Plan Management Agreement~'~l~ ~ S~Z~`i
PLAN MANAGEMENT AGREEMENT
for
Administrative Services
between
HUMANA INSURANCE COMPANY
and
CITY OF MIAMI BEACH
aoow- a~~3~
This Plan Management Agreement for administrative services is made and entered into by and between
Humana Insurance Company, a Wisconsin corporation (herein after, Plan Manager), and City of Miami
Beach a Florida municipal corporation, with principal offices in Miami, Florida (herein after, Client).
This Agreement is effective this first day of January 1, 2009, and revised January 1, 2010.
In consideration of the mutual promises and covenants contained in this Agreement, together with all
exhibits, the Client, and Humana Insurance Company hereby agree as follows:
ARTICLE I
Definitions
1.1 Agreement means this Plan Management Agreement for Administrative Services.
1.2 Client means City of Miami Beach, acting in accordance with this Agreement.
1.3 COBRA means the Federal Consolidated Omnibus Budget Reconciliation Act of 1986, as amended.
1.4 Emylover means the Client, as employer of a Participant.
1.5 ERISA means the Federal "Employee Retirement Income Security Act of 1974" as amended.
1.6 Participant means an employee or former employee of Client who is or may become eligible to receive
a benefit, or whose beneficiaries may be or become eligible to receive a benefit under the provisions of
the Plan.
1.7 Plan means the health care plan (or plans) maintained by the Client, or portions of that plan (or plans),
with respect to which administrative services are to be provided under this Agreement by the Plan
Manager. The Plan is identified in Exhibit "A" of this Agreement as to proper name and as to type.
1.8 Plan Administrator (or Administrator) means the person named in the documents describing the Plan
as responsible for the operation and administration of the Plan. If no such person is identified, then
the person establishing or maintaining the Plan will be deemed to be the Plan Administrator.
1.9 Plan Manager means Humana Insurance Company, acting in accordance with this Agreement.
ARTICLE II
Relationship Between the Parties
2.1 In performing its obligations under this Agreement, the Plan Manager operates within a framework of
the Plan's management policies and practices authorized or established by the Plan Administrator, in
accordance with the provisions of the Plan. In this context, the Plan Manager's normal operating
procedures, practices and rules will be followed unless they are inconsistent with the Plan's
management policies or practices.
2.2 The Plan Manager does not have discretionary authority or responsibility in the administration of the
Plan. The Plan Manager will not exercise discretionary authority or control respecting the disposition
or management of assets of the Plan.
2.3 The Plan Administrator and not the Plan Manager is ultimately responsible for interpreting the
provisions of the Plan and determining questions of eligibility for Plan participation.
2.4 Accordingly, except as may otherwise be expressly provided herein, the Plan Manager is not a trustee,
sponsor, or fiduciary with respect to directing the operation of the Plan or managing any assets of the
Plan.
2.5 The Plan Manager may act as an agent of the Client authorized to perform specific actions or conduct
specified transactions only as provided in this Agreement.
2.6 Plan benefits shall be funded exclusively through the Plan. The Plan Manager is not responsible or
accountable for providing funds to pay Plan benefits under any circumstances.
2.7 Except with respect to duties expressly assumed hereunder by the Plan Manager, the Plan Manager is
not responsible for maintaining the Plan incompliance with the requirements of the Internal Revenue
Code or any applicable laws and regulations governing or affecting the Plan.
ARTICLE III
General Duties of Client
3.1 The Client will identify and describe the Plan as to type (e.g. single employer) on Exhibit "A" of this
Agreement. The Client warrants that, to the best of its knowledge, information and belief, the Plan is
not a "multiple employer welfare arrangement".
3.2 The Client assures that sufficient funds will be available on a timely basis to honor all claims
reimbursements under the Plan. Sufficient funds for making claims payments must be made available,
in accordance with this Agreement, to enable services under this Agreement to continue without
interruption.
3.3 The Client shall use reasonable efforts to ensure that all methods employed to fund the Plan shall
comply with all applicable laws or regulations.
3.4 The Client agrees to furnish each Participant written notification of the source of funding for Plan
benefits as required by applicable law.
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3.5 The Client shall use reasonable efforts to ensure that current copies of the documents describing the
Plan will be provided timely to the Plan Manager along with other appropriate materials governing the
administration of the Plan. These documents and materials may include employee booklets, summary
descriptions, employee communications significantly affecting the Plan, and any amendments or
revisions.
3.6 The Client shall use reasonable efforts to ensure that timely written notice will be provided to the Plan
Manager of the Plan's management policies and practices, interpretations ofhe benefit provisions of
the Plan, and changes in the Plan provisions. The Plan Manager is not responsible for failure to
administer the Plan properly if expressly directed otherwise by the Client or if materials are not
provided timely by the Client, in writing, to the Plan Manager to implement changes.
3.7 The Client shall provide accurate information to the Plan Manager as to the number and names of
persons covered by the Plan and any other information necessary to enable the Plan Manager to
provide the services required by this Agreement. This information shall be kept current on at least a
monthly basis. The Plan Manager is not responsible for any claims paid in error due to inaccurate
eligibility information.
3.8 The Client is responsible for selecting legal and/or tax counsel to provide advice to the Client about
the law and the Plan. The Client acknowledges that the Plan Manager cannot provide professional tax
or legal services to the Client.
3.9 The Client is responsible for compliance with all applicable provisions of law addressing the Client's
duties in respect to the Plan. This includes compliance with all legal reporting and disclosure
requirements, adoption and approval of all required documents respecting the Plan, and compliance
with state escheat and unclaimed or abandoned property laws. Even though the Plan Manager maybe
required to perform certain duties under this Agreement, such as preparing drafts of documents for
approval and adoption, the Client agrees that the Plan Manager does not undertake the responsibility
for legal compliance for any other person.
3.10 The Client will make full payment for services rendered under this Agreement when due. The first
payment is due on or before the Effective Date of this Agreement. The subsequent payments must be
received by the due date provided in the monthly invoice. If the Plan Manager has not received
payment by the due date, payment in full must be made before the end of a thirty (30) day grace period
beginning the day after the due date, to ensure services under this Agreement continue without
interruption. The Plan Manager reserves the right to issue written notice to the Client requesting
payment of any deficiency in full within the thirty (30) day grace period.
3.11 The Client shall not duect the Plan Manager to act or refrain from acting in any way which would
violate any applicable law or regulation. The Client shall not behave in any way which could
implicate or involve the Plan Manager in a violation of these laws.
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3.12 The Client pays for services based on a payment roster that the Client has provided to the Plan
Manager in advance. The payment roster must be sent via electronic transmission at a time and in a
format agreed upon by the Client and the Plan Manager. A hard copy statement will only be provided
to the Client upon request. The Plan Manager will take the Client's payment roster and reconcile with
the Plan Manager's invoice and provide the Client with a list of discrepancies. The Client and the
Plan Manager agree to work together to resolve discrepancies in a timely manner and they will be
handled as a credit or debit when the next payment is due. The Client pays their administrative fees by
check or wire transfer equal to the monthly invoice. The amount of the fees may be adjusted monthly
to reflect enrolhnent changes. The Client can arrange wire transfers by completing a form provided by
the Plan Manager. Wire transfers will only be activated each month with prior approval from the
Client. If paying by check, the Client should submit the check to the address listed on the invoice and
should be accompanied by the return portion of the invoice. The Plan Manager must receive payment
by the due date on the invoice.
3.13 In the event that the general obligations of this Article III may be construed in such a manner so as to
conflict with more specific provisions of this Agreement regarding a particular issue, the more specific
and comprehensive provisions shall be given effect.
ARTICLE IV
General Duties of Plan Manager
4.1 The Plan Manager shall process claims and make payments in accordance with the provisions of the
Plan and related interpretations of the benefit provisions of the Plan which are made or approved by
the Plan Administrator on a timely basis and confirmed in writing.
4.2 The Plan Manager shall be entitled to rely and act based upon documents, letters, electronic
communications, or telephone communications which are confirmed in writing and provided to it by
the Client or the Plan Administrator. Reliance will continue until the time the Client or the Plan
Administrator notifies the Plan Manager in writing of any change or amendment to those
communications.
4.3 The Plan Manager shall on a timely basis, provide claimants who have had a claim wholly or partially
denied with a written explanation of the reason for the denial. The Plan Manager's written
explanation shall also provide claimants with information about what steps may be taken if the
claimant wishes to submit the denied claim for review. These obligations of the Plan Manager will be
discharged in accordance with the provisions of the Plan or authorization by the Plan Administrator.
4.4 The Plan Manager shall not be responsible for any delay or lack of performance of services under this
Agreement attributable to the Client's failure to provide any information as required under this
Agreement.
4.5 The Plan Manager will perform its duties under this Agreement using the same degree of ordinary
care, skill, prudence, and diligence that a reasonable provider of administrative services for
comparable health caze plans as the plan contemplated herein would use in similar circumstances.
This includes making a good faith effort to correct any mistake or clerical error which may occur due
to actions or inaction by the Plan Manager undertaken in good faith once the error or mistake is
discovered.
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4.6 With respect to its obligations under this Agreement, the Plan Manager will maintain professional
liability and errors and omissions insurance in amounts sufficient to protect against losses with respect
to occurrences arising out of failure to properly perform its obligations under this Agreement. Proof of
coverage is available upon request.
