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Agenda 12/13/2022 Item #16E 3 (Collier County Group Health and Dental Plan Administration Services)
16.E.3 12/13/2022 EXECUTIVE SUMMARY Recommendation to award Request for Proposal ("RFP") # 22-7977, "Group Health & Dental Plan Administration Services," to Allegiance Benefit Plan Management, Inc., and authorize the Chairman to sign the attached agreement. OBJECTIVE: To professionally administer the Collier County Group Health Plan through the selection of a Group Health Third Party Administration vendor. CONSIDERATIONS: The Board sponsors a comprehensive group insurance program for its employees and their eligible dependents. The program includes a partially self -funded group health and dental insurance plan also known as the "Plan." To administer the Plan, the County employs the services of a Group Health Third Party Administration company to adjudicate claims and perform Plan administration services. In addition, the vendor provides HIPAA and COBRA administration services, flexible spending account services, dependent care reimbursement account services, health reimbursement account services and access to preferred provider networks outside Collier County, as needed. These services are known as the "Core" services. Since 2012, the County has utilized Allegiance Benefit Plan Management, Inc. for those services, and the current Board approved Agreement #11-5729, and its associated amendments, expires on December 31, 2022. On March 30, 2022, the Procurement Services Division issued RFP No. 22-7977, Group Health & Dental Plan Administration Services. The County received three proposals by the May 2, 2022, deadline. Allegiance Benefit Plan Management, Inc. and Meritain Health, Inc. were found to be responsive/responsible, while staff deemed United Concordia Companies, Inc. non -responsive for not meeting the requirements of the solicitation. Allegiance Benefit Plan Management, Inc. and Meritain Health, Inc. were both contacted to resolve minor irregularities due to missing documents. A selection committee met on June 9, 2022, to review and score the proposals. The evaluation criteria included the firm's ability to comply with the Scope of Services; Implementation and Transition; Control over Administration/Service to Employees/Communication/Service Issues; Provider Network; Technology/Data Availability; Service to Providers/FSA/HRA/COBRA/Health Management/General Requirements; Community Health Partners; Cost of Services to the County; and Local Vendor Preference. The RFP required the firms to submit references from five clients for which they had implemented and provided Third Party Administrative Services during the past three years. After review of the proposals and deliberation, the selection committee initially ranked the proposals as follows: Proposers Final Ranking Allegiance Benefit Plan Management, Inc. 1 Meritain Health, Inc. 2 United Concordia Companies, Inc. Not Ranked The selection committee reconvened on June 22, 2022 to review the annual cost breakdown by County Consultant, Willis Towers Watson and to reach a final ranking. The selection committee members revisited their individual rankings and concluded that there were no changes from the original ranking. Allegiance Benefit Plan Management, Inc. is the incumbent firm and has over thirty-five (35) years of experience. Award is recommended to Allegiance Benefit Plan Management, Inc., Inc. with an effective date of January 1, 2023. FISCAL IMPACT: The annual fees paid to Allegiance Benefit Plan Management, Inc., are estimated to be $813,431 based upon current enrollment. Funds are available in Fund 517, Group Health and Life, for this Packet Pg. 1959 16.E.3 12/13/2022 purchase. The attached agreements contain an initial contract term of five (5) years with the option to renew for two additional one-year periods. Pricing for the renewal terms shall be brought back for future Board approval. The proposed agreement would commence on January 1, 2023. GROWTH MANAGEMENT IMPACT: There is no growth management impact associated with this item. LEGAL CONSIDERATIONS: This item is approved as to form and legality, and requires majority vote for Board approval.-SRT RECOMMENDATION: That the Board award RFP # 22-7977, "Group Health & Dental Plan Administrative Services," to Allegiance Benefit Plan Management, Inc., and authorize the Chairman to sign the attached Agreement. PREPARED BY: Jeff Walker, CPCU, ARM, Director, Risk Management ATTACHMENT(S) 1.22-7977 Allegiance Benefit Plan VendorSigned (PDF) 2. [Linked] 22-7977_ Allegiance —Proposal (PDF) 3.22-7977 Final Ranking (PDF) 4.22-7977 Notice of Recommended Award Executed (PDF) 5.22-7977 COI_AllegianceBenefitPlan (PDF) Packet Pg. 1960 16.E.3 12/13/2022 COLLIER COUNTY Board of County Commissioners Item Number: 16.E.3 Doe ID: 23915 Item Summary: Recommendation to award Request for Proposal ("RFP") # 22-7977, "Group Health & Dental Plan Administration Services," to Allegiance Benefit Plan Management, Inc., and authorize the Chairman to sign the attached agreement. Meeting Date: 12/13/2022 Prepared by: Title: Benefits Analyst — Risk Management Name: Sonja Sweet 11/16/2022 6:45 AM Submitted by: Title: Division Director - Risk Management — Risk Management Name: Jeff Walker 11/16/2022 6:45 AM Approved By: Review: Risk Management Jeff Walker Director Review Procurement Services Ana Reynoso Level 1 Purchasing Gatekeeper Procurement Services Barbara Lance Additional Reviewer Procurement Services Sue Zimmerman Additional Reviewer Procurement Services Sandra Herrera Additional Reviewer County Attorney's Office Scott Teach Level 2 Attorney Review Office of Management and Budget Debra Windsor Level 3 OMB Gatekeeper Review County Attorney's Office Jeffrey A. Klatzkow Level 3 County Attorney's Office Review Community & Human Services Maggie Lopez Additional Reviewer County Manager's Office Dan Rodriguez Level 4 County Manager Review Board of County Commissioners Geoffrey Willig Meeting Pending Completed 11/16/2022 8:49 AM Completed 11/16/2022 10:00 AM Completed 11/16/2022 10:24 AM Completed 11/18/2022 1:57 PM Completed 11/18/2022 3:03 PM Completed 11/18/2022 3:14 PM Completed 11/18/2022 3:16 PM Completed 11/18/2022 3:35 PM Completed 11/22/2022 8:15 AM Completed 12/05/2022 9:09 AM 12/13/2022 9:00 AM Packet Pg. 1961 16.E.3.a REQUEST FOR PROPOSAL (RFP) # 22-7977 1 �_ "GROUP HEALTH & DENTAL PLAN ADNIINISTRATION SERVICES" BETWEEN COLLIER COUNTY AND ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. EFFECTIVE DATE: JANUARY 1 2023 ATTACHED: ADMINISTRATIVE SERVICES AGREEMENT (42-pages) BUSINESS ASSOCIATE AGREEMENT (8-pages) Division Name: Risk Management Division 3311 Tamiami Trail East, Naples, FL 34112 Contract Administrator: Sonia Sweet, Manager- Group Insurance P: (239) 252-8966 E.()ilci�c c €Cif} r1_ic t_c c�zr�iy f ,3;E}v Packet Pg. 1962 16.E.3.a Request for Proposal (RFP) #22-7977 "Group Health & Dental Plan Administration Services" ADMINISTRATIVE SERVICES AGREEMENT THIS Administrative Services Agreement (hereinafter "Agreement"), effective for the sixty (60) month period beginning January 1, 2023, and ending December 31, 2027, and may be renewed for two (2) additional one (1) year periods as mutually agreed by the parties in writing, is entered into by COLLIER COUNTY GOVERNMENT, a political subdivision of the State of Florida, (hereinafter referred to as the "Plan Sponsor"), and ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC., a corporation duty organized and existing under the laws of the State of Montana (hereinafter referred to as the "TPA") (collectively known as the "Parties"). WHEREAS, the Plan Sponsor sponsors self -funded employee welfare benefit plans (the "Plan"); WHEREAS, the Plan Sponsor desires to make available a program of health care benefits under the Plan; WHEREAS, the Plan Sponsor wishes to contract with an independent third party administrator to perform certain administrative services with respect to the Plan as described herein; WHEREAS, the TPA desires to contract with the Plan Sponsor to perform certain administrative services with respect to the Plan as described herein; and THEREFORE, in consideration of the promises and mutual covenants contained herein, the Plan Sponsor and the TPA enter into this Agreement for administrative services for the Plan. ARTICLE 1. DEFINITIONS For the purposes of this Agreement, the following words and phrases have the meanings set forth below, unless the context clearly indicates otherwise and, wherever appropriate, the singular shall include the plural and the plural shall include the singular. 1.1 "Claim" means each bill, invoice, claim form or other document representing a request for payment for medical, dental or vision services, which is received by the TPA. Each such document will be considered to be one "claim", regardless of the number of itemized lines on the document and regardless of whether the document is a duplicate of previous documents or whether the services indicated on the document are eligible for coverage under the applicable Plan. 1.2 "Claimant' means a Covered Person or entity on behalf of a Covered Person, submitting expenses for payment or reimbursement from the Plan. 1.3 "Claims Payment Account" means an account utilized by the Plan Sponsor for payment or reimbursement for Covered Services, which account balances shall constitute assets of the Plan Sponsor and not the Plan. 1.4 "COBRA" means the Consolidated Omnibus Budget Reconciliation Act of 1985 or the Public Health Service Act, as amended, together with all regulations applicable thereto. 1.5 "COBRA Participant' means any person who is properly enrolled for and entitled to benefits from the Plan policy, pursuant to COBRA continuation coverage. 1.6 "Complete Claim" means a claim for benefits for a Covered Person that has been submitted by a licensed Health Care Provider or the Covered Person, void of any omissions of pertinent information, coordination of benefits or liability issues, in a form satisfactory to TPA and with sufficient documentation to substantiate the claim for benefits under the Plan that is necessary or required according to industry standards or requirements in order for the TPA to make a determination of benefits under the Plan. 1.7 "Covered Person" is a person who is properly enrolled and entitled to benefits from the Plan. 18 "Covered Services" means the care, treatments, services or supplies described in the Plan Document as eligible for payment or reimbursement from the Plan. 1.9 "Creditable Coverage" means health or medical coverage under which a Covered Person was covered prior to enrollment under this Plan which prior coverage was under any of the following: (a) A group health plan; (b) Health Insurance coverage; (c) Part A, Part B or Part C of Title XVIII of the Social Security Act (Medicare); (d) Title XIX of the Social Security Act, other than coverage consisting solely of benefits under §1928 (Medicaid); (e) Chapter 55 of Title 10, United States Code (active military and CHAMPUS); (f) A medical care program of the Indian Health Service or a tribal organization; (g) A state health benefits risk pool; MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 1 of 42 REV. 10-2022 Packet Pg. 1963 16.E.3.a (h) A health plan offered under Chapter 89 of 1.20 "Plan Document" means the instrument or instruments Title 5, United States Code (Federal that set forth and govern the duties of the Plan Sponsor Employee Health Benefits); and eligibility and benefit provisions of the Plan, which 0) A public health plan; or provide for the payment or reimbursement of Covered Q) A health benefit plan under §5(e) of the Peace Services. Corps Act. (k) A state Children's Health Insurance Program 1.21 "Plan Participant" is any employee, retiree or COBRA (CHIP). beneficiary who is properly enrolled and eligible for benefits under the Plan. 1.10 "Employer' means the Plan Sponsor and any successor organization or affiliate of such Employer 1.22 "Plan Year" means the twelve-month period of time which assumes the obligations of the Plan and this beginning with the effective date of the Plan as Agreement. specified in the Plan Document. 