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HomeMy WebLinkAboutCORRESPONDENCE - RFP - P985 BENEFITSJessica S. Sheriff Contractual Agreement Unit Manager CIGNA HealthCare 0 CIGNA HealthCare January 21, 2011 Routing 62CAU 900 Cottage Grove Road Ms. Amy Sharkey Hartford, CT 06152 Compensation, Benefits and HRIS Manager Telephone 860. Facsimile 860.730.3930.39 43 44 Human Resources jessica.sheriff@cigna.com City of Fort Collins 215 North Mason, 2nd Floor Fort Collins, CO 80522-0580 Re: Administrative Services Only Agreement by and between Connecticut General Life Insurance Company ("Connecticut General") and City of Fort Collins ("Employer") Dear Ms. Sharkey: Enclosed is an Administrative Services Only Agreement (the "Agreement") that Connecticut General has prepared to establish the terms under which it will administer a self -funded benefit plan on behalf of Employer beginning January 1, 2011 (the "Effective Date"). Employer may signify its acceptance of the tenns of the Agreement by: ■ Executing (i) this letter (where indicated below), or (ii) the signature page in the Agreement, and returning the executed page to me at the above address, or ■ Taking no action, in which case the Agreement shall become binding upon Employer and Connecticut General sixty (60) days following the date of this letter. If Employer does not accept all the terms of the enclosed Agreement, it must so notify Connecticut General either electronically or in writing (at the address indicated above) within sixty (60) days of the date of this letter. In that case, Connecticut General shall cooperate to negotiate mutually agreeable terms with Employer. Once a subsequent agreement is finalized, it will apply retroactively to the Effective Date. Until then, however, the enclosed Agreement, which may periodically be amended by Connecticut General, will govern the relationship between Employer and Connecticut General. The following information is required to implement the New York Public Goods Pool (New York Health Care Reform Act of 1996). Without receipt of this election information by the 15th day of the month PRIOR to the effective date claims will be adjudicated as non -elect and will not be re - adjudicated upon the subsequent receipt of the required infonnation. Connecticut General Life Insurance Company '1 �,_ZlcpshU4� By: Authorized Representative: Jessica S. Sheriff Title: Contractual Agreement Unit Manager Date: January 21, 2011 JSS/gm City of Fort Collin J`cRO wr'ru C-VAO.,UcsE 00C J �r0 -t O�iM� Grp By: 10' ZJ Authorized Representative: �14 �+ Q • �/ ���� r 1 Title:)in� U&,Z )4 Doyze--I/- "sS C, Date: d- /Z� S I�V`'t L f 31LtIIk "CIGNA" and "CIGNA HeahhCare" refer to various operating subsidiaries of CIGNA Corporation. Products and services are provided by these operating subsidiaries and not by CIGNA Corporation. These operating subsidiaries include Connecticut General Life Insurance Company, Tel -Drug, Inc. and its affiliates, CIGNA Behavioral Health, Inc, Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc. In Arizona, HMO plans are offered by CIGNA HealthCare of Arizona, Inc. In California, HMO plans are offered by CIGNA HealthCare of California, Inc. In Connecticut, HMO plans are offered by CIGNA HealthCare of Connecticut, Inc. In Virginia, HMO plans are offered by CIGNA HealthCare Mid - Atlantic, Inc. In North Carolina, HMO plans are offered by CIGNA HealthCare of North Carolina, Inc. All other medical plans in these states are insured or administered by Connecticut General Life Insurance Company. Customer Name: City of Fort Collins Administrative Services Only Agreement • "Pharmacy Benefit" means the terms of the Plan that govern coverage and care/utilization management of drugs and related supplies dispensed to Members and charged to the Plan by the Mail Service Pharmacy or Retail Pharmacies through Connecticut General's pharmacy claim processing system. • "Rebates" or "Manufacturer Formulary Payments" means amounts that Connecticut General collects under contracts it enters into with drug manufacturers that are based on utilization of certain of the manufacturers' brand drugs under the Plan's Pharmacy Benefit and the drug's status on the CIGNA drug formulary. • "Retail Pharmacy" is a pharmacy that is entitled to payment under the Plan for drugs it dispenses that are covered under the Plan's Pharmacy Benefit, and is not a Mail Service Pharmacy. • "Specialty Drug Claim" is a claim for a pharmaceutical product that is reasonably determined by Connecticut General to be a specialty drug in accordance with industry practice. Specialty drugs generally are (i) are injected or infused and derived from living cells, or are oral non -protein compounds (e.g., oral chemotherapy drugs); (ii) target the underlying condition, which is usually one of a relatively rare, chronic and costly nature; and/or iii) require restricted access and/or close monitoring. i 3 •.`52 — kd F t i ADMINIST"RATION=FEE „. �. `>r74, Y=' • CIGNA Pharmacy Product administration fee: Included in Medical Administration Fee aaCHA'RGES;FORDRUGS`_COVERED;UNDERTHE<PLAN'SPHARMACY-BENEFITt Drug Dispensed by Mail Service Pharmacy: Connecticut General will charge Employer the following for claims covered under the Plan's Pharmacy Benefit and dispensed by the Mail Service Pharmacy: Brand Drug Claims: AWP minus an average discount of 19.00% plus an average dispensing fee of $0.00. Generic Drug Claims: The drug's charge on a Connecticut General generic Maximum Allowable Charge schedule that generates an annual average aggregate discount across Generic Drug Claims dispensed at CIGNA Home Delivery Pharmacy to Connecticut General's group -client book of business of A W P minus 69.50% Plus an average dispensing fee across such Generic Drug Claims of not more than $0.00. Specialty Drug Claims: The drug's charge under a national specialty drug discount schedule that generates a 12.5% annual average aggregate discount off AWP across Specialty Drug Claims dispensed at CIGNA Home Delivery Pharmacy to Connecticut General's group - client book of business. Drugs Dispensed by Retail Pharmacies: Connecticut General will charge Employer the following for drugs covered under the Plan's Pharmacy Benefit and dispensed by a Retail Pharmacy to the Plan Members, subject to the "Drug Charges es — Additional Provisions" section: Retail Brand Drug Claims: The lesser of AWP minus the contracted discount plus the contracted dispensing fee charged by the Retail Pharmacy for the Brand Drug Claim; or (ii) the Retail Pharmac 's usual and Customary charge. 01/21/2011 Customer Name: City of Fort Collins Administrative Services Only Agreement Retail Generic Drug Claims (other than those to which the above brand discount applies): The lesser of: (i) the drug's charge on a Connecticut General generic Maximum Allowable Charge schedule that generates an annual average aggregate discount across Generic Drug Claims dispensed at Retail Pharmacies to Connecticut General's group -client book of business of AWP minus 68.00% (Plan -specific results may vary based on drug mix), plus an average dispensing fee across such Generic Drug Claims of no more than $1.90; or (ii) the Retail Pharmacy's usual and customary charge. Retail Specialty Drug Claims: The lesser of AWP minus an annual average aggregate discount of 10.5%, plus an average dispensing fee of no more than $1.80; or (ii) the Retail Pharmacy's usual and customary charge. I- I . DRUG CHARGES —ADDITIONAL PROVISIONS - I ,. I • CIGNA Flome Delivery Pharmacy's discounts are applied to -the manufacturer average wholesale price (AWP) for the dispensed size (or to the AWP for the manufacturer -packaged quantity closest to the dispensed size, if there is no AWP for the dispensed size). • CIGNA Home Delivery Pharmacy will be reimbursed through the Bank Account for the price (discounted as per this Schedule) for replacement prescriptions shipped by CIGNA Home Delivery Pharmacy which are reported as lost or damaged despite CIGNA Home Delivery Pharmacy's shipment to the Participant's correct name and address. • The amount paid to the Retail Pharmacy for Brand, Generic, or Specialty Drug Claims may or may not be equal to the amount charged to Employer, and Connecticut General will absorb or retain any difference. • An excess achieved in any Plan -specific discount floor or dispensing fee cap offered under this Agreement will be used to offset a shortfall in any other Plan -specific discount floor or dispensing fee cap offered under this Agreement. • Industry Changes to or Replacement of Average Wholesale Price. Notwithstanding any other provision in this Agreement, including in this Exhibit, in the event of any major change in market conditions affecting the pharmaceutical or pharmacy benefit management market, including, for example, any change in the markup, methodologies, processes or algorithms underlying the published AWP(s), Connecticut General may adjust any or all of the charges, rates, discounts, guarantees and/or fees in connection with Connecticut General's administration of the plan's Pharmacy Benefit hereunder, including any that are based on AWP, as it reasonably deems necessary to preserve the economic value or benefit of this Agreement as it existed immediately prior to such change. Additionally, and notwithstanding any other provision in this Agreement, including in this Exhibit, Connecticut General may replace AWP as its pharmaceutical pricing benchmark with an alternative benchmark and/or may replace First DataBank, Medi-Span, or other such publication as its source for the AWP or alternative benchmark with a different pricing source, provided that Connecticut General adjusts any or all such AWP-Based Charges or such alternative benchmark -based charges as it reasonably deems necessary to preserve the economic value or benefit of this Agreement as it existed immediately prior to such replacement or immediately prior to the event(s) giving rise to such replacement, as the case may be. 01/21/201 1 Customer Name: City of Fort Collins Administrative Services Only Agreement FEES FOR PROCESSING RUN -OUT CLAIMS;.". = OAP Run -Out Period of twelve (12) months No additional charge Connecticut General shall not be required to process Run -Out Claims until it has received full payment of the required fees. Pharmacy Run -Out Period of three (3) months for all pharmacy claims No additional charge Connecticut General shall not be required to process Run -Out Claims until it has received full payment of the required fees. _.. SUI3R0GAtlON` Subrogation/Conditional Claim Payment (Medical Only) 5% of recovery plus litigation costs if Counsel is retained; 29% of recovery if no Counsel is retained. Notwithstanding any other amount reflected in the Conditional Claim/Subrogation Recovery Services Exhibit. C.©ST'CON=TAINMENT'FEES Connecticut General, a CIGNA company, administers the following programs to contain costs with respect to charges for health care service/supplies that are covered by the Plan. In administering these programs, Connecticut General contracts with vendors to perform program related services. Specific vendor fees are available upon request. Connecticut General's charge for administering these programs is the percentage (indicated below) of either (1) the "net savings" (i.e. the difference between the charge that the provider would have made absent the program savings and the charge made as a result of the program savings, less the applicable vendor fee which generally ranges from 7-1 1% of the program savings) or (2) the "gross savings" (i.e. the difference between the charge that the provider would have made absent the program savings and the charge made as a result of the program savings; Connecticut General pays the applicable vendor fee) or (3) the "recovery" (i.e. the amount recovered) as applicable. For covered services received from non -participating providers, Connecticut General will apply discounts available under agreements with third parties or through negotiation of the billed charges. 'These programs are identified below as the Network Savings Program, Supplemental Network & Medical Bill Review (pre- payment). This is consistent with the claim administration practices applicable to Connecticut General's' own health care insurance business when these programs are implemented. Connecticut General charges the percentage shown for administering these programs. Applying these discounts may result in higher payments than if the maximum reimbursable charge is applied. Whereas application of the maximum reimbursable charge may result in the patient being balance billed for the entire umeimbursed amount_ applying g these discounts avoids balance billing and substantially reduces thepatient's out -of ocket cost. 01/21/2011 Customer Name: City of Fort Collins Administrative Services Only Agreement MEDICAL AND PHARMACY COST CONTAINMENT I . Network Savings Program 29% of net savings 2 Supplemental Network 29% of net savings 3. Medical Bill Review —(Pre- a meat Cost Containment for Non -contracted claims): Inpatient Hospital Bill Review • Line Item Analysis Lesser of 5% of hospital bill or the savings achieved • Professional Fee Negotiation 29% of net savings Out patient Hospital Bill Review • Professional 1'ee Negotiation 29% of net savings • Line Item Analysis Re -pricing 29% of net savings Physician/Professional Bill Review • Professional Fee Negotiation 29% of net savings 4. Medical Bill Review— (Pre or Post -payment Cost Containment for Non -contracted and Contracted claims): • Hospital Bill Audit 29% of the savings/recovery achieved plus hospital fees or expenses passed through DRG Validation and Appeals 29% of recovery plus any fees or expenses passed through by the hospital or regulatory agency Inpatient Admission Retrospective Review 29% of recover Medical Implant Device Audits 29% ot'recover 5. COB Vendor Recoveries [Exclusive of pharmacy programs where claims are adjudicated at time prescription is received. 29% of recovery 6. Secondary Vendor Recovery Program 29% of recover 7. Provider Credit Balance Recovery Program 29% of recover 8. High Cost Specialty Pharmaceutical Audits 29% of recover 9. Pharmacy Vendor Recoveries 30% of recover 01/21/2011 Customer Name: City of Fort Collins Administrative Services Only Agreement 10. Class Action Recoveries 35% of recover DENTAL COST CONTAINMENT I. Network Savings Program, if applicable. 