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<br />GROUP BENEFITS SERVICES AGREEMENT <br />NON-PARTICIPATING <br /> <br />This Agreement is between the Employer named in the Schedule and the TML Intergovernmental Employee <br />Benefits Pool, 1821 Rutherford Lane, Suite 300, Austin, Texas 78754 <br /> <br />SCHEDULE <br /> <br />1. Employer: City of Paris <br />2. Effective Date: 5/1/02 <br />3. Monthly Service Charge per employee per month: <br /> <br />. <br /> <br />Claims Administration <br />Medical <br />Medical Management <br />Self Funded Vision <br /> <br />5/1/02 <br />$12.50 <br />$2.55 <br />.50 <br /> <br />5. Optional Services (PEPM = per employee per month; PPPP = per participant per month) <br />o PPN Access Fee using direct contracts $3.50 <br />o HIP AA Compliance Adm.PEPM $0.50 <br />o Continuation of Coverage/Set Up $50.00 PEPM $0.50 <br />o Medical Conversion PEPM $0.40 <br />o Disease Management $0.00 (per coordination with PCS) <br />o Flex Plan PPPP/Set up $50.00 enrollee $5.00 <br />o Retiree Direct Billing (PRPR) $1.00 <br />o Alternate Plan $1.25 <br />o Dental (Self-funded) $2.10 <br />o Vision (Self-funded) $0.00 <br />o HealthChex - Auto Audit No Charge per Addendum A attached <br />o Custom Claims Reports $150.00/programming hour <br />o Rx Card Claims $ 0.32/c1aim PA $30.00 initial and every 6 or 12 <br />months after initial pre-authorization -pre-authorization is an optional service <br />o HIPAA Certificates Included in Medical Admin Fee <br />o Benefit Booklets (every 2 years) Included for Number ofEE Plus 10% <br />o PPO Directories Included For Number of EE Plus 10% <br />o Run-in/ 90 day Run-out $12.50 per claim <br />o Outpatient Audits 15% of savings - External Vendor <br />o Hospital Audit 20% of savings - External Vendor <br />o Subrogation 20% of savings - In-House CounsellExternal <br />Vendor <br />o Out of State Network <br />o Out of Network Claims (Concentra) <br />o Usual and Customary (Concentra) <br />o Dental Consultant <br /> <br />18% of savings - External Vendor <br />25% of savings - External Vendor <br />25% of savings- External Vendor <br />$23.00 dental, $50.00 medical, $75.00 TMJ referral <br /> <br />EXHIBIT A.. <br /> <br />0..._..... 1 ....ct: <br />