City Council Workshop or Special Called Meeting

CITY COUNCIL WORKSHOP MEETING WEDNESDAY - JUNE 26, 2024 - 5:00 PM Notice of AGENDA City Council Chamber/Municipal Courtroom 2801 Ranch Road 1869 Liberty Hill, TX 78642 Diane Williams Jacquetta Thayer Crystal Mancilla Wade Ashley Amanda L Young Michael Helbing LIVE VIDEO ACCESS AND RECORDINGS The live video link will be on the City's Facebook page. Following the meeting, the link for the live meeting will be removed. The recording of the meeting will be placed on the City's webpage: www.libertyhilltx.gov PLEASE SILENCE YOUR CELL PHONES 1) CALL TO ORDER AND ESTABLISH QUORUM 2) REGULAR AGENDA a) Presentation and discussion of a contract with Texas Health Benefits Pool for proposed group insurance benefits for city employees for fiscal year 2024-2025. (HR Director Scott) Council cover sheet 06-20-24.docx Copy of Insurance costs FY 2025-all tabs for Workshop Session 6.26.2024.pdf Liberty Hill_PLIBERT0_Letter2024-2025.pdf Liberty Hill_PLIBERT0_Options PY 2024-25_2024.06.12- HSA Options.pdf Liberty Hill_PLIBERT0_Renewal2024-2025.pdf 3) ADJOURNMENT 1 The City Council, Boards, and Commissions reserve the right to reconvene, recess, realign, change the order of business, or adjourn into Execu ve Session at any me during the course of the mee ng, prior to adjournment, to discuss any item listed above, as authorized by Texas Government Code Sec on §551.071 (Consulta on with A orney), §551.072 (Delibera ons about Real Property), §551.073 (Delibera ons about Gi s and Dona ons), §551.074 (Personnel Ma ers), §551.076 (Delibera ons about Security Devices), and §551.087 (Development). In compliance with the Americans with Disabili es Act, the City of Liberty Hill will provide reasonable accommoda on for persons a ending mee ngs. To be er serve you, requests need to be received 48 hours prior to the meeting. Contact the City Secretary at 512-778-5449 – Extension 125. POSTING CERTIFICATION: I, ELAINE SIMPSON – CITY SECRETARY – CITY OF LIBERTY HILL certify that the attached notice of meeting was duly posted on the bulletin board at City Hall located at 926 Loop 332, Liberty Hill, Texas 78642 and on the City website (www.libertyhilltx.gov) on the ______ day of ____________________, 202_ at ______. Elaine Simpson – City Secretary. REMOVAL CERTIFICATION: I ELAINE SIMPSON – CITY SECRETARY – CITY OF LIBERTY HILL certify that the attached notice of meeting was removed from the bulletin board at City Hall located at 926 Loop 332, Liberty Hill, Texas 78642 on the ______ day of __________________, 202_ at _______. INITIALS _______ 2  CITY COUNCIL WORKSHOP CITY COUNCIL WORKSHOP MEETING WEDNESDAY - JUNE 26, 2024 2801 Ranch Road 1869 - Liberty Hill AGENDA ITEM 2.a Presentation and discussion of a contract with Texas Health Benefits Pool for proposed group insurance benefits for city employees for fiscal year 2024-2025. (HR Director Scott) 3 City Council Meeting Date: June 26, 2024 Item No. Requested By: Paul Brandenburg, Candice Scott, Jaynette Odegaard, and Heather VonGonten Submitted/Prepared By: Candice Scott, Jaynette Odegaard, and Heather VonGonten Type: (Action/Discussion Only /Consent/Exec. Session/Public Hearing): Action AGENDA ITEM COVER SHEET ITEM/TITLE: Texas Health Benefits Pool (TX Health Benefits Pool) Health Insurance Renewal AGENDA ITEM WORDING: Discuss, consider, and possibly take action to approve a contract with TX Health Benefits Pool for group insurance benefits for city employees FY 2024-2025. EXECUTIVE / BACKGROUND SUMMARY: The group insurance benefits for city employees are renewed each year during the budget process for the next fiscal year. TX Health