Item D07
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: May 19. 2004
Division:
Manae:ement Services
Bulk Item: Y es ~ No
Department: Group Insurance
AGENDA ITEM WORDING: Approval of contract amendment with Acordia National for
monthly claim administration fees for the Florida Keys Mosquito Control District. This
amendment is required effective May 1. 2004 as the Florida Keys Mosquito Control District will
no lone:er be a covered entity under the Monroe County Employee Benefit Plan therefore
eliminatine: the need for administrative fees. except for the handline: of run-out claims.
ITEM BACKGROUND: Current contract effective October 1. 2002 throue:h September 30. 2003
with renewals for FY 03-04 & FY 04-05.
PREVIOUS RELEVANT BOCC ACTION: N/A
CONTRACT/AGREEMENT CHANGES: The per employee per month (PEPM) fee for claims
administration for the Florida Keys Mosquito Control District will expire April 30. 2004 and
run-out claims will be processed from May 1. 2004 throue:h July 31.2005 at a cost of 10% of paid
claims.
STAFF RECOMMENDATIONS: Approval
TOTAL COST:
$256.000.00
BUDGETED: Yes--X-
No
COST TO COUNTY:
$256.000.00
SOURCE OF FUNDS: Primarily Ad Valorem
REVENUE PRODUCING: Yes
No X
AMOUNTPERMONTH_ Year
APPROVED BY: County Atty _
OMB/Purchasing _ Risk Management ~
~A a.bc-hc-/
Sheila A. Barker
DIVISION DIRECTOR APPROVAL:
DOCUMENTATION:
Included 1L-
To Follow_
Not Required_
DISPOSITION:
AGENDA ITEM #~
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract #
Contract with: Acordia National Effective Date:October L 2003
Expiration Date:September 30.2004
Contract Purpose/Description:Approval of contract amendment with Acordia National for
monthly claim administration fees for the Florida Keys Mosquito Control District. Effective
May 1. 2004 the Florida Keys Mosquito Control District will no longer be an entity covered
under the Monroe County Employee Benefit Plan.
Contract Manager:Maria Z. Fernandez
(Name)
4448
(Ext. )
Administrative Services
(Department)
for BOCC meeting on May 19, 2004
Agenda Deadline: May 4 2004
CONTRACT COSTS
Total Dollar Value of Contract: $256.000.00
Budgeted? Yes[gJ No D Account Codes:
Grant: $N/ A
County Match: $N/ A
Current Year Portion: $_
502-08002-530310-_-_
- - - -
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- - - -
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ADDITIONAL COSTS
Estimated Ongoing Costs: $_/yr For: _
(Not included in dollar value above) (eg. maintenance, utilities, janitorial, salaries, etc.)
CONTRACT REVIEW
Changes Date Out
Date In Needed
Division Director YesDNo~ ~I
Risk Management S/q~1 ~r
O.M.B./Purchasing &/If ~
County Attorney 11- YesDNo~ 5)3
Comments: -
OMB Form Revised 9/11/95 MCP #2
AMENDMENT TO
ADMINISTRATIVE SERVICES AGREEMENT
THIS AGREEMENT, made and entered into this 1st day of May, 2004 by and between Board of
County Commissioners of Monroe County (hereinafter called "Employer") and ACORDIA NATIONAL,
of Charleston, West Virginia, (hereinafter called "Acordia National");
W !TNE~~ETH
WHEREAS, the Employer presently receives third party administration (TP A) seryices from
Acordia National for certain of Employer's employee benefit plans; and
WHEREAS, the services provided by Acordia National are defined in an administrative services
only agreement between the Employer and Acordia National dated July 1, 1996; and
WHEREAS, said agreement has been amended on June 18, 1997; July 16, 1997; February 11,
1998; June 10, 1998; April 14, 1999; a new administrative service agreement was entered September 8,
1999, between the parties; said agreement was renewed October 1,2003; and
WHEREAS, the Employer revised its employee benefits plan effective January 1,2004 and said
agreement was amended February 18, 2004; and
WHEREAS, the Florida Keys Mosquito Control Board, a covered entity under the Employer's
employee health benefit plan, effective May 1, 2004 will no longer participate in said health benefit plan;
NOW, THEREFORE, the parties hereto agree as follows:
1) The administrative fee for Acordia National's TPA services for run-out claims
shall be 10% of total claims paid for the Florida Keys Mosquito Control Board
from May 1,2004 through July 31,2005.
2) The per employee per month (PEPM) fee for Florida Keys Mosquito Control
Board expires April 30, 2004.
3) This administrative fee supersedes the stated administrative fee in any prior
agreements between employer and Acordia National.
TP A Services/ Acordia
4) All services between Employer and Acordia National remain the same as agree
upon the administrative services agreement dated September 8, 1999, as renewed
October 1, 2003.
IN WITNESS WHEREOF the Employer and Acordia National have caused this amendment to
agreement to be executed this [~ day of r 1,20L-].
ATTEST: D~L.KOHLAGE
CLERK
Board of County Commissioners of Monroe County
By:
By:
Deputy Clerk
Mayor
ACORDIA NATIONAL
By
Witness
Its
Ie:
AMENDMENT TO
ADMINISTRATIVE SERVICES AGREEMENT
THIS AGREEMENf, made and entered into this 18th day of February, 2004 by and between Board
of County Conmrissioners of Monroe County (hereinafter called "Employer") and ACORDIA NATIONAL,
of Charleston, West Virginia, (hereinafter called "Acordia National);
WIINE~~~IH
WHEREAS, the Employer presently receives third party administration (TP A) services from
Acordia National for certain of Employer's employee benefit plans; and
WHEREAS, the services provided by Acordia National are defined in an administrative services
only agreement between the Employer and Acordia National dated July I, 1996; and
WHEREAS, said agreement has been amended on June 18, 1997; July 16, 1997; February 11,
1998; June 10, 1998; April 14, 1999; and
WHEREAS, a new administrative service agreement was entered September 8, 1999, between the
parties; and
WHEREAS, said agreement was renewed October 1,2003; and
WHEREAS, the Employer revised its employee benefits plan effective JanUary 1, 2004;
NOW, THEREFORE, the parties hereto agree as follows:
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The administrative fee for Acordia National's TP A services for nm-out claims shall
be 10% of total paid dental and vision claims for January 1,2004 through March
31,2005.
The per employee per month (pEPM) fee for dental and vision expires December
31,2003.
This administrative fee supersedes the stated administrative fee in any prior
agreements between employer and Acardia National.
All services between Employer and Acardia National ~ the same as agreed
upon in the administrative services agreement dated September 8, 1999, as
renewed October 1, 2003.
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UZAN E . HUT ON
ACORDIA NATION~ A SISTANT CygN'U~RNEY
.~ -JJ Date ~ ~
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RENEWAL AGREEMENT
This renewal agreement is entered into by and between Board of County Commissioners of
Monroe County, Florida; 1100 Simonton Street, Room 2-268; Key West, Florida 33040 (hereafter
Employer) and Acordia National of 602 Virginia Street, East Charleston, WV 25301.
WHEREAS, on October 1,2002, the Employer and Acardia National entered into an agreement
(hereafter the original agreement) whereby Acardia National performs claim administration for the
Employer's employee welfare benefit plan; and
WHEREAS, the current contract will expire on September 30, 2003 and the Employer desires to
extend the original agreement for another year, therefore, the parties agree as follows:
1. This first one-year renewal term will commence immediately upon the expiration of the
current contract. Therefore this renewal will become effective October 1, 2003. and will
expire September 30,2004.
2. In all other respects the terms and conditions of the original agreement remain in full
force and effect.
