ADMINISTRATIVE SERVICES ONLY AGREEMENTAdministrative Services Only Agreement
By and Between
City of Clearwater
"Employer"
And
Connecticut General Life Insurance Company
"Connecticut General"
Effective Date: January 1, 2013
THIS AGREEMENT AND ITS TERMS ARE PROPRIETARY AND CANNOT BE DISCLOSED WITHOUT
THE PERMISSION OF EACH OF THE PARTIES
Table of Contents
Definitions 3
Section 1. Term and Termination of Agreement 4
Section 2. Claim Administration and Additional Services 4
Section 3. Funding and Payment of Claims 5
Section 4. Charges 5
Section 5. Enrollment and Determination of Eligibility 6
Section 6. Claim Audits and Confidentiality 6
Section 7. Plan Benefit Liability 7
Section 8. Modification of Plan and Charges 8
Section 9. Modification of Agreement 8
Section 10. Laws Governing Contract 8
Section 11. Information in Connecticut General's Processing Systems 8
Section 12. Resolution of Disputes 8
Section 13. Third Party Beneficiaries 9
Section 14. Waivers 9
Section 15. Headings 9
Section 16. Severability 9
Section 17. Force Majeure 10
Section 18. Assignment and Subcontracting 10
Section 19. Notices 10
Section 20. Identifying Information and Internet Usage 10
SIGNATURES 11
Schedule of Financial Charges 12
Exhibit A - Plan Document 23
Exhibit B — Services 24
Exhibit D — Privacy Addendum 35
Exhibit E — Conditional Claim/Subrogation Recovery Services 42
Client Name: City of Clearwater
Administrative Services Only Agreement
THIS AGREEMENT, effective January 1, 2013 (the "Effective Date ") is by and between City of Clearwater
( "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 2499162.
NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein, it is hereby
agreed as follows:
Definitions
Agreement — this entire document including the Schedule of Financial Charges and all Exhibits.
Applicable Law — means the state, federal and international laws and regulations that apply. Applicable Law
includes but is not limited to the Employee Retirement Income Security Act of 1974, as amended and the rules and
regulations thereunder ( "ERISA "), the Health Insurance Portability and Accountability Act of 1996, as amended
and the rules and regulations thereunder ( "HIPAA "), the Foreign Corrupt Practices Act ( "FCPA ") and any other
anti - bribery or anti - corruption laws in the countries where the Parties conduct business.
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.
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 terms of the Plan.
Party/Parties — refers to Employer and Connecticut General, each a "Party" and collectively, the "Parties ".
Plan Year — the twelve (12) month period, beginning on the Effective Date and, thereafter, each subsequent twelve
(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; termination of a Plan benefit option or eligible Members, as applicable.
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Administrative Services Only Agreement
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 this 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 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 1 (iii); (ii) termination of Plan benefit
option or (iii) termination of eligible Members, if the required fees have been paid in full, if any, 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, subject to the requirements of Section 6.b, 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
ply.
c. Employer hereby delegates to Connecticut General the authority, responsibility and discretion to determine
coverage under the Plan based on the eligibility and enrollment information provided to Connecticut General
by Employer. Employer also hereby delegates to Connecticut General the authority, responsibility and
discretion to (i) make factual determinations and to interpret the provisions of the Plan to make coverage
determinations on claims for Plan Benefits, (ii) conduct a full and fair review of each claim which has been
denied as required by ERISA, (iii) decide level one mandatory appeals of "Urgent Care Claims" (as that tern is
defined in ERISA), and (iv) 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.
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Administrative Services Only Agreement
Section 3. Funding and Payment 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 (ii i)
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 due Employer under a stop loss
policy issued by Connecticut General or an affiliate.
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.
e. 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 Section 3 shall survive termination of this 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 a Member's effective date is 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.
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Administrative Services Only Agreement
c. Retroactive Member Changes and Terminations. Employer shall remain responsible for all charges and Bank
Account Payments incurred or charged through the date Connecticut General processed 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 termination to the date Connecticut General processes the notice.
This Section 4 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 provided 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
format 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, 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
format, 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.
c. Reconciliation of Eligibility 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.
