Amendment No. 1 to the Agreement between the CMB and Health Care Service Corporation, A Mutual Reserve Company and Healthspring Life and Health Insurance Company, Inc. Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC /<.C�V n � Q/ L / V�.
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2D23 - 326zy
OCT 3 1 ��?5
AMENDMENT NO. 1 TO AGREEMENT
BETWEEN
THE CITY OF MIAMI BEACH, FLORIDA
AND
HEALTH CARE SERVICE CORPORATION,A MUTUAL RESERVE COMPANY
AND
HEALTHSPRING LI�E& HEALTH INSURANCE COMPANY, INC.
This Amendment No. 1 ("Amendment"}to the Agreement(defined belo���) is by and between the
C17Y OF MIAMI BEACH, FLORIDA (the "City") a municipal corporation organized and existing
under the laws of the State of Florida, having its principal place of business at 1700 Convention
Center Drive. Miami Beach, Florida 33139, HEALTH CARE SERVIGE CORPORATION, A
MUTUAL LEGAL RESERVE CCIMPANY, an Illinois corporation ("HCSC"), whose principal
address is 300 East Randolph Street, Chicago, Illinois 60601 and NEALTHSPRING LIFE &
HEALTH INSURANCE COMPANY, INC., a Texas corporation, whose principal address is 280Q
North Loop West, Houston, Texas 77092(together with HCSC, collectively, "HealthSpring" ""}is
entered into day of _____ , 2025.Any defined terms used but nof defired herein
shali have the meaning]��j forth in���.kgreement.
�J4..� � i ��!rh
RECITALS
WHEREAS, on June 28, 2023, the Mayor and City Commission, adopted Resolution No
2023-32624, pursuant to Request for Proposais(RFP)No. 2023-259-WG for Health, Pharmacy,
and Medicare Advantage Plans, authorizing the Administration to negotiate an agreement with
CHLIC, the top- ranked proposer for Health and Pharmacy Plans (Plan A} and Medicare
Advantage Plans(Plan C);
WHEREAS,on or about December 19,2023,the City and Cigna Health and Life Insurance
Company ("CHLIC") executed that certain Employer/Union Group MAPD Agreement for the
Medicare Advantage Plans(Plan C)(the"AgreemenY');
WHEREAS, CHLIC subsequently assignecl the Agreemeni to HeatthSpring; and
WHEREAS, the City and HealthSpring desire to amend the Agreement to bring the terms
of the Agreement into compliance with federal Medicare regulations.
NOW THEREFORE, in consideration of the mutual promises and conditions contaired
herein, and other good and valuable consideration, the sufficiency of which is hereby
acknovrledged, the City and HealthSpring hereby agree to amend the Agreement as follows:
1. ABOVE RECITALS. The above recitals are true and correct and are incorporated as part
of this Amendment.
2. MODIFICATIONS. The Agreement is hereby amended(deleted Items str�sk-�k�reagt?and
inserted items underlined)as follows:
(a) Exhibit A, 2024 Medicare Advantage Prescription Drug Plan coverage description, is
hereby deleted in its entirety and replaced with Amended Exhibit A, attached hereto.
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Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
(b) Exhibit B, Cigna Healthcare Medicare Advantage Prescription Drug (MAPD} Group
Administrative Guidelines is hereby deleted in its entirety and replaced with Amended Exhibit B,
attached hereto.
3. OTHER PRESCRIPTION DRUG COVERAGE/OTHER HEALTH INSURANCE. Client
acknowledges and agrees that to the extent that Client elects a plan benefit design that includes
ar incorporates other prescription drug coverage benefits, as that term is defined at 42 C.F.R.
423,464(f), such other prescription drug coverage benefits may be provided in certain states by
an affiliated or unaffiiiated insurer or heaith maintenance organization in conjunction with the
Medicare Part D benefits that are offered by HealthSpring in such states.
4. RAT4FICATION. Except as amended herein, all other terms and conditions of the
Agreement shali remain unchanged and in full farce and e(fect. In the event there is a conflict
between the provisions of this Amendment and the Agreement,the provisions of this Amendment
shall govern.
THE REMAINpER OF THIS PAGE IS INTENTIpNALLY LEFT BLANK.
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Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
IN WITNESS WHERE(?F,the parties hereto have caused this Amendment to be executed
by their appropriate officials, as of the date first entered above.
FOR CITY: GiTY OF MIAM{ BEACN, FLORIDA
ATTEST:
-- ----.__.___ __ _ _ ._ BY� _____ __ _ ___-- --_____._.--
Rafael E. Granado, Cify Clerk Eric T. Garpenter, City Manager
Date:
FOR HEA�THSPRfNG HEA�THSPRING LIFE & HEALTH
INSURANCE COMPANY, INC.
ATTEST:
(;,
y - _ -. �
. _-
� gy, f � __ �
—._^ _ _._ _ --- - �_' _
Signature
_ � 1�
Name: � � � '�
�t_�_ t'J�. Name: �� :.(;�_.�t.-- Gi�� ( �
� � �' , �, - _
Title:�- t�__ e�,�.�v`Q--,'��`. Title. ;-_�'1(`�:.�-�(_7�?�1"�t---`t��
--- S
Date:__'0 __�?""�._�"�._ _ ---
NEALTH CARE SERVICE CORPt�RATION,
A MUTUAL LEGAL RESERVE COMPANY
ATTEST:
�-
�1
� __-��'��`�__�/��� BY ,,��� ti--�.-- . .
Signature ,
Name:_��� ►V�,U'�� Name: _-sTt`11_'��_.___���i�Y�;j---
Title: J✓�- F a�. Title: �'1���� �',�lr'_. ��
----- _ - — -__ ___ L�-�{' ' ��-_C:'�::�1_L't�� i�
Date: r� �o� ��'�
APPROVED AS TO
FC�RM & LANGUAGE
& FQR EXECUTION
__
��;� � �`���s �'����,����
- _���---.T__ . _ ___ ---
;` j�City Attomey % Date
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Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
AMENDED EXHIBIT A
MEOlCARE ADVANTAGE PRESCRIPTION DRUG PLAN COVERAGE DESCRIP710N
(to be attached)
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Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
City of Miami Beach
Cigna Medicare Advantage Employer Group Plan
Effective Date 2025-01-Q1
End Date 2025-12-31
Number of Medicare Beneficiaries 53
Funding Type Fully Insured
Situs State FL
. .
PPO-High Cainsurance&CMBPQ 53 �354.27
Please refer to the Terms and Conditions of this proposal and the Benefit Summary with the
benefit details.
The proposed rates include the following Performance Guarantees,with further detafls provided
in the terms&conditions:
•Standard Service Performance Guarantee:$12500
Proposed rates include$16 PMPM for retiree administration.
The proposai includes a 2nd Year rate cap of 5°!0.
The proposed rates include the foilowing Optional Services:
•Communication Fund:$1Q000
All HealthSpring products and services are provided exclusively by or through operating subsidiaries or
affiliates of HealthSpring Life 8�Health Insurance Company, Inc. The HealthSpring name, logos,and
marks are owned by HealthSpring,or an affiliate of HealthSpring. HealthSpring contracts with Medicare
to offer Medicare Advantage HMO and PPO plans and Part D Prescription Drug Plans(PDP)in select
states,and with select State Medicaid programs. Enroliment in a HeaithSpring product depends on
contract renewal.
All Medco products and services are provided exclusively by or through operating subsidiaries or
afflliates of Medco, including Medco Containment Life Insurance Company and Medco Containment
Insurance Company of New York. The Medco name, logos,and marks are owned by Medco,or an
affiliate of Medco. Medco contracts with Medicare to offer Part Q Prescription Drug Plans(PDP)in select
states. Enroilment in a Medco product depends on contract renewal.
OO 2024 Cigna Nealthcare
� 11/4/2024 VA A6
Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
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teem wslome•s to neip Ihe cuslomar urCersiaM t�eir
a'�egroHs,eccese s�OPoNre�wrces e�a Oevebp a
per�nal�ze�suDGw; T�e leem also helps lo/ac.Gtete
d!lary 5elvito5 su�av pha:macy,tllelitinns,
behavioral suppaA Bntl Dur soCdl de;erminanta ot hxaHh
^,eam
Gre ManagemeM progrems ate pan of'he broatler
populalion�ealt�mar+aCemenl a'✓x;eqy ard apply o
Care Ylsnagemant �ompronens:ve.muitM:aap�inary ap0�aedi�o managa Comm�ea vn:n irvNetwork
. tuslanero w�th ch.roNc.comp'ex,eM dixaae�aoec�fic
neetls Ihioug�identiAcalron,asseasmenl,care
coordination,cuslomeretlucalion anE�si�mavgement.
TMs prcgram works as a paMenh�.p between cuafomer.
providers erA Whn:heall�services aiat(lo proviCe;he
Deheviora;HeaIN Eesl Uln�cal ouicamae for r.ia!omers This'u ec�iavea Ccm6 netl vnlh In-NeMa(k
throup�xordinalion with providM,hospi!a!staR and
commu-ily pannere using an avidence busetl aoproach to
creale e comprohmvve pMn ol we
Cn;nnic rcioneyiEna Sleqe Rene�ti�seese�.Fhohtlas in
nome kitlney care manapeman!aM a�tens.va eCuwtion
to cualomon wit�aavancetl kidney diaeaee In-tame
fGdney 65eas8 vi9ile ere p8rtortreC Dy�u!ses anC aoUel Workers lo ComD;ned with In-NeMwk
provitle etlucat:on,nr.lication mviaw wilh pnarmeasts
end asfesnment!o�aaci]I delertninanla o/heait�. 24?
avtd�bY.y ta upport
MeGicare tliatletea prav�nllon pregnm baneflt for
pre-���abetesSupport �ntlrviCualsatnsnlorrype2��abeteaLdes:y.eDenar�w Cefr�.6'neawUln�Nelwoifc
chanpe pmqram,in-Ferson casaes and co6a1 wppan
focus on NeIgM rndudion
Caro mmapemxM torcusicmus w!M e allong�ike��Tood
of a reaamisa�on baseA on diaynoses,como�9ftliliec
Trans�lion ofCaie(iOCj an0lortuncl;onoi na:u�ihe p�o9rem eneu�as e smooU comD;nca vnm m-NaMo;k
Vaunion�rom nospla�to home pntl retluces
�eadrrrossimn
Tren50�an1 rare menegemenl ia p�^oviEeC hy a leam ol
nuRCa skilied i�Ue IransplB�^�1 proCOss T'an&plant Cero
Menagers wi4 help witn;he preperation for a trensp:enl, ComUined w�f11n-�elwoAc
Transpiant Cere Meneqamen! educate on Ihe tranaplan�p;ocess,.^elp t�e wsioT.er
marage Ihair�xr�fits andcol�a6orate wilh the Irar.splanl
cenierlcam.
