HomeMy WebLinkAboutDoc 121 - Health Benefits Plan Admin SvcsDeschutes County Board of Commissioners
1300 NW Wall St., Suite 200, Bend, OR 97701-1960
(541) 388-6570 - Fax (541) 385-3202 - www.deschutes.org
AGENDA REQUEST & STAFF REPORT
For Board Business Meeting of 03/30/2011
Please see directions for completing this document on the next page.
DATE: 03/16/2011
FROM: Ronda Connor Personnel 541-385-3215
TITLE OF AGENDA ITEM:
Consideration of Board signature of Document No. 2011-121, Exhibit A renewal to health benefits plan
document.
PUBLIC HEARING ON THIS DATE? NO
BACKGROUND AND POLICY IMPLICATIONS:
Annual renewal of administration fees (Exhibit A) to EBMS for the following categories: Medical,
Dental, HIPAA, COBRA, Coordinated Care, Case Management, Health Impact. New fees include the
following- re -pricing fee for PPO services, a reduction in PPO access fees, peer review fees and
document printing fees. Amend to change Stop Loss carriers with new rates.
FISCAL IMPLICATIONS:
$768,000 The new fees listed above represent a net $46,000 in savings to the plan.
RECOMMENDATION & ACTION REQUESTED:
Approve Document No. 2011-121, exhibits to the EBMS contract.
ATTENDANCE: Ronda Connor
DISTRIBUTION OF DOCUMENTS:
Ronda Connor
$768,000 The new fees listed above represent a net
DESCHUTES COUNTY DOCUMENT SUMMARY
(NOTE: This form is required to be submitted with ALL contracts and other agreements, regardless of whether the document is to be
on a Board agenda or can be signed by the County Administrator or Department Director. If the document is to be on a Board
agenda, the Agenda Request Form is also required. If this form is not included with the document, the document will be returned to
the Department. Please submit documents to the Board Secretary for tracking purposes, and not directly to Legal Counsel, the
County Administrator or the Commissioners. In addition to submitting this form with your documents, please submit this form
electronically to the Board Secretary.)
Date:
02/22/2011
Please complete all sections above the Official Review line.
Department:
Contractor/Supplier/Consultant Name:
Contractor Contact:
3575
Julie Nelson
EBMS
Personnel
Type of Document: Services Agreement #2011-121
Contractor Phone #:
Goods and/or Services: #2011 -Health Benefit Plan administration services
800 -777 -
Background & History: Annual renewal of administration fees to EBMS for the
following categories: Medical, Dental, HIPAA, COBRA, Coordinated Care, Case
Management, Health Impact. New fees include the following- re -pricing fee for PPO
services, a reduction in PPO access fees, peer review fees and document printing fees.
Amend to change Stop Loss carriers with new rates.
Agreement Starting Date:
into 1/01/11 document)
08/01/10 and 01/01/11 (8/01/10 changes are incorporated
Annual Value or Total Payment:
$46,000 in savings to the plan.
Ending Date:
Renewed Annually
Insurance Certificate Received check box)
Insurance Expiration Date:
Check all that apply:
❑ RFP, Solicitation or Bid Process
❑ Informal quotes (<$150K)
❑ Exempt from RFP, Solicitation or Bid Process (specify — see DCC §2.37)
Funding Source: (Included in current budget? ® Yes ❑ No
If No, has budget amendment been submitted? ❑ Yes 1 I No
Is this a Grant Agreement providing revenue to the County? 1 Yes X No
Special conditions attached to this grant:
Deadlines for reporting to the grantor:
2/25/2011
If a new FTE will be hired with grant funds, confirm that Personnel has been notified that
it is a grant -funded position so that this will be noted in the offer letter: Yes No
Contact information for the person responsible for grant compliance: Name:
Phone #:
Departmental Contact and Title: Ronda Connor
3215
Department Director Approval:
Signatur
Distribution of Document: Ronda Connor in Personnel.
Phone #: 385 -
Date
Official Review:
County Signature Required (check one): J BOCC ❑ Department Director (if <$25K)
❑ Administrator (if >$25K but <$150K; if >$150K, BOCC Order No.
Legal Review
Document Number
Date
2/22/2011
SCHEDULE A
FEES
A. Pursuant to the Administrative Services Agreement, the Plan Sponsor shall submit to the Contract Administrator:
Administrative Fees
Medical
Dental
Vision
COBRA
HIPAA
Health Impact
Coordinated Care
Case Management
Priority Maternity
Subrogation Fee
Peer Review
Plan Document Printing
EBMS Re -pricing
First Choice Health$1.25 per employee per month in network
(Effective 1/1/2011)
$16.15 per employee per month
$2.50 per employee per month
$0.50 per employee per month
$1.00 per employee per month
$1.00 per employee per month
$4.25 per employee per month
$2.00 per employee per month
$1.60 per employee per month
$340.00 per screened case
15% per recovery
Cost + $50.00 per case
Cost
**2 year rate guarantee until 9/1/2011
(Additional Administrative Fees may be reflected on the pertinent Schedule.)
