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HomeMy WebLinkAboutFirst Administrators, Inc.-Administration Agreement-06.22.2009 4.- 22 - 05 BENEFIT SERVICES ADMINISTRATION AGREEMENT ADDENDUM FOR THE CITY OF WATERLOO EMPLOYEE HEALTH CARE BENEFIT PLAN THIS ADDENDUM is entered into this 1st day of July, 2009, by and between City of Waterloo (the "Plan Sponsor"), and First Administrators, Inc. (the "Benefit Services Administrator"). This Addendum relates to the Benefit Services Administration Agreement between the Plan Sponsor and the Benefit Services Administrator dated July 1, 2006. The provisions of this Addendum relate to the Sections of the Benefit Services Administration Agreement indicated. All words and phrases defined in the Benefit Services Agreement which are not also defined in this Addendum shall have the same meaning in this Addendum. Section 9. Drug Company Rebates. Not Applicable. Section 10. Administrative Fees. The Plan Sponsor shall pay administrative fees to the Benefit Services Administrator by the due date specified on the applicable billing statement as follows: (a) Monthly Administration Fees. The Plan Sponsor shall pay to the Benefit Services Administrator the monthly administrative fees for each Covered Employee, unless otherwise stated, who is determined to be eligible to receive Benefits under the Benefit Plan at the time the statement is prepared based upon information available to the Benefits Services Administrator at that time. Monthly administrative fees are based on First Administrators or the contracted vendor providing the below described service, any change in service may require an amendment to a fee amount. The monthly administrative fees effective July 1, 2009 are as follows: Administrative Service Monthly Fee/Covered Employee • Medical PlanNision Plan $23.50 • Communication Costs • Meeting Attendance • SelectFirstTM Network Access Fee • Utilization Review • Case Management • Summary Plan Descriptions) / Plan Document • Claim Forms • Self-addressed Envelopes • Check Stock • EOBs to Member 1 • Standard Reports • Identification Cards • Printing • Postage • COBRA Administration • HIPAA Certificates of Creditable Coverage • Ad Hoc Reports (available) Administrative Service Fees are guaranteed not to increase for the period beginning July 1, 2009 through June 30, 2012. (b) Monthly fees collected on behalf of Plan Sponsor and remitted to the appropriate vendor: Vendor Access Fees Monthly Fee/Covered Employee or as noted PPO Access Fee 27% of savings — MEDlnnovation/PHCS (TC3 Health, Inc.) - Secondary 27% of savings - MEDlnnovation/Multiplan (TC3 Health, Inc.) - Repricer (c) Other Fees: ID Cards mailed to individual plan members residence at $1.85 per envelope. The Benefit Services Administrator's subcontractor, TC3 Health, Inc. (TC3), may generate Claim savings through re-pricing, discounting, code edits, and fraud & abuse reviews. These savings will be processed through the claim payment process. Claim savings generated through TC3, will pay 22% of savings to TC3 plus 5% to the Benefit Services Administrator. Subrogation subcontracted through The Phia Group will pay 25% of recoveries to The Phia Group plus 2% to Benefit Services Administrator. Out of Network re-pricing and discounting fees, hospital bill audit fees, and pharmacy administration fees will be processed through claim payment process. (d) Increased expenses of the Benefit Services Administrator incurred by reason of any change in the Benefit Plan will give the Benefit Services Administrator the right to adjust monthly administrative fees to the extent necessitated by the increased expenses, to be effective on the date any such changes in the Benefit Plan are effective. The annual fees and monthly administrative fees are subject to change, to be effective on the commencement date of any Renewal Term, upon thirty (30) days prior written notice. Such administrative fees may also be adjusted on any date that increased expenses are incurred by reason of a change imposed by public bodies, such adjustment being limited to the amount necessary to administer the change. 