This program ulifzes Ihe Girvcai expaNse ol lhs Social
YYurx leam to oeat meet cus;aner neetln aca encouraqc
hea�thy Do�aviors.edtlreas neetl�equlry anA aoc�ai Cor.�inetl wi1��,n-NeN.ork
Sociel Kbrk Progmm tle;emii�aols cf heatlh(SDoH}cor_ems.antl Pe.p
pravenl mosi Common aW!Iisslon�caUsing t1oe1N
Ccntl'..IIO�s
7nis progrem ulifi:as the dinical expenise o/aur
Re9:slered D'�,el�tien leam wslcmers lo Ces1 meet
U onaea Pm9iam cusromar nu:nuonei neeas;promota�ea1!tNul ea�ing CombmeC witn:n-Na:work
pai:ams adoress footl in airAios.er�.011o1u prevent
dietary iss�a rc�a1eE tc wmmon heaPh ccn0�ione
Pmgam u�i:l:es i�e c�n�cai eaper.be of our Resptratoiy
Theropisc tc Ir!mp•ove;Ro c�s�rty o�care Ihrouqh
educo:ion laonl:nG3��an Jf Irlqgers a'Itl m.a^agomonlol
Resp ra:cry Progran COPD;CfiF O��sease p�cc¢ys The progrem is also Cornb��rAd w,ih in-Nefwork
Cesignetl fo tlecrease noxodal ena emerge�cy�vom
��tllizalion•a�cuslcmefs wnh COPU/CH F cendil:ona antl
of'e^a homa ca�o!�e�aFY managomanl clan
4 1�/4/2024 VA A6
Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
'.._,;'.i.�l..i
City of Mi�m18aic/i
Clpna MOGlare AN�ntpe Employar Orvup Plan
MeCIca1 Summ�ry ot Benenb
OA OwitGf l 4 8
Enjoy!!Be enlpping an bu�gel-!nOnA�y felnqOfBfOC n`eais
Mes's sont lo your home or ihe�ome ol m IovaC ano(0 9.a CombirteA wiM irvNehwB
ipoualizeC 0�01.Of an eqinq paRrH)
OisCaunly up to 2S°h oH uvBfal GL•bil rearaCi�f wtlh M1oe
F:In055 DCY[R9 ����p�� ComblMd wilh�M1Nelwark
Tatc fOva�laye o�more rMn Z W6 cn-Oam�nC vttlUOi
and sutlb-DeseG c�essec inc.�d�rg bt.i boCy workoWs,
Virfval FiY'ess Wne,kickDoxir,g,sf�enyl�traitdng,Yn0 P:lalaf Tha flsi Cambir!�tl vAti�In-Netwaik
3o tlaya ae free�.25%a:swual o91nc monthly
memCereMP
$avG 6M1 1}6M(iQ plOdldf NO feMN01 wdlr kadi��tM
teari�aiCs as bw as 5895 per Oevice You wAi afsc
Nearrg Aid�end Fxmre lnjoy B 6C�Oay tBe NYI Yfq i InOMy-Oatk 9uxanlx, (;p�6tt+etl Nilh IrvNeMrork
w:e year C frec tollow-.ry cerc.e S�ye��oallcry supply w
one Uis�ging s:alion in keep yo�pnwered up,�C a three
yaar warcanty wtn pur.hase
Receive OisCou�ls m vulon loats an�eyxwa�et e larya
numbar of indeDendenl and releil prowatrs Pror:dars
Vicbn EzamcanC Eyewea� �naude Pea�.e Via�on,Tsryal Qptiwl,Cm;er.sD've�t, �nC+r80 wl�in-NeNronc
Gl�saea mm.arA LennCrsllan
_.'—e".�.__...____.__""_ ._._____..__ _'
Improvo youf v's�cn w��l�your Ceep EiacouM on tA51{
lasfK Vleicn viaim cd-eclion now irtlutling a CroaCcr nenwrk of �p��oC wN In-NeMorlc
pnrvfverx��:.haose+rom savesi.o�wanoreroaea
p�Dv.tlefi alup t0 1$9F 0((Oul�ptl`<IWofk tNOYidM
s.ve ap l0 2sw,on awpcnaure,pnyqcal tne!apy,
Akemqivs MECiGn� occuDation�therapy.cnUap'acl�c ca�e.^fessage Itiefapy. CAmDi�Utl wth in-NeM�or!c
routina podetry sernws ar�re�slereA Cielioar visde
a w two
Wnons W a .m>ysmn s aromeryaroY
MeO�Mer!Sya:em nei6 e�1ho:O�cn ot e Cution,24 ho�n B tlYy.7 tiays a ComCfne6 w;�Ir.Natv.orlc
wcet
Clan�MWfuis AW�mapa Empbyer Otaup Han
Cave�d enG E�clusiorn
Only�el rees antl U�a�Capentlar.ts v.T.o ary anlNNd!o Motllurr Pa�A arG enrcil���n Pan tl e�e IrUutleC m In;s p�o:e II a reti�ae o.�6epenCerSt is nC
�:it1eG lo MOO�:ca�q Pi�A enC/Or�pi enio!btl ir.Part B,than they aro not eiigiC!e to�oin e Nedaro ACvanlage�lan
Byurg;arinuproOuctBonapermam6erpermonl�bae�a Ea�enroNeew�!ioesetuponlnaravna?�g�El4qmwNanOtl!e
emp oye�preup wilt Ue charye0 e ring�e pe�Med�care member per month prr.m.um�te
Cigna Heaflhrvre rw�rws tha egntla atl;uu IP�Cmmftts sod7or prembuns�n Ni�proposei d w�adjuCmer.ts ere neoessary to
compcy wiM wrrpnt Cenle(a lof MBEiCire 6 Medxaitl SaMaB!(CMS)rt�!es ano isg.da4ons
Bma�ld we co not wwr pxclwfonsj:
Batowu a Irot ot asrvrcaa antl��ems v�e:o�um aro frot corerea unoe�eny conCnien orarc covero0 onry unaer spearrocoraitions
1)Sernas ccnsiOeroC nd roneneDie and nerdaaery,xcording to the slentlarda U Oriqirol lk0�ra
2)Enpnrirne�taimed;�Iproceuurec,surplca�p�eeaurcs,eq:npmenlanCmetlieat���ana Esp�M»�rtalproce0uresa�Citmnsa�el�oseitamaantlprooeauresdem�niro�
by our0'an ertC Onpins:MaGl�an ro not be gsnera'�Iy accep�aQ by�e moCicsl cort+mun�ty EapeMronlal procetlums aM ilems may�e CoveroC Dy0!ipinel Modita'8
w�dar e Meaicere approve0 Gir,rt'Ai reseercn atudy or CY a+�qan
J)Privek roam C1�etgex in a�nspAal are not covered uNess meCicelFy nBCe668ry
4)Fersonai Nems�n your ioom�t a!wco�tat or a akiilsa nursi�g Ia�Nly such as a Iniepnone a�leleharon
5)FWI�lime nuf3ing cere�n your ROme
6)Gwloaial cere Cwladiei um is can proviaed in a wninq homa,�oswcc.ar olher/edtity aetling wMen you Co nof requ:re skilled ma0iul ure er�kiNW
nursngearo Cuetodialcueiaperaonalcaretnelaoesnotinqwretneconiinuingaltnr+lionott�a��edme0iralo�porametlirrlpenonnW,sucnas:antnathelp�
you n�M ac+.ivities ot tlaHy kHng.wco aa DaUiing ar Fnaaing
7�Mamemakar servicos.Homan9ker een:ws inUuOe Desic rou5and0 assialance.IntluOinQ I��..q�l hOubCkOeD��O w!Iq�t moel D�operalion
B)Fees d�arfletl fcr rvm by your immaolate reia�ives ormemoers of yau�nouneno:A
9)Cosmdicsu�geyorprocnCuras Gosmeticsurgoryorpraceduresmoyoecorare0�ncateaolar.acGtlenlalin�uryorforimpruvememo(IhaNnclWntrigola
malfortnetl boGy mOmDaf.CWerBC�or sll8taqee ol reconttn:cN�n fof a 6reest all�ra m96teCtOrtly,flSwe!I ai fof N[Jna(fxt00 broest!o pro0ut0�
sYmmetncal appearanca
t�j RouGna chiropradic care ax[ept manuel merc.publrn W Ine spi�e Io conea e sublu�adon unlesa noleA in Ihe EeneRt surtmery
11)Routine tvot are vibse roletl irt 1ne nerte0t aummary Some Nmited cove�epe is provMad asordlny!o Med:care gu:Ceilnes.a q,�fyou na�e a:aDeMs
1T)OflnopaCi<shces eKcept rt cnoos ara pert ol a kg braca ana are in�ivaea u+tne cosi o/tho orecc.ar;na sn�o�era ror a porson v/iM tl�eC¢ik Wol 0iae9ee
t 3)SuppoAive deir�.c.es Ier lM fee!ercepi�or e person with C�aEnic tuof d�s.esse
i�)Revefsal ol s�arr.ixa:icn procatluns an�Ya nn�yrewipUon ca+traup6w suppiiee
I5j Natumpslh sanices(uses nalural or NMmative ircatments)un!eu�w1ed�n Me Deneld wmrtwry
�e!+es¢nstx�o�oauas«,a wMoe..m P+e�,a.a s:ww..y ay«ww.�qh operaw�p we.amw.w�etea+as m`w.ensomp t��e a�acn m.,�..�c.eomo.ny.mc T�e NeuNFSpring
nam�,apns,a�a mar��am e.mm ey neaenspn,p,u an�mFqee ot neansarv�p na►cn5or.op canr�ns rrtn Alaui aro w oner Maacwr�Mv��da{m riUp�rA PPO pl�ns antl P�rt D
PrRKnpbon IXu�Plartf(W,le}M Wes!suiss,n�a�ntT seieci&ate MeacaW qroprams.Emofa�a�!n a Fw�nSprvp p�o0uct Cepsnw ai coniraC�enawa�
Ail Meeco p�eautti and set scas aro prouMaa ezews�ve�y by or Inroupn operal�ny suns�tlun¢a a atHw�es oi MCOco,uxtuu�q MeCca Conleim+eN Lih Insuru�re r:omq�rty end Medca
Co�tpnmani inlwarsce Con:pa!ry ot fJYW Yprt. T�e MOCoo nwne,loyoa,m0 mYrke cn o.me0 Ey MOOco.U m elfWte 4f MMdco MeGco conu�cl.s r�n McC�c�ro�o orterPM D Preecr.pwn
�r�Q?kns(P�P)in aa'etl sletes[nmilmeM in¢Metico proQuN Uepends on wntretl ienewa'
a 2024 Cipne HeottnCBro
5 11J4/2024 VA A6
Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
,:'�;=na
Clty of Miami Beech•Cigna Healthcare Madicare Adrantage Prescdp6on Drug Plan
PHARMACY SUMMARY OF BENEFITS
�
trtectrve ates �uary . , eoem er
untling ype u ylnsure
itus tate
;t Wion t,
2zr ortnulary MenceO
haRnaq Nehvork ~ CiCare ro e
annacy r�nzul�ai,a} n�sn0ar ear
e uct:,o� aso
� In maual etludlbl
j...._.__..._'___—_._.._.._- iftdlvldual OuCtlGIeMP 85 Ot pYte e
a�i f��F�Oc e ximum
18n ul- - el awmu
n a overage ava
ta aro etail hermaq(- ay upp �er S� �
Ti�tr' S50 0.7
Tier U5.00
Tier S75 00
tenOarC etail �artna�y( - ay p br 1 � Q
T�r 5100 00
Tie� St W 00
Tier Not Availa6k-Specially drugs only available up l0 30�
StanCartl Relaii Pherma�y(tii-90 6ay Supply)�l�ier t $30 00
Tier 51D0.00
Tter 5150 QO
Tier Not Availa6le-SDeciaily drugs only availaWe up to 30-tler
Long-Term are(t-37�aySupp�y)tler7 S1 00
Tier 550.00
Tler E75.00
Tier E75 00
StanCartiMed- rtnrPhartna�y(1-300ay upply)"icri 1
Tier' 550.00
Tier E75.00
Tier 575.00
Stanaard Meil- rCar Pnarmaq(3t-80 Day uppiy) ier t 530.00
Tier 5100.00
Tier f750.00
Tier Noc Available-Specialty tlrugs only avaAable up b 30.dey
Standertl MaM-Orc1er Pnertnacy(6L9U Day Supply�Tier 1 530.W
� Tier $100 OQ
Tier 5750.00
Tier Not Availabie-Specialry druqs only ava�IaWe up to 30.day
Qut-of-Nelwark Coveraqe(1-30 Dey SuPPN Cost-snannp is the aame as In-NeRvork Sta�a/d Retail Phartna�y,end benefit is
Hrtuted to a 30 Day Supply
e strop c oversge tan e a u o- oc a x mum
eneric
Brard D 50
n ce nagamen �
Slap Thera Irniuded
Prior Aulhonzalp Indude0
puantiy�imi Ir�cWded
Va� <Y
enencan ran ign ost pecia m[ toanemonmsu
P s
io s ers mite to one rtarn suppry
on aR u rtronta ovxsQa
Fertifry Druq No
Presctption utam Yes
CoIC 9 Caugb Prep Yes
Cold 8 Cougb Preps induding O7 G Allergy Med�cira No
Weiphl LOsslWeighl Gai Yes
Ereclile DystuncUo Ycs
Courtesy d OESI Dn,g Yes
Non-Setlatinq ArNiNslemi�s No
Coamelfc Oruqs inGudina Druas for Hair lo No
6 11/4;2024 VA A6
Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
mvanfve rugsat opay
Adherence PaCkage(Prevenlive Prelerretl 62n� �
� Gene6c Druys antl Diabetic�tups antl Supptiesy No
Preventi�e Gener'c Drug No
Preventiva Diabetic Dnqs and SuppAe No
PPACA Preventi�.e Aspi No
PPACA Preventive 9reas(Carxer pmg� No
PPACA PmvenGve Fl;:onU No
PPACA Preventrve Foi�c Ao No
PPACA PrevenUve HIV Qny No
PPAGA Preventive Stahns No
PPACA Smoking Cessa6oNDetement Medicasio�u No
Conlreceptive Dnigs and SupQiw No
ute anda ane
e nCaltd ene. e�or erepuarzaUonap ies.
