CARVE-OUT MENTAL HEALTH AND SUBSTANCE ABUSE AGREEMENT
CARVE-OUT MENTAL HEALTH
AND SUBSTANCE ABUSE AGREEMENT
This Agreement, entered into thiS.J.i! day of~,,; Sl ,2001 between CITY
MAR 2 8 2001
OF CLEARWATER (herein referred to as "CLEARWATER") and UNIPSYCH
BENEFITS OF FLORIDA, INC., a Florida corporation which contracts with duly
licensed providers of psychological and psychiatric services, other mental health
professionals and inpatient facilities for the provision of mental health and/or
substance abuse treatment, (hereinafter referred to as "UPB"):
WITNESSETH:
WHEREAS, CLEARW A TER desires to provide for the examination and
treatment of mental health and substance abuse conditions to its employees and their
authorized dependents as dermed by CLEARW A TER (hereinafter referred to as
"Eligible Employees and Dependents"); and
WHEREAS, UPB is a Florida corporation which contracts with duly registered
and duly licensed providers of psychological and psychiatric services, other mental
health professionals and inpatient facilities; and
WHEREAS, UPB is willing and able to arrange for examination and treatment
for mental health and substance abuse conditions to those Eligible Employees and
Dependents for whom CLEARW A TER desires to provide such benefits; and
WHEREAS, CLEARW A TER and UPB wish to enter into an Agreement
relating to the provision of such mental health and substance abuse examination and
treatment to said Eligible Employees and Dependents by UPB;
NOW, THEREFORE, in consideration of the promises and mutual covenants
herein contained, the parties hereto covenant and agree as follows.
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1. SERVICES TO BE PROVIDED
UPB agrees to provide those benefits necessary for the treatment of mental
health and substance abuse conditions as they are set forth in the "Summary Plan
Description" attached hereto as "EXHIBIT A", and as further described in
CLEARWATER'S RFP and UPB's Proposal in response to CLEARWATER'S RFP,
which are incorporated herein by reference. UPB also agrees to the Performance
Guarantees set forth in and attached hereto as "EXHIBIT C". CLEARWATER
acknowledges that the benefits being provided hereunder are limited in nature and
that there might be treatment necessary for mental health and substance abuse
conditions for Eligible Employees and Dependents covered hereby which will not be
provided pursuant to this Agreement and the Exhibits hereto. In the event that
CLEARW A TER wishes to have UPB cover any additional services for Eligible
Employees and Dependents, which are not covered under the terms of this Agreement,
then CLEARW A TER agrees to pay UPB additionally for those services at the rate of
80% of UPB's usual and customary charges.
2. PAYMENT FOR SERVICES
CLEARW A TER shall compensate UPB according to the fee schedule attached
hereto. UPB agrees to look solely to CLEARW A TER for payment for such services
rendered during the term of this Agreement and shall not seek to collect any sums
from Eligible Employees and Dependents, notwithstanding CLEARWATER's failure
to pay sums due under this Agreement for any reason provided, however, that UPB
may charge and collect copayments (a fIXed dollar amount to be paid by Eligible
Employees and Dependents receiving treatment) in addition to any payments received
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from CLEARWATER from Eligible Employees and Dependents as set forth in
"EXHIBIT A" hereto.
3. INDEMNIFICATION
a) Indemnification of CLEARW A TER: UPB agrees to indemnify and hold
harmless CLEARWATER, its agents, employees and other authorized representatives
against any and all invoices, causes of action, suits or demands including but not
limited to legal fees and costs incurred in defending any such action which might arise
out of the furnishing of or the failure to furnish the services contemplated hereunder.
b) Indemnification of UPB: CLEARWATER agrees to indemnify and hold
harmless UPB, its agents, employees and other authorized representatives against any
and all claims, causes of action, suits or demands including, but not limited to legal
fees and costs incurred in defending any such action which arises out of the sole
negligence of CLEARW A TER.
c) Any language in this Agreement to the contrary notwithstanding, the
maximum sum that CLEARW A TER shall be liable to reimburse UPB under any
theory of liability shall not exceed $100,000 per person and $200,000 per incident as
expressed in Section 768.28, Florida Statutes.
4. NON-INTERFERENCE OF CLEARWATER
CLEARWATER and UPB agree that UPB is an independent contractor
hereunder and that CLEARW A TER has no right or obligation of control over the
activities of UPB.
