Performance Guarantee Agreement with Cigna Health and Life Insurance Company Performance Guarantee Agreement
By and Between
City of Miami Beach
"Employer"
And
Cigna Health and Life Insurance Company
And Applicable Affiliates
Collectively "CHLIC"
Effective Date: October 1, 2016
Table of Contents
EXHIBIT A—Performance Guarantees and Penalties 3
Section 1.—Term and Termination 5
Section 2.—Definitions 5
Section 3.—Conditions Precedent 6
Section 4.—Evaluation of Performance and Payment Amounts 6
Section 5.—Measurement Methodology/Changes 7
Section 6.—Agreement Modification 7
Section 7.—Laws Governing Contract 7
Section 8.-Resolution of Disputes 7
Section 9.—Third Party Beneficiaries 7
Section 10.—Assignment and Subcontracting 7
Section 11.—Public Records Law;Nondisclosure 7
Section 12.—Waivers 9
Section 13.—Headings 9
Section 14.—Survival 9
Section 15.—Force Majeure 9
Section 16.—Notices 10
Section 17.—Entire Agreement 10
Signatures 11
EXHIBIT B1-IMPLEMENTATION 12
EXHIBIT B2-SERVICE 14
EXHIBIT B3—DISCOUNT 17
Table 1-Networks 17
EXHIBIT A—Performance Guarantees and Penalties
IMPLEMENTATION •
Identification Card Delivery Amount At Risk
Implementation ID Card Timeliness. 98%of the ID cards will be mailed by
the agreed upon commitment date in the Implementation Calendar.Results
measured at Account Level. $7,500.00
Claim Readiness Amount At Risk
Implementation Claim Readiness. Benefit Profile and eligibility information
loaded on claims processing system as of the Commitment Date set forth in the $7,500.00
approved Implementation Calendar. Results measured at Account Level.
Call Readiness Amount At Risk
Implementation Call Readiness. Service Center(s)ready to respond to customer
inquiries as of the Commitment Date set forth in the approved Implementation $7,500.00
Calendar.Results measured at Account Level.
Implementation Satisfaction Amount At Risk
Implementation Satisfaction. Score of no less than three(3)on Statement 1 of the
$7,500.00
Cigna HealthCare Implementation Survey.Results measured at Account Level.
SERVICE
Claim Time-to-Process Amount At Risk
Medical Time to Process. Measured for the Term of the Agreement,results will
meet or exceed: 98% of Claims processed w/in 30 Calendar Days. Results $7,500.00
measured at Account Level.
Financial Accuracy Amount At Risk
Medical Financial Accuracy. Measured for the Term of the Agreement,results
will meet or exceed:99%of total audited claim dollars are correctly paid.Results $7,500.00
measured at Office Level.
Payment Accuracy Amount At Risk
Medical Payment Accuracy. Measured for the Term of the Agreement, results
will meet or exceed: 97% of total audited claims are correctly paid. Results $7,500.00
measured at Office Level.
Averaee Speed of Answer Amount At Risk
Medical ASA. Measured for the Term of the Agreement,results will not exceed:
$7,500.00
45 seconds to answer a phone call.Results measured at Special Account Queue.
Call Abandonment Rate Amount At Risk
Medical Call Abandonment Rate. Measured for the Term of the Agreement,
results will not exceed:3%of calls received by Call Center(s)terminated.Results $7,500.00
measured at Special Account Queue.
First Call Resolution Amount At Risk
Medical First Call Resolution. 90%of calls resolved on first inquiry,45 day look
$7,500.00
back/forward.Results measured at Account Level.
CSA Quality Amount At Risk
Medical CSA Quality. 95%quality standard.Results measured at Office Level. $7,500.00
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Automated Maintenance Eliuibility Processing Amount At Risk
Medical Auto Eligibility Processing. Measured for the Term of the Agreement,
results will meet or exceed: 99% files processed in 2 Business Days after the $7,500.00
receipt of clean eligibility.Results measured at Account Level.
Account Management Amount At Risk
Medical Account Management.Composite Score(all categories)of 3.0 or better
on the Account Management Report Card based on four(4)quarterly scorecards. $7,500.00
Results measured at Account Level.
DISCOUNT
One Way Medical Discount Guarantee. See Exhibit B3 for details.
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This Performance Guarantee Agreement("Agreement")is between Cigna Health and Life Insurance Company and applicable affiliates
(collectively"CHLIC")and City of Miami Beach("Employer")and is effective on October 1,2016("Effective Date").
WHEREAS,in connection with certain services and programs that CHLIC is providing to Employer in connection with one or more employee
welfare benefit plans sponsored by Employer(the"Plan(s)")under the applicable agreements between the parties(individually or collectively,
the"Service Agreements and/or Policies"),CHLIC and Employer desire to implement the performance guarantees identified in Exhibit A
attached hereto,according to the terms set forth below.
