HomeMy WebLinkAboutHR14-321 - Original - Premera Blue Cross - Administrative Service Contract - 01/01/2015 -•����,a it
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ADMINISTRATIVE SERVICE CONTRACT
BETWEEN
PREMERA BLUE CROSS
AND
CITY OF KENT
EFFECTIVE JANUARY 1, 2015 THROUGH DECEMBER 31, 2015
(The "Contract Period")
This Contract is effective 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: ,r
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ADDRESS:
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Premera Blue Cross
BY: rwc DATE: January 1, 2015
Jeffrey Roe
President and Chief Executive Officer
P.O. Box 327
Seattle, WA 98111-0327
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TABLE OF CONTENTS
ADMINISTRATIVE SERVICE CONTRACT..................................................................................................1
PREMERABLUE CROSS............................................................................................................................1
CITYOF KENT..............................................................................................................................................1
1. DEFINITIONS...........................................................................................................................................1
2. DUTIES AND RESPONSIBILITIES OF THE PLAN SPONSOR.............................................................1
2.1. Documentation................................................................................................................................1
2.2. Plan Sponsor's Fiduciary Authority.................................................................................................1
2.3. Defense of the Plan.........................................................................................................................2
2.4. Administrative Duties......................................................................................................................2
2.5. Taxes, Assessments,And Fees .................................................................................................._.2
2.6. Compliance With Law......................................_.........................................................................._.2
2.7. Appeals........... ...... ......... .............. .................................-...................... ........................-- ..3
2.8. Funding...... .................... ............. ........................................................................................ ...3
3. DUTIES AND RESPONSIBILITIES OF THE CLAIMS ADMINISTRATOR.............................................3
3.1. Administrative Duties.................................................................................................................. ...3
3.2. Appeals...........................................................................................................................................4
3.3. Claims Processing ........ ......... .... ...... ............................................................. ..............-.4
3A. Funding Support..............................................................................................................................5
3.5. Annual Accounting....... ....... ....... ... ............ ................................................ ............ .................5
3.6. Participation In Class Action Suits..... ...... ................................................................... .............. ..5
4. LIMITS OF THE CLAIMS ADMINISTRATOR'S RESPONSIBILITY.......................................................6
4.1. Recoveries......................................................................................................................................6
4.2. Independent Contractor..................................._.......................................................................... ..6
4.3. Limits of Liability........................................................................ ........... ..................................... ...6
5. FEES OF THE CLAIMS ADMINISTRATOR............................................................................................6
5.1. Payment Time Limits.......................................................................................................................6
5.2. Late Payments................................................................................................................................6
5.3. Customization Fees......................_..,....................................... .....................................................6
6. AUDIT.......................................................................................................................................................7
7. SUBROGATION.......................................................................................................................................7
8. TERM OF CONTRACT............................................................................................................................7
8.1. Contract Period................................................................................................._............................7
8.2. Changes to Fees.............................................................................................................................8
9. TERMINATION.........................................................................................................................................8
9.1. Termination With Notice..................................................................................................................8
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92 Contract Period Expiration............_.........___....... ........._......8
9.3. Termination Due to Insolvency........... ........................ ............... ...... ........_.....8
9.4. Termination Due to Inability to Perform....... .................................... ....................... ......_........8
9.5. Termination For Nonpayment.....___............................................... .......................... .........9
9.6. Plan Sponsor Liability Upon Termination..............................................................................._......9
9.7. Final Accounting...... ...................................................................................... ......9
9.8. Claims Runout....... .................................................................... ............ .......9
10. DISCLOSURE........................................................................................................................................9
11. OTHER PROVISIONS..........................................................................................................................10
11.1. Choice of Law.......... ...... ...................................................................... ..........10
11.2. Proprietary Information... ...................................................................... .....10
11.3. Parties To The Contract............. ............ ............................................................__... ......_10
11.4. Notice........... ........... ........... ............................................................... ........__.10
11.5. Integration.......... ....................................................................................... ................10
11.6. Assignment........ ............. ................................................................. ........10
117. Survival ..... ............. ......... ........ .....-....................... ............................... ......... ..................11
12. ATTACHMENTS TO THE ADMINISTRATIVE SERVICE CONTRACT..............................................11
ATTACHMENT A—OUT-OF-AREA SERVICES............... ......... ........._................... ........................12
ATTACHMENT B—CENSUS INFORMATION.......................................................... ...............................is
ATTACHMENT C—REPORTING...... ........................................................................................................16
ATTACHMENT D—FEES OF THE CLAIMS ADMINISTRATOR..............................................................17
ATTACHMENT E—BUSINESS ASSOCIATE AGREEMENT....................................................................19
ATTACHMENT F—CARE FACILITATION.................. .............................................................................20
ATTACHMENT G—EXTENDED POST-PAYMENT RECOVERY SERVICES..........................................21
ATTACHMENT H— PERFORMANCE GUARANTEES ................................................................... .........23
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1. DEFINITIONS
Administration Fee Guarantee Period The multi-year period during which the Claims Administrator's base
administration fees will not exceed amounts agreed upon by the Claims Administrator and the Plan Sponsor. The
Administration Fee Guarantee Period is shown in"Attachment D— Fees Of The Claims Administrator."
Adverse Benefit Determination 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. It also includes a decision to rescind a Member's
coverage unless the rescission is due to nonpayment of subscription charges.
Affordable Care Act The Patient Protection and Affordable Care Act of 2010 (Public Law 111-148) as amended
by the Health Care and Education Reconciliation Act of 2010(Public Law 111-152).