IN WI~;:WH~REOF, the parties hereto have executed this Renewal Agreement this
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BOARD OF COUNTY COMMISSIONERS
OFM~O~F~
By
Mayor/Chairman
ACORDIA NATION~
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MCDroe CODty Oer"-s OfDce Origlaal
ADMINISTRATIVE SERVICE AGREEMENT
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THIS AGREEMENT. made and entered into the -L- day of
~'t~:J.. by and between Monroe County (hereinafter called "Employer")
and ACORDIA NATIONAL of602 Virginia Street, East, Charleston, WV 25301, is
hereinafter set forth:
WITNESSETH
WHEREAS, Employer has established an employee welfare benefit plan
(hereinafter called "Plan") for the purpose of providing medical, dental, vision, utilization
review, Consolidated Omnibus Budget Reconciliation Act. of 1985 ("COBRA"), Health
Insurance Portability and Accountability Act of 1996 ("HIPAA"), and other benefits for
its employees;
WHEREAS, Employer desires to engage the services of Acordia National
as agent for the Employer for the purpose of effecting claim administration under its
Plan; and
NOW, THEREFORE, in consideration of the mutual covenants and
promises hereinafter contained, the parties hereto agree as follows:
1)
2)
The effective date.oftbe Employer's Plan shall be October 1.
The Plan Year shall be from October 1 thru September 30 of each
year.
3)
4)
The Employer's Tax Identification Number is 596000749
For each Plan Year, the Employer shall provide monies sufficient
to pay benefits under the Employer's Plan on a timely basis. "Timely"
shall be defined as within thirty (30) days of Acordia National's
notification, oral or written, that benefit claims have been processed for
payment. In the event Employer shall fail to provide sufficient monies to
fund its claims in a timely manner, a ten percent (10%) surcharge shall be
added to the monthly administrative fee due Acordia National, which
surcharge shall become chargeable beginning on the thirty-first (31 st) day
after Acordia National's notification, as described herein. Employer
acknowledges and agrees that Acordia National shall not have any
financial duty or responsibility to release claim payments if ~mployer has
not sufficiently funded the same.
5) Employer acknowledges and agrees that Acordia National shall not
have any financial duty or responsibility to see that the Employer deposit
meets the Employer's Plan requirements; however, Acordia National shall
keep the Employer advised as to the amount of deposit needed to meet
said requirements on a timely basis. Employer further acknowledges and
agrees that Acordia National shall not be deemed a fiduciary for the Plan
within the meaning of the Employee Retirement Incom~ Security Act of
1974 ("ERISA"). Accordingly, the services to be performed by Acordia
National hereunder shall be limited to the ministerial services set forth
herein and the performance by Acordia National shall be subject in all
respects to review by Employer within the framework of Plan provisions
as well as polices, interpretations, rules, practices and procedures
established by Employer. Acordia National shall not have any
2
Medical Claims Administration
Dental Claims Administration
discretionary authority or control with regard to the management of Plan
assets. To the extent permitted by law, Acordia National shall not incur
any liability for any acts or for failure to act except for its own willful
misconduct in administering the Plan.
6) The monthly capitation fee for administrative services will be:
October 1. 2002
$10.19 PEPM*
$ 1.80 PEPM*
$ 0.41 PEPM*
PERFORMED BY KPHA
$ 0.40 PEPM*
Vision Claims Administration
Pre-certification Administration
HIP AA Administration
· Per Employee, Per Month
The above monthly capitation fee shall apply to renewal effective October 1,
2002, and will remain the same for renewals effective October 1, 2003 and October 1,
2004.
Payment of the fees established above is due from the Employer on or before the
10th day of each month, beginning on the 10lh day of October, 2002, ~he fee quoted is a
three (3) year guarantee effective October 1,2002. The cost of any additional services
rendered by Acordia National on behalf of the Employer necessitated by a change in
federal or state law will also be charged to the Employer in addition to the monthly fee.
Employee counts for purposes of monthly administrative fee billing may not be reduced
by more than 10% of the billed enrollment unless an explanation is provided.
Administrative fee adjustments must be done monthly and cannot be adjusted
3
retroactively in excess of 90 days prior to the month invoiced. Acordia National reseryes
the right to withhold any fees due to the client if administrative fees are outstanding.
Acordia National shall provide generic enrollment forms, claim forms and other
administrative and plan forms. In the event Employer desires customized administrative
and plan forms, Acordia National will direct the printing of same, however, the cost of
such printing shall be paid solely by the Employer.
7) Acordia National shall provide the following services in connection with
the administration of Employer's Planes):
a) Provide assistance to enroll all eligible Employees (as
defined in the Employer's Plan) in Employer's Plan, as agreed
with Employer;
b) Design and obtain other coordinating or supplemental types
of insurance coverage, where necessary, as requested by Employer
in writing;
c) Assist and advise employer in revising Plan Document.
Provide prototype Plan Documents and Identification Cards (ID
Cards) for the Employer. Arrange for printing ~nd preparation of
such documents. The cost of the printing will be the responsibility
of the Employer;
d) Conduct information programs for all eligible Employees
to fully explain the benefits available under the Employer's Plan,
as requested by Employer;
4
e) Respond to telephone and mail inquiries from Plan
participants regarding benefits available to them and their
dependents.
f) Provide information concerning Plan benefits and
participants, based upon information provided by Employer;
g) Review and analyze all claims and determine whether the
charges of health care providers submitted are within reasonable
payment guidelines and/or are related to diagnostic related groups,
preferred provider organization agreements or other i~dustry
standards;
h) Correspond with claimants, as necessary, to prove claims
and to ascertain whether other coverage exists which might pay the
claim in whole or part;
i)
Receive, review, and administer aU claims for benefits
under the Employer's Plan, including the evaluation of claims
made; standard evaluation of the eligibility status of aU claimants,
coordination of and at least annual auditing oft~e Utilization
Review and Case Management function, provide the County with
results of Utilization Review audit, appropriate Coordination of
Benefits evaluation of all claims, supply data to Health Recoveries,
Inc. necessary for subrogation and other functions usual to the
efficient and cost effective administration of claims;
5
j)
Aid the employer in developing an efficient claims control
program;
k) Provide information, on request, for the completion by the
Employer of all necessary IRS and ERISA filings;
I) Provide Employer with a monthly report of claims paid;
m) Do all things necessary to properly effect the
responsibilities of a claims administrator under the Employer's
Plan, provided that all such actions/non-actions not otherwise
required by this Agreement shall first be approved by.Employer.
n) Provide assistance and resources to Monroe County in
identifying, analyzing and maintaining the Employer's Plan in
accordance with state and federal laws, industry standards.
regulations and changes that affect the Plan;
0) Report all potential excess claims to the excess insur~r. and
provide Employer with monthly updates;
p) Make documents available to the Employer and/or their
Consultants for periodic audit of files for accura~y and efficiency
of Acordia National's claims administration, and;
q) Process, authorize, and issue payment of all complete and
eligible claims within twenty (20) days of receipt;
r) Provide the County with adequate training and make
available access to its on-line computerized claim system.
6
s) Acordia agrees that this contract is not assignable by
Acordia without prior written permission from Monroe County.
8) Acordia National shall provide COBRA administrative services, if desired by
Employer (check one blank below). It is agreed and understood that COBRA
administration services are provided for medical and dental plans only and are not
provided for 125 Reimbursement Account Plans.
Applicable
Non-applicable X
In the event Employer desires Acordia National to provide COBRA
administration services, Acordia National agrees to:
a) Provide initial notification of continuation of coverage
option to all employees;
b) Provide notification, enrollment information and
enrollment forms to all qualified beneficiaries within 14 days of
notification of Employer of a qualifying event;
c) Provide monthly billing and collection services for all
qualified beneficiaries who elect to continue coyerage under the
program and supply monthly reports of premiums collected by
Employer;
d) Track participating beneficiaries and notify them of their
right to convert if a conversion option is available under
Employer's Plan;
7
e) Process all claims for continuing beneficiaries under a
segregated category and report, through regular monthly reporting
series, claims experience of continuing beneficiaries (COBRA
claims will be aggregated during the normal check processing
cycle but reported separately at month's end);
f) On an annual basis, at the beginning of Employer's Plan
Year, provide rates to be charged continuing participants for
coverage in the new Plan Year;
g) Provide prototype language to be included in t.he Plan
document to ensure compliance with COBRA legislation;
h) Provide prototype language for inclusion in Employer's
Summary Plan Description and coordinate, at Employer's option,
the printing of new plan booklets at employer's expense; and
i) Mail all correspondence to Plan participants or qualified
beneficiaries directly to the last known address of the employee
and/or dependent by first class mail.
In consideration for receipt of these services from Acordia National, Employer
agrees to:
a) Notify Acordia National within thirty (30) days of
qualifying events for which the Employer has knowledge.