CLEARW A TER agrees that it shall not interfere nor attempt to interfere with
UPB's professional judgment as to the benefits to be afforded to any Eligible
Employees and Dependents receiving services hereunder.
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5. REFERRALS
CLEARW A TER acknowledges that UPB might be required to refer Eligible
Employees and Dependents for medical treatment not provided hereunder and agrees
that UPB shall not be liable for paying for such services unless such services are listed
in the "Summary Plan Description", "EXIDBIT A" hereto. UPB or its authorized
providers shall inform CLEARW A TER or its Health Plan of any such instances
within two (2) business days.
6. TERM OF AGREEMENT
The initial term of this Agreement shall be for three (3) years and this
Agreement shall run from the commencement date as set forth in Paragraph Eleven
(11) herein. Said Agreement shall automatically renew for another period of three (3)
years. However, either party hereto may cancel this Agreement by written notice to
the other, delivered at least ninety (90) days prior to the expiration of the term,
providing that, in the event of a termination of this Agreement, UPB shall continue
to treat those Eligible Employees and Dependents who are undergoing treatment, at
the time of termination, until satisfactory arrangements are made between
CLEARW A TER and Eligible Employees and Dependents undergoing treatment, for
the continuation of care by a similar provider and UPB has been notified by such
similar provider, in writing, that it has undertaken the responsibility to render such
services to Eligible Employees and Dependents undergoing treatment in question.
7. DEFINITIONS
a) An Eligible Employee or Dependent: Is any person who has been
authorized by CLEARW A TER to receive services hereunder and whose
authorization to receive services has been communicated to UPB by
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CLEARW A TER in the manner required by this Agreement and all Exhibits
hereto, together with such person's name, address and such other identifying
factors as are required by UPB for proper records keeping.
b) Mental Health and Substance Abuse Condition: Means an illness,
disorder or condition listed in the American Psychiatric Association's
Diagnostic and Statistical Manual (DSM), as it might be revised from time to
time, not including V-Codes.
c) Services Necessary for Treatment of Mental Health and Substance
Abuse Condition: Means those services which are appropriate for the
treatment of a mental health or substance abuse condition and within the
standards of practice recognized by the local mental health professional
communities.
d) Similar Provider: Means a person, professional association or other
entity, licensed to render mental health and/or substance abuse services under
applicable State laws and duly registered and authorized to provide those
services set forth in the "Summary Plan Description".
e) Undergoing Treatment: Means that Eligible Employees and Dependents
have been treated for a mental health and/or substance abuse condition by a
UPB authorized provider and have not yet been released from such treatment
by that provider.
8. ENROLLMENT
a) Determination and Notice of Eligibility: During the term of this
Agreement, CLEARW A TER shall be solely responsible for determining
whether an individual is eligible to receive services hereunder, to communicate
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such eligibility to UPB, along with such identifying factors as are required by
UPB for proper records keeping and CLEARW A TER shall be solely
responsible to communicate, to all Eligible Employees and Dependents, the
services provided hereunder as well as all restrictions and limitations
applicable thereto.
b) Roll of Eligible Employees and Dependents: CLEARWATER agrees to
provide UPB with a list of those employees and eligible dependents entitled to
receive care hereunder, to update said list monthly and to continuously
supplement said list of Eligible Employees and Dependents as is necessary due
to the termination or inception of memberships or otherwise. CLEARWATER
further agrees to reimburse UPB, at 80% of UPB's usual and customary rate
for such services, for any and all services provided under this Agreement to a
person who is not an Eligible Employee or Dependent, when such services are
provided due to erroneous, incomplete or delayed communication of the roll
of Eligible Employees and Dependents by CLEARW A TER to UPB. Eligibility
information and notices are to be submitted by CLEARW A TER to the Vice
President of Administration at UPB in a mutually agreed format.
