HomeMy WebLinkAboutTC Health Consortium Orientation Manual.pdf
GREATER TOMPKINS COUNTY MUNICIPAL
Health Insurance Consortium
Orientation Manual
Don Barber, Executive Director
(EDConsortium@twcny.rr.com)
January 22, 2015
Table of Contents
Welcome and Introduction .......................................................................... 1
Municipal Cooperative Agreement Introduction ......................................... 2
Municipal Cooperative Agreement ............................................................. 4
Organization ............................................................................................. 23
Chart ................................................................................................................... 25
Contact Information (Excellus, ProAct, Benefit Clerks) ...................................... 26
Board of Directors .................................................................................... 27
Board of Directors Policies
Whistleblower ...................................................................................................... 28
Code of Ethics & Conflict of Interest ................................................................... 29
Privacy Notice ..................................................................................................... 31
Procurement Policy ............................................................................................. 33
Policy for Private Advertising on Consortium Materials ...................................... 36
Committees .............................................................................................. 37
Joint Committee on Plan Structure and Design .................................................. 37
Bylaws ........................................................................................................... 39
Appeals ............................................................................................................... 37
Audit and Finance ............................................................................................... 37
Executive ............................................................................................................ 38
Owning Your Own Health ................................................................................... 38
Sample Wellness Policy ............................................................................... 40
Benefit Plan Menu .................................................................................... 41
Medical Benefit Administration Partners:
Excellus ............................................................................................................. 44
ProAct ............................................................................................................... 45
Claims Appeal Process ............................................................................ 46
Summary of Educational GTCMHIC Retreat of 9/15/2014 ...................... 47
Website ............................................................................................... 49
Annual Report........................................................................................... 50
Welcome to the Greater Tompkins County
Municipal Health Insurance
Consortium!!
The Greater Tompkins County Municipal Health Insurance Consortium received its Certificate of
Authority to conduct operations in October 2010 and began providing health insurance for 2000
employees and retirees of thirteen municipalities within Tompkins County on January 1, 2011.
GTCMHIC is an insurance company that creates benefit plans, collects premiums, and pays medical
and pharmaceutical claims for its cover members.
Currently the employees and retirees of the sixteen (16) municipalities of the towns of Caroline,
Danby, Dryden, Enfield, Groton, Ithaca, Lansing, and Ulysses, the villages of Cayuga Heights,
Dryden, Groton, Homer, and Trumansburg, the cities of Cortland and Ithaca and Tompkins County are
covered by one of the Consortium’s approved benefit plans for Medical and pharmaceutical claims.
Benefit plans are a contract between the employer, the employee, and the health care providers
including pharmacies. The insurance company is the intermediary that provides the mechanism for a
large group of persons to pool their risk of health conditions along with their premium payment.
Claims are paid that meet the benefit plan criteria. The amount paid to providers is negotiated by the
insurance company or its agent for the in-network and out of network claims.
The GTCMHIC is currently covering over 5,000 employees/retirees and eligible dependents. 2014
premiums totaled $37 Million. This represents 98% of all revenues. The other 2% is from
miscellaneous sources like interest on funds and premiums for ancillary benefits. The Consortium
paid out $31 million or 93% of its revenue for claims in 2014. This 93% efficiency of premium dollars to
claims is an extremely efficient model by industry standards. Currently, this is the reason to be a
Consortium member. The 2014 Annual report is found elsewhere in this manual.
You can learn much more about the GTCMHIC and Health Insurance in general by watching the
Education Retreat of 9/15/14. The link is located on the Home page of the Consortium’s website.
The topics covered are:
a. Define Health Care
b. Define Health Insurance and why important even necessary to you
c. Why does health care and insurance cost increase faster than other expenses?
d. Why create GTCMHIC and how does it work?
e. What are benefit plans?
f. How does the insurance system work?
g. How has the Consortium done so far?
A short summary is found elsewhere in this manual.
Welcome and thank you for your interest!
GTCMHIC Orientation Manual Page 1
Municipal Cooperative Agreement:
Municipal Cooperative Agreement Summary and Responsibilities of Participants, Board of
Directors, and Organized Labor
The Municipal Cooperative Agreement (MCA) is the foundational document for the GTCMHIC
that has been approved by the State Insurance Department, now Department of Financial
Services, resulting in the Certificate of Authority. The MCA is the agreement between the
participating municipalities that describes their responsibility to each other and the structure of
this Health Insurance Consortium. The MCA creates the Board of Directors (BoD); giving the
BoD sole responsibility for directing and protecting the operation and financial security of
GTCMHIC.
The MCA is organized as follows:
Sections A&B: describe Participants and their responsibilities
Sections C-H: describe the Board of Directors, their operating procedures, and
responsibilities
Section I: describes the Plan Administrator
Section J: describes the function of the Chief Financial Officer
Section K: describes the Joint Committee on Plan Structure and Design
Sections L-N: describe Premiums
Sections O-X: describe processes for Participants to work with each other for items
like changes to MCA, joining, leaving, dissolution, and disputes, etc.
Summary of Participant Responsibilities (MCA section):
1. All eligible employees and retirees of participants must be covered by
Consortium health Plan unless Board approval (A.3.)
2. Joining the Consortium is a minimum of three (3) year commitment (A.4.)
3. Costs and liabilities of the Consortium are assumed by the Participants on a pro-
rata based on premiums paid (B.1.&3.)
4. Each Participant appoints one Director and Alternate Director and delegate to
Joint Committee on Benefit Plan Design (C.1.)
5. Premium payments are due by 1st of month and penalty if late (L.3.)
6. Withdrawal can only occur on last day of plan year (P.1.) However, notice of
intent to withdraw is required by October 3rd (P.2.)
7. Description of withdrawing member’s pro-rata share of liabilities or assets (P.3.)
8. Participants acknowledge that all Directors are responsible for attending all
scheduled meetings. Non-attendance at any scheduled meeting is deemed
acquiescence by the absent Participant. However, a Participant that was absent
from a meeting will not be presumed to have acquiesced in a particular action
taken at the meeting if, within fifteen (15) calendar days after learning of such
action, the Participant delivers written notice to the Chairperson that it dissents
from such action. (R.5)
9. Requirement to review MCA every 5 years (Q.2.)
10. Disputes are subject to “Alternate Dispute Resolution” (V.)
11. Legislative Approval is required in writing to state ratification of the MCA (X.1-3)
GTCMHIC Orientation Manual Page 2
Summary of Directors responsibility:
1. No remuneration (C3)
2. Can only represent one municipality (C4)
3. Must comply with the Conflict of Interest Policy (C5)
4. BoD actions require a majority of entire Board (C6)
5. Alternate Director can vote in place of Director (C7)
6. Quorum of majority of Directors required to conduct business (C8)
7. Special meetings can be called (C9)
8. Process when Special meetings are impractical (C10)
9. Creation and responsibilities of Executive Committee (F)
10. Responsibilities of Officers (G, H, J)
11. All Directors are responsible for attending all scheduled meetings. Non-
attendance at any scheduled meeting is deemed acquiescence by the absent
Participant. However, a Participant that was absent from a meeting will not be
presumed to have acquiesced in a particular action taken at the meeting if, within
fifteen (15) calendar days after learning of such action, the Participant delivers
written notice to the Chairperson that it dissents from such action.
Summary of Organized Labor Responsibility:
1. A labor representative is chosen to be the Chairperson of the Joint Committee on
Benefit Plan Design and that person is also a Consortium Director (C.11)
2. Each bargaining unit has a seat on the Joint Committee on Benefit Plan Design
(K.1)
3. At least one and possibly more labor delegates are elected Consortium Directors
(K.5)
GTCMHIC Orientation Manual Page 3
2014 AMENDMENT TO THE
MUNICIPAL COOPERATION AGREEMENT
THIS AGREEMENT (the "Agreement") made effective as of 1st day of October 2010 (the
"Effective Date"), by and among each of the signatory municipal corporations hereto (collectively,
the "Participants").
W H E R E A S:
1. Article 5-G of the New York General Municipal Law (the "General Municipal
Law") authorizes municipal corporations to enter into cooperative agreements for the performance
of those functions or activities in which they could engage individually;
2. Sections 92-a and 119-o of the General Municipal Law authorize municipalities to
purchase a single health insurance policy, enter into group health plans, and establish a joint body
to administer a health plan;
3. Article 47 of the New York Insurance Law (the "Insurance Law"), and the rules and
regulations of the New York State Superintendent of Insurance (the "Superintendent") set forth
certain requirements for governing self-insured municipal cooperative health insurance plans;
4. Section 4702(f) of the Insurance Law defines the term "municipal corporation" to
include a county, city, town, village, school district, board of cooperative educational services,
public library (as defined in Section 253 of the New York State Education Law) and district (as
defined in Section 119-n of the General Municipal Law); and
5. The Participants have determined to their individual satisfaction that furnishing the
health benefits (including, but not limited to, medical, surgical, hospital, prescription drug, dental,
and/or vision) for their eligible officers, eligible employees (as defined by the Internal Revenue
Code of 1986, as amended, and the Internal Revenue Service rules and regulations), eligible
retirees, and the eligible dependents of eligible officers, employees and retirees (collectivel y, the
"Enrollees") (such definition does not include independent contractors and/or consultants) through
a municipal cooperative is in their best interests as it is more cost- effective and efficient.
Eligibility requirements shall be determined by each Participant's collective bargaining agreements
and/or their personnel policies and procedures.
NOW, THEREFORE, the parties agree as follows:
A. PARTICIPANTS.
1. The Participants hereby designate themselves under this Agreement as the Greater
Tompkins County Municipal Health Insurance Consortium (the "Consortium") for the purpose of
providing health benefits (medical, surgical, hospital, prescription drug, dental, and/or vision) to
those Enrollees that each Participant individually elects to include in the Greater Tompkins County
Municipal Health Insurance Consortium Medical Plan(s) (the "Plan(s)").
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2. The following Participants shall comprise the initial membership of the Consortium
(a) County of Tompkins; (b) City of Ithaca; (c) Town of Enfield; (d) Town of Caroline; (e) Town
of Ithaca; (f) Town of Danby; (g) Town of Dryden; (h) Town of Ulysses; (i) Village of Cayuga
Heights; (j) Village of Groton; (k) Village of Dryden; (l) Village of Trumansburg; (m) Town of
Groton. Membership in the Consortium may be offered to any municipal corporation within the
geographical boundaries of the County of Tompkins; provided however, in the sole discretion of
the Board (as defined below), the applicant provides satisfactory proof of its financial
responsibility and is of the same type of municipal corporation as the initial Participants.
Notwithstanding anything to contrary set forth in this Agreement, admission of new Participants
shall not require amendment of this Section A(2). Membership shall be subject to the terms and
conditions set forth in this Agreement, any amendments hereto and applicable law.
3. Participation in the Plan(s) by some, but not all, collective bargaining units or
employee groups of a Participant is not encouraged and shall not be permitted absent prior Board
approval. Further, after obtaining approval, any Participant which negotiates an alternative health
insurance plan offering other than the plan offerings of the Consortium with a collective bargaining
unit or employee group may be subject to a risk charge as determined by the Board.
4. Initial membership of additional participants shall become effective on the first day
of the Plan Year following the adoption by the Board of the resolution to accept a municipal
corporation as a Participant. Such municipal corporation must agree to continue as a Participant
for a minimum of three (3) years upon entry.
5. The Board, by a two-thirds (2/3) vote of the entire Board, may elect to permit a
municipal corporation which is not located in the geographical or political boundaries of the
County of Tompkins to become a Participant subject to satisfactory proof, as determined by the
Board, of such municipal corporation’s financial responsibility. Such municipal corporation must
agree to continue as a Participant for a minimum of three (3) years upon entry.
6. A municipal corporation that was previously a Participant, but is no longer a
Participant, and which is otherwise eligible for membership in the Consortium, may apply for re-
entry after a minimum of three (3) years has passed since it was last a Participant. Such re-entry
shall be subject to the approval of two-thirds (2/3) of the entire Board. This re-entry waiting period
may be waived by the approval of two-thirds (2/3) of the entire Board. In order to re- enter the
Consortium, a municipal corporation employer must have satisfied in full all of its outstanding
financial obligations to the Consortium. A municipal corporation must agree to continue as a
Participant for a minimum of three (3) years upon re-entry.