4.7 In the event that the general obligations of this Article N may be construed in such a manner so as to
conflict with more specific provisions of this Agreement with respect to a particular issue, the more
specific and comprehensive provisions shall be given effect.
ARTICLE V
Claims Administration
5.1 The Client hereby delegates to the Plan Manager authority to make determinations on behalf of the
Client or the Plan Administrator with respect to benefit payments under the Plan and to pay such
benefits, as specified in this Article V.
5.2 The Plan Manager will accept claims for benefits under the Plan which are made in accordance with
procedures established in the Plan documents and submitted for payment during the term of this
Agreement.
5.3 The Plan Manager will process claims in accordance with the provisions of the Plan which are in
effect and which have been communicated to the Plan Manager by the Client at the time the services
are provided.
5.4 Claims will be processed using the Plan Manager's normal claims processing procedures, practices and
rules unless they are (a) inconsistent with Plan management policies or practices authorized or
established by the Plan Administrator in accordance with the provisions of the Plan, and (b) such
alternate policies or procedures are timely described to the Plan Manager in writing as being
inconsistent.
5.5 The Plan Manager will timely approve or deny claims submitted for payment in accordance with an
initial determination by the Plan Manager or an appeal of a denied claim, except as provided in Article
5.6.
5.6 However, if the Plan Administrator makes a determination to approve or deny a claim which is
different than the determination made by the Plan Manager, the Plan Manager will timely issue an
approval or denial of the claim, provided the Plan Administrator's decision is first communicated to
the Plan Manager in writing.
5.7 In the event a claim is wholly or partially denied in accordance with Article 5.5, above, the Plan
Manager shall provide the Participant on a timely basis with a written explanation of the reason for the
denial, and information as to what steps may be taken if the Participant wishes to appeal the claim
denial.
However, if a claim is wholly or partially denied in accordance with Article 5.6, above, the Plan
Manager may decide that it will provide this explanation and information only as directed upon special
written instructions from the Plan Administrator.
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5.8 Appeals of denied claims shall be processed in accordance with the applicable provisions of the Plan.
The Client acknowledges that the Plan Administrator shall have the ultimate responsibility and
authority to make fmal determinations with respect to claims and is responsible for providing
Participants with a written explanation of that decision.
5.9 If adequate funds are not made available for the timely payment of claims, the Plan Manager may
notify Participants and payees who maybe affected if the Client or the Plan Administrator does not
notify Participants and payees within fourteen (14) business days after written request by the Plan
Manager to do so.
5.10 With respect to claims for which provider discounts are available ("Provider Discounts") the Client
authorizes and directs the Plan Manager to process claims under this Agreement taking the Provider
Discounts into account.
ARTICLE VI
Reports, Records and Audits
6.1 The Plan Manager will provide standard reports to the Client or the Plan Administrator as mutually
agreed upon by the Plan Manager and the Client. Reports requested outside of the standard reports are
considered "ad hoc reports" and maybe made available for an additional cost, upon mutual agreement
between the Client and the Plan Manager.
6.2 The Plan Manager will keep and maintain accounts and records pertaining to its activities under this
Agreement which are required by law or by mutual agreement of the parties.
6.3 The Plan Manager will prepare and make available records required to assist the Client or the Plan
Administrator regarding legal action or regulatory review and reporting, upon reasonable request by
the Client. The Client agrees to reimburse the Plan Manager for its reasonable costs in the
preparation, duplication, and transmission of these records.
6.4 Audits are governed by the Plan Manager's policy regarding Client audit requests (available upon
request). Audits maybe conducted by the Client or a third party on behalf of the Client provided all
security documents, non-disclosure agreements and authorizations are completed and accepted by the
Plan Manager. Request for an audit must be received sixty (60) days prior to the date in which the
Client is requesting to perform said audit. Audits for active Clients must be conducted within two (2)
years of the last day of the Plan year to be audited. Audits for Clients that have terminated their Plan
with the Plan Manager must be conducted within one (1) year of the last day of the Plan year to be
audited. For any audit that requires a review of more than three hundred (300) claims, or is requested
for more than one (1) week on-site, the Client agrees that it maybe subject to additional costs, and the
estimate for these costs will be provided prior to scheduling the audit. The audit will not be scheduled
until the Plan Manager and the Client are in mutual agreement of the estimated additional cost. A
report by the Plan Manager's independent accountant on the controls over claims adjudication (known
as a SAS 70 report) is provided at no cost upon request.
6.5 Claims records maybe maintained in micro-photographic or electronic media format, in accordance
with the Plan Manager's internal policies, rather than original hard copy. If the Client desires that
original hard copy records be maintained, the Client must notify the Plan Manager in writing no later
than forty-five (45) days after the effective date of this Agreement. The Plan Manager will then ship
the original documents to a location specified by the Client, and the Client agrees to pay the cost for
this service.
ARTICLE VII
Additional Administrative Services
7.1 Upon reasonable request by the Client or the Plan Administrator, the Plan Manager will provide
standard language concerning Plan benefits to assist the Plan Administrator in the preparation of the
summary description of the Plan. This service will be available at the commencement of this
Agreement and when language changes are made necessary by changes in Plan design or
governmental requirements.
7.2 The Plan Manager will work with the COBRA Service Provider in providing administrative services
regarding COBRA continuation coverage provided under the Plan only as specified in Exhibit "B".
The Client or the Employer shall continue to have all liability for funding of COBRA coverage
benefits under the Plan.
7.3 The Plan Manager will assist the Client or the Plan Administrator in arranging to provide Clinical
Program services with respect to the Plan only as specified in Exhibit "C".
7.4 The Plan Manager will provide the following miscellaneous administrative services, following its
normal procedures:
(a) Production of basic Participant identification cards.
(b) Routine claims processing audit controls.
(c) Fraud investigation services.
7.5 The Plan Manager will provide "Subrogation/Recovery" services (in addition to routine application of
the coordination of benefits provisions of the Plan) for identifying and obtaining recovery of claims
payments from all appropriate parties through operation of the subrogation or recovery provisions of
the Plan.
(a) Subrogation /Recovery services will be provided by the Plan Manager following its normal
procedures. Such services may also be performed by subcontractors and/or counsel selected
by the Plan Manager.
(b) Subrogation /Recovery services include the following activities:
(1) Investigation of claims and obtaining additional information to determine if a person
or entity maybe the appropriate party for payment;
(2) Presentation of appropriate claims and demands for payment to parties determined to
be liable;
(3) Notification to Participants that recovery or subrogation rights will be exercised with
respect to a claim; and
(4) Filing and prosecution of legal proceedings against any appropriate party for
determination of liability and collection of any payments for which such appropriate
party may be liable.
(c) In the event of termination of this Agreement, Subrogation/Recovery services will be
continued only in respect to claims processed under this Agreement and those continued
services will be provided until completion. Subrogation/Recovery services will cease
immediately if the termination of this Agreement results from a material default in the
delivery of such subrogation services.
(d) The cost to the Client for providing services under this Article 7.5 is presented within Exhibit
"F3.1 (a)", in accordance with Article IX. However, there will be no cost to the Client for
recovery of claims payments made in error by the Plan Manager exclusive of any other cause.
Also in this context, the Plan Manager may not be obligated to file and prosecute legal
proceedings against persons for determination of liability and collection of any payments.
(e) Subrogation/Recovery services will be provided by the Plan Manager following its normal
procedures when a group has contracted with a third party vendor (ex. Stop Loss carrier).
Any recoveries are reported to the Client. The Client is responsible for any required
notifications/reimbursements to their contracted third parties.
7.6 The Plan Manager may retain or coordinate with service providers, experts, or professional advisors to
assist the Plan Manager in providing services under this Agreement. Client shall not be obligated to
reimburse the Plan Manager for these services unless expressly agreed to in writing by Client prior to
Plan Manager's retention of any aforestated service providers, experts, or professional advisors.
7.7 The Client may choose to have the Plan Manager provide additional services to support its third party
stop loss agreement. The Plan Manager will provide a standard set of reports and submit claim
requests for stop loss reimbursement on behalf of the Client. However, all reimbursements should be
sent from the Third Party to the Client. The Plan Manager should only receive copies of
reimbursement reports for reconciliation purposes.
7.8 The Plan Manager will arrange access to one or more networks of health care providers which are
presently available through an arrangement with the Plan Manager only as specified in Exhibit "D".
7.9 The Plan Manager will arrange access for the Client to certain Shared Savings Program Provider
Discounts established by the Plan Manager which maybe available at the time services are rendered
only as specified in Exhibit "D-1 ".
7.10 In the event the Client's overall employee enrollment in this Plan (active employees and COBRA
continuees) has decreased by 10% or more since the beginning of each renewal policy period, due to
one of the following reasons:
(1) The Client makes design changes to the Plan or employee benefit programs, including
changes required by applicable law or regulatory action resulting in employees being
terminated from the Plan; or
(2) The Client revises its corporate structure or organization resulting in employees being
terminated from the Plan; or
(3) Due to employee choice of participation in the Plan, results in employees being terminated
from the Plan
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the Plan Manager will continue processing Claims, for the terminated employees, which are incurred
prior to the date of such change as provided in Article V of this Agreement.