9. MISCELLANEOUS PROVISIONS
a) Amendment: This Agreement may be amended only by written
instrument signed by both CLEARWATER and UPB.
b) Entire Agreement: This Agreement, attached Exhibits and any
documents incorporated by reference herein constitute the entire Agreement
between the parties and supersedes any prior Agreement, representations,
warranties or promises between the parties that are not set forth herein or
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otherwise incorporated into this Agreement by express reference.
c) Applicable Law: This Agreement and the covenants set forth herein, as
well as any Exhibit hereto, are to be construed in accordance with the
Statutory, Regulatory and Common Laws of the State of Florida as well as any
applicable Federal Laws and Regulations.
d) Non-Assignability: Neither party may assign either the obligations or
the benefits hereof without the written consent of the other party hereto.
e) Captions: Captions appearing in this Agreement are inserted only as a
matter of convenience and, in no way, defme or describe the provisions of this
Agreement nor do they affect the construction hereof.
g) Partial Invalidity: In the event any provision of this Agreement shall be
found to be invalid or unenforceable by any Court of competent jurisdiction,
such invalid or unenforceable provision shall be severed from this Agreement
and shall not affect the remaining provisions of this Agreement.
h) Pronouns: All pronouns shall be deemed to refer to the masculine,
feminine or neuter, singular or plural, as the identity or the number of the
person or persons, entity or entities might require.
i) Venue: Any and all actions arising out of this Agreement or the
transactions contemplated hereby shall lie in the Courts of the State of Florida
situated in Pinellas County, Florida.
j) Successor Parties: This Agreement shall inure to the benefit of and be
binding upon the parties hereto and their successors and permitted assigns.
k) Representations: No representations, negotiations, understandings or
communications between the parties shall be binding thereon, unless expressly
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set forth in this Agreement.
10. NOTICES
a) Notices to UPB: All notices to UPB hereunder shall be hand delivered
or sent by certified mail, return receipt requested, to:
Denise M. Scott
Vice President, Administration
UniPsych Benefits of Florida, Inc.
7777 Davie Road Extension, Suite 100
Hollywood, FL 33024
b) Notices to: All notices to CLEARWATER hereunder shall be hand
delivered or sent by certified mail, return receipt requested, to the
following address:
City of Clearwater
Human Resources Department
Attn: Cynthia Bender
100 South Myrtle Avenue
Clearwater, FL 33756
11. COMMENCEMENT DATE
The commencement date of this Agreement shall be the 1st day of January,
2001.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement the
day and year first above written.
UNIPSYC(iENEFITS O~ FLORIDA, INC.
BY: I f)JAALa-~
-
Its: Vice President, Administration
C~J-~
Brian J. A~st
Mayor-Commissioner
CL~R'FLOR]DA
By u.~:g.~.:IL
William B. Horne, II
Interim City Manager
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Approved as to form:
Attest:
rt~
Assistant City Attorney
Cy t ia E. Goudeau
Cit lerk
;;..
--- '.
-- -
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EXHIBIT A
SUMMARY PLAN DESCRIPTION
This is the Summary Plan Description which outlines those mental health and
substance abuse benefits which are being rendered pursuant to an Agreement entered
into lxtwem CITY OF CLEARWATER (heninafter referred to as "CLEARWATER") and
UNIPSYCH BENEFITS OF FLORIDA, INC., (hereinafter referred to as "UPB").
A. MENT AL HEALTH AND/OR SUBSTANCE ABUSE BENEFITS:
This Agreement provides for both office visits and inpatient care for mental
health and/or substance abuse disorders. Covered services must be authorized by
UPB. UPB shall have sole discretion as to determining coverage and authorized
providers.
Outpatient therapy is covered at Network Rates up to a maximum of 30 visits
per contract year with a copayment to be made by Eligible Employees and
Dependents, at the time of each service, in the amount of $10.00.
Inpatient care and the associated services of psychiatrists and other mental
health professionals are covered at Network rates up to a limit of 30 days per contract
year with a $100.00 co payment made by Eligible Employees and Dependents, at the
time of each admission.
The maximum limitations of available services are included in the Health Plan
lifetime dollar maximum for Mental Disorders and the maximum limitation of
available services for Substance Abuse Disorders is a lifetime maximum of $25,000.00.
B. MIXED SERVICES
UPB is responsible only for those services associated with the treatment of
mental health and/or substance abuse conditions. UPB shall not be responsible for
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the cost of any medical or surgical services or supplies, that are provided concurrently
or in conjunction with the treatment of mental health or substance abuse conditions
pursuant to this Agreement, whether or not UPB makes referrals or recommendations
for such medical or surgical services. These include but are not limited to all services
and supplies relating to neurological conditions and all ancillary services and supplies
relating to medical conditions.
All determinations as to whether services rendered are primarily for mental
health or substance abuse conditions or, in the alternative, for medical conditions,
shall be determined as set forth under Section J herein.
