1996-034-RES WHEREAS, CITY COUNCIL IS DESIROUS OF PROVIDING HEALTH CARE FOR COP
RESOLUTION NO. 96-034
WHEREAS, the City Council of the City of Paris is desirous of providing health care
for the City of Paris employees at the most reasonable price available for adequate coverage;
and,
WHEREAS, bids for the furnishing and delivery of (I) Term Life Insurance, (2)
Stoploss Insurance for its otherwise self-funded Medical/Dental/Vision Program, (3) Third-Party
Administrative Services for the above coverage, and (4) Maintenance Drug Program were
received until 10:00 a.m., Tuesday, March 5, 1996; and,
WHEREAS, the best bid for the furnishing and delivery of (1) Term Life Insurance, (2)
Stoploss Insurance for its otherwise self-funded Medical/Dental/Vision Program, (3) Third-Party
Administrative Services for the above coverage, and (4) Maintenance Drug Program was made
by the Texas Municipal League and it was awarded such bid by the City Council of the City of
Paris at its regular meeting on the 11th day of March, 1996; and,
WHEREAS, the form of the contract with the Texas Municipal League, attached hereto
as Exhibit A, should, in all things be approved, and the Mayor of the City of Paris, Eric S.
Clifford, should be authorized to execute the same; NOW, THEREFORE,
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF PARIS, that the
form of the contract with the Texas Municipal League, attached hereto as Exhibit A, be, and the
same is hereby, approved; and,
BE IT FURTHER RESOLVED, that Eric S. Clifford, Mayor of the City of Paris, be,
and he is hereby, authorized and directed to execute, on behalf of the City of Paris, the contact
with Texas Municipal League for (1) Term Life Insurance, (2) Stoploss Insurance for its
otherwise self-funded Medical/Dental/Vision Program, (3) Third-Party Administrative Services
for the above coverage, and (4) Maintenance Drug Program, upon the terms and conditions and
in the form shown in Exhibit A, attached hereto.
PASSED AND ADOYfED this 8th day of April, 1996.
~y ~
Eric . Clifford, Mayor
ATTEST:
~~~~~"~~'I"i'~~:J
Mattie Cunningham, City Clerk
CONTINUATION OF COVERAGE ADMINISTRATIVE AGREEMENT
WHEREAS, the undersigned Employer is an Employer Member of the Texas Municipal League Group Benelits Risk Pool
(hereinafter referred to as the 'Pool'):
WHEREAS, the undersigned Employer sponsors an employee benefit plan;
WHEREAS, the undersigned Employer is responsible for the administration of its employee benefit plan as the Plan
Administrator: and
WHEREAS, the undersigned Employer wants the Texas Municipal League Group Benefits Risk Pool to assist the Employer
in complying with the requirements of Continuation of Coverage.
NOW THEREFORE, in consideration of the promises. mutual covenants and agreemwts contained herein. the undersigned
Employer and the Pool agree as follows:
1. Effective Date
As ofthe Iirst day of May
for the undersigned Employer.
. 19 ~ the Pool will commence Continuation of Coverage administration~
11. Employer Duties
1. The undersigned Employer wal notify the Pool', Contract/Administrative Procedures Analyst assigned
to the Employer via FAX or Telephone (with a written follow up) within one (I) business day of a
qualifying event, as defined by the Continuation of Coverage statute and its amendments. of a Covered
Employee for which the Employer has immediate knowledge. Examples of this include termination:
resignation: death: retirement if the employee does not enroll for retiree coverage when oHered under the
Employer's benefit plan; reduction in hours (including reduction to zero hours) and absence from work
for a non job related injury or mnm after all earned sick leave, vacation leave and extended leave pursuant
to an adopted policy which is on file with the Pool has been exhausted.
2. The undersigned Employer wm distribute Attachment A, which advises each employee of their rights and
responsibilities under Continuation of Coverage. The Employer wal certify through a letter to the Pool
that the Attachment A was distributed to all Covered Employees as of the date the Pool conmlCnced
Continuation of Coverage Administration.
3. The undersigned Employer will distribute Attachment A to all employees who become covered by the
Employer's benefit plan after the date the Pool commenced Continuation of Coverage administration and
include verification of the distribution with the enrollment card when it is submitted to the Pool.
4. The undersigned Employer will notify the Pool via FAX or Telephone (with a written follow.up) within
one (I) business day of gaining knowledge tbt an employee has legally separated. divorced or a Covered
Dependent is no longer eligible for coverage (e.g. a child, over age 19, who is no longer a full-time stlldent
enrolled for 12 or more credit hours).
5. The undersigned Employer will notify the Pool at least ten (10) business days prior to any open
enrollment peclod. The notice to the Pool will include the dates of the open enrollment.
6. The undersigned Employer will immediately notily the Pool of any suspected claim, demand or suit
arising from the administration of Contlnuation of Coverage.
7.
The undersigned Employer will indemnify and hold harmless the Pool and its orficers, agents, employees
and representatives from all milS, actions. losses. damages, claims or liabaity of any type, including
without limiting the generality of the foregoing all expenses of litigation, court costS, and attorney's fees,
resulting from the failure of the undersigned Employer '0 give any notice required by this Agreement.
The undersigned Employer will fund this obligation out of current revenues in the year the obligation is
determined or will levy a t:llC to fund the obligation if current revenues are insufficient. .,~, =
TN11
EXHIBIT A
.... .._.._-
GItOUI' tn:Nt:nTS RISK PO(
CON'I1NUA'I10N OF COVER
ADMlNlSTRA llvE AGREEMENT. PACE 2
III. Pool Duties
1. The Pool .t.1I will monitor ch.nge. in Continu.tion of Coverage and the cose I.w which develops
interpreting Continuation of Cover:.lge.
2. The Pool will act within 14 days of the receipt of notices of qualifying events sent by the Employer.
3. The Pool will provide the appropriate notification letters to the employee or their dependent(s) as
required by Continuation of Cov~r:.lge statutes.