1.11 "ERISA" means the Employee Retirement Income 1.23 "Qualified Beneficiary' means a Covered Person under Security Act of 1974, as amended, together with all the Plan Sponsor's Plan, who is eligible to continue regulations applicable thereto. coverage under the Plan policy in accordance with the applicable provisions of Title X of COBRA or §609(a) 1.12 "Fee Schedule" means the listing of fees or charges for of ERISA regarding Qualified Medical Child Support services provided under this Agreement. This Fee Orders, or in accordance with any similar applicable Schedule may be modified from time to time in writing stale law. Qualified Beneficiary also means a child by the mutual agreement of the parties. The Fee born to, adopted or placed for adoption with a Schedule is contained in Appendix A and is a part of Participant or former Participant, who is a COBRA this Agreement. participant, at any time during active COBRA continuation coverage of that Participant or former 1,13 "Flexible Benefits Plan" for the Employees of Plan Participant. Sponsor, means the Flexible Benefits Plan which the Plan Sponsor has established pursuant to the Plan 1.24 "Qualifying Event" means: Document. (a) With respect to an eligible Participant: 1.14 "Health Care Providers" means physicians, dentists, hospitals, or other health care practitioners or health 1. The termination (other than by reason of care facilities that are duly licensed and authorized to gross misconduct) of the covered receive payment or reimbursement for Covered Particlpant's employment; or Services in accordance with the terms of the Plan. 2. The reduction in hours of the covered Participant's employment causing the 1.15 "HIPAA" means the Health Insurance Portability and Participant to become ineligible for coverage. Accountability Act of 1996, as amended, together with all applicable regulations thereto. (b) With respect to covered Dependents: 1.16 "Medical Expense Reimbursement Plan" (hereinafter referred to as the health reimbursement arrangement or HRA Plan) means a healthcare expense reimbursement plan within the meaning of Section 105 of the Internal Revenue Code of 1986, as amended, and regulations issued thereunder. 1.17 "Paid Claims" means claims for benefits under the Plan that have been processed for payment by the TPA, have been funded in U,S. Dollars by the Plan or the Plan Sponsor, and for which payment or electronic payment has been issued and transmitted to the Claimant or assignee. 1.18 "Plan" means the self -funded health and welfare benefit plan which is the subject of this Agreement and which the Plan Sponsor has established pursuant to the Plan Document. 1.19 "Plan Administrator" means the person or entity, including an insurance company, designated by the Plan Sponsor to manage the Plan and make all discretionary decisions regarding Plan terms and managing Plan assets. 1. Death of the covered Participant; 2. Termination of the covered Participant's employment; 3. Reduction in hours of the covered Participant's employment causing the Participant to become ineligible for coverage; 4. The divorce or legal separation of the covered Participant from his or her spouse; 5. The covered Participant's entitlement to Medicare; or 6. A covered Dependent child ceases to be a Dependent as defined by the Plan. (c) Qualifying Events for retired Participants, for purposes of this section, are: 1. Bankruptcy, if the covered Participant retired on or before the date of any substantial elimination of group health coverage due to bankruptcy. (d) Qualifying Events for the Dependents of retired covered Participants, for purposes of this section, a re: MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 2 or42 REV. 10-2022 Packet Pg. 1964 16.E.3.a 1. Bankruptcy, if the Dependent was a covered Dependent of a covered retiree on or before the day before the bankruptcy Qualifying Event. it is the plan sponsor, plan administrator and named fiduciary as such terms are defined by ER1SA, or other applicable law. 2.3 Except as specifically set forth herein, this Agreement 1,25 "Stop Loss or Excess Loss Insurance" means an shall inure to the benefit of and be binding upon the insurance policy obtained by the Plan or the Plan parties hereto and their respective legal successors Sponsor to provide coverage for individual claims at a provided, however, that neither party may assign this specified stop loss limit and/or group claims at an Agreement without the prior written consent of the aggregate stop loss limit that are incurred and paid other, which consent shall not be unreasonably during a defined period of time by the insurance policy. withheld. 1.26 "Summary Plan Description" means the document that describes the terms and conditions under which the Plan operates. 1.27 "Utilization Management" means the evaluation of medical necessity and appropriateness of the use of health care services, procedures, and facilities utilized by a Covered Person under the terms of the Plan, 1,28 "Working Days" shall mean a regular business day, which is not a recognized federal or banking holiday, and specifically excluding any Saturday or Sunday. ARTICLE 11. RELATIONSHIP OF THE PARTIES 2.1 The Plan Sponsor acknowledges that the TPA is an independent contractor for purposes of this Agreement, As such, the TPA is not an agent or employee of the Plan Sponsor and does not assume any liability or responsibility for any breach of duty or act of omission by the Plan Sponsor. The Plan Sponsor delegates to the TPA only non -discretionary authority with respect to assisting Plan Sponsor in the development, maintenance and administration of the Plan as specifically described in this Agreement. Any function not specifically delegated by Plan Sponsor to, and agreed to be assumed by the TPA in writing pursuant to this Agreement shall remain the sole responsibility of the Plan Sponsor. The Plan Sponsor shall retain all discretionary authority, control and responsibility for the operation and administration of the Plan. 2,2 The parties acknowledge that: (a) This is a contract for administrative services only as specifically set forth herein; (b) The TPA shall not be obligated to disburse more in payment for Claims or other obligations arising under the flan than the Plan Sponsor shall have made available in the Claims Payment Account; (c) This Agreement shall not be deemed a contract of insurance under any laws or regulations. The TPA does not insure, guarantee or underwrite the liability of the Plan Sponsor under the Plan. The TPA has no responsibility and the Plan Sponsor has total responsibility for payment of Claims under the Plan and all expenses incidental to the Plan; and (d) The TPA is not the plan administrator, plan sponsor or plan fiduciary and the Plan Sponsor will not identify the TPA or any of its affiliates as such, The Plan Sponsor acknowledges and agrees that 2.4 Dispute Resolution. Prior to the initiation of any action or proceeding permitted by this Agreement to resolve disputes between the parties, the parties shall make a good faith effort to resolve any such disputes by negotiation. The negotiation shall be attended by representatives of both parties with full decision - making authority and by Plan Sponsors staff person who would make the presentation of any settlement reached during negotiations to Plan Sponsor for approval. Failing resolution, and prior to the commencement of depositions in any litigation between the parties arising out of this Agreement, the parties shall attempt to resolve the dispute through Mediation before an agreed -upon Circuit Court Mediator certified by the State of Florida. The mediation shall be attended by representatives of TPA with full decision -making authority and by Plan Sponsor's staff person who would make the presentation of any settlement reached at mediation to Plan Sponsor's board for approval. Should either party fail to submit to mediation as required hereunder, the other party may obtain a court order requiring mediation under Section 44,102, Fla. Statutes. Any suit or action brought by either party to this Agreement against the other party relating to or arising out of this Agreement must be brought in the appropriate federal or state courts in Collier County, Florida, which courts have sole and exclusive jurisdiction on all such matters. 2.5 It is agreed by the parties to this Agreement that any cause of action brought by either party to this contract must be made within five (5) years of the date of occurrence of any alleged breach, infraction or dispute, or within five (5) years of the termination date of this Agreement, whichever occurs first, in compliance with Section 95.11, Florida Statutes. 2.6 The Plan Sponsor acknowledges and agrees that the TPA will not be deemed to be a legal or tax advisor for the Plan or the Plan Sponsor as a result of the performance of its duties under this Agreement. The TPA makes no representation to the Plan Sponsor concerning federal, state, or local laws, rules or regulations applicable to the Plan. The Plan Sponsor must seek its own counsel for legal advice and guidance. In no event shall the TPA be liable for ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 3 of 42 U ZiNUL tMN REV, 1D-2022 Packet Pg. 1965 1 16.E.3.a special or consequential damages, even if the TPA Current, valid insurance policies meeting the was advised of the possibility of such damages. requirement herein identified shall be maintained by the TPA during the duration of this Agreement. 2.7 The TPA may secure the services of actuaries, Renewal certificates shall be sent to the Plan Sponsor computer software companies, computer service firms, thirty (30) days prior to any expiration date. There shall insurance consultants and producers, legal counsel, be a thirty (30) day notification to the Plan Sponsor in accountants, utilization management consultants, the event of cancellation or modification to any pharmacy benefit management companies, preferred stipulated coverage. provider organizations, claims negotiation companies, subrogation firms, and any other entities that it deems TPA shall insure that all of TPA's sub Consultants necessary in the performance of its obligations under comply with the same insurance requirements that it is this Agreement. At the discretion of the TPA, such required to meet. The same TPA shall provide Plan services may be performed directly by the TPA, wholly Sponsor with certificates of insurance meeting the or in part, through a subsidiary or affiliate of TPA or required insurance provisions, under an agreement with an organization, agent, advisor or other person of its choosing. Any such 2.11 The TPA shall be entitled to rely upon, without services resulting in a fee not agreed to in the Fee investigation or inquiry, any written or oral information Schedule, Appendix A, must first be authorized in or communication of the Plan Sponsor or agents, writing by the Plan Sponsor. including but not limited to consultants, actuaries, attorneys, accountants, auditors, managed care 2,8 The TPA agrees to be duly licensed as a Third Party organizations, preferred provider organizations, Administrator to the extent required under applicable pharmacy benefit management companies, mental law and agrees to maintain such licensure throughout health care management companies or brokers the term of this Agreement, retained by the Plan Sponsor. 