NOW THEREFORE,in consideration of the mutual promises and covenants contained herein,CHLIC and Employer hereby agree as follows:
Section 1.—Term and Termination
1.1. This Agreement is effective on the Effective Date and shall remain in effect for one(1)year or such other period specified in the applicable
Exhibit B(the"Term")unless terminated sooner upon the earliest of the following dates:
1.1.1.The date when CHLIC ceases to administer the Plan(s)(other than run-out claim administration)or when the applicable Service
Agreements and/or Policies are terminated or suspended;
1.1.2.The date when any state or other applicable jurisdiction prohibits the activities of the parties under this Agreement;
1.1.3.The Effective Date,in the event that any condition precedent listed in Section 3 or in the applicable Exhibit B is not satisfied.
1.2. This Agreement is not renewable unless otherwise specified in the applicable Exhibit B.
Section 2.—Definitions
2.1. The following terms used in this Agreement are defined as follows. Additional definitions applicable to a specific Performance Guarantee
may be included in Exhibit B.Terms not defined in this section,the applicable Exhibit B,or otherwise in this Agreement shall be deemed
to reflect the commonly understood industry meaning.
2.2. Account Level—means that performance shall be measured based upon performance with respect to the Employer's Plan(s)to which the
Performance Guarantee applies.
2.2.1.Benefit Profile—means the benefits offered under a Plan,including plan design and structure.
2.2.2.Book of Business Level—means that performance shall be measured based upon all plans insured and or administered by CHLIC and its
affiliates as determined by CHLIC.
2.2.3.Business Days—means the days of the week that CHLIC is open to the public for conducting business.
2.2.4.Employee—means a person who is employed by Employer and covered under the Plan(s).
2.2.5.Guarantee Period—means the period during which CHLIC's performance that is the subject of the Performance Guarantee will be
measured,which shall be one(1)year from the Effective Date,unless otherwise specified in the applicable Exhibit B.
2.2.6.Payment Amount—means the amount payable,as determined by CHLIC under the criteria set forth in this Agreement,pursuant to the
terms of a Performance Guarantee.
2.2.7.Performance Guarantees—means the guarantees identified in Exhibit A pursuant to which CHLIC commits to achieving specified levels of
performance in connection with the applicable Service Agreements and/or Policies.
2.2.8.Plan Participants—means eligible persons enrolled in the applicable Plan(s)to which the specific Performance Guarantee applies.
2.2.9.Projected Population—means the number of Employees that Employer estimated would be enrolled in the applicable Plan(s)to which the
specific Performance Guarantee applies on the Effective Date which is 1,532 medical enrolled Employees.
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Section 3.—Conditions Precedent
3.1. Employer acknowledges and agrees that the following conditions precedent must be met in order for any Performance Guarantee set forth in
this Agreement to be in effect,otherwise such Performance Guarantee is null and void:
3.1.1.This Agreement is signed by both parties within three(3)months of the Effective Date;
3.1.2.Employer does not make a material change in Benefit Profile during the Term that,as reasonably determined by CHLIC,affects the
performance being measured in the applicable Performance Guarantee;
3.1.3.CHLIC continuously administers the services to which the applicable Performance Guarantee applies for the entire Term;
3.1.4.Employer must be an active client of CHLIC for the type of coverage(s)to which this Agreement relates(e.g.Medical,Dental,Pharmacy,
Vision,etc.)at the time any Payment Amount is otherwise payable by CHLIC under this Agreement;
3.1.5.This Agreement remains continuously in effect for the entire Term;
3.1.6.The Plan(s)applicable to a specific Performance Guarantee remains in effect throughout the Term;
3.1.7.The applicable Service Agreements and/or Policies to which the Performance Guarantee relates remains in effect throughout the Term of
this Agreement,or the Employer treats the applicable Service Agreements and/or Policies as being in effect by materially performing its
duties and obligations under the applicable Service Agreements and/or Policies throughout the Term of this Agreement;
3.1.8.The conditions precedent set forth in Exhibit B of a specific Performance Guarantee are met.
Section 4.—Evaluation of Performance and Payment Amounts
4.1. Performance Guarantees and the applicable levels of measurement and Payment Amounts are listed in Exhibit A. Any additional terms,
conditions precedent and definitions,if applicable,for any Performance Guarantee,are listed in the applicable Exhibit B. In the event of a
conflict between terms in the Agreement,the terms of the applicable Exhibit B shall control.
4.2. CHLIC will report to Employer on each Performance Guarantee(the"Performance Reports")within the specific time frame listed in the
applicable Exhibit B for each specific Performance Guarantee.
4.3. Employer shall notify CHLIC in writing within sixty(60)days of receiving the Performance Report of any dispute concerning the
Performance Report.
4.4. CHLIC shall pay any Payment Amount due under the Performance Report after the Guarantee Period. Upon prior written notice to
Employer,CHLIC may offset the Payment Amount against any payments owed by Employer to CHLIC.
4.5. In the event that Employer fails to perform any of its obligations under the applicable Service Agreements and/or Policies in a way that
affects CHLIC's ability to perform a function being measured in a Performance Guarantee,CHLIC reserves the right to adjust the Payment
Amount,if any,to account for Employer's act or omission.
4.6. Performance Reports measure results for the entire Guarantee Period. Any quarterly or other periodic results shared with Employer are for
informational purposes only.
4.7. No third party audit results will be used to measure performance under a Performance Guarantee.
4.8. Payment Amounts are based on the Projected Population and/or total amount of fees expected to be paid by Employer to CHLIC under the
applicable Service Agreements and/or Policies.Payment Amounts are subject to change by CHLIC in the event that the Projected
Population and/or total amount of fees paid by Employer under the applicable Service Agreements and/or Policies during the Guarantee
Period changes.