Qualifying events include:
Termination of employment for any reason short of gross
misconduct; and employee's reduction of work hours, the
8
Employer's filing for reorganization under Chapter XI of the
Bankruptcy Code; an Employee's divorce or legal separation;
death of an employee; an employee's child ceasing to be a
dependent; and a beneficiary's entitlement to Medicare. If the
Employer is not notified and does not have knowledge of a
qualifying event, the employee has sixty (60) days from the
qualifying event in which to notify Acordia National of the same to
be eligible or the continuation of coverage option; and
b) Notify Acordia National of any address chang~s or other
pertinent information regarding employee participation in the
Employer's Planes) to allow Acordia National to properly fulfill
the requirements of COBRA legislation.
It is acknowledged by employer that future legislation related to continuation of benefit
coverage or other matters not currently required by COBRA legislation and COBRA
regulations on the date of this Agreement may necessitate an adjustment in the fee for
COBRA administration.
9) In the event Employer does not desire COBRA administration seryices by
Acordia National, but instead the development of COBRA rates applicable to its Plan,
Acordia National shall provide the same upon terms, and for a fee, to be agreed upon
between Employer and Acordia National.
10) Acordia shall provide the following services related to HIP AA
administration for the Employer's Plan:
9
a)
Provide for the Employer's review, prototype modifications
to the plan document and SPD (Booklet) to address HIP AA
requirements;
b) Perform programming required to the Multi-Claim System
to track the applicable eligibility information and maintain credited
coverage information on both a current and future basis;
c) Coordinate the receipt of all certificates of coverage, or
other proof of coverage, for all new employees enrolling in the
benefit plan;
d) Perform the administrative requirements to analyze the
determination of pre-existing conditions and establish the waiting
periods that would apply for all new employees and existing
employees having pre-existing conditions;
e) Develop and distribute to all required parties the
notifications and correspondence documenting pre-existing
conditions;
f) Issue certificates of coverage for all emp!oyees and their
dependents upon termination or upon request;
g) Prepare and distribute standard reports documenting
completed HIP AA activities; and
10
h)
Serve as an information resource for HIP AA questions.
11) Subrogation and Fee Negotiation:
a) This will serve to confirm our understanding that the
Employer desires to utilize the subrogation and related services
offered by Healthcare Recoveries, Inc. in connection with the
Employer's health plan.
b) The administrative fee for Acordia National's Fee
Negotiation Services with health care providers shall be 25% of
savings.
12) In the absence of a designation by the Employer and except for disposition
of disputed claims, Acordia National shall determine the manner in which payment of
benefits shall be made as it shall deem it to be necessary and appropriate in accordance
with provisions of Employer's Plan, and shall not be responsible in the exercise of such
judgment in the absence of willful misconduct on the part of Acordia National.
13) To the extent required by law to purchase such coverage, each Employer
shall name Acordia National as an additional insured under its fiduciary bond which shall
be conditioned upon faithful performance of its duties hereunder, and s!lch fiduciary bond
shall in all respects comply with the requirements of the Employee Retirement Income
Security Act of 1974, as amended.
14) Acordia agrees to defend, indemnify and hold harmless Employer against
all claims, damages, liabilities and expenses actually and reasonably incurred or imposed
on Employer in connection with any actual or threatened claim, action, suit, proceeding,
settlement or compromise thereof which arises from Acordia's administration of claims
11
under Employer Planes) other than in accordance with Plan provisions as well as the
negligence, willful misconduct of Acordia, its employees, representatives, or agents. The
right to be defended, indemnified and held harmless shall extend to Employer's affiliates
as .well as the employees of Employer, their estates, executors, administrators, guardians,
conservators and heirs and shall apply after the employee cease employment with
Employer with respect to acts or omissions of Acordia prior to such cessation.
15) The terms of this Agreement shall be from the effective date hereof and
continue for a period of one year, This Agreement shall be renewed for two (2)
successive one-year periods at the sole discretion of the Employer, unless ei~her party
gives the other notice of cancellation in accordance with the terms set forth below, If
either party desires to modify or terminate this Agreement, it shall notify the other in
writing at least thirty (30) days prior to the effective date of such modification or
termination. In the case of proposed modification the party receiving the notification of
the proposed modification shall itself notify the other party within ten (10) days notice of
its agreement to the proposed modification. Failure to do so shall terminate this
Agreement as of the end of the Employer's Plan Year.
16) This Agreement may be terminated by either the Employer or Acordia
National at any time provided that Acordia National gives the Employer ninety (90) days
prior written notice or that the Employer gives Acordia National at least thirty (30) days
prior written notice. The prior written notice will state the prospective effective date of
the termination. Termination of this Agreement will not terminate the rights or
obligations of either party arising out of the period during which this Agreement was in
effect. Upon the termination of this Agreement, and if the same is not renewed, Acordia
12
National shall return all files of closed or pending claims covered by this Agreement to
the Employer or their designee.
17) Employer agrees that during the term of this Agreement and for a period
ofthree years after its termination it will not induce any employee of Acordia National to
leave Acordia National's employment or directly or indirectly assist any other person or
entity in requesting or inducing any such employee of Acordia National to leave such
employment.
18) Monroe County's performance and obligation to pay under this contract is
contingent upon an annual appropriation by the Board of County Commissioners.
19) Acordia National Warrants that it is not employed, retained or otherwise
had acted in its behalf any former County officer subject to the prohibition in Sec 2 of
Ordinance no 10-1990 or any County officer or employee in violation of Sec 3 Ordinance
10-1990 and that no employee or officer of the County had any interest, financially or
otherwise, in Acordia National except for such interest, permissible by law and fully
disclosed by affidavit attached hereto. For breach or violation of this paragraph, the
County may, in its discretion, terminate this agreement without liability and may also, in
its discretion, deduct from the contract or purchase price, or otherwise r..ecover, the full
amount of any fee, commission, percentage, give or consideration paid to the former
County officer or employee.
19) A person or affiliate who has been placed on the convicted vendor list
following a conviction for public entity crime may not submit a bid on a contract with a
public entity for the construction or repair of a public building or public work, may not
submit bids on leases of real property to public entity, may not be awarded or perform
13
work as a contractor, supplier, subcontractor, or consultant under a contract with any
public entity, and may not transact business with any public entity in excess of the
threshold amount provided in Section 287.017, for CATEGORY TWO for a period of36
months from the date of being placed on the convicted vendor list.
20) All notices hereunder shall be in writing and mailed by certified mail,
return receipt requested. Notices to the Employer shall be at the address first above
written and to Acordia National at 602 Virginia Street, East, Charleston, WV 25301,
Attention: President, at such other addresses as the parties may from time to time
designate in writing.
20) The Employer and Acordia National agree that this agreement shall be
administered and construed according to the laws of the State of Florida. In the event
that any matter of disagreement arises, it shall be decided by a court of competent
jurisdiction with venue in Monroe County, Florida.
21) In the event this Agreement is terminated, the parties will have the option
of agreeing to completion of claims administration services for claims existing at
termination for a ninety (90) day period following termination of this Agreement upon
terms negotiated between the parties.
22) This Agreement, together with the written proposal submitted by Acordia
and the Plan constitute the entire Agreement between the Employer and Acordia
National.
14
IN WITNESS WHEREOF, the Employer and Acordia National have
caused this Agreement to be executed by their respective proper corporate officers,
effective as of the / J ~ of {JelL , 20 ~
ATTEST:
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AN~,. '~Ul<?N
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COUNTY OF ~OE
By
Mayor Charles 'Sonny"
Its
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15
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Acordia National
1996 Edition
Prior to the commencement of work governed by this contract, the Contractor shall obtain
General Liability Insurance. Coverage shall be maintained throughout the life of the contract
and include, as a minimum:
· Premises Operations
· Products and Completed Operations
· Blanket Contractual Liability
· Personal Injury Liability
· Expanded Definition of Property Damage
The minimum limits acceptable shall be:
$500,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$250,000 per Person
$500,000 per Occurrence
$ 50,000 Property Damage
An Occurrence Form policy is preferred, If coverage is provided on a Claims Made policy, its
provisions should include coverage for claims filed on or after the effective date of this contract.
In addition, the period for which claims may be reported should extend for a minimum of twelve
(12) months following the acceptance of work by the County.
