HomeMy WebLinkAboutReso. 1988-148 - Approving the agreement to administer health care plan and amendments 1 through 4 411
RESOLUTION NO. 38-/1,51
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF REDDING
APPROVING THE AGREEMENT TO ADMINISTER HEALTH CARE PLAN AND
AMENDMENTS 1 THROUGH 4 BETWEEN THE CITY OF REDDING AND
CONCEPT ADMINISTRATORS INC. AS THIRD-PARTY ADMINISTRATOR OF
THE CITY OF REDDING GROUP MEDICAL AND DENTAL INSURANCE
CLAIMS, EFFECTIVE JUNE 1 , 1988 , AND AUTHORIZING THE MAYOR TO
SIGN ALL NECESSARY DOCUMENTATION.
BE IT RESOLVED by the City Council of the City of Redding as
follows:
1 . That the City Council of the City of Redding hereby
approves the Agreement to Administer Health Care Plan, together
with Amendments 1 through 4 inclusive, between the City of
Redding and Concept Administrators Inc. as third-party admini-
strator of the City of Redding group medical and dental insurance
claims, effective June 1 , 1988 , true copies of which are
attached hereto.
2 . That the Mayor of the City of Redding is hereby
authorized and directed to sign said Agreement, together with
Amendments 1 through 4 inclusive, and all necessary documentation
on behalf of the City of Redding in connection therewith, and the
City Clerk is hereby authorized and directed to attest the
signature of the Mayor and to impress the official seal of the
City of Redding on the aforesaid documents , when appropriate.
I HEREBY CERTIFY that the foregoing Resolution was
introduced and read at a regular meeting of the City Council of
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the City of Redding on the 19th day of April , 1988 , and was
duly adopted at said meeting by the following vote:
AYES: COUNCIL MEMBERS : Buffum, Carter , Dahl , Fulton , & Johannessen
NOES: COUNCIL MEMBERS: None
ABSENT: COUNCIL MEMBERS : None
ABSTAIN: COUNCIL MEMBERS: None
/ fj /
MAUflICE JOHANNESSEN , Mayor
City of Redding
ATTEST:
ETHEL A. NICHOLS , City Clerk
FORM "PROVED:
RANIALL A. HAYS , C ' ty Attorney
-2-
410 410
AGREEMENT TO ADMINISTER HEALTH CARE PLAN
SECTION I DECLARATIONS
This Agreement is entered into between City of Redding, 760 Parkview Avenue, Redding,
California, 96001 hereinafter referred to as "Employer" and Concept Administrators Inc. ,
9342 Tech Center Drive, Suite 600, Sacramento, California 95826, hereinafter referred to as
"Administrator".
WHEREAS Employer has established an employee benefit health care plan for certain of its
' employees and their dependents ; and
WHEREAS Employer is the general administrator of the employee benefit health care plan and
desires to engage the services of Administrator to provide certain specific services with
respect to the employee benefit health care plan;
NOW THEREFORE in consideration of the mutual promises contained in this Agreement and other
valuable consideration, Employer and Administrator hereby agree as follows:
SECTION II PLAN
Wherever in this Agreement reference is made to the term "Plan", it shall mean the health
' benefits for Employer's employees and their dependents as set forth in the listed materials:
Plan Benefit Descriptions are Described as follows:
Plan Document l6 501 and subsequent, Dated: 9/23/82 . Plan Effective Date: 8/1/82 .
Name of Plan: City of Redding Group Health Plan
' SECTION III EFFECTIVE DATE — AGREEMENT PERIOD
r;: i
(a) This Agreement shall be effective as of June 1, 1988 ""
' (b) The first Agreement Period shall be from the effective date to June 1, 1989
' (c) This Agreement shall be continued automatically, unless discontinued in accordance
with Section IX, for successive Agreement Periods of twelve (12) months each.
SECTION IV CERTAIN RESPONSIBILITIES OF EMPLOYER AND ADMINISTRATOR
(a) It is understood that subject to Section IV, Employer retains all final authority and
responsibility for the Plan and its operation and that Administrator is empowered to
act on behalf of Employer in connection with the Plan only as expressly stated in
this Agreement or as mutually agreed to in writing by Employer and Administrator.
• •
SECTION IV (Continued)
(b) Administrator shall, to the extent possible, advise Employer as to matters which come
to its attention involving potential legal actions involving the Plan and shall
promptly advise Employer of legal actions commenced against Employer which come to
its attention. It is understood and agreed that Administrator shall fully cooperate
with Employer in the defense of any action arising out of matters related to this
Agreement.
