06-B Health Insurance ContractDRAFT
F:kAttorney\LisakResolutions\CURRENT\TML-IEBP Contract 2003 Res.wpd
March 3, 2003
RESOLUTION NO.
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF PARIS,
PARIS, TEXAS, AUTHORIZING THE EXECUTION OF A GROUP
BENEFITS SERVICES AGREEMENT WITH TEXAS MUNICIPAL LEAGUE
INTERGOVERNMENTAL EMPLOYEE BENEFITS POOL (TML-IEBP)
FOR TERM LIFE INSURANCE, STOP-LOSS INSURANCE FOR
MEDICAL/DENTAL/VISION PROGRAM, THIRD-PARTY
ADMINISTRATION SERVICES FOR THE ABOVE COVERAGE,
MAINTENANCE DRUG PROGRAM, AND LONG TERM DISABILITY;
MAKING OTHER FINDINGS AND PROVISIONS RELATED TO THE
SUBJECT; AND PROVIDING AN EFFECTIVE DATE.
WHEREAS, the City Council of the City of Paris did heretofore, on the 8th day of April,
2002, in Resolution No. 2002-065, authorize the execution of a Group Benefits Services Agreement
with Texas Municipal League Intergovernmental Employee Benefits Pool (TML-IEBP) for the
furnishing and delivery of (1) Term Life Insurance, (2) Stop-loss Insurance for its otherwise self-
funded Medical/Dental/Vision Program, (3) Third-Party Administration Services for the above
coverage, (4) Maintenance Drug Program, and (5) Long Term Disability; and,
WHEREAS, said agreement expires on April 30, 2003, and it is deemed appropriate that a
new contract be executed; NOW, THEREFORE,
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF PARIS, PARIS,
TEXAS:
Section 1. That the findings set out in the preamble to this resolution are hereby in all things
approved.
Section 2. That the Mayor be, and he is hereby, authorized and directed to execute, on behalf
of the City of Paris, the Group Benefits Services Agreement with the Texas Municipal League
Intergovernmental Employee Benefits Pool (TML-IEBP) for (1) Term Life Insurance, (2) Stop-loss
Insurance for its otherwise self-funded Medical/Dental/Vision Program, (3) Third-Party
Administrative Services for the above coverage, (4) Maintenance Drug Program, and (5) Long Term
Disability, under the terms and conditions and in the form shown in Exhibit A, attached hereto, and
any and all other documents as may be necessary.
Section 3. That this resolution shall be effective from and after its date of passage.
PASSED AND APPROVED this 14th day of April, 2003.
ATTEST:
Michael J. Pfiester, Mayor
Mattie Cunningham, City Clerk
APPROVED AS TO FORM:
Larry W. Schenk, City Attorney
GROUP BENEFITS SERVICES AGREEMENT
NON-PARTICIPATING
This Agreement is between the Employer named in the Schedule and the TML Intergovernmental Employee
Benefits Pool, 1821 Rutherford Lane, Suite 300, Austin, Texas 78754
SCHEDULE
l. Employer: City of Paris
2. Effective Date: 5/1/03
3. Monthly Service Charge per employee per month:
· Claims Administration 5/1/03
Medical $12.75
Medical Management $2.55
4. Optional Services (PEPM = per employee per month; PPPP = per participant per month)
rn PPN Access Fee using direct contracts $3.75
[] Self Funded Vision $ .50
[] Self-funded Dental $2.15
[] H1PAA Compliance Adm. PEPM $0.50
[] Continuation of Coverage/Set Up $50.00 PEPM$0.50
cl Medical Conversion PEPM $0.40
ca Disease Management $1.50
ca Flex Plan PPPP/Set up $50.00 enrollee $5.00
ca Retiree Direct Billing (PRPR) $1.00
[] Alternate Plan $1.25
[] HealthChex - Auto Audit No Charge per Addendum A attached
[] Custom Claims Reports $150.00/programming hour
ca Rx Card Claims $ 0.32/claim PA $30.00 initial and every 6 or 12
months after initial pre-authorization -pre-authorization is an optional service
ca HIPAA Certificates Included in Medical Admin Fee
[] Benefit Booklets (every 2 years) Included for Number of EE Plus 10%
[] PPN Directories Included For Number of EE Plus 10%
ca Run-in/90 day Run-out $12.75 per claim
rn Outpatient Audits 15% of savings - External Vendor
ca Hospital Audit 20% of savings- External Vendor
[] Subrogation 20% of savings - In-House Counsel/External
Vendor
c~ Out of State Net~vork 18% of savings - External Vendor
ca Out of Network Claims (Concentra) 25% of savings - External Vendor
ca Usual and Customary (Concentra) 25% of savings- External Vendor
Ca Dental Consultant $23.00 dental, $50.00 medical, $75.00 TMJ referral
EXHIBIT
DEFINITIONS: The following ten'ns where used in this Agreement, have these meanings:
we, us, or our - The TML Intergovernmental Employee Benefits Pool, known as the Group
Benefits Administrator herein, or any subcontractor which it designates to perform the thnctions
and meet the obligations to which it agrees in this Agreement.