2.9 The TPA will possess through the term of this 112 The TPA will indemnify, defend, save and hold the Plan Agreement an in -force fidelity bond or other insurance Sponsor harmless from and against any and all claims, as may be required by state and federal laws for the suits, liabilities, losses, penalties or damages including protection of its clients. Additionally, the TPA agrees court costs and attorneys' fees with respect to the Plan to comply with any state or federal statutes or which directly result from or arise out of the dishonest, regulations regarding its operations. fraudulent, grossly negligent or criminal acts of the TPA or its employees, except for any acts taken at the 2.10 The TPA shall provide to Plan Sponsor: specific direction of the Plan Sponsor. A. Commercial General Liability, Coverage shall 2.13 The Plan Sponsor will indemnify, defend, save and have minimum limits of $1.000,000 Per hold the TPA harmless from and against any and all Occurrence, Combined Single Limit for Bodily claims, suits, actions, liabilities, losses, penalties or Injury Liability and Property Damage Liability. This damages, including court costs and attorneys' fees to shall include Premises and Operations; the extent that such claims, losses, liabilities, damages Independent 'Consultants; Products and and expenses arise out of or are based upon the gross Completed Operations and Contractual Liability. negligence, fraudulent, criminal or dishonest acts of the Plan Sponsor, its agents or employees, in the B. Business Auto Liability: Coverage shall have performance of their duties, a release of Claims data minimum limits of $1,000,000 Per Occurrence, by the TPA to the Plan Sponsor, or an interpretation of Combined Single Limit for Bodily Injury Liability the Plan by the Plan Sponsor on which the TPA acts. and Property Damage Liability. This shall include: To the extent authorized by law and applicable to Owned Vehicles, Hired and Non -Owned Vehicles contract and indemnity claims, the foregoing and Employee Non -Ownership. indemnification shall not constitute a waiver of sovereign immunity beyond the limit set forth in Section C. Workers' Compensation: Insurance covering all 768,28, Florida Statutes. employees meeting Statutory Limits in compliance with the applicable state and federal laws. ARTICLE Ill. THE TPA'S RESPONSIBILITIES D. Professional Liability Insurance; The TPA shall The TPA will provide the following Plan Administrative services maintain Insurance to insure its legal liability for for the Plan Sponsor: claims arising out of the performance of professional services under this Agreement. 3.1 Maintain Plan records based on eligibility information Coverage shall have minimum limits of $1,000,000 submitted by the Plan Sponsor as to the dates on which Per Occurrence, a Covered Person's coverage commences and terminates, Special Requirements: The Plan Sponsor shall be listed as the Certificate Holder and included as an Maintain Plan records of Plan coverage applicable to Additional Insured on the Comprehensive General each Covered Person based on information submitted Liability Policy, by the Plan Sponsor. MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 4 of 42 REV. 10-2022 Packet Pg. 1966 16.E.3.a Maintain Plan records regarding payment of Claims, denial of Claims, and Claims pending. 3.2 Administer enrollment of Covered Persons, create and distribute enrollment forms and answer inquiries, create and maintain enrollment records for Covered Persons, provide on-line electronic enrollment services for all benefits, and distribute identification cards to the Plan Sponsor in accordance with Appendix A, the Fee Schedule. Provide "Welcome Packets" in TPA's format for all Participants and for Community Health Partners and Lee County PHO providers. 3.3 Process Complete Claims submitted by Covered Persons or Health Care Providers according to the terms of the Plan Document as construed by the Plan Sponsor. These Claims will be processed in accordance with prevailing industry practices and the TPA will use an industry -recognized method of determining usual, customary, and reasonable charges or the prevailing fee allowance as determined by the Plan Sponsor in the Plan. The TPA will not be required by the Plan Sponsor to alter its standard claims processes, procedures or regular mail dates to manipulate the Paid Claims date for any purpose. The TPA will process claims received on a basis consistent with prevailing industry practice for timeliness and accuracy, in accordance with the terms of the Plan Document as construed by the Plan Sponsor, and consistent medical information forms, pre-existing conditions requirements, disability determinations and coordination of benefits situations. Unless specifically agreed by the parties in writing, the TPA's duties with respect to subrogation situations shall be limited to informing the Plan Sponsor that subrogation rights may exist. The terms, conditions and fees for any additional agreement regarding subrogation are as stated in the attached Subrogation Services Appendix B, if applicable. The TPA will process Claims or request additional information in order to be able to process a Complete Claim within an average of fourteen (14) Working Days from the date the Complete Claim is received by the TPA. If additional information is needed for a Complete Claim, the TPA will send through the U.S. Mail to the appropriate persons (with a copy to the Plan Participant) a follow-up request for the required information for a Complete Claim requesting a response to the request for additional information for a Complete Claim within a maximum of forty-five (45) days. The follow-up request will indicate that no additional requests for information will be sent and the file will be closed, and the initial incomplete claim will be denied, if the requested information is not provided within the specified time. When all necessary documents and Claim information have been received to constitute a Complete Claim and the Complete Claim has been approved, a Claim check or draft will be remitted on the next Paid Claims batch disbursal date provided that the Plan Sponsor has provided funds for such Complete Claims or advance funding has been provided by the Stop Loss or Excess Loss insurance company. All Complete Claims will remain in a processed but pended status until funded by the Plan Sponsor or its Stop Loss or Excess Loss insurance company. The Plan Sponsor must provide funding of all Complete Claims within five (5) Working Days of receipt of request for funding from the TPA. Customer Service Representatives of the TPA will inform any Plan Participant or Health Care Provider who inquires about any Claim which is pended for lack of funds that such Claim has been received and processed and is pending receipt of funds. No further explanation will be required of the TPA by the Plan Sponsor under such circumstances. Unless otherwise advised by the Plan Sponsor, the Plan Sponsor agrees that the order of claims payment by TPA of new claims submitted under the Plan shall be based on processing first the oldest claims with complete medical, repricing/discount, and other necessary information with permitted exceptions for those claims identified with excess loss Insurance reimbursement potential or which face loss of any available discounts for the medical services so rendered. Any payment by TPA is contingent upon the availability of adequate funding by the Plan Sponsor. If the funds provided by the Plan Sponsor are Insufficient to pay all adjudicated claims, then, at the specific direction of Plan Sponsor, the funds will be applied to pay claims as noted above to the extent funds are available except that large claims that cannot be funded by the then available funding will be skipped in favor of more recent claims that can be covered with then available funding. Further, all claims for a participant and his or her covered dependents subsequent to the first claim that cannot be funded due to insufficient funding from the Plan Sponsor shall be skipped in favor of more recent claims from other participants and/or their dependents if the Plan Sponsor funding is not sufficient to cover all adjudicated claims for the participant and/or his or her dependent. 3.4 After a preliminary review to determine that the Claim was correctly processed, the TPA will refer any doubtful, disputed or appealed Claims to the Plan Sponsor for a final decision. The TPA will provide initial claims adjudication and assist the Plan Administrator with appeals. The Plan will pay the actual cost of any expert medical consultation required to determine claims eligibility under the Plan as a claims cost. 3.5 Process, issue and distribute Claims checks, Explanations of Benefits, drafts or electronic funds transfer, as instructed by the Plan Sponsor to Plan Participants, Health Care Providers, or others as may be applicable. Every week the TPA will notify the Plan Sponsor of the Claims batch amount required to be prospectively MEDICAL ASA ME STD SNGL EMI' ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 5 of 42 REV. 1D-2022 Packet Pg. 1967 16.E.3.a deposited to the Claims Payment Account to pay the Claims liability after these Claims are processed for payment. The TPA shall establish and maintain customary investigative benefit and Claims review procedures within the prevailing standard of care in the TPA industry. The TPA shall take reasonable measures and precautions to prevent the allowance and payment of improper benefits and Claims. The TPA shall not be liable for fraud by any Health Care Provider or Covered Person or for errors in Claim payment made to Covered Persons or designated assignees in good faith. The TPA shall not be liable for any loss of discount or increase in charges arising from a Claim due to a delay in the payment of a Claim. If a Claim payment error is discovered, the Health Care Provider or Covered Person will be notified and requested to refund payment. In the event that the Covered Person or his/her assignee does not respond to the refund request or refuses payment, the Plan Sponsor will be notified. The Plan Sponsor shall have the right to bring action against any employee or provider of service who does not voluntarily agree to repay the Plan for payments made in error. The TPA shall not be liable for misrepresentations, inflated charges, omissions, errors or fraud by any Health Care Provider or Covered Person which may result in any ineligible or excessive Claim payments. 3.6 Notify Covered Persons in writing through the U.S. Mail of ineligible Claims received. The computerized Explanation of Benefits form (EOB) shall indicate the general reason why such Claim is ineligible for payment. The EOB shall also contain notice of the written Claims review and appeal procedure in the Plan. This notification will be made within an average of fourteen (14) Working Days of the date the TPA receives the Complete Claim documentation and any Plan interpretations by the Plan Sponsor. 3.7 Respond to Claims inquiries by a Covered Person, the estate of a Covered Person, an authorized member of a Covered Person's family unit, the Covered Person's authorized legal representative or an authorized Health Care Provider. 