nằm ở phía sau thẻ hội viên của quý vị. Nếu quý vị không phải là hội viên hoặc không có thẻ, gọi số 855-710-6984.

tel:855-710-6984

Health care coverage is important for everyone.

We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability.

To receive language or communication assistance free of charge, please call us at 855-710-6984.

If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.

Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail)300 E. Randolph St. TTY/TDD: 855-661-6965 35th Floor Fax: 855-661-6960Chicago, Illinois 60601 Email: [email protected]

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at:

U.S. Dept. of Health & Human Services Phone: 800-368-1019 200 Independence Avenue SW TTY/TDD: 800-537-7697 Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

bcbstx.com





$6,650 Individual / $13,300Family



Yes. Preventive care services arecovered before you meet yourdeductible.


preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.You don’t have to meet deductibles for specific services.No.Are there other

deductibles for specificservices?


$6,650 Individual / $13,300Family





Yes. Seewww.bcbstx.com/go/be or call1-877-299-2377 for a list ofParticipating Providers.



see a specialist?



: MTBEAC1CH Blue Essentials Access HSASM C1CH Coverage for: Individual/Family Plan Type: HMO




What You Will Pay

Services You May NeedCommonMedical Event

Non-ParticipatingProvider (Youwill pay the

most)

Participating Provider(You will pay the least)


Not CoveredNo ChargePrimary care visit to treat aninjury or illness


NoneNot CoveredNo ChargeSpecialist visitYou may have to pay for services that aren'tpreventive. Ask your provider if the services

Not CoveredNo Charge; deductibledoes not apply




Not CoveredNo ChargeDiagnostic test (x-ray, bloodwork)If you have a test

Not CoveredNo ChargeImaging (CT/PET scans, MRIs)

Limited to a 30-day supply at retail (or a90-day supply at a network of select retail

Not CoveredNo ChargePreferred generic drugsIf you need drugs totreat your illness orcondition

Not CoveredNo ChargeNon-preferred generic drugs

pharmacies). Up to a 90-day supply at mailNot CoveredNo ChargePreferred brand drugs

order. Specialty drugs limited to a 30-dayMore information aboutprescription drugcoverage is available athttps://www.bcbstx.com/member/prescription-drug-plan-information/drug-lists

Not CoveredNo ChargeNon-preferred brand drugs

supply. Payment of the difference betweenthe cost of a brand name drug and a genericmay also be required if a generic drug isavailable.

Not CoveredNo ChargePreferred specialty drugsNot CoveredNo ChargeNon-Preferred specialty drugs

Preauthorization required; failure topreauthorize will result in denial of benefits.

Not CoveredNo ChargeFacility fee (e.g., ambulatorysurgery center)

If you have outpatientsurgery

Abortion is not covered except in limitedcircumstances.For Outpatient Infusion Therapy, see yourbenefit booklet* for details.

Not CoveredNo ChargePhysician/surgeon fees



What You Will Pay

Services You May NeedCommonMedical Event

Non-ParticipatingProvider (Youwill pay the

most)

Participating Provider(You will pay the least)

None

No ChargeNo ChargeEmergency room careIf you need immediatemedical attention

No ChargeNo ChargeEmergency medicaltransportation

Not CoveredNo ChargeUrgent care


Not CoveredNo ChargeFacility fee (e.g., hospitalroom)If you have a hospital

stayNot CoveredNo ChargePhysician/surgeon fees

Outpatient: Certain services must bepreauthorized; refer to benefit booklet* for

Not CoveredNo ChargeOutpatient servicesIf you need mentalhealth, behavioralhealth, or substanceabuse services

Not CoveredNo ChargeInpatient servicesdetails. Failure to preauthorize will result indenial of benefits. Inpatient: Preauthorizationrequired; failure to preauthorize will result indenial of benefits.Cost sharing does not apply to certainpreventive services. Depending on the type of

Not CoveredNo ChargeOffice visits

If you are pregnantNot CoveredNo ChargeChildbirth/delivery professional

services services, deductiblemay apply.Maternity caremay include tests and services describedelsewhere in the SBC (i.e. ultrasound).

Not CoveredNo ChargeChildbirth/delivery facilityservices


Not CoveredNo ChargeHome health careIf you need helprecovering or haveother special healthneeds

Not CoveredNo ChargeRehabilitation servicesNot CoveredNo ChargeHabilitation services

60 days/year. Preauthorization required.Not CoveredNo ChargeSkilled nursing careNoneNot CoveredNo ChargeDurable medical equipmentPreauthorization required.Not CoveredNo ChargeHospice servicesEye screenings only. Does not includerefractions. One visit per year for membersages 17 and younger.

Not CoveredNo ChargeChildren’s eye exam

If your child needsdental or eye care

NoneNot CoveredNot CoveredChildren’s glassesNot CoveredNot CoveredChildren’s dental check-up



Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)Non-emergency care when traveling outside theU.S.

Cosmetic surgeryAbortion (Except for a pregnancy that, as certifiedby a physician, places the woman in danger ofdeath or a serious risk of substantial impairmentof a major bodily function unless an abortion isperformed)

Dental care (Adult)Weight loss programsLong-term care

AcupunctureBariatric surgery

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document)Routine eye care (Adult - One visit every two yearsfor members ages 18 and older)

Infertility treatment (Invitro not covered)Chiropractic careHearing aids (Limited to two hearing aids everythree years)

Private-duty nursing (Only when ordered orauthorized by the Primary Care Physician) Routine foot care (Only covered in connectionwith

diabetes, circulatory disorders of the lowerextremities, peripheral vascular disease, peripheralneuropathy, or chronic arterial or venousinsufficiency)



Does this plan provide Minimum Essential Coverage? Yes

If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemptionfrom the requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? Yes

If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.4 of 6



5 of 6



hospital delivery)







$6,710The total Peg would pay is









$6,710The total Joe would pay is


care)







$1,900The total Mia would pay is


bcbstx.com






Français French


Deutsch German




�हद� Hindi


日本語 Japanese


한국어 Korean




Diné Navajo


فارسیPersian




Español Spanish


Tagalog Tagalog


اردوUrdu





tel:855-710-6984








bcbstx.com





In-Network - $5,000 Individual /$14,700 FamilyOut-of-Network - $10,000Individual / $29,400 Family



Yes. Network office visits,prescription drugs and certain


preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.preventive care services arecovered before you meet yourdeductible.

You must pay all of the costs for these services up to the specific deductible amount beforethis plan begins to pay for these services.

Yes. ER $500. There are no otherspecific deductibles.

Are there otherdeductibles for specificservices?


In-Network - $5,600 Individual /$14,700 FamilyOut-of-Network - UnlimitedIndividual / Unlimited Family





Yes. Seewww.bcbstx.com/go/bcppo orcall 1-800-810-2583 for a list ofNetwork Providers.



see a specialist?



: MTBCBA7DB Blue Choice PPO BasicSM A7DB Coverage for: Individual/Family Plan Type: PPO








50% coinsurance$45/visit; deductible doesnot apply

Primary care visit to treat aninjury or illness


None50% coinsurance$90/visit; deductible doesnot apply

Specialist visit

You may have to pay for services that aren'tpreventive. Ask your provider if the services

50% coinsuranceNo Charge; deductibledoes not apply




50% coinsurance30% coinsuranceDiagnostic test (x-ray, bloodwork)If you have a test

50% coinsurance30% coinsuranceImaging (CT/PET scans, MRIs)






Limited to a 30-day supply at retail (or a90-day supply at a network of select retail

Retail - $10/prescription;deductible does not applyplus 50% additionalcharge

Retail - Preferred - NoChargeNon-Preferred -$10/prescriptionMail - No Charge;deductible does not apply

Preferred generic drugs

If you need drugs totreat your illness orcondition

More information aboutprescription drugcoverage is available athttps://www.bcbstx.com/member/prescription-drug-plan-information/drug-lists

pharmacies). Up to a 90-day supply at mailorder. Specialty drugs limited to a 30-daysupply. Payment of the difference betweenthe cost of a brand name drug and a genericmay also be required if a generic drug isavailable. All Out-of-Network prescriptionsare subject to a 50% additional charge afterthe applicable copay/coinsurance. Additionalcharge will not apply to any deductible orout-of-pocket amounts.