Such claims will be processed as long as this Agreement is in force. The Client will be billed an
additional administrative fee per employee as provided under Exhibit "F3.1(d)". Claims incurred prior
to the employee's termination date will be processed by the Plan Manager as long as this Agreement is
in force or if a supplemental agreement is entered into
This Article 7.10 will not apply in the event the Plan Administrator provides timely written
notification to the Plan Manager directing that services described in this Article are not required.
7.11 The Plan Manager will provide Pharmacy Management services as specified in Exhibit "H".
7.12 The Plan Manager will provide certificates of prior coverage ("COPC") required to be issued by the
Client under the federal Health Insurance Portability and Accountability Act of 1996 ("HII'AA")
requirement. The Client allocates responsibility for generating forms certifying prior coverage and
accompanying liability for noncompliance to the Plan Manager, to the extent of its obligations under
this Agreement.
(a) On a timely basis, the Plan Manager will issue a COPC form to persons whom the Client has
identified as having had coverage under the Plan which has ended ("Recipients").
(b) The Plan Manager will issue a COPC to the Recipients' last known addresses.
7.13 Pursuant to the Medicare, Medicaid and SCHIP Extension Act of 2007 ("MMSEA"), the Plan
Manager and the Client agree to the following:
(a) The Plan Manager will register with the Centers for Medicare & Medicaid Services'
Coordination of Benefits Contractor (COBC), and will continually collect and report specified
information regarding the Client's group health Plan arrangements to CMS, in compliance
with the Section 111 Medicare Secondary Payer provisions of the Act.
(b) The Plan Manager agrees to register with the COBC as a "Responsible Reporting Entity"
(RRE), if necessary, in order to report specified information regarding group health Plan
arrangements to the U.S. Department of Health and Human Services (HHS) and the Centers
for Medicare & Medicaid Services (CMS).
(c) The Plan Manager agrees to use best efforts to collect from the Client and Plan Participants
any information as specified by HHS and CMS.
(d) The Plan Manager agrees to submit to HHS and CMS all necessary information and data
elements in the required form, manner and frequency as specified by the Section 111
Medicare Secondary Payer Mandatory Reporting Provisions.
(e) The Client shall cooperate with the Plan Manager and use its best efforts to obtain and
provide any necessary data to assist the Plan Manager in complying with Section 111
Medicare Secondary Payer Reporting Provisions. The Client will agree to allow the Plan
Manager to take any steps reasonably necessary to compel cooperation from Participants.
This Article 7.13 is subject to the Hold Harmless provisions in Article XIII.
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ARTICLE VIII
Banking
8.1 The rights and obligations of the Client and the Plan Manager under this Article VIII shall be
regulated through a "Banking Arrangement" substantially in the form presented in Exhibit "E".
8.2 The Client shall use reasonable efforts to ensure that sufficient funds will be available on a timely
basis to honor all claims reimbursements under the Plan. Upon notice from the Plan Manager that
additional funds aze required, the Client shall use the same reasonable efforts to ensure that adequate
funds will be immediately provided to fund claims approved.
8.3 The Client agrees that funds provided to honor all claims reimbursements under the Plan will be
United States money, which may be transmitted by wire transfer or other medium agreed to by the
Plan Manager and the Client.
ARTICLE LY
Costs of Administrative Services
9.1 The Plan Manager shall be entitled to a fee for services provided under this Agreement described on
Exhibit "F" to this Agreement.
9.2 Payments received after the grace period (see Article 3.10) are subject to a late chazge of 1.25% per
month (or the maximum amount allowed by Florida law, if less) multiplied by the past due amount.
The Client must pay the late chazge along with all amounts due to the Plan Manager in order to bring
the account current.
9.3 The Client and the Plan Manager understand and agree that the fees for services under this Agreement
maybe renegotiated in the event that substantial changes to the Plan would significantly increase or
decrease the obligations or costs of providing administrative services with respect to the Plan.
ARTICLE X
Contract Period
10.1 The effective date of this Agreement is January 1, 2009 (the "Effective Date"). This Agreement shall
continue for an initial period of one (1) year from the Effective Date, unless terminated eazlier as
provided in Article XI, below.
10.2 This Agreement shall automatically renew for successive additional one-year periods unless it is
terminated as provided in Article XI.
ARTICLE XI
Termination
11.1 This Agreement may be terminated by the Plan Manager at the end of any contract period upon
advance written notice of at least one hundred eighty (180) days. This Agreement may be terminated
by the Client at the end of any contract period upon advance written notice.
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11.2 The Plan Manager, in its discretion, may terminate this Agreement before the end of any contract
ep riod upon sixty (60) days written notice, if the Client fails to cure any one or more of the following
deficiencies before the end of the sixty (60) day notice period:
(a) Failure to pay all or part of the fees payable under Article IX of this Agreement when due.
(b) Failure to provide adequate funds to honor claims reimbursement payments on a timely basis.
11.3 Either party may terminate this Agreement immediately upon written notice in the event of:
(a) The bankruptcy, insolvency or liquidation of the other party; or
(b) The commission by the other party of any material breach of this Agreement which is not
cured in connection with the performance of its duties under this Agreement. However, a
material breach of this Agreement maybe cured within thirty (30) days after written notice
from the other party.
11.4 The Plan Manager, in its discretion, may terminate this Agreement upon written notice in the event of
reyeated occurrences (two (2) or more) of the conditions described in Article 11.2 or two (2) or more
instances where services are interrupted in accordance with Article 3.10.
11.5 All obligations of the Plan Manager under this Agreement will end on the effective date of termination
of this Agreement, even though the claim for benefits was incurred or submitted for payment prior to
termination of this Agreement, unless a supplemental agreement is entered into prior to the termination
date.
11.6 In the event of the termination of this Agreement, the Plan Manager will provide the Client or the Plan
Administrator with reasonable access to records or information concerning the Plan in its possession,
upon written request. The Plan Manager will within a reasonable time honor requests for copies of
records and information provided they are reasonable and the Client agrees to pay for the services.
The Plan Manager shall have the right to retain copies of such property and records as reasonably
necessary or is otherwise required by Florida law or other applicable law.
11.7 Upon termination of this Agreement, any monetary obligation of the Client to the Plan Manager shall
become immediately due and payable.
11.8 Upon termination of this Agreement, the Client may elect to have the Plan Manager process claims for
a run-out period of either three (3) months or twelve (12) months. The administration fee for three (3)
months of run-out will be equal to a one time payment of three (3) months worth of Administrative
Fees. The administration fee for twelve (12) months of run-out will be equal to a one time payment of
four (4) months worth of the Administrative Fees. The monthly run-out administration fee will be the
full renewal Administrative fee times current enrollment. If commissions are to be paid to a broker
during the run-out period, they should be included in the renewal Administrative Fee before
calculating the amount to be billed to the Client for run-out. The total run-out administration fee must
be paid in full to the Plan Manager by the Client no later than the fifteenth (15th) of the month prior to
termination and an executed Supplemental Agreement must be received by the Plan Manager in order
for claims processing to continue after the active Agreement period has expired. The Client agrees
that the Plan Manager will have no obligation to process claims beyond the end date of the
Supplemental Agreement.
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11.9 Termination under this Article XI shall not cause either party to waive any rights it may have to
exercise any remedies available to it under any other Article or Exhibit in this Agreement or under any
applicable law.
ARTICLE XII
Confidentiality
12.1 For purposes of this Article XII:
(a) Covered Person means an individual with respect to whom benefits may be or become
payable under the provisions of the Plan.
(b) Private Health Information means any of the following categories of information:
(1) Patient Records includes, but is not limited to, all health records, physician and
provider notes and bills and claims with respect to a Covered Person.
(2) Patient Information includes Patient Records and all written and oral health
information received about a Covered Person.
(3) Individually Identifiable Health Information means any other information, including
demographic information, collected from an individual that:
(A) Is created or received by a health care provider, health plan, employer, or
health care clearinghouse; and
(B) Relates to the past, present, or future payment for the provision of health
care to an individual and identifies the individual, or with respect to which
there is a reasonable basis to believe that the information can be used to
identify the individual.
12.2 The Client and the Plan Manager acknowledge and agree that in the course of performing their
respective duties under this Agreement, they may acquire or obtain access to or knowledge of Private
Health Information or other personal information regarding Covered Persons. This information is at
all times the property of the Plan or the Client, depending upon its nature and source, and not the Plan
Manager, even if it is received by the Plan Manager. Information of this nature that is received by the
Plan Manager will be deemed to be information received on behalf of the Plan. However, information
that is produced incidentally through application of the computer systems employed by the Plan
Manager in the course of providing services under this Agreement will not be considered property of
the Plan or the Client or any Covered Person, if it is not specific to the Plan or not material to Plan
administration.
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12.3 The Client and the Plan Manager will safeguard Private Health Information and other personal
information to ensure that the information is not improperly disclosed. The Client, the Plan
Administrator, and the Plan Manager or any person appointed by or under their control, respectively,
will make sure that Plan functionaries and third party service providers having access to Private Health
Information and other personal information are trained in privacy policies directed at safeguarduig
against improper disclosure, made familiar with the confidentiality obligations set forth in this
Agreement, and abide by those requirements as minimum safeguards against improper disclosure. The
Client and the Plan Manager acknowledge with respect to Private Health Information, and other
personal information that:
(a) Disclosure is improper if it is not allowed by law or made for any purpose other than Plan
administration or benefits delivery. Disclosure to Plan functionaries or health care providers
may be proper, if the disclosure is allowed by law and made for Plan purposes.