3.8 Maintain local telephone service and toll -free telephone lines during regular business hours for inquiries made by Covered Persons regarding the status of their Claims. Such telephone conversations may be recorded by the TPA. Provide secure on-line internet web -based information for Participants and Dependents for claims information, PPO look -up, SPDs, and for on-line communication with TPA. 3.8 Maintain an Internet Inquiry site for Paid Claims, processed claims and related information. Maintain an interactive voice response system and fax back service for the convenience of Covered Persons and Health Care Providers for Claim or coverage inquiries. 3.10 Provide on -site claims and customer service personnel in a location provided by Plan Sponsor. 3.11 Maintain information that identifies a Covered Person in a confidential manner. The TPA agrees to take all reasonable precautions to prevent disclosure or use of Claims information for a purpose unrelated to the administration of the Plan. TPA shall not be liable for fraud, deceit, misrepresentation or any other false, misleading or erroneous representations made by the Plan Sponsor, any Covered Person, any Health Care Provider or any other person pertaining to any confidential, personal or protected health information or claim request. The TPA will only release non - protected health or Claims information for certificate of need reviews; for medical necessity determinations; to set uniform data standards; to update relative values scales; to use in claims analysis; to further cost containment programs; to verify eligibility; to comply with federal, state or local laws; for coordination of benefits; for subrogation; in response to a civil or criminal action upon issuance of a subpoena, or with the written consent of the Covered Person or his or her legal representative. 3.12 Provide and maintain a specimen Plan Document and Summary Plan Description in a format acceptable to the TPA for review and final approval by the Plan Sponsor and the Plan Sponsor's legal counsel. Upon approval of the Plan Document from the Plan Sponsor, the TPA will forward copies of plan document and amendments, if any, to the Stop Loss or Excess Loss insurance company. The TPA will furnish a master Summary Plan Description to the Plan Sponsor, either electronically (PDF format), or in printed form, and Summary Plan Description booklets in TPA's format for the fees stated in Appendix A. The TPA will maintain an electronic Claims file on every Claim reported to it by the Covered Persons. The TPA shall retain such files and all Plan -related information for a period of seven (7) years. Copies of such records shall be made available to the Plan Sponsor for inspection during a regularly scheduled Working Day at the office of the TPA for consultation, review and audit upon advance notice of a minimum of fourteen (14) Working Days. The Plan Sponsor shall pay for any audit made at its request. In the event this Agreement is terminated, the Plan Sponsor shall have a continuing obligation and liability to pay the TPA for all costs and professional, executive, managerial and clerical time expended by the TPA and its employees for any audit conducted by the Plan Sponsor or its Stop Loss or Excess Loss insurance company, and this obligation and liability shall survive and continue beyond the termination of this Agreement. The Plan Sponsor shall pay the TPA for the TPA's expenses to provide information and documentation to any such auditor. MEDICAL ASA MED STD SNGL E M P ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 6 of 42 REV. 10-2022 Packet Pg. 1968 16.E.3.a Any audit shall be conducted by an auditor mutually acceptable to the Plan Sponsor and the TPA and the audit shall Include, but not necessarily be limited to, producing photocopies of Claims and funding information in the TPA's existing format(s), a review of procedural controls, a review of system controls, a review of Plan provisions, a review of sampled Claims, and comparison of results to TPA industry performance standards or any statistical models previously agreed to by the Plan Sponsor and the TPA in writing. Nothing in this Agreement, expressed or implied, shall require the TPA disclose any proprietary information, including, but not limited, file layout or record formats of its Claims processing system or procedures, provide records or information in a format not in use by the TPA, or to create unique Information formats solely for the use of the auditor(s), consultant(s), agent(s) or broker(s) for the Plan Sponsor. 3.13 Upon request of the Plan Sponsor, provide COBRA continuation coverage services through a related corporation, Allegiance COBRA Services, Inc, (ACSI). A separate fee will be charged for COBRA continuation services, which fee is set out in a COBRA Services Agreement, Appendix C, attached hereto and incorporated by reference. If the Plan Sponsor does not request COBRA continuation services from ACSI, all responsibility and liability for administration of COBRA continuation shall remaln with the Plan Sponsor, and neither the TPA nor ACSI will have any obligation or responsibility for providing such services or consultation regarding such services. 3.14 Provide the following reports: (a) monthly summary of benefits paid analysis by type of Claim and total dollar amounts; (b) weekly check register; (c) monthly cumulative aggregate deductible to paid Claims report; (d) annual summary management report within sixty (60) days after the close of the Plan Year; (e) annual loss analysis report; (f) special ad hoc reports requested by the Plan Sponsor which the TPA agrees to produce; (g) Reports from TPA's IBIZ platform. 3.15 Procure, through Intermountain Underwriters, Inc., an affiliated company of TPA, Stop Loss or Excess Loss (specific and aggregate) insurance proposals and policies for the Plan Sponsor's consideration and selection, which Excess Loss or Stop Loss insurance will be an asset of the Plan Sponsor and not of the Plan. intermountain Underwriters, Inc. may act as agent of record for the Plan Sponsor in placing Stop Loss or Excess Loss for the Plan Sponsor. 3.16 If applicable; (a) Notify the Stop Loss or Excess Loss insurance company of any potential large Claims, which may become a Claim under the Stop Loss or Excess Loss coverage. (b) On behalf of the Plan Sponsor, the TPA will file with the insurance company or its designee any Complete Claims for consideration for reimbursement under the Stop Loss or Excess Loss policies. (c) Promptly forward to the Plan Sponsor any premium, claim reimbursement, Stop Loss or Excess Loss or other notices received from the Stop Loss or Excess Loss insurance carrier concerning the policy. 3.17 If applicable, conduct utilization review for the Plan, including pre -certification of hospital stays, concurrent review of hospital stays, discharge planning, preliminary review for potential hospital bill audits, large case management or any other managed care programs as agreed to between the Plan Sponsor and the TPA. A separate fee will be charged for these services as stated in Appendix A. Provide data extracts to Plan Sponsor's predictive modeling vendor. 3,18 Maintain working relationships with networks of Health Care Providers through Preferred Provider Organizations (PPO) contracted by the Plan Sponsor or arranged by the TPA. The TPA shall be entitled to rely upon any and all representations made by Health Care Providers/PPO regarding their qualifications as Health Care Providers, and shall have no obligation or liability to obtain, verify or monitor such qualifications or credentials. Reprice PPO or other similar provider discounted claims. If applicable, a separate fee will be charged for PPO network services, TPA coordination and system maintenance for PPO networks, as stated in Fee Schedule, Appendix A. The TPA will not be responsible for any services provided (or any failure to provide services) by a participating PPO or Health Care Providers and specifically makes no representation, warranty or guarantee whatsoever regarding any such PPO, Health Care Providers, or their representations, qualifications or Credentials. 3.19 If checked as an included service in Appendix A, the TPA will provide coordination of services for wellness and health assessment through a third party vendor, Behavioral Health Care Options, Inc, 3.20 Provide, within thirty (30) days after termination of this Agreement, a summary paid Claim report of all Claims paid twenty-four (24) months prior to the date of termination, copies of any governmental reports, and other plan documentation to the Plan Sponsor. Until that time, these records will be maintained at the TPA's principal administrative office. Claim fifes will be kept in secure storage facilities or electronic media for at least seven (7) years following the termination of the Plan Year. Copies of any materials in storage will be available to the Plan Sponsor for a copy fee of fifteen MECICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 7 of 42 REV. 90.2022 Packet Pg. 1969 16.E.3.a ($.15) cents per page copied plus a retrieval fee of Ten Dollars ($10,00) per box or electronic media access. At the end of the seven (7) year period or termination of this Agreement, if earlier, the TPA shall notify the Plan Sponsor that these records will be destroyed. TPA will not charge Plan Sponsor to retrieve data that is less than two (2) years old. 3.21 If applicable, provide Certificates of Creditable Coverage and other Creditable Coverage services as required by HIPAA for employees of the Plan Sponsor and their eligible dependents, 3.22 Provide Medicare, MSP, and §111 reporting services. 3.23 Provide non-proprietary information and documents as requested by the Plan Sponsor to brokers and agents designated by the Plan Sponsor. However, if the Plan Sponsor has entered into an agent of record agreement with any new agent or broker, and the TPA has notice of the same, the TPA shall not be required to provide any information or documentation to other agents or brokers unless or until the Plan Sponsor has terminated the original agent of record agreement and notified the original agent of record of the termination. The TPA shall have the express right to contact any agent of record to verify the agent of record agreement has been terminated. A separate fee will be charged for this service as stated in Appendix A. 3.24 For Plan Sponsors which have designated subsidiaries, divisions, or which are a Multiple Employer Welfare Arrangement (MEWA): when any designated subsidiary, division or member employer of a MEWA terminates coverage under the plan that is the subject of this Agreement, the TPA will automatically perform run -out services for a period of three (3) months after the date of such termination for such designated subsidiary, division or member employer, unless directed not to do so by the Plan Sponsor in writing. The fee for each month of run -out services will be equal to the claims processing fee(s) stated in Appendix A, based upon the designated subsidiary's, division's or MEWA member employer's number of enrolled Plan Participants for the month immediately prior to the date of termination of coverage. Plan Sponsor will also pay the TPA run -out services fees for any enrolled Plan Participants who were laid -off or otherwise terminated from the rolls of the Plan during the term of this Agreement if the total number of such laid -off or terminated Plan Participants exceeds five (5%) percent of the total number of enrolled Plan Participants during the first month of this Agreement. Final reconciliation of run -out services fees will be made within ninety (90) days of the end of this Agreement. 