Appendix A1_Disability RFP 26-042-DJ_ Questionnaire v2.xlsx
XLSX spreadsheet 19 KB Posted
- Solicitation number
- RFP 680 26-042/DJ 2
- Issued by
- Palm Beach County, Florida
About this file
This is a Long-Term Disability (LTD) and Short-Term Disability (STD) insurance questionnaire for Palm Beach County's RFP 26-042-DJ. The questionnaire requests responding carriers to confirm coverage details and identify any deviations from current benefit structures across three LTD benefit classes and one STD benefit class. The LTD Core plan (Class I) provides non-contributory coverage with a 50% benefit amount up to $1,000 monthly, while the LTD Buy-Up plan (Class I, Plan 2) and LTD Voluntary plan (Class II) offer 60% benefits up to $5,000 monthly on a contributory basis. The STD plan covers all eligible full-time employees working 30 hours weekly with benefits equal to the lesser of 67% of weekly covered earnings or a maximum of $1,200 weekly. All plans share common features including a 60-day eligibility waiting period, 90-day elimination period for LTD, 14-day elimination period for STD, waiver of premium provisions, rehabilitation and return-to-work incentives, and exclusions for war-related injuries, self-inflicted injuries, pre-existing conditions, loss of license or certification, and violent or criminal conduct.
Responding carriers must address conversion insurance availability with maximum benefits of $4,000 standard or $8,000 with satisfactory evidence of insurability, confirm provision of conversion notifications to employees on behalf of Palm Beach County and identify associated costs, and detail any deviations from the Certificate of Insurance provisions. The disability definition employs an own-occupation standard for the first 24 months, transitioning to any-occupation standards thereafter. Maximum benefit durations vary by age, with mental disorder and substance abuse claims limited to 24 months. The file requests complete and direct answers to all questions with supplemental attachments as necessary, with incomplete responses excluded from evaluation consideration.
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Appendix A Questionnaire
| APPENDIX A |
| QUESTIONNAIRE |
| RFP NO. 26-042-DJ |
| Provided in Excel as separate attachment at |
| https://pbcvssp.co.palm-beach.fl.us/webapp/vssp/AltSelfService |
| Complete and return the Questionnaire both electronically and on paper. |
| All questions must be answered directly and completely. Please attach additional information, if necessary, to fully explain a particular question. Incomplete answers will not be given consideration in the evaluation process. |
RESPONDING CARRIER NAME: ENTER CARRIER NAME HERE
| LTD Current Benefits | |||
| Benefits | Class I - Core (760741-B, Plan 1) | Confirm (Y/N) | Deviations |
| Eligible Employees | All active, full-time employees who are participating in the HMO medical plan or OAPIN medical plan, regularly working 30 hours per week, including employees classified as collective bargaining unit non-high risk Fire and Rescue employees | ||
| Benefit Amount | 50% of monthly covered earnings | ||
| Maximum Monthly Benefit | $1,000 | ||
| Minimum Monthly Benefit | Greater of $100 or 10% of monthly benefit | ||
| Eligibility Waiting Period | First of the month coinciding with or next following 60 days of active service | ||
| Elimination Period | 90 days | ||
| Annual Open Enrollment | If you are eligible but not insured for STD Insurance, EOI will be waived for you if you apply for STD Insurance during your Employer’s Annual Enrollment Period. | ||
| Contributions | Non-contributory | ||
| Disability Definition (less than or equal to 24 months) | Solely because of Injury or Sickness, you are either: |
1. unable to perform any or all of the material and substantial duties of your Regular Occupation; or
2. unable to earn 80% or more of your Indexed Earnings from working in your Regular Occupation.
Disability Definition (+24 months) After Disability Benefits have been payable for 24 months, you are considered Disabled if, solely due to Injury or Sickness, you are either:
1. unable to perform any or all of the material and substantial duties of any occupation for which you are, or may reasonably become, qualified based on education, training, or experience; or
2. unable to earn 60% or more of your Indexed Earnings.