C. SERVICE AREA
The Service Area covered under this Agreement is the continental United
States of America and the services covered under this Agreement are available to
Eligible Employees and Dependents in this Service Area. In order to obtain mental
health and/or substance abuse services outside of the Service Area, Eligible Employees
and Dependents shall be required to obtain such services with prior authorization of
UPB. UPB is available 24 hours per day through its national toll-free number, 1-800-
BRADMAN or 1-800-272-3626. UPB shall not be responsible for any cost of
transportation related to the transfer of Eligible Employees and Dependents to
facilities authorized by UPB.
D. EMERGENCY ADMISSIONS
In the event Eligible Employees and Dependents require emergency mental
health and/or substance abuse treatment and/or admissions, UPB shall be responsible
for the cost thereof only in the event that:
1. UPB is notified within 24 hours of the inception thereof.
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2. UPB specifically authorizes the admission/treatment.
3. The admission/treatment is for the purposes of acute crisis
intervention and stabilization only.
The maximum coverage allowable for non-authorized emergency, out-of-
network services will be up to $500.00 for services within the Service Area and up to
$1,500.00 for services outside the Service Area.
E. MEDICAL NECESSITY
A determination of the medical or clinical necessity for the provision of mental
health and/or substance abuse services to Eligible Employees and Dependents under
this Agreement shall be in the sole discretion of UPB authorized mental
health/substance abuse providers.
F. INFORMATION AND REPORTS
UPB agrees to make available to CLEARWATER, statistical information
compiled and retained by UPB, which CLEARW A TER reasonably requests for
reporting purposes. Detailed utilization reports shall be provided to CLEARWATER
on a regular basis.
G. LIMITATION ON BILLING ELIGIBLE EMPLOYEES & DEPENDENTS
UPB agrees that, in no event, including but not limited to non-payment by
CLEARW A TER for any reason including but not limited to insolvency of
CLEARWATER or breach of this Agreement by CLEARWATER, shall UPB bill,
charge, collect a deposit from, seek compensation, remuneration or reimbursement
from or have any recourse against Eligible Employees and Dependents or person other
than CLEARWATER acting on Eligible Employees and Dependents' behalf for
covered services provided pursuant to this Agreement. This provision shall not
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prohibit collection of co payments made in accordance with the terms of the
Agreement. This provision shall not prohibit collection for non-covered services or
from third parties when such parties are primarily responsible for paying for covered
services.
UPB shall aggressively and fully pursue and process any coordination of
benefit or subrogation invoices which relate to services provided by UPB. UPB shall
be entitled to any amounts collected by UPB, through coordination of benefits or
subrogation, related to mental health and substance abuse services.
UPB further agrees that (1) this provision shall survive the termination of this
Agreement regardless of the cause giving rise to termination and shall be construed
to be for the benefit of Eligible Employees and Dependents and that (2) this provision
supersedes any oral or written agreement to the contrary now existing or hereafter
entered into between UPB and Eligible Employees and Dependents or persons acting
on Eligible Employees and Dependents' behalf.
H. GRIEVANCE SYSTEM/LITIGA TION
UPB shall cooperate with CLEARW A TER in resolving any grievances by
Eligible Employees and Dependents and shall comply with the grievance system
established. UPB shall comply with the decision reached through the grievance
system established as to coverage and responsibility for payment of covered services
rendered to Eligible Employees and Dependents. A representative of UPB shall be
present and participate in all proceedings involving grievances regarding the provision
of services covered by this Agreement.
I. EXCLUSIONS AND LIMITATIONS
All medically or clinically necessary Mental Health and Substance Abuse
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Services and conditions as defined in this Agreement shall be covered only for the
period of evaluation, initial stabilization, case management and referral. The
following specific conditions or services are excluded, or limited, and may require
coordination of benefits.
1. Treatments rendered or conditions covered under the auspices or
funding of any governmental program.
2. A formal psychiatric disability which is covered under Disability Benefits.
3. A chronic condition requiring custodial, assisted living, long-term
residential or institutional care.
4. A neurological condition or treatment or a permanent organic
brain syndrome.
5. Relationship, family, marriage, or divorce counseling when such
services extend beyond the period necessary for crisis intervention
and short-term evaluation.