(b) The Employer or Plan sponsor may legally have access, on an as-needed basis, through the
Plan Administrator to limited health information for the purpose of determining Plan costs,
contributions, Plan design, and whether Plan modifications are warranted.
(c) Federal regulators such as the Department of Health and Human Services and the Department
of Labor may legally require access to Protected Health Information in order to investigate
compliance with federal legal requirements concerning confidentiality of Private Health
Information.
(d) The Plan Manager will not be responsible for determining the rights of Covered Persons to
acquire access to or modify Private Health Information and other personal information
concerning them (whether or not such information is at any time in the possession of the Plan
Manager).
(e) In the event that the Plan Manager is directed in writing by the Client or Plan Administrator to
disclose Private Health Information or other personal information concerning them for
purposes other than Plan operation or benefits delivery, the Plan Manager will not be
responsible for providing an accounting to Covered Persons of such disclosure(s) (whether or
not such information is at any time in the possession of the Plan Manager).
(f) The Plan Manager will immediately notify the Plan Administrator, in writing, of any
disclosure of Private Health Information in its possession or control that is not consistent with
the provisions of this Agreement of which the Plan Manager becomes aware.
(g) The Client, the Plan Administrator, and the Plan Manager acknowledge and agree that
improper disclosure of Private Health information or other personal information agreement
will amount to a material breach of this Agreement. In the event of improper disclosure, the
culpable party shall take reasonable steps to alleviate the effects of the improper disclosure;
but if those efforts to cure are not successful, the improper disclosure will constitute grounds
for immediate termination of this Agreement.
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12.4 Accordingly, the Plan Manager will afford access to Private Health Information or other personal
information received by it to the Plan Administrator or the Client, as permitted under this Agreement
and by law. The Plan Manager will afford access to this information to other persons only as
reasonably directed in writing by the Plan Administrator or the Client, with due regard for
confidentiality, and the Plan Manager shall have no further obligation with respect to that information.
The Plan Manager is directed to afford access to Private Health Information and other personal
information to the persons listed on Exhibit "G".
12.5 The Client represents and warrants that the Plan Administrator is and shall continue to be obligated to
safeguard Private Health Information in accordance with the provisions of this Agreement as
minimum standards. The Client further represents and warrants that security controls, restrictive
processes, and other appropriate safeguards have been put in place between the Employer and the Plan
to protect Private Health Information from improper disclosure.
12.6 In connection with performing its obligations under this Agreement, it may become necessary for the
Plan Manager to disclose to the Plan Administrator or the Client, then designees or third parties under
contract with either of them ("Recipients", for purposes of this subsection) trade secret and/or
proprietary information of the Plan Manager or its affiliates (referred to in this subsection collectively
as "Humana"). To the extent allowable under Florida law or other applicable law, the Client and the
Plan Administrator agree to safeguard and ensure the confidentiality of such trade secret and/or
proprietary information, which shall include information relating to (i) the business of Humana, its
affiliates, their clients and representatives, (ii) third parties under contract with Humana, (iii) medical
service provider arrangements or contracts, (iv) medical service provider network arrangements or
contracts, and (v) documentation relating to the computer systems utilized by Humana.
(a) Access to the trade secret and/or proprietary information described above will be permitted for
Recipients only; it maybe used by Recipients only in a manner necessary to accomplish the
purposes described above with respect to Private Health Information and other personal
information; and it may not be disclosed to any third parties, including their employees that do
not have a need to know, without authorization by Humana. Access to such records or
information does not constitute a transfer of ownership, permission to appropriate, or license
to use the same for any purpose not contemplated under this Agreement.
(b) The Client understands and agrees that the Client (or its designee) must recognize and abide
by restrictions upon disclosure of information and/or systems that are imposed by contracts
between Humana and third parties or by law, regulation, or order of a court or regulatory
agency.
(c) The Plan Manager understands and agrees that the Client, or its designee, must at all times,
and notwithstanding any term or condition of this Agreement, comply with any and all
disclosure requirements under applicable Florida law including, without limitation, Chapter
119, Florida Statutes, as amended.
12.7 Upon termination of this Agreement, records containing Private Health Information or other personal
information in the possession of the Plan Manager will be either delivered to the Plan Administrator or
destroyed when the Plan Manager's records retention obligations have been fulfilled. If such delivery
or destruction is not feasible, the protections of this Agreement will continue to apply to those records
and fiirther uses and disclosures of the Private Health Information or other personal information shall
be limited to those purposes that make the return or destruction of the information infeasible.
14
12.8 The Client and the Plan Manager agree that they will require other persons or entities that receive
Private Health Information or other personal information regarding Covered Persons and/or trade
secret or propriety information in connection with and as permitted by this Agreement to agree in
writing to observe the protections described herein and as required by HIPAA as minimum safeguards
against improper disclosure of such information.
ARTICLE XHI
Hold Harmless
13.1 To the extent permitted by Florida law, and subject to the limitations on Client's liability in section
768.28 Florida statutes, the Client agrees to be responsible for all loss, liability, or damage which the
Plan Manager may incur by reason of failure of the Client or its employees, agents or representatives
to abide by the provisions of the Plans or this Agreement or to administer the Plans or assets and funds
of the Plans in a prudent and proper manner; failure of the Plans or documents describing the Plan
prepared or adopted by the Plan sponsor to comply with applicable laws; fraud, embezzlement, willful
misconduct, or intentional disregard on the part of the Client or its employees, agents or
representatives; disputes concerning denials of benefits or benefit payments made by or at the direction
of the Client or the Plan Administrator; or actions taken by the Plan Manager at the drrection of the
Client or the Plan Administrator. Nothing herein shall preclude the Client from asserting any defenses
it may have under law. Additionally, nothing contained in this Agreement shall be deemed a waiver of
any rights of sovereign immunity of Client or a waiver of the limitation placed upon Client's liability
to third parties as set forth in section 768.28, Florida statutes. Client does not intend to waiver any of
such rights.
13.2 The Plan Manager agrees to be responsible for all loss, liability, or damage which the Client may incur
by reason of the failure of the employees, agents or representatives of the Plan Manager to abide by
this Agreement, or fraud, embezzlement, willful misconduct or intentional disregazd on the pazt of the
provisions of the Plan or Plan Manager or its employees, agents, or representatives. The Plan Manager
will not be liable on account of actions or inaction undertaken by it in good faith and performed in
accordance with the provisions of the Plan or this Agreement or for the cost of benefits under the Plan
which are claimed or awazded to a Participant. Nothing herein shall preclude the Plan Manager from
asserting any defenses it may have under law.
13.3 The obligations under this Article XIII shall continue beyond the term of this Agreement as to any act
or omission which occurred during the term of this Agreement.
13.4 In the event that the general obligations of this Article XIII may be construed in such a manner so as to
conflict with more specific provisions of this Agreement with respect to a particular issue, the more
specific and comprehensive provisions shall be given effect.
ARTICLE XIV
Taxes and Assessments
14.1 If a tax or other assessment, including a premium tax, with respect to the Plan (other than an income
tax with respect to the fees earned by the Plan Manager) is imposed upon the Plan Manager, the Plan
Manager will provide written notification to the Client together with a copy of the tax bill or
assessment within ten (10) business days of receipt.
15
14.2 If the Plan Manager pays the tax or assessment at the written direction of the Client, the Client shall
reimburse the Plan Manager for any amounts paid plus reasonable out-of-pocket expenses immediately
upon notification by the Plan Manager that the tax has been paid.
ARTICLE XV
Defense of Actions
15.1 The Client and the Plan Manager agree to cooperate with respect to (a) the determination, settlement
and defense of any and all claims for benefits undertaken by the Plan Manager pursuant to this
Agreement, and (b) the settlement of and conduct of a defense against any claim for benefits which
has been denied, which may include attending hearings and trials and assisting in securing the
attendance of witnesses and giving of evidence.
15.2 The payment of legal fees arising out of any transaction or activity under this Agreement shall be the
responsibility of the person incurring the expense, except as provided in Article XIII, or except as
expressly agreed to, in writing, between the Client and the Plan Manager. However, reasonable legal
fees incurred by the Plan Manager and attributable to a request, direction, or demand by the Client
shall be the responsibility of the Client, except when such request, direction or demand is the result of
a failure of Plan Manager to abide by the terms of this Agreement, in which case Article 13.2 controls.
Reasonable legal fees incurred by the Plan Manager and attributable to the defense of claims
determinations made in accordance with this Agreement shall be the obligation of the Client.
Provided, however, Client shall not be responsible for legal fees or costs incurred by the Plan Manager
with respect to a claim where it is determined the Plan Manager failed to adhere to the standard of Gaze
in Article 4.5 of this Agreement. In all matters where the Plan Manager seeks payment of legal fees
hereunder, the Plan Manger shall defer to Client with respect to the retention of counsel and the
settlement of the dispute.
ARTICLE XVI
Miscellaneous
16.1 Ancillary Agreements. The Client agrees to execute or cause to be executed all ancillary agreements
appropriate and necessary to enable the services described in this Agreement to be performed.
16.2 Entire Agreement. This Agreement (including the Exhibits and Plan documents as incorporated
herein by reference) constitutes the entire agreement between the parties with respect to the Plan, and
there are no agreements, representations or warranties regarding the subj ect matter of this Agreement
between the parties other than those set forth or provided for in this Agreement (including the Exhibits
and Plan documents as incorporated by reference).
