Loading...
HomeMy WebLinkAboutHR18-008 - Amendment - #4 - Premera Blue Cross - Administrative Service Contract - 1/1/2022 PREMERA 10. AMENDMENT #2 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. The Contract was later updated by the amendment or amendments listed below: Amendment 1 from January 1, 2021 to December 31, 2021 This Amendment shall further revise and extend the Contract for the period from January1, 2022 through December 31, 2022 (the "Contract Period"). The changes to the Contract for the new Contract Period shown below shall take effect on January 1, 2022. The changes are: Section 1 Definitions • The second paragraph in the Allowed Amount has been revised. The paragraph now reads: 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, emergency care services, and air ambulance services. These rules are shown below the general rules. • Subsection c. Emergency Care in the definition of Allowed Amount has been revised. The subsection now reads: c. Emergency Care As applicable law requires, for specified covered services received from Non-Contracted Providers or Out-of-Network Providers at facilities that have a Contract with the Claims Administrator or the local Blue Cross and/or Blue Shield Licensee, the cost-sharing for these services shall be the same as if the services were provided by an In-Network Provider. Note: Non-contracted ground ambulances are always paid based on billed charges. Consistent with applicable laws, Members are not responsible for charges received from Non-Contracted Providers above the Allowed Amount in addition to any deductible, copays, or coinsurance that may apply. • Subsection d. Air Ambulance in the definition of Allowed Amount has been created. The subsection reads: d. Air Ambulance Consistent with the requirements of the Federal No Surprises Act, the cost-sharing for out-of-network air ambulance services shall be the same as if the services were provided by an In-Network Provider. The cost sharing amount shall be counted towards the in-network deductible, if any, and any in-network out- of-pocket maximum amount, Cost-sharing shall be based upon the lesser of the qualifying payment amount(as defined under the Federal No Surprises Act)or the billed amount. An Independent Licensee of the Blue Cross Blue Shield Association • A definition of Program Manager has been added. It reads: Program Manager Certain vendors of Claims Administrator that provide certain of the administrative services. Claims Administrator arranges for the provision of services by Program Managers, as described in Attachments and Appendixes hereto, as well as other services which may include, based on your selections, provider quality performance information, supplemental networks, and outcomes-driven drug utilization review and medical drug rebate programs Please note: Where applicable,we added reference of Program Manager throughout the Contract. Section 2 Duties And Responsibilities Of The Plan Sponsor • A new bullet point is added to subsection 2.6 Compliance With Law: • The No Surprises Act, enacted as part of the Consolidated Appropriations Act, 2021 Attachment F CareCompass360° ■ The Care Facilitation Services in Appendix 1 has been revised. The impacted Care Facilitation Services now reads: Service Description Care Management Prospective and retrospective review for medical necessity, appropriate application of benefits. Independent medical review and independent clinical management Clinical review which may include advanced imaging (as well as Member shopping tools), radiation oncology therapy, sleep studies and genetic testing are administered by the Claims Administrator's designated Program Manager(s). 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. Round-the-clock access for Members to registered nurses NurseLine to answer questions about their health care administered by the Claims Administrator's designated Program Manager. 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 ePocrates Software to provide physicians with up-to-date drug and Plan formulary information. Enhanced Controlled Substances Our program, administered by the Claims Administrator's designated Program Manager, identifies and investigates Utilization Program (Opioid Members who show signs of drug misuse or addiction. Management) When warranted, these Members will only be able to get opioid prescriptions from a particular pharmacy and may also be restricted to one prescriber. 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 Virtual Care vendors (Program Managers)that uses interactive audio and video technology or using store and forward technology in real-time communication between the Member at the originating site and the provider for 2 diagnoses, consultation, or treatment. Services must meet the following requirements: • Covered service under this Plan • Originating site: hospital, rural health clinic, federally qualified health center, physician's or other health care provider office, community mental health center, skilled nursing facility, home, or renal dialysis center, except an independent renal dialysis center • If the service is provided through store and forward technology, there must be an associated office visit between the Member and the referring provider. • Is Medically Necessary Attachment J Surprise Billing Protection Attachment J describing the Surprise Billing Protection Program is hereby added to the Contract. Attachment I Performance Guarantees The revised Attachment I 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 KENT BY: DATEV;a f , J Title ADDRESS: 64� KN7'__ PREMERA IBLUt C OSS DyaF�� BY: DATE: January 1, 2022 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, 2022, are based on the following: Number of Active Members: Employee Dependents Medical/Rx 704 1,213 Number of COBRA Members: Employee Dependents Medical/Rx 6 3 Other Carriers Offered: None 4 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: 1/1/2022 through 12/31/2022 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) $50.35 Medical Commission $3 50 Electronic EOB Credit" -$1 00 Enhanced Controlled Substance Program-Standard $0 12 Telemedicine-General Medical and Mental Health(Virtual Care Only) $0 65 Total Fee $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 1/1/2022 through 12/31/2024 This period shall be known as the"administration fee guarantee period" a Amount Contract Period Begins Contract Period Ends $5035 1/1/2022 12/31/2022 $51 37 1/1/2023 12/31/2023 $52.41 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. Surprise Billing Protection Program f 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. 