HomeMy WebLinkAbout282969 GREATWEST - CONTRACT - RFP - P985 BENEFITSADMINISTRATIVE SERVICES CONTRACT
BY AND BETWEEN
CITY OF FORT COLLINS
(Herein called the Client)
_►i
GREAT -WEST LIFE & ANNUITY INSURANCE COMPANY
(Herein called the Service Contractor)
Whereas, the Client desires to provide benefits for certain classes of individuals (hereinafter called "Members") in
accordance with a written employee welfare benefit plan established by the Client;
Whereas, under said plan the Client will bear all liabilities but desires that the Service Contractor provide certain services
in connection with the administration and operation of the plan without assuming any such liability (hereinafter called "the
Plan");
Whereas, the Plan is an employee benefit plan and the Client, who is both the fiduciary of the Plan and the Plan
Administrator, hereby retains the Service Contractor to provide services for the Plan in accordance with the following
terms and conditions;
Now, therefore, in consideration of the payments to the Service Contractor as provided in the Payment Schedule,
Appendix A, and subject to the terms and conditions contained herein, it is hereby agreed as follows:
Section 1. Definitions
As used in this Contract, its Appendices and Attachments
a. "Affiliate' means a person or entity within the same common control group as determined under Internal
Revenue Code section 414(c) and the regulations thereunder, and for Service Contractor includes a
person or entity with whom the Service Contractor operates under a joint marketing or joint venture
contract.
b. "Claim Overpayment' is a claim payment, or a portion thereof, with a minimum amount of $250, that
(based on applicable Plan terms and provisions):
i. is in excess of the benefit amount otherwise payable;
ii. should not have been paid; or
iii. is paid to wrong payee(s).
C. "Health Information" means any information related to health care treatment, payment or operations that
identifies or could reasonably be used to identify a Member.
d. "Plan Administrator" shall have the meaning ascribed to the term "administrator as defined in ERISA
and shall have a comparable meaning for non-ERISA plans,
e. 'Plan Month" shall mean a calendar month.
b. upon failure of the Client to:
make payments set forth in Section 4 of this Contract, entitled "Payments to the Service
Contractor'; or
ii. fund the Transfer Account, in which instance the Service Contractor shall solely
suspend plan operations for a period not to exceed twenty-four (24) hours, during which
time the Client shall fund the Account in full.
11.5 Reinstatement after Termination. If the Service Contractor terminates this Contract under Section 11.3 or 11.4,
and the Client desires to reinstate this Contract, it will be reinstated only if:
a. the Service Contractor agrees; and
b. the Client pays a Reactivation Fee of the greater of five hundred dollars ($500) or two percent
(2%) of the average amount of the monthly claims for the last three months; and
C. the Client pays all outstanding amounts plus interest accruing from the date of termination at the
rate of the lesser of one and one-half percent (1.5%) per month or the maximum allowed
pursuant to state law; and
d. the Client reimburses the Service Contractor for any network access fees required to be paid by
the Service Contractor on behalf of the Client following termination of this Contract.
11.6 Termination by Law. If any state or other jurisdiction enacts a law which prohibits or effectively prevents the
continuance of this Contract, or the existing law is interpreted by a governmental entity to so prohibit or
effectively prevent the continuance of this Contract, the Contract shall terminate automatically as to such time or
jurisdiction on the effective date of such law or interpretation.
11.7 Termination for Breach. In addition to the foregoing, if one Party has materially breached this Contract (the
"Breaching Party") and the other Party (the "Nonbreaching Party") desires to terminate this Contract, the
Nonbreaching Party shall give the Breaching Party specific written notice of the nature of the breach. The
Breaching Party shall have 30 days to cure such breach. If the breach remains uncured 30 days following the
notice of breach, this Contract shall terminate as of the end of such 30 day cure period. This Section shall not
apply to immediate breaches as set forth in Section 11.4 above.
11.8 Effect of Termination.
11.8.1 If on the date this Contract terminates the Client has not made all payments then due under this
Contract, the Service Contractor will have the right to immediately stop providing the Services, including
but not limited to processing claims, on the effective date of such termination. In this case, information
regarding all outstanding claims which are unpaid (regardless of when the claim was incurred and
regardless of when the Service Contractor received the claim) or received after such date will be
returned by the Service Contractor to the Client. In addition, the Client will notify each Member covered
under the Plan of such termination.
11.8.2 Upon termination of this Contract or upon termination of individual Employee or Dependent coverages, it
is the Client's responsibility to take reasonable steps to prevent further use of I.D. cards, including
prescription drug cards, if applicable, by any Employees or their Dependents post termination. If the
Client fails to update the eligibility records in a timely manner using BENLink, the Client will be
responsible for reimbursing the Service Contractor for any claims incurred by the Service Contractor on
behalf of a former Member who retains and uses a health plan card or a prescription drug card after
Coverage ends under the Plan.
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11.8.3 With respect to claims incurred prior to and not processed before termination of this Contract, the
Service Contractor shall not be responsible for adjudicating the claims unless Service Contractor agrees
in writing to do so and the Client pays the terminal fee set forth in Appendix A. Such adjudication shall
be limited to claims incurred prior to the termination of this Contract and submitted for consideration
within the 15-month period immediately following the termination date. If the Service Contractor does
not process such claims, then the Service Contractor will send the claims to the Client or to Client's
designated representative upon request.
Section 12. Subcontractin
The material and significant duties to be performed by the Service Contractor under this Contract may, with the prior
approval of the Client, be performed directly, wholly or in part, under a contract with an organization of the Service
Contractor's choosing. Such approval shall not be unreasonably withheld. Except as provided above, the Service
Contractor may, at its discretion, contract with any organization to perform any other duties under this Contract.
Section 13. Compensation to Agents or Brokers
The Client acknowledges that Service Contractor may pay reasonable compensation to the agent or broker of record, if
any. Any and all agents and brokers are hereby declared to be (an) agent(s) of the Client and not of the Service
Contractor. The Client shall notify the Service Contractor, in writing, if the Client changes its agent or broker.
Section 14. Advertising
The Client will not use Service Contractor's name in any release or printed forms unless approved in advance by the
Service Contractor. The Service Contractor will not use the Client's name in any release or printed forms unless
approved in advance by the Client.
Section 15. Other Financial Provisions
15.1 Savings Initiatives.
15.1.1 In its sole discretion, Service Contractor may undertake initiatives in addition to the services described in
this Contract for the purpose of saving additional money for the Plan. Examples of such initiatives might
include, but are not limited to subrogation and right of recovery, provider and incentive bonus
arrangements, and provider bill/fee negotiation and discounts on claims from providers outside of the
Service Contractor's primary network of providers.
15.1.2 For purposes of pursuing savings under this provision, the Service Contractor may retain third party
vendors.
15.1.3 For its services in obtaining savings for the Plan, Service Contractor shall be entitled to retain:
a. for subrogation and right of recovery, the amount referred to in 15.2 below; and
b. for all other savings initiatives, 33.3% of the savings realized.
Such charges are reflected as a claim expense for the applicable Member.
15.2 Subrogation and Right of Recovery. For purposes of subrogation and right of recovery, the Service Contractor
in consultation with the Client, will have the sole right to make claims under the Subrogation and Right of
Recovery Provision contained in the Plan. In its sole discretion, the Service Contractor may litigate, negotiate,
settle, compromise, release or waive any such claim. The Client hereby assigns to the Service Contractor all of
its rights to make, litigate, negotiate, settle, compromise, release or waive any such claim.
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Recoveries under this Section will be distributed as follows:
a. first, to the Service Contractor to be applied to reduce the Service Contractor's payment of
specific stop -loss benefits under the excess loss contract, if any, issued by the Service
Contractor to the Client for the employee or dependent for whom the recovery was obtained;
and
b. second, to the Service Contractor to be applied to reduce the Service Contractor's payment of
aggregate stop -loss benefits under the excess loss contract, if any, issued by the Service
Contractor to the Client, and
C. third, 33.3% to the Service Contractor for its services in obtaining the recovery; and
d. fourth, the remainder, if any, to the Client.
Action taken under the Subrogation and Right of Recovery Provision contained in the Plan may result in
incurring legal expenses. Such legal expenses will be borne by the Service Contractor and the Client in the
same proportion as any money recovered under the Subrogation and Right of Recovery Provision and is
distributed between the Service Contractor and the Client. Legal expenses will not be included in the calculation
of specific stop -loss benefits, or the aggregate stop -loss benefits, if any, pursuant to the excess loss contract
issued by the Service Contractor to the Client.
15.3. Compensation and Financial Arrangements with Third Parties. The Contractholder acknowledges that the fees
charged to the Contractholder under this Contract are calculated on the basis that the Company may receive
compensation from third parties with which the Company Contracts or has other arrangements. For example,
the Company maintains Contracts with providers such as, but not limited to, hospitals, physician groups,
individual physicians, labs and clinics; and with vendors that assist the Company with certain services, such as,
but not limited to, pharmacy benefit management, disease management, claims negotiation and claims audit
vendors. Some of the Company's Contracts with providers and vendors provide compensation to the Company
in the form of discounts, rebates, allowances, rate differentials, commissions, administrative fees, distribution or
marketing fees, incentives, adjustments, settlements, minimum guaranteed payments, or other financial
arrangements. Such compensation is for the sole benefit of the Company. The Company may retain such
compensation, regardless of the form or manner in which it is received, to defray expenses of the Company and
to provide for a profit.
15.4 Access Fees. The Service Contractor may negotiate arrangements with third parties to provide Members
services and benefits that are not otherwise covered under the Plan. The Service Contractor may retain any
fees received from the third parties pursuant to their contractual arrangements.
15.5 Surcharge Payment. For any state in which a surcharge payment is required to be made to that state, to fund
medical care for uninsured populations, finance the operation of risk pools or other purposes required by the
state, Service Contractor shall render such payments in accordance with that state's requirements and shall
draw such funds from the Transfer Account.
Section 16. Miscellaneous
16.1 Reliance. The Service Contractor shall be entitled to rely upon any communication believed by the Service
Contractor to be genuine and to have been signed or presented by the proper party or parties. For verification of
persons eligible for the coverages provided under the Plan, the Service Contractor will rely solely upon
information in its computer records at the time eligibility verification is requested. These records will be based
upon eligibility information provided to the Service Contractor by the Client.
16.2 Notices. Any notice which may be given under this Contract shall be in writing and may either be personally
delivered, sent by registered or certified mail through the United States Postal Service, return receipt requested,
or by reputable overnight carrier, delivery prepaid addressed as follows. A notice so delivered shall be deemed
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given on the date of delivery if personally delivered or delivered by overnight carrier, and on the date indicated
on the return receipt if delivered by the United States Postal Services.
16.2.1 To the Service Contractor:
GREAT -WEST LIFE & ANNUITY INSURANCE COMPANY
Denver National Accounts Department, Employee Benefits
8505 E. Orchard Road
Greenwood Village, CO 80111
With a copy to
GREAT -WEST LIFE & ANNUITY INSURANCE COMPANY
General Counsel
8525 E. Orchard Road
Greenwood Village, CO 80111
16.2.2 To the Client:
CITY OF FORT COLLINS
215 North Mason, 2"d Floor
PO Box 580
Fort Collins, CO 80522-0580
Phone number: (970) 221-6843
16.2.3 A party's address may be changed by notice to the other in accordance with this section.
16.3 Waiver. Failure by the Client or the Service Contractor to insist upon compliance with any provision of this
Contract at any given time or under any given set of circumstances shall not operate to waive or modify such
provision or in any manner render it unenforceable, as to any other time or as to any other occurrence and no
waiver of any of the terms or conditions of this Contract shall be valid or of any force or effect unless contained
in a written instrument specifically expressing such waiver and signed by a person duly authorized to sign such
waiver.
16.4 Amendments. Except with respect to modification of fees as described in Section 4 of this Contract, no alteration
or modification of the terms and conditions of this Contract shall be valid or of any force or effect unless in each
instance it is contained in a written instrument expressing such alteration or modification and executed for the
Client and the Service Contractor by their officers duly authorized to execute such alteration or modification.
16.5 Assignment. Other than assigning the right to receive money, neither party shall transfer its rights or delegate its
duties under this Contract except as permitted elsewhere in this Contract, without the express written consent of
the other party; provided, however, that the Service Contractor may transfer any portion of its rights or delegate
any portion of its duties under this Contract to its Affiliate. The Client's reorganization, any merger in which the
Client is not the surviving company, and any transfer of the Client's assets whether by bulk sale or otherwise,
shall be deemed to be a transfer or delegation by Client. Any transfer or delegation by a party in violation of this
Section shall be void and of no force or effect and shall entitle the other party to immediately terminate this
Contract.
16.6 Inurement. This Contract shall be binding upon and shall inure to the benefit of the parties hereto and their
permitted respective successors and permitted assigns and delegates.
16.7 Force Maieure. In the event that either party is unable to perform under this Contract on account of strikes,
accidents, acts of Nature, severe weather conditions, fire, governmental restrictions, computer system failure or
any other reason which is beyond the reasonable control of the parties, then performance under this Contract
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shall be excused for a reasonable period of time to enable the parties to resume performance. If a party is
unable to resume its performance within such reasonable period of time, the other party may terminate this
Contract as provided herein.
16.8 Entire Contract. This Contract, including any schedules, appendices or supplements thereto, (together with the
Great -West Life & Annuity Insurance Company Application for Group Coverage and other attached papers, if
any), shall constitute the entire contract between the parties and shall govern the rights, liabilities and obligations
of the parties hereto, except as it may be modified in accordance with the provisions of this Contract. This
Contract supersedes all prior proposals, representations, communications, negotiations and contracts between
the parties, whether oral or written.
16.9 Controlling Law. This Contract shall be construed and enforced according to the laws of the state of Colorado to
the extent that such laws are not preempted.
16.10 Provisions Separable. The provisions of this Contract are independent of and separable from each other. In the
event any provision of this Contract shall be held illegal, invalid or unenforceable in whole or in part, for any
reason by law or a court of competent jurisdiction, said illegality or invalidity shall not affect the remaining parts
of this Contract, but it shall be construed and enforced as if said illegal or invalid provisions had not been
included herein either initially, or beyond the date it is first held to be illegal or invalid if after the effective date of
this Contract, provided the basic purposes hereof can be effectuated through the remaining valid and legal
provisions.
16.11 Gender and Number. Any reference in the masculine gender herein shall be deemed to also include the
feminine gender, unless expressly provided otherwise. Wherever appropriate, any reference in this Contract in
the singular shall include the plural, and any references in the plural shall include the singular.
16.12 Counterparts. This Contract may be executed in any number of counterparts, each of which shall be deemed
original and said counterparts shall constitute but one and the same instrument.
16.13 Currency and Place of Payments. All sums payable to, or payable by, the Service Contractor pursuant to this
Contract shall be payable in the lawful currency of the United States of America at its Greenwood Village,
Colorado office.
16.14 Headings. Section, sub -section or paragraph headings contained in this Contract are for reference purposes
only and shall not affect the meaning or interpretation of this Contract.