These letters m.y include any or ,]1 of tbe following:
a) benefit availability. initial notice, enrollment card and cost;
b) confirmation of enrollment and payment coupons
c) notice of termination leners
1. Failure to reply
2. Failure to make initial payment
3. Failure to make re&ular payment
4. End of eligibility (no longer qualified)
5. End of eligibility perind
d) open enrollment
e) contribution change and revised payment coupons
Q conversion to an individual policy
g) Medicare eligibility
h) verification of Cull.time student status
~ verification of inc:lpacitated child statuS
4. The Pool will provide the Continuation of Cover.ge p.rticip.nts witb ill cord., · benefit booklet, and
other materials as the need may arise.
s. The Pool will maintain record. th.t :Ill required notific:ltions were sent and copies ore .vaiI.ble to the
Member upon request.
6. The Pool will collect the required contribution..
7. The Pool will provide the Employer, for their review, with the text of the letter and notices to be used in
administering this Agreement. The Pool maintains final authority over the text of these letters and
notices. The Pool reserves unto itst:1f the right to modify the letters and notices as may be required
purruant tn the Continu:ltion of Cover.ge st:ltute, ;lIlY .pplicable cose bw ;lIld to promote the ellicient
administration of the Agreement.
8. The Pool will indemnify, defend, reimburse, and hold harmless the Employer and its employees from any
and all liabilities, claims, demands, or suits arising from or rel:1ted to the provision of Continuation of
Coverage administrative services unless those liabilities, claims, demands, or suits arise out of the
Employer'. failure to give ;lIlY notice :IS required in II, I, 2, 3, 4, 5 ;lIld G of this Agreement. The Pool.
upon notice by the Employer will immedi:ltely investigate, h.ndle, respond to :lnd defend;lIly ruch claims,
demands or suits at its sole expense. If the li~bility, claim, demand or suit is based on negligence this
contr.ct of indemnity .hall .pply ;lIld the negligence of the Employee ;lIld the Pool will be on a percentage
basi.s as in a pure comparative negligence situation under the law.
IV. Notice
Any notice to be given under this Agreement, other than those in II, 1, 2, 3, 4 and 5 of this Agreement, .hall be
deemed given ;lIld received on the lirst to occur nf the following: (a) actual receipt by the p:lrty to be notified; or (b)
five d.ys .fter deposit of such notice in the US M.il .ystem if sent by Certified Mail, Return Receipt Requested,
postage prep:lid, .nd addressed to the p.rty to be notified :It the .ddress of ruch p:lrty set forth below or as
designated from time to time in writing by giving not less than ten d.ys in adv.nce notice to the nther party. The
initial .ddresse. for the Pool :lnd Employer sldl be as follows:
GKOUI' IU:NEJo'ITS KISK I'OC
lleviaed2l2oJ9'
coc:aCmI.doc:
CONTINUA nON OF CQVERA
DMINISTRATIVE AGREEMENT - PAGE J
Address of Pool
Artdrp~s of Fmptoyer
Executive Director
Texas Municipal League Group Benefits Risk Pool
Texas Municipal Center
1821 Rutherford Lane, Suite 300
Austin, Texas 78754-5151
Personnel Director
City of Paris. Paris. Texas
P. O. Box 9037
Paris. TX 75461-9037
V. Compensation
1. The Employer will pay the Pool a one time fee of SSO.OO for each employee or any dependent that enrolls
in Continuation of Coverage. A family unit that enrolls together will pay only on $50.00 charge.
2. Other special services which may be requested by the Employer but arc not contained in this Agreement,
will be billed at a mutually agreeable hourly rate.
VI. Miscellaneous Provisions
1. This Agreement represents the complete understanding of the partics and may not be modified or
amended without the written agreement of both parties.
2. The parties agree that venue for any dispute arising under the terms of this Agreement shall be in Austin.
Travis County, Texas.
3. The parties agree that venue for any dispute arising out of the performance under their Agreement shall be
in Austin, Travis County, Texas.
4. In performing the administrative services under this Agreement, the Pool may rely without qualification
on the information provided by the Employer.
S. The Pool agrees to take over the remaining Continuation of Coverage administration for any of the
Employer's current Continuation of Coverage participants, without Employer compensation, so long as
the Employer furnishes the information necessary to effectUate the transfer.
6. This Agreement is entire as te ,tll of the performance to be rendered under it. If any term or provision of
this Agreement is held by a court of competent jurisdiction to be invalid, void or unenforceable, the
remainder of the provision of this Agreement shall be void and of no force and effect.
7. It is understood that the Pool will charge the Continuation of Coverage participant the administration fee
allowed by the Continuation of Coverage statute.
VII. Termination
April 30
1. Term of this initial Agreement shall be from its effective date through ~~m5eF}@, 19 9\1 , at 12:01 a.m.
The Employer member may annually renew the Agreement for the subsequent twelve (12) month period (May 1
through April 30) ~-t~~""""90) by executing and returning the Pool's rerate notice and benefit
selection for each year.
2.
Either party may terminate this Agreement at ;,\Oytime by giving the other party written notice at least
thirty (30) days prior to the specified date.
3.
This Agreement terminates, without further notice, on the date the undersigned Employer is no longer an
Employer Member 01 the Pool.
4.
All records in possession of the Pool relating to Continuation of Coverage administration at terminatiO~~ '
of the Agreement will be transferred to the Employer within five (5) business days. J r I
TML
flevised1l20/96
coc;~,mt.doc
GROUI' BENEFITS RISK POOL
CONTINUA nON OF COVER} ~DMINISTRA llVE AGREEMENT. PAGE 4
5. Should this Agreement terminate for any reason it does not relieve either party of their duties nor
obligations during the period when this A&reement was in full force :and effect.