You or your - The Employer named in the Schedule.
The Plan - The employee benefit plan which the Employer named in the Schedule has adopted to
provide medical expense benefits to eligible persons, as defined, and which is attached to this
Agreen~ent.
~,- Eligible Persons - Employees and dependents who are eligible for benefits under the Plan.
You have adopted the Plan and asked us to administer the benefits provided by the Plan. Therefore, in
consideration of the mutuat promises contained in this Agreement, it is agreed as follows.
I. OUR DUTIES
We agree to process all claims presented on behalf of eligible persons for the payment of
benefits according to the terms of the Plan. We will administer benefits per your plan
document unless authorized by you, in xwiting, to pay outside the plan guidelines. We will
not process any claim which was incurred prior to the Effective Date shov~q~ in the
Schedule, unless authorized by you in writing prior to determination.
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.
c. We agree to design, review and print standard forms to explain benefits to employees,
standard enrollment cards, standard ID cards and one (1) standard benefit book every two
(2) years.
d. We agree to provide under~vriting services including (i) annual cost projections, (ii) cost
projections for Plan modifications; and estimates of reserve amoonts required to fund the
Plan on a cun'ent basis.
e. We agree to provide assistance to you in designing your Plan benefits based on coverage
adequacy, cost control effectiveness, and medical or economic developments.
f. We agree to provide an annual report of tax reportable claim pa3nnents 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 uot 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.
i. We agree to use care and diligence in the exercise of our powers and the performance 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 resolting from
our gross negligence.
j. We agree to process any ,,witten requests, issues or comments received l'?om Eligible
Persons on appeals of denied benefits and forward the information to the Employer for
review and decision.
Page 2 oF 5
k. We agree upon receipt of the Employer's written decision of benefit appeals, to calculate
any amount due and payable, or issue a denial notice, all in accordance with written
iustruetions of the Employer.
I. We agree to notit~ stop loss carriers of potential claims and provide all reporting required
by stop loss carriers.
m. We agree to provide coordination of benefit serviaes and pursue subrogation on behalf of
the employer, when applicable. Subrogation is handled by in house counsel and a third
party vendor who retains a percent of the recovery.
n. We agree to rethnd all amounts paid over the specific stop loss limit within ten (10) days
of approval by the stop loss carrier.
o. We agree to refund all amounts paid over the aggregate stop loss attachment point within
ten (10) days of approval by the stop loss carrier.
p. We agree to provide pre-certification, 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 Addendum B to this Agreement.
r. We agree to receive claims electronically for your eligible persons to the extent providers
are capable of electronic 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 receipt.
t. We agree to provide your bank with a daily 'positive pay' file, which documents which
claims were paid each business day.