Claims Administrator Premera Blue Cross.
Contract Period The period shown on the face page of this Contract. The Contract Period begins at 12:01 a.m.
on the starting date shown on the face page and ends at midnight on the ending date shown on the face page.
Effective Date The date this Contract takes effect(the first day of the Contract Period). The Effective Date is
shown on the face page of this Contract.
Grandfathered Health Plan A Plan benefit package that meets the requirements to be a"grandfathered health
plan"set forth in the federal Affordable Care Act regulations. If the Plan consists of more than one benefit
package, the federal regulations on grandfathered plan status apply separately to each benefit package.
Member A Subscriber or dependent who is eligible for coverage as stated in the Plan and who is enrolled as
required in the Plan.
Non-Grandfathered Health Plan A Plan benefit package that does not meet the requirements to be a
grandfathered health plan set forth in the federal Affordable Care Act regulations. If the Plan consists of more
than one benefit package, the federal regulations on non-grandfathered plan status apply separately to each
benefit package.
PEPM "Per employee per month."
Plan The employee benefit plan established and maintained by the Plan Sponsor that is being administered
under this Contract. The Plan may consist of one or more benefit packages.
Plan Sponsor City of Kent.
Subscriber A person who is eligible for coverage under the Plan by virtue of an employee-employer relationship
or other relationship between the person and the Plan Sponsor, and who is enrolled as required in the Plan.
2. DUTIES AND RESPONSIBILITIES OF THE PLAN SPONSOR
2.1. Documentation
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.
2.2. Plan Sponsor's Fiduciary Authority
The Plan Sponsor shall have final discretionary authority to determine the benefit provisions and to construe and
interpret the terms of the Plan.
The Plan Sponsor shall have final discretionary authority to determine eligibility for benefits and the amount to be
paid by the Plan.
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2.3. Defense of the Plan
Except as stated in subsection 4.3, 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.
2.4. Administrative Duties
Unless specifically delegated to the Claims Administrator by this Contract, the Plan Sponsor shall be responsible
for the proper administration of the Plan including the following:
a. The Plan Sponsor shall provide 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.
Retroactive enrollments shall be effective on the most recent of two dates:
• The date the Member's coverage would have been validly in force
• The first day of the fifth full calendar month preceding the month in which the Claims Administrator
receives the request for retroactive enrollment.
Retroactive terminations of coverage shall be effective on the most recent of two dates:
• The date the Member's coverage would have been terminated, had notification been timely
• The first day of the fifth full calendar month preceding the month in which the Claims Administrator
receives the request for retroactive termination.
b. The Plan Sponsor shall distribute to all 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.
c. The Plan Sponsor shall provide 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.
d. 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.
The Plan Sponsor must also include BlueCard disclosure language approved by the Blue Cross Blue
Shield Association in its booklet.
2.5. Taxes, Assessments, And Fees
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.
2.6. Compliance With Law
• 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 of 1986, as amended
• The Affordable Care Act.
The Paul Wellstone Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)
• The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
• The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)
• Law and regulations governing the treatment and benefits of Members covered by Medicare. These
include, but are not limited to, the Medicare Secondary Payer law and regulations and the Medicare,
City of Kent 2 January 1,2015
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Medicaid, and SCHIP Extension Act of 2007 (MMSEA).
As required by MMSEA, the Plan Sponsor agrees to provide us the following information:
• Employer Tax Identification Number(TIN/EIN);
Social Security Numbers (SSNs) of all Members (employees and dependents); and
• Medicare Health Insurance Claim Numbers(HICNs)for all Medicare-entitled Members.
To comply with the Medicare Secondary Payer law and regulations, the Plan Sponsor also agrees to
notify us promptly if the Plan Sponsor experiences a change in total employee count that would
change the order of liability according to federal guidelines.
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
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.
• If the Plan Sponsor elects to opt out of compliance with certain federal mandates as allowed by federal
law, 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.
2.7. Appeals
If an adverse decision on a Member appeal results from the Plan's internal appeal process, the Plan shall offer
the Member a review by an Independent Review Organization (IRO) as described in subsection 3.2.
2.8. Funding
The Plan Sponsor shall be solely liable for all benefits payable to Members under the Plan that are subject to this
Contract. The Plan Sponsor agrees to the following:
a. Provision Of Funds The Plan Sponsor shall maintain adequate funds from which the total cost of all
claims for each preceding week will be paid to the Claims Administrator by electronic funds transfer
(EFT). Funds must be provided within two(2) business days of notification by the Claims Administrator to
a person designated by the Plan Sponsor.
b. Late Payments 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 period of two(2) business days stated above. This late charge is based on the
average monthly prime rate posted by Claims Administrator's designated 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.
c. Notices Notices required by this subsection and subsection 3.4 shall be by secure e-mail unless
another method is agreed upon in writing by the Plan Sponsor and the Claims Administrator.
3. DUTIES AND RESPONSIBILITIES OF THE CLAIMS ADMINISTRATOR
3.1. Administrative Duties
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 of the Plan; and distribute identification cards to Members.