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) 6 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. 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 J - SURPRISE BILLING PROTECTION PLAN SPONSOR RESPONSIBILITIES When a self-funded plan sponsor elects to participate in Washington State's Balance Billing Protection Act, the Washington State Office of the Insurance Commissioner(OIC) requires completion of the self-funded group health plan opt-in form/attestation. The form is on the OIC website. It must be completed electronically and submitted to the OIC public website no later than 30 days prior to the date the plan sponsor wants to start its participation. That date must be in any year starting in 2020, either on the January 1 of that year or on the first day of the Plan's plan year. Exceptions to the opt-in time limit may only be made by the OIC. The Plan Sponsor has two options: • Request to Complete Form. The Plan Sponsor must make the request that the Claims Administrator complete the OIC self-funded group health plan opt-in form on the Plan Sponsor's behalf no later than 45 days before the form is due. • Group Completed Form. If the Plan Sponsor wants to submit its own opt-in form, the Plan Sponsor is responsible for completing the form by the deadline above, or such other due date that the OIC may require. The Plan Sponsor must provide the Claims Administrator a copy of the form filed with the OIC at least 30 days prior to the effective date of the opt-in, in order to enable the Claims Administrator to perform the Claims Administrator's responsibilities outlined below. If the Group Completed form is not timely delivered to the Claims Administrator, and results in a need to re-process claims, the Plan Sponsor must pay an added administrative charge per re-processed claim. See Attachment D for the amount of this charge. If the Plan Sponsor decides to terminate participation in the surprise billing protection program, the Plan Sponsor must notify the Claims Administrator in writing at least 45 days before the termination date. CLAMS ADMINISTRATOR RESPONSIBILITIES The Claims Administrator will process the Members'claims in compliance with Sections 6 through 8 of the Balance Billing Protection Act on the participation date requested by the Plan Sponsor • Washington: For Members' Non-Contracted Provider claims in surprise billing situations in Washington, this means: • Setting the Member's cost-share at the in-network level, priced based on the Claims Administrator's median contracted rate for the same or similar service in the same or similar geographic area. • Showing the Member's cost-share on the explanation of benefits. • Paying the Non-Contracted Provider directly, based on what the Claims Administrator determines to be a commercially reasonable rate, less the Member's cost-share. • Representing the Plan's claims in good faith negotiations and the mandated arbitration process, with the Plan Sponsor being responsible for any additional payments for its claims resulting from these procedures. • Idaho and Oregon: For Non-Contracted Provider claims for Emergency Care, this means: • Setting the Member's cost-share at the in-network level, priced based on the Claims Administrator's median contracted rate for the same or similar service in the same or similar geographic area. • Paying the Non-Contracted Provider directly, based on 100 percent of billed charges, less the Member's cost-share. Please note: The Claims Administrator may attempt to negotiate lower rates for select high-dollar claims. • All States: In all states, this means: • Continuing to apply benefits and Allowed Amounts to Non-Contracted Providers'claims not covered by the Balance Billing Protection Act per existing Plan designs and Non-Contracted Provider Allowed Amounts used by the Plan. • Answering Members' questions regarding the application of cost-shares to particular claims and 8 whether the Member has any balance billing responsibility to a Non-Contracted Provider. • Count any amount the Member pays for services that qualify for surprise billing protection toward the Member's in-network deductible and out-of-pocket maximum, if any. The Claims Administrator will not change any of the existing administrative forms, such as prior authorization letters and explanations of benefits to comply with the transparency provisions of the Balance Billing Protection Act, which are mandated for insured members but not for self-insured. 9 ATTACHMENT I - PERFORMANCE GUARANTEES 10 PERFORMANCE GUARANTEE AGREEMENT BETWEEN Premera Blue Cross of Washington AND City of Kent EFFECTIVE 1/1/2022 THROUGH 12/31/2022 (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 $28,500.00 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 $4,350.00 1 of 4 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 $4,350.00 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 $4,350.00 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 $4,350.00 2 of 4 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 $2,400.00 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 $4,350.00 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 $4,350.00 SECTION 3. EVALUATION OF PERFORMANCE AND PAYMENT OF PENALTIES 3 of 4 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. 4 of 4