HomeMy WebLinkAboutHR18-008 - Amendment - #6 - Premera Blue Cross - Administrative Service Contract - 1/1/24 FOR CITY OF KENT OFFICIAL USE ONLY
Sup/Mgr:
Agreement Routing Form DirAsst:
• For Approvals,Signatures and Records Management Dir/Dep:
KENT This form combines&replaces the Request for Mayor's Signature and Contract Cover (Optional)
WASHINGTON Sheet forms. (Print on pink or cherry colored paper)
Originator: Department:
Laura Horea Human Resources
Date Sent: Date Required:
c 10/08/2024 10/10/2024
QAuthorized to Sign: Date of Council Approval:
Q ❑✓ Mayor or Designee 10/01/2024
Budget Account Number: Grant? Yes No�✓
Budget?❑✓ Yes E]No Type: N/A
Vendor Name: Category:
Premera Contract
Vendor Number: Sub-Category:
Other
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Project Name: Premera
OProject Details:
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40
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Basis for Selection of Contractor: Other
� Agreement Amount: $1 408 356
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r r *Memo to Mayormustbe attached .1111
Start Date: 1/1/2024 Termination Date: 12/31/2026
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a Local Business? Yes F]No*If meets requirements per KCC 3.70.100,please complete"Vendor Purchase-Local Exceptions"form on Cityspace.
Business License Verification: ❑Yes In-Process F1 Exempt(KCC 5.01.045) FlAuthorized Signer Verified
Notice required prior to disclosure? Contract Number:
F—]YesF—]No
Comments:
n Premera Administrative Services Contract
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Date Received:City Attorney: 10/9/24 Date Routed:Mayor's Office City Clerk's Office
adccW22373_7_20 Visit Documents.KentWA.gov to obtain copies of all agreements
rev.20221201
PREMEM 141
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, 2023.
This Amendment shall further revise and extend the Contract for the period from
January 1, 2024 through December 31, 2024 (the "Contract Period"). The changes to
the Contract for the new Contract Period shown below shall take effect on January 1,
2024.
The changes are:
Face Page of Contract.
NOW THEREFORE section is hereby amended by removing the last sentence and now reads as
follows:
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.
Section 2, Duties And Responsibilities Of The Plan Sponsor.
1. Subsection 2.4.e, is hereby amended to add the following Member Engagement
language. It reads:
• Plan Sponsor agrees that, and grants permission for, the following personal data to be used
by the Claims Administrator, and shared with Claims Administrator's vendors who provide a
health plan benefit service for use, for the purpose of sending directed notifications to
members regarding programs and services included in their health plan benefits: member
name, member address, member email and phone number. The first paragraph of
Subsection 2.8, Funding is hereby replaced. It now reads as follows:
The Plan Sponsor shall be solely liable for all benefits payable to Members under the Plan that are
subject to this Contract and for value-based program payments and any other payments authorized
under this Contract
Section 3, Duties And Responsibilities Of The Claims Administrator.
1. Subsection 3.1.i, is hereby amended. It now reads:
i. Pharmacy Benefit Program For pharmacy benefit claims, Claims Administrator will pay Plan
Sponsor a prescription drug rebate payment equal to a specific amount per paid brand-name
prescription drug claim. The actual refund will be the specific amount less applicable Washington
State B&O taxes. Prescription drug rebates Claims Administrator receives from its pharmacy
benefit administrator in connection with Claims Administrator's overall pharmacy benefit utilization
ASCAM (0 1-2024)
An Independent Licensee of the Blue Cross Blue Shield Association
may be more or less than the Plan Sponsor's rebate payment. The Plan Sponsor's rebate payment
shall be made to the Plan Sponsor on a calendar 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 parties hereby agree that the difference between the allowable charge for prescription drugs
and the price paid to the pharmacy benefit manager, and the prescription drug payments received
by Claims Administrator from its pharmacy benefit manager, constitutes our property, and not part
of the compensation payable to Plan Sponsor under this Contract, and that Claims Administrator is
entitled to retain and shall retain such amounts and may apply them to the cost of its operations
and the pharmacy benefit.
