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HomeMy WebLinkAboutPACIFICARE - CONTRACT - RFP - P682 BENEFITSFIRST AMENDMENT TO THE PACIFICARE HEALTH PLAN ADMINISTRATORS, INC ADMINISTRATIVE SERVICES AGREEMENT THIS FIRST AMENDMENT TO AGREEMENT ("First Amendment") is made and entered into this 151 day of January 2003, between PACIFICARE HEALTH PLAN ADMINISTRATORS, INC ("PHPA") and THE CITY OF FORT COLLINS (herinafter referred to as the "Client" ) RECITALS WHEREAS Client has contracted with PHPA to administer the Client's self -funded welfare benefit plan pursuant to the Employee Retirement Income Security Act of 1974 (hereinafter referred to as the "Plan") under the PHPA Administrative Services Agreement (hereinafter referred to in this amendment as the' Agreement") AMENDMENT NOW, THEREFORE, in consideration of the mutual agreements contained herein, and for other good and valuable consideration, the parties agree as follows In the section titled "Termination Agreement", delete -numbers 2 and 3, and replace with the following language 2 Upon termination for any cause, PHPA or its designee will administer all claims that were incurred up to the date of termination for a period of six (6) months after the termination date During this six (6) month period, all provisions of this Agreement will remain in force except that the Client agrees to pay PHPA in advance a Service Fee equal to four (4) times the Service Fee paid for the last full month before the termination date These fees are a one-time, lump sum payment and are due January 31, 2003 At the completion of the six (6) month period following the termination date, all obligations, duties and responsibilities of PHPA under this Agreement shall automatically cease without further notice or action by either PHPA or Client, including, without limitation, any further responsibility of PHPA for work in process but incomplete unless the Client and PHPA agree in writing that PHPA will complete this work for an additional mutually agreed upon fee PHPA will deliver a full and complete accounting and report as of the date of termination as to the status of the Plan payments Tlus report will be provided within seven (7) months after the termination date Upon request, PHPA will make all records and claim files in its possession, which pertain to the Plan available to Client within a reasonable period of time Both parties must retain copies of such files and records for a period of five (5) years, or longer if required by law 11/11/02 Page 1 of 2 PHPA Obligations PHPA will 1 Provide identification cards for each Benefit Program 2 Provide standard PHPA claim forms for Benefit Programs which require Plan Participants to complete claim forms 3 Provide provider directories and updates for Benefit Programs which utilize a provider network 4 Provide an administrative procedure manual 5 Suggest language for the Summary Plan Descnption(s) and subsequent amendments 6 Review Plan Participant's enrollment forms and make requests for additional information when necessary 7 Provide information so that the Client may prepare and file the Department of Labor Form 5500 8 Prepare and provide records required for audits of the Plan, legal action, or regulatory review 9 Process claims and issue claim checks in accordance with the terms of each Benefit Program in the Plan and any related interpretations, rules, and procedures approved by the Plan Administrator 10 Notify Client on a timely basis of the amounts necessary to fund all Plan Costs including Service Fees payable to PHPA, Capitation Payments, and claim payments issued under the terms of each Benefit Program in the Plan 11 Transfer funds electronically using the Automated Clearing House (ACH) process or a similar transfer mechamsm from the Chent's designated bank account to PHPA to cover all Plan Costs 12 Give timely notice and proof of loss to Chenfs specific and aggregate insurer (if any) if the reinsurance carrier chosen by the Client has an active admwstrative services agreement with PHPA. 13 Provide the Plan Participants with a written description of the claim calculation for any Benefit Program where the Plan Participant completed and submitted a claim form to PHPA. In addition, PHPA will provide an explanation for partial payment or denial, and information as to what, if anything, can be done to obtain payment under the plan These notifications will be in a form approved by the Client 14 Provide monthly financial reports that show all Plan Costs 15 Provide quarterly statistical reports that show all claim payments analyzed by type of service diagnosis, and network utilization 16 Maintain adequate blanket fidelity insurance and errors and omissions insurance 5 -9210 17 PHPA agrees to indemnify and hold the Client harmless against any and all loss, habdity, or damage (including payment of reasonable attorneys fees) which the Client may incur by reason of the negligence or misconduct of PHPA, its employees or agents in the admanstratton of the Plan and the provision of scram hereunder PHPA reserves the n& to subcontract any or all of these services to any subsidiary and/or affiliate of PHPA without notifying the Client PHPA may subcontract with any other parties by giving the Client written notice 6 -9210 Client Obligations The Client will Establish and maintain a bank account with sufficient funds to meet the Chent's obligation to fund all Plan Costs Grant PHPA the right to electronically transfer funds from the designated account to PHPA to cover Plan Costs for Service Fees payable under this Agreement which are due monthly in advance and which will be transferred by PHPA on or about the first business day of each month b Premiums due to Chent's insurer (if any) where billing is administered by PHPA which are due monthly in advance and which will be transferred by PHPA on or about the first business day of each month c Capitation Payments are due monthly, in advance or in arrears based on the underlymg provider arrangement, and which will be transferred by PHPA on or about the first business day of each month d Clain payments issued to providers in accordance with the teens of each Benefit Program in the Plan which are due weekly and which will be transferred by PHPA on or about the first business day of each week for the prior week's total issued claims under all Benefit Programs Grant PHPA the right to aggregate Plan claim payments with other payments to medical providers and to make such payments in draft, check, or electronic form Obtain legal counsel to provide advice to the Client as to lus Lability under the Plan, to defend lawsuits regarding benefits provided under the PLAN, or his duties under the law PHPA only provides administrative services and does not provide legal advice or services to the Client Be responsible for any action taken by PHPA at the Chent's request 6 Provide PHPA with timely written notice of rules, interpretations, procedures, or changes in the Plan terms Provide final determination on all disputed claims Be responsible for all language contained in the Plan Document(s), Summary Plan Descnption(s), amendments to either tend, and any employee communique which is related to the plan terms or plan business, and will provide PHPA with copies of all such document(s) on a timely basis All government reporting and disclosure requirements with regard to the Plan are Client's responsibility PHPA may rely on information provided by Client in this regard and is not required to verify the accuracy of such information Provide full enrollment information for each Covered Person under any Benefit Program in the Plan and any changes to this information as the changes occur -9210 9 Treat all Plan payments, reunbursement arrangements, and medical provider information as confidential and will not release information to other parties in other than an aggregate forth except as required by law 10 The Chat agrees to indemnify and hold PHPA harmless against any and all loss, liability, or damage ('including payment of reasonable atton*s fees) which PHPA may incur by reason of failure of the Client or its employees or agents to abide by the Plan terms or this Agreement, to administer Plan funds in a prudent or proper mariner, for any misconduct on the part of the Client or its employees or agents, for disputes ansing out of partial payment or denial of a claim by either the Client or PHPA or for action taken by PHPA at the direction of the Client -9210 General Proviswns 1 The Client must make all records and files pertaining to the Plan available to PHPA for inspection upon reasonable request during normal business hours 2 PBPA is not in the insurance business and none of its charges can be considered to be premium Notwithstanding the above, if it is determined by a regulatory or taxing authority either by legislation, regulation, or judicial decisions, that premium taxes, other taxes, or fees, including HMO or insurance guarantee fund contributions are due and payable for any charges associated with any Benefit Program, the Client shall pay to PHPA all amounts levied including, but not limited to, interest and penalties within thirty (30) days of receiving written notice from PHPA. 3 If a dispute exists between PHPA and the regulatory authority over whether the tax or fee is payable, PHPA shall hold the amounts collected from the Client in an escrow account until the dispute is resolved Any amounts held in escrow not necessary