| Partial Disability | During the Benefit Waiting Period and the Own Occupation Period, you are Partially Disabled when you work in your Own Occupation but, as a result of Physical Disease, Injury, Pregnancy or Mental Disorder, you are unable to earn 80% or more of your Indexed Predisability Earnings, in that occupation. Your Work Earnings may be Deductible Income. |
| Rehabilitation Incentive | Yes, see Certificate of Insurance for specifics |
| Return-to-Work Incentive | Yes, see Certificate of Insurance for specifics |
| Rehabilitation Plan | |
| A written plan designed to enable you to return to work. The Rehabilitation Plan will consist of one or more of the following phases: |
1. rehabilitation, under which we may provide, arrange or authorize education, vocational or physical rehabilitation or other appropriate services;
2. work, which may include modified work and work on a part-time basis
Maximum Benefit Duration Age 59 or under - to age 65 Age 60 to 64 - 5 years Age 65 to 69 - to age 70 Age 69 or older - 1 year
| Mental Disorder / Substance Abuse | 24 months |
| Pre-Existing Condition Limitations | A Pre-Existing means any Injury or Sickness for which you incurred expenses, received medical treatment, care or services including diagnostic measures, took prescribed drugs or medicines, or for which a reasonable person would have consulted a Physician within 3 months before you most recent effective date of insurance. This limitation will not apply to a period of Disability that begins after you are covered for at least 12 months after your most recent effective date of insurance, or the effective date of any added or increased benefits. |
| Survivor Income | If you die while LTD Benefits are payable, and on the date you die you have been continuously Disabled for at least 180 days, we will pay a Survivors Death Benefit according to 1 through 4 below. |
1. The Survivors Death Benefit is a lump sum equal to 3 times your LTD Benefit without reduction by Deductible Income.
2. The Survivors Death Benefit will first be applied to reduce any overpayment of your claim.
3. The Survivors Death Benefit will be paid at our option to any one or more of the following:
a. Your surviving spouse;
b. Your surviving unmarried children, including adopted children, under age 25;
c. Your surviving spouse's unmarried children, including adopted children, under age 25; or
d. Any person providing the care and support of any person listed in a., b., or c. above.
4. No Survivors Death Benefit will be paid if you are not survived by any person listed in a., b., or c. above.
Conversion Conversion Of Insurance Benefit When your insurance ends, you may buy LTD conversion insurance if you meet 1 through 5 below.
1. Your insurance ends for a reason other than:
a. Termination or amendment of the Group Policy;
b. Your failure to make a required premium contribution; or
c. Your retirement.
2. You were continuously insured under your Employer's long term disability insurance plan for at least one year as of the date your insurance ended.
3. You are not Disabled on the date your insurance ends.
4. You are a citizen or resident of the United States or Canada.
5. You must apply in writing and pay the first premium to us within 60 days after your insurance ends.
The maximum LTD conversion insurance benefit you may select is the smallest of:
1. $4,000 (however, if you provide satisfactory Evidence Of Insurability, this upper limit is $8,000);
2. 60% of your insured Predisability Earnings on the date your insurance ended; and
3. The LTD Benefit payable if you had become Disabled on the day before your insurance ended and you had no Deductible Income.
The maximum LTD conversion insurance benefit is reduced by deductible income. The certificate we will issue to you when your LTD conversion insurance becomes effective will contain other provisions which will also differ from the Group Policy.
| Conversion Notifications | The Standard provides Conversion notifications to employees on behalf of Palm Beach County. Please confirm you will provide this service and indicate what, if any, the cost would be for the service. Please also include any associated fees in the LTD pricing proposal. |
| Waiver of Premium | Yes |
| Exclusions | Disability Benefits will not be paid for a Disability that results, directly or indirectly, from: |
1. war or any act or war, whether declared or undeclared
2. intentionally self-inflicted injury
3. pre-existing condition
4. loss of license or certification
5. violent or criminal conduct Please refer to the Certificates of Insurance for the full detail of benefits, and provide/list any of deviations from the certificate of insurance.
| LTD Current Benefits | |||
| Benefits | Class I - Buy-Up (760741-B, Plan 2) | Confirm (Y/N) | Deviations |
| Eligible Employees | All active, full-time employees who are participating in the HMO medical plan or OAPIN medical plan, regularly working 30 hours per week, including employees classified as collective bargaining unit non-high risk Fire and Rescue employees | ||
| Benefit Amount | 60% of monthly covered earnings | ||
| Maximum Monthly Benefit | $5,000 | ||
| Minimum Monthly Benefit | Greater of $100 or 10% of monthly benefit | ||
| Eligibility Waiting Period | First of the month coinciding with or next following 60 days of active service | ||
| Elimination Period | 90 days | ||
| Annual Open Enrollment | If you are eligible but not insured for STD Insurance, EOI will be waived for you if you apply for STD Insurance during your Employer’s Annual Enrollment Period. | ||
| Contributions | Contributory - Employer and Employee share the cost of coverage. | ||
| Disability Definition (less than or equal to 24 months) | Solely because of Injury or Sickness, you are either: |
1. unable to perform any or all of the material and substantial duties of your Regular Occupation; or
2. unable to earn 80% or more of your Indexed Earnings from working in your Regular Occupation.