This Agreement is entered into Cor the Employer Member under authorization of Resolution No. 96-034 :U 3.
duly called meeting held on
April 8. 1996
by:
(Sign.ture) Eric S. Clifford
City of Paris. Paris. Texas
(Employer Member/Group Name)
Mayor
(Authorized Official Tide)
April 8, 1996
(Date)
This Agreement Entered IntO and Accepted By:
TEXAS MUNICll'AL LEAGUE GROUP BENEFITS RISK POOL
BY:
TITLE: Executive Director
at Austin, T ex:!.s
Date
CITY OF PARIS, PARIS, TEXAS
ATTEST:
Mattie Cunningham, City Clerk
APPROVED AS TO FORM:
T. K. Haynes, City Attorney
riiL
Il.niHd 1/20/%
cocatmt.doc
GROUP Ot;NUITS RISK POOL
ATIACHMENT A. PAGE I
VERY IMPORTANT NOTICE
Any questions about this notice should be addressed to the Plan Administrator, your Employer.
CONTINUATION OF COVERAGE NOTICE
In 1986, :l Fcderallaw was enacted requiring most employers sponsoring group health plans to offer employees and their
families the opportunity for :l temporary extension of health coverage-cilled continuation of coverage-at group rates in
certain inst:mces where covc:rage under the plan would otherwise end. This notice is intended to inform YOU, in a summ:uy
fashion, of your rights and obligations under the law. Both you and your spouse should take time to rod this notice
carefully.
II you uc 3n employee covered by a group health plan. you have a right to choose this continuation coverage if you lose
your group health coverage because of a reduction in your hours of employment or the termination of your employment,
except for reasons of gross misconduct on your part.
If you are the spouse of an employee covered by a group health plan, you have the right to choose continuation coverage for
yourself if your lose group health coverage under the group health plan for any of the foU~wi.ng reaSons:
1. the death of your spouse;
2. a termination of your spouse's employment (for re:lSons other than gross misconduct) or reduction in
your spouse's hours of employment;
3. divorce or legal separation from your spouse; or
4. your spouse becomes entitled to Medic:lre.
In case of a covered dependent child or an employee covered by a group he:1lth plan, he or she has the right to continu:ltion
coverage group health coverage is lost for any of the following reasons:
1. the death of a parent;
2. the termination of a parent's employment (for re:lsons other than gross misconduct) or reduction in
parent's hours of employment;
3. paren!"s divorce or legal sep:lration;
4. a parent becomes entitled to Medicare; or
5. the dependent ceases to be a dependent child under the group health plan.
Under the 13w, the employee or a family member has 60 days to inform the employer of a divorce, legal sepantion, or
a child's losing dependent status under the group health p13n.
When the employer is notified that one of these events has happened, the employer will in turn notify you and your covered
dependent that your have the right to choose continuation coverage.
UDder the Jaw, you have 60 days from the date you would lose coverage because of ODe of the previously described eveDlS to
inform your employer that you want continuation coverage.
If you choose continuation of coverage, your employer is required to offer you coverage which, as of the time coverage is
being provlded, the same as the coverage provided under the plan to active employees and their family members. The law
requires that you be afforded the opportunity to maintain conti.nuation of coverage for:
1.
Up to eighteen (18) months if you as an employee or dependent lose coverage due to:
a. Termination of employment;
b. Reducti.on i..n hours;
2.
Up to twenty-nine (29) months if you a'i an employee or dependent qualify as totally disabled under Social
Security and your di.sability began prior to your quali.fYlng event.
kniledU201?6
111llch.uloc
Tfi[
GHOUl' III::Nl::n'fS KISK POOL
ATIACHMENT A-PAGE2
3. Up to thirty-six (36) months if you as a dependent lose coverage due to:
a. Death of a 'powe;
b. Divorce from your spouse;
c. Your spowe's entitled to Medicare;
d. Ceasing to be a dependent child under the group bealth plan.
However, the law also provides that your continuation of cover:J.ge may be terminated for my of the following reasons:
1. your former employer no longer provides group health covenge to any of its employees;
2. you do not ID.ake the contribution for continuation of coverage;
3. you become covered under another group health planj however, you may continue your coverage if your
subsequent group phm reduces your benefits due to a prc-a.isting condition limitation;
4. you become entitled to Medicare.
You do not have to provide evidence of good health to choose continuation of coverage. However, under the law, you may
have to pay all of the contribution plus a 2% administration fee for your continuation of covenge. In situations where 18-
month continuation of coverage is extended to 29 months due to disability, the monthly contribution increases to an
additional 50% after the initial IS-month period. The law also states that at the end of the IS.month, 29-month or J6-month
continuation period, you may be allowed to enroll in an individual conversion bealtb plan provided under the group health
plan.
RcviMd2lzOl%
anado-uloc
Th~n~
GltUUI" uJ.:NI::....rs RISK rool.
GROUP BENEFITS SERVICES AGREEMENT
NON-P ARTICIP A TING
This Agreement is between the Employer named in the Schedule and the Tcxas Municipal League Group
Benefits Risk Pool, 1821 Rutherford Lane, Suite 300, Austin, Texas 78754
SCHEDULE
1. Employer: City of Paris
2. Plaee of Delivery: Austin, Texas
3. Effective Date: 5-1-96
4. Monthly Service Charge:
A.
B.
C.
D.
E.
Claims Administration
Medical
Dental
Vision
$ 7.50
$ .80
$
$ 1.65
$
UJ.5.
$10.10
U.R.
PPO Access Fee
Centers of Excellence
Total
F.
G.
H.
Health Check - AutoAudit
Large Case Management
Custom Claims Reports
No Charge
$65.00/hr as required
$60.00/programming hour
DEFINITIONS: The following terms where uscd in this Agreement, have these meanings:
o We, us, or our _ The Texas Municipal League Group Benefits Risk Pool, known as the Group
Benefits Administrator herein, or any subcontractor which it designates to perform the funetions
and meet the obligations to which it agrees in this Agreement.
o You oryour - The Employer named in the Schedule.
o The Plan _ The employee benefit plan which the Employer named in the Schedule has adopted to
provide medical expense benefits to cligible persons, as defined, and which is attached to and forms
a part of this Agreement.
o Eligible Persons - Employees and dependents who are eligible for benefits under the Plan.