for the payment of the tax or fee shall be retumed to the Client with interest accrued at a rate determined by PHPA. 4 If the amount collected from the Client or held in escrow does not satisfy the full payment of the tax or fee, including any interest or penalties that may be assessed, the Client shall remit this difference to PHPA within thirty (30) days upon receiving written notice from PHPA The Cheat's liability in regard to these taxes, fees, and associated payments shall survive the ternmation of this Agreement 6 Failure to enforce any provision of this Agreement does not affect the rights of the parties to enforce such provision in another circumstance Neither does it affect the rights of the parties to enforce any other provision of the Agreement at any time 7 If any provision of this Agreement is determined to be unenforceable or invalid, such determination will not affect the validity of the other provisions contained in the Agreement 8 This Agreement may be changed at any time by written amendment, provided such amendment is agreed to and signed by duly authorized representatives both PHPA and the Client -9210 Termination Agreement Either party may terminate tins Agreement at any time upon written notice to the other party thirty (30) days in advance of the date of termination, unless other date is agreed upon by both parties However, upon written nonce, this Agreement will terminate unmediately as of the date the first of these events occurs Funds necessary to cover the Plan Costs are not provided by the Client in the designated bank account, if desired by PHPA. b Either party ceases to do business or the date on winch the Client terminates the Plan, if sooner c PHPA ceases to be duly licensed, if licensing is required, and the Client desires that the Agreement terminate Upon termination for any cause, PHPA or its designee will administer all claim that were married up to the date of temnnaton for a period of three months after the termination date During tlus three month period, all provisions of this agreement will remain in force except that the Client agrees to pay PHPA in advance a Service Fee equal to three tunes the Service Fee paid for the last full month before termination At the completion of the three month period, all obligations, duties, and responsibilities of PHPA under tlus Agreement cease including further responsibility for work in process but incomplete unless the Client arranges for PHPA to complete this work PHPA will deliver a full and complete accounting and report as of the date of termination as to the status of the Plan payments Tlus report will be provided within four (4) months after the termination date PHPA will make all records and claim files in its possession which pertain to the Plan available to the Client within a reasonable period of time Both parties must retain copies of such files and records for a period of five (5) years or longer if required by law The signatures below bind both parties to the terms of this Agreement 10 -9210 OWNER CITY OF FORT COLLINS CONT R PacifiCare Health Plan A ministrators, Inc nn By i rfY7� JOHN F CHBACH CITY MANAGER BY J es J Swa ze JAMES NEIL II CPPO DIREC OF PURCHASING Title Vice President of Sales & Marketing AND RISK MANAGEMENT Date 1/ 1 Date 112609 (CORPORATE SEAL) Attest ~ Attest City Clerk Address for giving notices P 0 Box 580 Fort Collins Colorado 80522 Approved as to Form Assistant City Atton Address for giving notices yss r ASPm � sf zEiq/d wov,1 Co r�-0/// 1 ' License No A n ) 0 Z- 10A -9210 Fund Transfer Amendment to the PacifiCare Health Plan Administrators, Inc. Agreement Effective January 1 119 99 , The CZ, of Fort Collins (referred to in this Amendment as the Client) has established a bank account to fund all Plan Costs with Fist National Bank of Fort Collins Bank P O Box 578 Fort Collins, CO 80522 Address (970) 4824861 Telephone 93008 Bank Account Number 107000262 Transit Routing Number Checking Account Type This bank must be a member of the state or local Automated Clearing House (referred to in this Amendment as ACH) for debits and credits to be processed The Client will make proper arrangements with the bank to accept ACH transactions for debits or credits to the bank account identified above The Client will attach a voided check or a photocopy of a check reflecting the bank account number The Client authorizes PacrfiCare Health Plan Administrators, Inc (referred to in this Amendment as PHPA) to transfer funds from this designated account in accordance with the Service Agreement in force or committed to between the Client and PHPA. These transfers will be through the ACH PHPA will telephone a designated contact of the Chant on the day each transfer is made in addition to sending a monthly written confirmation to the first contact listed below of all transfers made during that month The Chent designates the following contacts (two are required) for PHPA to use 11 -9210 Donna Gorkowsla Name P O Box 580 Fort Collins. CO 80522-0580 Mailing Address (970)221-6782 FAX Gwen Fed Name (970)221-6943 Telephone Accountant Title (970) 221-7527 Telephone Benefits Technician Title �970) 221-6238 FAX in the event PHPA is unable to reach the designated contacts, the Client authorizes PHPA to proceed with the transfer of funds provided PHPA sends a separate written notice to the first contact indicated describing the funds being transferred The Client agrees to maintain standing instructions to their designated bank for the duration of this Amendment to execute all ACH transactions initiated by PHPA A copy of the ChenVs instructions to the bank is attached to this Amendment and incorporated by reference The Client will pay any fees charged by their bank to service the designated account and to participate in the transfer of funds to PHPA. The Client grants PHPA a limited right to transfer funds to satisfy Plan Costs described in the Service Agreement between PHPA and the Client PHPA has no right to transfer any funds not expressly outlined in the Agreement This Amendment will automatically terminate three (3) months after the Agreement terminates or when replaced by a succeeding Amendment 12 -9210 The signatures below bind both parties to the terms of this Agreement OWNER C Y OF FORT COLLINS By I IU JOHN F F SCHBACH, CITY MANAGER BY �` �f, JAME O'NEILL II CPPO DIRE OR OF PURCHASING AND RISK MANAGEMENT Date Attest a� \\ City Clerk Address for giving notices P 0 Box 580 Fort Collins Colorado 80522 Approved as to Form Assistant City Attor e PacifiCare Health Plan Wministrators Inc Title Vice President of Sales & Marketing Date 1116199 (CORPORATE SEAL) Attest Address for giving notices �ysr f 4 1't License No A--0/02- 13 -9210 vs (" C ➢ C � ,tea.^ f"_ ,tal r� d � yzY � � ��u, LJ Network Disclosure Amendment to PactfiCare Health Plan Administrators, Inc. Agreement Effective January 1 .119 99. The City of Fort Collins (referred to in this Amendment as the Client) has contracted with PacifiCare Health Plan Administrators, Inc (referred to in this Amendment as PHPA) to administer the Client's self -insured medical Benefit Programs PHPA has arranged for the Client's plan to use the provider network(s) of PHPA and its affihate(s) and for the Client to benefit from the negotiated arrangements with the network providers This Amendment discloses the basic nature of the network(s) which in part defines the Client's Plan Costs EXCLUSIVE BENEFIT PLAN The Client [XI is [ ] rs not offering Exclusive Plan(s) The networks use many contract models which define capitated services versus negotiated fee services Typical models include Primary Care Capitation Model where a Pnmary Care Physician (PCP) receives a fixed monthly payment for each Exclusive Plan member in exchange for providing basic medical services to that member Any services which are rendered by other contracted medical providers are paid on a negotiated fee bans Pnnwy and Multi -Specialty Care Capitation Model where a) a multi -specialty physician group provides both primary care services and specialist services on a capitated basis, or b) a primary care physician provides or arranges for both primary care services and specialist services on a capitated basis Hospital costs and other contracted services are paid on a negotiated fee basis Fully Capitatod Model where a medical group in association with a hospital provides all services to the Exclusive Plan member on a capitated bans 4 Contracted Fee Schedule for Primary Care Physicians and Specialists, Hospitals and Ancillary Providers Some hospitals have per diem arrangements Laboratory and behavioral health are fully capitated All capitation is paid to providers monthly Each covered person under an Exclusive Plan selects a PCP from the physician panel The services subject to capitation are based on the contracting relationship with that provider The Client's obligation to pay capitation and the resulting services which are funded by the Client on a negotiated fee basis are also determined by this contractual relationship with the provider The actual negotiated fee payments are determined by the contract with the provider of those negotiated fee services Emergency services or services authorized for non - contracted providers may be paid without discount or adjustment 14 -9210 PHPA or its affihate(s) may change the contract mix of their network, negotiate new payment arrangements or modify their network stricture from time to time The Chent's obligation