Item C32BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: April
16,
2008
Division: Employee Services
Bulk Item: Yes
X
No
Department: Benefits Office
Staff Contact Person/Phone#:Maria Gonzalez X4448
AGENDA ITEM WORDING: Approval to waive purchasing policy and extend the current contracts
for the County's Third Party Administrator -Wells Fargo and Utilization Review/Case Management
Provider -Keys Physician Hospital -Alliance for one (1) year with provisions to renew for two (2)
additional consecutive one year terms. Both of these contracts expire September 30, 2008. Both
Providers have agreed to renew at the current rate for three additional years.
ITEM BACKGROUND: Wells Fargo handles claims processing for covered individuals under the
county's group health plan. Keys Physician Hospital Alliance provides Pre -admission Certification,
Medical Case Management Services and an Employer -Provider Network.
PREVIOUS RELEVANT BOCC ACTION:
Third Party Administrator: In 2001 - The service went out for RFP and decided to continue with
Wells Fargo and renew their contract (02/03; 03/04; 04/05). In 2005 - The BOCC approved the request
to waive RFP and renew the contract (05/06; 06/07; 07/08).
Utilization Review/Case Management Provider: In 2004 - BOCC approved to continue with KPHA
and change the discounted rates, which Monroe County receives, from 15% to an improved 25%
(3/1/04 - 2/28/05; renewed: 05/06; 06/07). In January 2007 - BOCC approved extension of contract
until 9/30/08.
CONTRACT/AGREEMENT CHANGES: N/A.
STAFF RECOMMENDATIONS: Approval.
Wells Fargo — Approx $216,000 yr.
TOTAL COST: KPHA - Aaarox $26,000 yr. + $55.00 hr Large Case Mgmt. BUDGETED: XYes ❑No
COST TO COUNTY: Same as above SOURCE OF FUNDS: Ad Valorum
REVENUE PRODUCING: Yes No X AMOUNT PER MONTH Year
APPROVED BY: County Atty OMB/Purchasing ✓` Risk Management �
DOCUMENTATION: Included X
DISPOSITION:
Revised 8/06
Not Required
AGENDA ITEM #
BOARD OF COUNTY COMMISSIONERS
Mayor Charles "Sonny" McCoy, District 3
Mayor Pro Tem Mario Di Gennaro, District 4
U N TYSo�MONROE _ Dixie M. Spehar, District 1KEY WESTLORIDA 33040 George Neugent, District 2O2
305) 2q4-4641 f Sylvia J. Murphy, District 5
Office of the Employee Services Division Director�A!
The Historic Gato Cigar Factors '•
1100 Simonton Street, Suite 268 �-
Key West, FL 33040
(305) 292-4458 — Phone �G
(305) 2924564 - Fax
TO: Board of County Commissioners
FROM: Teresa Aguiar, Direct
Employee Services
DATE: March 25, 2008
At this time, I am requesting that the BOCC approve my request for permission to extend the current
contracts for the County's Third Party Administrator and Utilization Review/Case Management Providers for
one (1) year from October 1, 2008 and thereafter to renew for two (2) consecutive one year terms.
As you are already aware, Monroe County self -funds our group health plan. Below are some reasons why it
is best to continue to be self -funded:
VALUE OF SELF FUNDING:
■ Can control our health plan and only pay for what we use.
■ Only fund claims that are incurred rather than paying premiums for all employees.
■ Ability to build our own benefit plan and the ability to make exceptions for extraordinary situations.
■ Eliminate insurance carrier fees related to reserves and required profitability.
■ Flexibility to modify plans, services, and add and delete services or unique programs that can occur
and benefit the county and our employees.
■ Ability to implement innovative medical management as well as wellness and disease management
programs to control long term costs.
■ Ability to manage our benefit plan by having all of the data under our control by utilizing a third party
administrator.
■ Fees associated with self -funding are substantially lower than utilizing a fully insured carrier.
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Below is detailed information on why Monroe County should continue to do business
with the current providers, Wells Fargo and Kevs Physician -Hospital Alliance:
THIRD PARTY ADMINISTRATOR — WELLS FARGO
HISTORY:
Started Wells Fargo (Acordia) 1996:
2001 — RFP (02/03; 03/04; 04/05)
2005 — Waived RFP (05/06; 06/07; 07/08)
The Third Party Administrator handles claims processing for approximately 1300 active employees, 630
dependents and 300 retirees along with 19 Surviving Spouses on a direct submission basis. COBRA
participants are also eligible for participation in the plan. Domestic Partners are included as dependents
subject to the criteria in the Monroe County Resolution. Coverage is currently provided for the employees of
the Board of County Commissioners, the Clerk of the Circuit Court, Tax Collector, Property Appraiser,
Supervisor of Elections, Sheriff's Department and the Land Authority.
Claims are sent directly to Wells Fargo which reviews them for eligibility and processes them for payment
along with the Explanation of Benefits (EOBs). Wells Fargo prints claim checks for the County on its local
checking account and forwards the checks directly to the employee. The claim registers are then forwarded
to the County for monitoring. Wells Fargo meets with County and Keys Physician Hospital Alliance
(KPHA) on quarterly basis to provide usage reports and discuss trends and costs of the Health Plan.
JUSTIFICATION TO CONTINUE BUSINESS WITH WELLS FARGO•
■ Wells Fargo is one of the largest TPA's in the country and is technology driven at a very cost
competitive price.
■ Wells Fargo has intimate knowledge of our group health care plan (demographics, network of
providers, plan design/coverage).
■ They have a long history (since 1996) and service commitment with the County.
■ The experienced and professional staff has a clear understanding of the plan and the benefits
provided. The County's Customer Account Manager has been the same employee since 1996 and has
over 15 years experience. The Team Manager on our account has been the same employee since
1996 and has over 25 years experience.
• Wells Fargo has not requested an increase in administrative fees for seven (7) years and is proposing
holding them for three (3) additional years if no bid process.
■ The County relies on Wells Fargo for the financial reporting and forecasts related to funding the
County's Self -Insured Group Health Care Plan.
• Wells Fargo maintains a 6 business day claim turnaround. The current contract requires less than
thirty (30) days.
■ Wells Fargo has provided the County with any type of reporting that we have ever requested. They
are able to do this due to their system ownership.
■ Wells Fargo has substantially increased its savings in coordination of benefits from the previous TPA.
Typically, savings of around 50% are good. The County has averaged 60% under Wells Fargo
TPA/KPHA stewardship.
