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HomeMy WebLinkAbout2016-10-11-minutes-hr-study-sessionCOMMISSIONERS' MINUTES KITTITAS COUNTY, WASHINGTON BOCC CONFERENCE ROOM REGULAR MEETING TUESDAY 10:00 AM October 11, 2016 Board members present: Obie O’Brien, Paul Jewell, Laura Osiadacz Others: Lisa Young, Mark Hollandsworth, Daily Record REGULAR MEETING COMMISSIONERS 1) Call to order: 10:07 AM 2) Board Discussion and Decision Regarding Letter to HopeSource in Support of the 2017-2019 Department of Transportation Grant Application. Commissioners Jewell and Osiadacz briefly discussed the letter presented for signature; Chairman O’Brien recused himself. Commissioner Jewell moved to approve Board signature on the letter of support; Commissioner Osiadacz seconded; the motioned carried 2:0, with Chairman O’Brien abstaining from the vote. Mark Hollandsworth was present to express his gratitude. 3) Request for Chairman Signature on 2017 WCIF Master Applications HR Director Young provided an overview of plan selections and changes for 2017. Commissioner Jewell moved to approve Chairman signature on the Master Applications; Commissioner Osiadacz seconded. Motion passed 3:0. 4) Discussion Regarding the New FLSA Overtime Regulations HR Director Young provided an overview of the pending changes required under the new FLSA minimum income threshold for exemption from overtime. She indicated that there are 18 positions that would fall below the standard currently, with 10 that will require removal from exempt status regardless of the outcome of the pending wage survey. The Board approved removal of the 10 positions from exempt status effective 12/1/16 and recommended having a plan in place for the remaining positions pending the outcome of the survey/budget. 5) Discussion Regarding the Wage Survey Commissioner Jewell provided an update on the work that has been done to-date. The Board discussed the project briefly and determined that the departmental budgets would need to be reviewed prior to making any decisions on the survey. Commissioner Jewell and Director Young will prepare an update to share with the Board and Management Team. 6) Discussion Regarding HIPAA HR Director Young provided an update on HIPAA Compliance; she recommended hiring a consultant to conduct an assessment of our privacy/security policies, procedures, and compliance standards. She indicated that HIPAA could be a subject of future State Audits, and that there have been several security breaches in other Counties. She also reported that she located funding through the Auditor’s office. The Board agreed that she should move forward with the project. 7) Other Business Executive Session RCW 42.30.110 (g) To evaluate the qualifications of an applicant for public employment or to review the performance of a public employee. However, subject to RCW 42.30.140(4), discussion by a governing body of salaries, wages, and other conditions of employment to be generally applied within the agency shall occur in a meeting open to the public, and when a governing body elects to take final action hiring, setting the salary of an individual employee or class of employees, or discharging or disciplining an employee, that action shall be taken in a meeting open to the public. The Board entered executive session at 10:48 AM to discuss the performance of a public employee. Anticipated length: 10 minutes; anticipated action: None. The Board exited executive session at 10:58 AM with no action taken. 8) Adjourn: 10:58 AM KITTITAS COUNTY COMMISSIONERS KITTITAS COUNTY, WASHINGTON Lisa Young Chairman �AyLA4E5...rp Ty 4 hirrnnsr i xri October 11, 2016 Mark Hollandsworth Kittitas County, Washington BOARD OF COUNTY COMMISSIONERS District One District Two District Three Paul Jewell Laura Osiadacz Obie O'Brien HopeSource 700 East Mountain View Avenue #510 Ellensburg, WA 98926 Dear Mark Hollandsworth: We would like to express our strong support for HopeSource's 2017-2019 Department of Transportation Grant Application. HopeSource Transit System Dial- A -Ride will preserve a much needed demand response, door-to-door transportation service for the special needs populations that reside in the rural areas of Kittitas County. QuadCo's development of the Human Service Transportation Plan for Adams, Grant, Kittitas, and Lincoln counties included surveying individuals with special needs in each county. From the survey results for Kittitas County, 56% of those surveyed utilized HopeSource. The transportation is essential for accessing health care, nutrition, senior centers, job training and other basic services. HopeSource, a community action agency, has continued to respond to the essential transportation needs of Kittitas County's citizens with safe and reliable transportation service. We recognize the vital service that HopeSource provides to the rural residents of Kittitas County and we encourage continues support so that Kittitas County may retain the HopeSource Transit System Dial -A -Ride service. Sincerely, MSTAINED Obie O' n, Chairman Paul Jewell, Vice- airman aura Osiadacz, Board Member Kittitas County Courthouse . 205 West 5'"Avenue, STE 108 Ellensburg, WA 98926 (509) 962-7508 -FAX (509) 962-7679 www.co.kittitas.wa.us LEGACY MEDICAL GROUP MASTER APPLICATION FOR WCIF 2017 WCIF COVERAGE Attach separate sheets of paper if additional space is necessary. Plan summaries and other information WASHING T o ra c ; u �d r E 5 y 1PISURANCE Fus® may be found at www.wcif.net > Plan Information. Coverage Effective Date:01/01/17 This is an application for (check one): ® Annual Renewal ❑ New Participating Employer ❑ Mid -Year Plan Change ❑ Existing Employer, New Division If submitting multiple applications for SUBGROUPS: (Note: Employees with different benefits (i.e. subgroups) require a separate Group Master Application) Application Number: (i.e. "1 of 3') Subgroup Name: (i.e. "Health Dept.," "Union," etc.) 1 of 3 All Except Line and Probation Kittitas County Doing Business As (DBA): By what name would you prefer WCIF to refer to your oganization? ® Legal Name ❑ DBA Name Business Physical Address: (No PO Box orPMB) City: State: Zip: County: 205 W 5th Avenue Ellensburg WA 98926 Kittitas Business Mailing Address: (if different from physical) City: State: Zip: County: Federal Tax ID Number: BSI Account Number (assigned by BSI) Is your organization a public entity? 91-6001349 58 ® Yes ❑ No What type of entity is your organization? (check only ONE box) #1 ® County #2 ❑ Other local government entity (includes all taxing districts) #3 ❑ Non-profit organization receiving state or local government funding NOTE: Organizations that check only #3 must provide proof of funding with this application. #4 ❑ Other: COMMISSIONER / EXECUTIVE DIRECTOR / CEO (etc.) Name & Title: Phone: Fax: Obie O'Brien, Commissioner 509-962-7508 Email: obi e.obrien@co.kittitasma.us WCIF INSURANCE ADVISORY COMMITTEE (IAC) DESIGNEE (voting member) IAC members are initial points of contact for plan changes, renewal information and the WCIF voting member of the group. Name & Title: Phone: Fax Email: Obie O'Brien, Commissioner 509-962-7508 obie.obrien@co.kittitas.wa.us GROUP BENEFITS ADMINISTRATOR (Administrators' Committee for Excellence (ACE) Designee) ACE member will be the primary contact for WCIF plan benefit updates and administration. Name & Title. Phone: Fax: Email: Lisa Young, HR Director/Risk Manager 509-962-7084 lisa.young@co.kittitas.wa.us GROUP BILLING ADMINISTRATOR (Administrators' Committee for Excellence (ACE) Designee) ACE member will be