Medical Benefit Drug Program The medical benefit drug program is separate from the
pharmacy program. It includes claims for drugs delivered as part of medical services. For medical
benefit drug claims, the Claims Administrator may contract with subcontractors that have rebate
contracts with various manufacturers. Rebate subcontractors retain a portion of rebates collected
as a rebate administration fee. The Claims Administrator retains a portion of the rebate. The Plan
Sponsor's medical benefit drug rebate payment shall be made to the Plan Sponsor on an annual
basis if the rebate is $500 or more, less applicable Washington State B&O Taxes. If less than
$500, the Claims Administrator will retain the medical benefit drug rebate.
Notwithstanding the above as set forth in 3.1.i, if government action, changes in law or regulation,
or actions by a pharmaceutical manufacturer result in adverse effects to the availability of rebates
or to the Claims Administrator's expectation of future rebate payments, the Claims Administrator
shall have the right to update these terms.
2. Subsection 3.1.k,is hereby added to the contract. It reads:
Solely as a convenience, Claims Administrator will make available the provider directory of in network
healthcare providers as well as certain machine-readable files, and cost sharing information. Claims
Administrator will file prescription drug data collection (RxDC)on the Plan Sponsor's behalf as it
pertains to the Plan Sponsor's compliance requirements set forth below. Claims Administrator is not
responsible for self-funded Plan Sponsor health plan compliance. Plan Sponsor is responsible for its
self-funded health plan compliance and may choose to access and use the information provided as a
convenience solely at its discretion to address compliance requirements pursuant to the Transparency
Coverage rules set forth in 26 CFR 54.9815-2715A1 —2715A3; 29 CFR 2590.715-2715A1 —2715A3;
45 CFR 147.210—212; 26 CFR 54.9825-4T-6T and Federal No Surprises Billing Act set forth in 29
CFR 2590.716-1 to 29 CFR 2590.725-4; 45 CFR Part 149, as applicable; 26 CFR 54.9816-1T to 26
CFR 54.9831-1, as applicable. Claims Administrator will make available only the applicable data
described above for the services provided to the Plan Sponsor under this contract and only the portion
of that applicable data it currently has in its possession.
Section 4, Limits Of The Claims Administrator's Responsibilities.
The fourth paragraph is hereby amended. It now reads:
The Claims Administrator reserves the right to not administer any benefit or service that is at risk of
violating state or federal law or is illegal under state or federal law.
Section 7, Term of Contract.
Subsection 7.1, 3rd paragraph is hereby amended to capture changes to Premera's day to day
business practices. It reads as follows:
The Claims Administrator reserves the right to amend this Contract at any time if needed to comply
with applicable law or regulation and on an annual basis to reflect any necessary updates to Claims
Administrator's business practices applicable to this contract.
2
Section 8, Termination.
1. A new paragraph is hereby added to this section. It reads as follows:
If this contract is terminated, the Plan Sponsor shall be liable for any payments and services rendered
before the effective date of termination.
2. Subsection 8.2, Contract Period Expiration is hereby amended. It now reads:.
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 Sponsor. If there is an administration fee guarantee period set
forth in Attachment D—Fees Of the Claims Administrator and Plan Sponsor terminates pursuant to
this 8.2 for a contract period that is shorter than the aforementioned administration guarantee period,
liquidated damages as described in 8.6 below are applicable to Plan Sponsor.
3. Subsection 8.5, Termination for Nonpayment is hereby amended. It now reads:
The Claims Administrator may, at its sole discretion, terminate this Contract effective as of a missed
payment or payment of funds due date in the event that the Plan Sponsor fails to make a timely
payment required under this Contract.
4. Subsection 8.6, Plan Sponsor Liability Upon Termination, 3rd sentence is hereby
amended. It reads::
Therefore, in the event that the Contract terminates pursuant to subsections 9.1, 9.5, or 9.2 above, but
prior to the end of the administration fee guarantee period shown in Attachment D—Fees Of The
Claims Administrator, 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.
Section 10, Other Provisions
1. Subsection 10.5, Integration. The subtitle has been deleted in its entirety and replaced
with subtitle "Entire Agreement."
2. Subsection 10.9, Contract Amendments is hereby added to the contract. It reads:.
10.9. Contract Amendments.
This contract shall be modified by Claims Administrator at any time by changes to federal or state law
as of the implementation date of the law or regulation. If there is any inconsistency between this
contract or any state or federal law, the law shall govern.
Attachment D, Fees of the Claims Administrator.