B. PARTICIPANT LIABILITY.
1. The Participants shall share in the costs of, and assume the liabilities for benefits
(including medical, surgical, and hospital) provided under the Plan(s) to covered officers,
employees, retirees, and their dependents. Each Participant shall pay on demand such Participant's
share of any assessment or additional contribution ordered by the Board, as set forth in Section
L(4) of this Agreement. The pro rata share shall be based on the Participant's relative "premium"
contribution to the Plan(s) as a percentage of the aggregate "premium" contribution to the Plan(s),
as is appropriate based on the nature of the assessment or contribution.
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2. New Participants (each a "New Participant") who enter the Consortium may be
assessed a fee for additional financial costs above and beyond the premium contributions to the
Plan(s). Any such additional financial obligations and any related terms and conditions associated
with membership in the Consortium shall be determined by the Board, and shall be disclosed to the
New Participant prior to its admission.
3. Each Participant shall be liable, on a pro rata basis, for any additional assessment
required in the event the Consortium funding falls below those levels required by the Insurance law
as follows:
a. In the event the Consortium does not have admitted assets (as defined in
Insurance Law § 107) at least equal to the aggregate of its liabilities, reserves and
minimum surplus required by the Insurance Law, the Board shall, within thirty (30) days,
order an assessment (an "Assessment Order") for the amount that will provide sufficient
funds to remove such impairment and collect from each Participant a pro-rata share of
such assessed amount.
b. Each Participant that participated in the Consortium at any time during the
two (2) year period prior to the issuing of an Assessment Order by the Board shall, if
notified of such Assessment Order, pay its pro rata share of such assessment within ninety
(90) days after the issuance of such Assessment Order. This provision shall survive
termination of the Agreement of withdrawal of a Participant.
c. For purposes of this Section B(3), a Participant's pro-rata share of any
assessment shall be determined by applying the ratio of the total assessment to the total
contributions or premium equivalents earned during the period covered by the assessment
on all Participants subject to the assessment to the contribution or premium equivalent
earned during such period attributable to such Participant.
C. BOARD OF DIRECTORS.
1. The governing board of the Consortium, responsible for management, control and
administration of the Consortium and the Plan(s), shall be referred to as the "Board of Directors"
(the "Board"). The voting members of the Board shall be composed of one representative of each
Participant and representatives of the Joint Committee on Plan Structure and Design (as set forth in
Section C(11)), who shall have the authority to vote on any official action taken by the Board (each
a "Director"). Each Director, except the representatives of the Joint Committee on Plan Structure
and Design, shall be designated in writing by the governing body of the Participant.
2. If a Director designated by a Participant cannot fulfill his/her obligations, for any
reason, as set forth herein, and the Participant desires to designate a new Director, it must notify the
Consortium's Chairperson in writing of its selection of a new designee to represent the Participant
as a Director.
3. Directors shall receive no remuneration from the Consortium for their service and
shall serve a term from January 1 through December 31 (the "Plan Year").
4. No Director may represent more than one Participant.
5. No Director, or any member of a Director's immediate family shall be an owner,
officer, director, partner, or employee of any contractor or agency retained by the Consortium,
including any third party contract administrator.
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6. Except as otherwise provided in Section D of the Agreement, each Director shall be
entitled to one vote. A majority of the entire Board, not simply those present, is required for the
Board to take any official action, unless otherwise specified in this Agreement. The “entire
Board”, as used herein and elsewhere in this Agreement, shall mean the total number of Directors
when there are no vacancies.
7. Each Participant may designate in writing an alternate Director to attend the Board's
meeting when its Director cannot attend. The alternate Director may participate in the discussions
at the Board meeting and will, if so designated in writing by the Participant, be authorized to
exercise the Participant’s voting authority. Only alternate Directors with voting authority shall be
counted toward a quorum. The Joint Committee on Plan Structure and Design may designate
alternate Directors as set forth in Section C(11).
8. A majority of the Directors of the Board shall constitute a quorum. A quorum is a
simple majority (more than half) of the entire Board. A quorum is required for the Board to
conduct any business. This quorum requirement is independent of the voting requirements set forth
in Section C(6). The Board shall meet on a regular basis, but not less than on a quarterly basis at a
time and place within the State of New York determined by a vote of the Board. The Board shall
hold an annual meeting (the “Annual Meeting”) between October 3rd and October 15th of each Plan
Year.
9. Special meetings of the Board may be called at any time by the Chairperson or by
any two (2) Directors. Whenever practicable, the person or persons calling such special meeting
shall give at least three (3) day notice to all of the other Directors. Such notice shall set forth the
time and place of the special meeting as well as a detailed agenda of the matters proposed to be
acted upon. In the event three (3) days notice cannot be given, each Director shall be given such
notice as is practicable under the circumstances.
10. In the event that a special meeting is impractical due to the nature and/or urgency of
any action which, in the opinion of the Chairperson, is necessary or advisable to be taken on behalf
of the Consortium, the Chairperson may send proposals regarding said actions via facsimile to each
and all of the Directors. The Directors may then fax their approval or disapproval of said actions
to the Chairperson. Upon receipt by the Chairperson of the requisite number of written approvals,
the Chairperson may act on behalf of the Board in reliance upon such approvals. Any actions
taken by the Chairperson pursuant to this paragraph shall be ratified at the next scheduled meeting
of the Board.
11. The Chair of the Joint Committee on Plan Structure and Design and any At-Large
Labor Representatives (as defined in Section K) (collectively the “Labor Representatives”) shall
serve as Directors and shall have the same rights and obligations as all other Directors. The Joint
Committee on Plan Structure and Design may designate in writing alternate Directors to attend the
Board’s meetings when the Labor Representatives cannot attend. The alternate Director may, if
designated in writing, be authorized to exercise the Labor Representatives’ voting authority.
D. WEIGHTED VOTING.
1. Except as otherwise provided in this Agreement, any two or more Directors, acting
jointly, may require a weighted vote on any matter that may come before the Board. In such event,
the voting procedure set forth in this Section D shall apply in lieu of any other voting procedures
set forth in this Agreement. Such weighted voting procedures shall apply solely with respect to the
matter then before the Board.
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2. For purposes of this Section D, each Director shall receive votes as follows:
a. each Director representing a Participant with five hundred (500) or fewer
Enrollees shall be entitled to one (1) vote.
b. each Director representing a Participant with more than five hundred
(500) Enrollees shall be entitled to a number of votes equaling the total number of votes
assigned under subsection 2(a) above minus the number of Labor Representative votes,
divided evenly by the number of Participants eligible under this subsection 2(b) and
rounded down to the nearest whole number.
c. the Labor Representatives shall be entitled to one (1) vote each.
3. Attached as Addendum “A” to this Agreement is an example of the application of
the voting formula contained in subparagraph “2” of this Section.
4. Notwithstanding anything to the contrary contained in this Agreement, any action
taken pursuant to this Section D shall require the approval of two-thirds (2/3) of the total number of
votes, if all votes had been cast.
E. ACTIONS BY THE BOARD.
Subject to the voting and quorum requirements set forth in this Agreement, the Board is authorized
and/or required to take action on the following matters:
1. To fill any vacancy in any of the officers of the Consortium.
2. To fix the frequency, time and place of regular Board meetings.
3. To approve an annual budget for the Consortium, which shall be prepared and
approved prior to October 15th of each year, and determine the annual premium equivalent rates to
be paid by each Participant for each Enrollee classification in the Plan on the basis of a community
rating methodology filed with and approved by the Superintendent.
4. To audit receipts and disbursements of the Consortium and provide for independent
audits, and periodic financial and operational reports to Participants.
5. To establish a joint fund or funds to finance all Consortium expenditures, including
claims, reserves, surplus, administration, stop-loss insurance and other expenses.
6. To select and approve the benefits provided by the Plan(s) including the plan
document(s), insurance certificate(s), and/or summary plan description(s), a copy of the Plan(s)
effective on the date of this Agreement is incorporated by reference into this Agreement.
7. To annually select a plan consultant (the "Plan Consultant") for the upcoming Plan
Year, prior to October 1st of each year.
8. To review, consider and act on any recommendations made by the Plan Consultant.
9. To establish administrative guidelines for the efficient operation of the Plan.
10. To establish financial regulations for the entry of new Participants into the
Consortium consistent with all applicable legal requirements and this Agreement.
11. To contract with third parties, which may include one or more Participants, for the
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furnishing of all goods and services reasonably needed in the efficient operation and
administration of the Consortium, including, without limitation, accounting services, legal counsel,
contract administration services, consulting services, purchase of insurances and actuarial services.
Provided, however (a) the charges, fees and other compensation for any contracted services shall
be clearly stated in written administrative services contracts, as required in Section 92-a(6) of the
General Municipal Law; (b) payment for contracted services shall be made only after such services
are rendered; (c) no Director or any member of such Director's immediate family shall be an
owner, officer, director, partner or employee of any contract administrator retained by the
Consortium; and (d) all such agreements shall otherwise comply with the requirements of Section
92-a(6) of the General Municipal Law.
12. To purchase stop-loss insurance on behalf of the Consortium and determine each
year the insurance carrier or carriers who are to provide the stop- loss insurance coverage during
the next Plan Year, as required by Section 4707 of the Insurance Law.
13. To determine and notify each Participant prior to October 15th of each Plan Year of
the monthly premium equivalent for each enrollee classification during the next Plan Year
commencing the following January 1st.
14. To designate the banks or trust companies in which joint funds, including reserve
funds, are to be deposited and which shall be located in this state, duly chartered under federal law
or the laws of this state and insured by the Federal Deposit Insurance Corporation, or any
successor thereto.
15. To designate annually a treasurer (the "Treasurer") who may or may not be a
Director and who shall be the treasurer, or equivalent financial officer, for one of the Participants.
The Treasurer's duties shall be determined by the Chief Fiscal Officer to whom he/she will report.
16. To designate an Officer or Director to retain custody of all reports, statements and
other documents of the Consortium and take minutes of each Board meeting which shall be acted
on by the Board at a subsequent meeting.
17. To choose the certified public accountant and the actuary to provide the reports
required by this Agreement and any applicable law.
18. To designate an attorney-in-fact to receive summons or other legal process in any
action, suit or proceeding arising out of any contract, agreement or transaction involving the
Consortium. The Board designates John G. Powers, Esq. as the Consortium's initial attorney-in-
fact.
19. To take all necessary action to ensure that the Consortium obtains and maintains a
Certificate of Authority in accordance with the Insurance Law.
20. To take all necessary action to ensure the Consortium is operated and administered
in accordance with the law of the State of New York.
21. To take any other action authorized by law and deemed necessary to accomplish the
purposes of this Agreement.
F. EXECUTIVE COMMITTEE.
1. The Executive Committee of the Consortium shall consist of the Chairperson, the
Vice-Chairperson, and the Chief Fiscal Officer of the Consortium.
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2. The Executive Committee may meet at any time between meetings of the Board, at
the discretion of the Chairperson. The Executive Committee shall make recommendations to the
Board.
3. The Executive Committee shall manage the Consortium between meetings of the
Board, subject to such approval by the Board as may be required by this Agreement.
G. OFFICERS.
1. At the Annual Meeting, the Board shall elect from its Directors a Chairperson, Vice
Chairperson, Chief Fiscal Officer, and Secretary, who shall serve for a term of one (1) year or until
their successors are elected and qualified. Any vacancy in an officer's position shall be filled at the
next meeting of the Board.
2. Officers of the Consortium and employees of any third party vendor, including
without limitation the officers and employees of any Participant, who assist or participate in the
operation of the Consortium, shall not be deemed employees of the Consortium. Each third party
vendor shall provide for all necessary services and materials pursuant to annual contracts with the
Consortium. The officers of the Consortium shall serve without compensation from the
Consortium, but may be reimbursed for reasonable out-of-pocket expenses incurred in connection
with the performance of such officers’ duties.
3. Officers shall serve at the pleasure of the Board and may be removed or replaced
upon a two-thirds (2/3) vote of the entire Board. This provision shall not be subject to the
weighted voting alternative set forth in Section D.