Section 6. Claim Audits and Confidentiality
a. Claim Audit. 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:
i. Employer shall provide Connecticut General forty-five (45) days advance written request for audit from the
later of (i) receipt by Connecticut General of the audit scope letter or (ii) the fully executed Claim Audit
Agreement attached hereto as Exhibit C. Employer will designate with Connecticut General's consent,
such consent not to be unreasonably withheld, an independent, third party auditor to conduct the audit (the
"Auditor). In addition, Employer and Connecticut General will agree upon the date for the audit during
regular business hours at Connecticut General's office(s). Employer shall be responsible for its Auditor's
costs. Except as otherwise agreed to by the parties in writing prior to the commencement of the audit, 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 five thousand (5,000) or more employees who are Members, Employer may conduct one
such audit every Plan Year (but not within six (6) months of a prior audit); otherwise, Employer may
conduct one such audit every two (2) Plan Years (but not within eighteen (18) months of a prior audit).
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Administrative Services Only Agreement
iii. Auditor will review payment documents relating to a random, statistically valid sample of two- hundred
twenty -five (225) claims paid during the two prior Plan years and not previously audited (the "Audit ")
subject to any contrary terms in Participating Provider agreements. With respect to the Audit, 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. Any claim adjustments will be based upon the
actual claims reviewed and not upon statistical projections or extrapolations.
b. Confidentiality
i. 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 its 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.
ii. Connecticut General will maintain the confidentiality of all Protected Health Information in its possession
in accordance with the Privacy Addendum in Exhibit D and any applicable state privacy laws, including,
without limitation, 201 CMR 17.00: Massachusetts Standards for the Protection of Personal Information of
Residents of the Commonwealth.
c. Upon termination of this Agreement and subject to the provisions of Section 6.b above, 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 6 (b), shall survive termination of this Agreement.
Section 7. Plan Benefit Liability
a. Employer 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 Employer directs Connecticut General in writing to pay 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) Connecticut General 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, or (ii) under any unclaimed or abandoned property, or escheat law, with respect to
Plan Benefits and any penalties and/or interest thereon.
The reimbursement obligations set forth in this Section 7 shall survive termination of this Agreement.
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Client Name: City of Clearwater
Administrative Services Only Agreement
Section 8. Modification of Plan and Charges
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, (iv) upon any variation of fifteen percent (15 %) or more in the number of Members
used by Connecticut General to calculate its charges under this 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.
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 charges pursuant to Section 8 above may be
made by written notice to Employer by Connecticut General. If Employer pays such revised charges or fails to
object to such revision in writing within fifteen (15) days of receipt, this Agreement shall be deemed modified to
reflect the charges as communicated by Connecticut General.
Section 10. Laws Governing Contract
a. This Agreement shall be construed in accordance with the laws of the State of Florida without regard to
conflict of law rules, and both Parties consent to the venue and jurisdiction of its courts.
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 Systems
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.
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:
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Administrative Services Only Agreement
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 conducted in Clearwater, Florida. Each Party shall assume
its own costs and attorneys' fees. The mediator's compensation and expenses and any administrative fees or
costs associated with the mediation proceeding shall be borne equally by the Parties.
c. 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 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 an
appropriate post -award proceeding authorized by law and 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 Section 12 shall survive termination of this Agreement.
Section 13. Third Party 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 term, right or condition of this Agreement
shall be construed as a waiver of such term, right or condition. Waiver by either Party of any default shall not be
deemed a waiver of any other default.
Section 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, such invalidity or
unenforceability shall not invalidate or render unenforceable any other portion of this Agreement.
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Administrative Services Only 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,
their 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, their employees, officers, or
directors, acts of God, fires, wars, accidents, labor disputes or shortages, and governmental laws, ordinances, ru les
or regulations.
Section 18. Assignment and Subcontracting
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 this Agreement provided that Connecticut
General shall not be relieved of its obligations under this 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
401 Chestnut Street
Chattanooga, TN 37402
Attention: Jenny Wilson, Underwriting Director
To Employer:
City of Clearwater
100 South Myrtle Avenue
Clearwater, FL 33756
Attention: Mr. Allen Del Prete
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.
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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.
Countersigned: CITY OF CLEARWATER
By:
George N. Cretekos
Mayor b' t $' 11
Date: l
keoqt A a<kcl ws
Approved as to form:
By: •
Leslie K. Dougall -Side
Assistant City Attorney
Date: (ffri/f3
Dated at Hartford, Connecticut
This 31st day of May, 2013
05/31/2013
By: 4v/it/14 -ioaAJ Iqa? ? / r.