1. The first page of Attachment D of the contract is deleted in its entirety and replaced by
the first page of Attachment D to this amendment.
2. Value Based Program Payments section is hereby amended. It now reads as follows:
Value-Based Program Payments
Provider groups enter into agreements with Claims Administrator or other Blue Cross and/or Blue
Shield Licensees (Host Blues)for value-based programs. These programs offer payment and care
delivery models that support more coordinated, efficient and quality-driven healthcare aimed at
encouraging coordination and optimizing services to control cost. Such programs include but are not
limited to the following: the BCBSA Total Care program, shared savings arrangements like Global
Outcomes Contracts, accountable care organizations, patient-centered medical homes, global
payment/total cost of care arrangements, outcomes-based payment arrangements, provider
enablement arrangements, and coordinated care model arrangements.
3
Claims Administrator and the Host Blues may pay value-based program providers for meeting the
programs' standards for treatment outcomes, cost efficiency and quality. Claims Administrator and the
Host Blues plans may also pay value-based program providers for provider enablement activities to
facilitate patient care coordination and clinical support activities. Arrangements with these providers
and payments related to these programs require investments in health information technology
including but not limited to workflow automation, clinical and eligibility data exchanges, referral,
medication reconciliation and care transitional support to continue to improve cost and quality
outcomes for members.
The Plan Sponsor shall pay the Claims Administrator a per-member-per month (PMPM) amount
established for each value-based program provider's attributed or assigned members. The PMPM
amount will be multiplied by the number of the Plan Sponsor's Members that are attributed or assigned
to each provider group. The PMPM amounts differ between the provider groups and may change
during the Contract Period. All PMPM amounts are paid to the value-based program provider per the
arrangement between Claims Administrator and provider and the Claims Administrator receives no
compensation or mark-up associated with the PMPM payment. In the case of pay for performance
programs, the PMPM amount is tied to specific outcomes achieved by the provider. In the case of
care coordination, the PMPM amount is tied to productivity or development/maintenance activities
completed in support of patient care coordination and clinical support activities. Detailed reporting
including but not limited to program PMPM charges and available settlement or productivity reporting
will be provided to Plan Sponsor within or as a supplement to the Plan Sponsor billing statement.
Additional information is available upon request, and a charge may apply.
3. The Surprise Billing Protection Program has been renamed and updated. It now reads:
WA Surprise Billing Protection Program-
The Plan Sponsor will reimburse the Claims Administrator the following fees and amounts expended
by the Claims Administrator for each arbitration as defined by state law.
4. The Federal No Surprise Billing section is deleted in its entirety and replaced with the
following to further clarify expenses involved with the FNSA OR process. It describes
how the fees associated with the IDR process will be handled.
Federal No Surprises Act Independent Dispute Resolution (IDR) Process
The Plan Sponsor will reimburse the Claims Administrator the following fees and amounts expended
by the Claims Administrator or the Blue Cross Blue Shield Association licensee that are associated
with each Independent Dispute Resolution as defined under federal law:
Fee Amount
Arbitration Fee, per arbitration $2,500
For representation of the Plan in arbitration proceedings initiated by a
provider.
Federal IDR Process Fee, per arbitration. Variable
Administrative fee due from each party participating in the Federal OR
process. The fee is set by the Federal Government and subject to
adjustment.
Certified IDR Entity Fee, per arbitration Variable
The non-prevailing party in arbitration is responsible for the certified OR
entity fee. The Certified OR Entity Fee will vary within a range for single case
or batched determinations. The fee ranges will be adjusted annually by the
Federal Government.
4
5. The No Cost Rx Program is hereby added to the contract. It reads:
No Cost Rx Programs:
Right Price: Right Price is a no cost program offered through our existing pharmacy benefit manager.
Right Price embeds a discount card prick check and integrates the discount card price, if applicable,
into existing claim logic for retail generics.
Attachment F, CareCompass360.
Appendix 5, Chronic Condition Management Program has been removed in its entirety.
Attachment H, Premera Value-Based Provider Arrangements
Attachment H is amended and hereby made part of the contract. It reads as follows:
Value-Based Program Payments
Provider groups enter into agreements with Claims Administrator or other Blue Cross and/or Blue
Shield Licensees (Host Blues)for value-based programs. These programs offer payment and care
delivery models that support more coordinated, efficient and quality-driven healthcare aimed at
encouraging coordination and optimizing services to control cost. Such programs include but are not
limited to the following: the BCBSA Total Care program, shared savings arrangements like Global
Outcomes Contracts, accountable care organizations, patient-centered medical homes, global
payment/total cost of care arrangements, outcomes-based payment arrangements, provider
enablement arrangements, and coordinated care model arrangements.