H. CHAIRPERSON; VICE CHAIRPERSON.
1. The Chairperson shall be the chief executive officer of the Consortium.
2. The Chairperson, or in the absence of the Chairperson, the Vice Chairperson, shall
preside at all meetings of the Board.
3. In the absence of the Chairperson, the Vice Chairperson shall perform all duties
related to that office.
I. PLAN ADMINISTRATOR.
The Board, by a two-thirds (2/3) vote of the entire Board, may annually designate an administrator
and/or insurance company of the Plan (the "Plan Administrator") and the other provider(s) who are
deemed by the Board to be qualified to receive, investigate, and recommend or make payment of
claims, provided that the charges, fees and other compensation for any contracted services shall be
clearly stated in written administrative services and/or insurance contracts and payment for such
contracted services shall be made only after such services are rendered or are reasonably expected
to be rendered. All such contracts shall conform to the requirements of Section 92-a(6) of the
General Municipal Law.
J. CHIEF FISCAL OFFICER.
1. The Chief Fiscal Officer shall act as the chief financial administrator of the
Consortium and disbursing agent for all payments made by the Consortium, and shall have custody
of all monies either received or expended by the Consortium. The Chief Fiscal Officer shall be a
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fiscal officer of a Participant. The Chief Fiscal Officer shall receive no remuneration from the
Consortium. The Plan shall reimburse the Participant that employs the Chief Fiscal Officer for
reasonable and necessary out-of-pocket expenses incurred by the Chief Fiscal Officer in connection
with the performance of his or her duties that relate to the Consortium.
2. All monies collected by the Chief Fiscal Officer relating to the Consortium, shall be
maintained and administered as a common fund. The Chief Fiscal Officer shall, notwithstanding
the provisions of the General Municipal Law, make payment in accordance with procedures
developed by the Board and as deemed acceptable to the Superintendent.
3. The Chief Fiscal Officer shall be bonded for all monies received from the
Participants. The amount of such bond shall be established annually by the Consortium in such
monies and principal amount as may be required by the Superintendent.
4. All monies collected from the Participants by the Chief Fiscal Officer in connection
with the Consortium shall be deposited in accordance with the policies of the Participant which
regularly employs the Chief Fiscal Officer and shall be subject to the provisions of law governing
the deposit of municipal funds.
5. The Chief Fiscal Officer may invest moneys not required for immediate expenditure
in the types of investments specified in the General Municipal Law for temporary investments or as
otherwise expressly permitted by the Superintendent.
6. The Chief Fiscal Officer shall account for the Consortium's reserve funds separate
and apart from all other funds of the Consortium, and such accounting shall show:
a. the purpose, source, date and amount of each sum paid into the fund;
b. the interest earned by such funds;
c. capital gains or losses resulting from the sale of investments of the Plan's
reserve funds;
d. the order, purpose, date and amount of each payment from the reserve
fund; and
e. the assets of the fund, indicating cash balance and schedule of
investments.
7. The Chief Fiscal Officer shall cause to be prepared and shall furnish to the Board, to
participating municipal corporations, to unions which are the exclusive bargaining representatives
of Enrollees, the Board’s consultants, and to the Superintendent:
a. an annual audit, and opinions thereon, by an independent certified public
accountant, of the financial condition, accounting procedures and internal control
systems of the municipal cooperative health benefit plan;
b. an annual report and quarterly reports describing the Consortium’s
current financial status; and
c. an annual independent actuarial opinion on the financial soundness of the
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Consortium, including the actuarial soundness of contribution or premium equivalent
rates and reserves, both as paid in the current Plan Year and projected for the next Plan
Year.
8. Within ninety (90) days after the end of each Plan Year, the Chief Fiscal Officer
shall furnish to the Board a detailed report of the operations and condition of the Consortium's
reserve funds.
K. JOINT COMMITTEE ON PLAN STRUCTURE AND DESIGN.
1. There shall be a Joint Committee on Plan Structure and Design (the "Joint
Committee"), which shall consist of (a) a representative of each collective bargaining unit that is
the exclusive collective bargaining representative of any Enrollee or group of Enrollees covered by
the Plan(s) (the "Union Members"); and (b) a representative of each Participant (the "Management
Members"). Management Members may, but are not required to be, Directors.
2. The Joint Committee shall review all prospective Board actions in connection with
the benefit structure and design of the Plan(s), and shall develop findings and recommendations
with respect to such matters. The Chair of the Joint Committee shall report such findings and
recommendations to the Board at any regular or special meeting of the Board.
3. The Joint Committee shall select (a) from among the Union Members, an individual
who shall serve as Chair of the Joint Committee; and (b) from among the Management Members,
an individual who shall serve as Vice Chair of the Joint Committee. The Joint Committee shall
establish its own parliamentary rules and procedures.
4. Each eligible union shall establish such procedures by which its representative to the
Joint Committee is chosen and such representative shall be designated in writing to the Chairperson
of the Board and the Chair of the Joint Committee.
5. The Union Members on the Joint Committee on Plan Structure and Design shall
select from among the Union Members an individual to serve as an additional at-large voting
Labor Member on the Board of Directors of the Consortium. If the number of municipal members
on the Consortium rises to seventeen (17), the union members of the Joint Committee on Plan
Structure and Design shall select from among the Union Members an additional at-large voting
Labor Member on the Board of Directors of the Consortium. The at-large voting Labor Member(s)
along with the Joint Committee Chair shall collectively be the “Labor Representatives” as defined
in Section C(11) of this Agreement. If the number of municipal members on the Consortium rises
to twenty-three (23), the Union Members may select from among their members a third At-Large
Labor Representative to serve as a Director. Thereafter, for every increase of five (5) additional
municipal members added to the Consortium Union Members may select from among their
members one (1) At-large Labor Representative to serve as Director. Attached hereto as
Addendum “B” is a table illustrating the addition of At-Large Labor Representatives as set forth in
this Section. Any At-Large Labor Representative designated according to this section shall have
the same rights and obligations as all other Directors.
L. PREMIUM CALCULATIONS/PAYMENT.
1. The annual premium equivalent rates shall be established and approved by a
majority of the entire Board. The method used for the development of the premium equivalent
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rates may be changed from time to time by the approval of two-thirds (2/3) of the entire Board,
subject to review and approval by the Superintendent. The premium equivalent rates shall consist
of such rates and categories of benefits as is set forth in the Plan[s] that is determined and
approved by the Board consistent with New York law.
2. The Consortium shall maintain reserves and stop-loss insurance to the level and
extent required by the Insurance Law and as directed by the Superintendent.
3. Each Participant's monthly premium equivalent, by enrollee classification, shall be
paid by the first day of each calendar month during the Plan Year. A late payment charge of one
percent (1%) of the monthly installment then due will be charged by the Board for any payment
not received by the first of each month, or the next business day when the first falls on a Saturday,
Sunday, legal holiday or day observed as a legal holiday by the Participants.
The Consortium may waive the first penalty once per Plan Year for each Participant, but
will strictly enforce the penalty thereafter. A repeated failure to make timely payments, including
any applicable penalties, may be used by the Board as an adequate justification for the expulsion
of the Participant from the Consortium.
4. The Board shall assess Participants for additional contributions, if actual and
anticipated losses due to benefits paid out, administrative expenses, and reserve and surplus
requirements exceed the amount in the joint funds, as set forth in Section B(3) above.
5. The Board, in its sole discretion, may refund amounts in excess of reserves and
surplus, or retain such excess amounts and apply these amounts as an offset to amounts projected
to be paid under the next Plan Year’s budget.
M. EMPLOYEE CONTRIBUTIONS.
If any Participant requires an Enrollee's contribution for benefits provided by the Consortium, the
Participant shall collect such contributions at such time and in such amounts as it requires.
However, the failure of a Participant to receive the Enrollee contribution on time shall not diminish
or delay the payment of the Participant's monthly premium equivalent to the Consortium, as set
forth in this Agreement.
N. ADDITIONAL BENEFITS.
Any Participant choosing to provide more benefits, coverages, or enrollment eligibility other than
that provided under the Plan(s), will do so at its sole expense. This Agreement shall not be deemed
to diminish such Participant's benefits, coverages or enrollment eligibility, the additional benefits
and the payment for such additional benefits, shall not be part of the Plan(s) and shall be
administered solely by and at the expense of the Participant.
O. REPORTING.
The Board, through its officers, agents, or delegatees, shall ensure that the follow reports are
prepared and submitted:
1. Annually after the close of the Plan Year, not later than one-hundred twenty (120)
days after the close of the Plan Year, the Board shall file a report with the Superintendent showing
the financial condition and affairs of the Consortium, including an annual independent financial
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audit statement and independent actuarial opinion, as of the end of the preceding plan year.
2. Annually after the close of the Plan Year, the Board shall have prepared a statement
and independent actuarial opinion on the financial soundness of the Plan, including the
contribution or premium equivalent rates and reserves, both as paid in the current Plan Year and
projected for the next Plan Year.
3. The Board shall file reports with the Superintendent describing the Consortium’s
then current financial status within forty-five (45) days of the end of each quarter during the Plan
year.
4. The Board shall provide the annual report to all Participants and all unions, which
are the exclusive collective bargaining representatives of Enrollees, which shall be made available
for review to all Enrollees.
5. The Board shall submit to the Superintendent a report describing any material
changes in any information originally provided in the Certificate of Authority. Such reports, in
addition to the reports described above, shall be in such form, and containing such additional
content, as may be required by the Superintendent.
P. WITHDRAWAL OF PARTICIPANT.
1. Withdrawal of a Participant from the Consortium shall be effective only once
annually on the last day of the Plan Year.
2. Notice of intention of a Participant withdraw must be given in writing to the
Chairperson prior to October 3rd of each Plan Year. Failure to give such notice shall automatically
extend the Participant's membership and obligations under the Agreement for another Plan Year,
unless the Board shall consent to an earlier withdrawal by a two-thirds (2/3) vote.
3. Any withdrawing Participant shall be responsible for its pro rata share of any Plan
deficit that exists on the date of the withdrawal, subject to the provisions of subsection “4” of this
Section. The withdrawing Participant shall be entitled to any pro rata share of surplus that exists on
the date of the withdrawal, subject to the provisions of subsection “4” of this Section. The
Consortium surplus or deficit shall be based on the sum of actual expenses and the estimated
liability of the Consortium as determined by the Board. These expenses and liabilities will be
determined one (1) year after the end of the Plan Year in which the Participant last participated.
4. The surplus or deficit shall include recognition and offset of any claims, expenses,
assets and/or penalties incurred at the time of withdrawal, but not yet paid. Such pro rata share
shall be based on the Participant's relative premium contribution to the Consortium as a percentage
of the aggregate premium contributions to the Consortium during the period of participation. This
percentage amount may then be applied to the surplus or deficit which existed on the date of the
Participant's withdrawal from the Consortium. Any pro rata surplus amount due the Participant
shall be paid to the Participant one year after the effective date of the withdrawal. Any pro rata
deficit amount shall be billed to the Participant by the Consortium one year after the effective date
of the withdrawal and shall be due and payable within thirty (30) days after the date of such bill.
Q. DISSOLUTION; RENEWAL; EXPULSION.
1. The Board at any time, by a two-thirds (2/3) vote of the entire Board, may
determine that the Consortium shall be dissolved and terminated. If such determination is made,
the Consortium shall be dissolved ninety (90) days after written notice to the Participants.
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a. Upon determination to dissolve the Consortium, the Board shall provide
notice of its determination to the Superintendent. The Board shall develop and submit to
the Superintendent for approval a plan for winding-up the Consortium’s affairs in an
orderly manner designed to result in timely payment of all benefits.
b. Upon termination of this Agreement, or the Consortium, each Participant
shall be responsible for its pro rata share of any deficit or shall be entitled to any pro rata
share of surplus that exists, after the affairs of the Consortium are closed. No part of any
funds of the Consortium shall be subject to the claims of general creditors of any
Participant until all Consortium benefits and other Consortium obligations have been
satisfied. The Consortium’s surplus or deficit shall be based on actual expenses. These
expenses will be determined one year after the end of the Plan Year in which this
Agreement or the Consortium terminates.
c. Any surplus or deficit shall include recognition of any claims/expenses
incurred at the time of termination, but not yet paid. Such pro rata share shall be based on
each Participant's relative premium contribution to the Plan as a percentage of the
aggregate premium contributions to the Plan during the period of participation. This
percentage amount would then be applied to the surplus or deficit which exists at the
time of termination.