Willi B. Horne II
City Manager
Date: (o -.2./
Attest:
By: Nilk IL
Rosemarie Call
City Clerk
Date:
CONNECTICUT GENERAL LIFE INSURANCE
COMPANY
Name: Victoria A. Sirica
Its Account Management Lead
Duly Authorized
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Administrative Services Only Agreement
Schedule of Financial Charges
Certain fees and charges identified in this Schedule of Financial 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.
Product
Medical
Medical
Product
Descr + tion
• O . en Access Plus OAP with PHS Plus Medical Mana•ement
• Benefit Advisor Fees
Medical
Descri • Lion
• OAP Access Fee
$50.26 /employee /month
$6.00 /employee /month
Included in Medical
Administration Cha e
$25.61 /employee /month
Included in Medical
Administration Char. e
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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 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" excludes 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 Home Delivery Pharmacy" is a pharmacy that is owned or operated by Connecticut General or
an affiliated company(ies) (currently, Tel -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.
• "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) 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.
• Cigna Pharmacy Product administration fee: Included in Medical Administration Charge
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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 17% 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 group - client
book of business of AWP minus 73.5% plus an average dispensing fee across such Generic Drug Claims of not more than $0.00.
Specialty Brand Drug Claims: The drug's charge under a national discount schedule that generates a 13.2% annual average aggregate
discount off AWP for Specialty Drug Claims dispensed at CIGNA Home Delivery Pharmacy across Connecticut General 's group- client book
of business (including Specialty Drug Claims dispensed by Mail Service Pharmacy, whether covered under group - clients' Cigna Pharmacy
Benefit or Cigna medical benefit).
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 - Additional Provisions" section:
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Retail Brand Drug Claims: The lesser of (i) AWP minus the contracted discount plus the contracted dispensing fee charged by the Retail
Pharmacy for the Brand Drug Claim; or (ii) the Retail Pharmacy's usual and customary charge.
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 group - client book of business of AWP minus 70.5% (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 Brand Drug Claims: The lesser of (i) AWP minus an annual average aggregate discount of 10.5 %, plus an average
dispensing fee of no more than $1.35; or (ii) the Retail Pharmacy's usual and customary charge.
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OAP
• Cigna Home 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 (AWP). 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 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 ma be.
Run -Out Period of twelve (12) months
No Additional Cost
Pharmacy
Run -Out Period of three (3) months for all pharmacy claims
No Additional Cost
05/31/2013
15
Client Name: City of Clearwater
Administrative Services Only Agreement
Subrogation /Conditional Claim Payment. Identification, investigation and recovery of claim
payments involving other party liability or where another entity is responsible for payment
(including by way of example but not by limitation automobile insurance, homeowner
insurance, commercial property insurance, worker's compensation). (This service is only
provided with respect to Medical coverage).
05/31/2013
16
5% of recovery plus
litigation costs if Counsel
is retained and an
appearance is filed on
behalf of Connecticut
General or Employer in
any litigation, or a
lawsuit is filed on their
behalf;
29% of recovery if no
Counsel is retained and
in all other instances,
including cases where
state law requires that
employee benefit plans
be named as party
defendants or
involuntary plaintiffs.
Client Name: City of Clearwater
Administrative Services Only Agreement
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 -11% 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 may 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 unreimbursed amount, applying these discounts avoids balance billing and
substantially reduces the patient's out -of pocket cost.
MEDICAL AND PHARMACY COST CONTAINMENT
1.
Network Savings Program
29% of net savings
2.
Supplemental Network
29% of net savings
3.
Medical Bill Review — (Pre- payment 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
Outpatient Hospital Bill Review
• Professional Fee Negotiation
29% of net savings
• Line Item Analysis Re- pricing
29% of net savings
Physician/Professional Bill Review
29% of net savings
• Professional Fee Negotiation
29% of net savings
• Line Item Analysis Re-pricing
29% of net savings
4.
Medical Bill Review — (Pre or Post - payment Cost Containment for Non - contracted and
Contracted claims):
05/31/2013
17
Client Name: City of Clearwater
Administrative Services Only Agreement
• Bill Audit
29% of the
savings /recovery
achieved plus hospital
fees or expenses passed
through
Diagnosis Related Grouping (DRG) Validation/Audits and Recovery. An overpayment audit and
recovery program in which Connecticut General or its vendors review paid claim data to identify
overpayments based on inaccurate DRG coding.
29% of recovery plus
any fees or expenses
passed through by the
hospital or regulatory
agency
Inpatient Admission Retrospective Review
29% of recovery
Medical Implant Device Audits
29% of recovery
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 recovery
7.