to pay capitation costs and to fiord negotiated fee claims under the Agreement will be modified in accordance with any changes made which affects such payments and fiindmg The Client is using the Colorado networks in support of the Client's Exclusive Benefit Plan(s) where both primary care capitation and primary and multi specialty care capitation are used POINT OF SERVICE/PLUS BENEFIT PLAN The Client ]X] is ] ] u not offering PactfiCare Plus, a point -of -service (POS) product that allows covered members to choose between two types of coverage at the time treatment or service is requested and/or rendered PacifiCare provides in -network benefits TakeCare Insurance Company provides out -of -network benefits -Network Benefit Members receiving treatment or services from or under the direction of their primary care physicians are eligible for m-network benefits There are no claim forms to fill out or deductibles to satisfy, and most services do not require pre-authonzatmon Copayments are due at the time of service and the remaining covered charges are paid at 100% Wellness benefits, including child immunizations and physical exams, are covered under the in -network plan Out -of -Network Benefits Members choosing to receive care from a provider not participating in our network or a participating specialist without a referral, will be covered under an indemnity benefit Under the out -of --network plan, members are required to complete claim forms, satisfy deductibles and pre -certify certain services or procedures Wellness benefits are covered only under the in - network plan At the time of enrollment, eligible employees and dependents select a primary care physician Each enrolled employee and dependent then receives a PacifiCare I D card that allows them access to in - network participating providers Employees are encouraged to use participating providers and, as a result, pay a smaller portion of their medical bills in the form of established copayments However, the out -of -network benefit provides freedom of choice for individuals who prefer to receive services from outside the network This Amendment will automatically terminate when the Agreement terminates or when replaced by a succeeding Amendment 15 -9210 The signatures below bind both parties to the terms of this Agreement OWNER CITY OF FORT COLLINS By JOHN F VISCHBACH CITY MANAGER BY JAME 0 NEILL II, CPPO DIRE R OF PURCHASING AND RISK MANAGEMENT Date d"Z-1 45 Attest 1.1 �,;, v_.. .1. Address for giving notices P O Box 580 Fort Collins, Colorado 80522 Approved as to Form Assistant City Att rn PacifiCare Health Plan Ldministrators Inc 1 James J Swayze Title Vice President of Sales & Marketing Date 11za1 (CORPORATE SEAL) Attest Address for giving notices Gyrr s /9Sem 4P- r, alrw,�o l (O X-O/// i License No Iq - 01 D 2- 16 -9210 Benefit Payment Deposit Amendment to PacdiCare Health Plan Administrators, Inc. Agreement Effective January 1 19 99 The City of Fort Collins Client Tax ID Number (referred to in this Amendment as the Client) has contracted with PacifiCare Health Plan Administrators, Inc (referred to in this Amendment as PHPA) to administer the Client's self -insured medical Benefit Programs PHPA will establish and hold a Benefit Payment Deposit (referred to in this Agreement as BPD) on behalf of the Client The monies accumulated in the BPD shall be used to pay Plan Costs in the event the Client fads to fund Plan cost pursuant to the TakeCare Administrative Service Agreement between the Client and PHPA. The Client agrees to deposit funds equal to one-half month of total Plan costs in the BPD and to maintain funding at that level while the Agreement is in force For convenience, PHPA will normally establish the deposit amount at the beginning of each contract year However, PHPA reserves the right to increase the BPD deposit amount at any time the required deposit is underfunded by more than ten (10) percent of the needed amount Upon giving the Client written notice ten (10) days in advance, PHPA will transfer the additional funds from the Client's designated bank account for funding Plan costs PHPA may, at Its option, request payment from the Client using other means such as a bank check or other form of transfer PHPA will, annually at the end of each contract year, credit interest on the momes held in the BPD at a variable rate of interest to be set quarterly by PHPA. In the absence of a written request from the Client to pay the interest directly to the Client, PHPA will add the interest to the BPD No person other than PHPA and the Client shall have any rights against the BPD In the event that the Agreement terminated, PHPA may use the funds in the BPD to cover Plan costs as stated above If any funds remain in the BPD after all Plan costs have been satisfied, PUPA will return those funds to the Client As of the effective date of this Agreement, the BPD deposit required equals $ 55.268 00 Thus Agreement may be changed at any tune by written amendment, provided such amendment is agreed to and signed by duly authorized representatives of both PHPA and the Client 17 -9210 OWNER CITY OF FORT COLLINS By a I Iffg JOHN F F CHBACH, CITY MANAGER BY JAME B O'NEI L II CPPO DIRE R OF PURCHASING AND RISK MANAGEMENT Date L 12 C 2 Attest City Clerk Ad-qx6ss for giving notices P 'Cry Sox 580 Fort Collins Colorado 80522 Approved as to Form 1 Assistant City Attorn ifiCare Health Plan ziistrators, Inc By Title Vice President of Sales & Marketing Date j12V199 (CORPORATE SEAL) Attest Address for giving notices License No Bq - of 0 2-- IN Fiduciary Responsibility Amendment to PacdlCare Health Plan Administrators, Inc. Agreement Effective Jarwary 1 . 1999 The City of Fort Collins (referred to in this Amendment as the Client) has contracted with PacifiCare Health Plan Administrators, Inc (referred to in this Amendment as PHPA) to administer the Client's self -insured medical Benefit Programs Client has chosen to purchase excess remsurance from an insurance carver which does not have an administrative services agreement with PHPA Client wishes for PHPA to assume fiduciary responsibility to accumulate the necessary information and to give timely notice and proof of loss directly to Client's excess risk insurer PUPA will assume the fiduciary responsibility of accumulating enrollment, claims paid and medical information and file the necessary claim forms with the Client's excess risk insurer on the Client's behalf Compensation payable to PHPA for this service will be on a case basis The compensation will be $ 0 per case for the standard PacifiCare information package Additional reports may require a fee of $100 to $150 per data analyst hour to create The services covered by tins fee will be the accumulation of necessary clauns and medical information, completing necessary forms, reasonable copying of necessary documents PHPA reserves the right to bill the Client or the Client's excess risk insurer for copying and postage costs in excess of reasonable amounts Client will provide PUPA with a copy of the policy which shows the coverage and the attachment point for clamors reunbursement Client will also provide PUPA with a contact person name and phone number at the Client's excess risk insurer This Amendment will automatically terminate when the Agreement terminates or when replaced by a succeeding Fiduciary Responsibility Amendment The signatures below bind the parties to the terms of the Amendment 19 -9210 OWNER CITY OF FORT COLLINS By t JOHN F SCHBACH, CITY MANAGER p' BY JAMVRSK O'NEILL II CD -PO DIROF PURCHASING AND MANAGEMENT p Date tI t d C �7 Address for giving notices P O Box 580 Fort Collins, Colorado 60522 Approved as to Form Assistant City Att r PacifiCare Health Plan �tlministrators, Inc J Title vice President of Sales & Marketing Date I jzb(99 (CORPORATE SEAL) Attest Address for giving notices vs s y1 Ir Sf License No � -0 0 Z A -9210 Attachment to PacifiCare Health Plan Admtmstrators, Inc. Administrative Services Agreement COMPOSITE MONTHLY PREMIUM RATES Effective January 1.1999 throueh December 31,1999 EPO POS AdmuustraUon Fee — includes, but is not Imuted to $3127 $31 52 • Access Fees • Pre-Adnussion/Concurrent UR Review • Psycluatnc/Substance Abuse UR Review • Case Management • TPA Services Incentive Risk(Network Access Fee $ 556 $ 556 21 -9210 Exhibit "D" 1 wrsileIa IN CONNECTION W rM SERVICES provided to the City of Fort Collins (the "City") pursuant to this Agreement (the "Agreement") the Contractor hereby acknowledges that it has been informed that the City has established policies and procedures with regard to the handling of confidential information and other sensitive materials In consideration of access to certain information, data and material (hereinafter individually and collectrvely, regardless of nature, referred to as "information") that are the property and/or relate to the City or its employees, customers or suppliers, which access is related to the performance of services that the Contractor has agreed to perform, the Contractor hereby acknowledges and agrees as follows That information that has or will come into its possession or knowledge in connection with the performance of services for the City may be confidential and/or proprietary The Contractor agrees to treat as confidential (a) all information that is owned by the City, or that relates to the business of the City, or that is used by the City in carrying on business, and (b) all information that is