2 Section 11. Commissions. Not Applicable. Section 12. Plan Sponsor Election to Use Services of Related Parties. Plan Sponsor has selected Wellmark, Inc. to provide Utilization Review Services. Wellmark, Inc., the parent company of Benefit Services Administrator, charges the Benefit Services Administrator for the Utilization Review Services provided to clients of the Benefit Services Administrator. Benefit Services Administrator's charge to client for the Utilization Review Services is described in Section 10 above. Plan Sponsor has selected Wellmark, Inc. to provide Preferred Provider Network Services through SelectFirstTM. SelectFirstrM is a PPO owned by Wellmark, Inc., the parent company of Benefit Services Administrator. Wellmark, Inc. charges the Benefit Services Administrator for the PPO Services provided to clients of the Benefit Services Administrator. Benefit Services Administrator's charge to client for the PPO Services is described in Section 10 above. Section 13. Authorization of the Benefit Services Administrator to Process and Pay Claims. The Plan Sponsor hereby authorizes and directs the Benefit Services Administrator to draw checks, drafts or other instruments for the payment of Benefits, Auditing Fees, Re-pricing fees, vendor payment fees, and Case Management Fees in accordance with the terms and conditions of the Benefit Plan and this Agreement against the Benefit Fund account maintained by the Plan Sponsor for that purpose. Section 19. Notices. All notices, consents, waivers and other communications required or permitted by this Addendum or the Agreement shall be in writing and shall be deemed given to a party when (a) delivered to the appropriate address by hand or by nationally recognized overnight courier service (costs prepaid); (b) sent by facsimile with confirmation of transmission by the transmitting equipment; or (c) received or rejected by the addressee, if sent by certified mail, return receipt requested, in each case to the following addresses or facsimile numbers and marked to the attention of the person (by name or title) designated below (or to such other address, facsimile number or person as a party may designate by written notice to the other parties): To Benefit Services Administrator: First Administrators, Inc. PO Box 9900 Sioux City, IA 51102-0479 Facsimile Number: 712-279-8450 Attention: Debbie Miner, President & CEO To Plan Sponsor: City of Waterloo 715 Mulberry Street Waterloo, Iowa 50703 Facsimile Number: 319-291-4571 Attention: Nancy Eckert, City Clerk This Addendum supersedes any conflicting provisions in the Agreement and any prior Addendum to the Agreement. 3 IN WITNESS WHEREOF, the parties have executed this Addendum in duplicate counterparts by their respective officials duly authorized. FIRST ADMINISTRATORS, INC. By: Debbie Miner Title: President & CEO Date: -t FS..09 CITY OF WATERLOO By: Title: rhetv d r Date: 6, .) 'D 9 4 DISEASE MANAGEMENT ADDENDUM Effective Date: July 1, 2009 Disease Management Program THIS ADDENDUM is entered into this 1st day of July, 2009 by and between City of Waterloo (the "Plan Sponsor"), and First Administrators, Inc. (the "Benefit Services Administrator"). This Addendum relates to the Benefit Services Administration Agreement between the Plan Sponsor and the Benefit Services Administrator dated July 1, 2005. The provisions of this Addendum relate to the Sections of the Benefit Services Administration Agreement indicated. All words and phrases defined in the Benefit Services Agreement which are not also defined in this Addendum shall have the same meaning in this Addendum. Recitals: Whereas, Benefit Services Admiiistrator is an authorized beneficiary of a Health and Care Support Services Agreement with Healthways, Inc. ("Healthways") to deliver a comprehensive disease management program called FirstSteps to Health ("FirstSteps") to Participants; and Whereas, Plan Sponsor desires 1:o obtain FirstSteps for its Participants and Benefit Services Administrator, through Healthways, desires to provide the same to the Participants pursuant to the terms and conditions of this Addendum. I. HIPAA-AS/Protected Health Information 1. Benefit Services Administrai:or shall protect Protected Health Information ("PHI") as set forth in its Business Associate Agreement with Plan Sponsor and the group health plan sponsored by Plan Sponsor. 2. Benefit Services Administrator represents that its subcontractor Healthways has agreed, in a written contract, to protect PHI in a similar manner to Benefit Services Administrator. II. Term Benefit Services Administrator, through Healthways, shall begin providing FirstSteps services on the Effective Date specified above. FirstSteps services shall only be provided to Participants so long as the Health and Care Support Services Agreement and the Agreement between Plan Sponsor and Benefit Services Administrator remain in full force and effect. Either party may terminate this Addendum during the twelve-month period following the Effective Date upon ninety (90) days' advance written notice to the other party for material breach. Following the first anniversary of the Effective Date, this Addendum may be terminated by either party upon ninety (90) days