Claims Administrator and the Host Blues may pay value-based program providers for meeting the
programs' standards for treatment outcomes, cost efficiency and quality. Claims Administrator and the
Host Blues plans may also pay value-based program providers for provider enablement activities to
facilitate patient care coordination and clinical support activities. Arrangements with these providers
and payments related to these programs require investments in health information technology
including but not limited to workflow automation, clinical and eligibility data exchanges, referral,
medication reconciliation and care transitional support to continue to improve cost and quality
outcomes for members.
The Plan Sponsor shall pay the Claims Administrator a per-member-per month (PMPM) amount
established for each value-based program provider's attributed or assigned members. The PMPM
amount will be multiplied by the number of the Plan Sponsor's Members that are attributed or assigned
to each provider group. The PMPM amounts differ between the provider groups and may change
during the Contract Period. All PMPM amounts are paid to the value-based program provider per the
arrangement between Claims Administrator and provider and the Claims Administrator receives no
compensation or mark-up associated with the PMPM payment. In the case of pay for performance
programs, the PMPM amount is tied to specific outcomes achieved by the provider. In the case of
care coordination, the PMPM amount is tied to productivity or development/maintenance activities
completed in support of patient care coordination and clinical support activities. Detailed reporting
including but not limited to program PMPM charges and available settlement or productivity reporting
will be provided to Plan Sponsor within or as a supplement to the Plan Sponsor billing statement.
Additional information is available upon request, and a charge may apply.
Attachment J Chronic Condition Management Program
The Attachment J to the contract is replaced by the Attachment J to this amendment and is
hereby made part of the contract.
Attachment K Performance Guarantees
Attachment K to this amendment is hereby made part of the contract.
5
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: =4_ _ _ DATE: 10/16/2024
Mayor
Title
ADDRESS: 220 4th Ave S
Kent, WA 98032
PREMERA BLUE CROSS
71��
BY: DATE: January 1, 2024
Jeffrey Roe
President and Chief Executive Officer
P.O. Box 327
Seattle, WA 98111-0327
6
ATTACHMENT B - CENSUS INFORMATION
Administration Fees, effective January 1, 2024, are based on the following:
Number of Active and Retired Members: 1,884
Employee Dependents
Medical/Rx 710 1,174
Number of COBRA Members: None
Employee Dependents
Medical/Rx 0 0
7
ATTACHMENT D
to the Administrative Service Contract
between
PREMERA BLUE CROSS
and
City of Kent
Group Number:1018212
Effective: 1/1/2024 through 12/31/2024
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:
$53.93 per employee per month
Administration Fee Breakdown:
Administration Fee(Medical/Rx) $50.43
Producer Fee $3.50
Total $53.93
Administration Fee Guarantee:
The base administration fee,not including other charges such as producer fees,is guaranteed as shown below during the period from
1/1/2024 through 12/31/2026. This period shall be known as the"administration fee guarantee period."
Year Amount Contract Period Begins Contract Period Ends
Year 1 $50.66 1/1/2024 12/31/2024
Year 2 $51.67 1/1/2025 12/31/2025
Year 3 $52.70 1/1/2026 12/31/2026
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 Claims Administrator or other Blue Cross and/or Blue Shield
Licensees (Host Blues)for value-based programs. These programs offer payment and care delivery models
that support more coordinated, efficient and quality-driven healthcare aimed at encouraging coordination and
optimizing services to control cost. Such programs include but are not limited to the following: the BCBSA Total
Care program, shared savings arrangements like Global Outcomes Contracts, accountable care organizations,
patient-centered medical homes, global payment/total cost of care arrangements, outcomes-based payment
arrangements, provider enablement arrangements, and coordinated care model arrangements.
Claims Administrator and the Host Blues may pay value-based program providers for meeting the programs'
standards for treatment outcomes, cost efficiency and quality. Claims Administrator and the Host Blues plans
may also pay value-based program providers for provider enablement activities to facilitate patient care
coordination and clinical support activities. Arrangements with these providers and payments related to these
programs require investments in health information technology including but not limited to workflow
automation, clinical and eligibility data exchanges, referral, medication reconciliation and care transitional
support to continue to improve cost and quality outcomes for members.