3.25 Fees for the services described in Article lit are set out in Appendix A attached hereto. Such fees are fixed for the initial term of this Agreement except that the fees are subject to change under the following conditions, with sixty (60) days' written notice to Plan Sponsor: (a) if the Plan Sponsor's census of enrolled employees increases or decreases by more than ten (10%) percent from the number of employees that were enrolled on the commencement of this Agreement; (b) if the Plan Sponsor significantly alters the design or complexity of its health benefit plan; or (c) regularly requesting and obtaining extra - contractual services from the TPA. 3.26 The TPA will comply with the applicable laws and rules for the storage, transmission and release of any "protected health information" (used herein as such is defined in HIPAA), Notwithstanding any other provision of this Agreement, the TPA shall not be required to do any act which in its judgment violates H I PAA. 3.27 The TPA will provide consolidated billing services if checked as an included service in Appendix A, Specifically, the TPA will bill fees and premiums for other employee benefits including, but not limited to, group life, group AD&D and/or group short term and long term disability to the Plan Sponsor, and will remit the premium collected to the applicable carrier. 3.28 The TPA will perform such supervisory services with respect to the medical expense reimbursement plan (hereinafter referred to as the health reimbursement arrangement or HRA Plan) in accordance with Appendix D, attached hereto and incorporated by reference. 3.29 TPA will provide access to a partner telemedicine service vendor. 3,30 TPA will, if requested by Plan Sponsor, participate in quarterly meetings with the Collier County Health Care Consortium (CCHCC). ARTICLE IV: THE PLAN SPONSOR'S RESPONSIBILITIES The Plan Sponsor or Employer will: 4.1 Establish the Plan together with a framework of policies, interpretations and rules, which shall be the basis for the TPA`s performance of its duties under this Agreement. Maintain current and accurate Plan eligibility and coverage records, verify Covered Person eligibility and submit eligibility and coverage information monthly, or more often if requested by the TPA, to the TPA at its designated electronic or postal address. This information shall be provided in a format acceptable to the TPA and shall include the following for each Covered Person: name and address, Social Security number, date of birth, type of coverage, sex, relationship to employee, changes in coverage, date coverage begins or ends, and any other information as necessary to determine eligibility and coverage under the Plan. The Plan Sponsor assumes the responsibility for and will hold the TPA harmless from the erroneous MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Rage 8 of 42 REV. 10.2022 Packet Pg. 1970 16.E.3.a disbursement of benefits by the TPA in the event of error or neglect by the Plan Sponsor or Employer in providing eligibility and coverage information to the TPA, including, but not limited to, failure to give timely 4.6 notification if ineligibility or termination of a former Covered Person, or fraudulent enrollment and/or continuation of coverage, 4.2 The TPA shall make recommendations regarding Claims determinations. The Plan Sponsor shall have 4.7 the sole authority to resolve all Plan ambiguities and interpretations, questions and disputes relating to the Plan eligibility of a Covered Person, Plan coverage and denied Claims. The Plan Sponsor shall have the sole authority to make determinations regarding appeal of denied Claims. The Plan Sponsor will respond to any written request for information made by the TPA within ten (10) Working Days of receipt of the request. The Plan Sponsor shall resolve all Plan ambiguities, questions and disputes relating to the Plan eligibility of a Covered Person, Plan coverage, denial of Claims or decisions regarding appeal or denial of Claims, or any other Plan interpretation questions. The Plan Sponsor will respond to any written request made by the TPA within ten (10) Working Days of receipt of the request. The TPA will administer and process Claims in accordance with Article III if the Plan Document and Summary Plan description are clear and unambiguous as to the validity of the Claims and the Covered Person's eligibility for coverage under the Plan. The TPA will have no discretionary authority to interpret the Plan or adjudicate Claims. If processing a benefit Claim requires interpretation of ambiguous Plan language, and the Plan Sponsor has not previously indicated to the TPA the proper interpretation of the language, then the Plan Sponsor will be responsible for resolving the ambiguity or any other dispute, In any event, the TPA shall rely upon the Plan Sponsor's decision as to any Claim (whether or not it involves a Plan ambiguity or other dispute) and such decision by the Plan Sponsor shall be final and binding unless modified or reversed by a court or regulatory agency having jurisdiction over such Claim matter. 4.3 Fully fund the Claims Payment Account every week based upon the Claims batch report provided by the TPA. 4.4 Set funding levels for the Plan at a minimum level necessary to cover the expected Claims costs, administrative expenses and incurred but not reported Claims liability and fund the Plan at such level. 4.5 Not request or require the TPA, under any circumstances, to issue Claims drafts for Claims, stop loss or excess loss insurance premiums, or any other costs arising out of the subject matter of this Agreement, unless the Plan Sponsor has so authorized and has previously deposited sufficient funds to cover such Complete Claims or other Plan expense obligations and payment(s). Provide the TPA with copies of any and all revisions or changes to the Plan at least five (a) Working Days prior to the effective date of the changes. Failure to provide timely notice may result in additional claims processing fees as set forth in Appendix A. Provide, and timely distribute, all notices and information required to be given to Covered Persons, including Summary Annual Reports. Maintain and operate the Plan in accordance with applicable law. Maintain all recordkeeping and file all forms relative thereto pursuant to any federal, state or local law, unless this Agreement specifically assigns such duties to the TPA. 4.8 Acknowledge that it is the Plan Sponsor, Plan Administrator, and Named Fiduciary. As such, the Plan Sponsor retains full discretionary control and authority and discretionary responsibility in the operation and administration of the Plan. 4.9 Pay or reimburse TPA for any taxes, assessments for fees arising solely out of the operations of the Plan or the services provided under this Agreement that are levied against the Plan or against the TPA by any governmental entity whether federal, state or local, or any political subdivisions or instrumentality thereof. Taxes based on TPA's net income or licenses TPA is required to maintain to provide the services under this Agreement shall be the sole responsibility of TPA. 4.10 Hold confidential information that is proprietary to the TPA or information or material not generally known by personnel other than management employees of the TPA, The Plan Sponsor agrees not to use or disclose proprietary information of the TPA. Such proprietary information includes, but is not limited to, information designated as "trade secrets" under the Montana Uniform Trade Secrets Act, Title 30, Chapter 14, Part 4 of the Montana Code Annotated and any other constitutional protections. Except as prohibited by the Consolidated Appropriations Act of 2021, the Plan Sponsor acknowledges that such proprietary information shall include financial information, reasonable and customary Claims levels, and Claims administration guidelines or procedures of the TPA or its affiliates or subcontractors. Confidentiality is subject to Chapter 119, Florida Statutes, also known as the Public Records Law. 4.11 Pay, in accordance with the Fee Schedule, Appendix A, the TPA's fees for services rendered under this Agreement. The TPA is expressly directed by the Plan Sponsor to pay any excess loss insurance premiums (where applicable), fee, cost or charge then due to the TPA prior to application of funds to payment of Claims or any other costs arising out of the Plan or subject matter of this Agreement. The Plan Sponsor specifically directs that all funds provided to TPA under this Agreement will be disbursed in the following order: First to pay excess loss insurance premiums where applicable, claims administration fees, costs and MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 9 or 42 REV. 10-2022 Packet Pg. 1971 16.E.3.a related expenses incurred by TPA and second, to pay benefit claims arising under the Plan. 4.12 Maintain any fidelity bond or other insurance as may be requested by state or federal law for the protection of the Plan and Covered Persons, 4.13 Maintain Stop Loss or Excess Loss insurance with an admitted insurance company in the minimum amount set forth in the Fee Schedule, Appendix A. 4.14 Promptly notify the TPA of any termination notice, expiration lapse, or modification of Stop Loss or Excess Loss insurance, life insurance, disability insurance, conversion insurance or any other insurance purchased in conjunction with the Plan. 4.15 Ensure that there is adequate release and authorization from each participant and/or beneficiary under the Plan permitting Health Care Providers to share with TPA and TPA to share with Health Care Providers and other service providers to the Plan any and all information, whether protected or individually identifiable, which may be necessary to perform the services anticipated by this Agreement and any Appendices hereto, TPA may in its sole discretion, require participants and/or beneficiaries of the Plan to execute additional releases and authorizations for the use and disclosure of such information, TPA may refuse to release protected or other individually identifiable health care information to Plan Sponsor, its agents and designees if such authorizations and/or releases are not provided. 4.16 Have the sole responsibility for reporting and disclosure, including but not limited to plan documents, summary plan descriptions, summaries of material modifications, participant communications, pre - retirement counseling to participants, bonding filings or other compliance required of, by or for the Plan, their participants and beneficiaries, or the Plan Sponsor by ERISA, the Internal Revenue Code, or any other related and/or applicable federal, state or local laws, rules or regulations. Plan Sponsor shall indemnify and hold harmless TPA from any claim or expense incurred as a result of the Plan Sponsor's failure to comply with the requirements or provisions of applicable, federal, state, and local laws, rules and regulations. To the extent authorized by law, and applicable to contract and indemnity claims the foregoing indemnification shall not constitute a waiver of sovereign immunity beyond the limits set forth in Section 768.28, Florida Statutes, 4.17 Shall be solely responsible for paying all fees, expenses, or costs attributable to any legal action or proceeding brought to recover a refund of a claim for benefits under the Plan brought or prosecuted by or on behalf of the Plan Sponsor or Plan Administrator. TPA shall, however, make available to the Plan Sponsor and its counsel, such evidence which relates to or is relevant to such action or proceeding as TPA may have as a result of the performance of the services set forth in this Agreement. TPA shall promptly notify the Plan Sponsor in writing of any legal actions of which it becomes aware that involve the Plan or the Plan Sponsor. Any legal fees incurred by TPA in connection with any legal action or proceeding shall be the responsibility of the Plan Sponsor, 4.18 Provide timely, accurate