2. The continuation of the Consortium under the terms and conditions of the
Agreement, or any amendments or restatements thereto, shall be subject to Board review on the
fifth (5th) anniversary of the Effective Date and on each fifth (5th) anniversary date thereafter (each
a "Review Date").
a. At the annual meeting a year prior to the Review Date, the Board shall
include as an agenda item a reminder of the Participants’ coming obligation to review
the terms and conditions of the Agreement.
b. During the calendar year preceding the Review Date, each Participant
shall be responsible for independently conducting a review of the terms and conditions
of the Agreement and submitting to the Board of Directors a written resolution
containing any objection to the existing terms and conditions or any proposed
modification or amendment to the existing Agreement, such written resolution shall be
submitted to the Board on or before March 1st preceding the Review Date. Failure to
submit any such resolution shall be deemed as each Participant’s agreement and
authorization to the continuation of the Consortium until the next Review Date under the
existing terms and conditions of the Agreement.
c. As soon as practicable after March 1st, the Board shall circulate to all
Participants copies of all resolutions submitted by the Participants. Subject to Section S
hereof, any resolutions relating to the modification, amendment, or objection to the
Agreement submitted prior to each Review Date shall be considered and voted on by the
Participants at a special meeting called for such purpose. Such special meeting shall be
held on or before July 1st preceding the Review Date.
d. Notwithstanding the foregoing or Section T hereof, if at the Annual
Meeting following any scheduled Review Date the Board votes on and approves the
budget and annual assessment for the next year, the Participants shall be deemed to have
approved the continuation of the Consortium under the existing Agreement until the
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next Review Date.
3. The Participants acknowledge that it may be necessary in certain extraordinary
circumstances to expel a Participant from the Consortium. In the event the Board determines that:
a. a Participant has acted inconsistently with the provisions of the
Agreement in a way that threatens the financial well-being or legal validity of the
Consortium; or
b. a Participant has acted fraudulently or has otherwise acted in bad faith
with regards to the Consortium, or toward any individual Participant concerning matters
relating to the Consortium, the Board may vote to conditionally terminate said
Participant's membership in the Consortium. Upon such a finding by the affirmative vote
of seventy-five percent (75%) of the Participants, the offending Participant shall be
given sixty (60) days to correct or cure the alleged wrongdoing to the satisfaction of the
Board. Upon the expiration of said sixty (60) day period, an absent satisfactory cure, to
the Board may expel the Participant by an affirmative vote of seventy-five percent
(75%) of the Participants (exclusive of the Participant under consideration). This section
shall not be subject to the weighted voting provision provided in Section D. Any
liabilities associated with the Participant's departure from the Consortium under this
provision shall be determined by the procedures set forth in Section P of this
Agreement.
R. REPRESENTATIONS AND WARRANTIES OF PARTICIPANTS.
Each Participant by its approval of the terms and conditions of this Agreement hereby represents
and warrants to each of the other Participants as follows:
1. The Participant understands and acknowledges that its participation in the
Consortium under the terms and conditions of this Agreement is strictly voluntary and may be
terminated as set forth herein, at the discretion of the Participant.
2. The Participant understands and acknowledges that the duly authorized decisions of
the Board constitute the collective will of each of the Participants as to those matters within the
scope of the Agreement.
3. The Participant understands and acknowledges that the decisions of the Board made
in the best interests of the Consortium may on occasion temporarily disadvantage one or more of
the individual Participants.
4. The Participant represents and warrants that its designated Director or authorized
representative understands the terms and conditions of this Agreement and is suitably experienced
to understand the principles upon which this Consortium operates.
5. The Participant understands and acknowledges that all Directors, or their authorized
representatives, are responsible for attending all scheduled meetings. Provided that the quorum
rules are satisfied, non-attendance at any scheduled meeting is deemed acquiescence by the absent
Participant to any duly authorized Board-approved action at the meeting. However, a Participant
that was absent from a meeting will not be presumed to have acquiesced in a particular action
taken at the meeting if, within fifteen (15) calendar days after learning of such action, the
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Participant delivers written notice to the Chairperson that it dissents from such action. The
Participant shall also notify the other members of the Board of such dissent. The Chairperson shall
direct the Secretary to file the notice with the minutes of the Board.
6. The Participant understands and acknowledges that, absent bad faith or fraud, any
Participant's vote approving any Board action renders that Board action immune from later
challenge by that Participant.
S. RECORDS.
The Board shall have the custody of all records and documents, including financial records,
associated with the operation of the Consortium. Each Participant may request records and
documents relative to their participation in the Consortium by providing a written request to the
Chairperson and Chief Fiscal Officer. The Consortium shall respond to each request no later than
thirty (30) days after its receipt thereof, and shall include all information which can be provided
under applicable law.
T. CHANGES TO AGREEMENT.
Any change or amendment to this Agreement shall require the unanimous approval of the
Participants, as authorized by their respective legislative bodies.
U. CONFIDENTIALITY.
Nothing contained in this Agreement shall be construed to waive any right that a covered person
possesses under the Plan with respect to the confidentiality of medical records and that such rights
will only be waived upon the written consent of such covered person.
V. ALTERNATIVE DISPUTE RESOLUTION ("ADR").
1. General. The Participants acknowledge and agree that given their budgeting and
fiscal constraints, it is imperative that any disputes arising out of the operation of the Consortium
be limited and that any disputes which may arise be addressed as quickly as possible. Accordingly,
the Participants agree that the procedures set forth in this Section V are intended to be the
exclusive means through which disputes shall be resolved. The Participants also acknowledge and
agree that by executing this Agreement each Participant is limiting its right to seek redress for
certain types of disputes as hereinafter provided.
2. Disputes subject to ADR. Any dispute by any Participant arising out of or relating
to a contention that:
a. the Board, the Board's designated agents, or any Participant has failed to
adhere to the terms and conditions of this Agreement;
b. the Board, the Board's designated agents, or any Participant has acted in
bad faith or fraudulently in undertaking any duty or action under the Agreement; or
c. any other dispute otherwise arising out of or relating to the terms or
conditions of this Agreement or requiring the interpretation of this Agreement shall be
resolved exclusively through the ADR procedure set forth in paragraph (3) below.
3. ADR Procedure. Any dispute subject to ADR, as described in subparagraph (2),
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shall be resolved exclusively by the following procedure:
a. Board Consideration: Within ninety (90) days of the occurrence of any
dispute, the objecting party (the "Claimant") shall submit a written notice of the dispute
to the Chairperson specifying in detail the nature of the dispute, the parties claimed to
have been involved, the specific conduct claimed, the basis under the Agreement for the
Participant's objection, the specific injury or damages claimed to have been caused by
the objectionable conduct to the extent then ascertainable, and the requested action or
resolution of the dispute. A dispute shall be deemed to have occurred on the date the
objecting party knew or reasonably should have known of the basis for the dispute.
(i) Within sixty (60) days of the submission of the written notice,
the Executive Committee shall, as necessary, request further information from
the Claimant, collect such other information from any other interested party
or source, form a recommendation as to whether the Claimant has a valid
objection or claim, and if so, recommend a fair resolution of said claim.
During such period, each party shall provide the other with any reasonably
requested information within such party's control. The Executive Committee
shall present its recommendation to the Board in writing, including any
underlying facts, conclusions or support upon which it is based, within such
sixty (60) day period.
(ii) Within sixty (60) days of the submission of the Executive
Committee's recommended resolution of the dispute, the Board shall convene
in a special meeting to consider the dispute and the recommended resolution.
The Claimant and the Executive Committee shall each be entitled to present
any argument or material it deems pertinent to the matter before the Board.
The Board shall hold discussion and/or debate as appropriate on the dispute
and may question the Claimant and/or the Executive Committee on their
respective submissions. Pursuant to its regular procedures, the Board shall
vote on whether the Claimant has a valid claim, and if so, what the fair
resolution should be. The weighted voting procedure set forth in Section D
shall not apply to this provision. The Board's determination shall be deemed
final subject to the Claimant's right to arbitrate as set forth below.
b. Arbitration. The Claimant may challenge any Board decision under
subparagraph (V)(3)(a)(ii) by filing a demand for arbitration with the American
Arbitration Association within thirty (30) days of the Board's vote (a "Demand"). In the
event a Claimant shall fail to file a Demand within thirty (30) days, the Board's decision
shall automatically be deemed final and conclusive. In the event the Participant files a
timely Demand, the arbitrator or arbitration panel may consider the claim:
provided however;
(i) in no event may the arbitrator review any action taken by the
Board that occurred three (3) or more years prior to when the Chairperson
received notice of the claim; and
(ii) in no event may the arbitrator award damages for any period
that precedes the date the Chairperson received notice of the claim by more
than twenty-four (24) months.
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c. The Participants agree that the procedure set forth in this Section V shall
constitute their exclusive remedy for disputes within the scope of this Section.
W. MISCELLANEOUS PROVISIONS.
1. This instrument constitutes the entire Agreement of the Participants with respect to
the subject matter hereof, and contains the sole statement of the operating rules of the Consortium.
This instrument supersedes any previous Agreement, whether oral or written.
2. Each Participant will perform all other acts and execute and deliver all other
documents as may be necessary or appropriate to carry out the intended purposes of this
Agreement.
3. If any article, section, subdivision, paragraph, sentence, clause, phrase, provision or
portion of this Agreement shall for any reason be held or adjudged to be invalid or illegal or
unenforceable by any court of competent jurisdiction, such article, section, subdivision, paragraph,
sentence, clause, phrase, provision or portion so adjudged invalid, illegal or unenforceable shall be
deemed separate, distinct and independent and the remainder of this Agreement shall be and remain
in full force and effect and shall not be invalidated or rendered illegal or unenforceable or
otherwise affected by such holding or adjudication.
4. This Agreement shall be governed by and construed in accordance with the laws of
the State of New York. Any claims made under Section V(3)(b) except to the extent otherwise
limited therein, shall be governed by New York substantive law.
5. All notices to any party hereunder shall be in writing, signed by the party giving it,
shall be sufficiently given or served if sent by registered or certified mail, return receipt requested,
hand delivery, or overnight courier service addressed to the parties at the address designated by
each party in writing. Notice shall be deemed given when transmitted.
6. This Agreement may be executed in two or more counterparts each of which shall
be deemed to be an original but all of which shall constitute the same Agreement and shall become
binding upon the undersigned upon delivery to the Chairperson of an executed copy of this
Agreement together with a certified copy of the resolution of the legislative body approving this
Agreement and authorizing its execution.
7. The provisions of Section V shall survive termination of this Agreement, withdrawal
or expulsion of a Participant, and/or dissolution of the Consortium.
8. Article and section headings in this Agreement are included for reference only and
shall not constitute part of this Agreement.
9. No findings or recommendations made by the Joint Committee on Plan Structure
and Design or by the Chair of the Joint Committee shall be considered a waiver of any bargaining
rights under any contract, law, rule, statute, or regulation.
X. APPROVAL, RATIFICATION, AND EXECUTION.
1. As a condition precedent to execution of this Municipal Cooperative Agreement
and membership in the Consortium, each eligible municipal corporation desiring to be Participant
shall obtain legislative approval of the terms and conditions of this Agreement by the
municipality’s governing body.
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2. Prior to execution of this Agreement by a Participant, the Participant shall provide
the Chairperson with the resolution approving the municipality’s participation in this Consortium
and expressly approving the terms and conditions of this Municipal Cooperative Agreement. Each
presented resolution shall be attached to and considered a part of this Agreement.
3. By executing this Agreement, each signatory warrants that he/she has complied
with the approval and ratification requirements herein and is otherwise properly authorized to bind
the participating municipal corporation to the terms and conditions of this Agreement.