B. The Contract Administrator shall receive from the Plan Sponsor (for remittance to the appropriate entity) the
following:
Stop -loss Premiums Specific - Composite $24.31 per employee per month
Aggregate $3.03 per employee per month
C.
D.
E.
F.
PPO Fees Providence Preferred
First Choice Health
$3.35 per employee per month in network
(Termed 12/31/2010)
$2.65 per employee per month in network
(Effective 1/1/2011)
The MultiPlan Network (Multiplan) may provide fee negotiating services for claims
from providers who are not already participating in discount arrangements with Plan
Sponsor. Multiplan will retain eighteen percent (18%) and EBMS will retain three
percent (3%) of whatever savings is created by MultiPlan's fee negotiating services,
for a total of a twenty-one percent (21%) retention of savings.
The Contract Administrator shall be authorized to deduct the administrative fees for each month from the Plan's
claims paying account.
A binder fee of $ N/A representing the first month's estimated fees shall be payable on or before the effective
date of this Agreement.
An initial one-time set-up fee of $ N/A for eligibility loading, plan building and other services, shall be payable
prior to commencement of services under this agreement.
The Plan Sponsor shall pay to the individual responsible for service and support $ N/A per employee per month,
which amount shall be submitted to Contract Administrator, for delivery to the service/support representative.
G. The fee structure shall be renewed annually and revised to be mutually acceptable to both parties.
DC 2011
i tr
Effective Date: August 1, 2010
PLAN SPONSOR:
By:
Its:
Deschutes County
CONTRACT ADMINISTRATOR:
By:
Employee Benefit Management Services, Inc.
Its: Chief Executive Officer
SCHEDULE B
COBRA
The Plan Sponsor requests that the Contract Administrator provide certain services in compliance with the requirements of the
Consolidated Budget Reconciliation Act (COBRA) as amended, and all related regulations with respect to the Plan Sponsor's
COBRA responsibilities in consideration of the following:
DUTIES AND RESPONSIBILITIES OF PLAN SPONSOR
A. Notify the Contract Administrator in writing, of all Plan Participants and Plan Beneficiaries eligible under the Plan.
B. Notify the Contract Administrator of certain qualifying events, in writing, within thirty (30) days of the occurrence
of a qualifying event, including but not limited to a covered employee's end of employment, a covered employee's
reduction of hours of employment, death of a covered employee, commencement of a proceeding in bankruptcy
with respect to the employer, or the covered employee becoming entitled to Medicare benefits (under Part A, Part B,
or both). Said Notice shall contain sufficient information to satisfy the requirements as set forth in the Act.
C. Forward any necessary information and/or documentation on to Contract Administrator applicable to a Plan
Participant and/or a Plan Beneficiary and a Qualifying Event.
D. Assist Contract Administrator in obtaining any necessary information and/or documentation applicable to a Plan
Participant and/or Plan Beneficiary.
E. Notify Contract Administrator of any Plan Participant and/or Plan Beneficiary address change.
F. If applicable, forward the necessary COBRA premium on to the Contract Administrator.
DUTIES AND RESPONSIBILITIES OF CONTRACT ADMINISTRATOR
A. Upon receipt of complete eligibility documentation, Contract Administrator shall provide each Plan Participant and
all applicable Plan Beneficiaries with written initial notice of his or her continuation coverage rights under the Plan.
B. Following notice of a qualifying event, Contract Administrator will notify all qualified beneficiaries of
continuation coverage rights and premium amounts.
C. Contract Administrator shall receive elections and premiums from qualified beneficiaries, track all premium
payments received, and provide telephonic assistance for inquiries on COBRA benefits.
D. Contract Administrator shall notify qualified beneficiaries of rate changes, the unavailability of COBRA, and
COBRA termination.
COMPENSATION
A. In addition to 2% of the applicable premium of those who elect and pay COBRA, Contract Administrator shall be
compensated for COBRA services $1.00 per employee per month as reflected on Schedule A.
B. To be completed by sales representative: N/A
C. Contract Administrator shall be authorized to deduct the administration fees for each month from the Plan's claim
paying account.
D. A binder fee of $ N/A representing the first month's estimated fees shall be payable on or before the effective
date of this Agreement.