advance written notice to the other party, with or without cause. III. Disease Management Services. Benefit Services Administrator shall provide Plan Sponsor one of the following FirStStep Packages as noted by the checkrnark, each of which includes the listed disease conditions: ® Package A - Care Enhancement • Diabetes (DM) • Heart Failure (HF) • Coronary Artery Disease (CAD) • Chronic Obstructive Pulmonary Disease (COPD) • Asthma • Impact Conditions o Acid Related Stomach Disorders o Atrial Fibrillation o Decubitis Ulcers o Fibromyalgia o Hepatitis C o Inflammatory Bowel Disease o Irritable Bowel Syndrome o Low Back Pain o Osteoarthritis o Osteoporosis o Urinary Incontinence n Package B - Core • Diabetes (DM) • Heart Failure (HF) • Coronary Artery Disease (CAD) • Chronic Obstructive Pulmonary Disease ("COPD") • Asthma I I Package C - Basic • Diabetes (DM) • Heart Failure (HF) • Coronary Artery Disease (CAD) This program may also be referred to as the Disease Management Program. 1. Healthways shall identify from medical claims only, Identified Persons through application of its Disease Identification Methodology maintained by Healthways for this Agreement. Members may also become Identified Persons through referral from a Provider, Case Management, or other mutually agreed upon source of referrals. The Disease Management Program will maintain an opt out enrollment model, which means that Identified Persons are considered enrolled and participating unless they actively request to not be contacted by the Disease Management Program. 2. Healthways will apply its proprietary population rules-based stratification criteria, based on claims data and clinical assessments, to Identified Persons in order to determine the stratification level. 3. Identified Persons shall be assigned a primary Disease Management Program designation per the following hierarchy for purposes of fees and reports: 1) Diabetes, 2) Heart Failure, 3) Coronary Artery Disease, 4) Chronic Obstructive Pulmonary Disease, 5) Asthma and 6) Impact Conditions. The primary program assignment shall follow this hierarchy at the time the Program Eligible Person is identified and made known to Healthways. If a person is initially identified for more than one Disease Management Program, such Identified Persons shall be placed in the Disease Management Program of the highest-ranking disease for the package selected by an employer. For example, if a person is identified as having, both, Coronary Artery Disease and Chronic Obstructive Pulmonary Disease, such Identified Person shall be placed in the Coronary Artery Disease program for purposes of determining fees and producing reports. If a person is identified as having a disease and one or more Impact Conditions, the Identified Person shall be placed in the highest-ranking disease for fees and reports but will also receive services for the Impact Condition. A single Impact Condition fee shall be applied even if an Identified Person has more than one of the conditions addressed in the Impact Conditions Disease Management Program. Except as set forth below, an Identified Person beginning in one particular program shall remain in such program for purposes of both fees and reports, even if such Identified Person is subsequently identified as having another disease. For example, if a Chronic Obstructive Pulmonary Disease Identified Person is subsequently identified as having Coronary artery Disease, such Chronic Obstructive Pulmonary Identified Person shall remain in the Chronic Obstructive Pulmonary Disease program for purposes of fees and reports. However, notwithstanding the above, in the event either an Asthma Identified Person or an Impact Condition Identified Person is subsequently identified as having Diabetes, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, such Asthma Identified Person or Impact Condition Identified Person shall become an, Diabetes Identified Person, Coronary Artery Disease Identified Person, or Chronic Obstructive Pulmonary Disease Identified Person, as the case may be, subject to the above hierarchy, for purposes of fees and reports beginning on the date of such identification. 