and complete information required by TPA to provide the services that TPA has agreed to perform under this Agreement. TPA shall have the right to rely on such information. Such information shall include but not be limited to all necessary eligibility enrollment and participant data; and copies of all governing documents of the Plan and any amendments thereto, including any written policies, interpretations, rules, practices or procedure concerning same. Such information shall be provided upon execution of this Agreement and immediately following modification or amendment, TPA shall have the right to assume that all such information is accurate and complete and TPA shall be under no duty to question such information. Plan Sponsor shall reimburse TPA at its standard hourly rates for TPA's costs incurred for efforts expended to remedy data or information inaccuracies as were provided by the Plan Sponsor, 4.19 Provide suitable and adequate office space at Plan Sponsor's location for TPA's onsite claims and customer service personnel, at no cost to TPA, provided however, TPA shall bear all costs for its office equipment and telephone and internet services and connectivity, ARTICLE V: DURATION OF AGREEMENT 5.1 This Agreement shall commence and end on the dates first written above, unless terminated earlier in accordance with this Article. This Agreement may renew for two (2) one (1) year periods upon written approval of both Parties, or unless modified or terminated as described below. The fee quote in this subsection must be accepted, in writing, by the Plan Sponsor prior to the renewal date for the period to which the fee quote applies. Non -acceptance of the renewal fee quote shall cause this Agreement to lapse and terminate at 11:59 P.M. on the last Working Day of this Agreement. Notification will be no less than ninety (90) days prior to each renewal period. 5.2 At any time during the term of this Agreement, either the Plan Sponsor or the TPA may amend or change the provisions of this Agreement, These amendments or changes must be agreed upon in advance in writing by both the Plan Sponsor and the TPA. If any such amendment increases the anticipated Claims experience under the Plan or the TPA's cost of administering the Plan, the Plan Sponsor agrees to pay any increase in Claims expenses, as well as increases in administrative fees or other costs which the TPA reasonably expects to incur as a result of such modification. Any amendment which affects only the Fee Schedule, Appendix A, may be made subject to an amendment in writing by the parties and approved by the Collier County Board of County Commissioners. All fee quotes MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 10 of /2 REV. 10-2022 Packet Pg. 1972 16.E.3.a accepted by the Plan Sponsor for renewals of this Trustee fails to reaffirm this Agreement and Agreement will be incorporated into this Agreement as provide adequate assurances pursuant to 11 USC amendments to the Fee Schedule, Appendix A. 365; (d) The TPA loses its licensure or certification 5.3 Either the Plan Sponsor or the TPA may terminate this required by law to continue its business or Agreement at any time, by giving sixty (60) days continue as third party administrator; or advance written notice to the other party unless both (e) The TPA fails to comply with any federal, state or parties agree to waive such advance notice, At the other governmental statute, rule or regulation. option of the party initiating the termination, the other party may be permitted a cure period not to exceed ten 5.6 At the written request of the Plan Sponsor and subject (10) business days, to the Plan Sponsor's continuing obligation to fund the Claims Payment Account, and to timely pay any 5A The TPA may, at its sole option, terminate this outstanding amounts due and payable to the TPA Agreement with ten (10) days written notice upon the under the terms of this Agreement, the TPA will occurrence of any one or more of the following events process incurred but not reported Claims after the pertaining to the Plan Sponsor: termination of this Agreement (Run -Out Services), The written request of the Plan Sponsor for Run -Out (a) The Plan Sponsor fails to fund the Claims services must be received before the date of Payment account; termination of this Agreement, A separate Run -Out (b) The Plan Sponsor fails to pay administration fees Services Agreementwill be provided after receipt of the or other fees for the TPA's services upon request for Run -Out services, The fee for Run -Out presentation for payment and in accordance with Services is stated in Appendix A hereto. the Fee Schedule, Appendix A; (c) The Plan Sponsor fails to comply with any federal, 5.7 If this Agreement terminates for any reason and no state or other government statute, rule or Run -Out Service Agreement is requested, or if the TPA regulation; declines to provide Run -Out Services, the TPA shall (d) The Plan Sponsor, through its acts, practices, or have no obligation to: operations, exposes the TPA to any existing or potential investigation or litigation; (a) Complete the processing of any claim requests (a) The Plan Sponsor permits its stop loss or excess that were pending or otherwise not Complete loss insurance to lapse, whether by failure to pay Claims or complete the processing of any premiums or otherwise; Complete Claims if the Plan Sponsor has failed to (f) The flan Sponsor loses its licensure or provide funds for the payments of any benefits certification, if required by law, to continue the due; Plan; (b) Accept or process requests for claim payments (g) Insolvency of the Plan; presented to it after termination of this Agreement (h) Court appointment of a permanent receiver for irrespective of when such claim was incurred; substantially all of the Plan Sponsor's assets; (c) Issue claims checks after the termination date of (i) A general assignment of the benefit of credits by this Agreement for any request for claims the Plan Sponsor; or payments relative to conditions existing before, on (j) The filing of a voluntary or involuntary petition of or after such a date; bankruptcy, if such petition is not dismissed within (d) Provide ongoing customer service to Plan forty-five (45) days of the date of filing, provided Participants or Health Care Providers; or that an order for relief from automatic stay has (e) Perform any other task or requirement of this been obtained, or with respect to a Chapter 11 Agreement, except for those requirements that proceeding, that the bankrupt of Bankruptcy specifically survive termination of this Agreement, Trustee fails to reaffirm this Agreement and provide adequate assurances pursuant to 11 IISC 5.8 If the Plan Sponsor terminates this Agreement on or 365. before the expressed expiration date of this Agreement, but after such termination date becomes 5.5 The Plan Sponsor may, at its option, terminate this entitled to any reimbursement(s) pursuant to the Agreement with ten (10) days written notice upon the provisions of the Plan Sponsor's Stop Loss or Excess occurrence of any one or more of the following events Loss insurance policy aggregate or specific loss pertaining to the TPA: reimbursement provisions, and no separate Run -Out Services Agreement is executed, the Plan Sponsor (a) Court appointment of a permanent receiver for all shall pay to the TPA an hourly fee of One Hundred and or substantially all of the TPA's assets; no1100 Dollars ($100,00) per hour for all services (b) A general assignment of the benefit of credits by rendered by the TPA after termination of this the TPA; Agreement regarding such reimbursement(s) request (c) The filing of a voluntary or involuntary petition of made to or claims paid by a Stop Loss or Excess toss bankruptcy, if such petition is not dismissed within insurance company. forty-five (45) days of the date of filing, provided that an order for relief from automatic stay has 5.9 In the event this Agreement is terminated for any been obtained, or with respect to a Chapter 11 reason and Plan Sponsor cannot be located following proceeding, that the bankrupt or Bankruptcy reasonable efforts by TPA, TPA shall charge a $50.00 MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page ii of 42 REV, 10-2022 Packet Pg. 1973 16.E.3.a per check administralive charge for its efforts to return any stale dated funds (defined as a check with an original issue date greater than 180 days) belonging to Plan Sponsor or belonging to a plan participant who, likewise, cannot be located. The administrative charge may be paid from any funds of the Plan Sponsor held by TPA, or billed directly to the Plan Sponsor. This provision shall survive termination of this Agreement. ARTICLE VI, MISCELLANEOUS 6A This Agreement, together with all addenda, exhibits and appendices, supersedes any and all prior representations, conditions, warranties, understandings, proposals or other agreements between the Plan Sponsor and the TPA hereto, oral or written, in relation to the services and systems of the TPA, which are rendered or are to be rendered in connection with its assistance to the Plan Sponsor in the administration of the Plan, 6.2 This Agreement, together with the aforesaid addenda, exhibits, and appendices, constitutes the entire Administrative Services Agreement of whatsoever kind or nature existing between or among the parties, Appendices attached hereto and incorporated by reference include; Appendix A, Fee Schedule and Financial Arrangement; Appendix B, Subrogation and Reimbursement Services; Appendix C, COBRA Administrative Services and Certification of Creditable Coverage Agreement; Appendix D, Section 105 Medical Expense Reimbursement Plan and Appendix E, Flexible Benefits Plan. 6.3 The parties hereto, having read and understood this entire Agreement, acknowledge and agree that there are no other representations, conditions, promises, agreements, understandings or warranties that exist outside this Agreement which have been made by either of the parties hereto, which have induced either party or have led to the execution of this Agreement by either party. Any statements, proposals, representations, conditions, warranties, understandings or agreements which may have been heretofore made by either of the parties hereto, and which are not expressly contained or incorporated by reference herein, are void and of no effect. 6A Except as provided in Article V, no changes in or additions to this Agreement shall be recognized unless and until made in writing and signed by all parties hereto, 6.5 In the event any provision of this Agreement is held to be invalid, illegal or unenforceable for any reason and in any respect, such invalidity, illegality or unenforceability shall in no event affect, prejudice or disturb the validity of the remainder of this Agreement, which shall remain in accordance with its terms, 6.6 The Plan Sponsor will notify the TPA within ten (10) Working Days of any inquiry made by any Covered Person or authorized representative of any Covered Person related to Plan Documents, Plan Records, Claims, Claims Appeals, Claims Disputes, threatened litigation, lawsuits pertaining to the Plan or any inquiry made by federal or state authority regarding the Plan. 6.7 In the event that either party is unable to perform any of its obllgations under this Agreement because of natural disaster, fire, flood, wind storm, power outage, labor unrest, civil disobedience, acts of war (declared or undeclared), or actions or decrees of governmental bodies or any event which is referred to as a "Force Majeure Event", the party who has been so affected shall immediately notify the other party and shall do everything possible to resume performance, Upon receipt of such notice, all obligations under this Agreement shall be immediately suspended. If the period of non-performance exceeds fourteen (14) Working Days from the receipt of notice of the Force Majeure Event, the party whose ability to perform has not been so affected may terminate this Agreement by giving ten (10) Working Days' written notice. 