ADMINISTRATIVE SERVICES ONLY AGREEMENT (3) Docusign Envelope ID:3EOBF5F9-6505-4456-A71 B-371 B286A8AC9
Aimee E.Burnham
Contract Director %so
Cigna Healthcare
August 21, 2025
ciffi .,n,ia,
City of Clearwater 9 healthcare
100 South Myrtle Avenue
Clearwater, FL 33756 Routing W 122A
900 Cottage Grove Road
Hartford,CT 06152
Telephone 860.226.4422
RE: Administrative Services Only Account No. 2499162,3331468 Aimee.Burnham@evernorth.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, 2023 (the "Agreement") and as amended on January 1,
2024, and January 1, 2025.
Effective as of January 1, 2026, 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 3.d of the Administrative Services Only Agreement is hereby amended in its entirety as
follows:
d. CHLIC will promptly adjust any underpayment of Plan Benefits or pay-for-performance payments by
drawing additional funds due the claimant from the Bank Account. In the event CHLIC determines
that it has overpaid a claim for Plan Benefits,paid Plan Benefits to the wrong party,or overpaid a pay-
for-performance payment ("Overpayment"), CHLIC or its affiliates shall take all reasonable steps
consistent with the policies and procedures applicable to its own health care insurance business to
recover such Overpayment ("Overpayment Recovery"). Overpayment Recovery efforts for services
rendered by Participating Providers may include, subject to the terms of Participating Provider
agreements, reasonable steps to wholly or partially offset any Overpayment against other payments
owed to such Participating Providers for services provided under the Plan or other unrelated plans
administered by CHLIC or its affiliates. Employer also authorizes CHLIC and its affiliates to recover
Overpayment(s) made to Participating Providers for services provided under other, unrelated plans
administered by CHLIC or its affiliates by offsetting the amount of any such Overpayment(s) against
Plan Benefits and/or pay-for-performance payments otherwise payable to those Participating Providers
for services provided to Members. Claims subj ect to Overpayment Recovery as part of any reasonable
Overpayment Recovery efforts for the Plan,or Overpayment Recovery efforts for CHLIC's own health
care insurance business shall be selected based on factors such as the age and amount of the
Overpayment. CHLIC shall also take all reasonable steps consistent with the policies and procedures
applicable to its own health care insurance business to collect pay-for-performance payments due to
Employer or to recover pay-for- performance overpayments (collectively "Pay-for-Performance
Recoveries"). CHLIC shall not be required to initiate court, mediation, arbitration or other
administrative proceedings to recover any overpayment of Plan Benefits or to collect or recover Pay-
for-Performance Recovery. However, when it elects to do so, CHLIC is expressly authorized by
Employer to take all actions on behalf of the Employer and/or the Plan to pursue overpayment recovery
of Plan Benefits or to collect or recover Pay-for-Performance Recovery including, but not limited to,
retaining counsel,settling and compromising claims or Pay-for-Performance Recoveries,in which case
CHLIC shall be responsible for the attorney fees, court costs or arbitration fees incurred by CHLIC in
the specific overpayment recovery action of Plan Benefits(not applicable to subrogation or conditional
claim payment recoveries)or to collect or recover Pay-for-Performance Recovery,but not any indirect,
Docusign Envelope ID:3EOBF5F9-6505-4456-A71 B-371 B286A8AC9
City of Clearwater
August 21,2025
Page 2
associated third party costs absent consent of CHLIC. CHLIC shall not be responsible for reimbursing
any unrecovered payments of Plan Benefits or Pay-for-Performance Recoveries unless made as a result
of its gross negligence or intentional wrongdoing.