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Section 5.—Measurement Methodology/Changes
5.1. CHLIC shall apply its standard methodology,consistent with applicable industry standards,to measure its performance under a
Performance Guarantee.Additional information about methodology for specific Performance Guarantees,if applicable,is detailed in the
applicable Exhibit B. Industry standard codes,including but not limited to CPT,ICD-10,NDC and CDT codes,that are set by the industry
or a government agency are subject to update/change.Any such updates/changes occurring after the Effective Date will be deemed
incorporated into this Agreement without further action required by the parties.
5.2. CHLIC may replace or modify Performance Guarantees if necessitated by a change in the way CHLIC systematically tracks or measures the
applicable performance guaranteed. Any substitute Performance Guarantee will,to the extent reasonably possible,attempt to reflect the
same underlying objective and performance level reflected in the original Performance Guarantee,consistent with its new
measurement/tracking methodology. CHLIC shall explain the reasons for the change of a Performance Guarantee and the specifics of the
substitute Performance Guarantee in writing at least 30 days prior to such change.
Section 6.—Agreement Modification
This Agreement constitutes the entire contract between the parties relating to the subject matter herein and no modification or amendment hereto
shall be valid unless it is in writing and signed by an officer of Employer and by CHLIC's Regional Financial Officer.
Section 7.—Laws Governing Contract
This Agreement shall be construed in accordance with the laws of the State of Florida without regard to conflict of law rules,and both parties
consent to the venue and jurisdiction of its courts.
Section 8.-Resolution of Disputes(Intentionally Deleted)
Section 9.—Third Party Beneficiaries
This Agreement is for the exclusive benefit of Employer and CHLIC. It shall not be construed to create any legal relationship between CHLIC
and any other party.
Section 10.—Assignment and Subcontracting
No assignment of rights or interests hereunder shall be binding unless approved in writing by a duly authorized officer of each of the parties.
Section 11.—Public Records Law;Nondisclosure
11.1 Compliance with Public Records Laws
11.1 CHLIC shall comply with Florida Public Records law under Chapter 119,Florida Statutes,as may be amended from time
to time. Records made or received in connection with this Agreement may be public records under Florida law, as defined in
Section 119.011(12),Florida Statutes.
11.2 Pursuant to Section 119.0701 of the Florida Statutes, if the Cigna meets the definition of"Contractor" as defined in
Section 119.0701(1)(a),CHLIC shall:
11.2.1 Keep and maintain public records required by the City to perform the service;
11.2.2 Upon request from the City's custodian of public records,provide the City with a copy of the requested records
or allow the records to be inspected or copied within a reasonable time at a cost that does not exceed the cost
provided in Chapter 119,Florida Statutes or as otherwise provided by law;
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11.2.3 Ensure that public records that are exempt or confidential and exempt from public records disclosure
requirements are not disclosed,except as authorized by law,for the duration of the contract term and following
completion of the Agreement if CHLIC does not transfer the records to the City;
11.2.4 Upon completion of the Agreement,transfer,at no cost to the City,all public records in possession of CHLIC
or keep and maintain public records required by the City to perform the service.If CHLIC transfers all public
records to the City upon completion of the Agreement,CHLIC shall destroy any duplicate public records that
are exempt or confidential and exempt from public records disclosure requirements,unless otherwise required
to be maintained by CHLIC by law. If CHLIC keeps and maintains public records upon completion of the
Agreement, CHLIC shall meet all applicable requirements for retaining public records. All records stored
electronically must be provided to the City, upon request from the City's custodian of public records, in a
format that is compatible with the information technology systems of the City.
11.3 REQUEST FOR RECORDS;NONCOMPLIANCE.
11.3.1 A request to inspect or copy public records relating to the City's contract for services must be made directly to the
City.If the City does not possess the requested records,the City shall immediately notify CHLIC of the request,
and CHLIC must provide the records to the City or allow the records to be inspected or copied within a
reasonable time.
11.3.2 CHLIC's failure to comply with the City's request for records shall constitute a breach of this Agreement,and the
City,at its sole discretion,may:(1)unilaterally terminate the Agreement;(2)avail itself of the remedies set forth
under the Agreement;and/or(3)avail itself of any available remedies at law or in equity;
11.3.3 A Contractor who fails to provide the public records to the City within a reasonable time may be subject to
penalties under s. 119.10.
11.4 CIVIL ACTION.
11.4.1 If a civil action is filed against a Contractor to compel production of public records relating to the City's contract
for services, the court shall assess and award against CHLIC the reasonable costs of enforcement, including
reasonable attorney fees,if:
(a) The court determines that CHLIC unlawfully refused to comply with the public records request within a
reasonable time;and
(b) At least 8 business days before filing the action, the plaintiff provided written notice of the public records
request,including a statement that CHLIC has not complied with the request,to the City and to CHLIC.
11.4.2 A notice complies with subparagraph(1)(b)if it is sent to the City's custodian of public records and to CHLIC at
CHLIC's address listed on its contract with the City or to CHLIC's registered agent.Such notices must be sent by
common carrier delivery service or by registered,Global Express Guaranteed,or certified mail,with postage or
shipping paid by the sender and with evidence of delivery,which may be in an electronic format.
