3.01 3.1
INSURANCE\Empire MediBlue Freedom Medicare Advantage Renewal for 2022- 10-4-2021
RESOLUTION AUTHORIZING 2022 RENEWAL CONTRACT FOR
EMPIRE MEDIBLUE FREEDOM (PPO)
MEDICARE ADVANTAGE INSURANCE
RESOLUTION NO. ,2021
INTRODUCED BY:
WHO MOVED FOR ITS ADOPTION
SECONDED BY:
WHEREAS, the Town of Queensbury previously entered into an agreement for an
employee group health insurance plan with Empire MediBlue Freedom (PPO) Medicare
Advantage, and
WHEREAS, the Town Board, in conjunction with Upstate Agency LLC, has negotiated a
renewal contract for the year 2022 with Empire MediBlue Freedom (PPO) Medicare Advantage,
NOW, THEREFORE, BE IT
RESOLVED, that the Queensbury Town Board hereby approves and authorizes a renewal
contract for the year 2022 with Empire MediBlue Freedom (PPO) Medicare Advantage with the
2022 monthly premium to be$387.89 per member, and
BE IT FURTHER,
RESOLVED, that in the event that surcharges, fees or taxes are mandated or imposed on
the Town's health insurance policies that are beyond the Town's control, resulting rate changes
may be passed on to all employees without further Town Board Resolution, although the Town
will provide notice of any such rate changes to all employees and retirees, and
BE IT FURTHER,
RESOLVED, that the Town Board further authorizes and directs the Town Supervisor to
execute any contracts and documentation and the Town Supervisor and/or Town Budget Officer to
take such other and further action necessary to effectuate the terms of this Resolution.
Duly adopted this 4'1'day of October,2022, by the following vote:
AYES
NOES
ABSENT:
2
Town of Queensbury UPSTATE
AGENCY.
Medicare Advantage with Prescription Drug 14®INSURANCE
January 1,2022 Effective date EMPLOYEE BENEFITS DIVISION
Plan Benefits In-Network Out-of-Network
Deductible None
Coinsurance None
Out-of-Pocket Maximum $3,400
Primary Office Visit $5 $5
Specialist Office Visit $20 $20
LiveHealth Online Covered in Full Covered in Full
Preventive Services Covered in Full Covered in Full
Inpatient Hospital $100($300 OOP per year) $100($300 OOP per year)
Outpatient Surgery $50 $50
Emergency Room $50 $50
Urgent Care Center $20 $20
Ambulance $50 $50
Laboratory testing $20 $20
X-rays $20 $20
MRI/MRA,Cat Scan,PET $50 $50
Diabetic Supplies 10%Coinsurance ! 10%Coinsurance
Physical/Speech/Occupational Therapy $20 $20
Skilled Nursing Facility $10 per day for days 1-100 $10 per day for days 1-100
Durable Medical Equipment 10%Coinsurance 10%Coinsurance
Home Health Care Covered in Full Covered in Full
Acupuncture(Medicare-covered) $5(up to 12 visits in 90 days) $5(up to 12 visits in 90 days)
Routine Vision Exam $0(limited to a$70 max benefit)every 12 months
Lenses&Frames Allowance $100 Allowance every 24 months
Dental Allowance None
Routing Hearing Exam $0(limited to a$70 max benefit)every 12 months
Hearing Aid Benefit $500 Allowance(every 12 months)
Preferred Pharmacy: $10/$20/$40
Prescription Drug-Part D Standard Pharmacy: $15/$25/$40
Mail Order(90 day supply) $30/$50/$90
Coverage gap/donut hole No gap
Wellness Program SilverSneakers and Nurse Helpline
Healthy Meals 14 meals per qualifying event,allows up to
(4 events each year(56 meals in total)
Rate 93 $395.80 $387.89
Estimated Monthly Cost $36,809 $36,074
Estimated Annual Cost $441,713 $432,885
Percent Change From Current N/A -2.0%
This is a benefit summary only and is subject to the terms,conditions,limitations and exclusions set forth in the contract.