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LETTER AMENDING THE ADMINISTRATIVE SERVICES ONLYVictoria A. Sirica Account Management Lead Cigna January 17, 2014 Allen Del Prete City of Clearwater 100 South Myrtle Ave Clearwater, FL 33758 RE: Administrative Services Only Account No. 2499162 Dear Mr. Del Prete: Cigna. Routing B2CAU 900 Cottage Grove Road Hartford, CT 06152 Telephone 860 226.2785 Facsimile 860.730.3944 Victoria.Sirica@cigna.com This letter will serve as an amendment to the standard Administrative Services Only Agreement referenced in the Letter of Intent between Cigna Health and Life Insurance Company ( "CHLIC ") and City of Clearwater ( "Employer "), effective January 1, 2013 (the "Agreement "). Effective as of January 1, 2014, the Agreement is hereby amended as set forth below. Any provision or subsection set forth in this Amendment shall be deemed to: (a) replace in its entirety the same subsection in the current Agreement; and/or (b) add new provisions or subsections. Only those provisions and subsections set forth in this Amendment are deemed amended or added, and all provisions and subsections not identified herein shall be deemed unaffected by this Amendment and, accordingly, shall remain in full force and effect. Section 2.c of the Administrative Services Only Agreement is hereby amended in its entirety as follows: c. Employer hereby delegates to CHLIC the authority, responsibility and discretion to determine coverage under the Plan based on the eligibility and enrollment information provided to CHLIC by Employer. Employer also hereby delegates to CHLIC 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" "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. "Cigna" is a registered service murk, and the "Tree of Life" logo is a service mark, of Cigna Intellectual Property, Inc., licensed fur use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health Management, Inc.. and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. City of Clearwater January 17. 2014 Page 2 Section 3.a. of the Administrative Services Only Agreement is hereby amended in its entirety as follows: 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 the following (collectively "Bank Account Payments "): (i) Plan Benefits, (ii) those charges and fees identified in the Schedule of Financial Charges as payable through the Bank Account, and (iii) any sales or use taxes, or any similar benefit- or plan related charge or assessment however denominated which may be imposed by any governmental authority. Bank Account Payments may include without limitation: (i) capitated (i.e. fixed per Member) and pay- for - performance payments to Participating Providers; (ii) amounts owed to CHLIC; and (iii) amounts paid to CHLIC's affiliates and /or subcontractors for, among other things, network access or in- and out-of network health are services /products provided to Members. CHLIC may credit the Bank Account with payments due Employer under a stop loss policy issued by CHLIC or an affiliate. Section 3.e. of the Administrative Services Only Agreement is hereby amended in its entirety as follows: e. Employer shall promptly reimburse CHLIC for any Bank Account Payments paid by CHLIC with its own funds on Employer's behalf and no such payment by CHLIC shall be construed as an assumption of any of Employer's liability. Section 3, "Funding and Payment of Claims," of the Administrative Services Only Agreement is hereby amended to add provision f. to the existing language as follows: f. 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. The Schedule of Financial Charges and Exhibit B, "Services" is hereby deleted in its entirety and replaced with the Schedule of Financial Charges and Exhibit B, "Services," attached hereto. City of Clearwater March 4, 2014 Page 3 Please indicate your agreement to the Amendment by signing the enclosed copy of this letter where indicated and returning it to me. Alternatively, this Amendment shall become effective on the effective date indicated unless Employer notifies CHLIC either electronically or in writing (at the address indicated above) within sixty (60) days of the date of this letter that it does not accept all the terms of this Amendment notwithstanding any provision to the contrary in the Administrative Services Agreement,. In that case, CHLIC shall cooperate to negotiate mutually agreeable terms with Employer. Once agreement with respect to the terms of the Amendment is reached, the Amendment will apply retroactively to the effective date. Victoria A. Sirica Its Account Management Lead Duly Authorized Cigna Health and Life Insurance Company Accepted by: CITY OF CLEARWATER By: Name: Title: cukkaclaccl Strxcaua*c. e. am' Executed this } d day of )x.lc i , in the year -LC' ` f . Countersigned: CleOf \tekC^ AtiCOS George N. Cretekos Mayor Approved as to form: 4.,i /16 • eslie K. Dougal 'des Assistant City A •r, ey CITY OF CLEARWATER, FLORIDA By: tithkijA44, R. 4---rC William B. Horne II City Manager Attest: cL a. Rosemarie CaII City Clerk Client Name: City of Clearwater 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 CHLIC's then standard billing practices. However, CHLIC is authorized to pay all fees and charges from the Bank Account unless otherwise specified in this Agreement. 