16.3 Assignment. Neither the Plan Manager nor the Client may assign or otherwise transfer its rights and
obligations under this Agreement to any other person or entity without the prior written consent of the
other party. However, the functions to be performed by the Plan Manager may at any time be
transferred to an affiliate of the Plan Manager. Any other attempted assignment or delegation shall
render this Agreement voidable at the option of the non-assigning party.
16
16.4 Notices. All notices to the Client under this Agreement shall be personally delivered or sent by a
method no less rapid than fast class mail, with postage prepaid, or facsimile, to the Client at the
following address:
Attn: Ramiro Inguanzo, Director, Human Resources
City of Miami Beach
1700 Convention Center Drive
Miami Beach, FL 33139
Telephone: (305) 673-7524
FAX: (786) 394-4145
Email: ringuanzo@miamibeachfl.gov
All notices to the Plan Manager under this Agreement shall be personally delivered or sent by a
method no less rapid than first class mail, with postage prepaid, or facsimile, to the Plan Manager at
the following address:
Attn: Tim Batson
Humana Insurance Company
500 West Main Street
Louisville, Kentucky 40202
Telephone: 502-5 80-8508
FAX: 502-580-3639
Email: tbatson@humana.com
16.5 Severability. If any provision of this Agreement is determined to be unenforceable or invalid, such
determination will not affect the validity of the other provisions contained in this Agreement. Failure
to enforce any provision of this Agreement does not affect the rights of the parties to enforce such
provision in another circumstance. Neither does it affect the rights of the parties to enforce any other
provision of this Agreement at any time.
16.6 Ayylicable Law. This Agreement shall be governed by and construed in accordance with the internal
laws of the State of Florida, to the extent not preempted by federal law.
16.7 Amendment. This Agreement maybe amended by the Client and the Plan Manager at any time by a
writing duly executed by an appropriate officer of the Plan Manager and the Client.
16.8 Effect of Payment of Administration Charges. This Agreement shall be considered executed by the
Plan Manager and the Client, upon signature of both the Plan Manager and the Client. Payment of
fees prior to completion and signing of this Agreement will constitute execution of a written temporary
agreement, pending completion and signing of this Agreement.
17
IN WI~'NESS WHEREOF, the Client and the Plan Manager have executed this Agreement on
'h1~~^G .~~ ,20a~
CITY OF MIAMI BEAC
(By)
(signature)
Name: Matti Bower-Herrera
Title:
CITY OF r1B,E' AC
(Attested By) ~U V1/~~
(signature)
Name: Robert Parcher
Title: Cit Clerk
HUMANA INSURAllTCE COMPANY
Khalid Nazir
Vice President
HUMANA INSURANCE COMPANY
(Attested By) ~
Joan . Lenahan
Vice President & Corporate Secretary
~~ -~~
ate
18
APPROVED AS TO
FORM & LANGUAGE
EXHIBIT A
Identification of the Plan
City of Miami Beach Medical Plan
(Medical and Prescription Drug Coverage)
(A Non-Federal Governmental Entity)
EXHIBIT B
COBRA Administration Services
DEFINITIONS
B 1.1 "COBRA" means the Federal Consolidated Omnibus Budget Reconciliation Act of 1986, as amended,
which requires health care continuation coverage through amendments to the Employee Retirement
Income Security Act of 1974, the Internal Revenue Code of 1986, and the Public Health Services Act
of 1944.
B1.2 "COBRA Service Provider" means a provider of COBRA administrative services retained by the
Client or the Employer to provide specific COBRA administrative services as described in this
Exhibit "B".
B 1.3 "Covered Person" means an individual with respect to whom benefits may be or become payable
under the provisions of the Plan.
B1.4 "Qualified Beneficiary" means a current or former employee of the Employer who is entitled to
continued coverage under the Plan through COBRA and a spouse or dependent of a current or former
employee who is entitled to continued coverage under the Plan through COBRA. A Qualified
Beneficiary under COBRA law also includes a child bom to the current or former employee during the
coverage period or a child placed for adoption with the current or former employee during the
coverage period. At the time COBRA election is made, these individuals are also referred to as a
"COBRA Continuee".
DUTIES OF THE PLAN MANAGER
B2.1 The Plan Manager will provide claims processing and other administrative services as described in this
Agreement with respect to COBRA Continuees as Covered Persons under the Plan.
B2.2 The Plan Manager will not determine questions of eligibility for COBRA continuation under the Plan.
B2.3 The Plan Manager will record a termination date for each COBRA Continuee as designated to the Plan
Manager by the Employer or the Plan Administrator (the "Termination Date"). After the Termination
Date such individual will no longer be considered to be a COBRA Continuee and a Covered Person.
The Plan Manager will not provide services under this Agreement with respect to any COBRA
Continuee insofar as those services may pertain to time periods occurring after the Termination Date.
DUTIES OF THE COBRA SERVICE PROVIDER
B3.1 The COBRA Service Provider will notify the Plan Manager and the Employer of an individual's
election of COBRA continuation coverage.
B3.2 The COBRA Service Provider will, in accordance with its regular practices, bill COBRA Continuees
for the costs payable by them for COBRA continuation coverage under the Plan on a monthly basis.
B3.3 The COBRA Service Provider will, in accordance with its regular practices, collect the amounts billed
in accordance with Exhibit "B3.2" on a monthly basis from COBRA Continuees. A thirty-one (31)
day grace period will be allowed for payment of the amount due.
DUTIES OF THE CLIENT OR THE EMPLOYER
B4.1 The Client or the Employer will retain a COBRA Service Provider who is responsible for providing all
notices required by COBRA to Qualified Beneficiaries.
B4.2 The Client and the Employer understand and agree that the Employer is solely responsible for
compliance with COBRA and for deciding all questions, including matters of clerical error, arising out
of COBRA Continuees' eligibility for COBRA continuation coverage.
B4.3 The Client and the Employer understand and agree that the Plan Manager is in no way responsible and
does not assume responsibility for compliance with any obligations of the Employer under COBRA.
Performance of services under this Agreement shall not be construed by the Client or the Employer
that the Plan Manager endorses, warrants, or represents that the COBRA continuation coverage
provided by the Employer is in compliance with any legal obligation of the Employer.
B4.4 Notification to the Plan Manager and COBRA Service Provider by the Employer, or the Plan
Administrator of the termination date, qualifying event and eligibility of an individual to receive
COBRA continuation coverage.
B4.5 Notification to the COBRA Service Provider by the Employer or the Plan Administrator of the
appropriate amounts due for coverage under the Plan.
B4.6 The Client and the Employer understand and agree that the Client shall inform each affected entity
(e.g. HMO) of the existence of this Agreement and, by separate written agreement or otherwise, secure
each entity's acceptance of its pertinent provisions.
NOTICES
B5.1 The Plan Manager shall be entitled to rely and act based upon documents, letters, electronic
communications, or telephone communications which are confirmed in writing and provided to it by
the Client or the Employer. Reliance will continue until the time the Client or the Employer notifies
the Plan Manager in writing of any change or amendment to those communications.
B5.2 Notices provided by the Client regarding these COBRA Administration Services to the Plan Manager
shall be personally delivered or sent by a method no less rapid than fast class mail, with postage
prepaid, or facsimile, to the Plan Manager at the following address:
Attn: Tim Batson
Humana Insurance Company
500 West Main Street
Louisville, Kentucky 40202
Telephone: 502-5 80-8508
FAX: 502-580-3639
Email: tbatson@humana.com
EXIIIBIT C
Clinical Program Services
These Clinical Program services are performed by the Plan Manager in connection with Plan
provisions aimed at monitoring quality, containing costs, and promoting efficient delivery of Covered Services
(see below) in appropriate settings.
In all circumstances, the Client understands and agrees that these services are performed solely for the
purpose of implementing Plan provisions and assisting in utilization management decision making which
results in the delivery of appropriate levels of Plan benefits. The assistance provided through these services
does not constitute the practice of medicine.
None of the Clinical Program services performed by the Plan Manager under this Agreement constitute
a claims review determination or a guarantee of coverage or benefits eligibility. Benefits eligibility will be
determined in the normal course of claims processing.
C 1.1 "Covered Services" means health care services or supplies to which a health care coverage provision
of the Plan might apply.
C 1.2 "Emergency" care means Covered Services received by a Participant related to a sudden and
unexpected change in the Participant's physical or mental condition which is severe enough to require
immediate hospital level care.
C 1.3 "Health Care Provider" means any physician, practitioner, hospital, facility, laboratory, or any other
provider of health care services or supplies which are Covered Services under the terms of the Plan.
C 1.4 Clinical Program services are performed employing processes generally described as follows. These
concepts may be described similarly by the terms of the Plan, differing only with respect to
terminology.
(a) "Utilization Review" means the process of assessing the appropriateness, utility, or necessity
of hospital admissions, surgical procedures, outpatient care, and other health care services as
required under the provisions of the Plan. Utilization Review includes:
(1) "Precertification", which is the process of assessing the appropriateness, utility, or
necessity of proposed non-emergency hospital admissions, surgical procedures,
outpatient care, and other health care services.
(2) "Concurrent Review", which is the process of assessing the continuing
appropriateness, utility, or necessity of additional days of hospital confinement,
outpatient care, and other health care services.
