HomeMy WebLinkAboutHR18-008 - Amendment - #1 -Premera Blue Cross - Administrative Service Contract - 01/01/2018ApprovalOriginator:Department:
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rev. 200821
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An Independent Licensee of the Blue Cross Blue Shield Association
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 CareCompass360°
•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:
Virtual Care
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
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.
2
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: DATE:
Title
ADDRESS:
PREMERA BLUE CROSS
BY: DATE: January 1, 2021
Jeffrey Roe
President and Chief Executive Officer
P.O. Box 327
Seattle, WA 98111-0327
Dana Ralph
Mayor
220 Fourth Avenue S.
Kent, WA 98032
03/22/2021
3
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
4
ATTACHMENT D – FEES OF THE CLAIMS ADMINISTRATOR
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 12/31/2024. This period shall be known as the "administration fee guarantee period."
Year Amount
Year 1 $50.00
Year 2 $51.00
Year 3 $52.02
Year 4 $53.06
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.
Contract Period Begins
1/1/2021
1/1/2022
1/1/2023
1/1/2024
Contract Period Ends
12/31/2021
12/31/2022
12/31/2023
12/31/2024
5
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 wo rk 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.
CareCompass360°
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
(See Appendix 2)
Not included in Administration Fee. $245 per actively
engaged Member per month of active engagement.
BestBeginnings Maternity
(See Appendix 3)
Engagement fee: $50 one-time fee per
Member when the
Member registers for the
program and downloads
the mobile application
High Risk Maternity Case
Management
$350 additional one-time
fee for Members engaged
in high-risk case
management
Neonatal Intensive Care Risk Assessment
& Case Management
(See Appendix 4)
Fee waived
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
Category Contingent Fee
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.
6
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
7
ATTACHMENT F – CARECOMPASS360°
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.
Quality Programs
Includes provision of evidence-based clinical practice and
preventive care guidelines to Members and providers,
chart tools, and quality of care program activities.
NurseLine Round-the-clock access for Members to registered nurses
to answer questions about their health care.
Pharmacy
Prescription drug formulary
promotion
Development of formulary and access to providers and
Members on-line
Physician-based pharmacy
management
Physician education on cost-effective prescribing
Enhanced Controlled Substances
Utilization Program (Opioid
Management)
Standard Option
Our standard program identifies and investigates Members
who show signs of drug misuse or addiction. When
warranted, these Members will only be able to get opioid
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.
Point-of-sale Pharmacy
Follow-up with Members and physicians to minimize
inappropriate or excessive drug therapies identified when
drugs are dispensed.
Virtual Care
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
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.
8
ATTACHMENT I – PERFORMANCE GUARANTEES
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
BETWEEN
Premera Blue Cross of Washington
PERFORMANCE GUARANTEE AGREEMENT
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
ATTACHMENT I
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 I
SECTION 3. EVALUATION OF PERFORMANCE AND PAYMENT OF PENALTIES
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
ATTACHMENT I
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.
ATTACHMENT I