01/17/2014 4 MEDICAI ADMINISTRATION CHARGES (Includes ►±> eats agreed to by Employer) Product Description Charge Medical • Open Access Plus (OAP) with PI S Plus Medical Management 550.95 /employee /month Medical • Benefit Advisor Fees $6.00/employee/month Included in Medical Administration Charge EDICAL NETWORK ACS FEF, UTII ATIIIN MAr' AGEMENT FEE AND O PTIONAL >i tl RAM FEE Product Description Charge Medical • OAP Access Fee $25.65 /employee /month Included in Medical Administration Charge AMOUNTS OWED TO CHL C Amounts paid by CI JLIC with its own funds on behalf of Employer or the Plan with respect to charges for which Employer or the Plan is obligated to pay under this Agreement including Plan Benefits, Bank Account Payments (including capitated and pay- for - performance payments to Participating Providers), governmental taxes or assessments. 01/17/2014 4 Client Name: City of Clearwater Administrative Services Only Agreement 01/17/2014 5 GNA I A IACY lENWIT ANAGF� T V GIS A RELA. D PROVISION Definitions or "AWP" is the Average Wholesale Price for a given pharmaceutical product in effect on the dispense date for the as published by Medi -Span or other alternative publication or benchmark reasonably designated by CHLIC. a claim for a pharmaceutical product that is adjudicated as a brand drug as indicated on the claim record generated by the used by CHLIC. For application of discounts and dispensing fees, a "Brand Drug Claim" includes a claim for a generic period or other period of limited competition, as CHLIC reasonably determines under its standard policies. is a claim for a pharmaceutical product that is adjudicated as a generic drug as indicated on the claim record generated by used by CHLIC. For application of discounts and dispensing fees, a "Generic Drug Claim" excludes a claim for a exclusivity period or other period of limited competition, as CHLIC reasonably determines under its standard policies. or "Cigna Tel- Drug" or "Cigna Home Delivery Pharmacy" is a pharmacy that is owned or operated by CHLIC or an (currently, Tel -Drug, Inc. and Tel -Drug of Pennsylvania, LLC), which dispenses drugs covered under the Plan's Pharmacy not a Retail Pharmacy. the terms of the Plan that govern coverage and care /utilization management of drugs and related supplies dispensed to to the Plan by the Mail Service Pharmacy or Retail Pharmacies through CHLIC's pharmacy claim processing system. Formulary Payments" means amounts that CHLIC collects under contracts with drug manufacturers that are based on the manufacturers' brand drugs under the Plan's Pharmacy Benefit and the drug's status on the Cigna drug formulary. a pharmacy that is entitled to payment under the Plan for drugs it dispenses that are covered under the Plan's Pharmacy Service Pharmacy. is a claim for a pharmaceutical product that is reasonably determined by CHLIC to be a specialty drug in accordance with drugs generally are (i) injected or infused and derived from living cells, or are oral non - protein compounds (e.g., oral (ii) target the underlying condition, which is usually one of a relatively rare, chronic and costly nature; and /or (iii) require close monitoring. • "Average Wholesale Price" actual package size dispensed • "Brand Drug Claim" is claim processing system drug within its exclusivity • "Generic Drug Claim" the claim processing system generic drug within its • "Mail Service Pharmacy" affiliated company(ies) Benefit by mail, and is • "Pharmacy Benefit" means Members and charged • "Rebates" or "Manufacturer utilization of certain of • "Retail Pharmacy" is Benefit, and is not a Mail • "Specialty Drug Claim" industry practice. Specialty chemotherapy drugs); restricted access and/or PHARMACY AD I ISTRATION FEE • Cigna Pharmacy Product Administration Fee: Included in Medical Administration Charge 01/17/2014 5 Client Name: City of Clearwater Administrative Services Only Agreement l QYII' PI�A�ACY IIB�' ii Drug Dispensed by Mail Service Pharmacy: CHLIC 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 CHLIC generic Maximum Allowable Charge schedule that generates an annual average aggregate discount across Generic Drug Claims dispensed at Cigna Home Delivery Pharmacy to CHLIC group - client book of business of AWP minus 73.5% plus an average dispensing fee across such Generic