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HomeMy WebLinkAboutHR18-008 - Amendment - #1 - Premera Blue Cross - Administrative Services Contract - 1/1/19 PREMEM 10 AMENDMENT 1 TO ADMINISTRATIVE SERVICE CONTRACT BETWEEN PREMERA BLUE CROSS AND CITY OF KENT EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019 (The "Contract Period") The Administrative Service Contract ("Contract") between the above named group (the "Plan Sponsor") and Premera Blue Cross (the "Claims Administrator") was issued January 1, 2018. This Amendment shall further revise and extend the Contract for the period from January 1, 2019 through December 31, 2019 (the "Contract Period"). The changes to the Contract for the new Contract Period shown below shall take effect on January 1, 2019. The changes are: Section 1 Definitions 1. A Dialysis subsection has been added to the definition of Allowed Amount. We have made two changes to the definition to support the new language. • The second paragraph of the definition has been revised to read: The Claims Administrator reserves the right to determine the amount allowed for any given service or supply unless specified otherwise in this Contract. The Allowed Amount is described below. There are different rules for dialysis and emergency services. These rules are shown below the general rules. • A new section has been added after Emergency Care: c. Dialysis Due To End-Stage Renal Disease 1. Providers Who Have Agreements With the Claims Administrator Or Other Blue Cross Blue Shield Licensees The Allowed Amount is the amount explained above in this definition. 2. Providers Who Don't Have Agreements With the Claims Administrator Or Another Blue Cross Blue Shield Licensee The amount the Plan allows for dialysis will be no less than 125 percent of the amount allowed by Medicare and no more than 90 percent of billed charges. 2. A few defined terms have been changed throughout the Contract: • Network Providers are now called In-Network Providers. • Non-Network Providers are now called Out-Of-Network Providers. 2. A new provision is added to subsection 2.4, Administrative Duties. It asks the Plan Sponsor to confirm that subscriber and member telephone numbers were provided by the subscriber or member rather than through a lookup service or other third party. The new provision reads: e In order to place calls to Members, the Claims Administrator may receive Member phone numbers provided by the Plan Sponsor or by a third party (such as a producer) on the Plan Sponsor's behalf For the Claims Administrator and its affiliates to contact Members in accordance with telecommunication- related laws and regulations, the Plan Sponsor confirms the following with respect to Member phone numbers that the Plan Sponsor has provided or will provide to the Claims Administrator: • The Member provided his or her phone number on his or her Plan application, or otherwise provided ASCAM (09-2018) An Independent Licensee of the Blue Cross Blue Shield Association or updated his or her phone number with the Plan Sponsor with the expectation that it will be provided to the Claims Administrator in connection with the Member's coverage under the Plan. • The Plan Sponsor only obtains phone numbers directly from the Member and not through a lookup service or other third party. • The Plan Sponsor retains contact information and will furnish that information to the Claims Administrator upon request in a timely manner. Section 3 Duties And Responsibilities Of The Claims Administrator 1. A new provision h. has been added to Subsection 3.1: h. The Claims Administrator will work with its pharmacy benefit manager to manage the drug list chosen by the Plan Sponsor. A new provision j. has been added to Subsection 3.1: j. The Claims Administrator, at its sole discretion, reserves the right to delegate some or all of its duties and responsibilities under this Contract to a third party. Section 5 Fees Of The Claims Administrator 5.2 Late Payments We have revised the subsection to lengthen the grace period for administrative fees from 10 days to 30 days. The revised subsection reads: a. If, for any reason whatsoever, the Plan Sponsor fails to make a timely payment required under this Contract by the thirtieth 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 subsequent delinquent or nonpayment of fees. c. The Claims Administrator will charge interest to the Plan Sponsor on all payments received after the thirtieth 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. Section 8 Term of Contract 8.1. Contract Period We have added a sentence about mid-year changes to the second paragraph of subsection 8.1. The revised paragraph reads: 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. Midyear benefit or administrative changes (other than those in 8.2.a.6.) require thirty(30) days advance written notice and the advance approval of the Claims Administrator. The exception in the new sentence refers to the 120 days advance notice required for plan sponsors that want to change or add another third party administrator to manage tasks not included in this Contract, such as COBRA administration or processing of membership changes on behalf of the plan sponsor. 