#11-5729 Amendment #4 (Allegiance Benefit Plan Management, Inc.) 11-5729"Third Party Administrator for Health Benefits"
FOURTH AMENDMENT to the
ADMINISTRATIVE SERVICES AGREEMENT
and to
APPENDICES A,C, D,and E
between
COLLIER COUNTY GOVERNMENT and ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC.
THIS AMENDMENT,made and entered into on th•is�LQ day of Sp•lern� 2017,by and between ALLEGIANCE
BENEFIT PLAN MANAGEMENT, INC. (the"TPA)and Collier County Government, a political subdivision of the State of Florida, (the
"County"or"Plan Sponsor".
WHEREAS,on July 26,2011,Agenda Item 16.E.5.,the County entered an Agreement with the TPA for the Group Health Third
Party Administration Services;and
WHEREAS,on December 6,2011 the County administratively approved the First Amendment to the Agreement to clarify fees;
and
WHEREAS,on September 23,2014,Agenda Item 16.E.3.,the County approved the Second Amendment to the Agreement to
add administration services for dental insurance claims; and
WHEREAS,on October 14,2015 the County administratively approved a modification to the Agreement allowing employees to
utilize a debit card for medical flexible accounts; and
WHEREAS,on April 12,2016,Agenda Item 16.E.3.,the County approved the Third Amendment to the Agreement to adding an
additional one year renewal and an extension period; and
WHEREAS, Collier County participated in a joint solicitation through the local Collier County Healthcare Consortium,which
consisted of Collier County, the Collier County Sheriffs Office, the Collier County School Board District (the CCHCC), to procure the
services for administering the Collier County Group Health Plan through the selection of Group Health Third Party Administration and
Managed Care; and
WHEREAS, on March 21, 2017, the Collier County Public Schools purchasing department released a joint Request for
Proposal (RFP)#17-100"Medical/Dental Claims and Flexible Spending Account Administration"solicitation;and
WHEREAS, on June 22, 2017, the selection committee by unanimous consensus selected Allegiance Benefit Plan
Management, Inc.,for award of the Group Health Third Party Administration(existing vendor under Agreement#11-5729)and Allegiance
has requested to amend the existing agreement.; and
WHEREAS,because the core services under the Agreement remain unaltered and the existing language is sufficient to reflect
the scope of services sought under Collier County Public Schools RFP#17-100,and the primary changes resulting from the RFP are limited
to the contract term and fees to be charged, an amendment to the Agreement as set forth below is in the public's best interest;
NOW,THEREFORE, in consideration of the mutual promises and covenants herein,the parties agree as follows:
The term of the contract is extended from January 1, 2018 through December 31, 2020 and may be renewed for two (2)
additional one (1) year periods as mutually agreed by the parties in writing. Exhibit A2-A is replaced in its entirety with the attached
Appendix A. Appendix C is replaced in its entirety with the attached Appendix C. Appendix A to Appendix D is replaced in its entirety with
the attached Appendix A to Appendix D. Appendix A to Appendix E is replaced in its entirety with the attached Appendix A to Appendix E.
Except as amended herein,all other terms and conditions of the Agreement and any prior amendments remain unchanged and
in effect.
APPENDIX C: COBRA SERVICES AGREEMENT(Non-ERISA) APX C: COBRA SVCS
ALLEGIANCE BENEFIT PLAN MANAGEMENT,INC. RED.,'.12-2014
Page 1 of 13
IN WITNESS WHEREOF,the parties have caused this Amendment to be executed on their behalf by their duly authorized representatives'
signatures,effective as of the date first written above.
COLLIER COUNTY GOVERNMENT ALLEGIANCE BENEFIT PLAN MANAGEMENT,INC.
2808 S. Garfield St.
Missoula,MT 59801
By: P- Ch-irman / By: Ronald K.Dewsnup
P
/ N=me/Title) President and General Manager
By: By:
` ?1l nature) d (Signature)
Date: \ 0l Date:
ATTEST:
Dwight E.Brock,Clerk of Courts
By: L� • .! ''G
Dated: I - 4
(sem fir' ® ^'®
ignature
prov-d a• t fo d le:: su iciency:
.Teach
Deputy County Attorney
•
APPENDIX C: COBRA SERVICES AGREEMENT(Non-ERISA) APX C: COBRA SVCS
ALLEGIANCE BENEFIT PLAN MANAGEMENT,INC. REV.12-2014
Page 2 of 13
0
APPENDIX A
Fee Schedule
The Plan Sponsor and the TPA hereby agree to the compensation schedules set forth below as being the sole compensation to the TPA for
the performance of its obligations under this Agreement. Monthly fees are based upon Plan Participant enrollment as of the beginning of
each month.