35% of gross savings ELIGIBILITY OVERPAYMENT RECOVERY FEES FEligibility Overpayment Recovery Vendor Services 29% of recover EXTERNAL REVIEW PROGRAM FEES ']'he range of External Review charges is dependent on the nature and complexity of the appeal. $500-$4,000 Review In highly complex, non -routine cases or cases related to new technology or experimental - investigational treatment, a panel of reviewers may be necessary. External Review charges will be commensurate with the number of reviewers, as well as their level of expertise and time required to complete the review. VISION'CARE` w Capitation or fee -for -service charges for vision care services will be paid as claims and will All products appear in Employer's monthly check register. Such payments will be at Connecticut General's applicable capitation or fee -for -service charges then in effect, which may be revised from time to time. Some Vision services are provided by Connecticut General and/or designated vendors. The applicable rates to Employer for this product and identity of the provider of vision services will be made available upon request. PROVIDER NETWORK AFFILIATION FEES " Connecticut General contracts directly or indirectly with other managed care entities and third All products party network vendors for access to their provider networks and discounts. These third parties charge either a network access fee, which is included in Connecticut General's monthly charges, or a percentage of the savings realized on a claim by claim basis as a result of the application of their discounts. These "network savings fees" are paid from the Bank Account. Additional details regarding specific charges will be provided Upon request. OTHER VENDORS AND HEALTI4 CARE SERVICES PROVIDERS Capitation and fee -for -service charges for various vendors and other providers/arrangers of All products health care services and/or supplies will be paid as claims for Plan Benefits and will appear in Employer's monthly check register. Such payments will be at Connecticut General's applicable capitation or fee -for -service charges then in effect, which may be revised from time to time. Additional details regarding charges and the identity of the vendor or provider of health care services will be made available upon request. 01/21/2011 Customer Name: City of Fort Collins Administrative Services Only Agreement NOTICE REGARDING PAYMENTS FROM THIRD PARTIES Unless indicated otherwise in the Schedule of Financial Charges, Connecticut General retains all All products payments it may receive from manufacturers of pharmaceutical products covered under the Plan. Information on the amount of such payments with respect to the Plan will be provided upon request. From time to time, Connecticut General, either directly or through its affiliates, contracts with vendors, provider network managers and providers in connection with various cost containment Programs. Connecticut General and its affiliates may receive payments from such parties that are intended to help defray expenses associated with implementing such PrOgrarnS. ADDITIONAL SERVICES Service Description Charge Well Aware The CIGNA HealthCare "Well Aware Program for Better Health@". Specific charge For OAP: information available upon request. $4.80/employee/month Programs include: • Well Aware Asthma Program • Well Aware Low Back Pain • Well Aware Cardiac Program • Well Aware Chronic Obstructive Pulmonary Disease (COPD) Program • Well Aware Diabetes Program Pharmacy Clinical . CIGNA TheraCare Program — a targeted condition drug therapy management program that Included at No Programs targets individuals using specialty medications for certain chronic conditions and helps them Additional Charge better understand their condition, medication side effects and importance of adherence. 01/21/2011 Customer Name: City of Fort Collins Administrative Services Only Agreement THIS AGREEMENT, effective January 1, 2011 (the "Effective Date") is by and between City of Fort Collins ("Employer") and Connecticut General Life Insurance Company ("Connecticut General"). RECITALS: WHEREAS, Employer, as plan sponsor, has adopted the benefit described in Exhibit A, as may be amended, ("Plan") for certain of its employees/members and their eligible dependents (collectively "Members"); and WHEREAS, Employer has requested Connecticut General to furnish certain administration services in connection with the Plan 3333674. NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein, it is hereby agreed as follows: Section 1. Term and Termination of Agreement This Agreement is effective on the Effective Date and shall remain in effect until the earliest of the following dates: i. The date which is at least sixty (60) days from the date that either Party provides written notice to the other party of termination of the Agreement; ii. The effective date of any applicable law or governmental action which prohibits performance of the activities required by this Agreement; iii. The date upon which Employer fails to fund the Bank Account as required by this Agreement or fails to pay Connecticut General any charges identified in this Agreement when due provided Connecticut General notifies Employer of its election to terminate; iv. Any other date mutually agreed upon by the Parties. Section 2. Claim Administration and Additional Services a. While this Agreement is in effect, Connecticut General shall, consistent with, the claim administration policies and procedures then applicable to its own health care insurance business (i) receive and 01 /2 t /201 1 10 review claims for Plan Benefits; (ii) determine the Plan Benefits, if any, payable for such claims; (iii) disburse payments of Plan Benefits to claimants; and (iv) provide in the manner and within the time limits required by applicable law, notification to claimants of (a) the coverage determination or (b) any anticipated delay in making a coverage determination beyond the time required by applicable law. b. Following (i) termination of this Agreement, except pursuant to Section l.iii. or (ii) termination of eligibility of a Member, if the required fees have been paid in full, Connecticut General shall process Run -Out Claims for the applicable Run -Out Period (See Schedule of Financial Charges for applicable fees and Run -Out Period). At the termination of any applicable Run -Out Period, Connecticut General shall cease processing Run -Out Claims and make all relevant records in its possession relating to such claims reasonably available to Employer or Employer's designee. Connecticut General is not required to provide proprietary information to Employer or any other party. c. Employer hereby delegates to Connecticut General the authority, responsibility and discretion to (i) determine eligibility and enrollment for coverage under the Plan according to the information provided by the Customer Name: City of Fort Collins Administrative Services Only Agreement Employer, (ii) make factual determinations and to interpret the provisions of the Plan to make coverage determinations on claims for Plan Benefits, (iii) conduct a full and fair review of each claim which has been denied as required by ERISA, (iv) decide level one mandatory appeals of "Urgent Care Claims" (as that term is defined in ERISA), and (v) conduct both mandatory levels of appeal determinations for all "Concurrent", "Pre - service" and "Post -service" claims (as those terms are defined under ERISA) and notify the Member or the Member's authorized representative of its decision. Employer will ensure that all summary plan description materials provided to Members reflect this delegation. d. In addition to the basic claim administrative duties described above, Connecticut General shall also perform the Plan -related administrative duties agreed upon by the Parties and specified in Exhibit B. Section 3. Fundinz and Pavment of Claims a. Employer shall establish a Bank Account, and maintain in the Bank Account an amount sufficient at all times to fund checks written on it for (i) Plan Benefits; (ii) those charges and fees identified in the Schedule of Financial Charges as payable through the Bank Account (collectively `Bank Account Payments"); and (iii) any sales or use taxes, or any similar benefit- or plan -related charge or assessment however denominated, which may be imposed by any governmental authority. Bank Account Payments may include without limitation: (i) capitated (i.e. fixed per Member) payments to Participating Providers; (ii) amounts owed to Connecticut General; and (iii) amounts paid to Connecticut General's affiliates and/or subcontractors for, among other things, network access or in- and out -of network health care services/products provided to Members. Connecticut General may credit the Bank Account with payments O1/21/2011 due Employer under its or an affiliate's stop loss policy. b. Connecticut General, as agent for the Employer, shall make Bank Account Payments from the Bank Account in the amount Connecticut General reasonably determines to be proper under the Plan and/or under this Agreement. c. In the event that sufficient funds are not available in the Bank Account to pay all Bank Account Payments when due, Connecticut General shall cease to process claims for Plan Benefits including Run -Out claims. d. Connecticut General will promptly adjust any underpayment of Plan Benefits by drawing additional funds due the claimant from the Bank Account. In the event Connecticut General overpays a claim for Plan Benefits or pays Plan Benefits to the wrong party, it shall take all reasonable steps to recover the overpayment; however, Connecticut General shall not be required to initiate court, mediation, arbitration or other administrative proceedings to recover any overpayment. Connecticut General shall not be responsible for reimbursing any unrecovered payments of Plan Benefits unless made as a result of its gross negligence or intentional wrongdoing. Following termination of this Agreement, Employer shall remain liable for payment of all due Bank Account Payments and for all reimbursements due Members under the Plan. Employer shall promptly reimburse Connecticut General for any Bank Account Payments paid by Connecticut General with its own funds and no such payment by Connecticut General shall be construed as an assumption of any of Employer's liability. This provision shall survive termination of this Agreement. Customer Name: City of Fort Collins Administrative Services Only Agreement Section 4. Charges a. Charges. Connecticut General shall provide to Employer a monthly statement of all charges Employer is obligated to pay under this Agreement that are not paid as Bank Account Payments. Payment of all billed charges shall be due on the first day of the month, as indicated on the monthly statement. Payments received after the last day of the month in which they are due, shall be subject to late payment charges, from the due date at a rate calculated as follows: the one (1) year Treasury constant maturities rate for the first week ending in January plus five percent (5%). For purposes of calculating late payment charges, payments received will be applied first to the oldest outstanding amount due. Connecticut General may reasonably revise the methodology for calculating late payment charges upon thirty (30) days' advance written notice to Employer. b. Member Changes — Additions and Terminations. If an employee becomes a Member on or before the fifteenth (15th) day of the month, full charges applicable to that Member shall be due for that Member for that month. If coverage does not start or ceases on or before the fifteenth (15th) day of the month for a Member, no charges shall be due for that Member for that month. Retroactive Member Changes and Terminations. Employer shall remain responsible for all charges and Bank Account Payments incurred or charged through the date Connecticut General processes Employer's notice of a retroactive change or termination of Membership. However, if the change or termination would result in a reduction in charges, Connecticut General shall credit to Employer the reduction in charges charged for the shorter of (a) the sixty (60) day period preceding the date Connecticut General processes the notice, or (b) the period from the date of the change or 01/21/201 1 12 termination to the date Connecticut General processes the notice. This provision shall survive termination of this Agreement. Section 5. Enrollment and Determination of Eligibility a. Eligibility Determinations and Information. Employer is responsible for administering Plan enrollment. In determining any person's right to benefits under the Plan, Connecticut General shall rely upon enrollment and eligibility information furnished by the Employer. Such information shall identify the effective date of eligibility and the termination date of eligibility and shall be provided promptly to Connecticut General in a form and with such other information as reasonably may be required by Connecticut General for the proper administration of the Plan. b. Release of Liability. Notwithstanding any inconsistent provision of this Agreement to the contrary, if Employer, or its designee, fails to provide Connecticut General with accurate enrollment and eligibility information, benefit design requirements, or other agreed -upon information in Connecticut General's standard timeframe and fornat, Connecticut General shall have no liability under this Agreement for any act or omission by Connecticut General, or its employees, affiliates, subcontractors, agents or representatives, directly or indirectly caused by such failure. Reconciliation of Eli i�y and Information and Default Terminations. Connecticut General will periodically share potential discrepancies in eligibility information with Employer. Employer will review and reconcile any discrepancies within thirty (30) days of receipt. If Employer fails to timely do so, Connecticut General may terminate coverage for any Member not listed as eligible in Employer's submitted eligibility information. Customer Name: City of Fort Collins Administrative Services Only Agreement Section 6. Claim Audits and Confidentiality a. Employer may, in accordance with the following requirements and at no additional charge while this Agreement is in effect, audit Connecticut General's payment of Plan Benefits: Employer shall provide Connecticut General 45 days advance written request for audit. Employer and Connecticut General will agree on an independent, third party auditor to conduct the audit (the "Auditor') and the date for the audit during regular business hours at Connecticut General's office(s). Employer shall be responsible for