Loading...
HomeMy WebLinkAboutHR18-008 - Amendment - #3 -Premera Blue Cross - Administrative Service Contract - 1/1/21 FOR CITY OF KENT OFFICIAL USE ONLY Sup/Mgr: Agreement Routing Form Dir Asst: • For Approvals,Signatures and Records Management Dir/Dep: KENT This form combines&replaces the Request for Mayor's Signature and Contract Cover Sheet forms. (Optional) WASHINGTON (Print on pink or cherry colored paper) Originator: Department: Laura Horea Human Resources Date Sent: Date Required: > 03/08/2021 ASAP 0 Q Authorized to Sign: Date of Council Approval: QDirector or Designee �✓ Mayor 02/16/2021 Budget Account Number: Grant? Yes F,]No Budget?mYesr--]No Type: N/A Vendor Name: Category: Im Premera Contract Vendor Number: Sub-Category: Amendment 0 'M Project Name: amend #1 - Administrative Service Contract E 0 `b- Project Details: C a.+ C N Agreement Amount: $ 1,852,700. Basis for Selection of Contractor: Other W *Memo to Mayor must be attached 3- Start Date: 1/1/2021 Termination Date: 12/31/2024 Q ✓Local Business?�Yes No* If meets requirements per KCC3.70.100,pleose complete'VendorPurchose-Locol Exceptions"form onCityspoce. Business License Verification:El Yes On-Process 17]Exempt(KCC 5.01.045) Notice required prior to disclosure? Contract Number: 17]YesFlNo HR18-008 Comments: = Premera Administrative Services Contract OK to sign 3/19/2021, TW. 7w 3 30 a, N •> i 1= 4w Date Received by City Attorney: 3/12/21 0 Date Routed to the Mayor's Office: in Date Routed to the City Clerk's Office: adccW22313_1_20 Visit Documents.KentWA.gov to obtain copies of all agreements rev.200821 PREMEM AMENDMENT #1 TO ADMINISTRATIVE SERVICE CONTRACT BETWEEN PREMERA BLUE CROSS AND CITY OF KENT The Administrative Service Contract ("Contract") between the group named above (the "Plan Sponsor") and Premera Blue Cross (the "Claims Administrator") was issued January 1, 2020. This Amendment shall further revise and extend the Contract for the period from January 1, 2021 through December 31, 2021 (the "Contract Period"). The changes to the Contract for the new Contract Period shown below shall take effect on January 1, 2021. The changes are: Attachment D Fees Of The Claims Administrator* • The Claims Administrator's fee for recovering payments through a class action suit on behalf of the Plan Sponsor has been changed to $50,000. The fee amount appears in Fee For Class Action Recoveries in the Attachment. The method of calculating the Plan Sponsor's portion of the fee has not changed, and the fee amount will continue to be deducted from the money paid to the Plan Sponsor. Each participating plan sponsor pays its part of the fee based on the proportion of the amount the Claims Administrator recovers for that plan sponsor compared to the Claims Administrator's total amount recovered for all its lines of business. Attachment F CareCompass3600 • The Claims Administrator has ended its polypharmacy program. The Polypharmacy row in Appendix 1 of the CareCompass360° attachment is deleted. • The Telehealth provision in Appendix 1 is revised to reflect the changes to the new Virtual Care benefit. It reads: The Claims Administrator has contracted with one or more vendors that use technology to provide Members easier and more convenient access to medical care. Providers covered under the Virtual Care benefit offer their services Virtual Care exclusively through secure chat, text, voice or audio messaging and video chat. The virtual care services do not include real-time visits via online and telephonic methods between Members and their doctors or other providers who also maintain a physical location. Attachment I Performance Guarantees The revised Attachment I attached to this Amendment is hereby made a part of the Contract. An Independent Licensee of the Blue Cross Blue Shield Association All other provisions of the Contract remain unchanged. This amendment forms a part of your Contract. Please keep the amendment with your Contract. CITY OF KENT BY: Q °- `" DATE: 03/22/2021 ana a p Mnvnr Title ADDRESS: 220 Fourth Avenue S. Kent,WA 98032 PREMERA BLUE CROSS 7 V-n BY: DATE: January 1, 2021 Jeffrey Roe President and Chief Executive Officer P.O. Box 327 Seattle, WA 98111-0327 2 ATTACHMENT B - CENSUS INFORMATION Administration Fees, effective January 1, 2021, are based on the following: Number of Active Members: Employee Dependents Medical/Rx 720 1, 212 Other Carriers Offered: Kaiser 3 ATTACHMENT D - FEES OF THE CLAIMS ADMINISTRATOR 4 ATTACHMENT D to the Administrative Service Contract between PREMERA BLUE CROSS and City of Kent Group Number:1018212 Effective: 1/1/2021 through 12/31/2021 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: $53.62 per employee per month Administration Fee Breakdown: Administration Fee(Medical/Rx) $50.12 Administrative Fee(Dental) $0.00 Producer Fee 3.50 Total $53.62 Administration Fee Guarantee: The base administration fee,not including other charges such as producer fees,is guaranteed as shown below during the period from 1/1/2021 through 12131/2024. This period shall be known as the"administration fee guarantee period." Year Amount Contract Period Begins Contract Period Ends Year 1 $50.00 1/1/2021 12/31/2021 Year $51.00 1/1/2022 12/31/2022 Year 3 $52.02 1/1/2023 12/31/2023 Year $53.06 1/1/2024 12/31/2024 Claims Runout Processing Fee: 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. BlueCard Fee Amount: BlueCard Fees are tracked and billed monthly in addition to claims expense. 