on ra a en
Non- Iendar0 ane Is hone
City of Miaml Baach-Clyna Healthcare Medkara AdvanWge Prtacriptlo�Druq Plen
CAYEATS,EXCIUSION5 anC DEFINITIONS
The Emplayer Part D progrem does nol integrate with medical R�an deductibles,oul-of-pocket ma�dmums,or annual mabmums.
On7y retirees end their dependents who are enlitied to Metlicnre PaR A andlor enrolletl in Part B ere include.d in fhis quote.lf a retiree or
dependent is not entitled lo Medicare Part A antl/or not enrolled in Part B,Ihen tbey ere nol eligible to join this plan
Billing tor this protluct is on a per memCer per month basis.Each enrollee will be set up on their own eligibiAty record and U�e
employer group will be charged a single per Modicere memher per month premium iste.
Cigna HeaNhcare reserves the right to adjusl the bene(ds andlor premlums in fhis proposel if such adjustments are necessary M
compry vnth curtent Centers for MeAicere 8 Medicaid SeMces(CMS)rules and repulations,antl applicahle pharmacy stete mandates
Orua Excloslons:
A Medicare PrescripNon Drug Plan can't cover a drup Ihatwould be coveretl under Metlicare Parl A a Pert B.Also,while a Medicare
Prescrption Drup Plan can cover oft-label uses(meaning fa uses other Nan thase indicaled on e diug's lebel as approved by lhe fbo0 anQ Dnq
ACministretlon)01 a prescriplion drug,we cover Ihe oR-1a6e1 use only in cases where the use is suppoReO by cetlain raference Dook cilatlons
Congress speci(cally listed fhe reference 600ks iha(IIs1 whefher the off-1a6e1 use would be permiped(ihese re(erence books are:
(1)Amencan Hnspital Formulnry SeMce Orvp Inlormaiion,(2)ttu DRUGOEX Information System).
6y law,certa�n rypes of drugs,nr rateyones of Arups,ara not covered by Medicara Prescription Druq Plans.These drugs are not cansidered
Part D Arups and msy be rdenetl to as"exdusions"or'nan-PaR D drugs'These drugs indude:
•Non-prescriptian drugs(or ovcr-Ne-counter tlrugs).
•Drugs usetl for anorettts,weighl loss,or weipht pain.
•Drugs when used to promote teAiliry.
•Drugs when used tor cosmelic purposes or hair grvwih,
•Drugs when used tor the symplomatic relief of mugh end colds.
•Prescnplion vilemins antl mineral products,except prenatai Nlartdns antl Buoride preparations.
•Outpatient drugs for which�he manuladurer seeks to require that essodated tests or moniloring services De purdiaseG exdusively Uom
Ihe manulaciurer as a wiWdion ot sele.
•�rugs,such as Uiagra,Cialis,Lavitre,and Caverjed,when used for I�e treatment of sexual or erectile dysfuoclion.
In addition,fhe(ollwnng exd�sions apply to any senrice that is a coveretl ezpense uoder this plan,but is no!oovered by Medirare:
•Fxpenses ior supplies,rare,treatment,or surgery lhat are not medically necessary.
•To the eMent that payment is unlawful where the person resiQes when the expenses are incuRed.
•Charges which a customer is not obligated to pay or br which they are not bliled or ta which would not have been billed except that Ney Here
mHered unAr.r teis pen.
7 11/4/2024 VA A6
Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
Itions
Cipne FNalthcare:
For purposes of Ihis agreemenl mcans HeailhSpring Life&Health Insurance Company.Inc.
aV�+RR�Y ProraYron:
Uxually,ihe emount for a covere4 prescriplion�ug is a one montM1 suppry.Hawever,�t Ne artrounl is less I�an a aie month supply,Ihen fhe
ertaunl peiC is proreted Dased an the actual amou�t received Proration may not apply in certain arcumstances as outlined in CMS
puiCance.Typically p�oration epaies ta oral solid p�escffplions.
Reqil example:Plan has a S10 copay tor a 30 day wppiy Acival day suppry fpleed��s 10 Oay suppy.Copey is proratetl as foqows:
St0 diNtled 6y JQ a$.3333 per tlay.rounaeC lo S 33,timas tl�e Oay suppiy of 10.epuals 53 90 mpay owed by aisiomer
Loag-Tarm Cara�xample:Plan�as a 510 copay tor a 31 day suppy.Adual day supply Giled is 70 Oay wDD�Y.Copey is proraled as tollaws�. �
S10 divided Dy 31 a f.3226 par tlay,rounded to 5 32,times Ihe day suppry oi 1Q,equals 53 20 wpay oweA by cuslomer.
Employar Group WaWar Plans�EGWPsg
EGWPs are a rype ot Metlicare plan oRered by employers ta`ormer employees and memners of some companies,urrons or govemmenl apencies
EGWPs ere olfereA try insurers who contract with CMS to proviae coverage for medical and/or prescriplion drug benefils.CMS granls oertam
prvgram waivas andtor modificetions for EGN?'plans thet tlo nol appty to individual pans. Waivers enable LGWPs lo provide cuslomized bene5ts.
teilwed beneficiary educational msterfals,and rtmre fle�tiCle enroliment pmcedures.
tosulin Drug Producb:
Customere vroo't pay more than 535 for n one.mont�supply oF eact�insulin produd cavered�y our plan no matter whal cost-shari�lier ifs on,
eren if 8iey haven't paitl the deduclible If the inaulin is on a iMr where cos4 sharinp is bwer Ihan 535,Mey wil pay the lower oosf
Non•Part D�rugs:
The fdlowing drug categories are exduGeO from CMS covefaqe 1/a plan deCuctLie applies,aoy non-Pert D coverage edAe0lo Ne pian is not
suDject!o ihe plan deducti�e.The cosl share tor these drugs is the same as tAe coSEshares in Ihe initial corerape phase baseC on Mup
dassification
•Cosmetk Drugs i'xludinp Drufle for Hair loss:drvgs when used fur cosmetic purposes ot har qnwth.
•Courtesy Drupa�refers to Orvgs normally cavered unUer commercial phartnecy plans but are exclutled Dy CMS.
•DESI(Orup Ettcacy Study Imptemenbtion)Orups:refers ro drups that were inVaduced betvieen 1938-7962 entl approved tor safety but not
efTeaive�ss DE51 drugs are nol'qrand(athered"a Aenerally recognized as sata end effecliva(GRAStE).
•Frrti�ity Diugs-drups used to promote fertiliry
•Rreecription Vitamins-drugs used far prescnption vifami ns and rmnerel pioducls,excepl pi0netel vifsmins aod fluoride prep�rali�ns
•Cold b Cough Pnps-tlrvps used for symptomalic relief of couqh aad coWs
•Cold d Cooyh Propa including OTC Alle�gy Medicine-arups usetl for symptomelicreliel of cougA anC colds inGuAirq OTC ellergy metlxine.
•Non-Sadatinp Antihistaminos-Mcihisramloc abteu desisned co not make people drorrsy.
•Weight losslWeight Gain-drvgs used(or anorexia,weight ioss,weight gein
�Erectile Dysfunetion-Crups useA fw erecula dystunaion and temale sexual Aysfunction.
OpioM Orups:
Customers wno have received a recent f11 dan opioid pain medicadon(nol opidd rtelve)are timited lo up to a month's wpply of t�at metlication
at one time
Qutot-Network Coveraga:
Geixral{y,we cover Orvys fdled et an out-oi•network Dharmacy only when Ihe plan pertidpant is not aDle to use a network pharmacy Customers wil
most NMely be required to psy the ditterence behveen what Mey pay for the drug at the out-ol-network phaimaq and ihe oost Ihetwe would oover al an
in-nepwrk phamlacy.Here are the arcumstances when we would cover prasaiptwns filled al en out-of-netwak pharmacy:
•Custaner lravets a�tside the plan's service area mW runs out nf w loses uovere0 Part 0 drugs,or becomes ill and needs a covereC Part D drug
and cannotaccess a network phartnaq
•Gustomers xe unable to otrtain a wvcrod Part D tlrug in a fimely manrterwilhin�ha service area Decause,fo�example,tAera Is no neRwrk
pharmacyvnthin e reasonable d�virp Cislance thal Rravides 24ft servioe
•Cus�omers are filling e prescnptlon for a eoveretl Part D drug and that particular drug Is no�requlazy stacked at an accessible neMorte
Relait or Mail-Order phaanacy
•The Part D tlrups arc Aispensed Dy an out-of-neMrork Instltution-Dased p�ermacywhile in an emergency faciAty,provider-Dasetl Uinic.
outpa6ent wrgery,a other oulpatiu�t setting.
Part D Vaccines:
Our plen covers most Part D vaccines at no cost even when Ihe deduGiWe is not met
PreferteC Preventive orug�at SO Cop�y:
Certain Genenc andfor Brend Preventive Medicatlans iden6fied by Cigne Healtncare that are dispensed Dy a Retail or Maii-Order phartnacy
em not suqect�o the Eeductible pf appticaMe),mpay w tou�surance.