A. Administration fees are guaranteed from January 1,2018 through December 31,2020, as follows:
2018 2019 2020**
$17.26 $17.26 $17.70
The above fees shall include services for production and maintenance of Plan Documents/Summary Plan Description, plan
building,amendment production,plan document compliance,and HIPAA compliance,regulatory compliance(if applicable)and
production and mailing via bulk mail to the Plan Sponsor of health plan identification cards,and all of the following services that
are checked:
X Medical Claims
X Vision Claims
X PPO Management and Provider Network Coordination
X Predictive Modeling Disease Management Data Extracts
X Consolidated Billing
X COBRA services provided by Allegiance COBRA Services, Inc. pursuant to the COBRA Administrative Services
Agreement, Appendix C attached hereto. (In addition to this fee,the TPA will also retain two (2) percent of all COBRA
premiums as fees for COBRA services.)
X any administrative fees charged by the Pharmacy Benefit Management(PBM)company that is utilized by the Plan
Distribution of plan materials will be delivered to the Plan Sponsor. An additional postage and handling fee will be paid to
the TPA for mailing materials to individual Plan Participants, except for Welcome Packets and identification cards.
** Fees for 2020 are also guaranteed for two(2)additional one(1)year renewals.
B. Dental claims processing services per Employee per Month:
2018 2019 2020**
$2.75 $2.75 $2.85
** Fees for 2020 are also guaranteed for two(2)additional one(1)year renewals.
C. Hourly fees for Oncology Case Management services by StarPoint:
2018 2019 2020**
$115.00 $115.00 $115.00
** Fees for 2020 are also guaranteed for two(2)additional one(1)year renewals.
APPENDIX C: COBRA SERVICES AGREEMENT(Non-ERISA) APX C. COBRA SVCS
ALLEGIANCE BENEFIT PLAN MANAGEMENT,INC. REV.12-2014
Page 3 of 13
D. Case Management fee/Non-Oncology per Employee per Month effective January 1st of each year:
2018 2019 2020**
$2.40 $2.40 $2.45
** Fees for 2020 are also guaranteed for two(2)additional one(1)year renewals.
E. Utilization review services by StarPoint, LLC per Employee per Month effective January 1st of each year:
2018 2019 2020**
$1.65 $1.65 $1.70
** Fees for 2020 are also guaranteed for two(2)additional one(1)year renewals.
F. Disease Management fee for Deerwalk per Employee per Month effective January 1st of each year:
2018 2019 2020
$2.75 $2.75 $2.85
A monthly fee for Healthcare Bluebook transparency tool per Employee per Month effective January 1st of each year:
2018 2019 2020
$1.50 $1.50 $1.55
G. Run out fees.
Run Out services shall be based upon a separate run out agreement executed at the time Run Out is requested. However,the
fees therefore shall be calculated as follows:
There shall be a single fee payable in advance, equal to three times the administration fee paid for the month immediately
preceding the date Run Out Services are requested to process claims for a twelve(12)month period following termination of the
administrative services provided under this Agreement.
H. Hourly fee of$125.00 for welfare plan consulting. Such services must be agreed to in advance by the Plan Sponsor.
Hourly fee of$125.00 for stop-loss reimbursement services,audit assistance services and any other services provided by the
TPA after termination of this Agreement and in the absence of a separate Run-Out Services Agreement.
J. Hourly fee of$125.00 for special programming requests or research including production of any special claims history reports.
Such services must be agreed to in advance by the Plan Sponsor.
K. Special Reports requested by the Plan Sponsor and produced by the TPA upon prior agreement as to report(s)and fee(s),if any.
APPENDIX C: COBRA SERVICES AGREEMENT(Non-ERISA) APX C: COBRA SVCS
ALLEGIANCE BENEFIT PLAN MANAGEMENT,INC. REV.12-2014
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L. Final fee of$500.00 for providing eligibility/enrollment files in electronic format acceptable to TPA without special programming to
the Plan Sponsor(if requested in writing).
M. Final fee of$1,500.00 for providing Claims history file in electronic format acceptable to TPA without special programming to the
Plan Sponsor(if requested in writing).
N. Check customization,customized printed material,special statistical reports other than those enumerated in this contract,special
medical underwriting, new taxes assessed against the Plan,or other services mutually agreed upon will be billed separately at
the rate of$125.00 per hour for such services. Such services must be agreed to in advance by the Plan Sponsor.
O. A fee equal to the actual costs for printing Summary Plan Description Booklets,together with costs of shipping for each booklet.
P. A fee of$125.00 per hour for time expended producing and providing information to agents,consultants or brokers for whom the
Plan Sponsor requests Plan information be provided,together with any postage,shipping and copying costs. Paper copies will
be billed at fifteen($.15)cents per copy.