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. Premera 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 3.5. The fee shall be a proportionate share of$50,000 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. CareCompass3600 See Attachment F—CareCompass360° for an overview of services provided. Services are included in the Claims Administrator's Administration Fee except where stated below. Personal Health Support Not included in Administration Fee. $245 per actively (See Appendix 2) engaged Member per month of active engagement. BestBeginnings Maternity Engagement fee: $50 one-time fee per (See Appendix 3) Member when the Member registers for the program and downloads the mobile application High Risk Maternity Case $350 additional one-time Management fee for Members engaged in high-risk case management Neonatal Intensive Care Risk Assessment Fee waived &Case Management (See Appendix 4) 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 percent Subrogation 25 percent unless Claims Administrator, in its sole option or discretion, engages outside counsel, in which case the Contingent Fee amount shall be 35 percent, whether or not the case involves litigation or other dispute resolution process. 25 percent if, after Claims Administrator has worked a subrogation case, the Plan Sponsor takes over responsibility for the case and settles directly. 5 In all cases, Plan Sponsor is also responsible for payment of any court costs, such as filing fees, witness fees or court reporter fees. Provider Billing Errors 25 percent Credit Balance 25 percent Hospital Billing and Chart Review 35 percent 6 ATTACHMENT F — CARECOMPASS3600 Appendix 1 Care Facilitation Services Claims Administrator agrees to provide the following care facilitation services. Service Description Care Management Clinical review Prospective and retrospective review for medical necessity, appropriate application of benefits. 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. NurseLine Round-the-clock access for Members to registered nurses to answer questions about their health care. Pharmacy 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 Enhanced Controlled Substances Our standard program identifies and investigates Members Utilization Program (Opioid who show signs of drug misuse or addiction. When Management) warranted, these Members will only be able to get opioid Standard Option prescriptions from a particular pharmacy and may also be restricted to one prescriber. ePocrates Software to provide physicians with up-to-date drug and plan formulary information. Follow-up with Members and physicians to minimize Point-of-sale Pharmacy inappropriate or excessive drug therapies identified when drugs are dispensed. The Claims Administrator has contracted with one or more vendors that use technology to provide Members easier and more convenient access to medical care. Providers covered under the Virtual Care benefit offer their services Virtual Care exclusively through secure chat, text, voice or audio messaging and video chat. The virtual care services do not include real-time visits via online and telephonic methods between Members and their doctors or other providers who also maintain a physical location. 7 ATTACHMENT I — PERFORMANCE GUARANTEES s ATTACHMENT PERFORMANCE GUARANTEE AGREEMENT BETWEEN Premera Blue Cross of Washington AND City of Kent EFFECTIVE 1/1/2021 THROUGH 12/31/2021 (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. 