Drug Claims of not more than 50.00. Specialty Brand Drug Claims: The drug's charge under a national discount schedule that generates a 11.8% annual average aggregate discount off AWP for Specialty Drug Claims dispensed at Cigna Home Delivery Pharmacy across CHLIC '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: CHLIC 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: 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 (1) the drug's charge on a CHLIC generic Maximum Allowable Charge schedule that generates an annual average aggregate discount across Generic Drug Claims dispensed at Retail Pharmacies to CHLIC 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 $1.40; 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 $1.40; or (ii) the Retail Pharmacy's usual and customary charge. 01/17/2014 6 Client Name: City of Clearwater Administrative Services Only Agreement • 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 Horne 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 CHLIC 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), CHLIC may adjust any or all of the charges, rates, discounts, guarantees and /or fees in connection with CHLIC'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, CHLIC 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 CHLIC adjusts any or all such AWP - Based Charges or such alternative benchmark -based charges as it reasonably deems necessary to preserve the economic value or benefit of this Agreement as it existed immediately prior to such replacement or immediately prior to the event(s) giving rise to such replacement, as the case may be. 01/17/2014 7 Client Name: City of Clearwater Administrative Services Only Agreement 1i 3 FAR PROCl tIl RUN >hTi' CLAIMS OAP 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 51TJBRtI ATION 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). 5% of recovery plus litigation costs ifCounsel is retained and an appearance is filed on behalf of CHLIC 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. 01/17/2014 8 Client Name: City of Clearwater Administrative Services Only Agreement .lC tlri` tlNTt�II+ll1NT Fi CHLIC, 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, CHLIC contracts with vendors to perform program related services. Specific vendor fees are available upon request. CHL1C's charge for administering these programs is the percentage (indicated below) of either ( I ) 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, Tess 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; CHLIC pays the applicable vendor fee) or (3) the "recovery" (i.e. the amount recovered) as applicable. For covered services received from non - Participating Providers, CHLIC 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 CHLICs own health care insurance business when these programs are implemented. CHLIC 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 01/17/2014 9 Client Name: City of Clearwater Administrative Services Only Agreement 01/17/2014 10 • 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): • 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 CHLIC 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 recovery 01/17/2014 10 Client Name: City of Clearwater Administrative Services Only Agreement C CHLIC 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 CHLIC, and /or (ii) improve adherence to evidence based guidelines designed to promote patient safety and efficient patient care. Specific vendor fees and care management program services are available upon request. rLB OVEIk PAYMENT RECOVERY FEES 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 It LTA VE RE yI)l W ICI When a Member elects an External Review (as that term is defined in ERISA) of a benefit determination by an independent third party, 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 required to complete the review. $300- $4,000 Review SIiATI)�IC Ak.IAI+OE CHLIC 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 CI-ILIC'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 regarding specific charges will be provided upon request. All Medical Products 01/17/2014 11 Client Name: City of Clearwater Administrative Services Only Agreement O' ER VEi iii AND HEALTH CARE SEl(1<�VICES PROVIDERS 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 CHLIC'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 provider of health care services will be made available upon request. All Products NOTICE REGARDING PAYMENTS FROM THIRD PARTIES Unless indicated otherwise in the Schedule of Financial Charges, CHLIC 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 request. All Pharmacy Products From time to time, CHLIC, directly or through its affiliates, arranges with third party parties (e.g., service vendors, provider network managers) to provide