Q. PPO access fees for any PPO organization or claim negotiation company that assesses a per Plan Participant fee,a per Claim
fee,or a percentage of claims savings fees not to exceed twenty-five(25%)percent of the actual savings amount between the
charges billed by the Health Care Provider and the discounted amount agreed to between the PPO or Claims Negotiation
Company and the Health Care Provider,except for those entities specifically listed below,for which no service fee applies. The
amount charged under this Agreement shall be equal to the amount charged by the PPO or Claims Negotiation Company. The
TPA, its parents or its affiliates, may be paid a service fee by the PPO for claim repricing or other administrative services
associated with the claims discount or negotiation. The Plan Sponsor will receive a report that outlines the total billed charges,
the total discounts obtained, the net claims cost and the total claim savings to the Plan. Any additional fee in excess of this
amount must be approved in advance by the Plan Sponsor. The TPA may be paid a fee not to exceed twenty-five(25%)percent
of net savings payable to TPA, its parent or its affiliates, realized as a result of any negotiation or reduction in the amount of
claims paid or any recovered funds obtained by TPA through employment of cost containment companies.Specific fees at the
inception of this contract for which a per Participant per month rate is charged are:
$ -0- per Plan Participant per month for Community Health Partners PHO
Effective for 2018 and 2019,the network access fee for the Cigna PPO network is$5.50 PPPM.
Effective for 2020,the network access fee for the Cigna PPO network is$5.65 PPPM.
I I
Funding and Fee Payment Terms
Plan Sponsor will establish and maintain a zero balance Claims Payment Account for payment and reimbursement of Covered Services.
TPA will notify Plan Sponsor or its designee on a weekly basis of amount required to pay claims after they have been processed for
payment. Notification of the amount required will take place as follows:
On Wednesday of each week(Thursday,if Wednesday coincides with a recognized Federal holiday),an electronic notification
will be provided to Plan Sponsor that the weekly report of claims processed for payment is available on TPA's secured website.
TPA will release the claims checks issued for the batch for that week after notice has been sent.
APPENDIX C: COBRA SERVICES AGREEMENT(Non-ERISA) APX C: COBRA SVCS
ALLEGIANCE BENEFIT PLAN MANAGEMENT,INC. REV 12-2014
Page 5 of 13
TPA will generate a monthly bill for fees. Payment of monthly billing will be as follows:
On or about the 25th of each month,TPA will provide an electronic notification to Plan Sponsor that the monthly bill is available on
TPA's secured website.
Upon approval from Plan Sponsor,TPA will affect an electronic withdrawal of funds from an account designated by Plan Sponsor
on the Debit Authorization Form.
Initials
(Plan Sponsor)
lf'f�it
TPA Initials
APPENDIX C: COBRA SERVICES AGREEMENT(Non-ERISA) APX C: COBRA SVCS
ALLEGIANCE BENEFIT PLAN MANAGEMENT,INC. REV.12-2014
Page 6of13
c"�
APPENDIX C
COBRA ADMINISTRATIVE SERVICES AGREEMENT
This COBRA Administrative Services Agreement(hereinafter"Agreement") is entered into January 1, 2018, by and between COLLIER
COUNTY GOVERNMENT(hereinafter"Plan Sponsor"),whose address and phone number are 3299 Tamiami Trail East,Suite 303,Naples,
Florida 34112,(239)252-8461,and ALLEGIANCE COBRA SERVICES,INC.,(hereinafter"TPA"),whose address and phone number are
2806 S. Garfield St, PO Box 2097, Missoula, MT 59806; (406) 721-2222.
WHEREAS,the Plan Sponsor and/or the plan administrator of the group health plan sponsored by the Plan Sponsor is required to perform
certain duties pursuant to continuation of benefits coverage requirements;
WHEREAS, the Plan Sponsor has selected the TPA to perform certain nondiscretionary and ministerial duties pursuant to the Plan
Sponsor's continuation of benefits coverage requirements;
NOW THEREFORE, in consideration of the terms and conditions hereinafter set forth,the parties agree as follows:
SECTION 1: Definitions employee(except for termination as a result of gross
misconduct), or reduction of hours of employment
1.1 "COBRA" means the Consolidated Omnibus Budget causing the employee to become ineligible for
Reconciliation Act of 1985 or the Public Health Service coverage.
Act, as amended or interpreted from time to time, and
applicable regulations. b. With respect to an eligible dependent or spouse of a
covered employee or former employee,termination of
1.2 "COBRA Participant" means any person who is properly employment of the employee(except for termination
enrolled for and entitled to benefits from the Plan, as a result of gross misconduct), reduction of hours
pursuant to COBRA continuation coverage. of employment causing the employee to become
ineligible for coverage, the covered employee's
1.3 "Plan" means the self-funded health and welfare benefit entitlement to Medicare, the death of the covered
plan which is the subject of this Agreement and which the employee, the divorce or legal separation of the
Plan Sponsor has established pursuant to the Plan spouse from the covered employee, and an eligible
Document. dependent who ceases to be a dependent as that
term is defined by the Plan.
1.4 "Plan Administrator" means the person or entity
designated by the Plan Sponsor to manage the Plan and c. With respect to eligible retirees and their eligible
make all discretionary decisions regarding Plan terms and dependents, the commencement of a bankruptcy
managing Plan assets. proceeding.