Section 6, "Audit Rights," of the Administrative Services Only Agreement is hereby amended in its
entirety as follows:
Section 6.Audit Rights
a. Employer may audit CHLIC's administration of Plan Benefits at no additional charge while this
Agreement is in effect and in accordance with the following requirements:
i.Notification and timing of audit.
a.For a clinical audit, Employer shall provide to CHLIC a scope of audit letter, which scope
shall be mutually agreed upon by the parties, and a fully executed audit agreement, together
with a ninety(90) day advance written request to audit.
b.For all other audits described below,Employer shall provide to CHLIC a scope of audit letter,
and a fully executed audit agreement, together with a forty-five (45) day advance written
request for audit.
ii. Employer may designate with CHLIC's consent (which consent shall not to be unreasonably
withheld) an independent,third-party auditor to conduct the audit(the "Auditor").
Ili. Employer and CHLIC will agree upon the date for the audit during regular business hours in a
virtual/remote audit environment or at CHLIC's office(s), as business needs require.
iv. 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 CHLIC's audit agreements which
shall be signed by the Auditor prior to the start of the audit.
V. If the audit identifies any errors requiring adjustments, such adjustments will be made in
accordance with this Agreement and based upon the actual claims and fees reviewed and not
upon statistical projections or extrapolations.
vi. Employer shall be responsible for its Auditor's costs. In the event Employer requests to alter the
scope of the audit, CHLIC will endeavor to reasonably accommodate the Employer's request,
which may be subject to additional charges to be mutually agreed upon by the Employer and
CHLIC prior to the start of the audit.
vii. 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).
viii. In no event shall any audit involve Plan benefit payments or administration prior to the most
recent two (2) plan years, (unless otherwise noted) or involve Plan benefit payment or
administration that has been previously audited.
ix. New audits shall not be initiated until all parties have agreed that the prior audit is closed.
Docusign Envelope ID:3EOBF5F9-6505-4456-A71 B-371 B286A8AC9
City of Clearwater
August 21,2025
Page 3
X. Employer may (as determined by CHLIC based upon the resources required by the audit
requested) be responsible for CHLIC's reasonable costs with respect to the audit, except that
while this Agreement is in effect there shall be no additional cost to Employer for an audit of the
following:
• Claims: Payment documents relating to a random, statistically valid sample of two-hundred twenty-
five(225) claims paid.
o Requests to review provider contracts will be subject to CHLIC's current criteria and contrary
terms in Participating Provider Agreements.
• Appeals: Documents,including payment documents as appropriate,relating to a random sample of up
to thirty-five (35) appeals.
• Customer Service: Documentation and review of call recordings relating to a random sample of up to
thirty-five(35)Member calls.
o CHLIC maintains call recordings for up to twelve(12)months, and any customer service audit is
limited to the availability of the call recordings.
• Accumulator/Combined Deductible: Audits are allowed based on mutually agreed-upon scope of up
to thirty(30) cases.
• Benefit Implementation: Audits are allowed based on mutually agreed-upon scope and timing.
CHLIC will support the benefit implementation audits for review of benefit set up related to claim
processing.
• Medical Cost Containment Program Fees (MCCP) (Out-of-Network Protection and Payment
Integrity Program Fees): MCCP audits are limited to confirmation of fees paid by the Employer
related to the programs in place. The audits will not include review of documentation that is not
applicable to claim administration. In addition, Auditor will need to agree that it will not outreach to
Participating Providers or Members for claim or medical record information.
MCCP fee audits are based on the following criteria:
C) Random samples based on the following:
■ Twenty-five (25) claims in which fees were paid for Medical Out-of-Network Protection
Programs which include Network Savings Program and Bill Negotiation Services (Pre-
payment Cost Containment for Non-contracted claims)
■ One-hundred (100) claims in which fees were paid related to Payment Integrity Programs
which include Medical Bill Review; Medical Implant Device Review; Clinical Waste and
Abuse Claim Review; High-Cost Specialty Pharmaceutical Review; other target billing
accuracy review programs; Diagnosis Related Grouping Review; Coordination of Benefits
(COB)Investigation and Recoveries; Secondary Vendor Recovery Program;Provider Credit
Balance Recovery Program; Eligibility Overpayment Recovery Vendor Services; and
Subrogation/Conditional Claim Payment.