various services (e.g.. cost - containment initiatives) in connection with the Plan. CHLIC and its affiliates may receive payments from such third parties to help defray CHLIC's expenses associated with the implementation and/or ongoing administration of these arrangements. CHLIC may also receive compensation from third -party vendors that Employer may retain based upon a referral from CHL 1C. All Products 01/17/2014 12 Client Name: City of Clearwater Administrative Services Only Agreement 01/17/2014 13 CHLIC shall provide the following services to assist Employer in meeting its compliance obligations under section 2715 of the Public %Iealth 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. CHLIC will not be responsible for any changes that Employer makes to the SBC. No charge 2. Provide SBC, translation notices prepared by CHLIC 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 CHLIC with necessary carve -out benefit information at least 12 weeks prior to the date the SBCs are to be delivered to Employer. $500 for each benefit option under the Plan for which carve -out vendor benefits are included in SBC ADUTirON CES Service Description Charge HIPAA Certificates Individual HIPAA certificates for Members who leave active coverage. 50.15 /employeefmonth Included in Medical Administration Charge 01/17/2014 13 Client Name: City of Clearwater Administrative Services Only Agreement 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 impartial evidence based medical information, to empower Participants' to understand the potential benefits/ disadvantages ofa specific courses of action and make more informed care decisions. • Answeri:tg health and medical related questions • Counseling Participants on prevention and the benefits of compliance with prescribed medications and treatments • 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 Participants reach established goals. Included in Medical Access Fee Comprehensive Cigna Healthy Pregnancies, Healthy Babies program is a comprehensive maternity management Included in the Medical Maternity Program 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. Access fee Incentives Elected: Option 3: $150 — 1st Trimester /$ 75 — 2nd Trimester 01'17/2014 14 Client Name: City of Clearwater Administrative Services Only Agreement Comprehensive The Cigna Cancer Support Program - A program designed to deliver comprehensive oncology Included in the Medical Oncology Program 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. Access fee Pharmacy Clinical Step Therapy Program -a prior authorization/step therapy program that encourages cost - effective Included in Pharmacy Program 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. Administration Charge Clinical Program Cigna TheraCaree Program — a targeted condition drug therapy management program that targets Included at No Additional individuals using specialty medications for certain chronic conditions and helps them better understand their condition, medication side effects and importance of adherence. Cost 01; 17/2014 15 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 program involves services that span across the Member's health needs. Behavioral coaching principles and evidence based medicine guidelines are utilized to optimize self - management skills and foster sustained health improvements. 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 assess the effectiveness of our programs and/or test new ideas to further engage your employees around their health, a small sample of Members may be placed in a comparison group which for a defined period of time receives alternative services or is suppressed from receiving proactive outreach, such as engagement letters and/or calls. This could affect a few Members targeted for outreach during this limited time period. For OAP Products: Included in Medical Access Fee Medical Conversion Privilege Converting Employee Does Not Reside in NY, CO, FL. TX* Comprehensive /Major Medical Plans Base Plans (Limited Hospital /Surgical) 320,000 /conversion policy 313,000 /conversion policy Converting Employee Resides in NY: Comprehensive/Major Medical Plans Base Plans (Limited Hospital /Surgical) 320,000 /conversion policy 1513,000 /conversion policy Converting Employee Resides in CO: Comprehensive /Major Medical Plans Base Plans (Limited Hospital /Surgical) 520,000 /conversion policy 513,000 /conversion policy * CHLIC does not provide Medical Conversion coverage to Texas residents. Medical Conversion coverage for Texas residents is provided by the Texas Health insurance Risk Pool. 01/17/2014 16 Client Name: City of Clearwater Administrative Services Only Agreement 01/17/2014 17 Converting Employee Resides in FL: Comprehensive, Base PIan'Major Medical & PPO Plans $20,000 /conversion policy Client