11.4.3 A Contractor who complies with a public records request within 8 business days after the notice is sent is not
liable for the reasonable costs of enforcement.
11.5. IF CHLIC HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119,FLORIDA STATUTES,
TO CHLIC'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS AGREEMENT, CONTACT
THE CUSTODIAN OF PUBLIC RECORDS AT:
CITY OF MIAMI BEACH
ATTENTION:RAFAEL E.GRANADO,CITY CLERK
1700 CONVENTION CENTER DRIVE
MIAMI BEACH,FLORIDA 33139
E-MAIL:RAFAELGRANADO@MIAMIBEACHFL.GOV
PHONE: 305-673-7411
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11.6 Notwithstanding anything to the contrary in this Agreement, CHLIC acknowledges that Employer is a municipal corporation,
organized and existing under the laws of the State of Florida,and,as such,is subject to Chapter 119,Florida Statutes,and related
statutes known as the"Public Records Laws". To the extent that CHLIC provides Employer with any information which CHLIC
considers to be a trade secret, as defined pursuant to Section 812.081,Florida Statutes,as same may be amended from time to
time, CHLIC shall provide a cover sheet marked "confidential" or "trade secret" dated and containing a description of the
enclosed protected information or CHLIC shall mark the documents as"confidential"or"trade secret". If a request is made to
view Confidential Information for which a disclosure obligation exists(or which Employer believes may exist)pursuant to the
Public Records Law,Employer will notify CHLIC of such request and CHLIC will provide Employer with an affidavit consistent
with the requirements set forth in Section 624.4213 (1)(c),Florida Statutes to confirm the trade secret status of the information.
The affidavit will be provided by CHLIC within seven(7)days from receipt of Employer's request,and will be executed by a duly
authorized corporate officer of CHLIC. If a requester objects to the application of the trade secret exemption,the Employer will
promptly provide CHLIC with notice of the objection, so as to provide CHLIC with the opportunity to obtain a court order
enjoining such disclosure within thirty-(30)days from receipt of notification. If CHLIC fails to obtain that court order enjoining
disclosure within the thirty(30)days period,Employer may release the information as requested. Such release shall be deemed to
be made with Company's consent and will not be deemed to be a violation of law,including but not limited to laws concerning
trade secrets,copyright or other intellectual property. CHLIC agrees to indemnify and hold harmless the Employer with respect to
all expenses, including any court costs and attorney's fees, which may be incurred by the Employer in connection with any
administrative or court processing, including any appellate action, arising out of any public records request relating to this
Agreement.
Section 12.—Waivers
No course of dealing or failure of either party to strictly enforce any term,right or condition of this Agreement shall be construed as a waiver of
such term,right or condition. Waiver by either party of any default shall not be deemed a waiver of any other default.
Section 13.—Headings
Article,section,or paragraph headings contained in this Agreement are for reference purposes only and shall not affect the meaning or
interpretation of this Agreement.
Section 14.—Survival
Provisions contained in this Agreement that by their sense and context are intended to survive completion of performance,termination or
cancellation of this Agreement shall so survive.
Section 15.—Force Majeure
CHLIC shall not be liable for any failure to meet any of the obligations required under this Agreement where such failure to perform is due to
any contingency beyond the reasonable control of CHLIC,its employees,officers,or directors. Such contingencies include,but are not limited
to,acts or omissions of any person or entity not employed or reasonably controlled by CHLIC,its employees,officers,or directors,acts of God,
fires,wars,accidents,labor disputes or shortages,and governmental laws,ordinances,rules or regulations.
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Section 16.—Notices
Except as otherwise provided,all notices or other communications hereunder shall be in writing and shall be deemed to have been duly made
when(a)delivered in person,(b)delivered to an agent,such as an overnight or similar delivery service,(c)delivered electronically,or(d)
deposited in the United States mail,postage prepaid,and addressed as follows:
To CHLIC:
Cigna Health and Life Insurance Company
401 Chestnut Street
Chattanooga,TN 37402
Attention:John Uthlaut,Operations Director
To Employer:
City of Miami Beach
1700 Convention Center Drive,Fourth Floor
Miami Beach,FL 33139
Attention:Sonia Bridges
The address to which notices or communications may be given by either party may be changed by written notice given by such party to the other
pursuant to this Section.
Section 17.—Entire Agreement
This Agreement constitutes the entire Agreement between the parties on the subject matter herein. Any and all other Performance Guarantee
Agreements between the parties relating to the subject matter of this Agreement,if not already terminated,are terminated as of the Effective Date
of this Agreement.
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Signatures
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2016 Performance Guarantee Page 11
APPROVED AS TO
FORM & LANGUAGE
&FOR EXECUTION
•ity Attorn- � Dote
EXHIBIT B1 - IMPLEMENTATION
1. Additional Definitions
1.1. Commitment Dates—means the dates by which CHLIC must perform specific implementation services,as set forth in the Implementation
Calendar.
1.2. Implementation Calendar—means the schedule that sets out the mutually agreed upon obligations for Employer and CHLIC in connection
with the implementation of the Plan.