Retail - Preferred -$10/prescriptionNon-Preferred -$20/prescriptionMail - $30/prescription;deductible does not apply

Non-preferred generic drugs

Retail: $70/prescription;deductible does not applyplus 50% additionalcharge


Preferred brand drugs



Non-preferred brand drugs

$150/prescription;deductible does not applyplus 50% additionalcharge

$150/prescription;deductible does not apply

Preferred specialty drugs

$250/prescription;deductible does not applyplus 50% additionalcharge

$250/prescription;deductible does not apply

Non-Preferred specialty drugs

3 of 7





Preauthorization may be required. Abortionis not covered except in limitedcircumstances.For Outpatient Infusion Therapy, see yourbenefit booklet* for details.

50% coinsurance30% coinsuranceFacility fee (e.g., ambulatorysurgery center)If you have outpatient

surgery 50% coinsurance30% coinsurancePhysician/surgeon fees

Per occurrence deductible waived if admitted.$500/visit plus30% coinsurance

$500/visit plus30% coinsurance

Emergency room care

If you need immediatemedical attention

None

30% coinsurance30% coinsuranceEmergency medicaltransportation

50% coinsurance$75/visit; deductible doesnot apply

Urgent care

Preauthorization required. Preauthorizationpenalty: $250 Out-of-Network. See yourbenefit booklet* for details.

50% coinsurance30% coinsuranceFacility fee (e.g., hospitalroom)If you have a hospital

stay50% coinsurance30% coinsurancePhysician/surgeon fees

Outpatient: Certain services must bepreauthorized, failure to preauthorize at least

50% coinsurance$45/office visits or30%coinsurance for otheroutpatient services

Outpatient services

If you need mentalhealth, behavioralhealth, or substanceabuse services

two business days prior to service will resultin 50% reduction in benefits (not to exceed50% coinsurance30% coinsuranceInpatient services$500), refer to benefit booklet* for details.Inpatient: Preauthorization requiredOut-of-Network; failure to preauthorize at leasttwo business days prior to admission willresult in $250 reduction in benefits.Copay applies to first prenatal visit (perpregnancy). Cost sharing does not apply to

50% coinsurancePrimary Care: $45Specialist: $90;deductible does not apply

Office visits

If you are pregnantcertain preventive services. Depending on thetype of services, coinsurance may apply.50% coinsurance30% coinsuranceChildbirth/delivery professional

services Maternity caremay include tests and servicesdescribed elsewhere in the SBC (i.e.ultrasound).

50% coinsurance30% coinsuranceChildbirth/delivery facilityservices






60 visits/year. Preauthorization required forOut-of-Network.

50% coinsurance30% coinsuranceHome health care

If you need helprecovering or haveother special healthneeds

Preauthorization may be required. ForOutpatient, limited to combined 35 visits peryear, including Chiropractic.

50% coinsurance30% coinsuranceRehabilitation services50% coinsurance30% coinsuranceHabilitation services

25 day maximum per calendar year.Preauthorization required for Out-of-Network.

50% coinsurance30% coinsuranceSkilled nursing care

None50% coinsurance30% coinsuranceDurable medical equipmentPreauthorization required for Out-of-Network.50% coinsuranceNo ChargeHospice services

NoneNot CoveredNot CoveredChildren’s eye exam

If your child needsdental or eye care Not CoveredNot CoveredChildren’s glasses

Not CoveredNot CoveredChildren’s dental check-up


Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)Private-duty nursingDental care (Adult)Abortion (Except for a pregnancy that, as certified

by a physician, places the woman in danger ofdeath or a serious risk of substantial impairmentof a major bodily function unless an abortion isperformed)

Routine eye care (Adult and Child)Long-term careNon-emergency care when traveling outside theU.S.

Weight loss programs

AcupunctureBariatric surgeryCosmetic surgery

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document)Routine foot care (Only covered in connectionwithdiabetes, circulatory disorders of the lowerextremities, peripheral vascular disease, peripheralneuropathy, or chronic arterial or venousinsufficiency)

Infertility treatment (Invitro and artificialinsemination are not covered unless shown inyour plan document)

Chiropractic care (Outpatient -Max. 35 visits/year)Hearing aids (Limited to two hearing aids everythree years)

5 of 7



Does this plan provide Minimum Essential Coverage? Yes

If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemptionfrom the requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? Yes

If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.



6 of 7



hospital delivery)

The plan's overall deductible $5,000Specialist copayment $90Hospital (facility) coinsurance 30%Other coinsurance 30%




$5,000Deductibles$50Copayments

$600CoinsuranceWhat isn't covered

$60Limits or exclusions$5,660*The total Peg would pay is







$1,900Deductibles$1,200Copayments


$60Limits or exclusions$3,160The total Joe would pay is


care)





$1,600Deductibles$300Copayments


$0Limits or exclusions$1,900The total Mia would pay is

*The figure provided here does not take into consideration the out-of-pocket limitation.


bcbstx.com






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tel:855-710-6984








bcbstx.com


Status:

- Active

- Waiting Period

- Cobra / State

- Retiree

-Continuation

-Part Time

-Seasonal

Relationship Code

Employee/Spouse/

Dependent Gender

Date of

Birth

Home

Zip Code Date of Hire

Medical Plan Selected

HSA / PPO

Level of Medical Coverage

EE

EE+Sp

EE+Ch

EE+Fam

waive - other coverage

waive- due to cost

Active Employee F 6/2/1975 75605 9/8/1997 HSA EE+Ch

Child M 5/19/2001 75605 HSA

Child M 5/19/2001 75605 HSA

Active Employee M 1/29/1959 75771 7/13/1987 HSA EE

Spouse F 12/12/1953 75771 HSA

Active Employee F 10/11/1945 75647 2/1/2005 waive - other coverage

Active Employee F 7/31/1961 75693 2/8/2005 HSA EE


Child F 9/6/2005 75603 HSA

Child F 1/11/2007 75603 HSA


Child F 5/10/1994 75605

Child F 9/9/1999 75605

Child F 2/5/1997 75605




Part-Time Employee F 3/26/1947 75657 8/17/2017 Not Eligible

Active Employee F 6/24/1974 75662 2/11/2008 HSA EE+Fam

Spouse M 6/5/1970 75662

Child M 4/18/1996 75662 HSA

Child M 7/13/1998 75662 HSA

Child M 11/15/2000 75662 HSA




Active Employee F 4/28/1978 75773 9/23/2019 waive - other coveragewaive - other coverage

Spouse M 5/23/1974 75773

Child M 3/8/2004 75773

Child F 9/10/2007 75773

Child F 6/28/2007 75773

Child M 8/25/2011 75773

EXHIBIT II - Medical Census

Status:

- Active

- Waiting Period

- Cobra / State

- Retiree

-Continuation

-Part Time

-Seasonal

Relationship Code

Employee/Spouse/

Dependent Gender

Date of

Birth

Home



HSA / PPO


EE

EE+Sp

EE+Ch

EE+Fam


waive- due to cost


Child F 4/9/2002 75604

Child F 10/19/2003 75604

Active Employee F 3/1/1964 75602-5310 8/4/2008 HSA EE+Ch

Child F 10/2/1999 75602-5310 HSA

Part-Time (Medical Only) Employee F 9/14/1992 75605 5/21/2020 PPO EE


Active Employee M 8/21/1962 75604 5/14/2007 HSA EE+Fam

Spouse F 1/23/1964 75604 HSA

Child F 6/21/2000 75604 HSA

Child M 10/20/2002 75604 HSA

Child F 4/26/2004 75604 HSA


Child F 9/8/1997 75662

Child F 8/3/2003 75662

Part-Time Employee M 5/5/1976 91942 5/21/2020 Not Eligible


Active Employee M 5/31/1980 75650 1/22/2019 HSA EE+Ch

Spouse F 10/11/1980 75650

Child F 4/1/2003 75650

Child F 9/22/2004 75650

Active Employee F 9/6/1954 75684 5/1/2010 waive - other coveragewaive - other coverage




Spouse M 9/12/1970 75603

Active Employee F 4/5/1990 75701-7549 4/16/2019 HSA EE

Part-Time (Medical Only) Employee M 4/15/1950 75602 5/21/2019 waive - other coverage



Spouse M 8/7/1952 75684

Active Employee F 2/12/1982 75652 1/1/2004 HSA EE+Sp

Status:

- Active

- Waiting Period

- Cobra / State

- Retiree

-Continuation

-Part Time

-Seasonal

Relationship Code

Employee/Spouse/

Dependent Gender

Date of

Birth

Home



HSA / PPO


EE

EE+Sp

EE+Ch

EE+Fam


waive- due to cost

Spouse M 10/27/1974 75652 HSA



Child F 12/23/1997 75662

Child M 3/4/2007 75662





Spouse M 12/30/1986 75663

Child M 12/7/2015 75663 HSA

Child F 8/20/2018 75663 HSA


Spouse M 9/25/1975 75605 HSA

Child M 9/25/1995 75605

Child M 3/21/1998 75605


Spouse M 12/26/1979 75662

Child F 9/17/2004 75662 HSA

Child M 3/15/2006 75662 HSA


Spouse M 6/23/1953 75601



Active Employee M 9/20/1947 75751 8/22/2016 waive - other coverage


Spouse F 6/2/1953 75605

Active Employee F 7/16/1951 75662 6/9/2014 PPO EE


Child F 1/3/1996 79932 HSA

Child F 8/25/2002 79932 HSA


Status:

- Active

- Waiting Period

- Cobra / State

- Retiree

-Continuation

-Part Time

-Seasonal

Relationship Code

Employee/Spouse/

Dependent Gender

Date of

Birth

Home



HSA / PPO


EE

EE+Sp

EE+Ch

EE+Fam


waive- due to cost



Spouse M 5/20/1971 75644-1822

Part-Time (Medical Only) Employee F 5/21/1989 75662 1/28/2019 EE


Spouse M 5/24/1984 75771

Child F 9/20/2007 75771

Child M 7/5/2013 75771






Active Employee M 8/10/1960 75650 5/1/2018 HSA EE+Sp

Spouse F 6/9/1960 75650 HSA



Spouse M 9/11/1950 75604


Child F 7/9/1995 75607 HSA

Child F 9/19/1996 75607 HSA

Child M 2/13/2000 75607 HSA

Child F 3/6/2017 75607 HSA


Part-Time (Medical Only) Employee M 5/22/1962 75672 5/1/2010 HSA EE








Status:

- Active

- Waiting Period

- Cobra / State

- Retiree

-Continuation

-Part Time

-Seasonal

Relationship Code

Employee/Spouse/

Dependent Gender

Date of

Birth

Home



HSA / PPO


EE

EE+Sp

EE+Ch

EE+Fam


waive- due to cost


Active Employee F 1/19/1956 75701 4/16/2012 PPO EE

Spouse M 4/4/1949 75701


Active Employee M 1/8/1958 75605 1/4/2016 waive - other coverage



Child F 5/1/2005 75703 HSA

Child M 12/17/2007 75703 HSA

Child M 11/26/2018 75703 HSA




Child M 4/8/2004 75662

Child M 11/6/2006 75662

Child F 8/30/2011 75662


Part-Time (Medical Only) Employee F 10/28/1954 75701 4/22/2019 waive - other coverage


Spouse M 4/8/1954 75644

Child M 3/14/2002 75644 HSA


Part-Time (Medical Only) Employee F 1/6/1962 75602 6/14/2011 HSA EE


Child F 6/26/2001 75684 HSA

Child F 1/15/2004 75684 HSA

Child M 7/30/2007 75684 HSA



Active Employee M 12/2/1967 75604 10/16/2012 HSA EE+Fam

Spouse F 5/6/1972 75604 HSA

Child F 9/9/1996 75604 HSA

Status:

- Active

- Waiting Period

- Cobra / State

- Retiree

-Continuation

-Part Time

-Seasonal

Relationship Code

Employee/Spouse/

Dependent Gender

Date of

Birth

Home



HSA / PPO


EE

EE+Sp

EE+Ch

EE+Fam


waive- due to cost

Child M 1/28/1999 75604 HSA

Child M 4/25/2001 75604 HSA


Child F 6/3/2005 75662






Spouse M 6/12/1951 75670


Spouse M 3/14/1971 75662

Child F 9/21/2001 75662 HSA


Spouse M 11/3/1960 75666




Spouse M 6/11/1959 71119




Spouse F 3/17/1958 75701


Spouse M 9/17/1963 75645



Part-Time (Medical Only) Employee M 4/30/1949 75701 1/18/2017 waive - other coverage


Spouse F 11/1/1983 75803



Status:

- Active

- Waiting Period

- Cobra / State

- Retiree

-Continuation

-Part Time

-Seasonal

Relationship Code

Employee/Spouse/

Dependent Gender

Date of

Birth

Home



HSA / PPO


EE

EE+Sp

EE+Ch

EE+Fam


waive- due to cost



Child M 1/6/2011 75604 HSA

Child M 2/17/2016 75604 HSA





Spouse F 10/4/1946 75765


Spouse M 10/1/1970 75647 HSA

Child F 10/3/1995 75647

Child F 2/4/1999 75647



Spouse M 8/22/1964 75662 5/26/2020



Part-Time (Medical Only) Employee M 1/20/1965 75654 1/14/2019 PPO EE+Ch

Child F 5/20/2010 75654

Child M 9/19/2013 75654


Cobra Cobra F 4/27/1994 75604 HSA EE

EAST TEXAS COUNCIL OF GOVERNMENTS - 000242015Legislative Report - Tier 1 Totals by Month

Plan: TexasGroup Number(s): 000242015, 000242016, 000274364Paid Period: 06-2017 to 05-2020

Contracts Members

MonthEmployee

OnlyEmployee +

SpouseEmployee +

Child(ren)Employee +

FamilyEmployee

OnlyEmployee +

SpouseEmployee +

Child(ren)Employee +

FamilyBilled

PremiumTotal

Payments

May 2020 68 5 15 3 68 10 47 15 $59,371 $209,028

April 2020 68 5 15 3 68 10 47 16 $59,371 $51,263

March 2020 68 4 16 3 68 8 50 16 $59,119 $66,317

February 2020 68 4 16 3 68 8 50 16 $59,119 $43,035

January 2020 69 4 17 2 69 8 54 11 $58,968 $30,157

December 2019 69 4 18 2 69 8 58 11 $59,875 $65,506

November 2019 70 4 18 2 70 8 58 11 $60,598 $66,815

October 2019 70 4 19 2 70 8 60 11 $61,363 $61,452

September 2019 71 5 19 2 71 10 59 11 $60,988 $149,487

August 2019 68 5 20 2 68 10 61 11 $60,223 $103,577

July 2019 68 5 18 2 68 10 54 11 $58,140 $92,632

June 2019 68 5 18 2 68 10 54 11 $58,140 $66,383

May 2019 68 5 18 2 68 10 54 11 $58,140 $32,718

April 2019 67 5 18 2 67 10 54 11 $57,651 $42,191

March 2019 66 5 17 3 66 10 50 16 $57,797 $56,315

February 2019 66 5 17 3 66 10 50 16 $57,797 $142,434

January 2019 64 5 16 3 64 10 46 16 $55,938 $10,009

December 2018 61 6 16 3 61 12 46 16 $55,596 $64,132

November 2018 58 7 16 3 58 14 46 16 $55,253 $36,628

October 2018 59 7 16 3 59 14 45 16 $55,742 $13,711

This report includes all payments for health, pharmacy, dental and capitation.

Blue Cross Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association

Fees for ASO and Cost Accounts not reflected in Billed Premium. Tuesday, June 16, 2020This Report is intended for Fully Insured accounts. Userid: U414969

EXHIBIT III - MEDICAL CLAIM EXPERIENCE REPORTS

EAST TEXAS COUNCIL OF GOVERNMENTS - Account #242015Top Utilizers Over $15,000Paid Period 06/01/2019 - 05/31/2020

Notice of Withheld Information – Texas Insurance Code (TIC) § 1215.003(d) provides that protected health information (PHI) may be withheld from this claims report if subject to privacy restrictions more stringent than HIPAA. This constitutnotice that following categories of claims information are withheld from this report: Records obtained in performance of UR per TIC §4201.552; Records regarding the diagnosis, evaluation, or treatment of a mental or emotional disordincluding alcoholism or drug addiction per Chap 611 of the TX Health & Safety Code; Records regarding AIDS and HIV test results per TX Health & Safety Code § 81.101 et seq.; and Genetic information, if any, per TIC § 546.10

Subscriber Number Gender DOB Primary DX Code Primary DX Description Primary Procedure Code Primary Procedure Code Description Earliest Incurred Date Total Payments Case Management Y/N

000826919423 F 01/23/1964 S62323ADisplaced fracture of shaft of third metacarpal bone, left hand, initial encounter for closed fracture 97110

THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 06/19/2019 $38,070.44 N

000826410048 M 01/23/1965 D839 Common variable immunodeficiency, unspecified J1575 Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin 10/23/2019 $40,426.93 N

000826713142 F 09/12/1976 R1031 Right lower quadrant pain 74177 Computed tomography, abdomen and pelvis; with contrast material 08/05/2019 $25,388.57 N

000827018889 F 03/27/1967 D259 Leiomyoma of uterus, unspecified 49205

EXCISION OR DESTRUCTION, OPEN, INTRA-ABDOMINAL TUMORS, CYSTS OR ENDOMETRIOMAS, 1OR MORE PERITONEAL, MESENTERIC, OR RETROPERITONEAL PRIMARY OR SECONDARY TUMORS; LARGEST TUMOR GREATER THAN 10.0 CM DIAMETER 05/30/2019 $38,773.28 N

000846698275 F 09/04/1952 C3411 Malignant neoplasm of upper lobe, right bronchus or lung 78815

TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION; SKULL BASE TO MID-THIGH 04/30/2019 $80,511.28 Y

000847956962 M 06/18/1953 M4804 Spinal stenosis, thoracic region 97110


000844814038 F 03/21/1964 I214 Non-ST elevation (NSTEMI) myocardial infarction 99285

EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE THREE KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCYOF THE PATIENT'S CLINICAL CONDITION AND MENTAL STATUS; A COMPREHENSI 08/27/2019 $46,931.15 N

000827327154 M 12/02/1967 M48061 Spinal stenosis, lumbar region without neurogenic claudication 22612

ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; LUMBAR (WITH OR WITHOUT LATERAL TRANSVERSE TECHNIQUE) 08/29/2019 $98,224.23 N

000826759930 F 10/24/1971 K8010 Calculus of gallbladder with chronic cholecystitis without obstruction 47562 LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY 10/30/2019 $22,666.55 N

000827327154 F 04/27/1994 S53492A Other sprain of left elbow, initial encounter 99284

EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE THREE KEY COMPONENTS; A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. 07/12/2019 $15,202.22 N

000826577990 F 10/04/1974 C187 Malignant neoplasm of sigmoid colon J9263 INJECTION, OXALIPLATIN, 0.5 MG 06/06/2019 $110,276.89 N

000826976999 F 07/31/1961 S46012AStrain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, initial encounter 97110


000827669699 F 01/25/1960 R42 Dizziness and giddiness 99285

EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE THREE KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCYOF THE PATIENT'S CLINICAL CONDITION AND MENTAL STATUS; A COMPREHENSI 05/12/2019 $16,846.43 N

000846364129 F 04/19/1963 M0609 Rheumatoid arthritis without rheumatoid factor, multiple sites J0717 INJECTION, CERTOLIZUMAB PEGOL, 1 MG 06/06/2019 $45,823.46 N

000848355990 F 09/04/1969 K3533 Acute appendicitis with perforation and localized peritonitis, with abscess 99284

EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE THREE KEY COMPONENTS; A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. 04/14/2020 $35,309.54 N

000824184621 F 08/17/1950 M1712 Unilateral primary osteoarthritis, left knee 66984

Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation 10/03/2019 $37,250.40 N

CAS Page 1 of 2 Request #915569 - 06/16/2020

ACCOUNT NAME - #242015Texas Legislative PreCertCase Start Date Range 05/15/2020 - 06/15/2020

Notice of Withheld Information – Texas Insurance Code (TIC) § 1215.003(d) provides that protected health information (PHI) may be withheld from this claims report if subject to privacy restrictions more stringent than HIPAA. This constitutes

notice that following categories of claims information are withheld from this report: Records obtained in performance of UR per TIC §4201.552; Records regarding the diagnosis, evaluation, or treatment of a mental or emotional disorder,

including alcoholism or drug addiction per Chap 611 of the TX Health & Safety Code; Records regarding AIDS and HIV test results per TX Health & Safety Code § 81.101 et seq.; and Genetic information, if any, per TIC § 546.102

Case ID Group IDTx Total Approved

Unit CntCase Expected

Start Date Case Start DateCase Actual Start Date Case Dx Code Case Dx Desc

Case Expected End Date

Case Actual End Date

Case Status Desc

Case Tx Setting Desc

Case Type Desc Crspnd Desc

Referring Prov External ID

Referring Prov Name

NO DATA

CAS Page 2 of 2 Request #915569 - 06/16/2020

TEXAS - MANDATED REPORTING FOR INSURED BUSINESS

Section I:

Section II: Monthly aggregate Premium and Paid Claims Total covered Employees by Coverage Tier, on a monthly basis

Section III: Individual Claimants2 with paid amounts of $15,000 in the most current 12-month period

Conditions for Release

1

2 A plan sponsor is entitled to receive protected health information under Subsections C (5) and (6) and Section 1215.04 only after an appropriately authorized representative of the plan sponsor makes to the health insurance issuer a certification. PLEASE CONTACT your UnitedHealthcare account representative for additional information on an acceptable Certification.

In accordance with provisions of the state statute, a request for Additional Information may be made subsequent to the receipt of Individual Claimant (section III) information. The written request must come from theplan, plan administrator, or plan sponsor, and be receivedby the insurer no later than the 10th day following receiptof the initial Individual Claimant information.

Texas insurance code1 sets forth specific requirements for the release of claims information by Health insurance issuers upon written request of a plan, plan administrator, or plan sponsor. The information presented within this report is provided in accordance with Texas insurance code.

The following Additional Information 2 is available upon request, subject to Conditions for Release:Large Claim Information

For claims that are not part of this report, the number of pre-certification requests for hospital stays of 5 days or longer that were made during the 30-day period preceding this report.

Additional Information2, including prognosis or recovery case, management information, future expected cost and treatment plans that relate to the claims for those individuals whose total paid claims exceeded $15,000 during the preceding 12 month period.

Texas insurance code: Section 1. Subtitle A, Title 8, Chapter 1215. Enacted Sep 1, 2007, compliance date Jan 1, 2008.

1006396-EASTTEXASCOUNCILOFGOVERNMENTS-TXHB2015

EXHIBIT REPORTS EXPERIENCE CLAIM MEDICAL - III

1006396 EAST TEXAS COUNCIL OF GOVERNMENTS 909,225$ 4 Y G:\TEMP\SASDATA\DATA\20JUN19\1006396\1006396-EASTTEXASCOUNCILOFGOVERNMENTS-TXHB2015

TEXAS - MANDATED REPORTING FOR INSURED BUSINESSSection I, II: Hospital Pre-Certification, Premium, Claims, Enrollment

Customer Name: EAST TEXAS COUNCIL OF GOVERNMENTSPolicy Number: 6/20/19Reporting Period 6/20/19

10/01/2016-05/31/2019 1/1/00ALL 6/20/19

Section I:

0

Section II:

Bill / Book Year / Month

Restated Billed Premium Total Payments

Single Subscribers

Subscribers plus Spouse

Subscribers plus

Child/ChildrenSubscribers plus Family

Total Subscribers

Positively Enrolled

DependentsTotal

Members201610 58,232$ 3,355$ 62 5 22 4 93 61 154201611 58,937$ 83,139$ 63 6 21 4 94 60 154201612 58,780$ 24,815$ 61 6 22 4 93 58 151201701 58,323$ 52,383$ 60 6 22 4 92 59 151201702 59,783$ 68,941$ 60 6 22 5 93 61 154201703 59,327$ 32,087$ 59 6 22 5 92 62 154201704 57,867$ 67,507$ 59 6 22 4 91 59 150201705 57,411$ 45,466$ 58 6 22 4 90 58 148201706 58,415$ 76,256$ 58 7 22 4 91 59 150201707 58,871$ 84,870$ 59 7 22 4 92 59 151201708 59,330$ 65,557$ 61 7 22 4 94 59 153201709 57,323$ 47,333$ 60 5 22 4 91 57 148201710 56,169$ 76,707$ 63 3 17 4 87 48 135201711 57,627$ 57,244$ 66 3 17 4 90 48 138201712 56,485$ 54,543$ 66 4 18 2 90 46 136201801 56,485$ 73,731$ 66 4 18 2 90 46 136201802 55,415$ 22,174$ 66 3 18 2 89 45 134201803 55,586$ 28,388$ 65 3 17 3 88 46 134201804 54,021$ 45,720$ 62 3 17 3 85 46 131201805 54,604$ 67,343$ 61 4 17 3 85 47 132201806 56,210$ 23,162$ 60 5 18 3 86 50 136201807 55,792$ 89,608$ 59 6 17 3 85 50 135201808 56,278$ 38,720$ 59 5 17 4 85 51 136201809 54,965$ 27,737$ 60 5 15 4 84 49 133201810 34,883$ 0 0 0 0 0 0 0201811 7,908$ 0 0 0 0 0 0 0201812 (3,745)$ 0 0 0 0 0 0 0201901 (5,442)$ 0 0 0 0 0 0 0201902 130$ 0 0 0 0 0 0 0201903 (1,118)$ 0 0 0 0 0 0 0201904 146$ 0 0 0 0 0 0 0201905 490$ 0 0 0 0 0 0 0TOTAL 1,372,237$ 1,290,039$ 1473 121 469 87 2150 1284 3434