Tief l.�hoYng:
Tier 1:Genenc Dmgs
Tier 2�.Preferted Brend Drugs
Ter 3�Non-Pretertad Drups
Tier a�Specielty Urugs
All HealthSpring products and services are provided exclusively by or through operating subsidiaries or aKliates of HealthSpri�g Life 8�Heaith
Insurance Company,inc. The HealthSpring name,logos,and marks are owned by HealthSpring,or an afflliate of HealthSpring. HeatthSpring
contracts with Medicare to ofler Medicare Advantage HMO and PPO plans and PaA D Prescription Drug Plans(PDP)in seiect states,and with
select State Medicaid programs.Enroliment in a Heaith5pring product depends on contract renewal.
All Medco products and services are provided exdusively by or through operating subsidianes or a�liates of Medco,including Medco Containment
tife Insurance Company and Medco Containment insurance Company of New York. The Medco name,logos.and marics are ow�ed 6y Medco,or
an aKliate of Medco.Medco contracts with Medicare to offer Part D Prescription Drug Plans(P�P)in select states Enrollment in a Medco product
depends on contract renewal.
��2024 Cigna i leaithceic
8 11/4/2024 VA Afi
Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
Gity of Miami Beach-Cigna Medicare Advantage Prescription Drug Plan
Terms and Conditions
A. Generai Tertns of this Proposal
�Cigna is pleased to present ttiis Proposal for a Fully Insured group Medica�e Advantage and Gigna Rz Medicare(PDP)benetit plan.
•This proposal i&valid for 90 days from its origina!date of release of 2024-08-05.
•Any revisions or updates made to this proposal will not renew this valid Iimeframe unless expressly communicated by Cigna
•The infortnation contained In thls Proposal by Ggna is propnetary and highry confidential I[is heing provided with the understanding
lhat it wiil not be used by the employer,its representatives or consultants for any purpose other than[he evaluation of the Proposal.
Urder no circumstances is any of infom,ation contalned herein(inciuding excerpts,summaries,extracts,and evaluations thereo�to be
used,disseminated,disciosed or otherwise the communicated to any person or entity other than the emptoyer,its representatives and
consultants,and their respective employees who a2 tlirectly involved in the evaluation process.
Proposal Caveats
Cigna may revise or withdraw this Renewal Proposal A
•there is a change to the eHective date of the quote
•the policy penoQ length is differenf than the quote.
•the Plan benefits are ditferent than shown in the RFP or benefit modifcations are requested
•there is a change in law,regulation,tax rates,or the applicatlon of any of these that aHects Cigna's costs.
•there are tess than 25 retirees or Iess than 70%of total eligible individuais enroll in the Plan.
•enroliment in the Pian at any time varies by 10%or more irom the enrollment assumed by Cigna in establishing the rates andlor fees
set torth herein
�the employer changes its level of contribution toward the cost of the coverage
•the employer conlributes toward the cost of purchasing individual coverage fo�an eligible individual
•Cigna is not the exclusive provider of Medicare Advantage antl PDP benefits and the employer does not contribute the same
percentage to the cost of each employer-sponsored plan unless expressly communicated by Cigna.
•the census data or experience data provided is deemed inaccu2te
•there is a request to motlify Commissions andlor benetit advisor fees
•Cigna is requested to infertace with a third party vendor.
•Cigna is requested to provide optional sennces
•administration of the Plan will require more than the following:
-8illing lines:300
-Biliing and Ciaim B�anch Benefit Options 60
B. Scope and Application of this Proposal
•Unless olherwise indicated, the coverage reflected in thls proposal supersedes and renders null and void any pnor Cigna offer or
proposal w�th respect to the Plan
-Although this proposai may inciude multiple piansloptions for the empioyer sponsored plan,Cigna reserves the nght ro limit the
number ot plansloptlons based on the otfering environment and the total number of Medicare eligible indviduals.Final plan setection
requires approval dy underv✓riting prior to implemerrtation.
�The in(oima[ion and materiais provided for evaluation ot this quote were assumed to ba correct Ii matenal ertors or omissions are
found after the quote is issued,Cigna reserves the rght to revise or rescind the quote.
�Standard service perforriance guarantees up l0 12500 have been included in this Medicare proposal.
•This quote fs on an incurred besis.Cigna wili be responsible for all eligible claims incurred on or a/ter the effeclive date through the
end of the contract period
�Group agrees to restrict enrollment in the Plan to those individuals eligiWe for Group's employment-basetl retiree group coverage who
are eligible for Medicare.
•This proposal assumes all eligible individuals are enroiled in Medicare Part A and PaA 8 and the group provides the 6eneficiary
Medicare plan number to complete enroliment
•Infortnation provided here is pendirtg CMS approral unless otherwise noted
•Rates assume CMS recognizes the plan as an annual plan and it will renew on 1l�t2026.
9 11(4l2024 VA A6
Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
Cigna Medicare Advantage(MA)and Gigna Rx Med+care(PDP)
•The rates are contingent upon the eiigibie individual residing in the service area of the quoted Medicare Advantage(MA)and
Medicare Part D(PD)plan The enrWlment wiil be based on the eligible individual's pnmary residence as defined by CMS
•The benefits presented in the Proposal are a high-level summary Please consult the summary of benefits for a more detailed list of
benetits proposed in this Cigna plan.Due to annual changes in CMS mandated benefits,benefits may differ for certain service
ca(egorie5.
•Due to regulatory reQuirements tor the Medicare Advantage and/or Medicare Part D products,services and timing may differ Some
areas o(difference include,but are nof limited to:reporting,web services,disease and wellness management,quality iricentives,
provider directones and networlcs,eligibiliry timing,communication pieces for pre-enroilment and members,bilNng,pharmacy and
medical data integration,customer service,claims and appeals
•This proposal includes Medicare Advantage and Medicare Part D products,certain administ2tive services,such as audits and
certifications,wili be integrated Account management and implemeotations are also integrated,but with speciaf processes for
Medicare Advantage and Medicare Part D
•Cigna requires a m!nimum of 20 enrolled members per standard proauct oKering to renew a�Employer Sponsored plan.
�Rates will need to Oe re-evaluated if sold on a standalone basis
Rate Cap
•The proposal includes a 2nd Year rate cap pf 5°!0
•This assumes fuil-replacement and enrotlment of 53+1-10�.
•The Premium Rate CaplGuarantee is subject to negotiation 6`
-CfvtS MA reimtaursement rates increase by less than OA°h through actual reimaursement rates,adjusiments(e g,coding
intensity}antl/or other methodobgy changes to payment rates
^Any tnRation Reduction Ad pRA),or other matenal changes in laws and regulations that change premium considerations and
impad,including but not limited to:
-Changes to Part D Direct Subsidy estimates.
-Changes to pharmaceuticaf manufacturers level of rebates
-Amendments to recent CMS gwdance to actuarial assumptions for annual increase i�standard pa�t D henefit parameters.
-If rebates are required to be healed as a point-of-sale reductipn in drug costs
All HeaithSpring products and services are provided exdusively by or ihrough operating subsidianes or affiliafes of HealthSpring Life&Nealth
Insurance Company,Inc The HealthSpnng name,logos,and marks are owned dy HeaithSpri�g,or an affiiiate of HealthSpring HealthSpring
contracts with Medicare to offer Medicare Advantage HMO and PPO plans and Part D Prescnption Drug Plans(PDP)in seled states,and with
select State Medicaid programs Enrollment in a HealthSpring produd depends on contract renewal.
All Medco produds and services are provided exclusivery by or through operating subsidianes or aftiliates of Medco,including Medco
Containment Life Insurence Company and Medco Containment Insurence Comparry of New York. The Medco name,logos,and marks are
owned by Medco,or an affiliate of Medco Medco contracts with Medica2 to offer Part D Prescription Drug Plans(P4P)in select states
Enroliment in a Medco product depends on contract renewal
�2024 Cigna Healthcare
10 11/4/2024 VA A6
Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
AMENDED EXHIBIT B
GROUP ADMIN{STRATiVE GU{DEL{NES
(to be attached)
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Docusign Envelope�D:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
�igna Healt�care
1V�.edicare Advantage Plans
Group Administrative Guide
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Thank you for We're pleased to work with you to improve the health,
sharing our `�`�ell-being and peace of mind of your retirees.Our
goal is to provide yau with resources you need for
corrimitment to easier plan administration.Please take some time
quality care. to review the plan administration topics and refer
to this Cigna Heolthcare Medicare Advantage
Plans Group Admrnistrative Guide as needed.
Contents Terms to know I
Employer Group Portal 2
Eligibility and enrollment 3
Prernium billing and payment 10
Employer/Union 6roup Medicare Advantage Agreement 12
Customer communications 12
Customer resources 15
Claims administration 16
Additional resources 16
Docusign Envelope ID: F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
Terms to know
Group
The term"Group'throughout this document refers to employers,unions and trusts.
Customer
The term"customer"throughout this document refers to retirees,covered dependents,beneficiaries
and individuals.
Centers for Medicare&Medicaid Services(CMS)
This is the federaf agency that runs the Medicare program and regulates all plons ond provisions.
Additional informotion can be found at www.Medicare.gov or by calling I-800-MEDICARE.
Emptoyer Group Waiver Ptan(EGWP)
Group Medicare Advontoge Plans are aiso called Employer Group Waiver Plans(EGWPs),pronounced
"egg-whips"EGWPs are a type of Medicare Advantage plon offered to employees and retirees of some
companies,unions or government agencies.
Part D Low-Income Subsidy(LIS)
People with limited income and resources may qualify for Extra Help for their prescription drug benefit.
Extra Help is referred to as a Low-Income Subsidy(LIS).The amount of Extra Help an individual may receive
depends on their income and resources.
Some people automatically qualify for Extra Help and do not have to apply for it.If they answer"yes"to any
of the questians below,they automatically qualify for Extra Help.This means they will receive a certain
dallar amount that may go toword their premiums and thei�cost-shares for Part D prescription drugs:
• Qo you have Medicare and full coverage from a state Medicaid program?
• Ro you get Supplemental Security Income?
• Do you get help from your state Medicaid program paying your Medicore premiums?
For example,do you belong to a Medicare Savings Program,such as the Qualified Medicare
Beneficiary(QMB},Specified Low-Income Medicare Beneficiory(SLMB)or Qualified
Individual(QI}program?
Medicare will mail a gray Loss of Deemed Status Notice to individuals in September if Social Security
determines that they no longer automatically qualify for Extra Help for the coming year.Qur plan will also
mail a notice to encourage people to apply to determine if they still qualify for Extra Help.Customers who
no longer qualify for Extra Help will receive a notice in December.
If your enrollees have questions about Extra Help with prescription drug costs or need assistance
completing an application,they can contact the Social Security Administration(5SA)at I-800-772-1213
or visit SocialSecurity.gov.
I
Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
Terms to know(continued)
Medicare Advantage Pian(Part C} Medicare Prescription Drug Plan(Part D)
A type of Medicare plan offered by A stand-olone drug plan offered by insurers and
private health insurance carriers that other private companies to people who get
contract with Medicare to provide benefits through the Original Medicare Plan or
Medicare Part A and Part B benefits. through a Medicare Private Fee-for-Service Plan
Cigna Healthcare is one such carrier. that doesn't offer prescription drug coverage.
Medicare Advantage medical plans may Medicare Advantage Plans may also offer
be referred to as MA plans,and prescription drug coverage that must follow the
Medicare Advontage plans with same rules as Medicare Prescription Drug Plans,
integrated Part D coverage may be also referred to as PDP.
referred to as MAPD plans.