6.8 All notices required to be given to either party by this Agreement shall, unless otherwise specified in writing, be deemed to have been given three (3) days after deposit in the U.S. Mail, first class postage prepaid, certified mail, return receipt requested, Any official notice to the TPA will be mailed to the attention of: President, Allegiance Benefit Plan Management, Inc., 2806 South Garfield St., Missoula, MT 59801. Any official notice to the Plan Sponsor will be mailed to the attention of: Director of Risk Management, Collier County Government, 3311 Tamiami Trail East, Napfes, FL 34112. 6.9 This Agreement shall be interpreted and construed in accordance with the laws of the state of Florida except to the extent superseded by federal law, Venue shall be in the state and federal courts in and for the U.S, Middle District Court, Fort Myers, Florida. 6.10 The parties agree to use and disclose protected health information about a Covered Person in accordance with the terms of a separately provided Business Associate Agreement, 6.11 The TPA may enter into arrangements with a Health Care Provider or group of Health Care Providers to obtain discounts in charges for Covered Services. TPA makes no representations that such discounts will continue for any period of time or will apply in any particular factual context. In no event will TPA be responsible for the loss of any such discounts except in the sole event that such loss is directly cause by commissions or omissions of TPA which constitute gross negligence, 6.12 No forbearance or neglect on the part of either party to enforce or insist upon any of the provisions of this Agreement shall be construed as a waiver, alteration or modification of the Agreement. MEDICAL ASA MED sill SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 12 of 42 REV. 10-2022 Packet Pg. 1974 16.E.3.a 6.13 Should TPA's performance of its duties under this Agreement be made materially more burdensome or expensive due to an increase in US Postal Service rates or due to a change in federal, state or local laws or imposition of fees there under, any such additional fees shall be paid by Plan Sponsor upon sixty (60) days' notice In writing from TPA to Plan Sponsor. 6.14 The TPA and the Plan Sponsor specifically state, acknowledge and agree that it is their intent that no other parties including, but not limited to, all persons eligible for benefits under the Plan, all covered employees, and their assignees shall be third party beneficiaries of this Agreement. The parties further agree that nothing herein shall be deemed to impose on the TPA any obligation to any other party including, but not limited to, all persons eligible for benefits under the Plan, all covered employees, and their assignees. 6.15 The Plan Sponsor acknowledges that the TPA shall have no responsibility or liability for any fines or penalties assessed by the Internal Revenue Service as a result of the issuance of annual 1099 forms to medical service providers so long as the TPA has issued the 1099 to the same name, address and TIN as billed by the medical services provider at the point of claim submission. MEDIM ASA MEN STD SNGL EMP ALI_EGIANcE BENEFIT PLAN MANAGEMENT, INC. Page 13 of 42 REV. 10-2022 Packet Pg. 1975 1 ti.E.3.a IN WITNESS WHEREOF, the parties have caused this Agreement to be executed on their behalf by their duly authorized representatives' signatures, effective as of the date first written above. COLLIER COUNTY GOVERNMENT By: (Name/Title) By: {Signature] Date: ATTEST: By: Clerk of the Circuit Court and Comptroller By: (Signature) Dated; (SEAL) Approved as to form and legality Deputy County Attorney ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. 2806 S. Garfield St. Missoula, MT 59801 By: Stephen A, Talita President and General Manager By: J (Signature) Cate: (D z� 2azz REV, 10.2022 C ; N E :. 0 i M . Q� BENEFIT PLAN MANAGEMENT, INC. Page 14 of A Packet Pg. 1971i 1 ti.E.3.a APPENDIX A I 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 through December 31, 2027, as follows: 1/1/2023 — 12/31/2025 1/1/2026--12/31 /2027 $17,70 $18.59 The above fees are per Plan Participant per month. The fees shall include services for production and maintenance of Plar Documents/Summary Plan Description, plan building, amendment production, plan document compliance, and HIPN compliance, regulatory compliance (if applicable) and production and mailing via bulk mail to the Plan Sponsor of health plat identification cards, and all of the following services that are checked: X Medical Claims X Vision Claims 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 Agreemen 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 Plan materials will be delivered to the Plan Sponsor. An additional postage and handling fee will be paid to the TPA for mailinc materials to individual Plan Participants, except for Welcome Packets and identification cards. B. A monthly fee for Vision COBRA services per Plan Participant per month is guaranteed through December 31, 2027 as follows: 1 /112023 — 12/31 /2025 111 /2026 —12/31 /2027 $0.35 $0.37 C. A monthly fee for Dental claims processing services per Plan Participant per month is guaranteed through December 31, 202 as follows: 1 /1 /2023 — 12/31 /2025 111 i2026 —12/31 /2027 $2.85 $2,99 D. Hourly fee of $115.00 per hour for Oncology Case Management services by Allegiance Care Management Services, MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 16 of 42 REV, 10-2022 Packet Pg. 1977 16.E.3.a E. If elected by the Plan Sponsor during the terra of this Agreement or any renewal thereof, a monthly fee for Allegiance Care Management Services Case Management fee/Non-Oncology per Plan Participant per month effective January 111 of each year is guaranteed through December 31, 2027 as follows: 111 /2023 -- 12/3112025 1 /1 /2026 — 12131/2027 $2.45 $2.67 If elected by the Plan Sponsor during the term of this Agreement or any renewal thereof, a monthly fee for Utilization Review services by Allegiance Care Management Services per Plan Participant per month effective January 15S of each year is guaranteed through December 31, 2027 as follows; 1 /1 /2023 — 12/31 /2025 1 /1 /2026 — 12131/2027 $1.70 $1.79 G. If elected by the Plan Sponsor during the term of this Agreement or any renewal thereof, Disease Management fee for American Health Holding of $2.86 per Plan Participant per month effective January 181 of each year: H. If elected by the Plan Sponsor during the term of this agreement or any renewal thereof, a monthly fee for Healthcare Bluebook transparency tool of $1.90 per Plan Participant per month effective January 15I of each year. 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. J. Allegiance Care Management Medical Review fees: Doctors: $275.00/hour Nurses: $100.001hour K. Hourly fee of $125.00 for welfare plan consulting. Such services must be agreed to in advance by the Plan Sponsor. I , 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, M. 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. MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. rage 16 of 42 REV, 10-2022 Packet Pg. 1978 16.E.3.a N. Special Reports requested by the Plan Sponsor and produced by the TPA upon prior agreement as to report(s) and fee(s). O. Final fee of $500.00 for providing eligibility/enrollment files in electronic format acceptable TPA without special programming to the Plan Sponsor (if requested in writing). P. 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). Q. Check customization, customized printed material, special statistical reports other than those enumerated in this contract, special medical underwriting, calculation of or completion of any documentation necessary for 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. R. A fee equal to the actual costs for printing Summary Plan Description Booklets, together with costs of shipping for each booklet. S. 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 and electronic copies shall be billed at $500.00 per disk in DBC or ASCII format only. T. 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 Network access fee for the Cigna PPO network per Plan Participant per month as follows: 111 /2023 — 12131 /2023 1 /112024 — 12/31 /2024 1 /112025 — 12/31 /2025 1 / 1 /2026 —12/31 /2027 _d $6.00 $6.50 $7.00 $7.15 U. Any mandatory assessments charged by Network or Preferred Provider organizations based upon pay for performance criteria required of network providers, which assessments will be paid upon receipt of billing and supporting documentation from the Network or Preferred Provider organization. MEDICAL ASA IVIED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 17 of 42 REV, 10-2022 Packet Pg. 1979 16.E.3.a V. A monthly fee for WellVia of $0.25 per Plan Participant per month effective January 15I of each year. W. Pursuant to Section 2.7 of the Agreement, TPA has secured services of Cigna Health and Life Insurance Company (CHLIC) In order to assist TPA with TPA's performance of various services. CHLIC Is not a party to the Agreement or this Amendment. CHLIC may directly or indirectly contract with pharmaceutical manufacturers, or other third parties, for payments, Including rebates, service fees, and other remuneration, on CHLIC's own behalf and for its own benefit, as part of its global business efforts. CHLIC negotiates, contracts, and receives such payments not as part of CHLIC's compensation for any services it provides to the Employer or the Plan. Accordingly, CHLIC retains all right, title and interest to any and all such rebates, services fees, or other remuneration that CHLIC receives pursuant to its contracts with pharmaceutical manufacturers; neither Employer, its Members, nor the Plan retains any beneficial or property interest in any such contract remuneration, which shall be considered part of the general assets of CHLIC, and are not assets of any other party, including without limitation the Plan. Beginning retroactively as of January 1, 2020, TPA will provide payments to Plan that shall be calculated based on the rebates from pharmaceutical manufacturers that CHLIC receives, pursuant to its contracts with pharmaceutical manufacturers, on or after January 1, 2020, for certain drugs billed through the medical benefits, with respect to the Plan. TPA will provide programming, filing, reporting, accounting, processing, and maintenance services in order to process and account for such payments with respect to the Plan's utilization. TPA shall remit payments to the Plan that are calculated based on 75% of rebates that CHLIC receives from pharmaceutical manufacturers, pursuant to CHLIC's contracts with the manufacturers, for certain drugs billed through medical benefits for the Plan. TPA will be compensated for the services Identified in this amendment in an amount based on 25% of the aforementioned rebates that CHLIC receives. TPA shall remit the payments to Plan on a quarterly basis. CHLIC retains all right, title and interest in its proprietary contracts, and to any and all such rebates or other remuneration received from pharmaceutical manufacturers or other third parties. CHLIC is not and shall not be deemed to be a party to this Agreement for any purpose. Payments under this section are not guaranteed. X. Plan Out of Network Payment Limits: 25% Out of Network Savings Program Y. Regulatory