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IN WITNESS WHEREOF, the parties hereto have caused this Contract to be executed by their respective officers duly
authorized to do so, to be effective as of January 1, 2006.
Dated at FoRT COLL.1&& 4240 this 249TH
(City) (State) (Date)
day of E>=fjPu})QY. 26G16.
(Month) (Year)
CITY OF FORT COLLINS,
By: _L/
Darin Atteberry
City Manager
By: DI L'"` A
Ja s . O'Neill, II, CPPO, FNIGP
Director of Purchasing and Risk Manageme%�t
ATTEST:
O� FORT /
City Clerk SEAL
APPRO D AS TO M:
CO�Oi2A00
Assistant ity Attorney
GREAT -WEST LIFE & ANNUITY INSURANCE COMPANY
August 19, 2005
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Appendix A
Payment Schedule
To be attached to and made a part of the Administrative Services Contract
Effective Date January 1, 2006
By and between
CITY OF FORT COLLINS
AND
GREAT -WEST LIFE & ANNUITY INSURANCE COMPANY
Service Fees Schedule.
The Service Contractor shall have the right to adjust the fees listed below as specified under Section 4 of the Contract.
A. The Client shall make payments to the Service Contractor in advance for service fees listed below by the first
day of each Plan month in which the Service Contractor performs the listed services. A grace period of 30 days
is granted after such monthly payment due date.
Services Provided as described in Appendix B:
Includes:
Basic Claims Adjudication Services,
Direct Claim and Verification Service, and
Actuarial and Underwriting Services
('Basic ASO Service Fee")
Care Management (includes Utilization Management and Case Management)
Disease Management
Maternity Management
Access to Managed Health Care Network
Certificates of Creditable Coverage
Document Preparation
BENLink
I.D. Cards
Prescription Drug Card Service
2417 Nurseline
The monthly amount due will be determined as follows for the Plan Year beginning on January 1, 2006 and ending on
December 31, 2006:
For Employees Covered under the PPO Plan
For Employees Covered under the POS Plan
For Employees Covered under the POS Vision Plan
$ 31.58
$ 36.40
$1.06
The monthly amount due will be determined as follows for the Plan Year beginning on January 1, 2007 and ending on
December 31, 2007:
For Employees Covered under the PPO Plan
For Employees Covered under the POS Plan
For Employees Covered under the POS Vision Plan
$ 32.71
$ 37.77
$ 1.11
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B. The Client agrees to compensate the Service Contractor for services listed below as follows:
Amount Due
Subrogation and Recovery 33.3% of all recovered amounts
The Service Contractor reserves the right to offset the amount due for this service against recovery
amounts.
2. The cost of customized or bulk printing will be billed as charged to the Service Contractor for any
documents not specifically listed in Appendix B.
3. The cost of any mass mailings to plan participants will be billed separately.
C. For the adjudication of claims incurred prior to the termination of this Contract and submitted for consideration
within the15-month period immediately following the termination date, the Client shall pay to the Service
Contractor an administrative fee of :
$77.63 per Employee for the PPO Plan for Plan Year beginning on January 1, 2006 and ending on
December 31, 2006, and
$76.94 per Employee for the POS Plan for Plan Year beginning on January 1, 2006 and ending on
December 31, 2006
80.41 per Employee for the PPO Plan for Plan Year beginning on January 1, 2007 and ending on
December 31, 2007, and
$79.84 per Employee for the POS Plan for Plan Year beginning on January 1, 2007 and ending on
December 31, 2007
on the first day of the last Plan month prior to the end of this Contract.
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Appendix B
Services to be Provided by the Service Contractor
To be attached to and made a part of the Administrative Services Contract
Effective Date January 1, 2006
By and between
CITY OF FORT COLLINS
AND
GREAT -WEST LIFE & ANNUITY INSURANCE COMPANY
The Service Contractor will perform the following services which are included in the Basic ASO Service Fee:
Basic Claims Adjudication Services and Direct Claim and Verification Service
These Basic Services provide for the processing of all claims incurred and received while this Contract is in force. The
services to be performed by the Service Contractor are:
1. Preparation of claim checks and Explanation of Benefit forms on a universal check form to be mailed by the
Service Contractor;
2. Claims and correspondence and telephone inquiries come directly to the Service Contractor; claim checks and
correspondence are mailed directly to employees and/or assignees; copies of Explanation of Benefit forms are
sent to the Client upon request;
3. Maintenance of individual benefit records for determination of plan benefits and satisfaction of deductibles;
4. Follow up for additional medical or service information from provider;
5. Coordinate benefit payments with other employee plans;
6. Preparation of IRS Reports (1099) Medical Provider Fees;
7. Claim control practices; and
8. Verification of eligibility as to coverage and benefits.
9. Maintenance of records for the determination of overutilization or plan abuse by users and providers.
t8
Actuarial and Underwriting Services
This includes those services which concern the pricing of benefit types and the actuarial estimate of the incurred but
unreported claim reserve. Such services include:
1. Benefit design advice;
2. Annual re -rating of the existing plan;
3. Pricing proposed benefit plan alternatives; and
4. Advice on the expected financial results of plan changes.
The Service Contractor will perform the following services which are not included in the Basic ASO Service
Fee:
Document Preparation
Document Preparation includes basic drafting which consists of preparation of the employee Summary Plan Description.
The cost of printing the Summary Plan Description and other documents if any is included.
I.D. Cards
Identification cards will be prepared for enrolled employees based on eligibility information provided by the Client.
Certificates of Creditable Coverage
In accordance with federal regulations, individuals will be provided with Certificates of Creditable Coverage at specified
times which will contain documentation of prior coverage including coverage period.
19
The first "Plan Year" shall begin on January 1, 2006 and shall continue until the beginning of the second
Plan Year. The second Plan Year shall begin on January 1, 2007 and successive Plan Years shall begin
with the anniversary of such date.
Section 2. Services
The Service Contractor will provide the services listed in Appendices B through E subject to modification as provided
herein, for the administration and operation of the Plan; such services will be coordinated by a representative of the
Service Contractor to assure effective and efficient operation of the Plan.
It is understood that the Service Contractor performs purely non -discretionary and ministerial functions for the Client
within a framework of policies, interpretations, rules, practices and procedures made by the Client. The Service
Contractor shall perform Services in accordance with the terms of the Plan, including but not limited to the terms of the
summary plan description (SPD).
Any review by the Service Contractor of a claim or of charges declined is made as a service for the Client, who retains
the final responsibility for determining its liability under the Plan.
If the Client has not adopted a final SPD, the Service Contractor will process benefit payments in accordance with its
standard policies and procedures for the benefits selected by the Client as set forth on the master application form or
prior carrier booklet with appropriate modifications. When following such standard policies and procedures, the Service
Contractor will not be responsible for any act taken that may conflict with the terms of the SPD that is ultimately adopted.
However, in the event that the Client amends its Plan to include items that the Service Contractor cannot administer,
nothing herein shall be construed to require the Service Contractor to so administer said amendments but, rather, this
Contract shall remain in full force and effect as if said amendments had not been made. In the event a Plan amendment
is administratively burdensome for the Service Contractor to administer, a charge may be imposed or other fees, as
applicable, may be adjusted pursuant to the Client's knowledge and consent.
Section 3. Banking Arrangements
3.1 Establishment and Maintenance of Transfer Account. The Client shall establish and maintain a bank account
("the Transfer Account') with sufficient funds to comply with section 3.2 below. The Client shall make available
funds in the Transfer Account sufficient to honor all of the Client's obligations under this Contract.
3.2 Right of Service Contractor to Demand Monies from Transfer Account. The Service Contractor shall have the
right to demand monies from the Transfer Account on a weekly with week delay basis in an amount sufficient to
satisfy all of the Client's obligations under this Contract incurred as of the date of demand, including:
a. past due, overdue or other unsatisfied obligations, if any; and
b. benefit claims paid by the Service Contractor to Members who were not eligible for Plan benefits and
with respect to whom the Client does not in a timely manner notify Service Contractor of such Member's
lack of eligibility.
The Service Contractor shall not be authorized to demand monies from the Transfer Account for any purpose
other than in order to satisfy the Client's obligations as set forth in this Contract.
3.3 Notice to Bank of Service Contractor's Rights. The Client shall notify the bank:
a. that the Client has authorized the Service Contractor to demand monies from the Transfer Account;
b. that if the Transfer Account does not have sufficient funds to cover any demand by the Service
Contractor the bank shall honor such demand pursuant to a line of credit established by the Client; and
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Appendix C
Managed Care Services
(Not Included in the Basic ASO Service Fee)
To be attached to and made a part of the Administrative Services Contract
Effective Date January 1, 2006
By and between
CITY OF FORT COLLINS
AND
GREAT -WEST LIFE & ANNUITY INSURANCE COMPANY
1. Managed Care
Proarams. The Service Contractor agrees to provide services to allow the Client to establish the following
programs under its Plan:
a. Provider Network. A Provider Network consisting of participating hospitals, physicians, other health care
professionals and other types of providers as appropriate (collectively called "Providers"). A higher
level of benefits is typically paid when the Member receives covered health care services from the
Provider Network or as otherwise set forth in the Plan
b. Medical Management. A medical management program known as Care Management ("CM"). A care
manager will assess the health care needs of a Member with a long-term and/or complex illness or
injury, develop appropriate discharge plans, and coordinate needed medical services. A care manager
will also review medical necessity and appropriateness of care though pre-treatment authorization of
inpatient hospitalization and certain outpatient procedures, review of continuing hospital stays, and an
appeal process. Written notice will be promptly provided to the Member, the hospital where appropriate,
and the treating physician of the status of each authorization.
C. Subcontractors. The Service Contractor may occasionally utilize services of subcontractors to assist
with assessment of the case. Payment of said subcontractor fees will be the responsibility of the Client.
However, the Service Contractor will be liable for payment of the subcontractor fees if the benefits
payable exceed the applicable amounts pursuant to the excess loss contract.
The Service Contractor will develop mechanisms for early identification of potential cases to benefit from
the CM program. In the CM Program, the Members' individual needs are assessed with both the
Member and the attending physician. An alternative treatment plan to traditional care is developed and
presented to the Member and family members and the physician for approval. The alternative treatment
plan is implemented via coordination by the CM medical professionals. Claims reflective of the
alternative treatment plan are submitted and reviewed by the CM Program. The CM Program monitors
the medical necessity of the care until case closure.
The Service Contractor is not required to seek Client's approval prior to the implementation of any
alternative treatment plan where:
all expenses to be payable under the alternative treatment plan are normally covered under the
Client's Plan; or
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ii. with respect to the Client who has a separate excess loss policy in effect with the Service
Contractor covering its excess loss under the Plan, expected benefits payable outside or within
the alternative treatment plan exceed the applicable stop loss protection point.
In all cases, the Client agrees that expenses for the alternative treatment plan may be included as
eligible expenses even if they are not included as such under the Client's Plan.
d. Adverse Determination/Additional Review. If a Member receives an adverse determination under one of
these programs and seeks additional review (as entitled by law or by the terms of the Plan), by a third
party or an independent utilization review organization, any cost or fee for such additional review shall be
billed to the Client or charged against the Transfer Account.
2. Provider Network Product(s)
a. Networks. The Service Contractor shall contract with one or more networks of Providers to furnish
health care services in conjunction with the Provider Network Product.
b. Availability and Incentives to Members. The Service Contractor shall offer and the Client shall make the
Networks available to Members. It is the duty and responsibility of the Client to include in the Plan
incentives and/or disincentives to Members to encourage use of the services of the Networks.
C. Provider Network Directories. The Service Contractor shall include a listing of Network Providers on the
OneHealthPlan.com website, which will be periodically updated to reflect changes in the participation of
Providers.
d. Standard and Character of Performance. The Service Contractor, through its contracts with Networks,
shall use customary and reasonable care and proper diligence in the performance of its services under
this Appendix. For purposes of this contract, the Client will be deemed the "Administrator" and "Named
Fiduciary" of the Plan.
3. Disease Management Program for Chronic Medical Conditions
a. The Service Contractor, through its own employees, Affiliates and/or employees of contracted third -party
vendor(s), will provide Disease Management services to Members identified as and consenting to be
service recipients under the program.
b. The Service Contractor, through its own employees, Affiliates and/or employees of contracted third -party
vendor(s), will perform an initial identification of Members meeting predetermined medical criteria
indicating the potential to be service recipients. This identification process will be based on information
legally obtained through claims, Members' self -referral or other valid sources.
C. The Member who consents and is accepted into the program ("Participant") will receive services
consisting of assessment and education for targeted diseases. The services are designed to enable the
Participant to gain knowledge and skills necessary to prevent severe chronic medical conditions,
manage his or her life-long condition and improve quality of life. The program does not provide medical
treatment, therapeutic services or hands-on home nursing. The program neither warrants nor
guarantees the well-being or improvement of the Participant's chronic medical condition.
d. The Client agrees to provide 100% benefit reimbursement under its Plan, without application of the
deductible or copayment, for all services received under the disease management program. The benefit
reimbursement amount does not apply to the Member's lifetime maximum under the self -funded plan.
"Chronic Medical Condition" means an illness for which there is no cure; however, medical treatment is
available. It is a long-term illness that does not ordinarily pose an immediate threat to one's life. Chronic medical
conditions covered under this program may include, but are not limited to, intense diabetes, asthma or cardiac
conditions.
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4. Maternity Management Care ProgIram
This program monitors the health and well-being of pregnant mothers. Care managers are trained to identify
potential difficulties and maintain regular phone contact with pregnant mothers, checking the status of their
pregnancy and answering questions about pregnancy and delivery. The program neither warrants nor
guarantees a normal or safe pregnancy or delivery. Nor does it guarantee the health or well-being of pregnant
mothers or their newborn child(ren).
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Appendix D
BENLInk
To be attached to and made a part of the Administrative Services Contract
Effective Date January 1, 2006
By and Between
CITY OF FORT COLLINS
and
GREAT -WEST LIFE & ANNUITY INSURANCE COMPANY
For Clients using BENLink online services, the following provisions shall apply:
The Service Contractor grants the Client the non-exclusive, non -transferable right to use BENLink in accordance with
this Contract while this Contract is in effect.
The Client is responsible for performing all BENLink functions in order to administer the Plan, including but not limited to
the following:
Acquisition and maintenance of completed, executed and accurate enrollment applications for every eligible
employee or dependent;
2. Updating information regarding all Members including, but not limited to, recording changes for name,
beneficiary, benefits or primary care physicians, within 10 working days of the Client's receipt of notice or
change.
The Client shall be responsible for reimbursing the Service Contractor for any claims paid on behalf of a terminated
Member where the Client failed to update BENLink and remove the Member there form in a timely manner. Such
payments shall be funded through the Transfer Account as set forth in Section 3 of the Contract.
The Service Contractor is relieved of any duties imposed upon it under other terms of this contract to the extent those
duties can be performed by the Client using BENLink.