(c) Where a request for benefits has been made, and further information is required with
respect to eligibility of the patient for such benefits, Employer is obligated to
provide all information necessary to assist Administrator in determining such
eligibility. Employer shall hold Administrator harmless for any liability caused in
full or in part by Employer's failure to provide correct or sufficient information to
allow Administrator to determine such eligibility. Employer shall promptly respond to
inquiries of Administrator with respect to patient eligibility or any other
information required by Administrator. Failure of Employer to provide such
information within twenty (20) days after receipt of written request from
Administrator shall constitute breach of obligation under this Agreement.
(d) Administrator shall use ordinary care and due diligence in the exercise of its powers
and the performance of its duties under this Agreement, but shall not be liable for
any mistake of judgment or other action taken in good faith, or for any loss unless
resulting from its negligence. Administrator agrees to indemnify and hold harmless
Employer, its directors, officers, and employees against any and all claims, lawsuits,
settlements, judgments, costs, penalties and expenses, including attorney's fees, with
respect to this Agreement resulting from or arising out of the fraudulent or criminal
acts of Administrator or its employees, acting alone or in collusion with others.
(e) Employer agrees to indemnify and hold harmless Administrator and its directors,
officers and employees against any and all claims, lawsuits, settlements, judgments,
costs, penalties and expenses, including attorney's fees, resulting from or arising
out of or in connection with any function of Administrator under this Agreement or in
connection with a request for payment under the Plan during the continuance of this
Agreement unless it is determined that the liability therefor was the direct
consequence of criminal conduct, negligence or fraud on the part of Administrator or
any of its directors, officers or employees; provided that this provision shall not be
applicable to an action against Administrator by a governmental authority which
affects Administrator's ability to provide services of the type provided in this
Agreement.
(f) If it is determined that any payment has been made under this Agreement to an
ineligible employee or dependent, or if it is determined that more than the correct
amount has been paid by Administrator, Administrator will make a diligent attempt to
recover the payment made to an ineligible person or the overpayment, but Administrator
will not be required to initiate court proceedings for any such recovery. If it is
determined that Administrator has paid less than the correct amount, Administrator
will adjust the underpayment.
(g) If the payment referred to in paragraph IV (f) above is the result of any failure by
Employer to provide information to Administrator or information so provided is
incorrect, Employer shall hold Administrator harmless from any liability due to such
payment and shall reimburse Administrator for any such payment if Administrator
becomes liable.
4
SECTION V SERVICES TO BE PROVIDED BY ADMINISTRATOR
During the continuance of this Agreement, Administrator will perform benefit payment and
other services for Employer set forth as follows:
1. Benefit Entitlement Determination.
(a) During the continuance of this Agreement, all requests for benefit payments
under the Plan shall be made to Administrator on forms satisfactory to
Administrator. Administrator will determine the entitlement to Plan Benefits,
subject to final decision by Employer, as to any request for benefits in
accordance with (i) the Plan benefits applicable to the employee or dependent, as
specified to Administrator by Employer, and (ii) Administrator benefit cost
control standards and procedures and practices applicable to benefits under the
Plan.
(b) With respect to any person who makes a request for Plan benefits which is
denied, Administrator will notify such person of the denial and of his right of
review of the denial, in a manner agreed to between Employer and Administrator
designed to satisfy the requirements of the Employee Retirement Income Security
Act of 1974 (P. L. 93-406)
2. Benefit Payments. Whenever Administrator determines that benefits are payable under
this Plan, subject to final decision by Employer, Administrator shall issue a check in
payment of such benefits. Such check, subject to acceptance by Administrator, and
subject to the terms and conditions of this Agreement, shall be paid from the
Employer's Fiduciary bank account, as set forth in Section VI.
3. Plan Benefit Development. Administrator shall provide advice in connection with the
design and development of the Plan, both initially and in connection with revisions to
the Plan.
4. General Administration. Administrator's personnel will be available to assist Employer
in connection with the general administration of the Plan, including assistance as to
the enrollment of eligible persons under the Plan and administration and record keeping
systems for the ongoing operation of the Plan.
5. Benefit Payment Records. Administrator shall maintain all benefit payment records as
to requests for benefits for a period of four years following the month in which final
benefit payment was made as to a benefit file. In the event of discontinuance of this
Agreement, any such records in possession of Administrator shall be forwarded to
Employer as soon as there is no further need in connection with the services performed
by Administrator.
6. Plan Reports. Administrator shall prepare the following reports as to the Plan:
(a) Administrator shall provide necessary information to Employer for the completion
of any reports required by the United States Internal Revenue Service as to
benefit payments.