2 Attachment A Out-Of-Area Services The BlueCard Worldwide provision in the "Out-Of-Area Services"Attachment has been revised to show the new name of the program: Blue Cross Blue Shield Global Core. It reads: Blue Cross Blue Shield Global® Core If Members are outside the United States, the Commonwealth of Puerto Rico, and the U.S. Virgin Islands (the "BlueCard service area"), they may be able to take advantage of Blue Cross Blue Shield Global Core. Blue Cross Blue Shield Global Core is unlike the BlueCard Program available in the BlueCard service area in certain ways. For instance, although Blue Cross Blue Shield Global Core helps Members access a provider network, they will typically have to pay the provider and submit the claims themselves to get reimbursement for covered services. However, if Members need hospital inpatient care, the Service Center can often direct them to hospitals that will not require them to pay in full at the time of service. These hospitals will also submit the Member's claims to Blue Cross Blue Shield Global Core. Attachment C — Reporting We have revised the last paragraph of this attachment to be more flexible. The paragraph no longer says that fees for custom reports (when required) would have to be charged to the Plan Sponsor. The new language allows Premera to charge a third party when such an arrangement is agreed upon. The paragraph reads: If the Plan Sponsor requests a report that includes information not provided in our standard package of reports or a custom format for standard data, we reserve the right to charge additional fees as needed for that report. Attachment D Fees Of The Claims Administrator The revised Attachment D attached to this Amendment is hereby made a part of the Contract. Attachment H Performance Guarantees The revised Attachment H attached to this Amendment is hereby made a part of the Contract. 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 DENT BY: �. DATE: bkAR �V6%, vk.(,o Title ADDRESS: q O \0 co �03 -� PREMERA BLUE CROSS Dyn BY: DATE: January 1, 2019 Jeffrey Roe President and Chief Executive Officer P.O. Box 327 Seattle, WA 98111-0327 3 ATTACHMENT B - CENSUS INFORMATION Administration Fees, effective January 1, 2019, are based on the following: Number of Active Members: Employee Spouse Children Medical/Rx 637 394 774 Number of COBRA Members: Employee Spouse Children Medical/Rx 11 2 5 Number of Retiree Members: Employee Spouse Children Medical/Rx 63 2 0 Other Carriers Offered: None 4 i ATTACHMENT D - FEES OF THE CLAIMS ADMINISTRATOR 5 ATTACHMENT D to the Administrative Service Contract between PREMERA BLUE CROSS and CITY OF KENT Group Number:1018212 Effective: 1/1/2019 through 12/31/2019 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: $60 47 per employee per month Administration Fee Breakdown: Administration Fee(Medical/Rx) $56 97 Producer Fee 3.50 Total $60 47 Administration Fee Guarantee: The base administration fee,not including other charges such as producer fees,is guaranteed as shown below during the period from 1/1/2019 through 12/31/2020 This period shall be known as the"administration fee guarantee period" Year Amount Contract Period Begins Contract Period Ends Year 1 $56 97 1/1/2019 12/31/2019 Year 2 $58 68 1/1/2020 12/31/2020 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 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. 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 "3.6 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. 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 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) 6 i 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"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. 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 H - PERFORMANCE GUARANTEES i 8 ATTACHMENT H PERFORMANCE GUARANTEE AGREEMENT BETWEEN Premera Blue Cross of Washington AND City of Kent EFFECTIVE 1/1/2019 THROUGH 12/31/2019 (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 $31,400.00 Performance 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 $4,800.00 ATTACHMENT H Performance 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 $4,800.00 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 $4,800.00 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 $4,800.00 ATTACHMENT H Performance 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 $2,600.00 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 $4,800.00 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 $4,800.00 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.