its Auditor's costs. The audit shall be conducted in accordance with the terms of Connecticut General's Claim Audit Agreement attached hereto as Exhibit C, which is hereby agreed to by Employer and which shall be signed by the Auditor prior to the start of the audit. ii. If Employer has 5,000 or more employee Members, Employer may conduct one such audit every Plan Year (but not within 6 months of a prior audit); otherwise, Employer may conduct one such audit every two Plan Years (but not within 18 months of a prior audit). iii. Auditor will review payment documents relating to a random, statistically valid sample of 225 claims paid during the two prior Plan years and not previously audited (the "Audit") subject to any contrary terms in Participating Provider agreements. Connecticut General will reasonably cooperate with audits other than the "Audit" subject to mutually agreed charges. With respect to the audit and any other audits, the scope may include types of claims prone to overpayments provided the types of claims prone to underpayments are equally included and will exclude electronic analysis. With respect to the 01 /2 t /201 I 13 Audit and any other audit, any claim adjustments will be based upon the actual claims reviewed and not upon statistical projections or extrapolations. b. Subject to the requirements of applicable law, the terms of this Agreement and the Privacy Addendum in Exhibit D, a signed Business Associate, agreement between Employer and designee, and a signed Confidentiality Agreement by applicable designee, Connecticut General shall release copies of confidential claims and Plan Benefit payment information in Connecticut General's claims system ("Confidential Information") and may release copies of proprietary information relating to the Plan in Connecticut General's claims system ("Proprietary Information") to the Employer and/or its designees. Employer agrees that Employer and its designees will keep Confidential Information and Proprietary Information confidential and will use Confidential Information and Proprietary Information solely for the purpose of administering the Plan or as otherwise required by law. Employer is solely responsible for the consequences of any use, misuse, or disclosure of Confidential Information provided by Connecticut General pursuant to this paragraph b. c. Connecticut General will maintain the confidentiality of all Protected Health Information in its possession in accordance with the Privacy Addendum in Exhibit D. Connecticut General represents that it has developed, implemented and will maintain a written, comprehensive security program that includes appropriate security measures to protect Personal Information (as defined in 201 CMR 17.00: Massachusetts Standards for the protection of Personal Information of residents of the Commonwealth, the "MA Standards"), consistent with the MA Standards and other applicable state/federal regulations with the exception that Connecticut General is in the FOR INFORMATIONAL PURPOSES REGARDING YOUR NYHCRA ELECTION STATUS NEW YORK HEALTH CARE REFORM ACT ELECTION STATUS The following information is required to implement Exhibit B of the ASO Agreement regarding the New York Public Goods Pool (New York Health Care Reform Act of 1996). Without receipt of this election information by the 15`h day of the month PRIOR to the effective date, claims will be adjudicated as non -elect and will not be re -adjudicated upon the subsequent receipt of the required information. Employer is: [ X ] Currently elect with the NY Public Goods Pool under the following name and Tax ID number. Connecticut General will act as ( ) the sole or ( ) an additional TPA for the following medical coverage(s): Name Previous TPA(s) being replaced by CIGNA (if applicable): Run out claims will be handled by previous TPA until : Tax ID Number Date) [ ] Currently non -elect, but chooses to elect to the New York Public Goods Pool under the following name and tax identification number with Connecticut General as ( ) the sole or ( ) an additional TPA for the following medical coverage(s): Name Address Tax ID Number Contact Phone As required by the State of New York, the undersigned agrees to the following: By signature below, the above entity elects to make public goods surcharge payments directly to the Department's pool administrator for all its lines of business and agrees to: 1. remit to the Department's pool administrator required surcharge payments for all applicable services on a monthly basis on or before the 30th day following the calendar month for which monies have been paid to designated providers of service; 2. provide the Department's pool administrator monthly certified reports on or before the 30th day following the calendar month for which monies have been paid which separately report patient service expenditures for services provided by designated provider type(s) (i.e., hospital inpatient, hospital outpatient, diagnostic & treatment center, laboratory, or ambulatory surgery center) by product line; 3. provide the Department with certification of data and access to allowance expenditure data upon request for audit verification purposes: and 4. the jurisdiction of the state to maintain an action in the courts of the State of New York to enforce any provision of section 2807-j of the Public Health Law (see note below). Customer Name: City of Fort Collins Administrative Services Only Agreement process of finalizing the procedure for encrypting the back-up tapes of a number of smaller claim payment sites which should be completed by September, 2011. d. Upon termination of this Agreement, Connecticut General shall make information available to the extent administratively feasible if the Parties agree upon the charge to be paid by Employer. The obligations set forth in this section shall survive termination of the Agreement. Section 7. Plan Benefit Liabilitv a. Emplover Liability for Plan Benefits. Employer is responsible for all Plan Benefits including any Plan Benefits paid as a result of any legal action. Employer is responsible for reimbursing Connecticut General, its directors, officers and employees for any reasonable expense incurred (including reasonable attorneys fees) by them in the defense of any action or proceeding involving a claim for Plan Benefits. Connecticut General shall reasonably cooperate with Employer in its defense of such actions. If Connecticut General pays a claim for Extra -Contractual Benefits, Employer is responsible for funding the payment and such payments shall not be considered in determining reimbursements or payments under stop loss insurance or in determining any risk -sharing or performance guarantee reimbursements. Employer shall reimburse Connecticut General for any liability or expenses (including reasonable attorneys fees) it may incur in connection with making such payments. b. Employer Liability for Plan Related Expenses. Employer shall reimburse Connecticut General for any amounts Connecticut General may be required to pay (i) as state premium tax or any similar Plan - related tax, charge, surcharge or assessment, O t/2 t /20 t l 14 or (ii) under any unclaimed or abandoned property, or escheat law, with respect to Plan Benefits and any penalties and/or interest thereon. These reimbursement obligations shall survive termination of this Agreement. Section 8. Modification of Plan and Administrative Duties and Charees a. Connecticut General shall have the right to revise the charges identified in this Agreement (i) on each anniversary of this Agreement, (ii) at any time by giving Employer at least sixty (60) days' prior written notice, but not more frequently than once in a six (6) month period, (iii) upon any modification or amendment of the benefits under the Plan or Connecticut General's administrative duties, (iv) upon any variation of fifteen percent (15%) or more in the number of Members used by Connecticut General to calculate its charges under the Agreement, and/or (v) upon any change in law or regulation that materially impacts Connecticut General's liabilities and/or responsibilities under this Agreement. b. Employer shall provide Connecticut General written notice of any modification or amendment to the Plan sufficiently in advance of any such change as to allow Connecticut General to implement the modification or amendment. Employer and Connecticut General shall agree upon the manner and timing of the implementation subject to Connecticut General's system and operational capabilities. c. Modification of Connecticut Generals' duties shall be by mutual agreement. The parties shall reflect such modification and any revised charges (if applicable) in a letter agreement which shall become part of this Agreement. Customer Name: City of Fort Collins Administrative Services Only Agreement Section 9. Modification of Agreement This Agreement constitutes the entire contract between the parties regarding the subject matter herein. Except as otherwise provided herein, the provisions of this Agreement shall control in the event of a conflict with the terms of any other agreements. No modification or amendment hereto shall be valid unless in writing and signed by an authorized person of each of the parties, except that modification of fees pursuant to Section 8 above may be made by written notice to Employer by Connecticut General. If Employer pays such revised fees or fails to object to such revision in writing within fifteen (15) days of receipt, the Agreement shall be deemed modified to reflect the fees as communicated by Connecticut General. Section 10. Laws Governing Contract a. This Agreement shall be construed in cordance with the laws of the State of Gam' without regard to conflict of law rules, and both parties consent to the venue and jurisdiction of its courts. b. The Parties shall perform their obligations under this Agreement in conformance with all applicable laws and regulatory requirements. Section 11. Information in Connecticut General's Processing Svstems Connecticut General may retain and use all Plan related claim and Plan Benefit payment information recorded for or otherwise integrated into Connecticut General's business records including claim processing systems during the ordinary course of business (provided, however, that claim or payment information will be available to Employer pursuant to Section 6). Connecticut General will retain claim and payment information as required by applicable law. 01/21/201 I 15 Section 12. Resolution of Disputes Any dispute between the Parties arising from or relating to the performance or interpretation of this Agreement ("Controversy") shall be resolved exclusively pursuant to the following mandatory dispute resolution procedures: a. Any Controversy shall first be referred to an executive level employee of each party who shall meet and confer with his/her counterpart to attempt to resolve the dispute ("Executive Review") as follows: The disputing Party shall give the other Party written notice of the Controversy and request Executive Review. Within twenty (20) days of such written request, the receiving Party shall respond to the other in writing. The notice and the response shall each include a summary of and support for the Party's position. Within thirty (30) days of the request for Executive Review, an employee of each Party, with full authority to resolve the dispute, shall meet and attempt to resolve the dispute. b. If the Controversy has not been resolved within thirty-five (35) calendar days of the request of Executive Review under Section 12.a, above, the Parties agree to mediate the Controversy in accordance with the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for Mediation ("Mediation"). The mediation shall be N �oku rE/� conducted in 'cut. Each party shall assume its own costs and attorneys fees. The mediator's compensation i and expenses and any administrative fees or costs associated with the mediation proceeding shall be borne equally by the parties. If the Controversy has not been resolved by Executive Review or Mediation, the Controversy shall be settled exclusively by binding arbitration. The arbitration shall be conducted in the same location as noted in Section 12.b. above, in accordance with the Customer Name: City of Fort Collins Administrative Services Only Agreement American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for Arbitration. The arbitration shall be binding on the Parties to the Agreement and on any respective affiliates which joined in the arbitration. The arbitrator's decision shall be final, conclusive and binding, and no action at law or in equity may be instituted by either Party other than to enforce the arbitrator's award. Judgment on the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. Each Party shall assume its own costs and attorneys fees. The arbitrator's compensation and expenses and any administrative fees or costs associated with the arbitration proceeding shall be borne equally by the Parties. This provision shall survive termination of this Agreement. Section 13. Third Partv Beneficiaries This Agreement is solely for the benefit of Employer and Connecticut General. It shall not be construed to create any legal relationship between Connecticut General and any other party. Section 14. Waivers No course of dealing or failure of either Party to strictly enforce any tern, right or condition of this Agreement shall be construed as a waiver of such tern, right or condition. Waiver by either Party of any default shall not be deemed a waiver of any other default. Section 15. Headings Article, section, or paragraph headings contained in this Agreement are for reference purposes only and shall not affect the meaning or interpretation of this Agreement. Section 16. Severability If any provision or any part of a provision of this Agreement is held invalid or unenforceable, 0 uz uz0 1 i 16 such invalidity or unenforceability shall not invalidate or render unenforceable any other portion of this Agreement. Section 17. Force Maieure Connecticut General shall not be liable for any failure to meet any of the obligations required under this Agreement where such failure to perform is due to any contingency beyond the reasonable control of Connecticut General, its employees, officers, or directors. Such contingencies include, but are not limited to, acts or omissions of any person or entity not employed or reasonably controlled by Connecticut General, its employees, officers, or directors, acts of God, fires, wars, accidents, labor disputes or