You have adopted the Plan and asked tiS to administer the benefits it provides. Therefore, in eonsideration
of the mutual promises contained in this Agreement, it is agreed as follows.
GHOUl' lIt:Nt:t1TS RISK "OOL
I. OUR DUTIES
a. We agree to proeess all claims presented on behalf of eligible persons for the payment of
benefits according to the terms of the Plan. Payment of claims shall be advanced by our
check subject to immediate reimbursement by you in accordance with paragraph lI.a. of this
Agreement. We advanee funds only fnr purposes of administrative and accountiol:
eonvenience. We dn not insure the Plan. We will not pay any benefits which are not
payable under the Plan. We will not process any claim which was incurred prior to the
Effective Date shown in the Schedule, unless authorized by you in writing prior to
payment.
b. We agree to provide, at monthly intervals, a listing of all Plan benefits paid. One custom
report is provided, at your request, at no cost per plan year. Subsequent custom reports will
be billed as shown in the schedule.
e. We agree to design, review and print (i) standard forms to explain benefits to employees,
(ii) claim forms, and (iii) standard administrative forms such as enrollment cards, evidence
of good health forms and other necessary reporting forms.
d. We agree to provide actuarial services including (i) annual cost projections, (ii) cost
projections for Plan modifications; and (iii) estimates of reserve amounts required to fund
the Plan on a current basis.
e. We agree to provide assistance to you in designing your Plan benefits based on coverage
adequacy, cost control effcctiveness, and medical or economic developments.
f. We agree to provide an annual report of tax reportablc claim payments to medical care
providers.
g. We agree to allow you to obtain a third party to conduct an on site claims audit at our
offices. Such claims audit will be limited to once per agreement year and the date(s) will
be mutually agreed upon. We agree to not unnecessarily delay the claims audit by not
mutually agreeing to a date.
h. We agree to administer all provisions contained in the Plan booklet/document adopted by
the Employer.
1. We agree to use care and diligence in the exercise of our powers and the performanee of
our duties as Group Benefits Administrator hereunder but shall not be liable for any
mistake or judgment or other action taken in good faith or for any loss unless resulting from
our gross negligence.
J. We agree to process any written requests, issues or comments received from Eligible
Persons on appeals of denied benefits and forward the information to the Employer for
review and decision.
k. We agree upon rcceipt of the Employer's written decision of benefit appeals, to calculate
any amount due and payable and make payment, or issue a denial notice, all in accordance
with written instructions of the Employer.
\. We agree to notify stop loss carriers of potential claims and provide all reporting required
by stop loss carriers.
m. We agree to provide coordination of benefit services and pursue subrogation on behalf of
the employer, when applicablc.
n. We agree to refund all amounts paid over the specific stop loss limit within ten (10) days
of approval by the stop loss carrier.
2
rii:L
GMOUI' JU:Ny.nrs RISK POOL
O. We agree to refund all amounts paid over the aggregate stop loss attachment point within
ten (10) days of approval by the stop los~ carrier.
p. We agree to provide precertilication. continued stay review, discharge planning and large
case management as needed.
q. We agree to use the HealthChex auto-audit to review your claims at no additional cost, as
directed by you on Attachment B to this Agreement.
r. We agree to receive claims electronically for your eligible persons to the extent providers
are capable of electronie submission.
s. We agree to maintain claims processing data on microfilm or optical disk for three (3)
years and provide you with copies of this data for individual requests within two (2)
business days following reeeipt.
n. YOUR DUTIES
a. You agree to establish an arrangement with your bank whereby Federal Funds will be
transferred from your bank account to our bank account in accordance with Attachment A,
which is incorporated and made a part of this Agreement. The amount of funds requested
will represent the amount of funds advaneed in payment of Plan benefits: If transfer of
funds is not accomplished we may, at our option, take any or all of the following actions:
(i) suspend benefit payment without notice;
(ii) assess interest on the unpaid amount at a rate not to exceed the maximum allowed
bylaw.
(iii) terminate this Agreement immediately by written notice to you.
b. You agree to provide us in a timely fashion all information and assistance we may need to
properly administer the Plan.
e. You agree to verify according to your plan document, the eligibility of any persons who
request coverage under your plan. Your verification of eligibility will be indicated on the
enrollment record in the space provided for "Employer Acceptanee". Once accepted by
you and the enrollment record received by us, those persons will be considered eligible
persons.
d. You agree to remit any premium lar stop loss, life or other insured contracts by the
twentieth (20th) of each month and undcrstand we do not advance premiums in your behalf.
e. You agree that if we or any of our agents or employees are subjeet to any fine, penalty,
loss, damage, cost, expense or legal fee because of our administration of the Plan in good
faith according to the terms of the Plan document, you will payor reimburse us for any
such line, penalty, loss, damage, cost, expense or legal fee. In the event eurrent revenues
are inadequate to fund the obligation at the time it is determined, you agree to take the
appropriate budgetary action sufticient to pay the obligation.
f. You agree to pay us a monthly service charge determined by multiplying the Monthly
Service Charge shown in the Schedule of this Agreement by the number of employees
covered under the Plan as of the Iirst day of each calendar month commencing on the
Effective Date of this Agreement. Payment shall be due as of the first day of each calendar
month and shall be payable no later than the twentieth (20th) of the month. .
g. You agree to act on all benefit appeals in accordance with the provisions outlined by the Plan.
m:L
3
GROW' ht:NI':"'ITS RISK POOL
h. You agree that if a payment is made to or on behalf of an ineligible person or if an
overpayment is made to a covered person, the Group Benefits Administrator shall attempt, with
full cooperation and assistance of the Employer, to recover such payment through
reimbursement or from future benefits that become due to such person or entity. The Group
Benefits Administrator shall not be responsible for any sueh payment or overpayment unless it
was due to gross negligence of the Group Benefits Administrator.