II. YOUR DUTIES
a. You agree to establish a checking account at your bank, which will be used to pay all of
your claims per Addendum A. You will be the custodian of this account and will be
responsible tbr depositing all funds necessary to pay said claims. This account must utilize
thc 'positive pay' feature of the banking process. Through this process, TML IEBP will be
responsible for transmitting a daily file, which gives an electronic listing of all checks
written the night before. TML IEBP xvill be a signer on the account for check writing
purposes only. We will use the facsimile signature of the Chairman of our Board of
Trustees to sign your checks. You agree to have your own personnel listed as authorized
signers, l~br the purpose of inquiries, research or reconciliation of the account.
Any fees associated with the establishmcot or daily process and operation of this account
will be your responsibility.
If this account is not maintained and properly funded, we may at our option, take any of the
following actions:
(i) suspend thc processing and payment of your claims;
(ii) terminate this Agreement immediately by written notice to you.
b. You agree to provide us in a timely fashion all infomaation and assistance we may need to
properly administer the Plan.
c. You agree to verit~ according to your plan document, the eligibility of any persons who
request coverage tinder your plan. Your verification of eligibility will be indicated on the
enrollment record in the space provided for "Employer Acceptance". Once accepted by
I)agc 3 of 5
you and the enrollment record received by us, those persons will be considered eligible
persons.
d. You agree to remit any premium for stop loss, life or other insured contracts by the
twentieth (20th) of each month and understand we do not advance premiums in your behalf.
e. You agree that if we or any of our agents or employees are subject to any fine, penalty,
loss, damage, cost, expense or legal tee because of our administration of the Plan in good
faith according to the terms of the Plan document, you will pay or reimburse us for any
such fine, penalty, loss, damage, cost, expense or legal tee. In the event current revenues
are inadequate to fund the obligation at the time it isdetermined, you agree to take the
appropriate budgetary action sufficient to pay the obligatioo.
f. You agree to pay us a monthly sc~,vice charge deterrnined by multiplying the Monthly
See,ice Charge shoam in the Schedo!e of this Agreement by the number of employees
covered under the Plan as of the first 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 thirtieth (30th) of the month or the last day of
the month.
g. You agree to act on all benefit appeals in accordance with the provisions outlined by the Plan.
h. You agree that if a payment is made to or on behalf of an ineligible person or if an
overpayment is made lo 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 fature benefits that become due to such person or entity. The
Group Benefits Administrator shall not be responsible for any such payment or
overpayment unless it was due to gross negligence of the Group Benefits Administrator.
i. You agree to become a member of the TML Intergovernmental Employee Benefits Pool
and to be bound by the terms of the TML Intergovernmental Employee Benefits Pool
Interlocal Agreement.
III. DURATION OF AGREEMENT
This a~,q'eement 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 IV.
Modification of the agreement is acceptable as outlined in Section V.
IV. TERMINATION OF AGREEMENT
a. You can terminate this Agreement by giving us written notice of your intent to do so, at
least 31 days prior to the te~xnination date.
b. We can terminate this Agreement:
(i) immediately, by written notice to you, if you fail to maintain the bank account
required by the Plan, fail to pay onr 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.
c. You agree to pay us tbr any outstanding charges by the last day of the month of your
receipt of our bill. If you do not pay such charges by the end of the month, you will also pay
us for any attorney'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 Agn'eement terminates.
Page 4 of 5
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 first 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.
This Agreement is made bindiug by the signatt~re of your and our representatives who are duly authorized
to enter into such agreements.
For the TML Intergovernmental Employee Benefits Pool City of Paris
Susan L. Smith Michael J. Pfiester
Print name Print name
Executive Director Mayor
Title Title
April 14~ 2003
Date Date
Cage 5 of 5
ADDENDUM A
TML INTERGOVERNMENTAL EMPLOYEE BENEFITS POOL
ASO BANKING ARRANGEMENT
EMPLOYER: CITY OF PARIS
EFFECTIVE DATE: 5/1/03
THE CHECK REIMBURSEMENT FREQUENCY WILL BE PRIOR TO CLAIM ISSUANCE.