Disability Definition (+24 months) After Disability Benefits have been payable for 24 months, you are considered Disabled if, solely due to Injury or Sickness, you are either:
1. unable to perform any or all of the material and substantial duties of any occupation for which you are, or may reasonably become, qualified based on education, training, or experience; or
2. unable to earn 60% or more of your Indexed Earnings.
| Partial Disability | During the Benefit Waiting Period and the Own Occupation Period, you are Partially Disabled when you work in your Own Occupation but, as a result of Physical Disease, Injury, Pregnancy or Mental Disorder, you are unable to earn 80% or more of your Indexed Predisability Earnings, in that occupation. Your Work Earnings may be Deductible Income. |
| Rehabilitation Incentive | Yes, see Certificate of Insurance for specifics |
| Return-to-Work Incentive | Yes, see Certificate of Insurance for specifics |
| Rehabilitation Plan | |
| A written plan designed to enable you to return to work. The Rehabilitation Plan will consist of one or more of the following phases: |
1. rehabilitation, under which we may provide, arrange or authorize education, vocational or physical rehabilitation or other appropriate services;
2. work, which may include modified work and work on a part-time basis
Maximum Benefit Duration Age 59 or under - to age 65 Age 60 to 64 - 5 years Age 65 to 69 - to age 70 Age 69 or older - 1 year
| Mental Disorder / Substance Abuse | 24 months |
| Pre-Existing Condition Limitations | A Pre-Existing means any Injury or Sickness for which you incurred expenses, received medical treatment, care or services including diagnostic measures, took prescribed drugs or medicines, or for which a reasonable person would have consulted a Physician within 3 months before you most recent effective date of insurance. This limitation will not apply to a period of Disability that begins after you are covered for at least 12 months after your most recent effective date of insurance, or the effective date of any added or increased benefits. |
| Survivor Income | If you die while LTD Benefits are payable, and on the date you die you have been continuously Disabled for at least 180 days, we will pay a Survivors Death Benefit according to 1 through 4 below. |
1. The Survivors Death Benefit is a lump sum equal to 3 times your LTD Benefit without reduction by Deductible Income.
2. The Survivors Death Benefit will first be applied to reduce any overpayment of your claim.
3. The Survivors Death Benefit will be paid at our option to any one or more of the following:
a. Your surviving spouse;
b. Your surviving unmarried children, including adopted children, under age 25;
c. Your surviving spouse's unmarried children, including adopted children, under age 25; or
d. Any person providing the care and support of any person listed in a., b., or c. above.
4. No Survivors Death Benefit will be paid if you are not survived by any person listed in a., b., or c. above.
Conversion Conversion Of Insurance Benefit When your insurance ends, you may buy LTD conversion insurance if you meet 1 through 5 below.
1. Your insurance ends for a reason other than:
a. Termination or amendment of the Group Policy;
b. Your failure to make a required premium contribution; or
c. Your retirement.
2. You were continuously insured under your Employer's long term disability insurance plan for at least one year as of the date your insurance ended.
3. You are not Disabled on the date your insurance ends.
4. You are a citizen or resident of the United States or Canada.
5. You must apply in writing and pay the first premium to us within 60 days after your insurance ends.
The maximum LTD conversion insurance benefit you may select is the smallest of:
1. $4,000 (however, if you provide satisfactory Evidence Of Insurability, this upper limit is $8,000);
2. 60% of your insured Predisability Earnings on the date your insurance ended; and
3. The LTD Benefit payable if you had become Disabled on the day before your insurance ended and you had no Deductible Income.