(b) Administrator shall provide Employer with reports as to information available to
Administrator and required to be provided annually as to the Plan, in accordance
with the Employee Retirement Income Security Act of 1974 (P. L. 93-406).
(c) Other such reports as are set forth in amendment(s) to this Agreement.
1 7. Master Plan Document. Unless expressly stated in an amendment to the Agreement, or in
a separate agreement, Administrator accepts no responsibility under the Employee Income
Security Act of 1974 (P. L. 93-406) for the creation or production of the Master Plan
Document.
SECTION V (Continued) 411 Aft
8. Summary Plan Descriptions. Unless expressly stated in an amendment to the Agreement,
or in a separate agreement, Administrator accepts no responsibility under the Employee
Income Security Act of 1974 (P. L. 93-406) for the production of or distribution of
Summary Plan Descriptions (SPD) (AKA Employee Benefit Handbooks) to employees or
dependents, or for the filing of a copy of the SPD with the U. S. Department of Labor.
9. COBRA. Unless expressly stated in an amendment to the Agreement, Administrator accepts
no responsibility for Employer's compliance with the Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA) Continuation of Coverage requirements (P. L.
99-272).
SECTION VI DUTIES OF EMPLOYER
1
In order for Administrator to perform the payment of benefits and other services for
Employer as set forth in Section IV of this Agreement, Employer shall furnish to
Administrator certain information concerning the Plan and employees and dependents covered
under the Plan as may from time to time be required by Administrator as set forth as
follows:
1. Employer shall provide Administrator on a timely basis with such information as to
the employees and dependents covered under the Plan as will be necessary for
Administrator to determine eligibility as to requests for Plan benefits, and to
provide Plan cost estimates and reports as set forth in Section IV. Employer shall
indemnify and hold harmless Administrator and its directors, officers and employees
against any and all claims, lawsuits, settlements, judgments, costs, penalties and
expenses and attorney's fees resulting from, or arising out of the Employer's failure
to give information to Administrator or to give proper notice to its employee of
termination of employment, leave of absence or any other temporary or permanent loss of
employment affecting the employee's specific dates of eligibility for benefit payment.
2. Employer shall provide Administrator with such information as to employee and dependent
eligibility as will enable Administrator to determine benefits payable under the Plan,
in a format agreed upon by both parties.
3. Employer shall provide Administrator with such information as to the Plan benefits as
will enable Administrator to determine benefits payable under the Plan.
SECTION VII BANKING ARRANGEMENTS
(a) During the term of this Agreement:
(i) Employer/Administrator shall establish and maintain a bank account for the
payment of benefits under the Plan in the Sacramento Commercial Bank
(ii) All benefits made under the Plan will be issued by Administrator on checks
payable through the Sacramento Commercial Bank .
(b) Employer by this Agreement expressly authorizes Administrator to issue and accept
such checks for benefit payments under the Plan on behalf of Employer; provided that
checks issued for amounts in excess of $10,000.00 shall include the signature
of two employees of Administrator.
1 (c) Employer agrees that it will, in accordance with arrangements agreed to between
Administrator and Employer, maintain in the bank funds for the payment of checks
accepted by Administrator under the Plan. Failure to make deposits as required to pay
claims will relieve Administrator from further obligation to perform under this
agreement.
111 110
SECTION VII (Continued)
(d) Administrator will notify Employer in writing of any changes in banking arrangements.
SECTION VIII ADMINISTRATIVE SERVICES CHARGES
(a) In consideration of the previous Sections and subject to the following Paragraphs of
this Section, the Administrative Service Charge for each month of this Agreement shall
be as follows:
Administration Fee: $8.51 per covered employee per month(includes run in)
Initial One-Time Set-Up Fee: $1,000.00
(b) Payment of the amount of such charge shall be made by Employer to Administrator
within thirty (30) days of the billing date, which is designated as the first day of
each nonth.
(c) Unless expressly stated in Section VII(a) above, Administrator shall have the right
to change the Administrative Services Charge upon thirty (30) days prior written notice
at the end of the first Agreement Period and thereafter at twelve (12) month intervals
upon renewal and/or upon amendment of the Agreement.
(d) In addition to the Administrative Services Charges as set forth in this Section,
Employer shall reimburse Administrator for the amount of any taxes, or other charges
or fees in connection therewith, assessed against Administrator with respect to any
benefit payments made by Administrator under the Plan and this Agreement.
SECTION II DISCONTINUANCE OF AGREEMENT
(a) This Agreement may be discontinued at the earliest time specified below:
(i) As of the last day of an Agreement Period by either party giving thirty (30) days
prior written notice to the other party that the Agreement will not be renewed.