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It is not foreseeable that going through the bid process would provide an economical benefit to the
County. The RFP Process would require expenditures by the County of thousands of dollars in RFP
related costs, such as consulting fees for the preparation of the RFP document, distribution and
analysis of responses, not to mention work and hours on the part of staff:
o Advertisment of bid will cost between $600 - $1,000. Consultant fees were approximately
$5,000 - $6,000 the last time we bid these services (TPA & UR/Large Case Management
Provider).
o The County would incur additional costs for the printing and distribution of new ID cards to
the plan participants.
o The County would incur additional costs for reprinting the Plan Document to reflect the
changes.
o The County would incur additional cost of approximately $4,500 for re -printing forms or
documents to reflect the new TPA.
o The County would incur costs communicating the change to employees, retirees and
providers.
o Additional time associated with establishing a bank account setup and changes due to a
change in TPA.
o May incur addition IT costs in setting up new interfaces with a new system if a change were
made.
o Local Utilization Review/Management and Case Management by KPHA may not be an option
with another TPA — and if it is, the fees would likely be higher, as Wells Fargo does not
charge KPHA access fees for use of its online system.
WELLS FARGO CURRENT COSTS:
■ Agreed to 3 year rate extension: Currently $10.59 per individual per month ($10.19 + $.40
HIPAA) = approximately $216,000 yr.
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UTILIZATION REVIEW & LARGE CASE MANAGEMENT — KEYS PHYSICIAN -HOSPITAL
ALLIANCE (KPHA)
HISTORY:
Started KPHA 1996:
2004 — BOCC approved to continue with KPHA and change the discounted rates, which Monroe County
receives, from 15% to an improved 25% (3/1/04 — 2/28/05; renewed: 05/06; 06/07).
February 2007 — BOCC approved waiver to extend agreement until 9/30/08.
KPHA provides Pre -admission Certification and Medical Case Management services of the Health Insurance
Program and negotiates with physicians, hospitals and other ancillary health services for discounted fee
arrangements. KPHA also collects data and reports at the quarterly meeting with the County to discuss
trends, large case prognosis, costs of program, etc. and reviews inpatient admissions, continued hospital stays
and discharge planning. Review of office visits, ambulatory surgery and diagnostic or other outpatient
services.
JUSTIFICATION TO CONTINUE BUSINESS WITH KPHA:
■ Designed and implemented Worksite Wellness Program and other similar services to promote healthy
lifestyles and preventative health care. Health Fair coordination and implementation is included.
■ They have a long history (since 1996) and service commitment with the County.
■ The experienced and professional staff has a clear understanding of the plan and the benefits
provided. Meylan Watler, Chief Operating Officer of KPHA has been with the County since 1996.
■ Advertisement of bid will cost between $600 - $1,000. The last time we bid this service, cost (TPA
& UR/Large Case Management Provider) the County between $5,000 - $6,000 in Consultant fees.
■ The County would incur additional costs for reprinting Plan Documents to reflect the changes.
■ The County would incur additional cost of approximately $4,500 for re -printing forms or documents
to reflect the new UR/Large Case Management Provider.
■ The County would incur costs communicating the change to employees, retirees and providers.
■ Additional time associated with establishing a bank account setup and changes due to a change in
new Provider.
■ May incur addition IT costs in setting up new interfaces with a new system if a change were made.
■ KPHA provides a network of hospitals and physicians in the Keys to obtain discounted rates.
■ There would be a possible disruption of any current activities related to Case Management or related
Utilization Review/Management if the County changes to another source for these services.
■ Over the last three (3) years, the negotiated discounts and Case Management by KPHA has saved the
County over $5 million dollars ($5,078.307). This 3 year trend was consistent and representative of
the savings achieved over the last 12 years.
• The County is not charged an access fee to network doctors and hospitals.
KPHA CURRENT COSTS:
The County receives 25% off of billed charges. Monroe County has the best contracted discounted
rate than any other contracted entity in Monroe County - - approximately 15% more favorable rate
than what other entities receive.
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Oversees all Large Case Management services (cases estimated over $60,000) are performed on an as
needed basis ($55.00 Per Hour). In 2007, we spent $3,249.25 (if broken down, approximates to $17per
individual —for approx. 1,300 employees & 300 retirees per month). This service benefits the employee
and is also cost effective for the employer. Typical Case Management fees run $155 per hour.
Utilization Review which includes pre -certification (based on approx 1,300 employees & 300 retirees)
$1.35 per individual per month. Precertification (No precertification on Medicare eligible retirees).
to 3 year rate extension at the current rates.
The below costs will give you an idea of what the typical cost is of a TPA and Utilization Review/Case
Management Provider.
COSTS OTHER ENTITIES:
*The more employees the employer has covered, the lower the price of the TPA. Typical TPA fees range
from $30 - $50 pepm (per employee per month).
• School Board (approx 900 employees): TPA Blue Cross $45.00 pepm for combined TPA Claims
Administration, Utilization Review, Case Management and Network Access.
• Miami -Dade County (approx 40,000 employees): TPA AvMed $32.00 pepm for combined TPA
Claims Administration, Utilization Review, Case Management and Network Access.
• Keys Energy (approx 160 employees): TPA Claims Administration $16.00 pepm. Utilization
Management $2.45 pepm. $99.00 per hour for Case Management. Utilization Review $2.45 pepm.
Network Access $7.00 pepm.
• Sumter County (approx 830 employees): TPA Claims Administration $61.73 pepm. Fee includes
Utilization Review and Case Management.
• Other TPA's in the Southeastern U.S. with employer groups similar in size to Monroe County:
- Lowest found is $19.95 pepm.
In doing business with these two providers (KPHA & Wells Fargo) over the last 5 years, the County has
saved approximately 57.5% on the claims billed to the County, totaling over $75 million in savings. This
figure includes network discounts (currently receiving 25% discount); savings from the TPA's coordination
of benefits (example: Medicare eligible, deductible/co-insurance, reductions for charges (physician and/or
hospital) above reasonable & customary and non -covered items); and savings from fee negotiations of out of
county providers and network providers negotiated by KPHA.
It is my recommendation that the BOCC approve the request to extend the current contracts for the County's
Third Party Administrator and Utilization Review/Case Management Providers for one (1) year from October
1, 2008 and thereafter to renew for two (2) consecutive one year terms. If you have any questions, please do
not hesitate to contact me at X4458.
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MONROE COUNTY BOARD OF COUNTY COMMISSIONERS -
1 Contract with: WELLS FARGO
CONTRACT SUMMARY
Contract #
Effective Date: October 1, 2008
Expiration Date: September 30, 2011
Contract Purpose/Description:
Amend existing contract due to extend for one (1) year with provisions to renew for two
(2) additional consecutive one year terms. Provider has agreed to renew at the current rate
for three additional years.
Contract Manager: Maria Gonzalez
(Name)
for BOCC meeting on Aril 16, 2008
4448 Employee Services/Benefits
(Ext.) (Department/Stop #)
genda Deadline: April 1, 2008
CONTRACT COSTS
Total Dollar Value of Contract: $ 216,000 yr approx Current Year
Portion: $
Budgeted? Yes® No ❑ Account Codes: 502-08002-530-310-
Grant: $ n/a -
County Match: $ n/a - -
ADDITIONAL COSTS
Estimated Ongoing Costs: $ /yr For:
(Not included in dollar value above) (e . maintenance, utilities, janitorial
CONTRACT REVIEW
etc.