The Plan Sponsor shall pay the Claims Administrator a per-member-per month (PMPM) amount established
for each value-based program provider's attributed or assigned members. The PMPM amount will be multiplied
by the number of the Plan Sponsor's Members that are attributed or assigned to each provider group. The
PMPM amounts differ between the provider groups and may change during the Contract Period. All PMPM
amounts are paid to the value-based program provider per the arrangement between Claims Administrator and
provider and the Claims Administrator receives no compensation or mark-up associated with the PMPM
payment. In the case of pay for performance programs, the PMPM amount is tied to specific outcomes
achieved by the provider. In the case of care coordination, the PMPM amount is tied to productivity or
development/maintenance activities completed in support of patient care coordination and clinical support
activities. Detailed reporting including but not limited to program PMPM charges and available settlement or
productivity reporting will be provided to Plan Sponsor within or as a supplement to the Plan Sponsor billing
statement. Additional information is available upon request, and a charge may apply.
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.
WA Surprise Billing Protection Program
The Plan Sponsor will reimburse the Claims Administrator the following fees and amounts expended by the
Claims Administrator for each arbitration as defined by state law.
Self-Funded Group Health Plan Opt-in Form No charge
Completion
Arbitration Fee, per arbitration $2,500
For representation of the Plan in arbitration
proceedings initiated by a provider.
All other outside counsel fees will be passed through
to the Plan Sponsor. Should a provider submit
arbitration claims aggregating claims from more than
one client (fully insured or self-funded), the outside
counsel fees will be pro-rated based upon the
number of claims from the Plan as a percentage of
the total number.
Claim Reprocessing Fee, per claim $200
9
Federal No Surprises Act Independent Dispute Resolution (IDR) Process
The Plan Sponsor will reimburse the Claims Administrator the following fees and amounts expended by the
Claims Administrator or the Blue Cross Blue Shield Association licensee that are associated with each
Independent Dispute Resolution as defined under federal law:
Fee Amount
Arbitration Fee, per arbitration $2,500
For representation of the Plan in arbitration proceedings initiated by a provider.
Federal IDR Process Fee, per arbitration (for invoices paid prior to 8/2/2023) *$350
Administrative fee due from each party participating in the Federal IDR process.
Federal IDR Process Fee, per arbitration (for invoices paid after 8/2/2023) *$50
Administrative fee due from each party participating in the Federal IDR process.
Certified IDR Entity Fee, per arbitration Variable
The non-prevailing party in arbitration is responsible for the certified IDR entity fee.
The Certified IDR Entity Fee will vary within a range for single case or batched
determinations. The fee ranges will be adjusted annually by the Federal Government.
Outside Legal Counsel Fee, per arbitration Variable
All outside counsel fees will be passed through to the Plan Sponsor. Should a
provider submit arbitration claims aggregating claims from more than one client (fully
insured or self-funded), the outside counsel fees will be pro-rated based upon the
number of claims from the Plan as a percentage of the total number.
CareCompass360*
See Attachment G—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. $300 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)
No Cost Programs
Rx Programs:
Right Price: Right Price is a no cost program offered through our existing pharmacy benefit manager. Right
Price embeds a discount card prick check and integrates the discount card price, if applicable, into existing
claim logic for retail generics.
10
ATTACHMENT H — PREMERA VALUE-BASED PROVIDER
ARRANGEMENTS
Value-Based Program Payments
Provider groups enter into agreements with Claims Administrator or other Blue Cross and/or Blue Shield
Licensees (Host Blues)for value-based programs. These programs offer payment and care delivery models
that support more coordinated, efficient and quality-driven healthcare aimed at encouraging coordination and
optimizing services to control cost. Such programs include but are not limited to the following: the BCBSA Total
Care program, shared savings arrangements like Global Outcomes Contracts, accountable care organizations,
patient-centered medical homes, global payment/total cost of care arrangements, outcomes-based payment
arrangements, provider enablement arrangements, and coordinated care model arrangements.