(ii) As of any date mutually agreed upon between Employer and Administrator.
(iii) As of the date Employer fails to provide funds to the bank as necessary for the
payment of checks accepted by Administrator on behalf of Employer for benefit
payments under the Plan; provided Administrator gives actual notice to Employer
and Employer fails to provide such funds within forty-eight (48) hours of receipt
of such notice.
(iv) As of the end of a period of thirty (30) days after written notice has been given
by either party to the other of the other's breach of material obligation under
this Agreement; provided such breach has not been cured within such thirty (30)
day period.
(b) Neither Employer or Administrator will be bound by the Agreement in any jurisdiction
where prohibited by law or where either party would suffer disability by continued
performance under the Agreement.
(c) Discontinuance of this Agreement shall not terminate the rights or liabilities of
either party arising out of a period prior to such discontinuance.
(d) Upon discontinuance of this Agreement in a case where the Plan continues in force,
Administrator shall, upon request of Employer, complete the processing of all requests
for benefit payments under the Plan, information as to which has been received by
Administrator prior to the date of discontinuance, under the terms and conditions which
would be applicable if this Agreement were still otherwise in full force and effect.
410
SECTION IX (Continued) •
Employer will be liable for all checks issued by Administrator within the terms of this
Agreement during the continuance of this Agreement and within a reasonable time following
discontinuance of this Agreement. All checks issued by Administrator which are outstanding
upon the discontinuance of this Agreement or issued thereafter in accordance with the
immediately preceding paragraph (d) will continue to be the responsibility and liability of
Employer. . Requests for payment presented within thirty (30) days of the date of
discontinuance will be processed for the same administrative fee charged to the Employer
during the last month in which this Agreement was in force. Requests for payment presented
after thirty (30) days from the date of discontinuance will be processed for a fee of $10.00
per request until Administrator is released by Employer from further financial
responsibility. Requests for payment received after the date of such release will be
forwarded to Employer for disposition.
SECTION X EXAMINATION OF RECORDS
Employer shall have the right to examine any records of Administrator relating to benefit
payments and requests for benefit payments under the Plan and the issuing of checks for
payment of benefits under the Plan; provided, however, that any examination of individual
benefit payment records shall be carried out in a manner agreed to between Employer and
Administrator designed to protect the confidentiality of the individual's medical
information.
SECTION XI ASSIGNMENT
No assignment by either party pertaining to this Agreement shall be valid without the
express written consent of both parties.
SECTION XII APPLICABLE LAW
This Agreement shall be governed by the laws of the state of California, but is not to be
construed, in any part, to conflict with the requirements of the Employee Retirement Income
Security Act of 1974 (P. L. 93-406).
SECTION XIII COSTS OF LITIGATION
At any time, should there be litigation by either party to enforce the terms and conditions
of this Agreement on the other party, the prevailing party shall be entitled to the award of
the costs of suit therein, plus reasonable attorney's fees incurred.
SECTION XIV AMENDMENTS
This Agreement may be amended at any time with the express written consent of both parties.
j SECTION XV EXECUTION OF AGREEMENT
IN WITNESS WHEREOF, Employer and Administrator have caused this Agreement to be executed in
duplicate by their respective officers duly authorized to do so.
1 FOR THE EMPLOYER: FOR THE ADMINISTRATOR:�
By: By:
Title: Title: President
Dated at: Dated at: Sacramen o, California
This day of , 19 This 23rd day of March , 1988
111 110
AMENDMENT #1 to Administration Agreement between City of Redding, hereinafter called
"Employer", and Concept Administrators Inc., hereinafter called "Administrator".
REPORTS.
Administrator will furnish to Employer the following reports as to the Plan:
On a regular Monthly basis: On a Quarterly, Semi-Annual, or Annual
Basis, at Employer's option:
Itemized List Billing
Check Register Loss Ratio Report
Paid Claims Analysis Cost Containment Reports:
Pending Claims Listing Hospital Length of Stay by Cause
Fund Account Statement Hospital Average Length of Stay
Weekend Admissions Report
Initially at Plan inception and Hospital Discharges by Day
thereafter upon Employer request: Cause Code Analysis
Procedure Analysis
Eligibility Listing Individual Benefit Analysis
Coverage Analysis Report
Costs for Administrator to provide above-quoted reports to Employer are included in the
Administration Fee as quoted in Section VIII (a) of the Agreement to which this Amendment is
attached, or any subsequent Renewal Amendment.
Additional reports, reports issued more frequently than offered above, or custom reports may
be obtained from Administrator for an additional charge, to be quoted upon request.