shortages, and governmental laws, ordinances, rules or regulations. Section 18. AssiQnment and Subcontractine Neither Party may assign any right, interest, or obligation hereunder without the express written consent of the other Party; provided, however that Connecticut General may assign any right, interest, or responsibility under this Agreement to its affiliates and/or subcontract specific obligations under the Agreement provided that Connecticut General shall not be relieved of its obligations under the Agreement when doing so. Section 19. Notices Except as otherwise provided, all notices or other communications hereunder shall be in writing and shall be deemed to have been duly made when (a) delivered in person, (b) delivered to an agent, such as an overnight or similar delivery service, (c) delivered electronically, or (d) deposited in the United States mail, postage prepaid, and addressed as follows: To Connecticut General: Connecticut General Life Insurance Company 8505 East Orchard Road Greenwood Village, CO 80111 Attention: John Palmieri, Underwriting Senior Director Customer Name: City of Fort Collins Administrative Services Only Agreement To Employer: City of Fort Collins 215 North Mason, 2"d Floor Fort Collins, CO 80522-0580 Attention: Amy Sharkey, Compensation, Benefits and HRIS Manager Human Resources The address to which notices or communications may be given by either party may be changed by written notice given by one party to the other pursuant to this Section. Section 20. Identifying Information and Internet Usage Except as necessary in the performance of their duties under this Agreement, neither party may use the other's name, logo, service marks, trademarks or other identifying information or to establish a link to the other's World Wide Web site without its prior written approval. Section 21. Definitions Agreement — this entire document including the Schedule of Financial Charges and all Exhibits. Bank Account — a benefit plan account with a bank designated by Connecticut General. Established and maintained by Employer in its or a nominee's name. ERISA — the Employee Retirement Income Security Act of 1974, as amended and related regulations. Extra -Contractual Benefits — Payments which Employer has instructed Connecticut General to make for health care services and/or products that Connecticut General has determined are not covered under the Plan. Member — a person eligible for and enrolled in the Plan as an employee or dependent. 01/21/2011 17 Participant/Participating Members — Member(s) who is (are) participating in a specific program and/or product available to Members under the Plan. Participating Providers — providers of health care services and/or products who/which contract directly or indirectly with Connecticut General to provide services and/or products to Members. Plan Benefits — Amounts payable for covered health care services and products under the terns of the Plan. Partv/Parties — refers to Employer and Connecticut General, each a "Party" and collectively, the "Parties." Plan Year — the 12 month period beginning on the Effective Date and, thereafter, each subsequent 12 month period. Run -Out Claims — claims for Plan Benefits relating to health care services and products that are incurred prior to termination of this Agreement or termination of a Plan benefit option, as applicable. Customer Name: City of Fort Collins Administrative Services Only Agreement SIGNATURES IN WITNESS WHEREOF, the parties have caused this Agreement, and all Exhibits and Addenda to this Agreement, to be executed in duplicate and signed by their respective officers duly authorized to do so as of the dates given below. Employer executes as the authorized representative of the Plan with respect to the Privacy Addendum to this Agreement. w G6G4NC-, C-- 40 Dated at CITY OF FORT COLLINS G L� D 1,2,� G� i This _q day of By Nam Its Duly Authorized Dated at Hartford, Connecticut This 21" day of January, 2011 01 /21 /201 1 CONNECTICUT GENERAL LIFE INSURAtNCE COMPANY By: Name: Jessica S. Sheriff Its Contractual Agreement Unit Manager Duly Authorized 18 Customer Name: City of Fort Collins Administrative Services Only Agreement Exhibit A - Plan Document ERISA Plan No. 501 A "Summary Plan Document" or "Plan Booklet" that includes Plan Benefits and Members' rights and responsibilities under the Plan will be provided by Employer to Connecticut General and attached hereto. If Employer has not provided Connecticut General with a copy of its finalized Plan Booklet by the time this Agreement is effective, Connecticut General will administer the Plan in accordance with the medical management and claims administration policies and procedures and/or practices then applicable to its own health insurance business and the definitions and other language contained in the draft version of the Plan Booklet provided by Connecticut General to Employer. Connecticut General will continue to administer the Plan in this manner until Connecticut General receives the finalized Plan Booklet and follows its preparation and review process. After that time, Connecticut General will use the finalized Plan Booklet to administer Plan. 01/21/2011 19 Customer Name: City of Fort Collins Administrative Services Only Agreement Exhibit B — Services BANKINGsAND' ADMINISTRATION All products excludin Health Savings Account l . Furnishing Connecticut General's standard bank account activity data reports to Employer as and All Products when agreed upon. Connecticut General's administration of your plan does not include performing obligations, if any, under state escheat or unclaimed property laws. It is Employer's responsibility to determine the extent to which these laws may apply to the Plan and to comply With such laws. 2. Reporting to Employer the claim payment information required in connection with Section 6041 of All Products the Internal Revenue Code. 3. If Employer has elected, pursuant to section 63 of the New York Health Care Reform Act of 1996 All Products excluding (section 2807-t of the Public Health Law) ("the Act"), to pay the assessment on covered lives set Vision PPO forth in section 63 and has consented to the conditions set forth in section 63, Connecticut General shall file such forms and pay such assessment on covered lives on behalf of Employer through the Bank Accounttothe extent set forth in section 63. Such obligation shall end immediately upon Employer's failure to provide any information required by Connecticut General to fulfill this obligation, the failure to comply with any requirement imposed upon Employer pursuant to the Act or the failure of Employer to properly fund the Bank Account. Connecticut General shall file applicable forms and pay assessments/surcharge on covered lives on behalf of Employer in accordance with and as required by other applicable state law and regulations including: Massachusetts Uncompensated Care Trust Fund Maine Dirigo Health Reform Act Louisiana High Risk Health Insurance Association Fund .::GLA1M"ADM'fN15TRaA*TION , All products excluding Health Savings Account l . Calculation of benefits, check preparation and communications through Connecticut General's All Products standard processes. 2. Preparation and delivery of Connecticut General's standard claim forms to Employer for issuance All Products to Members. 01/21/201 I 20 Customer Name: City of Fort Collins Administrative Services Only Agreement Investigation of claims, as necessary. All Products cussion of claims, where appropriate, with providers of health services. All Products lormance of internal audits of Plan Benefit payments on a random sample basis. All Products lication of claim control rocedures. All Products onse to Insurance De artment com laints. ED All Products red toll -free tele hone service for Em to er calls to Connecticut General Claim office. All Products mber services and rovider relations services. All Products lanation of Benefit ("EOB") statements when a licable. All Products ification to Members of denied Plan Benefit claims, the reason for the denial and a eal rights. All Products ,ibilit verification using monthly Member eligibility list updated by Employer. All Products Medical Only I . Connecticut General's standard enrollment forms are prepared and delivered to Employer for distribution to individuals eligible to enroll in the Plan. All Medical Products 2. Connecticut General's standard ID card with toll -free telephone number are prepared and mailed directly to Members. All Medical Products 3. Administration of subrogation/conditional Claim Payment (terms described in Exhibit E). All Medical Products Pharmacy Only I . Connecticut General's standard ID cards with toll -free telephone number are prepared and delivered to Employer for distribution to Members. All Pharmacy Products 2. Pharmacy claims are adjudicated typically on-line at time of service without access to information on other coverage, and therefore coordination of benefits (COB) for pharmacy claims does not occur. Claims for Plan Benefits will be paid regardless of coverage under another plan. All Pharmacy Products 3. Connecticut General's standard drug utilization review services. All Pharmacy Products 4. Connecticut General will maintain a prescription drug fornudary(ies) and possibly other preferred pharmaceutical lists that identify preferred and non -preferred products. In selecting preferred products, Connecticut General attempts to manage to the lowest net cost in the aggregate; however, not every preferred formulary product is the product with the lowest net cost within the applicable therapeutic class for your plan and/or members in your plan. For example, the preferred product may be selected because it is clinically superior, the subject of favorable payment (rebate) arrangements between Connecticut General and the product's manufacturer, is anticipated to become available in a lower -cost generic drug form, or for other reasons. All Pharmacy Products 01/21/2011 21 Customer Name: City of Fort Collins Administrative Services Only Agreement DOCUMENT PRODUCTION All products excluding Health Savings Account I . Preparation and delivery of Member benefit booklet drafts to Employer. All Products UNDERWRITING SERVICES All products excluding Health Savings Account I . Provision of Connecticut General's standard annual year-end accounting summary of a) the All Products number and amount ofpaid claims and b) fees paid. 2. Connecticut General's standard Underwriting services: a) benefit design analysis, b) reserve All Products analysis, c) projected cost analysis, and d) multi -divisional reports and disclosures. HIPAA INDIVIDUAL RIGHTS - All products excluding Health Savings Account Handling of requests from Members for access to, amendment and accounting of protected health All Products information, and requests for restrictions and alternative communications as required under federal HIPAA law and regulations, as set out in this Agreement and its Exhibits. :. :. COST CONTAINMENT. I . MaximUm reimbursable charge determinations, application of non -duplication and coordination of All Medical except benefits rules and coordination with Medicaid. OAPIN Connecticut General's standard cost containment controls: maximum reimbursable charge OAPIN Medical determinations of non -Participating Provider charges for Covered Services (e.g., emergency/urgent care) and application of non -duplication and coordination of benefits rules and coordination with Medicaid. 2 Delivery of information, as necessary, regarding standard application of non -duplication or All Medical coordination of benefits. 3. Review of medical bills in accordance with Connecticut General's then current Medical Bill All Medical Review prograrn. 4. Network Savings Program, a national vendor network that provides discounted rates when a All Medical Member accesses care through a Network Savings Program contracted provider. 5. Annual reporting of Connecticut General's standard cost containment results upon Employer's All Medical request. 6. PharmacyVendor Recoveries (when implemented). All Medical Products 01/21/2011 22 Customer Name: City of Fort Collins Administrative Services Only Agreement CUSTOMER REPORTING I . Summary reports of medical, dental and pharmacy cost and utilization experience available All Medical and throe gh CIGNA web site. Pharmacy 2. Connecticut General's standard pharmacy utilization reports— eleven (1 1) pharmacy utilization Pharmacy Only re orts rovided at the prodUCt level and Updated quarterly at no charge. 3. Claim Reporting: Connecticut General will provide its standard reports and information based All Medical upon paid claim data only. Connecticut General will not provide information on incurred -but -not reported claims, projected claims, pre -certifications of coverage, case management information or information on a Member's prognosis or course of treatment. Stop Loss Reporting is an optional service provided at an additional fee to Employers who have stop loss through another entity other than Connecticut General. Connecticut General will provide its standard reporting only after the stop loss carrier and Employer have executed Connecticut General's standard Hold Harmless/Confidentiality Agreement. EXTERNAL REVIEW YROGRAIVI VOILIfilary Member appeal to selected external organization. All Medical MEDICAL MANAGEMENT SERVICES Connecticut General provides integrated medical management that includes (depending upon the terms of the Plan) the following core services. l . Pre -Admission Certification and Continued Stay Review (PAC/CSR) services to certify coverage All Medical Of acute and sub -acute inpatient admissions/stays or provides guidance to appropriate alternative settings. Administered in accordance with Connecticut General's then applicable medical management and claims administration policies, practices and procedUres. 2. Case Management and Retrospective Review of Inpatient Care, a service designed to provide All Medical assistance to a Member who is at risk of developing medical complexities or for whom a health incident has reci itated a need for rehabilitation or additional health care Support. 3. Assisting providers in developing Long Term Treatment Plans in the management of chronic or All Medical catastrophic cases. 