The Monroe County Board of County Commissioners shall be named as Additional Insured on
all policies issued to satisfy the above requirements,
GL2
Administration Instruction
#4709,3
ss
1996 Edition
WORKERS' COMPENSATION
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Acordia National
Prior to the commencement of work governed by this contract, the Contractor shall obtain
Workers' Compensation Insurance with limits sufficient to respond to the applicable state
statutes.
In addition, the Contractor shall obtain Employers' Liability Insurance with limits of not less
than:
$500.000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease, policy limits
$500,000 Bodily Injury by Disease, each employee
Coverage shall be maintained throughout the entire term of the contract.
Coverage shall be provided by a company or companies authorized to transact business in the
state of Florida.
If the Contractor has been approved by the Florida's Department of Labor. as an authorized self-
insurer, the County shall recognize and honor the Contractor's status. The Contractor may be
required to submit a Letter of Authorization issued by the Department of Labor and a Certificate
of Insurance, providing details on the Contractor's Excess Insurance Program.
If the Contractor participates in a self-insurance fund, a Certificate of Insurance will be required.
In addition, the Contractor may be required to submit updated financial statements from the fund
upon request from the County.
WC2
Administration Instruction
#4709.3
89
PROFESSIONAL LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Acordia National
1996 Edition
Recognizing that the work governed by this contract involves the furnishing of advice or services
of a professional nature, the Contractor shall purchase and maintain, throughout the life of the
contract, Professional Liability Insurance which will respond to damages resulting from any
claim arising out of the performance of professional services or any error or omission of the
Contractor arising out of work governed by this contract.
The minimum limits of liability shall be;
$500,000 per Occurrence/$ 1 ,000,000 Aggregate
PR02
Administration Instruction
#4709,3
78
1996 Edition
VEIDCLE LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Acordia National
Recognizing that the work governed by this contract requires the use of vehicles, the Contractor,
prior to the commencement of work, shall obtain Vehicle Liability Insurance. Coverage shall be
maintained throughout the life of the contract and include, as a minimum, liability coverage for:
· Owned, Non-Owned, and Hired Vehicles
The minimum limits acceptable shall be:
$300,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$100,000 per Person
$300,000 per Occurrence
$ 50,000 Property Damage
The Monroe County Board of County Commissioners shall be named as Additional Insured on
all policies issued to satisfy the above requirements.
VL2
Administration Instruction
#4709.3
82
1996 Edition
EMPLOYEE DISHONESTY
INSURANCE REQIDREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Acordia National
The Contractor shall purchase and maintain, throughout the term of the contract, Employee Dishonesty
Insurance which will pay for losses to County property or money caused by the fraudulent or dishonest
acts of the Contractor's employees or its agents, whether acting alone or in collusion of others.
The minimum limits shall be:
$100,000 per Occurrence
ED2
Administration Instruction
#4709.3
46
DRUG-FREE \VORKPLACE FORl\l
Thc undersigncd \cnJor in accordnncc with f10rida SIMutc 287.087 hereby ccrtilics Ihill:
Acord '"0 Md h.o'ltSl
(Name of fJlIsiness)
I. PlIblish a Slalcmcnt n01ifying cmplnyecs thilt lI,c unlawful lllanllr"cllIJ"e. distrihution. dispensin:!.
posscssion. or IIse of a cOlltrolkd SlIbsl:lnCC is prohibiled in the Hllrkpl"::!.: :lI1d ~rccif~ in;!. the :lc;i.1Ils I~;;I\
will be 1")..Cll :Ig:linst!.:mployecs ror \.illlali<?lls llf such prohibition.
2. Inform employees abOUl the dangcrs of drug abuse in the workplace. the business's policy of Illaintainin~
a drug-fi'cc workpl:lcc. all)' :Ivailabk drug counseling. rchabilitalion. aild elllplo>'e~ ilssislanc~ pmg.ralm~.
alld the penalties that may be imposed upon employees for drug. :Jbuse viol;ltions.
3. Give e:Jch employee engaged in providing the commodities or contractuJ] services that are under bid a
copy of the statement specified in subsection (1)_
4. In the statement specified in subsection (I), notify the employees that, as a condition of working on the
commodities or contractual services that are under bid, the employee will abide by the terms of lhe
statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to. any
violation of Ch:Jpler 893 (Florida Statutes) or of any controlled substance law of the United States or an)'
state, for a violation occurring in the workplace no later than five (5) days after such conviction.
5. Impose a sanction on, or require the satisf:Jctory participation in a drug abuse assistance or rehJbilitalioll
program if such is availJble in the employee's community, or any employee who is so convicted.
6. Make a good faith effort to continue to mJintain a drug-free workplace through implementation of this
section.
As the person authorized to sign the statement, I certifY that this firm complies fully with the above
requirements.
Bidder's Signature
<f /,/0/
Dale
ATTACHMENT C
OMfJ - ~lcrll5
NON-COLLUSION AFFIDAVIT
I, R.;cl1orcJ I.J L.P99 aft", tit)
of J'tco rJ i a IJ (1 tiOl"td I according to law on my oath, and under
penalty of perjury, depose and say that;
1) I am Ahhcu(,{ H L~9:1
Proposal for the project described as follows:
, the bidder making the
He-a Irk lJe,,~f}r PItS" (!.1(i/4ItS l1eJrni/ll-=-rnll 11-""1
2) The prices in this bid have been arrived at independently without collusion,
consultation, communication or agreement for the purpose of restricting cOlJ1petition, as
to any matter relating to such prices with any other bidder or with any competitor;
3) Unless otherwise required by law, the prices which have been quoted in this bid
have not been knowingly disclosed by the bidder and will not knowingly be disclosed by
the bidder prior to bid opening, directly or indirectly, to any other bidder or to any
competitor; and
4) No attempt has been made or will be made by the bidder to induce any other
person, partnership or corporation to submit, or not to submit, a bid for the purpose of
restricting competition;
5) The statements contained in this affidavit are true and correct, and made with
full knowledge that Monroe County relies upon the truth of the statements contained in
~h:: :~::v;::~:"';;:; 1::''301. for.ald Z;t. Ii ~
nature of Bidder)
COUNTY OF I"1Clna.u....ht& 0'1 ~ 01
DATE
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
RiChAt.d H. ~ who, after first being sworn by me, (name of
individual signing) alf1xed his/her signature in the space provided above on this
I day of Sepn- . 1;9'" 2m'
r6~l5 H. (~s
NOTARY PUBLI
OMB . MCP FORM #1
~ OFfiCIAL SEAL
I.;~ ~). NOTAllY 'Ual.IC
!..:.!./.. .r .'.t-' ST."T5 OF WEST VIRGINIA
'.~~:'.:.'f.q~-::~,... \j C::;:i~rIlS H. '000$
~ ..\:t~;!~/i~(:~:3>~~~~~ 1601 'ii.3: R:.,wv)ew Dr.
~::::~~..~:.....#...;..:. ~;. &cl!~, WV ~015
...~~:.~::.~;...:.~\;... My Ccmm:J:ion Explru 7.16-2t03
--....-.-....---It: ME NT 0
SWORl" ST..\TE\ 11:NT l.INDER ORDINANCE "n. Ill-I 990
ivl0NROE COUNT,'. fLORID..\
[TllICS CLAUSE
R ""1 a , J... If L t" f/..!j
\....arrants Ih:!1 he/it h:!s 110t employed. retained
or otherwise had acl on his/its hellal!" any 1~)("Jner County officer or employee in viobtion of
Scction 2 of Ordinance no. I O.IIN(} or ;lllY County officer or employee in violation of
Scctit1l1 .:; of Ordinance No. IO.Il)<)(). Fm hrcal:h or ....iolalion of this provision the County
llIay. ill its discretion. tCrlni'n;;tc lllis ~lllllr:H:t without liability and lIl:.!y a150. in its discretion.
deduct from the contract or purchase price. or otherwise recover. the full :lmounl of an)' fee.
cOlllmission. percentage. girl. or consideration paid to the former COllnt)' officer or employee.