Subject to all applicable terms and conditions of the Agreement to which this Amendment is
attached, Employer and Administrator have caused this Amendment to be executed in duplicate
by their respective officers duly authorized to do so.
FOR THE EMPLOYER: FOR THE ADMINISTRATOR:
By:
By:
,�
Title: Title: President
Dated at: Dated at: Sacramento, California
This day of , 19 This 23rd day of March , 1988
,AMENDMENT 12 to Administration Aggeement between City Redding,Reddin , hereinafter called
"Employer", and Concept Administrators Inc. , hereinafter called "Administrator".
COBRA CONTINUATION OF COVERAGE PROVISION.
Administrator will provide to Employer services as listed below to assist Employer in
complying with the Consolidated Omnibus Budget Reconciliation Act of 1985 (P. L. 99-272)
Continuation of Coverage Provision:
1) Administrator will provide Employer with available information required by Employer to
determine cost of contribution for eligible beneficiaries. Decisions regarding such costs
are Employer's responsibility and Administrator accepts no legal responsibility for such
decisions.
2) Administrator will provide Employer with an amendment to the Master Plan Document
setting forth the requirements of COBRA Continuation of Coverage, and forms for notifying
beneficiaries. Employer will be responsible for notifying all employees and their spouses
of the addition of this Amendment to the Plan and of a beneficiary's rights under COBRA
Continuation of Coverage at time of eligibility.
3) Administrator will establish and maintain beneficiary eligibility records separately and
pay claims according to such eligibility.
4) Administrator will list beneficiaries in a separate "COBRA" classification on Employer's
monthly fixed-cost billing. Employer will pay charges as billed.
5) Administrator will collect monthly contributions as directed by Employer and credit all
funds so received to Employer's fund account.
6) Administrator will issue late notices and notices of cancellation to beneficiaries as
necessary on Employer's behalf.
7) Administrator will notify Employer within 180 days of beneficiary's Continuation of
Coverage expiration date.
Costs for Administrator to provide the above services to Employer are included in the
Administrative Services Charges as quoted in Section VIII (a) of the Agreement to which this
Amendment is attached, or any subsequent Renewal Amendment.
This amendment may be cancelled at any time by Employer giving thirty (30) days prior
written notice to Administrator.
Subject to all applicable terms and conditions of the Agreement to which this Amendment is
attached, Employer and Administrator have caused this Amendment to be executed in duplicate
by their respective officers duly authorized to do so.
FOR THE EMPLOYER: FOR THE ADMINISTRATOR:
By: By:
Title: Title: President
Dated at: Dated at: Sacramento, California
1 This day of , 19 This 23rd day of March , 1988
•
. • •
•
AMENDMENT #3 to Administration Agreement between City of Redding, hereinafter called
"Employer", and Concept Administrators Inc., hereinafter called "Administrator".
HOSPITAL BILL AUDIT.
Employer authorizes Administrator to submit all hospital bills over $10,000.00 to an
independent auditor for screening. Such screening will be performed by the auditor at no
charge to Employer. If an audit is indicated by the screening process, Employer authorizes
Administrator to order such audit be done. All fees charged by the auditor for services
rendered are the responsibility of Employer and will be billed to Employer by Administrator
on behalf of the auditor. Copies of any audit may be obtained from Administrator upon
request.
Employer retains the right to rescind this amendment at any time upon written notice to
Administra tor.
Subject to all applicable terms and conditions of the Agreement to which this Amendment is
attached, Employer and Administrator have caused this Amendment to be executed in duplicate
by their respective officers duly authorized to do so.
FOR THE EMPLOYER: FOR THE ADMINISTRATOR:_,
By: By:
Title: Title: President
Dated at: Dated at: Sacramento, California
This day of , 19 This 23rd day of March , 1988
•
•
AMENDMENT #4 to Administration Agreement between City of Redding, hereinafter called
"Employer", and Concept Administrators Inc. , hereinafter called "Administrator".
CLAIMS ERROR RATIO AND TURN-AROUND TIME.
Administrator agrees to maintain a claims error ratio of 3% or less. If a claims audit is
conducted, Administrator will cover the cost of the audit if the payment error ratio exceeds
3%.
Administrator also agrees to maintain a claims turn-around of ten working days or less from
the time that all information necessary for processing a claim is received.
' Subject to all applicable terms and conditions of the Agreement to which this Amendment is
attached, Employer and Administrator have caused this Amendment to be executed in duplicate
by their respective officers duly authorized to do so.
FOR THE EMPLOYER: FOR THE ADMINISTRATOR:
By: By:
Title: Title: Presiders
Dated at: Dated at: Sacramento, California
This day of , 19 This 23rd day of March , 1988