the primary contact for WCIF plan billing updates and administration. Name & Title: Phone: Fax: Email: Judy Pless, Budget & Finance Manager 509-962-7502 judy.pless@co.kittitas.wa.us INSURANCE PRODUCER (as applicable) Does your organization use an insurance producer for WCIF plans? ❑ Yes (if YES, complete the following) ❑ No Producer Name: Phone: Fax: Email: 2017LMGMA2 Page 1 of 9 (092116JM) EMPLOYER NAME: KITTITAS COUNTY Name (used for payment purposes): Producer Physical Address (No PO Box or PMB) ... Secondary Producer Name: Phone11 : Fax: PRODUCER SIGNATURE: DATE: Producer must submit a Commission Rate Template to WCIF with this application. ..... ..... DEFINITIONS WCIF CLASS DEFINITION Group of employees (affiliates, subsidiaries, or office locations within the same employer) within the same employer with the same benefit options as the main group. Classes have the same BSI Account Number as the main group, and are included on the same bill, but are assigned class codes and will have separate class premium totals on the bill. WCIF ELIGIBLE EMPLOYEES DEFINITION WCIF requires that employees work a minimum of 20 hours per week or 80 hours per month (whichever is less) to be eligible for benefits. An Employer may require an employee to work more than 20 hours per week or 80 hours per month based on employer policy or contractual requirements, and WCIF will honor the organization's minimum threshold. (Note: A covered employee will remain covered during any unpaid furlough so long as the covered employee does not exceed 30 unpaid furlough days in a single calendar year. Furlough days DO NOT include FMLA qualified absences, whether paid or unpaid). Elected officials of participating employers are eligible for coverage and are exempt from the minimum hour requirement. WCIF EFFECTIVE DATE DEFINITION WCIF defines an employee's coverage effective date as follows. Employees hired: • On the first of the month are eligible for coverage effective the date of hire. (If the first of the month falls on a weekend or holiday and the employee reports for work on the first business day following, coverage is retroactive to the first.) . On the 2nd to the 31st of the month are eligible for coverage effective on the first day of the month following the date of hire. Employers may impose their own waiting periods. If an employer chooses to do so, the effective dates as listed above will apply after the employee completes the employer's waiting period and becomes eligible for benefits. Note: Special eligibility provisions are in place for firefighters. WCIF ELIGIBLE DEPENDENT DEFINITION Dependents who are eligible for WCIF coverage include: • A lawful spouse or domestic partner, • Children to age 26 including biological, step, foster, adopted children from the date of assumption of legal obligation for total or partial support, children required by court order or qualified medical child support order (QMCSO) to be covered by a participant. All other dependents are not eligible without evidence of legal guardianship. 2017LMGMA2 Page 2 of 9 (092116JM) EMPLOYER NAME: KITTITAS COUNTY EMPLOYEE COUNT .................. Average number of W-2 employees: Employees eligible for WCIF benefits: Employees enrolled in WCIF medical benefits ELIGIBILITY 394 293 199 A current census must accompany each new class designation. For additional classes, attach document. W lass Name: Class Code (to appear on bill): # Plan Participants: Census Attached: Non -Union, Courthouse, Corrections, Rod 264 1 ❑ Yes ® No Eligibility: 20 Minimum Hours per week - OR - F-1 Other: Effective Date: ® The same as WCIF ❑ 30 day waiting period ❑ Other: Employer Contribution: Employee: $ or %: 700.00 Dependents: $ or %: Composite: $ or W Class Name:- Class Code: (to appear on bill) # Plan Participants: Appraisers 7 Eligibility: 20 Minimum Hours per week - OR - ❑ Other: Effective Date: ® The same as WCIF ❑ 30 day waiting period ❑ Other: Hours per month ❑ 60 day waiting period ❑ Fire District Hours per month ensus Attacnea: ❑ Yes ® No ❑ 60 day waiting period ❑ Fire District Employer Contribution: Employee: $ or %: 763.97 Dependents: $ or %: Composite: $ or W Will the group process enrollment via the WCIF/Benefit Solutions, Inc. (BSI) Web Enrollment System? ® Yes ❑ No If YES, for access to the online enrollment system and billing services, indicate the individual(s) authorized for WCIF Web Enrollment System updates. An email invitation will be sent out to the designated individual(s) to register for Web Enrollment System functionality. Vame & Title: Email: (Mandatory) Phone: Lisa Young, HR Director/Risk Manager lisa.young@co.kittitas.wa.us 509-962-7084 Vame & Title: Email: (Mandatory) Phone: Chelsea Lierly, HR Representative chelsea.lierly@co.kittitas.wa.us 509-962-7082 If access for an additional user is desired, please contact BSI for request form. Does your organization offer non-WCIF medical plans to employees? ® Yes (if YES, list carrier(s) below) Other Medical Carrier 1: Washington Teamsters Welfare Trust/NW Administrators (Line and Probation Only) Other Medical Carrier 2: ❑ No 2017LMGMA2 Page 3 of 9 (092116JM) EMPLOYER NAME: KITTITAS COUNTY MEDICAL PLANS Directions: Enter X for 4 -tiered rates or C for composite rate (subject to carrier approval). If offering both Premera Blue Cross and Group Health plans, the SAME rate structure must be used. Note: All medical plans are bundled with base long term disability and an Employee Assistance Program (EAP). 1. PREMIERA BLUE CROSS ......................................... ❑ CHECK TO DECLINE COVERAGE The number of plans available to an organization is based on the group's total number of eligible employees. Employer groups may offer one Health Savings Account (HSA) plan in addition to the number of plan choices. a) Under 50 eligible employees: Up to 2 plan choices b) 50 - 150 eligible employees: Up to 3 plan choices c) 150+ eligible employees: Up to 4 plan choices Select Network Option: WCIF 200* ❑ LEOFF I Active ❑WCIF 200 LEOFF I Retiree <65 1-1 Heritage [ WCIF 500 WCIF 2000 * Only available to groups with enrollment prior to 1/1/2014. F-x, Prime F -X1 WCIF 750 i X WCIF 3000FX I WCIF 1250 WCIF 5000 EWCIF HSA** ** Groups may offer a Health Savings Account (HSA) with the WCIF HSA Plan. This is a Qualified High Deductible Health Plan (QHDHP). 11. GROUP HEALTH ................................................ ❑ CHECK TO DECLINE COVERAGE The number of plans available to an organization is based on the group's total number of eligible employees. Employer groups may offer plan choices as allowed under the Group Health matrix. ACCESS PPO PLANS: ElAccess 200 u Access 500 1XI Access 1000 Access 2000 FAccess 3000 Access 5000 1 X I Access HSA* 1:1� LEOFF I Retiree < 65 * Groups may offer a Health Savings Account (HSA) with the HSA Plan. This is a Qualified High Deductible Health Plan (QHDHP). HMO PLANS: CHMO 250 HHMO 500 FX- HMO 750 HMO 2000 LEOFF I Retiree < 65 2017GMA2 Page 4 of 9 (0921161sw) EMPLOYER NAME: KITTITAS COUNTY FWENTALPLANS CIF dental plans require 100% employee participation. If elected, all eligible employees must be covered. 1. DELTA DENTAL OF WASHINGTON .................... ........ ❑ CHECK TO DECLINE COVERAGE PLAN A 1 $1,000 Annual Maximum PPO Plan A-1 (100% Employer Paid) ❑ 2 -Tiered Rates (EE / 1+ Dependent) ❑ Composite Rate PLAN C 1 $1,000 Annual Maximum Enhanced Plan C-1 (100% Employer Paid) ❑ 2 -Tiered Rates (EE / 1+ Dependent) ❑ Composite Rate C-2 (100% Emplover Paid Except Dependents) ❑ 3 -Tiered Rates (EE / 1 Dependent / 2+ Dependents) INCENTIVE PLAN 1 $2,000 Annual Maximum Incentive -1 (100% Employer Paid) ❑ 2 -Tiered Rates (EE / 1+ Dependent) ❑ Composite Rate PLAN B 1 $2,000 Annual Maximum PPO Plan B-4 (100% Employer Paid Except Dependents) ® 3 -Tiered Rates (EE / 1 Dependent / 2+ Dependents) PLAN D 1 $2,000 Annual Maximum Enhanced Plan D-3 (100% Employer Paid) ❑ 2 -Tiered Rates (EE / 1+ Dependent) ❑ Composite Rate D-4 (100% Employer Paid Except Dependents) ❑ 3 -Tiered Rates (EE / 1 Dependent / 2+ Dependents) OTHER PLAN ❑ Plan Name: 11. WILLAMETTE DENTAL OF WASHINGTON INC .................... . ❑ CHECK TO DECLINE COVERAGE ® 3 -Tiered Rates OTHER PLAN ❑ Composite Rate ❑ Plan Name: VISION PLANS WCIF vision plans require 100% employee participation, employer paid. If elected, all eligible employees must be covered. 1. VSP Vision Care, Inc ............................................. ❑ CHECK TO DECLINE COVERAGE EXTENDED PLAN STANDARD PLAN BUDGET PLAN OTHER PLAN F -14 -Tiered Rates ® 4 -Tiered Rates E]4 -Tiered Rates ❑ Plan Name: ❑ Composite Rate ❑ Composite Rate ❑ Composite Rate 2017GMA2 Page 5 of 9 (092116JM) EMPLOYER NAME: KITTITAS COUNTY GROUP LIFE PLANS / ACCIDENTAL DEATH DISMEMBERMENT PLANS Employers are required to enroll all eligible employees. Basic Life is 100% employer paid. I. STANDARD INSURANCE COMPANY I BASIC LIFE PLANS 0 $12,000 ❑ $15,000 ❑ $20,000 0 $24,000 0 $36,000 ❑ $40,000 ❑ $48,000 ❑ $50,000 ❑ 1x Annual Salary I $50k max ❑ 1x Annual Salary 1$1001k max ❑ 1x Annual Salary I $150k max ❑ Other Plan: ❑ $1,000 Basic Life Dependent Benefit (100% participation, employer paid) 11. STANDARD INSURANCE COMPANY I VOLUNTARY PLANS ........ ❑ CHECK TO DECLINE COVERAGE ® Voluntary Term Life (VTL) (by employee election, employee paid) ® Voluntary Accidental Death & Dismemberment (VAD&D) (by employee election, employee paid) GROUP DISABILITY PLANS Base LTD may be purchased for employees not enrolled in WCIF medical plans by checking the applicable box below. If elected, this is an employer paid benefit that requires 100% employee participation. Must have Base LTD in place to offer voluntary Buy -Up LTD. 1. STANDARD INSURANCE COMPANY I DISABILITY PLANS ......... ❑ CHECK TO DECLINE COVERAGE ❑ Base Long Term Disability (Base LTD) for Non -Medical Participants (100% participation, employer paid) ® Voluntary Buy -Up Long Term Disability (Buy -Up LTD) (by employee election, employee paid) ® Voluntary Short Term Disability (VSTD) (by employee election, 2 waiting periods available to coincide with Base or Buy -Up LTD, employee paid) EMPLOYEE ASSISTANCE PROGRAM (EAP) EAP may be purchased for employees not enrolled in WCIF medical plans by checking the applicable box below. If elected, this is an employer paid benefit that requires 100% employee participation. This plan features a special "Stand -Alone" option for employees who are not otherwise benefit eligible. 1. MAGELLAN HEALTH SERVICES ................................. ® CHECK TO DECLINE COVERAGE ❑ Standard EAP Coverage (100% participation for all benefit -eligible employees, employer paid) ❑ Stand -Alone EAP Coverage (100% participation for all employees) When Stand -Alone Coverage is offered to otherwise non benefit eligible employees, do you want these employees included in the monthly combined bill? ❑ Yes (if YES, a census will need to be provided to BSI) ❑ No 2017GMA2 Page 6 of 9 (092116JM) EMPLOYER NAME: KITTITAS COUNTY CONSUMER DRIVEN HEALTH PLANS (CDHPs)............... ® CHECK TO DECLINE COVERAGE ` administered by Benefit Solutions, Inc. (BSI) ❑ FLEXIBLE SPENDING ARRANGEMENT (FSA) ❑ HEALTH SAVINGS ACCOUNT (HSA) Note: HSAs must be accompanied by Qualified High Deductible Health Plans (QHDHP) ACKNOWLEDGEMENTS Employer agrees to abide by the provisions of the Washington Counties Insurance Fund (WCIF) Trust Agreement Initials and Bylaws. Extent of Coverage Employee benefits will end on the last day of the month in which the employee becomes ineligible (except as specified under federal and/or Washington state mandated extension rights). Employers may not continue an employee's coverage on any active plan after the employee is no longer eligible. The only exception to this rule is i for employees who lose coverage due to a disability and need to continue The Standard Long Term Disability plan coverage in order to apply for Waiver of Premium at a later date. Continuation of coverage through COBRA and Initials retiree plans (for retirees under the age of 65) is available to employees who qualify; provided the employer maintains participation in a WCIF medical, dental, vision, EAP, and/or FSA plan(s). Continuation of coverage is available in accordance with federal and Washington state law to members who become ineligible for group coverage. Employers have a legal responsibility for certain notification requirements. Please reference the WCIF eACE Manual (www. wcif.net) for notification procedures and forms for WCIF plans. Employers may also reference the US Department of Labor(www.dol.gov) and the US Internal Revenue Service (www.irs.gov) for further guidance. Advisory assistance on compliance with federal and state employment law regulations should be obtained from an employment attorney_ Waiver of Medical Insurance (for groups offering WCIF medical coverage) Employer acknowledges that in order to allow an employee to waive WCIF medical coverage the employee must Initials provide the employer with proof of other group medical insurance coverage. Employer acknowledges that they may not offer cash incentives to employees who waive WCIF medical coverage. Initials Employers are required to offer the same coverage to their over age 65 employees (and over age 65 spouses/ domestic partners) as they do to all other eligible employees. Employer coverage is primary to Medicare. Medicare beneficiaries are free to reject employer plan coverage, in which case they retain Medicare as their Initials primary coverage. When Medicare is primary payer, employers cannot offer such employees (or their spouses) secondary coverage (or incentives) for items and services covered by Medicare. DISCLOSURES Employers who offer WCIF medical coverage are required to cover a minimum of 75% of all eligible employees. Allowable exclusions to this rule include enrollment in other verifiable group medical coverage (i.e. Tri -Care, Medicare, Medicaid, Washington Health Plan Finder), or waiver due to religious belief. These members with allowable exclusions are not used to calculate the group's participation percentage, and are thus netted out of the eligible employee count. NOTE: For current groups who do not submit the Master Application by December 1, group benefits will default to their prior year elections, if available, or mapped to most comparable plan. 2017GMA2 Page 7 of 9 (092116JM) EMPLOYER NAME: KITTITAS COUNTY The below signed applicant agrees that if the requested insurance is acceptable to WCIF under its current rules and practices and is legally permissible, a policy will be issued in the policy language customarily used by WCIF and will be effective on the date determined by WCIF. The below signed applicant acknowledges it is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Name & Title: Obie O'Brien, Chairman, BOCC Authorized Signature: Remarks: - Date: 10/11/16 Premera Blue Cross 7001 220th St SW Mountlake Terrace, WA 98403 Plan number unique to employer. Contact WCIF at (800) 344-8570 to obtain. Group Health Options, Inc. 320 Westlake Avenue N Suite 100 Seattle, WA 98109-5233 Plan number unique to employer. Contact WCIF