City of Kent 3 January 1,2015
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The Claims Administrator shall be responsible to include approved BlueCard program disclosure
language in the booklets it prepares. If the Plan Sponsor prepares its own booklets, the Claims
Administrator shall provide approved language to the Plan Sponsor for inclusion in the booklets;
b, perform reasonable internal audits as stated in section 6 of this Contract;
c. 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
Sponsors;
d, prepare and provide the Plan Sponsor with reports of the operations of the Plan in accordance with
"Attachment C—Reporting";
e. coordinate with any stop-loss insurance carrier;
f. When the plan makes use of one or more provider networks, maintain a network of healthcare facilities
and professionals as applicable to the plan design. Paid claims to such providers will reflect any
applicable provider discounts;
g. perform care facilitation services as identified in"Attachment F—Care Facilitation."
h. provide a Certificate of Group Health Coverage to Members when their coverage under this Plan
terminates or upon their request within 24 months of termination.
i. Brand-name prescription drug rebates are guaranteed on a per-prescription basis. The Claims
Administrator will pay to the Plan Sponsor the full amount of guaranteed rebates received by the Claims
Administrator in connection with the Plan Sponsor's pharmacy benefit utilization. Payment shall be made
to the Plan Sponsor on a calendar year quarterly basis unless agreed upon otherwise.
The allowable charge for prescription drugs is higher than the price paid to the pharmacy benefit manager
for those prescription drugs. The Claims Administrator retains the difference and applies it to the cost of
operations and the prescription drug benefit program.
3.2. Appeals
a. The Claims Administrator shall review and respond to the initial appeals made by Members of Adverse
Benefit Determinations(see section 1)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 Member 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.
b. If an adverse decision on a Member's appeal results from the Plan's internal appeal process, the Claims
Administrator 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 all required documentation regarding
the appeal to the IRO and work with the IRO as needed to complete its review.
The external appeal process for Non-Grandfathered Plans will be offered and administered in accordance
with the requirements of the Affordable Care Act.
The Plan Sponsor is responsible for all costs charged by the IRO to perform its review. If the Plan
Sponsor chooses to share that cost with Members to the extent allowed under the Affordable Care Act,
the Plan Sponsor is responsible to charge and collect any such fee from a Member.
3.3. Claims Processing
The Claims Administrator shall 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.
The Claims Administrator shall make reasonable efforts to determine that a claim is covered under the terms of
the Plan as described in the benefit booklet, to apply the coordination of benefits provisions, and prepare and
distribute benefit payments to Members and/or service providers. The Claims Administrator shall make
reasonable efforts to identify and recover overpayments due to claim processing errors that were within its
control, retroactive cancellations, or fraudulent billing practices. "Reasonable"for the purposes of this section
shall be determined by the Claims Administrator.
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3.4. Funding Support
The Claims Administrator shall follow the steps below to facilitate the Plan Sponsor's funding of its Plan.
a. Claim payment checks will be issued on the Claims Administrator's check stock. However, as stated in
subsection 2.8 above, the responsibility for funding benefits is the Plan Sponsor's and the Claims
Administrator is not acting as an insurer.
b. Each week, the Claims Administrator shall notify the Plan Sponsor of the amount due for the prior week's
claims. Notice will be by secure e-mail unless another method is agreed upon in writing by the Claims
Administrator and the Plan Sponsor.
3.5. Annual Accounting
Within 120 days of the end of the Contract Period, we shall perform an annual accounting of claims activity and
report to the Plan Sponsor.
3.6. Participation In Class Action Suits
The Plan Sponsor hereby delegates to the Claims Administrator the authority to participate on behalf of the Plan
Sponsor, and at the Claims Administrator's sole discretion, in class action lawsuits or settlements regarding any
services or supplies covered under the terms of the Plan. Examples of such services or supplies include
prescription or specialty drugs or medical devices. Such participation shall be limited to those instances in which
the Claims Administrator determines that it will submit a claim in the subject suit on behalf of its insured book of
business. The Claims Administrator shall have no obligation to participate on behalf of the Plan Sponsor in any
other lawsuit or settlement. The Claims Administrator will have no obligation to file claims on behalf of a Plan
Sponsor with which the Claims Administrator does not have a contract at the time the claims for recovery are
submitted.
The Plan Sponsor will recover the amount it is due under the terms of the settlement in question based upon the
data submitted by the Claims Administrator. Any amounts recovered by the Claims Administrator hereunder shall
be net of the Claims Administrator's fee as set forth below as well as fees paid to outside counsel in connection
with the lawsuit and/or settlement.
For each class action lawsuit or settlement in which the Claims Administrator participates hereunder on the Plan
Sponsor's behalf, the Plan Sponsor shall pay the Claims Administrator a fee representing a proportionate share of
a fixed amount intending to compensate the Claims Administrator for its work in connection with pursuing
recovery in these cases. The fixed amount is shown in "Attachment D—Fees Of The Claims Administrator." This
fixed amount is subject to change on an annual basis with at least 60 days' advance notice to the Plan Sponsor.
The amount of the Claims Administrator's fee payable by each Plan Sponsor shall be based on the proportion of
the total amount recovered by the Claims Administrator on behalf of the Plan Sponsor compared to the amount
recovered by Claims Administrator for all lines of business. The fee will be deducted from the amount of any
recovery received on behalf of the Plan Sponsor and will in no event exceed the amount of such recovery.
Payment hereunder shall be made within 60 days of the Claims Administrator's receipt of the settlement funds.
The Claims Administrator shall have no obligation to forward settlement funds to any group hereunder if the
amount due to the group is less than$5.
The Plan Sponsor may elect to decline to participate in the Claims Administrator's recovery process related to
class action lawsuits or settlements regarding any services or supplies covered under the Plan by providing the
Claims Administrator written notice. Except as set forth below, in the event the Plan Sponsor opts out, the Claims
Administrator shall have no further obligation whatsoever to the Plan Sponsor in connection with the recovery
process. The Plan Sponsor may request that the Claims Administrator gather data necessary for the Plan
Sponsor to submit its own claim. In any such case, the Plan Sponsor shall pay the amount shown in "Attachment
D—Fees Of The Claims Administrator"for the data-gathering services. Additionally, the Plan Sponsor shall make
any such request in writing a minimum of 30 days in advance of the claim filing deadline.