4. Healthways will apply its model for Identified Persons communication, as applicable to each disease, as described herein either through inbound calls and/or outbound calls with Healthways staff, through use of interactive speech recognition technology and/or by mail. The parties understand, acknowledge and agree that Healthways will follow its model for Identified Persons communication and intervention with Identified Persons and that Healthways does not warrant that application of such model shall result in Healthways making contact with each Identified Person. Further communication is dependent upon Healthways having a valid address and phone number for the Identified Person. Healthways shall perform regular, automated searches to locate Identified Person for whom the System has a valid address, but does not contain a correct telephone number. Communication will include, but not be limited to, the following: A. Introduction to Program Participants A "welcome letter" and "welcome packet" mailed to Identified Persons, or such other means of introduction as Healthways may utilize from time to time to introduce the Disease Management Program to Identified Persons. B. Welcome Call to Program Participants A "welcome call" placed to Identified Persons to provide information about the Disease Management Program. During such welcome call, Healthways' shall attempt to confirm the Identified Person's contact information and to identify and confirm such Identified Person's provider. C, Good Health Guidelines Mailings A series of reminders mailed to Identified Persons throughout the year regarding guidelines for good health. D. Newsletters Quarterly newsletters mailed to Identified Persons with Diabetes, Coronary Artery Disease or Heart Failure (one newsletter for both), Chronic Obstructive Pulmonary Disease and Asthma. E. Good Health Guidelines Reminder Calls Periodic phone calls placed to Identified Persons for the express purpose of reminding Program Participants of identified guidelines for good health. This call may be in combination with other scheduled calls. F. Care Calls Telephone calls placed by Healthways staff to Identified Persons providing education, advocacy and Provider Treatment Plan support. These calls include condition or disease-specific assessments and/or risk factor screening. The intensity and frequency varies with the particular disease and Identified Person's stratification level. G. Depression Screening Telephonic screening shall be conducted on an annual basis to identify Program Participants who may benefit from further evaluation for depression by their Provider. The validated Patient Health Questionnaire (PHQ-2) tool is used for these screenings. For Program Participants who screen positive, Healthways shall conduct the PHQ-9 and seek Identified Persons permission to contact the Identified Person's Provider. H. Self-Care Goal Agreement Self-care goals of Identified Persons mailed whenever new goals are established. These goals are developed via the telephone interaction between the Identified Person and Healthways and are focused on defining a behavior modification plan in support of the Provider's and Identified Person's care goals. Hotline A toll-free telephone service number that allows Identified Persons to speak with Healthways staff about the Disease Management Program. This toll-free service is accessible for inbound calls twenty-four (24) hours per day, seven (7) days a week. J. Quality of Live/Health Perception Question An annual quality of life question for Identified Persons. K. Health Education Educational materials, such as condition-specific workbooks and/or action plans, newsletters, and topic sheets, provider to Identified Persons. L. Program Specific Services Healthways shall provide in-home equipment for monitoring and transmission to Healthways of weight and blood pressure measurement for selected Program Participants with Heart Failure. Healthways shall place a series of Home Pulmonary Education calls ("HPE") to selected Identified Persons with Chronic Obstructive Pulmonary Disease. 5. Healthways Communication Protocol for Providers Healthways will apply its model for provider education and support programs as provided herein. The parties understand, acknowledge and agree that Healthways will follow its model for communication and intervention with providers and that Healthways does not warrant that application of such model shall result in Healthways making contact with each Provider. Further, communication is dependent upon Healthways having a valid address for the provider. The protocol will include the following: A. Introduction to Disease Management for Providers A "welcome letter" and "welcome packet" mailed to providers and Identified Persons, or such other means of introduction as Healthways may utilize from time to time, to provide a toll-free telephone service for Providers to respond to inquiries related to the introduction of the Disease Management Program. Healthways shall be responsible for the costs of its communications. B. Care Guidelines Disease-specific guidelines outlining key relevant clinical findings from scientific evident-based