Benefits Pool (Formerly known as TML Health Benefits) has issued the new rates for our current plans along with two options for each plan. The average increase for all participants of TX Health Benefits Pool was 0% with no cap. The increase to the City’s current PPO and HDHP plans is 0%, with Option 1 being a 0% increase respectively, and Option 2 being a 0% increase respectively, and Option 3 being a 0% increase respectively, with removal of Defined Credit with slightly higher payroll deduction rates for (3) employees + children with an increase deposit to employee HDHP/HSA account. We are required to sign and return to TX Health Benefits Pool a Renewal Notice and Benefit Verification Form by July 1, 2024. The Dental insurance had a 0% increase and only the current plan is offered. Vision insurance is a 9.51% increase respectively, and Life Insurance with no increase respectively. Page 1 of 2 4 FISCAL NOTES/FINANCIAL BACKGROUND/FINANCIAL IMPACT: Currently the City pays $731.76 per month for each full-time employee that accepts the City’s Option 1 PPO health insurance plan. The current PPO plan offered remains at $731.76, with no increase. The monthly cost per employee per month for the current Option 2 HDHP (high-deductible plan/HSA) offered is $518.86, with no increase. Option 3 there is a 1.74% decrease respectively from the PPO plan with lower rates for co-pay. The HDHP/HSA plan will have a 0% decrease respectively, with slightly higher payroll deduction rates. Currently the payroll deduction rate for employee + children is $90.73 and would increase to $197.18, with an HSA contribution of $200.18 monthly to employees currently on this plan. The City has 6 employees currently on the HDHP/HSA plan; 3 employee only and 3 employee + children. There is no change in Dental and Life Insurance premiums. There is a 9.51% increase in the Vision Insurance premium. The monthly cost per employee per month is currently $8.93. The new monthly cost per employee per month is $9.78. This is an increase of $645.48 monthly or $7,745.76 annually. Staff recommends Council approve Option 3 for both the PPO and HDHP health insurance plans and to continue with the current dental, vision, and life insurance plans. The cost to the City for all eligible employees annually will be $ 612,208.08 which is a decrease of $9,401.40 annually. SUGGESTED WORDING FOR MOTION(S) REGARDING ORDINANCES OR RESOLUTIONS: I make the motion to approve Option 3 for both the PPO and HDHP health insurance plans and to continue with the current dental, vision, and life insurance plans. ATTACHMENTS: 1. TX Health Benefits Pool Letter 2. TX Health Benefits Pool Renewal Notice and Benefit Verification Form with medical, dental, and Life Insurance costs. 3. TX Health Benefits Medical Cost Projections; Option 1, Option 2, and Option 3 4. City Health Benefits Medical Employee Costs breakdown – Option 3 Page 2 of 2 5 Medical CoPay Monthly Semi-monthly Employee Only (LEE) $ 719.04 $ 359.52 Employer Cost - no charge to employee Employee + Spouse (LES) $ 1,459.78 $ 370.37 Employee + Children (LEC) $ 1,265.54 $ 273.25 Employee + Family (LEF) $ 2,372.76 $ 826.86 Medical HSA Monthly Semi-monthly Defined Credit Employee Only (EHD) $ 518.86 $ 259.43 $ 200.18 Employer-funded Health Savings Account Employee + Spouse (SHD) $ 1,053.38 $ 267.26 $ 167.17 Employee + Children (CHD) $ 913.22 $ 197.18 $ 97.09 Employee + Family (FHD) $ 1,712.14 $ 596.64 $ 496.55 Dental Monthly Semi-monthly Total Cost per Employee - City paid Employee Only (ED) $ 40.66 $ 20.33 $ 772.99 Employee + Family (FD) $ 104.42 $ 31.88 $ 51,017.34 Monthly cost for 66 employees $ 612,208.08 