1. You agree to become a member of the TML Group Benefits Risk Pool and to be bound by the
terms of the TML Group Benefits Risk Pool lnterloeal Agreement. Where there are eonflicts
between this agreement and the Interlocal Agreement, the terms of this Agreement control.
m. DURATION OF AGREEMENT
This agreement shall take effect on the effective date and shall automatically be renewed for a
successive twelve (12) month period unless terminated by either party as set forth in Section lV.
Modification of the agreement is acceptable as outlined in Section V.
IV. TERMINATION OF AGREEMENT
a. You ean terminatc this Agreement by giving us written notice of your intent to do so, at least
31 days prior to the term ination date.
b. We ean terminate this Agrccment:
(i) immediately, by written notice to you, if you fail to provide funds required by the Plan,
fail to pay our charges when due, or in any other way fail to perform your duties under
the Agreement;
(ii) 31 days after giving you written notice of our intent to do so.
e. You agree to pay us for any outstanding charges within 31 days of your receipt of our bill. If
you do not pay such charges within the 31 day period, in addition to that payment, you will also
pay us for any attorneys's fees or other collection fees we incur, plus the maximum interest
allowed by law.
d. We will have no further obligation to process claims after this Agreement terminates.
V. MODIFICATION OF AGREEMENT
a. If you and we agree on the terms of the modifications, this Agreement can be modified at any
time. .
b. We can change any of the charges shown in the Schedule 31 days after giving you written
notice of our intent to do so. Such written notice shall supersede the applicable items(s) in the
schedule and any prior such notice(s). However, no such change shall take effect sooner than
the Iirst anniversary of the Effective Date shown in the schedule.
VI, DISCLAIMER
We act only as a provider of services to your Plan. We do not insure your Plan in any way. We are not
a fiduciary.
4
GROUP HENU1TS RISK "OOL
This Agreement is made binding by the signature of your and our representatives who are duly authorized to
enter into sueh agreements.
For you: I
Eric S. Clifford
, the
Mayor
Title
City of Paris, Paris, Texas
Employer
agree on its behalf to the terms of this Agreement.
I am authorized to enter into such agreements.
ATTEST:
Mattie Cunningham, City Clerk
APPROVED AS TO FORM:
Signature
T. K. Haynes, City Attorney
Signature
April 8, 1996
Date
Witness:
For us:
Terry D. Hale
Name
Executive Director
Title
for the
TML Group Benefits Risk Pool, agree on its behalf to the terms of this Agreement.
I am authorized to enter into such agreements.
Signature
Date
Witness:
Signature
Date
5
T~:L
GROUP Ut:N.:.'ITS RISK "OOL
Attachment A
TEXAS MUNICIPAL lEAGUE GROUP BENEFITS RISK POOl
Aso BANKtNG ARRANGEMENT
EMPLOYER:
EFFECTIVE DATE:
CITY OF PARIS
5-1-96
I ISSUED I ClEARED
REIMBURSEMENT PREFUNDING PREFUNDING
FREQUENCY REQUIREMENT AMOUNT REQUIREMENT AMOUNT
'"il WEEKLY 5 DAYS
NONE -0- AVG. CLAIMS 9,920
h BI-WEEKl Y 5 DAYS 10 DAYS
AVG. CLAIMS 9,920 AVG. CLAIMS 19,842
10 DAYS
I MONTHLY AVG. CLAIMS 19,842
AUTHORIZED OFFICIAL
Eric S. Clifford
TITlE
Mayor
DATE April 8, 1996
ATTEST:
Mattie Cunningham, City Clerk
APPROVED AS TO FORM:
T. K. Haynes, City Attorney
ASUf'Q
IIlIsobank.doe
T~n~
CROUP .t:to:nTS RISK POOL
Entity Name:
Group #:
Attachment "B"
HEALTHCHEX
City of Paris, Paris, Texas
Effective Date:
Selections:
YES
[!]
[!]
[!]
[!]
[i]
[!]
NO
D
D
D
D
D
D
May 1, 1996
CODE DESCRIPTIONS AND FUNCTIONS:
RULE #00 - CANNOT PROCESS
Whenever the claim does not have the minimum of
information required by the system to perform its auditing
functions, the claim will need to be placed on hold for review.
RULE #01 - OBSOLETE CODES
Whenever a procedure code is obsolete for the date of service
(DOS) being billed, it will deny. It will be replaced with the
current/suggested code if one is available.
RULE #02 - EXPERIMENTAL PROCEDURES
Whenever a procedure code exclusively representing an
experimental procedure is billed, it will pend for Utilization
Review.
RULE #03 - DISCRETIONARY/COSMETIC PROCEDURES
Whenever a procedure code considered to be cosmetic or
discretionary is billed, it will pend for Utilization Review
unless medically qualified.
RULE #04 - APPROPRIATE USE OF MODIFIERS
Whenever a modifier is used with a procedure code which
should not be used with that particular modifier, the procedure
will deny.
RULE #05 - SEPARATE PROCEDURES
Whenever a separate procedure, or a procedure considered to
be included in the major procedure is billed, it will deny.
TNfL
GROUP BENEFITS RISK POOL
YES
GJ
m
[!J
[i]
m
[i]
[!]
[!]
NO
D
D
D
D
D
D
D
D
RULE #06 - ASSISTANT SURGERY
Whenever assistant surgery is billed for a procedure that does
not warrant assistance, it will deny.
RULE #07 - OBSTETRICAL GLOBAL FEE
Whenever office visits are billed by physician who also bills for
the delivery procedure code, and the visits are within the global
fee period for the delivery, the visits will deny, unless the visit
is for a condition unrelatcd to the pregnancy.