BENLink may be used only to administer the Plan. With the Service Contractor's prior consent, the Client may
subcontract, delegate or assign its rights or duties related to BENLink, or allow a third party "read only access" to the
Client's data on BENLink. In this event, the following terms apply:
The Client shall retain ultimate responsibility for all duties and obligations under the Contract. Any third party
shall be subject to such duties and obligations. The Client shall be responsible for monitoring and overseeing the
third party's performance pursuant to said subcontract, delegation, or assignment and shall remain fully
responsible as stated herein notwithstanding said delegation. The Client shall be responsible for any breach by
a third party of such duties and obligations, and the Client indemnification provisions under the Contract shall
apply to any such breach by a third party.
2. The Service Contractor shall have no obligations to any third party, or any liability for the BENLink services
performed by any third party.
3. The Client shall abide by the Privacy of Health Information requirements set forth in Section 5.5 of the Contract.
BENLink must not be used in any manner not expressly allowed by this Contract.
Client acknowledges that Service Contractor is under no obligation to provide support for BENLink, except for
maintenance of the BENLink system itself and basic technical assistance via telephone, facsimile and electronic mail
23
during the Service Contractor's regular business hours, The Client shall be responsible for all Internet service provider
charges, and all related long distance charges, if any.
The Service Contractor shall have no liability with respect to the Client's use of BENLink, and further, makes no
representations or warranties with respect to BENLink. The Service Contractor is not responsible for mistakes make by
the Client in its use of BENLink.
BENLink online services will terminate immediately upon misuse of BENLink by the Client or its subcontractors,
delegates or assigns and may terminate, in the sole discretion of the Service Contractor, upon discontinuation of the
BENLink product.
24
Appendix E
License Agreement
for
Pharmacy Benefit Manager Service
To be attached to and made a part of the Administrative Services Contract
By and between
CITY OF FORT COLLINS
AND
GREAT -WEST LIFE & ANNUITY INSURANCE COMPANY
Services to be Provided by PBM
The Service Contractor shall arrange for services to be provided by the pharmacy benefit manager (PBM)
identified in this Appendix in support of the prescription drug benefit provided under the Client's Plan as follows:
a. The PBM services shall be provided by Express Scripts, Inc.
b. The PBM shall perform pharmacy services for Members through its network of participating pharmacies.
C. The PBM shall adjudicate claims for prescription drugs covered under the Plan submitted by participating
pharmacies using the PBM's electronic on-line claim adjudication system. The PBM's claim adjudication
system will include all Plan information regarding deductibles, copayments, coinsurance, Member out-of-
pocket maximums, benefit maximums and any other features of the Plan to be used in processing claims.
Participating pharmacies may collect from Members at point of sale the amount specified in the Plan. The
PBM shall reimburse participating pharmacies for such claims according to the terms of the PBM's contract
with the participating pharmacy.
d. The PBM shall accept claims submitted by Members directly to the PBM on the PBM's standard claim form,
or otherwise agreed upon form, together with proof of payment. The PBM shall process such claims and
produce and mail to the Member an explanation of benefits and, if any payment is due the Member, a
check for the reimbursement amount specified in the Plan.
2. Services to be provided by Service Contractor
The Service Contractor shall provide the following support for the prescription drug benefit provided under the
Client's Plan:
a. Based on information it receives from Client, timely notify PBM of the identity of each Member eligible for
prescription drug benefits under the Plan, the date the Member becomes eligible, and the date the
Member's eligibility ends.
b. Reimburse PBM for the total of the amount of all payments due pursuant to Section [91 of this Appendix for
drugs provided to Members during the preceding billing period. After reimbursing PBM, Service Contractor
shall be entitled to initiate recovery to its own account by including the full amount of such reimbursement to
PBM in the amount it next transfers from Client's account pursuant to Client's transfer schedule.
C. Support Client's efforts to improve the cost -benefit relationship of its prescription drug benefit plan through
regular consultation with Client and PBM.
d. Make available to Client the advisory and consulting services of Service Contractor's pharmacy services
support unit.
25
e. Provide Client with standard reports consisting of data provided by the PBM describing claims, utilization,
and other pertinent information.
f. Through Service Contractor's medical management unit support the prior authorization provisions of the
Plan.
3. Third -Party Litigation
Neither the Service Contractor nor the PBM shall have any duty on Client's behalf to participate in or in any way
pursue any claim in any class action or other litigation commenced by a third -party to recover damages of any
type whatsoever in connection with drugs provided to Members.
4. Prior Authorization
The PBM and Service Contractor will cooperate to administer the Plan's provisions whereby certain prescription
drugs or drug classes are subject to prior authorization before being approved as a covered benefit.
5. Mail Service Program
The PBM shall administer the Plan's provisions whereby certain prescription drugs may be provided through the
PBM's mail order pharmacy service.
a. The PBM shall provide Client with appropriate numbers of its standard information material explaining its
mail service and the forms necessary for Members to utilize the service. The PBM shall make available to
Members toll -free telephone access to a pharmacist and customer service representative. Access to a
pharmacist shall be available 24 hours per day, seven days per week.
b. Subject to and in accordance with the Plan and applicable law, the PBM shall dispense through its mail
service pharmacy new or refill prescription drug orders upon receipt from a Member of a valid prescription
order or a completed refill order form, and the applicable copayment or coinsurance amount. The PBM
shall cause the filled prescriptions to be mailed to each Member via common carrier at the address shown
on the PBM's records, so long as such address is in the United States. Neither Service Contractor nor the
PBM shall have any liability to Client or any Member for any delay in delivery due to circumstances beyond
the PBM's control.
C. PBM shall at all times while this Appendix is in effect operate its mail service pharmacy in compliance with
all applicable state and federal laws and regulations, and shall dispense only those prescription drugs
which, in its sole discretion, fulfill requirements of the prescription writer and comply with such laws. The
PBM shall have the right to refuse to fill or renew a prescription for any Member when, in the participating
pharmacist's professional judgment, the filling or renewing of such prescription is not in the best interest of
the Member, or the pharmacist has reason to doubt the authenticity of the prescription. The PBM may from
time to time implement programs through its mail service pharmacy to promote certain prescription drugs.
d. Client acknowledges that the PBM's mail service pharmacy may from time to time engage in therapeutic
interchanges.
e. The PBM's mail service pharmacy may dispense drugs to Members even if the prescription is not
accompanied by the correct copayment, coinsurance or deductible amount. If Service Contractor is
charged for any uncollectible copayment, coinsurance or deductible amount, Client shall be liable to Service
Contractor for such amount if reasonable collection efforts by the PBM fail.
6. Plan Changes
If Client elects to change the prescription drug benefits of the Plan, including but not limited to covered drugs,
copayment, coinsurance or deductible amounts, or prior authorization, Client shall advise Service Contractor in
writing, and Service Contractor shall inform PBM. Whether the changes can be implemented, and/or
implemented by the date Client requests, will be determined at least in part by the PBM.
26
Proprietary Rights
The format of all reports, printouts and copies therefrom, and any prior and future versions thereof by any name,
are the property of the PBM and are protected by copyright which the PBM owns.
8. Limitations
The Service Contractor does not direct or exercise any control over the professional judgment exercised by any
pharmacist in dispensing prescriptions or providing pharmaceutical -related services at a PBM participating
pharmacy. Participating pharmacies are independent contractors, not subcontractors or agents of the Service
Contractor, and the Service Contractor shall not have any liability to Client or any Member for any loss or damage
related to or in any way growing out of any act or omission of any PBM participating pharmacy or its agent or
employee.
9. Payments
For the PBM's services, Client shall pay Service Contractor the amounts Service Contractor bills for drugs
provided to Members during the preceding billing period.
Charges for drugs provided to Members may be based on the average wholesale price of a prescription drug as
calculated by the PBM using a variety of factors, including but not limited to the First DataBank National Drug Data
File or other nationally recognized pricing source. The PBM's method of calculating the average wholesale price
of a prescription drug may change from time to time, as the PBM shall determine. Service Contractor shall have
no duty to notify Client of any such change.
Client acknowledges that the Service Contractor's net cost to provide the pharmacy benefit management services
described in this Appendix might be more or less than the payments called for by this section, and Client agrees
that the Service Contractor is at risk for such difference.
10. Termination
This Appendix may be terminated at any time upon thirty (30) days prior written notice by either party to the
other. In addition, this Appendix shall terminate automatically when the first of the following events occurs:
i. the Administrative Services Contract ends;
ii. the Plan terminates;
iii. the Service Contractor no longer administers the Plan;
iv. the Plan no longer includes a prescription drug benefit that utilizes a PBM;
V. Client commits a material breach of this Appendix or defaults in the performance of any of its duties
or obligations under this Appendix and such breach or default continues for a period of fifteen (15)
days after Service Contractor gives Client written notice specifying the nature of the breach or
default.
b. Termination of this Appendix while the Administrative Service Contract continues in effect shall be a
modification of the Service Contractor's administrative duties for purposes of Section 4.2.1-b of the
Contract.
27
Appendix F
HIPAA Health
Information
Privacy & Security
To be attached to and made a part of the Administrative Services Contract
By and between
CITY OF FORT COLLINS
AND
GREAT -WEST LIFE & ANNUITY INSURANCE COMPANY
A. Obligations and Activities of the Business Associate (Great -West Life & Annuity Insurance Company)
1. Business Associate agrees to not use or disclose Protected Health Information other than as permitted or
required in the Administrative Services Agreement of which this Appendix is a part or as required by law.
2. Business Associate agrees to use appropriate safeguards to prevent use or disclosure of the Protected Health
Information other than as provided for by this Appendix, including reasonable safeguards for electronic
Protected Information. The Parties shall also establish and maintain administrative, physical and technical
safeguards to reasonably and appropriately protect the confidentiality, integrity and availability of electronic
Protected Information.
3. Business Associate agrees to mitigate, to the extent practicable, any harmful effect that is known to Business
Associate of a use or disclosure of Protected Health Information by Business Associate in violation of the
requirements of this Appendix. The Parties also agree to mitigate, to the extent practicable, any deleterious
effects from a Security Incident involving electronic Protected Information.
4. Business Associate agrees to report to the Plan Sponsor (City of Fort Collins, Colorado) any use or disclosure of
the Protected Health Information not provided for by this Appendix of which it becomes aware, including any
Security Incident related to electronic Protected Information.
5. Business Associate agrees to ensure that any agent, including a subcontractor, to whom it provides Protected
Health Information received from, or created or received by Business Associate on behalf of the Plan Sponsor
agrees to the same restrictions and conditions that apply through this Appendix to Business Associate with
respect to such information, including reasonable and appropriate safeguards for electronic Protected
Information.
6. Business Associate agrees to make internal practices, books, and records, including policies and procedures
and Protected Health Information, relating to the use and disclosure of Protected Health Information and the
security of electronic Protected Information received from, or created or received by Business Associate on
behalf of, the Plan Sponsor available to the Plan Sponsor, or to the Secretary, in a time and manner or
designated by the Secretary, for purposes of the Secretary determining the Plan Sponsor's compliance with the
Privacy Rule.
7. Business Associate agrees to document such disclosures of Protected Health Information and information
related to such disclosures as would be required for the Plan Sponsor to respond to a request by an Individual
for an accounting of disclosures of Protected Health Information in accordance with 45 CFR § 164.528.
8. Business Associate agrees to provide to the Plan Sponsor or an Individual, in a reasonable time and manner,
information collected in accordance with Section A.7. of this Provision, to permit Plan Sponsor to respond to a
request by an Individual for an accounting of disclosures of Protected Health Information in accordance with
45 CFR § 164.528.
28
9. Public Statements. The Parties agree that any public statements regarding the other Party's information security
program must be approved by the other Party, in advance, to protect the confidentiality, integrity and availability
of the security program.
10. Training. The Parties agree to maintain diligent hiring practices and train individuals granted access to
Protected Information about their privacy and security responsibilities.
B. Permitted Uses and Disclosures by Business Associate
Except as otherwise limited in this Appendix, Business Associate may use or disclose Protected Health
Information on behalf of, or to provide services to, the Plan Sponsor for the following purposes, if such use or
disclosure of Protected Health Information would not violate the Privacy and Security Rule if done by the Plan
Sponsor or the minimum necessary policies and procedures of the Plan Sponsor: performing plan
administration functions, obtaining premium bids from insurance companies or other health plans for providing
insurance coverage under or on behalf of the group health plan, or modifying, amending, or terminating the
group health plan.
2. Except as otherwise limited in this Appendix, Business Associate may use Protected Health Information to
provide data aggregation services to the Plan Sponsor as permitted by 42 CFR § 164.504(e)(2)(i)(B).
3. Business Associate may use Protected Health Information to report violations of law to appropriate Federal and
State authorities, consistent with § 164.502(j)(1).
C. Obligations of Plan Sponsor
1. Plan Sponsor shall notify Business Associate of any restriction to the use or disclosure of Protected Health
Information that the Plan Sponsor has agreed to in accordance with 45 CFR § 164.522, to the extent that such
restriction may affect Business Associate's use or disclosure of Protected Health Information.
2. Plan Sponsor shall not request Business Associate to use or disclose Protected Health Information in any
manner that would not be permissible under the Privacy Rule if done by Plan Sponsor.
D. Termination
In addition to the termination provisions set forth in the Administrative Services Agreement of which this
Appendix is a part, the following termination provisions are applicable:
a. Upon the Plan Sponsor's knowledge of a material breach by Business Associate of this
Appendix, the Plan Sponsor shall either:
i. Provide an opportunity for Business Associate to cure the breach or end the violation
and terminate the Administrative Services Agreement of which this Appendix is a part if
Business Associate does not cure the breach or end the violation within the time specified
by Plan Sponsor; or
ii. Immediately terminate the Administrative Services Agreement of which this Appendix is a part
if Business Associate has breached a material term of this Appendix and cure is not possible;
or
hL If neither termination nor cure are feasible, the Plan Sponsor shall report the violation to the
Secretary.
E. Effect of Termination
Except as provided in paragraph (2) of this section E, upon termination of the Administrative Services
Agreement of which this Appendix is a part, for any reason, Business Associate shall return or destroy
all Protected Health Information received from the Plan Sponsor, or created or received by Business
29
C. that the bank shall honor any such demand from the Service Contractor without reservation or proof of
rights of any kind whatsoever.
3.4 Maintenance of Transfer Account After Termination of Contract. The Client shall continue to maintain the
Transfer Account pursuant to the terms of this Section 3 for 15 months after the termination of this Contract in
order for Service Contractor to process claims that were incurred prior to the termination of this Contract.
Section 4. Payments to the Service Contractor
4.1 Service fees. The Client shall make payments to the Service Contractor of amounts due for monthly service fees
and other service fees and expenses as set forth in the Payment Schedule in Appendix A.
Charges for hourly services will be determined in accordance with the Service Contractor's established time
allocation procedures, and those of other organizations from whom hourly services are purchased. These
charges will be made only if both parties agree on the Service Contractor's providing any hourly services.
Printed material created at the Client's request and not listed in Appendix A will be billed for separately when
furnished.
4.1.1 The Client acknowledges that the Payment Schedule is based on information provided by the Client
including but not limited to the number of employees and dependents that the Plan will cover. The
Service Contractor has the right to revise any Payment Schedule retroactively to the effective date or the
anniversary date, as applicable, to reflect actual participation in the Plan. Any difference between
payments made under the Payment Schedule and the Revised Payment Schedule will be collected from
or credited to the Client.