Federat exemption
The Medicare Modernization Act of 2003 has a very strong p�eemption provision.This means that in
general,state laws don't apply to standard Part C and Port D benefits unless they pertain to state licensing
or financial solvency of the insurer.Beginning in 2014,Part D coverage under an EGWP that provides
customers with supplemental benefits beyond the porameters of the defined standard Part D benefit are
treated as non-Medicare Other Health Insu�ance(OHIJ that wraps around Part D.Employers/unions offering
EGWPs must ensure any supplementof benefits comply with any applicoble requirements for issuance under
state insurance lows andlor ERISA rules.This is simila�to commerciol heafth care products that are subject to
both state laws and federal laws.Certain state exemptions may apply.
Employer Group Portal
Go online to save time.
The Cigna Nealthcares'"Medicare Emplayer Group Portal helps you manage your plan.From requesting
replacement identification(ID)cards to having access to various reporting and plan documents,you have
immediate access to information to help simplify plan administration.The Employer Portal will provide
employers the ability to:
• View Group Enrollment Reports. • Submit address change requests.
• View Graup Billing Reports(invoices). • View customer eligibility details,including
- View when a customer's ID card was last information for access to care(enrolled.
ordered/rnailed. future and disenrolled in the last 12 months).
• Submit ID card replacement requests. • View/print plan documents and forms.
Get started.
To request Employer Portal access,provide your name and email address to your designated Medicare
Client Account Managec Saon after,you will receive an email invitation to register and access the portal at
Employer.HSConnect�nline.com/Home/Logln.Your Medicare Client Account Manager can provide
training and/or a user guide to get you started.
2
Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
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Eligibility and enrollment
Plan eligibility
Customers must be enrolled in both Medicare Part (HMO,HMOPOS,PPO)and on"800 series"
A and Part B to enroll in a Cigna Healthcare stand-alone PDP.CMS requires the separate
Medicare Advantage plan and must be entitled to medical and prescription drug carriers to work
Medicare Part A and Part B benefits as of the closely together with the employer sponsor to
effective date of coverage under the plan.If not, provide coordinated care and disease
CMS will reject the application and the customer management services between the medical and
will not hove coverage under the Cigna Healthcare pharmacy portions of the benefit.This coordination
EGWP Medicore plan.To avoid these situations,the is similar to the kind that would be offered if the
Group rnust validate the customer's Medicare employer purchased the medical coverage and the
status by requesting their Medicare ID card.Prior drug coverage from a single carrier under one
to sending pre-enrollment packages.Cigna Medicare Advantage pian with Part D.
Healthcare can verify Medicare Part A and B A customer is eligible to enroll in the Cigna Healthcare
enrollment to confirm eligibility for potentiai Medicare EGWP as long as the enrollee permanently
enrollees. In order to perform the verification, resides in the Cigna Healthcare Medicare service
the foliowing demographic information is required: area. To determine the service area foryour plan,
Medicare Beneficiary Identifier(MBI),name,dote of enrollees should refer to their Evidence of Coverage
birth(DOB)and gender.If the Group has customers (EOC)document. For purposes of enrollment in the
who don't meet the eligibility requirements to enroll Cigna Healthcare Medicare EGWP,incarcerated
in the Cig�a Healthcare Medicare E6WP,the Group customers are to be considered as residing out of the
should contact their Cigna Healthcare Sales p�an service area,regardless of the location of the
Representative to discuss possible alternative plans. �orrectional facility.
There are specific sign-up periods when a Customers must be U.S.citizens or lawfully
customer con enrol�in Medicare Part A and/or B. present in the United States.CMS will notify Cigna
If the customer does not enroll during their Initial Healthcare if the customer is not eligible to enroil
Enrollment Period or a Special Enroliment Period,they on this basis at the time oE enrollment.Cigna
will need to enroll during the General Enrollment Healthcare will notify the Group via the Group
Period,between lanuory I and March 31 each year. Enrollment Report.
Coverage will start the first day of the month after
they sign up.The customer may have to pay a higher Please reference Chapter 2 of the Medicore
Part A and/or Part B premium for late enrollment. Advontage Enrollment and Disenrollment manual
found on CMS.gov for complete enroliment and
A customer may not be enrolled in more than one disenrollment information.
Medicare plan at any given time.However,CMS has
granted a waiver for all employer and union groups
to simultaneously enroli their members in an"800
Series"Local MA-Only Coordinated Care Plan
3
Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
F.IigibiliTy ond enro(Iment(continued} � . . ., . ._ . . .. .... � _. . . �. ..
Medicare eligibility
Medicare is usually available for people age 65 ar older,younger people with disabilities,and people with
permanent kidney failure requiring dialysis or transplant,also known as end-stage renal disease(ESRDj.
Customers must be in a non-working status(i.e..retiree or disablec�or entitled to benefits due to a
retirement status(i.e.,spouse of retiree),and Medicare must be primary.
Age Disability
Custamers are typically eligible for Medicare at Customers can become Medicare eligible due to
age 65.To be eligible for our plan,the cusiomer disability.To be eligible for our plan,the customer
must also meet eligibility requirements outlined must also meet eligibility requirements outlined in
in the Plan eligibility section. the Plan eligibility section.
• For employer groups with 20 or more • For employer groups with 100 or more
employees,Medicare will pay secondary if employees,Medicare will poy secondary if
the customer has other coverage through the customer has other coverage through
their employer or spouse based on their their employer or spouse based on their
current employment status. current employment stotus.
• For employer groups with under 20 • For employer groups with under 100
employees,Medicare will pay primary. employees,Medicare wilt pay primary.
End-stage renal disease(ESRD)
Customers can become Medicore eligible due an ESRD diognosis.
� If Medicare already pays primary for the customer due to age or disability and subsequently
they are diagnosed with ESRD,Medicare will continue to pay primary.
• If the customer becomes eligible for Medicare because of ESRD only,Medicare coverage will
start the fourth month of dialysis treatments,unless certain criteria are met.Medicare will pay
secondary for the first 30 months.At the end of the 30-month coordination period,the
customer becomes eligible to enrof!in the employer group Medicare Advantage plan'
• If the customer turns 65 during the 30-month coordinotion period,Medicare remains
secondary until the end of the coordination period.
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Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
Eligibilityand enrollment(continued) , _
Medicare Beneficiary Identifier(MBI)
CMS requires that the customer MBI be included with eoch enroliment applicotion.The MBI can he
faund on the customer's Medicare ID card.The Group is responsible for providing the customer's MBI
to Cigna Healthcare with their enrallment application.Eligibility received without the MBI will be
considered an incomplete enrollment application(see Incomplete enrollment lnformation).The
customer will not have access to care due to incomplete enrollment.As a reminder.Cigna Healthcare
can verify Medicare Part A and B enrollment along with MBI for potential enrollees.See the Plan
eligibility section for more details.
Enrollment information required by CMS and Cigna Healthcare for Medicare customers
The Group must pravide all the information required by CMS and Cigna Healthcare in order to successfully
enroll the customer into the elected plan.
Required information
• Customer name > Disenrollment Reason Code when a concel
• Customer DOB date is present ond the disenrollment is not
• Customer gender vofuntory
• Permanent residence address: • Primory care provider(PCP),p�ovider ID or
National Provider ldentifier(NPI)
> If a P.O.Box is used for the mailing address, , Required for Medicare Advantage HMO:if
then the Group must also provide the
customer's physical address. not received,a PCP will be auto-assigned
> Optional but highly recommended for
> Enrollment opplications received without the Medicare Advantage PPO
permanent residence address will be
considered an incomplete application{see • Other insurance information
Incomplete enrollment information).
> If the permanent residence address cannot
be provided due to security concerns,a
Permanent Residence Attestation can be Recommended information
provided by the ciient or the customer. • Phone number
� Mailing address(if different than permanent • Email address
residence)
Newly enrolled customers with phone
• Customer MBI
numbers and email addresses will receive a
� Account number Welcome Call and Welcome Emails to answer
• Branch code any questions they moy have and review key
• Benefit option code benefits,features and resources to help
• Coverage effective date them make the most of their new plan.
• Coveroge cancel date(required for all At other pants during the year,phone
disenrollments,excluding those initiated numbers and email addresses may be used
by CMS) for clinical care outreaches or to share
plan information and updates.
5
Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
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Eligikaility and enrollment(continucd)
Eligibility format and processing Incorrfplete enrollment information
The following methods are acceptable for Enrollment information that is incomplete is not legolly
submitting enrollments to Cigna Healthcare: valid for enrollment into the Cigna Healthcare Medicare
• Automated eligibility file EGWP.In addition,an enrollment is not legally valid if it is
later determined that the customer did not meei all of
• CMS-compliant spreadsheet the CMS eligibility requirements.
Enrollment requests via phone call
or email ore never allowed,even in an �f there is missing or incorrect information,incfuding a
emergency situation.
missing permanent residence address when a P.O.Box is
provided,the customer will receive a letter instructing
CMS requires a seven-calendar-day them to contact the Cigna Healthcare Dedicated
processing time from the date completed Medicare Customer Service Team(see Customer
Medicore eligibility is received by Cigna resources);they can immediately update the missing
Healthcare.We wi11 send all enrollment informotion in order to expedite processing the initial
information to CMS.In the event an enrollment.Cigna Healthcare will notify the Group of the
enrollment is rejected,a letter will be sent to missing information on the Group Enrollment and Critical
the customer indicating the reoson for the Error Reports for the Group to update their records.
rejection.The Group will receive a Group
Enroliment Report that identifies the The customer has 21 days to respond to the request for
customers who have not been accepted missing information.If a valid MBI or permanent
by CMS. �esidence address cannat be obtained within 21 days,
Cigna Healthcare will send the customer a Denial of
• G�oup Enrollment Report Enrollment letter and they will notify the Group that the
This report is generated weekly upon customer must be terminaied from the Cigna Healthcare
receipt of the CMS response file and Medicare EGWP on the Group Enrollment Report.The
includes all accepted enrollments into, Graup may choose to move the customer to a non-
disenrollments from and address EGWP,provide the necessary information to complete
changes related to the plan.The report enrollment and resubmit the customer(effective date
will indicate when action is required bY must be within the CMS allowable time frame},or they
the Group. may choose to remove the customer from Cigna
• Critical Error Report Healthcare coverage on future files.If the inforrnation is
This report contains errors encountered provided after the 21 days,the customer's effective date
when the eligibility file is processed. will be postponed until the following month,when the
customer's completed information is received and
validated by CMS.
6
Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
Eligi6ilityandenrollment(continued) � ' . .. :� r: , '�'� � �'. � �� �
Start dates Terminations
CMS has sole authority to verify effective dates; Terminations will always be the last day
however,a proposed effective date may be of the month,including terminations resutting
communicated to the customer.Effective dotes will from the death of the customer.The
afways be the first day of the month.The effective date disenroflment is effective the last day of the
may not be eariier than the first of the month following month in which the customer(or his/her�egal
the month in which the customer enroilment request was representative)provides notice to disenroll to
made.The effective date may not be earlier than the the Group and the Group sends the
first day of the customer's entitlement to Medicare.If a disenroilment to Cigna Heolthcare.The
customer's enrollment is submitted with a date prior to disenrollment date may not be earlier than
their entitlement date,Cigna Nealthcare wili process the the end of the month in which the customer
enrollment using the Medicare entitlement date. disenrollment request was made or the
Enrollments cannot be processed earlier than three customer no longer quolifies for the plan.
months prior to the effective date.