Changes Date Out
Date In Needed eviewer,
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FIRST AMENDMENT
TO ADMINISTRATIVE SERVICE AGREEMENT
BETWEEN MONROE COUNTY AND
WELLS FARGO THIRD PARTY ADMINISTRATORS
THIS FIRST AMENDMENT, made and entered into this day of
2008, by and between Board of County Commissioners of Monroe County (hereinafter called "County")
and Wells Fargo Third Party Administrators, hereinafter referred to as "Wells Fargo".
WHEREAS, on June 15, 2005, the County entered into an agreement with Acordia National,
Inc., part of Wells Fargo & Company, whereby Acordia agreed to act as the third party administrator for
the County's medical, dental and vision plans ("Agreement"); and
WHEREAS, in or about February 2006, Acordia changed its name to Wells Fargo Third Party
Administrators; and
WHEREAS, the Agreement between the parties is to terminate on September 31, 2008; and
WHEREAS, the parties have mutually agreed to continue the Agreement; and
WHEREAS, it is in the best interest of the County and serves a public purpose to continue with
the services provided by Wells Fargo; and
WHEREAS, Wells Fargo wishes to continue with the service it provides County.
NOW THEREFORE, in consideration of the mutual promises and considerations, the parties
agree to amend the Agreement as follows:
1) Section 19 shall be amended as follows:
19) The terms of this Agreement shall be effective October 1, 2008 and continue
for a period of one year. This Agreement will be automatically renewed for
successive one-year periods until either 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 after
receipt of 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.
2) In all relevant places in the Agreement, the name of Acordia, Inc. is changed to
Wells Fargo Third Party Administrators.
3) In all other respects the terms and conditions of the original agreement remain in
full force and effect.
IN WITNESS WHEREOF, the Employer and Contractor have caused this amendment to
agreement to be executed this day of 12008.
ATTEST: DANNY L. KOLHAGE
Deputy Clerk
Witness
Board of County Commissioners of Monroe County
Mayor
Wells Fargo Insurance Services
President
MONROE COUNTY ATTORNEY
PROVE�AS 0 F RM:CYNTALL
ASSISTANT COUNTY ATTORNEY
r)ate 4- !— �opg
ADMINISTRATIVE SERVICE AGREEMENT
THIS AGREEMENT, made and entered into this ( I of [,2CC_lby and
between Monroe County (hereinafter "Employer") and ACORDIA NATIONAL, INC. (hereinafter
"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 CUIPAA"), 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 effbaing 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) The effective date of the Employer's Plan shall be October 1, 2005, and shall terminate
September 30, 2006.
2) The Plan Year shall be from October 1 to September 30 of each year.
3) The Employer's Tax Identification Number is 596000749.
4) The Benefit Committee designed under the Plan is comprised of County
Administrator, Director of Human Resources, and Director of Office of Management and Budget.
The Employer agrees to notify Acordia National in writing if the members of the Benefit
Committee change. Such notification shall be provided to Acordia National within ten (10) days
of adoption of the change and shall include the composition of the Benefit Committee, as
changed, and the effective date of any membership changes.
5) The Employer hereby acknowledges that no person shall be authorized to make
exceptions, unless the Employer provides written authorization to Acordia National. Employer
further agrees that any authorized exception to the Plan terms shall be given effect only if
communicated to Acordia National in writing.
6) The Employer agrees to provide Acordia National with any amendment or
restatement to the Plan on or before the effective date(s) of any such amendment or restatement.
7) For each Plan Year, the Employer shall sufficiently fund benefits under the
Acordia 10/05--9/06
1
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.
These claims will be funded in their entirety and in chronologic order with oldest dates always
funded and released first. In the event Employer shall fail to make available 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, or may
terminate this agreement. Employer acknowledges and agrees that Acordia National shall not
have any duty or responsibility to release claim payments if Employer has not sufficiently funded
the same.
8) 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.
9) If required by Acordia National, Employer shall pay Acordia National an initial fee
of S 0.00 for the purpose of establishing administrative services in connection with the Employer's
Plan, which fee shall be due and payable upon execution of this Agreement and which shall be
non-refundable to the Employer in the event this Agreement is terminated.
Acordia 10/05-9/06
2
Additionally, the monthly capitation fee for administrative services will be:
Medical Claims Administration
I-flPAA Administration
Fee Negotiation
$ I0.19 Per Employee Per Month
$ 0.40 Per Employee Per Month
25% of savings
The above monthly capitation fee shall apply to the renewal effective October 1, 2005, and
will remain in effect for renewals effective October 1, 2006 and October 1, 200T
Payment of the fees established above is due from the Employer on or before the 10th day
of each month, beginning on the 10t' day of October, 2005. The fee quoted is a three (3) year
guarantee effective October 1, 2005 and may only be increased by Acordia National if there are
additional services rendered by Acordia National on behalf of the Employer necessitated by a
change in federal or state law with a thirty (30) day notification. Employee counts for the
purpose 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 retroactively in excess of 90 ninety days prior to the month
invoiced. Acordia National reserves the right to withhold any fee due to the client if there are any
outstanding fees.
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.
10) Acordia National shall provide the following services in connection with the
administration of Employer's Plan(s):
a) Provide assistance to enroll all eligible Employees (as defined in the Employer's
Plan) in Employer's Plan, as agreed with Employer;
b) Provide for EmpIoyer's review sample prototype Plan documents, as requested by
Employer,
c) Conduct informational programs for all eligible Employees to fully explain the
benefits available under the Employer's Plan, as requested by Employer;
d) Respond to telephone and mail inquiries from Plan participants regarding benefits
Acordia 10105-9106
3
available to them and their dependents,
e) Provide information concerning Plan benefits and participants, based upon
information provided by Employer;
f) 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
industry standards;
g) Correspond with claimants, as necessary, to process claims and to ascertain
whether other coverage exists which might pay the claim in whole or part;
h) Receive, review, and administer all claims for benefits under the Employer's Plan,
including the evaluation of claims made;
i) Aid the employer in developing an efficient claims control program;
j) Provide information, on request, for the completion by the Employer of all
necessary IRS and ERISA filings; and
k) Provide Employer with a monthly report of claims paid.
11) 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 not provided for 125 Reimbursement Account Plans.
Appficable
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 fourteen (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;
Acordia 10/05-9/06
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 for Employer's review sample prototype language to be included
in the Plan document to ensure compliance with COBRA legislation;
h) Provide for Employer's review sample 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; an
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. 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 for 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 Plan(s) 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
Acordia 10/05-9/06
5
on the date of this Agreement may necessitate an adjustment in the fee for COBRA.
administration.
12) 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 and Acordia
National.