7f'u ~alu~l
Date: 0:1/07(01
STA TE OF U).eS-t V\(~I"I'"
COUNTY or KCtt'\Ci~
PERSONALLY APPEARED BEFORE ME. the undersigned authority,
~~vtl H. ~
who, after first being sworn by me, affixed his/her
signature (name of individual signing) in the space provided above on this I
day of
>ept.
, ~ 2 eLl.
'~C:5 1-\. f}~
NOTARY PU8L1C
:-'.1 Y Clllllm issioll expires:
OFl'ICIAL $6AL "{
NOTARY 'U8L1C I
STAT! OF WEST VIRGINIA
DfNNIS K. lOGOS
1801 W.t1 RI.....-vl.... Dr.
eorle, WV 25015
My Comllllollon uplr.. 7. ,..20Q3
,-~
0\-113 - Mep FORtv! #4
ATTACHMENT E
ADMINISTRATIVE SERVICE AGREEMENT
TIDS AGREEMENT, made and entered into this i'JJ.
Ofh-~
by and between Monroe County (hereinafter called "Employer") and ACORDIA
NATIONAL of 602 Virginia Street, East, Charleston, WV 25301, is hereinafter set forth:
WITNESSETH
WHEREAS, Employer has established an employee welfare benefit plan
(hereinafter called "Plan") for the purpose of providing medical, dental, vision, utilization
review, Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA"), Health
Insurance Portability and Accountability Act of 1996 ("HIP AA"), and other benefits for
its employees;
WHEREAS, Employer desires to engage the services of Acordia National
as agent for the Employer for the purpose of effecting claim administration under its Plan;
and
NOW, THEREFORE, in consideration of the mutual covenants and
promises hereinafter contained, the parties hereto agree as follows:
1)
2)
The effective date of the Employer's Plan shall be October 1.
The Plan Year shall be from October 1 thru September 30 of each
year.
3)
4)
The Employer's Tax Identification Number is 596000749
For each Plan Year, the Employer shall provide monies sufficient
to pay benefits under the Employer's Plan on a timely basis. "Timely" shall be
defined as within thirty (30) days of Acordia National's notification, oral or
written, that benefit claims have been processed for payment. In the event
Employer shall fail to provide sufficient monies to fund its claims in a timely
manner, a ten percent (10%) surcharge shall be added to the monthly
administrative fee due Acordia National, which surcharge shall become
chargeable beginning on the thirty-first (31st) day after Acordia National's
notification, as described herein. Employer acknowledges and agrees that Acordia
National shall not have any financial duty or responsibility to release claim
payments if Employer has not sufficiently funded the same.
5) Employer acknowledges and agrees that Acordia National
shall not have any financial duty or responsibility to see that the Employer deposit
meets the Employer's Plan requirements; however, Acordia National shall keep
the Employer advised as to the amount of deposit needed to meet said
requirements on a timely basis. Employer further acknowledges and agrees that
Acordia National shall not be deemed a fiduciary for the Plan within the meaning
of the Employee Retirement Income Security Act of 1974 ("ERISA").
Accordingly, the services to be performed by Acordia National hereunder shall be
limited to the ministerial services set forth herein and the performance by Acordia
National shall be subject in all respects to review by Employer within the
framework of Plan provisions as well as policies, interpretations, rules, practices
and procedures established by Employer. Acordia National shall not have any
discretionary authority or control with regard to the management of Plan assets.
To the extent permitted by law, Acordia National shall not incur any liability for
any acts or for failure to act except for its own willful misconduct in administering
the Plan.
2
6) The monthly capitation fee for administrative services will be:
October 1. 1999 October 1. 2000
Medical Claims Administration 9.48 PEPM'" 9,70 PEPM
Dental Claims Administration 1.65 PEPM 1.70 PEPM
Vision Claims Administration 0.38 PEPM 0.39 PEPM
Pre-certification Administration PERFORMED BY KPHA
HIPAA Administration 0.36 PEPM 0.37 PEPM
'" Per Employee, Per Month
The above monthly capitation fee for October 1, 2000 shall apply to
renewal effective October 1, 2001.
Payment of the fees established above is due from the Employer on or
before the 10th day of each month, beginning on the 10th day of October, 1999,
The fee quoted may be increased by Acordia National upon thirty (30) days prior
written notice to Employer, with any such increase to become effective
automatically following such notice period. Acordia National reserves the right to
initiate price increases without prior written notice on any renewal date of this
Agreement. The cost of any additional services rendered by Acordia National on
behalf of the Employer necessitated by a change in federal or state law will also be
charged to the Employer in addition to the monthly fee.
Acordia National shall provide generic enrollment forms, claim forms and
other administrative and plan forms. In the event Employer desires customized
administrative and plan forms, Acardia National will direct the printing of same,
however, the cost of such printing shall be paid solely by the Employer,
3
7) Acordia National shall provide the following services in connection with
the administration of Employer's Planes):
a) Provide assistance to enroll all eligible Employees
(as defined in the Employer's Plan) in Employer's Plan, as agreed
with Employer;
Design and obtain other coordinating or
supplemental types of insurance coverage, where necessary, as
requested by Employer in writing;
Assist and advise employer in revising Plan
Document. Provide prototype Plan Documents and Identification
Cards (ID Cards) for the Employer. Arrange for printing and
preparation of such documents. The cost of the printing will be the
responsibility of the Employer;
d) Conduct informational programs for all eligible
Employees to fully explain the benefits available under the
Employer's Plan, as requested by Employer;
e) Respond to telephone and mail inquiries from Plan
participants regarding benefits available to them and their
dependents;
b)
c)
f) Provide information concerning Plan benefits and
participants, based upon information provided by Employer;
g) Review and analyze all claims and determine
whether the charges of health care providers submitted are within
4
reasonable payment guidelines and/or are related to diagnostic
related groups, preferred provider organization agreements or other
industry standards;
h) Correspond with claimants, as necessary, to process
claims and to ascertain whether other coverage exists which might
pay the claim in whole or part;
i) Receive, review, and administer all claims for
benefits under the Employer's Plan, including the evaluation of
claims made; standard evaluation of the eligibility status of all
claimants, coordination of and at least annual auditing of the
utilization Review and Case Management function, provide the
County with results of Utilization Review audit, appropriate
Coordination of Benefits evaluation of all claims, supply data to
Health Recoveries, Inc. necessary for subrogation and other
functions usual to the efficient and cost effective administration of
claims;
j) Aid the employer in developing an efficient claims
control program;
k) Provide information, on request, for the completion
by the Employer of all necessary IRS and ERISA filings;
I) Provide Employer with a monthly report of claims
paid;
5
Do all things necessary to properly effect the
responsibilities of a claims administrator under the Employer's
Plan, provided that all such actions/non-actions not otherwise
required by this Agreement shall first be approved by Employer.
Provide assistance and resources to Monroe County
in identifying, analyzing and maintaining the Employer's Plan in
accordance with state and federal laws, industry standards,
regulations and changes that affect the Plan;
0) Report all potential excess claims to the excess
insurer, and provide Employer with monthly updates;
m)
n)
p) Make documents available to the Employer and/or
their Consultants for periodic audit offiles for accuracy and
efficiency of Acordia National's claims administration, and;
q) Process, authorize, and issue payment of all
complete and eligible claims within twenty (20) days of receipt;
r) Provide the County with adequate training and
make available access to its on-line computerized claim system.
s) Acordia agrees that this contract is not assignable by
Acordia without prior written permission from Monroe County.
8) Acordia National shall provide COBRA administration services, if desired by
Employer (check one blank below). It is agreed and understood that COBRA
administration services are provided for medical and dental plans only and are not
provided for 125 Reimbursement Account Plans.
6
Applicable
Non-applicable X
In the event Employer desires Acordia National to provide COBRA
administration services, Acardia National agrees to:
a) Provide initial notification of continuation of
coverage option to all employees;
b) Provide notification, enrollment information and
enrollment forms to all qualified beneficiaries within 14 days of
notification by Employer of a qualifying event;
c) Provide monthly billing and collection services for
all qualified beneficiaries who elect to continue coverage under the
program and supply monthly reports of premiums collected by
Employer;
d)
Track participating beneficiaries and notify them of
their right to convert if a conversion option is available under
Employer's Plan;
Process all claims for continuing beneficiaries under
a segregated category and report, through regular monthly
reporting series, claims experience of continuing beneficiaries
(COBRA claims will be aggregated during the normal check
processing cycle but reported separately at month's end);
e)
7
f) On an annual basis, at the beginning of Employer's
Plan Year, provide fates to be charged continuing participants fOf
coverage in the new Plan Year;
g) Provide prototype language to be included in the
Plan document to ensure compliance with COBRA legislation;
h) Provide prototype language for inclusion in
Employer's Summary Plan Description and coordinate, at
Employer's option, the printing of new plan booklets at employer's
expense; and
i) Mail all correspondence to Plan participants or
qualified beneficiaries directly to the last known address of the
employee and/or dependent by first class mail.