Retroactivity
Retroactive enrollments and disenrollments are not allowed,except i�extraordinary circumstances
(subject to audit by CM5)when the Group knew of the customer's enrollment or disenrollment intent
prior to the requested effective date.The effective date may be retroactive up to,but not
exceeding,three months from the dote Cigna Healthcare received the request from the Group.The
ability to submit limited retroactive enrollment transactions is to be used only for the purpose of
submitting a retroactive enrollment made necessary due to the Group's delay in forwarding the
completed enrollment request to Cigna Healthcare.Repeated retroactive requests by a Group may
indicate an ongoing problem to CMS and lead to a request from CMS to review the Group's
documentation of their records.
CMS requires a special review process when requesting enrollment/disenrollment effective dates
that are older than three manths.If the Group submits a request older than three months.Cigna
Heolthcare will request a completed form,including the required CMS documentation:
• The customer's enrollmentldisenrollment intent(election form,call notes,opt-out form,etc.,
doted prior to the requested effective date)
• The premium impact to the customer if the request is approved
• Hardship created for the customer if the request is not approved
• The reason for the Group's delay in submission to Cigna Healthcare and preventive
actions to avoid future occurrences
Once received,we will review the documentation to determine if it meets CMS requirements.If it
doesn't,we will work with you for alternative options.If the documentation supports the requested
enrollment/disenrollment effective date,we wilf submit the request to CMS for review.This review
can take CMS up to 60 days.In the event that CMS denies the retroactive request,we will work with
you to determine an alternative solution within CMS guidelines thot minimizes customer impact.
7
Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
F,ligibility and enrollment(continued)
Disenrollment/Cancellation
A customer may disenroll from a Medicare Advantage the effective date,retroactive disenroliment and
plon with or without Part D only during one of the rei�stotement actions may be necessory.This is only
CMS-approved election periods.If the customer is available on a very limited exception basis per
enrolied in an EGWP-sponsored plan,the EGWP CMS guidelines.See Retroactivity.
Special Election Period is ovailable,which allows the
customer to disenroll at any time during the plan year. CM$-initiated disenr'ollments
The customer must elect another Part D plan or other
creditable prescription drug coverage that is at least CMS will automatically disenroll a eustomer:
as good as the standard Medicare prescription drug • Upon notification of his/her death.
coverage or they may be subject to a late enrollment Disenrollments due to date of death can only be
penalty.When the customer elects another Medicare initiated by CMS.
Advantage plan with or without Part D,CMS will • Upon enrollment in another MA/MAPD or
generate an automatic disenrollment from the current individual PDP(MA plans).
Medicare Advantage plan.CMS will notify Cigna . Upon enrollment in another MA/MAPD or PDP
Healthcare,and Cigna Healthcare will send the P�an(MAPD plans).
customer a letter ond notify the Group through the
Group Enrollme�t Report.The Group must terminate ' Wha is no longer entitled to either Medicare Part
the customer from their plan upon notification from A andlor B benefits?
Cigna Healthcare using the date provided by CMS.This � For failure to pay their Part D income-related
individual may not remain enrolled in the Cigna monthly adjustment amount(IRMAA)to
Healthcare Medicare EGWP the government.
Cancellations may be necessary in cases of mistaken ' Upon notification of a change in residence that
enrollment or disenrollment mode by a customer.
results in the customer being outside of the
Requests for cancellations can only be accepted prior service area(including incarceration).
to the effective date of the enrollment or � If it is determined he or she is unlawfully present
disenrollment request.tf a cancellation occurs after in the United States.
CMS-initiated reinstatements
� CMS will automatically reinstate a custamer in the following situations:
• Customer was disenrolled due to enrollment in another plan and the new plan is cancelled.
• CMS disenrolled customer due to erroneous report of death and CMS has corrected
the retiree's information.
• CMS disenrolled customer for failure to pay IRMAA and the customer has been approved
for reinstatement due to good cause and customer fulfills requirements.
Customers who have been automaticQlly reinstated will appear on the Enrolled Members
tab of the Group Enrollment report.If the Gro�p does not agree to the reinstatement,Cigna
Healtheare will submit a disenrollment transoction to CMS.If the Group agrees to reinstate
the customer,the customer will remain enrolled in the plan.For failure to pay IRMAA,if CMS
notifies Cigna Healthcare prior to reinstating the customer,we will verify if the Group agrees to
the reinstatement prior to providing CMS approval for the reinstatement.If the Group agrees to
reinstate the customer,notification must be received within five calendar days.
8
Docusign Envelope ID: F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
Eligihilityandenrollment(cantinued) ��GN•�NE1�IJ�iC4hr,�ltl) �'.tcu.U' 4N7:.(-LF�_��SGROf1P,1i>7�IN.S(IiATIV-GU1Cn�
Termination due to non-payment af premiums
If the Group's policy is to disenroil enrollees for failure to pay their monthly premium,the Group must apply
the policy consistently across its enrollees.The Group must give an enrollee a minimum grace period and
provide them with written notice priar to disenroliment.The grace periad must be at least two calendar
months,and it begins on the first day of the month for which the premium is unpaid.If an enroilee fails to
pay his or her premium within the grace period,the enrollee can be disenralled on the first day after the
end of the grace period.The Group can attempt to collect the premium but cannot retroactively terminate
the enrollee.
Income-related monthly adjustment Income-related monthly adjustment amount
amount(IRMAA) (IRMAA)terminations
Medicare-eligible customers with Part D • When a customer does not pay their IRMAA to the
coverage couid be assessed a higher Part D Social Security Administration.CMS will notify Cigna
premium based on their annual income. Healthcare that the customer must be terminated.
• Customers with a single annual income Cigna Healthcare will then notify the Group via the
over$103,000 orjoint income of over Group Enrollment Report that the customer must be
$206,000 wil(be charged additional terminated per CMS.
premiums by the Socioi Security • CMS provides an opportunity for reinstatement of
Administration 3 customers into their Medicore Part D Pian for good
NOTE:These amounts Qre subject to cause situations.If the customer advises the Group
change annually. they have a good reason for failure to pay Part D
IRMAA premiums,the Group should tell the customer
• They may either have them deducted from to contact I-800-MEDICARE within 60 calendar
their monthly Social Security payment or,if days of the disenrollment effective date.CMS will
they are not receiving Social Security then determine whether the customer qualifies for
yet,Medicare will bill them directly. good cause reinstatement.If so,the customer works
• Customers who fail to pay the additionai with CMS to make payment arrangements in order
premium will be involuntarily terminated to get reinstoted into the plan.
from the plan. • CMS will notify Cigno Heaithcare if the customer
• IRMAA is administered by Medicare and qualifies for reinstatement for good cause.Cigna
the Social Security Administration.Cigna Healthcare will reach out to the Group to confirm
Healthcare is not provided any i�formation if the customer can be added back into the plan
regarding which persons are affected by based on the Group's eligibility rules.Once the
IRMAA.Any questions about IRMAA customer makes all the required payments,CMS will
shouid be directed to Social Security at reinstate the customer and Cigna Healthcare will
I-&QO-772-1213. notify the Group vio the Group Ertrollment Report.
Record retention
CMS requires that Cigna Healthcare has a record of all enrollment requests.CMS guidelines
require custome�enrollment elections to be retained for 10 years.Additionally,the Group will
maintain alf records and docurnentation relating to enrollment for a period of 10 years from
the final date of group coverage.
9
Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
�_��� �r � r
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Premium billing and payment
Wire and Automated
Clearing House
Biiling invoice (ACH)details
A separate invoice will be generated for your Cigna Heaithcare Bank:
Medicare plans.If there are multiple acco�nt numbers,each account Bank of America,N.A.
number will generate a separate invoice.The invoice will include a qCH ABA routing/transit
manthly summary and a detailed roster. number:0119Q0571
Payment due date Bank occount number:
Premium is due by the end of the month.Any premium not 385015921381
received after the last day of the month is considered past due.Cigna Bank account name:
Nealthcare will provide notice of the unpaid premiums on the next Cigna Health and Life
month's invoice and may provide a separate notice of late payment if Insurance Company
unpaid premiums are more than one month past due.Cigna Healthcare gank ACH address:
may terminate the agreement one month after it provides the Group 101 S Tryon Street
with a notice of late payment if the Group has not poid the premiums Charlotte,NC 28255
due. Wire transfer ABA:
Payment remittance method 026009593
Eligibility-based billing,or Pay as Billed(PAB),is the Cigna Healthcare Swift:BOFAUS3N
remittance method.The Group will need to remit payment for Cigna Bank:Bank of America
Healthcare Medicare plan coverage separately from other Cigno gank address:
Heaithcare plans.A separate W-9 is not required for Cigna Healthcare �OI West 33rd Street
Medicare clients with a Cigna Healthcare commercial relationship.A W9 New York,NY 10001
is required for clients with Cigna Healthcare Medicare plans only.
Part D low-income premium subsidy(LIPS)adjustment
Medicare provides a premium subsidy for those who qualify for Extra Help to ossist with payment of their plan
premiums. CMS will notify Cigna Healthcare of ony customers eligible for LIS premium adjustments and will
pass the LIPS adjustment amount to Cigna Healthcare for each eligible retiree.
If the retiree Part D monthly premium contribution is more than the LIPS amount,the Group should advise the
retiree that they can opt out of current coverage to enroll in a plan with a monthly premium equal to or below
the LIPS amount. The Group should communicate the potential financial impact ond implications of opting out
of their Group coverage.
CMS requires the LIPS adjustment amount be passed to eligible retirees within 45 doys of the date Cigna
Healthcare receives the LIPS odjustment. The Group or Cigna Healthcare would pvss the LIPS adjustment to
eligible retirees.
10
Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
PremstimbilIIn�andpnyntent(co�tinuedl ..�,_. n.,iJ'rl��,_ti�.il, .�,Kt"v`i.. ��.,�,;.� ., _;�� ..:�,.1�;< :i��A.�'%! �.1�:ir.
Late enrollment penalty(LEP} to calculate the actual amount of the penalty.
Customers may hove to pay a late enrollment CMS will inform Cigna Healthcare of the LEP
penalty(�EP)in addition to their monthly plon amount that the customer would be responsible
premium if there is a continuous period of 63 days for paying.Cigna Healthcare will pass the penalty
or more at any time after the end of their Part D on to the Group via the ernployer monthly bi�ting
initial enrollment period during which they were invoice.The detailed biiling roster will provide the
eligible to enroll but were not enrolled in a names of the applicoble customers and the
Medicare Part D plan and were not covered under amount of the LEP.The Group is responsible for
ony creditable prescription drug coverage. paying the penalty on behalf of the customer(s)
Creditable prescription drug coverage is pnd may choose to collect the LEP omount from
coverage that is at least as good as the standard them.