13) Acordia shall provide the following services related to HIPAA administration for
the Employer's Plan:
Applicable X
Non -applicable
a) Provide for the Employer's review prototype modifications to the plan
document and SPD (Booklet) to address HIPAA requirements;
b) 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) Distribute to all required parties the notifications and correspondence
documenting pre-existing conditions;
fl Issue certificates of coverage for all employees and their dependents upon
termination or upon request;
g) Prepare and distribute standard reports documenting completed HIPAA
activities; and
h) Serve as an information resource for HIPAA questions_
i) Distribute Privacy Practices Notices to all participants enrolled as of the
effective date of Employer's required compliance on or before said effective
date to new participant upon enrollment and to all participants upon material
revision to the Notice;
j) Distribute notices of the availability of the Privacy Practices Notice to
Acc:rdia 10/05-9/06
I
participants once every three (3) years;
k)
Coordinate the distribution, execution and maintenance of Business Assoaate
Agreements;
1)
Maintain designated record sets;
m)
Maintain records of all releases of Protected Health Information ("PHI") for
purposes other than treatment, payment or health plan operations;
n)
Administer access to PHI and maintain a logging system to track and document
activities. These documents include-
1. Request for restriction of PHI;
2. Request for accounting of disclosures;
3. Request to access PHI. (Employees requesting access to PHI wilt be
charged $0.50 per page in advance prior to sending out this
information);
4. Request to amend PHI;
5. Request for confidential cornnrunications;
6. Complaint forms; and
7. Authorization for release of PHI.
o)
Assist with the certification of the Group Health Plan;
P)
Update Policies and related privacy practices for approval of the Employer's
Privacy Officer; and
q)
Provide training information related to HIPAA Privacy requirements.
Employes" agrees to pay to Acordia NatKxtat the actual costs of mailing initial
notices, three-year notices and any other ffum mailing associated with HiPAA
Privacy compliance. Should Employer request customized documents in lieu
Of the prototypes provided by Acordia National. Employer agrees to Pay
Acordia National a separate fee for providing such customized documents such
fee to be agreed to by the parties.
14) 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
Services provided by HRI shall commence 1st day ofOctober, 1999.
Applicable X
Non -applicable
aPp
Acordia 10/05-9/06
7
15) 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 the 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.
16) The Employer shall name Acordia National as an additional insured under its
fidelity bond which shall be conditioned upon faithful performance of its duties hereunder, and
such fidelity bond which shall in all respects comply with the requirements of the Employee
Retirement Income Security Act of 1974, as amended.
17) Notwithstanding any other provision herein, Employer hereby agrees and
acknowledges that responsibility for all Plan documents, language or modifications remains at all
times with the Employer.
1 S) (a) Acordia National agrees to defend, indemnify and hold harmless Employer against
all claims, damages, liabilities and expenses actually and reasonably incurred or imposed on it 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 Plan(s) other than in
accordance with Plan provisions as well as the wMW misconduct of Acordia National, 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.
(b) Employer agrees to defend, indemnify and hold harmless Acordia National
against all claims, damages, liabilities and expenses actually and reasonably incurred or imposed
on Acordia National in connection with any actual or threatened claim, action, suit, proceeding,
settlement or compromise thereof which arises from the Employer or Benefit Committee's actions
or omissions to act relating to the Plan or any benefits provided thereunder or the breach by the
Employer or Benefit Committee of any provision of this Agreement. The right to be defended,
indemnified and held harmless shall extend to Acordia National's affiliates as well as the
employees of Acordia National, their estates, executors, administrators, guardians, conservators
and heirs and shall apply after the employee ceases employment with Acordia National with
respect to acts or omissions prior to such cessation.
19) The terms of this Agreement shall be from the effective date hereof and continue
Acordia 10/05-9/06
0
for a period of one year. This Agreement shall be automatically renewed for successive one-year
periods until either 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 after receipt of 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.
20) This Agreement may be terminated by either the Employer or Acordia National at
any time provided the terminating party gives the other party 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 expiration 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.
21) 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 employment.
22) 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 25301-3043, Attention: President, or at
such other addresses as the parties may from time to time designate in writing.
23) The Employer and Acordia National agree that this Agreement and the Acordia
National Trust for Employee Welfare Benefit Plans shall be administered and construed according
to the laws of the State of Florida.
24) 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
period following termination of this Agreement upon terms negotiated between the parties and is
typically a percentage of paid claims..
25) This Agreement together with the Plan constitute the entire Agreement between
the Employer and Acordia National.
Acordia 10/05-9/06
M
26) The undersigned hereby represents and warrants on behalf of the Employer that
the Employer (a) has duly approved the adoption of the Plan, this Agreement, and (b) has
authorized the Undersigned to execute this Agreement.
27) General Conditions:
a) Acordia National shall maintain all books, records, and documents directly
pertinent to performance under this Agreement in accordance with generally accepted accounting
principles consistently applied. Each party to this Agreement or their authorized representatives
shall have reasonable and timely access to such records of each other party to this Agreement for
public records purposes during the term of the Agreement and for four years following the
termination of this Agreement. If an auditor employed by the County or Clerk determines that
monies paid to Acordia National pursuant to this Agreement were spent for purposes not
authorized by this Agreement, the Acordia National shall repay the monies together with interest
calculated pursuant to Sec. 55.03, FS, running from the date the monies were paid to Acordia
National.
b) Administrative Action and Interpretation: In the event that any administrative
proceeding is instituted for the enforcement or interpretation of this Agreement, the County and
Acordia National agree that venue will he before the appropriate administrative body in Monroe
County, Florida.
The County and Acordia National agree that, in the event of conflicting
interpretations of the terms or a term of this Agreement by or between any of them the issue shall
be submitted to mediation prior to the institution of any other administrative or legal proceeding.
c) Severability. If any term, covenant, condition or provision of this Agreement (or
the application thereof to any circumstance or person) shall be declared invalid or unenforceable
to any extent by a court of competent jurisdiction, the remaining terms, covenants, conditions and
provisions of this Agreement, shall not be affected thereby, and each remaining term, covenant,
condition and provision of this Agreement shall be valid and shall be enforceable to the fullest
extent permitted by law unless the enforcement of the remaining terms, covenants, conditions and
provisions of this Agreement would prevent the accomplishment of the original intent of this
Agreement. The County and Acordia National agree to reform the Agreement to replace any
stricken provision with a valid provision that comes as close as possible to the intent of the
stricken provision.
d) Attorney's Fees and Costs. The County and Acordia National agree that in the
event any cause of action or administrative proceeding is initiated or defended by any party
relative to the enforcement or interpretation of this Agreement, the prevailing party shall be
entitled to reasonable attorney's fees, court costs, investigative, and out-of-pocket expenses, as an
award against the non -prevailing party, and shall include attorney's fees, courts costs,
investigative, and out-of-pocket expenses in appellate proceedings. Mediation proceedings
initiated and conducted pursuant to this Agreement shall be in accordance with the Florida Rules
of Civil Procedure and usual and customary procedures required by the circuit court of Monroe
County.
e) Adjudication of Disputes or Disagreements. County and Acordia National agree
that all disputes and disagreements shall he attempted to be resolved by meet and confer sessions
Acordia 10/0E-9/06
10
between representatives of each of the parties. If no resolution can be agreed upon within 30 days
after the first meet and confer session, the issue or issues shall be discussed at a public meeting of
the Board of County Commissioners. If the issue or issues are still not resolved to the satisfaction
of the parties, then any party shall have the right to seek such relief or remedy as may be provided
by this Agreement or by Florida law.