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 $28,200.00 Performance Guarantee Metrics: 1)Account Management: Quarterly Account Management Team Satisfaction Survey The Company will provide an online survey that measures the effectiveness of account management in providing superior service to the client. The Account Management Survey shall be distributed to appropriate members of the Group's benefits staff, and/or third party benefit consultants as selected by the Group, at the end of each quarter. The Group and its selected associates shall complete the Online Account Management Survey within thirty (30) days of receipt. The failure of the group to respond to one of the quarterly surveys shall nullify the Account Management Survey metric, and the Company will not pay the penalty. Following the end of each quarter and receipt of the survey response(s) from the Group, the Company will calculate the Mean Score in each performance assessment category by using a mean score calculation. The Account Management Commitment will be deemed as fulfilled if Question 8 "Overall Satisfaction with Account Management Team" is equal to or greater than 3 on a 5 point satisfaction scale. Surveys with no response will be removed from our scoring computation. Only completed survey's submitted within 30 days of distribution will be used to score Account Management performance. This metric is Corporate Standard and reporting will be Group Specific; Quarterly Survey; Annual Settlement The estimated penalty for this metric will be $4,300.00 ATTACHMENT Performance Guarantee Metrics: 2) Claims : Claims Accuracy - Dollars The Company guarantees that at least 99% of total benefit dollars payments shall be accurate (less than 1% to be in error) in a contract year, when overpayments and underpayments are combined, not offset against one another. Calculated as Total Dollars Paid less Total Absolute Value of Dollar Errors, divided by Total Dollars Paid, based on annual randomly selected audit sample, not less than 99%. This metric is Corporate Standard and reporting will be Group Specific. Reported annually. The estimated penalty for this metric will be $4,300.00 3) Claims : Claims Accuracy - Frequency 95% of the Groups clean claims shall be paid without error (payment and procedural) in a contract year. Calculated as Total Claims With No Errors divided by Total Claims Paid, and based on annual randomly selected audit sample, not less than 95%. This metric is Corporate Standard and reporting will be Group Specific. Reported annually. The estimated penalty for this metric will be $4,300.00 4) Claims : Claims Clean Claims Turnaround Time within 30 Days Turnaround Time (TAT) is measured from the date a clean claim is received by the Company (either via paper or electronic data interchanges) to the date it is processed for payment, denied, or pended for external information. A clean claim is defined as one that has been received by The Company with the relevant and correct information required to process the claim. This claim will have no defects or irregularities, includes any required substantiating documentation, and can be adjudicated without interruption. The calculation for the Claim Turnaround Time percentage will be measured on the percentage of all Clean Claims processed within 30 Days of Receipt divided by Total Clean Claims Processed (*excluding Blue Card claims), not less than 97%. *Performance Standard will be tolled with respect to a claim during the period the claim is suspended for information outside The Company's claims processing system or scope of responsibility or control (i.e., review by other organizations not integrated into processing system). This metric is Corporate Standard and reporting will be Group Specific. Reported quarterly. The estimated penalty for this metric will be $4,300.00 ATTACHMENT Performance Guarantee Metrics: 5) 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 $2,400.00 6) Customer Service: Customer Service - Abandonment Rate The Company guarantees that no more than 5 percent of incoming calls that are made to our toll-free customer service telephone line shall be dropped before speaking to a Customer Service Representative. Customer Service Abandonment Rate calculated as Total Abandoned Calls divided by Total Accepted Calls. This metric is Corporate Standard and reporting will be Combined score of all PG Groups in Customer Service Unit. Reported quarterly, settled using 12 mo avg. The estimated penalty for this metric will be $4,300.00 7) Customer Service: Customer Service - Service Level within 30 seconds The Company guarantees that 75% of all calls to their toll-free customer service telephone line will be answered in thirty seconds or less. Answered means the time from when the caller selects the option to speak with an agent until a Customer Service Representative answers the call. Results are calculated as Total Calls Answered Within 30 Seconds divided by Total Calls Received. This metric is Corporate Standard and reporting will be Combined score of all PG Groups in Customer Service Unit. Reported quarterly, settled using 12 mo avg The estimated penalty for this metric will be $4,300.00 SECTION 3. EVALUATION OF PERFORMANCE AND PAYMENT OF PENALTIES ATTACHMENT 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.