21-V6 - CITY OF BURLESON sold vision renewal 09112024 jmw.pdf
PDF 292 KB Posted
- Attached to
- RFP 2026-015 Dental & Vision Insurance Benefits
- Solicitation number
- RFP 2026-015
- Issued by
- Johnson County, Texas
About this file
This document is a vision insurance renewal proposal issued by UnitedHealthcare Vision for the City of Burleson, Texas, effective January 1, 2025, through December 31, 2026. The proposal outlines comprehensive vision coverage for eligible full-time employees, retirees, and dependents under policy number 00906435. The plan includes eye examinations with additional coverage for children ages 0-12 and pregnant or breastfeeding women, single vision and progressive lens options, frames with retail allowances, elective and necessary contact lenses, and supplemental benefits such as retinal screening photography for diabetics, laser vision correction discounts through QualSight LASIK, and blue light protection discounts. The contract carries a 24-month rate guarantee with a two-year term and includes dependent children coverage to age 26.
The renewal proposal assumes 167 employee enrollees at a monthly premium of $7.38 per employee and 174 employee-plus-family enrollees at $15.84 monthly, resulting in a total annual premium of $47,863.44. The plan features a $10 co-pay for in-network exams and material co-pays ranging from $25 for frames to $45 for contact lenses, with lens option pricing at 20-60% off retail. The proposal includes a 2.5% broker commission and assumes standard administrative services including claims processing, enrollment, billing, customer service, and reporting. The contract is fully insured with no participation requirements and is valid for 90 days from the September 11, 2024, issuance date, with rates subject to change based on enrollment fluctuations exceeding 10% or changes in group demographics.
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Text version
Renewal Sold UAF for
City of Burleson
Issued on: September 11, 2024
Legal Entity
Plan Options
Contribution
Product Type
Network Type
Exam(s) Co-pay
Material Co-pay
(Frames/Spectacle Lenses or Contact Lenses)
Service Frequency
Exams/ Lenses/ Frames/Contacts
Eye Examination
Exam(s)
(Includes additional eye exam for ages 0-12 and pregnant or breastfeeding women)
Lenses
Single Vision
Lined Bifocal
Lined Trifocal
Lenticular
Frames
Retail Frame Allowance
Discount on Frame Overage at participating providers
Elective Contact Lenses
Covered Formulary Contacts
Non-Formulary Contacts
Necessary Contact Lenses
Lens Options
Covered-in-full Lens Options
Other Lens Options
Additional Benefit(s)
Retinal Screening Photography for Diabetics
2nd Exam Benefit for Diabetics
Value Services
Laser Vision Discount
Blue Light Protection Discount
Children's and Maternity Eye Care
Replacement Eyeglasses
Additional eyeglass frame/lenses due to prescription change (ages 0-12 and pregnant or breastfeeding women).
Assumed Enrollment and Rates Current Renewal
Employee 167 $7.38 $7.56
Employee + Family 174 $15.84 $16.24
Monthly Premium $3,988.62
Annual Premium $47,863.44
Renewal Action
Participation Requirements
Dependent Children Coverage
Contract Basis
Benefit Period Basis
Exclusions and Limitations
Broker Commissions
Rate Guarantee
Expiration Date
VAS Client ID
Group Policy #
12/31/2026
336654
00906435
Standard
0%
24 months
To Age 26
Fully Insured
Date of Service
No Participation Requirement
Members ages 0-12 and members pregnant or breastfeeding who have a prescription change of 0.5 diopter or more are eligible for a replacement frame and lenses. The replacement benefits are the same as the benefits for the initial frame and lenses.
Not applicable for Exam Core or Exam with Discounted Material Plans.
$4,088.28
$49,059.36
2.5%
UnitedHealthcare is proud to add value to your vision care program by offering access to discounted laser vision correction procedures through QualSight
LASIK, the largest LASIK manager in the United States. Member savings represent up to 35% off the national average price of LASIK. Discounts are also provided on newer technologies such as Custom Bladeless (all laser) LASIK. Visit myuhcvision.com for more information.
UnitedHealthcare Vision has collaborated with industry partners to provide members with discount off the retail price on blue-light screen filters for their devices. Members can learn more and access discount information by visiting their plan website.
$10 Up to $40
Pricing for lens options may range from 20-60% off retail pricing at participating providers (except where not permitted by state law).