In consideration for receipt of these services from Acordia National, Employer
agrees to:
a) NotifY Acordia National within thirty (30) days of
qualifying events for which the Employer has knowledge.
Qualifying events include:
termination of employment or any reason short of gross
misconduct; and employee's reduction of work hours, the
Employer's filing for reorganization under Chapter XI of the
Bankruptcy Code; an employee's divorce or legal separation; death
of an employee; an employee's child ceasing to be a dependent;
and a beneficiary's entitlement to Medicare. Ifthe Employer is not
8
notified and does not have knowledge of a qualifying event, the
employee has sixty (60) days from the qualifying event in which to
notify Acordia National of the same to be eligible or the
continuation of coverage option; and
b) Notify Acordia National of any address changes or
other pertinent information regarding employee participation in the
Employer's Planes) to allow Acordia National to properly fulfill the
requirements of COBRA legislation.
It is acknowledged by employer that future legislation related to continuation of benefit
coverage or other matters not currently required by COBRA legislation and COBRA
regulations on the date of this Agreement may necessitate an adjustment in the fee for
COBRA administration.
9) In the event Employer does not desire COBRA administration services by
Acordia National, but instead the development of COBRA rates applicable to its Plan,
Acordia National shall provide the same upon terms, and for a fee, to be agreed upon
between Employer an Acordia National.
10) Acordia shall provide the following services related to HIP AA
administration for the Employer's Plan:
a) Provide for the Employer's review, prototype modifications to the
plan document and SPD (Booklet) to address HIP AA
requirements;
9
b) Perform programming required to the Multi-Claim
System to track the applicable eligibility information and maintain
credited coverage information on both a current and future basis;
c) Coordinate the receipt of all certificates of coverage, or
other proof of coverage, for all new employees enrolling in the
benefit plan;
Perform the administrative requirements to analyze the
determination of pre-existing conditions and establish the waiting
periods that would apply for all new employees and existing
employees having pre-existing conditions;
Develop and distribute to all required parties the
notifications and correspondence documenting pre-existing
conditions;
f) Issue certificates of coverage for all employees and their
dependents upon termination or upon request;
d)
e)
g) Prepare and distribute standard reports documenting
completed HIP AA activities; and
h) Serve as an information resource for HIP AA questions.
11) Subrogation and Fee Negotiation:
a) This will serve to confirm our understanding that the
Employer desires to utilize the subrogation and related services offered by
Healthcare Recoveries, Inc. in connection with the Employer's health plan.
10
b) The administrative fee for Acordia National's Fee
Negotiation Services with health care providers shall be 25% of savings.
12) In the absence ofa designation by the Employer and except for disposition
of disputed claims, Acordia National shall determine the manner in which payment of
benefits shall be made as it shall deem it to be necessary and appropriate in accordance
with provisions of Employer's Plan, and shall not be responsible in the exercise of such
jud8ement in the absence of willful misconduct on the part of Acordia National.
13) To the extent required by law to purchase such coverage, the Employer
shall name Acordia National as an additional insured under its fiduciary bond which shall
be conditioned upon faithful performance of its duties hereunder, and such fiduciary bond
shall in all respects comply with the requirements of the Employee Retirement Income
Security Act of 1974, as amended.
14) Acordia agrees to defend, indemnify and hold harmless Employer against
all claims, damages, liabilities and expenses actually and reasonably incurred or imposed
on Employer in connection with any actual or threatened claim, action, suit, proceeding,
settlement or compromise thereof which arises from Acordia's administration of claims
under Employer Planes) other than in accordance with Plan provisions as well as the
negligence, willful misconduct of Acordia, its employees, representatives, or agents. The
right to be defended, indemnified and held harmless shall extend to Employer's affiliates
as well as the employees of Employer, their estates, executors, administrators, guardians,
conservators and heirs and shall apply after the employee ceases employment with
Employer with respect to acts or omissions of Acordia prior to such cessation.
11
15) The terms of this Agreement shall be from the effective date hereof and
continue for a period of one year. This Agreement shall be renewed for two (2)
successive one-year periods at the sole discretion of the Employer, unless either party
gives the other notice of cancellation in accordance wit the terms set forth below. If
either party desires to modifY or terminate this Agreement, it shall notifY the other in
writing at least thirty (30) days prior to the effective date of such modification or
termination. In the case of proposed modification the party receiving the notification of
the proposed modification shall itself notifY the other party within ten (10) notice of its
agreement to the proposed modification. Failure to do so shall terminate this Agreement
as of the end of the Employer's Plan Year.
16) This Agreement may be terminated by either the Employer or Acordia
National at any time provided that Acordia National gives the Employer ninety (90) days
prior written notice or that the Employer gives Acordia National at least thirty (30) days
prior written notice. The prior written notice will state the prospective effective date of
the termination. Termination of this Agreement will not terminate the rights or
obligations of either party arising out of the period during which this Agreement was in
effect. Upon the termination of this Agreement, and if the same is not renewed, Acordia
National shall return all files of closed or pending claims covered by this Agreement to
the Employer or their designee.
17) Employer agrees that during the term of this Agreement and for a period of
three years after its termination it will not induce any employee of Acordia National to
leave Acordia National's employment or directly or indirectly assist any other person or
entity in requesting or inducing any such employee of Acordia National to leave such
12
employment.
18) Acordia National warrants that it has not employed, retained or otherwise
had acted on its behalf any former County officer subject to the prohibition in Sec 2 of
Ordinance no 10-1990 or any County officer or employee in violation of Sec. 3 Ordinance
10-1990 and that no employee or officer of the County had any interest, financially or
otherwise, in Acordia National except for such interest, permissible by law and fully
disclosed by affidavit attached hereto. For breach or violation of this paragraph, the
County may, in its discretion, terminate this agreement without liability and may also, in
its discretion, deduct from the contract or purchase price, or otherwise recover, the full
amount of any fee, commission, percentage, give or consideration paid to the former
County officer or employee.
19) All notices hereunder shall be in writing and mailed by certified mail,
return receipt requested. Notices to the Employer shall be at the address first above
written and to Acordia National at 602 Virginia Street, East, Charleston, WV 25301,
Attention:
President, or at such other addresses as the parties may from time to time designate in
writing.
20) The Employer and Acordia National agree that this agreement shall
be administered and construed according to the laws of the State of Florida, In the event
that any matter of disagreement arises, it shall be decided by a court of competent
jurisdiction with venue in Monroe County, Florida.
21) In the event this Agreement is terminated, the parties will have the option
of agreeing to completion of claims administration services for claims existing at
13
termination for a ninety (90) day period following termination of this Agreement upon
terms negotiated between the parties.
22) This Agreement, together with the written proposal submitted by Acordia
and the Plan constitute the entire Agreement between the Employer and Acordia
National.