Annual cost for 66 employees Vision Monthly Semi-monthly Employee Only (EV) $ 9.78 $ 4.89 Employee + Spouse (VSP) $ 18.56 $ 4.39 Employee + Children (VCH) $ 19.54 $ 4.88 Employee + Family (FV) $ 24.90 $ 7.56 Basic Life/AD&D Monthly Semi-monthly Life Insurance (LI) $ 3.51 $ 1.76 6 Medical CoPay Monthly Semi-monthly Employee Only (LEE) $ 653.74 $ 326.87 Employer Cost - no charge to employee Employee + Spouse (LES) $ 1,327.22 $ 336.74 Employee + Children (LEC) $ 1,150.64 $ 248.45 Employee + Family (LEF) $ 2,157.32 $ 751.79 Medical HSA Monthly Semi-monthly Defined Credit Employee Only (HDE) $ 453.18 $ 226.59 $ 200.56 Employer-funded Health Savings Account Employee + Spouse (HDS) $ 920.02 $ 233.42 $ 133.14 Employee + Children (HDC) $ 797.62 $ 172.22 $ 71.94 Employee + Family (HDF) $ 1,495.42 $ 521.12 $ 420.84 Dental Monthly Semi-monthly Employee Only (ED) $ 37.64 $ 18.82 Employee + Family (FD) $ 96.68 $ 29.52 Vision Monthly Semi-monthly Employee Only (EV) $ 8.93 $ 4.47 Employee + Spouse (VSP) $ 16.97 $ 4.02 Employee + Children (VCH) $ 17.86 $ 4.47 Employee + Family (FV) $ 22.78 $ 6.93 Basic Life/AD&D Monthly Semi-monthly Life Insurance (LI) $ 3.51 $ 1.76 7 Medical CoPay Monthly Semi-monthly Employee Only (LEE) $ 726.98 $ 363.49 Employer Cost - no charge to employee Employee + Spouse (LES) $ 1,475.92 $ 374.47 Employee + Children (LEC) $ 1,279.54 $ 276.28 Employee + Family (LEF) $ 2,399.00 $ 836.01 Medical HSA Monthly Semi-monthly Defined Credit Employee Only (EHD) $ 494.72 $ 247.36 $ 232.26 Employer-funded Health Savings Account Employee + Spouse (SHD) $ 1,004.36 $ 254.82 $ 138.69 Employee + Children (CHD) $ 870.74 $ 188.01 $ 71.88 Employee + Family (FHD) $ 1,632.48 $ 568.88 $ 452.75 Dental Monthly Semi-monthly Employee Only (ED) $ 37.64 $ 18.82 Employee + Family (FD) $ 96.68 $ 29.52 Vision Monthly Semi-monthly Employee Only (EV) $ 8.93 $ 4.47 Employee + Spouse (VSP) $ 16.97 $ 4.02 Employee + Children (VCH) $ 17.86 $ 4.47 Employee + Family (FV) $ 22.78 $ 6.93 Basic Life/AD&D Monthly Semi-monthly Life Insurance (LI) $ 3.51 $ 1.76 8 Medical CoPay Monthly Semi-monthly Opt-out Credit Monthly Semi-monthly Employee Only (LEE) $ 731.76 $ 365.88 Employer Cost - no charge to employee $ 540.38 $ 270.19 Employee + Spouse (LES) $ 1,485.62 $ 376.93 Employee + Children (LEC) $ 1,287.94 $ 278.09 Employee + Family (LEF) $ 2,414.76 $ 841.50 Medical HSA Monthly Semi-monthly Defined Credit Employee Only (EHD) $ 518.86 $ 259.43 $ 212.90 Employer-funded Health Savings Account Employee + Spouse (SHD) $ 1,053.38 $ 267.26 $ 160.81 Employee + Children (CHD) $ 913.22 $ 197.18 $ 90.73 Employee + Family (FHD) $ 1,712.14 $ 596.64 $ 490.19 Dental Monthly Semi-monthly Total Cost per Employee - City paid Employee Only (ED) $ 40.66 $ 20.33 $ 784.86 Employee + Family (FD) $ 104.42 $ 31.88 Vision Monthly Semi-monthly Employee Only (EV) $ 8.93 $ 4.47 Employee + Spouse (VSP) $ 16.97 $ 4.02 Employee + Children (VCH) $ 17.86 $ 4.47 Employee + Family (FV) $ 22.78 $ 6.93 Basic Life/AD&D Monthly Semi-monthly $ 51,800.76 Monthly cost for 66 employees Life Insurance (LI) $ 3.51 $ 1.76 $ 621,609.12 Annual cost for 66 employees 9  Current FY 24 deductions Proposed FY 25 Option 3 Medical CoPay Monthly Semi-monthly Medical CoPay Monthly Semi-monthly Employee Only (LEE) $ 731.76 $ 365.88 Employee Only (LEE) $ 719.04 $ 359.52 Employee + Spouse (LES) $ 1,485.62 $ 376.93 Employee + Spouse (LES) $ 1,459.78 $ 370.37 Employee + Children (LEC) $ 1,287.94 $ 278.09 Employee + Children (LEC) $ 1,265.54 $ 273.25 Employee + Family (LEF) $ 2,414.76 $ 841.50 Employee + Family (LEF) $ 2,372.76 $ 826.86 Medical HSA Monthly Semi-monthly Defined Credit Medical HSA