HomeMy WebLinkAboutCity Council Meeting - Council - Agenda - 06/21/2005 AGENDA . ,
City of Kent
CityCouncil Meeting
t
Agenda
June 21 , 2005
Mayor Jim White
Julie Peterson, Council President
Councilmembers
Tim Clark Debbie Raplee
Ron Harmon Les Thomas
Deborah Ranniger Bruce White
KEN
WASHINGTON
' City Clerk's Office
■
■
KENT CITY COUNCIL AGENDAS
11-1147KENT June 21, 2005
w,.s N i N o T O N Council Chambers
MAYOR. Jim White COUNCILMEMBERS: Julie Peterson, President
I Tim Clark Ron Harmon Deborah Ranniger
Debbie Raplee Les Thomas Bruce White
COUNCIL WORKSHOP AGENDA
' 5:30 p.m.
Item DescriptionSpeaker Time
1. Council Retreat Follow-up 60 min
COUNCIL MEETING AGENDA
7:00 p.m.
1. CALL TO ORDER/FLAG SALUTE
2. ROLL CALL
3. CHANGES TO AGENDA
' A. FROM COUNCIL, ADMINISTRATION, OR STAFF
B. FROM THE PUBLIC— Citizens may request that an item be added to the
agenda at this time. Please stand or raise your hand to be recognized by the
Mayor.
1 4. PUBLIC COMMUNICATIONS
A. Recognition of State Legislators
B. Certificate of Achievement for Excellence in Financial Reporting
' 5. PUBLIC HEARINGS
None
1 6. CONSENT CALENDAR
A. Minutes of Previous Meeting —Approve
B. Payment of Bills—Approve
C. 2005 lnterlocal Agreement for Waterfowl Management—Authorize
D. Pool/Recreation Facility Feasibility Study Contract—Authorize
E Local & Long Distance Telephone Service Vendor—Authorize
F. 2005-2007 Microsoft Software Assurance Renewal—Approve
G US Bank— One Card Agreement—Authorize
H The Standard Insurance Company Long Term Disability Application for 2005 —
Authorize
' (Continued on Back)
COUNCIL MEETING AGENDA CONTINUED
I. Premera Blue Cross Administrative Services Contract for 2005 —Authorize
J. Group Health Cooperative 2005 Contract—Authorize
K. Pacific Highway South—Fund Authorization Agreement North Phase—Kent
Des Moines Road to South 252nd Street—Accept and Amend Budget
L. Pacific Highway South—Fund Authorization Agreement South Phase— South
252nd Street to South 272nd Street—Accept and Amend Budget
M. Joint Trench Agreement with Qwest—Authorize
N Joint Trench Agreement with Comcast —Authorize
O South 228th Street Extension Consultant Services Contract—Authorize
P. Pacific Highway South Consultant Services Contract—Authorize
Q. W & H Pacific Contract for Pacific Highway South Inspection Services—
Authorize
R. Street Vacation for a Portion of 36th Avenue South—Resolution Setting Public
Hearing Date—Adopt 11G
S. 4th Avenue North/Ramsay Way Project—Accept as Complete
7. OTHER BUSINESS
A F1exPass Program Agreement 2005-2006 - Authorize
8. BIDS
A. LID 353: South 228th Street Corridor Military Road Widening—Phase I—Award
9. REPORTS FROM STANDING COMMITTEES, STAFF AND SPECIAL COMMJTTEES i
10. CONTINUED COMMUNICATIONS B - P
11. EXECUTIVE SESSION AND AFTER EXECUTIVE SESSION
A. Pending Litigation x
Q� 01,71 d r AlUTei cc
12. ADJOURNMEN
NOTE: A copy of the full agenda packet is available for perusal in the City Clerk's Office and the
Kent Library. The Agenda Summary page and complete packet are on the City of Kent
web site at www ci kent wa us.
An explanation of the agenda format is given on the back of this page.
Any person requiring a disability accommodation should contact the City Clerk's Office in advance at
(253) 856-5725 For TDD relay service call the Washington Telecommunications Relay Service at
1-800-833-6388
Zw<^ o< �ao $ o � � mom F� c- om3 d �9 a 'a�o�
n y \ c ° J ° n w d
3 rao `° ca �0 3 3 m tD o o m m d M �-o+ `� ° '� Cal
ni �.Um3N °i iuo oc 0° 3cN $a+rnxoo ° a 3 ^ J oa
O nrm
C d r J c d G in d 3 J O O_a C t y ni< u 7
w Oaa c,. a < 3 me �.^ J < n
m 3 0< ^ 2 y J on c c a m H < 3 a 3 0 _ •
�3 a- ? c $ p Sag°
� m 3 a<
ti �09 ^ cg ° o s w =
i
rn "O m ^ NCO 7C 7C N� T<<
3 Id r T n l / p c m m L n C G_n
y ° < y o < O > O� �N —oq
— roo ° — r'c n ddrJo n � a oN2 m
3 n� '^ � n� c � •c3 � �� � w c o= �
a„ o
rnER "'� v cn NN n a Vwn H
F o (D � 3 3 3
A y
c < oc m •
. 0 1
m
3
�z• T m
y
�� 1
i
�oc3�C3ooidm 0 3:cE0c oco?< nnrooKOoo n �`�. o�3o3' D f° sdT
Z `D --�� n ' 3 ° % 9 clr 2°A 3 3 c On o H c ° o-c n n °a1vmTwp�F Tt3oD'a3-`m3rT"wocD (nW
Vz MA' ouu ' dde '" m° 3 ^ � t2nc ° rm
.° : ^ r '6 3 n mN3 3 m o 3 a m
�o J o Z
3a 3.3O- NO �c T3T ?T - o � =
am E57w s 3nA >o ° A° °^ ° 0. ?o3 oan T=�m m to n
d�T - oOD 3CaC)F � n 3 � ' r) o on
m Oo �� v ° m h ^� O
s3 3 3 w CCFO o 33 3 oJ o o 3A m m <n N o3 co mm
3 < o
•
m
m m H o
j0 f=DS � ^. nR SO °.O OJin � NjC Goo Oo � G raq'<p^ � C
m 3 3 f U 3 m 3 o J f°? o o d o n CLCe Ta N o-3m m m an =9- •
3Fr n 3mmcc °.J ° u o
� m w30Jm � 3gmio °iNv °' 2 � co�m3 � g ,"„?;won
•� � NNo� O - < �E3 x 3a"-f'o � °ao33d �m �d
m wccmg0 °c_ Rmmcn �� a - 10 `-<o1 Oo°a cro_�n •
`° ° m m so '° a3 ° o-o T3 c 3 n T 3 o-io 3 <� a, =3 ^m
' d 'oN ccNW mmn '^ 33mT dJw3ooc �No mw3o
o ' $ J � yomumam �m 2 � mJ � JJ n ,a„ J
< moa�N mfw ' ^pJwD � -
3 cac o mN °e mvgn o< o mm a m3 3 z ➢ 0° d orn
m m W vm O d N y ° 7 C D w S O O 4 o N n
in x Tmmou .�c, cDJ aoam
O '^ o_ you n• m N r�>•m < p O J C a'^ a 2
�� 3 ? �>d,o aoc GoaQ3y< ? gT ' pq��
n —
� m
CHANGES TO THE AGENDA
Citizens wishing to address the Council will, at this time, make known the subject of
interest, so all may be properly heard.
A) FROM COUNCIL, ADMINISTRATION, OR STAFF
B) FROM THE PUBLIC
1
i
1
t
1
PUBLIC COMMUNICATIONS
A) RECOGNITION OF STATE LEGISLATORS
' B) CERTIFICATE OF ACHIEVEMENT FOR EXCELLENCE IN FINANCIAL
REPORTING
CONSENT CALENDAR
6. City Council Action:
Councilmember P&VM moves, Councilmember (xlv�
seconds to approve Consent Calendar Items A through S.
Discussion "
Action C
6A. Approval of Minutes.
Approval of the minutes of the regular Council meeting of June 7, 2005 and approval of
a correction to the "Amount" column in the Approval of bills:
Date Check Numbers Amount
5/5/05 Checks 283376-283679 $ 225,643.38
5/5/05 Advices 179311-179989 15265,383.63
6B. Approval of Bills.
Approval of payment of the bills received through May 31 and paid on May 31 after
auditing by the Operations Committee on June 7, 2005
Approval of checks issued for vouchers:
Date Check Numbers Amount
5/31/05 Wire Transfers 2059-2072 $1,323,508.23
5/31/05 PrePays & 578430 521,540 96
5/31/05 Regular 579086 2,136,362 34
5/16/05 Use Tax Payable 1,946.05
$3,983,357.58
Approval of checks issued for pa roll for May 1 through May 15 and paid on May 20, 2005:
Date Check Numbers Amount
5/20/05 Checks 283682-283982 $ 215,930 94
5/20/05 Advices 179990-180672 1,269,184.89
$1,485,115 83
1 Approval of checks issued for payroll for May 16 through May 31 and paid on June 5, 2005.
Date Check Numbers Amount
6/5/05 Checks 283983-284292 $ 233,766.49
6/5/05 Advices 180673-181356 1,254,846 76
$1,488,613 25
Council Agenda
Item No. 6 A-B
Kent City Council Meeting
's:!!5:KEN* June 7, 2005
WASHINGTON
The regular meeting of the Kent City Council was called to order at 7:00 p.m. by Mayor White.
Councilmembers present. Clark, Harmon, Peterson, Ranniger, Raplee, Thomas and White.
(CFN-198)
CHANGES TO AGENDA
A From Council, Administration, or Staff. (CFN-198) Councilmember Ranniger removed
Item 6V from the Consent Calendar to Other Business Item 7C.
B. From the Public. (CFN-198) Continued Communications Item A and B were added at the
request of audience members.
PUBLIC COMMUNICATIONS
A. Ouota Club International Donation Presentation. (CFN-118) Bobbie Dickerson, President
of the International Quota Club for the Kent Valley spoke about their donation to the ballfields
and the play area.
B. Lions Club Donation Presentation. (CFN-118) Brian Epson representative from the Lions
Club presented the 2nd and final payment of$35,000 for the Service Club Ballfields.
tC. Soroptimist International Donation Presentation. (CFN-118) Louise Lee, President of
Soroptimist International of Kent presented$10,000 to the City of Kent for the Service Club
Ballfields.
D. Employee of the Month. (CFN-147) Janet Perschek, Administrative Assistant to the Public
Works Director, was presented the Employee of the Month award.
E. Economic Development Update. (CFN-198) Nathan Torgelson, Economic Development
Manager, gave a brief update on the proposed projects that will connect Kent Station and historic
downtown, and events for the Washington Manufacturing Appreciation Week.
I CONSENT CALENDAR
PETERSON MOVED to approve Consent Calendar Items A through Y, with the exception of V
which was moved to Other Business. Harmon seconded and the motion carried.
A. Approval of Minutes. (CFN-198) The minutes of the regular Council meeting of May 17,
' 2005 were approved.
B. Approval of Bills (CFN-104) Payment of the bills received through May 16 and paid on
May 16 after auditing by the Operations Committee on May 17, 2005 were approved
Approval of checks issued for vouchers:
Date Check Numbers Amount
5/16/05 Wire transfers 2045-2058 $1,219,411.70
5/16/05 PrePays & 577803 1,766,863.68
5/16/05 Regular 578429 1,188,791.01
5/16/05 Use Tax Payable 1,30688
1 $4,176,373.27
1
Kent City Council Minutes June 7, 2005
1
Approval of checks issued for payroll for April 16 through April 30 and paid on May 5, 2005:
Date Check Numbers Amount
5/5/05 Checks 283376-283679 $ 215,930.94
5/5/05 Advices 179311-179989 1,269,184.89
5/5/05 Interim Check 283680 2701
5/5/05 Voided Check 282982 (27 01)
5/5/05 Interim Check 283681 181.22
5/5/05 Voided Check 283641 (181.22)
$1,485,115 83
C. Zoning Code Amendment ZCA-2004-1,Manufactured Housing, Ordinance. (CFN-131)
Ordinance No. 3753 which amends the Kent City Code to allow manufactured homes in all
residential zoning districts per the requirements of state statutes was adopted.
D. 2005 Interlocal Agreement with Auburn for Home Repair Services. (CFN-118) The
Mayor was authorized to sign the 2005 Interlocal Agreement with the City of Auburn for home
repair services and the budget was amended.
E. Eagle Creek Final Plat(Quasi-Judicial). (CFN-1272) The Final Plat Mylar for Eagle Creek j
was approved and the Mayor was authorized to sign the Mylar.
F. Quota Club International Donation for Service Club Park. (CFN-104) The donation of
$7,000 from Quota International of Kent Valley for Service Club Park development was accepted
and the expenditure of funds in the Service Club Ball Fields budget was authorized.
G. Kent Lions Club Donation For Service Club Park. (CFN-104) The donation of$24,000
from the Kent Lions Club for Service Club Park development was accepted and the expenditure of
funds in the Service Club Ball Fields budget was authorized.
H. Cultural Development Authority of King Countv 2005 Sustained Support Grant.
(CFN-118) The Sustained Support grant in the amount of$11,415 from the Cultural Development
Authority of King County to support 2005 Kent Arts Commission programs was accepted, the
expenditure of funds in the Kent Arts Commission budget was approved and the Mayor was
authorized to sign the agreement.
I. Interagency Committee for Outdoor Recreation Grant for Canterbury Park Expansion.
(CFN-118) The grant for$92,500 from the Interagency Committee for Outdoor Recreation for the
Canterbury Park expansion was accepted, the expenditure of funds in the Canterbury Acquisition
and Development budget was approved, and the Mayor was authorized to sign the agreement,
upon review by the City Attorney.
J. Interagency Committee for Outdoor Recreation Grant for Clark Lake Park Expansion. t
(CFN-118) The grant for$250,000 from the Interagency Committee for Outdoor Recreation for
Clark Lake Park expansion was accepted, the expenditure of funds in the Park Land Acquisition
budget was approved, and the Mayor was authorized to sign the agreement, upon review by the
City Attorney.
2
Kent City Council Minutes June 7, 2005
K Surplus Residential Structure and Allow Demolition at 13122 SE 251st Street (CFN-118)
The structure and all appurtenances at 13122 SE 251st Street in Kent was declared as surplus and
salvage and demolition was approved.
L. Surplus Residential Structure and Allow Demolition at 10808 SE 248th Street.
(CFN-118) The structures and all appurtenances at 10808 SE 248th Street in Kent was declared as
surplus and salvage and demolition was approved.
M. Johnson Creek Restoration/Condemnation Ordinance. (CFN-1297) Ordinance No. 3754
authorizing condemnation, if necessary, of certain property for natural resources and storm
drainage improvements was adopted.
N. Pioneer and Smith Street Project. (CFN-1038) The Pioneer and Smith Street project was
accepted as complete and release of the retainage to Rodarte Construction, Inc.upon standard
releases from the state and release of any liens was approved.
I O. Public Works Positions,Street System Vegetation Maintenance Proposal. (CFN-1038)
Hiring of one full time employee with benefits and two part-time employees with no benefits to be
assigned to the Street Vegetation Maintenance Sub-section of Public Works Operations was
authorized.
P. Washington Traffic Safety Commission Grant for Trailer, Speed Sign and Car Seats.
(CFN-122) The Washington Traffic Safety Commission(WTSC) additional grant funds in the
amount of$9,000 which will be used to purchase one radar trailer, one 18' speed sign and 46 car
seats, was accepted and the budget was amended.
Q. Washington Traffic Safety Commission Grant for Drinking Driver Countermeasure
Program. (CFN-122) The Washington Traffic Safety Commission (WTSC) grant in the amount
of$65,750 for the Kent Drinking Driver countermeasure Program was accepted and the budget
was amended.
R. Washington Traffic Safety Commission Grant For Intense Traffic Safety Enforcement
Program. (CFN-122) The Washington Traffic Safety Commission (WTSC)grant funds in the
I amount of$5,000 which will be used to participate in the Intense Traffic Safety Enforcement
program was accepted and the budget was amended.
S. Department of Social & Health Services, Division of Alcohol and Substance Abuse Grant
for Underage Youth. (CFN-122) The amount of$60,000 from the Department of Social &
Health Services, Division of Alcohol and Substance Abuse Grant for Underage Youth grant was
accepted and the budget was amended.
T. Interlocal Agreement with Washington State Department of Corrections for Community
1 Corrections Officer. (CFN-122) Provide community corrections services and facilities in a
manner best serving the needs and development of our local communities was authorized.
U. Ravensdale Range Interlocal Agreement. (CFN-122) The Mayor was authorized to sign an
agreement which provides the City of Kent Police Department the resources of the Ravensdale
Range in order to qualify its commissioned police officers per state law firearms requirements
3
Kent City Council Minutes June 7, 2005
W. Fire Station Exhaust Extraction Systems Sole Source Procurement. (CFN-120) The
Mayor was authorized to sign the agreement with Air Exchange, Inc. for the amount of$84,277.88
plus Washington State Sales Tax to furnish the Plymovent vehicle exhaust extraction systems for
Fire Stations 72 and 76
X. Fireworks Display Permits. (CFN-122) The Fire Department to issue fireworks display
permits for two separate activities,based upon their review and investigation of the events was
authorized.
Y. Surplus and Donate Engine/Aid Unit. (CFN-122) Surplus one(1) 1989 Pierce engine/aid
unit (VIN#040806)that has exceeded its expected performance was authorized.
OTHER BUSINESS
C. Ordinance Amendinii Kent City Code 13.05— Fireworks. (CFN-122) The ordinance
extends to the fire marshal authority to grant public fireworks display permits for all celebrations
officially sanctioned by public or private high schools and in the observation of certain approved
marriage ceremonies. Or. Ranniger said that it is not Council's intention to ban fireworks but
during years of drought there may be instances of extreme fire danger and it would be prudent in
the interest of community health, safety and public welfare to be able to either partially ban or ban
fireworks for that particular year only. RANNIGER MOVED to adopt Ordinance No. 3755
amending Chapter 13.05 of the Kent City Code relating to public fireworks display permits and
providing the authority, commencing one year from the date of passage and subject to prior
Council approval to ban the sale, use, and discharge of fireworks if a high fire danger exists.
Peterson seconded and the motion carried.
A. Eagle Creek Park Easement. (CFN-118) Soos Creek Water and Sewer District requires an '
agreement for Easement for the sanitary sewer line and appurtenances through Eagle Creek Park,
located at 13636 SE 282nd Street in Kent to serve the adjacent subdivision. WHITE MOVED to
authorize the Mayor to sign the agreement for Easement with Soos Creek Water and Sewer
District for Eagle Creek Park. Harmon second and the motion carried.
B. Interlocal Agreement with King County for Maintenance and Construction for: Grading
at East Hill Skate Park; S. 228th Street Corridor Mitigation Grading; and Garrison Creek.
(CFN-1038) The Interlocal Agreement with King County is for maintenance and construction to
include the following projects: Garrison Creek Channel Restoration, 228`h/224`h Corridor—
Wetland Mitigation, East Hill Skate Park Rough Grade and Fill and Pacific Highway South
Wetland Mitigation. WHITE MOVED to authorize the Mayor to sign an amendment to the King
County Interagency agreement approved on March 15, 2005 to include the projects.
BIDS
A. Fire Station 76 Underground Fire Pump Test Tank. (CFN-120) The bid opening was held
on May 12, 2005, with five (5)bids received The apparent low bid was submitted by JW
Developers, LLC in the amount of$49,206, excluding Washington State Sales Tax (WSST).
RANNIGER MOVED to authorize the Mayor to enter into an agreement with JW Developers,
LLC, in the amount of$49,206, plus Washington State Sales Tax, to furnish and install the
underground fire pump test tank at Fire Station No. 76. Thomas seconded and the motion carried.
4
IKent City Council Minutes June 7, 2005
B. 3rd Avenue South Street Improvements. (CFN-1038) The bid opening for this project
was held on May 24, 2005, with four bids received. The low bid was submitted by Rodarte
Construction, Inc. WHITE MOVED to authorize the Mayor to enter into a contract with Rodarte
Construction, Inc. in the amount of$386,620.80 for the 3rd Avenue South Street Improvements
Iproject. Clark seconded and the motion carried.
C. 2005 Asphalt Overlay. (CFN-103) The bid opening for this project was held on May 26,
2005, with three bids received. The low bid was submitted by ICON Materials. WHITE MOVED
to authorize the Mayor to enter into a contract with ICON Materials in the amount of$692,952.80
for the 2005 Asphalt Overlay Project. Raplee seconded and the motion carried.
REPORTS
Operations Committee. (CFN-198) Clark reminded Councilmembers of the Suburban Cities
dinner on Wednesday and the guest speaker will be State Attorney General Rob McKenna.
Parks & Human Services Committee. (CFN-198) Upon Ranniger's request, Parks Director
Hodgson noted that the aquatic feasibility study was on schedule and final negotiations were
underway with a consulting fine.
Administrative Reports. (CFN-198) CAO Martin reminded Council of an executive session that
will take 20-30 minutes and no action is expected.
CONTINUED COMMUNICATIONS
A. Municipal Lot(Town Square Plaza). (CFN-198&1298) Bob O'Brien, 1131 Seattle Street,
spoke about the LID and would like to see more public meetings.
B. Municipal Lot (Town Square Plaza). (CFN-198&1298) Robert Bonaci, 302 E. Smith
Street, spoke about the business that would be affected by this development.
C. Kent Youth Council. (CFN-i 98) Nisha Nariya, Kentridge High School, asked the Mayor to
create a"Kent Youth Council." A brief discussion in support was held.
EXECUTIVE SESSION
' The meeting recessed to Executive Session at 7:40 p.m. and reconvened at 8:07 p.m. (CFN-198)
ADJOURNMENT
At 8.07 p.m. THOMAS MOVED to adjourn. Hannon seconded and the motion carried.
(CFN-198)
Mary Simmons
Deputy City Clerk
1 5
' Kent City Council Meeting
' Date June 21, 2005
Category Consent Calendar
1. SUBJECT: 2005 INTERLOCAL AGREEMENT FOR WATERFOWL
MANAGEMENT—AUTHORIZE
' 2. SUMMARY STATEMENT: Authorize the Mayor to sign the 2005 Interlocal
Agreement for Waterfowl Management.
The goal of the Waterfowl Management Program and subsequent agreement is to
reduce and/or alleviate property damage and human health and safety concerns from
waterfowl, including contamination of potable water and recreation areas within King
' County. Each year the Interlocal Agreement must be renewed and authorized by each
city involved in the agreement with the Wildlife Services Program of the U.S.
Department of Agriculture. Participating agencies are: City of Bellevue, City of Kent,
City of Kirkland, City of Mercer Island, City of Mountlake Terrace, City of Renton,
City of SeaTac, City of Woodinville, City of Seattle Department of Parks and
Recreation, University of Washington, USDA Wildlife Services and USDI Fish and
' Wildlife Service.
' 3. EXHIBITS: 2005 Interlocal Agreement for Waterfowl Management
4. RECOMMENDED BY: Parks and Human Services Committee
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? X Revenue? N/A
Currently in the Budget? Yes X No
' If no:
Unbudgeted Expense: Fund Amount S
Unbudgeted Revenue- Fund Amount S
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No 6C
For Your Action
1
1
2005 Interlocal Agreement for
1 Waterfowl
1 (Canada Goose)
1 Management Program
i
i
1
1
Please Note:
Final Form Ready for Your Submittal for Signature and Funding Authorization
1
n staffuspldhlwaterfwllagreer ntlinter2" 1
1
t
2005 INTERLOCAL AGREEMENT FOR WATERFOWL (CANADA GOOSE) ,
MANAGEMENT PROGRAM
WHEREAS, Chapter 39.34.040 RCW(Interlocal Cooperation Act)permits local government
units to make the most efficient use of their powers by enabling them to cooperate with other
localities on a basis of mutual advantage and thereby to provide services in a manner pursuant to ,
forms of goverrument organization that will accord best with recreational, pack and natural
resources and other factors influencing the needs and development of local corrununities and
WHEREAS, the various agencies, cities,counties, Washington State and agencies of the Federal
Government listed in Exhibit A-Page 6 of this Agreement, desire to manage waterfowl,
especially Canada Geese, and
WHEREAS, all parties require assistance from the Wildlife Services Program of the U.S.
Department of Agriculture, to reduce negative impacts on water quality, minimize resource ,
damage, ensure safety from disease for park visitors, and entrance other property managed, and
WHEREAS, information dating to a 1989 Waterfowl Research Project done by the University ,
of Washington and current data indicates a large surplus of geese and other waterfowl species in
the greater Seattle area; and
WHEREAS, this program will be an ongoing resource management activity attempting to ,
maintain a manageable number of birds on a year-to-year basis; and
NOW,THEREFORE, in consideration of the covenants herein, it is mutually agreed as '
follows.
SECTION I-PURPOSE
The purpose of this Agreement is to provide joint funding for an egg addling program, '
lethal control,population monitoring and census,mainly of Canada Geese, within King County.
This program will assist each party in maintaining and managing public and selected and ,
approved private sites that are impacted by a surplus of waterfowl.
n staffospVdhlwaterfwl%aereemnt\Inter20olr 2 '
SECTION 1I- SCOPE OF PROGRAM
' Wildlife Services(WS)will receive funds from each participating member for the
continuation of an egg addling program, lethal control and evaluation during spring and summer
2005.
Using best management practices WS will carry out an egg addling program, seeking as
many accessible nesting areas as possible and will make every effort to minimize damage to the
surrounding environment.
WS will also implement a program of"lethal control'as requested by the Waterfowl
Management Committee, subject to the terms and conditions of a permit to be issued by the U.S.
Fish and Wildlife Service. This will be done on a case by case basis in situations where an over
population of Canada geese may result in an impact on human health and safety, such as potable
water contamination,bird aircraft strikes,disease transmission or other situations as determined
by WMC members.
Agency and corporate participants acknowledge by approval signature
(below) that their participation includes a request to WS for direct assistance
through the removal of Canada geese, and will rely on the experience and
expertise of WS to identify locations where goose removal is appropriate.
Participants may identify locations where control is not to be carried out.
Approved by: for
Agency
Date:
WS will provide an annual report to the members of the WMC which will include
information regarding egg addling,the general location of nests and number of eggs addled,
number of geese removed, difficulties encountered and whatever other information would be
valuable to the WMC.
2005 will be the thirteenth year of an egg addling program and the sixth year utilizing
' "lethal control'. All methods and tools utilized to accomplish addling and "lethal control'
activities in 2004 will again be used in 2005.
A census of urban Canada Geese will be conducted during 2005,however as in 2004
these census counts will be expanded using staff from local agencies and participants at times
and places to be specified.
Where possible, educational programs will be initiated to inform the public about urban
Canada Geese, the associated problems, and the efforts of this connnittee at addressing those
problems.
i
SECTION III-RESPONSIBILITIES '
Each party, represented on the Waterfowl Management Committee, as shown on Exhibit ,
"A", and incorporated by reference herein,will share in the ongoing review of the programs
carried out by WS. ,
Each party agrees that if necessary,an Oversight Committee will be appointed to monitor
and report back to the general committee on a regular basis. Three members of the Committee '
will make up the Oversight Committee chaired by the City of Seattle representative.
SECTION IV-COMPENSATION '
The total cost of the 2005 waterfowl management program shall not exceed
Thirty two thousand, one hundred sixty dollars ($32,160.00). ,
Each party shall contribute to the financial costs of the program as shown in Table I.
SECTION V-TERM AND EXTENSION '
The Term of this Agreement is from January 1,2005 to December 31,2005. This ,
Agreement may be extended in time,scope or funding by mutual written consent from all parties
referenced herein.
SECTION VI-TERMINATION '
This agreement may be unilaterally terminated by any of the parties referenced herein or
Wildlife Services upon presentation of written notice to the Oversight Committee at least 30 days '
in advance of the severance date shown in Section V.
Should tennination of this agreement occur without completion of the egg addling,each
party shall pay only its' pro rata share of any expenses incurred under the agreement at the date
of the termination, and each party shall receive copies of all products resulting from the addling
activities up to the time of the termination.
SECTION VII-DELIVERABLE
Wildlife Services will make every effort to conduct a 1,000-2,000 egg addling program.
Field conditions or changing condittons may increase or decrease these numbers.
Lethal control will be implemented as necessary and the total numbers are established by '
the U.S. Fish and Wildlife Service Pen-nit
Participants will receive a report on the number of eggs addled and geese euthanized in ,
2005.
4 '
1
SECTION VIII-FILING
1 As provided by RCW 39.34.040,this agreement shall be filed prior to its entry and force
with the City or County Clerks of the participating parties,the County Auditor and the Secretary
of State, and, if found to be necessary,with the State Office of Community Affairs as provided
by RCW 39 34 120.
1 SECTION IX- LIABILITY
Each party to this agreement shall be responsible for damage to person or property
1 resulting from the negligence on the part of itself, its employees, its agents or its officers No
party assumes any responsibility to another party for the consequences of any act or omission of
any person, finn, or corporation not at party to this agreement.
i
1
1
1
1
1
1
i
1
5
1
EXHIBIT A '
2005 WATERFOWL MANAGEMENT COMMITTEE PARTICIPANTS ,
Cityof Bellevue....................................................................................................... ........Pat Harris ,
Cityof Kent.............................................................. ......................Quientin Poil '
Cityof Kirkland...........................................................................................................Mike Metteer '
City of Mercer Island........................................................................................................Mike Elde
City of Mountlake Terrace...........................................................................................Don Sarcletti '
City of Renton ........ ...............................................................................................Terrence Flatley
Cityof SeaTac ............................... ................................................................................Curt Brees
City of Seattle Department of Parks and Recreation.............................................. Barbara DeCaro
City of Woodinville.......... ................ .. .... .........................................Brian Meyer
University of Washington................................ ............ .....................................Charles Easterberg
U.S.D.A. Wildlife Services...........................................................................Mike Linnel ,
U.S.D.I. Fish and Wildlife Service...............................................................................Brad Bortner
1
6 '
r
TABLE i
rAGENCIES CONTRIBUTIONS
City of Bellevue 2410
City of Kent 2410
City of Kirkland 2410
City of Mercer Island 2410
City of Mountlake Terrace 2410
' City of Renton 2410
City of SeaTac 2410
City of Woodinville 2410
Seattle Department of Parks and 3700
Recreation
rCity of Woodinville 2410
University of Washington 2410
' All checks will be made payable to the USDA-APHIS-ADC,earmarked for the Wildlife Services and sent
to the following addresses.
Mr Roger Woodruff
State Director-Wildlife Services Program
U S.Department of Agriculture
720 O'Leary Street Northwest
Olympia,Washington 98502
(360)753-9994
In case of procedural questions regarding this project,please contact:
Maggie Rayls,Administrative Officer
Wildlife Services Program
(360)753-9884 FAX: 753-9466
rFor questions regarding implementation of control measures and census,please contact:
Mike Luinell 360-753-9884
mike.alinnell a usda gov
SECTION X. -SEVERABILITY
...If any section of this agreement is adjudicated to be invalid,such action shall not affect the
validity of any section so adjudged
This agi eement shall be executed on behalf of each party by its authorized representative. It
shall be deemed adopted upon the date of execution by the last so authorized representative.
r
7
r
This agreement is approved and entered into by the undersigned county and local government '
units, uruversity and other private parties. 1
City of Bellevue City of Renton
By By. ,
Patrick Poran,Director of Paiks and Community Jesse Tanner,Mayor
Services Date-
Date
City of Kent City of SeaTac '
By By
John Hodgson,Director Calvui Hoggart,City Manager
Date: Date: 1
City of Kirkland Seattle Department of Parks and Recreation 1
By By:
Day id Ramsey, City Manager Kenneth R.Bounds,Superintendent
Date Date.
City, of Mercer Island City of Woodinville
By By. '
Rich Conrad,City Manager Donald D Rose,City Manager
Date- Date
University of Washington
City of Mountlake Terrace By:
By Karen VanDusen
Name/Title. Director of Env Health& Safety
Date. Date
1
i
1
1
8 �
WORK PLANIF[NANCIAL PLAN
Cooperator: Waterfowl Management Committee(WMC)
tContact: Barb DeCaro, 206-615-1660
Cooperative Service Agreement No.: 05-73-53-2065 (TF)
Accounting Code: 58373-53729
aLocation: King and Snohomish Counties
Dates: January—December 2005
In accordance with the Cooperative Service Agreement between the Waterfowl Management
Committee and the United States Department of Agriculture(USDA), Animal and Plant Health
Inspection Service (APHIS), Wildlife Services (WS),this Work Plan sets forth the objectives,
activities and budget of the wildlife control activities for the period of January—December 2005.
Program Objective/Goals
To reduce/alleviate property damage and human health and safety concerns including contamination of
potable water and recreational areas for the entities of the WMC. WS will provide a wildlife damage
management program which will include techmcal assistance, population monitoring, and population
control (reduction in the number of geese utilizing certain areas).
Plan of Action
1. APHIS-WS will provide technical assistance upon request, including on-site evaluation of
problem areas.
2. APHIS-WS will conduct monthly surveys of Canada geese in the Seattle area according to the
established survey route. Additional surveys may also be conducted.
' 3. APHIS-WS will conduct a direct control program (egg addling and lethal control) to reduce
damage in designated areas as requested by WMC participants.
4. Each member of the WMC will indicate to APHIS-WS whether their participation includes a
request to APHIS-WS to remove Canada geese. Participants will rely on the experience and
expertise of APHIS-WS to identify locations where egg addling and goose removal is
appropriate. Participants may identify locations where control is not to be carried out
5. Direct control piojects will be conducted during the period,March through August 2005.
During nesting season, WS will conduct an egg addling program within the junsdictional
boundaries represented by the WMC. During the mott season, flightless geese will be captured
in drive traps and euthanized. Alternative methods for goose removal that are analyzed and
discussed in the Environmental Assessment for Management of Conflicts Associated with Non-
migratory(Resident) Canada Geese in die Puget Sound Area may also be used.
6. APHIS-WS will be responsible for disposal of Canada geese.
7, APHIS-WS will provide a status report to members of the Inter-local at the annual WMC
meeting. Entities of the WMC will provide assistance with security measures, including police
protection if requested by APHIS-WS
8. The District Supervisor in the APHIS-WS District Office in Poulsbo will supervise this project ,
and can be reached at Area Code(360) 337-2778. Roger Woodruff, State Director, Olympia,
WA,will monitor this project and can be reached at Area Code(360) 753-9884. ,
9. In accordance with the Debt Collection Improvement Act(DCIA)of 1996,bills issued by
APHIS-WS are due and payable within 30 days of receipt The financial point of contact for ,
this Work Plan/Financial Plan is Roberta Bushman, Administrative Officer,who can be
reached at 360-753-9884.
BUDGET
Listed below are the costs of the wildlife control program outlined above: ,
Salary&Benefits $ 24,660
Vehicle Use 4,000
Supplies 1,500
Travel 2,000
TOTAL $ 32,160
WATERFOWL MANAGEMENT COMMITTEE
1600 DAKOTA STREET
SEATTLE,WA 98108
Date ,
UNITED STATES DEPARTMENT OF AGRICULTURE i
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
WILDLIFE SERVICES
State Director, WA/AK Date
Director, Western Region Date
r
i
Kent City Council Meeting
' Date June 21, 2005
Category Consent Calendar
1. SUBJECT: POOL/RECREATION FACILITY FEASIBILITY STUDY
CONTRACT —AUTHORIZE
2. SUMMARY STATEMENT: Authorize the Mayor to sign the consultant agreement
with GreenPlay, LLC to conduct a pool/recreation facility feasibility study in the
amount of$67,000.
The Parks, Recreation and Community Services Department will be conducting a
feasibility study to provide options relating to a pool/recreation facility in Kent.
GreenPlay, LLC has been selected from fourteen consulting firms to assist with the
feasibility study. The Parks Director recommends entering into an agreement with
GreenPlay, LLC for the feasibility study, upon review by the City Attorney.
3. EXHIBITS: Consultant agreement with GreenPlay, LLC
4. RECOMMENDED BY: Parks and Human Services Committee
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? X Revenue? N/A
Currently in the Budget? Yes X No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6D
•
KENT
wa» »ot ow
j CONSULTANT SERVICES AGREEMENT
between the City of Kent and
I GreenPlay, LLC
THIS AGREEMENT is made between the City of Kent, a Washington municipal corporation
(hereinafter the "City"), and GreenPlay, LLC organized under the laws of the State of Colorado, located and
doing business at 3050 Industrial Lane, Suite 200,Broomfield, Colorado, 80020, 303-439-8369 (hereinafter the
"Consultant").
1. DESCRIPTION OF WORK.
Consultant shall perform the following services for the City in accordance with the following described
plans and/or specifications.
Conduct a ConimunityAquatics/Recreation Center Feasibility Study, as noted in Exhibit A
j
Consultant furthei represents that the services furnished under this Agreement will be performed in
accordance with generally accepted professional practices in effect at the time those services are performed.
Il. TIME OF COMPLETION.The parties agree that work will begin on the tasks described in
1 Section I above immediately upon the effective date of this Agreement Upon the effective date of this
Agreement, Consultant shall complete the work described in Section I by November 30, 2005.
III. COMPENSATION.
A. The City shall pay the Consultant,based on time and materials, an amount not to exceed Sixty
Seven Thousand Dollars and no cents($67,000.00) for the services described in this Agreement.
This is the maximum amount to be paid under this Agreement for the work described ui Section I
above, and shall not be exceeded without the prior written authorization of the City in the form
of a negotiated and executed supplemental agreement. The Consultant agrees that the hourly or
flat rate charged by it for its services contracted for herein shall leniain locked at the negotiated
rate(s) for a period of one (1) year from the effective date of this Agreement. The Consultant's
1 billing rates shall be as delineated in Exhibit Exhibit A .
B. The Consultant shall submit monthly payment invoices to the City for work performed, and a
final bill upon completion of all services described in this Agreement. The City shall provide
payment within forty-five(45) days of receipt of an invoice If the City objects to all or any
portion of an invoice, it shall notify the Consultant and reserves the option to only pay that
portion of the invoice not in dispute. In that event, the parties will munediately make every effort
to settle the disputed portion.
IV. INDEPENDENT CONTRACTOR.The parties intend that an Independent Contractor-
Employer Relationship will be created by this Agreement and that the Consultant has the ability to control and
direct the performance and details of its work,the City being interested only in the results obtained under this
Agreement.
V. TERMINATION. Either party may terminate this Agreement, with or without cause, upon
providing the other party thirty (30) days written notice at its address set forth on the signature block of this
Agreement. After t ennination,t he C ity m ay t ake p ossession o f a 11 r ecords a nd d ata w ithin t he Consultant's
possession pertaining to this project, which may be used by the City without restriction If the City's use of
Consultant's records or data is not related to this project, it shall be without liability or legal exposure to the
Consultant.
VI. DISCRIMINATION. In the hiring of employees for the performance of work under this '
Agreement or any subcontract, the Consultant, its subcontractors, or any person acting on behalf of the
Consultant or subcontractor shall not,by reason of race, religion, color, sex, age, sexual orientation, national
origin, or the presence of any sensory,mental, or physical disability,discriminate against any person who is
qualified and available to perform the work to which the employment relates Consultant shall execute the
attached City of Kent Equal Employment Opportunity Policy Declaration, Comply with City Administrative
Policy 1.2, and upon completion of the contract work, file the attached Compliance Statement.
VII. INDEMNIFICATION.Consultant shall defend, indemnify and hold the City, its officers,
officials, employees, agents and volunteers harmless from any and all claims, injuries, damages, losses or suits.
including all legal costs and attorney fees, arising out of or in connection with the Consultant's performance of
this Agreement, except for that portion of the injuries and damages caused by the City's negligence.
The City's inspection or acceptance of any of Consultant's work when completed shall not be grounds to
avoid any of these covenants of indemnification.
Should a court of competent jurisdiction determine that this Agreement is subject to RCW 4.24.115,
then, in the event of liability for damages arising out of bodily injury to persons or damages to property caused
by or resulting from the concurrent negligence of the Consultant and the City, its officers,officials,employees,
agents and volunteers, the Consultant's liability hereunder shall be only to the extent of the Consultant's
negligence
IT IS FURTHER SPECIFICALLY AND EXPRESSLY UNDERSTOOD THAT THE
INDEMNIFICATION PROVIDED HEREIN CONSTITUTES THE CONSULTANT'S WAIVER OF
IMMUNITY UNDER INDUSTRIAL INSURANCE,TITLE 51 RCW,SOLELY FOR THE PURPOSES OF
THIS INDEMNIFICATION. THE PARTIES FURTHER ACKNOWLEDGE THAT THEY HAVE
MUTUALLY NEGOTIATED THIS WAIVER.
The provisions of this section shall survive the expiration or termination of this Agreement.
VIII. INSURANCE. The Consultant shall procure and maintain for the duration of the Agreement,
insurance of the types and in the amounts described in Exhibit B. attached and incorporated by this reference.
IX. EXCHANGE OF INFORMATION. The City will provide its best efforts to provide
reasonable accuracy of any information supplied by it to Consultant for the purpose of completion of the work
under this Agreement.
X. OWNERSHIP AND USE OF RECORDS AND DOCUMENTS. Original documents,
drawings, designs, reports, or any other records developed or created wider this Agreement shall belong to and
become the property of the City. All records submitted by the City to the Consultant will be safeguarded by the
Consultant. Consultant shall make such data, documents,and files available to the City upon the City's request
The city's use or reuse of any of the documents, data and files created by Consultant for this project by anyone
other than Consultant on any other project shall be without liability or legal exposure to Consultant.
XI. CITY'S RIGHT OF INSPECTION. Even though Consultant is an independent contractor with
the authority to control and direct the perfonnance and details of the work authorized under this Agreement, the
work must meet the approval of the City and shall be subject to the City's general right of inspection to secure
satisfactory completion.
XII. WORK PERFORMED AT CONSULTANT'S RISK. Consultant shall take all necessary
precautions and shall be responsible for the safety of its employees, agents, and subcontractors in the
performance of the contract work and shall utilize all protection necessary for that purpose. All work shall be
done at Consultant's own risk, and Consultant shall be responsible for any loss of or damage to materials,tools,
or other articles used or held for use in connection with the work.
XUL MISCELLANEOUS PROVISIONS.
A. Recyclable Materials. Pursuant to Chapter 3 80 of the Kent City Code, the City requires its
contractors and consultants to use recycled and recyclable products whenever practicable. A price preference
maybe available for any designated recycled product.
B. Non-Waiver of Breach. The failure of the City to insist upon strict performance of any of the
covenants and agreements contained in this Agreement, or to exercise any option conferred by this Agreement
in one or more instances shall not be construed to be a waiver or reluiquislunent of those covenants, agreements
or options, and the same shall be and remain in full force and effect.
C. Resolution of Disputes and Governing
_Law. This Agreement shall be governed by and construed
in accordance with the laws of the State of Washington. If the parties are unable to settle any dispute,difference
or claim arising from the parties' performance of this Agreement, the exclusive means of resolving that dispute,
difference or claim, shall only be by filing suit exclusively under the venue, rules and jurisdiction of the King
County Superior Court, King County, Washington, unless the parties agree in writing to an alternative dispute
resolution process In any claim or lawsuit for damages arising from the parties' performance of this Agreement,
each party shall pay all its legal costs and attorney's fees incurred in defending or bringing such claim or
lawsuit, in addition to any other recovery or award provided by law, provided,however,nothing in this
paragraph shall be construed to limit the City's right to indemnification under Section VII of this Agreement.
D. Written Notice.All communications regarding this Agreement shall be sent to the parties at the
addresses listed on the signature page of the Agreement, unless notified to the contrary. Any written notice
hereunder shall become effective three(3)business days after the date of mailing by registered or certified marl,
and shall be deemed sufficiently given if sent to the addressee at the address stated in this Agreement or such
other address as may be hereafter specified in writing
E. Assignment Any assignment of this Agreement by either party without the written consent of
the non-assigning party shall be void. If the non-assigning party gives its consent to any assignment,the terns
of this Agreement shall continue in full force and effect and no further assignment shall be made without
additional written consent.
F. Modification No waiver, alteration, or modification of any of the provisions of this Agreement 1
shall be binding unless in writing and signed by a duly authorized representative of the City and Consultant.
G. Entire Agreement. The written provisions and terms of this Agreement, together with any
Exhibits attached hereto, shall supersede all prior verbal statements of any officer or other representative of the
City, and such statements shall not be effective or be construed as entering into or forming a part of or altering
in any manner this Agreement. All of the above documents are hereby made a part of this Agreement. However,
should any language in any of the Exhibits to this Agreement conflict with any language contained in this
Agreement, the terms of this Agreement shall prevail.
H Compliance with Laws The Consultant agrees to comply with all federal, state, and municipal
laws, rules, and regulations that are now effective or in the future become applicable to Consultant's business,
equipment, and personnel engaged in operations covered by this Agreement or accruing out of the performance ,
of those operations
IN WITNESS, the parties below execute this Agreement, which shall become effective on the last '
date entered below.
CONSULTANT: CITY OF KENT:
By: By:
(s+gnnnn e) (s+gnnrm e)
Print Name: Print Name: Jim White
Its Its Mayor
(Pale) (Title)DATE: DATE:
NOTICES TO BE SENT TO: NOTICES TO BE SENT TO:
CONSULTANT: CITY OF KENT:
Chris Dropinski Lori Hogan,Supt. Recreation&Cultural Services
GreenPlay, LLC City of Kent
3050 Industrial Lane, Suite 200 220 Fourth Avenue South
Broomfield, CO 80020 Kent, WA 98032
303-439-8369 (telephone) (253) 856-5050 (telephone)
303-439-0628 (facsimile) (253) 856-6050 (facsimile)
APPROVED AS TO FORM:
Kent Law Department
p:Admin/Contract/GreenPlayLLCConsultant Agreement
CITY OF KENT
ADMINISTRATIVE POLICY
NUMBER: 1.2 EFFECTIVE DATE- January 1, 1998
SUBJECT: MINORITY AND WOMEN SUPERSEDES: April 1, 1996
CONTRACTORS APPROVED BY Jun White, Mayor
POLICY:
tEqual employment opportunity requirements for the City of Kent will conform to federal and state laws. All
contractors, subcontractors, consultants and suppliers of the City must guarantee equal employment opportunity
within their organization and, if holding Agreements with the City amounting to $10,000 or more within any
given year, must take the following affirmative steps:
1. Provide a written statement to all new employees and subcontractors indicating commitment as an equal
opportunity employer
2. Actively consider for promotion and advancement available minorities and women.
Any contractor, subcontractor, consultant or supplier who willfully disregards the City's nondiscrimination and
equal opportunity requirements shall be considered in breach of contract and subject to suspension or
termination for all or part of the Agreement
Contract Compliance Officers will be appointed by the Directors of Planning,Parks, and Public Works
Departments to assume the following duties for their respective departments
1. Ensuring that contractors, subcontractors,consultants, and suppliers subject to these regulations are
familiar with the regulations and the City's equal employment opportunity policy.
2. Monitoring to assure adherence to federal, state and local laws,policies and guidelines.
1
EEO COMPLIANCE DOCUMENTS-2
CITY OF KENT
EQUAL EMPLOYMENT OPPORTUNITY COMPLIANCE STATEMENT
This form shall be filled out AFTER COMPLETION of this project by the Contractor awarded the
Agreement
I, the undersigned, a duly represented agent of Company, hereby
acknowledge and declare that the before-mentioned company was the prime contractor for the Agreement
known as that was entered into on the (date)_, 1
between the firm I represent and the City of Kent.
I declare that I complied fully with all of the requirements and obligations as outlined in the City of Kent
Administrative Policy 1.2 and the Declaration City of Kent Equal Employment Opportunity Policy that was part i
of the before-mentioned Agreement.
i
Dated this day of ,200^
By. ,
For:
Title:
Date:
1
1
EEO COMPLIANCE DOCUMENTS-3 '
DECLARATION
CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY POLICY
The City of Kent is committed to conform to Federal and State laws regarding equal opportunity.As such all
contractors, subcontractors and suppliers who perform work with relation to this Agreement shall comply with
the regulations of the City's equal employment opportunity policies
tThe following questions specifically identify the requirements the City deems necessary for any contractor,
subcontractor or supplier on this specific Agreement to adhere to. An affirmative response is required on all of
the following questions for this Agreement to be valid and binding. If any contractor, subcontractor or supplier
willfully misrepresents themselves with regard to the directives outlines,it will be considered a breach of
contract and it will be at the City's sole determination regarding suspension or termination for all or part of the
Agreement;
The questions are as follows:
1. I have read the attached City of Kent administrative policy number 1.2.
2. During the time of this Agreement I will not discriminate in employment on the basis of sex,race,color,
national origin,age, or the presence of all sensory, mental or physical disability
3. During the time of this Agreement the prime contractor will provide a written statement to all new
employees and subcontractors indicating commitment as an equal opportunity employer.
4. During the time of the Agreement I,the prime contractor,will actively consider hiring and promotion of
women and minorities.
5. Before acceptance of this Agreement, an adherence statement will be signed by me,the Prime
Contractor, that the Prime Contractor complied with the requirements as set forth above.
By signing below, I agree to fulfill the five requirements referenced above.
Dated this day of 200_.
By
For:
Title:
Date:
EEO COMPLIANCE DOCUMENTS- t
lei h&A
Proposalfor
ar
- KENT
` W A S H I N G T O N
j
Community Aquatics/Recreation Center ,
Feasibility Study
June 2, 2005
4REEIVPLAYLLC
The Leading Edge In Parks,Recreation
And Open Space Consulting
Helping You Achieve Your Goals
Contact:
Chris Dropinski
Senior Principal and Managing Member
'P^
3050 Industrial Lane,Suite 200
Broomfield, CO 80020
303439-8369 �
Direct: 303-870-8674 '
FAX: 303-439-0628
Email: chrisd@greenplayllc.coin
www.greenplayllc.com ,
w="mzay�k'��` �
t3050 Industrial Lane, Suite 200
Broomfield,CO 80020
Phone: (303) 439.8369
FAX: (303) 439-0628
Email: Iii-fo@GreenPlayLLC.com
www.GreenPlayLLC.com
June 2, 2005
Mr.John Hodgson, Director
Ms.Lori Hogan,Project Manager and
Recreation and Cultural Services Superintendent
City of Kent
Department of Parks, Recreation and Community Services
220-4th Avenue South
Kent, Washington 98032-5895
Dear John and Lori:
We are honored to submit this proposal to work with the City of Kent,
Washington and the staff members with the Department of Parks, Recreation
and Community Services to conduct a Community Aquatics/Recreation Center
Feasibility Study.
Attached are the proposed Scope of Services Schedule and Preliminary Budget
based on our present understanding of your needs. This proposal is based on
our interpretation for what we feel will result in a successful effort,however we
are happy to discuss changes to the approach prior to contract signing. This
proposal is valid for a period of 90 days from today's date. We understand and
have addressed your need for completion of this project around the end of
October for the draft report and presentation to the Board, with the final product
to be complete by mid November.
I will be in the Kent area on June 6-71h and would be pleased to meet with you to
discuss the details of our proposal. Thanks so Much for your interest in our
work, we look forward to getting started!
Sincerely,
Chris Dropuiski
Senior Principal and Managing Member
Limn Line 303-439-8369 Ccll Pihone: 303-870-8674
tGREENPLAY« '
ne�nnrobh.r n.w wa.rw
�M•.sw..cwn.uM
Proposal Kent,WA-Feasibility Study 2
THE PROJECT SCOPE AND SCHEDULE
We will begin in June 2005,immediately upon contract signing, and have it completed
within five months, with a draft pieliminary report completed by October 30,2005. VVe
can have our team members available to complete the project as proposed. Final Length
of project will be determined by the final scope and is influenced by the time dedicated
to public meetumgs,presentations and time for approvals.
'M " 1,00 NOWOft, MUNA 11 aR
A. Start U
B. Community Involvement Process
1.Public Process-Focus Groups X
2.Staff Interviews-plan reviews
3. Optional Survey ,
C. Market and Program
1. Demographics and Trends Analysis
2.Inventory and Evaluation of Assets
3.Site Analysis
4. Market Analysis
5. Community X ,
Priorities/Concepts/Models
D. Public-Private Partnerships
1.Alternative funding ,
2.Partnership Opportunities
E. Plarming and Cost Analysis
1.Pricing and Cost Recover
2. Draft Project Estimates
3. Draft Business Plan
4.Summary of Financial Analysis X
F. Action Program and Schedule
1. Refine the Vision
2. Develop Action Steps
3.Funding Strategy
4. Develop Timeline
G. Final Report and Presentations
1. Compile Findings
2. Final Presentation X
X=Anticipated time for Team Member s to have meetings and make presentations
GREENPLAKC ,
IRn1.Muy Fl/eln Pare Heevlron
.UbOpm SPaee[nvraay
Proposal: Kent,WA-Feasibility Study 3 '
i
1
THE GREEMPLAY TEAM
Karon Badalamenti, CPRP and Principal and Project Manager, will lead the
process and manage the sub-consultants. Chris Dropinski, Senior Managing
Principal will be the Pi incipal in-Charge performing as the primary contact for
project oversight and will work to ensure that the plan is implemented and
successful GreenPlay's Statement of Qualifications that was previously sent
includes resumes for all GreenPlay consultants.
THE SUB-CONSULTANTS
' Keith Hayes, Principal with Barker Rinker Secat Architecture;David Thomas,
Principal-in-Charge and Project Manager with Annbia Architecture, Inc.; and
Doug Whiteaker, Principal with Water Teclulology, Inc will round out the team.
The Statement of Qualifications that was previously sent includes resumes for all
sub-consultants.
COST
GreenPlay establishes rates to inclusively cover the salaries of the professional
project team members and of support staff who enable them to function
effectively and efficiently. We consider the prevailing rates in our industry and
the level of specialized expertise that we provide. As a baseline,GreenPlay's
hourly rate is $125 per hour for all contracted professional consulting services.
While this hourly rate may sound high relative to typical governmental pay
rates, when considering the costs for implementing additional experienced and
professional full-time staff, benefits, insurances, office space,computers and
equipment,support staff, utilities, etc.,we find that this rate is usually
comparable to or lower than an agency would spend for in-house staff. An
additional benefit is that when the project is finished, the expense ends.
For projects that include more than 100 hours of work, such as this one,we
recommend using a Firm-Fixed Price model for compensation. This means that
the contract is preliminarily based on a projected number of hours,but that the
compensation is actually based on completion of pre-determined contracted
tasks or Scope of Work within a pre-specified timeline. This usually works well
for the client In that they will get all the work done that they need, regardless of
how many hours during the timeline that it takes to do it. In the event that the
contracted Scope of Work is changed by the client during the course of work,
GreenPlay can adjust total contract fees accordingly based on a$125 per hour fee.
dREEHP1aY«
MleaOxp F/K In Parlf RedNga
4/OReRpae Gnn.vuiy
Pioposal: Kent,WA-Feasibility Study 4
Our rates include: ,
• Professional staff salaries
• Taxes, employee benefits, and Worker's Compensation
• Administrative support staff and supplies,and local travel
• All office overhead, equipment, utilities, and insurances
Rates may not include (unless specified in the Scope of Work):
• Travel outside of the Metro Denver Area- (for this project we have
built necessary hips into the specific task costing)
• Materials and services outside of the pre-specified scope of work(may
include extra requested copies and printing of work products)
GreenPlay typically submits an invoice for payment to the Project
Manager/primary contact person on a monthly basis. Each invoice includes a
brief description of the services provided and percentage of Scope completed to
date. Invoices past due over 60 days will accrue 1.5`Yo interest per month.
Other structures for compensation and payment can be negotiable and discussed
prior to contract award.
Optional Services:
Leisure Vision- A Division of ETC Institute
Ron Vine,Vice President
Leisure Vision has conducted more than 100 needs assessments surveys for
parks, recreation and open space short and long range strategic plaluung efforts,
master planning efforts, and feasibility studies for conununity centers, family
aquatics centers community parks and trail systems. GreenPlay has worked with
Ron on many of our Master Planning and Needs Assessment projects. His firm
does excellent work that helps us understand the needs and desires of not only
the users of your facilities, but also the non-users,who are also your taxpayers
and voters.
Statistically-Valid Survey
Cost: $13,300
We believe that a statistically-valid survey is crucial in getting reliable
information from your community, both as a baseline for setting realistic and
achievable goals in the Feasibility Study We believe it is the only method that
gives us statistically valid information, not only from the users, but from your
non-users who are also taxpayers and voters. GreenPlay typically works with
Leisure Vision, a firm that specializes in creating,performing, and analyzing
these types of surveys. Leisure Vision is the top survey research firm in the
GREENPIAYIc
me U,aq tnor�.nn,uoenon
,.ehvn to.ret�m,.,
Proposal: Kent,WA-Feasibility Study 5
United States for parks, recreation,open space and other types of planning
research, and they have been doing this specific type of analysis for many years.
Working with GreenPlay,LLC, Leisure Vision will administer a statistically valid
random sampling Needs Assessment Survey of a minimum return of 400
households in the planning area. The number of surveys mailed will be
sufficient to achieve this statistically-valid result. The survey will be
administered by mail with phone follow up if needed to obtain desired valid
results. Leisure Vision specializes in conducting survey research that assists
clients in prioritizing the unmet need for outdoor and indoor facilities,
developing level of performance standards,voter referendums, and other
1 strategic issues to assist"Decision makers in making better decisions."
Questions on the survey will be developed in partnership with GreenPlay project
staff and Kent, WA. The survey instrument will be administered at a timeline
within the project where the information can best be used to help break down
barriers and build consensus. Overall results for the entire survey of the 400
households will have a 95% level of confidence with a margin of error of+/-5%
overall. If desired, we can additionally prepare the results for up to 3 sub-
geographical areas of the City with an inequitable return from each sub-area.
Leisure Vision will guarantee the completion of at least 400 surveys for the entire
City. Should we complete more surveys,those will be processed at no cost to the
City.
The Importance/Satisfaction Matrix is included as well as Sub Analysis/Banner
Crosstabultaion Analysis, National Benchmarking and a formal report with
charts and graphs. As a value added, if Kent,WA decides that there is merit in 3
zones, Leisure Vision will include the additional zone for no additional charge;
however, this decision will need to be determined prior to conducting the
survey.
The survey instrument will be 5-6 rages in length. This allows for between 22-28
questions to be asked, with many of the questions having multiple components.
The phone survey will take approximately 15 minutes to administer.
tHow Residents Find Out About
National Benchmarking (Included) Recreation Programs
1 Leisure Vision has an unparalleled 37%
database of more than 50,000 survey DepelkweeW81OCM1e.VW3
36e16
FnentlslCo-W°rken
responses from community services and Ne.dVC W.rkers /orecreation and parks needs assessment �e o °^visa°o ora�esurveys fioui cone nunities across the umby 9,pcountry Benchmarkinng"NationalWeb sae
GREENPIAY« 0% 10% 2D% 30% 40%
rb(e°Ap EheNIM,RnrW/w �Wtnnaieenchmarks
•YO)n SpM4w.ny 9..v 11Cle.w Mrb Rney(.nwy
Proposal: Kent,WA-Feasibility Study 6
Averages" have been developed for numerous strategically important recreation
plaiu-iing and management issues including- customer satisfaction and usage of
recreation programs; methods for receiving marketing information regarding
recreation programs;reasons that prevent members of households from using
recreation programs and facilities more often;priority recreation programs,
outdoor and indoor recreation facilities to improve or develop; priority
programming spaces to have in planned community centers and aquatic i
facilities;etc. This information will be provided as compared to survey findings •
from the District to aid in the planning process and consensus development.
Importance-Satisfaction Matrix and Ratings (Included)
Leisure Vision can develop an Importance-Satisfaction Matrix to display the
perceived importance of core services against the perceived quality of service
delivery. Leisure Vision currently provides this analysis for many governmental
organizations. The I-S(Importance-Satisfaction) matrix will allow GreenPlay and
the Parks and Recreation officials to further analyze the survey data to meet
priorities, identify areas of concern and where the Department is exceeding
community expectations,and those areas that are lower in priority.
The hmportaxice-Satisfaction Rating is a strong tool that is used by Leisure
Vision and GreenPlay to help public officials use survey data to help set
organizational priorities. More than 70 agencies currently use Leisure Visions I-
S Rating for this purpose. The Importance-Satisfaction Rating is based on the
concept that organizations will maximize their impact on the community by
emphasizing improvements in those areas where the level of satisfaction with a
service is relatively low and the perceived importance of the service is relatively
high.
Leisure Vision began using Importance-Satisfaction analysis in the 1980's to
allow civic and governmental organizations the ability to assess the quality of
service delivery During the past twenty years, Leisure Vision has continued
refining the analysis to maximize its usefulness as a decision-making tool.
An example that was developed for the City of Fort Worth,Texas is provided
below. Based on this analysis,the City of Foit Worth identified outdoor
swimming pools and walking/biking trails as the top two priorities for the City's
parks and recreation system.
GREENPIAKC ,
iPe(eMMfl✓U[kPM,flrkAFv
MO,[n SPa[LduoM,
Proposal: Kent,WA-Feasibility Study 7
i
1
t
Importance-Satisfaction Rating
City of Fort Worth - 2003
PARKS and RECREATION
Importance- 20031-S
tdast Most
luq,anaut hupnr+ant Satisfaction Satisfaction Satisfaction Rating
Category of Sewlce '. Rank •. Rank Rating Rank
Hr.rh Prforrry(!5 u+•201
Outdoor Swimming pools 200/r 5 270A 14 0.1460 1
Number ofwalkinglbilingtrails 24% 2 49% 9 0.1224 2
Quality of Facilmes at City Parks 24`%a 2 54`%. 4 0.1104 3
The City's youth athletic programs 191% 6 450/. 10 0.1045 4
hfe.lutrrr Puodn-11S! 7,M
Indoor Swmmrng Pools 13% 9 25%,. 15 0.0975 5
Maintenance of City parks 27`%a 1 67% 2 0.0891 6
Summer Recreation Programs 14'%a 8 44% 11 0.0724 7
The number of City parks 17'% 7 54% 4 0.0782 3
Maintenance of Community Centers 11`%a 10 56a/a 3 0.0434 9
City libraries 21% 4 79% 1 0.0441 10
The City's adult athletic programs 7`% 13 391%. 13 0.0427 11
Availability of Meeting Space 8% 11 511% 3 0-0392 12
Outdoor athleticfields SIX. 11 52% 6 0,0324 13
I Ease of registering for programs 5% 14 42% 12 0.0290 14
City Golf Courses 5% 14 5 X. 6 0.0240 15
Geocoding of Surveys (Optional) Dissatisfaction with Me Number of Chy Playgrounds
Cost: $1,750 !
Leisure Vision has capabilities to geocode
phone surveys.Geocoding allows =A
addresses of returned surveys to be
coded to allow for surveys to be ! Or ' I
identified and imported by the
consultant team and the City into a
geographic information system.
Geocoding allows the couununity a
visual picture of survey responses for J Lr�-
presentations as well as strategic analysis
and decision making.For example geocoding can show where gaps exist in
satisfaction levels for various recreation programs, indoor and outdoor
recreation facilities,marketing,etc.
GREENPL4KC
AM pye,SpKe CmvMrp
Proposal: Kent,WA-Feasibility Study g
. t
Videoconferencing- Additional Meetings
For additional team meetings outside the four scheduled on site visits for
meetings and presentations, videoconferencing through Arabia Architecture,
Inc.'s offices is available with a cost provided per two hour meeting.
Cost: $1,150 per two hour meeting
Additional Site Visits
GreenPlay consultants are available for additional on site meetings with staff,
Board, or public presentations if needed.
Cost: $1,500 per day per consultant,plus travel expenses
d REENPIAY« j
n uu�•Lea<.q£epC,h j. �m
������ Proposal: Kent,WA-Feasibility Study 9
„� v •', a
" E a�lf h a �������. r :�� a J. = I � - �• S1 ��a � k +�.t d� '
t GreenPlay GP BRS BRS Arr is Leisure Total
ins lri s Vision
A- Start Up 8750 $750
B. Community Involvement Process
1 PublicProcess-FocusGroups $3,9501 X I 1 1 $1,500 1 $5,450
2 StaffInterviews-planreview $750 $750
C. Market and Program
1 Demographics and Trends Analysis $1,500 $1,500
2.Inventory and Evaluation of Assets $438 $2,500 1 $1,000 $3,938
3 Site Analysis $325 $2,5D0 $5D0 $3,325
4, Market Analysis $2,500 $2,500
5 CommumtyPnordies!Concepts/Modets $2,700 X $3,200 X $5,900
0.Public-Private Partnerships
1 Alternativefunding $1.250 $1,250
2 Partnership opportunities $1.5001 1 1 1 1 $1,500
E Planning and Cost Analysis
1 Pricing and Cost Recovery $875 $875
2 Draft Project Estimates $312 $3,675 $3,987
3 Draft Business Plan $2,750 $2,750
4 Summary of Financial Analysis $1,875 X $3,200 X J $5,575
F. Action Program and Schedule
1 Refine the Vision $375 $375
2 Develop Action Steps $875 $1,825 $2,700
3 Funding Strategy $1,750 $1,500 $3,250
4 Develop Timeline $750 $750
G. Final Plans and Presentations
1 Compile Findings $1,125 1 $1,000 $2,125
2 Final Presentation-10 copies of the Final Plan* $2,700 X $2,700
%offproject �rWUM 56% 37'/, 7% 0% 100%
p
Add visits/GP learn member$1,500/day+travel exp $1,500 TBD
Videoconferencing-$1.150/2 hour meeting total $250 $450 $450 TBD
Water Technology-detailed aquatics assessment TBD
Statistically-Valid 15 min 5-6pg Survey-400 with unequal
d,stribution in 2 zones-+1-5%-IS matrix $1,500 $3D0 $11,500 $13,300
Additional to go to 3 zones-value added,no charge $0 $0
Geocodmg $250 $1,500 $1,750
tt rY y,",q�;YtlX.c;IGL71:&E.Nvre'v'*�:vy�o'�+tlr3^srrErrti'�,zwt'+ +-L.'#;4s��i4 Ovn}Fy, dco-a3:tis.I;+r- -„�«a •1-'.>t-+x,�s •r.:.)+;rt cQiti itb,?e agNilii,
'Additional copies are available al prevailing rates at the lime of request
This prvlect is billed as Firm-Fixed Fee,meaning that all travel and reimbursables are built into the per task cost.
GREENPIAKC
Ih Leitlmp Elpe MPafi Imxlr>
MpOyn Spa,i[ezutm/
Pioposai Kent,WA-Feasibility Study 10
ADDITIONAL DETAILS
Equal Employment Opportunity and Woman-Owned Business
Our firm will not discriminate against any employee or applicant for
employment because of race,color,religion, gender, sexual preference,
physical disability, or national origin. We take action to ensure that
applicants are employed and that employees are treated equally during
employment, without regard to their race, color,religion,gender,sexual
preference, physical disability, or national origin. Such action includes
but is not limited to the following: employment upgrading; demotion,
promotion or transfer; recruitment or recruitment advertising;layoff or
termination; rates of pay or other forms of compensation; and selection of
training, including apprenticeship.
GreenPlay, LLC,is a 100% Woman-Owned Business.
Workload and Availability
GreenPlay hexeby asserts that professional staff is available to perform the
duties as described herein within the proposed timelines. If for some
reason a listed team member should become unavailable during the
course of the project, GreenPlay would provide a suitable replacement,
with the understanding that Kent, Washington would have final approval
of any new team members, and training time for any new staff would not
be charged to you.