proprietary to a third party (including but not limited to customers and suppliers of the City) The Contractor shall not disclose any such information to any person not having a legitimate need -to -know for purposes authorized by the City Further, the Contractor shall not use such information to obtain any economic or other benefit for itself, or any third party, except as specifically authorized by the City The foregoing to the contrary notwithstanding, the Contractor understands that it shall have no obligation under this Agreement with respect to information and material that (a) becomes generally known to the public by publication or some means other than a breach of duty of this Agreement, or (b) is required by law, regulation or court order to be disclosed, provided that the request for such disclosure is proper and the disclosure does not exceed that which is required In the event of any disclosure under (b) above, the Contractor shall fiimish a copy of this Agreement to anyone to whom it is required to make such disclosure and shall promptly advice the City in writing of each such disclosure In the event that the Contractor ceases to perform services for the City, or the City so requests for any reason, the Contractor shall promptly return to the City any and all information described hereinabove, including all copies, notes and/or summaries (handwritten or mechanically produced) thereof, in its possession or control or as to wluch it otherwise has access The Contractor understands and agrees that the City's remedies at law for a breach of the Contractor's obligations under this Confidentiality Agreement may be inadequate and that the City shall, in the event of any such breach, be entitled to seek equitable relief (including without limitation preliminary and permanent injunctive relief and specific performance) in addition to all other remedies provided hereunder or available at law 22 -9210 I=WP® HEALTH CARE September 23, 1996 Mr Don R Heilman The Segal Company 6300 South Syracuse Way, Suite 200 Englewood, Colorado 80111-6722 Colorado Region 6455 South Yosemite Street Englewood CO 80111 303 220 3800 Fax 303 714 3998 Re City of Fort Collins, City of Loveland, Lanmer County, Platte River Power Authority, Poudre School District, and Town of Estes Park Dear Don Enclosed is our proposal for Group Life, AD&D, Supplemental Life and Dependent Life coverage Coverage will be underwritten by FHP Life Insurance Company The competitiveness of our pricing vanes by entity and by the current and proposed plans We appreciate the opportunity to provide you with our proposal and look forward to your questions Sincerely, Richard R. Ellis, Jr Senior Account Executive RRE/cjs Enclosure cc Ms Laurie Harvey, City of Fort Collins Ms Jo Mattoon, City of Loveland Ms Patsy Maroney, Larimer County Mr Dave Green, Platte River Power Authority Ms Julie Taylor, Poudre School District R-1 Ms Deborah Parrack, Town of Estes IN WITNESS WHEREOF, PHPA and Client have executed this First Amendment to the Agreement as of the date first written above PACIFICARE HEALTH PLAN ADMINISTRATORS, INC By Print Name b Title Vx)(.(iYl ts-w , Date / — / i-03 CITY OF FORT COLLINS Prin't /.e J -C S 13 O `A" —744- Title Gr'x �/C�•y/9j✓,QG �i�r�,sv7 Date //2-7/03 11/11/02 Page 2 of 2 NOV-16-1999 15 08 THE SEGRL WMF'HNY J✓JJ(I47 Vj r ✓Jl THE SEGAL COMPANY 6300 South Syracuse Way Suite 200 Englewood, Colorado 80111 6722 PHONE (303) 714-9900 FAX (303) 714-9990 or 714-9991 FROM TO FAX NO FAX TRANSMITTAL lraie— �� ��DATE _ ����) I , I%►1� U # 1 CC There will be a total of 4;�5 pages to follow MESSAGE ❑ For your information ❑ Per our conversation o For your action ❑ Per your request ❑ Original to follow by mail ❑ Please advise A-0a4-.a d I:� ` p, f�G�Gt �i CCl� e �pr�77 c�C 0614 H4.11rF Mr �' Nil ll� a4-1d .see da er a eau ex zqk,,.-2d Gam' 4 Telecopy Operator Extension —Y-Y� 6 THIS MESSAGE IS INTENDED ONLY FOR THE USE OF THE INDrM UAL EA= TO WHICH IT IS ADDRESSED AND MAY CONTAIN INFORMATION THAT IS PRIVILEGED CONFIDENTIAL. AND EXEMPT FROM DISCLOSURE If the reader of this message is not the intended recipient or an employee or agent responsible for delivering the message to the intended recipient you are hereby notified that any dissemination distribution or copying of this communication is strictly prohibited If you have received this communication in error please notify us immediately by telephone and retwn the original message to us by mail Thank you Atlanta/Bosron/Chicago/Clovoland/Denver/Edmommn/Hartford/Housron Los Angeles/MinricapoliaNew Orleans/New York/PhOMKISan Francisco Seattle/Toronto/Washington D C /West Palm Beach = CMMI 1 NOU-16-199e 15 08 I HE bEUHL C.Ut1HHNY �Uj r lv=U r U� PacffiCarelv November 6, 1998 Ms Irene Shallcross The Segal Company 6300 S Syracuse Way, Suite 200 Englewood, CO 80111-6722 Piu iCue of Colorado 64il Soatb Yostnute Street Englewood CoU+ tdu 80111 Irl 101 220 7800 RE The City of Fort Collins 1999 Administrative Services Agreement Dear Irene Per your request, enclosed are four sets of the 1999 Administrative Services Agreement between the City of Fort Collins and PacifiCare Health Plan Administrators, Inc As we discussed on the phone yesterday there is not a separate utilization review agreement as this is part of our standard administrative services provided Irene, please note that on page 18 of the agreement, the Benefit Payment Deposit is listed as $55,268 00 This is based upon recalculation of expected claims and membership The account with PacifiCare already has $51 322 00 of this amount Thus, PacifiCare will need an additional $3,946 00 Please have The City prepare this check and send to my attention as soon as possible Additionally as an attachment to the Agreement, I have listed the monthly premium rates The costs are shown on a coverage basis (i a employee, employee & spouse etc ) as this is how the costs will be billed monthly This may pose some questions on your part, so please don't hesitate to call me for clarification Please have The City of Fort Collins execute all four sets of the Agreement and return all to my attention for execution by PacifiCare I will then retain one for my files and return the remaining three to you for distribution Irene, as always, please feel free to contact me should you require anything further or have any questions at all at (303) 714-3463 Sincerely�,r��`....lai�/ Christine Lawrence Account Manager NUV-1b-l`:' i 15 b`J IHt btUHL W1 rHINT 1C1 1`1111t I C, rCUIcw ' 0 PaediCare Health Plan Administrators, Inc. Administrative Services Agreement , 0 Effective Jamary 1 19 99 PacifiCare Health Plan Administrators Inc (referred to in this Agreement as PHPA) agrees to provide The City of Fort Collins (referred to in tins Agreement as the Client) with the following services subject to all the terms of tins Agreement PHPA provides these services under the direction of the Plan Administrator as designated by the Client to control and manage the operation of the Point of Service/Plus and EPO Medical Managed Care Plans r Q m ttus Agreement as the Plan pursuant to the Employee Retirement Income Security Act of 1974, ERISA Definitions Benefit Program - A type or level of benefit which is offered to the Plan Participants A Plan may contain one or more Benefit Programs Mechcal Benefit Programs include Exclusive Benefit Plan in winch Plan Participants obtain services from a panel of medical providers The panel of medical providers may receive part of thew compensation on a pre -paid or capitated basis where the medical provider receives a fixed fee in exchange for offering certain services as needed The panel of medical providers may also receive mcentive payments if thew overall performance exceeds a predetermined threshold PactfiCare Plus/Pont of Service Plan is a point -of -service (POS) plan that allows covered members to choose between two types of coverage at the time treatment or service is requested and/or rendered PacifiCare provides m-network benefits The panel of medical providers may receive part of thew compensation on a pre -paid or capitated basis where the medical provider receives a fixed fee in exchange for offering certain services as needed The panel of medical providers may also receive incentive payments if their overall performance exceeds a predetermined threshold TakeCare Insurance Company provides out -of -network benefits, Benefits are paid on a fee for -service based upon reasonable & customary charges set by HIAA tables. -9210 NUV-1b-ly: tb lb ✓J'J I Ht bLUHL Dui 1rHNT .