Contract - Community Eye Care - 9/9/2021COMMUNITY EYE CARE, LLC
VISION SERVICES AGREEMENT
Employer: City of Round Rock
Address: 231 E. Main St., Ste. 100
City: Round Rock
Fax: 512-682-8766
State: TX Zip 78664
E-mail: tjarl@roundrocktexas.gov
Primary Contact: Tyler Jarl, Benefits Manager
Tax ID#: 74-6017485 Total Benefit Eligible Employees: 992
Telephone: 512-341-3143
Effective Date: 1 / 1 /2022
This vision services agreement is made and entered into by and between Community Eye Care, LLC, a
vision benefits company with its principal office located in Charlotte, North Carolina (hereinafter referred
to as "CEC"), and City of Round Rock, a group located in Round Rock, Williamson County, Texas.
RESPONSIBILITIES OF CEC. For the duration of this agreement, CEC shall:
• Administer the routine vision benefit outlined in Schedule 1 (Benefit and Rates).
• Maintain an up-to-date database of member eligibility.
• Invoice City of Round Rock once per month, based on the most current eligibility file.
• Maintain an adequate network of credentialed providers.
• Credential participating providers in accordance with NCQA standards.
• Manage claims processing and claims payment in an accurate and timely manner.
• Manage member services related to the CEC vision plan.
RESPONSIBILITIES OF City of Round Rock. For the duration of this agreement, City of Round
Rock shall:
• Offer the CEC vision plan to its employees as a shared contribution benefit.
• Offer the CEC vision plan to its retirees as a retiree contribution benefit (no employer
contribution).
• Periodically transfer accurate enrollment data to CEC.
• Payroll deduct on behalf of CEC vision employee enrollees, and forward the deducted
amounts to CEC once per month.
• Direct bill on behalf of CEC vision retiree enrollees, and forward the collected amounts to
CEC once per month.
• Include CEC plan descriptions in all appropriate City of Round Rock communications to
employees and retirees (e.g., benefits guides, informational mailings, etc.). Certificate of
insurance will be available upon request.
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BILLING. CEC will generate invoices by the 8th business day of each month. The invoices are made
available on CEC's Benefits Managers Portal, which can be accessed at www.cecvision.com on the Benefits
Managers page. CEC will send an email notification when the invoices are ready to be viewed online.
Please provide City of Round Rock billing contact information below.
Billing Contact: Tyler Jarl, Benefits Manager
Telephone: 512-341-3143
E-mail: tjar1*roundrocktexas.gov
Billing Address (if dif erentefrom company address):
City
State :
PERFORMANCE STANDARDS. CEC will administer the City of Round Rock vision plan in accordance
with industry standards. Should City of Round Rock identify any issues related to CEC's performance of
its duties, City of Round Rock will bring these to the attention of CEC, and CEC will take steps to resolve
the issues. Both CEC and City of Round Rock agree that deficiencies in service or other administrative
functions should be addressed promptly and that reasonable attempts should be made to achieve satisfactory
resolution within 60 days or less.
TERM. This agreement becomes effective on January 1, 2022 and will remain in effect for an initial term
of twelve (12) months. It will automatically renew on each anniversary date for a similar term until such
time as it is terminated in writing by City of Round Rock. In the absence of serious and persistent
performance issues, this contract cannot be terminated at any time during a twelve (12) month benefit cycle.
However, if City of Round Rock wishes to terminate the CEC vision plan at the end of a twelve (12) month
benefit cycle, the group may do so by providing 30 days' prior written notice to CEC.
COMPLIANCE WITH LAWS. CEC and the City of Round Rock shall comply with all applicable federal
and state laws. In accordance with Chapter 2271, Texas Government Code, a governmental entity may not
enter into a contract with a company for goods and services unless the contract has written verification from
the company that it: (1) does not boycott Israel; and (2) will not boycott Israel during the term of the contract.
The signatory executing this Agreement on behalf of CEC verifies that CEC does not boycott Israel and
will not boycott Israel during the term of this Agreement.
CEC: City
By: I�G,�-� C CA � �( K�Lti�- By:
Title: General Manager Title
Date: August 27, 2021 Date: l
Schedule 1-Benefit and Rates
The routine vision benefit offered by CEC to employees and retirees of City of Round Rock consists of:
One routine eye examination every 12 months ($10 co -pay)
A $225 allowance for eyewear every 12 months ($10 co -pay)
A contact lens fitting, re -fit or evaluation every 12 months ($10 co -pay)
The allowance can be applied to frames, spectacle lenses, contact lenses, special lens options,
or any combination. So long as the member selects eyewear having a retail price that's
less than or equal to the allowance, they incur no out-of-pocket expense for eyewear at the time
of service except for the eyewear co -pay. If the selected eyewear has a retail price that exceeds
$225, the member i*s responsible only for the balance (i.e., retail minus $225), plus the eyewear
co -pay. In addition, for the purchase of glasses (frames and/or lenses), members who exceed their
allowance are eligible at most CEC network providers fora 20% discount on the balance. For
the purchase of contact lenses, members who exceed their allowance are eligible at most CEC
providers fora 10% di*scount on the balance.