6. Psychiatric or psychological examinations, testing or treatments for
any of the following:
a. Services sought for the purposes of obtaining or
maintaining employment or insurance coverage;
b. Services sought in connection with, or in regard to,
Judicial or Administrative proceedings;
c. Services sought pursuant to a Court Order or as a
condition of parole or probation;
d. Treatment of a sex offender.
7. Sex therapy will only be covered when it is an adjunct to therapy
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for other mental health conditions for which benefits are afforded
under this Agreement.
8. Inpatient services for detoxification more than two times in anyone
calendar year for the removal of toxic substances from the system.
9. Educational or vocational counseling or testing, remedial
education, learning disabilities, speech therapy, behavioral
training, hearing therapy.
10. Attention Deficit Hyperactivity Disorder and therapy when services
are provided by a non-psychiatric physician.
11. Diet counseling, weight reduction therapy, or nutritional
counseling. Treatment for smoking cessation.
12. Psychotherapy or other mental health intervention for pain or
other medical conditions when such services are covered under the
Medical/Surgical portion of the Health Plan.
13. Electro-Convulsive Treatment (ECT) requires special pre-
authorization and a second psychiatric opinion or review. Each
ECT session is counted as a hospital day.
Services shall be rendered only by UPB authorized providers. Coverage shall
include reasonable follow-up consistent with the total benefit.
J. MEDICAL vs. MENTAL HEALTH DETERMINATIONS
I. HOSPITALIZATION
The intent of this Section is to establish guidelines to help avoid payment
disputes. UPB shall only be fmancially responsible for the hospital room and board
charges in the event that the primary treatment for which the patient has been
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hospitalized is mental health and/or substance abuse and the primary treatment is
being provided by a psychiatrist. Individual physician charges and charges for
psychological or psychiatric tests that the physician orders or causes to be ordered
shall only be the responsibility of UPB when the physician is a UPB-approved
psychiatrist.
The following guidelines shall be used in utilization review and in processing
provider invoices when the services rendered include a combination of mental health
and medical care:
1) When a patient is admitted with a primary medical diagnosis and
a mental health consultation is requested, UPB shall be fmancially
responsible only for the consultation.
2) When a patient is admitted for the treatment of a medical problem
and there is a concomitant psychiatric problem, UPB shall not be
responsible for the medical care rendered. In the event the patient
is medically cleared subsequent to admission and then transferred
to a Psychiatric Unit, UPB shall be fmancially responsible for only
that part of the admission occurring after the transfer to the
Psychiatric Unit. For example, if a patient ingests a toxic
substance in a suicide attempt and requires medical care in an
ICU, UPB shall not be responsible for the patient's care until the
patient is medically cleared and transferred to a Psychiatric Unit.
In the event medical care continues following transfer to a
Psychiatric Unit, UPB shall not be financially responsible for such
medical treatment including but not limited to tests ordered by a
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non-psychiatrist physician.
3) UPB shall be fmancially responsible only for that portion of the
provider invoice incurred due to the mental health diagnosis. For
example, if a patient is being treated for alcoholism with a
secondary diagnosis of hepatitis, the care rendered for the hepatitis
by a medical consultant, including ancillary charges, shall not be
the responsibility of UPB; the care rendered by a mental health
professional, including ancillary charges, shall be the responsibility
of UPB. Financial responsibility for the hospital room and board
will be determined by where the patient is housed and who the
primary care giver is (i.e. if the patient is admitted to a Psychiatric
Unit under the care of a psychiatrist, UPB shall be responsible; if
the patient is admitted to a medical unit under the care of a non-
psychiatrist physician, UPB shall not be responsible); when
inpatient detoxification requires treatment on a medical unit by a
non-psychiatrist physician, it shall be considered a medical expense
and shall not be the clinical or fmancial responsibility of UPB.
4) If a patient is admitted for a medical complaint but the medical
evaluation does not lead to a medical diagnosis and a psychiatric
diagnosis is then assigned to the case, the care rendered, other than
for psychiatric consultations, shall not be the responsibility of
UPB. When the patient is transferred to a Psychiatric Unit and the
primary care giver is a psychiatrist, UPB shall be financially
responsible. For example, if a patient is admitted for evaluation
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of pain of unknown etiology but no organic etiology is identified
and the patient is then given a diagnosis of psychogenic pain, the
care rendered, other than for the psychiatric consultation, shall not
be the responsibility of UPB. If and when the patient has been
transferred to a Psychiatric Unit, the care shall become the
responsibility of UPB.