For claims that are not part of this report, the number of pre-certification requests for hospital stays of 5 days or longer that were made during the 30-day period preceding the Reporting Period last Processed (paid) Date

Date of Information Request:Receipt Date of Information Request:Receipt Date of HIPAA Certification:Date of Report Production:

Processed (paid) Dates:Service (incurred) Dates:

909225

Prem,Claim,Enrollee1006396- Texas State Mandate - EAST TEXAS COUNCIL OF GOVERNMENTS

Created on 6/20/2019 By BatchUHC - Underwriting, Pricing, Actuarial

Request # 1006396

TEXAS - MANDATED REPORTING FOR INSURED BUSINESSSection III: Individual Claimants - Paid Claims >$15,000

Customer Name: EAST TEXAS COUNCIL OF GOVERNMENTSPolicy Number: 909225Reporting PeriodProcessed (paid) Dates: 06/01/2018-05/31/2019Service (incurred) Dates: ALL

Claimant ID 1 Amount Paid 74,731$

One or more of the following Diagnosis, Procedure, and Service Dates were indicated for this claimant during the reporting period. Diagnosis and Procedure information is listed in ascending order based on Code. Service Date information is listed chronologically.

Code Description Code DescriptionE29.1 TESTICULAR HYPOFUNCTION 00562 ANESTH HRT SURG W/PMP AGE 1+ 04/16/2018G89.4 CHRONIC PAIN SYNDROME 17000 DESTRUCT PREMALG LESION 05/01/2018I05.9 RHEUMATIC MITRAL VALVE

DISEASE UNS32555 ASPIRATE PLEURA W/ IMAGING 05/31/2018

I25.10 ASHD NATIVE CA W/O ANGINA PECTORIS

33430 REPLACEMENT OF MITRAL VALVE 06/01/2018

I25.9 CHRONIC ISCHEMIC HEART DISEASE UNS

36415 ROUTINE VENIPUNCTURE 06/04/2018

I34.0 NONRHEUMATIC MITRAL INSUFFICIENCY

36620 INSERTION CATHETER, ARTERY 06/11/2018

I42.9 CARDIOMYOPATHY UNSPECIFIED 71045 X-RAY EXAM CHEST 1 VIEW 06/12/2018I45.10 UNSPECIFIED RT BUNDLE-BRANCH

BLOCK71046 X-RAY EXAM CHEST 2 VIEWS 06/13/2018

I51.7 CARDIOMEGALY 71250 CT THORAX W/O DYE 06/14/2018I95.1 ORTHOSTATIC HYPOTENSION 80048 METABOLIC PANEL TOTAL CA 06/15/2018

J90 PLEURAL EFFUSION NEC 80305 DRUG TEST PRSMV DIR OPT OBS 06/16/2018J93.9 PNEUMOTHORAX UNSPECIFIED 81001 URINALYSIS, AUTO W/SCOPE 06/17/2018L57.0 ACTINIC KERATOSIS 82670 ASSAY OF ESTRADIOL 06/27/2018

M25.562 PAIN IN LEFT KNEE 83735 ASSAY OF MAGNESIUM 07/02/2018M47.812 SPONDYLS W/O MYELO-

/RADICULOP CERV84153 ASSAY OF PSA, TOTAL 07/03/2018

M54.2 CERVICALGIA 84270 ASSAY OF SEX HORMONE GLOBUL 07/05/2018M54.5 LOW BACK PAIN 84403 ASSAY OF TOTAL TESTOSTERONE 07/10/2018R00.0 TACHYCARDIA UNSPECIFIED 84443 ASSAY THYROID STIM HORMONE 07/12/2018

R06.02 SHORTNESS OF BREATH 85025 COMPLETE CBC W/AUTO DIFF WBC 07/16/2018R09.1 PLEURISY 87086 URINE CULTURE/COLONY COUNT 07/17/2018

Diagnosis ProcedureService Date

Notification of Withheld Information and Confidentiality Statement

The Texas Insurance Code section 1215.003(d) provides that protected health information may be withheld from this claims report if subject to privacy restrictions more stringent than HIPAA. This constitutes notice that the following categories of claims information for specified individuals is withheld from this report:

-Utilization review related records including individual medical records, personal information, or other confidential information about a patient obtained in the performance ofutilization review per Texas Insurance Code section 4201-552.-Records related to the diagnosis, evaluation, or treatment of a mental or emotional disorder, including alcoholism or drug addiction, per Chapter 611 of the Texas Health & Safety Code.-Records related to AIDS and HIV test results per Texas Health & Safety Code Section 81.101 et seq.-Genetic information, if any, per Texas Insurance Code Section 546.102.

Information included in this document is considered to be UnitedHealthcare's confidential and/or proprietary business information. Consequently, this information may be used only by the person or entity to which it is addressed by UnitedHealthcare. Such recipient shall be liable for using and protecting UnitedHealthcare's proprietary business information from further disclosure or misuse, consistent with recipient's contractual obligations under any applicable administrative services agreement, group policy contract, non-disclosure agreement or other applicable contract or law, including but not limited to, Exemption 4 of the U.S. Freedom of Information Act and state freedom of information law exemptions for "trade secrets". The report you have received may contain protected health information (PHI) and must be handled according to applicable state and federal law, including, but not limited to HIPAA. Individuals who misuse information may be subject to both civil and criminal penalties.

Claimant 11006396- Texas State Mandate -EAST TEXAS COUNCIL OF GOVERNMENTS


Request # 1006396



Code Description Code DescriptionDiagnosis Procedure

Service DateR91.8 OTH NONSPECIFIC ABN FIND LNG

FIELD88112 CYTOPATH CELL ENHANCE TECH 07/19/2018

R990002 UNKNOWN DIAGNOSIS 88305 TISSUE EXAM BY PATHOLOGIST 07/20/2018Z01.810 ENCOUNTER PREPROCEDURAL CV

EXAM90471 IMMUNIZATION ADMIN 07/25/2018

Z23 ENCOUNTER FOR IMMUNIZATION 90688 IIV4 VACCINE SPLT 0.5 ML IM 07/26/2018Z45.2 ENC ADJUSTMENT & MANAGEMENT

VAD93000 ELECTROCARDIOGRAM, COMPLETE 07/27/2018

Z95.2 PRESENCE OF PROSTHETIC HEART VALVE

93010 ELECTROCARDIOGRAM REPORT 08/13/2018

Z95.4 PRESENCE OTH HEART-VALVE REPLACEMNT

93306 TTE W/DOPPLER, COMPLETE 08/16/2018

93312 ECHO TRANSESOPHAGEAL 08/21/201893503 INSERT/PLACE HEART CATHETER 08/23/201893798 CARDIAC REHAB/MONITOR 08/24/201893880 EXTRACRANIAL BILAT STUDY 08/27/201896372 THER/PROPH/DIAG INJ, SC/IM 08/28/201899205 OFFICE/OUTPATIENT VISIT, NEW 08/31/201899212 OFFICE/OUTPATIENT VISIT, EST 09/04/201899213 OFFICE/OUTPATIENT VISIT, EST 09/05/201899214 OFFICE/OUTPATIENT VISIT, EST 09/06/201899223 INITIAL HOSPITAL CARE 09/13/201899232 SUBSEQUENT HOSPITAL CARE 09/17/201899233 SUBSEQUENT HOSPITAL CARE 09/20/201899285 EMERGENCY DEPT VISIT99291 CRITICAL CARE, FIRST HOURG0481 DR TST DEFIN DR ID M P D 8-14 DR CLG0482 DR TST DEFN DR ID M P D 15-21 DR CL