1.5 "Plan Participant" is any employee, retiree or COBRA d. Any other qualifying event as defined by law and as
beneficiary who is properly enrolled and eligible for the law may be amended or interpreted from time to
benefits under the Plan. time.
1.6 "Qualified Beneficiary"means a covered person under the SECTION 2: Relationship of Parties
Plan,who is eligible to continue coverage under the Plan
in accordance with the applicable provisions of COBRA, 2.1 Independent Contractor. Plan Sponsor acknowledges
regarding Qualified Medical Child Support Orders, or in that the TPA is an independent contractor as defined in
accordance with any other applicable Federal or State section 39-71-120 of the Montana Code Annotated, as
law. amended, for purposes of this Agreement. As such, the
TPA is not an agent or employee of Plan Sponsor and
"Qualified Beneficiary" also means a child born to, does not assume any liability or responsibility for any
adopted by or placed for adoption with a covered breach of duty or act of omission by Plan Sponsor.
employee or former employee, at any time during active
COBRA continuation coverage of that employee or former 2.2 Plan Fiduciary. Plan Sponsor acknowledges and agrees
employee. that the performance by the TPA of its obligations under
this Agreement does not make the TPA a plan
1.7 "Qualifying Event"means: administrator, plan sponsor, or fiduciary as defined by
ERISA or other applicable law,and Plan Sponsor will not
a. With respect to a covered employee or former identify the TPA or any of its affiliates as such.The Plan
employee, termination of employment of the Sponsor further acknowledges and agrees that it is the
APPENDIX C: COBRA SERVICES AGREEMENT(Non-ERISA) APX C: COBRA SVCS
ALLEGIANCE BENEFIT PLAN MANAGEMENT,INC- REV 12-2014
Page 7 of 13
plan sponsor,plan administrator,and named fiduciary as under the Plan, and such notice is made more than 60
defined by ERISA or other applicable law. As such, Plan days after the Qualifying Event, Plan Sponsor will notify
Sponsor retains full discretionary authority, control, and the TPA in writing of the same within ten (10)days after
responsibility for the operation and administration of the receiving the notice.
Plan.
The TPA will not enroll those persons who provided notice
2.3 No Legal or Tax Advice. Plan Sponsor acknowledges and in such manner for COBRA continuation coverage,unless
agrees that the TPA will not be deemed to be a legal or specifically directed to do so in writing, by the Plan
tax advisor as a result of the performance of its duties Sponsor and/or the Plan Administrator.
under this Agreement.
3.4 Qualified Beneficiary Information: Plan Sponsor will
2.4 Subcontractors. The TPA may subcontract the services provide the TPA the following information with notice of a
of computer companies, consultants, attorneys, Qualifying Event:
accountants, and other organizations that it deems
necessary in the performance of its obligations under this a. The name, address, and Social Security number of
Agreement. At the discretion of the TPA, such services the employee.
may be performed directly by the TPA,wholly or in part,
through a subsidiary or affiliate of the TPA or under an b. The name,address,and Social Security number for
agreement with an organization,agent,or other person of any covered dependents.
its choosing. Any such services resulting in a fee not
agreed to in Appendix A, Fee Schedule and Financial c. Date and description of the Qualifying Event,or if not
Arrangement in the Administrative Services Agreement a Qualifying Event,the date and reason,if known,for
between Plan Sponsor and Allegiance Benefit Plan dropping or terminating Dependent coverage. If the
Management,shall have prior written authorization by the Plan Sponsor knows that the Participant's reason for
Plan Sponsor. dropping or terminating Dependent coverage is in
contemplation of divorce or legal separation, Plan
2.5 Third Party Administrator Licensure. The TPA represents Sponsor shall notify the TPA of the same to assure
that during the term of this agreement it will be licensed or that any affected Dependent receives notice of any
registered as necessary in the Plan Sponsor's state of COBRA rights to which he or she is entitled.
domicile.
3.5 SSI Determination Letters: Plan Sponsor will forward
SECTION 3: Responsibilities of Plan Sponsor copies of any Social Security Disability Determination
letters it may receive from COBRA Participants within ten
3.1 Initial Notice: If applicable, Plan Sponsor will notify the (10)days after Plan Sponsor receives the same and has
TPA within thirty (30) days after employees and/or their date stamped the letter.
dependents enroll in Plan Sponsor's Plan of such
enrollment to allow the TPA to send the employee an 3.6 Plan Sponsor Plan, Changes, and Amendments Plan
initial COBRA notice. Sponsor will notify the TPA of any changes in benefits,
eligibility and/or premiums for Plan Sponsor's Plan, in
3.2 Qualifying Event Notice: Plan Sponsor will notify the TPA accordance with the terms of the Administrative Service
or cause the TPA to be notified when employees and/or Agreement for the Plan Sponsor's Plan.