medicine. Provided initially to providers, via the welcome packet, and whenever updated. C. Member Medication List A semi-annual report mailed to the providers listing the medications of their respective Program Participants to the extent available. The medications have been identified via claims to the extent available or self-reported by the Identified Persons. D. Disease Management Hotline A toll-free telephone service that allows providers to call Healthways staff twenty- four (24) hours per day, seven (7) days a week. E. Guidelines for Care Flowsheet A flow sheet included in the welcome packet for use by the provider to document the status of an Identified Person compliance with the Guidelines for Care. IV. Pricing Terms 1. Pricing for the Care Enhancement Services described herein shall be as listed on the FirstSteps Pricing Illustration attached hereto. The rates are based on a per "Program Participant Per Month" basis for each disease/condition. Such pricing shall be subject to increase upon renewal of the Agreement or this Addendum. Costs shall be based on actual participation, as determined by Benefit Services Administrator, and Plan Sponsor shall pay such costs in accordance with the terms and conditions of the Agreement and this Addendum. The fees for Disease Management services are in addition to any other fees which Plan Sponsor is obligated to pay Benefit Services Administrator. The quoted Disease Management Service fees include a nine percent (9%) mark-up by Benefit Services Administrator to cover its costs associated with the Disease Management Services. 2. For pricing and reporting purposes, Identified Persons shall be assigned to only one disease/condition category, based on their disease/condition. Identified Persons with more than one disease/condition listed in the program package shall be assigned to that disease/condition appearing first in the Hierarchy of Diseases at § VI. 2. If an Identified Person has more than one disease/condition listed in the program package, such Identified Person would receive program services for both conditions, but Plan Sponsor would be charged only the amount for the first disease/condition, and for reporting and other calculation purposes would be counted as an Identified Person for the first disease/condition only. A Participant shall be considered an Identified Person beginning on the first day of the month in which Benefit Services Administration or Healthways identifies the Participant as having a disease/condition covered by this Addendum. 3. Plan Sponsor agrees to pay all applicable fees for Identified Persons until they discontinue participation, even though such Identified Persons may be retroactively disenrolled by Plan Sponsor in the health benefits plan. V. Miscellaneous - Data Transfer All data feeds transferred to Healthways from a data source other than Benefit Services Administrator must be approved in advance by Benefit Services Administrator and Healthways. Extra fees shall apply. These fees apply only if the data being received by Healthways meets its standard data specifications format. In the event Plan Sponsor requires more than one data file to be transferred to Healthways , Plan Sponsor shall pay an additional fee for each additional data feed to be transferred to Healthways based on the complexity of programming required. The actual amount of any such fees shall be determined by Healthways after Healthways reviews the additional data files received by Healthways. In the event new programming is required after this Addendum has been in effect for twelve months due to changes made by the vendor supplying the data, Plan Sponsor shall be charged an hourly rate for any necessary programming. VI. Definitions 1. "Case Management" shall mean the case management program performed by or on behalf of the Benefit Service Administrator. 2. "Core 5" shall mean Diabetes, Heart Failure, Coronary Artery Disease, Chronic Obstructive Pulmonary Disorder, and Asthma. 3. "Disease Identification Methodology" means the criteria, algorithms, diagnosis, procedures and/or ICD-9 and NDC codes used to identify diseases and maintained by Healthways in writing or electronically, as modified and updated from time to time by Healthways to reflect current medical standards, practices and coding. 4. "Disease Management Program(s)" shall mean each and all of Healthways' disease management programs delivered on an opt-out basis by Healthways personnel that are designated to provide targeted disease specific education for the Core 5 and Impact Conditions, as applicable, to improve health care outcomes. 