4.1.2 Any proposed Payment Schedule will become final when the Service Contractor delivers a final written
schedule, signed by its officer, to the Client.
4.2 Amendment of Fees.
4.2.1 The Service Contractor or Client may propose changes to the fees under this Contract:
a. if the Client amends its Plan to modify benefits; or
b. upon modification of the Service Contractor's administrative duties; or
C. if the Service Contractor's cost of operation is increased by virtue of a change in charges to the
Service Contractor by a governmental unit, but such adjustment shall be limited to the amount
of the change; or
d. on the first anniversary of the Plan Year and annually thereafter; or
e. on any Plan Month subsequent to a Plan Year anniversary, provided that no renewal
adjustments were made at the time of such anniversary; or
upon addition or deletion of coverage for any subsidiary or Affiliate or corporate division of
Client; or
g. if the excess loss contract, if any, between the Service Contractor and Client is terminated; or
h. if there is a change in the number of employees and/or dependents covered under the Client's
Plan for any benefit coverage provided under the Client's Plan which equals or exceeds:
10% in any Plan Month when compared to any prior Plan Month; or
25% during any period of three consecutive months.
3
Associate on behalf of the Plan Sponsor. This provision shall apply to Protected Health Information that
is in the possession of subcontractors or agents of Business Associate. Business Associate shall retain
no copies of the Protected Health Information.
2. In the event that Business Associate determines that returning or destroying the Protected Health
Information is infeasible, Business Associate shall provide to the Plan Sponsor notification of the
conditions that make return or destruction infeasible. Upon the Plan Sponsor's agreement that return or
destruction of Protected Health Information is infeasible, Business Associate shall extend the
protections of this Appendix to such Protected Health Information and limit further uses and disclosures
of such Protected Health Information to those purposes that make the return or destruction infeasible,
for so long as Business Associate maintains such Protected Health Information.
Miscellaneous
1. The Parties agree to take such action as is necessary to amend this Appendix from time to time as is
necessary for Plan Sponsor to comply with the requirements of the Privacy Rule and the Health
Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191.
2. The respective rights and obligations of Business Associate under Section E of this Provision shall
survive the termination of the Administrative Services Agreement of which this Appendix is a part.
3. Any ambiguity in this Appendix shall be resolved to permit the Plan Sponsor to comply with HIPAA.
G. Security Standards
1. Business Associate agrees that it will implement policies and procedures to ensure that its creation,
receipt, maintenance, or transmission of electronic protected health information ("ePHI") on behalf of
Plan Sponsor complies with the applicable administrative, physical, and technical safeguards required to
protect the confidentiality and integrity of ePHI under the Security Standards 45 CFR Part 164.
2. Business Associate agrees that it will ensure that agents or subcontractors agree to implement the
applicable administrative, physical, and technical safeguards required to protect the confidentiality and
integrity of ePHI under the Security Standards 45 CFR Part 164.
3. Business Associate agrees that it will report security violations related to the Plan to the Plan Sponsor.
H. Definitions
"Protected Health Information" shall have the same meaning as the term "protected health information"
in 45 CFR § 164.501, limited to the information created or received by Business Associate from or on
behalf of the Plan Sponsor.
2. "Secretary" shall mean the Secretary of the Department of Health and Human Services or his designee.
30
Great - West
LIFE & ANNUITY INSURANCE COMPANY
8505 East Orchard Road
Greenwood Village, CO 80111
December 27. 2005
City of Fort Collins
215 North Mason, 2"� Floor
P.O. Box 580
Fort Collins, CO 80522-0580
Gentlemen:
Re: Excess Loss Insurance Policy No. 259613
The purpose of this Letter is to set out the terms of an Agreement between Great -West
Life & Annuity Insurance Company (Great -West) and the City of Fort Collins (the City)
whereby, subject to all other terms and conditions set out below, Great -West agrees to
modify the terms of the Excess Loss Insurance Policy by:
• Deleting Section G5 under the Article —Termination of Policy and replacing with the
following:
If one Party has materially breached this Contract (the 'Breaching Party") and the
other Party (the "Nonbreaching Party') desires to terminate this Contract, the
Nonbreaching Party shall give the Breaching Party specific written notice of the
nature of the breach. The Breaching Party shall have 30 days to cure such breach.
If the breach remains uncured 30 days following the notice of breach, this
Contract shall terminate as of the end of such 30-day cure period. This Section
shall not apply to immediate breaches.
• Deleting Section B under the Article -Premium Provisions and replacing with the
following:
GRACE PERIOD: A Grace Period of 31 days from the due date will be allowed for
the payment of each premium after the first premium payment. During the Grace
Period, the coverage will remain in effect provided that the premium is paid before
the end of the Grace Period. If the Policyholder does not pay the premium during the
Grace Period, the Service Contractor will suspend plan operations for a period not to
exceed twenty-four (24) hours, during which time the Client shall make full payment
of premium due. If payment is not received by the end of this twenty-four (24) hour
period, this Policy will terminate without further notice retroactively to the date for
which premiums were last paid.
Deletin( Section E under the Article — Miscellaneous Provisions and replacing with
the following:
HOLD HARMLESS: It is understood that the only parties to this Policy are the
Company and the Policyholder. No express or implied interest or rights are created
under this Policy, and to the extent permitted by law, including the Charter of the City
of Fort Collins, the policyholder agrees to hold harmless for any other persons or
entities, whether they are the Policyholder's employees, Ibrmer employees, providers,
their dependents, heirs or assignees; and no third -party beneficiary status is conferred
upon such persons or entities.
Based on the above understanding, except for a claim, demand or lawsuit arising out
of either party's tortious or wrongful act committed directly against either party's
employees or their dependents, neither party shall have any liability under this Policy,
and each party agrees to hold the other harmless and to indemnify the other party
against any and all such loss, damage, and expense including court costs and
attorney's fees, resulting from or arising out of claims, demands, or lawsuits brought
against either party by such employees, their dependents, heirs or assignees, and to
claims for paid claim or surcharge taxes by any local, state or other governmental unit
or other assessments (except for taxes on insurance premiums received under this
Policy as described in Article - Premium Provisions made against the Company by
any governmental unit. Nothing herein shall act as a waiver of rights or protections
under the Colorado Governmental Immunity Act.
1. Effective Date
This Agreement is effective as of January 1, 2006.
2. Definitions
The definition of all terms used herein is hereby deemed to have the same meaning as
those defined in the Excess Loss Insurance Policy.
Dated at (reenwood Village. Colorado this 1— day of o -"^^� r-"�, 2005.
GREAT -WEST LIFE & ANNUITY INSURANCE COMPANY
�. Gv. V� irk"'" � • . .. �C ���,,,,�;
Senior Vice President President
General CQlmSel and Secretary
For the Actuary
The terms of this Agreement are accepted by the City of Fort Collins this 20-Nday of
ki)AgY , 2006
FORT
City Clerk
APPR9VED AS TO M: `4ol_O
ssistant C y Attorney
THE CITY OF FORT COLLINS,
By:
Darin ATeber
City Manager
By: il 5QCZ-Q T,
JVmej B. O'Neill, II, CPPO, FNIGP
dIwAfor of Purch in�giand Risk Management
Date: Z Z O
GREAT -WEST LIFE $ ANNUITY INSURANCE COMPANY
Executive Office:
8505 East Orchard Road
Greenwood Village, Colorado 80111
303-737-3000
APPLICATION FOR EXCESS LOSS INSURANCE
Dated at FOi21 C,01.LIN5. C2D this �$ day of � �� jeV , 2006.
City, State Day Month
THE CITY OF FORT COLLINS,
By:
Darin Aeberry
City Manager
By: 1 J t
Ja es . O'Neill, II, CPPO, FNIGP
DirbGWr of Purchasing and Risk Management
Date: %t•� s_ K �D6
ATTEST: G`�yOF•FOR
�. Cr
City Clerk
APP50VED AS TO M:
Assistant C' y Attorney
Page 1
:-west LITe & Annuity insurance Company
Executive Office:
8505 East Orchard Road
Greenwood Village, Colorado 80111
303-737-3000
EXCESS LOSS INSURANCE POLICY°
Great -West Life & Annuity Insurance Company ("Company") issues this Excess Loss Insurance Policy number
259613 to CITY OF FORT COLLINS ("Policyholder" and/or "You") and thereby agrees to pay the benefits to the
Policyholder, pursuant to provisions and conditions of the Excess Loss Insurance Policy contained and specified
herein, upon receipt of satisfactory proof of loss.
The consideration for coverage under this Policy is the Policyholder's application and the payment of the required
premium as it becomes due.
The effective date of this Policy is January 1, 2006. All Policy and Agreement periods begin and end at 12:01
a.m. standard time at the Company's Executive office.
This Policy is delivered in the State of Colorado and is governed by its laws.
The provisions and conditions of the pages and Riders, if any, that follow will form a part of this Policy as fully as if
recorded in detail above the signature placed on this Policy's cover page.
The Company has executed this Policy at its Executive office on August 19 2005.
Secretary
,/W - o; // /e
Excess Loss Insurance Policy
(Non -Dividend Participation)
Cover Page
President
NEL-CP1(04-00)
Page 2
TABLE OF CONTENTS
ARTICLES
Application for Excess Loss Insurance
Article - Schedule of Excess Loss Insurance
Article - Definitions
Article - Specific Excess -Loss Insurance
Article - Aggregate Excess -Loss Insurance
Article - Limitations & Exclusions of Coverage
Article - Termination of Policy
Article - Premium Provisions
Article - Claim Provisions
Article - Miscellaneous Provisions
NEL-TOC(04-00)
Page 3
ARTICLE - SCHEDULE OF EXCESS LOSS INSURANCE
This Schedule is applicable only to the Excess Loss Insurance Policy issued to the Policyholder.
Each category, coverage basis, and optional feature of Excess Loss Insurance described herein and in each of
any attached Riders (hereafter, collectively referred to as "Categorized Coverage") applies to the Policyholder
only when the appropriate selection of such Categorized Coverage is indicated by the Company in the
appropriate space provided.
A. Policyholder's and Plan's Information, Policy's Important Dates and Coverage Periods
1. Policy's Important Dates & Renewal Term:
The Effective Date of this Policy: January 1, 2006
The Expiration Date of this Policy: 1-year term, subject to renewal
The Anniversary Date of this Policy: Each January 1 beginning in 2007
Expense Payment Period:
a. While the Policy is in effect:
Specific: The Policy Year
b . After the Policy ends for any reason except the Policyholder's insolvency or failure to pay premium
on time:
Specific: N/A
Aggregate: N/A
B. SPECIFIC EXCESS LOSS INSURANCE
You are insured for the Specific Excess Loss Insurance as specified below:
1. Specific Deductible Amount:
(a) $120,000 in Covered Benefits incurred by the same Covered Person (Individual
Deductible).
2. Covered Benefits:
Medical (excluding outpatient prescription drugs)
C. AGGREGATE EXCESS LOSS INSURANCE NIA
D. PREMIUMS
Monthly premium for each Categorized Coverage is determined by multiplying the applicable premium rate
(expressed as a dollar amount) by the applicable number of the specified premium units covered under the
Plan on the first day of each Policy Month.
If more than one type of premium unit is utilized, add all products of the multiplications for all identified types
of the premium unit together to arrive at the total monthly premium for such Categorized Coverage.
Page 4
As used throughout the Premiums section of this Schedule, the term Covered Benefits includes only those
amounts that meet the definition of Covered Benefits of Article - Definitions but which are not reimbursable by
the Company because, with respect to the Specific Excess Loss portion they do not exceed the applicable
Specific Deductible Amount or, with respect to the Aggregate Excess Loss portion, they do not exceed the
Cumulative Attachment Limit or the Annual Attachment Limit, whichever is applicable.
1. Specific Excess Loss Premium:
For the policy year beginning January 1, 2006
Per PPO Employee Premium Rate
$ 44.41
Per POS Employee Premium Rate
$ 44.41
For the policy year beginning January 1, 2007:
Per PPO Employee Premium Rate
$ 53.29
Per POS Employee Premium Rate
$ 53.29
2. Aggregate Excess Loss Premium: NIA
E. BANKING OPTIONS: (identifies the frequency of your withdrawals from Your Bank Account for claims
payments)
Weekly with week delay
NEL-SP(04-00)
ARTICLE - DEFINITIONS
As used in this Policy and its attached Riders, unless the context specifically indicates otherwise, the following
terms shall have the following meanings:
COMPANY
means Great -West Life & Annuity Insurance Company.
COVERED BENEFITS
for purposes of Excess Loss Insurance coverage under this Policy:
1. to the extent not limited further under Section 2 immediately below, are limited to expenses incurred
by a Covered Person, which are:
a. included in the class or classes of Covered Benefits; and
b. covered under the terms of the Plan, taking into account all of the exclusions and limitations
of the Plan; and
C. incurred:
i. during the Expense Incurral Period or during the Run -In Expense Incurral Period, if
applicable; and
ii. prior to the date this Policy ends; and
d. paid during the Expense Payment Period, shown in the Schedule.
Covered Benefits do not include: 1) any amount that is excluded from coverage under this Policy
pursuant to Article - Limitations and Exclusions of Coverage; or 2) with respect to any Policy Year,
any amount that qualifies as Covered Benefits for any previous Policy Year.
COVERED PERSON
means a person who is in a class or classes of persons included under Your Excess Loss Insurance Policy
who is enrolled for coverage and meets the eligibility requirements set forth under the Plan.
Page 5
EXPENSE INCURRAL PERIOD
As shown in the Schedule, means the period of time during which an expense covered under Your Plan
must be incurred by a Covered Person to count as a Covered Benefit under this Policy. If specified in the
Schedule to be applicable to Your Policy, covered expenses incurred during the Run -In Expense Incurral
Period may also be counted as Covered benefits under the Policy.
In no event shall the Expense Incurral Period extend beyond the date the Policy ends.
Unless specifically stated otherwise, an expense is considered incurred on the date the service, treatment
or supply is provided to a Covered Person.
EXPENSE PAYMENT PERIOD
As shown in the Schedule, means the period of time during which the Plan must actually make payment for
expenses covered under Your Plan in order to count as a Covered Benefit under this Policy.
Unless specifically stated otherwise, an expense is considered paid on the date a check or draft of the
Company is issued for payment.
PLAN
means the self -funded employee health benefit plan or plans established and maintained by You and
approved by You and the Company for purposes of this Excess Loss Insurance Policy. If so approved by
the Company, the term "Plan" shall, during the period immediately prior to the date on which the self -
funded plan as described in the first sentence is approved by both parties, mean either:
1. a draft Summary Plan Description(s), or a Brief Outline of Plan Benefit Design(s), or a copy(ies) of
Your plan's prior benefit booklets or certificates (with modifications, if any, as so specified),
whichever You have designated with the Company's acceptance to be Your self -funded Plan; or
2. magnetic or computer -readable records of plan's information maintained by the Company, which are
used by the Company as a source of information to provide claim payment and other administrative
services to the Policyholder's Plan.