their dependents have a Qualifying Event as follows:
3.7 COBRA Premiums: Plan Sponsor will determine the
a. Within thirty (30) days of the employee's death, amount to be charged for COBRA premiums and notify
termination from employment for any reason the TPA of the same, in writing, upon execution of this
including gross misconduct, or reduction of Agreement. Plan Sponsor will notify the TPA in writing of
employment hours. any premium changes at least thirty(30)days prior to the
effective date of the change or as soon as reasonably
b. Within sixty (60) days of the divorce or legal possible thereafter.
separation of the employee or the date at which a
dependent child ceases eligibility under the Plan. 3.8 COBRA Election Forms: If Plan Sponsor receives
requests for COBRA coverage, Plan Sponsor will record
c. Within sixty(60)days of a second Qualifying Event of on the form the date it was received by Plan Sponsor.
a Qualified Beneficiary dependent or spouse,such as Plan Sponsor will fax a copy of the form to the TPA on the
the divorce or legal separation from the covered date it is received by Plan Sponsor,and will mail a copy of
employee, death of the covered employee, the same to the TPA within five(5)days of receipt by Plan
entitlement to Medicare or the dependent child Sponsor.
ceasing eligibility under the Plan.
3.9 Premium Accounts:Plan Sponsor will establish,or cause
3.3 Late Notice of Qualifying Event: If any employee or to be established, a premium account at a bank
dependent of an employee provides notice to the Plan designated by the Plan Sponsor. Plan Sponsor, and not
Sponsor of divorce or legal separation, entitlement to the TPA,will be the owner of such account.
Medicare, or that a dependent child ceases eligibility
APPENDIX C: COBRA SERVICES AGREEMENT(Non-ERISA) APX C. COBRA SVCS
ALLEGIANCE BENEFIT PLAN MANAGEMENT,INC. REV 12-2014 ne•3 Page 8 of 13
Plan Sponsor authorizes the TPA to endorse COBRA 4.7 Plan Changes and Amendments: The TPA will inform
premium payments received by stamping the same with COBRA Participants under the Plan of any changes in
"FOR DEPOSIT ONLY" and the applicable premium benefits,eligibility requirements,or premiums of the Plan.
account number and to forward the payments to the Plan The obligations of the TPA under this subsection will be
Sponsor on a monthly basis for deposit in the premium limited to mailing to COBRA Participants copies of all Plan
account. amendments,changes,modifications,or other notices as
received from the Plan Sponsor.
3.10 Premium Payments Received from COBRA Participants:
If Plan Sponsor receives premium payments directly from 4.8 Customer Service Toll-Free Line: The TPA will provide
COBRA Participants, Plan Sponsor will notify the TPA in customer service assistance regarding COBRA issues to
writing on the date of receipt, or cause the TPA to be Plan Sponsor and beneficiaries under Plan Sponsor's
notified in writing on the date of receipt, of the premium Plan through a toll-free telephone number during regular
amount,the name of the COBRA Participant(s)for whom business hours.
the premium applies,the date of receipt, and the period
for which the premium applies. 4.9 COBRA Participant Premiums: The TPA will bill COBRA
Participants for the premiums as designated by Plan
3.11 Initial Grace Period: Plan Sponsor designates that the Sponsor and in accordance with applicable law. The TPA
initial forty-five (45) day grace period for the premium will not be required to bill for any premium amount that
payment will begin on the date of COBRA election. does not comply with applicable law.
3.12 Other: Plan Sponsor will provide any other information The TPA will direct COBRA Participants to make premium
required by the TPA to perform its obligations under this payments payable to the Plan Sponsor and to send
Agreement. payments to the TPA. If the TPA receives premium
SECTION 4: COBRA Services of the TPA checks made payable to the TPA, the TPA will endorse
them over to Plan Sponsor, without recourse. The TPA
will collect COBRA premiums and forward them .ro the
4.1 Initial Notice. If applicable, within fourteen (14) days of Plan Sponsor's on a monthly basis.
receipt of notice from Plan Sponsor of a newly-enrolled
employee and/or spouse, the TPA will mail to the The TPA will establish, or cause to be established, a
employee and/or spouse an initial notice of COBRA system to credit the premium payments to the appropriate
continuation coverage rights. Qualified Beneficiary or COBRA Participant.
4.2 Enrollment Packet:Within fourteen(14)days of receipt of 4.10 Late Premium Notices: The TPA will send a reminder
notice from the Plan Sponsor of a Qualifying Event, the notice to Qualified Beneficiaries and COBRA Participants
TPA will mail to Qualified Beneficiaries a notice of the whose premium payment has not been received on or
right to elect COBRA continuation coverage. about the twentieth day of the month.