4. The CIGNA HealthCare Healthy Babies Program, a no -cost to Member prenatal program that All Medical rovides education and support for a healthy pregnancyand healthy baby. 5. HealthCare Cost and Quality tools on m CIGNA.com All Medical 6. A panel of external medical experts to assess the safety and effectiveness of new medical All Medical technolo =ies. 01/21/2011 23 By signature below, the above entity also agrees to make public goods covered lives payments directly to the Department's pool administrator in instances where it provides inpatient coverage as a corporation organized and operating in accordance with Article 43 of the Insurance Law, an organization operating in accordance with Article 44 of the Public Health Law, a self -insured fund, or a commercial insurer licensed to do business in New York State and authorized to write accident and health insurance and whose policy provides inpatient coverage on an expense incurred basis. In such instances the above entity agrees to: 1. remit to the department's pool administrator within 30 days after the end of each month one -twelfth of both the individual and family unit annual assessment amounts for each of the individuals and family units residing in the state which were included on the payor's membership rolls for all or a portion of the prior month and for which the payor covered general hospital inpatient care, including retroactive additions and deletions; 2. provide the Department with data certification and access to individual and family unit data, upon request, for audit verification purposes; and 3. the jurisdiction of the state to maintain an action in the courts of the State of New York to enforce any provision of section 2807-t of the Public Health Law. Note: Payors making an election are only agreeing to the jurisdiction of ArYS courts for purposes of enforcing payments required under 2807 j and 2807-t. This does not, in any way, preclude a payor from litigating other issues in Federal court such as ERISA based challenges, etc. [ ] Currently non -elect and chooses to continue that non -elect status. [ ] Currently elect, but Connecticut General will not administer NYHCRA liability. Please sign below to indicate your acknowledgement of this arrangement. SIGNATURE: Mt_� D -ter v/-- _�? Nai e Title �c12�,�.pst, Date _+_2s SV�-Mt,T Customer Name: City of Fort Collins Administrative Services Only Agreement 7. The CIGNA HealthCare 24-Hour Health Information Lines", a service that provides 24 hour toll All Medical tree access to registered nurses and an extensive audio health information library. 8. The CIGNA LIFESOURCE Organ Transplant Network, that gives participants access to quality All Medical care at nationally recognized transplant centers for certain types of organ and tissue transplants. 9. A Health Education Program that delivers mailings to Members with certain conditions. All Medical Except Comprehensive/ Indemnity 10. If behavioral health services are provided/arranged by CIGNA Behavioral Health (CBH), CBH OAP Medical Products provides utilization review and case management for inpatient in -network behavioral health Only services. Applicable to non CA/NC members. 1 I. Implementing clinical quality measurements, managing data, tracking and validating performance All Medical Except and initiating continuous quality improvement. Comprehensive/ Indemnity 12. Transition of care services to allow Members with defined conditions to continue treatment with All Medical Except non -Participating Providers after enrollment for continued uninterrupted care for a limited time. Comprehensive/ Indemnity NETWORK MANAGEMENT SERVICES Connecticut General, and/or its affiliates shall: l . Provide or arrange access to the applicable network of Participating Providers to furnish health All Medical care services/products to Members at negotiated rates and methods of reimbursement (e.g. fee -for service, capitation, per diem charges, incentive bonuses, case rates, withholds etc.). The amount and type of negotiated reimbursement may vary depending upon the type of plan. For example, a hos ital ma accept less for patients enrolled in certain types of plans than others; 2 Credential and re -credential Participating Providers in accordance with Connecticut General's All Medical credentialing requirements and ensure that third -party network vendors credential/re-credential Participating roviders in accordance with Connecticut General's requirements; 3. Review Participating Provider compliance with protocols and procedures for quality, participant All Medical satisfaction, and grievance resolution; 4. Facilitate the identification of Participating Providers by Members; and All Medical 5. Maintain Member services staff to respond to Member inc uiries• All Medical 01/21/2011 24 Customer Name: City of Fort Collins Administrative Services Only Agreement CIGNA STAFF MODEL HEALTH PLAN SERVICES The CIGNA FlealthCare of Arizona, Inc. staff model ("Cigna Medical Group") is a Participating All Products Provider located in metropolitan Phoenix, Arizona. Plan Participants may at some time receive treatment from a Cigna Medical Group ("CMG") facility or provider even if they do not reside in Arizona (as when traveling). Participants utilizing the IPA network will access certain specialty and/or ancillary services (including laboratory and urgent care services) through the CMG system. Lab services are not provided by CMG for Members in PPO, PTO Plus or GPO plans. Except as provided below, for services provided to Participants, CMG is paid on a fee schedule basis at the rates in effect at the time of service (as may be revised from time to time). A representative CMG fee schedule of routinely performed services is attached. A copy of the full fee schedule is available on request and mutually agreed NDA. I f the Plan requires Participants to select a primary care physician (PCP), Phoenix area Participants who do not select a PCP during open enrollment are assigned to a CMG PCP. CMG is paid a monthly primary care capitation amount for those Phoenix area Participants who select or are assigned to a CMG PCP. Charges will appear on the monthly checl: register at the rates in effect at the time of payment. Primary care capitation charges are age/sex adjusted and may be revised from time to time. A primary care capitation rate grid and a list of the services included in the capitation are available upon request and mutually agreed NDA. Primary care services rendered to Participants in Open Access Plans that do not provide for PCP assignment are charged on a fee schedule basis, as described above. 01/21/2011 25 Customer Name: City of Fort Collins Administrative Services Only Agreement CIGNA HEALTHCARE OF ARIZONA - CIGNA MEDICAL GROUP (CMG) REPRESENTATIVE FEE SCHEDULE OF ROUTINELY PERFORMED MEDICAL SERVICES EFFECTIVE 06/01/2008 (Applicable to all Open Access Plus accounts) CPT Service Code Service Descriotion Charee 45330 Sigmoidoscopy, flexible; Diagnostic (combined rate, includes facility fee $485.00) $552.18* 45378 Diagnostic Colonoscopy (combined rate, includes facility fee $650) $888.35** 71020 Chest X-Ray, Pa & Lat $36.30 74000 Abdomen X-Ray (Kub) $29.84 77057 Mammogram, Screening (Bilateral) $81.73 80053 Comprehensive Metabolic Panel j $21.42 80061 Cardiac Risk S27.14 82565 Creatinine; Blood $10.38 82947 Glucose, Serum $7.95 84075 Phosphatase, Alkaline,Blood $10.48 84443 Tsh, Assay $34.03 84450 Sgot(Ast) Transaminase S10.47 84520 Bun Urea Nitrogen Assay $7.99 85025 CBC and Differential $13.01 87086 Culture, Urine, Colony Ct $16.36 88164 Cytopathology, Slides $21.40 88305 Surg Path, Gross and Micro $149.44 92014 Eye Exam & Treatment $95.91 92567 Tympanometry $21.98 93000 Electrocardiogram, Complete $26.83 94760 Oximetry Single Determination $2.31 951 t5 Allergy Injection, Single $15.47 95117 Allergy Injection, Multiple $19.61 99211 Office Visit, Est Min (Md Or Non-Md) $21.51 99212 Office Visit, Est Prob Focused S38.57 99213 Office Visit, Est Exp Prob Foc $52.55 99214 Office Visit, Est Detailed S82.44 99231 Subsequent Hospital Care $34.12 99242 Office Consult, Exp Prob Focused, 30 Minutes $92.04 99395 Well Exam, Est, 18-39 Years S97.18 99396 Well Exam, Est, 40-64 Years $107.41 0 U21/20 t t 26 Customer Name: City of Fort Collins Administrative Services Only Agreement The Urgent Care case rate excluding radiology and laboratory services is $ l 15. The CMG CareToday (CMG low acuity clinics) visit rate is $59. Lab tests performed at the CMG CareToday facilities are S10 per service. A complete CMG CareToday fee schedule is available on request. ASC (Ambulatory surgical center) grouper rates based on 2006 Medicare for facility component of outpatient surgery services: Group 1 - $485 Group 2 - $650 Group 3 - $740 Group 4 - $900 Group 5 - $950 Group 6 - $1100 Group 7 - $1420 Group 8 - S 1400 Group 9 - $1200 Unlisted - $740 Cigna Medical Group pharmacy fee schedule: Brand Name: AWP — 10.56% + $2.75*** dispensing fee Generic: If MAC pricing is available then MAC +$2.75*** If no MAC price available then AWP — 15% + $2.75 dispensing fee Plan charges are reduced by any applicable copayment, coinsurance and/or deductible for service. Services not identified by CPT code or codes without established RV -Us are billed at the 501h Percentile of the Arizona Regional Medicode Schedule. Notes: * Incorrectly reflected as S798.42 rather than S807.18 in prior CMG Fee Schedule dated 3/l/2007 (S807.18 charge was effective as of 3/l/2007). As of 6/l/2008, charge reduced to $485.00 facility charge and S552.18 total charge. **Incorrectly reflected as S857.26 rather than S888.35 in prior CMG Fee Schedule dated 3/1/2007 (S888.35 charge was effective as of 3/1/2007). As of 6/l/2008, charge remains S888.35. ***Incorrectly reflected as S2.50 rather than S2.75 in prior CMG Fee Schedule dated 3/I/2007. (S2.75 has been correct charge since inception of OAP product.) 01/21/2011 27 Customer Name: City of Fort Collins Administrative Services Only Agreement Exhibit C — Claim Audit Agreement (Sample) A. WHEREAS, Connecticut General Life Insurance Company ("Connecticut General") desires to cooperate with requests by (" Employer") to permit an audit for the purposes set forth below: and B. WHEREAS, ("Auditor") has been retained by Employer for the purpose of performing an audit ("Audit") of claims administered by Connecticut General. C. WHEREAS, the Auditor and the Employer recognize Connecticut General's legitimate interests in maintaining the confidentiality of its claim information, protecting its business reputation, avoiding unnecessary disruption of its claim administration, and protecting itself from legal liability; NOW THEREFORE, IN CONSIDERATION of the premises and the mutual promises contained herein, Connecticut General, the Employer and the Auditor hereby agree as follows: Audit Specifications The Auditor will specify to Connecticut General in writing at least forty-five (45) days prior to the commencement of the Audit the following "Audit Specifications": a. the name, title and professional qualifications of individual Auditors; b. the Claim Office locations, if any, to be audited; C. the Audit objectives; d. the scope of the Audit (time period, lines of coverage and number of claims); e. the process by which claims will be selected for audit; f. the records/information required by the Auditor for purposes of the Audit; and g. the length of time contemplated as necessary to complete the Audit. 2. Review of Specifications Connecticut General will have the right to review the Audit Specifications and to require any changes in, or conditions on, the Audit Specifications which may be necessary to protect Connecticut General's legal and business interests identified in paragraph C above. Access to Information Connecticut General will make the records/information called for in the Audit Specifications available to the Auditor at a mutually acceptable time and place. 01/21/2011 28 Customer Name: City of Fort Collins Administrative Services Only Agreement 4. Audit Report The Auditor will provide Connecticut General with a true copy of the Audit's findings, as well as of the Audit Report, if any, that is submitted to the Employer. Such copies will be provided to Connecticut General at the same time that the Audit findings and the Audit Report are submitted to the Employer. 5. Comment on Audit Report Connecticut General reserves the right to provide the Auditor and the Employer with its comments on the findings and, if applicable, the Audit Report. 6. Confidentiality The Auditor understands that Connecticut General is permitting the Auditor to review the claim records/information solely for purposes of the Audit. Accordingly, the Auditor will ensure that all information pertaining to individual claimants will be kept confidential in accordance with all applicable laws and/or regulations. Without limiting the generality of the foregoing, the Auditor specifically agrees to adhere to the following conditions: a. The Auditor shall not make photocopies or remove any of the claim records/information without the express written consent of Connecticut General; b. The Auditor agrees that its Audit Report or any other summary prepared in connection with the Audit shall contain no individually identifiable information. Restricted Use of the Audit Information With respect to persons other than the Employer, the Auditor will hold and treat information obtained from Connecticut General during the Audit with the same degree and standard of confidentiality owed by the Auditor to its clients in accordance with all applicable legal and professional standards. The Auditor shall not, without the express written consent of Connecticut General executed by an officer of Connecticut General, disclose in any manner whatsoever, the results, conclusions, reports or infonnation of whatever nature which it acquires or prepares in connection with the Audit to any party other than the Employer except as required by applicable law. The Employer and Auditor agree to indemnify and to hold harmless Connecticut General for any and all claims, costs, expenses and damages which may result from any breaches of the Auditor's obligations under paragraphs 6 and 7 of this Agreement or from Connecticut General's provision of information to the Auditor. The Employer authorizes Connecticut General to provide to the designated Auditor the necessary information to perform the audit in a manner consistent with all Health Insurance Portability and Accountability Act of 1996 ("HIPAX), Privacy Standards and in compliance with the signed Business Associate Agreement (`BAA"). 