[Signature Pages Follow]
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Addendum “A”
Example of Weighted Voting Formula under Section D(2)
If 11 Participants have 500 or fewer enrollees each and 2 Participants have more than 500
enrollees each, under subparagraph “a” the 11 each get 1 vote. Under subparagraph “b” the 2
large Participants get 4 votes each, which is calculated by taking the total number of votes under
subparagraph “a” [11] subtracting the number of Labor Representative votes [2], dividing by the
number of eligible Participants under subsection “b” [2], and rounding the result [4.5] down to
the nearest whole number [4]. The Labor Representative shall have 1 vote, irrespective of the
votes available to the Participants.
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Addendum "B"
Illustration of At-Large Labor Representative Calculation
Total Number of
Total Number of Participants At-Large Labor Representatives
< 17 1
17-22 2
23-27 3
28-32 4
33-37 5
38-42 6
GTCMHIC Orientation Manual Page 22
Organization:
As agreed in the Municipal Cooperative Agreement (MCA) the Board of Directors (BoD) has
sole responsibility for directing the operation of and protecting the viability of the GTCMHIC.
All of the functions below report to the BoD as shown in the subsequent graphic.
The Executive Director and Plan Consultant report to and support the BoD in providing
information and executing BoD decisions.
Executive Director:The Executive Director (currently Don Barber) is contracted to plan,
coordinate, direct and evaluate all programs and operations to ensure that services are
performed efficiently and effectively and in accordance with the Board’s direction. The Executive
Director is a contractor that works at the pleasure of the BoD.
Plan Consultant:The Plan Consultant (currently Locey and Cahill, LLC.) is contracted to
provide technical review and professional opinion regarding benefit plan design, financial
matters, and on any matters before the BoD. The Plan Consultant is the primary intermediary
between the BoD and the third party administrators and Insurance providers. The Plan
Consultant provides monthly financial updates and premium and reserve recommendations.
The Plan Consultant is a contractor that works at the pleasure of the BoD.
CLAIMS ADMINISTRATION
Medical Claims Administrator: Excellus provides medical claims administration for
GTCMHIC. Each municipality’s Benefit Clerk has an operations manual which describes the
medical and prescription claims process as well as enrollment and removing of covered lives.
Excellus also offers customized information for each covered employees, wellness support,
monthly health topic, and much more through this web portal:
https://www.excellusbcbs.com/wps/portal/xl/cwp/greatertompkins
Prescription Claims Administrator: Pro-Act provides pharmaceutical claims administration
for GTCMHIC. Pro-Act also offers customized information for each covered employees,
wellness support, quarterly newsletters, and much more through this web portal:
https://secure.proactrx.com/
COMMITTEES
Serving in an advisory role are the Joint Committee on Plan Structure and Design, Appeals,
OYOH, and the Audit and Finance Committees, which are led by Directors and provide the first
line of deliberative review of items that will come before the BoD.
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PROFESSIONAL SUPPORT SERVICES
Also advising and providing oversight functions are a number of professional support services
for: Legal, Claims and Financial Third party Auditing, Actuary, Article 47 Accounting.
Appeals procedure: The Claims Appeal procedure is described in detail on the Consortium
Website. The process begins with initial contact with Excellus or Pro-Act. The appeal can be
made by the patient, patient representative, or service provider. If the internal appeal process is
not satisfactory, a covered person is not satisfied with an appeal determination regarding a
claim that does not relate to a medical necessity or experimental/investigational services denial,
the covered person may request a claim review by the GTCMHIC Appeals Committee by filing a
written request for a review.
AUDIT
Financial and claims operations are audited annually by third party auditing firms. Their results
are reported to BoD and to DFS. For the years 2011 and the first 6 months of 2012, the
GTCMHIC was audited by DFS. The audit has been completed. The final report has been
shared with the Bod and it will soon be made available to the public through the DFS website.
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01/05/2014
Greater Tompkins County Municipal Health Insurance
Consortium
Board of Directors
Executive Committee
Executive Director
Treasurer
Medical Claims
Administrator
Prescription Drug
Manager
Professional Support
Advisory
Committees
Legal
Hancock &
Estabrook
CPA
Bonadio & CDLM
JCPSD
Audit
&
Finance
Appeals
OYOH
Actuary
Aquarius Capital
Benefit Plan
Consultant
Locey & Cahill
Claims
Auditor
GTCMHIC Orientation Manual Page 25
Contact Information:
Greater Tompkins County Municipal Health Insurance Consortium
125 E. Court Street
Ithaca, NY 14850
Administrative Clerk: Consortium@twcny.rr.com
Executive Director: Don Barber (EDConsortium@twcny.rr.com)
Membership and Billing Inquiry Unit:
Excellus BlueCross BlueShield
P.O. Box 22999
Rochester, NY 14692
Phone: 1-800-724-5032
Membership & Billing professionals are available:
Monday-Thursday 8 a.m. – 5 p.m., Friday 9 a.m. - 5 p.m.
Customer Care Department (Claims and Benefits)
Excellus BlueCross BlueShield
P.O. Box 22999
Rochester, NY 14692
Phone: 1-800-499-1275
Customer Care professionals are available:
Monday-Thursday 8 a.m.- 7 p.m.; Friday 9 a.m.-7 p.m.; Saturday 9 a.m. - 1 p.m.
Prescription Drugs:
ProAct Pharmacy Benefits
1230 Route 11
Gouverneur, NY 13624
Phone: 1-877-635-9545
The ProAct Help Desk Customer Service Team is available:
Monday-Friday 7 a.m. – 10 p.m.
Saturday8:30 a.m. – 5 p.m.
Municipal Health Insurance Benefit Clerks:
Village of Cayuga Heights – Joan Mangione jmangione@cayuga-heights.ny.us 257-1238
Village of Dryden – Debra Marrotte villageclerk@dryden-ny.org 844-8122
Village of Groton – Chuck Rankin crankingroton@gmail.com 898-4177
Village of Trumansburg – Tammy Morse –clerk@trumansburg-ny.gov 387-6501
Town of Caroline – Cindy Whitaker cwhitt9127@aol.com 539-6400
Town of Dryden – Jenn Case Bookkeeper@dryden.ny.us 844-8888
Town of Enfield – Ann Rider ann-rider@townofenfield.org 273-8256
Town of Groton – Chuck Rankin crankingroton@gmail.com 898-4177
Town of Ithaca – Judy Drake Jdrake@town.ithaca.ny.us 273-1721
Town of Danby – Laura Shawley danbyhwy@yahoo.com 277-4788
Town of Ulysses Carissa Parlato clerk@ulysses.ny.us 387-5767
Tompkins County – Brooke Jobin bjobin@tompkins-co.org 274-5526
TC3 – Sharon Dovi dovis@tc3.edu 844-8211
City of Ithaca – Denise Malone dmalone@cityofithaca.org 274-6539
City of Cortland – Mack Cook mcook@cortland.org 756-7312
Julie Maddren –payroll@cortland.org 758-8373
Town of Lansing – Sharon Bowman sbbowman@twcny.rr.com 533-8819
Village of Homer - LouAnne Randall -larclerk@yahoo.com 749-3322
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Consortium Board of Directors:
The Greater Tompkins County Health Consortium Board of Directors is composed on one
delegate from each municipality that has signed the Municipal Cooperative Agreement (MCA).
The municipality may also appoint an Alternate with the authority to vote when the delegate is
not in attendance. Labor has at least two Director positions and more if the number of municipal
partners increases. Section K of the MCA describes the number and how these Labor Directors
are selected.
The Board of Directors sets policy and delegates nearly all parts of their responsibility.
Specifically the Directors are responsible for management, control, and administration of the
Consortium and the approved Benefit Plan(s). There are twenty-one (21) responsibilities listed
in the MCA.
The Board of Directors shall meet not less than quarterly. Currently the Board meets bi-
monthly. Typically actions occur by a majority vote of the total number of Directors. However,
the MCA describes a weighted voting process. This process was developed because there are
a couple of members that bring to the Consortium the majority of contracts and therefore pay
the most premium. To date, the weighted voting process has not been used. The motions and
resolutions adopted by the Board of Directors, since its inception, can be found on the website,
“Board of Directors” page.
Board of Directors Motions and Resolutions
All Board of Directors decisions can be found on the website’s “Board of Directors” page since
the Board was first formed in 2009. All of the decisions are specific to the operations of the
Board and the Consortium and do not directly impact the participants and their employees
except two.
Resolution Nos. 005 and 018 of 2014 require that all participating municipalities to certify
that all of the dependents of their employees current and new hires and retirees meet the
definition of eligible dependents.
Resolution No. 015-2014 urges each participating municipality to develop a wellness
policy and urge at least one representative from their wellness committee to become
involved with the OYOH Committee.A sample policy is attached. See meeting times for
OYOH Committee on the Consortium website.
GTCMHIC Orientation Manual Page 27
Greater Tompkins County Municipal Health Insurance Consortium
Policy for Disclosing Possible Wrongful Conduct (Whistleblower Policy)
Overview
The Greater Tompkins County Municipal Health Insurance Consortium was established to provide cost
effective health and other related insurance benefits for the employees and retirees of member
municipalities and their dependents. The aggregate cost of the program affects the future benefits of all
members. Ultimately, the true payers of these benefits are the taxpayers of the municipalities in which
these employers are located. It is, therefore, incumbent upon everyone involved to ensure that any
wrongful acts, such as theft, fraud, waste or abuse are properly reported.
Disclosure Policy
It is the policy of the Consortium that all individuals involved in the administration of the plan, as well as
all members who receive benefits provided by the plan abide by the plan documents and all applicable
state and federal laws and regulations. Any expected acts of theft, fraud, waste or abuse should be
reported to the Consortium’s Audit Committee or directly to the Attorney-in-fact1 (John G. Powers of
Hancock Estabrook LLP) for further investigation. Such investigation shall be commenced within 30
days. A written report of findings shall be submitted to the Board of Directors within 60 days.
Anti-Discrimination Policy
Any employee who discloses an alleged act of theft, fraud, waste or abuse shall not be discriminated or
retaliated against by his/her employer or by any representative of the Consortium. In fact, all disclosures
or complaints shall be kept confidential to the maximum extent possible. Disclosures or complaints
submitted anonymously shall receive the same treatment as those submitted with identification. Any acts
of discrimination or retaliation due to an individual’s disclosure of theft, fraud, waste or abuse shall be
reported to the Consortium’s Audit Committee or directly to the Attorney-in-fact. Reports of
discrimination shall be investigated within 30 days. A written report of findings shall be submitted to the
Board of Directors within 60 days.
Distribution
This policy shall initially be distributed to each member municipality, each member of the Board of
Directors, and the Joint Committee on Plan Structure and Design. A copy shall also be posted in a
conspicuous location at each member municipality facility, and on the Consortium’s website.
Review
This policy shall be reviewed by the Board of Directors at least once every three (3) years.
GTCMHIC Orientation Manual Page 28
Greater Tompkins County Municipal Health Insurance Consortium
Code of Ethics and Conflict of Interest Policy
(Adopted 2-27-2014)
Employees and the Board of Directors of the Greater Tompkins County Municipal Health Insurance
Consortium shall:
1. Be dedicated to the concepts of an effective Consortium and believe that professional general
management is essential to the achievement of this objective.
2. Shall affirm the dignity and work of the services rendered by the Consortium and maintain a
constructive, creative, and practical attitude toward Consortium affairs and a deep sense of
responsibility as a trusted public servant.
3. Be dedicated to the highest ideals of honor and integrity in all public and personal relationships
in order that the member may merit the respect and confidence of the elected officials, of other
officials and employees, and of the public.
4. Conduct themselves so as to maintain public confidence in their profession, the Consortium,
and in their performance of the public trust.
5. Conduct their official and personal affairs in such a manner as to give the clear impression that
they cannot be improperly influenced in the performance of their official duties.
6. Recognize that the chief function of the Consortium at all times is to serve the interests of all
members.
7. Shall not disclose Confidential Information to others or use to further their personal interest,
confidential information acquired by them in the course of their official duties.
8. Shall not, except pursuant to such reasonable exceptions as are provided by regulation, solicit
or accept any gift or other item of monetary value from any person or entity seeking official
action from, doing business with, or conducting activities regulated by the employee’s agency,
or whose interests may be substantially affected by the performance or nonperformance of the
employee’s duties.