5) When a patient is admitted for a medical or a neurological problem
but is placed on a Psychiatric Unit because the patient has a
concomitant psychiatric diagnosis and is a management problem,
UPB shall not be financially responsible. The operative criterion
for determining payment responsibility shall be which diagnosis is
the condition which required the inpatient treatment which could
only be provided in a hospital setting. For example, in the case
where a patient with Alzheimer's Disease or mental retardation is
housed on a Psychiatric Unit for management purposes but the
primary care giver is a neurologist, UPB shall not be financially
responsible. Another example would be a patient with diabetes
mellitus who is also a stable chronic schizophrenic. If a patient is
admitted because his diabetes is out of control but is placed on a
Psychiatric Unit, UPB shall not be fmancially responsible since the
chronic schizophrenia would not have required hospitalization.
6) When the above guidelines are insufficient, the following additional
general principles shall be used to determine payment
responsibility:
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a) What is the primary cause for hospitalization?
Which condition could only be treated in a hospital setting?
b) What does the cover sheet on the medical record list as the primary
diagnosis for the admission?
c) Is the attending physician of record a psychiatrist or a medical
consultant?
d) Has the patient been admitted to a Psychiatric Unit or a Medical/Surgical
Unit?
e) Who is the primary care giver?
f) What condition is causing the patient to remain in the hospital
and who is treating this problem?
II. EMERGENCY ROOM
If Eligible Employees and Dependents are referred to or self-refer
to an Emergency Room, the cost of the emergency room evaluation
shall not be the responsibility of UPB. If a psychiatric consultation is
requested, UPB shall pay for the cost of the psychiatric assessment
and/or treatment. UPB shall not be responsible for the cost of
ambulance transfers.
III. BIOFEEDBACK
UPB shall not be responsible for the cost of Biofeedback unless same
is utilized by a UPB therapist as an adjunctive modality in the course
of treatment when specifically treating a DSM diagnosis (for example,
in the treatment of selected patients with anxiety, panic or phobic
disorders).
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K. PRE-EXISTING CONDITIONS: Benefits are not provided for symptomatology
related to any mental health or substance abuse (DSM diagnosis) condition for which
Eligible Employees and Dependents have received treatment within three months prior
to the inception of Eligible Employees and Dependent's coverage under this
Agreement. Coverage for such conditions shall be provided under this Agreement
only after:
a) Eligible Employees and Dependents have had three consecutive
months without any treatment for said condition after such
inception; or
b) Eligible Employees and Dependents have been covered under this
Agreement for twelve consecutive months.
This exclusion of pre-existing conditions shall be waived for all Eligible Employees
and Dependents who are on CLEARWATER's rolls as of the first effective date of
this Agreement.
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EXHIBIT B - FEE SCHEDULE
CLEARW ATER agrees to pay to UniPsych Benefits of Florida, Inc. as follows:
Mental Health/Substance Abuse Benefits Per Employee Per Month ..............$6.41
Employee Assistance Program (5 Visits)... .............. ....... ............... ......... ...... ..$1.48
Such fee is to be paid to UPB by the 1st day of each month commencing
January 1, 2001 and shall be paid on a monthly basis thereafter based upon the
number of employees of CLEARWATER and their respective dependents which are
on CLEARWATER's membership rolls each month.
Adjustments shall be made for additional Eligible Employees and discontinued
Eligible Employees during each month. If Eligible Employees and Dependents are
either added or dropped from the membership rolls between the 1st and 15th of the
month, there shall be an appropriate adjustment on the payment provided in the
following month. If the adjustment on the membership rolls takes place on the 16th
of the month or thereafter, there shall be no adjustment for that particular month.
The above-noted Per Employee Per Month cost shall be construed as a per
employee fee for both inpatient and outpatient benefits provided in accordance with
the Summary Plan Description attached hereto as EXlDBIT A. Such fee shall include
coverage for all dependents participating in the Group Medical Plan in accordance
with this Agreement. In addition to the above-noted fee, UPB shall collect from each
Eligible Employee and Dependent, the agreed upon co-payments as outlined in such
Summary Plan Description attached hereto. Also, the above-noted fee includes up to
25 hours of training and other on-site activities per contract year to be provided upon
request of CLEARWATER.