IN WITNESS WHEREOF, the Employer and Acordia National have
caused this Agreement to be executed by their respective proper corporate officers,
effective as of the F d,
day of Jt~, 19 99
/
-' ' t
,_.~_..v,,""""'.s-_:r......'-"~:'
ATTEST:
ACORDIA NATIONAL f /
By 7(J -hI. ~~
Its j{-::xt."~;(.;fr/';/ fJ/"F'/C~
~J1L
14
ATTACHMENT 2
PUBLIC GOODS SURCHARGE/COVERED LIVES
ELECTION FORl'vl
FEDERAL TAX
IDENTIFICATION #:
59-6000749
,
"
PAYOR NAME:
MONROE COUNTY BOARD OF COMMISSIONERS
DBAs (IF APPLICABLE)
N/A
5100 COLLEGE ROAD, ROOM 215
KEY WEST, FLORIDA 33040
ADDRESS:
CONTACT PERSON:
LEAH M. MARQUESS
PHONE #:
(305) 292-4448 FAX#: (305) 295-4301
By signature below, the above entity elects to make public goods surcharge payments directly to the Department's pool
administrator for all its lines of business and agrees to:
I. remit to the Department's pool administrator required surcharge payments for all applicable services on a monthly basis on
or before the 30th day following the calendar month for which monies have been paid to designated providers of service;
2. provide the Department's pool administrator monthly certified reports on or before the 30th day following the calendarmonth
for which monies have been paid which separately report patient service expenditures for services provided by designated
provider type(s) (i.e., hospital inpatient, hospital outpatient, diagnostic & treatment center, laboratory, or ambulatory surgery
center) by product line;
3. provide the Department with certification of data and access to allowance expenditure data upon request for audit verification
purposes; and
4. the jurisdiction of the state to maintain an action in the courts of the State of New York to enforce any provision of section
2807-j of the Public Health Law.
By signature below, the above entity also agrees to make public goods covered lives payments directly to the Department's pool
~<Iministrator in instances where it provides inpatient coverage as a corporation organized and operating in accordance with
Article 43 of the Insurance Law, an organization operating in accordance with Article 44 of the Public Health Law, a self-
insu)'cd fund or third party ndministrator acting on behalf of such fund or a commercial insurer licensed to do business in New
York State and authorized to write accident and health insurance and whose policy provides Inpatient cO\'crage on an cxpense
incurred bases. In such instances the above entity agrees to:
1. remit to the department's pool administrator within 30 days after the end of each month one-twelfth of both the individual
and family unit annual assessment amounts for each of the individuals and family units residing in the slate which were
included on the payor's membership rolls for all or a portion of the prior month and for which the payor covered general
hospital inpatient care, including retroactive additions and deletions;
2. provide the Department with data certification and access to individual and family unit data, upon request, for audit
verification purposes; and
3. the jurisdiction of the state to maintain an action in the courts of the State of New York to enforce any provision of section
2807.t of the Public Health Law.
By signature below, the Chief Financial Offieer of the above entity certifies that the data provided on Attachments #2 through
2.4 has been carefully prepared in accordance with instructions provided, and to the best of his/her knowledge, the information
pr~sented is accurate and correct.
Sign~turc
Date
Chief Financial. Officer
11
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ATTACHMENT 2.6
PUBLIC GOODS SURCHARGE/COVERED LIVES
ELECTION FOR!'\1
CHANGE OF THIRD PARTY ADMINISTRATOR (TPA) STATUS OF PAYORS
If an electing payor changes their third party administrator (IP A) or administrative
services only organization (ASO), the form below must be completed and submitted to
the Department's pool administrator. NOTE: This form is only to be utilized by payors,
not TP As. The TP As should file Attachment #2.4-A or #2.4-B Addendum.
Effective Date: January 1. 1997
File out all applicable information.
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PAYOR INFORMATION:
Federal Employer Identification #(EIN):59-6000749
Name: Monroe County Board of Commissioners
PREVIOUS TPAJASO INFORMATION
Federal Employer Identification #(EIN):HLA
Name: IYlA
PRESENT NEW TPA INFORMATION:
Federal Employer Identification #(EIN):SS-0579762
Name: Acordia National
Address; PO Box 3262
Charlt..,;ton. WV 25.332
Contact Person: Beverly Burdette
Phone #: 304-353-8781
Check one of the following (if applicable):
../ New TP A is assuming responsibility for all pending claims and HCRA reporting
requirements.
Signature of Payor
Date
DOH-4100 (6/97)
An. 2.6-Page 1 of 1
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RISK MANAGEMENT
POLICY AND PROCEDURES
.CONTRACT ADMINISTRATION
. MANUAL
General Insurance Requirements
For
Other Contractors and Subcontractors
As a pre-requisite of the work governed, or the goods supplied under this contract (including the
pre-staging of personnel and material), the Contractor shall obtain, at his/her own expense,
insurance as specified in any attached schedules, which are made part of this contract. The
Contractor will ensure that the insurance obtained, will extend protection to all Subcontractors
engaged by the Contractor. As an alternative, the Contractor may require all Subcontractors to
obtain insurance consistent with the attached schedules. .
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The Contractor will not be permitted to commence work governed by this contract (including
prestaging of personnel and materia]) until satisfactory evidence of the required insurance has
been furnished to the Count)' as specified below. Delays in the commencement of work, resulting
from the failure of the Contractor to provide satisfactory evidence of the required insurance, shall
not extend deadlines specified in this contract, and any penalties and failure to perform
assessments shall be imposed as if the work commenced on the specified date and time, except
for the Contractor's failure to provide satisfactory evidence.
The Contractor shal] maintain the required insurance throughout the entire term of this contract
and any extensions specified in the attached schedules. Failure to comply with this provision may
result in the immediate suspension of all work until the required insurance has been reinstated or
replaced. Delays in the completion of work resulting from the failure of the Contractor to
maintain the required insurance shall not extend deadlines specified in this contract and any
penalties and failure to perform assessments shall be imposed as if the work had not been
suspended, except for the Contractor's failure to maintain the required insurance...
The Contractor shall provide, to the County, as satisfactory evidence of the required insurance
either:
· Certificate of Insurance
or
. A Certified copy of the actual insurance policy.
The County, at its sole option, has the right to request a celtified copy of any or all insurance
policies required by this contract.
All insurance policies must specify that they are not subject to cancellation, now-renewal,
material change. or reduction in coverage unless a minimum of thirty (30) days prior notification
is given to the County by the insurer.
The acceptance and/or approval of the Contractor's insurance shall not be construed as relieving
the Contractor from any liability or obligation assumed under this contract or imposed by law.
The Monroe County Board of Coun~y Commissioners, its employees and officials will be
included as "Additional Insured" on all policies, except for Workers' Compensation.
Any deviations from these General Insurance Requirements must be requested in writing on the
Count)' prepared form entitled "Request for Waiver ofInsurance Requirements" and approved by
Monroe County Risk Manager.
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I ~96 Ed:I''''',
INSURANCE REQUffiEMENTS
FOR
CONTRACT
BETWEEN
.' MONROE COUNTY, FLORIDA
AND
ACORDIA NATlOOAL
Prior to the commencement of work governed by this contract, the Contractor shall obtain
General Liability Insurance. Coverage shall be maintained throughout the life of the contract and
include, as a minimum:
.
Premises Operations
.. Products and Completed Operations
Blanket Contractual Liabilitv
Personal Injury Liability .
Expanded Definition of Property Damage
.
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.
The minimum limits acceptable shall be:
$500,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$250,000 per Person .
$500,000 per Occurrence
$ 50,000 Property Damage
. An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its
provisions should include coverage for claims filed on or after the effective date of this contract.
In addition, the period for which claims may be reported should extend for a minimum of twelve
(12) months following the acceptance of work by the County.
The Monroe County Board of County Commissioners shall be named as Additional Insured on all
policies issued to satisfy the above requirements.
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GL2
Administralion Insuuction
#~709.3
54
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I Y96 Edilior.
\VORKERS' COMPENSATION
INSURANCE REQUm.EMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNlY, FLORIDA
AND
ACTIRDTA NATTOOAT.
Prior to the commencement of work governed by this contract, the Contractor shall obtain
Workers' Compensation Insurance with limits sufficient to respond to the applicable state statutes.
In addition, the Contractor shall obtain Employers' Liability Insurance with limits of not less than:
$500,000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease, policy limits
$500,000 Bodily Injury by Disease, each employee
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Coverage shall be maintained throughout the entire term of the contract.
Coverage shall be provided by a company or companies authorized to transact business in the
state of Florida.
If the Contractor has been approved by the Florida's Department of Labor, as an authorized self-
insurer, the County shall recognize and honor the Contractor's status. The Contractor may be
required to submit a Letter of Authorization issued by the Department of Labor and a Certificate
of Insurance, providing details on the Contractor's Excess Insurance Program.
If the Contractor participates in a self-insurance fund, a Certificate ofInsurance will be required.
In addition, the Contractor may be required to submit updated financial statements from the fund
upon request from the County. .