Provider Credit Balance Recovery Program
29% of recovery
8.
High Cost Specialty Pharmaceutical Audits
29% of recovery
9.
Pharmacy Vendor Recoveries
30% of recovery
10.
Class Action Recoveries
35% of recove
Connecticut General arranges for third parties to provide care management services to:
(i) contain the cost of specified health care services /items overall with respect to all plans
insured and /or administered by Connecticut General, and/or
(ii) improve adherence to evidence based guidelines designed to promote patient safety and
efficient • atient care.
Specific vendor fees and
care management
program services are
available upon request.
Eligibility Overpayment Recovery Vendor Services. Identification and recovery of funds in
situations where the overpayment is due to the late receipt of Member termination information.
(This service is only provided with respect to Medical coverage).
29% of recovery
05/31/2013
18
Client Name: City of Clearwater
Administrative Services Only Agreement
External reviews by a third party may be required on a consultative basis as part of the internal
appeal process, or pursuant to a formal external review following exhaustion of the internal
review process. The cost of a specific third party review is dependent on the nature and
complexity of the issue on appeal. In highly complex, non - routine cases or cases related to new
technology or experimental - investigational treatment, as part of the internal appeal process a
panel of reviewers may be necessary. Third party review charges will be commensurate with the
number of reviewers (usually only one is used), as well as their level of expertise and time
re • uired to com, lete the review.
Connecticut General contracts directly or indirectly with other managed care entities and third
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. Charges based on percentage of savings are paid from the Bank Account.
Additional details re.ardin: specific charges will be •rovided u.on re•uest.
Capitation and fee - for - service charges for various vendors and other providers /arrangers of health
care services and /or supplies will be paid as claims for Plan Benefits. Such payments will be at
Connecticut General's applicable capitation or fee - for - service charges then in effect, which may
be amended from time to time. Additional details regarding charges and the identity of the
vendor or . rovider of health care services will be made available u . on re • uest.
Unless indicated otherwise in the Schedule of Financial Charges, Connecticut General retains all
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
re • uest.
From time to time, Connecticut General, directly or through its affiliates, contracts with third
party parties (e.g., service vendors, provider network managers) for referring them to Employer
or to provide various services (e.g., cost - containment initiatives) in connection with the Plan.
Connecticut General and its affiliates may receive payments from such third parties for such
referrals or to help defray expenses associated with implementing the services provided to the
Plan.
$300 - $4,000 Review
All Medical Products
All Products
All Pharmacy Products
All Products
05/31/2013
19
Client Name: City of Clearwater
Administrative Services Only Agreement
Connecticut General shall provide the following services to assist Employer in meeting its
compliance obligations under section 2715 of the Public Health Service Act as added by the
Patient Protection and Affordable Care Act and applicable regulations with respect to the
provision of the Summary of Benefits ( "SBC), translation notice and glossary. Applicable to
all medical plans including HRA and FSA which are considered "group health plans" subject
to the SBC requirements.
1.
Preparation of SBC, translation notice. Connecticut General will not be responsible for any
changes that Employer makes to the SBC.
No charge
2.
Provide SBC, translation notices prepared by Connecticut General to Employer electronically
as well as any updates or material modifications.
No charge
3. Include in SBC a summary of benefits administered by carve -out vendor if Employer or carve -
out vendor provide Connecticut General with necessary carve -out benefit information at least
12 weeks prior to the date the SBCs are to be delivered to Employer.
Service
Description
$500 for each benefit
option under the Plan
for which carve -out
vendor benefits are
included in SBC
Charge
HIPAA Certificates
Individual HIPAA certificates for Members who leave active coverage.
$0.15 /employee /month
Included in Medical
Administration Charge
Comprehensive
Maternity Program
05/31/2013
Cigna Healthy Pregnancies, Healthy Babies program is a comprehensive maternity management
program. The goal of the program is to reduce the number of pre -term and underweight babies
by promoting a healthy pregnancy. The program delivers education and telephonic support to
pregnant women through the post- partum period. Nurses answer medical related questions and
make suggestions for behavior changes and medical interventions aimed at improving the health
of the mother and baby. Program support also covers preconception and infertility. Financial
incentives are awarded to women at the completion of this self - referral program based on the
trimester enrolled.