E. The fee structure shall be renewed annually and revised to be mutually acceptable to both parties.
Effective Date: August 1, 2010
PLAN SPONSOR:
By:
Its:
Deschutes County
CONTRACT ADMINISTRATOR:
By:
Employee Benefit Management Services, Inc.
Its: Chief Executive Officer
SCHEDULE D
CARE LINK ADDENDUM
The Plan Sponsor requests that the Contract Administrator provide certain cost management services.
A. COORDINATED CARE
Coordinated Care is a program designed to assist Covered Persons in understanding and becoming involved with their
diagnosis and medical plan of care, and advocates patient involvement in choosing a medical plan of care. This program is
not designed to be the practice of medicine or to be a substitute for the medical judgment of the attending Physician or other
health care providers. The final decision regarding health care always remains with the Covered Person and his or her
Physician.
The services provided through this program include the coordination of care for scheduled and emergent hospital
admissions.
• The program requires notifying CARE LINK for the following inpatient admissions: acute hospitalizations, free-
standing chemical dependency facilities, free-standing mental health facilities, and free-standing rehabilitation
facilities. A CARE LINK nurse may contact the Covered Person and/or the provider to provide health education,
pre -surgical counseling, inpatient care coordination, facilitation of discharge plan, and post -discharge follow-up.
• Prior to entering a medical care facility on a non -emergency basis, CARE LINK should be notified at least seven
(7) days before services are scheduled to be rendered, at which time CARE LINK should be provided adequate
information as set forth in the Plan Document and Summary Plan Description. A CARE LINK nurse will be
available at this time to help coordinate the plan of care, answer questions, and assist with any discharge needs.
• If it appears that a Covered Person has a continued stay, CARE LINK will contact the facility to confirm an
anticipated day of release, and if continued hospitalization is required, the CARE LINK nurse will coordinate
with the provider and facility to identify the member's current and continued plan of care.
• If there is an emergency admission to a medical care facility, the patient, patient's family member, medical care
facility or attending physician should notify CARE LINK within two (2) business days after the admission.
Hospital Observation Room stays in excess of 23 hours are considered an admission for purposes of this program.
CARE LINK's toll-free number and office hours are listed on the back of the member's card and are also provided in the
Plan Document and Summary Plan Description.
B. CASE MANAGEMENT
Upon the occurrence of a catastrophic condition, including but not limited to, a spinal cord injury, cancer, AIDS or a
premature birth, where a person may require long-term, perhaps lifetime care, a Case Manager will monitor these certain
patients and explore, discuss and coordinate alternate types of appropriate medically necessary care. The Case Manager will
consult with the patient, the family and the attending Physician in order to coordinate a plan of care approved by the patient's
attending Physician and the patient. This plan of care may include some or all of the following:
1. Individualized support to the patient;
2. Contacting the family to offer assistance for coordination of medical care needs;
3. Monitoring response to treatment;
4. Determining alternative care options; and
5. Assisting in obtaining any necessary equipment and services.
Note: Case Management is a voluntary service. There are no reductions of benefits or penalties if the patient and family
choose not to participate. Each treatment plan is individually tailored to a specific patient and should not be seen as
appropriate or recommended for any other patient, even one with the same diagnosis.
C. TELEPHONE CONSULTATION
CARE LINK nurses are available by a toll-free line during CARE LINK normal working hours to answer Covered
Person's health-related questions. Assistance ranges from providing a better understanding of specific medical
procedures, to translations of medical terminology and help in locating community support services.
D. MISCELLANEOUS
EBMS shall have no responsibility or liability to anyone for the results of professional services rendered by health care
providers. EBMS shall have no right or obligation under this Schedule or the Administrative Services Agreement to intervene
in the determination of what such services shall be or how they shall be rendered. Decisions to obtain or deliver any health
care service shall always be made only by the patient and/or the patient's treating professionals.
EBMS may rely on the recommendations of licensed health care professionals retained by EBMS to assist EBMS in
rendering the health care management services provided for under this Schedule.
EBMS' health care management services do not include a guarantee or certification to anyone that particular professional
services are covered under the Plan or that benefits will be paid for those services. Final eligibility and coverage decisions
can be made only after a complete claim is submitted and fully processed for payment.
Effective Date: August 1, 2010
PLAN SPONSOR:
By:
Its:
Deschutes County
CONTRACT ADMINISTRATOR:
By:
Employee Benefit Management Services, Inc.
Its: Chief Executive Officer
SCHEDULE E
HIPAA CERTIFICATION
The Contract Administrator will provide certification of creditable coverage with respect to the Plan Sponsor's
responsibilities in compliance with the requirements of the Health Insurance Portability and Accountability Act of 1996
(HIPAA), as amended, and all related regulations in consideration of the following:
DUTIES AND RESPONSIBILITIES OF PLAN SPONSOR
In a timely manner, Plan Sponsor shall submit, in writing, complete and accurate employment, health and coverage data to
Contract Administrator.