J1071 INJ TESTOSTERONE CYPIONATE 1 MGJ2550 INJECTION PROMETHAZINE HCL TO 50

MG



Request # 1006396





Code Description Code DescriptionE11.22 TYPE 2 DM W/DIABETIC CKD 00145 ANESTH, VITREORETINAL SURG 12/21/2017E11.65 TYPE 2 DM W/HYPERGLYCEMIA 36415 ROUTINE VENIPUNCTURE 04/24/2018

E11.8 TYPE 2 DM W/UNS COMPLICATIONS 67028 INJECTION EYE DRUG 04/30/2018

G47.33 OBSTRUCTIVE SLEEP APNEA 67039 LASER TREATMENT OF RETINA 05/29/2018H34.8320 TRIB RET VEIN OCCL LT EYE MAC

EDEMA67043 VIT FOR MEMBRANE DISSECT 06/11/2018

H35.62 RETINAL HEMORRHAGE LEFT EYE 80061 LIPID PANEL 06/23/2018

H43.12 VITREOUS HEMORRHAGE LEFT EYE 80069 RENAL FUNCTION PANEL 06/27/2018

I65.23 OCCLUSION & STENOS BIL CAROTID ART

82570 ASSAY OF URINE CREATININE 07/10/2018

N18.4 CKD STAGE 4 SEVERE 83036 GLYCOSYLATED HEMOGLOBIN TEST 07/13/2018Z00.00 ENC GEN ADULT EXAM W/O

ABNORM FIND84156 ASSAY OF PROTEIN URINE 07/23/2018

85025 COMPLETE CBC W/AUTO DIFF WBC 08/09/201892014 EYE EXAM&TX ESTAB PT 1/>VST 08/23/201892134 CPTR OPHTH DX IMG POST SEGMT 08/27/201893880 EXTRACRANIAL BILAT STUDY 09/19/201899213 OFFICE/OUTPATIENT VISIT, EST 09/21/201899214 OFFICE/OUTPATIENT VISIT, EST 09/23/201899223 INITIAL HOSPITAL CARE 09/27/2018A7032 CUSHN NASAL MASK INTF REPL ONLY

EA09/28/2018

A7034 NASL INTERFCE POS ARWAY PRSS DEVC








Request # 1006396




Service DateA7037 TUBING USED W/POS ARWAY PRESS

DEVCA7038 FLTR DISPBL W/POS ARWAY PRSS

DEVCE1390 O2 CONC 85%/>02 CONC PRSC FLW

RATEJ2778 INJECTION RANIBIZUMAB 0.1 MG



Request # 1006396





Code Description Code DescriptionM89.8X6 OTHER SPEC DISORDERS BONE

LOWER LEG71046 X-RAY EXAM CHEST 2 VIEWS 03/24/2018

R07.9 CHEST PAIN UNSPECIFIED 73590 X-RAY EXAM OF LOWER LEG 04/19/2018R22.31 LOC SWELL MASS LUMP RT UPPER

LIMB97110 THERAPEUTIC EXERCISES 05/01/2018

R52 PAIN UNSPECIFIED 99214 OFFICE/OUTPATIENT VISIT, EST 05/25/2018S82.102D UNS FX UP LT TIBIA SUBS CLOS FX

RTNA0425 GROUND MILEAGE PER STATUTE MILE 05/26/2018

Z47.89 ENC FOR OTHER ORTHOPEDIC AFTERCARE

A0427 AMB SRVC ALS EMERG TRANSPORT LEVL 1

05/29/2018

Z96.7 PRESENCE OTH BONE & TENDON IMPLANTS

E0143 WALKER FOLD WHEELED ADJUSTBL/FIX HT

06/03/2018

E0951 HEEL LOOP/HOLDER ANY TYPE EACH 06/05/2018E0971 MNL WC ACSS ANTI-TIPPING DEVC EA 06/08/2018

E0973 WC ACCSS ADJ HT DTACH ARMRST EA 06/11/2018

E0990 WC ACCSS ELEV LEG REST CMPL ASSMBL

06/13/2018

E2601 GEN WC SEAT CUSHN WIDTH < 22 DEPTH

06/15/2018

E2611 GEN WC BACK CUSHN WIDTH < 22 IN HT 06/18/2018

K0003 LIGHTWEIGHT WHEELCHAIR 06/19/2018Q0092 SET-UP PORTABLE X-RAY EQUIPMENT 06/20/2018








Request # 1006396




Service DateR0070 TRANS PRTBL XRAY EQP&PERS-TRIP 1

PT06/22/2018

S9123 NRS CARE HOM; REGISTERED NURSE-HOUR

06/25/2018

S9124 NURSING CARE THE HOME; LPN PER HOUR

06/26/2018

S9129 OCCUPATIONAL THERAPY HOME PER DIEM

06/27/2018

S9131 PHYSICAL THERAPY; HOME PER DIEM 07/02/2018

07/04/201807/06/201807/10/201807/11/201807/18/201807/26/201808/01/201808/02/201808/26/201809/06/2018



Request # 1006396





Code Description Code DescriptionE27.40 UNS ADRENOCORTICAL

INSUFFICIENCY00731 ANES UPR GI NDSC PX NOS 06/05/2018

E83.119 HEMOCHROMATOSIS UNSPECIFIED 36415 ROUTINE VENIPUNCTURE 06/07/2018

G43.009 MIGRAINE W/O AURA NOT INTRCT W/O SE

43235 EGD DIAGNOSTIC BRUSH WASH 06/19/2018

G89.29 OTHER CHRONIC PAIN 43450 DILATE ESOPHAGUS 1/MULT PASS 06/22/2018H04.123 DRY EYE SYNDROME BIL LACRIML

GLANDS51741 ELECTRO-UROFLOWMETRY, FIRST 06/27/2018

H40.41X1 GLAUCOMA D/T EYE INFLAM RT EYE MILD

51798 US URINE CAPACITY MEASURE 06/28/2018

J30.9 ALLERGIC RHINITIS UNSPECIFIED 52000 CYSTOSCOPY 07/25/2018J39.2 OTHER DISEASES OF PHARYNX 70450 CT HEAD/BRAIN W/O DYE 07/26/2018K21.9 GERD WITHOUT ESOPHAGITIS 70491 CT SOFT TISSUE NECK W/DYE 07/31/2018K58.0 IRRITABLE BOWEL SYND

W/DIARRHEA73110 X-RAY EXAM OF WRIST 08/01/2018

K76.0 FATTY CHANGE LIVER NEC 73130 X-RAY EXAM OF HAND 08/03/2018L81.4 OTHER MELANIN

HYPERPIGMENTATION73610 X-RAY EXAM OF ANKLE 08/06/2018

M13.0 POLYARTHRITIS UNSPECIFIED 73630 X-RAY EXAM OF FOOT 08/09/2018M76.61 ACHILLES TENDINITIS RIGHT LEG 74176 CT ABD & PELVIS W/O CONTRAST 08/10/2018N39.46 MIXED INCONTINENCE 74177 CT ABD & PELV W/CONTRAST 08/13/2018N60.11 DIFFUSE CYSTIC MASTOPATHY RT

BREAST76641 ULTRASOUND BREAST COMPLETE 08/14/2018

N83.202 UNSPECIFIED OVARIAN CYST LEFT SIDE

76830 TRANSVAGINAL US, NON-OB 08/21/2018

R10.11 RIGHT UPPER QUADRANT PAIN 76856 US EXAM, PELVIC, COMPLETE 09/07/2018








Request # 1006396




Service DateR10.13 EPIGASTRIC PAIN 77066 DX MAMMO INCL CAD BI 09/12/2018

R10.2 PELVIC AND PERINEAL PAIN 78227 HEPATOBIL SYST IMAGE W/DRUG 09/13/2018R10.31 RIGHT LOWER QUADRANT PAIN 80053 COMPREHEN METABOLIC PANEL 09/17/2018R10.84 GENERALIZED ABDOMINAL PAIN 80061 LIPID PANEL 09/18/2018

R10.9 UNSPECIFIED ABDOMINAL PAIN 80076 HEPATIC FUNCTION PANEL 09/19/2018R11.0 NAUSEA 81000 URINALYSIS, NONAUTO W/SCOPE 09/20/2018