(f) Cooperation. In the event any administrative or legal proceeding is instituted
against either party relating to the formation, execution, performance, or breach of this
Agreement, County and Acordia National agree to participate, to the extent required by the other
party, in all proceedings, hearings, processes, meetings, and other activities related to the
substance of this Agreement or provision of the services under this Agreement. County and
Acordia National specifically agree that no party to this Agreement shall be required to enter into
any arbitration proceedings related to this Agreement.
g) Authority. Each party represents and warrants to the other that the execution,
delivery and performance of this Agreement have been duly authorized by all necessary County
and corporate action, as required by law.
h) Claims for Federal or State Aid. Acordia National and County agree that each
shall be, and is, empowered to apply for, seek, and obtain federal and state funds to further the
purpose of this Agreement; provided that all applications, requests, grant proposals, and funding
solicitations shall be approved by each party prior to submission.
i) Binding Effect. The terms, covenants, conditions, and provisions of this
Agreement shall bind and inure to the benefit of the County and Acordia National and their
respective Iegal representatives, successors, and assigns.
j) Nondiscrimination. County and Acordia National agree that there will be no
discrimination against any person, and it is expressly understood that upon a determination by a
court of competent jurisdiction that discrimination has occurred, this Agreement automatically
terminates without any further action on the part of any party, effective the date of the court
order. County or Acordia National agree to comply with all Federal and Florida statutes, and all
local ordinances, as applicable, relating to nondiscrimination. These include but are not Limited to:
1) Title VI of the Civil Rights Act of 1964 (PL 88-352) which prohibits discrimination on the
basis of race, color or national origin; 2) Title IX of the Education Amendment of 1972, as
amended (20 USC ss_ 1681-1683, and 1685-1686), which prohibits discrimination on the basis of
sex; 3) Section 504 of the Rehabilitation Act of 1973, as amended (20 USC s. 794), which
prohibits discrimination on the basis of handicaps; 4) The Age Discrimination Act of 1975, as
amended (42 USC ss. 6101- 6107) which prohibits discrimination on the basis of age; 5) The
Drug Abuse Office and Treatment Act of 1972 (PL 92-255), as amended, relating to
nondiscrimination on the basis of drug abuse; 6) The Comprehensive Alcohol Abuse and
Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (PL 91-616), as amended,
relating to nondiscrimination on the basis of alcohol abuse or alcoholism; 7) The Public Health
Service Act of 1912, ss. 523 and 527 (42 USC ss. 690dd-3 and 290ee-3), as amended, relating to
confidentiality of alcohol and drug abuse patent records; 8) Title VIII of the Civil Rights Act of
1968 (42 USC s. et seq.), as amended, relating to nondiscrimination in the sale, rental or financing
of housing; 9) The Americans with Disabilities Act of 1990 (42 USC s. 1201 Note), as maybe
Acordia 10/05-9/06
11
amended from time to time, relating to nondiscrimination on the basis of disability; 10)
Monroe County Code Ch. 13, Art. VI, prohibiting discrimination on the bases of race, color, sex,
religion, disability, national origin, ancestry, sexual orientation, gender identity or expression,
familial status or age; and 11) any other nondiscrimination provisions in any Federal or state
statutes which may apply to the parties to, or the subject matter of, this Agreement.
k) Covenant of No Interest. County and Acordia National covenant that neither
presently has any interest, and shall not acquire any interest, which would conflict in any manner
or degree with its performance under this Agreement, and that only interest of each is to perform
and receive benefits as recited in this Agreement.
1) Code of Ethics. County agrees that officers and employees of the County
recognize and will be required to comply with the standards of conduct for public officers and
employees as delineated in Section 112.313, Florida Statutes, regarding, but not limited to,
solicitation or acceptance of gifts; doing business with one's agency; unauthorized compensation;
misuse of public position, conflicting employment or contractual relationship; and disclosure or
use of certain information.
m) Public Access. The County and Acordia National shall allow and permit
reasonable access to, and inspection of, all documents, papers, letters or other materials in its
possession or under its control subject to the provisions of Chapter 119, Florida Statutes, and
made or received by the County and Acordia National in conjunction with this Agreement; and
the County shall have the right to unilaterally cancel this Agreement upon violation of this
provision by Acordia National.
n) Non -Waiver of Immunity. Notwithstanding he provisions of Sec. 768.28, Florida
Statutes, the participation of the County and Acordia National in this Agreement and the
acquisition of any commercial liability insurance coverage, self-insurance coverage, or local
government liability insurance pool coverage shall not be deemed a waiver of immunity to the
extent of liability coverage, nor shall any contract entered into by the County be required to
contain any provision for waiver.
o) Privileges and Immunities. All of the privileges and immunities from liability,
exemptions from laws, ordinances, and rules and pensions and relief, disability, workers'
compensation, and other benefits which apply to the activity of officers, agents, or employees of
any public agents or employees of the County, when performing their respective functions under
this Agreement within the territorial limits of the County shall apply to the same degree and extent
to the performance of such functions and duties of such officers, agents, volunteers, or employees
outside the territorial limits of the County.
p) Legal Obligations and Responsibilities: Non -Delegation of Constitutional or
Statutory Duties, This Agreement is not intended to, nor shall it be construed as, relieving any
participating entity from any obligation or responsibility imposed upon the entity by law except to
the extent of actual and timely performance thereof by any participating entity, in which case the
performance may be offered in satisfaction of the obligation or responsibility. Further, this
Agreement is not intended to, nor shall it be construed as, authorizing the delegation of the
constitutional or statutory duties of the County, except to the extent permitted by the Florida
constitution, state statute, and case law.