AUTHORIZED OFFICIAL
TITLE t, ia.'vor DATE ~Apt-~_]. 14. 2003
CHECK TRACER STATUS PROCEDURE
$25.00 FEE FOR CHECKS OVER 90 DAYS OLD
$50.00 FEE FOR CHECKS ISSUEDPRIOR TO 10/'l/99
ALL FEES PAYABLE PRIOR TO INQUIRY BEING INITIATED. FEES WILL BE CHARGED TO ANYONE
REQUESTING CHECK STATUS ~'90 DAYS OLD.
AUTHORIZED OFFICIAL
TITLE t, tayoz' DATE Ap=~_l 14= 2003
AddendumB
HEALTHCHEX
Entity Name: CITY OF PARIS
Group #: APART-qO 1
Effective Date: 5/1/03
Selections: CODE DESCRIPTIONS AND FUNCTIONS:
YES NO
[~ ['"-] 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.
I--] 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 he included in the
major procedure is billed, it will deny.
/--~ ~ RULE #06- ASSISTANT SURGERY
Whenever assistant surgery is billed for a procedure that does not warrant
assistance, it will deny.
YES NO
~ ~ 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 unrelated to the pregnancy.
[~ ~ULE #08 .y ~._RGICALGLOBAL~_F_EE
Whenever a physician bills office visits, consults or hospital visits within the
global foe p~riod for the surgical procedure, the visits will deny. There are
exceptions to this nde, for i~stance, a diagnostic procedure, as well as any visit
which is tbr a ¢ondition unrolated to th~ surgery.
/Tq ~ RULE//09; N~ _E..w_.pAT[E~ir_ COpE
· ' Whenever a physician bills more 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 IHM/DISCHARGE CODE
Whenever a physician bflls more than one initial 1HM code for the same patient
for the same hospitalization, it will deny.
17'1 I--i RULE #n-Ice VISIT FaEQUZNCY
Whenever a Physician bifi~ more than-'a specified number of visits for the same
patient for the same date of service (DOS), the subsequent visit will pend for
Utilization Review.
15'3 F-'I RULE #12-i.n 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 FREQUENCY
whenever a physician bill~ for visits for the same patient for the same date of
service (DOS) (except ICU), the visit of highest value is paid and the other visits
will deny. If tile other visits are for different diagnoses, however, they will be
allowed.
F-'! RULE #,4-.EPEAT PROCEDURES
Whenever a physician bills for repeating a procedure within a specified period of
time after the original procedure, it will deny.
~ RULE #16 - RADIOLOGY UNBUNDLED Whenever more than one physician
is hilling for the same radiology episode, the physicians are paid according to the
correct component of the radiology service.
YES NO
~ [~ 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.
~ 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 perfon'ned, and if the care is within the global fee period of the
procedure and for a related condition, it will be denied.
I-ri I'-1 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.
[-'-] 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.
]'--"l 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.
['~ RULE #23 - BILATERAL PROCEDURE MANAGEMENT
Whenever a physician bills for a bilateral procedure, the payment is reduced to not
exceed the n~aximum allowed for that procedure.
1~ 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.
RULE #25 - CASE MANAGEMENT
Whenever a targeted procedure or diagnosis is identified, the patient's records are
flagged for a special report wbich is available for review to determine the need for
case management,
RULE #27_-._CHF~ _MI~STRY LAB UNBU~I}LED
Whenever a physician bills I~or more than one chemistry procedure code, they are
rebundled into the appropriate chemistry paoel.
RULE #Z9- - U CUa [V
RULE ~32, NON.COV ~D BENEFITS OR lNVALID CODES
Wheoever a procedure code that represents a non-covered benefit is billed it will
RULE g33 - MULTIPLE DISALLOWED PROCEDU~S
Whenever a physician bills for procedures beyond the frequency for which the
procedure could possibly be performed, it will deny, (i.e. more than 1
hysterectomy).
RULE ~34, DUPLICATE pROCEDURES
When~v~ ~ PhYsi6i~n bills the same procedure code more than once for the same
pat tnt on the same date of s~ice (DOS) it will deny.
RULE g36 - POTENTIAL COORDINATION OF BENEFITS
Whenever a physician bills for a diagnosis that is representative of possible motor
vabiclc accident origin or workers' compensation, it is flagged for review.