The maximum LTD conversion insurance benefit is reduced by deductible income. The certificate we will issue to you when your LTD conversion insurance becomes effective will contain other provisions which will also differ from the Group Policy.
| Conversion Notifications | The Standard provides Conversion notifications to employees on behalf of Palm Beach County. Please confirm you will provide this service and indicate what, if any, the cost would be for the service. Please also include any associated fees in the LTD pricing proposal. |
| Waiver of Premium | Yes |
| Exclusions | Disability Benefits will not be paid for a Disability that results, directly or indirectly, from: |
1. war or any act or war, whether declared or undeclared
2. intentionally self-inflicted injury
3. pre-existing condition
4. loss of license or certification
5. violent or criminal conduct Please refer to the Certificates of Insurance for the full detail of benefits, and provide/list any of deviations from the certificate of insurance.
| LTD Current Benefits | |||
| Benefits | Class II - Voluntary (76041-C) | Confirm (Y/N) | Deviations |
| Eligible Employees | All active, full-time employees who participate in the POS medical plan, or Opt out of medical coverage, regularly working a minimum of 30 hours per week, excluding employees participating in the HMO plan and employees classified as collective bargaining union non-high risk Fire and Rescue employees | ||
| Benefit Amount | 60% of monthly covered earnings | ||
| Maximum Monthly Benefit | $5,000 | ||
| Minimum Monthly Benefit | Greater of $100 or 10% of monthly benefit | ||
| Eligibility Waiting Period | First of the month coinciding with or next following 60 days of active service | ||
| Elimination Period | 90 days | ||
| Annual Open Enrollment | If you are eligible but not insured for STD Insurance, EOI will be waived for you if you apply for STD Insurance during your Employer’s Annual Enrollment Period. | ||
| Contributions | Contributory | ||
| Disability Definition (less than or equal to 24 months) | Solely because of Injury or Sickness, you are either: |
1. unable to perform any or all of the material and substantial duties of your Regular Occupation; or
2. unable to earn 80% or more of your Indexed Earnings from working in your Regular Occupation.
Disability Definition (+24 months) After Disability Benefits have been payable for 24 months, you are considered Disabled if, solely due to Injury or Sickness, you are either:
1. unable to perform any or all of the material and substantial duties of any occupation for which you are, or may reasonably become, qualified based on education, training, or experience; or
2. unable to earn 60% or more of your Indexed Earnings.
| Partial Disability | During the Benefit Waiting Period and the Own Occupation Period, you are Partially Disabled when you work in your Own Occupation but, as a result of Physical Disease, Injury, Pregnancy or Mental Disorder, you are unable to earn 80% or more of your Indexed Predisability Earnings, in that occupation. Your Work Earnings may be Deductible Income. |
| Rehabilitation Incentive | Yes, see Certificate of Insurance for specifics |
| Return-to-Work Incentive | Yes, see Certificate of Insurance for specifics |
| Rehabilitation Plan | |
| A written plan designed to enable you to return to work. The Rehabilitation Plan will consist of one or more of the following phases: |
1. rehabilitation, under which we may provide, arrange or authorize education, vocational or physical rehabilitation or other appropriate services;
2. work, which may include modified work and work on a part-time basis
Maximum Benefit Duration Age 59 or under - to age 65 Age 60 to 64 - 5 years Age 65 to 69 - to age 70 Age 69 or older - 1 year
| Mental Disorder / Substance Abuse | 24 months |
| Pre-Existing Condition Limitations | A Pre-Existing means any Injury or Sickness for which you incurred expenses, received medical treatment, care or services including diagnostic measures, took prescribed drugs or medicines, or for which a reasonable person would have consulted a Physician within 3 months before you most recent effective date of insurance. This limitation will not apply to a period of Disability that begins after you are covered for at least 12 months after your most recent effective date of insurance, or the effective date of any added or increased benefits. |
| Survivor Income | If you die while LTD Benefits are payable, and on the date you die you have been continuously Disabled for at least 180 days, we will pay a Survivors Death Benefit according to 1 through 4 below. |
1. The Survivors Death Benefit is a lump sum equal to 3 times your LTD Benefit without reduction by Deductible Income.
2. The Survivors Death Benefit will first be applied to reduce any overpayment of your claim.
3. The Survivors Death Benefit will be paid at our option to any one or more of the following:
a. Your surviving spouse;
b. Your surviving unmarried children, including adopted children, under age 25;
c. Your surviving spouse's unmarried children, including adopted children, under age 25; or
d. Any person providing the care and support of any person listed in a., b., or c. above.