9. Make no unauthorized commitment or promises of any kind purporting to bind the Consortium.
10. Shall act impartially and not give preferential treatment to any private organization or individual.
11. Shall not engage in outside employment or activities, including seeking or negotiating for
employment, that conflict with official Consortium duties and responsibilities.
12. Shall endeavor to avoid any actions creating the appearance that they are violating the law or
the ethical standards promulgated pursuant to this order.
13. Shall adhere to all laws and regulations that provide equal opportunity for all Americans
regardless of race, color, religion, sex, national origin, age, or disability.
14. Shall not invest or hold any investment, directly or indirectly, in any financial business,
commercial, or other private transaction that creates a conflict with their official duties.
GTCMHIC Orientation Manual Page 29
15.Reporting of Ethics Violations.When becoming aware of a possible violation of the
Consortium’s Code of Ethics, employees, Board of Directors, employees of members, and the
public may report the matter to the Consortium Attorney-in-fact, John Powers, Esq.. In reporting
the matter, members may choose to go on record as the complainant or report the matter on a
confidential basis.
16. Employees and the Board of Directors should not discuss or divulge information with anyone
about pending or completed ethics cases except as authorized by the Board of Directors.
GTCMHIC Orientation Manual Page 30
Notice of Privacy Practices
(Approved by Board of Directors 12/19/2013)
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW CAREFULLY.
We understand that personal and health information about you is personal. We are committed to safeguarding
your personal and protected health information (PHI.)PHI is any information that can identify you as an individual
and your past, present or future physical or mental health condition.
This policy supports your health plans need to collect information and the right of the individual to privacy. It ensures that
the health plan can collect personal and health information necessary for its functions, while recognizing the right of the
individuals to have their information handled in ways that they would reasonably expect and in ways that protect the
privacy of their personal and health information.We are required by law to maintain the privacy of your protected health
information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies
and practices that are outlined in this notice.
Use and Disclosures-Personal and health information is collected and used for the following purposes:
We will not disclose PHI to an unauthorized person not involved in your care or treatment, unless we are required
or permitted to do so by law.
Treatment:Your health information may be used by Greater Tompkins County Municipal Health Insurance Consortium
(GTCMHIC) or disclosed to other organizations for the purpose of evaluating your health, diagnosing medical conditions,
and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record
to all organizations who may provide treatment or who may be consulted by GTCMHIC representatives.
Payment:Your health information may be used to seekpayment from your health plan, from other sources of coverage
such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your
health plan may request and receive information on dates of service, the services provided, and the medical condition
being treated.
Health care operations:Your health information may be used as necessary to support the day-to-day activities and
management of GTCMHIC. For example, information on the services you received may be used to support budgeting
and financial reporting, and activities to evaluate and promote quality.
Business Associates:Your personal and health information may be disclosed to business associates independent of
our business with which we contract. However, we will only make such disclosures if we have received satisfactory
assurances that the business associate will properly safeguard your privacy and the confidentiality of your PHI. For
example, we may contract with a company to consult to us regarding the health plan.
Law enforcement:Your health information may be disclosed to law enforcement agencies, without your permission, to
support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government
mandated reporting.
Public health reporting:Your health information may be disclosed to public health agencies as required by law. For
example, we are required to report certain communicable diseases to the state's public health department.
Other uses and disclosures require your authorization:Disclosure of your health information or its use for any
purpose other than those listed above requires your specific written authorization. If you change your mind after
authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your
decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you
notified us of your decision.
GTCMHIC Orientation Manual Page 31
Information about treatments:Your health information may be used to send you information on the treatment and
management of your medical condition that you may find to be of interest. We may also send you information describing
other health-related goods and service that we believe may interest you.
Individual Rights
You have certain rights under the federal privacy standards. These include:
The right to request-restrictions-on-the-use and-disclosure-of-your-protected-health-information.
The right to receive confidential communication's concerning your medical condition and treatment.
The right to inspect and copy your protected health information.
The right to amend or submit corrections to your protected health information.
The right to receive an accounting of how and to whom your protected health information has been disclosed.
The right to receive a printed copy of this notice.
GTCMHIC:We are required by law to maintain the privacy of your protected health information and to provide you with this
notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this
notice.
Right to Revise Privacy Practices:As permitted by law, we reserve the right to amend or modify our privacy policies
and practices. These changes in our policies and practices may be required by changes in federal and state lawsand
regulations. Whatever the reason for these revisions, we will provide you with a revised notice. The revised policies and
practices will be applied to all protected health information that we maintain.
Requests to Inspect Protected Health Information:As permitted by federal regulation, we require that requests to
inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your
records by contacting the Privacy Official.
Complaints: If you would like to submit a comment or complaint about our privacy practices, you can do so by
sending a letter outlining your concerns to the Privacy Official.If you believe that your privacy rights have been
violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same
address.You will not be penalized or otherwise retaliated against for filing a complaint.
Contact Person: You can receive further information concerning our privacy practices by contacting:
Privacy Official
e-mail: consortiumprivacy@tompkins-co.org
GTCMHIC
125 East Court Street
Ithaca, NY 14850
607-274-5590
607-274-5558 (fax)
This Notice is effective on or after January 1, 2014.
GTCMHIC Orientation Manual Page 32
Greater Tompkins County Municipal Health Insurance
Consortium Procurement Policy
All procurements made by the Greater Tompkins County Municipal Health Insurance
Consortium involving the expenditure of the Consortium funds will be made in accordance with
the following procurement standards.
Purchases will be reviewed by the Consortium Treasurer to prevent duplication and to ensure
that costs are reasonable.
I. METHODS FOR PROCUREMENT
Procurements shall be made using one of the following methods:
A. Verbal or Written Quotations
Purchases which cost between $1.00 and $499.99 may be made by authorized purchasers
using the purchaser’s best discretion with expense(s) to be directly paid or reimbursed by the
Consortium upon receipt of a valid proof of purchase (i.e. receipt or invoice). Efforts will be
made to get the lowest and best price, but written documentation is not required.
Purchases which cost between $500.00 and $2,999.99 require three verbal (telephone) quotes.
A memorandum shall be prepared detailing the date of contact, company name, contact person,
pricing, and delivery terms. Purchaser shall make every attempt to ensure fair and competitive
pricing.
Purchases of supplies, equipment, and professional services between $3,000.00 and
$20,000.00 require written quotations. Reasonable attempts shall be made to obtain a
minimum of three responses. Documentation detailing such attempts shall be prepared and
filed with the paid bill file.
B. Bids or Request for Proposals
Bids will be sought for purchases of goods or equipment that exceed $20,000. Detailed
specifications will be developed for approval by the Consortium prior to posting on the
appropriate website(s). Bids shall be awarded to the lowest responsible bidder(s) meeting all
specifications with acceptable deviations. Bids shall be awarded by the Board of Directors.
Request for Proposals shall be sought when the cost for services is expected to exceed
$20,000. Specifications shall be developed and approved by the Consortium prior to posting on
the appropriate website(s). As a general rule, Request for Proposals shall be posted on the
appropriate website(s) for a minimum of twenty-one days. The Board of Directors shall
authorize the award and contract for the requested service(s).
Request for Proposal specifications shall detail the following:
Scope of Services
Evaluation Criteria
Project Schedule
Contract Term
Contract shall be awarded to the offerer that submits the proposal determined to be in the best
interest of the Consortium once proposals have been reviewed and, if needed, negotiated.
Written evaluations of each response must be provided.
The Consortium reserves the right to reject all proposals, to negotiate with an offerer, and to
solicit new Request for Proposals if determined to be in the best interest of the Consortium.
II. CONTRACTS
GTCMHIC Orientation Manual Page 33
Generally, all procurement involving services will require a written description of the service or,
when applicable, a written contract.
A contract for professional services shall be for up to three years with the option to renew for an
additional two years.
All contracts shall contain a cancelation clause which allows the Consortium to cancel any
contract for cause. All contracts shall contain a cancellation clause which allows the Consortium
to cancel any contract without cause with either a 30 or 60 day notice.
All contracts shall contain indemnification and hold harmless language and shall state required
insurance coverage as deemed sufficient and appropriate by the Board of Directors.
III. DOCUMENTATION
Supporting documentation for purchases that do not require bidding or seeking proposals shall
be retained and filed by the Consortium Treasurer or designee.
All bid and proposal responses shall be filed and maintained in accordance with the New York
State Records Retention laws, in the Tompkins County Finance Department, Purchasing
Division.
IV. ADDITIONAL GUIDELINES FOR RFP DEVELOPMENT (SEE ATTACHED)
Please see the following page for additional guidelines for writing an RFP.
GUIDELINES FOR WRITING AN RFP
Include Rules for Submitting a Proposal – The rules for submitting a proposal (instructions) must
be included in the specifications. Respondents will need to know who, where, and how (format)
to submit their response.
Make it a Performance Specification – Describe the performance desired rather than specifying
the exact goods or services that are required. For example, a janitorial contract for providing a
“clean work environment” should outline the program goals and ask for the qualifications of the
Respondent’s personnel rather than telling them the number of people needed to perform the
work, their required qualifications, or the number of times they must perform certain tasks.
Keep it Non-Proprietary – Do not specify the service so narrowly that it fits only one
provider.
Disclose the Contract Term – In the Statement of Work explain the term of the contract.
Disclose Award Criteria & Weights – Disclose the criteria that will be used to evaluate
the proposals and the weight that will be given to each criterion. This lets the
Respondents know what is important and how their proposals will be judged.
Require Only What Will be Evaluated – Do not ask for information that will not be
considered in making the award and that will contain a cost to the Respondent to provide
(such as financial statements). The Respondents will pass along that cost to you in their
proposals so ultimately you would pay for something you did not intend to use.
Do Not Over Specify –Do not ask for services that are not necessary. If you are not
willing to pay for additional services, do not include them in the specifications unless you
include them as “options”. To avoid the appearance of an arbitrary award, identify the
priority of options that will be selected if funds are available. For example: “within
budgetary limits, options will be awarded in the following priority: A, B, C, and F.”
Hold a Pre-Solicitation Conference if Necessary –A pre-solicitation conference may be
necessary to give Respondents a chance to clarify the specifications and propose
changes or corrections to them.
GTCMHIC Orientation Manual Page 34
Checklist for Developing RFPs
Meet and discuss the end-user’s needs before and during development of the RFP.
Establish the award criteria and include it in the RFP.
Explain award criteria and how to evaluate the proposals that are received.
Set up the scoring method and evaluation team before mailing the RFP.
Determine if you will hold a Pre-Solicitation Conference.
Determine the contract term and any options for extension.
Establish a timeline for the RFP to include, at a minimum, the following:
Release Date
Ending Date for Questions
Pre-Solicitation Conference Date, Location and Time
Due Date
Award Date
Contract Commencement
GTCMHIC Orientation Manual Page 35
RESOLUTION NO. 003-2013 - ESTABLISHMENT OF POLICY FOR PRIVATE
ADVERTISING ON CONSORTIUM MATERIALS
MOVED by Mr. Barber, seconded by Ms. Tyler, and unanimously adopted by
voice vote by members present.
WHEREAS, the Greater Tompkins County Municipal Health Insurance
Consortium (GTCMHIC) is a consortium of public entities that contracts with private
entities such as Third Party Administrators and consultants for technical services, and
WHEREAS, contracting firms are not restricted by the GTCMHIC from
autonomous decisions, actions, and communications with enrollees and GTCMHIC
members, now therefore be it
RESOLVED, That the Board of Directors of the GTCMHIC establishes the
Private Advertising on Consortium Materials Policy to be that all communications with
enrollees must state who they are, the relationship to the GTCMHIC, the purpose of this
particular piece of communication, and the necessary content to accomplish the stated
purpose,
RESOLVED, further, That information contracting firms want to send to enrollees
must first be approved by a majority of the Executive Committee of the GTCMHIC prior
to its release,
RESOLVED, further, That this policy is not intended to delay the distribution of
materials from vendors to members that may be informative and beneficial in nature.
* * * * * * * * *
GTCMHIC Orientation Manual Page 36
Committees:
Advisory committees perform most of the research and deliberation on policy, financial condition
and premium rates, planning and operations. The Committees share their work with the BoD.