Monthly Semi-monthly HSA Contribution Employee Only (EHD) $ 518.86 $ 259.43 $ 212.90 Employee Only (EHD) $ 518.86 $ 259.43 $ 200.18 Employee + Spouse (SHD) $ 1,053.38 $ 267.26 $ 160.81 Employee + Spouse (SHD) $ 1,053.38 $ 267.26 $ 200.18 Employee + Children (CHD) $ 913.22 $ 197.18 $ 90.73 Employee + Children (CHD) $ 913.22 $ 197.18 $ 200.18 Employee + Family (FHD) $ 1,712.14 $ 596.64 $ 490.19 Employee + Family (FHD) $ 1,712.14 $ 596.64 $ 200.18 10 May 30, 2024 BOARD OF TRUSTEES Chair City of Liberty Hill Mike Stelly, Region 16 Chief of Police/Director of Public Works, 926 Loop 332 City of West Orange Liberty Hill, TX 78642 Vice Chair Mike Smith, Region 5 Dear Candice Scott, City Manager, City of Jacksboro Joseph Price, Region 2 Thank you for your continued partnership with the TX Health Benefits Pool. We're City Manager, City of Canyon proud to serve public entities like yours, with a Board of Trustees composed entirely of Elena Quintanilla, Region 3 current or former local government officials. This unique governance ensures that your City Administrator, Town of Ransom Canyon voice is heard in shaping your healthcare coverage. Dru Gravens, Region 4 While the past couple years brought pandemic challenges with high medical costs, City Manager, City of Crane we've turned the corner thanks to your support. We're in a stronger position now, with a Tammie Coffman, Region 6 healthier Pool and slower cost increases, which means more stable rates for you this Councilmember, City of Clyde year. Joe A. Cardenas, Region 7 Assistant City Manager, City of Uvalde Here are some exciting enhancements for the upcoming plan year: Region 8 • NEW Circle Wellness: Free on-site health screenings to detect issues early and Vacant reduce treatment costs. Connie Standridge, Region 9 City Manager, City of Corsicana • NEW Twin Health: Our pilot project aims to help members with type 2 Ashley Wayman, Region 10 diabetes live healthier and potentially reverse their condition through a City Administrator, City of Rollingwood partnership with Twin Health. John Green, Region 11 • Continued Surgery Plus: We're continuing our partnership to offer high-quality, Mayor Pro-Tem, City of Portland cost-effective surgical care, with significant savings for your employees. Wendi Delgado, Region 12 Director of Operations, City of South Padre • Member Rewards: Get cash back when using cost-effective providers for Island imaging/tests. Jeff Jordan, Region 13 Mayor, City of Kaufman Your marketing rep Heather VonGonten will reach out soon to discuss your renewal Fabrice Kabona, Region 14 options, budget fit, and potential savings with an HMO, health accounts like HSAs, or City Manager, City of Madisonville our Direct Primary Care plan. Wendy Hudman, Region 15 City Accountant, City of Carthage Open enrollment is scheduled for 08/01/2024 - 08/15/2024. We offer convenient self- Larry Fields, Appointee service and phone enrollment options to make it easy for your employees. Former City Manager, City of Graham Stephen Haynes, Appointee To ensure a smooth transition, please provide your renewal decision at least 90 days Mayor, City of Brownwood before your anniversary date of 10/01/2024. Heather can assist you with completing the Glen Metcalf, Appointee renewal form. You can reach Heather at 512-719-6519 and Former City Manager, City of Canyon Heather.VonGonten@txhb.gov. Mike Slye, Appointee Former City Manager, City of Kaufman Thank you for your continued trust. We look forward to serving you and your employees again this year. Jay Stokes, Appointee City Manager, City of Deer Park Sincerely, Lew White DDS, Appointee Mayor, City of Lockhart