SUMMARY
Thank you very much for the opportunity to present this fee proposal for a
Community Aquatics/Recreation Center Feasibility Study to you. We look
forward to working with the Department of Parks,Recreation and Community
Services in Kent, Washington.
GREENPLAY«
�n.t.wn.,ny.wntir R.nno.
AN men VxeGrc.IliA
Proposal: Kent,WA-Feasibility Study it
l
EXHIBIT B
INSURANCE REQUIREMENTS FOR
CONSULTANT SERVICES AGREEMENTS
Insurance
The Consultant shall procure and maintain for the duration of the Agreement, insurance
against claims for injuries to persons or damage to property which may arise from or in
connection with the performance of the work hereunder by the Consultant, their agents,
representatives, employees or subcontractors.
A. Minimum Scope of Insurance
Consultant shall obtain insurance of the types described below:
1. Automobile Liability insurance covering all owned, non-owned,hired
and]eased vehicles Coverage shall be written on Insurance Services
Office (ISO) form CA 00 01 or a substitute form providing equivalent
liability coverage If necessary, the policy shall be endorsed to
provide contractual liability coverage.
2. Commercial General Liability insurance shall be written on ISO
occurrence form CG 00 01 and shall cover liability arising from
premises, operations, independent contractors, products-completed
operations,personal injury and advertising injury, and liability
assumed under an insured contract. The Commercial General Liability
insurance shalt be endorsed to provide the Aggregate Per Project
Endorsement ISO form CG 25 03 11 85. The City shall be named as
an insured under the Consultant's Commercial General Liability
insurance policy with respect to the work performed for the City.
B. Minimum Amounts of Insurance
Consultant shall maintain the following insurance limits:
1. Automobile Liability insurance with a minimum combined single limit
for bodily injury and property damage of $1,000,000 per accident.
2. Commercial General Liability insurance shall be written with limits no
less than$1,000,000 each occurrence, $1,000,000 general aggregate
and a $1,000,000 products-completed operations aggregate linut
� i
1
l
1
EXHIBIT B (Continued)
C. Other Insurance Provisions
The insurance policies are to contain,or be endorsed to contain,the following provisions
for Automobile Liability and Commercial General Liability insurance:
1. The Consultant's insurance coverage shall be primary insurance as respect the City.
Any Insurance, self-insurance, or insurance pool coverage maintained by the City
shall be excess of the Consultant's insurance and shall not contribute with it.
2. The Consultant's insurance shall be endorsed to state that coverage shall not be
cancelled by either party, except after thirty(30) days prior written notice by certified
mail, return receipt requested,has been given to the City.
3. The City of Kent shall be named as an additional insured on all policies(except
Professional Liability) as respects work performed by or on behalf of the Consultant
and a copy of the endorsement naming the City as additional insured shall be attached
to the Certificate of Insurance. The City reserves the right to receive a certified copy
of all required insurance policies. The Consultant's Commercial General Liability
insurance shall also contain a clause stating that coverage shall apply separately to
each insured against whom claim is made or suit is brought, except with respects to
the limits of the insurer's liability.
D. Acceptability of Insurers
Insurance is to be placed with insurers with a current A.M. Best rating of not less than
AN IL
II.
E. Verification of Coverage
Consultant shall furnish the City with original certificates and a copy of the amendatory
endorsements, including but not necessanly limited to the additional insured
endorsement, evidencing the insurance tequirements of the Consultant before
commencement of the work.
F. Subcontractors
Consultant shall include all subcontractors as insureds under its policies or shall furnish
separate certificates and endorsements for each subcontractor All coverages for
subcontractors shall be subject to all of the same insurance requirements as stated herein
for the Consultant.
Kent City Council Meeting
Date June 21, 2005
Category Consent Calendar
1. SUBJECT: LOCAL & LONG DISTANCE TELEPHONE SERVICE VENDOR—
AUTHORIZE
2. SUMMARY STATEMENT: Authorize the Mayor to sign a one-year contract with
World Communications, Inc. (WCI), for local and long distance telephone service that
replaces the City's current agreement with Focal Communications, subject to City
Attorney approval of contract documents.
Change our Local and Long Distance Service vendor from Focal Communications
(Focal) to World Communications, Inc. (WCI), a reseller of Focal local and long
distance services. The new rates will save the City approximately 18% (depending on
usage) for local and long distance telephone service.
3. EXHIBITS: Memo to Operations Committee and WCI Contract documents
4. RECOMMENDED BY: Operations Committee 6/7/05
(Committee, Staff, Examiner, Commission, etc)
5. FISCAL IMPACT
Expenditure? Yes Revenue?
Currently in the Budget? Yes X No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue• Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6E
+� INFORMATION TECHNOLOGY
Stan Waldrop, Director
KEN T Phone: 253-856-4600
W A S H I M O T O N Fax 253-856-4700
Address: 220 Fourth Avenue S.
Kent, WA 98032-5895
June 7, 2005
TO: Kent City Council Operations Committee
FROM Stan Waldrop, Information Technology Director
THROUGH: Mayor Jim White
SUBJECT: Change Local and Long Distance Service Vendor
MOTION: I move to authorize the Mayor to sign a 1 year contract with World
Communications Inc. (WCI), for local and long distance telephone service that replaces the
City's current agreement with Focal Communications, subject to City Attorney approval of
contract documents.
SUMMARY: Change our Local and Long Distance Service vendor from Focal Communications
(Focal),to World Communications Inc. (WCI), a reseller of Focal local and long distance services
BUDGET IMPACT: Included in the current operating budget.
BACKGROUND: The City currently obtains local and long distance telephone service through Focal.
WCI is a reseller of Focal telecommunication services and can offer the City lower rates because of the
volume business that they do with Focal. Because of WCI's relationship with Focal, Focal has agreed to
terminate the City's current agreement with no penalty and allow the City to enter into an agreement
with WCI under the same terms but with reduced rates The new rates will save the City approximately
18% (depending on usage) for local and long distance telephone service.
ATTACHMENTS: WCI Contract Documents
WCI t
Service Agreement
THIS AGREEMENT, DATED,May 11, 2005 is entered into between World
Communications Inc , 190 Queen Anne Avenue North, Suite 250, Seattle, WA 98109, for
and on behalf of its regional operating subsidiaries that will provide services hereunder
(each such subsidiary is referred to as "WCI,"or"Vendor"), and the City of Kent, 220
Fourth Ave S.,Kent, WA 98032 (hereinafter referred to as the"City").
1. General.
(a) This Agreement governs WCI's provision of local dial tone and long distance
services to the City or its affiliates under any service order from the City or an
affiliate accepted by WCI (each, a"Service Order")
(b) WCI shall meet the performance specifications, if any, contained in respective
Service Orders. If performance specifications are not contained in a Service
Order, WCI's performance will meet prevalent industry standards for
equivalent services. The prevalent performance standards for the provision of
this service include 99 999% availability of service throughout the life of this
Agreement.
(c) The City will cooperate with WCI to enable WCI to fulfill its obligations
under this Agreement and associated Service Orders (e g , The City will afford
WCI safe and reasonable access to the City's premises to enable WCI to use
the City's Proprietary Network Information("CPNI") to offer additional
services and otherwise assist the City. If WCI installs any equipment at the
City's premises, it shall remain the property of WCI and the City shall be
responsible for any loss or damage to such equipment,unless such loss or
damage is caused by WCI's negligence or willful misconduct
2. Prices and Payments
(a) Prices are set forth in the material attached Service Order. WCI may increase
prices effective after the initial term of a Service Order upon 90 days notice.
If, during the term of this Agreement, WCI offers a lower price for similar
service to a similar size client, with similar volume commitments,with similar
capital expenditures, other than a short term promotional rate, WCI will
immediately reduce the City's price to the same amount. WCI will invoice
monthly for all services and payment shall be due 45 days after receipt by the
City of the invoice.
(b) The City shall pay recurring charges monthly in advance and usage charges
monthly in arrears.
(c) The City will be liable for recurring charges as of the date that service is
accepted by the City, such acceptance not to be unreasonably withheld
(d) If the City requests that WCI make a service call to the City's premises, WCI
may charge rates as detailed in the Service Order for on-site service if WCI
determines that the service call was necessary due to actions by the City or
- 1 -
I another third party,other than any Local Exchange Carrier(LEC) from which
WCI is purchasing transport services to deliver WCI services to the City.
3. Credits.
(a) The City shall receive a credit equal in amount to(i) one days recurring
charges for any circuit where a Service Interruption of such circuit of a
duration of 4 hours or less occurs in any calendar month and(it)one month's
recurring charges where a Service Interruption of such circuit of a duration in
excess of 4 hours occurs in any calendar month.
"Service Interruption"means that the affected circuit is unusable and not in
use by the City as a result of the failure of WCI-controlled equipment or
personnel or the failure of equipment or personnel at the LEC from whom
WCI is purchasing services of the City. A Service Interruption shall not occur
or continue if the interruption occurs because of a failure in equipment that is
not under WCI's control or circumstances outside the control of WCI, other
than as stated in the previous sentence If WCI provides a reasonable notice
that a service disruption will occur to enable WCI to perform maintenance,
such service disruption will not be considered a Service Interruption.
4. Order of Documents. In the case of inconsistencies or disputes among this
Agreement,the City's RFP,and Focal Communications' Response to the RFP,the
following order of precedence shall prevail in descending order of priority.
(a) This Agreement and any written and fully signed authorized amendments
thereto.
(b) Focal Communications' Response to the RFP and any authorized written
amendment or clarifications thereto.
(c) The City's RFP and any written amendments thereto.
To the extent any terms or conditions of this Agreement are invalid under any
applicable statute or rule of law, they are deemed to be omitted and the remaining
provisions of this Agreement shall not in any way be affected or impaired
5. Independent Contractor. The parties intend that an Independent Contractor-Employer
relationship will be created by this Agreement,the City being interested only in the
results obtained under this Agreement. This Agreement does not create a partnership,
joint venture, agency, or similar relationship between parties.
6. Termination for Cause. The City may terminate the Agreement for good cause.
"Good Cause"shall include, without limitation, any one or more of the following
events.
(a) WCI's refusal,or failure,to supply a sufficient number of properly skilled
workers or proper materials for completion of the Agreement work
(b) WCI's failure to complete the work within 90 calendar days of WCI's receipt
of an Order.
(c) WCI's failure to make full and prompt payment of undisputed amounts to sub-
vendors or for material or labor
-2 -
(d) WCI's failure to comply with federal, state or local laws,rules or regulations.
(e) WCI's filing for bankruptcy or becoming adjudged bankrupt
(f) WCI's continued and/or flagrant failure to comply with any terms or
conditions of the contract, subject to the provisions for contract default
established in Section 9
If the City terminates the Agreement for good cause, the City shall not be responsible
for any monies due under this Agreement other that sums due for services rendered
up to the date of termination,however, the City shall have the right to offset for any
out of pocket expenses they have incurred due to WCI's failure to complete the work.
7. Termination without Cause.
(a) This Agreement shall terminate upon the termination of the last to expire
Service Order. Except as provided in paragraph(b),Service Orders may not
be cancelled or terminated during their respective initial terms. Service
Orders shall automatically renew on a month-to-month basis. Subsequent to
the initial term, Service Orders may be cancelled upon 30 days written notice
to the other party.
(b) If the City cancels a Service Order prior to the expiration of its initial term,
without cause, the City shall pay to WCI, as liquidated damages and not as a
penalty, the sum of(i)the nonrecurring charges associated with the
establishment of service as provided in the Service Order, (n)any
disconnection, cancellation, (m)the sum of the remaining recurring charges
for the initial term of the cancelled Service Order, less a present value
discount of 8% per annum, and(iv) the costs incurred by WCI to remove and
return to WCI's facility any WCI equipment at the City's premises.
8. Termination by WCI WCI may terminate or suspend this Agreement and/or any
associated Service Order at any time if the City uses services provided by WCI for
any illegal or fraudulent purpose.
9. Default. This Agreement may be terminated by either party if the other party is in
default of any provisions of the Agreement, so long as the default is not corrected
within thirty (30) calendar days of the receipt of written notice of the default from the
non-defaulting party, the non-defaulting party may extend time for cure, which
extension shall not be unreasonably withheld For the purposes of this Section
"default" shall include any failure to abide by the terms or conditions of this
Agreement including the City's RFP and Focal Communications' response to the
RFP This written notice must particularly describe the alleged default or material
breach.
10 Acts of Insolvency Without waiving any other rights granted to the City in this
Agreement, the City may terminate this Agreement between WCI and the City by
written notice if WCI makes a general assignment for the benefit of creditors, suffers
or permits an appointment of a receiver for its business assets,becomes subject to any
-3 -
proceeding under any bankruptcy or insolvency law whether domestic or foreign,or
has wound up or liquidated its business, voluntarily, or otherwise
1 I Court Orders The City may terminate the Agreement,including all related
agreements (e.g. maintenance agreements, etc ) in whole,or from time to time in part,
whenever WCI is prevented from proceeding with the project work by reason of a
preliminary, special, or permanent restraining order from a court of competent
jurisdiction where the issuance of such restraining order is primarily caused by either
acts or omissions of WCI
12. Changes.The City may issue a written change order for any change in the contract
work during the performance of this Agreement Any difference in the monthly cost
of providing the service due to a change order shall be controlled by the prices
1 contained in the Service Order. In other words, any additional services ordered and
any partial cancellation of services will be charged and credited back according to the
prices contained in the Service Order. The City has the right to cancel up to 100%of
the total service with 60 days prior written notice because of changes in the number
of locations or number of lines needed during the term of this Agreement.
13. Procedures and Protest by WCI. If WCI disagrees with anything required by a change
order, another written order,or an oral order from the City, including any direction,
instruction, interpretation,or determination by the City,WCI shall.
(a) Immediately give a signed written notice of protest to the City.
(b) Supplement the written protest within 14 calendar days with a written
statement that provides the following information:
1) The date of WCI's protest.
2) The nature and circumstances that caused the protest.
3) The provisions in this Agreement that support the protest.
4) The estimated dollar cost, if any,of the protested work and how that
estimate was determined.
(c) An analysis of the progress schedule showing the schedule change or
disruption, if WCI is asserting a schedule change or disruption.
(d) WCI shall keep complete records of extra costs and time incurred as a result
of the protested work The City shall have access to any of WCI's records
needed for evaluating the protest.
(e) The City will evaluate all protests,provided the procedures in this section are
followed. If the City determines that a protest is valid, the City, upon review,
may adjust payment for work or time by an established adjustment. No
adjustment will be made for an invalid protest
(f) In spite of any protest, WCI shall proceed promptly with the work as the City
has ordered.
(g) WCI accepts all requirements of change order by: (1) endorsing it, (2)
writing a separate acceptance,or(3)not protesting in the way this section
provides. A change order that is accepted by WCI, as provided in this section,
shall constitute full payment and final settlement of all claims for contract
time, and for direct, indirect and consequential costs, including costs of delays
related to any work, either covered or affected by the change.
-4-
(h) By not protesting as this section provides, WCI also waives any additional
entitlement and accepts from the City any written or oral order(including
directions, instructions, interpretations, and determination).
(i) Failure to Follow Procedures Constitutes Waiver By failing to follow the
procedures of this section, WCI completely waives any claims for protested
work and accepts from the City any written or oral order(including directions,
instructions, interpretations,and determination).
14. Claims WCI shall give written notice to the City of al claims within 14 calendar days
of the occurrence of the events giving rise to the claims, or within 14 days that WCI
discovers such facts, provided that WCI has used due diligence in the discovery of the
facts. Any claim for damages, additional payment for any reason, or extension of
time,whether under the Agreement or otherwise, shall be conclusively deemed to
have been waived by WCI unless a timely written claim is made in strict accordance
with the applicable provisions of the Agreement; or, if(and only if)no such provision
is applicable,unless that claim is set forth in detail in writing and received by the City
within seven calendar days from the date WCI knew, or should have known, of the
facts giving rise to the claim. Any claim filed before WCI has fully pursued and
exhausted all remedies for changes, including change orders and protests, shall also
be conclusively deemed to have been waived by WCI.
FAILURE TO PROVIDE A COMPLETE, WRITTEN NOTIFICATION OF
CLAIM WITHIN THE TIME ALLOWED SHALL BE AN ABSOLUTE
WAIVER OF ANY CLAIMS ARISING IN ANY WAY FROM THE FACTS OF
EVENTS SUROUNDING THAT CLAIM, OR CAUSED BY THAT DELY.
15 Indemnification. WCI, for itself, its employees,agents, consultants,and contractors,
shall defend, indemnify and hold the City, its officers,officials, employees, and
agents harmless from any and all third party claims, injuries, damages, losses or suits,
including all legal costs and attorney fees, arising out of or in connection with the
performance of the Agreement, but only to the extent of WCI's negligence.
IT IS FURTHER SPECIFICALLY AND EXPRESSLY UNDERSTOOD THAT
THIS INDEMNIFICATION CONSTITUTES FOCAL'S WAIVER OF IMMUNITY
UNDER INDUSTRIAL INSURANCE, TITLE 51 RCW, SOLELY FOR THE
PURPOSES OF THIS INDEMNIFICATION. THE PARTIES ACKNOWLEDGE
THAT THEY HAVE MUTUALLY NEGOTIATED THIS WAIVER.
The City's inspection or acceptance of any of WCI's work when completed shall not
be grounds to avoid any of these covenants of indemnification.
The provisions of this section shall survive the expiration or termination of the
Agreement.
16 Damaees and Limitation on Liability. WCI's indemnification shall apply to all
damages incurred by the City or third parties, whether direct, indirect, actual,
-5 -
consequential,or incidental. However,WCI's liability for damages to the City for
any cause whatsoever,regardless of form or action,whether in contract,or tort,shall
be limited to Two Million Dollars($2,000,000.00)
17. Royalties and Patents.WCI shall pay royalties and license fees and defend all suits
resulting from claims regarding same on all software and materials purchases outright
from WCI and installed according to the specifications of the City.
18. Insurance. WCI shalt procure and maintain for the duration of the Agreement
insurance of the types and in the amounts described below against claims for injuries
to persons or damage to the property which may arise from or in connection with the
performance of the work by WCI, its agents, representatives, employees, sub-
consultants, or subcontractors. WCI shall provide a Certificate of Insurance
evidencing:
1) Automobile Liability Automobile liability insurance(including
commercial automobile liability insurance) with limits no less than
$I,000,000 combined single limit per accident for bodily injury and
property damage; and
2) Commercial General Liability. Commercial General Liability
insurance written on an occurrence basis with limits no less than
$1,000,000 combined single limit per occurrence and in the
aggregate for personal injury, bodily injury, and property damage.
Coverage shall include but not be limited to: blanket contractual;
products/completed operations/broad from property damage,
explosion, and employer's liability.
3) Errors and Omissions Errors and omissions insurance written on a
claims-made basis with limits not less than$1,000,000 per
occurrence
4) Excess Liability. Excess Liability insurance with limits not less than
$1,000,000 per occurrence and aggregate.
5) Deductible. Any payment of deductible or self-insured retention
shall be the sole responsibility of WCI.
6) Endorsement Prior to contract execution, the City,its officers,
officials, employees, agents, and volunteers shall be named as an
additional insured on the insurance policy, as respects work
performed by or on behalf of WCI and a copy of the endorsement
naming the City as additional insured shall be attached to the
Certificate of Insurance. Copies of such documents shalt be
provided to the City prior to contract execution.
7) Coverage WCI's insurance shall contain a clause stating that
coverage shall apply separately to each insured against whom claim
I is made or suit is brought, except with respect to the limits of the
insurers liability.
8) Primary. WCI's insurance shall be primary insurance as respects the
City, and the City shall be given thirty(30) calendar days prior
-6 -
written notice by certified mail, return receipt requested, of any
cancellation, suspension or material change in coverage.
9) Worker's Compensation Insurance In compliance with RCW
51.12 020, which requires subject employers to provide workers'
compensation coverage for all their subject workers and Employer's
Liability or Stop Gap Insurance in the amount of$500,000.
A failure to provide and maintain insurance coverage and written acceptance of
the tendered policy shall be deemed to constitute a material breach of agreement
by WCI. The City reserves the right to then award the Agreement to another
bidder. In order to protect the public interest and notwithstanding any provisions '
herein to the contrary, WCFs failure to comply with any provision in this section
shall subject the Agreement to immediate termination without notice and without
recourse by any person.
19. 01y Business License. Persons/firms doing business with the City must have
a valid City business license if they maintain a permanent location within the
City, OR maintain a permanent location outside the City having an employee who
solicits business from the City. Questions may be directed to City of Kent,
Customer Service Department, Geneva Obencham (253)856-5210.
20.Anti-Kickback.No officer or employee of the City,having the power or duty
to perform an official act of action related to the Agreement, shall have or acquire
any interest in the contract, or have solicited, accepted or granted a present or
future gift, favor, service or other thing of value from or to any person involved in
the contract.
21.Nondiscrimination No individual shall be excluded from participation in,
denied the benefit of, subjected to discrimination under, or denied employment in
the administration of or in connection with the Agreements because of race, color,
creed,marital status, familial status, religion, sex,national origin, Vietnam era of
disabled veteran's status, age, or disability. WCI shall comply with all applicable
federal, state and local nondiscrimination laws,regulations and policies.
22. Equal Employment WCI shall comply with all federal, state, and local laws,
rules, regulations,and ordinances prohibiting discrimination in employment with
regard to age, sex,race, color,creed, national origin, or the presence of any
sensory,mental, or physical disability, unless based upon a bona fide occupational
qualification. Further, WCI will comply with the City's Minority and Women
Contractors Policy(Administrative Policy Number 1.2, attached as Appendix b)
and also provide all written statements required by that policy.
23 911 Calls. The City acknowledges that 911, E911, and similar emergency
service numbers("911 Calls") will not route properly if the City's services are
physically located in a rate center other than the rate center associated with the
calling number(a"Remote Rate Center") To assure the timely delivery of
emergency services if the City is located in a Remote Rate Center, the City will
-7 -
i
i
bar the routing of 911 calls through WCI's network and arrange for the proper
routing of 911 calls.
24.Miscellaneous.
(a)Compliance with Laws. Both, the City and WCI shall comply with all
federal, state, and local laws,rules and regulations throughout every
aspect in the performance of the Agreement
(b)Work Performed at WCI's Risk WCI shall take all precautions
necessary and shall be responsible for the safety of its employees, agents,
and subcontractors in the performance Agreement All work shall be done
at WCI's own risk, and WCI shall be responsible for any loss of or
damage to materials, tools,or other articles used or held for use in
connection with the work.
(c)Nonwaiver of Breach. The failure of the City to insist upon strict
performance of any of the terms and rights contained herein, or to exercise
any option herein conferred in one or more instances, shall not be
construed to be a waiver or relinquishment of those terms and rights, and
they shall remain in full force and effect.
(d)Resolution of Disputes and Governing Law The Agreement shall be
governed by and construed in accordance with the laws of the State of
Washington. If the parties are unable to settle any dispute, difference,or
claim arising from the parties' performance of the Agreement, the
1 exclusive means of resolving that dispute,difference, or claim, shall only
be by filing suit exclusively under the venue,rules, and jurisdiction of the
King County Superior Court located in Kent,King County,Washington,
-� unless the parties agree in writing to an alternative dispute resolution
process, provided, however, nothing in this paragraph shall be construed
to limit the City's right to indemnification under Section 15
(e) Attorney's Fees. Subject to the indemnification and limitation of
WCI's liability provisions set forth in the Agreement, if any action or suit
is brought with respect to a matter or matters covered by the Agreement,
each party shall be responsible for all its own costs and expenses incident
to such proceedings, including all costs and attorney's fees.
(f) Written Notice. All communications regarding the Agreement shall be
sent to the parties at the addresses listed on the Agreement, unless
otherwise notified. Any written notice shall become effective upon
delivery, provided that failure to accept delivery shall be deemed to be
delivery. Copies of all notices to Vendor shall be addressed to World
Communications Inc., 190 Queen Anne Avenue North, Suite 250, Seattle,
WA 98109, Attn: Michael Terpenmg.
(g) Assignment Any assignment of the Agreement by WCI, other than to
a subsidiary or affiliate, without the written consent of the City, such
consent not to be unreasonably withheld, shall be void However, the City
reserves the right to test the service performance of the Assignee for a
period of 90 days and if the Assignee fails to meet the performance
standards contained in the Agreement, the City may immediately cancel
- 8 -
the Agreement with no further obligation to the Assignee except for
payment of services provided up to the date of termination.
(h) Modification No waiver, alteration, or modification of any of the
provisions of the Agreement shall be binding unless in writing and signed
by a duly authorized representative of the City and WCI.
(i) Severabili If any one or more sections, sub-sections, or sentences of
the Agreement are held to be unconstitutional or invalid,that decision
shall not affect the validity of the remaining portion of the Agreement and
the remainder shall remain in full force and effect.
0)Publicity: Use of Information. WCI agrees that is will not sell,publish,
or reveal to any third party any information about the City which it obtains
during the RFP, implementation,or maintenance periods of the
Agreement. This restriction applies to any information obtained whether
it be in the public domain or considered proprietary. In addition,WCI
agrees that it will not at any time use the City in promotional materials or
as a reference without the prior written consent of the City, such consent
not to be unreasonably withheld.
25. Survival Beyond Termination The provisions of sections 4, 14, 15, and 22
shall survive the expiration or termination of this Agreement for any reason
26. Remedies. Any claim for damages incurred by either party resulting from
breach of the agreement by the other party shall survive termination The
remedies provided herein shall not be deemed exclusive but shall be cumulative
and shall be to addition to all other remedies provided by law and equity No
delay or omission in the exercise of any remedy herein provided or otherwise
available to WCI shall impair or affect its right to exercise the same.
27. Force Majeure. Notwithstanding anything to the contrary contained herein, in
no event shall Vendor be liable for failure to meet any deadline, or for any failure
of service, to the extent such failure was caused by acts of God, acts of war, acts
of civil disobedience, natural disasters, or any other cause of such nature beyond
the reasonable care and control of Vendor, including acts or omissions of third
party telecommunications carries In the event of a failure in service due to an act
or omission by a third party telecommunications carrier, WCI Agrees that it will
use its best efforts to manage resolution of such service failure.
28. Definitions.
Final Acceptance Final Acceptance means the date, as reasonably
determined by the City, that the services, vendor
supplied terminating equipment, and documentation
have been delivered,placed in operation, tested by
the City,and provided full functionality for a period
of at least 15 continuous calendar days. ,
Notice Any notice required or permitted to be made or
given pursuant to the Agreement shall be made or
- 9 -
i
given on the date of receipt if sent to the other party
by certified mail,postage prepaid, addressed to the
other party at the address set forth in this
Agreement.
Request for Proposal Request for Proposal or RFP means the City's
published document seeking proposals for
Telecommunications Services,issued August 4,
2000.
Response to RFP Response to RFP means Focal's proposal, dated,
September 19, 2000,in response to City's RFP,
together with Focal's subsequent documentation
submitted on October t 1, 2000.
lindates Update(s)means corrections, enhancements,or
upgrades to WCI's products, services, and
equipment within the scope of the City's voice
services.
Performance Warranty WCI will provide the industry standard of 99.99%
availability of service throughout the life of this
Agreement. If, during the term of the Service
Order, Customer experiences a total service
interruption caused solely by WCI (meaning the
total loss of all telecommunications Services
provided by WCI) for more than two hours or more
than two times within any 60 day period, then
Customer may be allowed to cancel the Service
r� Order and disconnect services with WCI without
incurring early termination costs.
WCI CITY
Signature- Signature
Print Name Print Name
Title Title
Date Date
1�
' 10 -
I
Kent City Council Meeting
Date June 21, 2005
Category Consent Calendar
1. SUBJECT: 2005-2007 MICROSOFT SOFTWARE ASSURANCE RENEWAL—
APPROVE
2. SUMMARY STATEMENT: Approve entering into a three-year agreement to
renew Microsoft Software Assurance on Microsoft Office, Exchange, and Windows
Server products through the Washington State Microsoft Select Agreement.
The City utilizes Microsoft products for office productivity, email and server operating
system applications. In an effort to stabilize their revenue stream, Microsoft has
adopted a licensing program that encourages organizations to adopt new software
releases while spreading the cost of purchasing the updated licenses over time.
Renewing the Software Assurance on Microsoft Office, Exchange and Windows Server
products enables the City to utilize the most up to date versions of these products at a
significantly reduced cost and to spread that cost over the three year term of the
agreement.
3. EXHIBITS: Memo to Operations Committee
4. RECOMMENDED BY: Operations Committee 6/7/05
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? Yes Revenue?
Currently in the Budget? Yes No X
If no:
Unbudgeted Expense: Fund T20095.63600.1901 Amount $89,461 in 2005
Fund 52001740.64830.1800 Amount $89,461 in 2006
Fund 52001740.64830.1800 Amount $89,461 in 2007
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION.
Council Agenda
Item No. 6F
INFORMATION TECHNOLOGY
Stan Waldrop, Director
KEN T Phone 253-856-400
WASHINGTON Fax 253-856-4700
Address 220 Fourth Avenue S
Kent, WA 98032-5895
June 7, 2005
TO: Kent City Council Operations Committee
FROM Stan Waldrop, Information Technology Director
THROUGH Mayor Jim White
SUBJECT: 2005 —2007 Microsoft Software Assurance Renewal
MOTION: I move to approve entering into a three-year agreement to renew the Microsoft
Software Assurance on Microsoft Office, Exchange CALs, and Windows Server CALS
through the Washington State DIS Microsoft Select Agreement.
SUMMARY: The City of Kent utilizes Microsoft products for office productivity, email, and server
operating system applications In an effort to stabilize their revenue stream, Microsoft has adopted a
licensing program that encourages organizations to adopt new software releases while spreading the cost
of purchasing the updated licenses over time Renewing the Software Assurance on Microsoft Office,
Exchange CALs, and Windows Server CALs enables the City to utilize the most up to date versions of
these products at a significantly reduced cost and spread that cost over the 3 year term of the agreement.
BUDGET IMPACT: Initial payment of$89,461 will come from Technology Plan 2002 Subsequent
payments in 2006 and 2007 will be included as part of the Information Technology Operating Budget
BACKGROUND: Over the last several years, Microsoft has attempted to shift the software licensing
model to a subscription system rather than a perpetual use system While the subscription model has
met with resistance, Microsoft has made considerable progress toward a model that generates steady
revenue through their Software Assurance (SA) and Enterprise Agreement (EA) arrangements. The
following table provides a comparison based on the City's current software usage
Software Assurance Enterprise Agreement
Term 3 Years 3 years
Cost $89,461/ ear= $268,383 $143,303/ ear=$429,909
Products ♦ Microsoft Office Professional ♦ Microsoft Office Professional
♦ Microsoft Exchange CAL ♦ Microsoft Exchange CAL
♦ Microsoft Server CAL ♦ Microsoft Server CAL
♦ Microsoft Windows Workstation
Operating System
♦ Microsoft Sharepoint Portal CAL*
♦ Microsoft System Management
Server CAL*
* Currently not used and no plans to implement
Kent City Council Meeting
Date June 21, 2005
Category Consent Calendar
1. SUBJECT: US BANK—ONE CARD AGREEMENT— AUTHORIZE
2. SUMMARY STATEMENT: Authorization for the Mayor to execute the contract
with the U S Bank One Card Program subject to approval of the agreement by the City
Attorney. This agreement will authorize small purchases through purchasing cards
rather than using petty cash and purchase orders. These purchases will be in
accordance with the Procurement Card Policy which sets out the authorized uses of
these cards. We believe that this program will reduce the paper flow involved with
small purchases as well as improving our business relations with suppliers by
improving the timing of payments.
There is no budget impact on the city from the authorization of these procurement
cards. The various departments have budgets for the expenditures that will be made
within their existing budgets.
3. EXHIBITS: One Card Program Application
4. RECOMMENDED BY: Operations Committee
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? N/A Revenue? N/A
Currently in the Budget? Yes No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6G
•
KENT
W w s w i w c T o H
FINANCE
R J Nachlinger,Director
Phone 253-856-5260
Fax 253-856-6255
Address; 220 Fourth Avenue S
Kent,WA 98032-5895
June 7,2005
TO: Kent City Council Operations Committee
FROM: R J. Nachlmger, Finance Director
THROUGH: Mike Martin, Chief Administrative Officer
SUBJECT: Authorize the contract for Procurement Cards
MOTION: I move to recommend that the Operations Committee authorize the Mayor to
execute the contract with the U S Bank One Card Program and forward the item to the
City Council agenda of June 21,2005.
SUMMARY: The Administration plans to begin a program of authorizing small purchases
through purchasing cards rather then using petty cash and purchase orders. These purchases will
be in accordance with the Procurement Card Policy, which sets out the authorized uses of these
cards. We believe that this program will reduce the paper flow involved with small purchases as
well as improving our business relations with suppliers buy improving the timing of payments
BUDGET IMPACT: These is no budget impact on the City from the authorization of these
procurement cards. The various departments have budgets for the expenditures that will be made
within their existing budgets
bank. **
Five Star Service Guaranteed
One Card Application
Corporate Payment Systems
i ,
CMbank. ONE CARD PROGRAM APPLICATION
A.,c5ur5nsxc Gm+nand CS+/
The creditor and isomer of the One Card a U S Bank National As atron ND("US Bank")
SECTION • •.
Your Legal Company Name
DBA or Company Name to be embossed on card(s)(Limit to 19 k=s and spacal Federal Tax LD.
Card Program Contact Title Contact Phone Number
Company Physical Mailing Address City State Zip Code
Company Phone Number Company Fax Number Contact a-Mail
Annual Company Sales Total Annual Budget Less Payroll Estimated Annual T&E Number of Travelers
Type of Organization:
❑Corporation (Public) ❑Corporation(Private) ❑Partnership ❑LLC ❑LLP ❑Government
❑If any of the above AND Non-Profit
Is your Company Rated by Dun and Bradstreet? ❑Yes ❑No If Yes,Duns Number
Do you have an existing relationship with U.S Bank? ❑Yes ❑No If Yes,what type of relationship?
Do you conduct busmesshransactions in a foreign country? ❑Yes ❑No
If Yes,what countries and the nature of business andfor transactions?
1SECTION2 13111ingMethod
Please select your preferred billing option. Each option is described in the attached Terms and Conditions. U.S. Bank reserves the right
to modify this selection based on Company qualification.Standard billing option is Monthly.
❑Central Billing for all Accounts
❑Central Billing for Purchasing Function Accounts and Individual Billing for T&E Function Accounts
' SECTION 3 Optional
❑Yes Check "Yes" here to add your Company's logo to your One Cards.There is a one-Lime setup fee of$300 for this option.
By sending your logo to U S.Bank you represent and warrant that Company has the right to use the logo and you agree to
[I No protect U.S.Bank against any claim of impermissible use
SECTION
Unless already supplied to U.S.Bank,please attach a copy of three(3)years audited financial statements along with completing a
Corporate Certificate of Authority.To expedite your Application,please ensure the Application is completely filled out,signed and all
requested documents are attached before submitting If financial statements are older than six(6)months,please attach interim financials
PATRIOT • •
In order to comply with the requirements of the USA Patriot Act,U S.Bank requires Company to provide its legal entity name,street
address,taxpayer identification number and other information that will allow U S.Bank to identify each Company entity prior to
establishing an Account for such entity.U S.Bank reserves the right to require that Company promptly provide to U.S.Bank sufficient
identification documents upon request in connection with USA Patriot Act compliance.
02004 U.S Banmrp•All tights reserved U S Bank•is registered to U S Bank National Association ND Al otw trademarks are the property of tlleir resneiA a owles.
CPS 3291(08/04)
i
• With,"the fourteen(14)day RaYtpe°tTerm
mayselectbdhngoPao on.
dUg an rtbe EFun
[b)5plitB' ....any. T& ve Central
the Cann`tdentifted on (uncti°n°
irted by �paity")to upon the Purchasing ion Acc unts z ounts
receive
�hcatian is satin rem( of urchasingFpp�
ram APl non the (i)All P ens Term for central�Iriier�e ycle Date.
One Cacd and tY e auctions.Bank")for thfPurpose any Billing,The PaYmS
the APPlrcanon and executing ND(US am Bitting Cycle-ro is 14 went Due to U .Bank
iation One Card profit cation of on a Monthly T
es the App Company stall pay the otalpa T
US,Bank Nananal Ass k�tabl sh a nk aPPrav any en
t e
uescing that U.S. eat U.S ins o4 this Applicaciop One Card fourteen(14)day ccounis directly
to
re4 United States'Lt the Coed n ally shall govern `Ibis wtthu Stank remits StaE Fun.On
A ousts[`Individual
in ate the Terms U S Bank to Comet Agreement 1 d g
Company, b (iCardholders for a{lTBt Accounts establish d`NtA alBi
rovided X Company( hcanon an v ual l{in
ate d terms P S Bank to oval 04 the AP4 couots wissuag"),C)cc U as The payment de pate Cardholders
P°Putt`_jr- a�jEtbecome effect veuup�s„ d�tablishmertt of Ac Ce of the CY , Of each M�'IY
any[ ve Date")• Accounts rs 25 days clusion
A4C Total
ee ce Cards to C i below(the"FdEecu �d is a business e t at the con
issuance of The O Company andreceiver ensuringer its a Statein the for GompanY
as provided m Secn°nCAV PVL04 R 6 for use Y travel and ng Cycle a is `a wies� the POLY statem nu°t
tea
e
Ol`1B des-$ rd fun") the pay receive Du Pa a or more rem dholder
OF Card ) use the Ca µ ith
1,SCOP
a cardmtimes the abilityCO[`TSB Funca acriv;ties of [nay elect to receiv e on
the
Fps c �ttiat co showing all ctan�`a'
orisbilled
to
Cardholders business expe related to the b°siites5 card rep0� 1 er£ails mu. a
ata
nk shall
nttertainment related and services a single Account tut�U 5 Bank
Accounts.In the event
PaymentTerm all Debts
to charge g°O unction ) shall designate ° tit Due within n shall be table Eor
bill company anded in d
3off this Agrement•
anY( Pitreltastctg Sues Company on bthar all purchases
ability ,. F an rises lE of
Como )ut tie United e " andloc be
are authorized to to dst"C Sd��Ccompleted, a prov
Company Y sr solely liable to U S.B
ank ade or iricuCt
inoSradma�that eve Ca
indivi and who are to recetringive U.S.Bank.*a 3.LIABILI�' other
e fide srons On
Company ant numbers in a format speCdied by other than tie United
C Catd Program'
Issued Acc° of advances,charges,f 'K under
hcations,in oti us in a country . Lt.S.Dollars cash l ds and AUOunts( b tithe V tttY
b
authorizcard
ed appitsed for t[arua anversion into 1n applicabEe on all Car is proem use f the OneBk of the
or MCI statement
is shall reflex the c rrency an�ued hereunder L�gTi TIY wANBthe evert yfr f
audul o the
States,the Statement red in a different cu Cards i ed by this 4 in °v t Pro notifies conditions
o�'r blished and a fl g°vein Waiver pYQBrar�cded tit COn'pwuh tie terms and c° any
transactions that
Accounts esta and sh C,ardho{der program,4 and comp as provided by b Tke COMP
tp b
etcchange to
rate- for tun urns pure° etit provided t- to time. fraudulent activity rogtam
`r'tu I.iabiV1 Watvet p t habdity waiver b eons s ate su 1 d
shall be used solely Cardholder Age'e ended from time ors cantins
hmitaitA
Agreement«id is i s as it ink bhshed by US.Bank�ndtor cknowledges a°d agrees
PrV a 'roles,pro am and related ter
an tied,
us afftltates of a Liainhcy WaiverWaiver grain
a
be
when the"moans any account CompanY> wlietber or n tilt Visa the Visa Liability ount of aance to
ardless of exclusiotu and Vis iced to the am wahout
4Account eat m the name of ed,ieg ut lunnarion,
to this Agin-m ebt is charg co rvely, orbo tin+lee. (including,but"aloaniended at any i G`v a provides c°Qerage
lders,to nh�tya�Shall ca llect a�the s° an visa,ve Cardholders,up
car, Can, ice Ms o[
nonal Set'+ canceled,m sCretson 5)
a Card is Issued-rid Visa lr,tert a anY for the One Card company le d
mPapy with more th
Visa USA,ltx Bank by Comp of an AuC°pa�.S B tik. for any CO Cardholder,
Or roll.$ the Sratemen�tte
2 B�Q.1G.Paym accepted m the ton" approved by 100,000 peramount shown on pant
any under this S UENCy,1f the ao be
Program will only electronic payment are [iodic en paid Se U Stalemen
S-Ba d on
non o or Ca for S.pELINQ due has n meat Term any tit is as
Debit)or other elect Efered to Comp cdholdet a PC
upon tie tilting°P d co ComF?°Y 1O older within the sb
will sea wilt-[Clear all transact tearer amount
on subsequentSuspend or
ount shownnalor e Cardh i fl s e nghx to pC
green ease U.S-I pk deiuen )s whch Accotsrit(s)•The am and payable of the T 1 Payment lie- 05 Bank sh E eta period C��edutg O[2}
billing scam vsph reset Rtettd Due,shall be u on Company's tile«Past Due Apt t that is debnquent t to'a,
Delay bClow
ate tilting Pe "Total Pay felt Depeodingl Billmg Cyde> cancel any Aa[IS.Bank shall have the ngfllted inSoon 1 fees
tie Statement a Payette Biweekly or Mnndt Y dung rles neat A is as peC1 sortable
°n Dollars wtthknY offer a n
s the period of ;me from
d' B fl delinq a rilit o recover anya�delinquent amount
in II-S.A U.S.Ban Ie mean ent is g F� g
n Cyr die next statement Billing all pens mc�red bt COI
Iectin
described herein. Belli a e after the n°f a US.Da or
describe generated ups outer expen eS or txll'mgs Bark
as Statement is g t per Due of reset an t_ rditig 1}S.
which a w means 1I Fapper Due must be 1 transactions will o�any ACConn .Al Idbputes tealedcBawntmg to
tiayment Tenn
Tot« Billmg-AI statements on BILLU n,sba COMM"eat.U.S mus s of the
nk
CYde withal Cycle and Cep S Bank remits S Bank and 6-Dl one
SP nU ecard Y�° -ded on Ctte Statem-thin sixtY(allegedly
incorteCt f
teal 60)
Z 1 Tliweekly Billing Y 1d)days U• ent to U.S. the
be billed every fourteen( to any Eor paym ctiotts to a at the address p dion aE a dispute N led or a11eg lotion
n
all Accounts dire U °°aaak will post all aL cer tral accounx of wtitte R the Sta�on v�C�u�t tins govern the reso
roll upto s or will Mll all oce� date sox c[ion first app�`red-
wi this option, B Acatt°".)for this lK tran
Cardholder Ao°ti td tit(Goliectively, mote aces. Olt COMFItO nk by
CompanY[�Centr t t°a Central Ace0o will receive one or billing d sp � CAS y U S M
«not+
transactions directly " Coptpany Cycle tot all U all OSED>LOST OR OL ediatel pwritten c 634{ t'
yCMtral Billing )- ct Billing CY [Went fora I.GL Ull S Company696.followed by o xyq 5M25 or
is defined as ate conclnston of ea c wrio Pay ACCO )V,4 634A>parg ' rdholder anal
Nor Gentral Account transact Billmg Cycle wB telephone at(gam p p.Box
S ask f.niployo,en °f an
Statements at BiGompapy shalt pay day sed to,U- One CacdPtogt rd
of an d
Catdholder ao Central&11mg oo a adder termination o
or
ounts With ga mentTepn with o fib`9CYe"f the event of:(i) rdholder>s amass to t e lost or to
ar rag
Agc
have a seven(7)dt day ue to U-S.nab termination
of Ca ccoungI(u)auy, �ottnation eg .
,,,en transrm acn°ps will be bill val by le same cancelced po,r�ant; A I any core data�cludtn$+b<ct¢OC rrds�,tic
tt,e Total PaY n[
Cc men
sieve � passw+O
pay Monthly BCrTL'ttg Cyr«ill I e ) Subiecr m a rattly Billmg cCazds,Accounts ppersona denah P°vide sulfa eon Such
anoP
for a to>Acc°ant num ray U.S.Sank to a
2'2 d Y every month( tiered
any anon Comp« all time from
tins offered m Com4 {atdholdez mE°tin Sank for
dlmgopt U.S. of ' w ben
the b emits Statements on aBltank as may be requeSred b limited to PCnOd ,t
lode: Ltabtl tY e t>
Cycle ins U.S.Bank c nonfrcations.
for paymenun Billing �dfu a t.0 �hrudd
[a)CentralBfllingto Company cycle Date
AUaunts direct for all Acc°aniays after the,I c flank
actually received and onlywith the
cannot either for those tra under Chaptexception�f dtsclosunsdehoe Compan make
'heCardholderrcombacktothe i"'ctiOt'sthatUSBank Revised company
merchant or collect di f Washington.
required C0 otherwise,of the Card n is lia for all u Y from only o employeesgton,
Y ble t
and! Se Unauthorizedor necessa
written notification of cl or Aaount until ry far mpanya CoinPanY and
gents of
n Car f a C US Bank receives U.S Bank, to pattin only to the
stole d and/or corn more o es nk agrees that it Pate in the One extent
8. Promised A aril of an Account,the lost or to Com will maintain Card Pro a * ,FEES.U S, ccount. conFid Pany and its Accounts m all nonpublic data I m'
Corn
Pany shall k may assess Company(inducting Cardholder re ardingiCom ormation. U.S.Ball under the One Card Pro....ae
One Card Prog Pam any of the following 1 and g PanY exdusivel gmi to
g Fees in connection with the CO1RPan h Y for the use such data
S 1 NSF Fee If a other Y erennder and not to ref pro of services to
US.Bank with on an Account is party,Provided,howeve ease such information 8.2 Del maY charge a non-sufficient returned unpaid Account Cardhotde S that U,S.Ban to any
quen
ry Fee.If an Account is not funds fee(`NSF*j o f$IS. �d/third- ;CP°Corn
nandlo k must disclose
molicatgi Parry service r rransattioa information
Pee Of,(a)IT,of tatetnent,U.S.Bank maid in full by the due date murs�l,law enforcement or r ,merchants merchant
to
Cycle b o Past Due Amount if notycharge a Delinquency of normal basin o opera lot ryanu ti
( )Z 5/, maintain and
Cycle and c of Past Due Amount if notpaid by second Bill, >at its o n°ns may e
Processors
es,during try
suye ()2.5 0 of Past Due Amount Paid by third Billing con emine cry e activity n,disseminate mfor Y collect
8.3 F 9uent$illin unt ifnot of contain ttivity of Compan oration and data
.reign Cu g Cycle. paid for each arty direct ❑dir ➢Provided that such data
foreign cur� my Conversion Fee U S. The Parries agree to to or i ect idencif, ta
amount in ncy cgnversion fee of 7,5%of k w ac tge a PfOPtietary information and reasonable steps to
of Company
exchan the foreign torten any Person or and not to oleo ° af'guard such
ge rare, cY multiplied b t applicable Pro Party not essential to release such information to
8.4 Annual Card Y the applicable gram as herein d Patric;
an Fee.n 0 Annual 11.TE described. nation in the
Y Coln an Card Fee will he a TEInNATlO One Card
durin P Y during the first year of the assessed for shalt re
g t at first One Card Program the Eff main in effect for t6eAiapa�reSPENSION This more than two hand d(200y rime thereahe;Com an ective Date and rm of three 3 Agreement
million U$Dollars )Cards and P Y is issued accordance with this S shall co therea ( )Years from
s ($1 O 01o' Fends less than one- Agreement Seaton 11. her until term;
f$ One(aril Program )with all and A at an )richer P Hated in
year,U Cards ccounts in to the other Y time upon ninety(9p) may terminated is
Of$4Adv.Card such f S Bank will assess an a have the Parry'Notwithstandin days nor written
8 S Cash Advance Fee !lowing yeae nnual fee tight to to g the fore n tide
in the a U.S.US Bank will as notice of such term. nate this Agreement i gong,U S.Bank s
mount of three percent sons a Cash Advance Fee of the folio urination to mmediately,by
shall
transaction,with a min' (3%)of each cash adv Ong events:(i)dusoCounPany upon any one 1 written
cash adv n. Cash Advance Fee of ante (ii)insolvency of Compm:y or the fiGn or liquidation of l)nm more
8.6 Logo Ern ❑ss transaction, $2per insolven
of Cam wing•One-time fee of$3 benefit c}Proceeding,the a rig ofa bankru My- Pan};
P y's lord issuance
tn�AuP sta g drto credit,( )arsr or Corti PPYintment Of into areceive,
eive otristee for
rnaY occur with g on the hot- mpfn its ere
shall be res Card (as rs Pan
ssuance and implemenrauo week delay condition of corn pa materr� and adverse 1 ,a!
responsible for verification of to Y 1
arrangement with
US.Bank harmless fro go des; COtnpan obhgarion of Aareernentn chan�a the£inane 8.71p99 Report tt gn and shall hold for this g
U eait" to Peron mazer
g 1099 re any usage ll such logo ou any Card, return aitnde t a�cy shall reoturn�tCard of this Ag reemrnt
anreason.
the U,S.Bank AecessOnlinee sseervr'ce[f U.S1eB�k charge through
e a data file outside US Bank.Co I f Proprietary infor cut in half,an
6e assessed AccessOnlin 'Ies a arisingY shall remain liable rmadon of US. d
a fee of$ISO by vitnre of Uthe use of a Card all Debt- $a k to
Soper file will termination date.U or Account REBATE Subject to the of this A r Port cancellation count prior o the
or
and this Agreement, terms and conditionsg cement,Corn .fan Accou as a Percenta U S.Bank will ,of this Section 9 lydhn occtirrin PanY and/or ditoldcr tit or termination
rebate(•Retyate, goal Spend of om�an F�ancyal incentive Tran aeons).jtlo g transaction,pawn shall cancel the
Y the twithsta Account
{.T .
"Annual to- de mpany based on the Annual��of U S company is solely liable to U S,g any term to the Contrary, ing
on a![Acco fined as transactions in y�m Bank for all
bat ants less cash ad tutted b any r Bank may suspend any Card TraJ,n
Chak' arges qualifying for tares,fees,fraudulent char Y the sus n R��'obligations or?rid/or Account at anransacn°ns.
g offs for each ge transaction' gess charge- the Pension or termination of liability,which arise Y time for
first such period twelve{12j month utrerchaage rates and sus termination o this A shall Prior to
followin Period beg Pension or
Agree Prior mean an g the Effectiv Date, liming with the 12.L1MrrA7lON OF f this Agreement survive
Go m Y amount duo and ow e COilfp �
(ISO)Pany or Cardholder that re g ro US'Bank o harge-off`shall ANY,PARTI II"m !1 l NO E
days after the mains on Its affiliates 6Y U S,B 7(S),U,S B EVENT f f SHALL
a Rebate date that it was first Paid for onehundred F oONSE AIVK BE 7 tABL$TO AT fK,OR q�tyDL
within the P Pany Will need to have billed [n order ro obtain DAtgA � AL>SPEC[gL ) OTlR Pt1RTyF0 TATE
our
d the
l p
mentr
maintain an Av age as
actpion Provided inaiSeaiTon 2 aVermentbue 13. W A111 NATURE NDIRECT OR pUNfIlV&ANY
Transatti°n 5�,.is cakalated b Size of$ISO ,as well as that this A ANTIES Each Party
re r Card Program b Y dividin Of greater("Average executi Agreement is valid, P events and warrants
y the total Hum g Annual Spend in the One on of this A d binding and a LO the other
a ma Rebate
the re bey of transactions).Provided are within such pa gCeetnent and the pert t "cable and the
earn a Rebate ! 9mregents of this Section 9,Com that mance of its
ess any Charge action and does not
powers,has been au
g rolls i Pany will constitute abrea thorized b obligations
•S basis , n the amount of duty art m law or equity. Pa Y of an Y all necesagree, sary
$3 000 t'o'nrs(O.OS°ol aFRebate For Annual$ to Us.•$
4� Q00 $M-07S j Pend of comp ete and accurate for anotr provided tp n�and warrancutts
7.S basis Points 0 0
.ComParty
>�0 $4,999,999)of Rebate for Annual S applicable taws rules ,it has and continues tole S Bank rs true
Re Pan"may receive a Rebate Adde Pend of Part c?imental aurhocities�locations and re ies" Comply with all bate P gram for Addendum with Fation in the red to the use
I0.CONFIDE Annual Spend of$S 000 a Customized financial ca aci One Card Pro ram of the t:ardand/o
to be a tin. t US.Bank considers the '�0 and greatee Agreement at the Elf rform ad of its Cobh d ttposs the r Noe service invo1 One Card earve Date an gations under this
Card program of a
S Eank' tit during 7' each transa or use
manuals,d��Pd"Y agrees that Pone rY tnEa brew °r Accou d u on
information of of this Section 13 s6�j�onsm�tti�f the won
(whether or not.motion,systems roc Card program repot Agreement and u Agreemernrot h ny
m x'rtling)are c P aces and related rs' tirmrediatel Pon written notice the a material b c of this
Confidential and will be ciriculated erials PROVIp Y terminate thD FIE is A non breachin
A�NW
RES REIN.,U.S.t Ment EXCEPT A g Party IWLTED SEXPRESSLY
,IN LAW ORAL Ill(CT,VARRADN72LS Y
NG,'
WITHOUT LIMITATION,THE IMPLIED WARRANTIES provided on any access,use or subscriber agreement provided when '
OF FITNESS FOR A PARTICULAR PURPOSE AND OF accessing any software service or ancillary service or as otherwise
MERCHANTABILITY,EITHER TO COMPANY OR TO provided on any addendum or schedule to this Agreement.
ANY OTHER PERSON IN CONNECTION WITH 19.REGISTERED MARKS AND TRADEMARKS.Neither party has
THIS AGREEMENT. any right,title or interest,proprietary or otherwise,in or to the
14 FINANCIAL INFORMATION.Company shall deliver to name or any logo,copyright,service mark or trademark owned
U.S.Bank as soon as available,and in any event not later than or licensed by the other parry.
thirty(30)days after the completion of the audit,Company's 20.NOTICES.Except with respect to notices relating to the
audited financial statements prepared by independent certified status of individual Cards wluch may be established if,writing
public accountants selected by Company Company authorizes between U.S Bank and Company,all notices,requests and other
U.S.Bank to obtain,from time to tune,from any other source, communication provided for hereunder must he directed to the other
including an affiliate of U.S.Bank,any credit or financial party at the respective addresses indicated herein and,unless otherwise
information on Company held by such source Company further specified herein,must be in writing,postage prepaid,hand delivered ,
agrees to provide to U S-Bank from tune to dine,other such or by any electronic means approved by U S Bank Either party may
information regarding the business,operations and financial change its notification address by written notice to the other;
condition of Company as U.S Bank may reasonably request.
1S.CREDIT LIMITS AND CREDIT LINE Based on the available 21.GOVERNING LAW.The validity,rote and
and performance '
financial information,U.S.Bank shall establish a Credit Limit for of this Agreement will rt Dakota,
it and coring effstruedect
under the
each Account and a Credit Line for all Accounts established for laws of the State in North Dakota,without giving effect a the
conflict of law principles[hereof,and applicable federal laws
Company pursuant to this Agreement.U.S.Bank,at its sole
discretion,shall have the right to revise Credit Limits on individual 22.EMPLOYMENT OF AGENTS.U.S Bank may,in its sole
discretion employ U.S Bancorp Card Services inc.as its agent to
Accounts and/or the aggregate Credit Line for all Accounts. discretion,
US Bank shall provide contemporaneous nonce to Company of perform part or all of its obligations under this Agreement at any
any decrease in a Credit Limit that results in a revised Credit Limit tune without the consent of Company;provided,however,that
that is lower than the current amount due on the Account Prior to such action shall not affect its obligations to Company hereunder
the effective date of any decrease in the Credit Limit and/or Credit 23.PROGRAM ADMINISTRATOR.Company shall designate a
Line,Company shall have ten(10)days to make a payment to representative to serve as the primary point of contact between the
U S.Bank on one or more Accounts that is sufficient to reduce the parties and such representative shall be trained and have thorough
outstanding aggregate amount due to an amount that is less than knowledge of One Card Program.Company agrees that the
the revised Credo Lima and/or Credit Line U.S Bank,at its sole Program Administrator is authorized to provide U S Bank with the
discretion,has the right to revise Credit Limits,the Credit Line information necessary to establish Accounts,Account records and
and/or limit spending activity on any Accounts "Credit Lima" Cards and other information regarding the One Card Program.
means the manmum amount of Debt that can remain outstanding 24.ASSIGNMENT.This Agreement shall be binding upon and inure
and unpaid on an Account "Credit Line"means,with respect to to the benefit of the parties and their respective successors and
all Accounts,the maximum aggregated amount of Debt that can assigns;provided,however,that this Agreement may not be assigned
remain outstanding and unpaid on all Accounts of Company. by Company without the prior written approval of U.S.Bank.
16.CHANGE IN TERMS OF THE AGREEMENT.U.S Bank 25.CUSTOMER SERVICE Company may contact U.S.Bank customer
may change the terms of this Agreement at any time by giving service center 24 hours a day,7 days per week at(800)344-5696
Company notice.If permitted by applicable law,such changes will for One Card Program customer service
apply to existing Account balances as well as future transactions.
If Company does not accept the changes,Company must notify
US.Bank in writing within twenty-five(25)days of the notification
date of the change in terms,pay all Debt in full for all Accounts to
U S Bank,according to the terms of the existing Agreement and
return the Cards,cut in half,to U S.Bank.Use of the Card or
Account by Company or Cardholder after the notification date of
the change in terms constitutes acceptance of the change,even if the
rwenry-five(25)days have not passed.
17.MERCHANT CATEGORY CODES.U.S.Bank will implement
standard charge authorization procedures designed to prevent or
restrict usage of Cards or Accounts for purchases based on
merchant category code("MCC").Company may modify the
standard MCC restrictions at any time upon written notice to
U.S.Bank.MCC restrictions do not apply to cash advance '
transactions.U.S.Bank has no liability for transactions declined
or approv ed contrary to the intent of Company.MCC restriction
capabilities are limited to the extent accurate MCC data regarding
the transaction authorization request is received and the accurate
designation of such MCC by Visa and merchant.MCC designation
is determined by Visa and the merchant.
18.ANCILLARY SERVICES.Upon request by Company and approval
by U S Bank,Company may utilize ancillary and/or software services
provided in connecnon with this One Card Program U.S Bank
and/or a third-party service provider may make such services
available to Company Company agrees to the terms of such services,
including,but not limited to granting authority to disclose One Card '
Program data of Company and/or Cardholder to such third-party
service provider in connection with such third-parry services,as
C2004 U S Bancorp`AN rights reserved U S Bank'is registered to U S Bank National Association ND AN other tradernarks are lime property of their respective owners '
CPS 3291 (08/04)
AUTHORIZATION
By completing this One Card Program Application,Company By signing below,each individual signing this Application in his
acknowledges and agrees that: (i)all information provided in or her capacity as an authorized signing n icer of Company and
this Application is true,complete and accurate and Company not in his or her personal capacity,certifies and warrants that
has authority to provide such information and complete such (a)all action required by Company's organizational documents to
' Application;(ii)it requests that U S Bank establish a One Card authorize the signer(s)to act on behalf of Companv in all actions
Program and Accounts in the name of Company and issue Cards taken under this Application and the Terms and Conditions,
to its designated employees and representative in accordance with including but not limited to,the authority to incur Debt on
the Terms and Conditions of this Application; (tit)U S Bank will behalf of Company,has been taken;(b)each signer is empowered
review this Application and may,at its sole discretion and at the in the name of and on behalf of Company to enter into all
terms unposed by it,grant such request,but that U S.Bank is transactions contemplated in this Application,and(c)the
under no obligation to approve such Application;(iv)Company signatures appearing on all supporting documents of authority
' shall be bound by the Terms and Conditions contained herein; are authentic. Company has read, understood and agrees to all
and(v)U_S Bank is authorized to investigate,obtain,and Terms and Conditions in this Application and US Bank is
exchange reports and information regarding this Application, entitled to act in reliance upon the authorizations and
any resulting accounts and the authorized officer executing this certifications set forth in this Application
' Application,with credit reporting agencies,and others with
legitimate business need for such reports or information.If this
Application is approved by U.S_Bank,ar its own discretion,
Company acknowledges and agrees that the Terms and Conditions V In witness whereof,Company has,by its duly authorized signer
' attached to this Application,with the Application information, executed this Application and agrees to the Terms and Conditions.
shall constitute the Terms and Conditions of the Agreement As signer I have read this Application and have authority to bind
between Company and US.Bank,which shall become effective Company and agree with the Terms and Conditions,individually
on the Effective Date as referenced in the Terns and Conditions. and on behalf of Company.
' Company certifies to U.S.Bank that the person executing this
Application is authorized by Company in accordance with its
organization rules and applicable law to bind the Company to the Signature Date
' Terms and Conditions of this Application,including the authority
to incur debt in the name of the Company.Company certifies that
the signer's authorization to bind the Company and incur debt in Print Name
the name of the Company is evidenced by the following-
0 The signer is an officer as indicated on Company's Print Title
SEC 10-K Form (no additional information needed).
❑Company is an existing U.S.Bank customer and the
' authority of the signer is already on file at U.S.Bank
(no additional information needed).
❑The signer has been granted authority by previous board
resolution (attach copy of board resolution signed by
' Corporate Secretary).
❑Company is a government entity and the signer is a
duly authorized contracting officer(attach copy of
' contracting warrant).
❑Company has completed the U.S.Bank Corporate Certificate
of Authority(attach copy of completed Certificate).
FOR U.S. BANK USE ONLY
' Please attach a copy of Personal Guarantee if required for lending purposes.
DATE of OFAC Searched by
OFFICER CODE TM IPM AM
' Billing Type Approved:
❑Biweekly Billing Cycle
❑Monthly Billing Cycle:Central Billing
❑Monthly Billing Cycle:Central Billing and Individual Billing
Kent City Council Meeting
Date June 21, 2005
Category Consent Calendar
1. SUBJECT: THE STANDARD INSURANCE COMPANY LONG TERM
DISABILITY APPLICATION FOR. 2005 — AUTHORIZE
2. SUMMARY STATEMENT: Authorize the Mayor to sign the The Standard
Insurance Company 2005 Application for long-term disability coverage for the
AFSCME, Teamster and Non-Represented employees. Standard quoted 73% of base
compensation for our long-term disability coverage for an annual cost of$199,656.
The long-term disability contract begins on July 1, 2005
i
1
3. EXHIBITS: The Standard Insurance Company 2005 Application
4. RECOMMENDED BY: Operations Committee
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? X Revenue?
Currently in the Budget? Yes X No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6H
STANDARD INSURANCE COMPANY Application for Group Insurance
Employee Benefits-Underwriting
900 SW Fifth Ave.Portland,OR 97204-1282
Please We or print REQUESTED EFFECTIVE DATE 07101105
APPLICANT
' Full Legal Name of Group(Exactly as it is to be shown in the policy)
City of Kent
Street Address 220 4th Ave S
City Kent State WA Zip Code 98032
Phone Number ( 253 )856-5290 FAX Number ( 253 ) ttSS-6270
Group Contact Becky Fowler Contact's Title Benefits Manager
Contact's Phone No.if different ( ) Contact's FAX No if different (J)
Nature of Business municipal employer
INSURANCE COVERAGE REQUESTED
' ❑ Life Only ❑ Supplemental Life ❑ DentallErnployess [d LTD ❑
❑ Life&AD&D ❑ AdditionaUOpbonal Life DentaflEmployees and Dep(s) ❑ STD ❑
❑ Dependent Life ❑ Stand Alone AD&D ❑ DentallOrthodontia ❑ LTD with Transitional Duty Agreement
OTHER INSURANCE
A. Does this insurance supplement other Insurance? ❑Yes m No
If yes,specify for each line of coverage and Insurance Carrier,
B. Does this insurance replace existing Insurance? m Yes ❑No
If yes,specify for each existing Ime of coverage:LTD-Assurant Employee Benefits
- Please submit a copy of each in force policy,certificate or plan document.
' Effective date of Prior Plan:07/01103 Termination date of Prior Plan: 06130105
ACTIVE WORK REQUIREMENT:A person must meet an Active Work requirement to become insured Members who have not met an
Active Work requirement are not insured until returning to work for one fA day and meeting all other contractual requirements.
Initial:
Note.Some members who do not meet an Active Work requirement may be eligible for Waiver of Premium with a priorcarner.The Active
Work requirement does not apply to Dental coverage.
APPLICANTAGREES7HAT.I hereby apply for Group Insurance as provided in the attached proposal.
The above information is"and correct to the best of the Applicant's I aMLdge and belief It forms the basis for this request for group insurance.
If the requested Insurance is acceptable to Standard Insurance Company under its current rules and practices and is legally permissible,
a Group Policy will be issued in the language customarily used by Standard.It will be effective on the date determined by Standard.No
producer has the authority to guarantee the acceptability of the requested insurance.
' Standard may issue separate Group Policies if more than one coverage is requested in this Application.The insurance,if approved,will
be subject to Standard Insurance Company's usual underwriting requirements, including the exclusions and limitations in the Group Policy
and,if applicable,Evidence 0(Insurability.The effective date of insurance for which a person is required to submit satisfactory Evidence Of
Insurability will be determined in accordance with the terms of the Group Policy,subject to the Active Work requirement No premiums will
be collected or paid by the Applicant for such insurance until notification of approval
No material describing coverage under the Group Policy will be distributed by the Applicant to any person to be insured without the prior
written consent of Standard Insurance Company
Premium rate quotations were based on data submitted to Standard Final premium rates will be determined by the actual composition of
' the group.
The consideration for any Group Policy which may be issued is this Application and the payment of premiums.Payment of premium after
receipt of the Group Policy is acceptance of the terms of the Group Policy
This Application,including the attached proposal,is made a part of the Group Policy.
Applicant authorizes the producer,broker of record,or consultant to receive udormatbri regarding the applicant's claims status and experience
that the applicant has a right to receive and which is reasonably necessary to assist the applicant in conducting a review of the information.
Signature and Title of Applicant's Authorized Representative
Signature of Witness Signature of Licensed Producer(where required by law)
Date License B
(Must be signed prior to the requested effective date.) initial Deposit$ 16,6 313. 0 0
sI oe-7364 1 of 2 (12103)
STANDARD INSURANCE COMPANY Receipt for initial Deposit
Employee Benefits-Underwriting
900 SW Fifth Ave.Portland,OR 97204-1282
Received from an initial deposit of
$ 'in connection with the Application for Group Insurance bearing the same date as this conditional receipt. '
Date
This receipt is subject to the terms and conditions below. '
Received By
Name Idle
'All premium checks must be made payable to Standard Insurance Company.
Do not make check payable to the producer or leave payee blank.
Terms of Receipt(Please read carefully.)
If the requested insurance is acceptable to Standard Insurance Companyunder ifs current rides and practices and is legally permissibie,
a Group Policy will be Issued In the language customarily used by Standard. It will be effective on the date determined by- ,
Standard.No producer has the authority to guarantee the acceptability of the requested insurance.
Standard may issue separate Group Policies if more than one coverage is requested in this Application The insurance, if approved,
wiN be subject to Standard Insurance Companys usual underwriting requirements, including the exclusions and limitations in the Group
Policy and, ff applicable, Evidence Of Insurability. The effective date of insurance for which a person is required to submit satisfactory '
Evidence Of insurability will be determined in accordance with the terms of the Group Policy,subject to the Active Work requirement No
premiums will be collected or paid by the Applicant for such insurance until notification of approval.