R13.10 DYSPHAGIA UNSPECIFIED 81001 URINALYSIS, AUTO W/SCOPE 09/24/2018R22.1 LOCALIZED SWELLING MASS &

LUMP NECK81002 URINALYSIS NONAUTO W/O SCOPE 09/26/2018

R51 HEADACHE 81382 HLA II TYPING 1 LOC HR 09/27/2018R79.89 OTH SPEC ABNORMAL FINDINGS

BLD CHEM82024 ASSAY OF ACTH

R79.9 ABNORMAL FINDING BLD CHEMISTRY UNS

82103 ALPHA-1-ANTITRYPSIN, TOTAL

Z00.01 ENC GEN ADULT EXAM W/ABNORMAL FIND

82306 VITAMIN D, 25 HYDROXY

82533 TOTAL CORTISOL82565 ASSAY OF CREATININE82728 ASSAY OF FERRITIN82784 ASSAY, IGA/IGD/IGG/IGM EACH82977 ASSAY OF GGT83010 ASSAY OF HAPTOGLOBIN, QUANT83516 IMMUNOASSAY, NONANTIBODY83540 ASSAY OF IRON83550 IRON BINDING TEST83883 ASSAY, NEPHELOMETRY NOT SPEC84165 PROTEIN E-PHORESIS, SERUM84439 ASSAY OF FREE THYROXINE84443 ASSAY THYROID STIM HORMONE84550 ASSAY OF BLOOD/URIC ACID85025 COMPLETE CBC W/AUTO DIFF WBC85652 RBC SED RATE, AUTOMATED86038 ANTINUCLEAR ANTIBODIES86376 MICROSOMAL ANTIBODY EACH86431 RHEUMATOID FACTOR, QUANT86677 HELICOBACTER PYLORI ANTIBODY91200 LIVER ELASTOGRAPHY92004 EYE EXAM, NEW PATIENT92012 EYE EXAM ESTABLISH PATIENT92014 EYE EXAM&TX ESTAB PT 1/>VST93000 ELECTROCARDIOGRAM, COMPLETE96361 HYDRATE IV INFUSION, ADD-ON96372 THER/PROPH/DIAG INJ, SC/IM99203 OFFICE/OUTPATIENT VISIT, NEW99204 OFFICE/OUTPATIENT VISIT, NEW99205 OFFICE/OUTPATIENT VISIT, NEW99213 OFFICE/OUTPATIENT VISIT, EST99214 OFFICE/OUTPATIENT VISIT, EST99215 OFFICE/OUTPATIENT VISIT, EST99282 EMERGENCY DEPT VISIT99284 EMERGENCY DEPT VISIT99386 PREV VISIT, NEW, AGE 40-64



Request # 1006396




Service DateG0279 DX DIGTL BRST TOMOSYNTHESIS

UNI/BILJ0780 INJ PROCHLORPERAZINE TO 10 MGJ0834 INJECTION COSYNTROPIN 0.25 MG



Request # 1006396

Data Element Definition

Policy NumberThis is the policy number(s) included in this report. Reporting has been limited based on this policy number(s). Identifies the claimant population for the entity that purchased products and/or services from UnitedHealth Group.

Reporting Period Process (Paid) Dates

These are the paid months that are included in this report. This option limits the report to claims for which a payment was processed into the financial accounting system within the time period you select. Events processed before or after the dates listed will not be included in this report.

Reporting Period Service Dates

These are the service months that are included in this report. This option limits the report to services rendered (claims incurred) within the time period you select. Events incurred before or after the dates listed will not be included in this report.

Date of Information Request: This is the date that the ad hoc request form was submitted.Receipt Date of Information Request: This is the date that we triaged the ad hoc form and assigned it out for production.Receipt Date of HIPAA Certification: This is the date that the Data Resources team received the HIPAA cert for this customer.Date of Report Production: This is the first date that the Data Resources team began producing this customers report.

Data Element DefinitionSection IFor claims that are not part of this report, the number of pre-certification requests for hospital stays of 5 days or longer that were made during the 30-day period preceding the Reporting Period last Processed (paid) date.

This is number of precertification requests for hospital stays of five days or longer that were made during the 30-day period preceding the date of the report. This number only contains individuals with a stay of 5+ days that are not already included in the claimant tabs of the report. The 30 day period preceding the date of the report has been defined as the 30 days preceeding the last Processed (paid) date included in the report.

Section II

Bill/Book Year/MonthThe year and month in which an invoice was sent to a customer for payment of an insurance premium, and/or payment for a claim is entered into the financial accounting system.

Restated Billed PremiumThe contracted amount sought by UnitedHealth Group for providing coverage. Data is updated monthly; therefore, the premium amount for a fixed point in time may change from month-to-month.

Total Payments

The total amount paid for claims derived from a premium product — including capitation payments.

= Capitation Payments + Managed Pharmacy Payments + HMO In-Network Claim Payments + Other Claim Payments.

Single SubscribersThe number of employees who are enrolled in a plan but have no dependents enrolled in the plan. Subscribers include eligible retirees and surviving spouses.

Subscribers plus Spouse The count of families consisting of an employee plus his/her married partner.

Subscribers plus Child/ChildrenThe count of families consisting of an employee plus 1 or more dependents (excluding the employee's spouse), just the employee's spouse and children, or the children alone.

Subscribers plus FamilyThe count of families consisting of an employee plus his/her spouse and child/children, or some variant of that composition.

Total SubscribersThe number of people (typically employees) who are the primary policy-holder of a benefit. Subscribers include eligible retirees and surviving spouses.

Positively Enrolled Dependents The number of spouses, children, and other individuals related to the subscriber who are registered for coverage.

Total MembersThe count of all people enrolled for coverage under a benefit. = Total Subscribers + [Positively Enrolled Dependents + Non-Positively Enrolled Dependents].

Section III (Without a HIPAA Cert for the specified customer, these definitions will not apply as "Individual Claimants" detail will not be provided)

Claimant IDUnique claimants are denoted by using a 1, 2, 3, etc next to the word Claimant. No identifying information will be released such as Social Security Numbers, Gender, Age, employee v/s dependent, etc.

Amount Paid Total Paid Claims for Claimant in this experience period.

Diagnosis Code

ICD-9/10 (International Classification of Disease, 9th/10th Revision, Clinical Modification) Code as entered on the claim (without decimal point). ICD-9/10-CM is designed for the classification of morbidity and mortality information for statistical purposes and for the indexing of hospital records by disease and operations, for data storage retrieval. ICD-9/10-CM is an accepted national standard for coding diagnostic and disease information. This code represents the diagnosis with the highest cumulative paid amount for this experience period. Claims with HIV-related diagnosis and claims with Mental Health Substance Abuse (MHSA) diagnosis are protected by existing federal regulations and must not be disclosed. The diagnosis provided in these cases must be indicated as “99999.”

TEXAS HOUSE BILL 2015 DATA DICTIONARY

This is the report provided to fulfill the Texas House Bill 2015 state mandate regarding Texas group health plan claim information. It contains hospital precert info for the most current 30 days (Section I), a premiums and claims history with a membership by month summary for up to 36 months (Section II), and large loss report at the $15,000 threshold for the most current 12 months (Section III). This is only upon completion of the HIPAA certificate, without a signed HIPAA cert the customer is not eligible to receive the large loss report, although they still get all other reporting mentioned above.

Filter Data Dictionary

Report Data Dictionary


Diagnosis Description

Describes the International Classification of Disease, 9th/10th Revision, Clinical Modification (ICD-9/10-CM) code. ICD-9/10-CM is designed for the classification of morbidity and mortality information for statistical purposes and for the indexing of hospital records by disease and operations, for data storage retrieval. ICD-9/10-CM is an accepted national standard for coding diagnostic and disease information. Claims with HIV-related diagnosis and claims with Mental Health Substance Abuse (MHSA) diagnosis are protected by existing federal regulations and must not be disclosed. The diagnosis provided in these cases must be indicated as “Other Diagnosis.”

Procedure Code

Procedure Code describes the type of procedure performed or service provided. This procedure code is usually a CPT-4 OR HCPCS Code. Claims with HIV-related diagnosis and claims with Mental Health Substance Abuse (MHSA) diagnosis are protected by existing federal regulations and must not be disclosed.

Procedure Description

Describes a specific procedure performed or service provided. A procedure code can be an ICD9, CPT4, or HCPC code. Claims with HIV-related diagnosis and claims with Mental Health Substance Abuse (MHSA) diagnosis are protected by existing federal regulations and must not be disclosed.

Service DateThese are the dates of service associated with the respective procedure and diagnosis codes for each individual claimant's history processed within the Reporting Period.