1.3. Service Center(s)—means a claim processing office of CHLIC that processes Claims and receives and responds to Plan Participant
telephone calls.
2. Additional Conditions Precedent
2.1. Benefit Profiles must be finalized and provided to CHLIC by Employer at least 60 days prior to the Effective Date or CHLIC confirms that
the non-standard design and structure can be reasonably implemented at least 30 days prior to the Effective Date.
2.2. Employer or its designated agent must provide to CHLIC eligibility information for Plan Participants that is accurate,complete,accessible,
and timely under the predetermined schedule.
2.3. The Implementation Calendar must be finalized and approved by Employer and CHLIC prior to the Effective Date.
2.4. Employer must fulfill its obligations in the Implementation Calendar,including timely,accurate and complete Plan Participant eligibility
information and Benefit Profiles.
2.5. Employer must return the completed Account Implementation Survey within sixty(60)days of receipt,in accordance with paragraph 4.4.1.
below.
3. Additional Terms
3.1. The Guarantee Period for the Implementation Performance Guarantees is six(6)months beginning on the Effective Date.
3.2. Implementation Performance Guarantees set forth in this Exhibit shall be measured solely based on the timely,complete and accurate
information provided by Employer or its designee to CHLIC as of the due dates set forth in the Implementation Calendar.
4. Implementation Performance Evaluation Measures
4.1. Identification Card Delivery
4.1.1.Identification Card Delivery—will be determined by whether CHLIC mailed identification cards to Plan Participants by the dates indicated
in the Implementation Calendar.
4.2. Claim Readiness
4.2.1.Claim Readiness-will be determined by whether all complete and accurate Benefit Profile and eligibility information for each eligible
Plan Participant under the Plan was loaded on CHLIC's claims processing system as of the Commitment Date set forth in the approved
Implementation Calendar.
4.3. Call Readiness
4.3.1.Call Readiness Performance—will be determined by whether Plan specifications were loaded into the applicable inquiry system with the
Service Center(s)ready to respond to Plan Participant inquiries as of the Commitment Date set forth in the approved Implementation
Calendar.
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4.4. Overall Satisfaction with Implementation Services
4.4.1.Overall Satisfaction with Implementation Services-will be determined by whether Employer is satisfied with the implementation process,
as reflected by a score of no less than"3"on Statement 1 of an Account Implementation Survey to be distributed to the Employer by
CHLIC. Statement 1 recites that the overall implementation of the account or account changes met the Employer's needs. A score of"3"
will mean that the Employer neither agrees nor disagrees with this statement. The Account Implementation Survey shall be provided to
the Employer within sixty(60)calendar days after the Effective Date;the Employer shall return the completed Account Implementation
Survey results to CHLIC within sixty(60)days of receipt. The Account Implementation Survey shall be distributed to appropriate
members of the Employer's benefits staff,and the above score shall be the average of all of the staff members'scores on Statement 1.
5. Evaluation of Performance and Payment Amounts
5.1. Within four(4)months of completion of Implementation,CHLIC shall compile the necessary documentation and perform the necessary
calculations to evaluate its fulfillment of each performance commitment set forth in this Agreement and any payments owed and make this
information available to the Employer in a Performance Report.
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EXHIBIT B2 - SERVICE
1. Additional Definitions
1.1. Average Speed to Answer—means the sum of the total elapsed time between the moment when a telephone call is queued and the time the
call is responded to.
1.2. Call—means a telephone call received by a Call Center from a Plan Participant about a Claim or benefit provided by the Plan.
1.3. Call Center—means the member service center of CHLIC that receives and responds to Plan Participant telephone calls.
1.4. Claim—means a claim received by CHLIC for benefits under the Plan(s). If the term"claim"is used without a capital c,it refers to a claim
received by CHLIC for benefits whether under the Employer's Plan(s)or under other plans.
1.5. CHLIC's Standard Quality Assurance Audit Methodology—means the method by which CHLIC objectively measures claim quality by
auditing claims to measure claim accuracy through identification of claim payment or processing errors that are based on data available to
the claim processor at the time/day the claim was paid,that caused incorrect payment or correspondence,that has a customer impact and
that results in correctional work by CHLIC.
1.6. Customer Service Associate("CSA")—means a person whose job it is to respond to callers to a Call Center.
1.7. Inquiry—means an activity generated as a result of a Call received by a Call Center about a Claim or benefit matter. One Call may result in
one or more activities.
1.8. Maintenance Eligibility—means additions,deletions and changes in eligibility that are processed during the Guarantee Period.
1.9. Maintenance ID Cards—means ID Cards issued during the Guarantee Period for changes in member address,changes in enrollment,etc.
1.10.Office Level—means the performance is measured using a random sample of all the claims processed for the Service Center(s)on the same
claim engine that processes Employer's Claims.
1.11.Processed—means that CHLIC has made a determination as to whether expenses for which a Claim/claim is made are covered and,if
covered,determined the amount of reimbursement or determined that the Claim/claim is missing critical data which must be requested from
an external source.
1.12.Service Center(s)—means a claim processing office of CHLIC that processes Claims and receives and responds to Plan Participant
telephone calls.