No material describing coverage under the Group Policy will be distributed by the Applicant to any person to be insured without the
prior written consent of Standard insurance Company ,
Premium rate quotations were based on data submitted to Standard Final premium rates will be determined by the actual composition
of the group
The consideration for any Group Policy which may be Issued is this Application and the payment of premiums.Payment of premium '
after receipt of the Group Policy is acceptance of the forms of the Group Policy.
This Applica bon,including the attached proposal,is made a part of The Group Policy
si o9-73ea 2 of 2 Itzias)
General Worksheet — One
�e�...�•v1
lido 4x�)iti a�n�i �. `cg `t
„ 1t'7EP�Fipr}n&:sj{gq, do,Sl60 only _SLgCode i 6 s
Name of Group-City of Kent
Exactly as it is to be shown In the pokey
State of Issue:WA Lp Code 98032 Client ID/Prospect A:
Group Rep: Service Rep Office
FORM OF ORGANIZATION rierlt the appropnmr bac
❑ Association ❑ Limited Liability Company ❑ other,Describe:municipal employer
❑ Corporation ❑ Partnership
❑ Sub-Chapter-S Corporation ❑ School Districts
® Government Unit/Publlc Unit ❑ Sole Proprietorship
(Federal,state,county,city,some hospMals,eta) ❑ Trust(Please include oust document)
❑ Labor Union
(Please include the collective bargaining agreement)
AFFrr rA'rES P&anprwide foil Lego!naam fex"j a"are to be Chown rxi the Mixqj!Dijon,nature of bxxnaas
List any affiliates to be excluded.
DEFINITION OFAMEMBER
A Describe the persons to be insured Include separate descriptions If they vary by coverage.If different by line of coverage,please specify on
corresponding worksheets in Comments&Special Requests section
' ❑ All active employees and partners(d a partnership)regularly working 30(or )or more hours per week
❑ All active employees and partners(if a partnership)regularly working 30 or more hours per week that participate in the employer sponsored
medical plan
❑ Other.(Specify-ours Per Week'requirement):
All employees who are regular part-time or regular full-time and work at least 21 hrs/wk and employees in a job
NOTE
Enrolment cards of a prior cancer and/or beneficiary designations on forms other than The Standard's will not be accepted unless the Applicant
submits a written request,together with a copy of all forms to be approved,and we approve the Applicant's request In wining
I
CONTRI BUrIONS rbmpwe the appro/nxn(e bnr fin each caterwge hang nrltvsted.
Life Dental Dental Stand TDDI
Lle With Dep Suppl Addt STD LTD for for Otho Alone D13U
AD&D Life Life Life Ee's Dep ADSD UCD
A Employer Pays Total Premium #1
Q Percentage of Premium
Employee Pays % % % % % % 0% % % % % %
1.Number Eligible
2.Number Enrolled
3.Participation%Required
C Premiums included in grass earnings
Edition 8 Attachments
sl T3n tot 2
{arot)
General Worksheet — One ,
POLICYHOLDER CORRESPONDENCE AND CONTACTS
Executive Correspondent(for formal notices), AdministrativefClalms Contact:
❑ Mr. ❑Mrs. 0 Ms ❑ Same as: ❑Executive ❑Billing
Name: Becky Fowler 0 Other.Fill out below:
Tide: Benefits Manager Name Ellen Mak
phone ( 253 )856.5290 Tide: HR Analyst
Fa)c ( 253 ) 856.6270 Phone f 253 )856-5297
Address: ®Same as Policyholder's. ❑Other.FIN out below: Fax: ( 253 )856-6270
Address
Billing: ®Same as Executive Correspondent. E-Services Administrator: ,
❑Other.Fill out below Same as: 0 Executive ❑Billing ❑AdminlCialma
Name: ❑ other.FIII out below:
Tile' Name*
Phony ( ) Title.
Fate ( ) Phone. ( )
Address, Email Address
Address:
Document Delivery Options Shipping Address for Printed Certificates (rhis edamutiwr Is neededQW n pnnted
❑ E-Contract Documents via AdminEase(M carviimies are requested Do nor use a Pct Bar,Cerulaaws are shipped inla U Ps.) '
(indudes Policies, Amendments, Certificates (0 Administrative Contact
Notices, etc) ❑ Broker(include street address below)
❑ Certificates via E-Mail to Group Office(E)
❑ Certificates via Diskette(D)to Group Office ❑ Group Office ❑ Other '
SUMMARYPLAN DESC1 IMON
A ERISA requires Stanmary Plan Descriptions(SPDs)for employee benefit plans other than church or government employers.The Certificate can '
serve as an SPD If certain plan information is added to it You may meet ERISA requirements by having a combined Certificate and SPD,
If the employer has an SPD,attach it for review It the employer does not have an SPD,provide plan information to add to the Certiflcata
Please check one of the following.
❑ ERISA information below ❑ SPD attached 6n Not subject to ERISA—Church or Gov't Employer
Complete B-H for Review Complete G.only
The following information is required by ERISA and MUST be included in combined SPOs/Certllicates.
B. 9 digit Employer Tax Identification Number assigned by IRS 91 - 6001254
C. Plan number assigned to each line of coverage by Policyholder(eg 501,502).
Life STD LTD Dental (Also Specify Coverage)
n Plan Year Ends on.Month Day ,
E Plan Administrator/Plan Fiduciary(can be Policyholder)
® Same as Policyholder name,address and telephone number. ❑ Other FIII out below-
Name:
Street Address: Phone No,
City. State: Zip,
F. Registered Agent for the Service of Legal Process•
0 Same as Plan Admfnfstralor name,address and telephone number ❑ Other Fill out below
Name
Street Address Phone No.
City State Zip:
G Are there any relevant Collective Bargaining Agreements?
❑ No ❑ Yes(if yes,please attach a copy of the pertinent sections.)
ft Plan Truslee(s)• City of Kent ,
$17372 2 of 2 (6101)
t
General Worksheet-Two
Name of Group City of Kent 4ollcy 6 2
EUGE91 ITY WATPING PERIOD
' A There are two options for persons employed on the proposed effective date Check one.
❑ All are eligible immediately,regardless of length of service.
® Only those who have satisfied the walling period selected below are eligible Others must serve the balance of the wailing period.(Please
provide hire dates for all employees on enrollment cards or census)
B. A new employee must be actively employed for the specific period checked below before becoming eligible for coverage.
❑ First day o1 the month coinciding with or next following days as a Member.
❑ First day after days as a Member.
❑ First day o1 the month coinciding with or nexl following becorning a Member.
® No waiting period.
❑ Tied to medical plan Medical plan waiting period days.
❑ Other:
DEFINITION OFF.ARNINGS
Earnings definition will automatically include base salary,commissions averaged over 12 months,shift differential pay,Internal Reveme Code 401(k),
403(b),or 457 deferred compensation,execultve nonqualified deferred compensation and contributions to fringe benefits under an Internal Revenue
Code Section 125 plan.408P earnings will be included in LTD and STD only and partnership earnings will always be included except for pudic groups
A. ® Normal wording as stated above.
❑ All of the above Items except commissions.
❑ Base salary only(does not inchide commissions ershill ddyerential).
❑ S-CorporationAimited Uabikty wording.
B If any other compensation Is to be included or excluded,describe:
❑ Include bornises averaged over 36 months.Bonuses included on census? ❑Yes ❑No
❑ Other Describe:
G if morn than one coverage Is requested,it will be assumed that the same definition of earnings will apply to all coverages,unless marked below
❑ Definition of earnings will very by coverage.Describe.
SECTION 125 PLANS
r
coverages are offered through a Section 125 Plan? WA
coverages are"core"or"required"benefits?
provide'cafeteda'enrollment materialstmenu to ensure proper administration of benefits.
COIA340NTS&SPECIAL RE MTS:
Eligible Classes
All employees who are regular part-time or regular full-time and work at least 21 hours per week and employees in a fob-share position working at
least 20 hours per week,excluding Uniformed Officers,Firefighters,and Assistant Fire Chiefs Note*Uniformed Officers are defined as Officers and
Sergeants or"Police Otfcere and Captains and Lieutenants or'Police AdW
See attached list of AFSCME union members paying premiums on a post lax basis
SI-7373 f of 2 (stab)
General Worksheet- Two
Estimated Premium: Life ADBD STD LTD Dental ,
In force policies with The Standard: A 339619 , A 100394 A A ,
Match in force policy ❑
INSTALLATION cluck
® Home Office with Policyholder ❑Group Office
Pool# Grace Period, Notice of Rate Change Premium Mode. ®Monthly ❑Other '
BROIIR/COMMLSSION INFORMATION
Commission Scale 1. Broker Douglas Evans
❑ Level-graded(non-Dental) R L Evans Comparry,Inc.
❑ Dental Level-graded Brokerage
Address, 600 Stewart St.Suite 1210 Seattle,WA 981 D1
❑ Dental HMO Seattle WA 98101
❑ None Cdy State, lap Code:
Please complete the question below: Telephone.1 206 1 448-7878 Tax I DJSocial Security 91-0849754
Is the broker receiving a fee for service? ACI 102% %Split Commissions paid to. ❑indnndual ®Firm
❑ Yes ®No
® Resident Agent ❑ lvon-resident Agent '
❑ Other: Already appointed with The Standard: Yes ❑ No
2 Broker:
Brokerage: ,
Address:
city. State Zip Code,
Telephone:( ► Tax I D/Social Security:
ACI %Split Commissions paid to. ❑ Individual ❑Firm
❑ Resident Agent ❑ Non-resident Agent
Already appointed with The Standard ❑Yes ❑ No
If&Third Party Administrator Is involved,please provide the Information below and Include a copy of the license.
Name TPA Services being provided
Address: ❑ Billing ❑ Collection ❑ Solicitation '
City ❑ Other Describe:
State, Zip Code. Note:TPA licensing may be required it involved in premium processing
Telephone. ( License ik ,
Drafting Notes- ❑ Hidden Schedule ❑ Separate Carts for
Changes: Elf.Date of Changes: Changed by: ,
517373 2 0(2 (allol
Contract 2000 LTD Worksheet
SHADED AREAS—Home Office use only Policy No.:
S.D.B.: Sold Rafe: No,of Lives:
Name of Group: City of Kent Effective Date: Renewal Date:
LONG TERM DISABILITY COVERAGE DESCRIPTION For Contract 2000 On
A. LTD Schedule of Insurance(d buy uR use f 1 for core and N2 foraddhionao
' Benefit Waiting
Description of Class LTD Benelft Schedule Period Maximum Benefit Period
1. 66 %of first$ 10,500.00 ❑ 30 days 3 to age 65
L of monthly Predisabilily Earnings; ❑ 60 days Standard Grading
$ 7,000.00 Maximum LTD Benefit 0 9D days ❑ Optional Grading 5R0
%of all sources,d applicable: ❑ 100 days ❑ 2 yr. ❑5 yr ❑SSNRA
❑ Other ❑ Other.
2. %of first$ ❑ 3D days ❑ to age 65
of monthly Predisability Earrings; ❑ 60 days ❑ Standard Grading
$ Maximum LTD Benefit ❑ 90 days ❑ Optional Grading 500
%of all sources,if applicable' ❑ 180 days ❑ 2 yr ❑5 yr• ❑SSNRA
❑ Other ❑ Other:
B. Social Security Offset
0 Full Offset(Primary and Dependent)
❑ Primary Offset Only
❑ Primary with %Dependents cap (Partial Dependents Offset)
C. LTD Underwriting Information
Are Members eligible for Income from any of the following sources It they become Disabled?
j1J Social Security or similar plans
Public Employees Rebremanl System Beneffls
❑ State Teachers'Retirement System Benefits
❑ State Disability Income Benefits(UCD,SDI,TDB,TDI,DBt,or other) Shared Leave (see att ched)
❑ other pension,retirement or disability benefits No offsets for sick leave or
m Workers'Compensation Benefits sjiared leave until of to
0 Sick Leave Offset ❑100 6 backdoor ❑None ❑PoI—Member choice ❑Fut—No Choice
months
D. Recovery
❑ Remove Subrogation and 3rd party
E_ Definition of Disability
❑ To age 65 own occ
List cassdreabon(s):
❑ Partial Plus(no carve out availability)
0 ?year own occ for: ❑All ❑Other.
❑ Other Describe:
❑ 2 year own Specially for, ❑Altorneys ❑Physicians
' LTD continued on next page.
SI 6719
(6a,)
Contract 2000 LTD Worksheet (cont.)
F. Other Plan Options
66 LTD Conversion $5,000
❑ Automatic 5%Maximum LTD Benefit increase
❑ Cola% ❑All Employees If not,1*1 classrfication(s):
❑ Survivor Benefit Removal '
❑ ALB: ❑80%Income Replacement
❑100%Income Replacement
❑ Medical Expense Benefit(Not available on Buy-ups)
❑$100 or ❑$200 '
❑ 12 months or ❑24 months
❑ Lifetime Secunly Benefit(Not offered with Converslon/Portebdao
❑ Housing Assistance Benefit
❑ Medex Travel Assist
❑ Transitional Duty Package
❑ Horizon Care-EAP
❑ Internet only ,
❑ Internet&Phone only
❑ Internet,Phone&1-3 Face to Face Consultations
4 of lives
Over 1000 lives rate $ '
G. Optional LTD Benefits
❑ EAP: ❑Telephone Only ❑In Person Service
❑ EIP: "A of 1st$ .$ Maximum LTD Benefit
Benefit Waiting Period_days Maximum Benefit Period months
Key employees oovared•
❑ PCB: %of 1 st$ $ Maximum LTD Benefit
%Employer Contribution %Employee Contribution
❑ HIV: %of 1 st$ ,$ Maximum LTD Benefit
❑Physicians or Dentists ONLY
❑Include nurses and other health care professionals
❑ RetumiTo Work Incentive-24 months
❑ Child Care Expense-(Expense penod will match RTW period)
H. Limitations
❑ 12 months for all limitations ❑24 months for at limitations
RI Add musculoskeietal/connective tissue disorders condition
+ ❑ Remove subjective limitations
❑ Remove Drug&Alcohol
❑ Remove Mental Nervous
❑ Remove prudent person requirement for MlYs and attorneys
I. All Insurance Offsets
❑ Direct Offset
❑ 60%Backdoor
❑ 80%Backdoor
I
SI aTt9 (601)
06/09/2003 16,52 2538566270 EMPLOYEE SERVICES PAGE 02
CITY OF KENT
POLICY
' NUMBER: 3.4 EFFECTIVE DATE: April 1, 1996
ISUBJECT: SHARED LEAVE SUPERSEDES: ecember 1 9
APPROVED:
P`I�Iiayor
QOL(CY:
It is the policy of the City of Kent to allow regular employees to donate a portion of their
accrued annual leave time to another City employee who has either been called to full lime
active military duty or who Is suffering from a catastrophic illness, injury, Impairment, or
physical or mental condition that has caused or is likely to cause the employee either to
take leave without pay or to terminate his/her employment, It is the intent of the City that
this program not be a gifting program and the City incur no additional cost excluding
administrative costs.
3.4.1 ELI 1i3�iLIiY:
A. Doneg/Recioient-An employee may be eligible for Shared Leave if he/she meets
all of the following criteria:
1. The employee must be a regular employee as defined in the Employee
' Definitions Policy,
2. The employee has or Wil soon exhaust ail his/her accrued leave balances
and is not entitled to industrial insurance compensation or LEOFF I disability
leave.
3. The employee's absence from work is as a result of one of the following:
a. The employee Is on an approved medical leave of absence,
b. The employee is suffering from a serious health condition which
disables the employee from performing the essential functions of
his/her position, as defined by FMLA-
0. The employee's presence is required to care for an immediate family
member who is suffering from a serious health condition, as defined
by FMLA.
B. Donor-Regular employees may donate annual leave in one(1)hour increments to
an employee who Is authorized to receive shared leave as provided in this policy.
All donations of annual leave shall be voluntary.
aesWwedvvd 3.4 -Page 1 of 2
06/09r2063 16:52 2538566270 EMPLOYEE SERVIrES PAGE 03
SHARED LEAVE NUMBER 3.4 ,
3.4.2 REQUEST&APPROVAL ,
A. Requestf Shared Leave-Employees requesting Shared Leave donations must
submit a written request to the Human Resources Director for approval. In the case ,
of an emergency where advance notice is not possible, a written request must be
made as soon as practicable. In such emergencies, a representative of the Human
Resources Department may make the request In place of the employee.
B. Review and Approval-The Human Resources Department will review all employee
requests, approve and monitor to insure equitable treatment for all employees of the
City. Inappropriate use or treatment of these shared leave provisions may result In
the denial or cancellation of shared leave,
3.4.3 ADMINISTRATION:
A Valuation-Annual leave shall be transferred on a dollar-for-dollar basis. The value
of the leave shall be determined at the current hourly wage of the donor and the
donee.
B. Computing-The Finance Department shall be responsible for computing the values
of shared leave, and for adjusting the accrued leave balances. Records of all leave ,
time transferred shall be maintained by the Finance Department.
C. Police and Fire-When reviewing Police or Fire Department employees, the Police
Chief or the Fire Chief may also consider whether additional adequate time off will ,
be provided through shift trades and/or other leave types unique to those
departments.
D. Human Resources Deoartmen#shall have the authority to adopt interpretive policies
consistent with and applicable to employees covered under this shared leave
program to the extent necessary for the proper and efficient administration of this
program. ,
E. Finance Deoartmggt will be responsible for monitoring donee leave usage balances.
At no time will shared leave or other leave use exceed the one hundred eighty(180) ,
calendar days allowable under the City's Leave of Absence Policy.
3.4.4 CQLLECTIVE BARGAINING AGREEMENTSICIVIL SERVICE LAWS*
Employees covered by Collective Bargaining agreements, Civil Service Laws and rules, or
covered by the Law Enforcement Officers and Firefighter's (LEOFF 1) disability provisions
will be subject to the specific terns or those agreements, laws or rules applicable to shared ,
leave arrangements and are excluded from the provisions of this policy. In the event such
collective bargaining agreements, laws or rules do not contain shared leave provisions,
then employees covered by same will be governed by this policy.
v:+vona�s�aharrmvccr 3.4 - Page 2 of 2
i
1
Employees paying their own LTD premium as of 4/13/05
Name Address Numl Employee Deduction Begin Date
Aguilar Jr, Esteban 45198 1321 6/16/2003
Curtis, Suzan R 45690 157 12/16/2003
Hastings,Lori A 45969 5.57 6/16/2003
Hoopes,Brigitte R 46043 16.49 6/16/2003
Jenkins, Bernard 46085 13.21 6/16/2003
Kinsella,Jill L 46163 13.21 6/16/2003
Knapp, Sheila P 46170 15.7 6/16/2003
Kulin, Scott A 46190 13.21 6/16/2003
Langsea, Joel D 46201 13.21 6/16/2003
Martinez, Manuel A 46309 15.7 6/16/2003
Michael, Dan L 46384 15.7 6/16/2003
Perkins-White, Mary E 45025 1321 6/16/2003
Phiel, Madelyn A 45042 11.73 6/16/2003
Stone, Marilyn J 45308 157 6/16/2003
Swanson, Mallorie L 45333 13.21 6/16/2003
Ward, Christopher P 45451 13.21 6/i6/2003
Warren, Shelley W 45456 14.22 12/16/2003
Kent City Council Meeting
Date June 21, 2005
Category Consent Calendar
1. SUBJECT: PREMERA BLUE CROSS ADMINISTRATIVE SERVICES
CONTRACT FOR 2005 —AUTHORIZE
2. SUMMARY STATEMENT: Authorize the Mayor to sign the Premera Blue Cross
2005 Administrative Services Contract. The City is self-insured for this program. The
2005 contract reflects a 6% increase in administrative fees by Premera Blue Cross and
is budgeted in the Health & Welfare fund. The annual cost is approximately $551,905.
The projected budget for self-funded Premera Blue Cross program claims for 2005 is
$819471787.
3. EXHIBITS: Premera Blue Cross 2005 Administrative Services Contract
1 4. RECOMMENDED BY: Operations Committee
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? X Revenue?
Currently in the Budget? Yes X No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 61
i
1
1 ADMINISTRATIVE SERVICE CONTRACT
BETWEEN
PREMERA BLUE CROSS
AND
CITY OF KENT
This Contract is effective January 1,2005, by and between the group named above(hereinafter
referred to as the"Plan Sponsor"), and Premera Blue Cross(hereinafter referred to as the
"Claims Administrator"or"we,""us,"or"our").
WHEREAS,the Plan Sponsor has established an employee benefit plan(hereinafter referred to
as the"Plan")which provides for payment of certain welfare benefits to and for certain eligible
individuals as defined in writing by the Plan Sponsor, such individuals being hereinafter referred
to as"Members", and,
WHEREAS,the Plan Sponsor has chosen to self-insure the benefit program(s)provided under
the Plan; and
WHEREAS,the Plan Sponsor desires to engage the services of the Claims Administrator to
provide administrative services for the Plan,
NOW THEREFORE, in consideration of the mutual covenants and conditions as contained herein
the parties hereto agree to the provisions in this Contract, including any Attachments and
endorsements thereto. The parties below have signed as duly authorized officers and have
hereby executed this Contract If this Contract is not signed and returned to the Claims
Administrator within sixty(60)days of its delivery to the Plan Sponsor or its agent,the Claims
Administrator will assume the Plan Sponsor's concurrence and the Plan Sponsor will be bound by
its terms.
IN WITNESS WHEREOF the parties hereto sign their names as duly authorized officers and
have executed this Contract.
City of Kent
BY. DATE:
Title
ADDRESS-
Premera Blue Cross
BY. ,/ DATE March 7,2005
1 H.R. Brereton Barlow
President and Chief Executive Officer
P.O. Box 327
Seattle,WA 98111-0327
1
SECTION I DUTIES AND RESPONSIBILITIES OF THE PLAN SPONSOR
101 The Plan Sponsor shall provide the Claims Administrator with a copy of any
documents describing the benefit program(s)that the Claims Administrator
needs to rely upon in performing its responsibilities under this Contract
102 The Plan Sponsor shall have final discretionary authority to determine the
benefit provisions and to construe and interpret the terms of the Plan.
1.03 The Plan Sponsor shall have final discretionary authority to determine ,
eligibility for benefits and the amount to be paid by the Plan.
1.04 Unless specifically delegated to the Claims Administrator by this Contract,
the Plan Sponsor shall be responsible for the proper administration of the
Plan including
a. providing the Claims Administrator a complete and accurate list of all
individuals eligible for benefits under the benefit program(s) and to
update those lists monthly The Claims Administrator shall be
entitled to rely on the most recent list until it receives documentation
of any change thereto.
b. notifying the Claims Administrator on a monthly basis of changes in
eligibility, '
C. distributing to all eligible Members all appropriate and necessary
materials and documents, including but not limited to benefit
program booklets, summary plan descriptions, material
modifications,enrollment applications and notices required by law or
that are necessary for the operation of the Plan,
d. providing the Claims Administrator with any additional information
necessary to perform its functions under this Contract as may be
requested by the Claims Administrator from time to time,
e. maintaining adequate funds from which the total cost of all claims for
each preceding week will be paid to the Claims Administrator by wire
transfer Funds must be provided within forty-eight(48) hours of
phone notification by the Claims Administrator to a person
designated by the Plan Sponsor
If timely payment for the claims is not received by the Claims
Administrator,the Plan Sponsor shall pay the Claims Administrator a
daily late charge This late charge is calculated from the first day
following the forty-eight(48) hour period stated above This late
charge is based on the average monthly prime rate posted by Bank
of America/Nations Bank during the Contract Period, plus two(2)
percent on the amount of the late payments for the number of days
late Late charges are due at the end of the Contract Period as part
of the annual accounting or, if earlier, upon termination of the
Contract
1 05 The Plan Sponsor shall be responsible for all taxes, assessments and fees
levied by any local, state or federal authority in connection with the Claims
Administrator's duties pursuant to this Contract
1 06 The Plan Sponsor shall be responsible for the Plan's continuing compliance
with all applicable federal, state and local laws and regulations, as currently
amended These include but are not limited to
• The Internal Revenue Code
• The Health Insurance Portability and Accountability Act of 1996
(H I PAA)
2
• The Consolidated Omnibus Budget Reconciliation Act of 1985
(COBRA)
• The Balanced Budget Act of 1997
The Plan Sponsor,and not the Claims Administrator, is the"plan
administrator"and the"plan sponsor"for purposes of all federal laws that
apply to the Plan Sponsor and impose duties or obligations on such
1 entities The Plan Sponsor shall be responsible for determining whether it
is subject to COBRA and, if so, for notifying Members of their COBRA rights
both initially and upon the occurrence of a qualifying event,for calculating
and collecting premiums for COBRA continuation of coverage and for
promptly notifying the Claims Administrator when an individual is no longer
eligible for COBRA continuation of coverage If the Plan Sponsor is subject
to ERISA,the Plan Sponsor is responsible to prepare and maintain its
ERISA plan document.
1.07 The Plan Sponsor shall be responsible for defending any legal action
brought against the Plan, including a claim for benefits by or on behalf of
any individual or entity, including but not limited to any Member or former
Member, any fiduciary or other party. This responsibility includes the
selection and payment of counsel The Plan Sponsor shall not settle any
legal action or claim without the prior consent of the Claims Administrator if
the action or claim could result in the Claims Administrator being liable,
including for example, any liability for contribution to or indemnification of
the Plan Sponsor or other third party either directly or indirectly
1.08 If the Plan Sponsor writes or revises its benefit booklet, the Claims
Administrator must review and approve in advance the draft of the benefit
booklet that is printed and distributed to Members
1 If an adverse decision is made in the Claims Administrator's second level of
review,the Plan Sponsor shall offer the Member a review by an
Independent Review Organization(IRO) The Plan Sponsor shall pay all
costs of the IRO review.
1.09 If the Plan Sponsor elects to opt out of compliance with certain federal
mandates as allowed by HIPAA, the Plan Sponsor is responsible to file its
opt-out with federal regulators for each contract period and to notify
Members of the opt-out in accordance with federal law and regulations then
in effect The Plan Sponsor agrees to hold the Claims Administrator and
the Network harmless for any and all consequences arising from the Plan
Sponsor's failure to file an opt-out as required by law for a given contract
period, errors in the opt-out filing, or failure to notify a Member as required
by federal law.
SECTION II DUTIES AND RESPONSIBILITIES OF THE CLAIMS ADMINISTRATOR
2.01 The Claims Administrator agrees to perform the following administrative
services for the Plan Sponsor The Claims Administrator shall-
a. assist in the preparation and printing of the benefit program booklets,
identification cards, and other materials necessary for the operation
1 of the Plan, and distribute identification cards to Members,
b. process all eligible claims incurred after the effective date of this
Contract which are properly submitted in accordance with the
' procedures set forth in the Plan Sponsor's benefit booklet Checks
will be issued on the Claims Administrator's check stock, but the
responsibility for funding benefits is the Plan Sponsor's and the
Claims Administrator is not acting as an insurer The Claims
Administrator shall make reasonable efforts to determine that a claim
is covered under the terms of the benefit program(s)as described in
3
the benefit booklet, to apply the coordination of benefits provisions,
identify subrogation claims, and make reasonable efforts to recover
subrogated amounts administratively as stated in section 7 01, and
prepare and distribute benefit payments to Members and/or service
providers,
C. notify the Plan Sponsor weekly by telephone or electronic medium of
the amount due for the prior week's claims,
d. perform reasonable internal audits as stated in Section VI,
e. answer inquiries from the Plan Sponsor, Members, and service ,
providers regarding the terms of the Plan, although final authority for
construing the terms of the Plan's eligibility and benefit provisions is
the Plan Sponsor's;
f. prepare and provide to the Plan Sponsor reports in accordance With
Attachment B;
g. prepare and provide the Plan Sponsor with reports of the operations
of the Plan in accordance with Attachment B;
h. coordinate with any stop-loss insurance carrier;
i when"preferred provider"benefits are provided, maintain a network
of hospital and professional providers, paid claims will reflect any
negotiated provider discounts, ,
j. perform care facilitation services as identified in Attachment E, Care
Facilitation,
k. provide a Certificate of Group Health Coverage to Members when i
their coverage under this Plan terminates or upon their request
within 24 months of termination In the event the Claims
Administrator does not have adequate information to complete the
Certificate,the Plan Sponsor will be responsible for completing the
missing information on the Certificate and forwarding it to the
Member
I. review and respond to the initial appeals of adverse benefit
determinations as described in the benefit booklet provided by the
Claims Administrator for this Plan The Claims Administrator shall
also provide a second review of adverse appeal decisions made
after its initial review This review will be conducted as described in
the benefit booklet provided by the Claims Administrator for this
Plan
An"adverse benefit determination"means any of the following. a
denial, reduction, or termination of, or a failure to provide or make
payment(in whole or in part)for, a benefit, including payment that is
based on a determination of the eligibility of a Member to participate
in the Plan This includes any denials, reductions, or failures to
provide or make payment resulting from the application of utilization
review or limitations on experimental and investigational services,
medical necessity, or appropriateness of care
If an adverse decision is made in the Claims Administrator's second
level of review, the Claims Administrator also agrees to facilitate a ,
review of the appeal by an Independent Review Organization (IRO)
on behalf of the Plan Sponsor The Claims Administrator will submit
ail documentation regarding the appeal to the iRO and work with the
IRO as needed to complete its review The Claims administrator ,
shall pass all costs of the IRO review on to the Plan Sponsor
4
SECTION III LIMITS OF THE CLAIMS ADMINISTRATOR'S RESPONSIBILITY
3.01 It is recognized and understood by the Plan Sponsor that the Claims
Administrator is not an insurer and that the Claims Administrator's sole
1 function is to provide claims administration services and the Claims
Administrator shall have no liability for the funding of benefits.
The Claims Administrator is empowered to act on behalf of the Plan
Sponsor in connection with the Plan only as expressly stated in this
Contract or as mutually agreed to in writing by the Claims Administrator and
the Plan Sponsor.
3.02 If, during the course of an audit performed internally by the Claims
Administrator pursuant to Section 2 01 d or by the Plan Sponsor pursuant to
Section VI of this Contract, any error is discovered,the Claims
Administrator shall use reasonable efforts to recover any loss resulting from
such error.
3.03 The Claims Administrator is an independent contractor with respect to the
services being performed pursuant to this Contract and shall not for any
purpose be deemed an employee of the Plan Sponsor
304 This Contract is between the Claims Administrator and the Plan Sponsor
and does not create any legal relationship between the Claims
Administrator and any Member or any other individual
305 It is recognized by the parties that errors may occur and it is agreed that the
Claims Administrator will not be held liable for such errors unless they
resulted from its gross negligence or willful misconduct. The Plan Sponsor
agrees to defend, indemnify, and hold harmless the Claims Administrator
from all claims, damages, liabilities, losses, and expenses arising out of the
Claims Administrator's performance of administration services under the
terms of this Contract, so long as they did not arise out of the Claims
Administrator's gross negligence or willful misconduct
SECTION IV FEES OF THE CLAIMS ADMINISTRATOR
401 By the first of each month,The Plan Sponsor shall pay the Claims
Administrator in accordance with the fee schedule set forth in Attachment C
that is incorporated herein by reference
1 402 Late Payments
a If, for any reason whatsoever,the Plan Sponsor fails to make a
timely payment required under this Contract by the tenth day of the
month in which payment is due, the Claims Administrator may
suspend performance of services to the Plan Sponsor, including
processing and payment of claims, until such time as the Plan
Sponsor makes the required payment, including interest as set forth
in b below.
b. In the event of late payment,the Claims Administrator may terminate
this Contract pursuant to Section 9 05 Acceptance of late payments
by the Claims Administrator shall not constitute a waiver of its right to
cancel this Contract due to delinquent or nonpayment of fees
5
C. The Claims Administrator will charge interest to the Plan Sponsor on
all payments received after the tenth day of the month in which they
are due, including amounts paid to reinstate this Contract after
termination pursuant to Section 9.05,at the average prime rate
posted by Bank of America/Nations Bank during the Contract Period
plus two(2) percent on the amount of the late payments for the
number of days late Interest will be in addition to any other amounts
payable under this Contract.
4.03 Customization Fees t
The Plan Sponsor shall pay the Claims Administrator a"customization fee"
when the Plan Sponsor requests either of the following
a. A plan benefit configuration that the Claims Administrator has not
determined to be standard for the plan type Customization fees for
nonstandard plan benefits assessed at this Contract's effective date are
listed in Attachment C.
b. An off-anniversary benefit change, regardless of whether the desired
benefit is standard for the plan type. The customization fee for each
off-anniversary change shall be$2,000 Customization fees for off-
anniversary changes shall be invoiced separately to the Plan Sponsor.
For purposes of customization fees,"benefits"include eligibility,
termination, continuation and benefit payment provisions, benefit terms,
limitations, and exclusions, funding arrangement changes, and any other
standard provisions of the Plan Fees are computed based on current
administrative costs to implement and administer the benefit
Customization fees for custom benefits that take effect on the effective date
shown on the Face Page of this Contract are due and payable prior to that
effective date Customization fees for off-anniversary benefit changes are
due and payable prior to the effective date of the change
SECTION V BLUECARD®PROGRAM
5.01 Premera Blue Cross,like all Blue Cross and/or Blue Shield Licensees,
participates in a program called "BlueCard " Whenever Members access
health care services in Clark County,Washington or outside Washington
and Alaska,the claim for those services may be processed through ,
BlueCard and presented to us for payment Payment is made according to
the terms and limitations of your plan document and network access rules in
the BlueCard Policies then in effect Under BlueCard,when Members
receive covered services within the area served by another Blue Cross
and/or Blue Shield Licensee(called the"Host Blue"in this section),
Premera Blue Cross remains responsible for fulfilling our obligations under
this contract The Host Blue will only be responsible for such services as
contracting with providers and handling all interaction with contracting
providers The Host Blue must perform these duties in accordance with
applicable BlueCard Policies The financial terms of BlueCard are
described generally below
5.02 Liability Calculation Method Per Claim t
The amount the Member pays for covered services obtained in Clark
County, Washington or outside Washington and Alaska through BlueCard is
calculated on the lower of 1)the billed charges for the covered services,
6
or 2)the"negotiated price"that the Host Blue passes on to Premera Blue
Cross for the covered services
Most often,the Plan Sponsor's liability for covered services processed
through BlueCard is calculated on the same amount on which the Member's
liability is calculated However, in rare cases required by the Host Blue's
contract with the provider,the Plan Sponsor's liability will be calculated on
the Host Blue's negotiated price even when that price exceeds the billed
charge
The methods used to determine the negotiated price will vary among Host
Blues according to the terms of their provider contracts Often,the
negotiated price will consist of a simple discount,which reflects the actual
price allowed as payable by the Host Blue But, sometimes, it is an
estimated price that factors in the Host Blue's expected settlements,
withholds, any other contingent payment arrangements and non-claims
transactions with the Member's health care provider or with a specified
group of providers The negotiated price may also be a discount from billed
charges that reflects an average expected savings with the Member's
health care provider or a specified group of providers The price that
reflects average savings may result in greater variation above or below the
actual price than will the estimated price In accordance with national
BlueCard policy,these estimated or average prices will also be adjusted
from time to time to correct for overestimation or underestimation of past
I prices However, the amount on which the Member's and the Plan
Sponsor's payments are based remains the final price for the covered
services billed on that claim
In addition, K the Host Blue's negotiated price is an estimated or average
price, as described above, some portion of the amount the Plan Sponsor
pays may be held in a variance account by the Host Blue, pending
settlement with its contracting providers Because all amounts paid are
final, any funds held in a variance account do not belong to the Plan
Sponsor and are eventually exhausted by provider settlements and through
prospective adjustments to the negotiated prices.
I Some states may mandate a surcharge or a method of calculating what
Members must pay on a claim that differs from BlueCard's usual method
noted above and is not pre-empted by federal law If such a mandate is in
force on the date the Member received care in that state, the amounts the
Member and the Plan Sponsor must pay for any covered services will be
calculated using the methods required by that state's mandate Such
methods might not reflect the entire savings expected on a particular claim
The calculation methods described above in this section 5.02 do not apply
to BlueCard Worldwide claims
Under BlueCard, recoveries from a Host Blue or from contracting providers
of a Host Blue can arise in several ways Examples are antifraud and
abuse audits, provider/hospital audits, credit balance audits, utilization
review refunds, and unsolicited refunds. In some cases, the Host Blue will
engage third parties to assist in discovery or collection of recovery amounts.
The fees of such a third party are netted against the recovery. Recovery
amounts, net of any fees, will be applied in accordance with applicable
BlueCard Policies, which generally require correction on a claim-by-claim or
prospective basis
503 BlueCard Worldwide®
7
If Members are outside the United States,the Commonwealth of Puerto
Rico, Jamaica and the British and U S Virgin Islands, they may be able to
take advantage of BlueCard Worldwide. BlueCard Worldwide is unlike the
national BlueCard program in certain ways For instance,although
BlueCard Worldwide provides a network of contracting hospitals, it offers
only referrals to doctors and other health care providers When receiving
care from doctors or other health care providers, Members will have to
submit claim forms on their own behalf to obtain reimbursement for the
services provided through BlueCard Worldwide
5.04 BlueCard Fees and Compensation-Overview
The Plan Sponsor understands and agrees to the following-
a. To pay certain fees and compensation to us which we are obligated
under BlueCard to pay to the Host Blue,to the Blue Cross and Blue
Shield Association, or to the BlueCard vendors These fees are billed
to the Plan Sponsor as shown in Attachment C, "Fees of the Claims
Administrator."
b. That fees and compensation under BlueCard may be revised from time
to time without the Plan Sponsor's prior approval in accordance with the
Blue Cross and Blue Shield Association's standard provisions for
revising fees and compensation under BlueCard.
Some of these fees and compensation are charged each time a claim is l
processed through BlueCard Examples of these are access fees(see 5 05
and 5 06 below), administrative expense allowance fees, Central Financial
Agency Fees, and ITS Transaction Fees Also, some of these claim-based
fees, such as the access fee and the administrative expense allowance fee,
may be passed on to the Plan Sponsor as an additional claim liability.
Examples of fees not charged for each claim are an 800 number fee and a
fee for providing provider directories If you want an updated listing of these
types of fees or the amount of these fees paid directly by you,please
contact us
505 Access Fees
Host Blues may charge the Claims Administrator an access fee for making
their discounted rates and the resulting savings available on claims incurred
by the Plan Sponsor's Members Access fees are based on the difference
between the amount paid by the Host Blue and the amount this Plan would
have paid if it had dealt with the out-of-area provider directly The access
fee, if one is charged, may equal up to 10 percent of the Host Licensee's
discount/differential savings, but may not exceed$2,000 per claim. The
access fee may be charged only if the Host Blue's arrangement with the
provider prohibits billing Members for amounts in excess of the discounted
rate However, providers may bill for deductibles, coinsurance, amounts in
excess of stated benefit maximums, and charges for noncovered services
In the event a participating provider discount cannot be passed along to the
Member, no discount or access fee will apply
506 How Access Fees Affect The Plan
When the Claims Administrator is charged an access fee, it will be charged ,
to the Plan Sponsor as a claims expense If the Claims Administrator
receives an access fee credit, it will be given to the Plan Sponsor as a
claims expense credit Access fees are considered a claims expense
8
because they represent claims dollars the Plan Sponsor is unable to avoid
paying.
Instances may occur in which the Claims Administrator does not pay a claim
(or pays only a small amount)because the amounts eligible for payment
were applied to the deductible and/or coinsurance In these instances,the
Claims Administrator will pay the access fee and pass it along to the Plan
Sponsor as a claims expense even though little or none of the claim was
paid.
SECTION VI AUDIT
6.01 Within thirty(30)days of written notice from the Plan Sponsor, the Claims
Administrator shall allow an authorized agent of the Plan Sponsor to inspect
or audit all records and files maintained by the Claims Administrator which
are directly pertinent to the administration of the Plan for the current or most
recently ended contract period Such documents shall be made available
at the administrative office of the Claims Administrator during normal
business hours The Plan Sponsor shall be liable for any and all fees
charged by the auditor All audits shall be subject to the Claims
Administrator's audit policies and procedures then in effect To the extent
that the Plan Sponsor requests data and reports that are beyond the scope
of the Claim Administrator's audit policies and procedures,the Plan
Sponsor shall reimburse the Claims Administrator for the additional
administrative costs incurred in producing such data and reports
Any agent or auditor who has access to the records and files maintained by
the Claims Administrator shall agree not to disclose any proprietary or
confidential information used in the business of the Claims Administrator
SECTION VII SUBROGATION
7.01 The Claims Administrator shall make reasonable efforts to pursue
subrogation claims administratively on behalf of the Plan However, the
Claims Administrator shall have no affirmative duty to pursue subrogation
claims beyond those specified in section 2 01 b The Plan Sponsor shall
have the sole discretion to bring any legal claim or action to enforce the
Plan's subrogation provisions The Claims Administrator will cooperate with
the Plan Sponsor in the event the Plan Sponsor brings any legal action to
enforce the subrogation provisions of the Plan Any costs and attorneys'
fees incurred in pursuing such subrogation claims shall be the responsibility
of the Plan Sponsor.
SECTION Vill TERM OF CONTRACT
801 The term of this Contract shall be the period from 12-01 a m on January 1,
2005,to midnight on December 31, 2005 (hereinafter referred to as the
"Contract Period")
802 Except as stated otherwise in section 9 03 below,the terms and conditions
of this Contract and the fee schedule set forth in Attachment C are
established for the Contract Period
803 The Plan Sponsor acknowledges that the fee schedule set forth in
Attachment C and the services provided for in this Contract are based upon
the terms of the Plan and the enrollment as they exist on the effective date
of this Contract Any substantial changes,whether required by law or
otherwise, in the terms and provisions of the Plan or in enrollment may
require that the Claims Administrator incur additional expenses The
9
parties agree that any substantial change, as determined by the Claims
Administrator, shall result in the alteration of the fee schedule, even if the
alteration is during the Contract Period The phrase "any substantial '
change"shall include, but not be limited to.
a. a fluctuation of ten(10)percent or more in the number of Members
as set forth on the census information included in Attachment A
which is herein incorporated by reference and made a part of this
Contract,
b. the addition of benefit program(s)or any change in the terms of the
Plan's eligibility rules, benefit provisions or record keeping rules that
would increase administration costs by more than$2,000;
C. any change in claims administrative services,benefits or eligibility
required by law,
d. any change in administrative procedures from those in force at the
inception of this Contract that is agreed upon by the parties,
e. any additional services which the Claims Administrator undertakes to
perform at the request of the Plan Sponsor which are not specified in
this Contract such as the handling of mailings or preparation of
statistical reports and surveys not specified in the Claims
Administrator's standard Employer Group Reporting set
SECTION IX TERMINATION
9.01 The Plan Sponsor may terminate this Contract at any time by giving the t
Claims Administrator thirty(30)days written notice.
9.02 This Contract will terminate on the last day of the Contract Period or the last
day of any extension of the Contract Period granted by the Plan
Administrator
903 Either party may terminate this Contract effective immediately by giving
written notice to the other if a party becomes insolvent, makes a general
assignment for the benefit of creditors, files a voluntary petition of
bankruptcy, suffers or permits the appointment of a receiver for its business
or assets, or becomes subject to any proceeding under any bankruptcy or
insolvency law, whether foreign or domestic. A party is insolvent if it has
ceased to pay its debts in the ordinary course of business,cannot pay its
debts as they become due, or the sum of its debts is greater than the value
of its property at a fair valuation
904 If loss of services is caused by, or either party is unable to perform any of
its obligations under this Contract, or to enjoy any of its benefits because of
natural disaster, action or decrees of governmental bodies or
communication failure not the fault of the affected party, such loss or
inability to perform shall not be deemed a breach The party who has been
so affected shall immediately give notice to the other party and shall do
everything possible to resume performance Upon receipt of such notice,
all obligations under this Contract shall be immediately suspended If the
period of nonperformance exceeds thirty(30) days from the receipt of such
notice,the party whose performance has not been so affected may, as its
sole remedy,terminate this Contract by written notice to the other party
effective immediately. In the event of such termination, the Plan Sponsor
shall remain liable to the Claims Administrator for all payments due,
together with interest thereon as provided for in Section 4 02
10
i
905 The Claims Administrator may,at its sole discretion,terminate this Contract
effective as of a missed payment due date in the event that the Plan
Sponsor fads to make a timely payment required under this Contract
906 In the event this Contract is terminated prior to the end of the Contract
Period,the Plan Sponsor shall remain liable to the Claims Administrator for
all delinquent sums together with interest thereon as provided for in section
4 02 above Furthermore,the Claims Administrator will have incurred fixed
costs which, but for the termination,would have been recouped over the
' course of the Contract Period Therefore, in the event that the Contract
terminates pursuant to Section 9 01 or 9 05,the Plan Sponsor shall also
pay the Claims Administrator as liquidated damages, and not as a penalty,
an amount equal to two(2) months administration fees This monthly fee
shall be determined by multiplying the rate set forth in Attachment C
multiplied by the average number of Members covered by the Plan for the
immediately preceding six(6)month period or such shorter period if this
Contract has not been in effect for a period of six(6) months The Plan
Sponsor shall remain liable for claims incurred during the Contract Period
but not paid during the Contract Period and for the claims run-out
processing fee set forth in subsection C of Attachment C.
i907 Within one hundred twenty(120)days of termination by either party,the
Claims Administrator shall deliver to the Plan Sponsor an interim
accounting. Within fifteen (15) months of termination the Claims
Administrator shall deliver to the Plan Sponsor a complete and final
accounting of the status of the Plan.
At the expense of the Plan Sponsor, the Claims Administrator shall make
available a record of deductibles and coinsurance levels for each Member
and deliver this information to the Plan Sponsor or its authorized agent
9.08 For the twelve(12)month period following termination of this Contract,the
Claims Administrator shall continue to process eligible claims incurred prior
to termination at the claims run-out processing fee rate set forth in
Attachment C
SECTION X DISCLOSURE
10.01 It is recognized and understood by the Plan Sponsor that the Claims
Administrator is subject to all laws and regulations applicable to Claims
Administrators and health care service contractors
10.02 It is recognized and understood by the Plan Sponsor that the Claims
Administrator is not acting as an insurer and also is not providing stop-loss
insurance
SECTION XI OTHER PROVISIONS
11.01 Choice of Law
The validity, interpretation, and performance of this Contract shall be
controlled by and construed under the laws of the state of Washington,
I unless federal law applies Any and all disputes concerning this Contract
shall be resolved in King County Superior Court or federal court as
appropriate
11.02 Trademarks
11
The Claims Administrator reserves the right to,the control of, and the use of
the words"Premera Blue Cross", "MSC Incorporated as Premera Blue Cross"
and all symbols,trademarks and service marks existing or hereafter
established The Plan Sponsor shall not use such words, symbols,
trademarks or service marks in advertising, promotional materials,materials
supplied to Members or otherwise without the Claims Administrator's prior
written consent which shall not be unreasonably withheld.
11.03 Independent Corporation
The Plan Sponsor hereby expressly acknowledges, on behalf of itself and
all of its Members, its understanding that this Administrative Service
Contract constitutes a Contract solely between the Plan Sponsor and the
Claims Administrator, that the Claims Administrator is an independent
corporation operating under a license with the Blue Cross and Blue Shield
Association, an association of independent Blue Cross and Blue Shield
Plans(the"Association")permitting the Claims Administrator to use the
Blue Cross Service Mark in the States of Washington and Alaska, and that
the Claims Administrator is not contracting as the agent of the Association.
The Plan Sponsor further acknowledges and agrees that it has not entered
into this Administrative Service Contract based upon representations by
any person other than the Claims Administrator, and that no person, entity
or organization other than the Claims Administrator shall be held
accountable or liable to the Plan Sponsor for any of the Claims
Administrator's obligations to the Plan Sponsor created under this
Administrative Service Contract This provision shall not create any
additional obligations whatsoever on the Claims Administrator's part other
than those obligations created under other provisions of this Administrative
Service Contract.
11.04 Notice
Except for the notice given pursuant to section 2.01 c.,any notice required
or permitted to be given by this Contract shall be in writing and shall be
deemed delivered three(3) days after deposit in the United States mail,
postage fully prepaid, return receipt requested, and addressed to the other
party at the address as shown on the face page of this Contract
11.05 Integration
This Contract, including any appendices or attachments incorporated
herein by reference, embodies the entire Contract and understanding of the
parties and supersedes all prior oral and written communications between
them. Only a writing signed by both parties hereto hereof may modify the
terms.
11.06 Assignment
Neither party shall assign this Contract or any of its duties or responsibilities
hereunder without the prior written approval of the other
SECTION XII ATTACHMENTS TO THE ADMINISTRATIVE SERVICE CONTRACT
1201 The following attach to and become part of the body of this Contract and
they are herein incorporated by reference
Attachment A-Census
12
Attachment B-Reporting
Attachment C -Fee Schedule
Attachment D—Business Associate Agreement
Attachment E—Care Facilitation
Attachment F-Right Of Conversion
13
1
1
ATTACHMENT A
CENSUS INFORMATION
Administration Fees, effective January 1, 2005, are based on the following:
Number of Active and Retired Members:
Employee Spouse Children
Medical 770 525 824
Dental 813 542 853
Number of COBRA Members:
Employee Spouse Children
Medical 8 5 5
Dental 8 5 5
Other Carriers Offered: Group Health Cooperative
PLAN SPONSOR: City of Kent
PLAN NUMBER: 1018212
PLAN DOCUMENT EFFECTIVE DATE: January 1,2005
ATTACHMENT B
iREPORTING
A standard package of reports covering the Contract Period wit be provided to the Plan Sponsor
within the fees set forth in Attachment C The reports will cover
• Eamed premium
• Paid claims
• Census data
• Claims summaries by.
• Provider type
• Service type
• Coverage type
Please note that reports,format, and content may be modified from time to time as needed.
I
1
i
PLAN SPONSOR: City of Kent
PLAN NUMBER: 1018212
PLAN DOCUMENT EFFECTIVE DATE: January 1,2005
i
t
t
l
I
t
!
z
t
1
PLAN SPONSOR: City of Kent
PLAN NUMBER: 1018212
PLAN DOCUMENT EFFECTIVE DATE: January 1, 2005
ATTACHMENT C
FEES OF THE CLAIMS ADMINISTRATOR
Pursuant to the Administrative Service Contract,the Group shall pay the Claims Administrator a
fee, as set forth below, for administrative services
A. Administration Fees
Composite
2005 2006
1018212 13596-99 $59 39 $61 77
1018212 22066, -01 $58 01 $60 33
B Other Fees:
Booklets $2 05 per book
I D Cards $0 88 per card
Prescription Dru Charge $1 40 per claim
Conversion Contract Fee $1,000 per conversion
I
C Brokerage Fees and Commission
Medical $2.36 per employee per month
Freestanding Dental $ 36 per employee per month
D Claims Runout Processing Fee
10 00% of runout claims processed by PBC
E BlueCard Fees:
Tracked and billed as part of the annual accounting for the Contract Period
F. Care Facilitation—Included in Administration Fee(See attachment E for an overview of
services provided)
i
PLAN SPONSOR: City of Kent
PLAN NUMBER: 1018212
PLAN DOCUMENT EFFECTIVE DATE: January 1, 2005
ATTACHMENT D
BUSINESS ASSOCIATE ATTACHMENT TO
ADMINISTRATIVE SERVICE CONTRACT
FOR GROUPS NOT SUBJECT TO ERISA
This Business Associate Attachment(the"Attachment") shall be entered into by and between the
Claims Administrator,the Plan Sponsor and the Health Plan (the"HP") (as defined below) on the
effective date of the Contract
Recitals
1. In 1996, Congress enacted the Health Insurance Portability and Accountability Act
("HIPAA"),which required, among other things,the promulgation of privacy rules
governing the use and disclosure of protected health information
2 In pertinent part,the HIPAA privacy rules, codified at 45 C F R Parts 160 and 164,
subparts A and E, and as amended (the"Privacy Rule")require that covered entities,
including the HP, maintain business associate agreements with third parties that provide
certain services for and on behalf of the HP, including the Claims Administrator, and
outline specific contractual requirements to be incorporated into the business associate
agreements
3 In addition to being the business associate of the HP,the Claims Administrator is also a
covered entity,as defined in the Privacy Rule, and has policies, procedures and
practices in place to ensure compliance with the Privacy Rule
4. Because the Claims Administrator is regulated under other state and federal privacy
laws, it has adopted the term"protected personal information"or"PPI"(as defined below)
and will apply the obligations contained in this Attachment to that information
NOW, THEREFORE, in consideration of these premises and the mutual promises and i
agreements hereinafter set forth, the Plan Sponsor,the HP and the Claims Administrator hereby
agree as follows
1. Definitions. The following definitions shall apply in interpreting this Attachment Terms
used, but not otherwise defined shall have the same meaning as those terms in the
Privacy Rule(as defined below)
1.1 Health Plan or HP. The HP shall be defined consistent with 45 CFR 160.103,
and as amended
1.2 Individual "Individual"shall mean the person who is the subject of the PPI or
their personal representative(as defined in §164 502(g) of the Privacy Rule).
1.3 Protected Personal Information or PPI "PPI"shall mean any and all information
created or received by the Claims Administrator,that identifies or can readily be
associated with the identity of an Individual,whether oral or recorded in any form
or medium, that directly related to (1)the past, present or future physical, mental
or behavioral health or condition of an Individual, (2)the past, present or future
payment for the provision of health care to an Individual, (3)the provision of
health care to an Individual, and (4)the past, present or future finances of an
Individual, including,without limitation, an Individual's name, address, telephone
number, Social Security Number, subscriber number or wage information
PLAN SPONSOR: City of Kent
PLAN NUMBER: 1018212
PLAN DOCUMENT EFFECTIVE DATE. January 1, 2005
14 Secretary "Secretary"shall mean the Secretary of the Department of Health and
Human Services or his designee
2. HP. The Claims Administrator, Plan Sponsor and HP all agree to add the HP as a party
to the Contract and acknowledge that the HP's obligations under the Contract are
contained completely in this Attachment
3. Safeguard of PPI. The Claims Administrator will maintain reasonable and appropriate
administrative,technical and physical safeguards, as required by applicable laws to
' protect against reasonably anticipated threats or hazards to, and to ensure,the security
and integrity of PPI,to protect against reasonably anticipated unauthorized use or
disclosure of PPI, and to reasonably safeguard PPI from any intentional or unintentional
use or disclosure in violation of the Attachment.
4. Permitted Uses and Disclosures of PPI by the Claims Administrator.
4.1 Functions and Activities on the HP's Behalf The Claims Administrator shall be
i permitted to use and disclose PPI for(a)the management, operation and
administration of the HP and (b)as otherwise necessary to provide the services
set forth in the Contract, including, but not limited to activities related to Payment
and Health Care Operations as defined in §164 501 of the Privacy Rule
4.2 Disclosures to the Plan Sponsor,the HP or other Business Associates of the HP.
Except as otherwise permitted by written directive from HP,the Claims
Administrator will not disclose PPI to the Plan Sponsor, the HP or to another
business associate of the HP The Claims Administrator, may disclose PPI only
to those individuals employed by the HP or business associates of the HP,
including,without limitation, the HP's broker, identified in writing by the HP as
individuals to whom PPI can be disclosed The HP must provide this written
directive to the Claims Administrator as soon as possible but in any event no
later than the effective date of this Contract The HP must promptly notify the
Claims Administrator of any changes to the written directive.
4.3 Functions and Activities on the Claims Administrator's Behalf The Claims
Administrator shall be permitted to use PPI as necessary for the Claims
Administrator's management and administration or to carry out its legal
responsibilities as permitted or required by law The Claims Administrator shall
also be permitted to disclose PPI to its business associates, subcontractors or
other third parties as necessary for proper management and administration of the
Claims Administrator, or to carry out the Claims Administrator's legal
responsibilities (a) if the disclosure is required by law or(b) if before the
disclosure is made, the Claims Administrator, obtains a contract from the entity to
which the disclosure is to be made containing reasonable assurances that the
entity will also comply with the Privacy Rule's business associate requirements.
5. Minimum Necessary. The HP and the Plan Sponsor will make reasonable efforts to
request from the Claims Administrator only the minimum amount of PPI necessary for its
needed purpose In addition, the HP and the Plan Sponsor will make reasonable efforts
to only disclose to the Claims Administrator the minimum amount of PPI necessary for
the Claims Administrator to perform the services identified in the Contract and other
functions and activities referenced in Section 3 of this Attachment. Finally, the Claims
Administrator will make reasonable efforts to use, disclose, or request only the minimum
amount of PPI necessary from any third party to perform the services identified in the
Contract and other functions and activities referenced in Section 3 of this Attachment.
i
PLAN SPONSOR: City of Kent
PLAN NUMBER: 1018212
PLAN DOCUMENT EFFECTIVE DATE: January 1, 2005
r
6. Other Privacy Obligations of the Claims Administrator The Claims Administrator
shall
6.1 Not use or further disclose PPI other than as permitted or required by the
Contract,the Attachment or law,
62 Report to HP any actual use or disclosure of PPI concerning HP's Members not
permitted or required by the Contract,the Attachment or law of which it becomes
aware,
6.3 Ensure that any agents, including a subcontractor,to whom it provides PPI
received from, or created or received by the business associate on behalf of, the
HP agree to the same restrictions and conditions as outlined in the Privacy Rule
that apply to a business associate with respect to such information,
64 Make available PPI as required by§164 524;
6.5 Make available PPI for amendment and incorporate any amendments to PPI as
required by§164 526,
6.6 Make available the information required to provide an accounting of disclosures
as required by§164 528,
6.7 Make its internal practices, books, and records relating to the use and disclosure
of PPI received from, or created or received by the Claims Administrator on
behalf of, the HP available to the Secretary for purposes of determining the HP's
compliance with the Privacy Rule; and
68 Restrict the use and disclosure of PPI in accordance with§164.522 and
consistent with the Claims Administrator's policies, procedures and practices.
7. The Claims Administrator's Privacy-Related Services Regarding Requests by
Individuals Upon receipt, the HP shall immediately provide notice to and forward any
and all individual requests received pursuant to§164 522, §164 524, §164 526 or
§164 528 of the Privacy Rule(collectively referred to as the"Requests")consistent with
Exhibit D-1 Upon the Claims Administrator's receipt of the Requests, either from the HP
or directly from the Individual, the Claims Administrator shall
7.1 Evaluate each request consistent with the Privacy Rule and the Claims
Administrator's policies, procedures and practices,
7.2 For Requests that may affect the policies, procedures or practices of the HP,
coordinate with the HP about evaluation of the Requests and mutually agree on ,
the result,
7.3 For Requests that may involve the HP's other business associates, request
information from the business associates identified by the HP necessary for
fulfilling the Requests,
7.4 Communicate the result of the evaluation directly to the Individual wnthin the legal
timeframes established for each type of request;and
7.5 Notify the HP of the outcome of each Request identified by the HP at the time of
notice to the Claims Administrator, and
76 Implement each Request that is granted
PLAN SPONSOR: City of Kent
PLAN NUMBER: 1018212
PLAN DOCUMENT EFFECTIVE DATE: January 1,2005
Such services shall be included in the Claims Administrator's Administration Fee set forth
in Attachment C.
8. HP's Notice of Privacy Practices.
81 Preparation of the HP's Notice of Privacy Practices. Claims Administrator will
provide the HP a copy of notice of privacy practices as it relates to the Claims
Administrator's functions and activities contained in the Contract and this
Attachment, which the HP shall incorporate into the HP's Notice of Privacy
Practices (the"Privacy Notice").
82 Amendment of the HP's Privacy Notice the HP shall be responsible for
modifying the Privacy Notice in the event that the HP,the Plan Sponsor or the
Claims Administrator materially changes its privacy policies, procedures or
practices that affect the Privacy Notice The party necessitating the change to
the Pnvacy Notice shall bear any reasonable costs associated with revising and
distributing the Privacy Notice. The HP,the Plan Sponsor and the Claims
Administrator will not institute such material change before the effective date of
the HP's revised Privacy Notice.
83 Distribution of the HP's Privacy Notice of Privacy Practices The HP shall be
responsible for the distribution of its Privacy Notice,and any revisions to its
Privacy Notice within a reasonable time
9. Term and Termination.
9.1 Term The Term of this Attachment shall begin as of the Effective Date
contained herein and shall remain in effect for the duration of the Contract
92 Termination for Breach of Privacy Obligations The HP will have the right to
terminate the Contract if the Claims Administrator has engaged in a pattern of
activity or practice that constitutes a material breach or violation of the Claims
Administrator's obligations regarding PPI under this Attachment The contractual
requirements for termination are outlined in the Contract
93 Effect of Termination.
a. Return or Destruction of PPI Upon Termination of Contract Upon
cancellation,termination,expiration or other conclusion of the Contract,
the Claims Administrator will, if feasible, return to the HP or else destroy
PPI, in whatever form or medium that the Claims Administrator, created
or received for or from the HP, including all copies of and any data or
compilations derived from such PPI that allow identification of any
Individual The Claims Administrator will complete such return or
destruction as promptly as practical, but not later than sixty days after the
effective date of the cancellation, termination, expiration or other
conclusion of the Contract
' b. Reimbursement The Plan Sponsor will reimburse the Claims
Administrator's reasonable costs and expenses incurred in returning or
destroying such PPI.
C. Disposition When Return or Destruction of PPI is Not Feasible In the
event that returning or destroying the PPI is not feasible as determined
by the Claims Administrator, the Claims Administrator will limit further
use or disclosure of the PPI to those purposes that make their return to
the HP or destruction infeasible and shall extend the privacy protections
PLAN SPONSOR: City of Kent
PLAN NUMBER: 1018212
PLAN DOCUMENT EFFECTIVE DATE: January 1, 2005
contained herein to that PPI for as long as the Claims Administrator
retains it
10. Order of Precedence. This Attachment shall supersede and replace any and all
provisions in the Contract concerning confidentiality or privacy In addition,the notice
provisions of this Attachment shall prevail over the Contract only to the extent that such
notice is related to the obligations contained herein Except as otherwise provided in this
section, in the event that any other terms or conditions contained in this Attachment
conflict or are inconsistent with the Contract,the terms and conditions of the Contract
shall prevail
IN WITNESS WHEREOF,the parties have signed this Attachment effective as of the date
indicated above
CLAIMS ADMINISTRATOR
Its: President and Chief Executive Officer
PLAN SPONSOR
Its.
Dated:
HP
i
Its:
Dated:
Z
I
PLAN SPONSOR: City of Kent
PLAN NUMBER: 1018212
PLAN DOCUMENT EFFECTIVE DATE: January 1, 2005
EXHIBIT D-1
NON-ERISA GROUP BUSINESS ASSOCIATE ATTACHMENT
Notification Requirements
Privacy-Related Services Regarding Requests
iAll notices required under Section 7 this Attachment shall be given in writing,delivered by
facsimile or in person, and addressed as follows
HP:
(Name)
(Department)
(Telephone Number)
(Fax Number)
Claims Administrator:
Premera Blue Cross Complaints and Appeals Department
P.O Box 91102
Seattle,WA 98111-9202
Telephone 1.800 345 6784
Fax 425 918 5592
PLAN SPONSOR: City of Kent
PLAN NUMBER: 1018212
PLAN DOCUMENT EFFECTIVE DATE: January 1, 2005
ATTACHMENT E
CARE FACILITATION
Claims Administrator agrees to provide the following care facilitation programs for the fees shown
in Attachment C
Service Description
Care Management ,
Clinical review Prospective and retrospective review for medical
necessity,appropriate application of benefits Prospective
review is not mandatory for provision of benefits.
Case management Voluntary program to provide cost-effective alternatives for
care of complex or catastrophic conditions.
Health Awareness Education Includes preventive care programs for members
immunization reminders, cancer screening reminders,and
health education and information.
Quality Programs Includes provision of evidence-based clinical practice and
preventive care guidelines to members and providers,
chart tools, and quality of care program activities
Prescription drug formulary Development of formulary and access to providers and
promotion members on-line
Physician-based pharmacy Physician education on cost-effective prescribing
management
ePocrates Software to provide physicians with up-to-date drug and
plan formulary information.
Polypharmacy Education for members using multiple drugs to review
prescriptions with their providers to decrease incidences of
adverse drug interactions
Point-of-sale Pharmacy Follow-up with members and physicians to minimize
inappropriate or excessive drug therapies identified when
drugs are dispensed
Disease Management
Oncology Educates members and assists members and providers in
managing breast& lung cancer This program is included
as a part of Care Management services.
Cardiac and Diabetes Educates members and assists members and providers in
managing coronary artery disease, congestive heart
failure, and diabetes ,
PLAN SPONSOR: City of Kent
PLAN NUMBER: 1018212
PLAN DOCUMENT EFFECTIVE DATE: January 1, 2005
Pharmacy Rebate
Demand Management Round-the-dock access for members to RNs to answer
questions about health care.
r
1
PLAN SPONSOR: City of Kent
PLAN NUMBER: 1018212
PLAN DOCUMENT EFFECTIVE DATE: January 1, 2005
I
i
ATTACHMENT F
j
RIGHT OF CONVERSION FOR TERMINATED
MEMBERS
The Plan Sponsor requests that the Claims Administrator provide a conversion privilege to
terminated Members in consideration of the following-
Responsibilities of the Claims Administrator
The Claims Administrator shall make available to Members an opportunity to obtain health care
coverage(hereinafter referred to as Conversion Contract)when they are no longer eligible for
coverage under the Plan due to,
Termination of employment.
• Termination of benefits for the class in which the Member belongs
• A covered dependent's attainment of the limiting age
• A covered spouse's legal separation or divorce
• Death of a covered employee.
The Claims Administrator shall not be required to issue a Conversion Contract if the Member
becomes covered under a group health insurance policy within 31 days after termination of his or
her coverage under the Plan.
Application and payment of the applicable rate for the Conversion Contract must be made by the
Member within 31 days after such mdividual's conversion pnvdege of its group health coverage
contracts
Rates for the Conversion Contract shall be determined by the Claims Administrator and be the
same as those then in effect for coverage offered under the standard conversion privilege of its
group health coverage contracts Rates will not be guaranteed and the Claims Administrator will
have the right to change the rate of any Conversion Contract
Compensation
The Plan Sponsor shall pay the Claims Administrator a$1,000 conversion privilege fee for each
conversion contract issued to a former Member The Claims Administrator shall notify the Plan
Sponsor of the conversion privilege fees owed in connection with the weekly notification of claims
paid
PLAN SPONSOR: City of Kent
PLAN NUMBER: 1018212
PLAN DOCUMENT EFFECTIVE DATE: January 1, 2005
i
Kent City Council Meeting
Date June 21, 2005
Category Consent Calendar
1. SUBJECT: GROUP HEALTH COOPERATIVE 2005 CONTRACT—
AUTHORIZE
2. SUMMARY STATEMENT: Authorize the Mayor to sign the 2005 Group Health
Cooperative of Puget Sound contract for the City's insured HMO plan. The 2005
contract reflects an approximate 5.8% increase in the health care premiums charged by
Group Health and is budgeted in the Health and Welfare fund.
3. EXHIBITS: Group Health Contract
4. RECOMMENDED BY: Operations Committee
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? X Revenue?