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EXHIBIT C
PERFORMANCE GUARANTEES
TO
THE CITY OF CLEARWATER, FLORIDA
Overview
The Bradman/UniPsych Companies (UniPsych) will provide mental health, substance
abuse, and Employee Assistance Program benefits to the City of Clearwater, Florida,
commencing January 1, 2001 and ending December 31, 2001 as described in its
proposal response to RFP 45-00, and subsequent clarifications.
Renewability
The contract will renew annually, with UniPsych providing at minimum a 180 day
notice of cancellation. The City will provide a 30 day notice of cancellation. Services
will continue at the discretion of the City, with UniPsych's rates guaranteed for a
period of three (3) years.
UniPsych's blended rates will be as follows for the City:
Benefit Category
Per Employee~ Per Month
Cost
$6.41
· Mental Health & Substance
Abuse
· Employee Assistance Program
Combined
$1.48
$7.89
The Bradman/UniPsych Companies are willing to provide guarantees of:
Untimely Cancellation
Number of County Providers
Claims Processing Time
Time to see an EAP Counselor
Penalties for Failure to Perform:
The performance of the Bradman/UniPsych Companies shall be reviewed within 45
days of the end of each calendar quarter and the following penalties shall apply for
failure to perform during that quarter.
Number of Pinellas County Providers - 0.5% of the earned premium for that quarter;
Claims Processing Time - 25% of the value of each claim not processed on a timely
basis;
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Time to see an EAP counselor - $100 for each EAP appointment not available on a
timely basis;
Customer Service Standard - $1,000 for each major problem (to be defined by the
City) not timely resolved.
Untimely Cancellation
Except for non-payment by the City of Clearwater, should UniPsych cancel its
contract with the City with less than 180 days formal written notice, UniPsych will
pay the City $25,000 within 30 days after contract termination.
Specific Performance Guarantees
Nmnber of Specified County Providers
Guarantee: The number of authorized providers located in each of the following
counties will be at least twenty (20) at all times and within 10 miles of
participating member zip codes: Pinellas, Pasco and Hillsborough.
Definition: A provider is a licensed psychiatrist or psychologist, a licensed social
worker, a licensed mental health counselor, or a licensed marriage and
family therapist treating mental and nervous disorders, alcoholism or
drug abuse.
Measurement
Criteria: The Bradman Network listing of participating providers on fIle with the
Human Resources Department of The City of Clearwater.
Claims Processing Time
Guarantee: Authorized out-of-network claims will be processed within 45 days of
the ending of the month received.
Definition: A claim is processed when a check is issued, or a notice is sent to an
appropriate party requesting additional information necessary to the
proper determination of benefits, or an audit is scheduled to determine
the correct amount payable.
Measurement
Criteria: UniPsych processing reports or employee complaints documented to the
City's Human Resources Department.
Time to see an EAP. Mental Health or Substance Abuse Counselor:
Guarantee: Persons calling the 800 telephone number and requesting an
appointment time with the following time limits, based upon request
and need.
23
(03121/01)
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Emergency:
a) Life or Death Situations - Direct referral to emergency facility or
authorities.
b) Other emergencies - 24 hours
Two (2) business days
Four (4) business days
Emergency means the patient is facing a crisis situation that requires
rapid intervention. Urgent means the patient feels they are unable to
conduct normal life activities without direct assistance. Routine means
the patient feels that assistance is necessary to deal with pressing
problems.
Urgent:
Routine:
Definitions:
Both routine and emergency calls can be processed through the 24-hour
toll-free number. After hours, the toll-free number is lived answered
by a medical answering service with strict instructions to immediately
page the on-call clinician. In addition, BradmanlUniPsych shall make
available at least two mental health professionals for direct access for
after-hours on-call emergencies.
Measurement
Criteria: UniPsych processing reports or employee complaints documented to the
City's Human Resources Department.
Customer Service Standard
Guarantee: All significant problems affecting customer satisfaction with the
programs will be resolved on a timely basis, but no later than 45 days
from the date that written notice of the problem is delivered to
Bradman/UniPsych Companies.
Definition: A significant problem is a continuing situation adversely affecting the
quality or availability of care afforded to plan members and not
consistent with the representations made by Bradman/UniPsych
Companies.
Measurement
Criteria: Representations made to City of Clearwater either in writing or on voice
recordings.
24
(03/21/01)
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