City of Kent 5 January 1,2015
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4. LIMITS OF THE CLAIMS ADMINISTRATOR'S RESPONSIBILITY
It is recognized and understood by the Plan Sponsor that the Claims Administrator is not an insurer and that the
Claims Administrator's sole 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.
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.
4.1. Recoveries
If, during the course of an audit performed internally by the Claims Administrator as described in subsection 3.1.b.
above or by the Plan Sponsor pursuant to section 6 below, any error is discovered, the Claims Administrator shall
use reasonable efforts to recover any loss resulting from such error.
4.2. Independent Contractor
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.
4.3. Limits of Liability
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.
5. FEES OF THE CLAIMS ADMINISTRATOR
5.1. Payment Time Limits
By the first of each month, The Plan Sponsor shall pay the Claims Administrator in accordance with the fee
schedule set forth in"Attachment a—Fees Of The Claims Administrator'that is incorporated herein by reference.
5.2. 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 c. below.
b. In the event of late payment, the Claims Administrator may terminate this Contract pursuant to subsection
9.5 below. 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.
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 subsection 9.5 below, at the average prime rate posted by Claims Administrator's designated
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.
5.3. Customization Fees
The Plan Sponsor shall pay the Claims Administrator a"customization fee"when the Plan Sponsor requests
either of the following:
City of Kent 6 January 1,2015
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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 D—Fees Of The Claims Administrator."
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.
6. AUDIT
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.
7. SUBROGATION
The Claims Administrator shall have no affirmative duty to pursue subrogation claims. However, the Claims
Administrator may pursue subrogation claims when the Plan Sponsor purchases subrogation services as
described in Attachment G— Extended Post-Payment Recovery Services. 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.
8. TERM OF CONTRACT
8.1. Contract Period
The term of this Contract shall be the Contract Period shown on the face page of this Contract. If the Plan
Sponsor and the Claim Administrator agree to extend the Contract for another contract period by means of an
amendment, the term of this Contract shall be the Contract Period shown on the amendment.
Except as stated otherwise in this section and in subsection 8.2 below, the terms and conditions of this Contract
and the fee schedule set forth in "Attachment D—Fees Of The Claims Administrator"are established for the
Contract Period.
The Claims Administrator reserves the right to amend this Contract at any time if needed to comply with
applicable law or regulation.
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8.2. Changes to Fees
The Plan Sponsor acknowledges that the fee schedule set forth in "Attachment D—Fees Of The Claims
Administrator"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 parties agree that any substantial change, as determined by the Claims
Administrator after consultation with the Plan Sponsor, 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 B—Census Information"which is herein incorporated by reference and made a
part of this Contract. Termination of Regional Fire Authority (RFA) employees from the plan will not be
considered a fluctuation.
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.
9. TERMINATION
9.1. Termination With Notice
The Plan Sponsor may terminate this Contract at any time by giving the Claims Administrator thirty(30)days
written notice.
9.2. Contract Period Expiration
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.
9.3. Termination Due to Insolvency
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.
9.4. Termination Due to Inability to Perform
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 subsection 5.2.c.
above.
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9.5. Termination For Nonpayment
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 fails to make a timely payment required under this Contract.
9.6. Plan Sponsor Liability Upon Termination
In the event this Contract is terminated prior to the end of the administration fee guarantee period shown in
"Attachment D—Fees Of The Claims Administrator," the Plan Sponsor shall remain liable to the Claims
Administrator for all delinquent sums together with interest thereon as provided for in subsection 5.2.c. above.
Furthermore, the Claims Administrator will have incurred fixed costs which, but for the termination, would have
been recouped over the course of the administration fee guarantee period. Therefore, in the event that the
Contract terminates pursuant to subsections 9.1 or 9.5 above, 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 D—Fees Of The
Claims Administrator" by the average number of Subscribers 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 liquidated damages amount shall then be reduced on a pro rate basis for the number of months of the
administration fee guarantee period that the Contract was in force. The Plan Sponsor shall remain liable for
claims incurred during the Contract Period but not paid during the Contract Period and for the claims runout
processing fee set forth in the"Fees Of The Claims Administrator"attachment. Liquidated damages will not apply
in the event Plan Sponsor provides a minimum 12 month notice of its intent to terminate this agreement.
9.7. Final Accounting
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.
9.8. Claims Runout
The Plan Sponsor continues to be solely liable for claims received by the Claims Administrator after the Contract
terminates. For the fifteen (15)-month period following termination of this Contract, the Claims Administrator shall
continue to process eligible claims incurred prior to termination, or adjustments to claims incurred prior to
termination, that the Claims Administrator receives no more than twelve (12) months after the date of termination
at the claims runout processing fee rate set forth in "Attachment D— Fees Of The Claims Administrator."
The runout processing charge will be due in full with the first request for claims reimbursement made during the
runout period.
If the Claims Administrator receives claims for Plan benefits more than twelve(12) months after the date this
Contract terminates, Claims Administrator shall deny those claims. If the Plan Sponsor wants to negotiate a
different arrangement, the Plan Sponsor must contact the Claims Administrator no later than the start of the
fourteenth month after the date this Contract terminates.
This"Claims Runout" provision shall survive termination of this Contract.
10. DISCLOSURE
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.
It is also 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.
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11. OTHER PROVISIONS
11.1. 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, unless federal law applies. Any and all disputes concerning this Contract shall be
resolved in King County Superior Court or federal court as appropriate.