Incentives Elected:
Option 3: $150 — 1st Trimester/ 75 — 2nd Trimester
20
Included in the Medical
Access fee
Client Name: City of Clearwater
Administrative Services Only Agreement
Comprehensive
Oncology Program
The Cigna Cancer Support Program - A program designed to deliver comprehensive oncology
support targeting Members through all stages of cancer; from those newly diagnosed, in post
cancer care, in active treatment and with or without complications and/or end of life status. The
program addresses cancer prevention through education; providing assistance to Members in
active treatment, utilizing evidence based clinical resources, development of survivorship plans
for cancer survivors, and supporting Members and their families with end -of -life decisions if
appropriate.
Included in the Medical
Access fee
Pharmacy Clinical
Program
• Step Therapy Program -a prior authorization/step therapy program that encourages cost-
effective clinically appropriate drug utilization and reduces costs by creating a sequence of
"steps" in the choice of medication used to treat some common medical conditions.
Included in Pharmacy
Administration Charge
Clinical Program
• Cigna TheraCare® Program — a targeted condition drug therapy management program that
targets individuals using specialty medications for certain chronic conditions and helps them
better understand their condition, medication side effects and importance of adherence.
Included at No
Additional Cost
Health Advisor — A
Cigna Health Advisor focuses on engaging targeted Members related to a variety of wellness and
prevention topics, and is designed to facilitate healthy behaviors and promote achievement of
health - related goals. The program includes the following components:
• Targeted health and wellness Coaching Outreach on program topics of focus to help drive behavior
change and help Members reach established goals
• Education & Referral Coaching on program topics with referral to appropriate internal and external
resources available
• Access to educational materials and web based Member tools and resources
• Identification of gaps in care and outreach to Members to provide coaching for those identified with
gaps for high cholesterol, high blood pressure
• Support of Participants identified through predictive modeling with certain preference
sensitive care conditions by supplying evidence based medical information, identifying
Participants' preferences and values, and using the Shared Decision Making process to
discuss potential benefits/ disadvantages of a specific course of action.
• Answering health and medical related questions
• Counseling Members on prevention, medical compliance
• Health and wellness coaching on high blood pressure, high cholesterol, healthy eating,
physical activity, prevention, and pre- diabetes using multiple coaching sessions, behavior
modification techniques and other motivational interviewing and coaching styles to
encourage behavior change that helps Members reach established goals.
Included in Medical
Access Fee
05/31/2013
21
Client Name: City of Clearwater
Administrative Services Only Agreement
Your Health First
A proactive health education and improvement program for those with a chronic condition. The
For OAP:
program involves services that span across the Member's health needs. Behavioral coaching
Included in Medical
principles and evidence based medicine guidelines are utilized to optimize self - management skills
and foster sustained health improvements.
Access Fee
The program targets a chronic population at high and moderate risk for near term and future high
cost medical expenses. Members are identified as having a chronic condition through a variety of
sources which may include: claims data, referrals, and self - identification. A variety of resources
is provided to those with a chronic condition, including access to online tools, personalized
support, and targeted materials.
The program includes the following components for those with a chronic condition:
• Chronic Condition - specific coaching
• Pre- and post - discharge calls
• Lifestyle management coaching: stress, weight management and tobacco cessation
• Treatment decision support and coaching
In order to continuously improve the effectiveness of our programs, a small sample of Members
may be placed in a comparison group which receives alternative services for a limited period of
time.
Medical Conversion
Converting Employee Resides in FL:
Privilege
Comprehensive, Base Plan/Major Medical & PPO Plans
$20,000 /conversion policy
05/31/2013
22
Client Name: City of Clearwater
Administrative Services Only Agreement
Exhibit A - Plan Document
A "Plan Booklet" that includes Plan Benefits and Members' rights and responsibilities under the Plan will be
provided by Employer to Connecticut General. If Employer has not provided Connecticut General with a copy
of its fmalized 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.
05/31/2013
23
Client Name: City of Clearwater
Administrative Services Only Agreement
Exhibit B — Services
Products excluding Health Savings Account
1 Furnishing Connecticut General's standard Bank Account activity data reports to Employer as and when
agreed upon. Connecticut General's administration of the 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.
All Products
2. Report to Employer the claim payment information required in connection with Section 6041 of the Internal
Revenue Code.
All Products
3.
If Employer has elected, pursuant to section 63 of the New York Health Care Reform Act of 1996 (section
2807 -t of the Public Health Law) ( "the Act "), to pay the assessment on covered lives set 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 Account to the 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.