- Capitation Payments - The 100 percent valuation of fees the Chent is obligated to pay to medical providers in exchange for certain medical services under a Benefit Program These fees represent the total liability to the Client for the indicated medical services Under some Benefit Programs, a portion of the Capitation Payment may be withheld from the medical provider and is allocated to an incentive fund Based on the medical provider's performance and/or the performance of the provider panel, the withhold may be returned to the provider at some point in the future The Client will always fund the full, 100 percent valuation of the Capitation Payment each month The client is not eligible for a refund of any unretumed withholds on the Capitation payment Covered Person - Plan Participant or a Plan Participant's dependent who is eligible for Plan Benefits and where the employee has elected coverage under a specific benefit program 4 Covered Unit - A grouping of Covered Persons used for billing purposes Common Covered Units include employee only COBRA cmrtinuee, all dependents, one dependent, two or more dependents, etc S Plan - The Ch s ERISA we benefit plan 6 Plan Costs - The total cost of Plan including, but not limited to, Service Fees payable to PBPA, Capitation Payment for medical services payable to medical providers, claim payments issued under the Plan either directly to medical providers or to reimburse Plan Participants for medical expenses they have paid, and premiums for certain insurance coverages provided by an insurer selected by Chent 7 Plan Document(s) - A written description(s) of the Plan {£filch is required by ERISA The Plan Document(s) governs the operation of the Plan f p,. �hrcL 8 Plan Parttapant - An employee of the Client who is eligible for Plan benefits and where the employee has elected coverage under a specific program 9 Service Fees - Fees paid by the Client to "A in exchange for various services provided to the Client The level and cost of services may vary based on the Benefit Programs included 10 Summary Plan Desch lion - A written description(s) of the Plan provisions fitmtshed to each Plan Particip as required by ERI -9210 NUV-ib-P77b 1J UJ IML =UHL WlirHIY1 n. i-r111e I 1. Benefit Programs Attached and incorporated into this Agreement is the Plan Document that describes the actual benefits provided by each Benefit Program under the Plan. PHPA agrees to provide services to the following Benefit Programs Plan 1 -UO (including LIWmation Review) Plan 2 Point of SerncdPlus (including Uyllption Revrgv,) -9210 NOV-16-1998 15 10 1 H6 bEL HL Wr t'HNT r 10 Service Fees ear In exchange for PHPNs services, the Client agrees to pay a monthly Service Fee per Covered Unit as shown on the rate notice provided to the Client. The rate notice is incorporated into tins Agreement by reference The Service Fee is guaranteed for each Plan year except that PHPA reserves the right to change the Service Fee a with respect to t �e&o�Plan years by advising t Client m writing Sit days prior to the change in service ee, b at anytime the terms of this Agreement or the terms of the Plan change, or at anytime the enrollment in a Benefit Program changes m total by more than 15 percent oft enrollment in that Benefit Program at the beginning of the current Plan year Each month, the Service Fee is due and payable on the first of that month PHPA reserves the right to withhold semoe from the Chant in the event that full payment is not made when due The amount of Service Fee due and Payable to PUPA shall never be less than the Service Fee multiplied by 73 employee Covered Units and the associated dependent Covered Units This munmum will be calculated on the basis of the employerldependent ratio as of the begntnmg of the current Plan year Relationship between the Pukes PHPA acts upon the instructions of the Plan Administrator PHPA is not a Plan fiduciary and its duties and authority are strictly limited as described in this Agreement In order that the relationship between the parties and the nature of the responsibilities and rights ofboth parties remain clear The Client agrees not to use the name, miage, promotional material, stahorw", letterhead, or logo of PHPA except as expressly authorized by PUPA - PUPA agrees not to use the name, image, promotional material, stationery letterhead, or logo of the Client except as expressly authorized by the Chant Uceesing PUPA is responsible for comphanoe with all state laws, including hcensmg, applicable to administrators who provide service to self -funded employee benefit plans PHPA M as of the date of tins Agreement, duly licensed, as required, to provide such assistance to the Chem and will continue to maintain such licensing. If PUPA fails to maintain such licenses, it will notify the Client on a tunely basis In that event the Chant may terminate this Agreement immediately 4 -9210 NOU-16-1998 15 10 THE SEGAL COMPANY r n r PHPA Obligations PHPA will 1 Provide identification cards for each Benefit Program 2 Provide standard PHPA claun forms for Benefit Programs winch require Plan Participants to complete claim forms 3 Provide provider directories and updates for Benefit Programs winch uukm a provider network. 4 Provide an administrative procedure manual 5 Suggest language for the Summary Plan Dewnption(s) and subsequent amendments 6 Review Plan Participant's enrollment forms and make requests for additional information when necessary 7 Provide Information so that the Client may prepare and file the Department of Labor Form 5500 8 Prepare and provide records required for audits of the Plan, legal action, or regulatory review 9 Process claims and issue claim checks in accordance with the terms of each Benefit Program in the Plan and any related interpretations, roles, and procedures approved by the Plan Admuustrator 10 Notify Chent on a timely basis of the amounts necessary to fund all Plan Costs including Service Fees payable to PHPA, Capitation Payments and claim payments issued under the terms of each Benefit Program in the Plan. 11 Transfer funds electronically using the Automated Clearing House (AM process or a similar transfer mechanism from the Client's designated bank account to PHPA to cover all Plan Costs 12 Clive timely notice and proof of loss to Client's specific and aggregate insurer (if any) if the reinsurance carrier chosen by the Client has an active administrative services agreement with PHP& 13 Provide the Plan Participants with a written description of the claim calculation for any Benefit Program where the Plan Participant completed and submitted a claim form to PHPA. In addition, p� PHPA will provide an explanation for partial payment or denial, and mformation as to what, if IN' anything, can be done to obtain payment under the plan These notifications will be in a form approved by the Client. �5 14 Provide monthly financial reports that show all Plan Costs 15 Provide quarterly statistical reports that show all claim payments analyzed by type of service, diagnosis, and network utilization 16 Maintain adequate blanket fidelity insurance and errors and omissions msurance 5 -9210 NOU-16-1996 15 11 mt 5tu� i Ul irnry r ------ .... 17 PUPA agrees to indemnify and hold the Cheat harmless against any and all loss, liability, or damage (including payment of reasonable attorney's fees) which the Client may incur by reason of the gross negligence or intentional misconduct of PUPA, its employees or agents in the admuustrabon of the Plan and the provmsmon of services hereunder PUPA reserves the right to subcontract any or all of these services to any subsidiary and/or affiliate of PHPA without notifying the Chemrt. PUPA may subcontract with any other parties by giving the Client written notice 6 -9210 NOV-16-1998 15 11 THE SEGRL CUMPRNY r r�� Client Obligations The Client will Establish and maintain a bank account with sufficient funds to meet the Chent's obligation to fund ail Plan Costs Grant PHPA the tight to electronically transfer funds from the designated account to PHPA to cover Plan Costs for a Service Fees payable under tins Agreement winch are due monthly in advance and which will be transferred by FUPA on or about the first business day of each month Premiums due to Climes mauer Cif any) where billing its administered by PHPA which arc due monthly in advance and which will be transferred by PHPA on or about the first business day of each month Capitation Payments are due monthly in advance or in arrears based on the underlying provider arrangement, and which will be transferred by PHPA on or about the first business day of each month d. Claim payments issued to providers in accordance with the terms of each Benefit Program in the Plan which are due weekly and which will be trinsf4red by PHPA on or about the fast business day of each week for the prior week's total issued claims under all Benefit Programs 3 Grant PHPA the right to aggregate Plan claim payments with other payments to medical providers and to make such payments in draft, check, or electronic form. 4 Obtain legal counsel to provide advice to the Client as to his liability under the Plan, to defend lawsuits regarding benefits provided snider the PLAN, or lus duties raider the law PBPA only provides administrative services and does not provide legal advice or services to the Client Be responsible for any action taken by PHPA at the Chenn's request 6 Provide PUPA with timely written notice of stiles interpretations, procedures, or changes in the Plan terms Provide final determination on all disputed claims Be responsible for all language contained in the Plan Doeument(s), Summary Plan Description(s), amendments to either text, and any employee communique winch is related to the plan terms or plan business, and will provide PHPA with copies of all such document(s) on a timely basis. All government reporting and disclosure requirements with regard to the Plan are Cherit s responsibility PHPA may rely on information provided by Client in tins regard and its not required to verity the accuracy of such information Provide full enrollment information for each Covered Person under any Benefit Program in the Plan and any changes to this uformaton as the changes occur -9210 NOV-16-1998 15 11 THE SEGAL COMPANY 3037149990 P 10 Treat all Plan payments, reimbursement arrangements and medical provider information as confidential and