(b) "Retrospective Review" means the process of assessing after the fact the appropriateness,
utility, or necessity of hospital admissions, additional days of hospital confinement, surgical
procedures, outpatient care, and other health care services, as required under the provisions of
the Plan.
(c) "Case Management" means the process of assessing whether an alternative plan of care would
more effectively provide necessary health care services in an appropriate setting, as required
under the provisions of the Plan.
(d) "Transplant Management" means hands-on support to Participants in need of organ and tissue
transplants. The Transplant Management Team guides Participants to the Plan Manager's
National Transplant Network (NTN), designed to control costs and deliver a superior
transplant experience. They review coverage, coordinate benefits, facilitate services and
follow the transplant recipient's progress from initial referral through treatment and recovery.
CLINICAL PROGRAM SERVICES
C2.1 Precertification, Concurrent Review, and Retrospective Review will be performed by the Plan
Manager, or a consulting health care professional engaged by the Plan Manager, which may use
criteria and protocols developed with input from health care experts.
C2.2 The Plan Manager will provide or arrange for the provision of Precertification services, under
applicable Plan provisions.
(a) In the event that a proposed treatment cannot be Precertified:
(1) The Plan Manager, the person requesting Precertification, and the attending Health
Care Provider may, if sufficient information is provided, discuss possible treatment
alternatives available under the Plan which might be Precertified.
(2) In the event that the attending Health Care Provider chooses not to select possible
treatment alternatives which might be Precertified or otherwise wishes to pursue
Precertification of the proposed treatment as originally proposed, the Precertification
process will proceed to resolution on the basis of available information.
(b) Precertification will be completed within the time periods prescribed in the Plan, or if there
are none, within a reasonable time after a request is made.
C2.3 During the Precertification and Concurrent Review processes, each hospital admission is evaluated for
discharge planning needs, and home health care, and Case Management potential, as appropriate.
C2.4 The Plan Manager will provide or arrange for the provision of Concurrent Review services, under
applicable Plan provisions.
C2.5 The Plan Manager will provide or arrange for the provision of Retrospective Review services, under
applicable Plan provisions.
(a) For Emergency inpatient admissions, Retrospective Review services will not be performed
unless they are requested within the earlier of:
(1) The period of time following admission specified in the Plan; or
(2) If no time is specified in the Plan, 48 hours following admission.
(b) When required notification is not provided so that Precertification is not performed,
Retrospective Review services will be performed only if specifically required by the Plan.
C2.6 Notices of the results of the Precertification, Concurrent Review, and Retrospective Review processes,
provided in accordance with the provisions of the Plan, will include information about the Plan
Manager's standard procedures for having those results reconsidered. Results of these processes do
not constitute claims determinations, and reconsideration ofthese results does not constitute an appeal
of a disputed claim.
C2.7 The Plan Manager will provide or arrange for the provision of Case Management services under
applicable Plan provisions.
C2.8 The Plan Manager will provide or arrange for the provision of Transplant Management services under
applicable Plan provisions.
C2.9 The Plan Manager will provide or arrange for the provision of the following additional services, under
applicable Plan provisions.
(a) HumanaFirst® nurse advice line which provides nurse triage and general health care
information and assistance in choosing the appropriate level of care through telephone contact
with licensed nursing professionals.
(b) HumanaBesinninss services for expectant mothers which assists in identifying high-risk
pregnancies at the Precertification stage and refers individuals with high-risk pregnancies for
individual Case Management services.
(c) Neonatal Intensive Care Unit Support provided to premature and sick newborns admitted
to the Neonatal Intensive Care Unit (NICU). Specialized Case Managers work on-site to
support parents with education and service coordination with the goal of sending the newborn
home to a supportive, prepared environment with informed caregivers and reducing the
newborn's length of stay in the hospital.
(d) Disease Management programs which provides education and assistance to Participants for
specified diseases through various contracted vendors. Eligibility in the Disease Management
programs is contingent upon specific diagnosis codes or procedural codes relative to each
program's disease focus. Specific programs and vendors may change at the Plan Manager's
sole discretion.
Such services are to include:
1. Asthma
2. Cancer (active treatment only)
3. Chronic Kidney Disease
4. Congestive Heart Failure
5. Coronary Artery Disease
6. Diabetes
7. End-Stage Renal Disease
8. Rare Diseases (Cystic Fibrosis, Hemophilia, Multiple Sclerosis, Myasthenia Gravis,
Systemic Lupus Erythematosis, Amyotrophic Lateral Sclerosis (a.k.a. Lou Gehrig's
Disease), Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP),
Dermatomyositis, Parkinson's Disease, Polymyositis, Rheumatoid Arthritis,
Scleroderma and Sickle Cell Anemia)
(e) Managed Behavioral Health, which applies a utilization management process to behavioral
health conditions (mental health and substance abuse) to produce better outcomes and cost
effective care.
(f) Personal Nurse® services which provide Participants with a specially trained nurse and
provides information and tools that can help Participants understand their health care options,
take control of their health needs and get the most from their plan benefits. Participation is
voluntary and Participants can choose to opt out at any time. Participants are identified as
potential candidates who meet all of the following criteria:
(1) Humana is the third party administrator;
(2) Active enrollment status;
(3) Expected/actual hospital admission.
(g) MvHumana, a personal, password-protected home page located at www.humana.com.
Participants can log-in anytime to fmd a participating provider, look up benefits or check the
status of a claim. Additional features include: shop-and-compare tools to help Participants
choose hospitals and doctors, prescription drug information, a health encyclopedia,
information on specific health conditions, fmancial tools to help with budgeting for health
care and more.
(h) Humana Health Assessment a confidential, online lifestyle questionnaire located at
MyHumana.com. Upon completion of the assessment, Participants will receive a customized
health report that identifies health risks and provides steps they can take to gain more control
of their health.
(i) Preventive Reminders, proactive, targeted campaigns that deliver messages to Participants of
primary prevention care. Messages are delivered in a variety of methods including Voice
Activated Technology (VAT), mailers/postcards or emails. Topics include mammography
screenings, vaccinations, immunizations and more.
(j) Wellness Calendar Program is an electronic package that the Employer will receive each
month with a dedicated focus on a wellness topic.
(k) Employee Assistance Program (EAP) provides confidential, personal assistance to
employees and their family members to address personal and work-life issues. The EAP also
provides employers consultative services to effectively manage performance challenges.
Participant support includes:
1. Face-to-face counseling sessions with an EAP counselor, up to 5 sessions per issue
per year.
2. Unlimited telephone assistance, 24 hours a day, 7 days a week, 365 days a year.
3. Telephonic and online EAP and Work-Life services for the following issues:
a. Life issues such as stress, anxiety, depression, addiction and recovery,
relationships, grief and loss.
b. Legal issues such as estate planning and legal forms (wills, power of attorney
and final arrangements). Free initial legal consultation and 25% discount
from standard legal fees for subsequent services for a network attorney.
c. Financial issues such as budgeting, tax planning, debt management,
retirement planning, insurance, home buying and refinancing and identity
theft.
d. Family issues such as childcare resources, summer school or vacation camp,
child development, parenting, college planning, adoption, emergency and
back-up care and caring for older adults.
e. Work issues such as co-worker relationships, j ob stress, balancing work and
personal life, change and transition, communication, relocation and business
travel.
f Everyday issues such as consumer information, big-ticket purchases, home
remodeling and repair, pet care resources and home and car buying.
4. Additional resource tools including a comprehensive website with calculators, tip
sheets, videos, articles, locators and more.
5. Follow-up.
Employer support includes:
1. Management consultation.
2. Regulatory assistance.
3. Monthly webinar training.
4. Promotional materials.
5. Quarterly reports.
6. Critical Incident Stress Debriefing (CISD) or training hours.
HEALTH CARE PROVIDERS
C3.1 The Client agrees that the Plan Manager shall not be held responsible for the actions of Health Care
Providers acting as licensed professionals within the scope of their professional practice, and that in no
event shall the hold harmless and indemnity provisions of this Agreement apply against the Plan
Manager with respect to any expense caused by the acts or omissions of Health Care Providers.
REPORTS
C4.1 Special reports may be provided by the Plan Manager, if requested by the Client and the contents,
composition, and cost is mutually agreed upon.
MISCELLANEOUS
C5.1 The Plan Manager will provide these Clinical Program services in accordance with the provisions of
the Plan which are in effect and which have been communicated to the Plan Manager by the Client at
the time the services are provided.
C5.2 If the Plan Administrator directs the Plan Manager to make a Clinical Program services determination
which is different than the determination which would otherwise be made by the Plan Manager, the
Plan Manager will follow the determination of the Plan Administrator, provided the Plan
Administrator's determination is first communicated to the Plan Manager in writing.
However, the Plan Manager may decide that it will communicate this determination only as directed in
special written instructions from the Plan Administrator which are acceptable to the Plan Manager.
C5.3 The Plan Manager is an independent contractor with respect to the services provided under Article 7.3
and Exhibit "C" of this Agreement, Article 2.5 of this Agreement notwithstanding.
C5.4 The obligations of the Plan Manager under Article 7.3 and Exhibit "C" of this Agreement shall
terminate upon the expiration of this Agreement.
EXHIBIT D
Networks
DEFINITIONS
D 1.1 "Covered Services" means health care services or supplies to which a health care coverage provision
of the Plan might apply.
D1.2 "Health Care Provider" means any physician, practitioner, hospital, facility, laboratory, or any other
provider of health care services or supplies which are Covered Services under the terms of the Plan.