1.13.Special Account Oueue—means a defined group of CHLIC associates that handle a specific block of business with similar Average Speed
of Answer and Abandonment Rate requirements. For measurement purposes,results are derived by compiling combined results for all
accounts with this requirement.
2. Performance Guarantee Metrics
2.1. Claim Time-to-Process(TTP)
2.1.1.Claim Time-to-Process-will be calculated by counting the number of Business Days or calendar days(as appropriate as determined by
CHLIC)from the day that a Claim is received by CHLIC to and including the day the Claim is Processed. The day that the Claim is
received will not be included in this calculation.
2.2. Claim Quality
2.2.1.Financial Accuracy
2.2.1.1.Financial Accuracy-will be determined by applying CHLIC's Standard Quality Assurance Audit Methodology to a statistically valid
sample of Claims(Account Level)or claims(Office Level)processed during the Guarantee Period.
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Financial Accuracy represents the sum of the absolute value of total dollars overpaid and the total dollars underpaid subtracted from the
total dollars paid,divided by the total dollars paid,expressed as a percentage. Overpayments and underpayments are determined from
auditing a statistically valid sample of Claims/claims paid during the Guarantee Period.
2.2.2.Claim Payment Accuracy
2.2.2.1.Claim Payment Accuracy-will be determined by applying CHLIC's Standard Quality Assurance Audit Methodology to a statistically
valid sample of paid Claims(Account Level)or claims(Office Level)processed during the Guarantee Period.
Claim Payment Accuracy represents the total number of Claims/claims processed without any payment errors,divided by the total
Claims/claims processed,expressed as a percentage. The calculation of Claims/claims paid with financial error is determined by CHLIC
from auditing a statistically valid sample of Claims/claims paid during the Guarantee Period.
2.3. Inquiry
2.3.1.Average Speed of Answer(ASA)
2.3.1.1.ASA-will be determined by measuring the sum of the total elapsed time between the moment when a telephone call is queued and the
time the call is responded to for all answered calls,and then dividing that number by the total number of telephone calls answered during
the Guarantee Period.
The calculation of ASA is based on all calls received during the hours of operation of the Service Center during the Guarantee Period that
are serviced in the Special Account Queue.
2.3.2.Call Abandonment Rate
2.3.2.1.Call Abandonment Rate-will be determined by dividing the total number of calls received during the Guarantee Period that result in the
caller terminating the call after it is queued to a CSA,by the total number of telephone calls received during the Guarantee Period,
expressed as a percentage.
The calculation of Call Abandonment Rate is based on all calls received during the hours of operation of the Service Center during the
Guarantee Period that are serviced in the Special Account Queue.
2.3.3.First Call Resolution
2.3.3.1.First Call Resolution Rate-will be determined by dividing the number of first Calls without a repeat call during the Guarantee Period by
the total number of original unique Inquiries received during the Guarantee Period,expressed as a percentage. A Call will be considered
a"first Call without a repeat call"if there is not a Call involving the same matter during the 45 day period prior to the Call or during the
45 day period following the Call.
2.3.4.CSA Quality
2.3.4.1.CSA Quality Rate-will be determined by averaging the quality scores of randomly monitored answered calls for a Client or Office
during the Guarantee Period,expressed as a percentage. The average quality score of randomly monitored answered calls for a
Client/Office during the Guarantee Period shall achieve CHLIC's quality standards.
2.4. Employer Service
2.4.1.Automated Maintenance Eligibility Processing*
*This Performance Guarantee shall not apply if Employer is using the Enrollment Maintenance Tool.
2.4.1.1.Additional Condition Precedent-This Maintenance Eligibility Processing Performance Guarantee is contingent upon the submission by
Employer(or Employer's agent)of full electronic eligibility files containing no more than two(2)percent erroneous records. An
"erroneous record"means any Plan Participant record lacking any of the accurate information necessary to correctly administer benefits,
such as:correct spelling of the Plan Participant's name;applicable Social Security Number;date of birth;account number;division(if
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any);branch number;information to correctly identify plan and benefit structure,such as benefit option code,benefit structure,plan
code,plan type,network ID(if the Plan uses provider networks);effective date of coverage;termination date;HIPAA privacy
information(if any);member address and any other demographic data.
2.4.1.2.Maintenance Eligibility Processing-will be determined by dividing the number of eligibility files that met the performance standard
during the Guarantee Period by the total number of eligibility files processed during the Guarantee Period,expressed as a percentage.
Whether the performance standard has been met will be determined by counting the number of Business Days from the Business Day that
the file is received by CHLIC to and including the Business Day the file is entered into the CHLIC eligibility system. The Business Day
the file is received will not be included in this calculation.
2.5. Account Management
2.5.1.Account Management Performance Guarantee—will be met if CHLIC's Account Management Sales Team provides services to Employer
of such quality that the designated Account Management Composite Score based upon four(4)quarterly scorecards during the Guarantee
Period is met on the Account Management Report Card(sample available upon request).
2.5.2.Account Management Condition Precedent—This commitment is contingent on Employer completing its obligations in the"Evaluation of
Account Management"subsection below,on a quarterly basis.
2.5.3.Evaluation of Account Management-At the beginning of the Term,Employer shall designate individuals on its benefits staff who will
receive and complete the Account Management Report Card on a quarterly basis.