Acordia 10/05-9/06
12
q) Non -Reliance by Non -Parties. No person or entity shall be entitled to rely upon
the terms, or any of them, of this Agreement to enforce or attempt to enforce any third -party
claim or entitlement to or benefit of any service or program contemplated hereunder, and the
County and Acordia National agree that neither the County nor the Acordia National or any
agent, officer, or employee of either shall have the authority to inform, counsel, or otherwise
indicate that any particular individual or group of individuals, entity or entities, have entitlements
or benefits under this Agreement separate and apart, inferior to, or superior to the community in
general or for the purposes contemplated in this Agreement.
r) Attestations. Acordia National agrees to execute such documents as the County
may reasonably require, to include a Public Entity Crime Statement, an Ethics Statement, and a
Drug -Free Workplace Statement.
s) No Personal Liability. No covenant or agreement contained herein shall be
deemed to be a covenant or agreement of any member, officer, agent or employee of Monroe
County in his or her individual capacity, and no member, officer, agent or employee of Monroe
County shall be liable personally on this Agreement or be subject to any personal liability or
accountability by reason of the execution of this Agreement.
t) Execution in Counterparts. This Agreement may be executed in any number of
counterparts, each of which shall be regarded as an original, all of which taken together shall
constitute one and the same instrument and any of the parties hereto may execute this Agreement
by singing any such counterpart.
u) Section Headings. Section headings have been inserted in this Agreement as a
matter of convenience of reference only, and it is agreed that such section headings are not a part
of this Agreement and will not be used in the interpretation of any provision of this Agreement.
IN WITNESS WHEREOF, the Employer and Acordia National have caused this
Agreement to be executed by their respective proper corporate officers.
ATTEST: DDANNY L. KOLHAGE, CLERK
4]
Dep Clerk
MONROE COUNTY BOARD
OF COUNTY COMMISSIONERS:
2
BY 14_ 'v1t7lvO N
R0E COUN ATTOf
Mayor Dixie M. Spehar
ROVED � F R
ACORDIA NATIONAL ZAN A. HUTTOP
LZ
ASSISTANT_�/�T RI
Date
By
Its2 Chief Operating
ATTEST:
Acordia 10/05-9/06
13
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract with: KEYS PHYSICIAN
Contract #
HOSPITAL ALLIANCE Effective Date: October 1, 2008
("KPHA") Expiration Date: September 30, 2011
Contract Purpose/Description:
Amend existing contract due to extend for one (1) year with provisions to renew for two
(2) additional consecutive one year terms. Provider has agreed to renew at the current rate
for three additional years.
Contract Manager: Maria Gonzalez
(Name)
for BOCC meeting on Apri1 16, 2008
4448 Employee Services/Benefits
(Ext.) (Department/Stop #)
genda Deadline: April 1, 2008
CONTRACT COSTS
Total Dollar Value of Contract: $ 26,000 yr approx Current Year
Budgeted? Yes®
Grant: $ n/a
County Match: $
+ $55.00 hr Large Portion: $
Case Management
No ❑ Account Codes: 502-08002-530-310-_
n/a
ADDITIONAL COSTS
Estimated Ongoing Costs: $ /yr For:
(Not included in dollar value above) (e . maintenance.
Date II
Division Director 3.31.
Risk Manag�nent�
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CONTRACT REVIEW
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Changes
Needed eviewer
Yes[-] NoEg'�
Yes❑ No� E t r
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YesErNo❑
salaries, etc.
Date Out
331.0E-1
County Attorney
Comments: Gt'
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THIRD AMENDMENT
TO EMPLOYER -PROVIDER NETWORK AND
UTILIZATION REVIEW AND CASE MANAGEMENT
SERVICES AGREEMENT
THIS THIRD AMENDMENT, made and entered into this day of
2008, by and between Board of County Commissioners of Monroe County (hereinafter
called "County") and Keys Physician -Hospital Alliance ("KPHA").
WHEREAS, the Agreement between the parties was to terminate on September
31, 2008; and
WHEREAS, the parties have mutually agreed to continue the Agreement; and
WHEREAS, it is in the best interest of the County and serves a public purpose
to continue with the services provided by KPHA; and
WHEREAS, KPHA wishes to continue with the service it provides County, and
NOW THEREFORE, in consideration of the mutual promises and
considerations, the parties agree to amend the Agreement as follows:
1) Section 10. TERM shall be amended as follows:
10) The terms of this Agreement shall be effective October 1, 2008
and continue for a period of one year. Thereafter, the Agreement
shall automatically renew for two (2) consecutive one (1) year
terms. KPHA agrees to provide the Employer with at least ninety
(90) days written notice of the intent to terminate, non -renew, or
amend this Agreement. The County agrees to provide KPHA with
at least ninety (90) days written notice of the intent to terminate or
non -renew this agreement. Any modifications of the terms of this
agreement may occur upon the mutual agreement of the parties.
2) In all other respects the terms and conditions of the original
agreement remain in full force and effect.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of
the date first written above.
ATTEST: DANNY L. KOLHAGE
By:
Deputy Clerk
Date:
Witness to KPHA:
Signature
Print Name
Date:
Board of County Commissioners
Of Monroe County
ME
Charles "Sonny" McCoy, Mayor
KPHA:
Robin Lockwood, President
Print Name
Date:
MONROE COUNTY ATTORNEY
PROVED AS 0 FORM:
CYNTHIA L. HALL
ASSISTANT COUNTY ATTORNEY
date 4-t- of
Witness to KPHA:
Signature
(l/ceJNLC ShoSaL
Print Name
Address: I P f--1 A
DATE: i - 1 -7 - 7
SECOND AMENDMENT
TO
EMPLOYER -PROVIDER NETWORK AND
UTILIZATION REVIEW AND CASE MANAGEMENT SERVICES
AGREEMENT
THIS SECOND AMENDMENT is entered into on the tl dLy of January 2007, to the
Agreement between Keys Physician -Hospital Alliance ("KPHA") and Monroe County
("County") dated the first day of March, 2004.
WHEREAS, the Agreement between the parties was to terminate on March 1, 2007 ; and
WHEREAS, the parties have mutually agreed to continue the Agreement; and
WHEREAS, it is in best interest of County and serves a public purpose to continue with
the services provided KPHA, and
WHEREAS, KPHA wishes to continue with the service it provides to County.
NOW THEREFORE, in consideration of the mutual promises and considerations, the
parties agree to amend the Agreement as follows:
SECTION 10. TERM shall be amended as follows:
1110. TERM. This Agreement shall continue to be in effect from March 1, 2007 until
September 30, 2008."
2. The remaining terms of the Agreement, not inconsistent herewith, shall remain in
full force and effect.
N WITNESS WHEREOF, the parties hereto have been executed this Agreement as of
the date wii ten above.
Board of County Commissioners
r Of Monroe County
Attests
DannY L. Kohlai Clerk
^^GJ BY "f
Mario DiGennaro, Mayor
Date: JAN 1 7 2007
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EMPLOYER -PROVIDER NETWORK
AND
UTILIZATION REVIEW AND CASE MANAGEMENT SERVICES
AGREEMENT
THIS AGREEMENT is entered into as of this first day of MARCH 2O04 by and between
Keys Physician -Hospital Alliance ("KPHA") and the County of Monroe ("County"), hereon
referred to as "Employer".