The monthly rates are as follows:
Employee Only $5*85
Employee + Spouse $9995
Employee + Chi*ld(ren) $10953
Employee + Family $15*62
The above rates are guaranteed for three years (36 months), starting with an effective date of
1/1/20220
The CEC vision plan will be offered to employees as a pre-tax benefit,
with payment handled through payroll deduction. Retirees will be direct billed by the City's
designated third -party billing administrator.
Services received from an out -of -network provider will be reimbursed as follows:
Exam.* Up to $50 minus any applicable co -pay
Eyewear: Up to 85% of the allowance minus any applicable co -pay
Contact Lens Fitting, Re -Fit or Evaluation: Up to $48 minus any applicable co -pay
NOTES
♦ The CEC vision plan applies solely to routine eye examinations and the purchase of eyewear. The
following are not covered under the plan: a) medical eye care, b) surgical eye care, c) low vision
services, d) emergency eye care.
♦ Benefits may not be carried forward to a subsequent benefit period.
♦ Coordination of benefits is not permitted.
♦ Existing employees and eligible dependents can enroll and/or make changes only during the company's
annual open enrollment period (unless a qualifying event occurs). New employees are permitted to enroll
mid -cycle during their new hire period (within 30 days after their hire date).
♦ Family coverage includes the employee or retiree, spouse and any children. Children must be under 26
years old.
♦ Vision benefit coverage will remain in effect for a minimum of twelve (12) months (or, with respect to
new employees who enroll mid -year, until the next renewal date). Covered members aren't permitted to
terminate coverage prior to the next open enrollment period unless: a) the employee is terminated from
employment, or b) the employee has undergone a qualifying event. At the time of open enrollment,
vision coverage will automatically renew unless voluntarily terminated by the employee.
♦ Enrollments are effective on the first of the month. Enrollments must be submitted by the 5th in order
to be included on that onth's invoice. Any enrollment submitted after the 5th will be included on the
next onth's invoice, and that member will become effective on the 1st day of the next month.
♦ Terminations are effective on the last day of the month. Terminations must be submitted byhte Sth for
the member to be removed from that onth's invoice. If submitted after the 51th, the member will still
be listed on that month's invoice, and the me ber's termination won't take effect until the last day of
that month.
♦ Agent of Record Change: If there is an Agent of Record for vision, and if that agent is terminated by
City of Round Rock, City of Round Rock should notify CEC at least 30 days prior to the termination
date. For a newly retained agent, CEC should be notified at least 30 days prior to the effective date.
♦ CEC vision plan members whose employment with City of Round Rock becomes terminated will be
given the option of continuing their vision coverage at the same rates that applied prior to termination of
employment. The administration of continued coverage will be entirely the responsibility of CEC. City
of Round Rock will retain no administrative or financial obligations whatsoever with respect to CEC
vision enrollees who are no longer employed by the group.
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
10fl
Complete Nos. l - 4 and 6 if there are interested parties. OFFICE USE ONLY
Complete Nos, 1, 29 31 5, and 6 if there are no interested parties. CERTIFICATION OF FILING
1
Name of business entity filing form, and the city, state and country of the business entity's place Certificate Number:
of business. 2021=789255
Community Eye Care LLC
Charlotte, NC United States gate Filed:
2
Name of governmental entity or state agency that is a party to the contract for which the form is 08/11/2021
being filed.
City of Round Rock Date Acknowledged:
3
Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a
description of the services, goods, or other property to be provided under the contract.
000000 Employee Benefits
Voluntary group vision benefits.
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
Intermediary
Calhoun, Karen
Sacramento, CA United States
X
5
Check only if there is NO Interested Party. ❑
6
UNSWORN DECLARATION
My name is Karen Calhoun ,and my date of birth is
My address is 4944 Parkway Plaza Blvd Ste 200 Charlotte NC 28217 USA
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in Mecklenburg county, state or North Carolina , on the 12 day of AugUSt , 20 21
(month) (year)
Signature of authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version vi.i.cencwtia
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
10fl
Complete Nos, 1 = 4 and 6 if there are interested parties. OFFICE USE ONLY
Complete Nos, 1, 21 3, 5, and 6 if there are no interested parties. CERTIFICATION OF FILING
1
Name of business entity filing form, and the city, state and country of the business entity's place Certificate Number:
of business. 2021w789255
Community Eye Care LLC
Charlotte, NC United States Date Filed:
2
Name of g--overnmental entity or state agency that is a party to the contract for which the form is 08/11/2021
being filed.
City of Round Rock Date Acknowledged:
08/16/2021
g
Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a
description of the services, goods, or other property to be provided under the contract.
000000 Employee Benefits
Voluntary group vision benefits.
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
Intermediary
Calhoun, Karen
Sacramento, CA United States
X
5
Check only if there is NO Interested Party. ❑
6
UNSWORN DECLARATION
My name is ,and my date of birth is
My address is I I.
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in County, State of , on the day of , 20
(month) (year)
Signature of authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www,ethics.state,tx,us version vii.cenautsa