The Account Management Report Card will be distributed to Employer's designated staff members on a quarterly basis,shall be
completed,signed and dated by them,and all returned to CHLIC by Employer within three(3)weeks of the distribution date.Failure of
Employer to meet its obligations in this subparagraph and the subparagraph above shall nullify the Account Management Performance
Guarantee.
Following the end of the Guarantee Period and receipt of the fourth(4th)quarterly survey from Employer,CHLIC will calculate the
composite score in each performance assessment category by averaging the scores for the four(4)quarters of the Guarantee Period. The
assessments of each of the designated staff members and each of the performance assessment categories will be weighted equally.The
Account Management Performance Guarantee will be deemed fulfilled if the average of the composite scores in each category("Account
Management Composite Score")is equal to or greater than the Account Management Composite Score indicated on Exhibit A.
2.5.4.Reservation of Right—CHLIC reserves the right to make changes during the Term in its staff/personnel assigned to provide Account
Management services to Employer.
3. Evaluation of Performance and Payment Amounts
3.1. Within four(4)months after the end of the Term,CHLIC 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
Employer in a Performance Report.
The Payment Amounts in Exhibit A have been established in relationship to the Projected Population. In the event that the actual number of
Employees enrolled on the Effective Date is greater than one-hundred and fifteen percent(115%)of the Projected Population,the Employer
reserves the right to increase the Payment Amounts in proportion to the variation between the actual and projected number of enrolled
Employees. Correspondingly,CHLIC reserves the right to decrease the Payment Amounts in proportion to the variation between the actual
and projected number of enrolled Employees in the event that the actual number of Employees enrolled on the Effective Date is less than
eighty-five percent(85%)of the Projected Population.
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EXHIBIT B3- DISCOUNT
Table 1-Networks
Rating Area Rating Area Description Guaranteed Discount
FLOAPJ FL,DADE 62.2%
FLOAPI FL,BROWARD 59.2%
FLOAPK FL,PALM BEACH 61.3%
FLOAPV FL,VOLUSIA 47.2%
FLOAPE FL,COCOA BEACH 64.6%
FLOAPL FL,MARTIN 60.8%
FLOAPG FL,POLK 27.6%
FLOAPC FL,OCALA/GAINESVILLE 49.3%
FLOAPA FL,ORLANDO 61.0%
GAOAPN GA,NE GEORGIA 48.8%
FLOAPB FL,LAKE 59.2%
FLOAPD FL,JACKSONVILLE 54.3%
FLOAPH FL,TAMPA 71.3%
CAOAPI SAN DIEGO 57.9%
FLOAPF FL,FORT MYERS 57.8%
ALOAPD AL,MONTGOMERY 44.7%
GAOAPS GA,ATLANTA SOUTH 47.0%
PAOAPD PITTSBURGH,PA 49.1%
SCOAPF SC,NON-PREFERRED 49.5%
AZOAPP AZ,PHOENIX IPA 61.5%
AZOAPR AZ,PHOENIX RURAL 16.3%
CAOAPK NORTH LA 52.6%
FLOAPN FL,PENSACOLA 59.2%
FLOAPS FL,SARASOTA 51.7%
FLOAPT FL,TALLAHASSEE 37.5%
GAOAPW GA,ATLANTA NORTHWEST 46.4%
MAOAPA MA,WESTERN 44.5%
MDOAPA MD,BALTIMORE 36.9%
MEOAPE ME,SOUTHERN 55.4%
NCOAPA NC,TRIANGLE 57.1%
NCOAPF NC,WILMINGTON 55.2%
NCOAPG NC,EAST 52.6%
NCOAPH NC,WEST 44.9%
NJOAPW NJ-NORTHWEST 51.7%
NYOAPA NY,MVP-ALBANY 58.1%
NYOAPU NY,MVP-SYRACUSE 45.8%
SCOAPE SC,PREFERRED 36.5%
TNOAPB TN,NASHVILLE INNER 45.3%
TNOAPI TN,KNOXVILLE 70.2%
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1. Additional Definitions
1.1. Actual Discount—means the weighted average of all Service Area Discounts.
1.2. Covered Charges—means the fee-for-service charges submitted for reimbursement under the Plan by Participating Providers for Covered
Services,exclusive of any discounts.
1.3. Covered Services—means health care services and supplies that are covered under the in-network coverage of the Plan and provided by
Participating Providers.
1.4. Discount Target—means the weighted average of the Service Area Discount Targets.
1.5. Eligible Charges—means Covered Charges minus discounts.
1.6. Fees at Risk—means the amount identified in Section 4 that will be used to calculate the amount that either party may be required to pay
the other under this Agreement.
1.7. Participating Provider—A hospital,physician or other provider of health care Covered Services that has directly or indirectly contracted
with CHLIC to provide Covered Services to Plan Participants at negotiated rates of reimbursement and is identified in CHLIC's provider
directory(excluding wrapper networks such as BeechStreet).
1.8. Plan—means the program of medical welfare benefits which Employer has adopted for its Plan Participants and which is administered by
CHLIC.The term"Plan"shall include each change,as of its effective date,which has been adopted by Employer and accepted by CHLIC
as compatible with its Performance Guarantee obligations hereunder. Such adoption and acceptance shall be documented in writing and
executed by an authorized officer of each of the parties.