Currently in the Budget? Yes X No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6J
@GwupHealth
COOPERATIVE
Group Medical Coverage Agreement
for
Kent,City Of
Group Health Cooperative(also referred to as"GHC")is a nonprofit health maintenance organization furnishing
health care coverage on a prepayment basis The Group identified below wishes to purchase such coverage This
Agreement sets forth the terms under which that coverage will be provided,including the rights and responsibilities
of the contracting parties,requirements for enrollment and eligibility, and benefits to which those enrolled under this
Agreement are entitled
The Agreement between GHC and the Group consists of the following
' • Standard Provisions
• Attached Benefit Booklet
• Signed Group application
• Premiums Schedule
• All attachments and endorsements included or issued hereafter
Group Health Cooperative
Signed
Title President and Chief Executive Officer
Kent,City Of,0036900
Signed
Title
This Agreement will become effective January I,2005 and will continue in effect until terminated
or renewed as herein provided for
PA-113302
C23687-0036900
1
1
@GroupHealth
COOPERATIVE
Group Medical Coverage Agreement
Table of Contents
Standard Provisions
Attachment 1 Medicare Endorsement
Attachment 2 Benefit Booklet
Attachment 3 Premiums Schedule
C23687-0036900 2
Standard Provisions
1. GHC agrees to provide benefits as set forth in the attached Benefit Booklet to enrollees of the Group
2. Monthly Premiums Payments. For the initial term of this Agreement,the Group shall submit to GHC for each
Member the monthly premiums set forth in the current Premiums Schedule and a verification of enrollment
Payment must be received on or before the due date and is subject to a grace period often(10)days Premiums
are subject to change by GHC upon thirty(30)days written notice Premium rates will be revised as apart of
the annual renewal process
In the event the Group increases or decreases enrollment at least twenty-five percent(25%)or more,GHC
reserves the right to require re-rating of the Group
3. Dissemination of Information. Unless the Group has accepted responsibility to do so,GHC will disseminate
information describing benefits set forth in the Benefit Booklet attached to this Agreement
4. Identification Cards.GHC will furnish cards,for identification purposes only,to all Members enrolled under
this Agreement
5. Administration of Agreement.GHC may adopt reasonable policies and procedures to help in the
administration of this Agreement GHC reserves the right to construe the provisions of this Agreement and to
make all determinations regarding benefit entitlement and coverage
6. Modification of Agreement. Except as required by federal and Washington State law,this Agreement may not
be modified without agreement between both parties
No oral statement of any person shall modify or otherwise affect the benefits,limitations and exclusions of this
Agreement,convey or void any coverage,increase or reduce any benefits under this Agreement or be used in
the prosecution or defense of a claim under this Agreement
7. Indemnification. GHC agrees to indemnify and hold the Group harmless against all claims,damages,losses
and expenses, including reasonable attorney's fees,arising out of GHC's failure to perform, negligent
performances or willful misconduct of its directors,officers,employees and agents of their express obligations
under this Agreement
The Group agrees to indemnify and hold GHC harmless against all claims,damages,losses and expenses,
including reasonable attorney's fees,arising out of the Group's failure to perform,negligent performances or
willful misconduct of its directors,officers,employees and agents of their express obligations under this
Agreement
The indemnifying party shall give the other party prompt notice of any claim covered by this section and
provide reasonable assistance(at its expense) The indemnifying party shall have the right and duty to assume
the control of the defense thereof with counsel reasonably acceptable to the other party. Either party may take
part in the defense at its own expense after the other party assumes the control thereof
S. Compliance With Law. The Group and GHC shall comply with all applicable state and federal laws and
regulations in performance of this Agreement
This Agreement is entered into and governed by the laws of Washington State,except as otherwise pre-empted
by ERISA and other federal laws
9. Governmental Approval. If GHC has not received any necessary government approval by the date when
notice is required under this Agreement,GHC will notify the Group of any changes once govemmental
approval has been received GHC may amend this Agreement by giving notice to the Group upon receipt of
government approved rates,benefits,limitations,exclusions or other provisions,in which case such rates,
benefits, limitations,exclusions or provisions will go into effect as required by the governmental agency All
C23687-0036900 3
amendments are deemed accepted by the Group unless the Group gives GHC written notice of non-acceptance
within thirty(30)days after receipt of the amendment,in which event this Agreement and all rights to services
and other benefits terminate the first of the month following thirty(30)days after receipt of non-acceptance
10. Confidentiality. Each party acknowledges that performance of its obligations under this Agreement may
involve access to and disclosure of data,procedures,materials,lists,systems and information,including
medical records,employee benefits information,employee addresses,social security numbers,e-mail addresses,
phone numbers and other confidential information regarding the Group's employees(collectively the
"information") The information shall be kept strictly confidential and shall not be disclosed to any third party '
other than (i)representatives of the receiving party(as permitted by applicable state and federal law)who have
a need to know such information in order to perform the services required of such party pursuant to this
Agreement,or for the proper management and administration of the receiving party,provided that such
representatives are informed of the confidentiality provisions of this Agreement and agree to abide by them,(u)
pursuant to court order or(in)to a designated public official or agency pursuant to the requirements of federal,
state or local law,statute,rule or regulation The disclosing party will provide the other party with prompt
notice of any request the disclosing party receives to disclose information pursuant to applicable legal
requirements,so that the other party may object to the request and/or seek an appropriate protective order
against such request Each party shall maintain the confidentiality of medical records and confidential patient
and employee information as required by applicable law.
11. Arbitration. Any dispute,controversy or difference between GHC and the Group arising out of or relating to
this Agreement,or the breach thereof,shall be settled by arbitration in Seattle,Washington in accordance with
the Commercial Arbitration Rules of the American Arbitration Association,and3udgment on the award
rendered by the arbitrator(s)maybe entered in any court having jurisdiction thereof Except as maybe required
by law,neither party nor an arbitrator may disclose the existence,content or results of any arbitration hereunder
without the prior written consent of both parties
12. HIPAA.
Definition of Terms. Terms used,but not otherwise defined,in this section shall have the same meaning as
those terms have in the Health Insurance Portability and Accountability Act of 1996("HIPAA").
Transactions Accepted. GHC will accept Standard Transactions,pursuant to HIPAA,if the Group elects to
transmit such transactions If the Group sends transactions to GHC that do not comply with applicable HIPAA
standards,the Group will be deemed by such action to be representing and warranting that it is not a Covered
Entity or otherwise required to comply with HIPAA standards for electronic transactions,either directly,or as
an agent of another individual or entity. The parties agree that all the terms,conditions,representations and
warranties contained in this section are express obligations of the Group,and the Group shall indemnify GHC
for any breach of this section
13. Termination of Entire Agreement. This is a guaranteed renewable Agreement and cannot be terminated
without the mutual approval of each of the parties,except in the circumstances set forth below
a. Nonpayment or Non-Acceptance of Premium.Failure to make any monthly premium payment or
contribution in accordance with subsection 2 above shall result in termination of this Agreement as of the
premium due date The Group's failure to accept the revised premiums provided as part of the annual
renewal process shall be considered nonpayment and result in non-renewal of this Agreement The Group
may terminate this Agreement upon fifteen(15)days written notice of premium increase,as set forth in
subsection 2 above
b. Misrepresentation. GHC may terminate this Agreement upon written notice in the event that material
misrepresentation,fraud or omission of information was used in order to obtain Group coverage Either
party may terminate this Agreement in the event of material misrepresentation,fraud or omission of
information by the other party in performance of its responsibilities under this Agreement
C23687-0036900 4
c. Underwriting Guidelines.GHC may terminate or non-renew this Agreement in the event the Group no
longer meets underwnting guidelines established by GHC that were in effect at the time the Group was
accepted
d. The Group may terminate this Agreement by giving thirty(30)days written notice to GHC
14. Withdrawal or Cessation of Services.
a GHC may determine to withdraw from a Service Area or from a segment of its Service Area after GHC has
demonstrated to the Washington State Office of the Insurance Commissioner that GHC's clinical,financial or
administrative capacity to service the covered Members would be exceeded
b. GHC may determine to cease to offer the Group's current plan and replace the plan with another plan offered
to all covered Members within that line of business that includes all of the health care services covered under
the replaced plan and does not significantly limit access to the services covered under the replaced plan GHC
may also allow unrestricted conversion to a fully comparable GHC product.
GHC will provide written notice to each covered Member of the discontinuation or non-renewal of the plan at least
ninety(90)days prior to discontinuation.
C23687-0036900 5
Medicare ,
Endorsement
For Persons Covered by Parts A and B of Medicare
THE PROVISIONS OF THE GROUP MEDICAL COVERAGE AGREEMENT SHALL
REMAIN IN EFFECT EXCEPT AS MODIFIED BY THE ADDITION OF THE PROVISIONS,
EXCLUSIONS, AND LIMITATIONS CONTAINED IN THIS MEDICARE ENDORSEMENT.
IN NO EVENT SHALL THE BENEFITS UNDER THIS ENDORSEMENT DUPLICATE THE
BENEFITS UNDER THE GROUP MEDICAL COVERAGE AGREEMENT. THE HIGHER
LEVEL OF BENEFIT WILL APPLY. COVERAGE UNDER THIS GROUP MEDICAL
COVERAGE AGREEMENT IS INTEGRATED WITH THE MEDICAL AND HOSPITAL
BENEFITS ESTABLISHED BY TITLE 18 OF THE SOCIAL SECURITY ACT AS
AMENDED, AND REFERRED TO AS "MEDICARE." THE BENEFITS AND EXCLUSIONS
DESCRIBED IN THIS ENDORSEMENT APPLY ONLY TO MEMBERS WHO ARE
COVERED UNDER BOTH PART A AND PART B OF MEDICARE
Group Health Cooperative(GHC) offers two parts of Medicare arrangements for employer
Group Members living in the Group Health Service Area.
1) If you are a Member living in the Service Area where the Group Health Medicare Advantage
Plan(previously called the Medicare+Choice Plan) is available you must have both Parts A '
&B of Medicare and be enrolled in this plan Those enrolled under GHC's Medicare plan,
as set forth in this Endorsement, may be subject to Copayment.
2) If you are a Member living in the Service Area where the Medicare Advantage plan is not
available,you must still enroll in and maintain both Medicare Parts A& B in order for your
employer Group plan to coordinate benefits with Medicare.
3) In order to be eligible for Part B only benefits Members must have been enrolled in Group
Health prior to January 1, 1999.
Except as defined by Federal Regulations, all Members entitled to, or eligible to purchase
Medicare must transfer to the GHC Medicare Advantage Plan upon such entitlement or
eligibility. A condition of enrollment under the GHC Medicare Advantage Plan requires that a
Member be continuously enrolled for the hospital (Part A) and medical (Part B)benefits
available from the Social Security Administration, and sign any papers that may be required by
GHC or Medicare For additional information,the Member may refer to"Medicare & You
handbook,"which can be obtained from your local Social Security office
NEITHER GHC NOR MEDICARE MAY PAY FOR SERVICES PROVIDED AT NON-GHC
FACILITIES UNLESS THE MEMBER HAS BEEN REFERRED BY GHC OR THE
MEMBER HAS RECEIVED EMERGENCY OR URGENTLY NEEDED SERVICES OR OUT ,
OF AREA RENAL DIALYSIS SERVICES ACCORDING TO SECTIONS III E., F , AND I.17.
OF THIS MEDICARE ENDORSEMENT OR THE MEMBER HAS RECEIVED NON-
'
C23687-0036900 I
EMERGENT AND/OR NON-URGENTLY NEEDED CARE AT FACILITIES OUTSIDE THE
SERVICE AREA UNDER YOUR POINT OF SERVICE(POS) BENEFIT AS SET FORTH IN
SECTION III G.
This Endorsement does not constitute a"Medicare supplemental"contract.
SECTION I. CLAIMS PROCEDURE
Claims for services or supplies and explanation of Medicare benefits for services or supplies
should be sent to: Medicare Claims, Group Health Cooperative, P O Box 34585, Seattle, WA
98124-1585 If you must receive Emergency or Urgently Needed Services from a non-GHC
Provider,be sure to show your GHC membership card Although you never need to give up
your Medicare red, white and blue card,you must now use your GHC MA Plan care to receive
Covered Services It is important that you use only your GHC MA plan membership card----
NOT your Medicare card.
A. The Provider must file claims for services rendered during the first nine (9) months of a
calendar year by December 31 of the following calendar year.
B. The Provider must file claims for services rendered in the last three(3)months of a calendar
year the same as if the services had been furnished in the subsequent calendar year The time
limit on filing claims for services furnished in the last three(3)months of the calendar year is
December 31 of the second calendar year following the calendar year in which the services
were rendered.
GHC will notify the Member and Provider of its decision within 60 days after receipt of the
claim If the claim is denied in whole or in part, GHC will provide the Member a reason for the
denial and an explanation of the Member's right to appeal the denial, as set forth in Section V. of
this Agreement.
See "Medicare & You"handbook for additional information regarding filing claims, which can
be obtained from your local Social Security office, or your Washington State Part B carrier's
office, or call 1-800-772-1213, or online at www.Medicare gov
GHC may obtain information which it deems necessary concerning the medical care and
hospitalization for which payment is requested
SECTION II. DISENROLLMENT
Enrollment under the GHC MA Plan for a specific Member may be terminated in the
circumstances set forth below.
Until such time as a Member's termination of enrollment from GHC is effective, neither
Medicare nor any other Medicare Advantage organization shall pay for services for which GHC
E is responsible While a Member is enrolled with GHC,GHC will only cover the following
services provided by non-GHC Providers or non-GHC Facilities- (1) Referrals authorized by a
C23687-0036900
2
i
1
GHC Provider; (2)Emergency services anywhere in the world,Urgently Needed Care, or out of 1
the area renal dialysis services as set forth in Sections III E , F , and 117 ; or(3)Non-Emergent
and/or Non-Urgently Needed Care at facilities outside the Service Area under your Point of
Service(POS)benefit, as set forth in Section 111.G Upon termination of membership in GHC, 1
neither GHC nor GHC Providers shall have further liability or responsibility under this
Agreement for Member's health care services
A. Voluntary Disenrollment 1
You may choose to end your membership in the GHC Medicare Advantage Plan for any
reason. If you want to disenrolI,write a letter or complete a disenrollment form and send it to
the GHC Medicare Enrollment and Reconciliation, P.O Box 34255, Seattle,WA 98124-
9986. Make sure you sign and date your letter and/or form To get a disenrollment form, call
GHC Customer Service. You may also disenroll through any Social Security Administration
or Railroad Retirement Board office or you can call 1 (800)MEDICARE.
The date of your disenrollment will depend on when your request to disenroll is received In 1
general, requests to disenroll will be effective the first day of the month after the month the
disenrollment request is received.
Even though you have requested disenrollment,you must still get all routine services from 1
GHC Providers until you are notified of the effective date of your disenrollment GHC will
send you a letter that confirms when your disenrollment is effective. You will be covered by 1
Original Medicare after you disenroll from GHC unless you have joined another Medicare
Managed Care Plan.
B. Involuntary Disenrollment 1
GHC must disenroll you from the GHC MA Plan if:
1. You move permanently out of the Service Area for more than six (6) months at a time
and do not voluntarily disenroll, i
2. You do not stay continuously enrolled in both Medicare Part A and/or Part B; or
3. The contract between GHC and CMS under which the GHC MA Plan is offered is '
terminated, or the GHC MA Plan Service Area is reduced
GHC may disenroll you from the GHC MA Plan under the following conditions. i
1. If you supply fraudulent information or make misrepresentations on your individual i
election form which materially affects your eligibility to enroll in the GHC MA Plan,
2. If you are disruptive,unruly, abusive or uncooperative to the extent that your
membership in the GHC MA Plan seriously impairs our ability to arrange Covered 1
Services for you or other individuals enrolled in the plan Involuntary Disenrollment
on this basis is subject to prior approval by CMS;
1
C23687-0036900 3
3. If you allow another person to use your GHC MA Plan membership card to obtain
Covered Services;
4. You fail to pay the Plan basic Premiums. We will notify you of a 90-day grace period
to pay the premiums before you are disenrolled Your 90-day grace period will start
as of the date you are notified of the delinquent payment.
C. Persons Hospitalized on the Date of Termination.A Member who is a registered bed
patient receiving Covered Services in a GHC Facility on the date of termination shall
continue to receive covered inpatient services, until discharge from the facility. This
continued coverage will also apply to a Member hospitalized in a Medicare-certified non-
GHC Facility as a result of Emergency or Urgently Needed Services or Referral as set forth
' in Section IV.B. of this Medicare Endorsement
D. Services Provided After Termination. Any services provided by GHC after the effective
' date of termination(except those services covered under Section II C of this Medicare
Endorsement) shall be charged according to the Fee Schedule The Subscriber shall be liable
for payment of all such charges for services provided to the Subscriber and all Dependents
SECTION III. SCHEDULE OF MEDICAL BENEFITS
' All benefits and services listed in this Schedule of Benefits: _
• are subject to all provisions of this Agreement and Medicare Endorsement;
• must be approved in advance by GHC except for Emergency and Urgently Needed Services
as set forth in Section III E. of this Medicare Endorsement, and
' • must meet Medicare guidelines and limitations unless otherwise specified.
GHC has procedures to assist GHC Providers in establishing a treatment plan for Members with
complex or serious Medical Conditions New Members should discuss all his/her medical
concerns with the GHC Personal Physician selected New Members may expect their health
' status to be assessed within 90 days of their enrollment.
GHC will ensure that services are provided in a culturally competent manner. GHC Providers
will provide information regarding treatment options in a culturally competent manner and will
' accommodate Members with disabilities
GHC covers all Medicare deductibles and coinsurance The booklet, "Medicare & You"
' provides additional information about Medicare benefits and can be obtained from your local
Social Security office, or your Washington State Part B carrier's office
' Services received at facilities outside the GHC Service Area may be covered for non-emergent
and/or non-Urgently Needed Care subject to the Point of Service benefits set forth in the
C23687-0036900 4
1
Summary of Medical Benefits. All Medicare non-covered expenses, including deductibles and '
coinsurance,are the responsibility of the Member.
A. Inpatient Hospital Care '
Covered services include,but are not limited to,the following:
• Semiprivate room(or a private room if Medically Necessary). '
• Meals including special diets
• Regular nursing services.
• Costs of special care units (such as intensive or coronary care units).
• Drugs and medications,
• Lab tests.
• X-rays and other radiology services.
• Necessary surgical and medical supplies.
• Use of appliances, such as wheelchairs. ,
• Operating and recovery room costs.
• Rehabilitation services, such as physical therapy, occupational therapy, and speech
therapy services. '
• Under certain conditions,the following types of transplants are covered: corneal, kidney,
pancreas, heart, liver, lung,heart/lung, bone marrow, stem cell, mtestmal/multi-visceral.
See the Group Medical Coverage Agreement for more information about transplants. '
• Blood- coverage of storage and administration begins with the first pint of blood that you
need.
• Physician services. ,
B. Skilled Nursing Facility. Upon Referral and following a Medicare-certified three(3) day
hospital stay, GHC will cover 100 days of Medicare covered Skilled Nursing Facility care ,
per benefit period All Medicare criteria must be met and the stay must be authorized in
advance by the plan When a 3 day Medicare covered hospital stay does not occur and the
plan determines that the Member otherwise meets all Medicare criteria, the plan may ,
authorize Medicare covered Skilled Nursing care for up to 100 days.
C. Hospice. '
Members with Part A and Part B of Medicare who elect to receive Medicare-covered hospice
services may select any Medicare-certified hospice program. Members who elect to receive ,
services from the GHC Hospice Program are entitled to hospice services as provided under
the Medicare Hospice Program Members who elect to receive hospice services do so in lieu
of curative treatment for their terminal illness for the period that they are in the hospice '
program. To receive hospice services, the Member is required to sign the Hospice Election
Form
Covered Services. In addition to the hospice services provided under the Group Medical
Coverage Agreement,the following hospice services shall be provided:
C23687-0036900 5
t
1. Home Services
Continuous care services per Member in the Member's home when prescribed by a GHC
Provider,as set forth in this paragraph Continuous care is defined as"skilled nursing
care provided in the home during a period of crisis in order to maintain the terminally ill
patient at home."Continuous care may be provided for pain or symptom management by
a Registered Nurse, Licensed Practical Nurse, or Home Health Aide under the
supervision of a Registered Nurse. Continuous care may be provided up to twenty-four
(24) hours per day during periods of crisis Continuous care is covered only when a GHC
Provider determines that the Member otherwise would require hospitalization in an acute
care facility.
2. Inpatient Hospice Services for short-term care shall be provided through a Medicare-
certified Hospice Program when Medically Necessary, and authorized in advance by a
GHC Provider. Respite care is covered for a maximum of five (5) consecutive days per
occurrence in order to continue care for the Member in the temporary absence of the
' Member's primary care-giver(s).
3. Other hospice services may include the following:
a. drugs and biologicals that are used primarily for the relief of pain and symptom
management;
' b. medical appliances and supplies primarily for the relief of pain and symptom
management;
' c. counseling services for the Member and his/her primary care-giver(s); and
' d. bereavement counseling services for the family.
D. Mental Health Care,Alcoholism and Drug Abuse Treatment Services.
' 1. Outpatient mental health, alcoholism and substance abuse treatment services are
covered for each Member in accordance with Medicare Guidelines
2. Inpatient mental health care services are covered subject to the applicable Copayment
up to a 190-day lifetime benefit when such services are provided in a Medicare-certified
psychiatric hospital.
3. Inpatient alcoholism and drug abuse treatment services are covered subject to the
applicable Copayment when such services are provided in a hospital-based treatment
center.
Coverage for Medical Emergencies incident to alcoholism and drug abuse or for acute
alcoholism or drug abuse, including acute detoxification, is provided as set forth in
Section III D of this Medicare Endorsement.
C23687-0036900 6
E. Emergency/Urgently Needed Services. When an Emergency meets the Medicare definition ,
for Emergency or Urgently Needed Services as defined in Section VII of this Medicare
Endorsement,services are covered subject to the applicable Copayments. '
F. If the Member is hospitalized in a non-GHC Facility and requires continued inpatient care
GHC will continue to cover the non-emergent care and services at the non-GHC Facility '
needed by the Member to remain medically stable until- (1)the Member is discharged, (2) a
GHC Provider assumes responsibility for the Member's care, or(3) GHC and the Member's
treating physician decide the Member may be transferred without harmful medical
consequences whichever occurs first. A decision to transfer the Member to a GHC Facility is
made at the discretion of GHC with the attending physician's concurrence
Post-stabilization care at a non-GHC Facility will be covered when: (a) Pre-approved by ,
Group Health,or(b)Not pre-approved because Group Health did not respond to the request
for pre-approval within one(1)hour after being requested to approve such care, or Group ,
Health could not be contacted for pre-approval.
G. Point of Service(POS). Non-Emergent and/or non-Urgently Needed Care received while
temporarily traveling outside GHC's Medicare Service Area is payable at Medicare benefit
levels up to $2,000.00 per Member per calendar year The plan pays 80%of the Medicare
allowable reimbursement schedules for Medicare covered services only. The enrollee is
responsible for all Medicare deductibles and coinsurance. Coverage under this benefit does '
NOT include coverage of prescription drugs or services received when traveling primarily for
the purpose of seeking medical care.
H. Medicare Ambulance Benefit (including air,water,or ground transport)Medically ,
Necessary ambulance transportation to or from a hospital or Skilled Nursing Facility is
covered subject to the applicable Copayment Medically Necessary Emergency ambulance '
transportation outside the United States or the U.S. territories is covered only if
transportation by any other vehicle could endanger the patient's health
I. Medical and Surgical Care.The following medical and surgical services are covered when ,
prescribed by GHC Medical Personnel and Medicare requirements are met
1. Eye examinations and treatment for eye pathology.
Evaluations and surgical procedures to correct refractions which are not related to eye ,
pathology are not covered. Complications related to such surgery are also excluded
2. Frames and Lenses. One pair of standard eyeglasses or contact lenses, including '
examination and fitting, following each cataract surgery with insertion of an mtraocular
lens (IOL) Covered eyeglasses and contact lenses must be dispensed through GHC
Facilities Replacements for Members following insertion of an mtraocular lens are set '
forth in Section IIl I.14. below. Replacements in the absence of an mtraocular lens will
C23687-0036900 7
be provided when needed due to change in the Member's Medical Condition or when
deemed appropriate by a GHC physician.
' 3. Blood,blood derivatives, including storage, and their administration.
4. Maternity and pregnancy-related services, including visits before and afterbirth,
involuntary termination of pregnancy, and care for any other complication of pregnancy.
5. Organ transplants, limited to those covered by Medicare when all Medicare criteria
have been met.
6. Physician calls (including consultations and second opinions by a GHC Personal
Physician) in the hospital, office,home, Skilled Nursing Facility,nursing home, or
convalescent center
7. Outpatient surgery in outpatient hospital facility or ambulatory surgical center covered
subject to applicable Copayment
8. Restorative physical, occupational, speech and language therapy, and cardiac
' rehabilitation following illness, injury, or surgery
9. Immunizations and vaccinations that are listed as covered in the GHC drug formulary
' (approved drug list) or approved by Medicare.
10. Services related to dysfunction of the jaw. When referred by a GHC Personal
Physician, evaluation and treatment by a GHC-approved temporomandibular joint(TMJ)
care provider.
All TMJ appliances,other than the occlusal splint and its fitting, are excluded.
Treatment of jaw dysfunction, including TMJ dysfunction, will NOT be provided when
the dysfunction is related to malocclusion or when TMJ services are needed due to dental
work performed All such services and related hospitalization, including orthodontic
therapy and orthognathic(law) surgery, are excluded regardless of origin or cause.
(See Section IV.B 17. of the Group Medical Coverage Agreement for Covered Services
not meeting Medicare guidelines).
11. Chiropractic care limited to spinal manipulations. Excluded are any other diagnostic or
therapeutic services,including x-rays, furnished by a chiropractor Members must receive
all chiropractor services from GHC's designated licensed providers in order to be
covered. A list of GHC-designated licensed practitioners is available by contacting any
GHC area medical center.
' 12. Podiatric care. Services are covered when all Medicare criteria are met and when
authorized in advance by your Personal Physician. Excluded is treatment of flat feet or
C23687-0036900
9
other misalignments of the feet; removal of corns and calluses; and routine foot care such '
as hygienic care, except in the presence of a non-related Medical Condition affecting the
lower limbs. Members must utilize GHC's designated providers in order to be covered
13. Home intravenous (1V) drug therapy services. 1
14. Routine eye examinations and refractions, limited to once every twenty-four(24)
months, except when Medically Necessary Services for routine eye examinations must
be received at a GHC Facility and in accordance with GHC medical criteria in order to be
covered and are not subject to Medicare requirements. '
Lenses. One pair of standard glass single vision, lenticular, or non-blended bifocal or
trifocal lenses, or contact lenses, will be covered subject to the GHC-approved Allowance ,
once every twenty-four(24) months, and replaced as specified below, when received at a
GHC Facility and in accordance with GHC medical criteria
Frames. An Allowance of up to $100 per Member once every 24 months will be '
provided for frames.
Replacements. Lens replacement for any reason(including loss,breakage or change in '
prescription)will be provided not more often than once every 24 months
Replacement of frames will be provided subject to the frames Allowance set forth above '
not more often than once every 24 months.
15.Hearing examinations to determine hearing loss. Hearing aids, including examinations '
and fitting, must be received at a GHC Facility and are covered up to a maximum of$250
per Member once every 24 months.
16. Diabetic education and training, including glucose monitors testing strips and lancets
for at] diabetics.
17. Renal dialysis services required while temporarily away from the Service Area will be '
covered if provided in a Medicare-approved facility when Medicare criteria is met
J. Prosthetic Devices, such as cardiac devices,intraocular lenses, artificial joints, breast '
prostheses, artificial eyes, and braces, are covered. Excluded are. orthopedic shoes unless
they are part of leg braces; dental plates or other dental devices; and experimental devices. ,
Therapeutic shoes for those suffering from diabetic foot disease are covered.
K. Medical/Surgical Supplies, such as casts, splints, post-surgical dressings, and ostomy '
supplies,are covered.
L. Rental or Purchase of Durable Medical Equipment,such as oxygen and oxygen ,
equipment, wheelchairs and other walk-aids,and hospital beds, is covered
C23687-0036900 9
M. Health Club Services(SilverSneakers®) and/or lifetime fitness at participating network
health clubs in the Service Area are provided to Members without charge Unlimited
Covered Services include. traditional weight and cardiac equipment,pools, aerobics,and
court facilities In addition to club member privileges, a Member may bring a guest who is
Medicare eligible for one visit up to four times per year without charge A list of
participating network health clubs may be obtained from GHC upon request.
SECTION IV. EXCLUSIONS AND LIMITATIONS
A. Exclusions.
1. Investigational procedures, including medical and surgical services, drugs and devices
until formally approved by Medicare unless specifically provided herein(See Section
V.19 in the Group Medical Coverage Agreement).
2. Supportive devices (shoe inserts)for the feet, except therapeutic shoes for people with
diabetes who have severe diabetic foot disease,including fitting of shoes or inserts.
3. Services directly related to obesity except as provided by Medicare.
4. Services or supplies not specifically listed as covered by Medicare or GHC.
B. Limitations.
Conditions and Extent of Coverage. EXCEPT AS PROVIDED IN SECTIONS III E,F.,
G AND I.17 , ALL SERVICES AND BENEFITS UNDER THIS AGREEMENT MUST BE
PROVIDED BY GHC MEDICAL PERSONNEL AT A GHC FACILITY UNLESS:
' 1. the Member has received a Referral from GHC,or
2. the Member has received Emergency or Urgently Needed Services as defined in Section
1 VII. and as set forth in Sections III.E. and F. of this Medicare Endorsement
SECTION V. APPEAL AND GRIEVANCE PROCEDURES
A. Grievances.
If a Member is dissatisfied with care or services received at a Medical or Dental Office or
' Hospital, or a Member disputes amounts owed, eligibility or membership status,the Member
may submit a written grievance to GHC GHC will conduct a formal review and provide a
written response within 60 days of the time all pertinent materials are received.
B. Standard Expedited Requests for Care or Service.
' 1. Standard Request. The Member may request that care or a service be covered by GHC
on the basis that it is a Medicare covered service GHC will reach a decision within 14
C23687-0036900 10
1
1
days GHC's decision may be delayed an additional 14 days if it is in the Member's best '
interest or upon the Member's request.
2. Expedited Request. If a Member requests care or a service they believe is covered by
Medicare and the Member believes and/or his/her physician states that a delay in making
a determination about coverage could jeopardize the Member's health or ability to
function, the Member may request an expedited decision In most instances, GHC will
reach a decision within 72 hours. GHC's decision may be delayed an additional 14
working days if it is in the Member's best interest to delay a decision or upon the
Member's request. GHC's decision may also be postponed in the event information for a
non-GHC Provider has not been received in a timely manner If GHC grants a Member's
request for an expedited decision, GHC will orally notify the Member and follow-up
within two(2) working days, with a written letter. If a Member disagrees with GHC's
decision not to expedite his/her request,the Member may file a grievance.
C. Appeals.
Members have a right to appeal any decision in which GHC declines to provide, cover,or
pay for services that the Member believes are covered by Medicare. If GHC declines to
provide or to cover a service,GHC will provide the Member with a Notice of Non-coverage
containing the reason(s) for the denial and an explanation of the Member's appeal rights
Members who disagree with a decision by GHC may submit a written appeal to GHC. ,
Members appealing a denied claim for payment for a service already provided or arranged
may request a standard 60-day appeal. Members appealing a request for a future service may
ask for either a standard 30 day appeal or an Expedited (72-hour) appeal if the Member '
believes (or the Member's Provider states) that a delay in responding to the Member's appeal
could seriously jeopardize his/her health or ability to function
Appeals will be reviewed by persons not involved in the initial decision. If GHC decides to '
uphold the original adverse decision, either in whole or in part, the entire file will be
forwarded by GHC to CMS's contractor, The Center for Health Dispute Resolution(CHDR)
for review
1. Standard Appeal. '
a. 60-Day Appeals for Claim for Payment. A Member may submit an appeal
requesting a second review at any time GHC denies coverage for services already ,
provided or arranged by either GHC or a non-GHC Provider or Facility, or for future
services Member must submit appeals in writing to GHC, or to any Social Security
Office,or in the case of a railroad retirement annuitant, a Railroad Retirement Board '
Office, within 60 days of receiving notice of GHC's initial decision. After receiving
all pertinent materials, GHC will conduct a formal review of the appeal GHC will
notify the Member of its decision within 60 days of receipt. If GHC decides fully in
the Member's favor, GHC will pay the claim(s) within 60 days of receipt of the
Member's appeal. If GHC upholds any part of the initial denial, the entire file will be
r
C23687-0036900 11
. 1
i
1 forwarded by GHC to CHDR for review. CHDR will make a reconsideration decision
and advise the Member of its decision, the reasons for the decision and the right to
additional appeal rights.
1 b. 30-Day Appeals for Denials of Future Services. A Member may submit an appeal
requesting a second review at any time GHC denies coverage for future services.
Members must submit appeals in writing to GHC, or to any Social Security Office, or
1 in the case of a railroad retirement annuitant,a Railroad Retirement Board Office,
within 60 days of the date of GHC's initial decision. After receiving all pertinent
materials, GHC will conduct a formal review of the appeal GHC will notify the
Member of its decision within 30 days of receipt GHC's decision may be extended
an additional 14 days if it is in the Member's best interest or upon the Member's
request. If GHC upholds any part of the initial denial, the entire file will be
1 forwarded by GHC to CHDR for review. CHDR will make a reconsideration
decision and advise the Member of its decision, the reason for the decision, and the
right to additional appeal rights.
1 2. Filing an Expedited(72-hour)Appeal(does not apply to denied claims for payment).
1 If a delay in receiving a decision could jeopardize the Member's health or ability to
function, the Member or his/her Physician may submit a request for an expedited appeal
either orally or in writing to GHC.
' D. Quality Improvement Organization ("QIO").
"QIO" stands for Quality Improvement Organization(these organizations used to be called
"Peer Review Organizations"or PROS) The QIO is a group of doctors and other health care
experts paid by the Federal Government to check on and help improve the care given to
Medicare patients There is a QIO in each state. QIOs have different names, depending on
which state they are in. In Washington State, the Q10 is called Qualis Health.
1 A Member may request a"QIO"review if GHC denies coverage of a continued inpatient
stay in a hospital on the basis of medical necessity. A Member may request immediate QIO
review by phone or in writing If a Member requests a QIO review by noon of the first
business day after a Member has received a Notice of Non-coverage, the Member will not be
financially responsible for the cost of the continued hospitalization until the QIO's
determination.
' GHC will provide the Member written notice of procedures by which to request a QIO
review If a Member requests a QIO review,the Member may not pursue the Standard
Appeal Procedure and/or the Expedited Appeal Procedure with respect to denial of the same
hospital stay
A Member may contact Qualis Health at P.0 Box 33400,Seattle, WA 98133-0400 or 10700
' Meridian Ave N, Suite 100, Seattle, WA 98133-9075;telephone number(206) 364-9700 or
Fax. (206) 368-2419.
C23687-0036900 12
t
E. Additional Appeal Rights. ,
If CMS upholds GHC's initial determination and denies the appeal and if the amount in ,
controversy is $100.00, or more the Member may request a hearing before an administrative
law judge of the Social Security Administration The Member may request a hearing before
an administrative law judge by writing to GHC, CMS, or a Social Security Office within 60 '
days after the date of notice of an adverse reconsideration decision.
If the administrative law judge denies a Member's appeal,either the Member or GHC may
request a review by the Social Security Administration's (SSA's) Appeals Council.
If a Member's appeal is denied by the SSA's Appeals Council and if the amount in '
controversy is$1,000 00,or greater the Member or GHC may request a review by the
Medicare Appeals Council.
An initial,revised, or reconsideration determination made by GHC, CMS, an administrative ,
law judge,or the SSA's Appeals Council can be reopened(a)within twelve months, (b)
within four years for just cause, or(c) at any time for clerical correction or in the case of
fraud.
The Medicare Appeals Coordinator can be reached by writing to Group Health Cooperative,
c/o Medicare Appeals Coordinator,P.O. Box 34593, Seattle WA 981324, or by calling(206) '
901-7350 or toll-free at 1-(888)-9014636 or TTY/TDD 711 or 1-800-833-6388, for the
"hearing impaired"or by fax at(206) 901-7340.
SECTION V1. SUBROGATION AND REIMBURSEMENT RIGHTS ,
"Injured Person"under this section means a Member covered by the Agreement who sustains an
injury and any spouse, dependent or other person or entity that may recover on behalf of such
Member, including the estate of the Member and, if the Member is a minor, the guardian or
parent of the Member. When referred to in this section, "GHC's Medical Expenses"means the ,
expense incurred and the reasonable value of the services provided by GHC for the care or
treatment of the injury sustained by the Injured Person.
If the Injured Person's injuries were caused by a third party giving rise to a claim of legal '
liability against the third party and/or payment by the third party to the Injured Person and/or a
settlement between the third party and the Injured Person, GHC shall have the right to recover '
GHC's Medical Expenses from any source available to the Injured Person as a result of the
events causing the injury, including but not limited to funds available through applicable thud
party liability coverage and uninsured/underinsured motorist coverage. This right is commonly ,
referred to as"subrogation" GHC shall be subrogated to and may enforce all rights of the
Injured Person to the extent of GHC's Medical Expenses
If the Injured Person is entitled to or does receive money from any source as a result of the ,
events causing the injury, including but not limited to any party's liability insurance or
C23687-0036900 13
uninsured/underinsured motorist funds,then GHC's Medical Expenses provided or to be
provided to the Injured Person are secondary, not primary, and will be paid only if the Injured
Person fully cooperates with the terms and conditions of the Agreement As a condition of
receiving benefits under the Agreement,the Injured Person agrees that acceptance of GHC
services is constructive notice of this provision in its entirety and agrees to reimburse GHC for
the benefits the Injured Person received as a result of the events causing the injury. GHC's
1 subrogation and reimbursement rights shall be limited to the excess of the amount required to
fully compensate the Injured Person for the loss sustained, including general damages. Full
compensation shall be measured on an objective case-by-case basis unless the Injured Person
settles with the at-fault party for less than available policy limits, in which GHC is entitled to full
compensation of GHC's Medical Expenses. However, in the case of Medicare Advantage
Members, GHC's right of subrogation shall be the full amount of GHC's Medical Expenses
and is limited only as required by Medicare.
The Injured Person and his/her agents shall cooperate fully with GHC in its efforts to collect
GHC's Medical Expenses. This cooperation includes,but is not limited to, supplying GHC with
information about any third parties, defendants and/or insurers related to the Injured Person's
claim and informing GHC of any settlement or other payments relating to the Injured Person's
injury. The Injured Person and his/her agents shall permit GHC, at GHC's option, to associate
with the Injured Person or to intervene in any legal, quasi-legal, agency or any other action or
claim filed. If the Injured Person takes no action to recover money from any source, then the
Injured Person agrees to allow GHC to initiate its own direct action for reimbursement or
subrogation,including, but not limited to, billing the Injured Person directly for GHC's Medical
Expenses.
The Injured Person and his/her agents shall do nothing to prejudice GHC's subrogation and
reimbursement rights The Injured Person shall promptly notify GHC of any tentative settlement
with a third party and shall not settle a claim without protecting GHC's interest If the Injured
Person fails to cooperate fully with GHC in recovery of GHC's Medical Expenses, the Injured
Person shall be responsible for directly reimbursing GHC for GHC's Medical Expenses and
GHC retains the right to bill the Injured Person directly for GHC's Medical Expenses.
1 To the extent that the Injured Person recovers funds from any source, the Injured Person agrees
to hold such monies in trust or in their possession until GHC's subrogation and reimbursement
rights are fully determined.
GHC shall not pay any attorney's fees or collection costs to attorneys representing the Injured
Person unless there is a written fee agreement signed by GHC prior to any collection efforts.
When reasonable collection costs have been incurred with GHC's prior written agreement to
recover GHC's Medical Expenses,there shall be an equitable apportionment of such collection
costs between GHC and the Injured Person subject to a maximum responsibility of GHC equal to
one-third of the amount recovered on behalf of GHC. Under no circumstance will GHC pay legal
fees for services which were not reasonably and necessarily incurred to secure recovery,which
do not benefit GHC and/or where no written fee agreement has been entered into with GHC.
C23687-0036900
14
If it becomes necessary for GHC to enforce the provision of this section by initiating any action ,
against the Injured Person or his/her agent,then the Injured Person agrees to pay GHC's
attorney's fees and costs associated with the action.
Implementation of this section shall be deemed a part of claims administration under the ,
Agreement and GHC shall therefore have sole discretion to interpret its terms.
SECTION V1I. DEFINITIONS
CENTER for MEDICARE and MEDICAID SERVICES (CMS): The Federal Agency that
runs the Medicare program(CMS was formerly known as the Health Care Financing
Administration).
CUSTODIAL CARE: Care furnished for the purpose of meeting non-Medically Necessary '
personal needs which could be provided by persons without professional skills or training,such
as assistance in mobility, dressing,bathing, eating,preparation of special diets,and taking ,
medication. Custodial Care is not covered by the GHC MA Plan or Medicare unless provided in
conjunction with Skilled Nursing Care and/or skilled rehabilitation services.
EMERGENCY CARE: Covered services that are 1) furnished by a provider qualified to furnish
emergency services; and 2) needed to evaluate or stabilize an Emergency Medical Condition.
EMERGENCY MEDICAL CONDITION: A Medical Condition brought on by acute
symptoms of sufficient severity(including severe pain) such that a prudent lay person with an
average knowledge of health and medicine, could reasonably expect that not getting immediate
medical attention could result in 1) Serious jeopardy to the health of the individual (or, in the
case of a pregnant woman, the health of the woman or her unborn child); 2) Serious impairment
to bodily functions, or 3) Serious dysfunction of any bodily organ or part.
MAXIMUM CHARGES: A term used to define the level of benefits which are payable by
GHC when expenses are incurred from a non-GHC Personal Physician or Provider Expenses are
considered Maximum Charges if(1)the charges are consistent with those normally charged by
the provider or organization for the same services or supplies; and (2)the charges are within the
general range of charges made by other providers in the same geographical area for the same
services or supplies.
MEDICARE:The federal health insurance program for people 65 years of age or older, some
people under age 65 with disabilities and people with End Stage Renal Disease(generally those
with permanent kidney failure who need dialysis or a kidney transplant).
MEDICARE ADVANTAGE (MA) COORDINATED CARE PLANS: These are MA Plans
that use a network of providers that are under contract or arrangement with a Medicare
Advantage Organization to provide covered benefits The GHC Medicare Advantage Plan is a
Coordinated Care Plan ,
C23687-0036900 15
MEDICARE ADVANTAGE(MA) ORGANIZATION: A public or private organization
licensed by the State as a risk-bearing entity that is under contract with the Center for Medicare
and Medicaid Services (CMS) to provide Covered Services Medicare Advantage Organizations
' can offer one or more Medicare Advantage Plans. GHC is a Medicare Advantage Organization
MEDICARE ADVANTAGE(MA) PLAN: A benefit package offered by a Medicare Advantage
Organization that offers a specific set of health benefits at a uniform premium and uniform level
' of cost-sharing to all people with Medicare who live in the Service Area covered by the Plan A
Medicare Advantage Organization may offer more than one plan in the same Service Area The
GHC Plan is a Medicare Advantage plan.
PERMANENT MOVE: A permanent change of residence out of the Service Area or an
uninterrupted absence of more than six(6)months from GHC's Service Area.
POINT OF SERVICE (POS): A benefit that GHC offers to its Medicare Advantage Members
while temporarily traveling outside-of-the GHC Medicare Advantage Plan Service Area for non-
emergent and/or non-Urgently Needed Care. In return for this flexibility,Members have higher
cost-sharing requirements for these services.
REFERRAL:A request by your Personal Physician for you to receive care from a Specialist,
Contracting Medical Provider, or Non-Contracting Medical Provider, or to receive certain
Covered Services
tSERVICE AREA: The geographic area comprised of parts of Grays Harbor,Island, King,
Krtsap, Lewis,Pierce,parts of Mason, San Juan, Skagit, Snohomish, Thurston, and Whatcom
Counties, and any other areas designated by GHC and approved by CMS, within which an
eligible individual may enroll in a particular plan offered by GHC.
SKILLED NURSING FACILITY: A facility(or distinct part of a facility) which is primarily
engaged in providing to its residents inpatient Skilled Nursing Care, rehabilitation services,or
other related health services and is certified by Medicare The term"Skilled Nursing Facility"
does not include a convalescent nursing home, rest facility, or facility for the aged which
furnishes primarily Custodial Care, including training in routines of daily living
URGENTLY NEEDED CARE:Covered Services provided when you are temporarily absent
from the GHC Medicare Advantage Plan Service Area(or, under unusual and extraordinary
circumstances,provided when you are in the Service Area but your Contracting Medical Group
is temporarily unavailable or inaccessible) when such services are Medically Necessary and
immediately required 1)as a result of an unforeseen illness, injury, or condition, and 2) it is not
reasonable, given the circumstances,to obtain the services through your Contracting Medical
Group.
C23687-0036900
16
Medicare
Endorsement
For Persons Covered by Part B only of Medicare ,
THE PROVISIONS OF THE GROUP MEDICAL COVERAGE AGREEMENT SHALL '
REMAIN IN EFFECT EXCEPT AS MODIFIED BY THE ADDITION OF THE PROVISIONS,
EXCLUSIONS AND LIMITATIONS CONTAINED IN THIS MEDICARE ENDORSEMENT.
IN NO EVENT SHALL THE BENEFITS UNDER THIS ENDORSEMENT DUPLICATE THE
BENEFITS UNDER THE GROUP MEDICAL COVERAGE AGREEMENT. THE HIGHER
LEVEL OF BENEFIT WILL APPLY. COVERAGE UNDER THE GROUP MEDICAL
COVERAGE AGREEMENT IS INTEGRATED WITH THE MEDICAL BENEFITS
ESTABLISHED BY TITLE 18 OF THE SOCIAL SECURITY ACT AS AMENDED, AND
REFERRED TO AS "MEDICARE."THE BENEFITS AND EXCLUSIONS DESCRIBED IN
THIS ENDORSEMENT APPLY ONLY TO MEMBERS WHO ARE COVERED UNDER ,
PART B ONLY OF MEDICARE.
Group Health Cooperative offers two parts of Medicare arrangements for employer Group ,
Members living in the Group Health Service Area.
1) If you are a Member living in the Service Area where the Group Health Medicare Advantage
Plan (previously called the Medicare+Choice Plan) is available you must have both Parts A
&B of Medicare and be enrolled in this plan Those enrolled under GHC's Medicare plan,
as set forth in this Endorsement, may be subject to Copayment.
2) If you are a Member living in the Service Area where the Medicare Advantage plan is not
available,you must still enroll in and maintain both Medicare Parts A&B in order for your ,
employer Group plan to coordinate benefits with Medicare.
In order to be eligible for Part B benefits Members must have been enrolled in Group Health
prior to January 1, 1999.
Except as defined by Federal Regulations, all Members entitled to, or eligible to purchase
Medicare must transfer to the GHC Medicare Advantage Plan upon such entitlement or ,
eligibility. A condition of enrollment under the GHC Medicare Advantage Plan requires that a
Member be continuously enrolled for medical (Part B)benefits available from the Social
Security Administration, and sign any papers that may be required by GHC or Medicare ,
Advantage For additional information,the Member may refer to"Medicare& You,"handbook
which can be obtained from your local Social Security office.
NEITHER GHC NOR MEDICARE MAY PAY FOR SERVICES PROVIDED AT NON-GHC
FACILITIES UNLESS THE MEMBER HAS BEEN REFERRED BY GHC OR THE
MEMBER HAS RECEIVED EMERGENCY OR URGENTLY NEEDED SERVICES OR OUT
OF AREA RENAL DIALYSIS SERVICES ACCORDING TO SECTIONS III.0 , D , AND
G 17. OF THIS MEDICARE ENDORSEMENT OR THE MEMBER HAS RECEIVED NON-
,
C23687-0036900 17
EMERGENT AND/OR NON-URGENTLY NEEDED CARE AT FACILITIES OUTSIDE THE
SERVICE AREA UNDER YOUR POINT OF SERVICE(POS) BENEFIT AS SET FORTH IN
SECTION III.E.
This Endorsement does not constitute a"Medicare supplemental"contract.
1 SECTION 1. CLAIMS PROCEDURE
Claims for services or supplies and explanation of Medicare benefits for services or supplies
should be sent to. Medicare Claims,Group Health Cooperative, P O Box 34585,Seattle,WA
1 98124-1585 If you must receive Emergency or Urgently Needed Services from a non-GHC
Provider, be sure to show your GHC membership card. Although you never need to give up
your Medicare red, white and blue card,you must now use your GHC MA Plan care to receive
Covered Services. It is important that you use only your GHC MA plan membership card-----
NOTyour Medicare card.
A. The Provider must file claims for services rendered during the first nine(9)months of a
calendar year by December 31 of the following calendar year.
' B. The Provider must file claims for services rendered in the last three(3)months of a calendar
year the same as if the services had been furnished in the subsequent calendar year The time
limit on filing claims for services furnished in the last three (3) months of the calendar year is
I December 31 of the second calendar year following the calendar year in which the services
were rendered.
GHC will notify the Member of its decision within 60 days after receipt of the claim. If the
claim is denied in whole or in part, GHC will provide the Member a reason for the denial and an
explanation of the Member's right to appeal the denial, as set forth in Section V. of this
Agreement.
See "Medicare & You" handbook for additional information regarding filing claims, which can
be obtained from your local Social Security office, or your Washington State Part B carrier's
office, or call 1-800-772-1213, or online at www.Medicare.gov.
GHC may obtain information which it deems necessary concerning the medical care and
hospitalization for which payment is requested
SECTION II. DISENROLLMENT
Enrollment under the GHC Medicare Advantage Plan for a specific Member, may be terminated
in the circumstances set forth below.
1 Until such time as a Member's termination of enrollment from GHC is effective,neither
Medicare nor any other Medicare Advantage organization shall pay for services for which GHC
is responsible While a Member is enrolled with GHC, GHC will only cover the following
services provided by non-GHC Providers or non-GHC Facilities: (1) Referrals authorized by a
C23687-0036900
l8
f
f
GHC Provider; (2)Emergency services anywhere in the world, Urgently Needed Care, or out of '
the area renal dialysis services as set forth in Sections III C , D , and G.17., or(3)Non-Emergent
and/or Non-Urgently Needed Care at facilities outside the Service Area under your Point of
Service (POS)benefit, as set forth in Section III E. Upon termination of membership in GHC,
neither GHC nor GHC Providers shall have further liability or responsibility under this
Agreement for Member's health care services.
A. Voluntary Disenrollment '
You may choose to end your membership in GHC Medicare Advantage Plan for any reason If '
you want to disenroll, write a letter or complete a disenrollment form and send it to the GHC
Medicare Enrollment and Reconciliation,P.O Box 34255, Seattle,WA 98124-9986 Make
sure you sign and date your letter and/or form To get a disenrollment form, call GHC
Customer Service You may also disenroll through any Social Security Administration or
Railroad Retirement Board office or you can call 1 (800)MEDICARE.
The date of your disenrollment will depend on when your request to disenroll is received In
general, requests to disenroll will be effective the first day of the month after the month the
disenrollment request is received.
Even though you have requested disenrollment,you must still get all routine services from
GHC Providers until you are notified of the effective date of your disenrollment GHC will ,
send you a letter that confirms when your disenrollment is effective. You will be covered by
Original Medicare after you disenroll from GHC unless you have joined another Medicare
Managed Care Plan.
B. Involuntary Disenrollment.
GHC must disenroll you from the GHC MA Plan if.
1. You move permanently out of the Service Area for more than six(6) months at a time
and do not voluntarily disenroll or choose Continuation of coverage, '
2. You do not stay continuously enrolled in both Medicare Part A and/or Part B, or
3. The contract between GHC and CMS under which the GHC MA Plan is offered is
terminated, or the GHC MA Plan Service Area is reduced.
GHC may disenroll you from the GHC MA Plan under the following conditions:
1. If you supply fraudulent information or make misrepresentations on your individual
electron form which materially affects your eligibility to enroll in the GHC MA Plan,
2. If you are disruptive,unruly, abusive or uncooperative to the extent that your
membership in the GHC MA Plan seriously impairs our ability to arrange Covered
C23687-0036900 19
Services for you or other individuals enrolled in the plan. Involuntary Disenrollment
on this basis is subject to prior approval by CMS,
3. If you allow another person to use your GHC MA Plan membership card to obtain
Covered Service,
4. You fail to pay the Plan basic Premiums We will notify you of a 90-day grace period
to pay the premiums before you are disenrolled Your 90-day grace period will start
as of the date you are notified of the delinquent payment.
C. Persons Hospitalized on the Date of Termination. A Member who is a registered bed
patient receiving Covered Services in a GHC Facility on the date of termination shall
continue to receive covered inpatient services, until discharge from the facility. This
I continued coverage will also apply to a Member hospitalized in a Medicare-certified non-
GHC Facility as a result of Emergency or Urgently Needed Services or Referral as set forth
in Section IV B of this Medicare Endorsement
iD. Services Provided After Termination. Any services provided by GHC after the effective
date of termination(except those services covered under Section II C. of this Medicare
Endorsement) shall be charged according to the Fee Schedule The Subscriber shall be liable
for payment of all such charges for services provided to the Subscriber and all Dependents.
SECTION III. SCHEDULE OF MEDICAL BENEFITS
All benefits and services listed to this Schedule of Benefits:
t . are subject to all provisions of this Agreement and Medicare Endorsement;
I • must be approved in advance by GHC except for Emergency and Urgently Needed Services
as set forth in Section III C. of this Medicare Endorsement; and
• must meet Medicare guidelines and limitations unless otherwise specified
GHC has procedures to assist GHC Providers in establishing a treatment plan for Members with
complex or serious Medical Conditions New Members should discuss all his/her medical
concerns with the GHC Personal Physician selected. New Members may expect their health
status to be assessed within 90 days of their enrollment.
GHC will ensure that services are provided in a culturally competent manner. GHC Providers
will provide information regarding treatment options in a culturally competent manner and will
accommodate Members with disabilities.
1 GHC covers all Medicare deductibles and coinsurance. The booklet, "Medicare & You"
provides additional information about Medicare benefits, and can be obtained from your local
Social Security office, or your Washington State Part B carver's office.
C23687-0036900
20
i
Services received at facilities outside the GHC Service Area may be covered for non-emergent
and/or non-Urgently Needed Care subject to the Point of Service benefit set forth in the
Summary of Medical Benefits All Medicare non-covered expenses, including deductibles and
coinsurance,are the responsibility of the Member.
A. Hospice.
It is understood and agreed that the following fully sets forth Covered Services for a Member '
with Part B Medicare only who elects to receive hospice services. Members who elect to
receive hospice services do so in lieu of curative treatment for their terminal illness for
the period that they are in the hospice program. To receive hospice services, the
Member is required to sign the Hospice Election Form.
Covered Services. Hospice services may include the following as prescribed by a GHC
physician and rendered pursuant to an approved hospice plan of treatment:
1. Home Services
Continuous care services per Member in the Member's home when prescribed by a GHC
physician, as set forth in this paragraph. Continuous care is defined as "skilled nursing
care provided in the home during a period of crisis in order to maintain the terminally ill
patient at home."Continuous care may be provided for pain or symptom management by
a Registered Nurse, Licensed Practical Nurse, or Home Health Aide under the
supervision of a Registered Nurse. Continuous care may be provided up to twenty-four
(24) hours per day during periods of crisis. Continuous care is covered only when a GHC
physician determines that the Member otherwise would require hospitalization in an
acute care facility.
2. Inpatient Hospice Services for short-tern care shall be provided in a facility designated
by GHC's Hospice Program when Medically Necessary and authorized in advance by a
GHC physician and GHC's Hospice Program Respite care is covered for a maximum of
five (5)consecutive days per occurrence in order to continue care for the Member in the
temporary absence of the Member's primary care-giver(s).
3. Other hospice services may include the following:
a. drugs and biologicals that are used primarily for the relief of pain and symptom
management; ,
b. medical appliances and supplies primarily for the relief of pain and symptom
management;
c. counseling services for the Member and his/her primary care-giver(s); and
d. bereavement counseling services for the family. ,
C23687-0036900 21
i
B. Mental Health Care,Alcoholism and Drug Abuse Treatment Services.
1. Outpatient mental health,alcoholism and substance abuse treatment services are
covered for each Member in accordance with Medicare Guidelines.
2. Inpatient mental health care services are covered subject to the applicable Copayment
up to a 190-day lifetime benefit when such services are provided in a Medicare-certified
psychiatric hospital.
3. Inpatient alcoholism and drug abuse treatment services are covered subject to the
' applicable Copayment when such services are provided in a hospital-based treatment
center.
Coverage for Medical Emergencies incident to alcoholism and drug abuse or for acute
alcoholism or drug abuse, including acute detoxification, is provided as set forth in
Section III.C. of this Medicare Endorsement.
C. Outpatient Emergency/Urgently Needed Services. When an Emergency meets the
Medicare definition for Emergency or Urgently Needed Services as defined in Section VII
1 of this Medicare Endorsement, services are covered subject to the applicable Copayments.
D. If the Member is hospitalized in a non-GHC Facility and requires continued inpatient care
' GHC will continue to cover the non-emergent care and services at the non-GHC Facility
needed by the Member to remain medically stable until- (1) the Member is discharged; (2) a
GHC Provider assumes responsibility for the Member's care; or(3) GHC and the Member's
treating physician decide the Member may be transferred without harmful medical
consequences whichever occurs first A decision to transfer the Member to a GHC Facility is
made at the discretion of GHC with the attending physician's concurrence.
Post-stabilization care at a non-GHC Facility will be covered when: (a)Pre-approved by
Group Health, or(b) Not pre-approved because Group Health did not respond to the request
for pre-approval within one (1)hour after being requested to approve such care,or Group
Health could not be contacted for pre-approval.
F. Point of Service(POS).Non-Emergent and/or non-Urgently Needed Care received while
temporarily traveling outside GHC's Medicare Service Area is payable at Medicare benefit
levels up to$2,000.00 per Member per calendar year. The Plan pays 80%of Medicare
allowable reimbursement schedules for Medicare covered services only. The enrollee is
responsible for all Medicare deductibles and coinsurance. Coverage under this benefit does
NOT include coverage of prescription drugs or services received when traveling primarily for
the purpose of seeking medical care
IF. Medicare Ambulance Benefit(including air, water, or ground transport) Medically
Necessary ambulance transportation to or from a hospital or Skilled Nursing Facility is
covered subject to the applicable Copayment Medically Necessary Emergency ambulance
C23687-0036900 22
transportation outside the United States or the U S.territories is covered only if '
transportation by any other vehicle could endanger the patient's health.
G. Medical and Surgical Care. The following medical and surgical services are covered when ,
prescribed by GHC Medical Personnel and Medicare requirements are met:
1. Eye examinations and treatment for eye pathology.
Evaluations and surgical procedures to correct refractions which are not related to eye
pathology are not covered Complications related to such surgery are also excluded.
2. Frames and Lenses. One pair of standard eyeglasses or contact lenses, including '
examination and fitting, following each cataract surgery with insertion of an mtraocular
lens (IOL) Covered eyeglasses and contact lenses must be dispensed through GHC
Facilities. Replacements for Members following insertion of an mtraocular lens are set
forth in Section III.G.14. below Replacements in the absence of an itraocular lens will
be provided when needed due to change in the Member's Medical Condition or when
deemed appropriate by a GHC physician.
3. Blood,blood derivatives, including storage,and their administration.
4. Maternity and pregnancy-related services,including visits before and after birth;
involuntary tennination of pregnancy; and care for any other complication of pregnancy. '
5. Organ transplants, limited to those covered by Medicare when all Medicare criteria
have been met.
6. Physician calls (including consultations and second opinions by a GHC Personal
Physician)in the hospital, office,home, Skilled Nursing Facility,nursing home, or
convalescent center.
7. Outpatient surgery in outpatient hospital facility or ambulatory surgical center covered
subject to applicable Copayment.
8. Restorative physical, occupational, speech and language therapy, and cardiac
rehabilitation following illness,injury, or surgery.
9. Immunizations and vaccinations that are listed as covered in the GHC drug formulary
(approved drug list) or approved by Medicare. ,
10. Services related to dysfunction of the jaw. When referred by a GHC Personal
Physician, evaluation and treatment by a GHC-approved temporomandibular joint(TMJ)
care provider
All TMI appliances, other than the occlusal splint and its fitting, are excluded. ,
C23687-0036900 23
i
t
Treatment of Jaw dysfunction, including TMJ dysfunction,will NOT be provided when
the dysfunction is related to malocclusion or when TMJ services are needed due to dental
work performed. All such services and related hospitalization, including orthodontic
therapy and orthognathic(jaw) surgery,are excluded regardless of origin or cause.
(See Section IV B.17. of the Group Medical Coverage Agreement for Covered Services
not meeting Medicare Guidelines).
11. Chiropractic care limited to spinal manipulations. Excluded are any other diagnostic or
therapeutic services, including x-rays, furnished by a chiropractor. Members must receive
all chiropractic services from GHC's designated licensed providers in order to be
covered. A list of GHC-designated licensed practitioners is available by contacting any
GHC area medical center.
12. Podiatric care. Services are covered when all Medicare criteria are met and when
authorized in advance by your Personal Physician. Excluded is treatment of flat feet or
other misalignments of the feet, removal of corns and calluses; and routine foot care such
as hygienic care, except in the presence of a non-related Medical Condition affecting the
lower limbs. Members must utilize GHC's designated providers in order to be covered
i13. Home intravenous (IV) drug therapy services.
14. Routine eye examinations and refractions, limited to once every twenty-four(24)
months, except when Medically Necessary. Services for routine eye examinations must
be received at a GHC Facility and in accordance with GHC medical criteria in order to be
covered and are not subject to Medicare requirements.
Lenses.One pair of standard glass single vision, lenticular,or non-blended bifocal or
trifocal lenses, or contact lenses, will be covered subject to the GHC-approved Allowance
once every twenty-four(24) months, and replaced as specified below, when received at a
GHC Facility and in accordance with GHC medical criteria.
Frames. An Allowance of up to $100 per Member once every twenty-four(24) months
will be provided for frames.
Replacements. Lens replacement for any reason(including loss,breakage or change in
prescription)will be provided not more often than once every 24 months.
Replacement of frames will be provided subject to the frames Allowance set forth above
not more often than once every twenty-four(24)months.
15. Hearing examinations to determine hearing loss. Hearing aids, including examinations
and fitting,must be received at a GHC Facility and are covered up to a maximum of$250
per Member once every twenty-four(24)months.
C23687-0036900 24
16.Diabetic education and training, including glucose monitors,testing strips and lancets '
for all diabetics.
17.Renal dialysis services required while temporarily away from the Service Area will be
covered if provided in a Medicare-approved facility when Medicare criteria is met
H. Prosthetic Devices, such as cardiac devices, intraocular lenses, artificial joints,breast
prostheses, artificial eyes, and braces, are covered. Excluded are. orthopedic shoes unless
they are part of leg braces, dental plates or other dental devices, and experimental devices.
Therapeutic shoes for those suffering from diabetic foot disease are covered.
I. Medical/Surgical Supplies,such as casts, splints,post-surgical dressings, and ostomy
supplies, are covered.
J. Rental or Purchase of Durable Medical Equipment, such as oxygen and oxygen
equipment,wheelchairs and other walk-aids, and hospital beds, is covered ,
K. Health Club Services(SilverSneakers®) and/or lifetime fitness at participating network
health clubs in the Service Area are provided to Members without charge. Unlimited ,
Covered Services include traditional weight and cardiac equipment, pools, aerobics, and
court facilities. In addition to club member privileges, a Member may bring a guest who is
Medicare eligible for one visit up to four times per year without charge. A list of
participating network health clubs may be obtained from GHC upon request.
L. Skilled Nursing Facility. Upon Referral and following a Medicare-certified three (3)day
hospital stay, GHC will cover 100 days of Medicare covered Skilled Nursing Facility care
per benefit period All Medicare criteria must be met and the stay must be authorized in
advance by the plan When a 3 day Medicare covered hospital stay does not occur and the
plan determines that the Member otherwise meets all Medicare criteria, the plan may
authorize Medicare covered skilled nursing care for up to 100 days.
SECTION IV. EXCLUSIONS AND LIMITATIONS
A. Exclusions.
1. Investigational procedures,including medical and surgical services,drugs and devices
until formally approved by Medicare unless specifically provided herein(See Section
V.19. in the Group Medical Coverage Agreement).
2. Supportive devices (shoe inserts) for the feet, except therapeutic shoes for people with
diabetes who have severe diabetic foot disease, including fitting of shoes or inserts.
3. Services directly related to obesity except as provided by Medicare.
4. Services or supplies not specifically listed as covered by Medicare or GHC.
i
C23687-0036900 25
i
B. Limitations.
Conditions and Extent of Coverage. EXCEPT AS PROVIDED IN SECTIONS III C, D.,
E. AND G.17 ,ALL SERVICES AND BENEFITS UNDER THIS AGREEMENT MUST
BE PROVIDED BY GHC MEDICAL PERSONNEL AT A GHC FACILITY UNLESS.
1. the Member has received a Referral from GHC,or
2. the Member has received outpatient Emergency or Urgently Needed Services as defined
in Section VII. and as set forth in Sections III.0 and D. of this Medicare Endorsement.
SECTION V. APPEAL AND GRIEVANCE PROCEDURES
A. Grievances.
If a Member is dissatisfied with care or services received at a Medical or Dental Office or
Hospital, or a Member disputes amounts owed, eligibility or membership status, the Member
may submit a written grievance to GHC. GHC will conduct a formal review and provide a
written response within 60 days of the time all pertinent materials are received.
B. Standard Expedited Requests for Care or Service.
1 1. Standard Request. The Member may request that care or a service be covered by GHC
on the basis that it is a Medicare covered service GHC will reach a decision within 14
days. GHC's decision may be delayed an additional 14 days if it is in the Member's best
interest or upon the Member's request.
2. Expedited Request. If a Member requests care or a service they believe is covered by
Medicare and the Member believes and/or his/her physician states that a delay in making
a determination about coverage could jeopardize the Member's health or ability to
function, the Member may request an expedited decision. In most instances, GHC will
reach a decision within 72 hours. GHC's decision may be delayed an additional 14
working days if it is in the Member's best interest to delay a decision or upon the
Member's request. GHC's decision may also be postponed in the event information for a
non-GHC Provider has not been received in a timely manner. If GHC grants a Member's
request for an expedited decision, GHC will orally notify the Member and follow-up
within two(2) working days, with a written letter If a Member disagrees with GHC's
decision not to expedite his/her request, the Member may file a grievance.
C. Appeals.
Members have a right to appeal any decision in which GHC declines to provide,cover,or
pay for services that the Member believes are covered by Medicare. If GHC declines to
provide or to cover a service, GHC will provide the Member with a Notice of Non-coverage
Icontaining the reason(s) for the denial and an explanation of the Member's appeal rights.
C23687-0036900
26
Members who disagree with a decision by GHC may submit a written appeal to GHC.
Members appealing a denied claim for payment for a service already provided or arranged
may request a standard 60-day appeal Members appealing a request for a future service may
ask for either a standard 30 day appeal or an Expedited (72-hour) appeal if the Member
believes (or the Member's Provider states) that a delay in responding to the Member's appeal
could seriously jeopardize his/her health or ability to function
Appeals will be reviewed by persons not involved in the initial decision. If GHC decides to
uphold the original adverse decision,either in whole or in part, the entire file will be
forwarded by GHC to CMS's contractor, The Center for Health Dispute Resolution(CHDR)
for review.