01/21/2011 29 Customer Name: City of Fort Collins Administrative Services Only Agreement 8. Termination Connecticut General may terminate this agreement with prior written notice. The obligations set forth in Sections 4 through 7 shall survive termination of the Agreement. Connecticut General Life Insurance Company By: TO BE SIGNED AT TIME OF AUDIT Duly Authorized Print Name: Title: Date: Employer:. By: TO BE SIGNED AT TIME OF AUDIT Duly Authorized Print Name: Title: Date: Auditor: By: TO BE SIGNED AT TIME OF AUDIT Duly Authorized Print Name: Title: Date: 01/21/201 l 30 Customer Name: City of Fort Collins Administrative Services Only Agreement Exhibit D — Privacy Addendum (`Business Associate Agreement") I. GENERAL PROVISIONS Section 1. Effect. As of the Effective Date, the terms and provisions of this Addendum are incorporated in and shall supersede any conflicting or inconsistent terms and provisions of (as applicable) the Administrative Services Only Agreement and/or Flexible Spending Account or Reimbursement Accounts Administrative Services Agreement to which this Addendum is attached, including all exhibits or other attachments to, and all documents incorporated by reference in, any such applicable agreements (individually and collectively any such applicable agreements are referred to as the "Agreement"). This Addendum sets out terms and provisions relating to the use and disclosure of Protected Health Information ("PHI") without written authorization from the Individual. Section 2. Amendment to Comply with Law. Connecticut General, Employer (also referred to as "Plan Sponsor") and the group health plan that is the subject of the Agreement (also referred to as the "Plan") agree to amend this Addendum to the extent necessary to allow either the Plan or Connecticut General to comply with applicable laws and regulations including, but not limited to, the Health Insurance Portability and Accountability Act of 1996 and its implementing Administrative Simplification regulations (45 C.F.R. Parts 142, 160, 162 and 164) ("HIPAA"), also known as the HIPAA Standards for Electronic Transactions, the HIPAA Security Standards, and the HIPAA Privacy Rule; the Health Information Technology for Economic and Clinical Health Act, which was included in the American Recovery and Reinvestment Act of 2009 (P.L. 111-5 ("ARRA")) and its implementing regulations and guidance ("HITECH"). Section 3. Definitions. Certain capitalized terms used in this Addendum are defined in Article V. Terms used in this Addendum shall have the meanings ascribed to them by HIPAA and HITECH including their respective implementing regulations and guidance. If the meaning of any term defined herein is changed by regulatory or legislative amendment, then this Addendum will be modified automatically to correspond to the amended definition. All capitalized terms used herein that are not otherwise defined have the meanings described in HIPAA and HITECH. A reference in this Addendum to a section in the HIPAA Privacy Rule, HIPAA Security Rule, or HITECH means the section then in effect, as amended. II. OBLIGATIONS OF CONNECTICUT GENERAL Section 1. Use and Disclosure of PHI. Connecticut General may use and disclose PHI only if such use or disclosure is permitted or required by the HIPAA Privacy Rule, including the applicable provisions of45 C.F.R. §164.504(e), is required to satisfy its obligations or is permitted under the Agreement, and/or is permitted or required by law, but shall not otherwise use or disclose any PHI. Connecticut General shall not use or disclose, and shall ensure that its directors, officers and employees do not use or disclose, PHI in any manner that would constitute a violation of the HIPAA Privacy Rule or HITECH if done by the Plan, except that Connecticut General may use and disclose PHI as penmitted under the HIPAA Privacy Rule (i) for the proper management and administration of Connecticut General, (ii) to carry out the legal responsibilities of Connecticut General or (iii) to provide Data Aggregation services relating to the health care operations of the Plan if such services are required under the Agreement. 01 /21/201 l 3l Customer Name: City of Fort Collins Administrative Services Only Agreement Section 2. Receiving Remuneration in Exchange for PHI Prohibited. Effective for exchanges occurring on or after the date that is six (6) months after the date of the promulgation of final regulations by the Secretary implementing Section 13405(d) of HITECH, Connecticut General shall not directly or indirectly receive remuneration in exchange for any PHI of an Individual, unless the Plan obtained from the Individual, in accordance with 45 C.F.R. § 164.508, a valid authorization that, in accordance with such section, specifies whether the PHI can be further exchanged for remuneration by the entity receiving PHI of that Individual, unless the purpose of the exchange is: (A) For public health activities (as described in 45 C.F.R. §164.512(b)); (B) For research (as described in 45 C.F.R. §§ 164.501 and 164.512(i)) and the price charged reflects the costs of preparation and transmittal of the data for such purpose; (C) For the treatment of the Individual, subject to any applicable regulation preventing PHI from inappropriate access, use, or disclosure; (D) The health care operation specifically described in the definition of health care operations in 45 C.F.R. §164.501(6)(iv); (E) For remuneration provided by the Plan to Connecticut General for activities involving the exchange of PHI that Connecticut General undertakes on behalf of and at the request of the Plan pursuant to the Agreement and this Addendum; (F) To provide an Individual with a copy of his or her PHI pursuant to 45 C.F.R. § 164524; or (G) Otherwise determined by regulations of the Secretary to be similarly necessary and appropriate as the exceptions described in subsections (A) through (F), above. Section 3. Limited Data Set or Minimum Necessary Standard and Determination. Connecticut General shall, to the extent practicable, limit its use, disclosure, or request of Individuals' PHI to the Limited Data Set (as defined in 45 C.F.R. § 164.514(e)(2)) or, if needed by Connecticut General, to the minimum necessary amount of Individuals' PHI to accomplish the intended purpose of such use, disclosure, or request and to perform its obligations under the underlying Agreement and this Addendum. Connecticut General shall determine what constitutes the minimum necessary to accomplish the intended purpose of such disclosure. Connecticut General's obligations under this Section 3 shall be subject to modification to comply with future guidance to be issued by the Secretary. Section 4. Security Standards. As required by HITECH Section 13402(a), Connecticut General shall comply with the administrative, physical, and technical safeguards and standards set out in 45 C.F.R. § 164.308, § 164.310, and § 164.312, and with the policies and procedures and documentation requirements set out in 45 C.F.R. § 164.316. On and after the effective date of final regulations issued by the Secretary requiring Connecticut General's compliance with 45 C.F.R. § 164.314, Connecticut General shall comply with the organizational requirements set forth at 45 C.F.R. § 164.314, to the extent applicable. 01/21/201 t 32 Customer Name: City of Fort Collins Administrative Services Only Agreement Section 5. Protection of Electronic PHI. With respect to Electronic PHI, Connecticut General shall: (A) Implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the Electronic PHI that Connecticut General creates, receives, maintains, or transmits on behalf of the Plan as required by the Security Standards; (B) Ensure that any agent, including a subcontractor, to whom Connecticut General provides such information agrees to implement reasonable and appropriate safeguards to protect it; and, (C) Report to the Plan any Security Incident of which it becomes aware. Section 6. Reporting of Violations. Connecticut General shall report to the Plan any use or disclosure of PHI not provided for by this Addendum of which it becomes aware. Connecticut General agrees to mitigate, to the extent practicable, any hannful effect from a use or disclosure of PHI in violation of this Addendum of which it is aware. Section 7. Security Breach Notification. Connecticut General will notify the Plan of a Breach without unreasonable delay. This notification will include, to the extent known: i. the names of the individuals whose PHI was involved in the Breach; ii. the circumstances surrounding the Breach; iii. the date of the Breach and the date of its discovery; iv. the information Breached; v. any steps the impacted individuals should take to protect themselves; vi. the steps Connecticut General is taking to investigate the Breach, mitigate losses, and protect against future Breaches; and, vii. a contact person who can provide additional information about the Breach. For purposes of discovery and reporting of Breaches, Connecticut General is not the agent of the Plan or the Employer (as "agent" is defined under common law). Connecticut General will investigate Breaches, assess their impact under applicable state and federal law, including HITECH, and make a recommendation to the Plan as to whether notification is required pursuant to 45 C.F.R. §§ 164.404-408 and/or applicable state breach notification laws. With the Plan's prior approval, Connecticut General will issue notices to such individuals, state and federal agencies - including the Department of Health and Human Services, and/or the media as the Plan is required to notify pursuant to, and in accordance with the requirements of applicable law (including 45 C.F.R. §§ 164.404-408). Connecticut General will pay the costs of issuing notices required by law and other remediation and mitigation which, in Connecticut General's discretion, are appropriate and necessary to address the Breach. Connecticut General will not be required to issue notifications that are not mandated by applicable law. Connecticut General shall provide 01/21/2011 33 FOR INFORTNAATIONAL PURPOSES REGARDING YOUR NYHCRA ELECTION STATUS NEW YORK STATE DEPARTMENT OF HEALTH Division of Health Care Financing Electronic Filing User ID Application HEALTH CARE REFORM ACT — PUBLIC GOODS POOL INSTRUCTIONS All electing payors/third party administrators (TPA)/administrative services only (ASO) organizations and designated providers are required to file Public Goods Pool reports electronically. This also applies to the 1% Statewide Assessment report filed by hospitals. To file electronically, you must establish an electronic filing account and be assigned a secure password. A website has been established at www.hcrapools.org to facilitate this process. While electronic filing is designed to be user friendly, a help desk has been established to aid those users requiring assistance. If you need general assistance or assistance in obtaining copies of the electronic filing screens and the electronic reporting certification forms, please contact the help desk at (315) 671-3800 or via email at webpoolsRhcrapools.org. Upon receipt of a fully completed Electronic Filing User ID Application (DOH-4264), the Office of Pool Administration will assign a secure electronic filing user ID and password to your organization, which you will receive via return mail. New Request/Revision to Existing Account: Check the appropriate box. An entity requesting an initial account/password should check the New Request box; an entity that has an existing account and is advising the Department of a change to that account should check the Revision to Existing Account box. Payor/TPA/ASO/Provider Name: Enter name of entity that will be submitting the reports electronically. Federal Employer Identification Number (FEIN): Enter FEIN assigned to the entity named above. Operating Certificate #: (For providers only): Enter Operating Certificate number assigned by the Department of Health to the entity named above. Report(s) being filed electronically (check ALL applicable types): Check all applicable types of reports that your entity will be filing electronically — Public Goods Pool and/or Statewide Assessment. Signature: Must be signed by the Chief Executive/Financial Officer and/or Administrator of the entity named above. Name/Title/Phone Number (Please Print): Enter name, title and phone number of the person signing above. Address/City/State/Zip Code: Enter address of the person signing above. E-mail Address: Enter e-mail address of the person signing above. Date: Enter date this form is signed. DOH -4264 (9/2006) Customer Name: City of Fort Collins Administrative Services Only Agreement the Plan with information necessary for the Plan to fulfill its obligation to report Breaches affecting fewer than 500 Individuals to the Secretary as required by C.F.R. § 164.408(c). Section 8. Disclosures to and Agreements by Third Parties. Connecticut General shall ensure that each agent and subcontractor to whom it provides PHI agrees to the same restrictions and conditions with respect to such PHI that apply to Connecticut General pursuant to this Addendum. Section 9. Access to PHI. Connecticut General shall provide an Individual with access to such Individual's PHI contained in a Designated Record Set in response to such Individual's request in the manner and time required in 45 C.F.R. § 164.524. Section 10. Availability of PHI for Amendment. Connecticut General shall respond to a request by an Individual for amendment to such Individual's PHI contained in a Designated Record Set in the manner and time required in 45 C.F.R. § 164.526, except that the Plan shall handle any requests for amendment of PHI originated by the Plan, Plan Sponsor or the Plan's other business associates, such as enrollment information. Section 11. Modifications to Individual Rights and Accounting of Disclosures. Connecticut General shall comply with, and shall assist the Plan in complying with, responding to Individuals' requests to restrict the uses and disclosures of their PHI under 45 C.F.R. § 164.522. This shall include complying with valid requests to restrict the disclosure of certain PHI in accordance with Section 13405(A) of the HITECH Act. As required by HITECH, Connecticut General shall provide Individuals with access to certain PHI in electronic form. Connecticut General shall provide an accounting of disclosures of PHI to an Individual who requests such accounting in the manner and time required in 45 C.F.R. § 164.528. Section 12. Requests for Privacy Protection. Connecticut General shall handle requests by an Individual for privacy protection for such Individual's PHI pursuant to the requirements of 45 C.F.R.