11.2. Proprietary Information
The Claims Administrator reserves the right to, the control of, and the use of the words"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.
The Claims Administrator's provider reimbursement information is proprietary and confidential to the Claims
Administrator and will not be disclosed to the Plan Sponsor unless and until a separate Confidentiality Agreement
is executed by the parties. For the purposes of this section, "provider reimbursement information" means data
containing, directly or indirectly(a)diagnostic, procedures or other code sets; and (b) billed amount, allowed
amount, paid amount or any other financial information for network and non-network hospitals, clinics, physicians,
other health care professionals, pharmacies and any other type of facility. Such data may or may not specifically
identify providers. No other provision of this Contract or any other agreement or understanding between the
parties shall supersede this provision.
11.3. Parties To The Contract
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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.
11.4. Notice
Except for the notice given pursuant to the"Funding"subsection of section 2, 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 or such other address provided in writing by the parties.
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11.5. 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.
11.6. Assignment
Neither party shall assign this Contract or any of its duties or responsibilities hereunder without the prior written
approval of the other.
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11.7. Survival
The following provisions shall survive the termination of this Contract,
a. The funding of claims incurred prior to termination and processed during the runout period described in
9.8 Claims Runout. The funding provisions are described in subsections 2.8 and 3.4
b. The payment of runout processing fees described in 9.8
c. The liability, hold harmless and indemnification provisions of subsection 4.3
d. The Effect on Termination section in the Business Associate Agreement
e. The provisions of subsection 9.6
f. The final accounting provisions in subsection 9.7
12. ATTACHMENTS TO THE ADMINISTRATIVE SERVICE CONTRACT
The following attach to and become part of the body of this Contract and they are herein incorporated by
reference.
ATTACHMENT A—OUT-OF-AREA SERVICES
ATTACHMENT B—CENSUS INFORMATION
ATTACHMENT C—REPORTING
ATTACHMENT D—FEES OF THE CLAIMS ADMINISTRATOR
ATTACHMENT E—BUSINESS ASSOCIATE AGREEMENT
ATTACHMENT F—CARE FACILITATION
ATTACHMENT G— EXTENDED POST-PAYMENT RECOVERY SERVICES
ATTACHMENT H —PERFORMANCE GUARANTEES
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ATTACHMENT A — OUT-OF-AREA SERVICES
Premera Blue Cross participates in Inter-Plan Arrangements with other Blue Cross and/or Blue Shield Licensees.
They include"the BlueCard®Program"and arrangements for payments to non-network providers. We are
required by the Blue Cross Blue Shield Association (BCBSA)to disclose the information below about these Inter-
Plan Arrangements to groups with which we do business. The Plan Sponsor has consented to this disclosure to
permit us to satisfy our contractual obligations to BCBSA. However, this provision defines or modifies the rights
and obligations of the parties under this Contract only with regard to the processing of claims for care outside
Washington and Alaska or in Clark County,Washington (our"Service Area").
Whenever Members access healthcare services outside our Service Area, the claims are processed through one
of these Inter-Plan Arrangements and presented to us for payment. Payment is made in accordance with the
terms and limitations of the Plan and the rules of the applicable BCBSA Inter-Plan Programs policies then in
effect. Under these policies, we remain responsible to the Plan Sponsor for fulfilling our obligations under this
Contract. The local Blue Cross and/or Blue Shield Licensee (the"Host Blue") is responsible for such services as
contracting and handling substantially all interactions with its network providers.
When Members are outside our Service Area, they may obtain care from providers that are in the network of a
Host Blue or from non-network providers. Our payment calculation practices in both instances are described
below. Circumstances may arise that are not directly covered by this description; however, in those instances,
our practices will be consistent with the spirit of this description.
It is important to note that receiving services through these Inter-Plan Arrangements does not change covered
benefits, benefit levels, or any stated residence requirements of the Plan.
Liability Calculation Method Per Claim
Network Providers The calculation of the Member's liability for claims processed through the BlueCard Program
will be based on the lower of the network provider's billed charge for the covered services or the allowable charge
made available to us by the Host Blue. Most often, the Plan Sponsor's liability for those claims is calculated
based on the same amount on which the Member's liability is calculated. In rare cases, the Plan Sponsor's
liability may be greater than billed charges if the Host Blue has negotiated with a network provider an inclusive
allowance(such as a per-case or per-day amount)for specific services.
Host Blues may use various methods to determine an allowable charge, depending on the terms of their network
provider contracts. The allowable charge can be one of the following:
An actual price. An actual price is a priced amount passed to us without any of the adjustments made to
estimated or average prices, as explained below.
An estimated price. An estimated price is a negotiated price that is reduced or increased by a percentage
to take into account certain payments negotiated with the provider and other claim-and non-claim-related
transactions. Such transactions may include, but are not limited to, anti-fraud and abuse recoveries,
provider refunds not applied on a claim-specific basis, retrospective settlements, and performance-related
bonuses or incentives.
• An average price. An average price is a percentage of billed charges for the covered services
representing the aggregate payments negotiated by the Host Blue with all of its providers or with a similar
classification of its providers. It may also include the same types of claim-and non-claim-related
transactions as an estimated price.
Host Blues using either an estimated price or an average price may, in accordance with Inter-Plan Programs
policies, prospectively increase or reduce such prices to correct for over-or underestimation of past prices.