D 1.3 "Network" means a network of Preferred Providers which is available to provide services with respect
to Participants in connection with this Agreement.
D1.4 "Preferred Provider" means a Health Care Provider that is available by virtue of this Agreement to
furnish services or supplies with respect to Participants under applicable utilization management or
case management provisions of the Plan.
D1.5 "Preferred Provider Services" means Covered Services provided by a Preferred Provider or for
emergency care.
D1.6 "Service Area" means the Zip Code Areas in which each Network provides health care services in
accordance with the terms of this Agreement and the Plan.
D 1.7 "Zip Code Area" means the geographical area described by any five-digit zip code established by the
United States Post Office.
NETWORKS
D2.1 The Plan Manager will engage one or more Networks to provide Covered Services under the Preferred
Provider Services provisions of the Plan, within each Service Area served by the Networks. The Plan
Manager will provide a listing of Network locations and Preferred Provider locations within each
Service Area.
PROVIDERS
D3.1 The Client agrees that the Plan Manager shall not be held responsible for the actions of Health Care
Providers, including providing health care services, and that in no event shall the hold harmless and
indemnity provisions of this Agreement apply against the Plan Manager with respect to any expense
caused by the acts or omissions of Health Care Providers.
D3.2 The Plan Manager represents that provider agreements entered into by it in connection with its
obligations under this Agreement comply with all of the requirements of applicable law. With respect
to its obligations under this Agreement, the Plan Manager will exercise due diligence in selecting
Health Care Providers.
D3.3 The Plan Manager acknowledges that providers of professional health care services under contract
with a Network maintained by the Plan Manager or by companies under common control with it
comply with credentialing standards no less stringent than those prevailing in the industry.
EXHIBIT D-1
Shared Savings Program Provider Discounts
In accordance with Article 7.9, the Plan Manager will arrange access for the Client to certain provider
discounts established by the Plan Manager that may be available at the time when services are rendered and/or
provider fee negotiations occur. The Shared Savings Program does not extend to services by providers that the
Client has already contracted for by selecting a network through the Plan Manager or through contracting
duectly with a network or provider.
D-1.1 The "savings" are the expenses charged by the provider above the discounted provider fee.
D-1.2 The Client realizes that the Shared Savings Program provider discounts and/or fee negotiations are
only available with respect to hospital or facility services that are part of the current program structure
but that the program structure may change over time.
D-1.3 The Shared Savings Program does not include discounts with respect to (a) providers that the Client
has already contracted for by selecting a network through the Plan Manager, or (b) networks or
providers with which the Client has directly contracted.
D-1.4 After application of the Shared Savings Program, Plan benefits will be determined as if the services
were provided in anout-of-network setting, unless it is appropriate that they be considered as in-
network due to the application of the urgent/emergencybenefits provision of the Plan.
D-1.5 The Client agrees to pay a fee for access to and application of the Shared Savings Program as specified
in Exhibit "F".
D-1.6 The Client agrees to hold the Plan Manager and its affiliates harmless and indemnify them for any and
all loss, liability, or damage (including payment of reasonable attorney's fees) which they may incur by
virtue of the Client's authorization and direction to apply the Shared Savings Program provider
discounts to claims submitted under the Client's health care Plan.
EXIIIBIT E
Appendix B, Banking Arrangement is made a part of this document.
EXHIBIT F
Schedule of Fees
F 1.1 The monthly fees presented in this Exhibit "F" are valid for the period of time beginning January I ,
2009 and ending on December 31, 2009 and January 1, 2010 and ending on December 31, 2010,
except as otherwise stated.
F2.1 General:
Administrative Fees:
January 1, 2009 Per Employee Per Employee + Per Employee Per Family
Through Spouse + Child
December 31, 2009
Medical and $39.77 $39.77 $39.77 $39.77
Prescription Drug
January 1, 2010 Per Employee Per Family
Through
December 31, 2010
Medical and Prescription Drug $38.44 $38.44
Services NOT included in the Administrative Fees Listed Above*:
*Administrative fees indicated below are only applicable January 1, 2009 through December 31, 2009.
HumanaBeginnings°"
Neonatal Intensive Care Unit Support Program:
Telephonic
Onsite
Asthma, Disease Management Program:
Low to Moderate Acuity -Telephonic
High Acuity -Telephonic
High Acuity -Ongoing
Cancer, Disease Management Program:
Telephonic
$257 Per Case
$2,073 Per Case
$2,742 Per Case
$143 Per Case
$489 Per Case
$91 Per Participant Per Month
$328 Per Participant Per Month
Chronic Kidney Disease, Disease Management Program:
Onsite
Congestive Heart Failure, Disease Management Program:
Telephonic
Coronary Artery Disease, Disease Management Program:
Telephonic
Diabetes, Disease Management Program:
Telephonic
End Stage Renal Disease, Disease Management Program:
Onsite
Telephonic
$173 Per Participant Per Month
$196 Per Participant Per Month
$69 Per Participant Per Month
$150 Per Participant Per Month
$431 Per Participant Per Month
$173 Per Participant Per Month
Rare Diseases, Disease Management Program:
High Intensity Disease -Interactive $115 Per Participant Per Month
Low Intensity Disease -Interactive $81 Per Participant Per Month
Low Intensity Disease -Self-directed $35 Per Participant Per Month
External Stop Loss Interface
$1,000
Services NOT included in the Administrative Fees Listed Above*:
*Administrative fees indicated below are only applicable January 1, 2010 through December 31, 2010.
HumanaBeginnings~' $285 Per Case
Neonatal Intensive Care Unit Support Program:
Telephonic $2,073 Per Case
Onsite $2,742 Per Case
Asthma, Disease Management Program:
Low to Moderate Acuity -Telephonic $143 Per Case
High Acuity -Telephonic $489 Per Case
High Acuity -Ongoing $91 Per Participant Per Month
Cancer, Disease Management Program:
Telephonic
Chronic Kidney Disease, Disease Management Program:
Onsite
Congestive Heart Failure, Disease Management Program: ,
Telephonic
Coronary Artery Disease, Disease Management Program:
Telephonic
$334 Per Participant Per Month
$173 Per Participant Per Month
$196 Per Participant Per Month
$69 Per Participant Per Month
Diabetes, Disease Management Program:
Telephonic
End Stage Renal Disease, Disease Management Program:
Onsite
Telephonic
$150 Per Participant Per Month
$431 Per Participant Per Month
$173 Per Participant Per Month
Rare Diseases, Disease Management Program:
High Intensity Disease -Interactive $115 Per Participant Per Month
Low Intensity Disease -Interactive $81 Per Participant Per Month
Low Intensity Disease -Self-directed $35 Per Participant Per Month
Employee Assistance Program (EAP) -Work-Life Face to Face
5 Visits $1.35 Per Employee Per Month
External Stop Loss Interface
F3.1 Specific:
$750
(a) Under Article 7.5 of this Agreement, the administrative fee for providing Subrogation /
Recovery Services is 30% of all amounts recovered under that Article. The administrative fee
will be applied towards the gross recovery, exclusive of any legal fees. Fees are calculated
based on gross recovery. Expenses incurred are taken out of the Plan Manager's fee when it
is the Plan Manager's choice to retain counsel If the Client requests legal action outside the
normal course of handling, it will be the Client's responsibility to pay legal fees incurred.
(b) With respect to access to provider networks in accordance with Article 7.8 of this Agreement
or other similar provider arrangements arranged through the Plan Manager, the Client
understands that a special access fee may be payable, depending upon the network or
arrangement. The Client and the Plan Manager agree that the Client will be obligated to pay
any special fee under this Exhibit "F3.1(b)" only upon advance written notice to and written
consent by the Client.
(c) With respect to access to and application of the Shared Savings Program in accordance with
Article 7.9 and Exhibit "D-1 ", the Client agrees to pay a fee equal to 30% of the "savings" on
medical services realized by virtue of application of the Shared Savings Program Provider
Discounts.
(d) The fee payable for run-out claims processing under Article 7.10 of this Agreement can be
one of two options. The Client can choose for the Plan Manager to process run-out claims for
either three (3) or twelve (12) months. The fee for handling these run-out claims for three (3)
months is equal to three (3) months of Administrative fees or for twelve (12) months is equal
to four (4) months of Administrative fees. The run-out fee will be calculated based on the
total number of employees that were terminated from the Plan. The total run-out fee must be
received by the Plan Manager to begin the claims processing for the selected run-out period.
F4.1 Payment:
(a) Fees set forth in Exhibit "F2.1" are payable to the Plan Manager once per month, unless
otherwise indicated.
(b) Any special access fees payable under Exhibit "F3.1(b)" shall be paid by the Client to the
Plan Manager as billed.