Jennifer Hoff Executive Director Follow us: (800) 282-5385 @TXHB P.O. Box 140526 For more information, visit us at Austin, Texas 78714-0526 txhb.gov 11  6/12/2024 11:15 AM MEDICAL COST PROJECTION Liberty Hill - PLIBERT0 06/12/24 MEMBER OPTION $0.00 $0.00 0% Increase 0% Increase Current Plans PPO Plan HDHP Plan 2023-2024 2024-2025 2023-2024 2024-2025 Current Rates New Rates Current Rates New Rates Copay-2K-6K ER Copay-2K-6K ER Consumer HSA-6K-6900 E Consumer HSA-6K-6900 E 80% / 50% 80% / 50% 80% / 50% 80% / 50% PPO PPO HSA HSA $2,000 In Ded $2,000 In Ded $6,000 In Ded $6,000 In Ded $4,000 Out Ded $4,000 Out Ded $12,000 Out Ded $12,000 Out Ded $6,000 In OOP $6,000 In OOP $6,900 In OOP $6,900 In OOP $0 Tela Health Copay $0 Tela Health Copay $44 Tela Health Copay $44 Tela Health Copay $30 OV/$60 SP/$75 UC/$500 ER Copay $30 OV/$60 SP/$75 UC/$500 ER Copay No OV/SP/UC/ER Copay No OV/SP/UC/ER Copay DAW1&2 Rx Plan DAW1&2 Rx Plan DAW1&2 Rx Plan DAW1&2 Rx Plan EE $731.76 $731.76 $518.86 $518.86 EE + Spouse $1,485.62 $1,485.62 $1,053.38 $1,053.38 EE + Child(ren) $1,287.94 $1,287.94 $913.22 $913.22 EE + Family $2,414.76 $2,414.76 $1,712.14 $1,712.14 New Plan Options Option 3 2024-2025 1.74% Decrease 0% Decrease (from PPO Plan) (from HDHP Plan) Copay-2500-6K ER Consumer HSA-6K-6900 E 80% / 50% 80% / 50% PPO (copay) HSA Embedded $2,500 In Ded $6,000 In Ded $5,000 Out Ded $12,000 Out Ded $6,000 In OOP $6,900 In OOP $0 Tela Health Copay $48 Tela Health Copay $30 OV/$60 SP/$75 UC/$500 ER Copay No OV/SP/UC/ER Copay DAW1&2 Rx Plan DAW1&2 Rx Plan EE $719.04 $518.86 EE + Spouse $1,459.78 $1,053.38 EE + Child(ren) $1,265.54 $913.22 EE + Family $2,372.76 $1,712.14 Option 3 Please sign & date option chosen: Signature / Date 7/1/2024 10/1/2024 6/18/2024 THIS DOES NOT COMPLETE THE RERATE PROCESS. YOU WILL NEED TO SIGN THE MEMBER OPTION AND RETURN TO YOUR MARKETING CONTACT BY 06/18/2024 THEN A NEW RERATE NOTICE WILL BE GENERATED AND MAILED TO YOU. THE RERATE SHEET MUST BE SIGNED AND RECEIVED IN AUSTIN BY 07/01/2024 FOR THE NEW BENEFITS AND RATES TO BE EFFECTIVE FOR 10/01/2024 The information contained in this option includes proprietary information that should not be shared with other competitors or used to circumvent the requirements of Texas Competitive Bidding laws. 12  Renewal Notice and Benefit Verification Form Liberty Hill Original Plan Year 10/01/2024 - 09/30/2025 (12 Months) IMPORTANT NOTICE: A signed renewal is required by the due date in your cover letter. If TX Health Benefits Pool does not receive the fully executed renewal notice by the indicated due date, you will no longer have an option to change benefits which will result in renewal of the benefit plans listed below at the new rates and the current employer contributions. Medical Employer Group Medical Plan Plan Benefit In Net Out Net In Net Office Rates Current New Percent Ded Ded OOP Visit Copay-2K-6K ER-DAW1&2 80/50 $2000 $4000 $6000 $30 EE Only: $731.76 $731.76 EE + Spouse: $1,485.62 $1,485.62 EE + Child(ren): $1,287.94 $1,287.94 EE + Family: $2,414.76 $2,414.76 Consumer HSA-6K-6900 E-DAW1&2 80/50 $6000 $12000 $6900 N/A EE Only: $518.86 $518.86 EE + Spouse: $1,053.38 $1,053.38 EE + Child(ren): $913.22 $913.22 EE + Family: $1,712.14 $1,712.14 In Network Deductible applies towards In Network OOP. Medical and Dental Plan Accumulators will be based on Calendar Year. Defined Contribution TX Health Benefits Pool requires 60% employer contribution toward employee medical – Minimum employer contribution is $311.32. Note: All Defined Contributions will be allocated as follows (if offered): Medical, Dental, Vision, & all Employee Paid Voluntary Products (ex: voluntary life, voluntary spouse life, voluntary AD&D…). Any left-over contribution dollars will then be applied to an employee’s HRA or HSA (as applicable) depending on medical plan election. Please enter your defined contribution amounts for active employees here: 1. Employer’s MONTHLY Defined Contribution of $_____________equal to a full ANNUAL Defined Contribution of $_____________ (monthly contribution x12). 