POLICY MONTH
means a calendar month during a Policy Year.
POLICY YEAR
means the Policy Period which is a period beginning on the Effective Date or the most current Renewal
Date of the Policy and consisting of 12 consecutive Policy Months. The first Policy Year may contain any
number of Policy Months as shown in the Schedule. For purposes of this Policy, the Policyholder's Final
Active Policy Year will end on the date the Policy ends, even if this results in a Policy Year consisting of
less than 12 Policy Months.
REIMBURSABLE SPECIFIC LOSSES
means the total Covered Benefits paid under the Plan with respect to each Covered Person less any
applicable Specific Deductible Amount as shown in the Schedule.
SCHEDULE
means the Schedule of Excess Loss Insurance coverage included and specified under Article —Schedule of
Excess Loss Insurance as applicable to You, or such Schedule as amended or supplemented by the
Renewal Schedule of Excess Loss Insurance issued specifically to You, or any Amendments thereto,
showing the category, coverage basis, feature and applicable rates, factors and points of Your Excess Loss
Insurance coverage under the Policy.
YOU, YOUR, POLICYHOLDER or POLICYHOLDER'S
means the Policyholder whose name is shown in the Application.
NEL-DEF(04-00)
Page 6
The Client agrees to make available to the Service Contractor all information necessary to
determine whether the changes set forth in i. or ii. above have occurred. If the change in the
number of employees and/or dependents covered under the Plan is such that a change in fees
results, then the Service Contractor will advise the Client of its intention to change the fees.
The effective date of the change in fees under subsections a. through h. above will be the effective date of the
event that causes such change.
4.2.2 Modification of fees may be made by written notice to the Client by the Service Contractor. If the Client
pays such revised fees or fails to object to such revision in writing within 15 calendar days of receipt, this
Contract shall be deemed modified to reflect the fees as communicated by the Service Contractor.
4.3 Claims. The Client shall pay the Service Contractor:
a. an amount equivalent to the claims incurred by Members under Client's Plan as determined by
the Service Contractor, including costs and expenses of investigation of claims. The Service
Contractor will make a good faith attempt to contact Client to inform it of any such investigation
and provide an estimate of the cost of it;
b. the deficit permitted to be recovered by the Service Contractor, if any, and other payments owed
by the Client, other than premium, under an excess loss policy, if any; and
C. the Client's portion of network access fees and provider incentive payments, if any, as
determined by the Service Contractor, under fee arrangements negotiated by the Service
contractor with health care providers.
4.4 Premiums for Insurance. The Client and the Service Contractor acknowledge that:
a. the Client may have purchased one or more insurance policies from the Service Contractor, in
its capacity as an insurer, including but not limited to insurance for group life and accidental
death and dismemberment, excess loss insurance, long term disability insurance, dental
insurance, vision insurance, or other insurance; and
b. the Client is required to pay the Service Contractor a periodic premium for such policies.
4.5 Lack of Sufficient Funds. To the extent that the bank in which the Transfer Account is established and
maintained honors any demand for funds by the Service Contractor in an amount less than the amount
demanded, any funds that are made available to the Service Contractor from the Transfer Account shall be
applied first to the payment of the Service Contractor's service fees, second to any premiums for insurance, and
third to the payment of claims. To the extent that any check, draft, money order, or other financial instrument
issued by or on behalf of the Client is honored in an amount less than the face amount of that instrument any
funds that are made available to the Service Contractor through such instrument shall be applied in the same
manner. Nothing in this subsection shall limit the Service Contractor's rights under this Contract, including but
not limited to the right to terminate this Contract.
Section 5. Client Responsibilities
5.1 Payments to Service Contractor. The Client shall make all payments as set forth in this Contract.
5.2 Enrollment and Determination of Eligibility.
5.2.1 The Client shall:
a. handle routine inquiries from Members and prospective Members, including inquiries
concerning enrollment in the Plan; and
4
ARTICLE - SPECIFIC EXCESS LOSS INSURANCE
The provisions under this Article apply to You only if You are insured for the Specific Excess Loss Insurance as
indicated in the Schedule or added by an amendment.
While the Policyholder's Specific Excess Loss Insurance remains in effect, the Company will pay to the
Policyholder, subject to the terms, conditions and limitations of the Policy, the Specific Excess Loss Insurance
reimbursement due, if any, pursuant to Article - Claims Provisions.
NEL-SPEC(04-00)
ARTICLE - LIMITATIONS & EXCLUSIONS OF COVERAGE
A. This Policy is solely between the Company and the Policyholder, and shall not create any rights or legal
relationship between the Company and any Covered Person or agent, assignee or beneficiary thereof. The
Company's sole liability hereunder is to the Policyholder, subject to the terms, conditions and limitations of
this Policy.
B. Expenses incurred for or in connection with the following, as reasonably determined by the Company, will
not be considered Covered Benefits under this Policy and the Company shall not be liable to reimburse the
Policyholder or any person for any such expenses:
1. For expenses incurred while the Plan's coverage is not in force with respect to the Covered Person.
2. For expenses which are not covered, or are in excess of the amount payable, under the terms and
provisions of the Plan.
3. For expenses to the extent the Policyholder or Plan receives any payment or receives a reduction in
charges because of a claims reduction negotiation program, a coordination of benefits provision in
the Plan or any right of recovery or subrogation.
4. For or in connection with procedures, drugs or treatment methods that are deemed Experimental,
Investigational or Unproven, as defined in the Plan, except to the extent agreed to otherwise in
writing in advance by the Company.
5. For any liability or obligations assumed by the Policyholder under any contract or service agreement
other than the Plan.
6. For cost of the administration of claims payments or expense of litigation with individual claimants,
service or professional providers relating or unrelating to benefits under the Plan including, but not
limited to, costs of defense and liability for punitive or exemplary or extracontractual damages.
7. For liabilities, expenses, losses or fines which are based upon noncompliance or violation of any
court judgment or order, any federal or state statute, rule, or regulation.
8. For premium or surcharge taxes, other assessments, or similar payment obligations regardless of
what their title is and regardless of who or what entity the designated payee is, as levied by any
local, state or other governmental unit against the Plan, Policyholder or Company, unless the
Company has agreed in writing in advance to cover such specific payment.
9. For expenses or losses that were caused by a wrongful, criminal or tortuous act of any person or
entity and for which the Policyholder or Plan released such person or entity from its legal liability
without just compensation to the Plan.
Page 7
10. For expenses or claims paid by any person or entity other than the Company, unless the Company
has agreed in writing in advance to cover.such specific payment.
11. With respect to Specific Excess Loss Insurance, for expenses incurred for third party vendor
prescription drug coverage; for dental, vision, or weekly indemnity (short term disability) coverage;
for health conversion charges; for health care surcharges imposed by or authorized by any local,
state or federal authority; and for capitation or provider bonus payments.
NEL-EX(04-00)
ARTICLE - TERMINATION OF POLICY
The Policy and all coverages hereunder will terminate upon the earliest of the following dates.
A. Except as provided under the Grace Period Section under Article - Premium Provisions, at the end of any
period for which the last premium is paid.
B. The date the Policy ends.
C. The date of termination of the Plan.
D. The date of cancellation of the administrative services agreement between the Policyholder and the
Company.
E. If any state or other jurisdiction enacts a law which prohibits the continuance of this Policy, or the existing law
is interpreted to so prohibit the continuance of this Policy, as reasonably determined by the Company, the
Policy shall terminate automatically as to such time or jurisdiction on the effective date of such law or
interpretation.
F. The Policyholder may terminate this Policy at any time by giving written notice to the Company at least 30
days in advance of such date.
G. The Company may terminate this Policy:
1. On any Expiration Date of the Policy, by giving written notice to the Policyholder at least 60 days prior to
such date;
2. Immediately upon written notice to the Policyholder in the event the Policyholder files a petition for
bankruptcy or for voluntary reorganization for the benefit of creditors, or is the subject of an involuntary
petition for bankruptcy. However, such termination will not relieve the Company from its liability existing
prior to the date of termination;
3. Immediately upon written notice to the Policyholder of the discovery of the Policyholder's material
misrepresentation which affects the insurability of the risk;
4. Retroactively to the Policy Effective Date or the latest Renewal Date as applicable, upon written notice to
the Policyholder, if it is discovered that the Policy was obtained or was renewed through fraudulent
statements, omissions or concealment of facts material to the acceptance of the risk assumed by the
Company;
5. Immediately and without notice upon failure of the Policyholder to comply with any material term of this
Policy; and
6. Immediately and without notice upon Company's receipt of information that the Policyholder has failed to
fund its Bank Account established to pay benefits under its Plan or if the Company has had any checks
Page 8
issued for benefit payments which have been returned for non -sufficient funds. This provision shall
survive the termination of this Policy.
If this Policy terminates for any reason, the Policyholder shall remain liable for any unpaid amounts that have
accrued under this Policy including amounts accrued during the grace period.
NEL-TP(04-00)
ARTICLE - PREMIUM PROVISIONS
A. PREMIUM DUE DATE AND PAYMENT: The first premium is due on the Effective Date of this Policy.
Future premiums are due on the first day of each Policy Month. All premiums shall be paid in U.S. currency
to the Company at its Administrative Office in Greenwood Village, Colorado. Premiums are not considered
paid until the full premium payment is received by the Company.
B. GRACE PERIOD: A Grace Period of 31 days from the due date will be allowed for the payment of each
premium after the first premium payment. During the Grace Period, the coverage will remain in effect
provided that the premium is paid before the end of the Grace Period. If the Policyholder does not pay the
premium during the Grace Period, this Policy will terminate without further notice retroactively to the date
for which premiums were last paid.
C. COMPUTATION OF PREMIUMS: Monthly premium for each Categorized Coverage will be computed as
stated in the Schedule. Add all monthly premiums for all Categorized Coverages together, as applicable to
the Policyholder, to arrive at the total monthly premiums for the Policyholder.
D. PREMIUM REFUNDS: Any error or correction to any premium paid for the preceding Policy Year must be
reported to the Company promptly. The premiums will be adjusted retroactively to reflect changes in
insurance amounts. For a decrease in, or termination of insurance, a credit will be given only for the 2-
month period prior to receipt of such notice. No premium refunds will be owed or made to the Policyholder
or any person if an error or a correction in paid premium is failed to be reported to the Company within this
time limit.
E. CHANGES IN RATES: The Company reserves the right to change any premium rates and to propose
changes to the Specific Deductible Amount(s) on any of the following dates:
On the date when the terms of this Policy are changed;
2. On the second Anniversary Date of the Policy (however, any such change which represents an
increase in rates or Specific Deductible Amount(s), will not become effective until after the date
which is 60 days after the Company has given written notice to the Policyholder informing the
Policyholder about the increase);
3. On the effective date of any change to the Plan having material effects on benefits provided under
the Plan;
4. On the first day of a Policy Month following a change in Policyholder's primary business or in
Policyholder's geographical location;
5. On the date the Policyholder adds or deletes subsidiary or affiliated companies or divisions with the
Company's approval;
6. On the first day of a Policy Month following a change in the number of Covered Persons under the
Plan if such change exceeds 10% in any Policy Month or 25% over any period of three consecutive
Policy Months; and
Page 9
On any date that the Policyholder requests the addition of a Covered Person who should have been
included as a Covered Person earlier, such change to be retroactive to the date the Covered Person
should have been included; provided, however, that Company reserves the right to consider that
such Covered Person shall be included under this Policy no earlier than 60 days prior to the
Policyholder's request to add the person(s).
The effective date of the change in factors will be the effective date of the event in 1, 2, 3, 4, 5, 6, or 7
above, that causes such change, except that no increase will take effect before 60 days after the date
written notice of such increase is given to the Policyholder by the Company.
NEL-TP(04-00)
ARTICLE - CLAIMS PROVISIONS
A. PAYMENT OF CLAIMS: Contingent upon the Company's receipt of the Policyholder's timely submitted
notice and satisfactory proof of claim, the Company will thereafter pay to the Policyholder any Excess Loss
Insurance reimbursement due within a reasonable time, but not to exceed 30 working days.
B. ADJUDICATION OF CLAIMS: The Company shall have no obligation under this Policy for the settlement or
adjustment of claims filed by Covered Persons under the Policyholder's Plan. The Policyholder shall
always have the final right to determine the availability or extent of benefits payable under its Plan and the
Company shall always have the final right to determine the availability and extent of coverage to the
Policyholder under this Policy.
C. AUDITS: The Company or its authorized representative shall have the right to inspect and audit all records
and procedures of the Policyholder and to require, upon request, proofs of records satisfactory to the
Company that payment has been made to the Covered Person or the provider of such services or benefits
which are the basis for any claim by the Policyholder under this Policy.
RECOVERY OF OVERPAYMENT: If the Company reimbursed You more than it should have, the
Company has the right to recover the excess amount directly from you. If the Company reimbursed You
less than it should have, You have the right to recover the shortage from the Company.
The provisions in this Section D. shall survive beyond the termination of this Policy.
E. INSOLVENCY: In the event of the insolvency or bankruptcy of the Policyholder, all reimbursements made
or becoming due after the effective date of this Policy shall be payable by the Company on the basis of the
amount of liability of the Plan under the terms and conditions of this Policy as finally determined in the
liquidation or receivership proceeding without diminution because of the insolvency or bankruptcy of the
Policyholder. Such amount shall be paid directly to the Policyholder or its liquidators, receiver, or other
statutory successor. The Company shall be discharged from its obligations under this Policy to the extent
of such payments.
Nothing in this Section shall increase the Company's liability beyond that which would have existed had the
Policyholder not become insolvent or bankrupt.
NEL-TP(04-00)
ARTICLE - MISCELLANEOUS PROVISIONS
A. ENTIRE CONTRACT: This Policy together with the Policyholder's applications and the Policyholder's Plan,
a copy of which is on file with the Company, and any Riders, Renewal Schedules and amendments
attached hereto, constitute the entire contract regarding the Excess Loss Insurance between the parties.
In the event of a conflict between the provisions of the Plan and the provisions of this Policy, the latter shall
prevail. The Company has relied upon the underwriting information provided by the Policyholder or its
authorized representative in the issuance of this Policy and the Policyholder represents such information as
accurate. Should subsequent information become known which, if known prior to the issuance of this
Page 10
Policy, would affect the rate(s), deductible(s), or terms and conditions for coverage hereunder, the
Company shall have the right to revise the rate(s), deductible(s), or terms or conditions as of the effective
date of issuance of this Policy or, at the option of the Company as of the next premium due date, by
providing written notice to the Policyholder.
B. DATA REQUIRED: The Policyholder shall maintain adequate records regarding administration of the Plan
covered under this Excess Loss Insurance Policy. The Policyholder must maintain records of all Covered
Persons under the Plan during the period the Policy is in effect and for a period of five years after the end
of the Policy. Upon request by the Company, the Policyholder shall make available to the Company any
such records and information deemed necessary for the Company's administration of this Excess Loss
Insurance Policy. The Company may periodically examine any of the Policyholder's records relating to the
coverage under this Policy and any claims filed under the Plan, and as a result of any examination of the
Policyholder's records shall be entitled to readjust premiums, deductibles, or reimbursements paid as may
be necessary to reflect the true intent of this Policy. This provision shall survive the termination of this
Policy.