RECITALS
WHEREAS, the KPHA has established a network of participating health care providers,
which providers, pursuant to the terms and conditions of provider agreements with KPHA, have
agreed to deliver medical services in a cost effective manner to persons covered under the health
benefit plans and policies of Employer.
WHEREAS, KPHA has agreed to provide utilization review and case management services
to Employer and personnel, dependents, Cobra beneficiaries and eligible retirees covered under
the health benefit plans and policies of Employer.
WHEREAS, Employer administers the health care benefit plans and has the express
authority, by signing this Agreement, to bind the Employer to all of the terms and conditions of
this Agreement.
WHEREAS, Employer desires and agrees to offer KPHA Provider Network to persons
covered under the Employers health benefits plans;
Now, THEREFORE, the parties agree as follows:
1. RECITALS. The foregoing recitals are hereby incorporated by reference and made a
substantive part hereof.
2. LIST OF PARTICIPATING PROVIDERS. KPHA shall provide Employer with a list of
Participating Providers, to include hospitals, physicians, dentists, pharmacies, and other
ancillary health services, and shall provide Employer with periodic updates of the Network
roster of Participating Providers from time to time. Such updates will be at least semi-
annually and in such a printed format as distributable to persons covered under the
Employers health benefits plans.
OUT -OF COUNTY PROVIDERS. KPHA agrees to negotiate and contract with
"Dimension Network" in Dade, Broward and Palm Beach Counties for discounted fee
arrangements with physicians, hospitals, and other ancillary health services as needed for the
benefit of the Employer. If the 'Dimension Network" is not utilized, or becomes
unacceptable to the Employer, KPHA will propose other alternative arrangements for such
out of county services.
KPHA agrees to negotiate and contract with or work collaboratively with a national network
for discounted fee arrangements with physicians, hospitals, and other ancillary health
services as needed for the benefit of the Employer. If the current network is not utilized, or
becomes unacceptable to the Employer, KPHA will propose other alternative arrangements
for such out of county services.
3. UTILIZATION MANAGEMENT AND QUALITY ASSURANCE. KPHA shall provide
for Employer Utilization Review services to include
• Review of inpatient admissions and of continued hospital stay
• Discharge planning
• Data collection and reporting
• Review of supportive or treatment services
• Review of office visits, ambulatory surgery and diagnostic or other outpatient services
• Participation in the review of billing practices and appropriateness of charges of network
providers in conjunction with the Claims Administrator if requested
• Large Case Management services
The monthly capitation fee for such services will be $1.35 per employee per month. This fee
will be payable by the County to KPHA by the 20th of each month beginning on the 20th day
of March, 2004. The number of enrollees will be determined on the lst business day of each
month.
KPHA shall provide for Large Case Management services for a fee of $55.00 per hour on an
as -needed basis. Large Case Management services may be pre -approved by the County on a
case by case basis and billings for such fees incurred shall be provided monthly with details
of all charges.
Utilization Review and Large Case Management services will be performed according to pre-
set protocols developed in conjunction with the claims administrator's (Acordia National)
standards and will be documented in the claims administrators' computer system.
4. WELLNESS PROGRAMS AND OTHER EDUCATIONAL SERVICES. KPHA shall
design and implement with the coordination of Employer's staff, the Worksite Wellness
Program and other similar services to the Employer and Covered Persons to promote healthy
lifestyles and preventative health care. The Worksite Wellness Program will include, at no
additional charge to Employer or Covered Persons, a health risk assessment for each
employee and may include, for a charge by a Participating Provider, Health Physical
Packages. Health Fair coordination and implementation or other services as negotiated and
deemed to promote healthy lifestyles and preventative health care may also be included in
this service.
PARTICIPATING PROVIDER COMPENSATION. Employer shall compensate
Participating Providers for covered services minus any plan participant responsibilities.
Employer has the responsibility for implementation of the applicable claims payment
submitted by Participating Providers for services rendered or for any billing or other function
related to the health care services provided by Participating Providers to Covered Persons.
All claims for covered services, whether payable by the Employer or a Covered Person will
receive a discount off of provider billed charges as specified in Attachment A. This discount
will be rescinded if an appropriately documented and non -contested claim is not paid to the
Participating Provider within thirty (30) days of being received by the claims administrator
(Acordia National).
NON -APPROPRIATIONS CLAUSE. Monroe County's performance and obligation to
pay under this contract is contingent upon an annual appropriation by the BOCC. Monroe
County may not deny payment for valid and accurate claims properly submitted and rendered
during the plan year.
PROVIDER REIMBURSEMENT TERMS. Physician UCR charges will be based upon
the "P.H.C.S" fee schedule, formerly known as "HIAA". The above agreed upon discount
will be applied to the billed charge, not to exceed the UCR charge for a service.
KPHA further agrees that no other self -insured employer contracting with KPHA will be
provided with better overall terms than what is being here agreed. If however, better terms
are provided to another self -insured employer contracting with KPHA, such terms will also
be extended to the Employer.
CLEAN CLAIM. A "Clean Claim" means a claim submitted by the Provider/Hospital that
has been properly and accurately completed on the appropriate paper or electronic claim
form, HCFA 1500 and/or UB 92 together with any information that was requested in writing
by Acordia National within 15 days of Acordia National's receipt of a claim.
NOTIFICATION OF CLAIM STATUS. Payor/Plan shall notify Provider/Hospital within
15 days of receipt of a claim that said claim is not considered "Clean" and reasons therefore.
Failure to do so shall deem the claim being considered "Clean" and set for, -timely payment.
DISPUTED CLAIMS. If the Payor/Plan does not object in writing to a claim within 15
days of receipt by the Payor/Plan, the claim will be considered clean and complete. If the
Payor/Plan disputes any portion of the billing for services rendered, Payor/Plan will promptly
seek to resolve the dispute and return the claim to the regular processing status. Should the
claim remain in dispute for more than 30 days, Payor/Plan will pay the Provider/Hospital
90% of the fees as outlined in the "Provider Agreement Amendment/ Reimbursement
Addendum" within 7 days with payment for the remaining 10% subject to the outcome of
the dispute. Those items requiring further resolution prior to the remaining payment shall be
reconciled by the Payor/Plan and the Provider/Hospital and the appropriate payments or
adjustments made within 60 days.
6. COVERED PERSON IDENTIFICATION. Employer shall supply Covered Persons with
identification cards or other means of identification which clearly identifies KPHA, reflects
the Covered Person's coverage under the applicable Employers health benefit plan, and
reflects the Covered Person's eligibility to receive services from Participating Providers in
accordance with the terms of this Agreement. Employer shall also provide such other
services as may be required in order for Participating Providers promptly to verify the status
of individuals as Covered Persons, the terms of the Covered Person's health care benefits,
including but not limited to the applicable terms of coverage, deductible status and co-
insurance.
7. NETWORK EXCLUSIVITY. During the course of the agreement Employer agrees not to
participate or enter agreements to utilize other provider networks other than that agreed upon
with KPHA and the Employer. Employer during the term of this Agreement shall not seek to
negotiate with individual network members for care or services outside of contractual
provisions without prior notification to KPHA.