4.3 Enrollment of Qualified Beneficiaries:The TPA will enroll 4.11 Late Premium Payments: If the TPA receives a premium
all Qualified Beneficiaries who elect COBRA continuation payment past the premium due date(including any grace
coverage within the time permitted by law. period provided by law or the Plan),the TPA will return the
payment to the sender with a notice that it cannot be
4.4 Notice of Open Enrollment. The TPA will notify COBRA accepted. The TPA will return the payment to the sender,
participants of any open enrollment periods held for with such notice, within five (5) days of receiving the
employees under Plan Sponsor's Plan. payment.
4.5 Contemplation of Divorce:Upon receipt of notice from the 4.12 COBRA Terminations: The TPA will notify the Plan
Plan Sponsor, the TPA will provide notices to spouses Sponsor of the date COBRA continuation coverage will
and other Dependents whose coverage is being expire, in the absence of any default, for each COBRA
terminated in contemplation of divorce or legal separation Participant. Such notice will be given in an eligibility
that they may have rights to COBRA continuation report provided by the TPA to the Plan Sponsor on a
coverage when the divorce decree or legal separation is monthly basis.
entered by a court.
4.13 Notice of Default: The TPA will notify each COBRA
4.6 Post-Election Notices: The TPA will provide all post Participant, in writing, of any default in payment of
election notices to employees and their spouses required premium, or other default causing loss of coverage,
by applicable law, including but not limited to notice of including the date of default and the date COBRA
ineligibility for COBRA continuation coverage, notice of continuation coverage terminated. Notice will be sent by
nonpayment of premium, and notice of termination of first class mail within five (5) days following receipt of
COBRA coverage. If the notice of ineligibility is due to the notice from Plan Sponsor and/or Plan Administrator.
employee's termination of employment for gross
misconduct,the Plan Sponsor shall be solely responsible
for the determination of gross misconduct.
APPENDIX C: COBRA SERVICES AGREEMENT(Non-ERISA) APX C: COBRA SVCS
ALLEGIANCE BENEFIT PLAN MANAGEMENT,INC. 17.1'„ REV.12-2014
,;F Page 9 of 13
4.14 Notice of COBRA Exhaustion: The TPA will notify each SECTION 7: Indemnification
COBRA Participant of the date COBRA continuation
coverage will expire in the absence of any default. Such 7.1 Plan Sponsor Indemnification: The TPA will indemnify,
notice will be sent by first class mail within thirty(30)days defend, save and hold the Plan Sponsor harmless from
of the termination date. and against any and all claims, suits, actions, liabilities,
losses, penalties or damages including court costs and
4.15 Conversion Coverage:If applicable,the TPA shall provide attorneys'fees with respect to the Plan to the extent they
notices to eligible COBRA Participants of their rights to are caused by the gross negligence, malfeasance, or
obtain conversion coverage. Such notices shall be criminal acts or omissions of the TPA or its employees in
supplied at the expense of the Plan. The TPA shall the performance of its duties under this Agreement and
administer conversion rights in accordance with the for any acts taken at the specific direction of the Plan
provisions of the Plan document. Sponsor.
SECTION 5: TPA Compensation 7.2 TPA Indemnification: The Plan Sponsor will indemnify,
Plan Sponsor agrees to pay the TPA its compensation for services defend, save, and hold the TPA harmless from and
provided under this Agreement in accordance with the terms and against any and all claims, suits, actions, liabilities,
conditions outlined in Appendix A, "Fee Schedule and Financial losses, penalties or damages, including court costs and
Arrangement" in the Administrative Services Agreement between attorneys' fees, to the extent that such claims, losses,
Plan Sponsor and Allegiance Benefit Plan Management. liabilities, damages and expenses are caused by the
gross negligence, malfeasance or criminal acts or
SECTION 7: Limitations on Liability omissions of the Plan Sponsor, its agents or employees,
in the performance of its duties under this Agreement and
6.1 Premium Payments/Loss of Coverage: Except as in those situations under Section 7 where the TPA is
exculpated from liability.To the extent authorized by law,
provided for under section 8.1, the TPA will have no
and applicable to contract and indemnity claims the
liability to any person or entity regarding the processing of
foregoing indemnification shall not constitute a waiver of
premium payments. Provided the TPA acts in accordance
sovereign immunity beyond the limits set forth in Section
with this Agreement,the TPA will have no liability to any
person or any entity for loss of COBRA coverage as a 768.28, Florida Statutes.
result of late or nonpayment of premium. SECTION 8: Term and Termination of Agreement
6.2 Failure of Plan Sponsor to Notify:The TPA will provide all
8.1 Term and Renewal Term. The term of this Agreement
notices to COBRA Participants and Qualified Beneficiaries shall commence on January 1, 2018, and end on
in accordance with this Agreement. Provided the TPA December 31, 2020, unless terminated earlier in
acts in accordance with this Agreement,the TPA will have accordance with this Section. This Agreement may be
no liability to any COBRA Participant or Qualified renewed for an additional two-year renewal term upon
Beneficiary for failure of the Plan Sponsor to properly mutual agreement in writing by the parties.
notify the TPA and provide the information required for the
TPA to perform its obligations under this Agreement. The
8.2 Termination. This Agreement shall be terminated in
TPA will have no liability for the accuracy of the accordance with the provisions of Article V: Term and
information provided by the Plan Sponsor nor for any Termination of the Administrative Services Agreement
actions taken in reliance upon any such information. between the Plan Sponsor and Allegiance Benefit Plan
6.3 NSF Checks:This Agreement will not be construed in any Management, Inc.,effective as of the 1St day of January,
manner to require the TPA to collect insufficient funds, 2018.