Prospective adjustments may mean that a current price reflects additional amounts or credits for claims already
paid to providers or anticipated to be paid to or received from providers. However, the BlueCard Program
City of Kent 12 January 1,2015
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requires that the Host Blue's allowable charge for a claim is final for that claim; no future estimated or average
price adjustment will change the pricing of past claims.
If a Host Blue uses either an estimated price or an average price on a claim, it may also hold some portion of the
amount that the Plan Sponsor pays in a variance account, pending settlement with its network providers.
Because all amounts paid are final, neither variance account funds held to be paid, nor the funds expected to be
received, are due to or from the Plan Sponsor. Such payable or receivable amounts would be eventually
exhausted by provider settlements and/or through prospective adjustments to the negotiated prices. Some Host
Blues may retain interest earned, if any, on funds held in variance accounts.
Clark County Providers Some providers in Clark County, Washington do have contracts with us. These
providers will submit claims directly to us and benefits will be based on our allowable charge for the covered
service or supply.
Non-Network Providers When covered services are provided outside our Service Area by providers that do not
have a contract with the Host Blue, the allowable charge will generally be based on either our allowable charge
for these providers or the pricing requirements under applicable state law. Members are responsible for the
difference between the amount that the non-network provider bills and this Plan's payment for the covered
services.
Exceptions Required By Law In some cases, federal law or the laws of a small number of states may require
the Host Blue to include a surcharge as part of the liability for Members'covered services. If either federal law or
any state laws mandate other liability calculation methods, including a surcharge, we would then use the
surcharge and/or other amount that the Host Blue instructs us to use in accordance with those laws as a basis for
determining the Plan's benefits and any amounts for which Members are responsible.
Return of Overpayments
Recoveries from a Host Blue or its network providers can arise in several ways. Examples are anti-fraud and
abuse recoveries, provider/hospital audits, credit balance audits, utilization review refunds, and unsolicited
refunds. In some cases, the Host Blue will engage a third party to assist in identification or collection of recovery
amounts. Recovery amounts determined in these ways will be applied in accordance with applicable Inter-Plan
Programs policies, which generally require correction on a claim-by-claim or prospective basis.
Unless otherwise agreed to by the Host Blue, we may request adjustments from the Host Blue for full refunds
from providers due to the retroactive cancellation of Membership, but never more than one year after the date of
the Inter-Plan financial settlement process for the original claim. In some cases, recovery of claim payments
associated with retroactive cancellations may not be possible if, as an example, the recovery conflicts with the
Host Blue's state law or its provider contracts or would jeopardize its relationship with its providers.
BlueCard Worldwide®
If Members are outside the United States, the Commonwealth of Puerto Rico, and the U.S. Virgin Islands, they
may be able to take advantage of BlueCard Worldwide when accessing covered health services. BlueCard
Worldwide is unlike the BlueCard Program available in the United States, the Commonwealth of Puerto Rico, and
the U.S. Virgin Islands in certain ways. For instance, although BlueCard Worldwide provides a network of
contracting inpatient hospitals, it offers only referrals to doctors and other outpatient providers. Also, when
Members receive care from doctors and other outpatient providers outside the United States, the Commonwealth
of Puerto Rico and the U.S. Virgin Islands, the Members will typically have to submit the claims themselves to
obtain reimbursement for these services.
Fees and Compensation
Network Providers The Plan Sponsor understands and agrees to reimburse us for certain fees and
compensation which we are obligated under applicable Inter-Plan Programs requirements to pay to the Host
Blues, to BCBSA, and/or to Inter-Plan Programs vendors, as described below. The fees may be revised in
accordance with Inter-Plan Programs standard procedures, which do not provide for prior approval by any plan
sponsor. Such revisions typically are made annually, but may occur at any time. Revisions do not necessarily
coincide with the Plan Sponsor's benefit period under this Contract.
City of Kent 13 January 1,2015
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Only the access fee can be charged separately each time a claim is processed. If such a fee is charged, it will be
either a percentage of the discount/differential we receive from the Host Blue or a set fee, based on the current
rate in accordance with the applicable Inter-Plan Program's standard procedures for establishing the access fee
rate. The access fee will not exceed $2,000 for any claim.
All other Inter-Plan Programs-related fees are covered by our general administrative fee. See"Attachment d—
Fees of the Claims Administrator."
Non-Network Providers All fees related to non-network provider claims are covered by our general
administrative fee.
Value-Based Programs
Members might access covered services from providers that participate in a Host Blue's value-based program
(VBP). Value-based programs focus on meeting standards for treatment outcomes, cost and quality, and
coordinating care when the member is seeing multiple providers. Some of these programs are similar to those we
have in Washington. Types of value-based programs are accountable care organizations, global payment/total
cost of care arrangements, patient-centered medical homes and shared savings arrangements.
The Host Blue may pay VBP providers for meeting standards for treatment outcomes, cost and quality, and
coordinating care over a period of time called a measurement period. We then pass these payments through to
the Plan Sponsor. Sometimes, VBP payments are made before the end of the measurement period.
The Host Blue may bill VBP payments for Members in one of two ways:
In the Allowable Charge. Host blues may adjust the allowable charges for VBP providers claims to include VBP
payments.
If the VBP pays a fee to the provider for coordinating the Member's care with other providers, the Host Blues may
also bill these fees with claims. They will use a separate procedure code for care coordination fees.
Members will have to pay a share of VPB payments when Host Blues include VBP charges in claims and a
deductible, copay or coinsurance applies to the claim. Members will not be billed for any VBP care coordination
fees.
Billed Separately. Instead of adjusting clams, some Host Blues bill VPB payments as a"per member per month"
(PMPM)charge for each Member who participates in the Value Based Program. We pass these PMPM amounts
on to the Plan Sponsor.