Claims Administrator and the Host Blues may pay value-based program providers for meeting the programs'
standards for treatment outcomes, cost efficiency and quality. Claims Administrator and the Host Blues plans
may also pay value-based program providers for provider enablement activities to facilitate patient care
coordination and clinical support activities. Arrangements with these providers and payments related to these
programs require investments in health information technology including but not limited to workflow
automation, clinical and eligibility data exchanges, referral, medication reconciliation and care transitional
support to continue to improve cost and quality outcomes for members.
The Plan Sponsor shall pay the Claims Administrator a per-member-per month (PMPM) amount established
for each value-based program provider's attributed or assigned members. The PMPM amount will be multiplied
by the number of the Plan Sponsor's Members that are attributed or assigned to each provider group. The
PMPM amounts differ between the provider groups and may change during the Contract Period. All PMPM
amounts are paid to the value-based program provider per the arrangement between Claims Administrator and
provider and the Claims Administrator receives no compensation or mark-up associated with the PMPM
payment. In the case of pay for performance programs, the PMPM amount is tied to specific outcomes
achieved by the provider. In the case of care coordination, the PMPM amount is tied to productivity or
development/maintenance activities completed in support of patient care coordination and clinical support
activities. Detailed reporting including but not limited to program PMPM charges and available settlement or
productivity reporting will be provided to Plan Sponsor within or as a supplement to the Plan Sponsor billing
statement. Additional information is available upon request, and a charge may apply.
11
ATTACHMENT J — CHRONIC CONDITION MANAGEMENT PROGRAM
The Chronic Condition Management program helps members with chronic conditions to manage them in order
to live healthier lives. The Claims Administrator's Chronic Condition Management Program Manager(the
Program Manager) monitors participating Members' health data and uses it to create actionable, personalized
and timely coaching and reminders. The Program Manager receives Members' health data in real time via
cellular technology.
The Program Manager is able to share the data with the Member's doctor or someone close to the Member if
the Member requests it.
Personalized support and interaction are available during normal business hours. However, coaches are
available to support acute events 24 hours a day, 365 days a year.
Covered Services
Diabetes Management:
For members who have Type 1 or Type 2 diabetes.
Members receive:
• A blood glucose meter from the Program Manager that uploads blood sugar readings to the Member's
personal online account. Members must use the Program Manager's meter. A carrying case comes
with the meter.
• Unlimited test strips for this meter. Members can reorder test strips using the meter or online. The
strips will be sent to the Member directly.
• A lancing device and lancets.
• Control solution
• Real-time reminders to check blood sugar or to take medication, and tips based on the Member's
blood sugar readings that can help keep blood sugar levels within a healthy range.
• One on one live coaching and support via phone, text, e-mail, or the program manager's mobile app.
Coaches are health professionals, such as dietitians or registered nurses, that are certified diabetes
educators.
• Health summary reports that Members can share with their doctors
• The Program Manager's mobile application
Access To Services
• The Claims Administrator will work with the Program Manager to identify Members who meet the
qualifications for the Diabetes Management and Hypertension programs. The Claims Administrator will
transmit eligibility files weekly to the Program Manager.
• For the Diabetes Prevention program, the Program Manager will ask Members to complete a brief
screening questionnaire to determine if the member meets eligibility criteria.
Billing
The Program Manager will submit medical claims for the services. Members pay nothing.
The Program Manager will contact Members who stop participating in the program by phone to engage or re-
engage them. If the Member does not re-engage, the Program Manager will not bill for that Member beyond
the initial period.
Members have the option to cancel the program at any time.
12
ATTACHMENT K
PERFORMANCE GUARANTEE AGREEMENT
BETWEEN
Premera Blue Cross of Washington
AND
City of Kent
EFFECTIVE 1/1/2024 THROUGH 12/31/2024 (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 $29,500.00
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 $4,500.00
1 of 4
Performance Guarantee Metrics:
2) 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 Book of Business; Reported quarterly and settled
annually
The estimated penalty for this metric will be $4,500.00
3) 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 Book of Business; Reported quarterly and settled
annually
The estimated penalty for this metric will be $4,500.00
4) 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 Book of Business; Reported quarterly and settled
annually
The estimated penalty for this metric will be $4,500.00
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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 $2,500.00
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 $4,500.00
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 $4,500.00
SECTION 3. EVALUATION OF PERFORMANCE AND PAYMENT OF PENALTIES
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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.
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