In addition, where permitted, Connecticut General will file applicable forms and pay on behalf of Employer
and /or the Plan any assessment, surcharge, tax or other similar charge which is required to be made by you or
the Plan based on covered lives and /or paid claims or otherwise in accordance with and as required by other
applicable state and /or federal laws and regulations and your bank account will be charged for any such
a ments made b Connecticut General.
Products excluding Health Savings Account
All Products
1.
Calculate benefits, check and/or electronic payments disbursed from Employer's Bank Account. Bank
Account payments will appear in Employer's standard Bank Account activity data reports.
All Products
2.
Prepare and make available Connecticut General's standard claim forms.
All Products
3.
Investigate claims, as necessary, by Connecticut General's Special Investigations Unit.
All Products
4.
Discuss claims, when appropriate, with providers of health services.
All Products
5.
Perform internal audits of plan benefit payments on a random sample basis.
All Products
6.
Claim control procedures reported annually in Statement on Standards for Attestation Engagements (SSAE)
No. 16 Report (SAS70 successor report).
All Products (excluding
Vision)
7.
Respond to Insurance Department complaints.
All Products
05/31/2013
24
Client Name: City of Clearwater
Administrative Services Only Agreement
8.
9.
10.
1.
2.
3.
1.
2.
3.
4.
Dedicated toll -free telephone line for Member and Provider calls to Connecticut General Service Centers.
Member Explanation of Benefit (`BOB ") statements including, when applicable, notice of denied claims,
denial reason(s and as seal ri :hts.
Verify enrollment and eligibility using Member information submitted by Employer and/or its authorized
a:ent.
Medical Onh
Connecticut General's standard enrollment forms are prepared and delivered to Employer for distribution to
individuals eli :ible to enroll in the Plan.
Connecticut General's standard ID card with toll -free telephone number are prepared and mailed directly to
Members.
Administration of subro:ation/conditional Claim Pa ment terms described in Exhibit E).
Pharmac Onl
Connecticut General's standard ID cards with toll -free telephone number are prepared and mailed directly to
Members.
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 said re :ardless of covera :e under another plan.
Connecticut General's standard dru: utilization review services.
Connecticut General may receive and retain payments under contracts with drug manufacturers with respect to
utilization covered under the Employer's medical benefit for the manufacturer's specialty drugs, which are
drugs that typically are injected or infused and derived from living cells; target an underlying rare, chronic or
costly condition; and/or require restricted access and/or close monitoring. If Connecticut General enters into
an such contracts, it does so on its own behalf, and not as a:ent of the Em • to er or the Plan.
All Products
All Products
All Products
All Medical Products
All Medical Products
All Medical Products
All Pharmacy Products
All Pharmacy Products
All Pharmac Products
All Pharmacy Products
Products excludin ' Health Savin s Account
1.
2.
3.
Pre 'are Member benefit booklet drafts to Ems lo er.
5500 Schedule C reporting.
5500 Schedule A or Annual Reconciliation Disclosure re.ortin: when applicable
Connecticut General's standard Underwritin• services: a) benefit desi:n anal sis -b Iro'ected cost anal sis.
All Products
All Products
All Products
All Products
05/31/2013
25
Client Name: City of Clearwater
Administrative Services Only Agreement
1.
2.
3.
4.
5.
6.
7.
1.
2.
3.
Products excludin , Health Savin s Account
Handling of requests from Members for access to, amendment and accounting of protected health information,
and requests for restrictions and alternative communications as required under federal HIPAA law and
re•ulations, as set out in this A • reement and its Exhibits.
Maximum reimbursable charge determinations of non - Participating Provider charges for covered services.
Connecticut General's standard cost containment controls: Application of non - duplication and coordination of
benefits rules and coordination with Medicare.
Delivery of information, as necessary, regarding standard application of non - duplication or coordination of
benefits.
Review of medical bills in accordance with Connecticut General's then current Medical Bill Review .ro: am.
Network Savings Program, a national vendor network that provides discounted rates when a Member accesses
care throu .h a Network Savings Pro :ram contracted .rovider.
Annual re.ortin• of Connecticut General's standard cost containment results u.on Em.lo er's re•uest.
Pharmac Vendor Recoveries.
Summary reports of medical and pharmacy cost and utilization experience are available through Cigna's web
site, Ci•naAccess.com.
[tt.SU.: MAIU.I. ..y�:.r. to it s11Y.limirOO'���i�irkisrjata..
Claim Reporting: Connecticut General will provide its standard reports and information based 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 /Confidentiali A:reement.