at (800) 344-8570 to obtain. Group Health Cooperative 320 Westlake Avenue N Suite 100 Seattle, WA 98109-5233 Plan number unique to employer. Contact WCIF at (800) 344-8570 to obtain. Standard Insurance Company 1100 SW 6th Avenue Portland, OR 97204 645273 Delta Dental of Washington 9706 4th Avenue NE Seattle, WA 98115 00497 00498 00500 00501 00502 00478 Willamette Dental of Washington Inc 6950 NE Campus Way Hillsboro, OR 97124 WA204 VSP Vision Care, Inc. 3333 Quality Drive Rancho Cordova, CA 95670 30029829 Magellan Health, Inc. 55 Nod Road Avon, CT 06001 2017GMA2 Page 8 of 9 (092116JM) FOR ADMINISTRATOR USE ONLY: Approved by: ❑ Premera Base Demographic Risk Level: ❑ Group Health Base Demographic Risk Level: Special Notes: FOR CARRIER USE ONLY: Date: ❑ Producer Commissions Attached ❑ Proof of Funding Received ❑ Bundled (Base LTD) Medical Only ❑ Bundled (EAP) Medical Only 2017GMA2 Page 9 of 9 (092116JM) LEGACY MEDICAL GROUP MASTER APPLICATION FOR 2017 WCIF COVERAGE Attach separate sheets of paper if additional space is necessary. Plan summaries and other information WCIF `"G`o`" °°1i "k5 INSURANCE FUND may be found at www.wcif.net > Plan Information. This is an application for (check one): Coverage Effective Date:01/01/17 ® Annual Renewal ❑ New Participating Employer ❑ Mid -Year Plan Change ❑ Existing Employer, New Division If submitting multiple applications for SUBGROUPS: (Note: Employees with different benefits (i.e. subgroups) require a separate Group Master Application) Application Number: (i.e. "1 of 3') Subgroup Name: (i.e. "Health Dept.," "Union," etc.) 2 of 3 Line Only Legal Group Name: Kittitas County Doing Business As (DBA): Business Physical Address: (No PO Box or PMB) City: State: 205 W 5th Avenue Ellensburg WA Business Mailing Address: (if different from physical) City: State: Federal Tax ID Number: BSI Account Number (assigned by BSI) 91-6001349 58 By what name would you prefer WCIF to refer to your oganization? I ® Legal Name ❑ DBA Name Zip: County: 98926 Kittitas Zip: County: Is your .organization a public entity? ® Yes ❑ No What type of entity is your organization? (check only ONE box) #1 ® County #2 ❑ Other local government entity (includes all taxing districts) #3 ❑ Non-profit organization receiving state or local government funding NOTE: Organizations that check only #3 must provide proof of funding with this application. #4 ❑ Other: COMMISSIONER / EXECUTIVE DIRECTOR / CEO (etc.) Name & Title: Obie O'Brien, Commissioner Phone: Fax Email: 509-962-7508 obie.obrien@co.kittitas.wa.us WCIF INSURANCE ADVISORY COMMITTEE (IAC) DESIGNEE (voting member) IAC members are initial points of contact for plan changes, renewal information and the WCIF voting member of the group. . ... ....-- ---- ---- ..- Name & Title: Phone: Fax: Email: Obie O'Brien, Commissioner 509-962-7508 obie.obrien@co.kittitas.wa.us GROUP BENEFITS ADMINISTRATOR (Administrators' Committee for Excellence (ACE) Designee) ACE member will be the primary contact for WCIF plan benefit updates and administration. Name & Title: Phone: Fax: Email: Lisa Young, HR Director/Risk Manager 509-962-7084 lisa.young@co.kittitas.wa.us GROUP BILLING ADMINISTRATOR (Administrators' Committee for Excellence (ACE) Designee) ACE member will be the primary contact for WCIF plan billing updates and administration. i Name & Title: Phone: Fax: Email: — IJudy Pless, Budget & Finance Manager 509-962-7502 judy.pless@co.kittitas.wa.us INSURANCE PRODUCER (as applicable) Does your organization use an insurance producer for WCIF plans? ❑ Yes (if YES, complete the following) ❑ No Producer Name: Phone: Fax: Email: 2017LMGMA2 Page 1 of 9 (092116JM) EMPLOYER NAME: KITTITAS COUNTY Agency Name (used for payment purposes): ............ . Producer Physical Address No PO Box or PMB) City: State: _...... .......... _ Secondary Producer Name: Phone: Fax: Email: PRODUCER SIGNATURE: DATE Producer must submit a Commission Rate Template to WCIF with this application. DEFINITIONS WCIF CLASS DEFINITION Group of employees (affiliates, subsidiaries, or office locations within the same employer) within the same employer with the same benefit options as the main group. Classes have the same BSI Account Number as the main group, and are included on the same bill, but are assigned class codes and will have separate class premium totals on the bill. WCIF ELIGIBLE EMPLOYEES DEFINITION WCIF requires that employees work a minimum of 20 hours per week or 80 hours per month (whichever is less) to be eligible for benefits. An Employer may require an employee to work more than 20 hours per week or 80 hours per month based on employer policy or contractual requirements, and WCIF will honor the organization's minimum threshold. (Note: A covered employee will remain covered during any unpaid furlough so long as the covered employee does not exceed 30 unpaid furlough days in a single calendar year. Furlough days DO NOT include FMLA qualified absences, whether paid or unpaid). Elected officials of participating employers are eligible for coverage and are exempt from the minimum hour requirement. WCIF EFFECTIVE DATE DEFINITION WCIF defines an employee's coverage effective date as follows. Employees hired: • On the first of the month are eligible for coverage effective the date of hire. (If the first of the month falls on a weekend or holiday and the employee reports for work on the first business day following, coverage is retroactive to the first.) • On the 2nd to the 31st of the month are eligible for coverage effective on the first day of the month following the date of hire. Employers may impose their own waiting periods. If an employer chooses to do so, the effective dates as listed above will apply after the employee completes the employer's waiting period and becomes eligible for benefits. Note: Special eligibility provisions are in place for firefighters. WCIF ELIGIBLE DEPENDENT DEFINITION Dependents who are eligible for WCIF coverage include: • A lawful spouse or domestic partner, • Children to age 26 including biological, step, foster, adopted children from the date of assumption of legal obligation for total or partial support, children required by court order or qualified medical child support order (QMCSO) to be covered by a participant. All other dependents are not eligible without evidence of legal guardianship. 2017LMGMA2 Page 2 of 9 (092116JM) EMPLOYER NAME: KITT1TA5 COUNTY EMPLOYEE CUNT Average number of W-2 employees: 394/31 Employees eligible for WCIF benefits: 293/31 Employees enrolled in WCIF medical benefits: 199/0 ELIGIBILITY A current census must accompany each new class designation. For additional classes, attach document. Class Name: Class Code (to appear on bill): # Plan Participants: Census Attached:..OR .. Line 31 ❑ Yes ® No Eligibility: 20 Minimum Hours per week - OR - Hours per month ❑ Other: Effective Date: ® The same as WCIF ❑ Other: Employer Contribution: Employee: $ or %: 90% ❑ 30 day waiting period ❑ 60 day waiting period ❑ Fire District Class Mame. Eligibility: Dependents: $ or %: Composite: $ or %: Class Code: (to appear on bill) # Plan Participants: Census Attached: ❑ Yes ❑ No Minimum Hours per week - OR - ❑ Other: Effective Date: ❑ The same as WCIF ❑ Other: _mployer Contribution: Employee: $ or W ❑ 30 day waiting period Hours per month ❑ 60 day waiting period Dependents: $ or % ❑ Fire District Composite: $ or W Will the group process enrollment via the WCIF/Benefit Solutions, Inc. (BSI) Web Enrollment System? ® Yes ❑ No If YES, for access to the online enrollment system and billing