will not release information to other parties in other than an aggregate form except as required by law 10 The Cheat agrees to mdemrafy and hold PHPA harmless against any and all loss Lability, or damage (mcludmg payment of reasonable attomeys fees) which PHPA may incur by reason of failure of the Chad or its employees or agents to abide by the Plan terms or this Agreement, to administer Plan funds in a prudent or proper manner for any misconduct on the part of the Cheat or its employees or agents, for disputes ansng out of partial payment or demal of a claim by either the Client or PHPA or for action taken by PHPA at the direction of the Client -9210 PacifiCare ° PacifiCare of Colorado 6455 South Yosemite Street Englewood Colorado 80111 TeI 303 220.580Q March 24, 1999 James B O'Neill II, CPPO City of Fort Collins P O Box 580 Fort Collins, CO 80522-0580 RE 1999 Service Agreement for PacifiCare Benefit Program Dear Jim Enclosed are three fully executed sets of the City of Fort Collins agreement with PacifiCare for the 1999 plan year My apologies for not having returned this sooner We do not utilize a corporate seal and I have therefore enclosed a letter stating such signed by our President and CEO Should you have any questions please do not hesitate to contact me at (303) 714-3463 Thank you for your continued business with PacifiCare of Colorado Sincerely, Christine Lawrence Account Manager /cl Enclosures cc Irene Shallcross, The Segal Company oNMQA 9/97 7/99 NOU-16-1999 15 12 THE SEGAL COMPANY 3037149990 P 11 General Provisions 1 The Client must make all records and files pertau tg to the Plan available to PHPA for inspection upon reasonable request during normal business hours 2 PHPA its not in the msurance business and none of its charges can be considered to be premium Notwithstanding the above, if nits determined by a regulatory or taxing authority either by legislation, regulation, or judicial demons, that premium taxes, other taxes, or fees, Including TWO or insurance guarantee fund contributions are due and payable for any charges associated with any Benefit Prograrq the Client shall pay to PHPA all amounts levied including, but not limited to, interest and penalties within thirty (30) days of receiving written notice from PHPA. If a dispute exists between PHPA and the regulatory authority over whether the tax or fee its payable, PHPA shall hold the amounts collected from the Client in an escrow account until the duilwte is resolved Any amounts held in escrow not necessary for the payment of the tax or fee shall be returned to the Chan with interest accrued at a rate determined by PHPA 4 If the amount collected from the Client or held in escrow does not satisfy the full payment of the tax or fee including any interest or penalties that may be assessed, the Client shall remit this difference to PHPA vathn thirty (30) days upon receiving written notice *om PHPA. The Chent's liability in regard to these taxes, fees and associated payments shall survive the termination of this Agreement Failure to enforce any provision of this Agreement does not affect the tights of the parties to enforce such provision in another circumstance Neither does it affect the rights of the parties to enforce any other provision of the Agreement at any time 7 If any provision of this Agreement is determined to be unenforceable or invalid, such determination will not affec the validity of the other provisions contained in the Agreement S This Agreement may be changed at any time by written amendment, provided such amendment is agreed to and signed by duly authorized representatives both PHPA and the Chem -9210 NOV-16-1999 15 12 THE SEGAL COMPANY 3037149990 P 12 Termination Agreement 41erH V� Father party may terminate tlus Agreement at any tune upon written notice to the other party thirty (30) days in advance of the date of termination, unless other date is agreed upon by both j2►`y Q parties However, upon written notice, this Agreement will terminate unmedt"y as of the date the first of these events occurs a Funds necessary to cover the Plan Costs are not provided by the Client in the designated bank account, if desued by PHPA b Either party ceases to do business or the date on which the Client terminates the Plan, if sooner c PUPA ceases to be duly licensed, if licensing is required, and the Cheat desues that the Agreement terminate Upon termination for any cause, PHPA or its designee will administer all claim that were incurred up to the date of termination for a period of three mouths after the termination date During this three month period, all provisions of this agreement will remain in force except that the Client agrees to pay PHPA in advance a Service Fee equal to three tunes the Service Fee paid for the last full month before termination At the completion of the three month period, all obhgauons, duties, and responsibilities of PHPA under tins Agreement cease including further responsibility for work in process but incomplete unless the Client arranges for PHPA to complete this work 3 PHPA will deliver a full and complete accounting and report as of the date of termination as to the status of the Plan payments This report will be provided within four (4) months after the termination date PHPA will make all records and claim fihx in its possession which pertam to the Plan available to the Chem within a reasonable period of time Both parties must retain copies of such files and records for a period of five (5) years or longer if required by law dK The signatures below b both parties to terms of this Agreement PecifiCare Health Plan Adtnuustrators, Inc ('"A") Name Title Date 10 -9210 NOV-16-1998 15 13 THE SEGAL COMPANY 3037149990 P 13 Client") Name Title Date 11 -9210 NOV-16-1990 15 13 THE SEGAL COMPANY 3037149990 P 14 Fund Transfer Amendment to the PaciSCare Health Plan Administrators, Inc. Agreement Effective January 1 19 99 The Ca of Fort Collins (referred to in this Amendment as the Chent) has established a bank account to fund all Plan Costs with First National Bank ofFort Collin Batik P O Box 578 Fort CoLm CO 80522 Address (970)482-4961 Telephone 93009 Bank Account Number 107000262 Transit Routing Number This bank must be a member of the state or local Automated Clearing House (referred to in this Amendment as ACH) for debits and credits to be processed. The Client will make proper arrangements with the bank to accept ACH transactions for debits or credits to the bank account identified above The Chent will attach a voided check or a photocopy of a check reflecting the bank account number The Chent authonzes PacifiCare Heft Plan Administrators, Inc (referred to in this Amendment as PHPA) to tivisfer funds from this designated account in accordance with the Service Agreement in force or committed to between the Client and PHPA. These transfers will be through the ACH process PHPA will telephone a designated contact of the Client on the day each transfer is made in addition to sending a monthly written confirmation to the first contact listed below of all transfers made during that month The Client designates the following contacts (two are required) for PHPA to use 12 -9210 NOU-16-1999 15 13 THE SEGAL COMPANY Dotaaa Gorkowskn Accountant Name Title P 0 Box 580 (970)221-678 FAX (970) 221-684 Telephone (970)221-7527 Telephone Benefits Teclaaelan Title (970)2221.6238 FAX 3037149990 P 15 In the event PBPA its unable to teach the designated contacts, the Chat authorizes PBPA to proceed with the transfer of Hinds provided PUPA sends a separate written notice to the first contact indicated describing the funds being transferred The Client agrees to initiation standing instructions to their designated bank for the duration of this Amendment to execute all ACH transactions imitated by PUPA A copy of the Chem's instructions to the bank is attached to this Amendment and incorporated by reference. The Cheat will pay any fees charged by their bank to service the designated account and to participate in the transfer of Ws to PBPA. The Cheat grants PHPA a lulled right to trivLew Hinds to satisfy Plan Costs described in the Service Agreement betweeri PBPA and the Client PBPA has no night to transfer any fiends not expressly outlined in die Agreement This Amendment will automatically terminate three (3) months after the Agreement terminates or when replaced by a succeeding Amendment 13 -9210 NOV-16-1998 15 13 THE SEGAL COMPANY 3037149990 P 16 The signatures below hind both parties to the terms of this Amendment PaciflCare Health Plan Administrators, Inc (THPA") Name Title Date ("Chart") Name Title Date 14 -9210 NOV-16-199e 15 14 THE SEGAL COMPANY 3037149990 P 17 Network Disclosure Amendment to PacifiCare Health Plan Administrators, Inc. Agreement Effective Iamiary I 19 99 , sty ofFort Collins (referred to in this Amendment as the Chant) has contracted with PacifiCare Health Plan Administrators, Inc (referred to in this Amendment as PHPA) to administer the Chent's self -insured medical Benefit Programs PHPA has arranged for the Chent's plan to use the provider network(s) of PHPA and its affdnate,(s) and for the Client to benefit from the negotiated arrangements with the network providers This Amendment discloses the basic ninum of the network(s) winch in part defines the Chesit s Plan Costs EXCLUSIVE BENEFIT PLAN The Client [XI is [ 1 at not offenng Exclusive Plan(s) The networks use many contract models which define capitatod services versus