Fund Wellness Employer For clinical /wellness/behavioral programs offered by CHLIC that are purchased, CHLIC will establish a Wellness /Health Improvement Employer in the amount of $50,000.00. These funds will be used to defray the cost of CHLIC designated and arranged health and wellness improvement programs for Employees (e.g., biometric screenings, flu shots, etc.) and to reward participation in these programs. Wellness /Health Improvement Employers are a one -time credit to be used from January 1, 2014 — December 31, 2014. Unused funds cannot be rolled over and CHLIC must pre- approve use of the Wellness/Health Improvement Employer 01/17/2014 17 Client Name: City of Clearwater Administrative Services Only Agreement Exhibit B— Services BANKI G AID A MINISTRATION Products excluding Health Savings Account 1. Furnishing CHLIC's standard Bank Account activity data reports to Employer as and when agreed upon. CHLIC'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, CHLIC shall file 1 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 CHLIC 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 and agreed to by CHLIC, CHLIC 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 payments made by CHLIC. All Products 01/17/2014 18 Client Name: City of Clearwater Administrative Services Only Agreement C� A3#iitA't'IO1 Products excluding Health Savings Account 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 CHLIC's standard claim forms. All Products 3. Investigate claims, as necessary, by CHLIC'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 8. Dedicated toll -free telephone line for Member and Provider calls to CHLIC Service Centers. All Products 9. Member Explanation of Benefit ( "EOB ") statements including, when applicable, notice of denied claims, denial reason(s) and appeal rights_ All Products 10. Verify enrollment and eligibility using Member information submitted by Employer and/or its authorized agent. All Products Medical Only 1. CHLIC's standard enrollment forms are prepared and delivered to Employer for distribution to individuals eligible to enroll in the Plan. All Medical Products 2. CHLIC's standard ID card with toll -free telephone number are prepared and mailed directly to Members. All Medical Products 3. Administration of subrogation /conditional Claim Payment (terms described in Exhibit E). All Medical Products 01/17/2014 19 Client Name: City of Clearwater Administrative Services Only Agreement Pharmacy Only 1. CHLIC's standard ID cards with toll -free telephone number are prepared and mailed directly to Members. All Pharmacy Products 2. Pharmacy claims are adjudicated typically on -line at time of service without access to information on other coverage, and therefore coordination of benefits (COB) for pharmacy claims does not occur. Claims for Plan Benefits will be paid regardless of coverage under another plan. All Pharmacy Products 3. CHLIC's standard drug utilization review services. All Pharmacy Products 4. CHLIC 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 CHLIC enters into any such contracts, it does so on its own behalf, and not as agent of the Employer or the Plan, Alt Pharmacy Products DOCUMENT P ODUCTI N Products excluding Health Savings Account Prepare Member benefit booklet drafts to Employer. I All Products Ul+l$R4tiritl<'t`G SERVICES I . 5500 Schedule C reporting. All Products 2. 5500 Schedule A or Annual Reconciliation Disclosure reporting (when applicable) All Products 3. CHLIC's standard Underwriting services: a) benefit design analysis -b) projected cost analysis. All Products Hl[PAA II UAL RIGHTS Products excluding Health Savings 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 regulations, as set out in this Agreement and its Exhibits. All Products 01!17/2014 20 Client Name: City of Clearwater Administrative Services Only Agreement �T t NTAIN NT 1. Maximum reimbursable charge determinations of non - Participating Provider charges for covered services. All Medical Products (with out-of-network benefits) 2. CHLIC's standard cost containment controls: Application of non - duplication and coordination of benefits rules and coordination with Medicare. All Medical Products 3. Delivery of information, as necessary, regarding standard application of non- duplication or coordination of benefits. All Medical Products 4. Review of medical bills in accordance with CHLIC's then current Medical Bill Review program. All Medical Products 5. Network Savings Program, a national vendor network that provides discounted rates when a Member accesses care through a Network Savings Program contracted provider. All Medical Products 6. Annual reporting of CHLIC's standard cost containment results upon Employer's request. All Medical Products 7. Pharmacy Vendor Recoveries. All Pharmacy