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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 />l. Employer: City of Paris <br />2. Effective Date: 5/1/03 <br />3. Monthly Service Charge per employee per month: <br /> <br /> · Claims Administration 5/1/03 <br /> Medical $12.75 <br /> Medical Management $2.55 <br /> <br />4. Optional Services (PEPM = per employee per month; PPPP = per participant per month) <br /> rn PPN Access Fee using direct contracts $3.75 <br /> [] Self Funded Vision $ .50 <br /> [] Self-funded Dental $2.15 <br /> [] H1PAA Compliance Adm. PEPM $0.50 <br /> [] Continuation of Coverage/Set Up $50.00 PEPM$0.50 <br /> cl Medical Conversion PEPM $0.40 <br /> ca Disease Management $1.50 <br /> ca Flex Plan PPPP/Set up $50.00 enrollee $5.00 <br /> ca Retiree Direct Billing (PRPR) $1.00 <br /> [] Alternate Plan $1.25 <br /> [] HealthChex - Auto Audit No Charge per Addendum A attached <br /> [] Custom Claims Reports $150.00/programming hour <br /> ca Rx Card Claims $ 0.32/claim PA $30.00 initial and every 6 or 12 <br /> months after initial pre-authorization -pre-authorization is an optional service <br /> ca HIPAA Certificates Included in Medical Admin Fee <br /> [] Benefit Booklets (every 2 years) Included for Number of EE Plus 10% <br /> [] PPN Directories Included For Number of EE Plus 10% <br /> ca Run-in/90 day Run-out $12.75 per claim <br /> rn Outpatient Audits 15% of savings - External Vendor <br /> ca Hospital Audit 20% of savings- External Vendor <br /> [] Subrogation 20% of savings - In-House Counsel/External <br /> Vendor <br /> c~ Out of State Net~vork 18% of savings - External Vendor <br /> ca Out of Network Claims (Concentra) 25% of savings - External Vendor <br /> ca Usual and Customary (Concentra) 25% of savings- External Vendor <br /> Ca Dental Consultant $23.00 dental, $50.00 medical, $75.00 TMJ referral <br /> <br /> EXHIBIT <br /> <br /> <br />