1. Standard Appeal.
a. 60-Day Appeals for Claim for Payment. A Member may submit an appeal
requesting a second review at any time GHC denies coverage for services already
provided or arranged by either GHC or a non-GHC Provider or Facility, or for future
services Member must submit appeals in writing to GHC, or to any Social Security
Office,or in the case of a railroad retirement annuitant, a Railroad Retirement Board
Office, within 60 days of receiving notice of GHC's initial decision. After receiving
all pertinent materials,GHC will conduct a formal review of the appeal GHC will
notify the Member of its decision within 60 days of receipt. If GHC decides fully in
the Member's favor, GHC will pay the claim(s)within 60 days of receipt of the
Member's appeal If GHC upholds any part of the initial denial, the entire file will be
forwarded by GHC to CHDR for review. CHDR will make a reconsideration decision
and advise the Member of its decision,the reasons for the decision and the right to
additional appeal rights
b. 30-Day Appeals for Denials of Future Services. A Member may submit an appeal
requesting a second review at any time GHC denies coverage for future services.
Members must submit appeals in writing to GHC, or to any Social Security Office, or
in the case of a railroad retirement annuitant, a Railroad Retirement Board Office,
within 60 days of the date of GHC's initial decision. After receiving all pertinent
materials, GHC will conduct a formal review of the appeal. GHC will notify the
Member of its decision within 30 days of receipt. GHC's decision may be extended
an additional 14 days if it is in the Member's best interest or upon the Member's
request. If GHC upholds any part of the initial denial,the entire file will be
forwarded by GHC to CHDR for review. CHDR will make a reconsideration ,
decision and advise the Member of its decision, the reason for the decision, and the
right to additional appeal rights.
2. Filing an Expedited (72-hour)Appeal (does not apply to denied claims for payment). r
If a delay in receiving a decision could jeopardize the Member's health or ability to
function, the Member or his/her Physician may submit a request for an expedited appeal
either orally or in writing to GHC.
C23687-0036900 27
D. Quality Improvement Organization("QIO").
"QIO" stands for Quality Improvement Organization(these organizations used to be called
"Peer Review Organizations"or PROS) The QIO is a group of doctors and other health care
experts paid by the Federal Government to check on and help improve the care given to
Medicare patients There is a QIO in each state QIOs have different names, depending on
which state they are in. In Washington State, the QIO is called Qualls Health
A Member may request a"QIO"review if GHC denies coverage of a continued inpatient
stay in a hospital on the basis of medical necessity A Member may request immediate QIO
review by phone or in writing. If a Member requests a QIO review by noon of the first
business day after a Member has received a Notice of Non-coverage, the Member will not be
financially responsible for the cost of the continued hospitalization until the QIO's
determination.
GHC will provide the Member written notice of procedures by which to request a QIO
review If a Member requests a QIO review,the Member may not pursue the Standard
Appeal Procedure and/or the Expedited Appeal Procedure with respect to denial of the same
hospital stay.
A Member may contact Qualis Health at P O Box 33400, Seattle, WA 98133-0400 or 10700
Meridian Ave N, Suite 100, Seattle,WA 98133-9075, telephone number(206) 364-9700 or
Fax (206)368-2419.
E. Additional Appeal Rights.
If CMS upholds GHC's initial determination and denies the appeal and if the amount in
controversy is $100 00, or more the Member may request a hearing before an administrative
law judge of the Social Security Administration The Member may request a hearing before
an administrative law judge by writing to GHC, CMS, or a Social Security Office within 60
days after the date of notice of an adverse reconsideration decision.
If the administrative law judge denies a Member's appeal, either the Member or GHC may
request a review by the Social Security Administration's (SSA's) Appeals Council.
If a Member's appeal is denied by the SSA's Appeals Council and if the amount in
controversy is $1,000 00,or greater the Member or GHC may request a review by the
Medicare Appeals Council.
An initial,revised,or reconsideration determination made by GHC, CMS, an administrative
law judge, or the SSA's Appeals Council can be reopened(a) within twelve months, (b)
within four years for just cause, or(c) at any time for clerical correction or in the case of
fraud.
C23687-0036900 28
The Medicare Appeals Coordinator can be reached by writing to Group Health Cooperative, '
c/o Medicare Appeals Coordinator, P O Box 34593, Seattle WA 981324, or by calling(206)
901-7350 or toll-free at ]-(888)-901-4636 or TTY/TDD 711 or 1-800-833-6388, for the
"hearing impaired"or by fax at(206) 901-7340.
SECTION VI. SUBROGATION AND REIMBURSEMENT RIGHTS
"Injured Person"under this section means a Member covered by the Agreement who sustains an i
injury and any spouse, dependent or other person or entity that may recover on behalf of such
Member, including the estate of the Member and, if the Member is a minor,the guardian or
parent of the Member. When referred to in this section,"GHC's Medical Expenses"means the
expense incurred and the reasonable value of the services provided by GHC for the care or
treatment of the injury sustained by the Injured Person.
If the Injured Person's injuries were caused by a third party giving rise to a claim of legal
liability against the third party and/or payment by the third party to the Injured Person and/or a
settlement between the third party and the Injured Person, GHC shall have the right to recover
GHC's Medical Expenses from any source available to the Injured Person as a result of the
events causing the injury, including but not limited to funds available through applicable third
party liability coverage and unmsured/underinsured motorist coverage.This right is commonly ,
referred to as"subrogation"GHC shall be subrogated to and may enforce all rights of the
Injured Person to the extent of GHC's Medical Expenses.
If the Injured Person is entitled to or does receive money from any source as a result of the
events causing the injury, including but not limited to any party's liability insurance or
uninsured/underinsured motorist funds,then GHC's Medical Expenses provided or to be
provided to the Injured Person are secondary, not primary, and will be paid only if the Injured
Person fully cooperates with the terms and conditions of the Agreement. As a condition of
receiving benefits under the Agreement, the Injured Person agrees that acceptance of GHC
services is constructive notice of this provision in its entirety and agrees to reimburse GHC for
the benefits the Injured Person received as a result of the events causing the injury. GHC's
subrogation and reimbursement rights shall be limited to the excess of the amount required to
fully compensate the Injured Person for the loss sustained, including general damages. Full
compensation shall be measured on an objective case-by-case basis unless the Injured Person
settles with the at-fault party for less than available policy limits, in which GHC is entitled to full
compensation of GHC's Medical Expenses. However, in the case of Medicare Advantage
Members, GHC's right of subrogation shall be the full amount of GHC's Medical Expenses
and is limited only as required by Medicare.
The Injured Person and his/her agents shall cooperate fully with GHC in its efforts to collect
GHC's Medical Expenses. This cooperation includes,but is not limited to, supplying GHC with
information about any third parties, defendants and/or insurers related to the Injured Person's
claim and informing GHC of any settlement or other payments relating to the Injured Person's
injury The Injured Person and his/her agents shall permit GHC, at GHC's option,to associate
with the Injured Person or to intervene in any legal, quasi-legal, agency or any other action or
claim filed. If the Injured Person takes no action to recover money from any source,then the
C23687-0036900 29
1
!
Injured Person agrees to allow GHC to initiate its own direct action for reimbursement or
subrogation, including, but not limited to, billing the Injured Person directly for GHC's Medical
Expenses.
The Injured Person and his/her agents shall do nothing to prejudice GHC's subrogation and
reimbursement rights. The Injured Person shall promptly notify GHC of any tentative settlement
with a third party and shall not settle a claim without protecting GHC's interest If the Injured
Person falls to cooperate fully with GHC in recovery of GHC's Medical Expenses,the Injured
Person shall be responsible for directly reimbursing GHC for GHC's Medical Expenses and
GHC retains the right to bill the Injured Person directly for GHC's Medical Expenses.
To the extent that the Injured Person recovers funds from any source, the Injured Person agrees
to hold such monies in trust or in their possession until GHC's subrogation and reimbursement
rights are fully determined.
GHC shall not pay any attorney's fees or collection costs to attorneys representing the Injured
Person unless there is a written fee agreement signed by GHC prior to any collection efforts.
When reasonable collection costs have been incurred with GHC's prior written agreement to
recover GHC's Medical Expenses,there shall be an equitable apportionment of such collection
costs between GHC and the Injured Person subject to a maximum responsibility of GHC equal to
one-third of the amount recovered on behalf of GHC Under no circumstance will GHC pay legal
fees for services which were not reasonably and necessarily incurred to secure recovery,which
do not benefit GHC and/or where no written fee agreement has been entered into with GHC.
If it becomes necessary for GHC to enforce the provision of this section by initiating any action
against the Injured Person or his/her agent,then the Injured Person agrees to pay GHC's
attorney's fees and costs associated with the action
Implementation of this section shall be deemed a part of claims administration under the
Agreement and GHC shall therefore have sole discretion to interpret its terms
SECTION VII. DEFINITIONS
CENTER for MEDICARE and MEDICAID SERVICES (CMS): The Federal Agency that
runs the Medicare program (CMS was formerly known as the Health Care Financing
Administration.
CUSTODIAL CARE: Care furnished for the purpose of meeting non-Medically Necessary
personal needs which could be provided by persons without professional skills or training,such
as assistance in mobility, dressing, bathing, eating,preparation of special diets, and taking
medication. Custodial Care is not covered by the GHC MA Plan or Medicare unless provided in
conjunction with Skilled Nursing Care and/or skilled rehabilitation services.
EMERGENCY CARE: Covered services that are 1) furnished by a provider qualified to furnish
emergency services, and 2) needed to evaluate or stabilize an Emergency Medical Condition
C23687-0036900
30
EMERGENCY MEDICAL CONDITION: A Medical Condition brought on by acute ,
symptoms of sufficient severity(including severe pain)such that a prudent lay person with an
average knowledge of health and medicine could reasonably expect that not getting immediate
medical attention could result in 1) Serious jeopardy to the health of the individual or, in the case
of a pregnant woman, the health of the woman or her unborn child, 2) Serious impairment to
bodily functions, or 3) Serious dysfunction of any bodily organ or part.
MAXIMUM CHARGES: A term used to define the level of benefits which are payable by ,
GHC when expenses are incurred from a non-GHC Personal Physician or Provider Expenses are
considered Maximum Charges if(1) the charges are consistent with those normally charged by '
the provider or organization for the same services or supplies, and(2)the charges are within the
general range of charges made by other providers in the same geographical area for the same
services or supplies.
MEDICARE: The federal health insurance program for people 65 years of age or older, some
people under age 65 with disabilities, and people with End Stage Renal Disease (generally those
with permanent kidney failure who need dialysis or a kidney transplant)
MEDICARE ADVANTAGE(MA) COORDINATED CARE PLANS: These are MA Plans
that use a network of providers that are under contract or arrangement with a Medicare
Advantage Organization to provide covered benefits The GHC Medicare Advantage Plan is a
Coordinated Care Plan.
MEDICARE ADVANTAGE (MA) ORGANIZATION: A public or private organization
licensed by the State as a risk-bearing entity that is under contract with the Center for Medicare
and Medicaid Services CMS to provide Covered Services Medicare Advantage Organizations
can offer one or more Medicare Advantage Plans. GHC is a Medicare Advantage Organization
MEDICARE ADVANTAGE(MA) PLAN: A benefit package offered by a Medicare Advantage
Organization that offers a specific set of health benefits at a uniform premium and uniform level
of cost-sharing to all people with Medicare who live in the Service Area covered by the Plan A
Medicare Advantage Organization may offer more than one plan in the same Service Area The
GHC Plan is a Medicare Advantage plan
PERMANENT MOVE: A permanent change of residence out of the Service Area or an
uninterrupted absence of more than six(6)months from GHC's Service Area.
POINT OF SERVICE (POS): A benefit that GHC offers to its Medicare Advantage Members
while temporarily traveling outside of the GHC Medicare Advantage Plan Service Area for non-
emergent and/or non-Urgently Needed Care In return for this flexibility, Members have higher
cost-sharing requirements for these services.
REFERRAL: A request by your Personal Physician for you to receive care from a Specialist,
Contracting Medical Provider, or Non-Contracting Medical Provider, or to receive certain
Covered Services.
C23687-0036900 31
SERVICE AREA: The geographic area comprised of parts of Grays Harbor,Island,King,
Kitsap, Lewis,Pierce, parts of Mason, San Juan, Skagit, Snohomish,Thurston, and Whatcom
Counties, and any other areas designated by GHC and approved by CMS, within which an
eligible individual may enroll in a particular plan offered by GHC.
SKILLED NURSING FACILITY: A facility(or distinct part of a facility) which is primarily
engaged in providing to its residents which provides inpatient Skilled Nursing Care,
rehabilitation services, or other related health services and is certified by Medicare. The term
"Skilled Nursing Facility" does not include a convalescent nursing home, rest facility, or facility
for the aged which furnishes primarily Custodial Care, including training in routines of daily
living
URGENTLY NEEDED CARE: Covered Services provided when you are temporarily absent
from the GHC Medicare Advantage Plan Service Area (or, under unusual and extraordinary
circumstances,provided when you are in the Service Area but your Contracting Medical Group
is temporarily unavailable or inaccessible)when such services are Medically Necessary and
immediately required 1) as a result of an unforeseen illness, injury, or condition, and 2) it is not
reasonable, given the circumstances,to obtain the services through your Contracting Medical
Group.
C23687-0036900 32
Dear Group Health Subscriber
This booklet contains important information about your healthcare plan.
This is your 2005 Group Health Benefit Booklet(Certificate of Coverage) It explains the services and benefits you
and those enrolled on your contract are entitled to receive from Group Health Cooperative The benefits reflected in
this booklet were approved by your employer or association who contracts with Group Health for your healthcare
coverage
We recommend you read it carefully so you'll understand not only the benefits,but the exclusions,limitations,and
eligibility requirements of this certificate Please keep this certificate for as long as you are covered by Group
Health We will send you revisions if there are any changes in your coverage
This certificate is not the contract itself,you can contact your employer or group administrator if you wish to see a '
copy of the contract(Medical Coverage Agreement)
We'll gladly answer any questions you might have about your Group Health benefits Please call our Group Health
Customer Service Center at 901-4636 in the Seattle area,or toll-free in Washington, 1-888-901-4636
Thank you for choosing Group Health Cooperative. We took forward to working with you to preserve and enhance
your health
Very truly yours,
Scott Armstrong
President
PA-1133a02
CA-139502,CA-1984,CA-107600,CA-1385,CA-6100,CA-2220
i
1
- t
t
t
t
t
t
C23687-0036900
Benefit Booklet
Table of Contents
iSection I. Introduction
A Accessing Care
B Cost Shares
C. Subscriber's Liability
D Claims
Section II. Allowances Schedule
Section IIl. Eligibility, Enrollment and Termination
A Eligibility
B Enrollment
C. Effective Date of Enrollment
D. Eligibility for Medicare
E Termination of Coverage
F Services After Termination of Agreement
G Continuation of Coverage Options
Section IV. Schedule of Benefits
A Hospital Care
B Medical and Surgical Care
C Chemical Dependency Treatment
L D Plastic and Reconstructive Services
E Home Health Care Services
F Hospice Care
G. Rehabilitation Services
H Devices,Equipment and Supplies
I Tobacco Cessation
J. Drugs,Medicines, Supplies and Devices
K Mental Health Care Services
L Emergency/Urgent Care
M Ambulance Services
N Skilled Nursing Facility
Section V. General Exclusions
Section VI. Grievance Processes for Complaints and Appeals
Section VII. General Provisions
A. Coordination of Benefits
B Subrogation and Reimbursement Rights
C. Miscellaneous Provisions
Section VIIL Definitions
Attachment: Group Medicare Coverage
C23687-0036900 1
i
Section I. Introduction
Group Health Cooperative(also referred to as"GHC")is a nonprofit health maintenance organization furnishing
health care primarily on a prepayment basis
Read This Benefit Booklet Carefully
This Benefit Booklet is a statement of benefits,exclusions and other provisions,as set forth in the Group Medical
Coverage Agreement("Agreement")between GHC and the employer or Group
A full description of benefits,exclusions,limits and Out-of-Pocket Expenses can be found in the Schedule of
Benefits,Section IV,General Exclusions,Section V,and Allowances Schedule,Section II These sections must be
considered together to fully understand the benefits available under the Agreement Words with special meaning are
capitalized They are defined in Section VIII
A. Accessing Care
Members are entitled to Covered Services only at GHC Facilities and from GHC Personal Physicians.
Except as follows:
• Emergency care,
• Self-Referral to women's health care providers,as set forth below,
• Visits with GHC-Designated Self-Referral Specialists,as set forth below,
• Care provided pursuant to a Referral Referrals must be requested by the Member's Personal Physician and
approved by GHC,and
• Other services as specifically set forth in the Allowances Schedule and Section IV.
Primary Care. Members must select a GHC Personal Physician when enrolling under the Agreement One
Personal Physician may be selected for the entire family,or a different Personal Physician may be selected for
each family member if the Personal Physician is not selected at the time of enrollment,GHC will assign a
Personal Physician,and a letter of explanation will be sent to the Member
Selecting a Personal Physician or changing from one Personal Physician to another can be accomplished by
contacting GHC Customer Service,or accessing the GHC websrte at www ghc org The change will be made
within twenty-four(24)hours of the receipt of the request,if the selected physician's caseload permits
A listing of GHC Personal Physicians,Referral specialists,women's health care providers and GHC-Designated
Self-Referral Specialists is available by contacting GHC Customer Service at(206)901-4636 or(888)901-
4636,or by accessing GHC's websrte at www ghc org
In the case that the Member's Personal Physician no longer participates in GHC's network,the Member will be
provided a written notice offering the Member a selection of new Personal Physicians from which to choose
Specialty Care. Unless otherwise indicated in this section,the Allowances Schedule or Section IV,Referrals
are required for specialty care and specialists.
GHC-Designated Self-Referral Specialist. Members may make appointments directly with GHC-Designated
Self-Referral Specialists at GHC-owned or-operated medical centers without a Referral from their Personal
Physician Self-Referrals are available for the following specialty care areas allergy,audiology,cardiology,
chemical dependency,chiropractic/manipulative therapy,dermatology,gastroenterology,general surgery,
hospice,manipulative therapy,mental health,nephrology,neurology,obstetrics and gynecology,occupational
medicine*,oncology/hematology,ophthalmology,optometry,orthopedics,otolaryngology(ear,nose and
throat),physical therapy*,smoking cessation,speech/language and learning services* and urology
*Medicare patients need a Referral for these specialists
1
C23687-0036900 2
Women's Health Care Direct Access Providers. Female Members may see a participating General and
Family Practitioner,Physician's Assistant,Gynecologist,Certified Nurse Midwife, Licensed Midwife,Doctor
of Osteopathy,Pediatrician,Obstetrician or Advanced Registered Nurse Practitioner who is contracted by GHC
to provide women's health care services directly,without a Referral from their Personal Physician,for
Medically Necessary maternity care,covered reproductive health services,preventive care(well care)and
general examinations,gynecological care and follow-up visits for the above services Women's health care
services are covered as if the Member's Personal Physician had been consulted,subject to any applicable Cost
Shares,as set forth in the Allowances Schedule If the Member's women's health care provider diagnoses a
condition that requires Referral to other specialists or hospitalization,the Member or her chosen provider must
obtain preauthorization and care coordination in accordance with applicable GHC requirements
Second Opinions. The Member may access,upon request,a second opinion regarding a medical diagnosis or
treatment plan from a GHC Provider
Emergent and Urgent Care. Emergent care is available at GHC Facilities If Members cannot get to a GHC
' Facility,Members may obtain Emergency services from the nearest hospital Members or persons assuming
responsibility for a Member must notify GHC by way of the GHC Emergency Notification Line within twenty-
four(24)hours of admission to a non-GHC Facility,or as soon thereafter as medically possible Members may
refer to Section IV for more information about coverage of Emergency services
In the GHC Service Area,urgent care is covered only at GHC medical centers,GHC urgent care clinics or GHC
Provider's offices Urgent care received at any hospital emergency department is not covered unless authorized
in advance by a GHC Provider. Members may refer to Section IV for more information about coverage of
urgent care services
Outside the GHC Service Area,urgent care is covered at any medical facility Members may refer to Section
IV for more information about coverage of urgent care services
Recommended Treatment.GHC's Medical Director or his/her designee will determine the necessity,nature
and extent of treatment to be covered in each individual case and the judgment,made in good faith,will be
final
Members have the right to participate in decisions regarding their health care A Member may refuse any
recommended treatment or diagnostic plan to the extent permitted by law Members who obtain care not
recommended by GHC,do so with the full understanding that GHC has no obligation for the cost,or Lability
for the outcome,of such care Coverage decisions may be appealed as set forth in Section VI
Major Disaster or Epidemic.In the event of a major disaster or epidemic,GHC will provide coverage
according to its bestjudgment,within the limitations of available facilities and personnel GHC has no liability
for delay or failure to provide or arrange Covered Services to the extent facilities or personnel are unavailable
due to a major disaster or epidemic
Unusual Circumstances.If the provision of Covered Services is delayed or rendered impossible due to unusual
circumstances such as complete or partial destruction of facilities,military action,civil disorder,labor disputes
or similar causes,GHC shall provide or arrange for services that,in the reasonable opinion of GHC's Medical
Director, or his/her designee,are emergent or urgently needed In regard to nonurgent and routine services,
GHC shall make a good faith effort to provide services through its then-available facilities and personnel GHC
shall have the option to defer or reschedule services that are not urgent while its facilities and services are so
affected In no case shall GHC have any liability or obligation on account of delay or failure to provide or
arrange such services
B. Cost Shares
The Subscriber shall be liable for the following Cost Shares when services are received by the Subscriber and
any of his/her Dependents
C23687-0036900 3
1
1. Copayments Members shall be required to pay Copayments at the time of service as set forth in the
Allowances Schedule. Payment of a Copayment does not exclude the possibility of an additional billing if
the service is determined to be a non-Covered Service
2. Coinsurance.Members shall be required to pay Coinsurance for certain Covered Services as set forth in
the Allowances Schedule
3. Out-of-Pocket Limit.Total Out-of-Pocket Expenses incurred during the same calendar year shall not
exceed the Out-of-Pocket Limit set forth in the Allowances Schedule Out-of-Pocket Expenses which apply
toward the Out-of-Pocket Limit are set forth in the Allowances Schedule
4. Deductibles. In addition to any applicable annual Deductible,there may be service-specific Deductibles as
set forth in the Allowances Schedule.
C. Subscriber's Liability
The Subscriber is liable for(1)payment to the Group of his/her contribution toward the monthly premiums,if
any, (2)payment of Cost Share amounts for Covered Services provided to the Subscriber and his/her
Dependents,as set forth in the Allowances Schedule,and(3)payment of any fees charged for non-Covered
Services provided to the Subscriber and his/her Dependents,at the time of service
Payment of an amount billed by GHC must be received within thirty(30)days of the billing date
D. Claims
Claims for benefits may be made before or after services are obtained. To make a claim for benefits under the
Agreement,a Member(or the Member's authorized representative)must contact GHC Customer Service,or
submit a claim for reimbursement as described below Other inquiries,such as asking a healthcare provider
about care or coverage,or submitting a prescription to a pharmacy,will not be considered a claim for benefits
If a Member receives a bill for services the Member believes are covered under the Agreement,the Member
must,within ninety(90)days of the date of service,or as soon thereafter as reasonably possible,either(1)
contact GHC Customer Service to make a claim or(2)pay the bill and submit a claim for reimbursement of
Covered Services to GHC,P O Box 34585,Seattle,WA 98124-1585 In no event,except in the absence of
legal capacity,shall a claim be accepted later than one(1)year from the date of service
GHC will generally process claims for benefits within the following timeframes after GHC receives the claims
• Pre-service claims—within fifteen(15)days
• Claims involving urgently needed care—within seventy-two(72)hours
• Concurrent care claims—within twenty-four(24)hours
• Post-service claims—within thirty(30)days
Timeframes for pre-service and post-service claims can be extended by GHC for up to an additional fifteen(15)
days Members will be notified in writing of such extension prior to the expiration of the initial timeframe
C23687-0036900 4
Section II. Allowances Schedule
The benefits described in this schedule are subject to all provisions,limitations and exclusions set forth in the Group
Medical Coverage Agreement
"Welcome"Outpatient Services Waiver
Not applicable
Annual Deductible
No annual Deductible
Plan Coinsurance
No plan Coinsurance
Lifetime Maximum
No Lifetime Maximum unless otherwise indicated.
Hospital Services
• Covered inpatient medical and surgical services,including acute chemical withdrawal(detoxification)
Covered in full
• Covered outpatient hospital surgery(including ambulatory surgical centers)
Covered subject to the outpatient services Copayment.
iOutpatient Services
• Covered outpatient medical and surgical services
Covered subject to a$5 outpatient services Copayment per Member per visit
• Allergy testing
Covered subject to the outpatient services Copayment.
• Oncology(radiation therapy,chemotherapy)
Covered subject to the outpatient services Copayment.
Drugs—Outpatient(including mental health drugs,contraceptive drugs and devices and diabetic supplies)
• Prescription drugs, medicines,supplies and devices for a supply of thirty(30)days or less when listed in the
GHC drug formulary
Covered subject to the lesser of GHC's charge or a$5 Copayment
1 • Over-the-counter drugs and medicines
jC23687-0036900 5
Not covered
• Allergy serum
Covered subject to the applicable prescription drug Cost Share for each thirty(30)day supply
• Injectables
Injections that can be self-administered are subject to the applicable prescription drug Cost Share Injections
necessary for travel are not covered
• Mad order drugs and medicines
Covered subject to the applicable prescription drug Cost Share for each thirty(30)day supply or less
• Growth hormones
Covered in full
Out-of-Pocket Limit(Stop Loss)
Limited to an aggregate maximum of$2,000 per Member and$4,000 per family per calendar year Except as
otherwise noted in this Allowances Schedule,the total Out-of-Pocket Expenses for the following Covered Services
are included in the Out-of-Pocket Limit
• Inpatient services
• Outpatient services
• Emergency care at a GHC or non-GHC Facility
• Ambulance services
Acupuncture i
Covered subject to the outpatient services Copayment for Self-Referrals to a GHC Provider up to a maximum of five
(5)visits per Member per medical diagnosis per calendar year When approved by GHC,additional visits are
covered subject to the outpatient services Copayment
Ambulance Services
• Emergency ground/air transport
Covered at 80%
• Non-emergent ground/air tnterfac lity transfer
Covered at 801/6 for GHC-initiated transfers,except bosprtal-to-hospital ground transfers covered in full.
Chemical Dependency
• Inpatient services
Covered subject to the applicable inpatient services CopaymenL
• Outpatient services ,
Covered subject to the applicable outpatient services Copayment.
C23687-0036900 6
• Benefit period Allowance
Covered up to$12,500 per Member per any twenty-four(24)consecutive calendar month period
Acute detoxification covered as any other medical service Charges incurred are not subject to the twenty-four(24)
month maximum.
Dental Services(including accidental injury to natural teeth)
Not covered,except as set forth in Section 1V B 24
Devices,Equipment and Supplies(for home use)
Covered at 80%for
! • Durable medical equipment
• Orthopedic appliances
• Ostomy supplies
• Post-mastectomy bras[limited to two(2)every six(6)months]
Covered at 801/o for
• Prosthetic devices
Diabetic Supplies
Insulin,needles, syringes and lancets-see Drugs-Outpatient External insulin pumps,blood glucose monitors,
testing reagents and supplies-see Devices, Equipment and Supplies When Devices,Equipment and Supplies have
a dollar maximum,diabetic supplies are not subject to this maximum benefit limit
Diagnostic Laboratory and Radiology Services
Covered in full.
Emergency Services
• At a GHC Facility
Covered subject to a$75 Copayment per Member per Emergency visit Copayment is waived if the Member is
admitted as an inpatient to the hospital directly from the emergency department Emergency admissions are
covered subject to the applicable inpatient services Cost Share.
• At a non-GHC Facility
Covered subject to a$125 Deductible per Member per Emergency visit Emergency care Deductible is waived
if the Member is admitted as an inpatient to the hospital directly from the emergency department Emergency
admissions are covered subject to the applicable inpatient services Cost Share
1� Hearing Examinations and Hearing Aids
• Hearing examinations to determine hearing loss
Covered subject to the outpatient services Copayment
C23687-0036900 7
i
• Hearing aids, including hearing aid examinations
Not covered
Home Health Services
Covered in full No visit limit
Hospice Services
Covered in full Inpatient respite care is covered for a maximum of five(5)consecutive days per occurrence.
Infertility Services(including sterility)
Not covered
Manipulative Therapy
Covered subject to the outpatient services Copayment for Self-Referrals to a GHC Provider for manipulative therapy
of the spine in accordance with GHC clinical criteria up to a maximum of ten(10)visits per Member per calendar
year When approved by GHC,additional manipulation visits are covered subject to the outpatient services
Copayment
Maternity and Pregnancy Services
• Delivery and associated Hospital Care
Covered subject to the applicable inpatient services Copayment
• Routine prenatal and postpartum care
Covered subject to the outpatient services Copayment.
• Pregnancy termination
Covered subject to the applicable Copayment for involuntary/voluntary termination of pregnancy
Mental Health Services
• Inpatient services
Covered at 901/6 for up to twelve(12)days per Member per calendar year at a GHC-approved mental health '
care facility Coinsurance does not apply to the Out-of-pocket Limit
• Outpatient services
Covered subject to a$20 Copayment per individual session and a$10 Copayment per Member per group
session for up to twenty(20)visits per Member per calendar year Copayments do not apply to the Out-of-
Pocket Limit
Naturopathy
C23687-0036900 9
Covered subject to the outpatient services Copayment for Self-Referrals to a GHC Provider up to a maximum of two
(2)visits per Member per medical diagnosis per calendar year When approved by GHC,additional visits are
covered subject to the outpatient services Copayment.
Nutritional Services
• Phenylketonuria(PKU)supplements
Covered in full
1 • Enteral therapy(formula)
Covered at 80%for elemental formulas Necessary equipment and supplies are covered under Devices,
Equipment and Supplies
• Parenteral therapy(total parenteral nutrition)
Covered in full for parenteral formulas Necessary equipment and supplies are covered under Devices,
Equipment and Supplies
Obesity Related Services
Covered subject to the applicable Copayment for banatnc surgery.Weight loss programs,medications and related
physician visits for medication monitoring are not covered
On the Job Injuries or Illnesses
Not covered,including injuries or illnesses incurred as a result of self-employment
Optical Services
• Routine eye examinations
Covered subject to the outpatient services Copayment once every twelve(12)months.
• Lenses,including contact lenses,and frames
Not covered,except contact lens after cataract surgery is covered in full when in lieu of intraocular lens
Organ Transplants
Covered subject to the applicable Copayment up to a$200,000 lifetime benefit maximum(including donor costs up
to$50,000), and a twelve(12)month benefit wait period
Plastic and Reconstructive Services(plastic surgery,cosmetic surgery)
• Surgery to correct a congenital disease or anomaly,or conditions following an injury or resulting from surgery
Covered subject to the applicable Copayment.
' • Cosmetic surgery,including complications resulting from cosmetic surgery
Not covered
C23687-0036900 9
Podiatric Services
• Medically Necessary foot care
Covered subject to the applicable Copayment.
• Foot care(routine)
Not covered,except in the presence of a non-related Medical Condition affecting the lower limbs
Pre-Existing Condition
Covered with no watt
Preventive Services(well adult and well child physicals,immunizations,pap smears,mammograms)
Covered subject to the outpatient services Copayment when in accordance with the well care schedule established
by GHC Eye refractions are not included under preventive care Physicals for travel,employment,insurance,
license,etc.,are not covered.
Rehabilitation Services
• Inpatient physical,occupational and restorative speech therapy services combined, including services for
neurodevelopmentally disabled children age six(6)and under
Covered subject to the inpatient services Copayment for up to sixty(60)days per calendar year
• Outpatient physical,occupational and restorative speech therapy services combined, including services for
neurodevelopmentally disabled children age six(6)and under
Covered subject to the outpatient services Copayment for up to sixty(60)visits per calendar year.
Sexual Dysfunction Services
Not covered.
Skilled Nursing Facility(SNF)
Covered up to thirty(30)days per condition per Member per calendar year.
Sterilization(vasectomy,tubal ligation)
Covered subject to applicable Copayments.
Temporomandibular Joint(TMJ)Services ,
• Inpatient and outpatient TMJ services
Covered subject to the applicable Copayment up to$1,000 maximum per Member per calendar year.
• Lifetime benefit maximum
Covered up to$5,000 per Member
C23687-0036900 10
Tobacco Cessation
• Individual/group sessions
Covered in full
• Approved pharmacy products
Covered subject to the lesser of GHC's charge or the applicable prescription drug Cost Share for a supply of
thirty(30)days or less of a prescription or refill when prescribed by a GHC Provider and obtained at GHC
Facilities
Section III. Eligibility, Enrollment and Termination
A. Eligibility
In order to be accepted for enrollment and continuing coverage under the Agreement,individuals must meet any
eligibility requirements imposed by the Group,and/or all applicable plan documents,reside or work in the
Service Area and meet all applicable requirements set forth below,except for temporary residency outside the
Service Area for purposes of attending school,court-ordered coverage for Dependents or other unique family
arrangements,when approved in advance by GHC GHC has the right to verify eligibility
1. Subscribers.Bona fide LEOFF II employees who have been continuously employed on a regularly
scheduled basis of not less than twenty(20)hours per week shall be eligible for enrollment
Elected officials and council members shall be eligible for enrollment
LEOFF I employees will not be covered under this plan.
2. Dependents.The Subscriber may also enroll the following:
a. The Subscriber's legal spouse.
b Unmarried dependent children who are under the age of twenty-three(23)and are chiefly dependent on
the Subscriber for support and maintenance,provided proof of such dependency is furnished to GHC
upon request
"Children"means the children of the Subscriber,including adopted children,stepchildren,children for
whom the Subscriber has a qualified court order to provide coverage and any other children for whom
the Subscriber is the legal guardian
c. Dependents of LEOFF I employees are eligible for coverage under this agreement.
1 3. Temporary Coverage for Newborns. When a Member gives birth,the newborn will be entitled to the
benefits set forth in Section iV from birth through three(3)weeks of age After three(3)weeks of age,no
benefits are available unless the newborn child qualifies as a Dependent and is enrolled under the
Agreement All contract provisions,limitations and exclusions will apply except Section[it F and III G
4. Limiting Age Extension. Eligibility may be extended past the limiting age for an unmarried person
enrolled as a Dependent on his/her twenty-third(23rd)birthday if
The Dependent is totally incapable of self-sustaining employment because of a developmental or physical
disability incurred prior to attainment of the limiting age set forth in 2 above,and is chiefly dependent
iC23687-0036900 11
upon the Subscriber for support and maintenance Enrollment for such a Dependent may be continued for ,
the duration of the continuous total incapacity,provided enrollment does not terminate for any other reason
Medical proof of incapacity and proof of financial dependency must be furnished to GHC upon request,but
not more frequently than annually after the two(2)year period following the Dependent's attainment of the
limiting age
B. Enrollment
1. Application for Enrollment.Application for enrollment must be made on an application form furnished
and approved by GHC Applicants will not be enrolled or premiums accepted until the completed
application form has been received and approved by GHC The Group is responsible for submitting
completed application forms to GHC
GHC reserves the right to refuse enrollment to any person whose coverage under any Medical Coverage
Agreement issued by Group Health Cooperative or Group Health Options,Inc has been terminated for
cause,as set forth in Section III E below
a. Newly Eligible Persons.Newly eligible Subscribers and their Dependents may apply for enrollment in
writing to the Group within thirty-one(31)days of becoming eligible
b. New Dependents. A written application for enrollment of a newly dependent person,other than a
newborn or adopted newborn child,must be made to the Group within thirty-one(31)days after the
dependency occurs
A written application for enrollment of a newborn child must be made to the Group within sixty(60)
days following the date of birth,when there is a change in the monthly premium payment as a result of
the additional Dependent.
A written application for enrollment of an adoptive child must be made to the Group within sixty(60)
days from the day the child is placed with the Subscriber for the purpose of adoption and the
Subscriber assumes financial responsibility for the medical expenses of the child,if there is a change in
the monthly premium payment as a result of the additional Dependent
When there is no change in the monthly premium payment,it is strongly advised that the Subscriber
enroll the newborn or newly adoptive child as a Dependent with the Group to avoid delays in the
payment of claims
c. Open Enrollment. GHC will allow enrollment of Subscribers and Dependents,who did not enroll
when newly eligible as described above,during a limited period of time specified by the Group and
GHC
d. Special Enrollment. GHC will allow special enrollment for persons who initially declined enrollment ,
when newly eligible because such persons had other health care coverage and have had such other
coverage terminated due to cessation of employer contributions,exhaustion of COBRA continuation
coverage or loss of eligibility,except for loss of eligibility for cause, GHC or the Group may require
confirmation that when initially offered coverage such persons submitted a written statement declining
because of other coverage Application for coverage under the Agreement must be made within thirty-
one(31)days of the termination of previous coverage
In the event a Subscriber or person eligible to be a Subscriber acquires a person eligible to be a
Dependent by birth,marriage,adoption or placement for adoption,GHC will allow special enrollment
for the person eligible to be a Subscriber,his/her spouse and the newly acquired Dependent
Application for coverage under the Agreement must be made within thirty-one(31)days of the
acquisition of the new Dependent,except that sixty(60)days is permitted to enroll newborn and
adopted children as described above
C23687-0036900 12
2. Limitation on Enrollment.The Agreement will be open for applications for enrollment as set forth in this
Section III B Sub3ect to prior approval by the Washington State Office of the Insurance Commissioner,
GHC may limit enrollment,establish quotas or set priorities for acceptance of new applications if it
determines that GHC's capacity,in relation to its total enrollment,is not adequate to provide services to
additional persons
' C. Effective Date of Enrollment
I. Provided eligibility criteria are met and applications for enrollment are made as set forth in Sections III.A.
and III B above,enrollment will be effective as follows
• Enrollment for a newly eligible Subscriber and listed Dependents is effective on the date of hire
• Enrollment for a newly dependent person,other than a newborn or adoptive child,is effective the first
(1st)of the month following application
• Enrollment for newborns is effective from the date of birth
• Enrollment for adoptive children is effective from the date that the adoptive child is placed with the
Subscriber for the purpose of adoption and the Subscriber has assumed financial responsibility for the
medical expenses of the child
2. Commencement of Benefits for Persons Hospitalized on Effective Date.Members who are admitted to
an inpatient facility prior to their enrollment under the Agreement,and who do not have coverage under
another agreement,will receive covered benefits beginning on their effective date,as set forth in subsection
C I above If a Member is hospitalized in a non-GHC Facility,GHC reserves the right to require transfer
of the Member to a GHC Facility The Member will be transferred when a GHC Provider,in consultation
with the attending physician,determines that the Member is medically stable to do so. If the Member
refuses to transfer to a GHC Facility,all further costs incurred during the hospitalization are the
responsibility of the Member
D. Eligibility for Medicare
Under the Tax Equity and Fiscal Responsibility Act of 1982(TEFRA),actively employed Members and their
spouses who are eligible for Medicare benefits must decide whether to choose the benefits of the Agreement or
the Medicare program as their primary source of health care coverage The Group is responsible for providing
the Member with necessary information regarding TEFRA eligibility and the selection process
Members Residing Outside the GHC Medicare Advantage Service Area. Except as defined by federal
regulations(i e,TEFRA),if a Member or their spouse is or becomes eligible for Medicare,they must,effective
the date that Medicare becomes the primary payer,enroll in and maintain both Medicare Parts A and B
coverage Failure to enroll in both Medicare Parts A and B,upon the effective date of eligibility,will result in
termination of coverage under the Agreement
An individual shall be deemed eligible for Medicare when he/she has the option to receive Part A Medicare
benefits
Medicare primarylsecondary payer guidelines and regulations will determine primary/secondary payer status
Members Residing inside the GHC Medicare Advantage Service Area. Except as defined by federal
regulations,(i e,TEFRA), if a Member or their spouse is or becomes eligible for Medicare,they must,effective
the date that Medicare becomes the primary payer,enroll in and maintain both Medicare Parts A and B
coverage and enroll in the GHC Medicare Advantage Plan Failure to do so upon the effective date of Medicare
eligibility will result in termination of coverage under the Agreement
An individual shall be deemed eligible for Medicare when he/she has the option to receive Part A Medicare
benefits
C23687-0036900 13
All applicable provisions of the GHC Medicare Advantage Plan are fully set forth in the Medicare
Endorsement(s)attached to the Agreement(if applicable)
E. Termination of Coverage
1. Termination of Specific Members.Specific Members may be terminated from the Agreement for any of
the following reasons
a. Loss of Eligibility. If a Member no longer meets the eligibility requirements set forth in Section
III A,and is not enrolled for continuation coverage as described in Section III G below,coverage
under the Agreement will terminate at the end of the month during which the loss of eligibility occurs,
unless otherwise specified by the Group
b. For Cause.Coverage of a Member may be terminated upon written notice for
i. Material misrepresentation,fraud or omission of information in order to obtain coverage This
includes failure to answer fully and correctly all questions contained in the application forms In
such event,GHC may,within two(2)years from the date of the application,refuse to cover any
service for a condition(s)to which such question was relevant,or may non-renew or cancel the
Member's coverage upon ten(10)working days written notice
ii Permitting the use of a GHC identification card or number by another person,or using another
Member's identification card or number to obtain care to which a person is not entitled
in Nonpayment of charges,as set forth in Section I C
c. Premium Payments Nonpayment of premiums or contribution for a specific Member by the Group
In no event will a Member be terminated solely on the basis of their physical or mental condition provided
they meet all other eligibility requirements set forth in the Agreement
Any Member may appeal a termination decision through GHC's grievance process as set forth in Section
VI
2. Certificate of Creditable Coverage. Unless the Group has chosen to accept this responsibility,a
certificate of creditable coverage(which provides information regarding the Member's length of coverage
under the Agreement)will be issued automatically upon termination of coverage,and may also be obtained
upon request
F. Services After Termination of Agreement
1. Members Hospitalized on the Date of Termination.A Member who is receiving Covered Services as a
registered bed patient in a hospital on the date of termination shall continue to be eligible for Covered
Services while an inpatient for the condition which the Member was hospitalized,until one of the following
events occurs
• According to GHC clinical criteria,it is no longer Medically Necessary for the Member to be an
inpatient at the facility
• The remaining benefits available under the Agreement for the hospitalization are exhausted,regardless
of whether a new calendar year begins
• The Member becomes covered under another agreement with a group health plan that provides benefits
for the hospitalization
• The Member becomes enrolled under an agreement with another carrier that would provide benefits for
the hospitalization if the Agreement did not exist
• The Member becomes eligible for Medicare
C23697-0036900 14
This provision will not apply if the Member is covered under another agreement that provides benefits for
the hospitalization at the time coverage would terminate,except as set forth in this section,or if the
Member is eligible for COBRA continuation coverage as set forth in subsection G below
2. Services Provided After Termination.The Subscriber shall be Fable for payment of all charges for
services and items provided to the Subscriber and all Dependents after the effective date of termination,
except those services covered under subsection F 1.above Any services provided by GHC will be charged
according to the Fee Schedule
G. Continuation of Coverage Options
1. Continuation Option. A Member no longer eligible for coverage under the Agreement(except in the
event of termination for cause,as set forth in Section IIi E)may continue coverage for a period of up to
three(3)months subject to notification to and self-payment of premiums to the Group This provision will
not apply if the Member is eligible for the continuation coverage provisions of the Consolidated Omnibus
Budget Reconciliation Act of 1985("COBRA") This continuation option is not available if the Group no
longer has active employees or otherwise terminates
2. Leave of Absence. While on a Group approved leave of absence,the Subscriber and listed Dependents can
continue to be covered under the Agreement,provided
t • They remain eligible for coverage,as set forth in Section III A,
• Such leave is in compliance with the Group's established leave of absence policy that is consistently
applied to all employees,
• The Group's leave of absence policy is in compliance with the Family and Medical Leave Act when
applicable,and
• The Group continues to remit premiums for the Subscriber and Dependents to GHC
3. Self-Payments During Labor Disputes. In the event of suspension or termination of employee
compensation due to a strike,lock-out or other labor dispute,a Subscriber may continue uninterrupted
coverage under the Agreement through payment of monthly premiums directly to the Group Coverage may
be continued for the lesser of the term of the strike,lock-out or other labor dispute,or for six(6)months
after the cessation of work.
If the Agreement is no longer available,the Subscriber shall have the opportunity to apply for an individual
GHC Group Conversion Plan or,if applicable,continuation coverage(see subsection 4 below),or an
Individual and Family Medical Coverage Agreement at the duly approved rates
The Group is responsible for immediately notifying each affected Subscriber of his/her rights of self-
payment under this provision.
4. Continuation Coverage Under Federal Law. This section applies only to Groups who must offer
continuation coverage under the applicable provisions of the Consolidated Omnibus Budget Reconciliation
Act of 1985("COBRA"),as amended,and only applies to grant continuation of coverage rights to the
extent required by federal law
Upon loss of eligibility,continuation of Group coverage may be available to a Member for a limited time
after the Member would otherwise lose eligibility,if required by COBRA The Group shall inform
Members of the COBRA election process and how much the Member will be required to pay directly to the
Group
5. GHC Group Conversion Plan. Members whose eligibility for coverage under the Agreement,including
continuation coverage, is terminated for any reason other than cause,as set forth in Section IIi E I b,and
who are not eligible for Medicare or covered by another group health plan,may convert to GHC's Group
tC23687-0036900 15
Conversion Plan, if the Agreement terminates,any Member covered under the Agreement at termination
may convert to a GHC Group Conversion Plan,unless he/she is eligible to obtain other group health
coverage within thirty-one(31)days of the termination of the Agreement
An application for conversion must be made witlun thirty-one(31)days following termination of coverage
under the Agreement Coverage under GHC's Group Conversion Plan is subject to all terms and conditions
of such plan,including premium payments A physical examination or statement of health is not required
for enrollment in GHC's Group Conversion Plan The Pre-Existing Condition limitation under GHC's
Group Conversion Plan will apply only to the extent that the limitation remains unfulfilled under the
Agreement.
By exercising Group Conversion rights,the Member may waive guaranteed issue and Pre-Existing
Condition waiver rights under Federal regulations
Persons wishing to purchase GHC's Individual and Family coverage should contact GHC Marketing.
Section IV. Schedule of Benefits
Benefits are subject to all provisions of the Group Medical Coverage Agreement,including,without
limitation,the Accessing Care provisions and General Exclusions. Members must refer to Section 11.,the
Allowances Schedule,for Cost Shares and specific benefit limits that apply to benefits listed in this Schedule
of Benefits. Members are entitled to receive only benefits and services that are Medically Necessary and
clinically appropriate for the treatment of a Medical Condition as determined by GHC's Medical Director or
his/her designee,and as described herein. All Covered Services are subject to case management and
utilization review at the discretion of GHC.
A. Hospital Care
Hospital coverage is limited to the following services•
1. Room and board,including private room when prescribed,and general nursing services
2 Hospital services(including use of operating room,anesthesia,oxygen,x-ray,laboratory and radiotherapy
services)
3 Alternative care arrangements may be covered as a cost-effective alternative in lieu of otherwise covered
Medically Necessary hospitalization,or other covered Medically Necessary institutional care Alternative
care arrangements in lieu of covered hospital or other institutional care must be determined to be
appropriate and Medically Necessary based upon the Member's Medical Condition Coverage must be
authorized in advance by GHC as appropriate and Medically Necessary Such care will be covered to the
same extent the replaced Hospital Care is covered under the Agreement
4 Drugs and medications administered during confinement
5 Special duty nursing,when prescribed as Medically Necessary.
If a Member is hospitalized in a non-GHC Facility,GHC reserves the right to require transfer of the Member to
a GHC Facility,upon consultation between a GHC Provider and the attending physician If the Member refuses
to transfer,all further costs incurred during the hospitalization are the responsibility of the Member
B. Medical and Surgical Care
Medical and surgical coverage is limited to the following
1. Surgical services.
C23687-0036900 16
t
2 Diagnostic x-ray,nuclear medicine,ultrasound and laboratory services
3. Family planning counseling services
4 Hearing examinations to determine hearing loss.
5. Blood and blood derivatives and their administration
6 Preventive care(well care)services for health maintenance in accordance with the well care schedule
established by GHC Preventive care includes routine mammography screening,physical examinations
and routine laboratory tests for cancer screening in accordance with the well care schedule established by
GHC,and immunizations and vaccinations listed as covered in the GHC drug formulary(approved drug
list) A fee may be charged for health education programs
Covered Services provided during a preventive care visit,which are not in accordance with the GHC well
care schedule,are subject to the applicable Cost Shares
7. Radiation therapy services
8 Reduction of a fracture or dislocation of the jaw or facial bones,excision of tumors or non-dental cysts of
the jaw,cheeks,lips,tongue,gums,roof and floor of the mouth,and incision of salivary glands and ducts
9. Medical implants
Excluded internally implanted insulin pumps,artificial hearts,artificial larynx and any other implantable
device that has not been approved by GHC's Medical Director,or his/her designee
10 Respiratory therapy
11 Outpatient total parenteral nutritional therapy,outpatient elemental formulas for malabsorption,dietary
formula for the treatment of phenylketonuria(PKU).Coverage for PKU formula is not subject to a Pre-
Existing Conditions waiting period,if applicable
Equipment and supplies for the administration of enteral and parenteral therapy are covered under Devices,
Equipment and Supplies
Excluded any other dietary formulas,oral nutritional supplements,special diets,prepared foods/meals and
formula for access problems
12 Visits with GHC Providers,including consultations and second opinions,in the hospital or provider's
office
13. Optical services.
Routine eye examinations and refractions received at a GHC Facility once every twelve(12)months,
except when Medically Necessary
When dispensed through GHC Facilities,one contact lens per diseased eye in lieu of an mtraocular lens,
1 including exam and fitting,is covered for Members following cataract surgery performed by a GHC
Provider,provided the Member has been continuously covered by GHC since such surgery Replacement
of a covered contact lens will be covered only when needed due to a change in the Member's Medical
Condition,but no more than once in a twelve(12)month period
C23687-0036900 17
r
Excluded evaluations and surgical procedures to correct refractions not related to eye pathology and
complications related to such procedures,and contact lens fittings and related examinations,except as set
forth above
14 Maternity care,including care for complications of pregnancy and prenatal and postpartum visits
Prenatal testing for the detection of congenital and heritable disorders when Medically Necessary as
determined by GHC's Medical Director,or his/her designee,and in accordance with Board of Health
standards for screening and diagnostic tests during pregnancy
Hospitalization and delivery,including home births for low nsk pregnancies Planned home births must be
authorized in advance by GHC
Voluntary(not medically indicated and non-therapeutic)or involuntary termination of pregnancy
The Member's physician,in consultation with the Member,will determine the Member's length of j
inpatient stay following delivery Pregnancy will not be excluded as a Pre-Existing Condition under the
Agreement Treatment for post-partum depression or psychosis is covered only under the mental health
benefit. ,
Excluded birthing tubs and genetic testing of non-Members for the detection of congenital and heritable
disorders
15. Transplant services,including heart,heart-lung,single lung,double lung,kidney,pancreas,cornea,
intestinal/multi-visceral,bone marrow,liver transplants and stem cell support(obtained from allogeneic or
autologous peripheral blood or marrow)with associated high dose chemotherapy Services are limited to
the following
a Evaluation testing to determine recipient candidacy,
b Matching tests,
c Inpatient and outpatient medical expenses listed below for transplantation procedures. Covered
Services must be directly associated with,and occur at the time of,the transplant The following
transplantation expenses are subject to the organ recipient's lifetime benefit maximums set forth in the
Allowances Schedule
• Hospital charges,
• Procurement center fees,
• Professional fees,
• Travel costs for a surgical team,
• Excision fees,and '
• Donor costs for a covered organ recipient are limited to procurement center fees,travel costs for a
surgical team and excision fees
d Follow-up services for specialty visits,
e Rehospitalization,and
f. Maintenance medications
Excluded donor costs to the extent that they are reimbursable by the organ donor's insurance,treatment of
donor complications,living expenses and transportation expenses,except as set forth under Section IV M
Coverage for all transplants and any related services,items and drugs shall be excluded until the Member
has been continuously enrolled under the Agreement,or any prior GHC or GHO Medical Coverage
Agreement,for twelve(12)consecutive months without any lapse in coverage,except for children who
C23687-0036900 18
have been continuously enrolled with GHC since birth,or if the Member requires a transplant as the result
of a condition which had a sudden unexpected onset after the Member's effective date of coverage
16 Manipulative therapy
Self-Referrals for manipulative therapy of the spine only are limited to one(1)evaluation and ten(10)
manipulations when provided by GHC Providers
Additional visits are covered when approved by GHC
Excluded supportive care rendered primarily to maintain the level of correction already achieved,care
rendered primarily for the convenience of the Member,care rendered on a non-acute,asymptomatic basis,
charges for office visits other than the initial evaluation and any other services that do not meet GHC
clinical criteria as Medically Necessary
IT Medical and surgical services and related hospital charges,including orthognathic(Jaw)surgery,for the
treatment of temporomandibular Joint(TMJ)disorders Such disorders may exhibit themselves in the form
of pain,infection,disease,difficulty in speaking or difficulty in chewing or swallowing food TMJ
appliances are covered as set forth under Section IV H I ,Orthopedic Appliances
Orthognathic(law) surgery for the treatment of TMJ disorders,radiology services and TMJ specialist
services,including fitting/adjustment of splints are subject to the benefit lima set forth in the Allowances
Schedule
Excluded are the following,regardless of origin or cause, orthognathtc(law)surgery in the absence of a
TMJ or severe obstructive sleep apnea diagnosis,treatment for cosmetic purposes,dental services,
including orthodontic therapy and any hospitalizations related to these exclusions
18. Treatment of growth disorders by growth hormones
19 Diabetic training and education
20 Detoxification services for alcoholism and drug abuse
For the purposes of this section,"acute chemical withdrawal"means withdrawal of alcohol and/or drugs
from a Member for whom consequences of abstinence are so severe that they require medical/nursing
assistance in a hospital setting,which is needed immediately to prevent serious impairment to the Member's
health
Coverage for acute chemical withdrawal is provided without prior approval If a Member is hospitalized in
a non-GHC Facility/program,coverage is subject to payment of the Emergency Deductible The Member
or person assuming responsibility for the Member must notify GHC by way of the GHC Notification Line
within twenty-four(24)hours following inpatient admission,or as soon thereafter as medically possible
Furthermore,if a Member is hospitalized in a non-GHC Facility/program,GHC reserves the right to require
transfer of the Member to a GHC Facility/program upon consultation between a GHC Provider and the
attending physician. If the Member refuses transfer to a GHC Facility/program,all further costs incurred
during the hospitalization are the responsibility of the Member.
21 Circumcision
22 Banatnc surgery and related hospitalizations when GHC criteria are met.
Excluded pre and post surgical nutritional counseling and related weight loss programs,prescribing and
monitoring of drugs, structured weight loss and/or exercise programs,and specialized nutritional
counseling
C23687-0036900 19
t
23 Sterilization procedures i
24 General anesthesia services and related facility charges for dental procedures will be covered for Members
who are under seven(7)years of age,who are physically or developmentally disabled or who have a
Medical Condition where the Member's health would be put at risk if the dental procedure were performed
in a dentist's office Such services must be authorized in advance by GHC and performed at a GHC
hospital or ambulatory surgical facility
Excluded dentist's or oral surgeon's fees
25 Self-Referrals to GHC acupuncturists and naturopaths for Covered Services,as set forth in the Allowances
Schedule. Additional visas are covered when approved by GHC Laboratory and radiology services are
covered only when obtained through a GHC Facility.
Excluded herbal supplements,preventive care visits to acupuncturists and naturopaths and any services not
within the scope of their licensure
26 Once Pre-Existing Condition wait periods,if any,have been met,Pre-Existing Conditions are covered in
the same manner as any other illness
C. Chemical Dependency Treatment.
Chemical dependency means an illness characterized by a physiological or psychological dependency,or both,
on a controlled substance and/or alcoholic beverages,and where the user's health is substantially impaired or
endangered or his/her social or economic function is substantially disrupted
For the purposes of this section,the definition of Medically Necessary shall be expanded to include those
services necessary to treat a chemical dependency condition that is having a clinically significant impact on a
Member's emotional,social,medical and/or occupational functioning
Chemical dependency treatment services are covered as set forth below at a GHC Facility or GHC-approved
treatment program,subject to the benefit period Allowance set forth in the Allowances Schedule Any Cost
Shares for chemical dependency services under the terms of the Agreement shall not be applied toward the
benefit period Allowance
1. Chemical Dependency Treatment Services.All alcoholism and/or drug abuse treatment services must be
(a)provided at a facility as described above,and(b)deemed Medically Necessary as defined above
Chemical dependency treatment may include the following services received on an inpatient or outpatient
basis diagnostic evaluation and education,organized individual and group counseling and/or prescription
drugs and medicines,unless excluded under the Agreement
Court-ordered treatment shall be covered only if determined to be Medically Necessary as defined above.
2. Benefit Period.For the purposes of this section,"benefit period"shall mean a twenty-four(24)consecutive
calendar month period during which the Member is eligible to receive covered chemical dependency
treatment services,as set forth in this section The first benefit period shall begin on the first day the
Member receives covered chemical dependency services and shall continue for twenty-four(24)
consecutive calendar months,provided that coverage under the Agreement remains in force All subsequent
benefit periods thereafter will begin on the first day Covered Services are received after the expiration of
the previous twenty-four(24)month benefit period
D. Plastic and Reconstructive Services.Plastic and reconstructive services are covered as set forth below
C23687-0036900 20
I Correction of a congenital disease or congenital anomaly,as determined by a GHC Provider A congenital
anomaly will be considered to exist if the Member's appearance resulting from such condition is not within
the range of normal human variation
2. Correction of a Medical Condition following an injury or resulting from surgery covered by GHC whir,h
has produced a major effect on the Member's appearance,when in the opinion of a GHC Provider,such
services can reasonably be expected to correct the condition
3 Reconstructive surgery and associated procedures,including internal breast prostheses,following a
mastectomy,regardless of when the mastectomy was performed
Members will be covered for all stages of reconstruction on the non-diseased breast to make it equivalent to
size with the diseased breast after definitive reconstructive surgery on the diseased breast has been
performed
Complications of covered mastectomy services,including lymphedemas,are covered
Excluded complications ofnoncovered surgical services
E. Home Health Care Services. Home health care services,as set forth in this section,shall be covered when
provided by and referred in advance by a GHC Provider for Members who meet the following cntena
1 The Member is unable to leave home due to his/her health problem or illness Unwillingness to travel
and/or arrange for transportation does not constitute inability to leave the home
2. The Member requires intermittent skilled home health care services,as described below
3 A GHC Provider has determined that such services are Medically Necessary and are most appropriately
rendered in the Member's home
For the purposes of this section,"skilled home health care"means reasonable and necessary care for the
treatment of an illness or injury which requires the skill of a nurse or therapist,based on the complexity of the
service and the condition of the patient and which is performed directly by an appropriately licensed
professional provider.
Covered Services for home health care may include the following when rendered pursuant to an approved home
health care plan of treatment nursing care,physical therapy,occupational therapy,respiratory therapy,
restorative speech therapy and medical social worker and limited home health aide services Home health
services are covered on an intermittent basis in the Members home "Intermittent"means care that is to be
rendered because of a medically predictable recurring need for skilled home health care services.
Excluded custodial care and maintenance care,private duty or continuous nursing care in the Membees home,
housekeeping or meal services,care in any nursing home or convalescent facility,any care provided by or for a
member of the patient's family and any other services rendered in the home which do not meet the definition of
skilled home health care above or are not specifically listed as covered under the Agreement
F. Hospice Care. Hospice care is covered in lieu of curative treatment for terminal illness for Members who meet
all of the following criteria
• A GHC Provider has determined that the Member's illness is terminal and life expectancy is six(6)months
or less
• The Member has chosen a palliative treatment focus(emphasizing comfort and supportive services rather
than treatment aimed at curing the Member's terminal illness)
• The Member has elected in writing to receive hospice care through GHC's Hospice Program or GHC's
approved hospice program
• The Member has available a primary care person who will be responsible for the Member's home care.
tC23687-0036900 21
1
• A GHC Provider and GHC's Hospice Director,or his/her designee,have determined that the Member's
illness can be appropriately managed in the home
Hospice care shall mean a coordinated program of palliative and supportive care for dying Members by an
interdisciplinary team of professionals and volunteers centering primarily in the Member's home.
1. Covered Services Care may include the following as prescribed by a GHC Provider and rendered pursuant
to an approved hospice plan of treatment '
a. Home Services
i Intermittent care by a hospice interdisciplinary team which may include services by a physician,
nurse,medical social worker,physical therapist,speech therapist,occupational therapist,
respiratory therapist,limited services by a Home Health Aide under the supervision of a
Registered Nurse and homemaker services
ii. Continuous care services in the Member's home when prescribed by a GHC Provider,as set forth —in this this paragraph "Continuous care"means skilled nursing care provided in the home during a
period of crisis in order to maintain the terminally ill Member at home Continuous care may be
provided for pain or symptom management by a Registered Nurse,Licensed Practical Nurse or ,
Home Health Aide under the supervision of a Registered Nurse Continuous care is covered up to
twenty-four(24)hours per day during periods of crisis Continuous care is covered only when a
GHC Provider determines that the Member would otherwise require hospitalization in an acute
care facility.
b. Inpatient Hospice Services. For short-term care,inpatient hospice services shall be covered in a
facility designated by GHC's Hospice Program or GHC-approved hospice program when authorized in
advance by a GHC Provider and GHC's Hospice Program or GHC-approved hospice program
Inpatient respite care is covered for a maximum of five(5)consecutive days per occurrence in order to
continue care for the Member in the temporary absence of the Member's primary care giver(s)
c Other covered hospice services may include the following
i Drugs and biologicals that are used primarily for the relief of pain and symptom management '
u Medical appliances and supplies primarily for the relief of pain and symptom management
in Counseling services for the Member and his/her primary care-giver(s)
iv Bereavement counseling services for the family
2. Hospice Exclusions. All services not specifically listed as covered in this section are excluded,including
a Financial or legal counseling services
b Meal services '
c. Custodial or maintenance care in the home or on an inpatient basis,except as provided above.
d Services not specifically listed as covered by the Agreement
e Any services provided by members of the patient's family '
£ All other exclusions listed in Section V,General Exclusions,apply.
G. Rehabilitation Services.
I Rehabilitation services are covered as set forth in this section,limited to the following physical therapy, '
occupational therapy,and speech therapy to restore function following illness,injury or surgery Services
are subject to all terns,conditions and limitations of the Agreement,including the following
a All services must be provided at a GHC or GHC-approved rehabilitation facility and must be
prescribed and provided by a GHC-approved rehabilitation team that may include medical,nursing,
physical therapy,occupational therapy,massage therapy and speech therapy providers
C23687-0036900 22
1
' b. Services are limited to those necessary to restore or improve functional abilities when physical,
sensors-perceptual and/or communication impairment exists due to injury,illness or surgery Such
services are provided only when GHC's Medical Director,or hislier designee,determines that
significant,measurable improvement to the Member's condition can be expected within a sixty(60)
' day period as a consequence of intervention by covered therapy services described in paragraph a,
above
' c Coverage for inpatient and outpatient services is limited to the Allowance set forth in the Allowances
Schedule
Excluded specialty rehabilitation programs not provided by GHC,long-term rehabilitation programs,
physical therapy,occupational therapy and speech therapy services when such services are available
(whether application is made or not)through governmental programs,programs offered by public school
districts;therapy for degenerative or static conditions when the expected outcome is primarily to maintain
the Member's level of functioning(except as set forth in subsection 2 below),recreational,life-enhancing,— --
' - —- relaxation or palliative therapy,implementation of home maintenance programs,programs for treatment of
learning problems,any services not specifically included as covered in this section,and any services that
are excluded under Section V
2. Neurodevelopmental Therapies for Children Age Six(6)and Under. Physical therapy,occupational
therapy and speech therapy services for the restoration and improvement of function for
neurodevelopmentally disabled children age six(6)and under shall be covered Coverage includes
' maintenance of a covered Member in cases where significant deterioration in the Member's condition
would result without the services Coverage for inpatient and outpatient services is limited to the
Allowance set forth in the Allowances Schedule
' Excluded specialty rehabilitation programs not provided by GHC;long-term rehabilitation programs,
physical therapy,occupational therapy and speech therapy services when such services are available
(whether application is made or not)through governmental programs,programs offered by public school
districts,recreational,life-enhancing,relaxation or palliative therapy,implementation of home maintenance
' programs,programs for treatment of learning problems,any services not specifically included as covered in
this section,and any services that are excluded under Section V
H. Devices,Equipment and Supplies.
Devices,equipment and supplies,which restore or replace functions that are common and necessary to perform
basic activities of daily Irving,are covered as set forth in the Allowances Schedule Examples of basic activities
' of daily living are dressing and feeding oneself,maintaining personal hygiene, lifting and gripping in order to
prepare meals and carrying groceries
1. Orthopedic Appliances.Orthopedic appliances,which are attached to an impaired body segment for the
' purpose of protecting the segment or assisting in restoration or improvement of its function
Excluded arch supports,including custom shoe modifications or inserts and their fittings except for
therapeutic shoes,modifications and shoe inserts for severe diabetic foot disease,and orthopedic shoes that
are not attached to an appliance
2. Ostomy Supplies.Ostomy supplies for the removal of bodily secretions or waste through an artificial
' opening,
3. Durable Medical Equipment Durable medical equipment is equipment which can withstand repeated
use,is primarily and customarily used to serve a medical purpose,is useful only in the presence of an
' illness or injury and used in the Member's home Durable medical equipment includes hospital beds,
wheelchairs,walkers,crutches,canes,glucose monitors,external insulin pumps,oxygen and oxygen
' C23687-0036900 23
1
equipment GHC,in its sole discretion,will determine if equipment is made available on a rental or
purchase basis
4. Prosthetic Devices. Prosthetic devices are items which replace all or part of an external body part,or ,
function thereof
When authorized in advance,repair,adjustment or replacement of appliances and equipment is covered
Excluded items which are not necessary to restore or replace functions of bask activities of daily living,and ,
replacement or repair of appliances,devices and supplies due to loss,breakage from willful damage,neglect or
wrongful use,or due to personal preference
I. Tobacco Cessation.When provided through GHC,services related to tobacco cessation are covered,limited to ,
1. Participation in one individual or group program per calendar year, '
2. Educational materials,and -
-- 3. One course of nicotine replacement therapy per calendar year,provided the Member is actively
participating in a GHC-designated tobacco cessation program
J. Drugs,Medicines,Supplies and Devices. Legend medications are drugs which have been approved by the '
Food and Drug Administration(FDA)and which can,under federal or state law,be dispensed only pursuant to
a prescription order These drugs,including off-label use of FDA-approved drugs(provided that such use is
documented to be effective in one of the standard reference compendia,a majority of well-designed clinical ,
trials published in peer-reviewed medical literature document improved efficacy or safety of the agent over
standard therapies,or over placebo if no standard therapies exist,or by the federal secretary of Health and
Human Services),contraceptive drugs and devices and their fitting,diabetic supplies,including insulin syringes,
lancets,unne-testing reagents,blood glucose monitoring reagents,and insulin,are covered as set forth below
All drugs,supplies,medicines and devices must be prescribed by a GHC Provider for conditions covered by the
Agreement,obtained at a GHC pharmacy and,unless approved by GHC in advance,be listed in the GHC drug ,
formulary The prescription drug Copayment as set forth in the Allowances Schedule applies to each thirty(30)
day supply Copayments for single and multiple thirty(30)day supplies of a given prescription are payable at
the time of delivery Injectables that can be self-administered are also subject to the prescription drug
Copayment Drug formulary(approved drug list)is defined as a list of preferred pharmaceutical products, ,
supplies and devices developed and maintained by GHC
Generic drugs will be dispensed whenever available Brand name drugs will be dispensed if there is not a ,
generic equivalent In the event the Member elects to purchase brand-name drugs instead of the generic
equivalent(if available),or if the Member elects to purchase a different brand-name or generic drug than that
prescribed by the Member's Provider,and it is not determined to be Medically Necessary,the Member will also
be subject to payment of the additional amount above the applicable pharmacy Cost Share set forth in the '
Allowances Schedule Generic drugs are defined as a drug that is the pharmaceutical equivalent to one or more
brand name drugs Such generic drugs have been approved by the Food and Drug Administration as meeting
the same standards of safety,purity,strength and effectiveness as the brand name drug Brand name drugs are
defined as a prescription drug that has been patented and is only available through one manufacturer '
"Standard reference compendia"means the American Hospital Formulary Service-Drug Information,the
American Medical Association Drug Evaluation,the United States Pharmacopoeia-Drug Infomiation,or other
authoritative compendia as identified from time to time by the federal secretary of Health and Human Services
"Peer-reviewed medical literature"means scientific studies printed in healthcare journals or other publications
in which original manuscripts are published only after having been critically reviewed for scientific accuracy,
validity,and reliability by unbiased independent experts Peer-reviewed medical literature does not include m-
house publications of pharmaceutical manufacturing companies
I
C23687-0036900 24 I
1
1 +
I
I °
Excluded. over-the-counter drugs,medicines,supplies and devices not requiring a prescription under state law
' or regulations,drugs used in the treatment of sexual dysfunction disorders,medicines and injections for
anticipated illness while traveling,vitamins,including Legend(prescription)vitamins,and any other drugs,
medicines and injections not listed as covered in the GHC drug formulary unless approved in advance by GHC
as Medically Necessary
The Member will be charged for replacing lost or stolen drugs,medicines or devices
The Member's Right to Safe and Effective Pharmacy Services.