RULE #08 - SURGICAL GLOBAL FEE
Whenever a physician bills office visits, consults or hospital
visits within the global fee period for the surgical procedure,
the visits will deny. There are exceptions to this rule, for instance, a
diagnostic procedure, as well as any visit which is for a
condition unrelated to the surgery.
RULE #09 - NEW PATIENT CODE
Whenevcr a physician bills morc than one new patient
procedure code for the same patient. it will deny, and insert a
more appropriate visit code associated with an established
patient and allow payment accordingly.
RULE #10 - INPATIENT IHMIDISCHARGE CODE
Whenever a physician bills more than one initiallHM code for
the same patient for the samc hospitalization, it will deny.
RULE #11 - ICU VISIT FREOUENCY
Whenever a physician bills more than a spccified number of
visits for the same patient for the same date of service (DOS), the
subsequent visit will pend for Utilization Review.
RULE #12 - IHM VISIT FREQUENCY
Whenever more than one physician bills for the same date of
service (DOS) for the same patient, and each is billing for a
condition within the same "body system", the later claims will
be denied.
RULE #13 - PHYSICIAN VISIT FREOUENCY
Whenever a physician bills for visits for the same patient for
the same date of service (DOS) (except leU), the visit of highest
value is paid and the other visits will deny. If the other visits are for
different diagnoses, however, they will be allowed.
2
TML
GROUP BENF.FlTS RISK POOL
YES NO
[i] D RULE #14 - REPEAT PROCEDURES
Whenever a physician bills for repeating a procedure within a
specified period of time after the original procedure, it will
deny.
[i] D RULE #15 - PROFESSIONAL COMPONENT
When the physician is billing for the professional component of a
procedure only, the corresponding technical component is reduced,
so that the total does not exceed the maximum allowed for that
procedure.
[!] D RULE #16 - RADIOLOGY UNBUNDLED
Whenever more than one physician is billing for the same
radiology episode, the physicians are paid according to the
correct component of the radiology service.
GJ D RULE #17 - MUTUALLY EXCLUSIVE PROCEDURES
Whenever a physician bills for "mutually exclusive"
procedures (can not be performed during the same operative
episode). The procedure of the highest value is paid, the
remaining procedure( s) are denied.
[!] D RULE #18 - POST-OP CARE, RULE #19 - PRE-OP CARE
Whenever a physician is billing for care before or after a
procedure that another physician has performed, and if the
care is within the global fee period of the procedure and for
a related condition, it will be denied.
[!] D RULE #20 - MEDICAL PROTOCOL
Whenever a physician bills for a procedure more frequently
than is justified by the condition of the patient, it will pend
for Utilization Review.
[!] D RULE #21 - FRAGMENTED PROCEDURES
Whenever a physician bills for multiple procedures on the same
date of service (DOS) that are components of a major procedure for
which there is a unique procedure code, the procedures are
rebundled into the appropriate major procedure code.
3
. ~
rl-,Ni L
GROUP BENEFITS RISK POOL
YES NO
[!] D RULE #22 - SECONDARY PROCEDURE
MANAGEMENT
Whenever a physician bills for multiple procedures, all of
which qualify for payment, the procedure of highest value is
paid in full. The remaining second procedures are
reduced to the specified amount allowed for that procedure,
all other procedures are denied.
GJ D RULE #23 - HILA TERAL PROCEDURE MANAGEMENT
Whenever a physician bills for a bilateral procedure, the
payment is reduced to not exceed the maximum
allowed for that procedure.
m D RULE #24 - UTILIZATION REVIEW
Whenever a physician bills for certain procedures that usually
signify upcoding, are of questionable appropriateness, or are
inherently vague, and the patient's condition does not warrant
it, it will pend for Utilization Review.
m D RULE #25 - CASE MANAGEMENT
Whenever a targeted procedure or diagnosis is identified, the
patient's records are flagged for a special report which is
available for review to determine the need for case
management.
GJ D RULE #26 - ASSISTANT SURGERY UCR
Whenever assistant surgery is qualified for payment, payment
is reduced to not exceed a specified amount allowed for that
procedure.
GJ D RULE #27 - CHEMISTRY LAB UNBUNDLED
Whenever a physician bills for more than one chemistry
procedure code, they are rebundled into the appropriate
chemistry panel.
GJ D RULE #28 - UCR/FEE SCHEDULE
Whenever a physician bills for a procedure, payment is
reduced to the maximum allowed for that procedure.
GJ D RULE #29 - 31 - NO RULES CURRENTLY EXIST
4
GROUP BJ,;NI-:nTS RISK POOL
YES NO
Gl D RULE #32 - NON-COVERED BENEFITS OR INVALID
CODES
Whenever a procedure code that represents a non-covered
benefit is billed it will deny.
[i] D RULE #33 - MULTIPLE DISALLOWED PROCEDURES
Whenever a physician bills for procedures beyond the
frequency for which the procedure could possibly be
performed, it will deny, (ie. more than I hysterectomy).
I2J D RULE #34 - DUPLICATE PROCEDURES
Whenever a physician bills the same procedure code more
than once for the same patient on the same date of service (DOS) it
will deny.
[i] D RULE #35 - MANDATORY OUTPATIENT
PROCEDURES
Whenever a physician bills for a procedure that is generally
accepted as being done only in an ambulatory setting, however
is done on an inpatient basis, it is flagged for investigation.
[II D RULE #36 - POTENTIAL COORDINATION OF
BENEFITS
Whenever a physician bills for a diagnosis that is
representative of possible motor vehicle accident origin or
workers' compensation, it is flagged for review.
[!] D RULE #37 - OFFICE VISIT UPCODING
Whenever a physician bills for an extensive or comprehensive
office visit that is in excess of the appropriate frequency for
that diagnosis of the patient, it is flagged for review.
[!] D RULE #38 - INAPPROPRIATE CODES
Whenever a procedure code that is not appropriate for the
gender or age of the patient is billed, it will deny.