negotiated fee services Typical models include Primary Care Capitation Model where a Primary Care Physician (PCP) receives a fixed monthly payment for each Exclusive Plan member in exchange for providing basic medical services to that member Any services which are tendered by other contracted medical providers are paid on a negotiated fee basis 7 Primary and Multi -Specialty Care Capitation Model where a) multi -specialty physician group provides both primary camservices anst services on a capttated basis, or b) a pmmary care physician provides or arranges for both primary care services and specialist wrAces on a capained basis. Hospital costs and other contracted services are paid on a negotiated fee basis Fully Capitated Model where a medical group in association with a hospital provides all services to the Exclusive Plan member on a capitate d basis Contracted Fee Schedule for Primary Care Physicians and Specialists, Hospitals and Ancillary Providers Some hospitals have per diem arrangements Laboratory and behavioral health are fully capnated All capitation is paid to providers monthly Each covered person under an Exclusive Plan selects a PCP from the physician panel The services subject to capitation are based on the contracting relationship with that provider The Chents obligation to pay capitation and the resulting services winch are funded by the Chant on a negotiated fee basis are also determined by this contractual relationship with the provider The actual negotiated The payments are determined by the contract with the provider of those negotiated fee services Emergency services or sernces authorized for non - contracted providers may be paid without discount or adjustment iS -9210 NOU-16-1998 15 14 THE SEGAL COMPANY 3037149990 P 16 PUPA or its a$hate(s) may change the contract mix of then' network, negotiate new payment arrangements or modify their network structure from time to time The Chen's obligation to pay capitation costs and to fund negotiated fee claims under the Agreement will be modtfied in accordance with any changes made which affects such payments and funding The Chem is using the Colorado networks in support of the Chest's Exclusive Benefit Plan(s) where both primary rue capitation and primary and muiti-spe salty care captabon are used POINT OF SERVICE/FLUS BENEFIT PLAN The Chem [XI Is [ J is not offering PacifiCare Plus, a point -of -service (POS) product that allows covered members to choose between two types of coverage at the time treatment or service is requested and/or rendered PaeifiCare provides in network benefits TakeCare Insurance Company provides out -of -network berefits In -Network Benefit, Members receiving treatment or services from or under the direction of their primary care physicians are eligible for m-network benefits There are no clann forms to fill out or deductibles to satisfy, and most services do not require pre -authorization. Copayments are due at the time of service and the remaining covered charges are paid at IWI* Wellness benefits, including child immunizations and physical exams, are covered under the in -network plan Out -of -Network Bendpts Members choosing to receive care from a provider not participating in our network or a participating spectabst without a referal, will be covered under an indemnity benefit Under the out -of -network plan, members are required to complete dawn forms, Batt* deductibles and pre-ceitify certain services or procedures Wellness benefits are covered only under the in - network plan At the time of enrollment, eligible employees and dependents select a primary care physician Each enrolled employee and dependent then receives a PactfiCare I D card that allows them access to By, network participating providers Employees are encouraged to use participating providers and, as a result, pay a smaller portion of their medical bills in the forth of established copaymetns However, the out -of -network benefit provides freedom of choice for individuals who prefer to receive services from outside the network This Amendment will automatically terminate when the Agreement terminates or when replaced by a succeeding Amendment 16 -9210 NOU-16-1998 15 15 THE SEGAL COMPANY 3037149990 P 19 The signattaes below bid the parties to the terms of the Amendment PacifiCare Health Plan Administrators, Inc ("PHPA") Name Title Company Date ('Chart') Name Title Date 17 -9210 NOU-16-1998 15 15 THE SEGAL COMPANY 3037149990 P 20 Benefit Payment Deposit Amendment to PacdiCare Health Plan Adorn ustrators, Inc, Agreement Effective Jos iery 1 19 99 Cheat Tax iD Number (referred to m this Amendment as the Che t) has contacted with PaafiCare Health Plan Administrators, Inc (referred to in tins Amendment as PHPA) to administer the Climes wW-insured medical Benefit Programs PHPA will establish and hold a Bendrt Payment Deposit (referred to in this Agreement as BPD) on behalf of the Client The monies accumulated in the BPD shall be used to pay Plan Costs in the evert the Chant fade to fund Plan cost pursuant to the TakeCare Administrative Service Agreement between the Client and PUPA. The Cheat agrees to deposit funds equal to one-half month of total Plan costs in the BPD and to maintain fimdmg at that level while the Agreement is in force For convenience, PHPA will normally establish the deposit amount at the beginning of each contract year However, PHPA reserves the right to increase the BPD deposit amount at any time the required deposit is underfimded by more than ten (10) percent of the needed amount Upon giving the Client written notice ten (10) days in advance, PHPA will transfer the additional funds from the Cheds designated frank account for funding Phi costs PHPA may, at its option, request payment from the Chant using other means such as a bank check or other form of transfer PHPA will, annually at the end of each contract year, credit interest on the monies held in the BPD at a variable rate of interest to be set quarterly by PUPA In the absence of a written request from the Chest to pay the rrrtcest directly to the Client, PHPA will add the interest to the BPD No person other than PHPA and the Client shall have any rights against the BPD In the event that the Agreement terminated, PHPA may use the fords in the BPD to cover Plan costs as stated above If any funds remain in the BPD afar all Plan costs have been satisfied, PUPA will return those finds to the Client As of the dkfive date of this Agreement, the BPD deposit required equals S U,268 00 This Agreement may be changed at any time by written amendment, provided such amendnrem is agreed to and signed by duly authorized representatives of both PHPA and the Chaff is -9210 PacifiCare of Colorado, Inc (a Colorado corporation) I, Eric D Sipf, hereby certify that I am the duly elected and qualified President of PacifiCare of Colorado, Inc (the "Corporation"), and that the Corporation does not utilize a corporate seal in connection with its books and records EnA Sipf, President and C Date 1-� "l6 NOV-16-1999 15 15 THE SEGAL COMPANY 3037149990 P 21 ("Client") Name Title Date ("PHPA") Name Title Date 19 -9210 NOV-16-1998 15 16 THE SEGAL COMPANY 3037149440 P 22 Ftdocnary Rnpoosabdtty Amendment to PacifiCare Health Plan Adounrstrators, Inc. Agreement Effective January 1 19 9�9 (referred to in this Amendment as the Client) has contracted with Pac&Care Health Plan Admuustrators, Inc (referred to in this Amendment as PHPA) to administer the Client's self-ummd medical Benefit Programs Client has chosen to purchase excess reinsurance from an tnau nine carrier which does rot have an administrative services agreement with "A. Chem washes for PHPA to assume fiduciary responsibility to ace rnuhtte the necessary information and to gin tunety notice and proof of loss directly to Cbent's excess risk insurer PHPA will assume the fiductary, responsibility of accumulating enrollment, claims paid and medical mformabon and file the necessary clam forms with the Client's excess risk msurer on the Cheat's behalf Com on payable to PHPA for this servicewd i be on a case bases The compensation will be S 0 per case for the standard PacifiCare udormabon oackaga Addtttotta�l�poK reauue a fix of 00 to S150 ner data hour tos [cafe The services covered by this fee will be the 1�, analyst accumulation of necessary claims and medical uTonnabon, completing necessary forms, reasonable copying of necessary documents PHPA reserves the right to bill the Chem or the Client's excess risk insurer for copying and postage costs in excess of reasonable amounts Client will provide PHPA with a copy of the policy which shows the coverage and the attachment point for claims teunbursemern Client will also provide "A with a contact person name and phone number at the Chem's excess risk insurer Pus Amendment will automatically terminate when the Agroem>ent terminates or when replaced by a succeeding Fiduciary Responsibility Amendment The signatures below bind the parties to the terms ofthe Amendment. 