C. CLERICAL ERROR: Clerical error whether by the Policyholder or by the Company in keeping any records
pertaining to the coverage will not invalidate coverage otherwise validly in force nor continue coverage
otherwise validly terminated, but no such error shall expand the Company's obligations under this Policy.
D. NOTICE: All notices and communications required under the terms of this Policy shall be given in writing
by one party addressed to the other.
1. Notices to the Company, to the following address, or other address as the Company may from time to
time specify to the Policyholder in a written notice:
Great -West Life & Annuity Insurance Company
8505 East Orchard Road
Greenwood Village, Colorado 80111
2. Notices to the Policyholder, to the Policyholder's address specified in the Application for Group
Coverage or other address as the Policyholder may from time to time specify to the Company in a
written notice.
E. HOLD HARMLESS: It is understood that the only parties to this Policy are the Company and the
Policyholder. No express or implied interest or rights are created under this Policy for any other persons or
entities, whether they are the Policyholder's employees, former employees, providers, their dependents,
heirs or assignees; and no third -party beneficiary status is conferred upon such persons or entities.
Based on the above understanding, except for a claim, demand or lawsuit arising out of either party's
tortuous or wrongful act committed directly against either party's employees or their dependents, neither
party shall have any liability under this Policy, and each party agrees to hold the other harmless and to
indemnify the other party against any and all such loss, damage, and expense including court costs and
attorney's fees, resulting from or arising out of claims, demands, or lawsuits brought against either party by
such employees, their dependents, heirs or assignees, and to claims for paid claim or surcharge taxes by
any local, state or other governmental unit or other assessments (except for taxes on insurance premiums
received under this Policy as described in Article - Premium Provisions made against the Company by any
governmental unit.
F. AMENDMENT TO THE PLAN: The Plan shall not be amended while this Policy is in force without the prior
written consent of the Company. Notice of any amendment to the Plan must be given to the Company in
writing at least 30 days prior to the effective date of the amendment. No change in benefits payable under
the Plan or any amendment to the Plan will be binding on the Company until such change or amendment is
approved in writing by the Company. In the event that such advance written notice is not received by the
Company in accordance with this provision, the Company's reimbursement liability will be limited to the
Plan provisions in effect prior to the change or amendment. The Company may, in its sole discretion and at
the written request of the Policyholder, approve a Plan amendment retroactively to the date requested by
the Policyholder, but the Company shall have no obligation to do so.
Page 17
G. CONFORMITY WITH THE LAW: If any provision of this Policy at time of issue is contrary to any law to
which it is subject, that provision is changed to meet the law's minimum requirements.
LEGAL ACTION: No action at law or in equity shall be brought to recover on this Policy prior to the
expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of
the Policy. No such action shall be brought after the expiration of three years after the time written proof of
loss is required to be furnished.
AMENDMENTS TO THE POLICY: Only the President, a Vice President, the Secretary or an Assistant
Secretary of the Company have the authority to alter this Policy, or to waive any of the Company's rights or
requirements and then only in writing. No such alteration to this Policy shall be valid unless amended on or
attached to this Policy. Notwithstanding anything in this Policy to the contrary, Company reserves the right
to amend the Policy at any time on 90 days advance written notice, such amendment to be effective at the
expiration of said 90 days.
J. OFFSET: The Company shall be entitled to offset payments due to the Policyholder under this Policy
against premiums due and unpaid by the Policyholder to the Company.
K. ASSIGNMENT: Any assignments of this Policy or of any rights hereunder shall be void and of no force or
effect.
L. NOT WORKERS' COMPENSATION: The coverage provided under this Policy applies only to benefits
under Your Plan of benefits for non -occupational accidents or illnesses. It is not the intent of this Policy to
provide benefits or coverage under any Plan in lieu of Worker's Compensation Insurance.
NEL-TP(04-00)
Page 12
GREAT -WEST LIFE & ANNUITY INSURANCE COMPANY
PERFORMANCE GUARANTEE AGREEMENT
This Agreement (the "Agreement"), entered into as of this 13th day of December, 2005,
is made and entered into by and between City of Fort Collins ("Contractholder') and Great -West
Life & Annuity Insurance Company for the benefit of and on behalf of itself and its Affiliates
(collectively "Great -West") for the purpose of extending certain guarantees for acceptable
performance levels in the defined areas and for setting penalties for the failure to meet the
acceptable performance levels.
SECTION I.
DEFINITIONS
1.1 "Aggregate Reporting Results" means result as specified in Schedule A that
are drawn from the aggregation of specified or stratified data across several Health Care Plans
for the Calendar Quarter.
1.2 "Annual Penalty Percentage" means the penalty for failure of Great -West to
meet a Performance Guarantee as expressed as a percentage of the total amount payable by
Contractholder for services rendered by Great -West under the Administrative Services Contract,
or a set dollar amount.
1.3 "Benefit Summary" means the short summary of the Summary Plan Document
as described in ERISA section 102 (b).
1.4 "Business Day" means Monday through and including Friday of each week
excluding days designated by Great -West as holidays or furlough days or when the Great -West
offices are closed pursuant to Section 5.1 (d) of this Agreement.
1.5 "Calendar Quarter' means a rotating period of three (3) full calendar months
commencing in January and continuing throughout a calendar year.
1.6 "Claim" means a request by a Member or Provider for the payment of Covered
Services which includes information adequate to allow Great -West to process the Claim.
Submissions of requests for payment are counted as Claims on the date the request is received
by the Great West Mail Processing Center and assigned a number unique to that Claim.
1.7 "Claim Paid" means a Claim for which a payment was made to either the
Member or a Participating Provider or a credit provided toward the fulfillment of the Member's
annual plan deductible for the Plan Year in which payment is made. A Claim is considered paid
on the date when the payment or credit is processed internally by Great -West and does not
include any time period for transmitting the payment electronically or by mail to the Member or
Participating Provider or any Contractholder specified time period during which payment is held
before issuance.
01.13.05 Veision I I
1.8 "Claim Processed" means a Claim for which Great -West has issued a payment,
denial of benefits or an explanation of benefits to the Member or Participating Provider or issued
a notification to the Member or Participating Provider that additional information is necessary to
process the Claim. The date a Claim is processed is the date when any of the actions listed
above is completed by Great -West not including any time period for transmitting the action to
the Member or Participating Provider either electronically or by mail or any Contractholder
specified time period during which payment is held before issuance.
1.9 "Client Specific Reporting" means result as specified in Schedule A that are
drawn from the specified data from the Contractholder's Health Care Plan for the Plan Quarter.
1.10 "Contractholder' means the Party in the position of the contract holder as
denominated in the Administrative Service Contract between the Parties and who wishes
provide benefits for Members in accordance with a Health Care Plan.
1.11 "Covered Services" means those health services and benefits to which
Members are entitled under the terms of the applicable Health Care Plan of Contractholder.
1.12 "Effective Date of the Agreement" means the date in which the agreement
becomes effective as specified in the first paragraph of this document.
1.13 "Guarantee Period" means the period of time during which the guarantee
described herein is effective but in no event for a period to exceed a single plan year for each
attached Schedule A.
1.14 "Health Care Plan" means the written plan document(s), including, if applicable,
related trust agreements, established and/or maintained by the Contractholder which specifies
the terms and conditions under which Covered Services shall be provided to Members.
1.15 "in -Network Claims" means Claims that are billed by Participating Providers
who are part of the Great -West network of preferred providers or providers who are part of a
national Third -Party network or a network provided by Contractholder.
1.16 "Maximum Operational Penalty" means the maximum penalty amount to be
paid by Great -West on the aggregate of all Performance Guarantees related to the
Administrative Services Contract. The Maximum Operational Penalty cannot exceed 10% of the
Basic Administrative Services Fee excluding any other fees for services rendered by Great -
West under the Administrative Services Contract including without limitation COBRA service
fees, HSA fees, commissions and any other service fee, payable by Contractholder for services
rendered by Great -West under the Administrative Services Contract.
1.17 "Member' means both the employee and his or her eligible dependents enrolled
in a Health Care Plan in accordance with Contractholder's enrollment policies and procedures.
1.18 "Network" means the network of Participating Providers.
1.19 "Participating Provider' means a physician, hospital, skilled nursing facility,
home health agency, medical group, or any other provider of Covered Services, which is duly
licensed or authorized under Applicable Law to provide or arrange for the provision of Covered
01.13.05 Version 1 2
Services to Members and has entered into an agreement with Great -West or Contractholder to
provide or arrange for the provision of Covered Services to Members.
1.20 "Payment Error" means the claims payment of a duplicate Claim, resulted in an
incorrect benefit, caused a stop payment or adjustment or the Claim has an error discoverable
by the Member or Provider.
1.21 "Party" means the Contractholder and/or the Company and when used
collectively is "Parties."
1.22 "Performance Guarantee" means a voluntary specification of performance
under the Administrative Services Contract between the parties that is undertaken by Great -
West.
1.23 "Performance Guarantee Requirements" means information or performance
by Contractholder that must occur before the Performance Guarantee becomes effective and
without which Great -West cannot be penalized for failure to meet the goal stated in Schedule A.
1.24 "Plan Quarter" means a rotating period of three (3) full calendar months
commencing on the date the Health Care Plan first becomes effective and continuing
throughout the following nine (9) months.
1.25 "Plan Year" means a period of time equal to twelve (12) months in duration.
1.26 "Provider" means a physician, hospital, skilled nursing facility, home health
agency, medical group, or any other provider of Covered Services, which is duly licensed or
authorized under Applicable Law to provide or arrange for the provision of Covered Services to
Members
1.27 "Health Plan Performance Report' ("HPP Report") means the report containing
a set of Health Care Plan utilization and cost explanations through per member, per month
analysis of Claims Paid.
1.28 "Summary Plan Document" means the document contemplated by ERISA
section 102(d).
SECTION II.
OBLIGATIONS AND REPRESENTATIONS OF GREAT -WEST
Great -West expressly agrees to the following duties, obligations and responsibilities as
to all Performance Guarantees enumerated in Schedule A of this Agreement.
2.1 Reporting. Reporting requirements under this Agreement shall commence on
the Effective Date of the Agreement. Great -West shall provide, on a Calendar Quarter basis,
the Performance Guarantee Report Card summarizing the activities undertaken by Great -West
to achieve the Performance Guarantees delineated herein with respect to the Health Care Plan.
The Performance Guarantee Report Card and any other determinations of numbers or totals
required to measure performance will measure this performance by using data from internal
Great -West or its delegates reporting systems. Internal Great -West auditing processes,
procedures or reporting used to determine Great -West performance are not subject to external
review or auditing by the Contractholder. Reports relating to Performance Guarantees for
01.13.05 Version 1 3
Financial Accuracy of Claims Processed, Payment Accuracy of Claims Processed and Claims
Processed Timelines as described in Schedule A, if applicable, shall commence 90 days after
the Effective Date of this Agreement. Reports relating to Performance Guarantees for telephone
response times, if applicable, shall be based on reports from computerized tracking and
monitoring on the Great -West customer service center or its contractor's telephone lines and
Contractholder expressly agrees to this monitoring.
Any Plan Quarter report or Performance Guarantee Report Card is provided for informational
purposes only and is subject to reconciliation with actual annual results or internal auditing
procedures instituted by Great -West; results for the purposes of measuring performance shall
be based on full calendar year results. Great -West will prepare an annual report at the end of
the Guarantee Period.
2.2 Reporting Specificity. The performance of Great -West relative to any
performance Guarantee listed in Schedule A shall be reported as specified by Schedule A.
2.3 Settlement of Penalties. If the actual, annual performance is less than the
performance specified in Schedule A for that Performance Guarantee, Great -West will pay the
Annual Penalty Percentage detailed in Schedule A. All reports submitted by Great -West shall
be supplied in an electronic form or in writing at the discretion of Great -West.
2.4 Penalty Amount. The penalty amount will be determined by the actual
performance for the applicable plan year subject to the Maximum Operational Penalty shown in
Schedule A.
2.5 Payment of Penalties. At the sole discretion of Great -West, penalties owed by
Great -West will be paid to Contractholder within a reasonable time following the assessment.
The failure of Great -West to satisfy any stated Performance Guarantee shall not result in the
payment of a penalty where the performance of Great -West was dependent on the completion
of requested tasks by the Contractholder and Contractholder failed to complete the requested
tasks.
SECTION III.
OBLIGATIONS AND REPRESENTATIONS OF CONTRACTHOLDER
Contractholder expressly agrees to the following duties, obligations and responsibilities.
3.1 Cooperation with Claims Handling and Verification. Contractholder is
responsible for using normal business means to assist Great -West as requested in the
verification of eligibility or claims related to performance of the duties of Great -West in
connection with these Performance Guarantees.
3.2 Case Installation Requirements. Contractholder is responsible for providing
complete and accurate eligibility information including the current name and mailing and/or
contact information for each Member of the Health Care Plan as specified by Schedule A .
3.3 Initial Booklet Proof. Contractholder is responsible for providing complete Health
Care Plan benefit and other related information including without limitation all information
concerning the Health Care Plan necessary for preparation of the initial Summary Plan
Document and Benefit Summary as specified by Schedule A.
01.13.05 Version 1 4
b. handle enrollment activity; and
C. notify prospective Members of their right to enroll in the Plan.
5.2.2 In determining any person's right to benefits under the Plan, the Service Contractor shall rely on
eligibility information consistent with the description in the Plan and information provided by the Client. It
is mutually understood that the effective performance of this Contract by the Service Contractor will
require that it be advised on a timely basis by the Client of the identity of persons covered under the
Plan, and the effective date or the termination date of their coverage. For the purpose of determining
fees under this Contract, a Member shall be considered to be:
a. enrolled on the first day of the first month following the month in which the Member is eligible to
receive benefits under the Plan; and
b. terminated on the last day of the last month in which the Member is eligible to receive benefits
under the Plan.
Retroactive adjustments for Member enrollment or termination will be allowed for periods not exceeding
sixty (60) days. Retroactive adjustments for termination are limited to Basic ASO Service Fees as set
forth in Appendix A.
5.3 Plan Benefits. Except as otherwise explicitly provided in this Contract, the Client shall retain the responsibility for
all Plan benefit claims and all expenses incident to the Plan. The Client shall be responsible for:
a. Any state premium or similar tax, however denominated, including any penalties and interest if
applicable, payable with respect thereto, assessed against the Service Contractor on the basis
of and/or measured by the amount of Plan benefits administered by the Service Contractor
pursuant to this Contract;
b. The consequence of any acts or omissions by Client occurring during the operation of this
Contract alleged to be a breach of fiduciary duty, or a breach of duty or trust, or other
contractual duty regardless of the source of law serving as a basis for such allegation;
C. Reimbursing the Service Contractor for any Plan benefit claims paid by the Service Contractor
to Members who were not eligible for Plan benefits and with respect to whom the Client does
not timely notify Service Contractor of such Member's lack of eligibility.