Variance Accounts. Some Host Blues' claims adjustments or PMPM amounts used for VBP payments maybe
estimates. As a result, these Host Blues hold part of the amounts paid by the Plan Sponsor and member in a
variance account. The Host Blues will use these funds to adjust future VPB payments following the process
explained under"Liability Calculation Method Per Claim" above. Neither positive variance account amounts
(funds available to be paid in the following year), or negative variance amounts (the funds needed to be received
in the following year)are due to or from City of Kent. If City of Kent terminates, it will not receive a refund or
charge from the variance account.
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ATTACHMENT B - CENSUS INFORMATION
Administration Fees, effective January 1, 2015, are based on the following:
Number of Active Members:
Employee Spouse Children
MedicalJRx 622 353 683
Number of COBRA Members:
Employee Spouse Children
Medical/Rx 9 4 1
Other Carriers Offered: Group Health
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ATTACHMENT C - REPORTING
A standard package of reports covering the Contract Period will be provided to the Plan Sponsor within the fees
set forth in"Attachment D—Fees Of The Claims Administrator." The reports will cover:
• Earned 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.
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ATTACHMENT D - FEES OF THE CLAIMS ADMINISTRATOR
Pursuant to the Administrative Service Contract, the Plan Sponsor shall pay the Claims Administrator the fees, as
set forth below, for administrative services.
Administration Fees:
$56.65 per employee per month
Administration Fee Guarantee:
The base administration fee, not including other charges such as producer fees, is guaranteed as shown below
during the period from January 1, 2015 through December 1, 2017. This period shall be known as the
"administration fee guarantee period."
Year Amount Contract Period Begins Contract Period Ends
Year 1 $56.65 PEPM January 1, 2015 December31, 2015
Year 2 $56.65 PEPM January 1, 2016 December 31, 2016
Year $58.35 PEPM January 1, 2017 December31, 2017
PEPM — Per Employee Per Month
Other Fees:
Network Management Fee $6.90
B&O Tax $0.82
The charge for processing runout claims is an amount equal to the active administration fee at the time of
termination, times the average number of subscribers for the 3-month period preceding the termination date,
times two.
Value-Based Program Payments
Provider groups enter into agreements with Premera or other Blue Cross and/or Blue Shield Licensees (Host
Blues) for value-based programs. Such programs include the Blue Distinction Total Care program, Global
Outcomes Contracts, accountable care organizations, patient-centered medical homes, shared savings
arrangements, and global payment/total cost of care arrangements. Premiere and the Host Blues may pay value-
based program providers for meeting the programs' standards for treatment outcomes, cost, quality and care
coordination. The Plan Sponsor shall pay the Claims Administrator a per-member-per month (PMPM)amount
established for each value-based program provider group. The PMPM amount will be multiplied by the number of
the Plan Sponsor's members that are attributed to each provider group. The PMPM amounts differ between the
provider groups, and may change during the Contract Period.
Fee For Class Action Recoveries
The Plan Sponsor shall pay the Claims Administrator a fee for its work in pursuing class action recoveries on
behalf of the Plan Sponsor as described in Subsection"3.6. Participation In Class Action Suits." The fee shall be
a proportionate share of$10,000, based on the proportion of the amount recovered on behalf of the Plan Sponsor
compared to the total amount recovered by the Claims Administrator for all lines of business.
BlueCard Fee Amount:
BlueCard Fees are tracked and billed monthly in addition to claims expense.
City of Kent 17 January 1,2015
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Care Facilitation:
Included in Administration Fee. See"Attachment F—Care Facilitation"for an overview of services provided.
Extended Post-Payment Recovery Services:
Claims Administrator will perform the services listed below on a pay-for-performance, contingent fee("Contingent
Fee") basis, which shall be calculated as a percentage of the gross amount recovered with respect to any
particular claim. See"Attachment G—Extended Post-Payment Recovery Services"for an overview of services
provided.
Post Payment Recovery Contingent Fee
Category
Coordination of Benefits 25°f°
Subrogation 25% unless claim requires engagement of outside
counsel, in which case the Contingent Fee amount
shall be 35%.
Provider Billing Errors 25%
Credit Balance 1 25%
Hospital Billing and Chart Review 35%
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ATTACHMENT E - BUSINESS ASSOCIATE AGREEMENT
The Plan Sponsor should keep its signed business associate agreement and any signed amendments behind this
page.
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ATTACHMENT F - CARE FACILITATION
Claims Administrator agrees to provide the following care facilitation programs for the fees shown in "Attachment
D—Fees Of The Claims Administrator."
Service Description
Care Management
Prospective and retrospective review for medical
Clinical review necessity, appropriate application of benefits. Prospective
review is not mandatory for provision of benefits.
Voluntary program to provide cost-effective alternatives for
Case management care of complex or catastrophic conditions. This service
also educates Members and assists Members and
providers in managing breast&lung cancer.
Includes provision of evidence-based clinical practice and
Quality Programs 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.
Education for Members using multiple drugs to review
Polypharmacy prescriptions with their providers to decrease incidences of
adverse drug interactions
Follow-up with Members and physicians to minimize
Point-of-sale Pharmacy inappropriate or excessive drug therapies identified when
drugs are dispensed.
Demand Management Round-the-clock access for Members to RNs to answer
questions about health care.