Art. 21.49-16

WAIVER

Art. 21.49-16 Sec. 2 of the Texas Insurance Code (see below) requires insurers who provide bids subject

to competitive bidding and competitive proposal requirements adopted under Section 252.021, Local

Government Code to submit the entire bid without qualifications. This statute also prohibits the

exclusion of an individual based on prior medical history who is otherwise eligible for coverage. Nor is

the insurer allowed to assign a higher deductible to such an individual.

This statute allows a municipality to waive these requirements.

Therefore in the interest of obtaining the most advantageous stop loss and/or other insurance for health

benefit coverage available under the circumstances, [municipality], waives both subsections (a) and (b)

of Article 21.29-16 Sec.2 (below).

Signature: ______________________________

Title: _Assistant Executive Director___________

Municipality Name: _East Texas Council of Governments_

Dated: ___6/23/2020______________________________

Texas Insurance Code, Art. 21.49-16. Bid Requirements for Insurers Who Contract With Municipalities

Sec. 1. In this article:

(1) "Insurer" means:

(A) an insurance company, including a company providing stop-loss or excess loss insurance;

(B) a health maintenance organization operating under the Texas Health Maintenance Organization Act

(Chapter 20A, Vernon's Texas Insurance Code);

(C) an approved nonprofit health corporation that holds a certificate of authority issued by the

commissioner under Article 21.52F of this code; or

(D) a third party administrator that holds a certificate of authority under Article 21.07-6 of this code.

(2) "Municipality" has the meaning assigned by Section 1.005, Local Government Code.

Sec. 2. (a) Except as provided by Subsection (c) of this section, an insurer who bids on a contract subject

to the competitive bidding and competitive proposal requirements adopted under Section

252.021, Local Government Code, may not submit a bid for a contract to provide stop-loss or other

insurance coverage that is subject to any qualification imposed by the insurer that permits the insurer to

modify or limit the terms of insurance coverage to be provided after the contract has been made. An

insurer's bid submitted under Section 252.021, Local Government Code, must contain the entire offer

made by the insurer.

(b) Except as provided by Subsection (c) of this section, an insurer who provides stop-loss or other

insurance coverage for health benefits under a contract subject to this article may not, based on an

individual's prior medical history, exclude an individual who is otherwise eligible for the health benefits

coverage from coverage or assign a higher deductible to the individual.

(c) By executing a written waiver in favor of the insurer, a municipality may waive the requirements of:

(1) Subsection (a) of this section; or

(2) Subsection (b) of this section regarding the assignment of a higher deductible to the individual.

Note: The statutory excerpt above was current as of May 18, 2005.

EXHIBIT IV - Tx Ins Code Municipality Bid Waiver



RFP 1001-2020

Group Health Insurance, Direct Provider Contracts, TPA & Specific and Aggregate Stop Loss Re-Insurance

BIDDERS PLEASE NOTE: COPIES OF THE FOLLOWING BID SHEETS HAVE BEEN ENCLOSED FOR YOUR CONVENIENCE

• Bid Affidavit Form (required)

• Response Form (required)

• Conflict of Interest Form (required)

• Actual fees, terms & conditions of proposal (required) Proposals MUST BE RETURNED TO THE BRINSON BENEFITS ANALYTICS DEPARTMENT NO LATER THAN 10:00 AM CST, JULY 15, 2020, WEDNESDAY.



EAST TEXAS COUNCIL OF GOVERNMENTS BID AFFIDAVIT (REQUIRED)

The undersigned certifies that they are a duly authorized officer/agent and authorized to execute the foregoing on behalf of the bidder. The bid prices contained in this bid has been carefully reviewed and is submitted as correct. Bidder further certifies and agrees to furnish any and all services effective October 1, 2020 upon the acceptance of the final proposal as firm and final on or before August 15, 2020 (including any amendments and/or negotiations) and upon the conditions contained in the Specifications of this REQUEST FOR PROPOSAL. Subsequent renewals, specifically the initial renewal, must be delivered to the Council no later than June 30, 2021 and firm and final no later than August 1, 2021 for an October 1, 2021 effective date. The period of acceptance of this bid will be ___90______ calendar days from the date of the bid opening. (Period of acceptance will be ninety (90) calendar days unless otherwise indicated by Bidder.)

I hereby certify that the foregoing bid has not been prepared in collusion with any other Bidder or individual(s) engaged in the same line of business prior to the official opening of this bid. Further, I certify that the Bidder is not now, nor has been for the past six (6) months, directly or indirectly concerned in any pool, agreement or combination thereof, to control the price of services/commodities bid on, or to influence any individual(s) to bid or not to bid.

Bids provided (check all that apply): Medical – Group Medical Insurance Medical – Direct Provider Contract Medical – TPA Medical – Specific and Aggregate Stop Loss Re-Insurance

Company Name

Company Address (street, Town, state, zip)

Telephone Number

E-mail address

Fax Number

Contact Name

Title

Authorized Signature

Date



EAST TEXAS COUNCIL OF GOVERNMENTS RESPONSE FORMS (REQUIRED)

Buy-Up

NET OF COMMISSION

Employee Only

EE+ Spouse

EE+ Child(ren)

EE+ Family


Core

NET OF COMMISSION

Employee Only

EE+ Spouse

EE+ Child(ren)

EE+ Family


HSA

NET OF COMMISSION

Employee Only

EE+ Spouse

EE+ Child(ren)

EE+ Family


Specific and Aggregate Stop Loss 10/1/2020 – 9/30/2021

Employee

Family

$40K Specific premiums Aggregate premiums Aggregate stop loss factors (attach actual quote, terms & conditions)

$_____________ $_____________ $_____________

$_________ $_________ $_________




Employee

Family


$_____________ $_____________ $_____________

$_________ $_________ $_________


Employee

Family


$_____________ $_____________ $_____________

$_________ $_________ $_________

TPA Services 10/1/2020 – 9/30/2021

Medical Administration Utilization Review

Preferred Provider Network Fee

Direct Provider Contract 10/1/2020 – 9/30/2021

Base Plan

Buy-Up

(attach actual quote, terms & conditions)

$_____________ $_____________

$_________ $_________



CONFLICT OF INTEREST QUESTIONNAIRE

FORM CIQ (REQUIRED) For vendor or other person doing business with local governmental entity

This questionnaire is being filed in accordance with chapter 176 of the Local Government Code by a person doing business with the governmental entity. By law this questionnaire must be filed with the records administrator of the local government not later than the 7th business day after the date the person becomes aware of facts that require the statement to be filed. See Section 176.006, Local Government Code. A person commits an offense if the person violates Section 176.006, Local Government Code. An offense under this section is a Class C misdemeanor.

OFFICE USE ONLY

Date Received

1

Name of person doing business with local governmental entity.

2 ❑ Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than September 1 of the year for which an activity described in Section 176.006(a), Local Government Code, is pending and not later than the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.)

3

Name each employee or contractor of the local governmental entity who makes recommendations to a local government officer of the governmental entity with respect to expenditures of money AND describe the affiliation or business relationship.

4

Name each local government officer who appoints or employs local government officers of the governmental entity for which this questionnaire is filed AND describe the affiliation or business relationship.

Adopted 11/02/2005



FORM CIQ

CONFLICT OF INTEREST QUESTIONNAIRE Page 2 For vendor or other person doing business with local governmental entity

5 Name of local government officer with whom filer has affiliation or business relationship. (Complete this section only if the answer to A, B, or C is YES. This section, item 5 including subparts A, B, C & D, must be completed for each officer with whom the filer has affiliation or other relationship. Attach additional pages to this Form CIQ as necessary. A. Is the local government officer named in this section receiving or likely to receive taxable income from the filer

of the questionnaire? ❑ Yes ❑ No B. Is the filer of the questionnaire receiving or likely to receive taxable income from or at the direction of the local

government officer named in this section AND the taxable income is not from the local governmental entity? ❑ Yes ❑ No

C. Is the filer of this questionnaire affiliated with a corporation or other business entity that the local government

officer serves as an officer or director, or holds an ownership of 10 percent or more? ❑ Yes ❑ No D. Describe each affiliation or business relationship.

6

____________________________________________________ ___________________ Signature of person doing business with the governmental entity Date

Adopted 11/02/2005

Documents

REQUEST FOR PROPOSAL INSTRUCTIONS ......final proposal as firm and final on or before August 15, 2020 (including any amendments and/or negotiations) and upon the conditions contained