State and federal laws establish standards to assure safe and effective pharmacy services,and to guarantee
Members' rights to know what drugs are covered under the Agreement and what coverage limitations are in the
Agreement Members who would like more information about the drug coverage policies under the Agreement,
or have a question or concern about their pharmacy benefit,may contact us at(206)901-4636 or(888)901-
4636
Members who would like to know more about their rights under the law,or think any services received while
enrolled may not conform to the terms of the Agreement,may contact the Washington State Office of Insurance
Commissioner at(800)562-6900, Members who have a concern about the pharmacists or pharmacies serving
them,may call the State Department of Health at(360)236-4825
K. Mental Health Care Services. GHC and Washington State law have established standards to assure the
competence and professional conduct of mental health service providers,to guarantee Members'rights to
informed consent to treatment,to assure the privacy of their medical information,to enable Members to know
which services are covered under the Agreement and to know the limitations on their coverage Members who
would like a more detailed description than is provided here of covered benefits for mental health services
under the Agreement, or have questions or concerns about any aspect of their mental health benefits,may
contact GHC at(888)901-4636
Members who would like to know more about their rights under the law,or think any services received while
enrolled may not conform to the terms of the Agreement or their rights under the law,may contact the
Washington State Office of the insurance Commissioner at(800)562-6900 Members who have a concern
about the qualifications or professional conduct of their mental health provider may call the State Health
Department at(360)236-4902.
Services that are provided by a mental health practitioner will be covered as mental health care,regardless of
the cause of the disorder
' 1. Outpatient Services.Outpatient mental health services place priority on restoring the Member to his/her
level of functioning prior to the onset of acute symptoms or to achieve a clinically appropriate level of
stability as determined by GHC's Medical Director,or his/her designee. Treatment for clinical conditions
may utilize psychiatric,psychological and/or psychotherapy services to achieve these objectives
tCoverage for each Member is provided according to the outpatient mental health care Allowance set forth
in the Allowances Schedule Psychiatric medical services,including medical management and
prescriptions,are covered as set forth in Sections IV B and IV J
' 2. Inpatient Services.Charges for services described in this section,including psychiatric Emergencies
resulting in inpatient services,shall be covered to the maximum benefit set forth in the Allowances
Schedule This benefit shall include coverage for acute treatment and stabilization of psychiatric
Emergencies in GHC-approved hospitals.When medically indicated,outpatient electro-convulsive therapy
(ECT)is covered in lieu of inpatient services Coverage for services incurred at non-GHC Facilities shall
exclude any charges that would otherwise be excluded for hospitalization within a GHC Facility
Partial hospitalization and outpatient electro-convulsive therapy treatments are covered subject to the
maximum inpatient benefit limit described in the Allowances Schedule Every two(2)partial
' C23687-0036900 25
i
hospitalization days or two(2)electro-convulsive therapy treatments are equivalent to one inpatient
hospital day The total maximum annual benefit under this section shall not exceed the number of inpatient
days described in the Allowances Schedule
Subject to the maximum inpatient mental health care Allowance set forth in the Allowances Schedule, '
services provided under involuntary commitment statutes shall be covered A facilities approved by GHC
Services for any involuntary court-ordered treatment program beyond seventy-two(72)hours shall be
covered only if determined to be Medically Necessary by GHC's Medical Director,or his/her designee ,
Coverage for voluntarylinvoluntary Emergency inpatient psychiatric services is subject to the Emergency
care benefit set forth in Section IV L,including the twenty-four(24)hour notification and transfer
provisions. ,
3. Exclusions and Limitations for Outpatient and Inpatient Mental Health Treatment Services.
Covered Services are limited to those provided for covered clinical conditions for which,in the opinion of
GHC's Medical Director,or his/her designee,the reduction or removal of acute clinical symptoms or-
-" _---- stabilization can be expected
Partial hospitalization programs and electro-convulsive therapy are covered only under subsection K 2
(Inpatient Services)
Excluded treatment specific to and solely for personality disorders,learning,communication and motor
skills disorders,mental retardation,academic or career counseling,sexual and identity disorders,and '
personal growth or relationship enhancement Also excluded assessment and treatment services that are
primarily vocational and academic,court-ordered or forensic treatment,including reports and summaries,
not considered Medically Necessary,written information other than clinical records,work or school
ordered assessment and treatment not considered Medically Necessary,counseling for overeating, '
psychoanalysis,nicotine related disorders,treatment or consultations provided by telephone,relationship
counseling or phase of life problems(V code only diagnoses),all forms of day treatment(non-partial
hospital programs), custodial care,and specialty programs for mental health therapy not specifically
authorized by Behavioral Health Services and approved by GHC
Any other services not specifically listed as covered in this section All other provisions,exclusions and
limitations under the Agreement also apply '
L. Emergency/Urgent Care.
All services are covered subject to the Cost Shares set forth in the Allowances Schedule
Emergency Care(See Section Vlll.for a definition of Emergency)
1. At a GHC Facility.GHC will cover Emergency care for all Covered Services '
2. At a Non-GHC Facility.Usual,Customary and Reasonable charges for Emergency care for Covered
Services are covered subject to
a. Payment of the Emergency care Deductible,and
b. Notification of GHC byway of the GHC Notification Line within twenty-four(24)hours following
inpatient admission,or as soon thereafter as medically possible. '
Outpatient medications prescribed by a non-GHC Provider are excluded.
3. Waiver of Emergency Care Cost Share.
I
C23687-0036900 26 1
1
a. Waiver for Multiple Injury Accident.If two or more Members in the same Family Unit require
Emergency care as a result of the same accident,coverage for all Members will be subject to only one
(1)Emergency care Cost Share
b. Emergencies Resulting in an Inpatient Admission.If the Member is admitted to a GHC Facility
directly from the emergency room,the Emergency care Copayment is waived However,coverage will
be subject to the inpatient services Cost Share
4. Transfer and Follow-up Care.If a Member is hospitalized in a non-GHC Facility,GHC reserves the right
' to require transfer of the Member to a GHC Facility,upon consultation between a GHC Provider and the
attending physician If the Member refuses to transfer to a GHC Facility,all further costs incurred during
the hospitalization are the responsibility of the Member
Follow-up care which is a direct result of the Emergency must be obtained from GHC Providers,unless a
GHC Provider has authorized such follow-up care from a non-GHC Provider in advance
Urgent Care(See Section VIiI for a definition of Urgent Condition)
Inside the GHC Service Area,care for Urgent Conditions is covered only at GHC medical centers,GHC urgent
care clinics or GHC Providers'offices,subject to the applicable Cost Share Urgent care received at any
' hospital emergency department is not covered unless authorized in advance by a GHC Provider
Outside the GHC Service Area,Usual,Customary and Reasonable charges are covered for Urgent Conditions
received at any medical facility,subject to the applicable Cost Share
M. Ambulance Services. Ambulance services are covered as set forth below,provided that the service is
authorized in advance by a GHC Provider or meets the definition of an Emergency(see Section VIII)
1. Emergency Transport to any Facility. Each Emergency is covered as set forth in the Allowances
Schedule
2. Interfacility Transfers GHC-initiated non-emergent transfers to or from a GHC Facility are covered as
set forth in the Allowances Schedule
N. Skilled Nursing Facility(SNF). Skilled nursing care in a GHC-approved skilled nursing facility when full-
time skilled nursing care is necessary in the opinion of the attending GHC Provider,is covered as set forth in
the Allowances Schedule
When prescribed by a GHC Provider,such care may include room and board;general nursing care,drugs,
biologicals,supplies and equipment ordinarily provided or arranged by a skilled nursing facility,and short-term
physical therapy,occupational therapy and restorative speech therapy
Excluded personal comfort items such as telephone and television,rest cures and custodial,domiciliary or
convalescent care
Section V. General Exclusions
In addition to exclusions listed throughout the Agreement,the following are not covered:
' I. Services or supplies not specifically listed as covered in the Schedule of Benefits,Section IV.
2. Except as specifically listed and identified as covered in Sections IV B,IV.D.,IV H and IV J,corrective
appliances and artificial aids including eyeglasses,contact lenses and services related to their fitting,
hearing devices and hearing aids,including related examinations,take-home drugs,dressings and supplies
following hospitalization,and any other supplies,dressings,appliances,devices or services which are not
specifically listed as covered in Section IV
C23687-0036900 27
3. Cosmetic services,including treatment for complications resulting from cosmetic surgery,except as t
provided in Section IV D
4. Convalescent or custodial care.
5 Durable medical equipment such as hospital beds,wheelchairs and walk-aids,except while in the hospital
or as set forth in Section IV B,IVE.,IV F or IV H ,
6. Services rendered as a result of work-related injuries,illnesses or conditions,including injuries,illnesses or
conditions incurred as a result of self-employment
7. Those parts of an examination and associated reports and immunizations required for employment,unless ,
otherwise noted in Section IV B,immigration,license,travel or insurance purposes that are not deemed
Medically Necessary by GHC for early detection of disease
8. Services and supplies related to sexual reassignment surgery,such as sex change operations or
transformations and procedures or treatments designed to alter physical characteristics
9. Diagnostic testing and medical treatment of sterility,infertility and sexual dysfunction,regardless of origin '
or cause,unless otherwise noted in Section IV B.
10 Any services to the extent benefits are available to the Member under the terms of any vehicle, ,
homeowner's,property or other insurance policy,except for individual or group health insurance,whether
the Member asserts a claim or not,pursuant to (a)medical coverage,medical"no fault"coverage,Personal
Injury Protection coverage or similar medical coverage contained in said policy,and/or(b)uninsured
motorist or undermsured motorist coverage contained in said policy For the purpose of this exclusion, ,
benefits shall be deemed to be"available"to the Member if the Member is a named insured,comes within
the policy definition of insured,is a third-party donee beneficiary under the terms of the policy or otherwise
has the right to receive benefits under the policy
The Member and his/her agents must cooperate fully with GHC in its efforts to enforce this exclusion This
cooperation shall include supplying GHC with information about any available insurance coverage The
Member and his/her agents shall permit GHC at GHC's option,to associate with the Member or to
intervene in any action filed against any party related to the injury The Member and his/her agents shall
do nothing to prejudice GHC's right to enforce this exclusion in the event the Member fails to cooperate
fully, the Member shall be responsible for reimbursing GHC for such medical expenses
GHC shall not enforce this exclusion as to coverage available under uninsured motorist or undermsured ,
motorist coverage until the Member has been made whole,unless the Member fails to cooperate fully with
GHC as described above
GHC shall not pay any attorneys'fees or collection costs to attorneys representing the injured person where
it has retained its own legal counsel or acts on its own behalf to represent its interests and unless there is a
written fee agreement signed by GHC prior to any collection efforts Under no circumstances will GHC pay
legal fees for services which were not reasonably and necessarily incurred to secure recovery and/or which
do not benefit GHC If it becomes necessary for GHC to enforce the provisions of this section by initiating
any action against the injured person or his/her agent,then the injured person agrees to pay GHC's
attorneys'fees and costs associated with the action ,
11 Voluntary(not medically indicated and nontherapeutic)termination of pregnancy,unless otherwise noted
in Section IV B
12. The cost of services and supplies resulting from a Member's loss of or willful damage to appliances, '
devices,supplies and materials covered by GHC for the treatment of disease,injury or illness
C23687-0036900 28
13 Orthoptic therapy(i e,eye training).
14 Specialty treatment programs such as weight reduction,"behavior modification programs"and
rehabilitation,including cardiac rehabilitation
15. Services required as a result of war,whether declared or undeclared.Care needed for injuries or conditions
resulting from active or reserve military service
16. Nontherapeuhc sterilization,unless otherwise noted in Section IV B,and procedures and services to
reverse a therapeutic or nontherapeutic sterilization
17. Dental care,surgery,services and appliances,including:treatment of accidental injury to natural teeth, j
' reconstructive surgery to the law in preparation for dental implants,dental implants,periodontal surgery
and any other dental services not specifically listed as covered in Section IV GHC's Medical Director,or
his/her designee,will determine whether the care or treatment required is within the category of dental care
or service --
18 Drugs,medicines and injections,except as set forth in Section IV J. Any exclusion of drugs,medicines and
injections,including those not lusted as covered in the GHC drug formulary(approved drug list),will also
exclude their administration
' 19 Experimental or investigational services.
' GHC consults with GHC's Medical Director and then uses the enteria described below to decide if a
particular service is experimental or investigational.
a A service is considered experimental or investigational for a Member's condition if any of the
following statements apply to it at the time the service is or will be provided to the Member.
i. The service cannot be legally marketed in the United States without the approval of the Food and
Drug Administration("FDA")and such approval has not been granted
it, The service is the subject of a current new drug or new device application on file with the FDA.
in The service is provided as part of a Phase I or Phase 11 clinical trial,as the experimental or
research arm of a Phase III clinical trial,or in any other manner that is intended to evaluate the
safety,toxicity or efficacy of the service
' iv The service is provided pursuant to a written protocol or other document that lists an evaluation of
the service's safety,toxicity or efficacy as among its objectives
v The service is under continued scientific testing and research concerning the safety,toxicity or
efficacy of services
vi The service is provided pursuant to informed consent documents that describe the service as
experimental or investigational,or in other terms that indicate that the service is being evaluated
for its safety,toxicity or efficacy
vii The prevailing opinion among experts,as expressed in the published authoritative medical or
scientific literature,is that(I)the use of such service should be substantially confined to research
settings,or(2)further research is necessary to determine the safety,toxicity or efficacy of the
service
b In making determinations whether a service is experimental or investigational,the following sources of
information will be relied upon exclusively.
_ i. The Member's medical records,
u The written protocol(s)or other document(s)pursuant to which the service has been or will be
provided,
in Any consent document(s)the Member or Member's representative has executed or will be asked
to execute,to receive the service,
C23687-0036900 29
iv The files and records of the Institutional Review Board(IRB)or similar body that approves or
reviews research at the institution where the service has been or will be provided, and other
information concerning the authority or actions of the IRB or similar body,
v The published authoritative medical or scientific litcrature regarding the service,as applied to the
Member's illness or injury,and '
vi Regulations,records,applications and any other documents or actions issued by,filed with or
taken by,the FDA or other agencies within the United States Department of Health and Human
Services,or any state agency performing similar functions
Appeals regarding denial of coverage can be submitted to the Member's regional Member Services
Department,or west of the Cascade Mountains to GHC's Appeals Department,Administration and
Operations Campus,P O Box 34593, Seattle,WA 98124-1593,or east of the Cascade Mountains to ,
GHC's Patient Relations Department,5615 West Sunset Highway,Spokane,WA 99224 GHC will
respond in writing within twenty(20)working days of the receipt of a fully documented appeal request An
expedited appeal is available if a delay would jeopardize the Member's life or health
ental health care,except as specifically provided in Section IV K
21 Pre-Existing Conditions,except as specifically provided in Section IV B 26
22 Hypnotherapy,and all services related to hypnotherapy.
23 Genetic testing and related services,unless determined Medically Necessary by GHC's Medical Director,
or his/her designee,and in accordance with Board of Health standards for screening and diagnostic tests,or
specifically provided in Section iV B Testing for non-Members is also excluded
24 Follow-up visits related to a non-Covered Service
25 Fetal ultrasound in the absence of medical indications.
26. Routine foot care,except in the presence of a non-related Medical Condition affecting the lower limbs
27 Complications of non-Covered Services
28. Treatment of obesity,including bariatric surgery,except as set forth in Section IV B ,
29 Services or supplies for which no charge is made,or for which a charge would not have been made if the
Member had no health care coverage or for which the Member is not liable,services provided by a member
of the Member's family
30 Autopsy and associated expenses '
31 Services provided by government agencies,except as required by federal or state law.
32 Services related to temporomandibular joint disorder(TMI)and/or associated facial pain or to correct '
congenital conditions,including bite blocks and occlusal equilibration,except as specified as covered in
Section IV B
33. Services covered by the national health plan of any other country.
Section VI. Grievance Processes for Complaints and Appeals
The grievance processes to express a complaint and appeal a denial of benefits are set forth below.
Filing a Complaint or Appeal
C23687-0036900 30
The complaint process is available for a Member to express dissatisfaction about customer service or the quality or
availability of a health service
The appeals process is available for a Member to seek reconsideration of a denial of benefits
tComplaint Process
Step 1: The Member should contact the person involved,explain his/her concerns and what he/she would like to
have done to resolve the problem The Member should be specific and make his/her position clear
Step 2: If the Member is not satisfied,or if he/she prefers not to talk with the person involved,the Member should
call the department head or the manager of the medical center or department where he/she is having a problem That
person will investigate the Member's concerns Most concerns can be resolved in this way
Step 3: If the Member is still not satisfied he/she-should-call the-GHC-Customer-Smice-Center toll-free-at-(M8
-4636 Most concerns are handled by phone within a few days In some cases the Member will be asked to
writedown his/her concerns and state what he/she thinks would be a fair resolution to the problem A Customer
Service Representative or Service Quality Coordinator will investigate the Member's concern by consulting with
involved staff and their supervisors,and reviewing pertinent records,relevant plan policies and the Member Rights
and Responsibilities statement This process can take up to thirty(30)days to resolve after receipt of the Member's
written statement
' If the Member is dissatisfied with the resolution of the complaint,he/she may contact the Service Quality
Coordinator or the Customer Service Center
Appeals Process
Step 1: If the Member wishes to appeal a decision denying benefits,he/she must submit a request for an appeal
either orally or in writing to the Appeals Department,specifying why he/she disagrees with the decision The appeal
must be submitted within 180 days of the denial notice he/she received If the Member is located west of the
Cascade Mountains,appeals should be directed to GHC's Appeals Department,P O Box 34593,Seattle,WA
98124-1593,(206)901-7359 or toll free(888)901-4636,or if the Member is located east of the Cascade Mountains,
to GHC's Appeals Department,P O Box 204,Spokane,WA 99224-0204,(509)838-9100 or toll free(800)497-
2210
An Appeals Coordinator will review initial appeal requests GHC will then notify the Member of its determination
or need for an extension of time within fourteen(14)days of receiving the request for appeal Under no
' circumstances will the review timeframe exceed thirty(30)days without the Member's written permission
If the appeal request is for an experimental or investigational exclusion or limitation,GHC will make a
determination and notify the Member in writing within twenty(20)working days of receipt of a fully documented
request In the event that additional time is required to make a determination,GHC will notify the Member in
writing that an extension in the review timeframe is necessary Under no circumstances will the review timeframe
exceed twenty(20)days without the Member's written permission
1 There is an expedited appeals process in place for cases which meet criteria or where the Member's doctor states
clinical urgency exists If a delay would jeopardize the Member's life,or materially jeopardize the Member's
health,the Member can request an expedited appeal in witting to the above address,or by calling GHC's Appeals
Department in western Washington at(206)901-7359 or toll free(888)901-4636,or in eastern Washington at(509)
838-9100 or toll free(800)497-2210,and ask to be connected with the Appeals Department The Member's request
for an expedited appeal will be processed and a decision issued no later than seventy-two(72)hours after receipt
If GHC fails to grant or reject the Member's request within the applicable required timeframe,the Member may
proceed as if the complaint has been rejected
C23687-0036900 31
Step 2: (Optional step)If the Member is not satisfied with the decision reached by the Appeals Coordinator '
regarding a denial of benefits,he/she may request a hearing by the appeals committee by submitting a request within
thirty(30)days of the date of the decision letter If the Member is located west of the Cascade Mountains, the
request can be mailed to GHC's Appeals Department,P O Box 34593,Seattle,WA 98124-1593,or if the Member
is located east of the Cascade Mountains,to GHC's Appeals Department,P O Box 204,Spokane,WA 99224-0204
s
The appeals committee is the final review authority within GHC and its decisions are final The Member is ,
encouraged to present his/her case to the appeals committee in person The hearing,and written notification to the
Member of the appeals committee decision,will be made within thirty(30)working days of the Member's request
As an alternative to this appeal step,the Member may proceed to Step 3 below
Step 3: If the Member is not satisfied with the decision made in Step l or Step 2 above,or if GHC exceeds the
timeframes stated in Step 1 or Step 2 above without good cause and without reaching a decision,a final level of
appeal is available through an independent review organization An independent review organization is not legally
affiliated or controlled by GHC Once a decision is made through an ni ft-endentreview the-decision is-final-an
cannot e appealed through GHC '
*If the Member's health plan is governed by the Employee Retirement Income Security Act,known as"ERISA"
(most employment related health plans,other than those sponsored by governmental entities or churches—ask
employer about plan),the Member has the right to file a lawsuit under Section 502(a)of ERISA to recover benefits
due to the Member under the plan at any point after completion of Step I of the appeals process Members may have
other legal rights and remedies available under state or federal law
Section VII. General Provisions
A. Coordination of Benefits '
1. Benefits Subject to This Provision.As described in subsection 6 below,all benefits provided under the
Agreement are subject to the provisions listed in this section.
2. Definitions.
a. Plan.The definition of a"plan'includes the following sources of benefits or services ,
i Individual,group or blanket disability insurance policies and health care service contractor and
health maintenance organization group or individual agreements,issued by insurers,health care
service contractors and health maintenance organizations,
ii Labor-management trusteed plans,labor organization plans,employer organization plans or
employee benefit organization plans,
ui. Governmental programs,and '
iv. Coverage required or provided by any statute ,
The term"plan"shall be construed separately with respect to each policy,agreement or other
arrangement for benefits or services,and separately with respect to the respective portions of any such
policy,agreement or other arrangement which do and which do not reserve the right to take the
benefits or services of other policies,agreements or other arrangements into consideration in
determining benefits
b. Allowable Expense."Allowable expense"means any necessary,reasonable and customary items of
expense at least a portion of which is covered under at least one of the plans covering the person for
whom the claim is made When a plan provides benefits in the form of services rather than cash
C23687-0036900 32
t
payments,the reasonable cash value of each service rendered shall be considered an allowable
expense
c. Claim Determination Period."Clain determination period"means a calendar year, except the
Member's first claim determination period shall begin on the Member's effective date of coverage
' under the Agreement and end on December 31 of that same calendar year 1n no event will a claim
determination period for any Member extend beyond the last day the Member is covered under the
Agreement
3. Right to Receive and Release Information.For the purpose of determining the applicability of and
implementing this provision and any provision of similar purpose in any other plan,GHC may,with any
consent necessary,release to or obtain from any other insurer,organization or person any information,
regarding any person which GHC considers necessary for such purpose Any Member claiming benefits
under the Agreement shall provide GHC with the information necessary for such purpose
4. Facility of Payment.Whenever coves en n a has berovidedD"aid_for under-an"ther plan-which-shout
i have been provided under the Agreement in accordance with this provision,GHC shall have the right,
exercisable alone and in its sole discretion,to pay over to any plan making such payments any amounts
GHC shall detemune to be warranted in order to satisfy the intent of this provision Amounts so paid shall
be considered as coverage or benefits paid under the Agreement and,to the extent of such payments,GHC
' shall be fully discharged from liability under the Agreement
5. Right of Recovery.Whenever benefits have been provided by GHC with respect to allowable expenses in
' total amount,at any time,in excess of the maximum amount of payment necessary at that time to satisfy
the intent of this provision,GHC shall have the right to recover the reasonable cash value of such benefits,
to the extent of such excess,from one or more of the following,as GHC shall determine any persons to or
for or with respect to whom such benefits were provided,any other insurers,service plans,other
organizations or other plans
6. Effect on Benefits.
a This provision shall apply in determining the benefits for a Member covered under the Agreement for a
particular claim determination period if,for the allowable expenses incurred by the Member during
such period,the sum of
i. The reasonable cash value of the benefits that would be provided under the Agreement in the
absence of this provision,and
ii The benefits that would be payable under all other plans in the absence therein or provisions of
similar purpose to this provision would exceed such allowable expenses
b As to any claim determination period with respect to which this provision is applicable,the reasonable
cash value of the benefits provided under the Agreement in the absence of this provision for the
allowable expenses incurred as to such person during such claim determination period shall be reduced
to the extent necessary so that the sum of the reasonable cash value of benefits and all benefits payable
for such allowable expenses under all other plans,except as provided in subparagraph c of this
section,shall not exceed the total of such allowable expenses Benefits payable under another plan
include benefits that would have been payable had a claim been duly made therefor In determining
liability under this paragraph,GHC is not required,and will not take into consideration,Deductibles,
Copayments or other Cost Share prop isions
c. If another plan which is involved in subparagraph b of this section and which contains a provision
coordinating its benefits with those of the Agreement would,according to its rules,determine its
benefits after the benefits of this plan have been determined,and the rules set forth in subparagraph d
of this section would require the Agreement to determine its benefits before such other plan,then the
fC23687-0036900 33
i
benefits of such other plan will be ignored for the purposes of determining the benefits under the
Agreement.
d. For the purposes of subparagraph c,of this section,the rules establishing the order of benefit ,
determination are
i The benefits of a plan which covers the person on whose expenses a claim is based as a Subscriber
shall be determined before the benefits of a plan which covers such person as a Dependent.
it. If a Dependent is covered under both parents'medical plans,the benefits of the plan of the parent
whose birthday,excluding year,falls earlier in the calendar year are determined before those of
the plan of a parent whose birthday,excluding year,falls later in the calendar year
a) When the parents are separated or divorced and the parent with custody of the child has not
remarried,the benefits of a plan which covers the child as a Dependent of the parent with
custody of the child will be determmedbdoreAhehenefits-Gfaplan which covers the-chit
a Dependent of the parent without custody,and
b) When the parents are divorced and the parent with custody of the child has remained,the '
benefits of a plan which covers the child as a Dependent of the parent with custody shall be
determined before the benefits of a plan which covers that child as a Dependent of the
stepparent,and the benefits of a plan which covers that child as a Dependent of the stepparent
will be determined before the benefits of a plan which covers that child as a Dependent of the ,
parent without custody
Notwithstanding items a)and b)above,if there is a court decree which would otherwise establish
financial responsibility for the health care expenses of the child,the benefits of a plan which ,
covers the child as a Dependent of the parent with such financial responsibility shall be
determined before the benefits of any other plan which covers the child as a Dependent.
iii When rules i,and ii do not establish an order of benefit determination,the benefits of a plan ,
which has covered the person on whose expenses claim is based for the longer period of time shall
be determined before the benefits of a plan which has covered such person the shorter period of
time,provided that
a) The benefits of a plan covering the person as a laid off or retired employee,or Dependent of
such person shall be determined after the benefits of any other plan covering such person as
an employee,other than a laid off or retired employee,or Dependent of such person,and
b) If either plan does not have a provision regarding laid off or retired employees,which results
in each plan determining its benefits after the other,then the provisions of a)of this
subsection shall not apply
iv. If none of the above rules determines the order of benefits,the benefits of the plan which covered
an employee,Member or Subscriber for the longer period of time shall be determined before those
of the plan which covered that person for the shorter time period
e. When this provision operates to reduce the total amount of benefits otherwise to be provided to a
person covered under the Agreement during any claim determination period,the reasonable cash value
of each benefit that would be provided in the absence of this provision shall be reduced proportionately
and such reduced amount shall be charged against any applicable benefit limit of the Agreement
7. Effect of Medicare.
Members Residing Outside the GHC Medicare Advantage Service Area. If a Member is or becomes
eligible for Medicare coverage and Medicare is determined to be the primary bill payer,the Member must !
C23687-0036900 34
enroll in,and maintain both Medicare Part A and B coverage in order to be eligible for continuing coverage
under the Agreement
Medicare primary/secondary payer guidelines and regulations will determine primarylsecondary payer
status
When GHC renders care to a Member who is eligible for Medicare benefits,and Medicare is deemed to be
the primary bill payer under Medicare primary/secondary payer guidelines and regulations,GHC will seek
Medicare reimbursement for all Medicare covered services
B. Subrogation and Reimbursement Rights
"Injured Person"under this section means a Member covered by the Agreement who sustains an injury and any
spouse,dependent or other person or entity that may recover on behalf of such Member,including the estate of
the Member and,if the Member is a minor,the guardian or parent of the Member When referred to in this
section "GHC's Medical peflges"me nca�thesxpenseancurrad aad the reasonable-value of Ei+e�erthee
provided by GHC for the care or treatment of the injury sustained by the Injured Person
If the Injured Person's injuries were caused by a third party giving rise to a claim of legal liability against the
third party and/or payment by the third party to the Injured Person and/or a settlement between the thud party
and the Injured Person,GHC shall have the right to recover GHC's Medical Expenses from any source
available to the Injured Person as a result of the events causing the injury,including but not limited to funds
available through applicable third party liability coverage and unmsured/undennsured motorist coverage This
1 right is commonly referred to as"subrogation"GHC shall be subrogated to and may enforce all rights of the
Injured Person to the extent of GHC's Medical Expenses
If the Injured Person is entitled to or does receive money from any source as a result of the events causing the
1 injury,including but not limited to any parry's liability insurance or umnsured/underinsured motorist funds,
then GHC's Medical Expenses provided or to be provided to the Injured Person are secondary,not primary,and
will be paid only if the Injured Person fully cooperates with the terms and conditions of the Agreement As a
condition of receiving benefits under the Agreement,the Injured Person agrees that acceptance of GHC services
1 is constructive notice of this provision in its entirety and agrees to reimburse GHC for the benefits the Injured
Person received as a result of the events causing the injury GHC's subrogation and reimbursement rights shall
be limited to the excess of the amount required to fully compensate the Injured Person for the loss sustained,
including general damages Full compensation shall be measured on an objective case-by-case basis unless the
Injured Person settles with the at-fault party for less than available policy limits,in which GHC is entitled to full
compensation of GHC's Medical Expenses However,in the case of Medicare Advantage Members,GHC's
right of subrogation shall be the full amount of GHC's Medical Expenses and is limited only as required by
Medicare.
The Injured Person and his/her agents shall cooperate fully with GHC in its efforts to collect GHC's Medical
Expenses This cooperation includes,but is not limited to,supplying GHC with information about any third
parties,defendants and/or insurers related to the Injured Person's claim and informing GHC of any settlement
or other payments relating to the Injured Person's injury The injured Person and his/her agents shall permit
GHC,at GHC's option,to associate with the Injured Person or to intervene in any legal,quasi-legal,agency or
any other action or claim filed If the Injured Person takes no action to recover money from any source,then the
Injured Person agrees to allow GHC to initiate its own direct action for reimbursement or subrogation,
including,but not limited to,billing the Injured Person directly for GHC's Medical Expenses
' The Injured Person and his/her agents shall do nothing to prejudice GHC's subrogation and reimbursement
rights The Injured Person shall promptly notify GHC of any tentative settlement with a third party and shall not
settle a claim without protecting GHC's interest If the Injured Person fads to cooperate fully with GHC in
recovery of GHC's Medical Expenses,the Injured Person shall be responsible for directly reimbursing GHC for
GHC's Medical Expenses and GHC retains the right to bill the Injured Person directly for GHC's Medical
Expenses
C23687-0036900 35
To the extent that the Injured Person recovers funds from any source,the Injured Person agrees to hold such
monies in trust or in their possession until GHC's subrogation and reimbursement rights are fully determined
GHC shall not pay any attorny's fees or collection costs to attorneys representing the Injured Person unless
there is a written fee agreement signed by GHC prior to any collection efforts When reasonable collection costs
have been incurred with GHC's prior written agreement to recover GHC's Medical Expenses,there shall be an
equitable apportionment of such collection costs between GHC and the Injured Person subject to a maximum
responsibility of GHC equal to one-third of the amount recovered on behalf of GHC.Under no circumstance
will GHC pay legal fees for services which were not reasonably and necessarily incurred to secure recovery,
which do not benefit GHC and/or where no written fee agreement lids been entered into with GHC.
If it becomes necessary for GHC to enforce the provision of this section by initiating any action against the
Injured Person or his/her agent,then the Injured Person agrees to pay GHC's attorney's fees and costs
associated with the action
Implementation of this section shall be deemed a part of-claims admimstatim under the A greemet"rid-GHC
shall therefore have sole discretion to interpret its terms
C. Miscellaneous Provisions
1. Identification Cards.GHC will famish cards,for identification purposes only,to all Members enrolled
under the Agreement
2. Administration of Agreement.GHC may adopt reasonable policies and procedures to help in the '
administration of the Agreement GHC reserves the right to construe the provisions of the Agreement and
to make all determinations regarding benefit entitlement and coverage
3. Modification of Agreement.No oral statement of any person shall modify or otherwise affect the benefits,
limitations and exclusions of the Agreement,convey or void any coverage,increase or reduce any benefits
under the Agreement or be used in the prosecution or defense of a claim under the Agreement
4. Confidentiality. GHC and the Group shall keep Member information strictly confidential and shall not ,
disclose any information to any third party other than (i)representatives of the receiving party(as
permitted by applicable state and federal law)who have a need to know such information in order to
perform the services required of such party pursuant to the Agreement,or for the proper management and
administration of the receiving party,provided that such representatives are informed of the confidentiality
provisions of the Agreement and agree to abide by them,(u)pursuant to court order or(m)to a designated
public official or agency pursuant to the requirements of federal,state or local law,statute,rule or
regulation
5. Nondiscrimination.GHC does not discriminate on the basis of physical or mental disabilities in its
employment practices and services. '
Section VIII. Definitions
Agreement: The Medical Coverage Agreement between GHC and the Group.
Allowance: The maximum amount payable by GHC for certain Covered Services under the Agreement,as set forth
in the Allowances Schedule. ,
Coinsurance: The percentage amounts the Member and GHC are required to pay for Covered Services received
under the Agreement Percentages for Covered Services are set forth in the Allowances Schedule
Contracted Pharmacy Network: A pharmacy that has contracted with GHC to provide covered legend i
(prescription)drugs and medicines for outpatient use under the Agreement
C23687-0036900 36
Copayment: The specific dollar amount a Member is required to pay at the time of service for certain Covered
Services under the Agreement,as set forth in the Allowances Schedule
Cost Share: The portion of the cost of Covered Services the Member is liable for under the Agreement Cost
Shares for specific Covered Services are set forth in the Allowances Schedule Cost Share includes Copdyments,
Comsurances and/or Deductibles
Covered Services: The services for which a Member is entitled to coverage under the Agreement
Deductible: A specific amount a Member is required to pay for certain Covered Services before benefits are
payable under the Agreement The applicable Deductible amounts are set forth in the Allowances Schedule
Dependent: Any member of a Subscriber's family who meets all applicable eligibility requirements,is enrolled
hereunder and for whom the premiums prescribed in the Premiums Schedule have been paid
Emergency: The sudden,unexpected onset of a Medical Condition that in the-reasonabledudgment-o€-a-prudent
person is of such a nature that failure to render immediate care by a licensed medical provider would place the
Member's life in danger,or cause serious impairment to the Member's health
Family Unit: A Subscriber and all his/her Dependents
Fee Schedule: A fee-for-service schedule adopted by GHC,setting forth the fees for medical and hospital services
GHC-Designated Self-Referral Specialist: A GHC specialist specifically identified by GHC to whom Members
may self-refer
GHC Facility: A facility(hospital,medical center or health care center)owned,operated or otherwise designated
1 by GHC
GHC Medicare Plan: A plan of coverage for persons enrolled in Medicare Part A(hospital insurance)and Part B
(medical insurance)
' GHC Personal Physician: A provider who is employed by or contracted with GHC to provide primary care
services to Members and is selected by each Member to provide or arrange for the provision of all non-emergent
Covered Services,except for services set forth in the Agreement which a Member can access without a Referral
Personal Physicians must be capable of and licensed to provide the majority of primary health care services required
by each Member
GHC Provider: The medical staff,clinic associate staff and allied health professionals employed by GHC,and any
other health care professional or provider with whom GHC has contracted to provide health care services to
Members enrolled under the Agreement,including,but not limited to physicians,podiatrists,nurses,physician
assistants,social workers,optometrists,psychologists,physical therapists and other professionals engaged in the
delivery of healthcare services who are licensed or certified to practice in accordance with Title 18 Revised Code of
Washington
Group: An employer,union,welfare trust or bona-fide association which has entered into a Group Medical
Coverage Agreement with GHC
Hospital Care: Those Medically Necessary services generally provided by acute general hospitals for admitted
patients. Hospital Care does not include convalescent or custodial care,which can, in the opinion of the GHC
Provider,be provided by a nursing home or convalescent care center
Lifetime Maximum: The maximum value of benefits provided for Covered Services under the Agreement after
which benefits under the Agreement arc no longer available as set forth in the Allowances Schedule The value of
Covered Services is based on the Fee Schedule,as defined above
C23687-0036900 37
Medical Condition:A disease,illness or injury
Medically Necessary: Appropriate and clinically necessary services,as determined by the GHC's Medical
Director,or his/her designee,according to generally accepted principles of good medical practice,which are
rendered to a Member for the diagnosis,care or treatment of a Medical Condition Services must be medically and
clinically necessary for benefits to be covered under the Agreement The cost of services and supplies which are not
Medically Necessary shall be the responsibility of the Member in order to be Medically Necessary,services and
supplies must meet the following requirements (a)are not solely for the convenience of the Member,his/her family
or the provider of the services or supplies,(b)are the most appropriate level of service or supply which can be safely
provided to the Member,(c)are for the diagnosis or treatment of an actual or existing Medical Condition unless
being provided under GHC's schedule for preventive services,(d)are not for recreational,life-enhancing,relaxation
or palliative therapy,except for treatment of terminal conditions,(e)are appropriate and consistent with the
diagnosis and which,in accordance with accepted medical standards in the State of Washington,could not have
been omitted without adversely affecting the Member's condition or the quality of health services rendered,(0 as to
inpatient care,could not have been provided in a provider's office, the outpatient department of a hospital or a non-
residential facility without affecting the Member's condition or-quaLty_ofhealthsenuces.renderedr(g}are�ot
primarily for research and data accumulation,and(h)are not experimental or investigational The length and type
of the treatment program and the frequency and modality of visits covered shall be determined by the GHC Medical
Director,or his/her designee
Medicare: The federal health insurance program for the aged and disabled i
Member: Any Subscriber or Dependent enrolled under the Agreement '
Out-of-Pocket Expenses:Those Cost Shares paid by the Subscriber or Member for Covered Services,which are
applied to the Out-of-Pocket Limit
Out-of-Pocket Limit(Stop Loss): The maximum amount of Out-of-Pocket Expenses incurred and paid,during the ,
calendar year for Covered Services received by the Subscriber and his/her Dependents within the same calendar
year The Out-of-Pocket Limit amount and Cost Shares that apply are set forth in the Allowances Schedule
Charges in excess of UCR,services in excess of any benefit level and services not covered by the Agreement are not
applied to the Out-of-Pocket Limit
Pre-Existing Condition: A condition for which there has been diagnosis,treatment(including prescribed drugs)or
medical advice within the three(3)month period prior to the effective date of coverage The Pre-Existing Condition
wait period will begin on the first day of coverage,or the first day of the enrollment waiting period if earlier
Referral: A written temporary agreement requested in advance by a GHC Provider and approved by GHC that
entitles a Member to receive Covered Services from a specified healthcare provider Entitlement to such services
shall not exceed the limits of the Referral and is subject to all terms and conditions of the Referral and the
Agreement Members who have a complex or serious medical or psychiatric condition may receive a standing
Referral for specialist services
Self-Referred: Covered Services received by a Member from a designated women's health care specialist or GHC-
Designated Self-Referral Specialist that are not referred by a GHC Personal Physician
Service Area:Western Washington counties of Island,King,Kitsap, Lewis,Mason,Pierce,San Juan,Skagit, '
Snohomish,Thurston and Whatcom, Eastern Washington counties of Benton,Columbia,Franklin,Kittitas,
Spokane,Walla Walla,Whitman and Yakima,Idaho counties of Kootenai and Latah,and any other areas designated ,
by GHC
Stop Loss: See Out-of-Pocket Limit.
Subscriber: A person employed by or belonging to the Group who meets all applicable eligibility requirements,is
enrolled under the Agreement and for whom the premiums specified in the Premiums Schedule have been paid
C23687-0036900 38
Urgent Condition. The sudden,unexpected onset of a Medical Condition that is of sufficient seventy to require
medical treatment within twenty-four(24)hours of its onset
Usual,Customary and Reasonable(UCR): A tern used to define the level of benefits which are payable by GHC
when expenses are incurred from a non-GHC Provider Expenses are considered Usual,Customary and Reasonable
if the charges are consistent with those normally charged to others by the provider or organization for the same
services or supplies, and the charges are within the general range of charges made by other providers in the same
geographical area for the same service or supplies
C23687-0036900 39
EMPLOYER GROUP PROGRAMS
GROUP MEDICARE COVERAGE
E
C23697-0036900 i
This brief outline describes the benefits available to you when you combine your employer
Group healthcare benefits with Medicare. ALL MEDICARE GUIDELINES AND
CRITERIA MUST BE MET.
BENEFITS
OUT-OF-POCKET LIMIT (STOP LOSS)
iTotal Out-of-Pocket Expenses for the following services are limited to SI,000 maximum per
Member per calendar year.
• Inpatient Services
• Outpatient Services
• 1 mergency Urgently Needed Care
• Ambulance Services
INPATIENT HOSPITAL (Medical/Surgical)
• Covered subject to the applicable Copayment up to 365 days per year.
SKILLED NURSING FACILITY
• Group benefit or up to 100 days per benefit period after a 3 day Medicare certified hospital
stay
1 Note: When a 3 day Medicare covered hospital stay does not occur and the plan determines
that the Member otherwise meets all Medicare criteria,the plan may authorize Medicare
covered skilled nursing care for up to 100 days
INPATIENT MENTAL HEALTH
• Group benefit or up to 190 days per lifetime benefit covered subject to the applicable
LCopayment in a Medicare-certified psychiatric hospital
INPATIENT ALCOHOLISM& DRUG ABUSE TREATMENT
• Covered subject to the applicable Copayment when such services are provided in a hospital-
based treatment center
fHOME HEALTH CARE (SUCH AS PART-TIME SKILLED NURSING CARE,
PHYSICAL THERAPY, SPEECH THERAPY, OCCUPATIONAL THERAPY)
• Covered in full, in accordance with Medicare guidelines.
MEDICAL CARE
• Physician care in a hospital and home covered in full.
1 C23687-0036900 2
• Office and outpatient hospital care covered, subject to the applicable Copaymenk
• Outpatient Surgery in outpatient hospital facility or ambulatory surgical center covered
subject to the applicable Copayment
• Alcoholism and substance abuse treatment services covered in full.
AMBULANCE
• Covered subject to the applicable Copayment.
CARDIAC REHABILITATION
• Covered in full.
CHIROPRACTIC& PODIATRIC CARE (Medical Need)
• Covered, subject to the applicable Copayment.
EMERGENCY AND OUT-OF-AREA URGENTLY NEEDED SERVICES i
• You pay$50 for each hospital emergency room visit, you do not pay this amount if you are
admitted directly to the hospital from the emergency room.
• Worldwide coverage is provided. ,
HEARING EXAMINATIONS & HEARING AIDS
• Hearing exams to determine hearing loss are covered, subject to the applicable Copayment.
Purchase of hearing aids covered once every 24 months limited to$250 hearing aid purchase
Allowance.
HEALTH/WELLNESS EDUCATION
• Health club services (SilverSneakersO) and/or lifetime fitness programs at participating
network health clubs are covered in full.
• Services related to tobacco cessation and education materials are covered in full, limited to.
1. One individual or group program per calendar year
2. When participating in the GHC Tobacco Cessation program,your employer Group
covers one course of nicotine replacement or other approved pharmacy products once per
calendar year. Your employer Group outpatient prescription drug Copayment applies.
ORGAN TRANSPLANT
C23687-0036900 3
• Medicare covered organ transplants covered in full.
OUTPATIENT MENTAL HEALTH CARE
• Covered, subject to the applicable Copayment.
OUTPATIENT PRESCRIPTION DRUGS
t • Medicare covered outpatient prescription drugs are covered in full. Your employer Group
may cover outpatient prescription drugs Please see the employer Group section of this
Certificate of Coverage for more information.
POINT OF SERVICE (POS)
• Non-emergent and/or non-Urgently Needed Care received while temporarily traveling
outside GHC's Medicare Service Area is payable at Medicare benefit levels up to $2,000 per
Member per calendar year The Plan pays 80%of Medicare allowable reimbursement
schedules for Medicare covered services ONLY. The enrollee is responsible for all
Medicare deductibles
PHYSICAL,OCCUPATIONAL, SPEECH AND LANGUAGE THERAPY
• Covered subject to the applicable Copayment.
PROSTHETIC DEVICES, PACEMAKERS,BRACES, ARTIFICIAL LIMBS & EYES
1 • Covered in full.
RENTAL OR PURCHASE OF DURABLE MEDICAL EQUIPMENT
• Covered in full
URGENTLY NEEDED SERVICES
• Urgently needed services are covered,subject to the applicable Copayment.
• Worldwide coverage is provided.
VISION CARE (Eye Care Medical Need)
• Examinations for illness and injury covered subject to the applicable Copayment.
• One pair of standard eyeglasses or contact lenses are covered after each cataract surgery with
1 insertion of an mtraocular lens (IOL).
• Routine eye exams for glasses covered subject to the applicable Copayment once every 24
months
C23687-0036900 4
1
• One pair of standard vision lenses, or contact lenses will be covered subject to the GHC-
approved Allowance once every twenty-four(24) months.
• Frames are covered by Group benefit or up to $100 once every 24 months.
Please see your employer Group Certificate of Coverage for more information
Please contact our Group Health Customer Service Center for more information and the location
of participating reciprocal facilities at 206-901-4636, toll-free 1-888-901-4636, or TTY/TDD
711 or 1-800-833-6388 for the"hearing impaired," Monday-Friday, 7:30 a.m. to 5.00 p.m
i
l 1
1
1
1
1
1
1
!
1
C23687-0036900 5
Kent City Council Meeting
Date June 21, 2005
Category Consent Calendar
1. SUBJECT: PACIFIC HIGHWAY SOUTH — FUND AUTHORIZATION
AGREEMENT NORTH PHASE — KENT DES MOINES ROAD TO
SOUTH 252ND STREET — ACCEPT AND AMEND BUDGET
2. SUMMARY STATEMENT: Authorize the Mayor to sign a Fund Authorization
Agreement with Washington State Department of Transportation for the Pacific
Highway South — North Phase construction project expenses in the amount of
$5,043,538 upon concurrence of the language by the Public Works Director and the
City Attorney and to establish a budget accordingly.
3. EXHIBITS: Public Works memorandum and WSDOT Fund Authorization
Agreement
4. RECOMMENDED BY: Public Works Committee
1 (Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? X Revenue?
Currently in the Budget? Yes X No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
' DISCUSSION:
ACTION:
Council Agenda
Item No. 6K
1 PUBLIC WORKS DEPARTMENT
Larry R Blanchard, Public Works Director
Phone0 Fax 251456-6500
KEN T Address 220 Fourth Avenue
w A e H i x a r o H Kent,WA 98032-5895
DATE: June 6,2005
TO: Public Works Committee
FROM: Mark Howlett
THROUGH Larry Blanchard,Public Works Director 4M
SUBJECT: Fund Authorization Agreement
For Pacific Highway South-North Phase—Kent-Des Moines Road
to S. 252nd Street
Motion: Recommend authorizing acceptance of the Fund Authorization Agreement for
the Pacific Highway South HOV Lanes Project — North Phase and authorize the
' establishment of the budget for same along with directing staff to. spend the money
accordingly
SUMMARY:
This giant agreement,in the amount of S5,043,538,is for the construction phase of the City's
Pacific Highway South HOV Lanes Project—North Phase In order for the City to be reimbursed
for construction expenses,the City must accept the grant and establish a budget for these funds
The Public Works Department recommends that the City Council accept the grant funds and
authorize the establishment of the budget for the grant fiends and direct staff to spend the money
accordingly
BUDGET IMPACT No Unbudgeted Fiscal/Personnel Impact
BACKGROUND:
The Highways and Local Programs Division of the Washington State Department of
Transportation adnunisters federal funds and has authorized the construction phase of the City of
Kent's Pacific Highway South HOV Lanes Project—North Phase This grant authorization is for
$5,043,538
Mayor White and Kent City Council Pacific Highway South-North Phase STP Grant
June 6.2005
1 1
AdIkkk At)
M ! 3 '��05
Washington State Transportation Building
OF Department of Transportatiog�lr,iLor-FO Nf+ f)E Pb Mike Park Mops Avenue sE
Douglas 0. M L acDonald `""'
Sacrstar#of Transpoltabor� Olimpta,WA 98504-7300
360-705-7000
TTY t-800.833-008
~,i-%W wa guv
April 2005
Mr Lary Blanchard
Acting Public Works Director
City of Kent
220 Fourth Avenue S
Kent,WA 98032-5895
City of Kent
Pacific Highway South—Kent/Des Moines Road
to 252od Street
STPF-CM-0099(045)
FUND AUTHORIZATION
Dear ancliard
We have received FHWA fiord authorization,effective April 6,2005,for this project as
follows
PHASE TOTAL FEDERAL SHARE
Construction $5,830,679 $5,043,538
Enclosed for your information and file is a fully executed copy of Supplement Number 2
to Local Agency Agreement LA-3467 between the state and your agency
Also your requested scope change is approved,extend project limits to include section
from 240t'to 252nd
You may proceed with the administration of this project in accordance with your
WSDOT approved Certification Acceptance agreement
Sincerely,
t
Step4
hanie Tax
Manager,Program Management
ffighways&Local Programs Division
ST ds ac
Enclosure
cc Ed Conyers,Northwest Region Local Programs Engineer,MS NB82-121
i
t
p� Washington State
•0 Department of Transportation AMLocal Agency Agreement Supplement
Agency Supplement Number
City of Kent 2
Federal Aid Project Number Agreement Number CFDA No 20.205
STPUL-009 045 LA-3467 fCatabgotFedera DolnestsAssistaxe)
The Local Agency desires to supplement the agreement entered into and executed on December 4, 1996
All provisions in the basic agreement remain in effect except as expressly modified by this supplement
The changes to the agreement are described as follows
Project Description
Name Pacific Ffnghway South HOV Lanes(KEN-15) Length 125 Miles
Termini Kent-Des Moines Road to South 252nd Street
Description of Work ❑No Change
Construction Phase of Protect STPUL-0099(060)is combined into ibis project revising the!units to 150'south of Kent-Des Moines
Road to S 252nd Street
Reason for Supplement
Request construction funds and tranfer constriction funds fiom STPUL-0099(060)into this project
Estimate of Funding
Type of Work t'> (2) (3) ta) (51
Previous Supplemant Estimtod Total Esbmaled Agency Eslimalad
i A(yearneriVSUD01 Protect Funds Funds Federal Funds
PE a Agency ! i
865 % b Other Consultant 707,0920Q 707,09200 95,45700 611,63500
c Other
Federal Aid Padiapation d State 1,000 00 1,00000 135 00 86500
Ratio for PE a Total PE Cost Estimate(a+b+cM) 708,D92 0 708,09200 95,9200 612,500 00
Right of Way f Agency 179,816 DO 179,816 00 24,275 00 155,541 00
865 % g other Consultant 64,00000 64,OD0 00 8,640 00 55,360 OD
Federal Aid h Other
Participation
Ratro for RW i State 5,00000 5,000 00 67500 4,32500
Total R!W Cost Estimate +h+i 248,8160 248,816001 33,590 00 215,226 00
Construction It Contract 5,495,67900 5,495,679001 741,91700 4,753,763 00
I Other
in Other
n Other
865 % o Agency 315,00D 00 315,000 00 42,525 00 272,475 00
Federal Ad
Participation state 20,000DO 20,00000 2,70000 17,30000
Ratio for CN Total CN Cost Esbmale k4,m 5,830,679 00 5,11M,679 001 797,142 00 5,043,538 00 '
r Total Prd ect Cost Estimate 956y08 001 5,W0,679 00 6,M587 00 916,324 001 5,87I,264 00
The Local Agency further stipulates that pursuant to said Title 23,regulations and p0hceee,and procedures, and as a condition
to payment of the Federal funds obligated,it accepts and will comply with the applicable provisions
Agency Official Washington State Department of Transportation
BY
Title arertnr affinhhrWorkc Assistant Secretary for HVhways and Local Programs
Date Executed r 0 5 2005 �
DOT Form 140-041 EF
Revised 4rhM
Kent City Council Meeting
Date June 21, 2005
Category Consent Calendar
1. SUBJECT: PACIFIC HIGHWAY SOUTH —FUND AUTHORIZATION
AGREEMENT SOUTH PHASE — SOUTH 252ND STREET TO
SOUTH 272ND STREET — ACCEPT AND AMEND BUDGET
2. SUMMARY STATEMENT: Authorize the Mayor to sign a Fund Authorization
Agreement with Washington State Department of Transportation for the Pacific
Highway South— South Phase construction project expenses in the amount of$674,726
upon concurrence of the language by the Public Works Director and the City Attorney
and to establish a budget accordingly.
3. EXHIBITS: Public Works memorandum and WSDOT Fund Authorization
Agreement
4. RECOMMENDED BY: Public Works Committee
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? X Revenue?
Currently in the Budget? Yes X No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6L
1
iPUBLIC WORKS DEPARTMENT
Larry R Blanchard, Public Works Director
Phase 2535500
KENT Fax 253-856-6600-a58-
W 4 H 1 µ¢T p µ Address 220 Fourth Avenue S
Kent,WA 96032-5895
DATE: June 6,2005
TO: Public Works Committee
FROM: Mark Howlett ' �//��
THROUGH Larry Blanchard,Public Works Director L£ci�
SUBJECT: Fund Authorization Agreement
For Pacific Highway South-South Phase—S.252ua Street to S.272id Street
Motion: Recommend authorizing acceptance of the Fund Authorization Agreement for
the Pacific Highway South fIOV Lanes Project - South Phase and authorize the
establishment of the budget for same along with directing staff to spend the money
accordingly
iSUMMARY:
This grant agreement,in the amount of$674,726,is for the construction phase of the City's
Pacific Highway South HOV Lanes Project-South Phase In order for the City to be reimbursed
for construction expenses,the City must accept the grant and establish a budget for these funds
The Public Works Department recommends that the City Council accept the grant funds and
authonze the establishment of the budget for the grant funds and direct staff to spend the money
accordingly
I
BUDGET IMPACT No Unbudgeted Fiscal/Personnel Impact
BACKGROUND:
The Highways and Local Programs Division of the Washington State Department of
Transportation administers federal funds and has authorized the construction phase of the City of
Kent's Pacific Highway South HOV Lanes Project—South Phase This grant authorization is for
$674,726
Mayor White and Kent City Council Pau&Highway South-South Phase STP Gnat
flute 6,2005
cUrY OF 'BENT
MA
State Transpertatien Bwfding
/A Department of TransporlAu"FERIK4 N!1''1 310 MOW Park Avenue S E
Douglas A.MacDonald PC) W.t 47300
SecretaN of Transportation Olympia,WA 98504-7300
360-705-7000
m t-aoo-an-63ee
wrw wsdot wa gm
April 7,2005
1 Mr Larry Blanchard
Acting Public Works Director
City of Kent
1 220 Fourth Avenue S
Kent,WA 98032-5895
City of Kent
Pacific Highway South—252°d to 272nd
STPF-CM-0099(067)
�*-^�� FUND AUTHORIZATION
1 Dear cshard
' We have received FHWA fund authorization,effective April 6,2005,for this project as
follows-
PHASE TOTAL FEDERAL SHARE
Construction $4,362,928 $674,726
Enclosed for your information and file is a fully executed copy of Supplement Number 2
to Local Agency Agreement LA4607 between the state and your agency
You may proceed with the administration of this prof eel in accordance wath your
WSDOT approved Certification Acceptance agreement.
Sincerely,
Step a Tax
Manager,Program Management
Highways&Local Programs Division
ST ds ac
Enclosure
cc Ed Conyers,Northwest Region Local Programs Engineer,MS NB82-121
r -
1
Washington State 'AM
'
•/ Department of Transportation Local Agency Agreement Supplement
Agency Supplement Number
City of Kent 2
Federal Aid Project Number Agreement Number CFOA No 20 205
STPF-0099(067) LA-4607 Cataby otFeOe�sl OaneabcAss sfan�l
The Local Agency desires to supplement the agreement entered into and executed on November 1,2000
All provisions in the basic agreemend remain in effect except as expressly modified by this supplement
The changes to the agreement are desenbed as follows
Project Description
Name Pacific Highway South HOV Lanes Length 125 mules
Termini South 252ud Street to South 272nd Street
Description of Work IM NoChange
Reason for Supplement
Request Constmcuon Funds
i
Estimate of Funding ,
Type of Work S�1 nl t31 (4) ts!
Previous Supplement Est mated Total Estimated Agency Estimated
aetn"Il e I Project Funds Funds Federal Funds
PE a Agency 896,0000 896,00000 537,60000 35a,40000
40 96 b other
c Other
Federal Aid Participation d State 4,0000( 4,00000 2,40000 1,60000
Raba for far PE a Tofat PE Cost Estimate(a+D4c+d) 900,000.0 900,000 00 541%000 00 360,400 00
Right of Way f Agency 1,412,5000 1,412,5t30 00 $47.500 00 565,000 00
40 96 u Other Consultant 177,5000 177,50000 106,50000 71,00000
Federal Aid It Other
Particiption
Ratio rare RW i State 10,000 10,000 00 6,00000 4,00000
Total WW Cost Estimate(f+o+"l 1,600,000 00f [A MAN 001 960,000 00 646,000 00
Construction A Contract 725,658001 725,659 00 97,964 001 627,694 00
I Other (Non participation) 3,592,899 00 3,582,899 00 3,592,999 00
m Other
n other
865 96 0 Nency 50,796 00 50,796 00 6.85700 43,939 00 �
Federai Aid ParticipationState 3,57500 3,57500 482 00 3.093 00 /
Ratio for CN Total CN Cast Estimate k.i 4�62,9I8 00 4,362,928 G01 3,688,202 DO 674,726.00
r Total Projecl Cost Esiumats 2,500,000 0$ 4,362,928 09 I 6,862,928.00; 5,198,202.00 1,674,726 00 '
The Loral Agency further stipulates that pursuant to said Title 23,regulations and policies and procedures,and as a condition
to payment of the Federal funds obligated,It accepts and will comply with the applicable provisions '
Agency Official Washington St to U partment o Transportation
r
By / cam' % By
Title a pngInenne_rin�VIPddwgor Assistant Seuelary for Rghways and local Programs
Date Executed fir" 0 5 2005
DOT Form 140041 EF
Renssd 4/Aneo
r
Kent City Council Meeting
Date June 21, 2005
Category Consent Calendar
1. SUBJECT: JOINT TRENCH AGREEMENT WITH QWEST —AUTHORIZE
2. SUMMARY STATEMENT: Authorize the Mayor to sign a Joint Trench
Agreement with Qwest for work on Military Road upon concurrence of the language by
the Public Works Director and the City Attorney.
3. EXHIBITS: Public Works memorandum and Joint Trench Agreement
1 4. RECOMMENDED BY: Public Works Committee
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? X Revenue?
Currently in the Budget? Yes X No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6M
PUBLIC WORKS DEPARTMENT
Larry R Blanchard, Public Works Director
400 Phone 253-856-5500
KENT FaX 253-856-6500
WAS M I N G T O N Address 220 Fourth Avenue S
Kent,WA 98032-5895
DATE: May 27, 2005
TO: Public Wo Committee
FROM: Chad Bie k,, Senior Project Engineer
THROUGH- Larry Blanchard,Public Works Director
SUBJECT: Joint Trench Agreement with Qwest
MOTION Recommend authorizing the Mayor to sign the Joint Trench Agreement with Qwest
for work on Military Road upon concurrence of the language therein by the City Attorney and
the Public Works Director
i
SUMMARY: The Public Works Director recommends approval of the agreement and
authorization for the Mayor to sign same upon concurrence of the final language by the City
Attorney
1 BUDGET IMPACT No Unbudgeted Fiscal/Personnel Impact
BACKGROUND: As part of the S 228th Street Extension project Military Road will be
widened to five lanes The overhead utilities need to be converted to underground in accordance
with City ordinance Pursuant to the attached joint trench agreement, Qwest will pay the City to
install Qwest conduit and vaults This allows the City to control the construction schedule for
installation of Qwest's vault and conduit system, thus reducing construction time and minimizing
construction-related traffic impacts Qwest will repay the City for work related to Qwest
facilities based on bid prices submitted by the contractor with the lowest bid Bids for the project
will be opened later in June
Mayor White and Kent City Council I
CITY OF KENT
MAY ) 4 2905 Qwest.—
ENGINEERING DEPT Spint of Service
WASHINGTON CONTRACT ADMINISTRATION LETTER OF TRANSMITTAL
Date May 23. 2005
To. Chad Bieren, City of Kent
cc
From Jeff Watson, Contract Manager, Washington —Contract Administration
Re Military Rd Joint Trench agreement
Chad, please note the enclosed two copies of the Military Rd joint trench agreement
Please sing both copies Keep one for oyur fiels and return the other tome at 23315 66�'
Ave , So , Kent, Wa , 98032, Attn Jeff Watson Please insert the execution date in the 1s`
paragraph of the agreement upon signature.
Jeff
Confidential,distribute and disclose solely to those individuals with a need to know
i
1
1
1
JOINT TRENCH AGREEMENT
Between the City of Kent and Qwest
for Military Road Improvements
THIS AGREEMENT is entered into between the City of Kent, a Washington municipal
corporation ("City"), and QWEST CORPORATION, a Colorado corporation ("Qwest") as of
2005 (the"Effective Date").
RECITALS
WHEREAS, the City is undertaking a roadway improvement project along Military Rd and
making nght-of-way improvements to Military Rd (the"Project");and
WHEREAS, the City has notified Qwest that the Project will require relocation of Qwest
facilities from aerial to underground;and
WHEREAS,under RCW 35.99.060(3)(b),Qwest may seek reimbursement from the City for the
additional incremental cost of aenal to underground relocation compared to aerial to aenal
relocation if Qwest is a service provider with an ownership share in the aerial supporting
structures, and
WHEREAS, the City and Qwest do not agree on the appropriate interpretation of RCW
35 99.060(3)(b); and ,
WHEREAS, both the City and Qwest desire to move forward with the Project to avoid potential
delays to the Project and the potential costs and expenses associated with Project delays,
AGREEMENT
To facilitate construction of a joint trench,the parties agree as follows:
1. SCOPE OF WORK
The City of Kent will advertise for construction bids and enter into a contract for the
construction of a trench which shall include the City, Comcast, Qwest, and PSE facilities This
trench will be placed along the west side of Military Road between Gai's Bakery located at
23009 Military Road South and one span north of the Military Road South/South 239 b Street
Intersection. This trench will include an open cut trench crossing of SR 516. There will be
approximately seven (7)trench crossings of Military Road to serve customers on the east side of
the street. All utilities will use these trenches.
2. CONTRACTOR REQUIREMENTS
The independent contractor hired by the City to perform this work shall be referred to as
"the contractor" in this Agreement The contractor, pursuant to a contract with the City, shall
excavate the trench, install City, PSE, and Qwest conduits and vaults, accommodate and
coordinate the installation of other utilities,install the bedding material,backfill and compact the
trench, and perform any restoration required by the City, all to be performed in a good and
JOINT TRENCH AGREEMENT—Page 1 of 9 (May 9.2005)
(between City of Kent and Qwest Re Military Road)
workmanlike manner consistent with industry standards. The City represents that any such
contract shall further require of contractor that the work be conducted in confomuty with (1) the
applicable procedures and requirements of the parties as described herein; (it)all applicable laws,
ordinances and regulations of any governmental authority, and, (iii) all applicable terms and
provisions of the National Electric Safety Code, as may be amended, supplemented or replaced
from time to time, including but not limited to those pertaining to protection and separation of
conductors buned in earth.
1 3. RESPONSIBILITY OF THE PARTIES
A Drawings Qwest shall provide engineering drawings to the City and obtain a
permit from the City for the underground relocation of Qwest's facilities These drawings shall
show in detail the location and elevation of the conduits, trench, and vaults, and shall include a
general traffic control plan for activities not associated with installation of facilities within the
contractor controlled open trench area
B Installation Qwest shall be responsible for supplying conduits and vaults within
ten (10) days notice provided by the City or its contractor The City's contractor shall install
conduits and vaults in the joint trench. Qwest shall also be responsible for supplying and
i installing all conductors. All right, title and interest in the facilities and associated equipment
I shall at all times remain with Qwest. Parties hereto acknowledge and agree that Qwest shall in
no event be required to perform a cut-over or transfer or to remove their respective, affected
aerial facilities prior to completion of the underground facilities in accordance with this
Agreement, and so long as said installation is completed in conformity with this Agreement and
Qwest has approved the new facilities
C Traffic Control. The City's contractor shall perform all traffic control associated
with installation of Qwest facilities within the contractor controlled open trench area. Qwest
shall pay the proportionate share of traffic control required forjomt trench construction as noted
in Exhibit A Qwest shall be responsible for providing traffic control during installation of its
facilities not associated with the controlled open trench area
D Qwest Coordination Qwest shall maintain reasonable coordination with the
contractor regarding the installation of Qwest's facilities, as requested by the contractor from
time to time. This coordination shall include but not be limited to the following:
1. Tmnng of when and where materials will be delivered on-site.
2. Inspection of job by a Qwest inspector.
3 Coordination with other utility companies included in the joint trench for the
I placement of conduit within the trench and during conversion of overhead
facilities to underground
Qwest shall have the right at all times to observe and inspect the performance of the work
performed in connection with this Agreement
E Surveys The City will provide the survey for the location of the trench and
vaults
r
JOINT TRENCH AGREEMENT—Page 2 of 9 (May 9,2005)
(between City of Kent and Qwest Re Military Road)
F Election Not to Proceed If Qwest elects not to proceed with joining in the trench
provided by the contractor, Qwest shall remain liable for completing all work described in the
approved permit within the time frame specified on the permit.