services, indicate the individual(s) authorized for WCIF Web Enrollment System updates. An email invitation will be sent out to the designated individual(s) to register for Web Enrollment System functionality. dame & Title: Email: (Mandatory) Phone: Lisa Young, HR Director/Risk Manager lisa.young@co.kittitas.wa.us 509-962-7084 dame & Title: Email: (Mandatory) Phone: Chelsea Lierly, HR Representative I chelsea.lierly@co.kittitas.wa.us 509-962-7082 We: If access for an additional user is desired, please contact BSI for request form. Does your organization offer non-WCIF medical plans to employees? ® Yes (if YES, list carrier(s) below) Other Medical Carrier 1: Washington Teamsters Welfare Trust/NW Administrators (Line and Probation Only) Other Medical Carrier 2: ❑ No 2017LMGMA2 Page 3 of 9 (092116JM) EMPLOYER NAME: KITTITAS COUNTY ELECTIONSECTION V: PLAN MEDICAL PLANS Directions: Enter X for 4 -tiered rates or C for composite rate (subject to carrier approval). If offering both Premera Blue Cross and Group Health plans, the SAME rate structure must be used. Note: All medical plans are bundled with base long term disability and an Employee Assistance Program (EAP). 1. PREMERA BLUE CROSS ......................................... ® CHECK TO DECLINE COVERAGE The number of plans available to an organization is based on the group's total number of eligible employees. Employer groups may offer one Health Savings Account (HSA) plan in addition to the number of plan choices. a) Under 50 eligible employees: Up to 2 plan choices b) 50 - 150 eligible employees: Up to 3 plan choices c) 150+ eligible employees: Up to 4 plan choices Select Network Option: CWCIF 200* LEOFF I Active 1 1 WCIF 200 J LEOFF I Retiree <65 1-1 Heritage F-1WCIF 500 FWCIF 2000 F-1 Prime l WCIF 750 nWCIF 3000 �I WCIF 1250 __ WCIF 5000 F—IWCIF HSA** * Only available to groups with enrollment prior to 1/1/2014. ** Groups may offer a Health Savings Account (HSA) with the WCIF HSA Plan. This is a Qualified High Deductible Health Plan (QHDHP). 11. GROUP HEALTH ................................................ ® CHECK TO DECLINE COVERAGE The number of plans available to an organization is based on the group's total number of eligible employees. Employer groups may offer plan choices as allowed under the Group Health matrix. ACCESS PPO PLANS: Access 200 Access 3000 1-1 Access 500 ElAccess 5000 El LEOFF I Retiree < 65 � Access 1000 FAccess HSA* ❑ Access 2000 * Groups may offer a Health Savings Account (HSA) with the HSA Plan. This is a Qualified High Deductible Health Plan (QHDHP). HMO PLANS: HMO 250 F-1 HMO 500 JHMO 750 1 HMO 2000 1-1 LEOFF I Retiree < 65 2017GMA2 Page 4 of 9 (0921161sw) LOMV PLOYER NAME KITT1TA5 COUNTY DENTAL PLANS WCIF dental plans require 100% employee participation. If elected, all eligible employees must be covered. 1 DE LTA DENTAL OF WASHINGTON .................... ........ ® CHECK TO DECLINE COVERAGE PLAN A 1 $1,000 Annual Maximum PPO Plan A-1 (100% Employer Paid) ❑ 2 -Tiered Rates (EE / 1+ Dependent) ❑ Composite Rate PLAN C 1 $1,000 Annual Maximum Enhanced Plan C-1 600% Employer Paid) ❑ 2 -Tiered Rates (EE / 1+ Dependent) ❑ Composite Rate C-2 (100% Employer Paid Except Dependents) ❑ 3 -Tiered Rates (EE / 1 Dependent / 2+ Dependents) INCENTIVE PLAN 1 $2,000 Annual Maximum Incentive -1 (100% Employer Paid) ❑ 2 -Tiered Rates (EE / 1+ Dependent) ❑ Composite Rate PLAN B 1 $2,000 Annual Maximum PPO Plan B-4 (100% Employer Paid Except Dependent ❑ 3 -Tiered Rates (EE / 1 Dependent / 2+ Dependents) i PLAN D 1 $2,000 Annual Maximum Enhanced Plan D-3 (100% Employer Paid) ❑ 2 -Tiered Rates (EE / 1+ Dependent) ❑ Composite Rate D-4 (100% Employer Paid Except Dependents) ❑ 3 -Tiered Rates (EE / 1 Dependent / 2+ Dependents) OTHER PLAN ❑ Plan Name: 11. WILLAMETTE DENTAL OF WASHINGTON INC .................... . ® CHECK TO DECLINE COVERAGE ❑ 3 -Tiered Rates OTHER PLAN ❑ Composite Rate ❑ Plan Name.- VISION ame: VISION PLANS WCIF vision plans require 100% employee participation, employer paid. If elected, all eligible employees must be covered. 1. VSP Vision Care, Inc ............................................. ® CHECK TO DECLINE COVERAGE EXTENDED PLAN STANDARD PLAN BUDGET PLAN OTHER PLAN ❑ 4 -Tiered Rates ❑ 4 -Tiered Rates ❑ 4 -Tiered Rates ❑ Plan Name: ❑ Composite Rate ❑ Composite Rate ❑ Composite Rate 2017GMA2 Page 5 of 9 (092116JM) EMPLOYER NAME: KITTITAS COUNTY 1 GROUP LIFE PLANS / ACCIDENTAL DEATH DISMEMBERMENT PLANS Employers are required to enroll all eligible employees. Basic Life is 100% employer paid. { I. STANDARD INSURANCE COMPANY I BASIC LIFE PLANS ® $12,000 ❑ $15,000 ❑ $20,000 ❑ $24,000 ❑ $36,000 ❑ $40,000 ❑ $48,000 ❑ $50,000 . ❑ 1x Annual Salary I $50k max ❑ 1x Annual Salary I $100k max ❑ 1x Annual Salary I $150k max ❑ Other Plan: [E] $1,000 Basic Life Dependent Benefit (100% participation, employer paid) 11. STANDARD INSURANCE COMPANY I VOLUNTARY PLANS ........ ❑ CHECK TO DECLINE COVERAGE ® Voluntary Term Life (VTL) (by employee election, employee paid) ® Voluntary Accidental Death & Dismemberment (VAD&D) (by employee election, employee paid) GROUP DISABILITY PLANS Base LTD may be purchased for employees not enrolled in WCIF medical plans by checking the applicable box below. If elected, this is an employer paid benefit that requires 100% employee participation. Must have Base LTD in place to offer voluntary Buy -Up LTD. 1. STANDARD INSURANCE COMPANY I DISABILITY PLANS ......... ❑ CHECK TO DECLINE COVERAGE ❑ Base Long Term Disability (Base LTD) for Non -Medical Participants (100% participation, employer paid) ❑ Voluntary Buy -Up Long Term Disability (Buy -Up LTD) (by employee election, employee paid) ® Voluntary Short Term Disability (VSTD) (by employee election, 2 waiting periods available to coincide with Base or Buy -Up LTD. employee paid) EMPLOYEE ASSISTANCE PROGRAM (EAP) EAP may be purchased for employees not enrolled in WCIF medical plans by checking the applicable box below. If elected, this is an employer paid benefit that requires 100% employee participation. This plan features a special "Stand -Alone" option for employees who are not otherwise benefit eligible. 1. MAGELLAN HEALTH SERVICES ................................. ® CHECK TO DECLINE COVERAGE ❑ Standard EAP Coverage (100% participation for all benefit -eligible employees, employer paid) ❑ Stand -Alone EAP Coverage (100% participation for all employees) When Stand -Alone Coverage is offered to otherwise non benefit eligible employees, do you want these employees included in the monthly combined bill? ❑ Yes (if YES, a census will need to be provided to BSI) ❑ No 2017GMA2 Page 6 of 9 (092116JM) EMPLOYER NAME: KITTITAS COUNTY CONSUMER DRIVEN HEALTH PLANS (CDHPs)............... ® CHECK TO DECLINE COVERAGE administered by Benefit Solutions, Inc. (BSI) ❑ FLEXIBLE SPENDING ARRANGEMENT (FSA) ❑ HEALTH SAVINGS ACCOUNT (HSA) Note: HSAs must be accompanied by Qualified High Deductible Health Plans (QHDHP) ACKNOWLEDGEMENTS ........ .,, .... _ ......... Employer agrees to abide by the provisions of the Washington Counties Insurance Fund (WCIF) Trust Agreement Initials and Bylaws. Extent of Coverage Employee benefits will end on the last day of the month in which the employee becomes ineligible (except as specified under federal and/or Washington state mandated extension rights). Employers may not continue an employee's coverage on any active plan after the employee is no longer eligible. The only exception to this rule is for employees who lose coverage due to a disability and need to continue The Standard Long Term Disability plan coverage in order to apply for Waiver of Premium at a later date. Continuation of coverage through COBRA and Initials retiree plans (for retirees under the age of 65) is available to employees who qualify; provided the employer maintains participation in a WCIF medical, dental, vision, EAP, and/or FSA plan(s). Continuation of coverage is available in accordance with federal and Washington state law to members who become ineligible for group coverage. Employers have a legal responsibility for certain notification requirements. Please reference the WCIF eACE Manual (www.wcif.net) for notification procedures and forms for WCIF plans. Employers may also reference the US Department of Labor(www.dol.gov) and the US Internal Revenue Service (www.irs.gov) for further guidance. Advisory assistance on compliance with federal and state employment law regulations should be obtained from an employment attorney. Waiver of Medical Insurance (for groups offering WCIF medical coverage) ' Employer acknowledges that in order to allow an employee to waive WCIF medical coverage the employee must Iniliais provide the employer with proof of other group medical insurance coverage. Employer acknowledges that they may not offer cash incentives to employees who waive WCIF medical coverage. Initials Employers are required to offer the same coverage to their over age 65 employees (and over age 65 spouses/ domestic partners) as they do to all other eligible employees. Employer coverage is primary to Medicare. �- Medicare beneficiaries are free to reject employer plan coverage, in which case they retain Medicare as their Initials primary coverage. When Medicare is primary payer, employers cannot offer such employees (or their spouses) secondary coverage (or incentives) for items and services covered by Medicare. DISCLOSURES Employers who offer WCIF medical coverage are required to cover a minimum of 75% of all eligible employees. Allowable exclusions to this rule include enrollment in other verifiable group medical coverage (i.e. Tri -Care, Medicare, Medicaid, Washington Health Plan Finder), or waiver due to religious belief. These members with allowable exclusions are not used to calculate the group's participation percentage, and are thus netted out of the eligible employee count. NOTE: For current groups who do not submit the Master Application by December 1, group benefits will default to their prior year elections, if available, or mapped to most comparable plan. 2017GMA2 Page 7 of 9 (092116JM) EMPLOYER NAME: KITTITAS COUNTY The below signed applicant agrees that if the requested insurance is acceptable to WCIF under its current rules and practices and is legally permissible, a policy will be issued in the policy language customarily used by WCIF and will be effective on the date determined by WCIF. The below signed applicant acknowledges it is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Name & Title: Obie O'Brien, Chairman, BOCC Authorized Signature: Remarks: Date 10/11/16 Premera Blue Cross 7001 220th St SW Mountlake Terrace, WA 98403 Plan number unique to employer. Contact WCIF at (800) 344-8570 to obtain. Group Health Options, Inc. 320 Westlake Avenue N Suite 100 Seattle, WA 98109-5233 Plan number unique to employer. Contact WCIF at (800) 344-8570 to obtain. Group Health Cooperative 320 Westlake Avenue N Suite 100 Seattle, WA 98109-5233 Plan number unique to employer. Contact WCIF at (800) 344-8570 to obtain. Standard Insurance Company 1100 SW 6th Avenue Portland, OR 97204 645273 Delta Dental of Washington 9706 4th Avenue NE Seattle, WA 98115 00497 00498 00500 00501 00502 00478 Willamette Dental of Washington Inc 6950 NE Campus Way Hillsboro, OR 97124 WA204 VSP Vision Care, Inc. 3333 Quality Drive Rancho Cordova, CA 95670 30029829 Magellan Health, Inc. 55 Nod Road Avon, CT 06001 2017GMA2 Page 8 of 9 (092116JM) FOR ADMINISTRATOR USE ONLY: Approved by: ❑ Premera Base Demographic Risk Level: ❑ Group Health Base Demographic Risk Level: Special Notes: FOR CARRIER USE ONLY: Date: ❑ Producer Commissions Attached ❑ Proof of Funding Received ❑ Bundled (Base LTD) Medical Only ❑ Bundled (EAP) Medical Only 2017GMA2 Page 9 of 9 (092116JM) LEGACY MEDICAL GROUP MASTER APPLICATION FOR WCIF 2017 WCIF COVERAGE Attach separate sheets of paper if additional space is necessary. Plan summaries and other information INSURANCE FUND `` �' "� ` c o u 114 " � may be found at www.wcif.net > Plan Information. Coverage Effective Date:01/01/17 This is an application for (check one): ® Annual Renewal ❑ New Participating Employer ❑ Mid -Year Plan Change ❑ Existing Employer, New Division E SECTION If submitting multiple applications for SUBGROUPS: f • r (Note: Employees with different benefits (i.e. subgroups) require a separate Group Master Application) Application Number: (i.e. "1 of 3) Subgroup Name: (i.e. "Health Dept.," "Union," etc.) Wim" 3 of 3 Probation Only Legal Group Name: By what name would you prefer , Kittitas County WCIF to refer to your oganization? Doing Business As (DBA): ® Legal Name ❑ DBA Name Business Physical Address: (No PO Box or PMB) City: State: Zip: County: 205 W 5th Avenue Ellensburg WA 98926 Kittitas 'Business Mailing Address: (if different from physical) City: State: Zip: County: Federal Tax ID Number: BSI Account Number (assigned by BSI) Is your organization a public entity? 91-6001349 58 ® Yes ❑ No What type of entity is your organization? (check only ONE box) #1 ® County #2 ❑ Other local government entity (includes all taxing districts) #3 ❑ Non-profit organization receiving state or local government funding NOTE: Organizations that check only #3 must provide proof of funding with this application. #4 ❑ Other: COMMISSIONER / EXECUTIVE DIRECTOR / CEO (etc.) Name & Title: Phone: Fax: Email: Obie O'Brien, Commissioner 509-962-7508 obie.obrien@co.kittitas.wa.us WCIF INSURANCE ADVISORY COMMITTEE (IAC) DESIGNEE (voting member) IAC members are initial points of contact for plan changes, renewal information and the WCIF voting member of the group. Name & Title: Phone: Fax Email: Obie O'Brien, Commissioner 509-962-7508 obie.obrien@co.kittitas.wa.us GROUP BENEFITS ADMINISTRATOR (Administrators' Committee for Excellence (ACE) Designee) ACE member will be the primary contact for WCIF plan benefit updates and administration. Name & Title: Phone: Fax: Email: Lisa Young, HR Director/Risk Manager 509-962-7084 lisa.young@co.kittitas.wa.us GROUP BILLING ADMINISTRATOR (Administrators' Committee for Excellence (ACE) Designee) ACE member will be the primary contact for WCIF plan billing updates and administration. Name & Title: Phone: Fax: Email: Judy Pless, Budget & Finance Manager 509-962-7502 judy.pless@co.kittitas.wa.us INSURANCE PRODUCER (as applicable) Does your organization use an insurance producer for WCIF plans? ❑ Yes (if YES, complete the following) ❑ No Producer Name: Phone: Fax: Email: 2017LMGMA2 Page 1 of 9 (092116JM) EMPLOYER NAME: KITTITAS COUNTY Agency Name (used for payment purposes): ... ......... Producer Physical Address (No PO Box or PMB) .................................................................. .............. Secondary Producer Name: Phone: PRODUCER SIGNATURE: City: State: Zip: Fax: Email: DATE. Producer must submit a Commission Rate Template to WCIF with this application. ............ DEFINITIONS WCIF CLASS DEFINITION Group of employees (affiliates, subsidiaries, or office locations within the same employer) within the same employer with the same benefit options as the main group. Classes have the same BSI Account Number as the main group, and are included on the same bill, but are assigned class codes and will have separate class premium totals on the bill. WCIF ELIGIBLE EMPLOYEES DEFINITION WCIF requires that employees work a minimum of 20 hours per week or 80 hours per month (whichever is less) to be eligible for benefits. An Employer may require an employee to work more than 20 hours per week or 80 hours per month based on employer policy or contractual requirements, and WCIF will honor the organization's minimum threshold. (Note: A covered employee will remain covered during any unpaid furlough so long as the covered employee does not exceed 30 unpaid furlough days in a single calendar year. Furlough days DO NOT include FMLA qualified absences, whether paid or unpaid). Elected officials of participating employers are eligible for coverage and are exempt from the minimum hour requirement. WCIF EFFECTIVE DATE DEFINITION WCIF defines an employee's coverage effective date as follows. Employees hired: • On the first of the month are eligible for coverage effective the date of hire. (if the first of the month falls on a weekend or holiday and the employee reports for work on the first business day following, coverage is retroactive to the first.) • On the 2nd to the 31st of the month are eligible for coverage effective on the first day of the month following the date of hire. Employers may impose their own waiting periods. If an employer chooses to do so, the effective dates as listed above will apply after the employee completes the employer's waiting period and becomes eligible for benefits. Note: Special eligibility provisions are in place for firefighters. WCIF ELIGIBLE DEPENDENT DEFINITION Dependents who are eligible for WCIF coverage include: • A lawful spouse or domestic partner, • Children to age 26 including biological, step, foster, adopted children from the date of assumption of legal obligation for total or partial support, children required by court order or qualified medical child support order (QMCSO) to be covered by a participant. All other dependents are not eligible without evidence of legal guardianship. 2017LMGMA2 Page 2 of 9 (092116JM) EMPLOYER NAME: KfTTITAS COUNTY EMPLOYEE COUNT ....................... _ Average number of W-2 employees: 394/9 Employees eligible for WCIF benefits: 293/9 Employees enrolled in WCIF medical benefits: 199/0 ELIGIBILITY A current census must accompany each new class designation. For additional classes, attach document. Glass Name: Class Code (to appear on bill): # Plan Participants: Census Attached: x Probation 9 _ ❑ Yes ® No Eligibility: 20 Minimum Hours per week - OR - Hours per month ❑ Other: Effective Date: ® The same as WCIF ❑ Other: ❑ 30 day waiting period ❑ 60 day waiting period ❑ Fire District Employer Contribution: Employee: $ or %: 700.00 Dependents: $ or W Composite: $ or W Class Name: Class Code: (to appear on bill) # Plan Participants: Census Attached: _ E] Yes ❑ No Eligibility: Minimum Hours per week - OR - Hours per month ❑ Other: Effective Date: ❑ The same as WCIF ❑ Other: Employer Contribution: Employee: $ or W. Dependents: $ or W Composite: $ or W ❑ 30 day waiting period ❑ 60 day waiting period ❑ Fire District Will the group process enrollment via the WCIF/Benefit Solutions, Inc. (BSI) Web Enrollment System? ® Yes ❑ No If YES, for access to the online enrollment system and billing services, indicate the individual(s) authorized for WCIF Web Enrollment System updates. An email invitation will be sent out to the designated individual(s) to register for Web Enrollment System functionality. ,.Name & Title: Email: (Mandatory) Phone: Lisa Young, HR Director/Risk Manager lisa.young@co.kittitas.wa.us 509-962-7084 Name & Title: Email: (Mandatory) Phone: Chelsea Lierly, HR Representative chelsea.lierly@co.kittitas.wa.us 509-962-7082 : If access for an additional user is desired, please contact BSI for request form. Does your organization offer non-WCIF medical plans to employees? ® Yes (if YES, list carrier(s) below) Other Medical Carrier 1: Washington Teamsters Welfare Trust/NW Administrators (Line and Probation Only) Other Medical Carrier 2: ❑ No 2017LMGMA2 Page 3 of 9 (092116JM) MFLOYER NAME: KITTITAS COUNTY MEDICAL PLANS Directions: Enter X for 4 -tiered rates or C for composite rate (subject to carrier approval). If offering both Premera Blue Cross and Group Health plans, the SAME rate structure must be used. Note: All medical plans are bundled with base long term disability and an Employee Assistance Program (EAP). 1. PREMERA BLUE CROSS ......................................... ® CHECK TO DECLINE COVERAGE The number of plans available to an organization is based on the group's total number of eligible employees. Employer groups may offer one Health Savings Account (HSA) plan in addition to the number of plan choices. a) Under 50 eligible employees: Up to 2 plan choices b) 50 - 150 eligible employees: Up to 3 plan choices c) 150+ eligible employees: Up to 4 plan choices Select Network Option: F1WCIF 200* ❑ LEOFF I Active l WCIF 200 LEOFF I Retiree <65 LI Heritage FWCIF 500 FWCIF 2000 ❑ Prime ❑ WCIF 750 ❑ WCIF 3000 WCIF 1250 ❑ WCIF 5000 J WCIF HSA** * Only available to groups with enrollment prior to 1/1/2014. ** Groups may offer a Health Savings Account (HSA) with the WCIF HSA Plan. This is a Qualified High Deductible Health Plan (QHDHP). 11. GROUP HEALTH ................................................ ® CHECK TO DECLINE COVERAGE The number of plans available to an organization is based on the group's total number of eligible employees. Employer groups may offer plan choices as allowed under the Group Health matrix. ACCESS PPO PLANS: u Access 200 Access 3000 FlAccess 500 1-1 Access 5000 L7 LEOFF I Retiree < 65 Access 1000 F-� Access HSA* Access 2000 * Groups may offer a Health Savings Account (HSA) with the HSA Plan. This is a Qualified High Deductible Health Plan (QHDHP). HMO PLANS: 1-1 HMO 250 F-1 HMO 500 1-1 HMO 750 F_ HMO 2000 LEOFF I Retiree < 65 2017GMA2 Page 4 of 9 (0921161sw) EMPLOYER NAME: IC"TAS COUNTY DENTAL PLANS WCIF dental plans require 100% employee participation. If elected, all eligible employees must be covered. 1. DELTA DENTAL OF WASHINGTON ............................ ❑ CHECK TO DECLINE COVERAGE PLAN A 1 $1,000 Annual Maximum PPO Plan A-1 (100% Employer Paidl ❑ 2 -Tiered Rates (EE / 1+ Dependent) ❑ Composite Rate PLAN C 1 $1,000 Annual Maximum Enhanced Plan C-1 (100% Employer Paidl ❑ 2 -Tiered Rates (EE / 1+ Dependent) ❑ Composite Rate C-21100% Emolover Paid Exceut DeDendentsl 3 -Tiered Rates (EE / 1 Dependent / 2+ Dependents) INCENTIVE PLAN 1 $2,000 Annual Maximum Incentive -1 (100% Employer Paid) ❑ 2 -Tiered Rates (EE / 1+ Dependent) ❑ Composite Rate PLAN B 1 $2,000 Annual Maximum PPO Plan B-4 (100% Employer Paid Except Dependents) ® 3 -Tiered Rates (EE / 1 Dependent / 2+ Dependents) PLAN D 1 $2,000 Annual Maximum Enhanced Plan D-3 (100% Employer Paid) ❑ 2 -Tiered Rates (EE / 1+ Dependent) ❑ Composite Rate D-4 (100% Employer Paid Except Dependents) ❑ 3 -Tiered Rates (EE / 1 Dependent / 2+ Dependents) OTHER PLAN FE -Plan Name: 11. WILLAMETTE DENTAL OF WASHINGTON INC .................... . ❑ CHECK TO DECLINE COVERAGE ® 3 -Tiered Rates OTHER PLAN ❑ Composite Rate ❑ Plan Name: VISION PLANS WCIF vision plans require 100% employee participation, employer paid. If elected, all eligible employees must be covered. 