• Clinical Cases/Calls: Subject to CHLIC staff availability, the standard annual allowable number of
cases/calls for audit and standard number of days allowed to conduct the audit is as follows, based on
number of Employer Subscribers during the time period covered by the audit:
Number of Subscribers #Cases #Calls #Days*
Docusign Envelope ID:3EOBF5F9-6505-4456-A71 B-371 B286A8AC9
City of Clearwater
August 21,2025
Page 4
51000&under 10 3 1
>51000&<25,000 15 4 1
>251000&<759000 20 5 1.5
>755000 25 6 2
All cases and calls related to case selection will be prepared and presented in compliance with all Applicable
Laws,Privacy Addendum in Exhibit D,including but not limited to the HIPAA Privacy and Security Rules
and 42 C.F.R. Part 2.. Cases selected will have been managed during the rolling twelve(12)month period
prior to the date of the written request to conduct an audit and not previously audited for the current audit
scope.
*Takes into consideration length of time to complete the standard number of cases and calls based on a one
(1)year lookback scope period.
b. Pharmacy Audits. The rights and obligations regarding pharmacy audits are set forth in Appendix
A.
The"Schedule of Financial Charges" and"Exhibit B","Services"are hereby deleted in their entirety
and replaced with the "Schedule of Financial Charges" and "Exhibit B, "Services," as attached
hereto.
Docusign Envelope ID:3EOBF5F9-6505-4456-A71 B-371 B286A8AC9
City of Clearwater
August 21,2025
Page 5
The terms of the Administrative Services Only Agreement identified above, as mentioned herein, will be
effective as of January 1, 2026. 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 Only
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.
Sincerely,
Pv
Printed Name: Aimee E. Burnham
Title: Its Contract Director
Duly Authorized
Cigna Health and Life Insurance Company
Accepted by: CITY OF CLEARWATER
By:
Printed Name:
Title: Its
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Docusign Envelope ID:3EOBF5F9-6505-4456-A71 B-371 B286A8AC9
Administrative Services Only Agreement for City of Clearwater
Appendix B - Cigna Home Delivery Pharmacy Specialty Drug List
THIS SPECIALTY DRUG LIST IS CONFIDENTIAL, PROPRIETARY INFORMATION OF
CHLIC. IT IS PROVIDED SOLELY FOR EMPLOYER'S PLAN ADMINISTRATION
PURPOSES. RE-DISCLOSURE IS STRICTLY PROHIBITED EXCEPT AS OTHERWISE
PROVIDED BY APPLICABLE LAW. CHLIC RESERVES ALL LEGAL RIGHTS AND
REMEDIES TO ENFORCE THESE PROHIBITIONS ON USE AND DISCLOSURE.
The Specialty Drug List shall be provided separately to Employer, and is hereby incorporated into
the Agreement by reference, inclusive of any changes made subsequent to CHLIC's initial issuance
of the Specialty Drug List to Employer to the pharmaceutical products included on the Specialty
Drug List or the discounts, if any, pertaining to such pharmaceutical products. Upon Employer's
request on or after the Effective Date, CHLIC shall provide to Employer an updated Specialty Drug
List.
New-to-Market Specialty Products. Specialty Drug Claims, excluding Limited Distribution Drugs and
Exclusive Distribution Drugs,that are for new-to-market drugs will have a minimum market-
introduction guaranteed discount of 11.45% off the drug's AWP.
Cigna Health and Life Insurance 72 08/21/2025
Company
Docusign Envelope ID:3EOBF5F9-6505-4456-A71 B-371 B286A8AC9
Countersigned: CITY OF CLEARWATER, FLORIDA
Signed by: Signed by:
By:
YUA/U* r p6t,mir
Bruce Rector Jennifer Poirrier
Mayor City Manager
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Approved as to form: Attest:
Signed by:
DocuSigned by:
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Owen Kohler Rosemarie Call
Assistant City Attorney City Clerk