Retinal Screening Photography for Diabetics
2nd Exam Benefit for Diabetics
$0 Not Applicable
100% Up to $210
Polycarbonate Lenses for Children up to Age: 19
Standard Scratch Coating
Not Applicable
Up to $150 Up to $150
30% Not Applicable
Up to 6 boxes Up to $150
Up to $150 Up to $45
100% Up to $80
100% Up to $60
100% Up to $80
100% Up to $40
100% Up to $40
12/12/12/12
$25 Not Applicable
Standard Network
$10 Not Applicable
Voluntary
Exam with Materials
In Network Out of Network
Vision Services
VH652
New Standard
UnitedHealthcare Insurance Company (30100)
UnitedHealthcare Vision Renewal Sold UAF for City of Burleson
Effective Date: 01/01/2025 | Policy Number: 00906435
Type
Scratch Warranty
Tint
UV Coating
Photochromic for Adults
Photochromic for Children
Tier 1 Anti-Reflective
Tier 2 Anti-Reflective
Tier 3 Anti-Reflective
Tier 4 Anti-Reflective
Roll and Polish Edges
Tier 1 Progressive
Tier 2 Progressive
Tier 3 Progressive
Tier 4 Progressive
Tier 5 Progressive
High Index < 1.66
High Index 1.66 - 1.73
Polycarbonate for Adults
Polycarbonate for Children
Standard Scratch Coating
Prices reflected are subject to change.
$0
$33
$0
$53
$63
$200
$250
$100
$150
$13
$55
$75
$95
$30
$50
$67
$67
$14
$16
$10
Effective Date: 01/01/2025 | Policy Number: 00906435
Lens Options
The list below outlines the out of pocket charge a member may pay for particular lens options in-network, which reflect amounts of 20% to 60% of retail charges. In some cases members may pay less! Based on state guidelines, lens materials and options may not be available at these prices at all provider locations.
VH652
UnitedHealthcare Vision Sold UAF for City of Burleson
Please note that the summary of benefits in this document provides a brief description of coverage. State mandates may preclude certain benefit plan design features. This is not a policy, certificate of insurance or coverage document. For complete details on coverage, exclusions, limitations and the terms under which coverage may continue, please contact your sales representative.
This premium may include state and federal taxes and fees.
Quote assumes a complete product replacement.
Rates listed above are not included in quoted Medical rates (if applicable).
Rates listed above assume plan designs quoted. Rates may change, if plan design changes.
- Rates assume standard administrative services including Claims & Data processing, Enrollment & Billing, Customer Service, Case
Management, Provider Relations, and Reporting
- Assumed contract situs is Texas.
- Employees must be U.S. citizens or residents regularly working and living in the U.S. Coverage for U.S. citizens working outside of the U.S.
must be approved in writing by us. Approval depends on locale and length of assignment.
- Employer's assumed primary business is classified as 9111 SIC Code.
- Rates may increase on renewal in accordance with the terms of the policy.
Vision Assumptions
UnitedHealthcare Assumptions for City of Burleson
Effective Date: 01/01/2025 | Policy Number: 00906435
General Assumptions
- We reserve the right to change rates and/or plan provisions if the number of lives or volume of insurance change by more than 10% before, on, or after the effective date listed above or if factors used to generate this quote such as group demographics or effective date are changed, found to be incomplete or incorrect.
- Rates assume no changes in legislation or regulation that affects the benefits payable, eligibility or contract.
72916900-03
UnitedHealthcare Disclaimers for City of Burleson
Effective Date: 01/01/2025 | Policy Number: 00906435
This proposal is valid for 90 days from the issued date, unless otherwise noted within this document.
Brokers and agents may receive commissions, bonuses and other compensation for selling the products presented in this proposal.
The cost of this compensation may be directly or indirectly reflected in the premium or fees for those products. Contact your broker and/or agent if you have questions regarding their compensation relating to products in this proposal.
This proposal is subject to negotiation and execution of a written agreement, which will supersede the proposal contents. This proposal does not constitute an agreement, and is based on assumptions made from the written information in our possession and provided by you. We retain the right to modify our proposal if the information upon which this proposal is based is changed or is supplemented.
We consider much of the information contained in the proposal to be proprietary or otherwise confidential, and are releasing this proposal to you on the understanding that you and your representatives will only use it, and any data included in the proposal, for the specific purpose of evaluating its content. If this is not consistent with your understanding, please notify us before reviewing the proposal.
In addition, by accepting and reviewing the contents of this proposal, you and your agents or other designees agree, to the extent permitted by law, that certain information contained herein, or other information provided to you in connection with this proposal response or associated request for proposal (RFP), is proprietary and/or confidential to UnitedHealthcare and its related entities, and may not be copied, used, distributed or disclosed without prior written consent from an authorized representative of UnitedHealthcare, other than is necessary to evaluate this proposal.
© 2021 United HealthCare Services, Inc. All Rights Reserved 0004411-05 - 9/11/2024
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