5.4 COBRA. If COBRA is applicable to the Client, the Client is responsible for performing the duties required by the
Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA), including but not limited to:
a. notifying employees and covered spouses and dependents at their last known address of their
rights under COBRA when they first become covered under the Plan;
b. notifying qualified beneficiaries of their continuation rights upon occurrence of qualifying events;
C. notifying Service Contractor of COBRA -related eligibility changes as they occur. This includes
but is not limited to termination of coverage under the Plan as a result of a qualifying event,
subsequent election of coverage and payment of premiums and reinstatement of coverage;
d. processing elections from continuants; and
e. billing and collection.
At the Clients' option and for a fee payable to the Service Contractor, the Service Contractor will arrange with a
third party administrator to perform some or all of the required duties. Whether the Client or a third party
E
3.4 Claim System Release Requirements. Contractholder is responsible for
providing all case set up details requested by the Great -West sales representative assigned to
Contractholder within time frame specified in Schedule A, including without limitation complete
Health Care Plan designs, complete banking information as required in the Administrative
Services Contract, account classes, complete and accurate eligibility information for all Health
Care Plan Members, client demographic information for Contractholder itself including all
contact names and addresses for service representatives and Contractholder liaisons with
Great -West, Internet services projected to be used by Contractholder for web -based interface
with employees and beneficiaries, and a fully completed and executed application for services.
SECTION IV.
TERM AND TERMINATION OF AGREEMENT
4.1 Initial Term of Contract. This Agreement shall take effect on the Effective Date
and shall remain in effect for the Guarantee Period. This Agreement will expire at the
termination of the Guarantee Period.
4.2 Immediate Termination. Upon written notice by Great -West, this Agreement and
its obligations will immediately terminate for any of the following reasons:
(a) A material change in the Health Care Plan initiated by the Contractholder
or by legal action that impacts the ability of Company to process claims, the claim
process or provider network, or the ability of the Company to negotiate discounts for In -
Network claims;
(b) Termination of Contractholder's Health Care Plan;
(c) Termination of the Administrative Service Contract between Company
and Contractholder;
(d) Failure of the Contractholder to provide requested information or
cooperation as required in Section 3.1 or Section 3.2;
SECTION V.
MISCELLANEOUS
5.1 Miscellaneous.
(a) Provisions Separable. In the event one or more of the provisions
contained in this Agreement are declared invalid, illegal, or unenforceable in any
respect, the validity, legality, and enforceability of the remaining provisions shall not in
any way be impaired thereby unless the effect of such invalidity is to substantially impair
or undermine either Party's rights and benefits hereunder.
01.13.05 Version 1 5
(b) Notice. Any and all notice required to be given pursuant to the terms of
this Agreement must be given by United States mail, postage prepaid, return
receipt requested and forwarded to the following addresses or such other
address as either Party may submit in writing:
For Contractholder:
Name: City of Fort Collins
Address: PO Box 580
City/State/Zip: Fort Collins, CO 80522-0580
For Great -West: Great -West Life & Annuity Insurance Company
8525 East Orchard Road, 10T1
Greenwood Village, CO 80111
Attention: Sales Support, Client Guarantees Unit
(c) Assignment. This Agreement may not be assigned or transferred by
either Party without the express written consent of the other Party; provided,
however, both parties acknowledge and agree that each Party may delegate,
through contract or otherwise, certain duties and obligations described in this
Agreement. In addition, Great -West shall have the right, exercisable at its sole
discretion, to assign and/or transfer this Agreement and any provision herein to
an Affiliate, successor of Great -West, or purchaser of all or any portion of the
assets or stock of Great -West.
(d) Force Maieure. In the event that either Party is unable to perform under
this Contract on account of strikes, accidents, acts of Nature, severe weather
conditions, inability to secure necessary labor, fire, governmental restrictions,
terrorist attack, computer system failure or any other reason which is beyond the
reasonable control of the Parties, then performance under this Contract shall be
excused for a reasonable period of time to enable the Parties to resume
performance. If a Party is unable to resume its performance within such
reasonable period of time, the other Party may terminate this Contract as herein
provided.
(e) Waiver. The failure of either Party to insist in any one or more instances
upon performance of any terms or conditions of this Agreement shall not be
construed as a waiver of future performance of any such term, covenant, or
condition; but the obligations of such Party with respect thereto shall continue in
full force and effect.
(f) Amendment. This Agreement may be amended only by written
agreement of the parties.
(g) Entire Agreement. This Agreement including any exhibits and appendices
attached hereto constitutes the entire agreement between the parties and
supersedes all prior written and oral statements and understandings except that
Administrative Service Contract signed by the parties is expressly incorporated
into this Agreement as set out herein. No handwritten changes to this document
other than the correction of address information can be accepted. To the extent
that any section of the Agreement is found to be in conflict with any term of the
01.13.05 Version 1
Administrative Services Contract, the Administrative Services Contract term will
control.
(h) Binding Effect. This Agreement shall bind and inure to the benefit of
Contractholder and Great -West, and their successors, assigns and legal
representatives.
(i) Governing Law. The substantive laws of the state of Colorado shall
govern this Agreement.
(j) No Third Party Beneficiary. This Agreement is made solely and
specifically among and for the benefit of the parties hereto, and their respective
successors and assigns, and no other person or entity shall have any rights,
interest, or claims hereunder or be entitled to any benefits hereunder or on
account of this Agreement as a third party beneficiary or otherwise, including, but
not limited to, Members.
01.13.05 Version 1 7
IN WITNESS WHEREOF, this Agreement is executed by Great -West and
Contractholder on the date set forth on the first page of this Agreement.
GREAT -WEST LIFE & ANNUITY
INSURANCE COMPANY
By:
Date:
GREAT -WEST LIFE & ANNUITY
IN RANCE COMPANY- Underwriting Division
By.
Title: Attoto,. r .
Date: �- - i. ) - D 16
CONTRACTHOLDER
Ely: :%F.6 AflWat40D A4Geg
Title:
Date:
111.13.05 Version 1 8
THE CITY OF FORT COLLINS,
By: _.--
Darin Atteberry
City Manager
By: CA
Jaikes B O'Neill, II, CPPO, FNIGP
Dire f Purchasing and Risk Management
Date: Z.I O,6
ATTEST: q'� OF.FORT
City
AS TO
Attorney
Great -West Healthcare Performance Guarantee Schedule A - For Year 2006
For Citv of Fnrt Cnllinc
Applicable Annual
Reporting
Penalty
Specificity
All Applicable Annual
Category of
Performance
Penalties are subject to
Performance
Guarantee
Performance
the Maximum
Performance Guarantee
Guarantee
Descri tion
Measurement Criteria
Tar et
Operational Penalty
Requirements
ID Cards for Members will be
placed into the US Mail by the
target calendar day following
This Performance Guarantee will be
the loading of the information
inapplicable if the information
required in Section 3.2 of the
required by Section 3.2 is not
Agreement. Provider
2% of 1st month admin
received by Great -West in the time
Mailing of ID Cards
directories can be accessed
fee to be shared among
frame specified in the Agreement.
and Network
via our Web site and a hard
all Case Installation
This guarantee does not apply to
Case Installation
Directories
copy can be downloaded.
10 Business Day
Guarantees
subsequent mailing of ID Cards
Client Specific
This Performance Guarantee will be
Initial Proof of the Summary
inapplicable if the information
Plan Document will be to the
required by Section 3.2 and 3.3 is
designated representative of
not received by Great -West in the
the Contractholder by the
Initial proof released
time frame specified in the
target calendar day following
within 30 Calendar
2% of 1st month admin
Agreement. The Performance
the receipt of information
Days of receipt of
fee to be shared among
Guarantee does not apply to
Summary Plan
required by Section 3.2 and
complete case set
all Case Installation
subsequent drafts or proofs of the
Case Installation
Document
3.3 of the Agreement
up information
Guarantees
Summary Plan Document
Client Specific
For electronic submissions, Claim is
Percentage of accuracy is
deemed submitted on the Business
calculated as the dollar
Day an inventory number is
amount of the Claims Paid
assigned. For paper submissions,
that were paid inaccurately,
Claim is deemed submitted on the
divided by the amount of all
Business Day a claim number is
Claims audited for the Health
assigned by the designated Mail
Care Plan during the
Processing Center. An audit of the
Guarantee Period, subtracted
claims processed for The City of
from 1.00
Fort Collins will be performed by the
Accuracy based on audit of
Service Contractor using claims
Claims Processed conducted
selected at random of a sufficient
Financial Accuracy
by Great -West Quality
quantity to guarantee the statistical
Claims and
of Claims
Assurance for the Guarantee
99% of claims paid
accuracy of the audit - audited
Customer Service
Processed 1
Period I
at the correct rate
2% if result is < 99% lannually.
I
Client Specific
Claims and
Customer Service
Payment Accuracy
of Claims
Processed
Percentage of accuracy is
calculated as the number of
audited Claims Paid that were
subject to a Payment Error,
divided by the total number of
audited Claims Paid for the
Guarantee Period, subtracted
from 1.00
Accuracy based on audit of
Claims Processed conducted
by Great -West Quality
Assurance for the Guarantee
Period
97.5% of claims paid
accurately
2% if result is < 97.5%
An audit of the claims processed for
The City of Fort Collins will be
performed by the Service Contractor
using claims selected at random of a
sufficient quantity to guarantee the
statistical accuracy of the audit -
audited annually.
Client Specific
For electronic submissions, Claim is
90% of Claims
deemed submitted on the Business
Processed in 14
Day an inventory number Is
calendar days and
assigned. For paper submissions,
98% of Claims
Claim is deemed submitted on the
Processed within 30
Business Day a claim number is
calendar days of
2% if result is <90% in
assigned by the designated Mail
Percentage of Claims
Claim submission to
14 calendar days and
Processing Center. Results will be
Claims and
Timeliness of
Processed within the target
Great -West Mail
98% in 30 calendar
determined by internally produced
Customer Servicel
Claims Processed
number of Calendar Days
Processing Center
days
system generated reports.
Client Specific
Telephone Response Time
shall not be greater than the
average target number of
seconds (30) that lapse from
the time a caller is connected
to the Great -West Automated
Voice Response customer
service system or opts out of
the Automated Voice
Response system by either
exiting the system voluntarily
or the caller is transferred
automatically to speak to a
Great -West customer service
representative and when the
caller is connected to the
Results are based on Blended
Claims and
Telephone
customer service
1 % if result is >30
Customer Service Representative
Customer Servicel
Response Time
Irepresentative
1 30 Seconds
I Seconds
land IVR results
I Aggregate
No more than target number
(3%) of the total calls
connecting to the Great -West
Automated Voice Response
customer service system
during the Guarantee Period
can result in the caller being
disconnected from the call
between the time the caller
exits or is transferred from the
Automated Voice Response
Results are specific to callers who
Claims and
Call Abandonment
system to speak to a customer
are Members of the Health Care
Customer Service
Rate l
service representative
3%
1% if result is >3% JPlan
Aggregate
r+aaitionai inTormation
The overall amount at risk ("Maximum Operational Penalty" as defined in the Agreement) is the aggregate of all Performance Guarantees related to the
Administrative Services Contract and will not exceed 10% of the Administrative Services Fee as defined in the Performance Guarantee Agreement.
This guarantee covers only the 2006 Plan Year and does not automatically renew. This guarantee will not apply if termination of the Policy occurs prior to
the end of the guarantee period.
This document is intended to be used only in conjunction with the Performance Guarantee Agreement including without limitation the definitions contained
in that Agreement.
Great -West Healthcare Performance Guarantee Schedule A - For Year 2007
For Citv of Fort Collins
Applicable Annual
Reporting
Penalty
Specificity
All Applicable Annual
Category of
Performance
Penalties are subject to
Performance
Guarantee
Performance
the Maximum
Performance Guarantee
Guarantee
Description
Measurement Criteria
Target
Operational Penalty
Requirements
ID Cards for Members will be
placed into the US Mail by the
target calendar day following
This Performance Guarantee will be
the loading of the information
inapplicable if the information
required in Section 3.2 of the
required by Section 3.2 is not
Agreement. Provider
2% of 1 st month admin
received by Great -West in the time
Mailing of ID Cards
directories can be accessed
fee to be shared among
frame specified in the Agreement.
and Network
via our Web site and a hard
all Case Installation
This guarantee does not apply to
Case Installation
Directories
copy can be downloaded.
10 Business Day
Guarantees
subsequent mailing of ID Cards
Client Specific
This Performance Guarantee will be
Initial Proof of the Summary
inapplicable if the information
Plan Document will be to the
required by Section 3.2 and 3.3 is
designated representative of
not received by Great -West in the
the Contractholder by the
Initial proof released
time frame specified in the
target calendar day following
within 30 Calendar
2% of 1st month admin
Agreement. The Performance
the receipt of information
Days of receipt of
fee to be shared among
Guarantee does not apply to
Summary Plan
required by Section 3.2 and
complete case set
all Case Installation
subsequent drafts or proofs of the
Case Installation
Document
3.3 of the Agreement
up information
Guarantees
Summary Plan Document
Client Specific
For electronic submissions, Claim is
Percentage of accuracy is
deemed submitted on the Business
calculated as the dollar
Day an inventory number is
amount of the Claims Paid
assigned. For paper submissions,
that were paid inaccurately,
Claim is deemed submitted on the
divided by the amount of all
Business Day a claim number is
Claims audited for the Health
assigned by the designated Mail
Care Plan during the
Processing Center. An audit of the
Guarantee Period, subtracted
claims processed for The City of
from 1.00
Fort Collins will be performed by the
Accuracy based on audit of
Service Contractor using claims
Claims Processed conducted
selected at random of a sufficient
Financial Accuracy
by Great -West Quality
quantity to guarantee the statistical
Claims and
of Claims
Assurance for the Guarantee
99% of claims paid
accuracy of the audit - audited
Customer Service
Processed 1
Period I
at the correct rate
2% if result is < 99% lannually.
I
Client Specific
Claims and
Customer Service
Payment Accuracy
of Claims
Processed
Percentage of accuracy is
calculated as the number of
audited Claims Paid that were
subject to a Payment Error,
divided by the total number of
audited Claims Paid for the
Guarantee Period, subtracted
from 1.00
Accuracy based on audit of
Claims Processed conducted
by Great -West Quality
Assurance for the Guarantee
Period
97.5% of claims paid
accurately
2% if result is < 97.5%
An audit of the claims processed for
The City of Fort Collins will be
performed by the Service Contractor
using claims selected at random of a
sufficient quantity to guarantee the
statistical accuracy of the audit -
audited annually.
Client Specific
For electronic submissions, Claim is
90% of Claims
deemed submitted on the Business
Processed in 14
Day an inventory number is
calendar days and
assigned. For paper submissions,
98% of Claims
Claim is deemed submitted on the
Processed within 30
Business Day a claim number is
calendar days of
2% if result is <90% in
assigned by the designated Mail
Percentage of Claims
Claim submission to
14 calendar days and
Processing Center. Results will be
Claims and
Timeliness of
Processed within the target
Great -West Mail
98% in 30 calendar
determined by internally produced
Customer Service
Claims Processed
number of Calendar Days
Processing Center
days
system generated reports.