Medicare prescription drug coverage.The If a customer hos been Qssessed an�EP under a
customer may have to pay this late enrollment non-Cigna Heolthcare plan and disagrees with
penalty for as long os they have Medicare
the penalty,the customer must initiate the
prescription drug coverage. appeal process by contacting Medicare ot
If the customer must pay a late enrollment penalty, 1-800-MEDICARE(I-800-633-4227);TTY users
the penalty is applied when a customer joins a should call I-877-486-2048.The customer will
Medicare plan with drug coverage and has a gap need to fill out a reconsideration request form and
in coverage of 63 days or more. The penaity provide proof that they hod previous creditable
amount may change eoch year based on the coverage'Cigna Healthcare is unable to assist in
national base beneficiary premium omount. the appeal process when the customer did not
Although you can estimate,only CMS is authorized have coverage through Cigna Healthcare.
i
Attestation
Cigna Heolthcare wilt accept on attestatio�from notified of tF�e opportunity to enroll and the process
the Group that all customers submitted on the for opting out of coverage in the Cigna Healthcare
eligibility file for initial enrollment into the Cigna Medicare EGWP.
Healthcare Medicare EGWP were previausly These attestations apply to valid and complete
enrolled in a plan that provided creditable enroliment applications/records processed prior to
pharmacy coverage and did not have a gap in the initial effective date of the pian.Enroliment
creditable coverage for 63 days or longer. requests processed ofter the initial effective date
if the retirees were enroiled in a Retiree Drug will receive communications regarding creditable
Subsidy filed plan,Cigna Healthcare will alsa accept coverage and/or Retiree Drug Subsidy as required
an attestation that the customers have been by CMS.
if
Docusign Envelope ID: F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
Pr4iniumbiliing<indpaym�nt(contintied} .';i�N .riE,ti.i-iL���:', .�U( �2E,1^'v tf��C,EP',.:!_�_�4�.U� �.CPhiP�.i_lR�.1.':�t ..�.�;;it
F.mployer/Union Group 1�Iedicare Advantage
Agreement
The CMS contract adde�dum with Cigna Healthcare(Employer/Union-Only Group Addendum}
requires that Cigna Healthcare obtain written agreements from each employer or union with
which it contracts for employer/union-only group Medicare Advantage plans and that such
agreements contain certain terms and provisions.This agreement will be provided to you by your
account team and will need to be fully executed prior to the effective date.A full agreement is
provided with the initial plan year,and a�amendment is provided for each renewing year.
Employer/Unian Group 1Viedicare Advantage policy
and certificate
Cigna Healthcare will provide electronic copies of policy and certificate documents to fully insured
plans that offer prescription drug coverage as part of your plan.The policy and certificate
comprise our contract with you.
The policy and certificate will be provided to you by your occount team along with the Employer/
Union Group Medicare Advantage Agreement or Amendment.
Customer communications
Required group communications to customers
Pre-enrollment kits
Group pre-enrollment kits are required to go out to all eligible customers and must be received na later than
21 days before the effective date for passive enrollment or 21 days before the open enrollment period for
octive enrollment.
Further,pre-enrollment kits are required to be sent to retirees as they reach the age of Medicare eligibility
and meet the Group's enrollment rules.Cigna Healthcare will provide the client with a bulk shipment of
pre-enrollment(or age-in)kits prior to the start of the colendar yeor.The client will send a kit to each retiree
60 days prior to their Medicare eligibility.Both the pre-enrollment and age-in kits will include the following:
• Pre-enrollment/Age-in letter Optional flyers(if applicoble):
• Summary of Benefits • Over-the-Counter brochure
� Online resource insert(Directory and Drug List) • Home-Based Care flyer
• Information guide • Vaccinations flyer
• How to Find a Provider guide � B vs.D flyer
• Notice of Non-Discrimination and Multi-Languoge insert
• Formulary Addendum(MAPD only)
Additional genera!plan information is available at CignaMedicare.com/group/MAresources.
See page 18 for more details.
12
Docusign Envelope ID: F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
Customercommunications(continuad) ;' .. :, , . , :
Renewal kits
Group renewal kits are required to go out to all enrolled customers and must be received
15 days before the beginning of the Group's health plan open enrollment period.If the
Group does not have an open enroliment period,then the materials are required to be
received or available to review online by the customers no iater than 15 days before the
beginning of the plan year.
• Renewal cover letter � Formulary Addendum(MAPD only)
• Annual Notice of Change(ANOC) _ Multi-language insert
• Evidence of Coverage(EOCj Snapshot
Optional flyers(if applicable):
� Online resource insert(Directory and
Drug Ust) • Over-the-Counter brochure
• How to Find a Provider guide • Home-Based Care flyer
• Notice of Privacy Proctices
Post-enrollment communications
Upon completion of the customer's enrollment into the Cigna Healthcare Medicare EGWP,the following will be
mailed to the customer within 10 calendar days from receipt of CMS confirmation of enrollment or by the last
day of the month prior to the effective date,whichever is later:
• Welcome letter • Multi-language interpreter services
• Evidence of Coverage(EOC}Snapshot • Acknowledgment/Confirmation
• Online resource insert(Directory and Drug List) of Enrollment Acceptance Notices
• Customer Handbook (mailed separately)
• Extra Benefits Guide • Cigna Healthy Today°card(mailed separately)
• Notice of Privacy Practices Qptional flyers(If applicable):
• ID card(mailed separately) • pver-the-Counter brochure
• myCigna°Guide - How to Find a Provider Guide
• Medicare Prescription Payment Plan Information . PPO Frequently Asked Questions
and Enrollment Form(MAPD only)
Newly enrolled customers who have provided phone numbers and
email addresses will also receive a Welcome call and Welcome emails
to discuss any questions they may have and review key benefits,
features and resources to help them make the most of their new plan.
13
Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
Customercarttmunications(wnfinued) C.uN�NFaL;�_r+�[��tE���.:'.a?t-nf. �:,N i aC�,� :� ..P�S GR'_�1,: ..ibt' d;1 .:..I�r �lll�:i
Required plan communicatians to custamers
Cigna Healthcare will provide o copy of the followi�g items and other communications to the
Group and/or broker,if requested.
• Acknowledgement/Confi�mation of calendar days of receipt of opplication when there
Enrollment Acceptance Notices is a poteritial gap in coverage of 63 days or more.
The notices are mailed to the customer within ond it must be returned within 30 calendar days of
7-10 calendar days af the CMS confirmation of the date on the form.
enroliment.The notices can be used by the • Acknowledgement of Disenroliment Notice
customer as proof of coverage prior to receiving The notice is mailed to the customer within 10
the IQ card. calendar days of Cigna Healthcare receiving the
• ID Card disenrollment election.
ID cards are mailed to the customer within 10 . Confirmation of Disenrollment Notice
days from receipt of CMS confirmation of This notice is mailed within 7-10 calendar doys of
enrollment(approval)or by the last day of the the CMS confirmation of disenrollment.
month prior to the effective date.Under most . Explanations of Benefits(EOBs)
circumstances,ID cards are mailed within 10 days EOBs wi(1 be produced for cloim activity and will
to the mailing address on file.Replocement be moiled to the eustomer's mailing address in
Cigna Healthcare Medicare ID cards con be accordance with CMS guidelines.
ordered by calling the dedicated customer
service team(see Customer resources). • Research Potential Out-of-Area Status Notice
Replacement ID cards can also be requested on This notice is mailed to the customer when we
behalf of the c�stomer via the Group Employer receive notice(undeliverable mail with no
Portal.Cigna Healthcore customers will receive a fQrwarding address,CM5 notification,etc.)that
new customer identifier when moving to the they may have moved out of the service area.
Cigna Nealthcare Medicare EGWP from The customer must confirm that they stili live in
commercial coverage.Cigna Healthcare the service area within six months or they will 6e
Medicare Plans are member-based products, disenrolled from the plan.
which require all customers to be loaded as • Notice of Disenrollment Due to
individual subscribers. Out-of-Area Status
• Low-Income Subsidy(L1S)Rider Pa�t D onlY (�pon new address verification from customer)
(if applicoble} This notice is mailed within 10 calendar days of
The rider is mailed to the customer within 30 Cigna Healthcore verifying that the customer
calendar days of notification from CMS that the hps permanently moved out of the service area.
customer qualifies for on LIS. • Termination Letter
• Medicare Prestription Payment Plan Likely CMS allows a Group to disenroll its customers
to Benefit Letter from a Medicare plan using the group
This letter is mailed to customers who have high disenrollment process.The process requires a
drug costs and may benefit from having those letter of notification of disenrollment sent to
costs spreod evenly over a year's time. eoeh customer 21 days prior to the effective date
of their disenrollment from the Group-sponsored
• Late Enrollment Penelty(LEPj Attestation Notice Medicare plan.
This notice is moiled to the customer within IQ
This is not a complete list of all communications that may be sent throughout the plan year.There are
system-generated letters thqt ore sent to request information in order to process claims,update customer
records,etc.Electronic samples of these system-generated letters can be provided upon request.
Docusign Envelope ID:F39520E3-4AEA-47C3-SA79-FE973DD4AEDC
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Customer resources
Medicare Advantage Dedicated Customer Se�vice Team
Phone number:f-888-281-7867(TTYlTDD users should call 711j
Hours of operation:
October I-March 31,7 days a week,S a.m.to 8 p.m.local time.
April I-September 30,Monday-Friday,8 a.m.to 8 p.m.loeal time.
Our outomated phone system may answer your call during weekends or holidays and after hours.
Home delivery with Express Scripts Pharmacys
To set up on account,retirees should have their Cigno Healthcare Medicare ID card and
medication list nearby and call Express Scripts Pharmacy at I-877-860-0982(TTY 711j,
24 hours a day,365 days a year.
Customer web access
Customers can sign in to myCignc.com°,which is a personalized website where they can:
• View Medicare Advantage benefits • Manage prescriptions
• Manage profiles and preferences • Price a medication
• View plan coverage documents • Access Healthy Rewards"discount programs6
• Find a doctor,including telehealth • View and print ID cards
• Find a network pharmacy • Complete incentive program registration
• Review claim history and EOB details
The Cig�aMedicare.com/group/MAresources public website provides customers with access to general
plan infarmation that does not list client-specific benefits.
• EOC shell(the legal languoge of the plan) • C�uantity limit criteria
• The ability to find a Medicare Advantage • Step therapy criteria
provider or pharmacy • Prior authorization criteria
� Choin pharmacy listings • Vaccinations flyer
• Information on how to transition to a new • B vs.D flyer
plan policy
• Medicare Prescription Payment Plan
• Drug lists • Health Risk Assessment
• Claim forms
• Personal medicatfon list
• Medication therapy management
15
Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
Claims administration
c�Qims
When a manual claim is necessary(majority of providers will submit electronically),customers will
need to complete a claim form to request payment.Copies of the form can be downloaded from
CignoMedicare.com/group/MAresources,or customers can contact customer service to request
a form be mailed ta them.Claims should be mailed to the following:
Pharmacy Medicare Advantage
Cigna Heaithcare Cigna Healthcare
Attn:Medicare Part D Attn:Direct Member Reimbursement
P.O.Box 14718 Medical Claims
Lexington,KY 40512-4718 P.O.Box 20002
Nashville,TN 37202
Claims payment
Cigna Healthcare will administer claims in accordance with the EOC document.From time to time,Cigna
Healthcare Medicare will reprocess or adjust claims that have been processed under the plan for several
potentia!reasons including,but not limited to,obtaining additional information from the customer,the
customer's provider or CMS and upon identifying errors.If Cigna Healthcare reprocesses or adjusts a
processed claim ond this results in a change to the amount due from the customer,Cigna Healthcare sholl
notify the customer of the change and,as applicable,ref�nd the difference to the customer or request
payment of the difference.