"stop-payment"or otherwise dishonored checks,or other 8.3 Survival: The provisions of Sections 2, 6, and 7 shall
negotiable instruments received for premium payments, survive termination of this Agreement.
which are subsequently not paid by the maker. The TPA
will not be liable for any losses to Plan Sponsor or Plan SECTION 9: General Provisions
Sponsor's Plan as a result of such checks or negotiable
instruments.
9.1 Authorization: Plan Sponsor grants to the TPA the
6.4 Determinations of Gross Misconduct: The TPA shall not authority to do all acts it deems necessary to carry out the
make any determinations of any nature regarding whether terms of this Agreement.
a Qualified Beneficiary's termination from employment
was due to gross misconduct.The TPA shall be entitled to 9.2 Waiver: No forbearance or neglect on the part of either
rely upon any determinations of gross misconduct as party to enforce or insist upon any of the provisions of this
made by the Plan Sponsor and shall have no liability for Agreement will be construed as a waiver, alteration, or
actions taken in reliance upon any such information as modification of this Agreement.
provided by the Plan Sponsor.
9.3 Entire Agreement, Amendments, Modification: This
Agreement and any attachments constitute the entire
agreement between the parties with respect to its subject
APPENDIX C: COBRA SERVICES AGREEMENT(Non-ERISA) APX C: COBRA SVCS
ALLEGIANCE BENEFIT PLAN MANAGEMENT,INC. REV.12-2014
Page 10 of 13
matter. This Agreement supersedes all existing mail transmission
agreements and all other oral, written or other
communications between them concerning its subject Notice to the TPA shall be directed to:
matter. This Agreement or any attachment shall not be
amended or modified except as agreed upon in writing Ronald K. Dewsnup, President, Allegiance Benefit Plan
and signed by the parties. If any such modification or Management,Inc.,2806 South Garfield St.,PO Box 3018,
amendment increases the direct costs to the TPA under Missoula, MT 59806-3018; Phone: (406) 721-2222;
this Agreement, the Plan Sponsor agrees to pay any Fax: (406)721-2252;
increases in direct costs that the TPA reasonably expects Email: skallegiancecorn.
to incur as a result of such modification.
Notice to the Plan Sponsor shall be directed to:
9.4 Severability: If any provision of this Agreement is held to
be invalid, illegal, or unenforceable by any court of final Jeff Walker, Director, Collier County Risk Management
jurisdiction, it is the intent of the parties that all other Department, 3311 Tamiami Trail East, Naples, Florida
provisions of this Agreement be construed to remain fully 34112; Phone: (239) 252-8906; Fax: (239) 252-8048;
valid,enforceable,and binding on the parties. Email: JeffWalkerna-coiileryo'. .
9.5 Agreement Counterparts: This Agreement may be 9.10 Choice of Law and Venue. This Agreement shall be
executed in two or more counterparts, each and all of governed and construed in accordance with the laws of
which will be deemed an original and all of which together the State of Florida.
will constitute but one and the same instrument.
9.11 Prior to the initiation of any action or proceeding permitted
9.6 Assignment. Neither party shall assign, transfer, or by this Agreement to resolve disputes between the
subcontract any portion of this Agreement without the parties, the parties shall make a good faith effort to
prior written consent of the non-assigning party. resolve any such disputes by negotiation. The negotiation
shall be attended by representatives of the TPA with full
9.7 Notice of Threatened Litigation: The Plan Sponsor will decision-making authority and by Plan Sponsor's staff
notify the TPA within ten (10) days of any threatened person who would make the presentation of ai y
litigation, lawsuits or regulatory complaints or inquiries settlement reached during negotiations to Plan Sponsor
pertaining to the subject matter of this Agreement,or any for approval. Failing resolution, and prior to the
inquiry made by any federal or state authority regarding commencement of depositions in any litigation between
the same. the parties arising out of this Agreement,the parties shall
attempt to resolve the dispute through Mediation before
9.8 Compliance with Laws.The TPA shall,in the performance an agreed-upon Circuit Court Mediator certified by the
of its obligations under this Agreement, comply with State of Florida. The mediation shall be attended
applicable federal, state or local laws, rules and representatives of the TPA with full decision-makigg
regulations,including the Montana Human Rights Act,the authority and by Plan's Sponsors staff person who would
Civil Rights Act of 1964, the Age Discrimination Act of make the presentation of any settlement reached at
1975,the American Disabilities Act of 1990,and Section mediation to Plan Sponsor's board for approval. Should
504 of the Rehabilitation Act of 1973. In accordance with either party fail to submit to mediation as required
section 49-3-207, Montana Code Annotated, the TPA hereunder, the other party may obtain a court order
agrees that the hiring of persons to perform the requiring mediation under Section 44.102, Fla. Stats.