G. Franchise. Qwest shall, if so required by the Washington State Department of
Transportation("WSDOT"), subnut for and obtain, at its cost,a utility franchise permit from the
WSDOT for its facilities that cross SR 516 The City has developed a traffic control plan for the
crossing and the City agrees that Qwest may use this plan in its permit application.
H Completion The City shall notify Qwest within ten (10) calendar days after
completion of the work. Upon receipt of the notification, Qwest shall have ten (10) calendar
days to inspect the work and accept or reject the work by delivery of written notice to the City.
The City will, at its own expense,correct the problem within ten (10) calendar days after receipt
of Qwest's notice. The foregoing procedure will be repeated until Qwest finally approves the
work. If Qwest fails to reject the work within the ten (10) day period set forth above, the work
shall be deemed accepted by Qwest. Qwest shall prepare as-builts for its own facilities and
work
4. COMPENSATION
A. Compensation. The parties agree that cost obligations with regard to the Project
shall be consistent with the outcome of the parties' pending federal court litigation (Qwest v
City of Kent,No CV4-2216P,filed in the United States District Court for the Western District of
Washington (the "litigation")) over the meaning and effects of RCW 35.99.060(3) Until such ,
time as the litigation is complete, compensation rights and obligations shall be as follows, and
shall ultimately be modified to the full extent necessary to be consistent with the final outcome
of the litigation. By agreeing to the compensation system set forth herein, Qwest in no way
admits to Kent's interpretation of RCW 35.99.060, nor does it waive any rights to cost recovery
for this or any other project which Qwcst may undertake at the request of the City Qwest
specifically reserves any and all rights under the law, including, but not limited to, those ansing
in connection with the litigation. If the litigation determines that Qwest is not responsible for the
payment of a proportionate share of joint trench costs, the City shall refund to Qwest, within
sixty (60) days after such determination any payments due Qwest consistent with the final
I outcome of this litigation.
i
B. Trench costs. Qwest agrees to pay the City for installation of Qwest conduit and
vaults, a portion of the trench costs, including trench bedding and backfill, and associated traffic
control commensurate with their proportionate share of trench usage as shown in Exhibit A
attached hereto and incorporated by this reference. Preliminary costs will be agreed upon prior
I to construction based on an estimate from the bid accepted by the City. Costs will be finalized
I after completion of construction to account for actual construction costs.
C. Survey Qwest agrees to pay the reasonable costs for the City surveyor's time to
provide Qwest vault locations and elevations and any other survey that may be required to locate
and place Qwest facilities.
D Additional Expenses. Qwest agrees to pay their proportionate share of additional
expenses incurred due to Qwest's approved change requests requiring additional trench depth or
JOM TRENCH AGREEMENT—Page 3 of 9 (May 9,2005)
(between City of Kent and Qwest Re Military Road)
width and for unforeseen conditions, including but not limited to dewatenng for ground water
Qwest will not pay for any share of additional expenses incurred due to approved change
requests from PSE,Comcast and/or the City. If unforeseen conditions anse,the City and Qwest
shall work together to negotiate in good faith Qwest's contribution to costs incurred on account
of such unforeseen conditions If the parties are unable to agree on Qwest's contribution to costs
incurred on account of unforeseen conditions, the conflict will be resolved by Qwest relocating
its facilities at its sole expense. Qwest shall always have the right to perform the relocation of its
own facilities.
E Claims by Contractor. Qwest agrees to pay the cost of any claims for damages
made by the contractor that are proven to be proximately caused by Qwest. These claims may
include delays caused by installing Qwest facilities or delays caused by Qwest providing
materials.
F Vaults Qwest agrees to pay for the excavation, site preparation, and installation
for their vaults(in the percentages set forth in Exhibit A)separately and in addition to any survey
costs and trench costs discussed above. These additional costs shall be preliminarily determined
from the bid price accepted by the City The cost to excavate for and install Qwest's vaults will
be finalized after completion of construction to account for actual construction costs.
G Invoice. Qwest agrees to pay the City within sixty(60) days of being invoiced by
the City for amounts that the contractor has invoiced the City and which Qwest has agreed to pay
under this Agreement
H. Defective or Unauthorized Work Per the terms of the agreement between the
City and contractor, Qwest reserves the right to withhold payment from the City for any
defective or unauthorized work performed by the contractor. Defective or unauthorized work
includes, without limitation work and materials that do not conform to the requirements of this
Agreement, and extra work and materials furnished without Qwest's written approval If for any
reason it is necessary to satisfactorily complete any portion of the work,Qwest may complete the
work using its own means and the City shall be liable to Qwest for any additional costs incurred
by Qwest. "Additional costs" shall mean all reasonable costs, including legal costs and attorney
fees, incurred by the parties beyond the price included in the bid accepted by the City Qwest
further reserves the right to offset the cost to complete the work, including any additional costs,
from any and all amounts due or to become due the City.
I Final Payment/Waiver of Claims The making of final payment by the parties
shall constitute a waiver of claims by the City, except those previously and properly made and
identified by the City as unsettled at the time request for final payment is made
5. CHANGES.
Qwest shall submit any changes requested to be performed by the City's contractor to the
City The City shall submit this to the contractor; obtain a price from the contractor to perform
the work, and notify Qwest of this price. Qwest shall have 24 hours from receiving the price
from the City within which to respond. If Qwest chooses not to accept the contractor's price
then this work shall only be performed by Qwest according to a mutually agreed upon schedule
with the contractor so as not to cause delay to the contractor. Neither party may change any
JOINT TRENCH AGREEMENT—Page 4 of 9 (May 9,2005)
(between City of Kent and Qwest Re Military Road)
i
provision of this Agreement, including without limitation costs, without the prior written consent
of the other.
6. INDEMNIFICATION;LIENS AND ENCUMBRANCES.
Each party shall defend, indemnify and hold the other party harmless from any and all
claims, injuries, damages, losses or suits including all legal costs and attorney fees (except each
party shall be responsible for its own costs and fees for subsection in below, as provided in
Section 12 (D)of this Agreement), ansing out of or in connection with (i) the performance of the
party's work required under this Agreement, (it) any personal injuries or property damage
received or sustained by any person or property ansing in whole or in part in connection with the
party's performance of the Agreement, (iii) any breach by the party of the Agreement, and (iv)
any act or omission, neglect, negligence, gross negligence or willful misconduct of the party in
connection with this Agreement. Notwithstanding the foregoing, this indemnification shall only
apply to injuries and damages caused by the negligence or willful misconduct of the party For
purposes of this Section 6, the term"party" shall include each party to this agreement, plus their
officers,officials,employees, agents,contractors and subcontractors.
Should a court of competent junsdiction determine that this Agreement is subject to
RCW 4.24.115, then, in the event of liability for damages ansing out of bodily injury to persons
or damages to property caused by or resulting from the concurrent negligence of the parties,their
officials, employees and agents, a party's liability hereunder shall be only to the extent of the
party's negligence. The provisions of this section shall survive the expiration or termination of
this Agreement.
No party, directly or indirectly (including, in the case of the City, any action by the
contractor or any subcontractor), shall create or impose any lien on the property of another, or on
the rights or title relating thereto, or any interest therein, or in this Agreement. Each party shall
promptly, at its own expense, take such action as may be necessary to duly discharge any lien
created by it on the property of another
7. INSURANCE.
The contract between the City and the contractor shall require that the contractor procure
and maintain for the duration of the project insurance of the types and in the amounts described
below against claims for injuries to persons or damage to property which may anse from or in
connection with the performance of the work by the contractor, its agents, representative,
employees,subconsultants or subcontractors
1. Automobile Liability insurance with limits no less than $1,000,000 combined
single limit per accident for bodily injury and property damage.
2 Commercial General Liability insurance written on an occurrence basis with
limits no less than $1,000,000 combined single limit per occurrence and
general aggregate for personal injury, bodily injury and property damage
i Coverage shall include but not be limited to: blanket contractual,
products/completed operations/broad form property damage; explosion,
collapse and underground
p gr (XC U); and employer's liability.
JOINT TRENCH AGREEMENT—Page 5 of 9 (May 9,2005)
(between City of Kent and Qwest Re Military Road)
3. Excess Liabili msurance with limits not less than $1,000,000 per occurrence
and aggregate
Any payment of deductible or self insured retention shall be the sole responsibility of
the contractor. The parties, their officials, employees, agents and volunteers shall be named as
additional insureds on the insurance policy, with respect to work performed by or on behalf of
the parties and a copy of the endorsement naming the parties as additional insured shall be
�I attached to the Certificate of Insurance, copies of which shall be provided to the parties prior to
commencement of construction by the contractor The contractor's insurance shall contain a
clause stating that coverage shall apply separately to each insured against whom claim is made or
suit is brought,except with respects to the limits of the insurer's liability
S. WARRANTY
In addition to any other express or implied obligations under the Agreement, the City
warrants for a period of one (1) year (or longer,if so provided by law, and to the extent provided
by law) after final payment by Qwest for the work, that all labor, workmanship, components,
materials and other parts of the work performed by the City's contractor will be free from defects
in material and workmanship under normal use and service in accordance with Qwest's
subirutted engineering design This time period relates only to the specific obligation of the City
to correct the work, and has no relationship to the time within which Qwest may seek to enforce
the City's obligations under the Agreement or within which the City must comply with the
Agreement. If any defects in the City's work occur during the warranty period,upon notice from
Qwest, the City will immediately, at its own expense, correct and remedy those defects in the
City's work If the City fails to promptly correct these defects in the City's work, Qwest may
correct the work itself or hire another contractor to do so and the City shall pay for all reasonable
Iand verifiable costs of correction promptly upon demand by Qwest.
9. LIMITATION OF LIABILITY
Except for each party's indemnification obligations or breach of the section titled
Confidential Information, neither party is liable to the other for consequential, incidental,
indirect, punitive or special damages, including commercial loss and lost profits, however
caused, and regardless of legal theory or foreseeabihty, directly or indirectly arising under this
Agreement,even if such party has been apprised of the possibility of the damages.
10. RECORDS AND AUDITS
The City will maintain complete and accurate records with respect to this Agreement,
invoicing and payment The records will, to the extent applicable, be kept in accordance with
generally accepted accounting principles and will be kept for a period of three (3) years after
termination of the Agreement Qwest or its designee may audit,copy and inspect the records and
accounts at all reasonable times during this period.
11. CONFIDENTIAL INFORMATION
"Confidential Information" means trade secrets, systems, data, and customer information
provided, disclosed or made accessible by Qwest to the City or the contractor under this
JOWr TRENCH AGREEMENT—Page b of 9 (May 9,2005)
(between Ctry of Kent and Qwest Re Mduary Road)
Agreement or in connection with the work. The parties acknowledge that the City is a public entity
subject to the Washington State Public Disclosure Act(RCW 42 17 et seq) Subject to applicable law,
the City will: (a) not use Confidential Information for any purpose other than the fulfillment of
its obligations under the Agreement, (b) not disclose Confidential Information to any third party
(including any affiliate of itself or of Qwest) without the prior written consent of Qwest; (c) not
make any copies of Confidential Information without Qwest's prior consent; and (d) protect and
treat all Confidential Information with the same degree of care as it uses to protect its own
confidential information of like importance. In the event the City or the contractor is required to
disclose Confidential Information pursuant to law, the City will notify Qwest of the required
disclosure with sufficient time for Qwest to seek relief, will cooperate with Qwest in taking
appropriate protective measures, and will make such disclosure in a fashion that maximizes
protection of the Confidential Information. Subject to applicable law, at the conclusion of the
Agreement, or any time at the specific request of Qwest, any and all Confidential Information
will be returned to Qwest
12. MISCELLANEOUS.
A. Compliance with Laws The parties shall comply with all federal, state and local
laws,rules and regulations throughout every aspect in the performance of this Agreement.
B Nonwaiver of Breach. The failure of a party to insist upon strict performance of
any of the terms and rights contained herein,or to exercise any option herein conferred in one or
more instances, shall not be constructed to be a waiver or relinquishment of those terms and
rights and they shall remain in full force and effect.
C. Governing Law. This Agreement shall be governed and construed in accordance
with the laws of the State of Washington If any dispute arises between the pares or between
any party and the contractor under any of the provisions of this Agreement, the parties shall
attempt in good faith to resolve the dispute arising out of or relating to this Agreement promptly
by negotiation between executives or senior officials who have authority to settle the controversy
and who are at a higher level than the persons with direct responsibility for administration of this
Agreement All reasonable requests for information made by one party to the other will be
honored. All negotiations pursuant to this clause are confidential and shall be treated as
compromise and settlement negotiations for purposes of applicable rules of evidence If the
parties are unable to resolve the dispute within sixty (60) days after commencement of such
negotiations, the parties shall subject the dispute to mediation with a mediator agreed to by both
parties. If the parties are unable to agree to a mediator or the dispute is not resolved through
mediation, resolution of the dispute shall be available only through the jurisdiction, venue and
rules of the King County Superior Court,King County,Washington.
D. Attorney's Fees To the extent not inconsistent with RCW 39 04 240, in any
claim or lawsuit for damages ansing from the pares' performance of this Agreement,each party
shall be responsible for payment of its own legal costs and attorney's fees incurred in defending
or bringing such clam or lawsuit, however, nothing in this subsection shall limit a party's right
to indemnification under Section 6 of this Agreement. '
E Written Notice All communications regarding this Agreement shall be sent to the
parties at the addresses listed on the signature page of this Agreement,unless otherwise notified
JOINT TRENCH AGREEMENT—Page 7 of 9 (May 9,2005)
(between City of Kent and Qwest Re Military Road)
Any written notice shall become effective upon delivery, but in any event three(3)calendar days
after the date of mailing by registered or certified mail, and shall be deemed sufficiently given if
sent to the addressee at the address stated on this Agreement.
F. Modification No waiver, alteration, or modification of any of the provisions of
this Agreement shall be binding unless in writing and signed by a duly authorized representative
of each of affected party
G. Severability If any one or more sections, sub-sections, or sentences of this
Agreement are held to be unconstitutional or invalid, that decision shall not affect the validity of
the remaining portion of this Agreement and the remainder shall remain in full force and effect.
H Relationship It is understood and agreed that no agency, employment, joint
venture,co-employer or partnership is created by this Agreement. No party hereto shall (i)have
the power or authority to act for another in any manner to create obligations or debts which
would be binding upon another,and, (n)be responsible for any obligation or expense whatsoever
of another.
1. Force Majeure. Parties shall not be deemed to be in breach of this Agreement if
unable to perform their respective obligations hereunder as a result of the occurrence of an event
of "force majeure;' which shall include, but not be limited to, acts of God, acts of the
government of the United States or of any state or political subdivision thereof,strikes,civil nots
or disturbances, fire, floods, explosions,earthquakes, wind,storms,hurricanes, lightning or other
similar catastrophes or other causes beyond the parties' reasonable control The scope of events
of force majeure shall not extend to payment of money owed hereunder.
K. Entire Agreement. The written provisions and terms of this Agreement, together
with any attached Exhibits, supersede all prior verbal statements by any representative of the
City, and those statements shall not be construed as forming a part of or altering in any manner
this agreement. This Agreement and any attached Exhibits contain the entire Agreement
between the parties. Should any language in any Exhibit to this Agreement conflict with any
language contained in this Agreement,the terms of this Agreement shall prevail.
L Term. The term of this Agreement will commence on the Effective Date and
continue until all obligations are met unless the Agreement is otherwise terminated in accordance
with the Agreement. In no event will the Term extend beyond 12/3112006. Either party may
terminate this Agreement,in whole or in part, for its convemence upon thirty(30)calendar days'
prior wntten notice. The City will be entitled to payment for all Work satisfactorily completed
as of the date of termination Qwest will be entitled to receive all Work completed or in progress
as of the date of termination. Neither party will have any other liability ansing out of
termination All representations, warranties and indemnifications contained in the Agreement
will survive the termination of this Agreement. In addition and not in limitation of the foregoing,
the sections entitled Warranty, Confidential Information, Indemnification, Liens and
Encumbrances, Limitation of Liability, Records and Audits and Dispute Resolution will survive
the termination or expiration of this Agreement. Expiration or termination of this Agreement
will not relieve either party from its obligations ansing under the Agreement prior to expiration
or termination.
JOINT TRENCH AGREEMENT—Page 8 of 9 (May 9,2005)
(between City of Kent and Qwest Re Military Road)
1
i
IN WITNESS WHEREOF, the parties below have executed this Agreement.
i
WEST OF WASHIINGTONIV,INC. CITY OF KENT
WAb( (Awdr I
Print Name: Mark D. Schmidt Print Name.
Title:Director Process Management Title
DATE 06-" `W05 DATE
NOTICES TO BE SENT TO: NOTICES TO BE SENT TO:
i
QWEST CITY OF KENT
Qwest City of Kent
23315 66th Avenue South 220 Fourth Avenue South
Kent,WA 98032 Kent,WA 98032
Attn Jeff Watson Attn Chad Bjeren
(253)372-5358(Desk) (253)856-5534(Desk)
(877)506-3732 (Pager) (253)856-6500(Fax)
(253)372-5174(Fax)
APPROVED AS TO FORM:
Kent Law Department
i
i
JOINT TRENCH AGREEMENT—Page 9 of 9 (May 9,2005)
(between Cory of Kent and Qwes[Re Military Road)
Exlubit A
Nbhtary Road Trench Agreement
EXHIBIT A-JOINT TRENCH AGREEMENT—MIIITARY ROAD
(between Ctty of Kent and Qwest)
NIORery Road Trench Agr er*
*QONDII 7AGE OF 70T FJ,iR-FTr�
STATION LINEAR FT PSE CONCAST ��- ���, 3 Y � -QWESf CITY OF KENT� TOTAL
4+20 TO S+09 89 4 5714% 356 2 26 57% 179 0 0 m% 0 1 14 29% 89 7 '
S+09 TO 7+29 22D 6 66 67% 1320 2 2222% 440 0 000% 0 1 11 l l% 220 9
7+29 TO 7+S1 22 5 62 50% L30 2 25 00% 44 0 0 00% 0 1 12 50% 22 8
7+51 TO 7+88 37 4 40 DD% 148 2 20 00% 74 3 30 DO% Ill 1 10 00% 37 30
7+88 TO 8+90 102 4 44 44% 408 2 2222% 204 2 2222% 2D4 1 11 11% 202 9
e+90 TO 10+98 208 4 28 57% 832 2 14 29% 416 2 14 29% 426 6 42 86% 1248 14
30+98 TO 12+10 112 4 40 DD% 448 2 2D 00% 224 2 20 00% 224 2 20 00% 224 10
12+10 TO 13+98 188 4 5D 00% 752 2 25 DO% 376 0 0 DO% 0 2 25 00% 376 8
13+99 TO 14+80 82 4 57 14% 328 2 28 57% 164 0 0 DO% 0 1 14 29% 82 7
14+80 TO 14+99 19 6 66 67% 114 2 2222% 38 0 0 DO% 0 1 11 11% 19 9
14+99 TO 15+26 27 4 4444% 108 2 2222% S4 2 2222% 54 1 1111% 27 9
15+26 TO 18+00 274 4 57 14% 1D96 2 28 57% 548 0 0 00% 0 1 14 29% 274 7
18+00 TO 20+66 266 5 62 50% 1330 2 25 00% 532 0 000% 0 1 12 50% 266 8
20+66 TO 20+96 30 7 70 00% 210 2 20 00% 60 0 D OD% 0 1 10 00% 30 10
20+96 TO 21+80 84 7 63 64% 598 3 27 27% 2S2 0 0 00% 0 1 9 09% 94 11
21+80 TO 22+08 28 6 60 00% 168 3 30 00% 84 0 0 OD% 0 1 10 DO% 28 10
22+08 TO 22+SO 42 5 55 56% 210 3 33 33% 126 0 0 0D% 0 1 11 11% 42 9
22+30 TO 23+82 132 5 50 DO% 660 3 30 00% 396 0 0 00% 0 2 20 00% 264 10
23+92 TO 26+02 220 4 36 36% 800 2 18 18% 440 3 27 27% 660 2 18 18% 440 11
26+02 TO 26+45 43 6 4615% 2S8 2 15 38% 86 3 23 08% 129 2 15 38% 86 13
26+45 TO 26+56 Il 7 50 00% 77 2 14 29% 22 3 2143% 33 2 14 29% 22 14
26+56 TO 26+67 11 6 46 15% 66 2 15 38% 22 3 23 ca% 33 2 15 39% 22 13
26+67 TO 27+54 89 6 50 00% 534 2 16 67% 178 3 25 00% 267 1 8 33% 89 12
27+56 TO 27+89 33 4 40 00% 132 2 20 DO% 66 3 30 OD% 99 1 10 00% 33 10
£= 11133 R £= 5024 ft E- 2.230 ft 4126 ft
lr _HtY.pN, M tnk,,�e
STATION LINEAR FT. PSE CONCAST QWEST CITY OF KENT TOTAL
SR 516 130 4 30 77% 520 2 15 38% 260 3 23 08% 390 4 30 77% 520 13
5+09 2 100 DO% 0 0 0 DO% 0 0 0 DO% 0 D 000% 0 2
7+31 157 1 25 DO% 157 1 25 00% 157 1 25 00% 157 1 25 00% 100 4
14+99 210 1 33 33% 210 0 0 m% 0 2 66 67% 420 0 0 00% 0 3
18+10 4 100 DD% 0 0 000% 0 0 000% 0 0 0 m% 0 4
22+08 1 1DO OD% D 0 000% 0 0 D00% 0 0 000% 0 1
23+02 151 7 4375% 1057 1 625% 151 3 1875% 453 5 3125% 500 16
26+45 1 100 OD% 0 0 000% 0 0 000% 0 0 000% 0 1
1424 ft = 308 ft 1030 ft E= 600 ft
Kent City Council Meeting
Date June 21, 2005
Category Consent Calendar
1. SUBJECT: JOINT TRENCH AGREEMENT WITH COMCAST —AUTHORIZE
2. SUMMARY STATEMENT: Authorize the Mayor to sign a Joint Trench
Agreement with Comcast for work on Military Road upon concurrence of the language
by the Public Works Director and the City Attorney.
3. EXHIBITS: Public Works memorandum and Joint Trench Agreement
4. RECOMMENDED BY: Public Works Committee
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? X Revenue?
Currently in the Budget? Yes X No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6N
PUBLIC WORKS DEPARTMENT
Larry R Blanchard, Public Works Director
Phone 253-856-5500.
KEN T Fax 253-856�500
W A S H I N O T O N Address 220 Fourth Avenue S
Kent,WA 98032-5895
DATE: May 27,2005
TO: Public Wor s ommittee
FROM: Chad Bie , enior Project Engineer THROUGH Larry Blanchard,Public Works Director hy21J
SUBJECT: Joint Trench Agreement with Comcast
MOTION Recommend authorizing the Mayor to sign the Joint Trench Agreement with
Comcast for work on Military Road upon concurrence of the language therein by the City
Attorney and the Public Works Director
SUMMARY: The Public Works Director recommends approval of the agreement and
authorization for the Mayor to sign same upon concurrence of the final language by the City
Attorney
BUDGET IMPACT No Unbudgeted Fiscal/Personnel Impact
BACKGROUND: As part of the S 228th Street Extension project Military Road will be
widened to five lanes The overhead utilities need to be converted to underground in accordance
with City ordinance Pursuant to the attached joint trench agreement, Comcast will pay the City
to install Comcast conduit and vaults This allows the City to control the construction schedule
for installation of Comcast's vault and conduit system, thus reducing construction time and
minimizing construction-related traffic impacts Comcast will repay the City for work related to
Comcast facilities based on bid prices submitted by the contractor with the lowest bid Bids for
the project will be opened later in June
' Mayor White and Kent City Councd ]
JOINT TRENCH AGREEMENT
Between the City of Kent and Comcast
for Military Road Improvements
THIS AGREEMENT, is entered into between the City of Kent, a Washington municipal
corporation ("Ctty"), and Comcast of Washington IV, Inc a Washington corporation
("Comcasf)
RECITALS
WHEREAS,the City is making right-of-way improvements to Military Road
WHEREAS, it is the City's belief that, pursuant to local ordinance and the franchise
agreement between the City and Comcast dated May 4, 1993, and the Franchise Clarification
Agreement dated May 5, 2004, that these right-of-way improvements require Comcast to
underground its facilities that are currently located above ground
WHEREAS, relocation requires trenching within the right-of-way and the patties
recognize the efficiencies of entering into an agreement whereby one trench will be dug for all of
the parties to relocate their facilities
' AGREEMENT
To facilitate construction of a}outt trench,the patties agree as follows
1. SCOPE OF WORK
The City of Kent will advertise for construction bids and enter into a contract for the
construction of a trench which shall include the City, Comcast, Qwest, and PSE facilities This
trench will be placed along the west side of Military Road between Gai's Bakery located at
23009 Military Road South and one span north of the Military Road South/South 239'h Street
intersection This trench will include an open cut trench crossing of SR 516 There will be
approximately seven(7) trench crossings of Military Road to serve customers on the east side of
the street All utilities will use these trenches
2. CONTRACTOR REQUIREMENTS
The independent contractor hired by the City to perform this work shall be referred to as
"the contractor" in this Agreement The contractor, pursuant to a contract with the City, shall
excavate the trench, install City, PSE, and Qwest facilities, accommodate and coordinate the
installation of Comcast facilities, install the bedding material, backfill and compact the trench,
and perform any restoration required by the City, all to be performed in a good and workmanlike
JOINT TRENCH AGREEMENT—Page 1 of 8 (May 3,2005)
' (between Cary of Kent and ComcartRe MthtaryRoad)
manner consistent with industry standards The City represents that any such contract shall
further require of contractor that the work be conducted in conformity with (i) the applicable
i procedures and requirements of the parties as described herein, (u) all applicable laws,
ordinances and regulations of any governmental authority, and, (iti) all applicable terms and
provisions of the National Electric Safety Code, as may be amended, supplemented or replaced
from time to time, including but not limited to those pertaining to protection and separation of
conductors buried in earth '
3. RESPONSIBILITY OF THE PARTIES
I
A Drawings Comcast shall provide engineering drawings to the City and obtain a
permit from the City for the underground relocation of Coincast's facilities These drawings
shall show in detail the location and elevation of the conduits, trench, and vaults, and shall
include a general traffic control plan for activities not associated with installation of facilities
within the contractor controlled open trench area
B Installation Comcast shall be responsible for supplying and/or installing within
the open trench their own facilities, including all conductors, vaults and conduits as outlined in
subsection 3 D in a timely manner All right, title and interest in the facilities and associated
equipment shall at all times remain with Comcast Parties hereto acknowledge and agree that
Comcast shall in no event be required to remove their respective, affected aerial facilities prior to
completion of the underground facilities in accordance with this Agreement, and so long as said '
installation is completed in conformity with this Agreement
C Traffic Control. The City's contractor shall perform all traffic control associated
with installation of facilities within the contractor controlled open trench area Comcast shall be
responsible for providing traffic control during installation of facilities not associated with the
controlled open trench area
I
iD Comcast Coordination. Comcast shall maintain continued coordination with the
contractor regarding the installation of Comcast's facilities This coordination shall include but
not be limited to the following
1 Timing of when and where materials will be delivered on-site
2 Time and duration of work including project schedule by Comcast's
contractor to install facilities in the trench Once the contractor has given one week notice to '
Comcast of when the trenching work will begin, Comcast shall abide by the following schedule
a Comcast shall have necessary manpower and equipment on site and shall
have a three (3) hour window per day with which to complete installation of conduits when the
trench is provided and plumb them into the vaults The City's contractor will install Comcast's
conduit in the street crossings
I
JOINT TRENCH AGREEMENT—Page 2 of S (May 3,2005)
(between City of Kent and Comcast Re Military Road) '
1
' b The City's contractor shall provide Comcast daily notification as to the
exact timing of when Comcast's three(3)hour installation window will start
c The City's contractor will excavate for and place Comcast vaults in the
' trench
d Comcast shall coordinate closely with the City's contractor to provide all
necessary materials in a timely manner
' 3 Location of where Comcast's contractor will begin the work
4 Coordination with other utility companies included in the joint trench for the
placement of conduit This may include the staclang of conduits with another utility, and
locating conduits below or around other vaults
' E Surveys The City will provide the survey for the location of the trench and
vaults
' F Electron Not to Proceed If Comcast elects not to proceed with joining in the
trench provided by the contractor, Comcast shall remain liable for completing all work within the
approved permit at the time frame specified on the permit
�. G Franchise. Comcast shall, if so required by the Washington State Department of
Transportation C WSDOT"), submit for and obtain, at its cost, a utility franchise permit from the
'I WSDOT for its facilities that cross SR 516 The City has developed a traffic control plan for the
crossing and the City agrees that Comcast may use this plan in its permit application
4. COMPENSATION
A Trench costs Comcast agrees to pay the City a portion of the trench costs,
including trench bedding and backfill, commensurate with their proportionate share of trench
usage as shown in Exhibit A attached hereto and incorporated by this reference Preliminary
' costs will be agreed upon prior to construction based on an estimate from the bid accepted by the
City Costs will be finalized after completion of construction to account for actual construction
costs
' B Street Crossings Comcast agrees to pay for the installation costs for the City's
contractor to install Comcast's conduits in the street crossings These costs are in addition to the
' trench costs outlined in subsection 4 A herein
C Survey Comcast agrees to pay the reasonable costs for the City surveyor's time
' to provide vault locations and elevations and any other survey that may be required to locate and
place Comcast facilities
JOINT TRENCH AGREEMENT—Page 3 of 8 (May 3,2005)
(between CIO of Kent and Comcast Re Military Road)
D Traffic Control Comcast agrees to pay the City a proportionate share of traffic '
control set-up costs related to the contractor controlled open trench areas where Comcast
facilities are present The proportionate share shall be based on trench usage as shown in Exhibit
A Comcast shall be responsible for all traffic control costs during installations of Comcast '
facilities not associated with the controlled open trench area
E Additional Expenses Comcast agrees to pay their proportionate share of ,
additional expenses incurred due to Comcast's approved change requests requiring additional
trench depth or width and for unforeseen conditions, including but not limited to dewatering for
ground water Comcast will not pay for any share of additional expenses incurred due to
approved change requests from PSE, Qwest and/or the City
F Claims by Contractor. Comcast agrees to pay the entire cost of any claims made
by the contractor that are proximately caused by Comcast These claims may include delays
caused by installing Comcast facilities, delays caused by Comcast providing materials, or any
other conflicts between the contractor and Comcast's contractor '
G Vaults Comcast agrees to pay for the excavation, site preparation, and
installation for their vaults separately and in addition to any survey costs and trench costs
discussed above These additional costs shall be preliminarily determined from the bid price
accepted by the City The cost to excavate for and install Comcast's vaults will be finalized after
completion of construction to account for actual construction costs '
H Invoice Comcast agrees to pay the City within sixty(60) days of being invoiced
by the City for amounts that the contractor has invoiced the City and wluch Comcast has agreed
to pay under this Agreement
I Defective or Unauthorized Work Per the terms of the agreement between the '
City and contractor, Comcast reserves the right to withhold payment from the City for any
defective or unauthorized work performed by the contractor Defective or unauthorized work
includes, without limitation work and materials that do not conform to the requirements of this
Agreement, and extra work and materials furnished without Comcast's approval If for any ,
reason it is necessary to satisfactorily complete any portion of the work, Comcast may complete
the work using its own means and the contractor shall be liable to Comcast for any additional
costs incurred by Comcast "Additional costs" shall mean all reasonable costs, including legal ,
costs and attorney fees, incurred by the parties beyond the price included in the bid accepted by
the City Comcast further reserves the right to offset the cost to complete the work, including
any additional costs, from any and all amounts due or to become due the contractor ,
J Final Payment/Walver of Claims The making of final payment by the parties
shall constitute a waiver of claims by the contractor, except those previously and properly made '
and identified by the contractor as unsettled at the time request for final payment is made
JOINT TRENCH AGREEMENT-Page 4 of 8 (May 3,2005) '
(between City of Kent and Comcast Re MibtaryRoad)
5. CHANGES.
Comcast shall submit any changes requested to be performed by the City's contractor to
the City The City shalt submit this to the contractor, obtain a price from the contractor to
j perform the work, and notify Comcast of this price Comcast shall have 24 hours from receiving
the price from the City within which to respond If Comcast chooses not to accept the
contractor's price then this work shall only be performed by Comcast according to a mutually
agreed upon schedule with the contractor so as not to cause delay to the contractor
' 6. INDEMNIFICATION; LIENS AND ENCUMBRANCES.
Each party shall defend, indemnify and hold the other party, their officers, officials,
' employees and agents harmless from any and all claims, injuries, damages, losses or suits
including all legal costs and attorney fees, arising out of or in connection with the performance
of the party's work required under this Agreement, except for injuries and damages caused by
the negligence or willful misconduct of the other party
The indemnification from Comcast to the City shall include all claims, injuries, damages,
' losses or suits from third parties arising out of the fact that the specific portion of the trench at
j issue was being made available to Comcast for more than the three(3) hour time frame provided
for in Section 3 D 2 by the contractor, except for injuries and damages caused by the negligence
' or willful misconduct of the City
Should a court of competent jurisdiction determine that this Agreement is subject to
RCW 4 24 115, then, in the event of liability for damages arising out of bodily injury to persons
or damages to property caused by or resulting from the concurrent negligence of the parties, their
iofficials, employees and agents, a parry's liability hereunder shall be only to the extent of the
party's negligence The provisions of this section shall survive the expiration or termination of
this Agreement
' No party,directly or indirectly, shall create or impose any hen on the property of another,
or on the rights or title relating thereto, or any interest therein, or in this Agreement Each party
shall promptly, at its own expense, take such action as may be necessary to duly discharge any
' lien created by it on the property of another
7. INSURANCE.
tThe contract between the City and the contractor shall require that the contractor procure
and maintain for the duration of the project insurance of the types and in the amounts described
below against claims for injuries to persons or damage to property which may arise from or in
connection with the performance of the work by the contractor, its agents, representative,
employees, subconsultants or subcontractors
JOINT TRENCH AGP EEMENT—Page 5 of 8 (May 3,2005)
(between City ojKent and Comcast Re MiktaryRoad)
I Automobile Liability insurance with limits no less than $1,000,000 combined
single limit per accident for bodily injury and property damage, and
2 Commercial General Liability insurance written on an occurrence basis with '
limits no less than $1,000,000 combined single limit per occurrence and
general aggregate for personal injury, bodily injury and property damage ,
Coverage shall include but not be limited to blanket contractual,
products/completed operations/broad form property damage, explosion,
collapse and underground(XCU),and employer's liability ,
3 Excess Liability insurance with limits not less than$1,000,000 per occurrence
and aggregate '
Any payment of deductible or self insured retention shall be the sole responsibility of
the contractor The parties, their officials, employees, agents and volunteers shall be named as ,
additional insureds on the insurance policy, as respects work performed by or on behalf of the
parties and a copy of the endorsement naming the parties as additional insured shall be attached
to the Certificate of Insurance, copies of which shall be provided to the parties pnor to '
commencement of construction by the contractor The contractor's insurance shall contain a
clause stating that coverage shall apply separately to each insured against whom claim is made or
suit is brought,except with respects to the limits of the insurer's liability '
i
S. FRANCHISE AGREEMENT. '
The City and Comcast agree that as to future projects, by entering into this Agreement,
neither party has waived any rights it may have under the existing franchise agreement between ,
the City and Comcast, and the City and Comcast expressly herem reserve such rights
Notwithstanding anything in this Agreement to the contrary, Comcast's participation in the joint
trench activity contemplated in this Agreement, and its very participation in this Agreement,
shall in no event be construed as acceptance, affirmation or ratification of the City's construction ,
of Comcast's obligation to underground and enter into a writing pursuant to the franchise
agreement, and parties understand and agree that the terms and conditions of this Agreement
shall not be considered as a basis for future undergrounding projects that may be franchise- '
required
9. MISCELLANEOUS.
A Compliance with Laws The parties shall comply with all federal, state and local
laws, rules and regulations throughout every aspect in the performance of this Agreement
JOINT TRENCH AGREEMENT-Page 6 of 8 (May 3, 2005) ,
(between City of Kent and Comcast Re Military Road)
B Nonwwver of Breach The failure of a party to insist upon strict performance of
any of the terms and rights contained herein, or to exercise any option herein conferred in one or
more instances, shall not be constructed to be a waiver or relinquishment of those terms and
rights and they shall remain in full force and effect
C Governing Law This Agreement shall be governed and construed in accordance
' with the laws of the State of Washington If any dispute arises between the parties or between
any party and the contractor under any of the provisions of this Agreement, resolution of that
dispute shall be available only through the jurisdiction, venue and rules of the King County
Superior Court, King County,Washington
D Attorney's Fees To the extent not inconsistent with RCW 34 04 240, in any
claim or lawsuit for damages ansmg from the parties' performance of this Agreement, each party
shall be responsible for payment of its own legal costs and attorney's fees incurred in defending
or bringing such claim or lawsuit, however, nothing in this subsection shall limit a parry's right
to indemnification under Section 8 of this Agreement
E Written Notice Alt communications regarding this Agreement shall be sent to the
parties at the addresses listed on the signature page of this Agreement, unless otherwise notified
Any written notice shall become effective upon delivery, but in any event three(3)calendar days
after the date of marling by registered or certified mail, and shall be deemed sufficiently given if
sent to the addressee at the address stated on this Agreement
F Modification No waiver, alteration, or modification of any of the provisions of
this Agreement shall be binding unless in writing and signed by a duly authorized representative
of each of the affected parties
G Severabihty If any one or more sections, sub-sections, or sentences of this
Agreement are held to be unconstitutional or invalid,that decision shall not affect the validity of
the remaining portion of this Agreement and the remainder shall remain in full force and effect
H Relationship It is understood and agreed that no agency, employment, joint
venture, co-employer or partnership is created by this Agreement No party hereto shall (i) have
the power or authority to act for another in any manner to create obligations or debts which
would be binding upon another, and, (ii)be responsible for any obligation or expense whatsoever
of another
I Force Maleure Parties shall not be deemed to be in breach of this Agreement if
unable to perform their respective obligations hereunder as a result of the occurrence of an event
of "force mateure," which shall include, but not be limited to, acts of God, acts of the
government of the Umted States or of any state or political subdivision thereof, strikes, civil hots
or disturbances, fire, floods, explosions, earthquakes, wind, storms, hurricanes, lightning or other
similar catastrophes or other causes beyond the parties' reasonable control The scope of events
of force majeure shall not extend to payment of money owed hereunder
JOINT TRENCH AGREEMENT-Page 7 of 8 (May 3,2005)
(between City of Kent and ComcastRe Military Road)
K Enure Agreement The written provisions and terms of this Agreement, together ,
with any attached Exhibits, supersede all prior verbal statements by any representative of the
City, and those statements shall not be construed as forming a part of or altering in any manner '
this agreement This Agreement and any attached Exhibits contain the entire Agreement
between the parties Should any language in any Exhibit to this Agreement conflict with any
language contained in this Agreement,the terms of this Agreement shall prevail ,
IN WITNESS WHEREOF, the parties below have executed this Agreement
COMCAST OF WASHINGTON IV,INC. CITY OF KENT ,
klll�/Z&
Print 14ame ken Rhoades Print Name ,
Title Area Vice President Title
DATE DATE ,
NOTICES TO BE SENT TO: NOTICES TO BE SENT TO: '
COMCAST CITY OF KENT
CQmcast City of Kent ,
4020 Auburn Way N 220 Fourth Avenue South
Auburn_WA 98002 Kent_WA 98032
Attn Jim Nies Attn Chad Breren
253 288-7531(Desk) (253) 856-5534(Desk)
206) 571-8893 (Cell) (253) 856-6500(Fax)
(253)288-7500(Fax) '
With a copy to APPROVED AS TO FORM: ,
Comcast Cable Communications, LLC
1500 Market Street ,
Philadelphia, PA 19102 Kent Law Department
Attention General Counsel
P tChMFILES1OpmiFaecll1177-200NmR{'rtn�Mlm[yRoeLdcc '
JOINT TRENCH AGREEMENT-Page 8 of 8 (May 3,2005)
(between City of Kent and Conz=t Re MihtaryRoad) '
I
r
Ex}ubrt A
1ltihtary Road Trench Agreement
,I
i
r
EXHIBIT A-TOINT TRENCH AGREEMENT—MILITARY ROAD
' (between City of Kent and Comcast)
Milk"Read Trench Agreement ,
pCONDUITY7jV„E,�,CFi.jj4GE OFTOTA47^J.T,�„EAW i
STATION LINEAR FT PSE COMCAST QWEST CITY OF KENT TOTAL
4+20 TO S+09 89 4 57 14% 356 2 28 57% 179 0 0 0D% 0 1 14 29% 89 7 '
S+09 TO 7+29 22D 6 66 67% 1320 2 22 22% 44D 0 0 OD% 0 1 Il ll% 220 9
7+29 TO 7+51 22 5 62 50% 110 2 25 DO% 44 0 0 00% 0 1 12 50% 22 e
7+51 TO 7+88 37 4 40 DO% 148 2 20 DO% 74 3 30 00% 111 1 10 00% 37 10
7+88 TO 8+90 102 4 44 44% 408 2 22 22% 204 2 22 22% 204 1 11 ll% 102 9
8+90 TO 10+98 20B 4 28 57% 832 2 14 29% 416 2 14 29% 416 6 42 86% 1248 14
10+98 TO 12+10 112 4 40 00% 448 2 20 DO% 224 2 20 00% 224 2 20 OD% 224 10
12+10 TO 13+98 188 4 50 DO% 752 2 25 00% 376 0 0 00% 0 2 25 OD% 376 6
13+98 TO 14+80 82 4 57 14% 328 2 28 57% 164 0 0 00% 0 1 14 29% 82 7
14+80 TO 14+99 19 6 66 67% 114 2 22 22% 38 0 0 00% 0 1 11 11% 19 9
14+99 TO 15+26 27 4 44 44% 308 2 22 22% 54 2 22 22% 54 L 11 11% 27 9 '
15+26 TO 18+00 274 4 5714% ID96 2 2852% 548 0 00096 D 1 142996 274 7
16+00 TO 20+66 266 5 62 50% 1330 2 25 00% 532 0 0 00% D 1 12 50% 266 8
20+66 TO 20+96 30 7 70 00% 210 2 20 00% 60 0 0 00% 0 L 10 00% 30 10
20+94 TO 21+80 84 7 63 64% 588 3 27 279b 252 0 0 OD% 0 1 9 09% 84 11
21+80 TO 22+08 28 6 600096 168 3 3000% 84 0 0OD% 0 1 1000% 28 LO ,
22+09 TO 22+50 42 5 55 56% 210 3 33 33% 126 0 0 OD% 0 l I1 ll% 42 9
22+50 TO 23+82 132 5 50 DO% 66D 3 30 00% 396 0 0 00% 0 2 20 00% 264 10
23+82 TO 26+02 220 4 36 36% 880 2 1918% 440 3 27 27% 660 2 18 18% 440 11
26+02 TO 26+45 43 6 46 15% 258 2 15 38% 86 3 23 08% 129 2 15 36% 86 13
26+45 TO 26+56 11 7 50 OD% 77 2 14 29% 22 3 2143% 33 2 14 29% 22 14 ,
26+56 TO 26+67 11 6 46 15% 66 2 15 38% 22 3 23 08% 33 2 15 38% 22 13
26+67 TO 27+56 89 6 50 00% 534 2 16 67% 178 3 25 00% 267 1 6 33% 89 12
27+56 TO 27+89 33 4 40 00% 132 2 20 00% 66 3 30 00% 99 1 10 00% 33 10
11133 ft Z= 5�0�2y4��/ft�p,� ��w 2�2y300 R = 4126 ft
3{.4'Y'�eML'N9 'PIr�Ca`iT�"'#CnlKC1M!] &ffl_">-iaLR11111MPWT�UNEA:.Y.V1 AM.' __
STATION LINEAKFT. PSE COMCAST QWESf CITY OF KENT TOTAL
SR S16 130 4 30 77% 520 2 15 38% 260 3 23 08% 390 4 30 77% 520 13
5+09 2 100 OD% 0 0 0 D0% 0 0 0 00% 0 0 0 OD% 0 2
7+51 157 1 25 DO% 157 1 25 DO% 157 1 25 00% 157 1 25 00% 100 4 '
14+99 210 1 33 33% 210 0 0 00% 0 2 66 67% 420 0 0 00% 0 3
16+10 4 100 009k 0 0 0 00% 0 0 00096 0 0 0 OD% 0 4
22+08 L 100 00% 0 O 0 00% 0 0 0 00% 0 0 0 00% 0 1
23+82 151 7 43 75% 1057 1 6 2S% 151 3 18 75% 453 5 31 25% 500 16
26+45 1 LOD 00% 0 0 0 DD% 0 0 0 00% 0 0 0 00% 0 1 ,
= 1424 ft = 308 ft 1030 ft = 600 ft
Kent City Council Meeting
Date June 21, 2005
Category Consent Calendar
1. SUBJECT: SOUTH 228TH STREET EXTENSION CONSULTANT
SERVICES CONTRACT—AUTHORIZE
2. SUMMARY STATEMENT: Authorize the Mayor to sign consultant services
agreements for the following disciplines. structural engineering for Riverview
Boulevard Bridge and Military Road retaining walls; utility seismic designer; wetland
mitigation inspection and wetland mitigation monitoring; inspection services for
structural, geotechnical, materials testing and roadway construction; traffic signal
design; and real property appraiser and property negotiation services.
3. EXHIBITS: Public Works memorandum
4. RECOMMENDED BY: Public Works Committee
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? X Revenue?
Currently in the Budget? Yes X No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
' Councilmember moves, Councilmember seconds
1
DISCUSSION:
ACTION:
Council Agenda
Item No. 60
1
PUBLIC WORKS DEPARTMENT
' Larry R Blanchard, Public Works Director
. Phone 253-856-5500
K E N T Fax 253-856-6500
W A S H I N 6 T O N Address 220 Fourth Avenue S
Kent,WA 98032-5895
' DATE: May 31,2005
TO: Public Works Committee
FROM: Tim LaPorte,Design Engineering S pervisor
' THROUGH Larry Blanchard, Public Works Director
SUBJECT: S. 228th Street Extension Consultant Services Contracts
MOTION Recommend authorizing the Mayor to sign consultant services agreements for the
following disciplines structural engineering for Riverview Boulevard Bridge and Military Road
retaining walls, utility seismic designer, wetland mitigation inspection and wetland mitigation
monitoring, inspection services for structural, geotechnical, materials testing, and roadway
construction, traffic signal design, and,real property appraiser and property negotiator
SUMMARY: Public Works will need to utilize consultants to complete specialized design
elements of the S 228th Street Extension project Consultants will be selected in the next few
months to assist with the completion of structural plans and specifications,right of way purchase,
and construction inspection Authorizing the Mayor to sign the contracts for these services will
allow work to begin as soon as possible and will help to keep the project on schedule
BUDGET IMPACT No Unbudgeted Fiscal/Personnel Impact—The costs for these
contracts were already accounted for in the S 2281h Street Extension project budget
BACKGROUND: As part of the S 228th Street Extension project,Riverview Boulevard will
be extended southward to meet S 228th Street. Riverview Boulevard will pass over S 228th
Street on a new bridge The Public Works Department has begun the process to select a
structural engineering consultant to design the bridge The bridge is scheduled to go out for bids
in October.
Construction inspection services will be needed in areas such as structural,geotechnical,and
materials testing
As part of the S 228th Street Extension,the Military Road/SR 516 signal system will be
replaced and new signals will be installed at Military RoadlS 228th Street and at Lakeside
Boulevard/S 228th Street The Public Works Department will be selecting a consultant in June
to design the three signal systems
Mayor White and Kent City Council I
Kent City Council Meeting
Date June 21, 2005
Category Consent Calendar
1. SUBJECT: PACIFIC HIGHWAY SOUTH CONSULTANT SERVICES
CONTRACT—AUTHORIZE
2. SUMMARY STATEMENT: Authorize the Mayor to sign consultant services
agreements for wetland mitigation inspection and wetland mitigation monitoring upon
concurrence from the City Attorney and Public Works Director.
i
1
3. EXHIBITS: Public Works memorandum
4. RECOMMENDED BY: Public Works Committee
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? X Revenue? _
Currently in the Budget? Yes X No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
L6. CITY COUNCIL ACTION:
' Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6P
PUBLIC WORKS DEPARTMENT
Larry R Blanchard, Public Works Director
Phone 253-856-5500
IK E N T Fax 253-856-6500
W A S H I N CS T O N Address 220 Fourth Avenue 5
Kent,WA 98032-5895
1 DATE: June 1,2005
TO: Public Works Committee
FROM: Tim LaPorte,Design Engineering Supervisor
THROUGH Larry Blanchard,Public Works Director
SUBJECT: Pacific Highway South Consultant Services Contract
MOTION Recommend authorizing the Mayor to sign a consultant services agreement for
wetland mitigation inspection and wetland mitigation monitoring upon concurrence from the
City Attorney and Public Works Director
SUMMARY: Public Works needs to hire inspection and wetland monitoring experts to complete
the wetland mitigation for the Pacific Highway South project Selection of the consultants would
take place this summer,and the work would be completed this summer and autumn
IBUDGET IMPACT No Unbudgeted Fiscal/Personnel Impact—The costs for these
contracts were already accounted for in the project budget
IBACKGROUND: The Corps of Engineers has issued a permit for wetland fill related to the
Pacific Highway South HOV project The permit requires the City to complete a wetland
mitigation project on the Birk Property, which is located off of 25th Ave. South near S 260th
Street Design plans for the project have already been completed This request would allow
Public Works to hire an inspector to oversee construction of the project, and a consultant to
monitor the wetland—a requirement of the permit
Mayor White and Kent City Council l
' Kent City Council Meeting
Date June 21, 2005
Category Consent Calendar
1. SUBJECT: W & H PACIFIC CONTRACT FOR PACIFIC HIGHWAY SOUTH
INSPECTION SERVICES — AUTHORIZE
2. SUMMARY STATEMENT: Authorize the Mayor to sign the Local Agency
Standard Consultant Agreement with W & H Pacific for inspection services on the
Pacific Highway South HOV Lanes Project upon concurrence from the City Attorney
and Public Works Director.
3. EXHIBITS: Public Works memorandum and Local Agency Standard Consultant
agreement
4. RECOMMENDED BY: Public Works Committee
(Committee, Staff, Examiner, Commission, etc )
5. FISCAL IMPACT
Expenditure? X Revenue?
Currently in the Budget? Yes X No
If no:
Unbudgeted Expense: Fund Amount S
Unbudgeted Revenue: Fund Amount S
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
t
DISCUSSION:
ACTION.
Council Agenda
Item No. 6Q
PUBLIC WORKS DEPARTMENT
Larry Blanchard Public Works Director
Phone 253-856-5500
Fax 253-856-6500
KENT
WASHINGTON Address 220 Fourth Avenue S
Kent,WA 98032-5895
DATE: June 6,2005
TO: Public Works Committee
FROM: Stan Wade, Construction Engineering Manager
THROUGH Larry Blanchard, Public Works Director
SUBJECT: W & H Pacific Contract
MOTION Recommend authorizing the Mayor to sign the contract with W & H Pacific for
1 $188,000 00 to provide the City of Kent inspection services on the Pacific Highway South HOV
Lanes project upon concurrence of the language therein by the City Attorney and Public Works
Director
1 .
SUMMARY: This contract will provide the City of Kent construction inspection assistance for
' the Pacific Highway South HOV Lanes project Specific work will consist of project submittal
review and approval, federal and state document compliance preparation and auditing, training
Kent personnel in federal and state document compliance, field inspection,project record
keeping and filing, contractor communications and RFI(request for information) review, and
miscellaneous duties as assigned.
BUDGET IMPACT•There will be no unbudgeted fiscal impacts as a result of this contract
BACKGROUND: The Pacific Highway South HOV Lane construction project is a Federal
Highway Administration funded project Inspection services and project documentation are
strictly regulated by both the State of Washington and the Federal Government and require a
1 much higher level of administrative oversight and control than the current City of Kent
Construction Management Team is able to provide The consulting firm of W & H Pacific is one
of only a few firms whose management and numerous of its employees are former WSDOT
(Washington State Department of Transportation) employees who possess unique qualities to
provide the oversight, assistance and training necessary to successfully complete this project
within the legal guidelines
Mayor White and Kent City Council ]
Consultant/Addresslrelephone
Local Agency W&H Pacific
Standard Consultant 3350 Monte Villa Parkway
Agreement Bothell,Washington 98021
Agreement Number
LA-4296 (425)951-4860
Federal Aid Number Project Title And Work Description
STPUL-099(060) Pacific Highway S HOV Lanes
Agreement Type(Choose one)
Provide inspector to perform field observations of
❑Lump Sum the Contractor's activities
Lump Sum Amount $
❑Cost Plus Fixed Fee
Overhead Progress Payment Rate % DEA Participation
Overhead Cost Method ❑Yes N No %
❑Actual Cost WBE Participation
❑Actual Cost Not To Exceed % ❑Yes N No %
Federal ID Number or Social Security Number
❑Fixed Rate % 91-1412195
�. Fixed Fee $ Do you require a 1099 for IRS9 Completion Date
Specific Rates Of Pay N Yes ❑No December 31,2006
®
N Negotiated Hourly Rate Total Amount Authorized$ 188,785 00
❑Provisional Hourly Rate Management Reserve Fund$
❑Cost Per Unit of Work
Maximum Amount Payable$ 188,785 00
THIS AGREEMENT,made and entered into this 24th day of May 2005
between the Local Agency of City of Kent Washington, hereinafter called the
"AGENCY", and the above organization hereinafter called the"CONSULTANT"
WITNESSETH THAT
WHEREAS, the AGENCY desires to accomplish the above referenced project,and
WHEREAS, the AGENCY does not have sufficient staff to meet the required commitment and therefore
deems it advisable and desirable to engage the assistance of a CONSULTANT to provide the necessary
services for the PROJECT, and
WHEREAS, the CONSULTANT represents that he/she is In compliance with the Washington State
Statutes relating to professional registration, if applicable, and has signified a willingness to furnish
Consulting services to the AGENCY,
i NOW THEREFORE, in consideration of the terns,conditions,covenants and performance contained
herein, or attached and incorporated and made a part hereof, the parties hereto agree as follows
DOT Form 140-089 EF Page 1 of 8
Revised 12199
I All reports,PS&E materials,and other data,furnished
GENERAL DESCRIPTION OF WORK to the CONSULTANT by the AGENCY shall be
returned All designs,drawings,specifications,
The work under this AGREEMENT shall consist of documents,and other work products prepared by the
the above described work and services as herein CONSULTANT prior to completion or termination of
defined and necessary to accomplish the completed this AGREEMENT are instruments of service for this
work for this PROJECT The CONSULTANT shall PROJECT and are property of the AGENCY Reuse
furnish all services,labor and related equipment by the AGENCY or by others acting through or on
necessary to conduct and complete the work as behalf of the AGENCY of any such instruments of
designated elsewhere in this AGREEMENT service,not occurring as a part of this PROJECT,
shall be without liability or legal exposure to the
(( CONSULTANT
SCOPE OF WORK
IV
The Scope of Work and project level of effort for this TIME FOR BEGINNING AND COMPLETION
project is detailed in Exhibit"B"attached hereto,and
I by this reference made a part of this AGREEMENT The CONSULTANT shall not begin any work under
t the terms of this AGREEMENT until authorized in
III writing by the AGENCY All work under this
GENERAL REQUIREMENTS AGREEMENT shall be completed by the date
shown in the heading of this AGREEMENT under
All aspects of coordination of the work of this completion date
AGREEMENT,with outside agencies,groups or
individuals shall receive advance approval by the The established completion time shall not be extended
AGENCY Necessary contacts and meetings with because of any delays attributable to the CONSULT-
agencies,groups or individuals shall be coordinated ANT,but may be extended by the AGENCY,m the
through the AGENCY event of a delay attributable to the AGENCY,or
because of unavoidable delays caused by an act of
The CONSULTANT shall attend coordination, GOD or governmental actions or other conditions
progress and presentation meetings with the beyond the control of the CONSULTANT A prior
AGENCY or such Federal,Community,State,City supplemental agreement issued by the AGENCY is
or County officials,groups or individuals as may be required to extend the established completion time
requested by the AGENCY The AGENCY will
provide the CONSULTANT sufficient notice prior V
to meetings requiring CONSULTANT participation PAYMENT
The minimum number of hours or days notice—
required shall be agreed to between the AGENCY The CONSULTANT shall be paid by the AGENCY
and the CONSULTANT and shown in Exhibit"B" for completed work and services rendered under this
AGREEMENT as provided In Exhibit"C attached
attached hereto and made part of this AGREEMENT
The CONSULTANT shall prepare a monthly hereto,and by this reference made part of this
progress report, in a form approved by the AGENCY, AGREEMENT Such payment shall be full compen-
sationthat will outline in written and graphical form the for work performed or services rendered and
venous phases and the order of performance of the for all labor,materials,supplies,equipment,and
incidentals necessary to complete the work
work in sufficient detail so that the progress of the
work can easily be evaluated Goals for Disadvan- specified in Section II,"Scope of Work" The
taged Business Enterprises(DBE)and Women CONSULTANT shaft conform with all applicable
Owned Business Enterprises(WBE)if required shall portions of 48 CFR 31
be shown in the heading of this AGREEMENT
Page 2 of 8
• V1 employees of the CONSULTANT only and not of the
SUBCONTRACTING AGENCY,and any and all claims that may or might
The AGENCY permits subcontracts for those items arise under any Workmen's compensation Act on
of work as shown in Exhibit G to this Agreement behalf of said employees or other persons while so
engaged,and any and all claims made by a thud party
Compensation for this subconsultant work shall be as a consequence of any act or omission on the part of
based on the cost factors shown on Exhibit G,at- the CONSULTANT's employees or other persons
tached hereto and by this reference made a part of this while so engaged on any of the work or services
AGREEMENT provided to be rendered herein,shall be the sole
The work of the subconsultant shall not exceed its obligation and responsibility of the CONSULTANT
maximum amount payable unless a prior written The CONSULTANT shall not engage,on a full or
approval has been issued by the AGENCY part time basis,or other basis,during the period of the
All reimbursable direct labor,overhead,direct non- contract,any professional or technical personnel who
salary costs and fixed fee costs for the subconsultant are,or have been,at any time dunng the period of the
shall be substantiated in the same manner as outlined contract,in the employ of the United States Depart-
in Section V All subcontracts exceeding$10,000 in ment of Transportation,the STATE,or the
cost shall contain all applicable provisions of this AGENCY,except regularly rebred employees,
AGREEMENT without written consent of the public employer of
The CONSULTANT shall not subcontract for the such person
performance of any work under this AGREEMENT Vill
without prior written permission of the AGENCY No NONDISCRIMINATION
permission for subcontracting shall create,between
the AGENCY and subcontractor,any contract or any The CONSULTANT agrees not to discriminate
L other relationship against any client, employee or applicant for employ-
ment or for services because of race,creed,color,
VII national ongin,mantal status,sex,age or handicap
EMPLOYMENT except for a bona fide occupational qualification with
The CONSULTANT warrants that he/she has not regard to,but not limited to the following employ-
ment upgrading,demotion or transfer,recrrxtment or
employed or retained any company or person,other
any recruitment advertising,a layoff or terminations,
than a bona fide employee working solely for the
rates of pay or other forms of compensation,selection
CONSULTANT,to solicit or secure this contract,and for training,rendition of services The CONSULT-
that it has not paid or agreed to pay any company or ANT understands and agrees that if it violates this
person,other than a bona fide employee working provision,this AGREEMENT may be terminated by
solely for the CONSULTANT, any fee,commission,
the AGENCY and further that the CONSULTANT
percentage, brokerage fee, gift,or any other consider- shall be barred from performing any services for the
abon,contingent upon or resulting from the award or
AGENCY now or in the future unless a showing is
making of this contract For breach or violation of this made satisfactory to the AGENCY that discnnina-
warrant,the AGENCY shall have the right to annul tory practices have terminated and that recurrence of
this AGREEMENT without liability,or in its discre- such action is unlikely
tion,to deduct from the AGREEMENT pnce or
consideration or otherwise recover the full amount of During the performance of this AGREEMENT,the
such fee,commission,percentage,brokerage fee,gift, CONSULTANT,for itself,its assignees and
or contingent fee successors in interest agrees as follows
Any and all employees of the CONSULTANT or A COMPLIANCE WITH REGULATIONS The
other persons while engaged in the performance of CONSULTANT shalt comply with the Regula-
I any work or services required of the CONSULTANT bons relative to nondiscrimination in the same
under this AGREEMENT,shalt be considered manner as in Federal-assisted programs of the
Page 3 of 8
Department of Transportation.Title 49,Code of sive possession of another who fails or refuses to
Federal Regulations, Part 21, as they may be furnish this information the CONSULTANT shall ,
amended from time to time, (hereinafter referred so certify to the AGENCY,or the United States
to as the Regulations),which are herein incorpo- Department of Transportation as appropriate,and
rated by reference and made a part of this shall set forth what efforts it has made to obtain
AGREEMENT The consultant shall comply the information
with the American Disabilities Act of 1992,as
E SANCTIONS FOR NONCOMPLIANCE In the
amended
event of the CONSULTANT's noncompliance
8 NONDISCRIMINATION-The CONSULTANT, with the nondiscrimination provisions of this
with regard to the work performed by it during the AGREEMENT,the AGENCY shall impose
AGREEMENT,shag not discrirrunate on the such sanctions as it or the Federal Highway
grounds of race,creed,color,sex,age,marital Administration may determine to be appropriate,
status,national origin or handicap except for a including,but not limited to,
bona fide occupational qualification in the selec- t Withholding of payments to the CONSULT-
tion and retention of subconsultants, including ANT under the AGREEMENT until the
procurements of materials and leases of equip- CONSULTANT complies,and/or
ment The CONSULTANT shall not participate
either directly or indirectly in the discrimination 2 Cancellation,termination or suspension of the
prohibited by Section 21 5 of the Regulations, AGREEMENT,in whole or in part
including employment practices when the contract
covers a program set forth in Appendix II of the F INCORPORATION OF PROVISIONS The
Regulations CONSULTANT shall include the provisions of
paragraphs(A)through(G)in every subcontract,
C SOLICITATIONS FOR SUBCONSULTANTS, including procurements of materials and leases of
INCLUDING PROCUREMENTS OF MATERI- equipment,unless exempt by the Regulations or
ALS AND EQUIPMENT In all solicitations directives issued pursuant thereto The CON-
either by competitive bidding or negotiation made SULTANT shall take such action with respect to
by the CONSULTANT for work to be performed any subconsultant or procurement as the
under a subcontract,including procurements of AGENCY or the Federal Highway Administra-
materials or leases of equipment,each potential tion may direct as a means of enforcing such
subconsultant or supplier shall be notified by the provisions including sanctions for noncompti-
CONSULTANT of the CONSULTANT's ance,provided,however,that,in the event a
obligations under this AGREEMENT and the CONSULTANT becomes involved in,or is
Regulations relative to nondiscrimination on the threatened with,litigation with a subconsultant or
grounds of race,creed,color,sex,age,marital supplier as a result of such direction,the CON-
status,national origin and handicap ULTANT may request the AGENCY to enter
D INFORMATION AND REPORTS The
into such litigation to protect the interests of the CONSULTANT shall provide all information AGENCY,and in addition,the CONSULTANT
and reports required by the Regulations,or may request the United States to enter into such
directives issued pursuant thereto,and shall
litigation to protect the interests of the United
States
permit access to its books, records, accounts,
other sources of information,and its facilities as G UNFAIR EMPLOYMENT PRACTICES The
may be determined by the AGENCY to be CONSULTANT shall comply with RCW
pertinent to ascertain compliance with such 49 60 180
Regulations or directives Where any information
required of the CONSULTANT is in the exclu-
Page 4 of 8 '
IX In the event of the death of any member,partner or
TERMINATION OF AGREEMENT officer of the CONSULTANT or any of its superva
The right is reserved by the AGENCY to terminate sory personnel assigned to the project,or,dissolution
this AGREEMENT at any time upon ten days written of the partnership,termination of the corporation,or
notice to the CONSULTANT disaffiliation of the principally involved employee,
the surviving members of the CONSULTANT hereby
In the event this AGREEMENT is terminated by the agree to complete the work under the terms of this
AGENCY other than for default on the part of the AGREEMENT,if requested to do so by the
CONSULTANT,a final payment shall be made to the AGENCY The subsection shall not be a bar to
CONSULTANT as shown in Exhibit F for the type of renegotiation of the AGREEMENT between the
AGREEMENT used surviving members of the CONSULTANT and the
AGENCY,if the AGENCY so chooses
No payment shall be made for any work completed
after ten days following receipt by the CONSULT- In the event of the death of any of the parties listed in
ANT of the Notice to terminate If the accumulated the previous paragraph,should the surviving members
payment made to the CONSULTANT prior to Notice of the CONSULTANT,with the AGENCY's concur-
of Termination exceeds the total amount that would rence,desire to terminate this AGREEMENT,
be due computed as set forth herein above,then no payment shall be made as set forth in the second
final payment shall be due and the CONSULTANT paragraph of this section
shall immediately reimburse the AGENCY for any
excess paid Payment for any part of the work by the AGENCY
shall not constitute a waiver by the AGENCY of any
If the services of the CONSULTANT are terminated remedies of any type it may have against the CON-
by the AGENCY for default on the part of the CON- SULTANT for any breach of this AGREEMENT by
SULTANT,the above formula for payment shall not the CONSULTANT,or forfarlure of the CONSULT-
apply In such an event,the amount to be paid shall be ANT to perform work required of it by the
determined by the AGENCY with consideration AGENCY Forbearance of any rights under the
given to the actual costs incurred by the CONSULT- AGREEMENT will not constitute waiver of entitle-
ANT in performing the work to the date of ment to exercise those rights with respect to any
1 termination,the amount of work originally required future act or omission by the CONSULTANT
which was satisfactorily completed to date of termina-
X
bon,whether that work is in a form or a type which is CHANGES OF WORK
usable to the AGENCY at the time of termination,
the cost to the AGENCY of employing another firm The CONSULTANT shall make such changes and
to complete the work required and the time which revisions in the complete work of this AGREEMENT
maybe required to do so,and other factors which as necessary to correct errors appearing therein,when
affect the value to the AGENCY of the work per- required to do so by the AGENCY,without additional
formed at the time of termination Under no compensation thereof Should the AGENCY find rt
circumstances shall payment made under this subsec- desirable for its own purposes to have previously
bon exceed the amount which would have been made satisfactorily completed work or parts thereof
using the formula set forth in the previous paragraph changed or revised,the CONSULTANT shalt make
If it is determined for any reason that the CONSULT- such revisions as directed by the AGENCY This
ANT was not in default or that the CONSULTANT's work shall be considered as Extra Work and will be
failure to perform is without it or it's employee's fault
paid for as herein provided under Section XIV
or negligence,the termination shall be deemed to be a
termmabon for the convenience of the AGENCY in
accordance with the provision of this AGREEMENT
Page 5 of 8
XI that nothing herein shag require a CONSULTANT to
DISPUTES indemnify the AGENCY and the STATE against and
Any dispute concerning questions of fact in conrtec-
hold harmless the AGENCY and the STATE from
claims,demands or suits based solely upon the
tion with the work not disposed of by AGREEMENT conduct of the AGENCY and the STATE,then
between the CONSULTANT and the AGENCY shall
agents,officers and employees and provided further
be referred for determination to the Director of Public that of the Gams or scats are caused by or result from
Works or AGENCY Engineer,whose decision in the the concurrent negligence of(a)the
matter shall be final and binding on the parties of this CONSULTANT's agents or employees and(b)the
AGREEMENT,provided however,that if an action is AGENCY and the STATE,their agents,officers and
brought challenging the Director of Public Works or employees,this indemnity provision with respect to
AGENCY Engineer's decision,that decision shall be
subject to de novo judicial review (1)claims or suits based upon such negligence, (2)the
costs to the AGENCY and the STATE of defending
XII such claims and suits,etc shall be valid and enforce-
VENUE, APPLICABLE LAW AND able only to the extent of the CONSULTANT's ,
PERSONAL JURISDICTION negligence or the negligence of the CONSULTANT's
agents or employees
In the event that either party deems it necessary to
institute legal action or proceedings to enforce any The CONSULTANT's relation to the AGENCY shall
right or obligation under[his AGREEMENT,the be at all times as an independent contractor
parties hereto agree that any such action shall be The CONSULTANT specifically assumes potential
initiated in the Superior court of the State of Washing- liability for actions brought by the CONSULTANT'S
ton,situated In the county the AGENCY is located in
own employees against the AGENCY and,solely for ,
The parties hereto agree that all questions shall be the purpose of this indemnification and defense,the
resolved by application of Washington law and that CONSULTANT specifically waives any immunity
the parties to such action shall have the right of appeal
under the state industrial insurance law.Title 51
from such decisions of the Superior court in accor- RCW The CONSULTANT recognizes that this
dance with the laws of the State of Washington The waiver was specifically entered into pursuant to the
CONSULTANT hereby consents to the personal provisions of RCW 4 24 115 and was the subject of
jurisdiction of the Superior court of the State of `
mutual negotiation
Washington,situated in the county in which the
AGENCY is located in Unless otherwise specified in the AGREEMENT,the
AGENCY shall be responsible for administration of
XIII construction contracts, If any,on the project Subject
LEGAL RELATIONS AND INSURANCE to the processing of an acceptable,supplemental
The CONSULTANT shall comply with all Federal, agreement,the CONSULTANT shall provide on-call
State,and local laws and ordinances applicable to the assistance to the AGENCY during contract adminis-
work to be done under this AGREEMENT This tration By providing such assistance,the
AGREEMENT shall be interpreted and construed in CONSULTANT shall assume no responsibility for
accord with the laws of Washington proper construction techniques,job site safety,or any
construction contractor's failure to perform its work
The CONSULTANT shall indemnify and hold the in accordance with the contract documents
AGENCY and the STATE,and their officers and
employees harmless from and shall process and The CONSULTANT shall obtain and keep in force
defend at its own expense all claims,demands,or during the terms of the AGREEMENT,or as other-
suits at law or equity arising in whole or In part from wise required,the following insurance with
the CONSULTANT's negligence or breach of any of companies or through sources approved by the State
Its obligations under this AGREEMENT,provided Insurance Commissioner pursuant to RCW 48
Page 6 of 8
XIV
Insurance Coverage EXTRA WORK
A Worker's compensation and employer's liability A The AGENCY may at any time,by written order,
insurance as required by the STATE make changes within the general scope of the
AGREEMENT in the services to be performed
B General commercial liability insurance in an
amount not less than a single limit of one million B If any such change causes an increase ordecrease
and 001100 Dollars($1,000,000 00)for bodily in the estimated cost of,or the time required for,
' injury,including death and property damage performance of any part of the work under this
per occurrence AGREEMENT,whether or not changed by the
order,or otherwise affects any other terms and
Excepting the Worker's Compensation insurance and conditions of the AGREEMENT,the AGENCY
any professional liability insurance secured by the shall make an equitable adjustment in the
CONSULTANT,the AGENCY will be named on all (1)maximum amount payable,(2)delivery or
certificates of insurance as an additional insured The completion schedule,or both,and(3)other
CONSULTANT shall fumish the AGENCY with affected terns and shall modify the AGREE-
verification of insurance and endorsements required MENT accordingly
by this AGREEMENT The AGENCY reserves the
right to require complete,certified copies of all C The CONSULTANT must submit its'request
required insurance policies at any time for equitable adjustment'(hereafter referred to
as claim)under this clause within 30 days from
All insurance shall be obtained from an insurance the date of receipt of the written order However,
company authorized to do business in the State of if the AGENCY decides that the facts justify it,
' Washington The CONSULTANT shall submit a the AGENCY may receive and act upon a claim
venfication of insurance as outlined above within submitted before final payment of the
14 days of the execution of this AGREEMENT to AGREEMENT
the AGENCY
D Failure to agree to any adjustment shall be a
No cancellation of the foregoing policies shall be dispute under the Disputes clause However
effective without thirty(30)days prior notice to nothing in this clause shall excuse the CON-
the AGENCY SULTANT from proceeding with the
The CONSULTANT's professional liability to the AGREEMENT as changed
AGENCY shall be limited to the amount payable E Notwithstanding the terms and condition of
underthis AGREEMENT or one million dollars, paragraphs(a)and (b)above,the maximum
whichever is the greater unless modified by amount payable for this AGREEMENT,shall
Exhibit H In no case shall the CONSULTANT's not be increased or considered to be increased
professional liability to third parties be limited in except by specific wntten supplement to this
any way AGREEMENT
The AGENCY will pay no progress payments XV
under Section V until the CONSULTANT has fully ENDORSEMENT OF PLANS
complied with this section This remedy is not exclu-
sive,and the AGENCY and the STATE may take The CONSULTANT shall place his endorsement on
such other action as is available to them under other all plans, estimates or any other engineering data
Provisions of this AGREEMENT,or otherwise in taw furnished by him
Page 7 of 8
XVI XVII I
FEDERAL AND STATE REVIEW COMPLETE AGREEMENT
The Federal Highway Administration and the This document and referenced attachments contains
Washington State Department of Transportation all covenants,stipulations and provisions agreed upon
shall have the right to participate in the review or by the parties No agent,or representative of either
examination of the work in progress party has a ithonty to make,and the parties shall not
be bound by or be liable for,any statement,represen-
XVII tation,promise or agreement not set forth herein No
CERTIFICATION OF THE CONSULTANT
AND THE AGENCY changes,amendments,or modifications of the terns
hereof shall be valid unless reduced to writing and
Attached hereto as Exhibit`A-1%are the signed by the parties as an amendment to this
Certifications of the Consultant and the Agency, AGREEMENT
Exhibit"A-2"Certificabon regarding debarment. XIX
suspension and other responsibility matters-primary EXECUTION AND ACCEPTANCE
covered transactions,Exhibd"A-3"Certification
regarding the restrictions of the use of Federal funds This AGREEMENT may be simultaneously executed
for lobbying,and Exhibit`A-4"Certificate of Current in several counterparts,each of which shall be
j Cost or Pricing Data Exhibits"A-3"and"A-4"are deemed to be an original having identical legal effect
only required in Agreements over$100,000 The CONSULTANT does hereby ratify and adopt all
statements,representations,warranties,covenants,
and agreements contained in the proposal,and the
I
supporting materials submitted by the CONSULT-
ANT.and does hereby accept the AGREEMENT and '
agrees to all of the terms and conditions thereof
In witness whereof,the parties hereto have executed this AGREEMENT as of the day and year first
above written
By By
Consultant W&H Pacific Agency City of Kent
Page 8 of 8
ConsultantlAddress/Telephone
Supplemental Signature W&HPacific
Page for 3350 Monte Villa Parkway
Standard Consultant Bothell,Washington 98021
Agreement
Agreement Number Protect Title And Work Description
LA-4296 Pacific Highway S HOV Lanes
Federal Aid Number
STPUL-099(060) Provide inspector to perform field observations
Local Agency of the Contractor's activities
City of Kent
THIS AGREEMENT, made and entered into this 24th day of May 2005 ,
between the Local Agency of City of Kent Washington,hereinafter caged the
"AGENCY', and the above organization hereinafter called the"CONSULTANT"
In witness whereof,the parties hereto have executed this AGREEMENT as of the day and year first
above written
CONSULTANT LOCALAGENCY
By ,3 71 �i —' �' 4�.. By
Consultant W&H Pacific Agency City of Kent
By By
Consultant _ Agency
I
By
Agency
By
Agency
DOT Form 140-ONA EF
Remsed 4198
Exhibit A-1
Certification Of Consultant
Project No STPUL 4296
Local Agency
I hereby certify that I am Vim Pr-es K}frlt and duly authorized
representative of the firm of W&H Pacific whose address is
3350 Monte Villa Parkway,Bothell,WA 98021 and that neither I nor the above
firm I here represent has
(a) Employed or retained for a commission,percentage,brokerage,contingent fee or other consideration,any
firm or person(other than a bona fide employee working solely for me or the above CONSULTANT)to
solicit or secure this contract
(b) Agreed,as an express or implied condition for obtaining this contract,to employ or to retain the services of
any firm or person in connection with carrying out the contract
(c) Paid,or agreed to pay, to any firm,organization or person(other than a bona fide employee working solely
for me or the above CONSULTANT)any fee,contribution donation or consideration of any kind for,or to
connection with procuring or carrying out the contract, except as here expressly stated(if any)
I further certify that the firm I hereby represent is authorized to do business in the State of Washington and
that the firm is in full compliance with the requirements of the board of Professional Registration
I acknowledge that this certificate is to be available to the State Department of Transportation and the Federal
Highway Administration,U S Department of Transportation,in connection with this contract involving
participation of Federal aid funds and is subject to applicable State and Federal laws,both criminal and civil
oS '� L.