1.9. Service Area—means all geographic locations,listed in Table 1.
1.10.Service Area Discount—means the discount that is calculated by dividing the Eligible Charges by the Covered Charges and subtracting the
result from one(1). [Example—if Covered Charges are$100 and Eligible Charges are$75,then 75 divided by 100 is.75;one minus.75 is
.25, resulting in a 25%discount].
1.11.Service Area Discount Target—means the percentage discount from Covered Charges that CHLIC expects to achieve through its
Participating Provider agreements during the Guarantee Period for all Covered Services in a given Service Area. The Service Area
Discount Target for each Service Area is identified in Table 1.
1.12.Service Termination Date—means the date on which the CHLIC Service Agreement(s)and/or Policy(ies)with respect to the Plan ends(not
counting any run-out periods).
2. Additional Conditions Precedent
2.1. This Discount Performance Guarantee applies only to Service Areas approved by CHLIC and identified in Table 1.
2.2. This Discount Performance Guarantee Agreement and the calculations herein do not apply to:
2.2.1.Charges that are not fee-for-service charges for Covered Services(including e.g.capitation payments and performance-based incentive
payments,etc.);
2.2.2.Charges for services/supplies that are not Covered Services(including e.g.charges that are not covered due to coordination of benefits,
plan exclusions,utilization management denials,pended/duplicate claims,etc.);
2.2.3.Charges made by providers that are not Participating Providers in a Service Area;
2.2.4.Services from a provider that is"pay as billed"defined as a provider who either routinely files claims with Covered Charges=Eligible
Charges or the provider does not file Covered Charges;
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2.2.5.Charges made by any CHLIC company(e.g.,including but not limited to Tel-Drug,Inc.,Tel-Drug of Pennsylvania,Inc.,Cigna Behavioral
Health and Cigna HealthCare of Arizona,Inc.'s staff model medical group);
2.2.6.Claims exceeding$100,000,which will be removed in their entirety from the calculations related to CHLIC's performance;and
2.2.7.Claims for persons age 65 or over.
2.3. In the event any federal,state or local legislation or regulation(a)impacts CHLIC's ability to enter into Participating Provider agreements
in one or more Service Areas,or(b)affects the Eligible Charges in one or more Service Areas,CHLIC reserves the right to revise the
Service Area Discount Targets to account for such changes.
2.4. When projecting the Discount Target for future periods,CHLIC based the Discount Target on a projected increase in Covered Charges
using projections from a third party("Projected Trend")and computed the Discount Target based on that projection. In the event that the
actual increase in Covered Charges during a period for which that projection was used(including the Guarantee Period)is lower than the
Projected Trend forCovered Charges by 1.0%or more,for all Service Areas combined,CHLIC may revise the Discount Target to reflect
the difference between the actual increase in Covered Charges and the Projected Trend.
2.5. In the event there is a substantial change(including but not limited to the addition or termination of a participating hospital)in CHLIC's
network in the Service Area that affects the financial discounts expected in the Service Area,CHLIC may revise the Performance
Guarantees hereunder to account for such change.
3. Performance Guarantee Evaluation Methodology
3.1. Discount Target—Prior to the Guarantee Period,CHLIC will identify the Service Area Discount Target(s)to be achieved during the
Guarantee Period in each Service Area. These Service Area Discount Targets are identified in Table 1. After the end of the Guarantee
Period,CHLIC shall calculate the weighted average of all Service Area Discount Targets for the Guarantee Period(the"Discount
Target"). In calculating the Discount Target,the proportional relevance assigned to each Service Area Discount Target will be determined
by dividing the total of all Covered Charges for that Service Area during the Guarantee Period by the total Covered Charges for all Service
Areas within the same period.
3.2. Actual Discount—Within five months after the end of the Guarantee Period,CHLIC shall calculate the Service Area Discount(s)actually
achieved during the Guarantee Period in each Service Area. CHLIC shall then calculate the weighted average of all the Service Area
Discounts during the Guarantee Period(the"Actual Discount"). In calculating the Actual Discount,the proportional relevance assigned to
each Service Area Discount will be determined by dividing the total Covered Charges for that Service Area during the Guarantee Period by
the total Covered Charges for all Service Areas during the same period.
4. Risk-Sharing Performance Guarantees
4.1. If the Actual Discount is within 1 percent-that is,that number of percentage points plus or minus-of the Discount Target(the"Risk Free
Corridor"),no amounts will be owed by CHLIC under this Agreement.
4.2. If the Actual Discount is less than the Discount Target and not within the Risk Free Corridor,CHLIC will pay or credit to Employer:
4.2.1.$2.00 Per Employee Per Month if the Actual Discount is greater than 1 percentage points to 5 percentage points of the Discount Target;or
4.2.2.$4.00 Per Employee Per Month if the Actual Discount is greater than 5 percentage points of the Discount Target.
5. Evaluation of Performance and Payment Amounts
5.1. CHLIC shall provide the Performance Report to Employer within five(5)months following the end of the Guarantee Period.
5.2. CHLIC shall pay or credit to the Employer any amounts due under this Agreement within sixty(60)days)following delivery by CHLIC of
the Performance Report.
Employer shall not have any liability pursuant to this Agreement.
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