1. VSP Vision Care, Inc.... ......................................... ❑ CHECK TO DECLINE COVERAGE EXTENDED PLAN STANDARD PLAN BUDGET PLAN ❑ 4 -Tiered Rates ® 4 -Tiered Rates ❑ 4 -Tiered Rates ❑ Composite Rate ❑ Composite Rate ❑ Composite Rate OTHER PLAN ❑ Plan Name: I 2017GMA2 Page 5 of 9 (092116JM) EMPLOYER NAME: KITTiTAS COUNTY GROUP LIFE PLANS / ACCIDENTAL DEATH DISMEMBERMENT PLANS Employers are required to enroll all eligible employees. Basic Life is 100% employer paid. 1. STANDARD INSURANCE COMPANY I BASIC LIFE PLANS ® $12,000 ❑ $15,000 ❑ $20,000 ❑ $24,000 ❑ $36,000 ❑ $40,000 ❑ $48,000 ❑ $50,000 1 ❑ 1x Annual Salary 1$50k max ❑ 1x Annual Salary I $100k max ❑ 1x Annual Salary I $150k max ❑ Other Plan: FO$1,000 Basic Life Dependent Benefit (100% participation, employer paid) 11. STANDARD INSURANCE COMPANY I VOLUNTARY PLANS ........ ❑ CHECK TO DECLINE COVERAGE ® Voluntary Term Life (VTL) (by employee election, employee paid) u ® Voluntary Accidental Death & Dismemberment (VAD&D) (by employee election, employee paid) GROUP DISABILITY PLANS Base LTD may be purchased for employees not enrolled in WCIF medical plans by checking the applicable box below. If elected, this is an employer paid benefit that requires 100% employee participation. Must have Base LTD in place to offer voluntary Buy -Up LTD. ` 1. STANDARD INSURANCE COMPANY I DISABILITY PLANS ......... ❑ CHECK TO DECLINE COVERAGE ❑ Base Long Term Disability (Base LTD) for Non -Medical Participants (100% participation, employer paid) ❑ Voluntary Buy -Up Long Term Disability (Buy -Up LTD) (by employee election, employee paid) ® Voluntary Short Term Disability (VSTD) (by employee election, 2 waiting periods available to coincide with Base or Buy -Up LTD, employee paid) EMPLOYEE ASSISTANCE PROGRAM (EAP) EAP may be purchased for employees not enrolled in WCIF medical plans by checking the applicable box below. If elected, this is an employer paid benefit that requires 100% employee participation. This plan features a special "Stand -Alone" option for employees who are not otherwise benefit eligible. 1. MAGELLAN HEALTH SERVICES ................................. ® CHECK TO DECLINE COVERAGE ❑ Standard EAP Coverage (100% participation for all benefit -eligible employees, employer paid) ❑ Stand -Alone EAP Coverage (100% participation for all employees) When Stand -Alone Coverage is offered to otherwise non benefit eligible employees, do you want these employees included in the monthly combined bill? ❑ Yes (if YES, a census will need to be provided to BSI) ❑ No 2017GMA2 Page 6 of 9 (092116JM) EMPLOYER NAME: KITTITA5 COUNTY 'CONSUMER DRIVEN HEALTH PLANS (CDHPs)............... ® CHECK TO DECLINE COVERAGE administered by Benefit Solutions, Inc. (BSI) ❑ FLEXIBLE SPENDING ARRANGEMENT (FSA) ❑ HEALTH SAVINGS ACCOUNT (HSA) Note: HSAs must be accompanied by Qualified High Deductible Health Plans (QHDHP) ACKNOWLEDGEMENTS Employer agrees to abide by the provisions of the Washington Counties Insurance Fund (WCIF) Trust Agreement Initials and Bylaws. Extent of Coverage Employee benefits will end on the last day of the month in which the employee becomes ineligible (except as specified under federal and/or Washington state mandated extension rights). Employers may not continue an employee's coverage on any active plan after the employee is no longer eligible. The only exception to this rule is Oki-, for employees who lose coverage due to a disability and need to continue The Standard Long Term Disability plan coverage in order to apply for Waiver of Premium at a later date. Continuation of coverage through COBRA and Initialscoverage plans for retirees under the a of 65 is available to employees who uali p ( g ) 'qualify; provided the employer maintains participation in a WCIF medical, dental, vision, EAP, and/or FSA plan(s). Continuation of coverage is available in accordance with federal and Washington state law to members who become ineligible for group coverage. Employers have a legal responsibility for certain notification requirements. Please reference the WCIF eACE Manual (www. wcif. net) for notification procedures and forms for WCIF plans. Employers may also reference the US Department of Labor(www.dol.gov) and the US Internal Revenue Service (www.irs.gov) for further guidance. Advisory assistance on compliance with federal and state employment law regulations should be obtained from an employment attorney. Waiver of Medical Insurance (for groups offering WCIF medical coverage) Employer acknowledges that in order to allow an employee to waive WCIF medical coverage the employee must �Initials provide the employer with proof of other group medical insurance coverage. Employer acknowledges that they may not offer cash incentives to employees who waive WCIF medical coverage. Initials Employers are required to offer the same coverage to their over age 65 employees (and over age 65 spouses/ domestic partners) as they do to all other eligible employees. Employer coverage is primary to Medicare. Medicare beneficiaries are free to reject employer plan coverage, in which case they retain Medicare as their Initials primary coverage. When Medicare is primary payer, employers cannot offer such employees (or their spouses) secondary coverage (or incentives) for items and services covered by Medicare. 1E-1qS•l-il1 l 4� Employers who offer WCIF medical coverage are required to cover a minimum of 75% of all eligible employees. Allowable exclusions to this rule include enrollment in other verifiable group medical coverage (i.e. Tri -Care, Medicare, Medicaid, Washington Health Plan Finder), or waiver due to religious belief. These members with allowable exclusions are not used to calculate the group's participation percentage, and are thus netted out of the eligible employee count. NOTE: For current groups who do not submit the Master Application by December 1, group benefits will default to their prior year elections, if available, or mapped to most comparable plan. 2017GMA2 Page 7 of 9 (092116JM) EMPLOYER NAME: KITTITAS COUNTY The below signed applicant agrees that if the requested insurance is acceptable to WCIF under its current rules and practices and is legally permissible, a policy will be issued in the policy language customarily used by WCIF and will be effective on the date determined by WCIF. The below signed applicant acknowledges it is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Name & Title: Obie O'Brien, Chairman, BOCC Authorized Signature: Remarks: Date: 10/11/16 Premera Blue Cross 7001 220th St SW Mountlake Terrace, WA 98403 Plan number unique to employer. Contact WCIF at (800) 344-8570 to obtain. Group Health Options, Inc. 320 Westlake Avenue N Suite 100 Seattle, WA 98109-5233 Plan number unique to employer. Contact WCIF at (800) 344-8570 to obtain. Group Health Cooperative 320 Westlake Avenue N Suite 100 Seattle, WA 98109-5233 Plan number unique to employer. Contact WCIF at (800) 344-8570 to obtain. Standard Insurance Company 1100 SW 6th Avenue Portland, OR 97204 645273 Delta Dental of Washington 9706 4th Avenue NE Seattle, WA 98115 00497 00498 00500 00501 00502 00478 Willamette Dental of Washington Inc 6950 NE Campus Way Hillsboro, OR 97124 WA204 VSP Vision Care, Inc. 3333 Quality Drive Rancho Cordova, CA 95670 30029829 Magellan Health, Inc. 55 Nod Road Avon, CT 06001 2017GMA2 Page 8 of 9 (092116JM) FOR ADMINISTRATOR USE ONLY: Approved by: ❑ Premera Base Demographic Risk Level: ❑ Group Health Base Demographic Risk Level: Special Notes: FOR CARRIER USE ONLY: Date: ❑ Producer Commissions Attached ❑ Proof of Funding Received ❑ Bundled (Base LTD) Medical Only ❑ Bundled (EAP) Medical Only 2017GMA2 Page 9 of 9 (092116JM)