tL a`a igna ure
Certification of Agency Official
I hereby certify that I am the AGENCY Official of the Local Agency of City of Kent Washington ,
and that the above consulting firm or their representative has not been required,directly or mdirectly as an
express or implied condition in connection with obtaining or carrying out this contract to
(a) Employ or retain,or agree to employ or retain,any firm or person,or
(b) Pay or agree to pay to any firm,person or organization,any fee,contribution, donation or consideration of
any kind,except as here expressly stated(if any)
I acknowledged that this certificate is to be available to the Federal Highway Administration,U S Department of
Transportation, in connection with this contract involving participation of Federal aid highway funds and it
subject to applicable State and Federal laws,both criminal and civil
Date Signature
Exhibit A-2
Certification Regarding Debarment, Suspension, and Other Responsibility
Matters-Primary Covered Transactions
1 The prospective primary participant certifies to the best of its knowledge and belief,that it and its
principals
(a) Are not presently debarred,suspended,proposed for debarment,declared meligible, or voluntarily
excluded from covered transactions by any federal department or agency,
(b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment
rendered against them for commission or fraud or a criminal offense in connection with obtaining,
attempting to obtain, or performing a public(federal,state,or local)transaction or contract under a public
transaction,violation of federal or state antitrust statues or commission of embezzlement,theft, forgery,
Ibribery, falsification or destruction of records,mating false statements,or receiving stolen property,
(c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity(federal,
state,or local)with commission of any of the offenses enumerated in paragraph 1 b of this certification,
and
(d) Have not within a three-year period preceding this application/proposal lead one or more public
transactions(federal,state,or local)terminated for cause or default
2 Where the prospective primary participant is unable to certify to any of the statements in this certification,
such prospective participant shall attach an explanation to this proposal
Consultant(Firm) W&H Pacific
05.Z-1-0
(Date) ure)President ut zed official of consuaant
Exhibit A-3
Certification Regarding The Restrictions
of The use of Federal Funds for Lobbying
The prospective participant certifies,by signing and submitting this bid or proposal,to the best of his or her
knowledge and belief,that
1 No federal appropriated funds have been paid or will be paid,by or on behalf of the undersigned,to any
person for influencing or attempting to influence an officer or employee of any federal agency, a member of
Congress,an officer or employee of Congress,or an employee of a member of Congress in connection with
the awarding of any federal contract, the making of any federal grant,the making of any federal loan,the
entering into of any cooperative agreement,and the extension,continuation,renewal,amendment,or
modification of any federal contract,grant,loan,or cooperative agreement
2 If any funds other than federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any federal agency,a member of Congress,
an officer or employee of Congress,or an employee of a member of Congress in connection with this federal
contract, grant, loan,or cooperative agreement,the undersigned shall complete and submit Standard
Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions
This certification is a material representation of fact upon which reliance was placed when this transaction
was made or entered into Submission of this certification is a prerequisite for making or entering into this
transaction imposed by Section 1352,Title 31,U S Code Any person who fails to file the required
certification shall be subject to a civil penalty of not less than$10,000 and not more than$100,000 for each
such failure
The prospective participant also agrees by submitting his or her bid or proposal that he or she shall require
that the language of this certification be included in all lower tier subcontracts which exceed$100,000 and
that all such subrecipients shall certify and disclose accordingly
Consultant(Firm) W&H Pacific
(Date) ( e)President or uthonzed Official of Consultant
1
Exhibit A-4
Certificate of Current Cost or Pricing Data
This is to verify that,to the best of my knowledge and belief,the cost or pricing data(as defined in
section 15 401 of the Federal Acquisition Regulation(FAR)and requtred under FAR subsection 15.403-4)
submitted,either actually or by specific identification in writing,to the contracting officer or to the
contracting officer's representative in support of Pacific Highway South HQV Lanes
* are accurate,complete, and current as of 1)5- ** This certification includes
the cost or pricing data supporting any advance agreements and forward pricing rate agreements between
the offeror and the Government that are part of the proposal
Firm W&H Pacific
Name
Title
Date of Execution***
* Identify the proposal,quotation,request for price adjustment,or other submission involved,
giving the appropriate identifying number(e g,RFP No)
** Insert the day,month,and year when price negotiations were concluded and price agreement
was reached
*** Insert the day,month, and year of signing,which should be as close as practicable to the date
when the price negotiations were concluded and the contract price was agreed to
Exhibit B-1
Scope of Work
Project No. STPIJL 4296
Sre_attache.d _ ,
1
L
1
I
I
Documents To Be Furnished By The Consultant
See-attached_ __, ,
EXHIBIT B-1
SCOPE OF SERVICES
W&H Pacific will provide the following professional services to assist the City of Kent in
implementing the Pac Hwy S HOV Lanes North/South projects
100. Field Inspection
W&H Pacific will provide one inspector to perform field observation of the
Contractor's activities. Field observations will be conducted in accordance with
the requirements of Washington State Department of Transportation's Local
1 Agency Guidelines and Construction Manuals Specifically the Inspector will
provide the following services
I
101. Inspect Contractor's work to ensure that the protect is built according to the
Plans and Specifications.
102. Attend weekly project site meetings as directed by the City with the
Contractor, City staff, utilities, and others associated with the project
construction
103. Prepare daily inspection reports
104. Prepare and submit field quantity record for payment as directed by City
105. Review material submittals
106. Assist the City with project documentation
200. Project Administration
W&H Pacific will provide continuous project administration services including
scheduling and coordinating staff and invoices
Schedule
The inspector will perform these services during the period of June 1, 2005, to
June 1, 2006
The contract calls for 303 working days with Monday thru Saturday being work
days Any work performed by W& H Pacific over 40 hours a week will be
overtime
1 C0oc nfa and Settvgs SWadekacal SelGngs{7empaary lnlemetF ealOGKiE3 Scvpa ofsemcaldoe
Additional Services
Upon written approval by the City,W&H Pacific will provide additional services '
Additional services may include reviewing material submittals, providing
additional inspection services beyond, attending additional meetings, providing
design services, providing additional overtime
The Inspector will be equipped with necessary tools to perform construction
observations Cell phone and vehicle will be provide if requested by the City as
an additional cost
1
1
C IDoc 016 and Sedm9s1SWadeVi 1 SW&n9S17eRWnNY Infeme1FdWOLK/E51Scape O(a",ces doc
Exhibit D-2
Consultant Fee Determination -Summary Sheet
(Specific Rates of Pay)
Fee Schedule
Hourly Overhead Profit Rate
Discipline or Job Tide Rate @ % @ % Per Hour
See attached
i
r
i
i
Wade, Stan EXHIBIT D-2
From. Richard, Sam[SRichard@whpacific ccm]
Sent: Friday, May 20,2005 2 31 PM
To. Wade, Stan
Subject- CMCost 0317 05 As
City of Kent
Inspection services labor costs
Project: Pac Hwy S HOV Lanes North &South Projects
Direct Salary Cost (DSC):
Classification Man Hours Rate Cost
Manager 10x $12000= $1,20000
Administration Sox $60 00= $600 00
Project Inspector(reg) 2104x $70 00= $147,280 00
Protect Inspector(OT) 320x $90 00 $28,800 00
Reimbursibles
Vehicle 303 x $35 00= $ 10,605 00
Days
Cell Phone 10x $30 00 $ 30000
Months
Total $188,785.00
Prepared by Sam Richard
Date May 18, 2005
t
5/23/2005
Exhibit F
Payment Upon Termination of Agreement
By the Agency Other Than for
Fault of the Consultant
(Refer to Agreement, Section IX)
Lump Sum Contracts
A final payment shall be made to the CONSULTANT which when added to any payments previously made shall
total the same percentage of the Lump Sum Amount as the work completed at the time of termination is to the
total work required for the PROJECT In addition,the CONSULTANT shall be paid for any authorized extra
work completed
Cost Plus Fixed Fee Contracts
A final payment shall be made to the CONSULTANT which when added to any payments previously made,shall
total the actual costs plus the same percentage of the fixed fee as the work completed at the time of termination is
to the total work required for the Project In addition,the CONSULTANT shall be paid for any authorized extra
work completed
Specific Rates of Pay Contracts
A final payment shall be made to the CONSULTANT for actual hours charged at the time of termination of this
AGREEMENT plus any direct nonsalary costs incurred at the time of termination of this AGREEMENT
Cost Per Unit of Work Contracts
A final payment shall be made to the CONSULTANT for actual units of work completed at the time of
termination of this AGREEMENT
Kent City Council Meeting
Date June 21, 2005
Category Consent Calendar
1. SUBJECT: STREET VACATION FOR A PORTION OF 36TH AVENUE
SOUTH— RESOLUTION SETTING PUBLIC HEARING DATE
2. SUMMARY STATEMENT: Adoption of Resolution No. setting a public
hearing date of August 2, 2005, for the street vacation located along a portion of 36`h
Avenue South, between Rerth Road and South 2601" Street.
3. EXHIBITS: Public Works Director's memorandum, vicinity map and resolution
4. RECOMMENDED BY: Public Works Committee
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? N/A Revenue? N/A
Currently in the Budget? Yes No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6R
PUBLIC WORKS DEPARTMENT
Larry R Blanchard, Public Works Director
Phone 253-856-5500
Fax 253-856-6500
K E N T
W A 5 H I N O T O N Address 220 Fourth Avenue S
Kent,WA 98032-5895
DATE: June 6, 2005
TO: Mayor White and Kent City Council
FROM: Larry R Blanchard, Public Works Director
SUBJECT: 36th Avenue South, Between Reith Road and South 260th Street—
Street Vacation
MOTION: Recommend Council adoption of a resolution setting a public hearing date of August
2, 2005 for the Street Vacation located along a portion of 36th Avenue South, between Reith
Road and South 260th Street.
SUMMARY: We have received a valid petition to vacate a portion of 36th Avenue South,
between Reith Road and South 2601h Street In accordance with state law, a public hearing must
be held The Public Works Department recommends adoption of a resolution setting the public
hearing date
BUDGET IMPACT: No Unbudgeted Fiscal/Personnel Impact
BACKGROUND: By law upon receipt of a valid street vacation petition the City, via
adopting a resolution is required to hold a public hearing thereon within 60 days of passage of
said resolution
I
Mayor White and Kent City Council I 36th Avenue South —Street Vacation
RESOLUTION NO.
A RESOLUTION of the City Council of the City
of Kent, Washington, re arding the vacation of a portion
the right-of-way on 36' Avenue South, between Reith
Road and South 2601h Street, located in the City of Kent,
' Washington, and setting the public hearing on the proposed
street vacation for August 2, 2005
RECITALS
A. A petition, attached as Exhibit A, has been filed, to vacate a portion of
the right-of-way on 36'h Avenue South, between Reith Road and South 260'h Street,
located in the City of Kent, Washington.
B. The petition is signed by the owners of at least two-thirds of the real
property abutting that portion of 36"'Avenue South to be vacated. .
C. The petition is in all respects proper.
NOW THEREFORE, THE CITY COUNCIL OF THE CITY OF KENT,
WASHINGTON, DOES HEREBY RESOLVE AS FOLLOWS:
RESOLUTION
1 36`h Avenue S—R.O.W. Vacation
SECTION I. —Public Hearing A public hearing on the street vacation petition
requesting the vacation of a portion of the right-of-way on 36`h Avenue South, between
Reith Road and South 260`h Street, shall be held at a regular meeting of the Kent City
Council at 7.00 p m, Tuesday, August 2, 2005, in the Council Chambers of City Hall
located at 220 4th Avenue South,Kent, Washington, 98032.
SECTION Z. —Notice The City Clerk shall give proper notice of the hearing
and cause the notice to be posted as provided by state law, Chapter 35.79 RCW.
SECTION 3. — Information The Planning Manager shall obtain any other '
necessary information from appropriate departments and shall transmit the information
to the Council so that the Council may consider the matter at its regularly scheduled
meeting on August 2, 2005.
SECTION 4. — Severability If any section, subsection, paragraph, sentence,
clause or phrase of this resolution is declared unconstitutional or invalid for any
reason, such decision shall not affect the validity of the remaining portions of this
resolution
SECTION 5. — Ratification Any act consistent with the authority and prior to
the effective date of this resolution is hereby ratified and affirmed.
SECTION 6. —Effective Date This resolution shall take effect and be in force
immediately upon its passage.
PASSED at a regular open public meeting by the City Council of the City of
Kent,Washington,this day of 12005.
2 3e Avenue S—R.O.W. Vacation
CONCURRED in by the Mayor of the City of Kent this day of
12005
JIM WHITE,MAYOR
ATTEST:
' BRENDA JACOBER, CITY CLERK
APPROVED AS TO FORM:
TOM BRUBAKER,CITY ATTORNEY
I hereby certify that this is a true and correct copy of Resolution No. _passed
by the City Council of the City of Kent, Washington, the day of ,
2005.
BRENDA JACOBER,CITY CLERK
PVCrvdUdESOLUT10N1STVAC-36thAvcS-ROW PubhcHonngdoc
�t
3 36`*Avenue S—R.O.W. Vacation
EXHIBIT A 1
STREET VACATION APPLICATION AND PETITION
1
1
1
1
1
1
KENT I(IVAU:RE5V �509�Z6
Mayor Jim White
APPLICANT:
MAIL To: NAME: LEGEh1D DFy�-r,fr'
CITY OF KENT ADDRESS: 510 RAiK1E42 ANE_ 5.
Property Management
220 S.41h Avenue SEA-rtt€ WA cla l 44--
Kent,WA 98032
ATTN. Jerry McCaughan Pl10NR• L2.of') 271o'7I7-4-
STREET AND/OR ALLRY VACATION APPLICATION AND PETITION
Dear Mayor and Kent City Council:
We,the undersigned abutting property owners,hereby[espoctfully icqucst that certain D Alley
KSlreet hereby be vacated described as follows(include square feet)
60fwee'r+ RetTR RoAp � S. 2tao'� sT
' Lt�v. tuts(itns£¢oFaw*of ,vw' /+unSwFoftvg+ e Nw* in see.l7Tw ZA)d. paq:Fwht
�/aco�� eals`{In� oW. sd t� G �� Pu�ItC-
stir cox, 6� �,,5-rry t,dt d�4t C,.+Y
wtth c� cAt�Fer4vcE o�ll�9nme.t�r. To be. chyle. CAs
V mev c+A:S �elwhtv�o.� R� (File 7o4144fa�
BRIEF STATEMRAT WHY VACATION IS BEING SOUGHT
A "CURRrNT" ownership and cncumbrince icpor[ must be obtained from a Titic
Company and submitted with this application That covers all the abutting properties
contiguous to alley or street sough to be vacated When Corpoiations, partnerships, etc
are being signed for, and [lien pioef of individual's authouty to sign roi same shall also
be submitted.
Attach a color-coded map of a scale of not less than 1" =200' or the area sought for vacation.
' (NOTE) Map must correspond with legal description
AUBUTTING PROPERTY OWNERS TAX LOT it
SIGNATURES AND ADDRESSES LOT, BLOCK&PLAT/SEC,TOWN.R G.
Lrjoee-z — C l L .# 277-7-04- -Qoo(g
$150 00 Pee Paid Ticasuccr's P.ece+pt No
Appraisal Pee Paid ! TledSuiCr'S Receipt No
Land Value Paid Treaswci's RLMI)tNo
Deed Accepted Date
' Trade Accepted Data
' I'WYLIM1IYGjN11yMl1111?^kMN.nrY uln.,I'AII VfllbwµJ1�111MTJi4
t -
EXISTING 7
36th AVE S. �f���; TRINITY
VACATED j // .' -Y REFORMED �% '
28051 SF CHURCH
/c}y' �' ;, #272204 9132103
LEGEND 1%
DEVELOPMENT,
LLC
TL
#272204 9006 f /
- -------- -/ ;
------------
----------1--------
-- -------- S._ 260th ST.-------------
s I a SCALE 1' 100
v
i
i
Kent City Council Meeting
' Date June 21, 2005
Category Consent Calendar
1. SUBJECT: 4TH AVENUE NORTH/RAMSAY WAY PROJECT— ACCEPT AS
COMPLETE
2. SUMMARY STATEMENT: Accept the 4"' Avenue North'Ramsay Way project as
complete and release of retainage to Transtech Electric upon standard releases from the
state and release of any liens. The original contract amount was S387,572.90. The
final contract amount was $3593274.31.
3. EXHIBITS: None
4. RECOMMENDED BY: Public Works Committee
(Committee, Staff, Examiner, Commission, etc )
5. FISCAL IMPACT
Expenditure? X Revenue? X
Currently in the Budget? Yes No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
iCouncilmember moves, Councilmember seconds
' DISCUSSION:
ACTION:
Council Agenda
Item No. 6S
Kent City Council Meeting
Date June 21, 2005
tCategory Other Business
1. SUBJECT: FLEXPASS PROGRAM AGREEMENT 2005-2006 —AUTHORIZE
' 2. SUMMARY STATEMENT: The FlexPass agreement renewal was placed on the
Council agenda under "Other Business" by the Operations Committee for further
discussion. The FlexPass Agreement is a King County/Sound Transit/Pierce Transit
Program, allowing all eligible employees to choose from a variety of non-single
occupancy vehicle commute options provided by King County, Sound Transit, and
' Pierce Transit.
' 3. EXHIBITS: FlexPass Agreement 2005-2006
4. RECOMMENDED BY: Operations Committee
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? X Revenue?
Currently in the Budget? Yes X No
If no:
Unbudgeted Expense: Fund Amount $
1 Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
1 Councilmember c_,La.2,.J moves, Councilmember d seconds
to authorize the Mayor to sign the renewal of the 2005-2006 FlexPass Agreement with
King County/Sound Transit/Pierce Transit Program.
DISCUSSION:
ACTION: C-
Council Agenda
Item No. 7A
' AGREEMENT FOR SALE OF FLEXPASSES BETWEEN KING COUNTY, SOUND
TRANSIT, PIERCE TRANSIT AND THE CITY OF KENT
This Agreement(hereinafter,"Agreement")is made and entered into by and between King County(hereinafter
individually,"KING COUNTY"),Sound Transit(hereinafter"SOUND TRANSIT"),Pierce Transit(hereinafter
PIERCE TRANSIT'),or collectively referred to hereinafter as"TRANSPORTATION PARTIES",and the City of
Kent(hereinafter,"CITY")
RECITALS
A. CITY and TRANSPORTATION PARTIES share the desire to provide a comprehensive transportation pass
program that will reduce single occupant vehicle(SOV)commute trips and improve the mobility of CITY
employees
B KING COUNTY,SOUND TRANSIT and PIERCE TRANSIT are authorized to provide public transportation
and generally promote alternatives to SOV commuting in King County,Pierce County and Snohomish County
C CITY has a desire to provide incentives and benefits to its employees,which promote non-SOV commuting to
its worksite
D CITY and TRANSPORTATION PARTIES desire to create a single pass media that can be used to access a
variety of services and benefits,which enable CITY employees to commute,by non-SOV modes.
AGREEMENT
NOW,THEREFORE,in consideration of the terms,conditions and covenants herein contained,the sufficiency of
which is hereby acknowledged,the parties hereto agree to the following
1. PURPOSE
1.1 Purpose
This Agreement establishes a cooperative arrangement between TRANSPORTATION PARTIES and CITY for sale
and distribution of FlexPasses to CITY's Eligible Employees at the rate set forth herein
2. DEFINITIONS
2.1 Eligible Employees
Eligible Employees shall mean only those employees of the CITY who meet the following criteria-
All CTR-affected employees
22 FlexPass Card
A FlexPass Card is a pass of predetermined duration,usually twelve(12)months,that allows each Eligible
Employee,as defined in Paragraph 2 1,to choose from a variety of non-SOV commute options provided by CITY
' or TRANSPORTATION PARTIES Each FlexPass Card shall bear the inscriptions"FlexPass",each
TRANSPORTATION PARTIES' logo or an agreed to regional logo,and beginning and expiration dates in a design
and color scheme mutually agreed upon by TRANSPORTATION PARTIES FlexPass Cards shall also bear a fare
amount on the face of the card,the amount of which shall be agreed upon by TRANSPORTATION PARTIES prior
' to the start of this Agreement FlexPass Cards shall be produced by TRANSPORTATION PARTIES or their
designated contractor CITY shall pay the amount specified in Attachment A for production of FlexPass Cards
FlexPass Card's are non-refundable by TRANSPORTATION PARTIES,except as set forth in Paragraph 8 2
Eligible Employees may be asked to present a valid CITY identification card when using a FlexPass
1 2 3 Trip Revenue
In the event of a generally applicable fare increase adopted by KING COUNTY,SOUND TRANSIT or PIERCE
' TRANSIT,the amounts shown in Attachment A may be increased at such time as a generally applicable fare
increase is implemented by KING COUNTY,SOUND TRANSIT or PIERCE TRANSIT,and CITY shall be
required to pay the amount of such increase to the appropriate TRANSPORTATION PARTY
3. EMPLOYEE CONTRIBUTIONS AND COMMUTE BENEFITS AND INCENTIVES
3 1 Eligible Employee Contributions
CITY may require Eligible Employees to contribute toward the cost of a FlexPass Card,in the amount specified in
Attachment A CITY shall not require Eligible Employees to contribute more than fifty percent(50%)of the cost of
an individual FlexPass Card,as set forth in Attachment A
FlexPass Agreenienr Page I of 11
City of Kent
July 1,2005—June 30,2006
4. CITY RESPONSIBILITIES ,
41 Eligible Recipients Of A FlexPass Card
CITY shall ensure that only Eligible Employees,as defined in Paragraph 2 1,receive FlexPass cards
42 Ordering FlexPass Cards
CITY shall provide to TRANSPORTATION PARTIES'representative,as listed in Section 16,the number of
FlexPass Cards that CITY shall provide to Eligible Employees The number of FlexPass Cards shall be listed in
Attachment A CITY shall allow TRANSPORTATION PARTIES at least four(4)weeks in advance of the cards'
effective date to fulfill the request for FlexPass Cards CITY understands that failure to provide the number of
FlexPass Cards desired at least four(4)weeks in advance,may incur additional and extraordinary costs Such costs
may be related to,but are not limited to,overtime staffing,additional manufacturing charges and express delivery ,
charges These additional and extraordinary charges shall be borne solely by CITY
43 Ordering Additional FlexPass Cards
CITY shall retain the right to purchase additional FlexPass Cards for distribution to Eligible Employees,over and ,
above the number specified in Attachment A,during the term of this Agreement CITY shall allow
TRANSPORTATION PARTIES at least four(4)weeks to fulfill the request for additional FlexPass Cards
Requests shall be made to the TRANSPORTATION PARTIES'representative,as listed in Section 16 The cost for
a single additional FlexPass Card shall be the Monthly Rate For Additional FlexPass Cards specified in Attachment ,
A,times the number of whole and partial months remaining in the Agreement.
44 Receipt And Security Of FlexPass Cards
CITY agrees that all FlexPass Cards received from TRANSPORTATION PARTIES shall become the sole financial
responsibility of CITY upon receipt and signature by an employee,official or agent of CITY CITY agrees that it is
solely responsible for providing proper storage and secunty measures for any and all FlexPass Cards received by
CITY while in the custody of CITY CITY shall be held liable for the equivalent value of a combination King '
County/Sound Transit/Pierce Transit fare for each month remaining in this Agreement for each FlexPass Card that
CITY cannot account for,either by distribution to an Eligible Employee,storage in a secure area,for each FlexPass
Card not collected from an Eligible Employee who terminates their employment with CITY or otherwise becomes
ineligible to receive and use a FlexPass Card under the terms of this Agreement,or for each FlexPass Card CITY
cannot return to TRANSPORTATION PARTIES upon termination of this Agreement,as specified in Section 8
45 Reporting '
CITY shall immediately report to each of the TRANSPORTATION PARTIES any FlexPass Cards that are lost,
stolen,damaged or otherwise not functioning properly in TRANSPORTATION PARTIES' transit coaches'
electronic registering fareboxes CITY shall return any and all FlexPass Cards to TRANSPORTATION PARTIES
that CITY believes to be defective CITY shall report to TRANSPORTATION PARTIES all FlexPass usage, ,
changes to CITY's transportation program or other details as necessary
46 Roster Of FlexPass Card Recipients
CITY shall maintain a roster of Eligible Employees who have been provided a FlexPass Card by CITY. Upon
demand,CITY shall provide each TRANSPORTATION PARTY a copy of the roster
47 FlexPass Employee Use Agreement Form ,
Each Eligible Employee who receives a FlexPass Card from CITY shall be required to read,sign and return to their
employee transportation coordinator or department supervisor,an agreement form stipulating the uses and
conditions of a FlexPass Card The Employee Use Agreement Form,asset forth in Attachment B,is deemed
mutually acceptable to both CITY and TRANSPORTATION PARTIES Use Agreement Forms shall be kept on ,
file by CITY for the term of this Agreement
48 Collection of FlexPass Cards
CITY shall return to TRANSPORTATION PARTIES all FlexPass Cards issued to CITY within five(5)days of the
effective date of termination of this Agreement CITY shall be held liable for the equivalent retail value of a
combination King County/Sound TransiUPierce Transit fare for each month remaining in this Agreement for each
FlexPass Card not returned to TRANSPORTATION PARTIES upon termination of this Agreement
FlexPass Agreement Page 2 of I I
City of Kent
July 1,2005—June 30,2006
49 Collection of Transit Ridership Data
CITY shall survey,or otherwise collect from CITY's Eligible Employees,any and all necessary daily transit
ndershrp and commute data that TRANSPORTATION PARTIES deem necessary to accurately and fairly estimate
Trip Revenue and the number of bus trips taken by Eligible Employees TRANSPORTATION PARTIES shall
provide to CITY a mutually agreed upon survey instrument or other suitable means in which to collect the most
current and accurate ridership and commute data possible
410 FlexPass Program Evaluation
CITY shall participate in any TRANSPORTATION PARTIES'evaluation of the FlexPass program,should such an
evaluation be deemed necessary by any of the TRANSPORTATION PARTIES. Evaluation may be through such
means as employee surveys,employee focus groups,and management interviews TRANSPORTATION PARTIES
shall provide CITY at least thirty(30)days advance notice prior to beginning such an evaluation
411 Home Free Guarantee
CITY shall fulfill all conditions and responsibilities of the Home Free Guarantee program in accordance with the
terms attached hereto and made part hereof as Attachment C
4.12 Vanpool Services
The amount of the vanpool fare subsidy for each Eligible Employee shall be stated in Attachment A If actual
vanpool fares incurred by an Eligible Employee exceed the amount of the subsidy specified in Attachment A,the
Eligible Employee shall pay the difference directly to the vanpool bookkeeper
4 13 Vanshare Services
Eligible Employees can elect to participate in KING COUNTY's Vanshare program The amount of the Vanshare
subsidy for each Eligible Employee will be stated in Attachment A, If actual vanpool fares incurred by an Eligible
Employee exceed the amount of the subsidy specified in Attachment A,the Eligible Employee shall pay the
difference directly to the vanpool bookkeeper
5. TRANSPORTATION PARTIES RESPONSIBILITIES
1 5 1 Transit Access
TRANSPORTATION PARTIES shall allow each CITY Eligible Employee displaying a valid FlexPass Card to ride
on all parts of its regular route transportation system without additional charge,for trips up to the value printed on
the card TRANSPORTATION PARTIES shall honor each FlexPass Card issued under this agreement up to the
expiration date on the Card or until this agreement is otherwise terminated TRANSPORTATION PARTIES
reserve the right to request additional payment at the time the transit trip is taken,if the cost of a trip on any
TRANSPORTATION PARTY's regular transit service exceeds the fare value printed on the FlexPass Card
FlexPass Cards are not valid on any Husky,Manners,Fourth of July,Tacoma Dome Station event parking,or other
special event service at the sole discretion of TRANSPORTATION PARTIES
52 FlexPass Card Administration
TRANSPORTATION PARTIES' Designated Representative shall manage production,ordering,replacement and
delivery of FlexPass Cards to CITY,and other administrative tasks related to the FlexPass Card under this
Agreement,other than those responsibilities stated as CITY responsibilities in Section 4,
53 Replacement FlexPass Cards
TRANSPORTATION PARTIES shall replace,at no additional cost to CITY,any FlexPass Cards deemed to be
defective or otherwise unusable or inoperative CITY may be issued temporary passes until TRANSPORTATION
PARTIES can manufacture and deliver replacement FlexPass Cards TRANSPORTATION PARTIES shall replace
a lost or stolen FlexPass Card only once at a charge of$50 per replacement card
54 Confiscation of FlexPass Cards
In addition to any other rights under law,TRANSPORTATION PARTIES reserve the right to cancel and confiscate
a FlexPass Card which is used out of date,altered,duplicated,counterfeited,transferred or distributed to
unauthorized persons or otherwise invalid under the terms of this Agreement
FlexPass Agreement Page 3 of I 1
City of Kent
July 1,2005—June 30,2006
L
55 Collection Of Transit Ridership Data t
TRANSPORTATION PARTIES shall provide to CITY,at no additional cost to CITY,a mutually agreed upon
survey instrument or other suitable means in which to collect and measure the most current and accurate transit
ridership and commute data of CITY's Eligible Employees In addition,TRANSPORTATION PARTIES shall pay '
for all costs incurred in processing this survey instrument,but not costs incurred by CITY in distributing to and
collecting from Eligible Employees,this survey instrument TRANSPORTATION PARTIES shall make available
to CITY,all data collected from CITY's Eligible Employees
56 Home Free Guarantee
KING COUNTY shall fulfill all conditions and responsibilities of the Home Free Guarantee program in accordance
with the terms attached hereto and made part hereof as Attachment C
57 Vanpool Services
KING COUNTY shall allow each Eligible Employee holding a FlexPass Card to register as a vanpool participant
subject to the availability of vanpool vehicles and minimum ridership requirements The FlexPass Card will be ,
honored as full or partial payment of vanpool fares,up to the amount specified in Attachment A
5.8 Vanshare Services
TRANSPORTATION PARTIES may allow each Eligible Employee holding a FlexPass Card to register as a '
Vanshare participant,subject to the availability of Vanshare vehicles and minimum ridership requirements If
applicable,the FlexPass Card may be honored as partial payment of Vanshare fares,as specified in Attachment A.
6. PAYMENTS AND BILLING ,
6.1 Payment For This Agreement
CITY agrees to pay TRANSPORTATION PARTIES the total amount stated in Attachment A for participation in
TRANSPORTATION PARTIES' FlexPass program. KING COUNTY and PIERCE TRANSIT shall present an
invoice for amounts due to CITY's representative listed in Section 16 Payment shall be made in full by CITY
according to the terms listed on the invoice,unless a payment schedule is mutually agreed upon by both parties and
incorporated into this Agreement, in Attachment A KING COUNTY shall invoice CITY for the amount(s)due for
SOUND TRANSIT for additional FlexPass Cards purchased by CITY
62 Late Payment Penalty
If any scheduled payments are not made by their due date,then the entire amount due under this Agreement may ,
become immediately due and payable Any late payment shall be subject to a penalty accruing at the maximum rate
allowable by state law for each month that the payment remains due If any check made payable to any of the
TRANSPORTATION PARTIES by CITY is returned to a TRANSPORTATION PARTY for insufficient funds
(NSF)in CITY's checking account,then CITY shall be assessed a$25(twenty-five)penalty by the
TRANSPORTATION PARTY receiving the NSF check
7. TERM OF AGREEMENT
71 Term
This Agreement shall take effect upon the exact day and expire on the exact day specified in this paragraph,unless
terminated in accordance with the terms set forth in Section 8 This Agreement shall take effect at 12 00 a in on
July 1,2005 and shall expire at 11 59 p in on June 30,2006
8 TERMINATION
8 1 Termination For Cause
Any party may terminate this Agreement in the event the other fails to perform its obligations as described in this '
Agreement by providing written notice not less than fourteen(14)days prior to the effective date of termination
82 Termination For Convenience
Any party may also terminate this Agreement for convenience and without cause by providing the other party with
written notice not less than sixty(60)days in advance. If CITY has made payments in advance,CITY shall be
entitled to reimbursement from each TRANSPORTATION PARTY for each valid FlexPass Card returned to
TRANSPORTATION PARTIES Such reimbursement shall be at the monthly rate set forth in Attachment A for ,
the full months remaining in the term of the Agreement
FlexPass Agreement Page 4 of 11 ,
City of Kent
July 1,2005—June 30,2006
If CITY has accrued additional financial obligations to any TRANSPORTATION PARTY as a result of the
provisions of this Agreement,either prior to termination or as a result of termination,CITY agrees to pay any
outstanding amount due to the TRANSPORTATION PARTY The TRANSPORTATION PARTY shall invoice
CITY for the amount due according to the procedures outlined in Section 6
1 9. RECORDS
9.1 Rights Of Review
Both CITY and TRANSPORTATION PARTIES shall retain the right to review records and documents related to
this Agreement. If a records review is commenced more than sixty(60)days after the termination of the contract,
the TRANSPORTATION PARTY requesting the review shall give ten(10)days notice to CITY of the date on
which the records review will begin
10. SUCCESSORS AND ASSIGNS
101 Written Approval
This Agreement and all terms,provisions,conditions and covenants hereof shall be binding upon the parties hereto
i and their respective successors and assigns All parties,however,agree that they will not assignor delegate the
duties to be performed under this Agreement without prior,written approval from the other parties
11. LEGAL RELATIONS
11 1 No Partnership And No Third Party Beneficiaries
CITY and TRANSPORTATION PARTIES agree that this Agreement does not create a partnership or joint venture
relationship between the parties,and does not benefit or create any rights in a third party
11 2 Force Majeure
TRANSPORTATION PARTIES shall be excused from performance of any responsibilities and obligations under
this Agreement,and shall not be liable for damages due to failure to perform,resulting directly or indirectly from
causes and circumstances beyond their control,including but not limited to late delivery or nonperformance by
vendors of materials or supplies, incidences of fire,flood, snow,earthquake or other acts of nature,accidents,nots,
insurrection,terrorism,acts of war,order of any court or civil authority, and strikes or other labor actions
11 3 Costs of Legal Action
CITY shall be liable for any and all reasonable attorney fees,court costs and other expenses incurred by
TRANSPORTATION PARTIES in the event TRANSPORTATION PARTIES pursue legal action to obtain the
return of any F1exPass Cards or amount owing under this Agreement
12. APPLICABLE LAW,FORUM
121 Terms
This Agreement shall be governed by and construed according to the laws of the State of Washington Nothing in
this Agreement shall be construed as altering or diminishing the rights or responsibilities of the parties as granted or
imposed by state law In the event that any litigation maybe filed between the parties regarding this Agreement,
1 CITY and TRANSPORTATION PARTIES agree that personal jurisdiction and venue shall rest in the Superior
Court of the county where the TRANSPORTATION PARTY pursuing the action resides
13. DISPUTES
13 1 Dispute Resolution Procedure
All claims or disputes ansuig out of or relating to this Agreement shall be referred to a panel consisting of CITY's
Benefits Manager,KING COUNTY's General Manager,Transit Division,SOUND TRANSIT's Executive
Director,PIERCE TRANSIT's Chief Executive Officer or their designees
If this panel is unable to reach a mutually acceptable resolution,it shall appoint another person to serve as mediator
in the effort to resolve the claim or dispute Such mediation shall be required before an action may be filed to
adjudicate the claim or dispute in a court of law
14. ENTIRE AGREEMENT AND AMENDMENT
141 Entire Agreement
This Agreement constitutes the entire agreement between the parties and supersedes all prior negotiations,
representations and agreements between the parties relating to the subject matter hereof.
1 F1exPws Agreement Page 5 of 11
City of Kent
July 1,2005—June 30,2006
142 Amendments And Modifications
This Agreement may be amended or modified only by written instrument signed by the parties hereto.
15 SAVINGS ,
151 Definition
Should any provision of this Agreement be deemed invalid or inconsistent with any federal,state or local law or
regulation,the remaining provisions shall continue in full force and effect All parties agree to immediately attempt
to renegotiate such provision that is invalidated or superseded by such laws or regulations
16 CONTACT PERSONS
161 Definition '
CITY and TRANSPORTATION PARTIES shall designate a contact person for purposes of sending inquiries and
notices regarding the execution and fulfillment of this Agreement,as well as ordering of all fare media and
vouchers
CITY KING COUNTY, FLEXPASS CARD ,
ORDERS & RETURNS
Contact Name Ellen Bradle -Mak Jeff Won
Title Human Resources Analyst Transit Planner
Address City of Kent King Co nty Metro Transit
220 4ih Avenue S 400 Yesler Way,MS-YES-TR-0600
Kent,WA 98032 Seattle, WA 98104
Telephone 253-856-5297 206-263-3452
Fax 253-856-6270 206-684-2058
E-Mad Ebmak ci kent.wa us Jeff-mkt-dev wong@metrokc gov ,
SOUND TRANSIT PIERCE TRANSIT
Contact Name Christie Parker Daphne Tackett
Title Policy Analyst Community Services Manager
Address Sound Transit Pierce Transit ,
401 S Jackson Street PO Box 99070
Seattle,WA 98104-2826 Lakewood,WA 98499-0070
Telephone 206-398-5405 253-581-8037
Fax 206-398-5215 253-984-8227
E-Mail arkerc soundtransit org I dtackett iercetransit or
FlexPass Agreement Page 6 of I 1 !
City of Kent
July I,2005-June 30,2006
17. EXECUTION OF AGREEMENT
17.1 Definition
This Agreement shall be executed in four(4)counterparts,each one of which shall be regarded for all purposes as
one original In Witness Whereof,the parties have executed this Agreement as of the date first written above
CITY OF KENT KING COUNTY
BY
Jim White Eric Gleason
Title- Mayor Title- Manager,Transit-Service Development
Date: Date-
PIERCE TRANSIT SOUND TRANSIT
BY BY King County per Agent Agreement
Daphne Tackctt
Title Community Services Manager
Date
FlexPass Agreement Page 7 of 11
City of Kent
July 1,2005—June 30,2006
FlexPass Agreement Attachment A - Agreement Costs t
Company City of Kent Start Date July 1, 2005
Area FlexPass zone South Kinp-County Agreement Year 5
Quantity Rate ($/card) Cost
King County
• Transit access 393 $38.88 $ 15,279 84
• Home Free Guarantee
(Up to 8 ndes/employee/agreement)
• Up to $65 per month per vanpooler
• Up to $20 per month for Vanshare
• FlexPass Card administration
• Commuter Bonus Plus voucher pool. 1 pool $5,895.00 Included ,
393 FlexPass cards x $15 00
Additional Van pool Subsidy Funds 1 $3,500 00 $ 3,50000
Total— IGnR County 1 If '" = $ 18,779.84
Sound Transit 393 $16.08 $ 6,319.44
• Transit access '
k'°i-k °As,
Pierce Transit 393 2.04 $ 801.72
• Local transit bus access ,
-=,_3tp._w'=,1,,: _e4 7u€a i
Total — FlexPass Agreement 1 $25,901.00
Number of FlexPass Cards issued under this Agreement = 393
Payment Schedule = % in 60 and 180 days.
Eligible Employee Contribution ($per employee) = TBD
Monthly Rate For ONE Additional FlexPass Card = $3.50
(Note: Calculation based on$42 00/12 months.
The Monthly rate does not include Commuter Bonus Plus vouchers.)
Allocation: King County =$1.99
Sound Transit =$1.34
Pierce Transit =$0.17
FlexPass Agreement Page 8 of 11
City of Kent
July 1,2005—June 30,2006
i
FlexPass Agreement—Attachment B
Sample Employee Use Agreement Form
CITY OF KENT
FlexPass Use Agreement
As a FlexPass holder, I agree to the following:
1. The FlexPass is a benefit provided to me as an employee and is to be used only during the
period I am employed by my employer.
2. I will use my FlexPass for my own transportation only. I will not transfer my FlexPass to
any other person.
3. 1 will keep my FlexPass secure and in good condition. I will immediately report a lost,
stolen or damaged FlexPass to the Transportation Coordinator. I understand a lost FlexPass
will be replaced only once per year at a charge of$50.00. A non-working FlexPass will be
replaced free of charge
t 4. I will return my FlexPass upon request or when I leave my employment with this company.
If I do not return my FlexPass, I authorize the amount of$144.00, for each whole and partial
month remaining on the FlexPass,to be withheld from my paycheck.
5. I understand that the FlexPass card is valid for up to $65 per month on King County Metro
vanpools only. I am responsible for the balance of the vanpool fare each month,payable to
the vanpool bookkeeper,which is in excess of the$65 amount.
I acknowledge the receipt of my FlexPass, and understand and agree to the terms stated above on
using the FlexPass
1 Employee's Signature Date
Employee's Printed Name FlexPass Serial #
�I
Employee's Department or Section
Transportation Coordinator Use Only-FlexPass returned:
' Employee's Signature Date
LFlexPass Serial #
FlexPass Agreement Page 9 of 11
City of Kent
July 1,2005-June 30,2006
FlexPass Agreement Attachment C —Home Free Guarantee t
Home Free Guarantee(hereinafter,"HFG")is a KING COUNTY program that guarantees payment for taxi fares
incurred by Eligible Employees who meet the eligible criteria,as set forth below,and taken in accordance with the
terms set forth below
C.1 DEFINITIONS
C 1 1 Approved Commute Modes
Eligible Employees must have commuted from their principal residence or Park&Ride to the CITY's worksite by
one of the following modes. Bus,carpool,vanpool,walk-on or bicycle-on ferry,bicycle,or walk
CA 2 Eligible Reasons For Using HFG
The following are the only eligible reasons for using HFG-
a. Eligible Employee's or family member's unexpected illness or emergency.
b. Unexpected schedule change such that the normal commute mode is not available for the return commute ,
to the starting place of their commute Unexpected means the employee learns of the schedule change that
day
c Missing the employee's normal return commute to the starting place of their commute for reasons,other
than weather or acts of nature which are beyond the employee's control,and of which they had no prior
knowledge For example,the employee's carpool driver left work or worked late unexpectedly
C 1 3 Non-Eligible Reasons For Using HFG
Reasons which are not eligible for HFG use include,but are not limited to,the following.
a Pre-scheduled medical or other appointments.
b. To transport individuals who have incurred injury or illness related to their occupation An HFG ride
should NEVER be used where an ambulance is appropriate,nor should an HFG nde replace CITY's legal ,
responsibility under workers' compensation laws and regulations
c. Other situations where,in the opinion of the CITY's Program Coordinator,alternate transportation could
have been arranged ahead of time.
C.1 4 Eligible Destinations For An HFG Ride
a From the CITY's worksite to the Eligible Employee's principal place of residence
b From the CITY's worksite to the Eligible Employee's personal vehicle,e g vehicle located at a Park&
Ride lot
c From the CITY's worksite to the Eligible Employee's usual commute ferry terminal on the east side of
Puget Sound
C 1.5 Intermediate Stops L
Intermediate stops are permitted only if they are of an emergency nature and are requested in advance by the
Eligible Employee and are authorized in advance of the HFG ride by the CITY's Program Coordinator(i e.pick up
a necessary prescription at a pharmacy,pick up a sick child at school)
C 2 CITY RESPONSIBILITIES
C 2 1 HFG Program Payment
CITY's payment for HFG services is accounted for in the base pnce of the FlexPass Agreement,as indicated in
Attachment A
C 2.2 Program Coordinator ,
CITY shall designate as many Program Coordinators as necessary to administer and perform the necessary HFG
program tasks as set forth in this Attachment
C 2 3 Number Of HFG Rides Per Eligible Employee
CITY shall ensure that each Eligible Employee does not exceed eight(8)HFG rides per twelve(12)month period
FlexPass Agreement Page 10 of 11
City of Kent
July 1,2005—June 30,2006
FlexPass Agreement Attachment C —Home Free Guarantee (continued)
C 3 HFG Program Tasks
C 3 1 Process
To access HFG rides,Eligible Employees shall contact the Program Coordinator The Program Coordinator shall
call directly an answering service provider,contracted for by KING COUNTY The phone number shall be
supplied to CITY by KING COUNTY CITY agrees to make information about how to access HFG rides available
to all Eligible Employees Program Coordinator shall obtain the following information from the Eligible Employee,
and provide the information to the answering service provider
a Verify the Eligible Employee has commuted to the worksite by an eligible mode
b Verify the Eligible Employee has an eligible reason and eligible destination for an HFG ride.
c. Ensure the Eligible Employee has valid identification to show the taxi driver
d. Once an Eligible Employee takes the emergency taxi ride,obtain from the Eligible Employee a receipt of
the taxi trip
e. CITY's Program Coordinator shall forward copies of such receipts to KING COUNTY at the end of each
month for record keeping and accounting purposes
f. The answering service provider will arrange taxi rides for the Eligible Employee
CA KING COUNTY RESPONSIBILITIES
C 4 1 Participating Taxi CITY(s)
CITY agrees that neither KING COUNTY or answering service provider is responsible for providing transportation
services under the HFG program CITY further agrees that KING COUNTY makes no guarantee or warranty as to
the availability,quality or reliability of taxi service,and that the KING COUNTY's sole obligation under the
program is to make payment of the taxi provider for trips actually taken in accordance with the terms of this
Agreement CITY agrees it shall make no claims of any kind or bring any suits of any kind against the KING
COUNTY for damages or injuries of any kind arising out of or in anyway related to the HFG program Without
limiting the foregoing and by way of example only,the CITY agrees that KING COUNTY shall not be liable for
any injuries or damages caused by negligence or intentional acts occurring before,during or after a taxi ride or for
any injuries or damages caused by failure of a taxi to provide a ride due to negligence,intentional acts or causes
beyond the taxi's control, including but not limited to incidence of fire,flood,snow,earthquake or other acts of
nature,nots,insurrection,accident,order of any court or civil authority,and strikes or other labor actions
' C.4.2 Payment Of Authonzed HFG Taxi Fares
KING COUNTY shall pay the metered fare amount of a CITY's Program Coordinator-authorized HFG ride,as
defined in the DEFINITIONS section above, for a one-way distance of up to sixty(60)miles CITY or Eligible
Employee taking the HFG ride shall pay any fare for a one-way distance in excess of sixty(60)miles KING
COUNTY shall not pay any taxi driver gratuity Taxi driver gratuity will be at the sole discretion of CITY or the
Eligible Employee taking the HFG ride
CA.3 Reporting
KING COUNTY shall keep a complete record of all authorized HFG ride requests on a semi-annual basis and
provide a copy of this record to the designated CITY's Contact Person
' CAA Program Abuse
KING COUNTY reserves the right to investigate and recover costs from the CITY of intentional abuse of the HFG
program by Eligible Employees Program abuse is defined as,but not limited to,taking trips for inappropriate
reasons,unauthorized destinations and intermediate stops,and pre-scheduled appointments not defined in the
DEFINITIONS section above.
FlexPass Agreement Page 11 of 11
City of Kent
July 1,2005—June 30,2006
1
o u o
O O N O O
ri O
N p M OCY) p 00
1fl M Ln
,-q Mlq- N ON N N N 01
O G N N Wy
N 41 iR
Ln O O K 0 N O'
M '1 M N O1 A
a M a1
Ln
N „x " i
N �►
O x N O
'
AC 1 C N IOA d' 74
� N .�-i M N .N-� 01 M N C11
= iul
M �i
M W4 N N V4
Ol N
U. C O d O
O O `� O
N ` Ln N Ln =
00 - 00
M C M
N f/� Z
O O
N V)
O Ln
T4 00 M C O
M M
O � a.+
N G
� Z yF
cm
•0 w M U
S °u
0 p• 0 C t'+ U) — ran � c 1
# aEi # � 10 m o�C m I0— u Z r
Kent City Council Meeting
Date June 21, 2005
Category Bids
1. SUBJECT: LID 353: SOUTH 228TH STREET CORRIDOR MILITARY ROAD
WIDENING —PHASE I —AWARD
2. SUMMARY STATEMENT: The bid opening for this project was held on June 14,
2005, with 6 bids received. The low bid was submitted by Pilchuck Diversified
Services in the amount of$713,691.38. The Engineer's estimate was $856,769.
3. EXHIBITS: Public Works memorandum
4. RECOMMENDED BY: Staff
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? X Revenue?
Currently in the Budget? Yes X No
If no:
Unbudgeted Expense: Fund Amount S
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councitmember moves, Councilmember Ruiz& seconds
to authorize the Mayor to enter into a contract with Pilchuck Diversified Services in the
amount of$713,691.38 for the LID 353. S. 228th Street Corridor Military Road
Widening—Phase I project.
DISCUSSION: -�
ACTION: �Y1G
Council Agenda
Item No. 8A
f
f
PUBLIC WORKS DEPARTMENT
Larry Blanchard Public Works Director
Phone 253-856-5500
K E N T Fax 253-856-6500
W A s M I N O r o N Address 220 Fourth Avenue S
Kent,WA 98032-5895
June 21, 2005
TO: Mayor White and Kent City Council
FROM. Tim LaPorte, Design Engineering Manager
THROUGH: Larry Blanchard, Public Works Director
SUBJECT: LID 353 South 2281h Street Corridor Military Road Widening—Phase I
Bid opening for this project was held on June 14, 2005 with six bids received The low bid was
submitted by Pilchuck Diversified Services in the amount of$713,691.38. The Engineer's
estimate was $856,769 The Public Works Director recommends awarding this contract to
Pilchuck Diversified Services
Bid Summary
Pilchuck Diversified Services $713,691 39
Prospect Construction $747,293 92
Prvetta Brothers $755,609 58
Rodarte Construction $797,312 92
R W Scott Construction $846,036 24
Ceccanti Construction 5882,612.82
Engineer's Estimate $856,769.00
i
f
Mayor White and Kent City Council LID 353 S 228*St Corridor Military Road Widening Phase I -Award
1
REPORTS FROM STANDING COMMITTEES AND STAFF
A. COUNCIL PRESIDENT
B. OPERATIONS COMMITTEE
C. PUBLIC SAFETY COMMITTEE Rq�� UI have �ec�
D. PUBLIC WORKS w Q.c.✓te� 1 WU Q-
I
E. PLANNING AND ECONOMIC DEVELOPMENT COMMITTEE a&A)<
34 5
F. PARKS AND HUMAN SERVICES COMMITTEE
G. ADMINISTRATIVE REPORTS (RaAlc.A -4 chk-r"
nA o� 8v` ra0 Yv`vv��
REPORTS FROM SPECIAL COMMITTEES
KENT
W...I..TO.
OPERATIONS COMMITTEE MINUTES
MAY 179 2005
Committee Members Present: Chair Tim Clark, Julie Peterson, and Bruce White
tThe meeting was called to order by Tim Clark, Chair at 4:03 p.m.
1. APPROVAL OF MINUTES DATED MAY 3,2005
Bruce White moved to approve the minutes of the May 3, 2005, Operation Committee
meeting. Julie Peterson seconded the motion,which passed 3-0.
2. APPROVAL OF VOUCHERS DATED MAY 13,2005
Assistant Finance Manager Cliff Craig presented the vouchers for May 13,2005,for approval.
Julie Peterson moved to approve the vouchers dated May 13, 2005. Bruce White
seconded the motion,which passed 3-0.
3. PUBLIC WORKS DEPARTMENT—STREET SYSTEM VEGETATION
MAINTENANCE PROPOSAL—AUTHORIZE FILLING THREE (3) POSITIONS
Public Works Director Larry Blanchard requested authorization from the full City Council to
create and fill one Street Maintenance Worker 3 (F"TE) and two Street Maintenance Assistants
(PTE's) positions to be assigned to the Street Vegetation Maintenance Sub-section of the
Public Works Operations Division which would staff the Street Vegetation Maintenance Sub-
section at the same level it was prior to the 2003 lay-offs. Mr. Blanchard advised that these
positions will be funded by charging 50%of the cost to the Street Maintenance Fund and 50%
of the cost to Projects. In most cases 50%of the work is performed in and around property that
is fully developed has curb, gutter, and sidewalks adjacent to them, and requires more
manicured vegetation maintenance. The other 50% of [lie work is performed adjacent to
property that is undeveloped and needs to be mowed because it is in the City's right-of-way,
and the cost of said mowing can be identified to benefit these undeveloped properties or
projects. Thereby a portion of each of the projects will provide for the cost of this service. The
estimated cost of these positions for the remainder of the 2005 Budget including benefits for
the full-time employee is $47,455. The general fund portion of cost is $23,723 allocated by
general fund contingencies. Prior to the lay-offs that occurred in 2003 the Street Vegetation
Maintenance staff included 2 Full-tile and 2 Part-time employees. Total work hours available
to complete the 8,500,000 SF of maintenance was 6400 work hours. The number of tall grass
1
1
Operations Committee Minutes
May 17,2005
Page• 2
and noxious weed complaints at that time averaged 30-40 per year. After the lay-offs street
vegetation staff was reduced by 1 FTE and 2 PTE's leaving only 1,800 work hours to complete
the same work listed above. The one Street Vegetation Maintenance Worker left could only
respond to emergency mowing/ trimming, and site distance/vision area maintenance call-outs.
Complaint/service calls for tall grass and noxious weeds now averages between 300-400 per
year, and many of the calls are going directly to City Council members. Operations is
currently only doing reactive maintenance responding to service calls and cannot, due to
staffing, provide a preventative maintenance program for Street Vegetation Maintenance.
Since 2003 the area maintained by the Street Vegetation Sub-section has increased by 24%
from 8,500,000 SF to 10,540,000 SF, and as we head into summer will only multiply our
backlog of vegetation call-outs. To maintain the Downtown area Public Works Operations,
utilize one of the authorized Part-time Street Vegetation Assistants to keep the Downtown area
maintained to an acceptable preventative maintenance level.
Julie Peterson moved to recommend the full City Council authorize the creation and
filling of one Street Maintenance Worker 3 and two Sheet Vegetation Assistants to be
assigned to the Street Vegetation Maintenance Sub-section of Public Works Operations.
Bruce White seconded the motion,which passed 3-0.
The meeting was adjourned at 4:14 p.m.
Renee Cameron
Operations Committee Secretary
2
1
' PUBLIC WORKS COMMITTEE MINUTES
May 16, 2005
COMMITTEE MEMBERS PRESENT Committee Chair Bruce White and
Committee Members Ron Harmon and Debbie Raplee. The meeting was called to order
at 5.12 P.M.
Approval of Minutes Dated May 2,2005
Committee Member Ron Harmon moved to approve the minutes of May 2, 2005. The
motion was seconded by Debbie Raplee and passed 3-0
Pacific Highway South Puget Sound Easement
Mark Howlett, Design Engineering Supervisor said as part of the Pacific Highway South
HOV Lanes project Puget Sound Energy is asking for an overhang easement from the
City as part of their electrical facility relocation work
Debbie Raplee moved to recommend granting the Mayor authorization to execute
the respective documents granting an easement to Puget Sound Energy for overhead
electrical facilities as part of the Pacific Highway South HOV Lanes Project. The
motion was seconded by Ron Harmon and passed 3-0.
Condemnation Ordinance for Natural Resources and Storm Drainage
Mike Mactutis, Environmental Engineering Manager said this property was historically
farmed but currently is not farmed and has not been for several years A previous owner
sold the development rights to King County under the Farmland Preservation Program,
the current owner would like to change the property use. The current owner is proposing
to provide this site to the City for the relocation and restoration of Johnson Creek away
from the roadway, and for a regional detention and water quality facility. King County is
requesting the City condemn the property so it can be removed from the Farmland
Preservation Program and transferred to the City. The property owner will pay to KC
through the City to restore the property rights, which KC can apply to the FPP to acquire
land more suitable for farming preservation.
Debbie Raplee asked for further clarification on the condemnation. Tom Brubaker, City
Attorney said condemning the property will give King County a legal way to release the
restrictions on the property Ron Harmon asked why the owner did not go through King
County, Brubaker said the County cannot convey the restrictions through a private owner.
Mike Mactutis clarified the City has been working on plans for Johnson Creek restoration
project for the past 2-3 years,this was before the owner inquired about changing the
development rights.
Ron Harmon moved to recommend authorization to adopt a Condemnation
Ordinance to obtain property for natural resources and storm drainage
improvements. The motion was seconded by Debbie Raplee and passed 3-0.
Montessori School Request to Lease City Property
Larry Blanchard, Public Works Director said the City has received a request from the
Montesson Plus School in regards to overflow parking for their facility. Staff evaluated
the request and negotiated conditions for the lease with the owner. The City will
maintain access to the property, the City will have a potential revenue of up to $9,000 and
any repairs made due to MPS parking in the this area shall be billed and paid by the MPS
2
2
Debbie Raplee asked why the area to the east could not be used, Garry Gill, City
Engineer said that area was being used as a playground for the school.
Debbie Raplee moved to recommend the full City Council authorize the Legal
Department to prepare a Lease Agreement for overflow parking requested by the
Montessori Plus School. Terms of the Lease Agreement to be approved by the City
Attorney and Public Works Director prior to signature by Mayor. The motion was
seconded by Ron Harmon and passed 3-0.
The meeting adjourned at 5:41 P M.
Janet Perschek
Administrative Assistant
CONTINUED COMMUNICATIONS
Let
vLo
of cQcQe c+ 3(!�>o
d, L f-n
g,�d.�c,�, � s-�o'C�� wc9A l� �-�-c�v►
�rvv.�., ��..�; C�-,�.-c�nnn�� �� n�- ��;,..le,..,.� -,�1-�->�cam•
. , 3 8'3 1 t GL
I-[Q -A.0 c cg L HOC cam_ 11 cu-�s�
ear d �l A h * 6�
rn 0- Icy a w e%� ( d c _ c)
WkA
1
EXECUTIVE SESSION
c
ACTION AFTER EXECUTIVE SESSION
1 mc-
1
1
1 -
1