20 -9210 NOV-16-1999 15 16 THE SEGAL COMPANY 3037149990 P 23 PacifiCam Health Plan Admwstrators, Inc ("PHPA") Name Title Date Name Ttle Date 21 -9210 NOU-16-1998 15 16 THE SEGAL COMPANY 303714999P P 24 Attachment to PactfiCare Health Plan Administrators, Inc Administrative Services Agreement COMPOSITE MONTHLY PREMIUM RATES EPO POS Admuustratton Foe — mcludes, but is not lmuted to $31 27 $31 52 • Access Foes • Pro-Adnitmon/Conam'ent UR Review • Psyclvamc/Substance Abuse UK Review • Case Manoganert • TPA Services Incentive Risk(Network Access Fee $ 556 $ 5 56 22 -9210 TOTAL P 24 SEP 09 98 15 12 FR PACIFICARE 303 714 3999 TO 919702216707 P 01/02 PacifCare of Colorado 6455 South Yosemite Strect Fnglcwood Colorado SOIII Tcl 303 220 5800 Via Facsimile (970) 221-6707, 2 pages September 9, 1998 James B. O'Neill II, CPPO Director of Purchasing & Risk Management The City of Fort Collins 256 West Mountain Avenue Fort Collins, CO 80521 RE Proposed 1999 TPA Rates Dear Jim This letter is in response to my manager, Barb Towle s conversation with Don Heilman and Jacob Lawrence from The Segal Company this morning PacifiCare values our long standing relationship with the City of Fort Collins and would never want to jeopardize this partnership Having said that, should the City choose to move the stop loss coverage from Lincoln Reinsurance there will be go change to our originally quoted TPA rates of $34 31 PPO $31 52 Point of Service and $3127 EPO We are still concerned that significant administrative inefficiencies could occur based upon our past experience with some stop loss tamers For this reason we originally quoted an 8-12% increase in our TPA fees should the stop loss carrier be other than Lincoln Reinsurance We agree that this fee would be more reasonably addressed by charging a fee for service on special reporting requests as outlined below The current services provided to the City would remain and would cost nothing extra to adriunister Examples of some current services include • Large Claims Listing • Demographic Data at Renewal • Assist the City with the Filing of Any Stop Loss Claims We would provide the City with the same type of information we currently provide to Lincoln Reinsurance However arty additional reports requested by the new stop loss tamer would need to be set up by our adhoc reporting unit to determine the data elements required for the report A charge for each adhoc report request will be assessed at the r NCpA o irto 9/97 799 SEP 09 99 15 12 FP PACIFICARE 303 714 3999 TO 919702216707 P 02/02 September 9, 1998 The City of Fort Collins O Neill II, James Page 2 time of request and will be based upon the number of data analysts hours required to create the report Charges will be based upon a $100 to $150 per data analyst hour to create any special reports Jim, I look forward to hearing from you soon and welcome any questions you may have at (303) 714-3463 Again thank you for your continued business) Sincerely, "OLA. 0 stine Lawrence ne\� Account Manager Icl cc Don Heilman, The Segal Company, (303) 714-9990 Jacob Lawrence, The Segal Company (303) 714-99" Barb Towle, PactfiCare ** TOTAL PAGE 02 ** Pacd�Care Health Plan Administrators, Inc. Administrative Services Agreement Effective January 1 , 19 99 , PactfiCare Health Plan Administrators, Inc (referred to in this Agreement as PHPA) agrees to provide The Croy of Fort Collins (referred to in this Agreement as the Client) with the following services subject to all the terms of this Agreement PHPA provides these services under the direction of the Plan Administrator as designated by the Client to control and manage the operation of the Point of Service/Plus and EPO Medical MK"ed Care Plans (referred to in this Agreement as the Plan Definitions Benefit Program - A type or level of benefit which is offered to the Plan Participants A Plan may contain one or more Benefit Programs Medical Benefit Programs include Exclusive Benefit Plan in which Plan Participants obtain services from a panel of medical providers The panel of medical providers may receive part of their compensation on a pre -paid or capitated basis where the medical provider receives a fixed fee in exchange for offering certain services as needed The panel of medical providers may also receive incentive payments if their overall performance exceeds a predetermined threshold PacifiCare Plus/Point of Service Plan is a point -of --service (POS) plan that allows covered members to choose between two types of coverage at the time treatment or service is requested and/or rendered PactfiCare provides m-network benefits The panel of medical providers may receive part of their compensation on a pre -paid or capitated basis where the medical provider receives a fixed fee in exchange for offering certam services as needed The panel of medical providers may also receive incentive payments if their overall performance exceeds a predetermined threshold TakeCare Insurance Company provides out -of -network benefits Benefits are paid on a fee -for -service based upon reasonable & customary charges set by HIAA tables -9210 Capitation Payments - The 100 percent valuation of fees the Client is obligated to pay to medical providers in exchange for certain medical services under a Benefit Program These fees represent the total liability to the Client for the indicated medical services Under some Benefit Programs, a portion of the Capitation Payment may be withheld from the medical provider and is allocated to an incentive fund Based on the medical provider's performance and/or the performance of the provider panel, the withhold may be returned to the provider at some point in the future The Client will always fund the full, 100 percent valuation of the Capitation Payment each month The client is not eligible for a refund of any unretumed withholds on the Capitation payment 3 Covered Person - Plan Participant or a Plan Participant's dependent who is eligible for Plan Benefits and where the employee has elected coverage under a specific benefit program 4 Covered Unit - A grouping of Covered Persons used for billing purposes Common Covered Units include employee only, COBRA continuee, all dependents, one dependent, two or more dependents, etc Plan - The Chent's welfare benefit plan 6 Plan Costs - The total cost of Plan including, but not limited to, Service Fees payable to PUPA, Capitation Payment for medical services payable to medical providers, claim payments issued under the Plan either directly to medical providers or to reimburse Plan Participants for medical expenses they have paid, and premiums for certain insurance coverages provided by an insurer selected by Client 7 Plan Documerit(s) - A written description(s) of the Plan The Plan Document(s) governs the operation of the Plan 8 Plan Participant - An employee or retiree of the Client who is eligible for Plan benefits and where the employee has elected coverage under a specific program 9 Service Fees - Fees paid by the Client to PUPA in exchange for various services provided to the Client The level and cost of services may vary based on the Benefit Programs included 10 Summary Plan Description(s) - A written description(s) of the Plan provisions furnished to each Plan Participant -9210 Benefit Programs Attached and incorporated into this Agreement is the Plan Document that descnbes the actual benefits provided by each Benefit Program under the Plan PHPA agrees to provide services to the following Benefit Programs Plan 1 EPO Madan t U 1izatnon Review) Plan 2 Point of Service/Plus (n&-h-na Utilization Review) -9210 Service Fees In exchange for PUPA's services, the Client agrees to pay a monthly Service Fee per Covered Unit as shown on the rate notice provided to the Client The rate notice is incorporated into this Agreement by reference The Service Fee is guaranteed for each Plan year except that PUPA reserves the right to change the Service Fee a with respect to the second and subsequent Plan years by advising the Client in writing at least 31 days prior to the change in service fee (there is a 5% fee increase cap for the year 2000), at anytime the terms of this Agreement or the terms of the Plan change, or c at anytime the enrollment in a Benefit Program changes in total by more than 15 percent of the enrollment in that Benefit Program at the beginning of the current Plan year Each month, the Service Fee is due and payable on the first of that month PUPA reserves the right to withhold service from the Client in the event that full payment is not made when due The amount of Service Fee due and Payable to PUPA shall never be less than the Service Fee multiplied by 73 employee Covered Units and the associated dependent Covered Units This minimum will be calculated on the basis of the employee/dependent ratio as of the beginning of the current Plan year Relationship between the Parties PUPA acts upon the instructions of the Plan Administrator PUPA is not a Plan fiduciary and its duties and authority are strictly limited as descnbed in this Agreement In order that the relationship between the parties and the nature of the responsibilities and rights of both parties remain clear The Client agrees not to use the name, image, promotional material, stationery, letterhead, or logo of PUPA except as expressly authorized by PUPA 2 PUPA agrees not to use the name, image, promotional matenal, stationery letterhead or logo of the Client except as expressly authorized by the Client Licensing PUPA is responsible for comphance with all state laws, including licensing, applicable to administrators who provide service to self-fiinded employee benefit plans PUPA is, as of the date of this Agreement duly hcensed, as required, to provide such assistance to the Client and will continue to maintain such licensing If PUPA Fads to maintain such licenses, it will notify the Client on a timely basis In that event the Client may terminate this Agreement immediately -9210