Committee work is volunteer and is the key to keeping Consortium costs low. Directors,
municipal officials (elected and appointed), and employees covered by a Consortium benefit
plans are all encouraged to share their wisdom and experiences to guide the Consortium.
Joint Committee on Plan Structure and Design
This is a special Committee of the GTCMHIC. It is comprised of a delegate from each
municipality and a delegate from each bargaining group. The Chair of the Joint
Committee on Plan Structure and Design (JC) is elected from the committee members
and must be a labor delegate. The Vice Chair is also elected from the committee
members and must be a management delegate. The JC adopts by-laws consistent with
the MCA. The most recent adopted by-laws are attached.
The JC has been meeting monthly on the first Thursday at 1:30 PM. If a delegate cannot
attend, the by-laws allow them to send in a proxy to an attending delegate.
The JC, like all other GTCMHIC committees, are advisory to the BoD which has ultimate
responsibility to take action.
In addition to serving on the Joint Committee on Plan Structure and Design, employees
can be elected to be a Director, and serve on the Own Your Own Health Committee and
by appointment the Audit and Finance Committee.
Appeals Committee
The Appeals process can be found on the “Employee Information” page of the website.
The role of the Consortium’s Appeals Committee is to ensure that the Appeals process
stays current with regulation and legal decisions and decide on appeals that have not
been resolved through the Claims Administrator’s appeals process and a neutral third
party’s appeal process.
Appeals procedure: The Claims Appeal procedure is described in detail on the
Consortium Website. The process begins with initial contact with Excellus or Pro-Act.
The appeal can be made by the patient, patient representative, or service provider. If the
internal appeal process through the benefit plan administrator is not satisfactory, a
covered person is not satisfied with an appeal determination regarding a claim that does
not relate to a medical necessity or experimental/investigational services denial, the
covered person may request a claim review by the GTCMHIC Appeals Committee by
filing a written request for a review.
Audit and Finance Committee
Appointing membership to Audit and Finance Committee is the responsibility of the Board of
Directors. Current membership can be found on the “Special Committee” website page. The
Committee has been charged with these responsibilities:
GTCMHIC Orientation Manual Page 37
recommend a budget
recommend premium rates
review financial reports and filings including JURAT reports
recommend reinsurance, retention, and reserving policies
audit policies and procedures to ensure compliance with Article 47 and the Certificate of
Authority
review medical claims audit reports
establish a list of all reports due to the Board and regulators and the process and time
line to insure accurate and timely reporting
Executive Committee
From the MCA: The Executive Committee of the Consortium shall consist of the
Chairperson, the Vice-Chairperson, and the Chief Fiscal Officer of the Consortium.
The Executive Committee may meet at any time between meetings of the Board at the
discretion of the Chairperson. The Executive Committee shall make recommendations to
the Board.
The Executive Committee shall manage the Consortium between meetings of the Board,
subject to such approval by the Board as may be required by the Agreement.
Owning Your Own Health Committee
Owning Your Own Health Committee would be typically called Wellness in other
organizations but is called OYOH for the Consortium because it speaks to the culture
change that is needed to improve each of our lives and retain more of our labor’s value in
our pockets. The OYOH Committee has the potential to be strategic planning arm of the
Consortium. It current membership includes community professionals in health care and
health policy, human resource professionals, municipal and labor representatives.
The cost of health care in our region has been increasing at a rate of 8.5% per year. At
this rate and over ten (10) years, the cost on health care more than doubles (2.25 times
greater). The current municipal government climate is limiting resources to two (2) percent
increase per year which means 1.22 greater after ten years.
The PPACA requires employers to provide health insurance coverage. When taking
wages and health insurance cost as a compensation unit, one concludes that without a
change in health care costs, all of an employees increased value will be translated into
maintenance of health insurance premium for a similar benefit plan.
The GTCMHIC Health Insurance Forum of September 15, 2014 can be found on the
website. It provides the background as to why health care and health insurance are
increasing much faster than inflation. The main external reasons are rapid changes in
care technology and mandated coverage. The main internal reason is life style choices
including exercise and diet. The OYOH committee is cognizant that the key to improving
our health and comfort is through becoming more aware of the effect our daily choices
have on our health. Hence the term “Own Your Own”.
The value of the Health Consortium described in the introduction can be multiplied many
times by successful wellness strategies. We have individual needs and triggers to
become healthier. Your participation in wellness programs and developing wellness
strategies will have profound impact on our individual and collective quality of life.
GTCMHIC Orientation Manual Page 38
Joint Committee on Plan Structure and Design
updated 11-07-2013
1.The Joint Committee will consist of one representative from each bargaining unit with enrollees covered
by the Consortium plans and one representative from each of the participating municipalities.
2.The purpose of the Joint Committee will be to review all prospective Board actions in connection with the
benefit structure and design of the plans offered by the consortium in order to develop findings and make
recommendations to the Board with regard to such actions.
3.The Joint Committee will: be involved in reviewing benefits; investigate creative program designs for
optimal use of resources; receive (quarterly ) reports regarding use of benefits, UCR changes, and
potential cost increases; compare benefits and costs about any carrier change; gather information about
benefits, service levels, and related program costs.
4.The Joint Committee will present their findings and recommendations with respect to benefit structure and
design issues to the Consortium Board through the Committee Chair who will be a Director on the
governing Board of the Consortium. Any proposed change to plan benefit structure or design must be
approved by the Joint Committee prior to being brought to the Consortium Board of Directors for
consideration.
5.All Joint Committee decisions shall be by one-third of the municipal membership and one-third of the
union membership.
6.The Joint Committee Chairperson will be (elected/chosen) by the members of the Committee and must be
a union representative on the Joint Committee. The Vice-Chairperson of the Committee will also be
(elected/chosen) by the Joint Committee and must be a representative from one of the participating
municipalities.
7.The Joint Committee Chairperson will serve as a voting Director on the Consortium Board of Directors,
representing the unions. The Joint Committee will also (elect/choose) from among the union
representatives on the Committee one more voting Director to the Board of the Consortium to represent
the unions. If the number of participating municipalities in the Consortium increases to 17, there may be
an opportunity for the Joint Committee to (elect/choose) one more voting Director to the Board from
among the union representatives on the Committee to represent the unions, for a possible total of 3 voting
Directors on the Consortium Board to represent the unions.
8.Bargaining unit representatives will be the president of each bargaining unit or that persons’ designee
from the unit. Management representatives will be appointed by the respective elected leader of each
participating municipality. (so the term of appointments will vary according to the pleasure of the
appointing authority).
9.The Joint Committee will meet (quarterly, bi-monthly, or as determined by the Chair and Vice-Chair of
the Committee). Meetings will generally be scheduled (on the first Thursday of a month from 12 p.m. to 2
p.m. Paid release time will be granted to both union and municipal representatives to attend Joint
Committee meetings. Future meeting dates and times will be reflected on the agenda of each meeting.
10.The County representative (or some other appropriate person) on the Joint Committee will be responsible
for distributing agendas and handouts, scheduling meetings, taking notes, creating draft minutes and
posting materials on the GTCMHIC website.
GTCMHIC Orientation Manual Page 39
Wellness Policy Resolution Sample
Whereas, physical health or wellness is a personal asset that frees one to concentrate on
work, family and relationships, and hobbies, and
Whereas, wellness is a dynamic process of learning new life skills and becoming aware
of and making conscious choices toward a balanced and healthy lifestyle, and
Whereas, wellness cannot be guaranteed by any set of actions, yet wellness can be
improved and increased by personal choices, and
Whereas, workplace environment, policies, and incentives can support and provide
awareness for wellness choices, and
Whereas, Article 47 of NYS Insurance Law requires and envisions a partnerships
between employer and employees in directing their health insurance, and
Whereas, employer and employees are collaborating to fund Health Insurance, and
Whereas, the cost of health insurance and time loss due to illness and injury are both
directly reduced when its members are in good health,
Now therefore be it resolved that the (municipality) seeks to become an active partner
with staff in raising healthy choice awareness, promoting healthy behaviors by providing
information and opportunities, and facilitating wellness action steps
Be it further resolved that the (municipality) creates a Wellness Advisory Committee
charged promoting health and wellness of staff and their family through education and program
initiatives that:
Encourage habits of wellness
Increase awareness of factors and resources contributing to well-being
Inspire and empower individuals to take responsibility for their own health
Recommend action steps to create a workplace culture that encourages
environmental and social support for healthy lifestyle choices
Be It Further Resolved that the (municipality) appoints: ___________ to the Wellness
Committee and directs the committee to report back to the (municipality) the status of their
deliberations by __________.
GTCMHIC Orientation Manual Page 40
Benefit Plan Menu:
The Consortium’s benefit plan menu currently offers medical plans (PPO and indemnity) with
prescription drug benefits through a copay card, medical plans with the prescription drug
benefits embedded in the “major medical” portion of the plan, a Medicare Supplement plan, and
PPACA Metal Level plans.
Indemnity Plans
The reference to indemnity plans is a fairly old description of a medical benefits plan which is
structured to provide paid-in-full basic hospital, medical, and surgical care coverage. These
plans typically have a “major medical” component which is subject to a deductible, coinsurance,
and an out-of-pocket maximum. These plans are usually coupled with a prescription drug card
program to provide the covered members with a complete benefit plan to treat their illnesses
and/or injuries. The Consortium currently offers the following Indemnity Plans:
Plan
Code Medical Plan Benefit Description
MM1 GTCMHIC Indemnity Medical Plan 1 ($50/ $150 Deductible and $400/$1,200 OOP Max.)
MM2 GTCMHIC Indemnity Medical Plan 2 ($100 / $200 Deductible and $400/$800 OOP Max.)
MM3 GTCMHIC Indemnity Medical Plan 3 ($100 / $200 Deductible and $750/$2,250 OOP Max.)
MM4 GTCMHIC Indemnity Medical Plan 4 ($100 / $250 Deductible and $400/$1,200 OOP Max.)
MM5 GTCMHIC Indemnity Medical Plan 5 ($100 / $300 Deductible and $400/$1,200 OOP Max.)
MM6 GTCMHIC Indemnity Medical Plan 6 (Comprehensive Value Plan)
MM7 GTCMHIC Indemnity Medical Plan 7 (Rx Embedded in MM)
PPO Plans
A Preferred Provider Organization (PPO) Plan is a more modern plan design which requires the
covered members to pay a modest copayment for certain in-network medical services.
However, as with indemnity plans, many of the in-network basic hospital, medical, and surgical
services are paid-in-full. This type of plan also provides benefits for out-of-network services
which are usually subject to a deductible, coinsurance, and out-of-pocket maximum. These
plans are typically coupled with a prescription drug card program to provide the covered
members with a complete benefit plan to treat their illnesses and/or injuries. The Consortium
currently offers the following PPO Plans:
Plan
Code Medical Plan Benefit Description
PPO1 $10.00 GTCMHIC PPO Plan
PPO2 $15.00 GTCMHIC PPO Plan
PPO3 $20.00 GTCMHIC PPO Plan
PPOT $10.00 GTCMHIC "Teamsters Look Alike" PPO Plan
Medicare Supplement Plan
Currently the Consortium does offer a medical plan for retirees who are Medicare-eligible which
is designed to provide benefits to compliment the Federal Medicare Program Parts A and B.
This Medicare Secondary Plan can be offered as a medical only plan or it can be coupled with a
prescription drug card program.
GTCMHIC Orientation Manual Page 41
PPACA Metal Level Plans
To stay competitive with benefit plan offerings available in the health insurance marketplace, the
Consortium recently approved the inclusion of the GTCMHIC Standard Platinum Plan. In
addition, the Joint Committee on Plan Structure and Design is continuing its work on the
possible addition of the GTCMHIC Standard Gold Plan, GTCMHIC Standard Silver Plan, and
the GTCMHIC Bronze Plan. The PPACA Metal Level Plans are designed to maintain the
actuarial value of the plan which means the benefits are subject to possible alteration each year.