2. Will employees receive this Defined Contribution if medical coverage is waived? No Yes (if yes, see 2a). a. Will employee’s receive the full monthly Defined Contribution or a partial amount? Full Partial $______________ 3. Are there different contributions based on other factors (ex: hourly vs salary, department, location…)? If so please explain here: Dental Rates Current (Dental III) New (Dental III) EE Only: $40.66 $40.66 EE + Family: $104.42 $104.42 Vision Rates Current (Premium) New (Premium) EE Only: $8.93 $9.78 EE + Spouse: $16.97 $18.56 EE + Child(ren): $17.86 $19.54 EE + Family: $22.78 $24.90 Page 1 of 3 Original PLIBERT0 - Oct-01 13  Basic Life and AD&D: Plan 9 ($15,000) Current Rate New Rate Life: $0.194 $0.194 AD&D: $0.040 $0.040 Note: Plan requires 100% Participation and is 100% EMPLOYER paid. Additional Employee Life and AD&D Age of Employee Current Rate per $1000 New Rate per $1000 Under 30 0.041 0.041 30 - 34 0.052 0.052 35 - 39 0.091 0.091 40 - 44 0.129 0.129 45 - 49 0.198 0.198 50 - 54 0.332 0.332 55 - 59 0.595 0.595 60 - 64 0.913 0.913 65 - 69 1.513 1.513 70 and over 2.431 2.431 Note: Plan is EMPLOYEE paid. Dependent Life: Plan 3 ($10,000/$2,000) Current Rate New Rate $2.76 per $2.76 per dependent unit dependent unit Note: Plan is EMPLOYEE paid. Voluntary AD&D Current Rate New Rate Employee $0.035 per $1000 $0.035 per $1000 Family $0.058 per $1000 $0.058 per $1000 Note: Plan is EMPLOYEE paid. COBRA Eligibility and Administration (Continuation of Coverage) COBRA Eligible? Yes COBRA Administration through TX Health Yes Benefits Pool? NOTE: Employer will be charged a flat monthly fee of $80 per month regardless of how many members are utilizing COBRA, as well as $10 per month for each member who elects COBRA. Benefit Waiting Period 1st of mo after date of hire Consumer-Driven Health Plans FSA Admin DCA Admin HRA Admin HSA Admin RRA Admin No No No Yes No Note: If employer accesses FSA and/or HRA, HSA, or RRA, one charge of $3.70 per participant per month will be incurred and paid by EMPLOYER. Page 2 of 3 Original PLIBERT0 - Oct-01 14  HSA Administration Defined Contribution (amount will vary). Employer/Applicant acknowledges that TX Health Benefits Pool is not a Bank and cannot operate as a Bank Custodian. Because an HSA is a tax-exempt trust or custodial account set up with a qualified HSA trustee/custodian to pay or reimburse certain medical expenses incurred by a participating employee, TX Health Benefits Pool has no responsibility or liability for HSA trustee/custodian services. Employer Applicant further acknowledges that TX Health Benefits Pool can only assist with accessing the HSA vendor by assisting with enrollment, billing, and import of HSA contributions for deposit with the HSA vendor and only associated with Employer Applicant’s qualifying High Deductible Health Plans (HDHP Plans). Employer/Applicant assumes the liability and responsibility of complying with any IRS or other federal regulations related to HSAs. Required Annual Eligibility and Enrollment Information Please provide the following information: 1. Will you allow Employee Self Service (ESS) via TXHB Online for Open Enrollment and Qualifying Life Events? No Yes Signature Section The undersigned