§164.522. Section 13. Processes and Procedures. In carrying out its duties set forth in Article II, Sections 9 — 12, above, Connecticut General will implement the Standard Business Associate Processes and Procedures (the "Processes and Procedures") attached hereto for requests from Individuals, including the requirement that requests be made in writing, the creation of forms for use by Individuals in making such requests, and the setting of time periods for the Plan to forward to Connecticut General any such requests made directly to the Plan or Plan Sponsor. In addition, Connecticut General will implement the Processes and Procedures relating to disclosure of PHI to Plan Sponsor or designated third parties. Section 14. Availability of Books and Records. Connecticut General hereby agrees to make its internal practices, books and records relating to the use and disclosure of PHI received from, or created or received by Connecticut General on behalf of the Plan, available to the Secretary for purposes of determining the Plan's compliance with the Privacy Rule. III. TERMINATION OF AGREEMENT WITH CONNECTICUT GENERAL Section 1. Tennination Upon Breach of Provisions Applicable to PHI. Any other provision of the Agreement notwithstanding, the Agreement may be terminated by the Plan upon prior written notice to Connecticut General in the event that Connecticut General materially breaches any 01/21/2011 34 Customer Name: City of Fort Collins Administrative Services Only Agreement obligation of this Addendum and fails to cure the breach within such reasonable time as the Plan may provide for in such notice; provided that in the event that termination of the Agreement is not feasible, in the Plan's sole discretion, the Plan shall have the right to report the breach to the Secretary. If Connecticut General knows of a pattern of activity or practice of the Plan that constitutes a material breach or violation of the Plan's duties and obligations under this Addendum, Connecticut General shall provide a reasonable period of time, as agreed upon by the parties, for the Plan to cure the material breach or violation. Provided, however, that, if the Plan does not cure the material breach or violation within such agreed upon time period, Connecticut General shall terminate the Agreement, if feasible, at the end of such period. However, if neither termination of the Agreement nor cure are feasible, Connecticut General shall report the violation to the Secretary. Section 2. Use of PHI upon Termination. The parties hereto agree that it is not feasible for Connecticut General to return or destroy PHI at tennination of the Agreement; therefore, the protections of this Addendum for PHI shall survive tennination of the Agreement, and Connecticut General shall limit any further uses and disclosures of such PHI to the purpose or purposes which make the return or destruction of such PHI infeasible. IV. OBLIGATION OF THE PLAN The Plan will not request Connecticut General to use or disclose PHI in any manner that would not be permissible under HIPAA or HITECH if done by the Plan. V. DEFINITIONS FOR USE IN THIS ADDENDUM "Breach" means the unauthorized acquisition, access, use, or disclosure of Unsecured PHI which compromises the security or privacy of such information, except where an unauthorized person to whom such information is disclosed would not reasonably have been able to retain such information. A Breach does not include any unintentional acquisition, access, or use of PHI by an employee or individual acting under the authority of Connecticut General if such acquisition, access, or use was made in good faith and within the course and scope of the employment or other professional relationship of such employee or individual with Connecticut General; any inadvertent disclosure from an individual who is otherwise authorized to access PHI at a facility operated by Connecticut General to another similarly situated individual at the same facility; and such information is not further acquired, accessed, used, or disclosed without authorization by any person. "Designated Record Set" shall have the same meaning as the tern "designated record set" as set forth in the Privacy Rule, limited to the enrollment, payment, claims adjudication, and case or medical management record systems maintained by Connecticut General for the Plan, or used, in whole or in part, by Connecticut General or the Plan to snake decisions about Individuals. "Effective Date" shall mean the earliest date by which the Plan is required to have executed a Business Associate Agreement with Connecticut General pursuant to the requirements of applicable law. 01 /2 t /20 l t ,5 Customer Name: City of Fort Collins Administrative Services Only Agreement "Electronic Protected Health Information" shall mean PHI that is transmitted by or maintained in electronic media as that term is defined in 45 C.F.R. § 160.103. "Limited Data Set" shall have the same meaning as the term "limited data set" as set forth in as defined in 45 C.F.R. § 164.514(e)(2). "Protected Health Information" or "PHI" shall have the same meaning as set forth at C.F.R. § 160.103. "Secretary" shall mean the Secretary of the United States Department of Health and Human Services. "Security Incident" shall have the same meaning as the term "security incident" as set forth in 45 C.F.R. § 164.304. "Unsecured Protected Health Information" shall mean PHI that is not rendered unusable, unreadable, or indecipherable to unauthorized individuals through the use of a technology or methodology specified by the Secretary in the guidance issued under Section 13402(h)(2) of ARRA. 01/21/201 l 36 Customer Name: City of Fort Collins Administrative Services Only Agreement Connecticut General Life Insurance Company Standard Business Associate Processes and Procedures These Standard Business Associate Processes and Procedures apply to each self -funded group health plan ("Plan") of an entity ("Plan Sponsor") that has entered or will enter into an Administrative Services Only Agreement, Flexible Spending Account or Reimbursement Accounts Administrative Services Agreement and/or Continuation Coverage Services Agreement (collectively, as applicable, the "Administrative Services Agreement") with Connecticut General Life Insurance Company ("Connecticut General"). The Plan and Connecticut General are parties to a Business Associate Agreement/Privacy Addendum. Unless otherwise defined, capitalized terms have the meaning provided therein, or if not defined in such agreement, as defined in 45 C.F.R. parts 142, 160, 162 and 164 ("HIPAA"), also known as the HIPAA Standards for Electronic Transactions, the HIPAA Security Standards, and the HIPAA Privacy Rule and/or the Health Information Technology for Economic and Clinical Health Act, which was included in the American Recovery and Reinvestment Act of 2009 (P.L. 111-5 ("ARRA")). Section 1. Access to PHI. When an Individual requests access to PHI contained in a Designated Record Set and such request is made directly to the Plan or Plan Sponsor, the Plan shall forward the request to Connecticut General within five (5) business days of such receipt. Upon receipt of such request from the Plan, or upon receipt of such a request directly from an Individual, Connecticut General shall make such PHI available directly to the Individual within the time and manner required in 45 C.F.R. § 164.524. The Plan delegates to Connecticut General the duty to determine, on behalf of the Plan, whether to deny access to PHI requested by an Individual and the duty to provide any required notices and review in accordance with the HIPAA Privacy Rule. Section 2. Availability of PHI for Amendment. (a) When an Individual requests amendment to PHI contained in a Designated Record Set, and such request is made directly to the Plan or Plan Sponsor, within five (5) business days of such receipt, the Plan shall forward such request to Connecticut General for handling, except that the Plan shall retain and handle all such requests to the extent that they pertain to Individually Identifiable Health Information (such as enrollment information) originated by the Plan, Plan Sponsor, or the Plan's other business associates. Connecticut General shall respond to such forwarded requests as well as to any such requests that it receives directly from Individuals as required by 45 C.F.R. § 164.526, except that Connecticut General shall forward to the Plan for handling any requests for amendment of PHI originated by the Plan, Plan Sponsor, or the Plan's other business associates. (b) With respect to those requests handled by Connecticut General under subparagraph (a) above, the Plan delegates to Connecticut General the duty to determine, on behalf of the Plan, whether to deny a request for amendment of PHI and the duty to provide any required notices and review as well as, in the case of its determination to grant such a request, the duty to make any amendments in accordance with the terns of the Privacy Rule. In all other instances, the Plan retains all responsibility for handling such requests, including any denials, in accordance with the HIPAA Privacy Rule. (c) Whenever Connecticut General is notified by the Plan that the Plan has agreed to make an amendment pursuant to a request that it handles under subparagraph (a) above, Connecticut General shall incorporate any such amendments in accordance with 45 C.F.R. § 164.526. 01 /21/201 l 37 Customer Name: City of Fort Collins Administrative Services Only Agreement Section 3. Accounting of Disclosures. When an Individual requests an accounting of disclosures of PHI held by Connecticut General directly to the Plan or Plan Sponsor, the Plan shall within five (5) business days of such receipt forward the request to Connecticut General to handle. Connecticut General shall handle such requests, and any such requests for an accounting of disclosures received directly from Individuals, in the time and manner as required in 45 C.F.R. § 164.528. Section 4. Requests for Privacv Protection. Connecticut General shall handle Individuals' requests made to it for privacy protection for PHI in Connecticut General's possession pursuant to the requirements of 45 C.F.R. § 164.522. The Plan shall forward to Connecticut General to handle any such requests the Plan receives from Individuals that affect PHI held by Connecticut General. Section 5. General Provisions Regarding Requests. Connecticut General may require that requests pursuant to Sections I through 4 above be made in writing and may create forms for use by Individuals in making such requests. When responding to an Individual's request as provided above, Connecticut General may inform the Individual that there may be other "protected health information" created or maintained by the Plan and/or the Plan's other business associates and not included in the Connecticut General's response. Connecticut General shall not be responsible for performing any duties described in the Business Associate Agreement with respect to any such other "protected health information." In carrying out its duties set forth herein, Connecticut General may establish such additional procedures and processes for requests from Individuals as permitted by the Privacy Rule. Section 6. Disclosure of PHI to the Plan Sponsor. To the extent that the fulfillment of Connecticut General's obligations under the Administrative Services Agreement requires Connecticut General to disclose or provide access to PHI to Plan Sponsor or any person under the control of Plan Sponsor (including third parties), Connecticut General shall make such disclosure of or provide such access to PHI only as follows: (i) Connecticut General shall disclose Summary Health Information to any employee or other person under the control of Plan Sponsor (including third parties) upon the Plan Sponsor's written request for the purpose of obtaining premium bids for the provision of health insurance or HMO coverage for the Plan or modifying, amending or tenninating the Plan; and (ii) If the Plan elects to provide PHI to the Plan Sponsor, Connecticut General shall disclose or make available PHI, other than Summary Health Information, at the written direction of the Plan to only those employees or other persons identified in the Plan documents and under the control of Plan Sponsor solely for the purpose of carrying out the Plan administration functions that Plan Sponsor performs for the Plan. Such employees or other persons (including third parties) will be identified by the Plan in writing (by name, title, or other appropriate designation) to Connecticut General as a condition of disclosure of PHI pursuant to this Section 6(ii). The Plan may modify such list from time to time by written notice to Connecticut General. Section 7. Disclosures of PHI to Third Parties. Upon the Plan's written request, Connecticut General will provide PHI to certain designated third parties who assist in administering the Plan and who are authorized by the Plan to receive such information solely for the purpose of assisting in carrying out Plan administration functions ("Designated Third Parties"). Such parties may include, but are not limited to, third -party administrators, consultants, brokers, auditors, successor administrators or insurers, and stop - loss carriers. As a condition to providing PHI to a Designated Third Party, Connecticut General may require that the Plan have a business associate agreement (within the meaning of the Privacy Rule) with such Designated Third Party. 01/21/20t I 38 Customer Name: City of Fort Collins Administrative Services Only Agreement Exhibit E — Conditional Claim/Subrogation Recovery Services Plans Without Connecticut General Stop Loss Coveraee If Employer has not purchased individual or aggregate stop loss coverage from Connecticut General or an affiliate with respect to its self -funded employee welfare benefit plan: A. All conditional claim payment and/or subrogation recoveries under the Plan will be handled by the entity checked below; Employer An independent recovery vendor whose name and address follow: Connecticut General and its subcontractor(s) B. If Employer has designated Connecticut General and its subcontractors to act as its recovery agent in paragraph I.A. above, then: Employer hereby confers upon Connecticut General and its subcontractors discretionary authority to reduce recovery amounts by as much as fifty percent (50%) of the total amount of benefits paid on Employer's behalf, and to enter into binding settlement agreements for such amounts. ii. In the event a settlement offer represents a reduction greater than the percentage identified above, Connecticut General and its subcontractors should seek settlement advice from: Name: Title: Address: Telephone: iii. All amounts reimbursed to Employer's benefit payment account shall be refunded at the gross amount. Connecticut General's and its subcontractors' subrogation administration fee on cases where Connecticut General and its subcontractors' have retained counsel and in cases where no counsel has been retained by Connecticut General and its subcontractors, are both reflected in the Schedule of Financial Charges. For the purposes of such fee calculations, the use of counsel to perform ministerial acts such as filing of appearances or defenses in states which require plaintiffs to name employee benefit plans as party defendants and in similar circumstances shall not constitute the retention of counsel. 