DUTIES AND RESPONSIBILITIES OF CONTRACT ADMINISTRATOR
A. Issue certificates of coverage to those who, based upon data provided by Plan Sponsor, lose coverage under the
Plan.
B. Issue certificates of coverage to those who elect COBRA, then cease to be covered by the COBRA continuation
coverage provided by the Plan.
C. Issue certificates of coverage to those who request such certificate, but no later than twenty-four (24) months after
cessation of coverage as set forth in the preceding two paragraphs.
COMPENSATION
A. Contract Administrator shall be compensated for HIPAA Certification services at the rate of $1.00 per employee per
month as reflected on Schedule A.
B. The Contract Administrator shall be authorized to deduct the administration fees for each month from the Plan's
claim paying account.
C. The fee structure shall be renewed annually and revised to be mutually acceptable to both parties.
Effective Date: August 1, 2010
PLAN SPONSOR:
By:
Its:
Deschutes County
CONTRACT ADMINISTRATOR:
By:
Employee Benefit Management Services, Inc.
Its: Chief Executive Officer
SCHEDULE L
SUBROGATION AND THIRD PARTY RECOVERY
The Plan Sponsor requests that the Contract Administrator provide certain services in order to protect the assets of the Plan
in the event any recovery is available from a third party source.
DUTIES AND RESPONSIBILITIES OF PLAN SPONSOR
A. The Plan Sponsor agrees that Contract Administrator shall provide subrogation and third party recovery services
to the Plan. Plan Sponsor agrees that it will furnish all information it may possess regarding claims subject to
third party recovery.
B. Certain cases will require referral to an outside attorney and additional legal work beyond the scope of the
services contemplated by this Schedule. The Plan Sponsor agrees that engagement of an outside attorney shall be
the Plan's responsibility and that upon engagement of such, the Contract Administrator shall cooperate with the
outside attorney but will have no further obligation to pursue recovery.
C. The Plan Administrator shall timely respond to settlement offers presented by Contract Administrator.
D. The Plan Administrator shall have the right to terminate the pursuit and/or recovery efforts against a third party,
the participant, or any other liable party at any time.
DUTIES AND RESPONSIBILITIES OF CONTRACT ADMINISTRATOR
A. The Contract Administrator shall provide subrogation and third party recovery services necessary to pursue the
Plan's equitable interests including the initial determination as to whether a subrogation or third party action
exists, supervision, follow-up and closure. If the Plan Sponsor does not agree to the course of recovery action
proposed by the Contract Administrator, the Contract Administrator shall have no further obligation or liability
whatsoever for the recovery and reimbursement of the Plan's equitable interests. Services such as filing an
action in State or Federal Court are beyond the scope of the services contemplated by this Agreement.
B. The Contract Administrator may engage such outside consultants and services as the Contract Administrator
deems necessary to pursue the Plan's interests. Fees of such outside consultants and services shall not be the
responsibility of the Plan, without its prior written consent.
C. The Contract Administrator agrees to provide summary status reports of subrogation and third party recovery
upon request of the Plan Sponsor.
D. The Contract Administrator agrees that it shall have no authority to compromise the Plan's equitable interests in
excess of Ten Thousand ($10,000) without consent of the Plan Sponsor.
E. Plan Sponsor hereby grants Contract Administrator authority to accept settlement of the Plan's equitable interests
for offers received between Two Thousand One ($2,001) and Ten Thousand ($10,000) Dollars without the Plan
Sponsor's specific consent, if the settlement offer is more than or equal to sixty-six percent of the Plan's
equitable interests. Offers less than sixty-six percent will be presented to the Plan Sponsor for its review.
F. The Contract Administrator shall have no obligation to pursue the Plan's equitable interests between One ($1)
and Two Thousand ($2,000) Dollars. If the Contract Administrator does pursue such an interest on the Plan's
behalf, the Plan Sponsor agrees that the Contract Administrator shall have the authority to compromise the lien
and accept settlement on the Plan's behalf.
COMPENSATION
The Plan Sponsor agrees to engage the Contract Administrator on a contingency fee basis upon the terms and
conditions as set forth herein and the Contract Administrator agrees to accept fifteen percent (15%) of all recoveries
by Contract Administrator received as payment in full for all subrogation and third party recovery services.
Effective Date: August 1, 2010
PLAN SPONSOR:
By:
Its:
Deschutes County
CONTRACT ADMINISTRATOR:
By:
Employee Benefit Management Services, Inc.
Its: Chief Executive Officer