5. "Identified Person" shall mean a person who has been identified for the Disease Management Program as having a disease identified by BSA as eligible for the program and included in the Package selected by Employer. 6. "Impact Conditions" means the following group of conditions, as identified by the Disease Identification Methodology maintained by Healthways for this Agreement: low back pain, osteoporosis, osteoarthritis, hepatitis C, arterial fibrillation, inflammatory bowel disease, irritable bowel syndrome, acid related stomach disorders, decubitus ulcers, urinary incontinence and fibromyalgia. 7. "Provider Treatment Plan" shall mean the Provider generated treatment plan for the Participant, as communicated to Healthways. VII. Notices All notices, consents, waivers and other communications required or permitted by this Addendum or the Agreement shall be in writing and shall be deemed given to a party when (a) delivered to the appropriate address by hand or by nationally recognized overnight courier service (costs prepaid); (b) sent by facsimile with confirmation of transmission by the transmitting equipment; or (c) received or rejected by the addressee, if sent by certified mail, return receipt requested, in each case to the following addresses or facsimile numbers and marked to the attention of the person (by name or title) designated below (or to such other address, facsimile number or person as a party may designate by written notice to the other parties): To Benefit Services Administrator: First Administrators, Inc. PO Box 9900 Sioux City, IA 51102-0479 Facsimile Number: 712-279-8450 Attention: Debbie Miner, President and CEO To Plan Sponsor: City of Waterloo 715 Mulberry Street Waterloo, Iowa 50703 Facsimile Number: 319-291-4571 Attention: Nancy Eckert, City Clerk This Addendum supersedes any conflicting provisions in the Agreement and any prior Addendum to the Agreement. IN WITNESS WHEREOF, the parties have executed this Addendum in duplicate counterparts by their respective officials duly authorized. FIRST ADMINISTRATORS, INC. CITY OF WATERLOO By: 0.<_a2CL% 7 By: 1.___- Debbie Miner Title: President and CEO Title: }'11p r Date: o.,1 Date: ' a D q First FirstSteps to Health Programs Administrators Inc Disease Management Illustrative Estimate GENERAL INFORMATION Group Name City of Waterloo Contracts 657 Account Key 1111 Total Live 1,445 Program Start Date JULY 2009 DISCLAIMER Fees on this illustration are demonstrated as aggregate fees for illustrative purposes only,Actual program fees will be billed on a per participant per month(PPPM)basis. Actual results for your account may vary due to the prevalence of disease conditions within your account and participation rates by the account's members. The group specific prevalence and cost numbers can vary due to the group size.Prevalence rates may fluctuate over time. These fees are in addition to your administrative fees. The fees below include a nine percent(9%) mark up to cover the costs associated with administering the program. PER PARTICIPANT PER MONTH FEES 2009 Fees for 2009 Fees for Program Core and Core+ Basic Package Diabetes $ 19.48 $ 21.04 Heart Failure(HF) $ 60.55 $ 65.39 Coronary Artery Disease(CAD) $ 24.46 $ 26.41 Chronic Obstructive Pulmonary Disease $ 27.80 Asthma $ 8.16 Impact Conditions $ 8.89 STANDARD PREVALENCE RATES AND COSTS DM HF CAD COPD ASTHMA IMPACT PDMPM Costs $ 809.57 $2137.31 $ 1,217.18 $ 1,061.34 $ 368.99 $ 427.14 Prevalence Rates 3.90% 0.30% 1.08% 0.45% 3.42% 10.38% PACKAGE DESCRIPTION Package Basic Diabetes (DM), Heart Failure (HF), Coronary Artery Disease (CAD) includes Package Core 5 Diabetes (DM), Heart Failure (HF), Coronary Artery Disease (CAD), Chronic includes Obstructive Pulmonary Disease (COPD), and Asthma. Package Core 5 + Diabetes (DM), Heart Failure (HF), Coronary Artery Disease (CAD), Chronic Impact includes Obstructive Pulmonary Disease (COPD), Asthma, and Impact Conditions (includes Acid Related Disorders, Atrial Fibrillation, Decubitus Ulcer, Fibromyalgia, Hepatitis C, Inflammatory Bowel Disease, Irritable Bowel Syndrome, Low Back Pain, Osteoarthritis, Osteoporosis, and Urinary Incontinence) Page 1 PACKAGE SUMMARY Basic Core 5 Core 5 + Impact Year 1 Costs Covered Members 76 132 282 Estimated fees $22,601 $27,934 $43,947 Estimated PDMPM $24.68 $17.61 $12.98 Estimated PMPM $1.30 $1.61 $2.53 Estimated PEPM $2.87 $3.54 $5.57 SAVINGS PROJECTION The savings projections are not a guarantee of savings and are based on validated financial outcomes of past performance by our vendor, Healthways.Actual results may vary based on the group specific prevalence and experience. Basic Core 5 Core 5 + Impact Year 1 Estimated Savings $37,275 $ 49,922 $ 77,453 Page 2 i i i I i i