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ATTACHMENT G - EXTENDED POST-PAYMENT RECOVERY SERVICES
Claims Administrator, through its affiliate, Calypso, shall provide a set of Extended Post Payment Recovery
Services to the Plan Sponsor as described below. Claims Administrator will perform these services on a pay-for-
performance, contingent fee("Contingent Fee") basis, which shall be calculated as a percentage of the gross
amount recovered with respect to any particular claim. Contingent Fees are shown in "Attachment D—Fees Of
The Claims Administrator."
Post Payment Recovery
Category Explanation of Services
Claims Administrator's investigators and auditors will work to identify
and pursue overpayments due to Member's missing or inaccurate COB
information. Claims Administrator utilizes questionnaires and
Coordination of Benefits interviews with providers, employers and Members to determine if Plan
Sponsor's Plan is primary or secondary.
Claims Administrator's investigators, auditors and attorneys identify and
pursue overpayments due to Subrogation opportunities. Claims
Administrator's research to obtain accurate subrogation information and
determine group's subrogation rights include questionnaires and
interviews with providers, employers and Members as well as a review
of medical records. For verified overpayments Claims Administrator
Subrogation manages attorney and Member notification, files necessary liens,
coordinates case documentation, and provides representation for
arbitration hearings.
The Plan Sponsor will be pre-notified of Claims Administrator's intent to
file suit and retains the right to authorize or deny any legal action.
Claims Administrator's post-payment editing programs and
investigators and auditors perform additional screens and tests where
billing information is inconsistent with agelservices rendered or where
Provider Billing Errors there appears to be up-coding or unbundling of services. A recovery
process is then employed to request and recover verified
overpayments.
This service requires an on-site review of the provider's financial
records and discussions with their staff Credit balances are verified as
Credit Balance owed to Plan Sponsor and the source of the credit is determined. The
credit is reviewed with the provider and approved for payment back to
Claims Administrator or the Plan Sponsor.
This service requires an on-site review of the Members medical charts
and interviews with provider staff by registered nurses. Calypso out-
Hospital Billing and Chart sources the on-site review work to an independent vendor who ensures
Review that:
Service is consistent with diagnosis and billing is consistent
City of Kent 21 January 1,2015
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Post Payment Recovery Explanation of Services
Category
with services.
• There has been no unbundling of services, diagnosis up-coding
or billing maximization.
• Services rendered were prescribed by the physician and the
doctor's notes were signed.
• Standardized billing and payment policies were used.
Calypso provides support for this vendor's efforts as well as processes
all recoveries.
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ATTACHMENT H - PERFORMANCE GUARANTEES
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ATTACHMENT H
PERFORMANCE GUARANTEE AGREEMENT
BETWEEN
Premera Blue Cross of Washington
AND
City of Kent
EFFECTIVE 1/1/2015 THROUGH 12/31/2015 (The "Agreement Period")
This Performance Guarantee Agreement is between Premera Blue Cross of Washington ("the Company"), and
City of Kent ("the Group"). The Company will provide an acceptable level of service as described herein or will
pay the penalties also described herein.
SECTION 1. TERM
The term of this Agreement shall only be the Agreement Period.
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Provided this Agreement is executed prior to or on the Effective Date, the Company's fulfillment of the
performance guarantees set forth in this Agreement shall be measured from the Effective Date.
In the event that this Agreement is not executed prior to or on the Effective Date, the Company's performance
shall be measured in accordance with Section 3.C.
The performance guarantees under this Agreement are contingent on the Company receiving timely payment of
administrative fees or subscription charges, as applicable, from the Group.
SECTION 2. PERFORMANCE GUARANTEES AND PENALTY AMOUNTS
The Company guarantees its performance as stated below. The maximum amount of accumulated penalties
for the Agreement Period shall be $2,500.00
Performance Guarantee Metrics:
1)Contract Services: Booklets
Premera will guarantee booklet proofs within 45 business days of receipt of the group renewal confirmation.
Additional drafts or final (electronic) booklets will be provided within 10 business days of producer/client edits to
initial draft and repeat with each revision as necessary. Printing and mailing of booklets are not subject to
performance guarantee.
This metric is non-standard and reporting will be Group specific settled annually
The estimated penalty for this metric will be $2,500.00
SECTION 3. EVALUATION OF PERFORMANCE AND PAYMENT OF PENALTIES
ATTACHMENT H
A) At the end of the Agreement, the Company shall compile the necessary documentation and perform the
necessary calculations to evaluate its fulfillment of each performance guarantee set forth in this Agreement and
make this information available to the Group.
B) If the Company fails to meet any of the performance guarantees set forth in Section 2, the Company shall
pay to the Group the financial penalty based on the percentage set forth in Section 2.
C) In the event that this Agreement is not executed by the Effective Date, the Company's performance shall be
measured from the first day of the month following the month this Agreement is executed. In such event the
applicable penalty amounts will be pro-rated for that portion of the year for which performance guarantee
metrics are in force.
D) Refer to Section 4 if the contract under which the Company provides insurance and/or administrative
services to the Group is terminated prior to the end of the term of this Agreement.
SECTION 4. TERMINATION OF AGREEMENT
If this Agreement terminates prior to the last day of the Agreement Period the Group is not entitled to any
penalties under Section 2 of this Agreement. This Agreement shall terminate upon the earliest of the following
dates:
A) the end of the Term of this Agreement;
B) the effective date of any state's or other jurisdiction's action which prohibits activities of the parties under this
Agreement;
C) the date upon which the Group either fails to meet its obligation to sufficiently fund the bank account from
which claims are paid (if applicable), or fails to make timely payments of either administrative fees or
subscription charges anytime during the plan year;
D) the date upon which the contract under which the Company provides services to the Group is terminated;
E) any other date mutually agreeable to the Company and Group.