All Products
All Medical Products (with
out -of- network benefits
All Medical Products
All Medical Products
All Medical Products
All Medical Products
All Medical Products
All Medical and Pharmacy
Products
Pharmac Product Onl
All Medical Products
05/31/2013
26
Client Name: City of Clearwater
Administrative Services Only Agreement
Connecticut General contracts with three (3) independent review organizations that meet the Patient Protection
and Affordable Care Act (PPACA) external review requirements. Members may appeal eligible claims to an
external independent review organization which is selected by Connecticut General on a random basis. If
Employer has chosen not to participate in this program, the Employer may be responsible for making other
arran ements to meet the Patient Protection and Affordable Care Act PPACA external review re • uirements.
Connecticut General provides integrated medical management that includes
Plan) the following core services.
(depending upon the terms of the
All Medical Products
1.
Pre - Admission Certification and Continued Stay Review (PAC /CSR) services to certify coverage 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.
All Medical Products
2.
Case Management and Retrospective Review of Inpatient Care, a service designed to provide assistance to a
Member who is at risk of developing medical complexities or for whom a health incident has precipitated a need
for rehabilitation or additional health care support.
All Medical Products
3.
Assisting providers with resources and tools to enable them to develop long term treatment plans in the
management of chronic or catastrophic cases.
All Medical Products
4.
The Cigna HealthCare Healthy Babies® Program is a one time educational mailing which provides Participants
with prenatal care education and resources to help them better manage their pregnancy.
All Medical Products
5.
HealthCare Cost and Quality tools on myCigna.com
All Medical Products
6.
A panel of physicians and other clinicians to assess the safety and effectiveness of new and emerging medical
technologies. The panel meets monthly to review and update coverage policies.
All Medical Products
7.
Cigna HealthCare 24 -Hour Health Information LinesM a service that provides 24 hour toll free access to
registered nurses who provide answers to healthcare questions, recommend appropriate settings for care and
assist Participants in locating physicians. It also includes access to an extensive audio library on a wide range of
medical topics.
All Medical Products
8.
Cigna LifeSOURCE Transplant Network® contracts with over six - hundred (600) transplant programs at more
than one - hundred forty five independent transplant facilities and provides access to solid organ and bone
marrow /stem cell transplantation while improving cost containment and reducing financial risk.
All Medical Products
9.
A health education program that delivers mailings to Members with certain conditions.
05/31/2013
27
All Medical Products
Except Comprehensive and
Indemnity
Client Name: City of Clearwater
Administrative Services Only Agreement
10.
Implementing clinical quality measurements, managing data, tracking and validating performance and initiating
continuous quality improvement.
All Medical Products
Except Comprehensive and
Indemnity
11.
Transition of care services to allow Members with defined conditions to continue treatment with non -
Participating Providers after enrollment for continued uninterrupted care for a limited time.
All Medical Products Except
Comprehensive and
Indemnity
12.
Focused utilization management of outpatient procedures and identification of appropriate alternatives.
Administered in accordance with Connecticut General's then applicable medical management and claims
administration olicies, ractices and .rocedures.
Connecticut General, and /or its affiliates shall:
All Medical Products with
PHS Plus
1.
Provide or arrange access to the applicable network of Participating Providers to furnish health 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 hospital may accept less for patients
enrolled in certain types of plans than others;
All Medical Products
2.
Credential and re- credential Participating Providers in accordance with Connecticut General's credentialing
requirements and ensure that third -party network vendors credential/re- credential Participating Providers in
accordance with Connecticut General's requirements;
All Medical Products
3.
Review Participating Provider compliance with protocols and procedures for quality, Participant satisfaction,
and grievance resolution;
All Medical Products
4.
Facilitate the identification of Participating Providers by Members; and
All Medical Products
5.
Dedicated toll -free telephone line for Member and Provider calls to Connecticut General Service Centers.
All Medical Products
05/31/2013
28
Client Name: City of Clearwater
Administrative Services Only Agreement
The Cigna HealthCare of Arizona, Inc. staff model ( "Cigna Medical Group ") is a Participating 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 Participants in PPO or
EPO plans.
Except as provided below, for services provided to Participants, CMG is paid at the rates in effect at the time of
service (as may be revised from time to time). Representative rates for routinely performed services are
attached. A complete copy of the rates is available on request under a mutually agreed nondisclosure
agreement (NDA).
If 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 in Employer's standard Bank Account activity data reports 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 under a
mutually agreed NDA.
Primary care services rendered to Participants in Open Access Plans that do not provide for PCP assignment are
paid at the rates then in effect, as described above.