[II D RULE #39 - SENTINEL EVENTS
Whenever a physician bills for a procedure or diagnosis that is
representative of a possible quality of care issue, it is flagged
for review.
5
mL
GROUP Bt:NEFITS RISK POOL
YES
E!J
[i]
[!]
[i]
Signature:
NO
D
D
D
D
RULE #40 - PROVIDER CUSTOMIZA TION
Whenever a physician or specialty has been customized to
identifY certain procedures and/or diagnoses, they will be
flagged for review.
RULE #41- PROCEDURE AND DIAGNOSIS CODE
CaMPA TIBTLITY
Whenever a physician bills for a condition unrelated to a
procedure which is also being billed for, it is flagged for
revIew.
RULE #42 - PRE-EXISTING CONDITIONS
Whenever a physician bills for services which are related to a
pre-existing condition for a new enrollee who is still in the
grace period for coverage, it will be flagged for review.
RULE #43 - SECOND SURGICAL OPINION
Whenever a physician bils for a surgical procedure which
requires a second surgical opinion, and one has not been
performed, it will be flagged for review.
Eric S. Clifford, Mayor
Date: April 8, 1996
ATTEST:
MatXie Cunningham, City Clerk
APPROVED AS TO FORM:
T. K. Haynes, C'
INTERNAl. USE ONl. Y:
.
Aulo Audit Plan #:
6
rilL
GROU" Dt:NIi.'ITS RISK POOL
Attachment C
TEXAS MUNICIPAL LEAGUE GROUP BENEFITS RISK POOl
STOP LOSS/LIFE AND AD&D COVERAGE
EMPLOYER:
EffECTIVE DATE:
CITY Of PARIS
5-1-96
PURSUIT TO SECTION 252.021 OF THE LOCAL GOVERNMENT CODE. THE TEXAS MUNICIPAL
LEAGUE GROUP BENEfiTS RISK POOl WILL PROCURE THE COVERAGE INDICATED BELOW ON
BEHALF Of SAID EMPLOYER.
YES No
I X I=:J STOP Loss COVERAGE
I X D LIFE & ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGE
I GJ LONG TERM DISABILITY
I [i] SHORT TERM DISABILITY
AUTHORIZED OFFICIAL
Eric S. Clifford
TITlE
Mayor
DATE April 8, 1996
ATTEST:
Mattie Cunningham, City Clerk
APPROVED AS TO FORM:
T. K, Haynes, City Attorney
ASUlsg
sloploll.doc
TI1L
GROUP Bt:NEI'ITS RISK fOOL
TEXAS MUNlClPAL LEAGUE
. GROUP BENEFITS RISK POOL
GROUP BENEFITS RISK POOL
*
DEDICATED TO SERVICE
1 NTERLOCAL
AGREEMENT
NON-RISK PARTICIPATING MEMBER
~_._-_.-----------_.__._--_._-_..._- ---_._-_..,_._~---,-----_.- ------,. -
.__...----~_.-------~----_..._---- ---------......-.-..-----.-..
_ .___.._ __ ___._.___ _~.n.___ _..__.-____...__..__n ., _______..________._..'n_____U_____
-_.__.----_..,---------_._--_._------,._-------_._-~_.
Texas Municipal Leaguc Group l3enelits Risk Pool
^ustin, Texas
INTERLOCAL AGREEMENT
(NON-RISK PARTICIPATING MEMBER)
WHEREAS, the Texas Municipal League Group Bcnelits Risk Pool, hcreinafter refcrred to as TML-
GBRP, is a legal entity created by political subdivisions of'the state, subject to the Texas Trust Code (Title
9, Subtitle B, Texas Property Code), and goverened by Trustecs, and is the suecessor of the Texas
Municipal Lcague Insurance Trust Fund establishcd May I, 1979; and
WHEREAS, thc undcrsigned Employcr Mcmbcr reprcsents that it is a political subdivision of the state
and that its board and governing body has actcd by majority votc, at a duly called and posted public
meeting, to authorize lll1d participate in this Intcrlocal Agrcemcnt; and
WHEREAS, the undersigned political subdivision has examined all the raets and issues it dcems relevant
and determined that it is in the best interest of the political subdivision, its orJiccrs and employees, to enter
into this agreement and obtain the services providcd;
NOW, THEREFORE, in consideration of the covenants and agreements herein set forth, the undersigned
politieal subdivision, together with other political subdivisions exeeuting identical or substantially similar
interlocal agreements, enters into this agreemcnt for the purpose or providing certain services for the
political subdivision. The services will be provided under the authority of the laws of the State of Texas
including the Interlocal Cooperation Act (Chaptcr 791, Government Code). The Employer Members
hereby designate the Texas Municipal Leaguc Group Bcnelits Risk Pool to administer the business and
supervise the performancc of the intcrlocal agreemcnl. The eonditions of membership in the TML-GBRP
are agreed upon by and between thc parties as set rorth hereinafter.
1. When used in this Interlocal Agreement, thc capitalized terms shall have thc meanings specified in this
paragraph unless the context c1carly rcquires othcrwise:
,
I
II
!
"Board or Trustees" or "Board" or "Trustecs" means the Irustees selected pursuant to the Bylaws
to supervise thc operation of thc TML-GBRP.
"Employer Member" means a political subdivision entering into this intcrlocal agreement.
"Plan" or "Plans" mean the hcalth benelit plan(s) adopted and provided by the Employer Member.
"Political subdivision" means any Icgal entity ineludcd within the definition of political
subdivision in Chapter 791, Government Code.
I,
I,
i I
"TML-GBRP" means the Texas Municipal Leaguc Group Benelits Risk Pool.
2. The Employer Member agrees to be bound by this Interlocal Agreement and the bylaws, policies and
procedures established by the TML-GBRP which collectively establish the conditions for membership in
the TML-GDRP.