Products CUSTOMER REPORTING 1. Summary reports of medical and pharmacy cost and utilization experience are available through Cigna's web site, CignaAccess.com. All Medical and Pharmacy Products 2. CHLIC's standard pharmacy utilization reports. Pharmacy Product Only 3. Claim Reporting: CHLIC will provide its standard reports and information based upon paid claim data only. CHLIC 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 CHLIC. CHLIC will provide its standard reporting only after the stop loss carrier and Employer have executed CHLIC's standard Hold Harmless /Confidentiality Agreement. All Medical Products 01/17/2014 21 Client Name: City of Clearwater Administrative Services Only Agreement M A+i > i(�»itfiA1L �V' EW PROGL4M CHLIC 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 CHLIC on a random basis. If Employer has chosen not to participate in this program, the Employer may be responsible for making other arrangements to meet the Patient Protection and Affordable Care Act (PPACA) external review requirements. All Medical Products A LCAL.1M At+i: T 'll' SER , CHLIC provides integrated medical management that includes (depending upon the terms of the Plan) the following core services. 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 CHLIC'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 Lines"' 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 01/17/2014 22 Client Name: City of Clearwater Administrative Services Only Agreement 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. All Medical Products Except Comprehensive and Indemnity 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 CHLIC's then applicable medical management and claims administration policies, practices and procedures. All Medical Products with PHS Plus l� Q C MAMA MENT S) VI< CHLIC, and/or its affiliates shall. 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 CHLIC's credentialing requirements and ensure that third -party network vendors credential /re- credential Participating Providers in accordance with CHLIC'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 CHLIC Service Centers. All Medical Products 01/17/2014 23 Client Name: City of Clearwater Administrative Services Only Agreement C GNA STAFF MODEL HEAI[:i< H#"1<.AN SII I The Cigna HealthCare of Arizona, Inc. staff model ( "Cigna Medical Group ") is a Participating All Medical Products Provider located in metropolitan Phoenix, Arizona. Plan Participants may at some time receive treatment from a Cigna Medical Group ( "CMG ") facility or provider even if they do not reside in Arizona (as when traveling). Participants utilizing the IPA network will access certain specialty and /or ancillary services (including laboratory and urgent care services) through the CMG system. Lab services are not provided by CMG for 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. 01/17/2014 24 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 JULY 1, 2013 (Applicable to all Open Access Plus Products) CPT Service Code Service Description Rates 45330 Sigmoidoscopy, flexible; Diagnostic (combined rate, includes $400.97 facility fee $328.00) 45378 Diagnostic Colonoscopy (combined rate, includes facility fee $726.75 $469) 71020 Chest X -Ray, Pa & Lat $30.38 74000 Abdomen X -Ray (Kub) $24.57 80053 Comprehensive Metabolic Panel $14.87 80061 Cardiac Risk 818.85 82565 Creatinine; Blond 87.22 82947 Glucose, Serum $5.52 84075 Phosphatase, Alkaline,Blood $7.28 84443 Tsh, Assay $23.64 84450 Sgot (Ast) Transaminase $7.28 84520 Bun (Urea Nitrogen)Assay $5.56 85025 CBC and Differential $9.03 87086 Culture, Urine, Colony Ct $11.36 88164 Cytopathology, Slides $14.87 88305 Surg Path, Gross and Micro $104.59 92014 Eye Exam & Treatment $109.35 92567 Tympanometry $15.62 93000 Electrocardiogram, Complete $21.86 94760 Oximetry Single Determination $2.47 95115 Allergy Injection, Single $9.69 95117 Allergy Injection, Multiple $11.85 99211 Office Visit, Est Min (Md Or Non -Md) $19.21 99212 Office Visit, Est ?rob Focused $39.18 99213 Office Visit, Est Exp Prob Foc $65.80 99214 Office Visit, Est Detailed $98.58 99231 Subsequent Hospital Care $38.26 99242 Office Consult, Exp Prob Focused, 30 Minutes $92.15 99395 Well Exam, Est, 18 -39 Years $94.20 99396 Well Exam, Est, 40 -64 Years $102.94 G0202 Mammogram, Screening (Bilateral) Digital $129.54 01/17/2014 25 Client Name: City of Clearwater Administrative Services Only Agreement 77052 Add on for iCad The Urgent Care case rate excluding radiology and laboratory services is $115. $11.48 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: Group 1 - $328 Group 2 - $469 Group 3 - $1159 Group 4 - $1451 Group 5 - $1454 Group 6 - $1025 Group 7 - $1717 Group 8 - $1104 Group 9 - $1432 Unlisted - $469 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. 01/17/2014 26