All Medical Products
05/31/2013
29
Client Name: City of Clearwater
Administrative Services Only Agreement
CIGNA HEALTHCARE OF ARIZONA - CIGNA MEDICAL GROUP (CMG)
REPRESENTATIVE RATES FOR ROUTINELY PERFORMED MEDICAL SERVICES EFFECTIVE
OCTOBER 1, 2012
CPT Service Code
05/31/2013
(Applicable to all Open Access Plus Products)
Service Description
Sigmoidoscopy, flexible; Diagnostic (combined rate, includes
45330 facility fee $485.00)
45378 Diagnostic Colonoscopy (combined rate, includes facility fee $650)
71020 Chest X -Ray, Pa & Lat
74000 Abdomen X -Ray (Kub)
80053 Comprehensive Metabolic Panel
80061 Cardiac Risk
82565 Creatinine; Blood
82947 Glucose, Serum
84075 Phosphatase, Alkaline,Blood
84443 Tsh, Assay
84450 Sgot (Ast) Transaminase
84520 Bun (Urea Nitrogen)Assay
85025 CBC and Differential
87086 Culture, Urine, Colony Ct
88164 Cytopathology, Slides
88305 Surg Path, Gross and Micro
92014 Eye Exam & Treatment
92567 Tympanometry
93000 Electrocardiogram, Complete
94760 Oximetry Single Determination
95115 Allergy Injection, Single
95117 Allergy Injection, Multiple
99211 Office Visit, Est Min (Md Or Non -Md)
99212 Office Visit, Est Prob Focused
99213 Office Visit, Est Exp Prob Foc
99214 Office Visit, Est Detailed
99231 Subsequent Hospital Care
99242 Office Consult, Exp Prob Focused, 30 Minutes
99395 Well Exam, Est, 18 -39 Years
99396 Well Exam, Est, 40 -64 Years
G0202 Mammogram, Screening (Bilateral) Digital
77052 Add on for iCad
Rates
$557.97
$907.75
$30.38
$24.57
$14.87
$18.85
$7.22
$5.52
$7.28
$23.64
$7.28
$5.56
$9.03
$11.36
$14.87
$104.59
$109.35
$15.62
$21.86
$2.47
$9.69
$11.85
$19.21
$39.18
$65.80
$98.58
$38.26
$92.15
$94.20
$102.94
$129.54
$11.48
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Administrative Services Only Agreement
The Urgent Care case rate excluding radiology and laboratory services is $115.
The CMG CareToday (CMG low acuity clinics) visit rate is $59. Lab tests performed at the CMG CareToday facilities
are $10 per service. A complete list of rates for CMG CareToday services 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 - $1400
Group 9 - $1200
Unlisted - $740
CMG pharmacy rates:
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 RVUs are reimbursed at the 50th Percentile of the Arizona Regional
Medicode Schedule.
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Client Name: City of Clearwater
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:
1. 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.
3. 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.
4. Audit Report
The Auditor will provide Connecticut General with a true copy of the Audit's findings, as well as
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.
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Administrative Services Only Agreement
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.
7. 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 information 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 ( "HIPAA "), Privacy Standards and in
compliance with the signed Business Associate Agreement ("BAA").
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 this agreement.
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Client Name: City of Clearwater
Administrative Services Only 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:
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Client Name: City of Clearwater
Administrative Services Only Agreement
Exhibit D — Privacy Addendum
( "Business Associate Agreement ")
L 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 of 45
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 permitted 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.
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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. §164.524; 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 13401(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.
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Client Name: City of Clearwater
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 harmful 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 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.
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Administrative Services Only Agreement
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. Termination 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 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.
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Client Name: City of Clearwater
Administrative Services Only Agreement
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 termination of the Agreement; therefore, the protections of this
Addendum for PHI shall survive termination 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 term "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 make 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.
"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 45 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.
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Client Name: City of Clearwater
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 terms 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.
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Client Name: City of Clearwater
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 Privacy 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 1 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 terminating 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.
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Client Name: City of Clearwater
Administrative Services Only Agreement
Exhibit E — Conditional Claim /Subrogation Recovery Services
I. Plans Without Connecticut General Stop Loss Coverage
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:
i. 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 Bank Account shall be refunded at the gross amount.
Connecticut General's and it 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. 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.
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Client Name: City of Clearwater
Administrative Services Only Agreement
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.
B. All amounts reimbursed to Employer's Bank 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.
05/31/2013
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