Additional resources
Medicare website:Medicare.gov
Cigna Healthcore website:Cigna.com
Employer Group customer resources:
CignaMedica re.cam/Group/MAresources
Group Medicare Online Provider and Pharmacy Directory:
Providersearch.HSConnectOnline.com/EGW P
Group Employer Portal:
Employer.HSConnectOnline.com/home/login
16
Docusign Envelope ID:F39520E3-4AEA-47C3-SA79-FE973DD4AEDC
Notes
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Docusign Envelope ID: F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
�
cIglltx
heatthcare
1.Effective January 1,2021,Medica!e allows individuals with an ESRD diagnosis to enroll in'viedicare Advantage plans af the end ot the
30-month coordination perio�.
2.A customer can ask Cigna Healthcare to reirstate�overage if they`eel that CMS disenroiled them in error.!f the Group agrees,Cigna
Heaithcare wili reinstate coverage for the customer`or a pericd of 60 days.If CMS systems are updated��vithin 6�days,the reinstatement
w�it be submitted to CMS and the customer vli!I receive ihe Ackno�vledgement of Reinstatement letter If CMS systems are not updated after
60 days,Cigna Heaithcare�vill disenroll the customer back to the original disenro(iment date and the customer�vii!receive a fetter to close
the reinstatemeni request.
3 For the most up-to-date income ranges,visit https:i/�v�vw,PAedicare gov/Drug Goverage-Parf-OiCosts-For-Medicare-Drug-Coveragei
Monthly-Prem ium-Fo r-D rug-Pla ns.
4 CMS.Understandrng Medicare Advantage&Medicare Drug Pfan Enrotlmenf Periods.Ch�,S Pmduct�o.11219.Page{ast accessed August
18,2024 https•l/www.medicare.govlpublications/11219-Understandi�g-Medica�e-Advantage-M;edicare-Drug-Pian-ErroElment-Periods.pdf
5.Express Scripts Pharmacy:s a trademark of Express Scripts Strategic Development,Inc.0?her pharmacies are availaole in our nehvork.
6.Some discount programs are not available in all states,and prcgrams may be disconiinued ai any time.A discount program is NOT
i�surance,and custome�s must pay the entire discounted charge.Aii goods;services ano ciscou�ts offered through discount programs are
provided by third parties thai are soiely responsibie`or their products,services and discounts.
All Haa.;aSFr�ny p�oduc:s ar�se�wces are p�o����:e��s ex�lusivziy f1y er throuyh nperaiu�y s�.i;�n�anes nr eif���Iiates oi HeaIt2�Spnny Liie&Heaiih
� Insur�nca�c����ary fi�c Th�I�eaIU;Sp��ing rarzi�_{og�,s.ana marks ar� ��r,�ned b� H.,ai[i��,r,�;g:or�n a'fiiiate oi Heai,hSp(,ng.HealthSF�;ng
contracts with Medicare tc e�`er Medicare Advantage Hh?a and PPC plans and Part D Presc�iptior Drug Plans(PDP)in select sta:es, and
�vith select State Medicaid arograms.Enroli�en�in a HeaithSprlrg preduct depends on contract renewaL
,all P�%�edco prnd,i�ts�r,�i serv��es a;e p�ovided ex i�:�;�eely o�o�;i rc,:�,h ope�at:ng:uositliaries cr affiiiates ef(,�edco.�ncluding IN:euco
Confa��:mer,t Ufe Insurance Cam�ary ard Anedro Can;a��nm2n;L,suranc?�empariy o��:e�.�Ybrk 7ne�Jedco name.logos.and marks are
evv�ies op"vle�ica or an a(fil�ale cr�•J�dco.(v?edco ccntracts wi:h h,ledica�e;o of`er Pa�t D rretcr;pticn Drug Plans IPDP`in select states.
�n�olirnent;n at�/iecico pro�iu�;deper:ds c�co^`ract��nevv�::.
:�2024 Cigna Healthcare. 983413 a t0/24
Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
ASSIGNMENT AND ASSUMPTION OF AGREEMENT
AND
GONSENT TQ ASSIGNMENT AND ASSUMPTION QF AGREEINENT
This Assignment and Assumption of Agreement (the "Assignment") is entered into with
the date of day of____^�____, 2025 ("Effective Date"), by and among the CITY OF
MiAMI BEACH {the "City"}, a Fiorida municipal corporation, whose address is 1700 Convention
Center Drive, Miami Beach, Florida 33139(the City); CIGNA HEALTH ANp LIFE INSURANCE
COMPANY(°CHLIC° or "Assignor"), a Connecticut corporation, whose principal address is 900
Cottage Grove Raad, Nartford, Connecticut 06152; and, jointly and severally, HEALTH CARE
SERVICE CORPORATION, A MUTUAL LEGAL RESERVE COMPANY, an Iilinois corporation
{"HCSC"), whose principal address is �00 East Randolph Street, Chicago, Iliinois 60601 and
HEALTHSPRING LIFE& HEALTH INSURANCE COMPANY, INC., a Texas corporation,whose
principal address is 2800 North Loop West, Houston, Texas 77092("HealthSpring" and, together
with HCSC, collectively, "Assignee"). Any defined terms used but not defined herein shall have
the meaning set foRh in the Agreement(defined below}.
WtTNESSETH:
WHEREAS, on June 28, 2023, the Mayor and City Commissian, adopted Resolution No
2023-32624, pursuant to Requesi for Propasals(RFP)No. 2023-259-WG for Health, Pharmacy,
and ti1edicare Advantage Plans, authorizing the Administration to negotiate an agreement with
CHLIC, the top- ranked proposer for Health and Pharmacy Plans (Plan A} and Medicare
Advantage Plans (Plan C};
WHEREAS, on or about December 19, 2023, the City and CHLIC executed that certain
Employer/Union Group MAPD Agreement for the Medicare Advantage Plans (Plan C) (the
"Agreement"}, which Agreement is attached hereta as Exhlbit A and incorporated herein;
WFtEREAS, at the tirne of execution of the Agreement, HealthSpring was a wholly owned
subsidiary of CHLIG, and was the entity primarily responsible for the administration of the Plan;
WHEREAS, on November 5, 2024, HCSC was approved for acquisition of control of
HealthSpring under Texas Insurance Code Section 823.157 and 28 Texas Administrati�e Code
Sections 7.205 and 7.209;
WHEREAS, pursuant to Section 25 of the Agreement, any assignment of the Agreement
by CHLIC requires the written consent of the City;
WHEREAS, accordingiy, Assignor and Assignee seek the City's consent to the
assignment and assumption of the Agreement from GHL.IC to HCSC and HealthSpring, jointly
and severally; and
WHEREAS, Assignee is authorized to do business in Florida.
NOW, THEREFORE, ihe City, Assignor and Assignee, for and in consideration of the
mutual covenants, agreements, and undertakings herein contained, do by these presents
mutually covenant and agree as follows:
ra��e I oi i
Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
1. The above recitals are true and correct and are incorporaled herein as part of this
Assignment.
2. Assignor hereby assigns and transfers to Assignee all of its rights, title, interest and
obligations in and to the Agreement.
3. Assignee hereby accepts the assignment of the Agreement and further assumes and agrees
to perform all of the duties and obligations of Assignor under the Agreement. Assignee
further agrees to be liable and subject to all conditians and restitutions which Rssignor is
subject to under the Agreement.
4. Upon execution of this Assignment, and for purposes of interpreting the Agreement, all
references to CHLIG or Cigna under the Agreement shall hereinafter be deemed to refer to
Assignee.
5. Assignee agrees to honor and maintain ail required warranties and responsibilities for all
projects previously compieted by Assignor, and any ongoing projects it has with the City,as
of the Effective Date.
6. Notwithstanding the execution of this Assignment, Assignor and Assignee shall remain
jointly and severally liable under the Agreement for services prior to the Effective Date of
this Assignment.
7. 5imultaneously herewith, Assignee shail furnish to the City's Risk Manager Certificates af
Insurance or endorsements evidencing the insurance coverage as specified in the
Agreement.
8. All written notices given to Assignee under the Agreement shall be addressed to:
HEALTHSPRING LIFE& HEALTH INSURANCE COMPANY, INC.
300 East Randolph Street
Ghicago, Illinais 606Q1
Attn:
_. ____�.
Tel:
_____ _ .___._.._ ___
Email:
[REMAINDER OF PAGE INTENTI�NALLY LEFT B�ANK]
Pxgc 2,,'i�
Docusign Envelope ID:F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
!N WITN�SS WHEREOF, Assignor and Assignee have caused this Assignment to be
executed by their appropriate officials, as of the date first entered above.
�OR ASSJGNOR: CIGNA HEALTH AND LIFE tNSURANCE
COMPANY
ATTEST:
�`�'uG ������
.____ _ ��. _ __.____ . . gY;_ ��`�T���''r�C�e
_ _ _____ _.____� _
Signature
Name: Eric Cayford Name: Mary DiMattea
Title: Senior Counsel Title: AVP, Cigna Health and Life Insurance Co
Qa��: 10.16.2025
FC�R ASSIGNEE: HEALTNSPRING LIFE& HEALTH
(NSURANCE CQMPANY, INC.
ATTES7': � %�-�.
; ,.
.� �1 , � �1
�___. . � _,,� ,' 1
___ _-- __- -_--___- �Y -�= =��--`�. � -�:�-:�1
ignafure -� � r`� �_
Name: � a `^ (^ � '
��tiv���..�- � 4 Name: ,�r�J.'7��i`l. .__._��t_�;�_.l_�
�" �2:.��-� F �� Tiile: j �
Titie:.__ __ - —___�''ji��st I.��t.t�i,.r�'. --�5�n.,�:�jt� �"�h''�
) /
Date:_ �� ��--p./�-�-_ -—
HEALTH CARE SERViCE CORPORATION,
A MUTUAL LEGAL RESERVE COMPANY
ATTEST: '�--.�
� � � . ,
_ _ , . �
---- ___—___ ------- �Y _-/-_.. _.___ .-_____
Si nature � ��-�'�± __
9
n � . - � �
Name: lv�vtJ� Name: �� � � _��il�-�� �_.
- ---- . �- � -
1 1
Title:-------t��vpi �-�� ` Title: ��,'�",��.�,L�1l.,'�'�k ��j
Date:..---�� ����-"� ,
Pake 3 of 5
Docusign Envelope ID: F39520E3-4AEA-47C3-8A79-FE973DD4AEDC
CONSENT TQ ASSIGNMENT AND ASSUMPTION OF AGREEMENT
The Cify hereby acknawledges and consents to the Assignment and Assumption Agreement,
pursuant to Section 25 of the Agreement,without warranties of any kind whatsoever being made
incident to this consent or the Assignment and Assumption Agreement.
FOR CITY: CITY OF MIAMI BEAGH, FLORIDA
ATTEST:
DocuSigned by: �� '�
�KA�a.t,l, �. GV'aan.a.d.4 �
_ .----.�. �aeasAoeFesEss� , gY�. (_,�!��.._. _ � �'l�i'ul_ �_. ..
Rafael E. Granado, City Clerk Eric T. Carpenter, City Manager
10l31/2025� 5:14 PM EDT
Date:
APPROVED AS TO
FORM& LANGUAGE
& FOR EXECUTION
/- � �
r ��,1��.r`�;�ti�.^ 'tf,��� ��';
,�._
�;�iiy Attomey •. Date
Page A of`5
Docusign Envelope ID:F39520E3-4AEA-47C3-SA79-FE973DD4AEDC
EXHIBIT 1
AGREEMENT
(to be attached)
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