employer hereby acknowledges that for an employee to receive coverage, TX Health Benefits Pool must receive enrollment information within thirty-one (31) days of the date of hire or within thirty-one (31) days of the coverage effective date, whichever is later, regardless of whether the Employer has a waiting period or a waiting and orientation period. If an enrollment is not submitted within this timeline, the employee cannot be added to the Plan until the next Open Enrollment period or a qualifying event occurs. Employer Member Additional Acknowledgements and Agreements 1. Employer Member acknowledges and agrees that its signature on this Renewal Notice and Benefit Verification Form indicates its binding selections for renewal services through TX Health Benefits Pool. 2. Employer Member acknowledges that certain benefit service selections require completion and execution of additional forms and agreements and agrees that it will work with all due diligence and in good faith to complete, execute, and return all necessary forms and agreements to TX Health Benefits Pool prior to the beginning of the Group’s open enrollment. 3. Employer Member acknowledges that TX Health Benefits Pool will only allow open enrollment for renewal services in good faith and without receiving all necessary signed benefit service forms and agreements if: A. A signed Renewal Notice and Benefit Verification Form with all necessary Employer Member selections and information has been received; and B. Employer Member has in good faith attempted but failed to approve and return the applicable benefit service forms and agreements timely. 4. Employer certifies that it has adopted an Employee Flexible Benefits Plan under Section 125 of the Internal Revenue Code. This Plan is offered to all eligible employees who are qualified by employment status. 5. Employer certifies that it will provide notice of the creditable status of the coverage it offers to new enrollees prior to the effective date of their coverage, as required by the Medicare Modernization Act. 6. TX Health Benefits requires groups to enroll 100% of their benefit eligible employees. This is also known as the 100% Participation Rule. Employers may have employees that wish to waive Medical coverage through TX Health Benefits Pool, however, waivers may only be granted for the reasons enumerated in your Plan Book. Please sign by the due date and return this completed form via email to your Account Executive/Account Manager or marketing@txhb.gov. 742917656 Tax ID Number Authorized Signature Date Printed Name Title The rates are based on census information five months prior to plan year. If the census changes by more than 10%, TX Health Benefits Pool reserves the right to revise rates due to census change and underwriting impact. Rates are subject to change due to intervening events such as action taken by the TX Health Benefits Pool Board of Trustees, legislation passed during the plan year, or other events affecting benefits. Supplemental benefits cannot be accessed without accessing the TX Health Benefits Pool Medical Benefit Plan. YOUR RENEWAL QUOTE INCLUDES PROPRIETARY INFORMATION THAT SHOULD NOT BE SHARED WITH OTHER COMPETITORS OR USED TO CIRCUMVENT THE REQUIREMENTS OF TEXAS COMPETITIVE BIDDING LAWS. IN THE EVENT YOU RECEIVE A RENEWAL QUOTE AND LATER DECIDE TO ISSUE AN RFP, THE RENEWAL QUOTE MAY NOT BE SHARED WITH ANY OTHER COMPETITORS AS DOING SO WOULD DISADVANTAGE TX HEALTH BENEFITS POOL IN THE COMPETITIVE PROCESS. TX HEALTH BENEFITS POOL ALSO RESERVES THE RIGHT TO REVISE PREVIOUSLY ISSUED RATES IN RESPONSE TO YOUR RFP. Page 3 of 3 Original PLIBERT0 - Oct-01 15