01/21/2011 39 Customer Name: City of Fort Collins Administrative Services Only Agreement Except where agreed to by Connecticut General and Employer, Connecticut General and its subcontractors shall have no duty or obligation to represent Employer in any litigation or court proceeding involving any matter which is the subject of this Agreement, but shall make available to Employer and/or Employer's counsel such information relevant to such action or proceeding as Connecticut General and its subcontractors may have as a result of its handling of any matter under this Agreement. D. In the event Employer purchases individual or aggregate stop loss coverage from Connecticut General or an affiliate with respect to its self -funded employee welfare benefit plan at any time during the life of this Agreement, the provisions of paragraph II., below, shall control. II. Plans with Connecticut General Stop Loss Coverage If Employer has purchased individual or aggregate stop loss coverage from Connecticut General or an affiliate with respect to its self -funded employee welfare benefit plan: A. Connecticut General and its subcontractors shall have the right and responsibility to manage all conditional claim payment and/or subrogation recoveries under the Plan. Connecticut General and its subcontractors shall reimburse to the Plan the recovery minus relevant individual and aggregate stop loss payments made by Connecticut General. All amounts reimbursed to Employer's benefit payment account shall be refunded at the gross amount. Connecticut General's and its subcontractors' subrogation administration fee on cases where Connecticut General and its subcontractors' have retained counsel and in cases where no counsel has been retained by Connecticut General and its subcontractors, are both reflected in the Schedule of Financial Charges. C. Connecticut General and its subcontractors shall have no duty or obligation to represent Employer in any litigation or court proceeding involving any matter which is the subject of this Agreement but shall make available to Employer and/or Employer's counsel such information relevant to such action or proceeding as Connecticut General and its subcontractors may have as a result of its handling of any matter under this Agreement. Notwithstanding the foregoing, Connecticut General and its subcontractors reserve to itself the right to retain counsel to represent Connecticut General's own interests in any subrogation and/or conditional claim recovery action under the Plan. 01/21/2011 40 FOR INFORIMATIONAL PURPOSES REGARDING YOUR NYHCRA ELECTION STATUS NEW YORK STATE DEPARTMENT OF HEALTH Division of Health Care Financing Electronic Filing User ID Application HEALTH CARE REFORM ACT — PUBLIC GOODS POOL New Request Revision to Existing Account Payor/Third Party Administrator/Administrative Services Only Organization/Provider Name: Federal Employer Identification It (FEIN): Operating Certificate # (FOR PROVIDERS ONLY); Report(s) being filed electronically (check ALL that apply): Public Goods Pool 1% Statewide Assessment (for hospitals only) By signature below, the Chief Financial Officer or other duly authorized individual of the above named entity authorizes the Office of Pool Administration to assign a secure electronic filing user ID and password to the entity. This information will be mailed directly to the attention of the signer and must remain secured. It is the responsibility of the above named entity to ensure that this information is released only to those individuals requiring knowledge thereof. Signature Name (Please Print) Title Phone Number Address City E-mail Address Date State Zip Code Note: All fields on this form are required to be accurately completed in order for your request to be processed. Please mail completed form to: Mr. Jerome Alaimo, Pool Administrator Office of Pool Administration Excellus BlueCross BlueShield, Central New York Region P.O. Box 4757 Syracuse, New York 13221-4757 DOH -4264 (9/2006) Page 1 of I FOR INFORMATIONAL PURPOSES REGARDNG YOUR NYHCRA ELECTION STATUS NEW YORK HEALTHCARE REFORM ACT (NYHCRA) SURCHARGE & ASSESSMENTS NYHCRA BASIC INFORMATION: The New York Health Care Reform Act (NYHCRA) establishes a system of surcharges and covered lives assessments in order to fund uncompensated care, professional medical education, and other health care initiatives. The amount of liability is determined by the election status of the payor. A payor is either "Elect" or "Non -Elect." Insured clients are automatically `Elect'. Administrative Services Only (ASO) clients must decide whether to `Elect' and allow CIGNA to pay the surcharge liability directly to the New York Public Goods Pool during claim payment or to pay it themselves at a higher cost. EMPLOYER RESPONSIBILITY & CIGNA RECOMMENDATION It is ultimately the Employer's responsibility to ensure they understand NYHCRA and complete the appropriate election paperwork. Employers must register with the State of New York a NYHCRA election status of either `Elect" or 'Non -Elect'. There are two components to each of the status choices: Elect employers pay to the State of New York Public Goods Pool a patient services charge per affected claim plus a covered lives assessment. • Non -Elect employers pay a surcharge directly to the New York provider of services per claim plus an additional percentage of the inpatient facility claim amount for Graduate Medical Education (GME). CIGNA, as the Third Party Administrator (TPA) payor for your claims, recommends that all of our ASO clients register as 'Elect' and pay the surcharge to the Public Goods Pool. There are significant financial savings for an `Elect' client. Effective 4/l/2009, the patient services surcharge for an elect payor is 9.63%. Covered Lives Assessment amounts vary by region, depending on the employee's residence, and they also vary by whether the employee has individual or family coverage. Surcharge and covered lives assessments are calculated and paid monthly by CIGNA to the Public Goods Pool on behalf of the emplover. • Non -Electors do not pay to the Public Goods Pool and their liability is based solely on affected claims incurred with a New York provider. They pay a surcharge of 37.90% to the provider of services and instead of paying a Covered Lives Assessment, they also pay an additional percentage of the inpatient facility claim amount for Graduate Medical Education. That amount varies from 2.25% to 27.28% depending on the region. Due to the significant savings, we have indicated your status as "elect"on the attached Letter of Intent. If you choose not to 'Elect', a waiver form must be signed. The waiver indicates that you have been advised of NYHCRA requirements but choose to remain 'Non -Elect'. Please contact your Sales representative if you would like to change the status which has been pre -selected for you. Administrative Services Only Agreement By and Between City of Fort Collins "Employer" And Connecticut General Life Insurance Company "Connecticut General" Effective Date: January 1, 2011 THIS AGREEMENT AND ITS TERMS,ARE PROPRIETARY AND CANNOT BE DISCLOSED WITHOUT THE PERMISSION OF EACH OF THE PARTIES Table of Contents Schedule of Financial Charges..........................................................................................................................3 Section 1. Term and Termination of Agreement...........................................................................................10 Section 2. Claim Administration and Additional Services............................................................................10 Section 3. Funding and Payment of Claims................................................................................................... l i Section4. Charges.........................................................................................................................................12 Section 5. Enrollment and Determination of Eligibility................................................................................12 Section 6. Claim Audits and Confidentiality................................................................................................. 13 Section 7. Plan Benefit Liability.................................................................................................................... 14 Section 8. Modification of Plan and Administrative Duties and Charges.....................................................14 Section 9. Modification of Agreement..........................................................................................................15 Section 10. Laws Governing Contract........................................................................................................... 15 Section 11. Information in Connecticut General's Processing Systems........................................................ 15 Section 12. Resolution of Disputes................................................................................................................15 Section 13. Third Party Beneficiaries............................................................................................................ 16 Section14. Waivers.......................................................................................................................................16 Section15. Headings.....................................................................................................................................16 Section16. Severability.................................................................................................................................16 Section17. Force Majeure............................................................................................................................. 16 Section 18. Assignment and Subcontracting.................................................................................................16 Section19. Notices........................................................................................................................................16 Section 20. Identifying Information and Internet Usage............................................................................... 17 Section21. Definitions.................................................................................................................................. 17 SIGNATURES................................................................................................................................................ 18 ExhibitA - Plan Document............................................................................................................................. 19 ExhibitB — Services........................................................................................................................................20 Exhibit C — Claim Audit Agreement (Sample)...............................................................................................28 ExhibitD — Privacy Addendum......................................................................................................................31 Exhibit E — Conditional Claim/Subrogation Recovery Services.....................................................................39 Customer Name: City of Fort Collins Administrative Services Only Agreement Schedule of Financial Charges Certain fees and charges identified in this Schedule of Charges will be billed to Employer Monthly in accordance with Connecticut General's then standard billing practices. However, Connecticut General is authorized to pay all fees and charges from the Bank Account unless otherwise specified in this Agreement. MEDICAL/DENTAL ADMINISTRATION CHARGES Includes Commission payments agreed to by Employer) Product Description Charge Medical Open Access Plus (OAP) with PHS Medical Management $32.71/employee/month NIEDICAUDENTAL NETWORK ACCESS FEE Product Description Charge Medical OAP Access Fee $10.50/employee/month Included in Medical Administration Fee CIGNA PHARMACY BENEFIT MANAGEMENT SERVICES CHARGES AND RELATED PROVISIONS Definitions • "Average Wholesale Price" or "AWP" is the Average Wholesale Price for a given pharmaceutical product in effect on the dispense date for the actual package size dispensed as published by First DataBank, Medi-Span or other alternative publication or benchmark reasonably designated by Connecticut General. • "Brand Drug Claim" is a claim for a pharmaceutical product that is adjudicated as a brand drug as indicated on the claim record generated by the claim processing system used by Connecticut General. For application of discounts and dispensing fees, a `Brand Drug Claim" includes a claim for a generic drug within its exclusivity period or other period of limited competition, as Connecticut General reasonably determines under its standard policies. • "Generic Drug Claim" is a claim for a pharmaceutical product that is adjudicated as a generic drug as indicated on the claim record generated by the claim processing system used by Connecticut General. For application of discounts and dispensing fees, a "Generic Drug Claim" does not include a claim for a generic drug within its exclusivity period or other period of limited competition, as Connecticut General reasonably determines under its standard policies. • "Mail Service Pharmacy" or "CIGNA Tel -Drug" or "CIGNA 1-lome Delivery Pharmacy" is a pharmacy that is owned or operated by Connecticut General or an affiliated company(ies) (currently, 'fel-Drug, Inc. and Tel -Drug of Pennsylvania, LLC), which dispenses drugs covered under the Plan's Pharmacy Benefit by mail, and is not a Retail Pharmacy. 01/21/2011