8. BOOKS AND RECORDS. KPHA shall make available to claims administrator (Acordia
National) and County of Monroe (employer)_ all records and other data relating to both the
network and utilization review and case management services for the purposes of periodic
audits of KPHA's services. Information/data will be maintained, as required, to assure
confidentiality and compliance with all applicable regulations.
9. RESPONSIBILITY FOR HEALTH CARE SERVICES. Employer agrees that KPHA
shall not have any responsibility or liability for any act, omission, or decision related to
medical services rendered by Participating Providers to a Covered Person.
10. TERM. This Agreement shall continue in effect for one (1) year from the date first above
written. Thereafter, the Agreement shall renew for two (2) consecutive one (1) year terms.
KPHA agrees to provide the Employer with at least ninety (90) days written notice of the
intent to terminate, non -renew, or amend this Agreement. The Employer agrees to provide
KPHA with at least ninety (90) days written notice of the intent to terminate or non -renew
this agreement. Any modification of the terms of this agreement may occur upon the mutual
agreement of the parties.
BREACH AND CURE. Notwithstanding the foregoing, this Agreement may be terminated
by either party upon a material breach of this Agreement by the other party, providing that
the breaching party does not cure the breach within thirty (30) days following receipt of a
written notice from the non -breaching party specifying the nature of the breach and
requesting that it be cured.
11. GENERAL PROVISIONS.
A. THIRD PARTIES: The terms and provisions of this Agreement are for the benefit of
the parties hereto and are not intended to provide any other person with any right or cause
of action on account thereof.
B. NOTICES: Any notice required to be given pursuant to the terms and provisions thereof
shall be in writing and shall be hand -delivered, with return receipt thereof, or sent by
certified or registered mail, return receipt requested and first-class postage prepaid to the
addresses as follows:
Employer: County of Monroe
Manager- Employee Benefits
Gato Building
1100 Simonton Street, Room 2-268
Key West, Florida 33040
KPHA: Keys Physician -Hospital Alliance
c/o Lower Florida Keys Physician Hospital Organization, Inc.
P.O. Box 9107
Key West, Florida 33041-9107
Attn.: Nicki Will, Secretary
C. ASSIGNMENT: This Agreement may not be assigned, subcontracted, delegated,
transferred by either party without the express written consent of the other party, and any
attempted assignment, subcontract, delegation or transfer shall be void.
D. INDEPENDENT CONTRACTORS: None of the provisions of this Agreement are
intended to create, nor shall be deemed to, or construed to create any relationship
between KPHA and Employer other than that of independent entities contracting with
each other hereunder solely for the purposes of effecting the provisions of this
Agreement. Neither of the parties hereto, nor any of their respective officers, directors, or
employees shall be construed to be the agent, employee, or representative of the other.
E. GOVERNING LAW: This Agreement shall be governed in all respects by the laws of
the State of Florida without regard to Florida's choice of law statutes or decisions. Any
action by any party, whether at law or in equity, relating to this Agreement shall be
commenced and maintained, and venue shall be proper, only in Monroe County, Florida.
F. ORDINANCE 10-1990: KPHA warrants that it has not employed, retained or otherwise
had acted on his 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 of
Ordinance 10-1990, and that no employee or officer of the County had any interest,
financially or otherwise, in KPHA 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, gift or consideration paid to the former
County officer or employee.
G. CONFLICT OF INTEREST: KPHA assures the County that to the best of its
knowledge information and belief, the signing of this agreement does not create conflict
of interest.
H. OWNERSHIP OF INFORMATION: All Utilization Review and Case Management
documents which are prepared in the performance of this agreement are to be, and shall
remain, the property of the County and shall be transferred to the County or to a
replacement Utilization Review/Case Management service provider upon request and no
later than thirty (30) days after termination of this agreement. Any patient identifying
information shall not be disclosed without written consent of the patient.
I. INSURANCE REQUIREMENTS- KPHA is required to maintain the types of
insurance identified in Attachment B.
J. SEVERABILM: If any provision of this Agreement is held to be illegal, invalid, or
unenforceable, under present or future laws effective during the term hereof, such
provision shall be fully severable. In such event, this Agreement shall be construed and
enforced as if the illegal invalid or unenforceable provision had never been a part hereof,
and the remaining provisions shall remain in full force and effect unaffected by such
severance- provided that if the illegal, invalid or unenforceable provision is material to
the overall purpose and operation of this Agreement, then this Agreement shall terminate
upon the severance of such provision.
K. COUNTERPARTS: This Agreement and any amendment hereto may be executed in
multiple originals, all counterparts together constituting one and the same instrument.
L. ENTIRE AGREEMENT: This Agreement, along with its exhibits, contains all the
terms and conditions agreed upon by the parties hereto regarding the subject matter of
this Agreement and supersedes any prior Agreements, promises, negotiations, or
representations either oral or written, relating to the subject matter of this Agreement.
M. HOLD HARMLESS: KPHA shall indemnify and hold the County harmless from and
against any and all losses, penalties, damages, professional fees, including attorney fees
and all costs of litigation and/or judgment arising, out of any willful misconduct or
negligent act, error or omission of KPHA incidental to the performance of this agreement
or work performed thereunder. This indemnity shall extend to amounts the County
becomes legally obligated to pay and shall be limited by any sovereign immunity limit
applicable to the underlying claim plus costs of litigation.
In witness wherof, the Employer and KPHA have caused this Agreement to be executed by
their respective corporate officers, effective as of the first day of March 2004.
Employer: Board of County Commissioners
Monroe Coun/�da
By:
MCAL) Its:
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Keys Physician -Hospital Alliance
By:
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MONROE GUUNTY ATTORNEY
AP ED AS TO F
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ASSISTANT CO TY T RNEY
Date _ /�
Attachment A
Reimbursement Schedule
*KPHA Members 75% of billed charges with the cap of the 90'h percentile of the P.H.C.S.
(formerly known as HIAA) Fee Schedule.
*In County Providers (J PN) 75% - 85% of billed charges with the cap of the 90' percentile of the
P.H.C.S. (formerly known as HIAA) Fee Schedule.
Out -of -County Providers (IPN) 70% of billed charges with the cap of the 90"' percentile of the P.H.C.S.
(formerly known as HIAA) Fee Schedule.
Dimension Providers Dimension Network'Fee Schedule.
MultiPlan Providers MultiPlan Network Fee Schedule.
Fisherman's Hospital 75% of billed charges.
Lower Keys Medical Center 75% of billed charges.
*HOPS codes shall be reimbursed at 75% of billed charges.
A list of specific providers and discount percentages will be provided to Acordia National bKPHA for
implementation. y
James Roberts, County Ad�trator Date
Robin Lockwood, M.D. Date
KPHA President