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WC2
~f;l1j
Administration instruction
#~709.3
88
1996 EdJlIon
PROFESSIONAL LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
. .MONROE COUNTY, FLORIDA
AND
ACORDIA NATlOOAL
Recognizing that the work governed by this contract involves the furnishing of advice or services
of a professional nature, the Contractor shall purchase and maintain, throughout the life of the
contract, Professional Liability Insurance which will respond to damages resulting from any claim
arising out of the performance of professional services or any error or omission of the Coritractor
arising out of work governed by this contract.
The minimum limits ofliability shall be:
$500,000 per Occurrence/$l,OOO,OOO Aggregate
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PR02
Administration Instruction
#4709.3
77
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1996 E.d.lum
VEHICLE LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
. MONROE COUNTI', FLORIDA
AND
ACORDIA NATIONAL
Recognizing that the work governed by this contract requires the use of vehicles, the Contractor
prior to the commencement of work, shfl1l obtain Vehicle Liability Insurance. Coverage shfl1l be'
maintained throughout the life of the contract and include, as a minimum., liability'coverage for:
. Owned, Non-Owned, and Hired Vehicles
The minimum limits acceptable shall be:
$300,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$100,000 per Person
$300,000 per Occurrence
$ 50,000 Property Damage
The Monroe County Board of County Commissioners shall be named as Additional Insured on all
policies issued to satisfy the above requirements.
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VL2 .
Administration Instruction
1/4709.3
81
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1996 1:01:lon
EMPLOYEE DISHONESTY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
1YI0NROE COUNTY, FLORIDA
AND
ACORDIA NATlOOAL
The Contractor shall purchase and maintain, throughout the term ofthe contract, Employee Dishonesty
Insurance which will pay for losses to County property or money caused by the frauduleI:lt or dishonest
- -' acts of the Contractor's employees or its agents, whether acting alone or in collusion of others.
The minimum limits shall be:
$100,000 per Occurrence
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<-II
ED2
Admini~trlllion wuuc;tion
:14709.3
45
PUBLIC ENTITY CRIME STATEMENT
orA person or affiliate who has been pbced on the convicted vendor list
lollo\l,'ing a con\'icti9-n for public entity crime may not submit a bid on a
contract to provide any goods or services to a publicelllit)', may not submit
a bid on a contract with a public entity for the construction or repair ofa
public building or public work. may not submit bids on leases c. f real
property to public entity, may not be awarded or perform work as a
contractor, supplier. subcontractor. or consultant under a contract with any
public entity, and may not lrnnsuct..ousincss with any public emi.ty in excess
of the threshold amoullt provided ill Section 2X7.0 17. tor CA TEGOR Y
T\VO for a period of 36 months li'om the date orbcing placed on the
convicted vendor lisl."
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ATTACHMENT B
DRUG-FREE \VORKPLACE FORM
The undcrsigned ,.clldor in accord<111Ce Wilh Florida Statule 287.087 hereby cenllies Ihnt:
k~//1 ~7Ta.V.4~. -4Ve.
(N,II11e of Ollsim:ss) /
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I. PlIhlish a SI:1ICmel11 1lC1IilYing cll1r1o)"ces Ihal rhe unlawlill manuracllln:. t.IislrihUlion. uispcnsin!..!.
possession. or IIS~' of:J contmlkd suhslance is prohihilcJ in the wnrkplacc and srccifyillg. Ihe :Iclions Ih;1\
will be taken ngainsl employces fllr "illlati~ll!; tlf such prohibition.
2. Inform employees :JhoUl Ihe dangers of drug ilbusc in the workplace. the business's policy Ilr lll:1intainin!..!
a drug-free workplace. ;II1Y available drug counseling. rchabilitntion, and employee assislancc Jlrog.r3m~.
;lI1d the penahies that may be imposed upon employees for drug. abuse violations.
3. Give e:Jeh employee engaged in providing the commodities or contractual services that are under bid a
copy of the statement specified in subsection (I).
4. In the statement specified in subsection (I). notify the employees that. as a condition of working on the
commodities or contractual services that are under bid. the employee will abide by the tenns of the
statement and will notify the employer of any conviction of. or plea of guilty or nolo contendere to, an\'
violation of Chapter 893 (Florida Statutes) or of any controlled substance law of the United Slates or an~'
state, for a violation occurring in Ihe workplace no later than five (5) days after such conviction. .
5. Impose a silnction on, or require the satisfactory panicipation in a drug abuse assistance or rehabilitation
program if such is available in the employee's community, or any employee who is so convicted.
6. Make a good faith effon to continue to maintain a drug-free workplace through implementation of Ihis
section.
As the person authorized to sign the statement. I cenify that thisfinn complies fully with the above
requirements.
Bidder's Signature
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ATTACHMENT C
OMO - Me"/I:;
NON-COLLUSION AFFfOA Vfr
/lC()R.lJ/4 Af/l-?7tJ~4~/.:z:vC..
(!/14~~"ft ?1YJ. wV4
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I,
of the city"
of
according to law on my oath, and under
penalty of perjury, depose and say that:
1) I am A<2Y.eD/;f N4?7CVt//Tt; :::z;u e . , the bidc.'er making the
Proposal for the project described as follows:
l?e~Ve:>T ~. MalbrOdL I/6Y1-C?7f /UW eL.4/'?L/.--Pk)//AlI,s7X~tJ1)
'l>~7'Ii714 t/.f/~M Nr{f#/!662> ~c-~.f.) V77L/Z'.4?r6V-eev/~ /'
//-,u/J LM.6€ M/?cF ).I~/l-d.6~~;Vr ~l:.?eWc~?
2) The prices in this bid have been arrived at independently without collusion,
consultation, communication or agreement for the purpose of restricting competition, as
to any matter relating to such prices with any other bidder or with any competitor;
3) Unless otherwise required by law, the prices which have been quoted in this bid
have not been knowingly disclosed by the bidder and will not kri'owjngly be disclosed by
the bidder 'prior to bid opening, directly or indirectly, to any other bidder or to any
competitor; and
4) No attempt has been made or will be made by the bidder to induce any other
person, partnership or corporation to submit, or not to submit, a bid for the purpose of
restricting competition;
5} The statements contained in this affidavit are true and correct, and made with
full knowledge that Monroe County relies upon the truth of the statements contained in
this affidavit in awarding contracts for said project.
STATE OF We71- Vllrq 1(\. '" U i/ U
(Signature of Bidder)
V ftt /1;
Kana whet
COUNTY OF
DATE
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
Pi ck H. Le~ who, after first being sworn by me, (name of
individual signing) affix d hIs/her sIgnature In the space prOVided above on thIS
2.{, day of A(~V' i \
It~ is (J. 11r1ff
NOTARY PUSUC
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OMS - MCP FORM #1
\' ~y ,.nromi~si.an..expires:_____ ';
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ATTACHMENT 0
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SWORN ST:\TE:-,'1FNT l :NDER ORDINANCE ~(). to-I qq()
MONROF COUNTY. FLORIDA
ETHICS CLAUSE
,1 cak'.;t!..'}'/-l #.&-?7ck//?L" 2/VC. warrants that he/it has not cmployed. rctaincd
l)r otherwise had act on his!its hehnlr nny former County officcr or cmployce ill violation of
Section 2 of Ordinancc no. 10- J 1)l}O or :II1Y COllllty officer or cmployee in viol<ltion of
Sect il)n .lllr Ordinance No. 11I-1l}<)O. For hrcac;h or viol<llion of this prnvi5ion thc County
may. in its discrction. terminale this ":lllllract without liability <lnd Ill:!)' also. in its'discretion.
deduct from the contract or purdl:lSC pri..:c. ur otherwise recovcr. the full amount of :1I\Y fec.
commission. percentage. girl. or cl)llsitlernlioll paid to the former County officer or cmployee.
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(Signature)~
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Date:
STATEOF Wet;l- VJr't\Itl,'U
COUNTY OF K"ahatvntt
PERSONALLY APPEARED BEFORE ME. the undersigned authority.
Rick H. ~
who, after first being sworn by me, affixed his/her
signature (name of individual signing.) in the space provided above on this 2"
day of
Apvil
.19~.
ttfMIVl is toOL ~~JJ
NOTARY PUBLIC
:>'1y cllllllnission expires:
OMB - ~ICP FORM #4
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