3. TML-GBRP and thc Employer Member will comply in all respects with their respective obligations
Inlcrlocal Agreement (rev. 3/1/%) I'<lce I
under the Group l3enelits Services Agreement which is aflixed hereto and incorporated for all purposes
as if fully set out herein. The payments required to be made by the Employer Member under the terms of
the Group l3enefits Servicc ^grccment shall be made at Mlstin, Travis County, Texas on the dates and in
the amounts as thc TML-GI3RP requires for providing scrvices. Intercst, bcginning the first day after the
due date and continuing until paid. shall accruc at thc maximum rate allowed by law on thc balance of any
payment or contribution not paid whcn duc. All such p'lyments and intercst shall be paid from then
current revenues.
4. Except as may be otherwisc spccilied in the TML-GI3RP bylaws, this agrecmcnt may be terminated
by either the Employer Member or the TML-GI3RP in accordance with the terms of the attached Group
13enelits Services Agreemcnt.
5. The Employer Member shall furnish allthc information thc TML-GrlRP decms neccssary and useful
for the purposes or this agrcemcnt and shall abide by thc rulcs and r"cgulations adopted for the
administration of the benelits plan. The TML-GI3RP may amcnd its rulcs and regulations at the time of
annual renewal of this agreement and its bylaws at anytime to the extcnt it deems advisable except that no
amendment shall change the purpose of the TML-GI3RP.
II
6. Each Employer Member will designate and appoint a coordinator or department head rank or above
and agrees that the TML-GI3RP shall not be required to contact or providc noticcs to any other person.
Further, any notice to, or agreement by an Employer Member's Coordinator, with respect to scrvices or
claims hereunder, shall be binding on the Employer Member. The Employer Member reserves the right
to change the coordinator from time to time by giving written noticc to thc TML-GI3RP.
7. The Employer Membcr hereby appoints the TML-GI3RP as it agcnt to act in all mailers pertaining to
the processing and handling of claims and agrees to coopcratc fully and provide all information necessary.
8. Each Employer Member, as Plan Administrator, retains the right. dutics and privilegcs of the Plan
^dministrator and acknowledges it has rcsponsibility for compliance with the state and federal laws
applicable to employees benelits.
9. The Employer Member agrees to indcmnify and hold harmless thc TML-GBRP for all claims,
damages and expenses, including but not limited to attorney's fces and costs of court, arising out of acts
or omissions of ofliccrs or employees of the Employcr Mcmber in eonncction with the Plan. The
Employer Membcr agrees to pay all such claims, damages, and expenses out of current revenues at the
time the obligation is determincd. In the event currcnt revenucs arc inadequate to fund the obligation at
the time it is determined. the Employer Member agrees to take the appropriatc budgetary action suflicient
to pay the obligation.
10. The Employer Member and the TML-GI3RP may contract for additional administrative scrvices
related to the Employer Member's employee benelit programs.
11. No bond is required of the Board of Trustees of the TML-GI3RP.
12. Ifany part of this agreement, save and except paragraph 3, is declared invalid, void or unenforceable,
the remaining parts and provisions shall continue in fulllorce and cffect. It is further agreed that venue
for any dispute arising under the terms of this agreement shall bc in Austin, Travis County, Texas.
InlcrloCill Agreement (rev. J/I/%) Puge 2
I
I
i
I
I
II
I
I
I
II
: I
, I
I
I
I
I
,
I
I
I
Ii
! !
i i
II
, I
II
I'
I
I
, I
I'
II
, i
I
I........-"_...__no_-
~ ,
II
13. This agreement with attachment rcprcscnts the completc undcrstanding or the TML-GBRP and the
Employer Membcr and may not bc amcnded, modi lied or altcrcd without thc written agreement of b9th
parties.
14. The term of (his Interlocal Agreemcnt shall bc concurrcnt with that or thc Group Benelits Services
Agreement which is aflixcd hcreto. Abscnt nolicc or tcrmination, the Employer Mcmber may annually
rcnew and extcnd this Agrcemcnt by cxccuting and rcturning thc Group Bcnclits Scrviccs Agreement.
This agreement is cntercd into for thc Employc,' Membcr' undcr authorization or
City of Paris, Paris, Texas
(EMPLOYER MEMBER)
at duly called meeting held on April 8, 1996
(Date or Meeling)
By Eric S. Clif ford
(SIGNATURE) (Printed or Typed Name)
Authorized Oflieial TitJ,' Mayor of the City of Paris, Paris, Texas
Date April 8, 1996
ATTEST: APPROVED AS TO FORM:
Mattie Cunningham T. K. Haynes
City Clerk City Attorney
This Agreement Entered into 'lIId Appointment Aceepled By: The Texas Municipal Leaguc Group [lenelits Risk Pool at Austin. Tcxas
By
Date
-
I,
I'
II
Ii
I!
, I
, ,
! I
I'
11
, I
11
, ,
I'
: I
, I
II
, I
II
, I
I'
II
\
I
I
II
i
Ii
II
II
Inlcrlt".:al ^l rccmcnl (rev. 3/1/96) I)agc J
I
I
I
II
I
I
TO BE COMPLETED BY EMPLOYER MEMBER:
EMPLOYER MEMBER BENEFITS COORDINATOR
Name W. E. Anderson
Title Personnel Director
Mailing Address P. o. Box 9037
Street Address (if different from above)
135 1st Street S.E,
City/State/Zip' Paris, Texas 75461-9037
Phone 903-785-7511 ext. 241
FAX 903-785-8519
I i-~-::~:::::::"
I,
II
I
~===-:::~:==:::_-::::=:::=:::::=::::~::::::::::::=
Inlcrlocal Agreement (rev. 3/1/96) )'''gc 4
-" :::::, :::::~::=-=-I
I
I
I
I
I
II
'I
II
i I
, '
, ,
i
I
I!
II
II
Ii
! I
I
,
! :
i!
i!
I'
, I
'I
: I
,
I
II