Agreement will be made on the basis of merit and
qualifications and there will be no discrimination based Any suit or action brought by either party to this
upon race,creed,religion,color,national origin,sex,age, Agreement against the other party relating to or arising
physical or mental disability, marital status, or political out of this Agreement must be brought in the appropriate
ideas in the right to obtain and hold employment. federal or state courts in Collier County. Florida, which
courts have sole and exclusive jurisdiction on all such
9.9 Service of Notice. Neither party will be bound by any matters.
notice,directive or request unless and until it is received
in writing, or by facsimile transmission, or by e-mail 9.12 Headings: Section headings are included only for
address at the addresses in this subsection. All notices convenient reference and do not describe the sections to
given to either party under this Agreement shall, unless which they relate.
otherwise specified in writing, be deemed to have been
given three (3) days after deposit in the U.S. Mail, first 9.13 Interpretation of Words: Words denoting the singular
class postage prepaid, certified mail, return receipt include the plural and vice versa.
requested.; date of facsimile transmission; or date of e-
Initials
(Plan Sponsor
Initials
(TPA)
APPENDIX C: COBRA SERVICES AGREEMENT(Non-ERISA) APX C. COBRA SVCS
ALLEGIANCE BENEFIT PLAN MANAGEMENT,INC. REV.12-2014
Page 11 of 13
APPENDIX D
11-5729 "Third Party Administrator for Health Benefits"
ADMINISTRATIVE SERVICES AGREEMENT
SECTION 105 MEDICAL EXPENSE REIMBURSEMENT PLAN
APPENDIX A to APPENDIX D
FEE SCHEDULE AND FINANCIAL ARRANGEMENT
1. FEE SCHEDULE
The Plan Sponsor and the TPA hereby agree to the compensation schedules set forth below as being the sole compensation to the TPA for
any of its services which relate to the Section 105 HRA Plan. Monthly fees are based upon Plan Participant enrollment as of the beginning
of the month.
All fees stated below are subject to Chapter 218, Florida Statutes, also known as the"Local Government Prompt Payment Act".
Plan Sponsor shall pay THE TPA the following fees as indicated:
SERVICE AMOUNT DUE
2018 2019 2020**
A. Monthly Service Fee HRA: Per Participant per Month $4.00 $4.00 $4.10
** Fees for 2020 are also guaranteed for two (2)additional one(1)year renewals.
B. Hourly fee of$50.00 for reconciliation of contribution listing and related accounting services.
C. Hourly fee of$100.00 for welfare plan consulting. Such services must be agreed to in advance by the Plan Sponsor.
D. Hourly fee of$100.00 per hour for audit assistance services and any other services provided by the TPA not specifically provided
for in this Agreement.
MEDICAL ASA Page 12 of 13 MED STD SNGL EMP
ALLEGIANCE BENEFIT PLAN MANAGEMENT,INC627).
REV.2011-2(6-11)
APPENDIX E
11-5729 "Third Party Administrator for Health Benefits"
ADMINISTRATIVE SERVICES AGREEMENT
FLEXIBLE BENEFITS PLAN
APPENDIX A to APPENDIX E
FEE SCHEDULE AND FINANCIAL ARRANGEMENT
1. FEE SCHEDULE
The Plan Sponsor and the TPA hereby agree to the compensation schedules set forth below as being the sole compensation to the TPA for
any of its services which relate to the FLEX Plan. Monthly fees are based upon Plan Participant enrollment as of the beginning of the
month.
All fees stated below are subject to Chapter 218, Florida Statutes, also known as the"Local Government Prompt Payment Act".
Plan Sponsor shall pay THE TPA the following fees as indicated:
SERVICE AMOUNT DUE
2018 2019 2020**
A. Monthly Service fee FSA including Electronic
Per Participant per Month $5.00 $5.00 $5.15
Payment Card Service:
** Fees for 2020 are also guaranteed for two(2)additional one(1)year renewals.
B. Hourly fee of$50.00 for reconciliation of contribution listing and related accounting services.
C. Hourly fee of$100.00 for welfare plan consulting. Such services must be agreed to in advance by the Plan Sponsor.
D. Hourly fee of$100.00 per hour for audit assistance services and any other services provided by the TPA not specifically provided
for in this Agreement.
E. Fee for FSA COBRA services $.25/participant/month together with 2%of the
COBRA fees collected.
MEDICAL ASA Page 13 of 13 MED STD SNGL EMP
ALLEGIANCE BENEFIT PLAN MANAGEMENT,INC. REV.2011-2(6-11)
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