Client Specific
Telephone Response Time
shall not be greater than the
average target number of
seconds (30) that lapse from
the time a caller is connected
to the Great -West Automated
Voice Response customer
service system or opts out of
the Automated Voice
Response system by either
exiting the system voluntarily
or the caller is transferred
automatically to speak to a
Great -West customer service
representative and when the
caller is connected to the
Results are based on Blended
Claims and
Telephone
customer service
1 % if result is >30
Customer Service Representative
Customer Service
Response Time I
representative
30 Seconds
I Seconds land
IVR results
I Aggregate
administrator performs COBRA administration, the Service Contractor shall have no liability resulting from the
failure of the Client, including its employees, directors, or officers, or a third party administrator, to fulfill any
obligations under the COBRA laws or this Contract.
5.5 Privacy of Health Information. The Parties agree to protect the privacy of Health Information in
accordance with the Privacy Agreement, which is incorporated herein by reference. 5.5.1 The Client or
the Service Contractor may terminate this Contract if the Service Contractor reasonably determines that
the Client or any of its subcontractors or agents, to whom Health Information has been disclosed under
this Contract, has materially violated any provision of this Section.
5.6 Delays. It is mutually agreed that the Service Contractor shall not be responsible for delay in the performance of
its duties under this Contract or for non-performance hereunder, if such delay or non-performance is caused or
contributed to in whole or in part by the failure of the Client to promptly furnish any required information.
5.7 Furnishing of Information. The Client shall furnish the Service Contractor with correct and complete information
required by the Service Contractor to provide services in accordance with this Contract, including, but not limited
to, eligibility information, identity of agents and brokers, confirmation of overdraft protection on the Transfer
Account, and information to verify contribution and participation requirements with respect to insurance policies
issued by the Service Contractor. The information will be furnished at the times and in such manner as the
Service Contractor may request. The Service Contractor will assume that all such information is complete and
accurate and will be under no duty to question the accuracy of such information. The Service Contractor, at its
discretion, may charge additional reasonable fees to the extent additional services are required because
information is not furnished, is incomplete or inaccurate or is not furnished at the time or in the manner as
requested.
5.8 Member Appeals. The Client acknowledges that its Plan provides Members with the right to appeal benefit
claims that have been denied and file other complaints and grievances with the Plan Administrator. The Client
shall encourage Members to exhaust their opportunity to resolve such matters under the internal grievance and
complaint procedure described in the SPD. The Client shall notify the Service Contractor of any appeal that the
Client receives and shall notify the Service Contractor of the resolution of such appeal. The Service Contractor
shall not be responsible for any costs related to such appeal and shall not be required to process any benefit
payments approved by the Client as the result of an appeal by or on behalf of any Member without written
direction from the Client. In the event Plan Administrator determines claims should be paid which are not
considered covered benefits under the Plan, and Client has purchased excess loss coverage from Service
Contractor, such amounts shall be paid outside of such agreements, and shall be the Client's full liability. The
Client shall offer all appeals and make all appeal decisions with due regard for state and federal law to the
extent it may apply including but not limited to Internal Revenue Code section 105(h), and ERISA if the Client's
Plan is an ERISA plan.
5.9 Client's Affiliates. Employees and Dependents of Client's Affiliates may be added to the Plan by giving advance
notice to and receiving approval from the Service Contractor. The Client will ensure that the Transfer Account is
adequately funded and that all other required payments are rendered to reflect such additions.
5.10 Disclosure to Members. The Client will distribute SPDs to all Members as may be required by law. The Client
will make all disclosures to employees and dependents under its Plan required by applicable law including but
not limited to the Health Insurance Portability and Accountability Act, the Newborn's And Mother's Health
Protections Act, the Women's Health and Cancer Rights Act, ERISA and COBRA.
5.11 Legal Proceedings. The Service Contractor shall consult with the Client or legal counsel designated by the
Client in claim matters that are beyond the ordinary. Client shall be responsible for its own defense of any legal
action brought by a third party related to the Plan. Nothing herein shall require the Client to defend the Service
Contractor in an action in which the Service Contractor is a named party. Nothing herein shall require the
Service Contractor to defend the Client. The Service Contractor and the Client shall cooperate in the defense of
6
No more than target number
(3%) of the total calls
connecting to the Great -West
Automated Voice Response
customer service system
during the Guarantee Period
can result in the caller being
disconnected from the call
between the time the caller
exits or is transferred from the
Automated Voice Response
Results are specific to callers who
Claims and
Call Abandonment
system to speak to a customer
are Members of the Health Care
Customer Service
Rate I
service representative 1
3%
1 % if result is >3% IPlan
I
Aggregate
r+amoonai inrormaxion
The overall amount at risk ("Maximum Operational Penalty" as defined in the Agreement) is the aggregate of all Performance Guarantees related to the
Administrative Services Contract and will not exceed 10% of the Administrative Services Fee as defined in the Performance Guarantee Agreement.
This guarantee covers only the 2007 Plan Year and does not automatically renew. This guarantee will not apply if termination of the Policy occurs prior to
the end of the guarantee period.
This document is intended to be used only in conjunction with the Performance Guarantee Agreement including without limitation the definitions contained
in that Agreement.
Management Fees
Demonstration Solutions Corp 9999999
Management Fees Paid by Plan
Current Plan YTD
Prior Plan YTD
Prior Full Plan Year
February 2004 -
February 2003 -
February 2003 -
Category
January 2005
January 2004
January 2004
Second Tier Network Fees
$5,674
$2,051
$2,051
CorSolutions Common Chronic Fees
$2,018
Other Care Management Fees
$107
$1,722
$1,722
Other Fees
$7,993
$1,256
$1,256
Total
$15,792
$5,030
$5,030
3,000
6,000
4,000
1,000
Secotui Tier Network Fees Cot�,olutinns Conutton Cl=iuc Fees Other Cue B1I€uiagement Fees Other Fees
❑Currerrt Pl..o 1`TD M Prier Flar, (TD
Great -West""
HEALTHCARE
04/06/2005 2 Management Fees
any legal proceeding and each party will furnish the other and its legal counsel with all pertinent information
regarding the proceeding.
Section 6. Indemnification and Limitation of Liability
6.1 Client's Indemnification. To the extent permitted by law and The Charter of the City of Fort Collins, the Client
shall indemnify, protect and hold the Service Contractor harmless from any and all loss, liability, claim, damage
or expense (including attorneys fees, court costs and expenses of litigation) arising out of any act or omission of
the Client, its Affiliates or subcontractors in connection with the Plan or in connection with this Contract, including
compensatory, punitive, or other damages. The Client's duty to indemnify and hold the Service Contractor
harmless shall not extend to acts or omissions of providers who render health care services to Members.
Nothing herein shall be construed as a waiver of procedural and other requirements of the Colorado
Governmental Immunity Act.
6.2 Service Contractor's Indemnification. To the extent permitted by law and The Charter of the City of Fort Collins,
the Service Contractor shall indemnify, protect and hold the Client harmless from any and all loss, liability, claim,
damage or expense (including attorneys fees, court costs and expenses of litigation) arising out of any act or
omission of the Service Contractor, its Affiliates or subcontractors in connection with the Plan or in connection
with this Contract, including compensatory, punitive, or other damages.
The Service Contractor's duty to indemnify and hold the Client harmless shall not extend to acts or omissions of
providers who render health care services to Members.
6.3 Exclusion from Indemnification. The Parties shall not be responsible for each other's lost profits, exemplary,
special, punitive or consequential damages or be liable to the other for the same.
6.4 Survival. The terms of this Section shall survive the termination of this Contract.
Section 7. Authority to Control and Manage the Plan
7.1 Agency Relationship. The Service Contractor in performing its duties under this Contract is acting only as an
agent of the Client, and the rights and responsibilities of the parties shall be determined in accordance with the
law of agency except as otherwise herein provided.
7.2 Service Contractor's Control and Authority.
7.2.1 The Service Contractor and the Client agree that while this Contract is in effect the Service Contractor
and its delegates shall have exclusive authority to provide the Plan with the services listed in the
attached Appendices, and that during such time the Client shall not undertake on its own nor shall it
authorize or allow any other person or entity to provide any of those services without the prior written
consent of the Service Contractor.
7.2.2 The Service Contractor and the Client agree that the Service Contractor shall have no liability under this
or any other agreement between the said parties with respect to any payment of benefits or other act
that violates the provisions of subsection 7.2.1 above.
7.3 Client's Control and Authority. The parties acknowledge that the Client and the Plan Administrator have the
exclusive authority to control and manage the Plan. The Client expressly agrees that the Service Contractor is
not the Plan Administrator. The Client expressly agrees that the Service Contractor is not the named fiduciary or
a fiduciary of the Plan and that neither the Client nor the Plan Administrator will designate the Service Contractor
as the named fiduciary or a fiduciary of the Plan.
The Service Contractor shall have no power, discretion or authority or control over the Plan or Plan assets or
responsibility for the terms or validity of the Plan or to alter, modify, or waive any terms or conditions of the Plan,
or to waive any breach of any such terms or conditions, or to bind the Client, or to waive any of its rights, by
making any statement or by receiving at any time any notice or information.
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The Service Contractor shall have no power, discretion or authority to act for or on behalf of the Client other than
as herein expressly granted, and no other or greater power or authority shall be implied by the grant or denial of
power or authority specifically mentioned herein.
7.4 Plan Documents. The Client acknowledges that the Plan Administrator has the responsibility to provide
Members with a summary plan description ("SPD") and to make available to Members certain other materials
and information. To the extent that the Client uses documents, including but not limited to the SPD, or other
materials or information provided to the Client by the Service Contractor for the purpose of satisfying the Plan
Administrator's obligations, the Client acknowledges that it adopts such documents and other material and
information as its own as if they were drafted and made available to Members solely by the Client and under the
authority of the Plan Administrator. The fact that the Service Contractor has drafted or assisted in drafting any
document, including but not limited to the SPD, or provided any other materials or information to the Client, shall
not be construed as the exercise of any discretion, authority or control by the Service Contractor with respect to
the Plan, and shall not be construed as establishing any fiduciary, agency, trust, or other similar relationship
whatsoever between the Service Contractor and any Member.
7.5 Relationship to Members. Nothing herein will be deemed to impose upon the Service Contractor any obligation
to any Member under the Plan.
Section 8. Right to Audit
Each party shall have the right at all reasonable times to inspect and copy the records of the other that are pertinent to
the operation of the Plan. Such inspection shall be conducted at the office of the party being inspected where the
records are kept. Any costs of such inspection shall be borne by the inspecting Party. The parties shall cooperate with
each other and make all reasonable efforts to confine any audit to a reasonable length of time.
Section 9. Service Contractor's Use and Disclosure of Records
9.1 Confidentiality. The Service Contractor shall maintain confidentiality, in accordance with applicable law, with
respect to all Health Information of Members, including but not limited to medical records, in its possession
pertaining to Members under the Plan.
9.2 Use and Disclosure of Medical Records. The Service Contractor will use Health Information solely for the
purpose of fulfilling its duties under this Contract, and will not disclose such information to anyone other than its
officers, employees, its delegates, Affiliates, those parties with whom the Service Contractor has a contract or
other, arrangement whereby that third party assists the Service Contractor in performing its duties under this
Contract and upon lawful order of a court or a public agency with appropriate jurisdiction over the subject matter;
provided, however, that such disclosure shall not exceed the extent reasonably necessary for that third parry to
provide such assistance, and further provided, that the Service Contractor shall require that third party maintain
those medical records as strictly confidential. The parties shall comply with the provisions of Appendix F,
attached hereto and incorporated herein by this reference.
9.3 Custody of Records. The Service Contractor shall hold all papers, books, files, correspondence and records of
all kinds which at any time shall come into its possession or under its control relating to the transactions
performed by the Service Contractor for the Client under this Contract, and shall, to the extent permitted by law,
surrender them to the Client upon prior request, except the Service Contractor may periodically destroy such
material as it would usually destroy in the normal course of business.
Section 10. Collection of and Liability for Claim Overpayments
10.1 Procedure. The Service Contractor shall take appropriate steps as it would for its own business under similar
circumstances to collect claim overpayments, whether or not the overpayment results from the Service
Contractor's error or mistake.
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10.2 Responsibility.
10.2.1 The Service Contractor will be responsible for Claim Overpayments resulting from the Service
Contractor's error or mistake, provided the overpayment is:
a. discovered and determined to be a Claim Overpayment before the end of a 24-month
period immediately following the date on which the claim in question was paid; and
b. uncollected at the end of the Service Contractor's collection process. Such process
shall not last longer than 24 months after the date on which the claim is determined to
be the claim overpayment.
10.2.2 The Service Contractor will not be responsible for claim overpayments that are caused directly or
indirectly by the Client, its agents or employees, or providers.
10.2.3 The Client agrees to reimburse the Service Contractor a maximum of 25% of the returned overpayment
for collection costs.
Section 11. Term and Termination of Contract
11.1 Contract Term. This Contract shall be effective on January 1, 2006, (the "Effective Date"), and shall continue in
force for one year (the "Initial Term"), unless terminated earlier pursuant to this Section. This Contract shall
expire at the end of the Initial Term, subject to the right of the parties to renew the Contract as set forth herein, in
which case, the Contract shall remain in force until the expiration of the period for which the Contract was
renewed (the "Renewal Term"), unless terminated earlier pursuant to this Section.
11.2 Contract Renewal. The Service Contractor shall submit to the Client, not later than sixty (60) days prior to the
expiration of the Initial Term and 120 days prior to any Renewal Term, the Service Contractor's proposed terms
and conditions for the renewal of the Contract (the "Renewal Proposal"). If prior to the expiration of the Contract,
the parties do not agree on the terms and conditions under which the Contract will be renewed, unless expressly
directed by the Client to discontinue service as of the expiration date, the Service Contractor may elect to
continue providing Services beyond the expiration date in order to facilitate continuity of service for Members. In
that case, this Contract shall be deemed to have been renewed under the terms and conditions of the Renewal
Proposal as if the Client had affirmatively assented to the Renewal Proposal and this Contract shall be deemed
to have been renewed. Notwithstanding anything above to the contrary, the Service Contractor shall not be
obligated to provide services after the expiration of this Contract, except to the extent expressly required to do
so under another provision of this Contract. Once this Contract is renewed, whether by express agreement or
deemed renewal, this Contract may be terminated only as set forth below in this Section. In the event Service
Contractor does not provide Client with a timely Renewal Proposal, the current Contract terms shall apply until
30 days after such Renewal Proposal is sent.
11.3 Termination Upon Notice. This Contract may be terminated:
a. at any time by either the Service Contractor or the Client, provided written notice of such
termination is given at least ninety (90) days in advance of the effective date of the termination;
b. upon amendment of the Plan in a manner deemed unsatisfactory by the Service Contractor,
and on notice to the Client, such termination shall be effective on the effective date of such
amendment.
11.4 Immediate Termination. This Contract shall terminate immediately and without notice:
a. at the option of the Service Contractor upon termination of the excess loss policy, if any;
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