EXHIBIT G
Persons Authorized to Receive
Private Health Information
Name: Romiro Inguanzo
Title: Director, Human Resources
Company: City of Miami Beach
Address: 1700 Convention Center Drive
Miami Beach, FL 33139
Telephone: (305) 673-7524
Fax: (786) 394-4145
Email: ringuanzo@miamibeachfl.gov
Name: Sue Radig
Title: Human Resources Administrator, Employee Benefits
Company: City of Miami Beach
Address: 1700 Convention Center Drive
Miami Beach, FL 33139
Telephone: (305) 673-7000 ext. 6452
Fax: (786)394-5375
Email: sradig@miamibeachfl.gov
Name: Frank Esteves
Title: HR Specialist
Company: City of Miami Beach
Address: 1700 Convention Center Drive
Miami Beach, FL 33139
Telephone: (305) 673-7526
Email: festeves@miamibeachfl.gov
Name: Sandra Dellacasa-Diaz
Title: HR Tech
Company: City of Miami Beach
Address: 1700 Convention Center Drive
Miami Beach, FL 33139
Telephone: (305) 673-7000 Ext. 6536
Email: sdellacasadiaz@miamibeachfl.gov
Name: Heather Ramos
Title: HR Tech
Company: City of Miami Beach
Address: 1700 Convention Center Drive
Miami Beach, FL 33139
Telephone: (305) 673-7000 Ext. 6071
Email: hramos@miamibeachfl.gov
Name: Alison Williams
Title: Chief Accountant
Company: City of Miami Beach
Address: 1700 Convention Center Drive
Miami Beach, FL 33139
Telephone: (305) 673-7466
Name: Kristin Tigner
Title: Assistant Director, Human Resources
Company: City of Miami Beach
Address: 1700 Convention Center Drive
Miami Beach, FL 33139
Telephone: (305) 673-7524
Fax: (305) 673-7529
Email: ktigner@miamibeachfl.gov
Name: Georgina P. Echert
Title: Assistant Finance Director
Company: City of Miami Beach
Address: 1700 Convention Center Drive
Miami Beach, FL 33139
Telephone: (305) 673-7000 ext. 7451
Fax: (305) 673-7795
Email: gechert@miamibeachfl.gov
Name: Michael Fritz
Title: HR Tech
Company: City of Miami Beach
Address: 1700 Convention Center Drive
Miami Beach, FL 33139
Telephone: (305) 673-7000 ext. 7526
Email: michaelfritz@miamibeachfl.gov
Name: Mauricio Gonzalez
Title: HR Tech
Company: City of Miami Beach
Address: 1700 Convention Center Drive
Miami Beach, FL 33139
Telephone: (305) 673-7000 ext. 7526
Email: mauriciogonzalez@miamibeachfl.gov
Name: Indira Cano
Title: HR Tech
Company: City of Miami Beach
Address: 1700 Convention Center Drive
Miami Beach, FL 33139
Telephone: (305) 673-7000 ext. 7526
Email: indiracano@miamibeachfl.gov
Name: Arnita Hall
Title: HR Tech
Company: City of Miami Beach
Address: 1700 Convention Center Drive
Miami Beach, FL 33139
Telephone: (305) 673-7000 ext. 7526
Email: arnitahall@miamibeachfl.gov
Name: Sandra Sicily
Title: HR Tech
Company: City of Miami Beach
Address: 1700 Convention Center Drive
Miami Beach, FL 33139
Telephone: (305) 673-7000 ext. 7526
Email: sandrasicily@miamibeachfl.gov
Name: Richard Schell
Company: Gallagher Benefit Services
Address: One Boca Place
Boca Raton, FL 33431
Telephone: (561) 998-6733
Fax: (561)995-6708
Email: richard_schell@aig.com
Name: Colleen Ramos
Company: Gallagher Benefit Services
Address: One Boca Place
Boca Raton, FL 33431
Telephone: (561) 998-6743
Fax: (561)995-6708
Email: colleen ramos@aig.com
Name: Ivette Irizarry
Company: Gallagher Benefit Services
Address: One Boca Place
Boca Raton, FL 33431
Telephone: (561) 998-6734
Fax: (561)995-6708
Email: ivette_irizarry@aig.com
Name: Eric Hicks
Company: Symetra Financial
Address: 7300 Corporate Center Drive, Suite 205
Miami, FL 33126
Telephone: (305) 715-6145
EXIIIBIT H
Pharmacy Management
DEFINITIONS
H 1.1 "Brand Name Medication" means a drug, medicine or medication that is manufactured and distributed
by only one pharmaceutical manufacturer, or any drug product that has been designated as brand name
by anindustry-recognized source used by the Plan Manager.
H 1.2 "Dispensing Limit" means the monthly drug dosage limit and/or the number of months the drug usage
is usually needed to treat a particular condition, as determined by the Plan Manager.
H 1.3 "Drug List" means a list of prescription drugs, medicines, medications and supplies specified by the
Plan Manager. This list indicates applicable Dispensing Limits and/or any Prior Authorization
requirements. This list is subject to change without notice. Drugs may be subject to specific time
constraints.
H1.4 "Prior Authorization" means the required prior approval from the Plan Manager for the coverage of
certain prescription drugs, medicines and medications, including the dosage, quantity and duration, as
appropriate for the Participant's diagnosis, age and sex.
H 1.5 "Specialty Drug" means a drug, medicine or medication used as a specialized therapy developed for
chronic, complex sicknesses or bodily injuries. Specialty Drugs may:
(a) Require nursing services or special programs to support patient compliance;
(b) Require disease-specific treatment programs;
(c) Have limited distribution requirements; or
(d) Have special handling, storage or shipping requirements.
DRUG LIST AND PHARMACY PROGRAMS
H2.1 Pharmacy Management administers a standard Drug List that is updated on an annual basis, or as
appropriate, as drugs enter or exit the market. Changes may also occur as Brand Name Medications
lose their patents. Annual changes are effective January 1 of each year. Additional fees may be
assessed to Clients that opt out of the annual changes.
H2.2 Pharmacy Management administers the Dispensing Limits and Prior Authorization Programs. These
programs are designed to promote lower cost alternatives and patient safety.
REBATES
H3.1 Rebates are defined as revenue received from pharmaceutical manufacturers for the placement of their
product within the Plan Manager's Drug List and for the market share that product achieved within its
therapeutic class.
H3.2 Rebates are quoted on every paid prescription and include Specialty Drugs and prescriptions for less
than a 30-day supply. Rebates are calculated bi-annually and are paid within 60 days of the end of the
period.
H3.3 Rebates can be impacted by government, regulatory or pharmaceutical industry action. In the event
that changes impact the Plan Manager's pharmacy rebate program, the Plan Manager reserves the right
to calculate the impact these changes have on guaranteed rebates.
H3.4 With respect to rebates which maybe available for pharmacy benefits provided under the Plan, the
Client agrees that the Plan Manager will retain amounts attributable to rebates as reasonable
compensation for services under this Agreement, including arranging pharmacy discount programs.
PHARMACY NETWORK DISCOUNTS AND DISPENSING FEES
H4.1 The Plan Manager will assume all of the risks associated with negotiating and contracting with
participating pharmacies and pharmaceutical manufacturers. In accordance with the pricing listed
herein, the Plan Manager will be responsible for any amounts that it owes participating pharmacies
that exceeds the reimbursement it receives. The Plan Manager will also retain any amounts that it
receives that are in excess of the amounts it is obligated to pay. These amounts will be used to
contribute to the cost of administering the pharmacy and rebate program as well as corporate margin
goals.
H4.2 The Plan Manager's retail and mail order discounts exclude Specialty Drugs and prescription drug
claims that the Plan Manager pays as secondary claims.
METHODOLOGY
H5.1 Pricing Benchmarks: The parties understand that pricing indices historically used, (and that are the
basis in this quote), for determining the fmancial components of pharmacy billing rates are outside the
control of Client and the Plan Manager. The parties also understand there are extra-market industry,
legal, government and regulatory activities which may lead to changes relating to, or elimination of,
these pricing indices that could alter the financial positions of the parties as intended under this quote.
The parties agree that, upon entering into an agreement and thereafter, their mutual intent has been and
is to maintain pricing stability as intended and not to advantage either party to the detriment of the
other. Accordingly, to preserve this mutual intent, if Plan Manager undertakes any of the following:
(a) Changes the AWP source across its book of business (e.g., from First DataBank to
MediSpan); or
(b) Maintains AWP as the pricing index, in the event the AWP methodology and / or its
calculation is changed, whether by the existing or alternative sources; or
(c) Transitions the pricing index from AWP to another index or benchmark (e.g., to Wholesale
Acquisition Cost).
H5.2 Participating Pharmacy, Specialty, and Mail Service Pharmacy rates, rebates and guarantees, as
applicable, will be modified as reasonably and equitably necessary to maintain the pricing intent under
this quote and subsequent agreement. The Plan Manager shall provide Client with at least sixty (60)
days notice of the change (or if such notice is not practicable, as much notice as is reasonable under
the circumstances), and written illustration of the fmancial impact of the pricing source or index
change (e.g., specific drug examples). If Client disputes the illustration of the financial impact of the
pricing source, the parties agree to cooperate in good faith to resolve such disputes.
EMERGENCY AND CRISIS RESPONSE
H6.1 The Plan Manager will allow immediate refills of medications to any Participant located in an
"emergency area," defined as the area in which the President has declared a major disaster or the
Secretary of the Department of Health and Human Services (DHHS) has declared a public health
emergency. For those Participants residing in the emergency area, the Plan Manager will remove all
"refill too soon" edits for the period of the emergency declaration. Additionally, because the following
conditions might exist during an emergency: a limited number of operational pharmacies, limitations
on transportation and travel, and the disruption of U. S. mail, the Plan Manager may allow an affected
Participant to obtain the maximum extended day supply, if requested and available at the time of refill.
H6.2 The manner in which policy and reaction to a crisis is administered is within the sole discretion of the
Plan Manager.