RULE ~37 - OFEICE VIS1T UPCODING
Whenever a physician bills Cot an extensiw or comprehensive office visit that is
in excess o~ tba appropriate frequency for that diagnosis of the patient, it is
flagged for review.
RULE g38-INAPPROP~ATE CODES
Whenever apr°cerium code that is not appropriate for the gender or age of the
patient is billed, it will deny.
Whenever a physician bills for a procedure or diagnosis that is representative of a
possible quality of care issue, it is flagged for review.
~-1 ~'1 RULE #40 - PROVIDER CUSTOMIZATION
Whenew:r a physician or specialty has beeo customized to identify certain
procedures and/or diagnoses, they will be flagged for review.
F~ F~ RULE #41 - PROCEDURE AND DIAGNOSIS CODE COMPATIBILITY
' ' Whenever a physician bills for a condition unrelated to a procedure which is also
being billed for, it is flagged for review.
F~ F'~ RULE #42 - PRE.EXISTING CONDITIONS
' ' Whenever a physician bills for services which are related to a pre-existing
condition for a new enrollee xvho is still in the grace period for coverage, it will be
flagged for review.
~ RULE #43 - SECOND SURGICAL OPINION
' ' Whenever a physician bills for a surgical procedure which requires a second
surgical opinion, and one has not been performed, it will be flagged for review.
Signature:
Date: Apr±~ 16, .200~
r~'~P~rAr. U$~ oiqr'Y:
Auto Audit Plan #:
ADDENDUM
TML INTERGOVERNMENTAL EMPLOYEE BENEFITS POOL
STOP LOSS/LIFE AND AD&D COVERAGE
EMPLOYER: CITY OF PARIS
EFFECTIVE DATE: 5/1/0:]
PURSUANT TO SECTION 252.02t OF THE LOCAL GOVERNMENT CODE, THE TML EMPLOYEE
BENEFITS POOL WILL PROCURE THE COVERAGE INDICATED BELOW ON BEHALF OF SAID
EMPLOYER.
YES NO
~ STOP LOSS COVERAGE
~ LIFE & ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGE
~ LONG TERM DISABILITY
~ SHORT TERM DISABILITY
NEWSPAPER OF RECORD: ]~he Paris News
AUTHORIZED OFFICIAL:
TITLE: Mayor .............
DATE: April !4, 2003 .....
ADDENDUM D
TML INTERGOVERNMENTAL EMPLOYEE BENEFITS POOL
REASONABLE AND CUSTOMARY
EMPLOYER: CITY OF PARIS
EFFECTIVE DATE: 5/1/03
THE UNDERSIGNED EMPLOYER HAS CHOSEN THE FOLLOWING PERCENTILE TO BE USED FOR
DETERMINING REASONABLE AND CUSTOMARY CHARGES. THIS SAME PERCENTILE WILL BE USED
FOR BOTH MDR AND HCPCS.
~ 90TM
~ 85TM
~ 80TM
AUTHORIZED OFFICIAL:
TITLE: ·
DATE: April 14
i~DD ENDLrM E
TML INTERGOVERNMENTAL EMPLOYEE BENEFITS POOL
USUAL AND CUSTOMARY ~HARGE ANALYSIS
EMPLOYER: CITY OF PARIS
EFFECTIVE DATE: 5/1/03
THE UNDERSIGNED EMPLOYER HAS CHOSEN TO HAVE USUAL AND CUSTOMARY
CHARGE ANALYSIS { COST TO CHARGE OR "C2C") PERFORMED BY AN
EXTERNAL VENDOR ON ALL HOSPITAL CHARGES THAT ARE NOT PER DIEM OR
CASE RATED IN EXCESS OF ~25~000.00 · THE FEE FOR THIS SERVICE
SHALL BE 25% PERCENT OF SAVINGS.
EMPLOYER AUTHORIZED OFFICIAL SIGNATURE:
TITLE: Mayor
DATE:
April 14. 2003