Prescription Drug Plans
The Consortium currently offers both two-tier and three-tier copayment structure prescription
drug plans. The overwhelming majority of the covered members are enrolled in the three-tier
prescription drug programs which is a formulary based product that charges a different
copayment based on the tier classification of the medication being purchased. The following
are the current two-tier and three-tier prescription drug options available:
Two-Tier Plans
Plan
Code
Retail Pharmacy Mail-Order Pharmacy
Generic Brand Name Generic Brand Name
2T1 $1.00 $1.00 $0.00 $0.00
2T2 $2.00 $5.00 $0.00 $0.00
2T3 $2.00 $10.00 $0.00 $0.00
2T4 $0.00 $15.00 $0.00 $30.00
2T5 $5.00 $15.00 $10.00 $30.00
2T6 $5.00 $20.00 $10.00 $40.00
Three-Tier Plans
Plan
Code
Retail Pharmacy Mail-Order Pharmacy
Tier 1 Tier 2 Tier 3 Tier 1 Tier 2 Tier 3
Generic Preferred
Brand
Non-Preferred
Brand Generic Preferred
Brand
Non-Preferred
Brand
3T1 $0.00 $5.00 $20.00 $0.00 $10.00 $40.00
3T2 $5.00 $10.00 $25.00 $5.00 $10.00 $25.00
3T3 $5.00 $10.00 $25.00 $10.00 $20.00 $50.00
3T4 $5.00 $10.00 $25.00 $15.00 $30.00 $75.00
3T5 $5.00 $15.00 $25.00 $5.00 $15.00 $25.00
3T5a $5.00 $15.00 $30.00 $5.00 $15.00 $30.00
3T6 $5.00 $15.00 $30.00 $10.00 $30.00 $60.00
3T7 $5.00 $20.00 $35.00 $10.00 $40.00 $70.00
3T8 $10.00 $20.00 $35.00 $20.00 $40.00 $70.00
3T9 $10.00 $25.00 $40.00 $20.00 $50.00 $80.00
3T10 $15.00 $30.00 $45.00 $30.00 $60.00 $90.00
3T11 20% 20% 40% 15% 15% 40%
3T12 20% 30% 45% 20% 30% 45%
3T13 20% 30% 50% 20% 30% 50%
It should be noted that the plan designs shaded grey above are no longer available for
additional members to join. The particular plan designs are for the current enrolled members
only.
GTCMHIC Orientation Manual Page 42
Adding New Plan Designs
The process for development and review of a new plan requires a participating employer, a
committee, or a Director to make a request to the Consortium Board of Directors to add a new
benefit plan. Most commonly, this request would come from the Joint Committee on Plan
Structure and Design. The Board of Directors would ask the Benefit Plan Consultant to develop
a proposal based on certain criteria. The Benefit Plan Consultant would then bring forward a
draft plan for review by the Joint Committee. Once the plan specifics are firmed up, the Benefit
Plan Consultant would develop the premium equivalent rates which are presented to the Audit
and Finance Committee. The Audit & Finance Committee would the financial impact of adding
such a plan. At any time after the new benefit plan has been brought before Joint Committee on
Plan Structure and Design and the Audit & Finance Committee, a Director may bring a
resolution forward to the Board of Directors for consideration regardless of the degree of
support by the Consortium’s advisory committees.
Benefit Plan Summaries
The Benefit Plan summaries for each municipality may be found on the “Employee/Retiree
Information” page of the Consortium’s website. A listing of the currently offered plans is
attached for your reference and review. For more detailed information or questions please start
with your Municipal Health Insurance Clerk whose contact information can be found on
“Resource and other Information” page of the Consortium website. The next stop for
information is Excellus BlueCross BlueShield and their contact information is found on the
“Employee/Retiree Information” page of the website.
If you need to make changes with you plan’s coverage, contact your Municipal Health Insurance
Clerk (contact information is attached).
Ancillary Benefit Offerings
In addition to the traditional medical and prescription drug plan offerings, the Consortium also
has several fully-insured ancillary benefit plans which are made available to the participating
municipalities to be used at their discretion. These ancillary benefits include the following:
CSEA Employee Benefit Fund Dutchess Dental Plan
CSEA Employee Benefit Fund Platinum 12 Vision Plan
Upstate Union Health and Welfare Fund Legal Benefit Plan
Lincoln Financial Group Life Insurance
Lincoln Financial Group Accidental Death & Dismemberment Insurance
Lincoln Financial Group Disability Insurance
If your municipality is interested in adding one or more of the above ancillary benefit packages,
please contact the Consortium’s Executive Director who will assist you with this process.
GTCMHIC Orientation Manual Page 43
Benefit Plan Administration Partne r s:
Medical Plan Administrator: Excellus:
https://www.excellusbcbs.com/wps/portal/xl/cwp/greatertompkins
GTCMHIC Orientation Manual Page 44
Prescription Drug Manager: ProAct
https://secure.proactrx.com/
GTCMHIC Orientation Manual Page 45
Claims Appeals Process:
For Claims Other Than Medical Necessity or Experimental/Investigational Services:
If a claim is denied in whole or in part, the covered person will receive notification of a claim
denial via an explanation of benefits (EOB) form. The EOB form will be provided by the plan
administrator. The EOB will show the calculation of the total amount payable, charges not
payable, and the reason. If additional information is needed for the consideration of the claim,
the plan administrator will request it.
If a covered person does not agree with the denial of a claim, the covered person may call the
claims clerk on the toll-free number (1-800-499-1275). If the claim is not resolved to the covered
person’s satisfaction, the covered person should then speak to the manager of the plan
administration office. At that point, a final determination will be made by the plan administrator.
The covered person will be notified in writing of the plan administrator’s determination. A review
by the Appeals Committee of the Plan and/or arbitration may be available; see the Sections
titled “Review By the Appeals Committee” and “Arbitration” below.
Review by the Appeals Committee
If a covered person is not satisfied with an appeal determination regarding a claim, the covered
person may request a claim review by the Plan’s Appeals Committee by filing a written request
for a review with the plan administrator. Upon receipt of a written request, copies of all pertinent
information will be gathered and presented to the Appeals Committee. The covered person may
also submit written opinions and/or any comments regarding the claim to the plan administrator,
who will include the information with the materials that are presented to the Appeals Committee.
Requests for review by the Appeals Committee should be filed promptly; however, requests
may be filed at any time within 120 days of the final adverse determination by the plan
administrator.
The Appeals Committee will render its decision within 60 days of the receipt of the written
request for review, unless specific circumstances warrant an extension. The decision of the
Appeals Committee pertaining to the review will be delivered in writing to the covered person,
stating the specific reasons for the decision and the specific reference to the pertinent plan
provisions upon which the decision is based.
Arbitration
If the covered person and/or the covered person’s labor organization is not satisfied with the
decision of the Appeals Committee; and if the labor organization determines that the claim is
meritorious and further appeal is in the best interests of the labor organization, the labor
organization may submit the claim to arbitration, the outcome of which will be binding on all
parties.
A request for arbitration must be submitted, in writing, to the plan administrator within 30 days of
receipt of the written decision of the Appeals Committee.
Claims Related to Medical Necessity or Experimental/Investigational Services: Utilization
Review Procedure
Appeals concerning medical necessity or experimental/investigational services will not be heard
through the Consortium’s Appeal Committee. See the website for complete details of this
appeals procedure and timelines. This process can start pre-admission.
GTCMHIC Orientation Manual Page 46
Summary of Educational Retreat of
GTCMHIC of September 15, 2014:
Basics of Health Care, Health Insurance and the Consortium Operations
Health Care
Health care is the diagnosis, treatment, and prevention of disease, illness, injury, or
impairments.
Health care is delivered by practitioners and professionals (physicians, nurses, pharmacists,
psychologists, etc.).
Health care is private sector business that sells services and products, that in 2013 amounted to
$3 trillion; and is growing as a percentage of spending much faster than other major purchases.
Patient Choices: If you want service, which type of service, and where to receive service.
Prescription Drugs
Tier 1: Generic- average cost = $18
Tier 2: Brand Name – average cost = $246
Tier 3: Specialty – average cost = $2,205
Health Insurance
Health Insurance is an agreement between the patient, who pays premiums to an insurance
company, which pays for agreed medical services and Rx formularies.
Health Insurance is a premium/risk pool from persons of varying age and health conditions that
cooperatively cover each other’s cost of health care within agreed parameters. 20% of the risk
pool accumulate 80% of the claims cost.
We need health insurance because time of health care need is unpredictable and cost can be
exorbitant.
Premiums
Actuaries use statistical science to predict for a population claims expense based on specific
benefit plan(s).
Premiums are then calculated to raise enough revenue to cover predicted claims cost plus other
operational cost- including insurance for the rare large expense treatments.
Benefit Plans
Benefit Plans are a contract between a person and the health insurance company to cover
specified services and prescription formularies. Health Insurance Companies contract with “in-
network” providers for specific costs for services.
Benefit plans must provide Federal and State mandated benefits.
GTCMHIC has a menu of medical and Rx plans that were necessary to meet pre-existing labor
contracts and now PP&ACA metal plan requirements.
GTCMHIC has a process to change, delete, and add benefit plans.
Benefit Plans have member cost sharing such as deductibles, co-insurance, and Co-payments.
GTCMHIC Orientation Manual Page 47
Although the Consortium Board has not made chances to existing benefit plans, benefits are
expanding due to federal and state mandates, new medical procedures, and new
pharmaceuticals.
Advancements in Medical Technology Reasons for Hyper-inflation of Health Insurance
Advancement in Pharmaceuticals
Federal and State Mandated benefits
GTCMHIC-Beginning
Tompkins County Council of Governments was granted a Shared Service Incentive grant for
$250,000 to establish the first Article 47 Insurance Consortium since the law for their creation
was passed in 1993.
Article 47 allows large and small employers to form a consortium and provides a meaningful role
for labor.
Consortium was issued its Certificate of Authority in October 2010 and started operating 1/1/11.
It started with 13 municipalities, 2000 contracts, covering 4360 total lives.
The Municipal Cooperating Agreement is the agreement between partners and foundation for
operations.
GTCMHIC Financial Model
Self-Insured pooling of risks and premiums for Tompkins County and adjacent county municipal
governments.
Board of Directors are volunteers.
Claims are 93% of operational cost – which is exceptionally efficient compared to Non-Profits.
Pooling risks of a large number increases buying power and stabilizes claims predictions- which
stabilizes premiums.
Premiums are established by October 15th ahead of municipal budget adoption
GTCMHIC Growing Stronger
Consortium now has 16 municipal partners with over 2,300 contracts and 5,100 covered lives.
In 2014, $37.8 million was the anticipated revenue.
Anticipated claims for 2014 are 93% of premium.
Over the four year history, claims have been within 1% of actuary prediction.
The premium increases for 2012, 2013, 2014, and 2015 were 9%, 9%, 8% and 5% respectively.
Since 2011, average annual Consortium premiums increase is 4% less than competition.
Opportunities and Challenges
Medical care inflation
Advancements in medical technology
Advancements in pharmaceuticals
Regulatory mandates
State and Federal taxes and fees
GTCMHIC Orientation Manual Page 48
Website (www.tompkinscountyny.gov/hconsortium):
The GTCMHIC website is not only an archive but also contains working documents and is the
depository for information that is designed to be useful to Board and committee members,
employees and retirees, municipal staff, and others seeking to learn more about GTCMHIC.
Below is a summary of the information that is continually updated and accessible through the
main tabs on the website:
Board of Directors: Membership
Meeting Schedule
Actions and Resolutions
Agendas & Minutes
Policies
Employee and Retiree Information:
Appeals Information
Link to Medical Claims Administrator and Health Plans
Link to Prescription Drug Benefit Manager and Formulary Chart
Premium Equivalent Rates
Financials: Quarterly and Annual Financial Filings
Fiscal Year Results
Audit Reports
Budget Information
Joint Committee on Plan Structure and Design:
Agendas & Minutes
Meeting Schedule
Bylaws
Proxy Form
Membership
Special Committees: Agendas & Minutes
Meeting Schedule
Membership
History: Archived Consortium Information
News: News Articles and Announcements
Resources and Other Information:
Resources for Employers
Reports
Wellness: Links to Wellness Information and Programs
Affordable Care Act: Resources for Employers on Health Care Reform
GTCMHIC Orientation Manual Page 49