4. No Survivors Death Benefit will be paid if you are not survived by any person listed in a., b., or c. above.
Coversion Conversion Of Insurance Benefit When your insurance ends, you may buy LTD conversion insurance if you meet 1 through 5 below.
1. Your insurance ends for a reason other than:
a. Termination or amendment of the Group Policy;
b. Your failure to make a required premium contribution; or
c. Your retirement.
2. You were continuously insured under your Employer's long term disability insurance plan for at least one year as of the date your insurance ended.
3. You are not Disabled on the date your insurance ends.
4. You are a citizen or resident of the United States or Canada.
5. You must apply in writing and pay the first premium to us within 60 days after your insurance ends.
The maximum LTD conversion insurance benefit you may select is the smallest of:
1. $4,000 (however, if you provide satisfactory Evidence Of Insurability, this upper limit is $8,000);
2. 60% of your insured Predisability Earnings on the date your insurance ended; and
3. The LTD Benefit payable if you had become Disabled on the day before your insurance ended and you had no Deductible Income.
The maximum LTD conversion insurance benefit is reduced by deductible income. The certificate we will issue to you when your LTD conversion insurance becomes effective will contain other provisions which will also differ from the Group Policy.
| Conversion Notifications | The Standard provides Conversion notifications to employees on behalf of Palm Beach County. Please confirm you will provide this service and indicate what, if any, the cost would be for the service. Please also include any associated fees in the LTD pricing proposal. |
| Waiver of Premium | Yes |
| Exclusions | Disability Benefits will not be paid for a Disability that results, directly or indirectly, from: |
1. war or any act or war, whether declared or undeclared
2. intentionally self-inflicted injury
3. pre-existing condition
4. loss of license or certification
5. violent or criminal conduct Please refer to the Certificates of Insurance for the full detail of benefits, and provide/list any of deviations from the certificate of insurance.
| STD Current Benefits | |||
| Benefits | All | Confirm (Y/N) | Deviations |
| Eligible Employees | All active, full-time employees regularly working 30 hours per week, including employees classified as collective bargaining unit non-high risk Fire and Rescue employees, but excluding employees classified as collective bargaining unit employees of Fire and Rescue | ||
| Benefit Amount | The lesser of 67% of your weekly covered earnings or your Maximum Disability Benefit | ||
| Maximum Weekly Benefit | $1,200 | ||
| Minimum Weekly Benefit | $100 | ||
| Eligibility Waiting Period | First of the month coinciding with or next following 60 days of active service | ||
| Elimination Period | 14 days | ||
| Annual Open Enrollment | If you are eligible but not insured for STD Insurance, EOI will be waived for you if you apply for STD Insurance during your Employer’s Annual Enrollment Period. | ||
| Contributions | Contributory | ||
| Sick Leave | No STD Benefits will be paid for any period when you are receiving or are eligible to receive paid sick leave or other salary continuation (but not vacation pay or donated amounts) from your Employer. | ||
| Disability Definition | You are Disabled if, as a result of Physical Disease, Injury, Pregnancy, or Mental Disorder you are unable to perform with reasonable continuity the Material Duties of your Own Occupation. | ||
| Pre-Existing Condition Limitations | None | ||
| Partial Disability | Yes, see Certificate of Insurance for specifics | ||
| Return-to-Work Incentive | Yes, see Certificate of Insurance for specifics | ||
| Rehabilitation Plan | |||
| A written plan designed to enable you to return to work. The Rehabilitation Plan will consist of one or more of the following phases: |
1. rehabilitation, under which we may provide, arrange or authorize education, vocational or physical rehabilitation or other appropriate services;
2. work, which may include modified work and work on a part-time basis
| Maximum Benefit Duration | 90 days |
| Exclusions | Disability Benefits will not be paid for a Disability that results, directly or indirectly, from: |
1. war or any act or war, whether declared or undeclared
2. intentionally self-inflicted injury
3. work related disability Please refer to the Certificates of Insurance for the full detail of benefits, and provide/list any of deviations from the certificate of insurance.
APPENDIX A - QUESTIONNAIRE
RFP NO. 26-042-DJ
CONFIDENTIAL AND PROPRIETARY Page &P of &N https://pbcvssp.co.palm-beach.fl.us/webapp/vssp/AltSelfService
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