Compliance Fees: Transparency Machine readable file maintenance fee of $100.00 per month. QPA/Mediation fees of 13% of savings, and as applicable federal mediator's fee set by law. ID Card reprint: Pass through of Allegiance's costs. Continuity of Care fee of $12.00 per COC letter sent and up to $276.00 per case for case review. NQTL analysis fee of $250.00 per analysis. A pass through fee to Healthcare Bluebook for maintenance of top 500 procedures shoppable files website as required by the Consolidated Appropriations Act (CAA) of $1.00 per Plan Participant per month. MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 18 of 42 REV. 1D•2022 Packet Pg. 1980 16.E.3.a 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. TPA will generate a monthly bill for fees. Payment of monthly billing will be as follows: On or about the 251' 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. III Stop Loss Arrangement The Plan Sponsor agrees to do the following: Purchase and maintain Stop Loss insurance and provide a copy of the Stop Loss contract to the TPA prior to the effective date of this Agreement. Excess loss insurance will be purchased with Employer contributions or funds and NOT with Employee contributions or Plan Assets. MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 19 of 42 REV, 10-2022 Packet Pg. 1981 16.E.3.a APPENDIX B RFP #22-7977 "Group Health & Dental Plan Administration Services" SUBROGATION AND REIMBURSEMENT SERVICES The Plan Sponsor and TPA hereby agree that TPA will perform certain services in connection with the Plan regarding subrogation and reimbursement rights of the Plan and for the fees stated in this Appendix. A. TPA shall provide recovery services for subrogationlreimbursement of Complete Claims paid by the Plan. Subrogation services shall include direct recovery on behalf of the Plan against third parties and reimbursement services shall include recovery of Plan funds from those Covered Persons who have recovered damages from third parties. Such services shall include review of paid Complete Claims and applicable medical records, identifying potential subrogation and reimbursement claims, follow up questionnaires to Covered Persons and Health Care Providers, additional research as necessary, notification to Health Care Providers, Covered Persons, and their authorized representatives, settlement of claims with prior authorization from the Plan Administrator, and other acts necessary to effectuate recovery of Plan funds. B. The Plan Sponsor shall pay direct costs incurred by the TPA if written approval is given in advance by Plan Sponsor for subrogation and reimbursement services, including, but not limited to costs of consultants, outside legal counsel, and other professionals. The Plan Sponsor shall also pay the TPA fifteen percent (15%) of the total funds recovered from subrogation or reimbursement less any direct costs incurred by the TPA. Plan Sponsor shall never receive less than eighty-five percent (85%) of any subrogation recovery. C. If necessary to retain outside legal counsel for recovery of Plan funds, the Plan Sponsor shall have sole discretion to select and retain legal counsel. Plan Sponsor and TPA acknowledge that negotiation or waiver of a subrogation/reimbursement claim may be necessary as a result of stale or federal law or the specific facts and circumstances of the disputed Claim. The TPA shall refer any requests for negotiation or waiver of a claim to the Plan Sponsor for final settlement. MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 20 of 42 REV. 10.2022 Packet Pg. 1982 16.E.3.a APPENDIX C RFP #22-7977 "Group Health & Dental Plan Administration Services" COBRA ADMINISTRATIVE SERVICES AND CERTIFICATION OF CREDITABLE COVERAGE AGREEMENT This COBRA Administrative Services and Certification of Credible Coverage Agreement (hereinafter "Agreement") is entered Into January 1, 2023, by and between COLLIER COUNTY GOVERNMENT (hereinafter "Plan Sponsor"), whose address Is 3311 Tamiami Trail East, Naples, FL 34112, 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 and certification of credible 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 and certification of credible coverage requirements. NOW THEREFORE, in consideration of the terms and conditions hereinafter set forth, the parties agree as follows: plan which is the subject of this Agreement and which the SECTION 1: Definitions Plan Sponsor has established pursuant to the Plan Document. 1.1 "COBRA" means the Consolidated Omnibus Budget Reconciliation Act of 1985 or the Public Health Service 1.6 "Plan Administrator" means the person or entity and Act, as amended or interpreted from time to time, and designated by the Plan Sponsor to manage the Plan and applicable regulations, make all discretionary decisions regarding Plan terms and managing Plan assets. 1.2 "COBRA Participant" means any person who is properly enrolled for and entitled to benefits from the Plan, 1.7 "Plan Participant" is any employee, retiree or COBRA pursuant to COBRA continuation coverage. beneficiary who is properly enrolled and eligible for benefits under the Plan. 1.3 "Creditable Coverage" means health or medical Coverage under which a Covered Person was covered prior to 1.8 "Qualified Beneficiary" means a covered person under enrollment under this Plan, which prior coverage was the Plan, who is eligible to continue coverage under the under any of the fallowing: Plan in accordance with the applicable provisions of COBRA, regarding Qualified Medical Child Support (a) A group health plan Orders, or in accordance with any other applicable (b) Health Insurance coverage Federal or State law, (C) Part A, Part B or Part C of Title XVIII of the Social Security Act (Medicare) "Qualified Beneficiary' also means a child born to, (d) Title XIX of the Social Security Act, other than adopted by or placed for adoption with a covered coverage consisting solely of benefits under employee or former employee, at any time during active Section 1928 (Medicaid) COBRA continuation coverage of that employee or (e) Chapter 55 of Title 10, United States Code former employee. (active military and CHAMPUS) (f) A medical care program of the Indian Health 1.9 "Qualifying Event" means: Service or a tribal organization (g) A state health benefits risk pool a. With respect to a covered employee or former (h) A health plan offered under chapter 89 of Title employee, termination of employment of the 5, United States Code (Federal Employee employee (except for termination as a result of gross Health Benefits) misconduct), or reduction of hours of employment (i) A public health plan causing the employee to become Ineligible for Q) A health benefit plan under section 5(e) of the coverage. Peace Corps Act (k) A state Children's Health Insurance Program b. With respect to an eligible dependent or spouse of a (CHIP) covered employee or former employee, termination of employment of the employee (except for 1A "HIPAA" means the Health Insurance Portability and termination as a result of gross misconduct), Accountability Act of 1996, as amended or Interpreted reduction of hours of employment causing the from time to time, together with applicable regulations. employee to become ineligible for coverage, the covered employee's entitlement to Medicare, the 1.5 "Plan" means the self -funded health and welfare benefit death of the covered employee, the divorce or legal MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC, Pape 21 of 42 REV. 1 D-2022 Packet Pg. 1983 16.E.3.a separation of the spouse from the covered enrollment to allow the TPA to send the employee an employee, and an eligible dependent who ceases to initial COBRA notice. be a dependent as that term is defined by the Plan. 3.2 Qualifying Event Notice: Plan Sponsor will notify the TPA c. With respect to eligible retirees and their eligible or cause the TPA to be notified when employees and/or dependents, the commencement of a bankruptcy their dependents have a Qualifying Event as follows: proceeding. a. Within 30 days of the employee's death, termination d. Any other qualifying event as defined by law and as from employment for any reason including gross the law may be amended or interpreted from time to misconduct, or reduction of employment hours. time. b. Within 60 days of the divorce or legal separation of SECTION 2: Relationship of Parties the employee or the date at which a dependent child ceases eligibility under the Plan. 2.1 Independent Contractor. Plan Sponsor acknowledges that the TPA is an independent contractor for purposes c. Within 60 days of a second Qualifying Event of a of this Agreement. As such, the TPA is not an agent or Qualified Beneficiary dependent or spouse, such as employee of Plan Sponsor and does not assume any the divorce or legal separation from the covered liability or responsibility for any breach of duty or act of employee, death of the covered employee, omission by Plan Sponsor. entitlement to Medicare or the dependent child ceasing eligibility under the Plan. 2.2 Plan Fiduciary, Plan Sponsor acknowledges and agrees that the performance by the TPA of its obligations under 3.3 Late Notice of Qualifying Event: If any employee or this Agreement does not make the TPA a plan dependent of an employee provides notice to the Plan administrator, plan sponsor, or fiduciary as defined by Sponsor of divorce or legal separation, entitlement to ERISA or other applicable law, and Plan Sponsor will not Medicare, or that a dependent child ceases eligibility identify the TPA or any of its affiliates as such. The Plan under the Plan, and such notice is made more than 60 Sponsor further acknowledges and agrees that it is the days after the Qualifying Event, Plan Sponsor will notify plan sponsor, plan administrator, and named fiduciary as the TPA in writing of the same within 10 days after defined by ERISA or other applicable law. As such, Plan receiving the notice. Sponsor retains full discretionary authority, control, and responsibility for the operation and administration of the The TPA will not enroll those persons who provided Plan. notice in such manner for COBRA continuation coverage, unless specifically directed to do so in writing, by the Plan 2.3 No Le al or Tax Advice. Plan Sponsor acknowledges Sponsor and/or the Plan Administrator. and agrees that the TPA will not be deemed to be a legal or tax advisor as a result of the performance of its duties 3.4 Qualified Beneficiary Information: Plan Sponsor will under this Agreement. provide the TPA the following information with notice of a Qualifying Event: 2.4 Subcontractors. The TPA may subcontract the services of computer companies, consultants, attorneys, a. The name, address, and Social Security number of accountants, and other organizations that it deems the employee. necessary in the performance of its obligations under this b. The name, address, and Social Security number for Agreement. At the discretion of the TPA, such services any covered dependents. may be performed directly by the TPA, wholly or in part, c. Date and description of the Qualifying Event, or if not through a subsidiary or affiliate of the TPA or under an a Qualifying Event, the date and reason, if known, for agreement with an organization, agent, or other person dropping or terminating Dependent coverage. If the of its choosing. Any such services resulting in a fee not Plan Sponsor knows that the Participant's reason for agreed to in Appendix A, Fee Schedule and Financial dropping or terminating Dependent coverage is in Arrangement in the Administrative Services Agreement contemplation of divorce or legal separation, Plan between Plan Sponsor and Allegiance Benefit Plan Sponsor shall notify the TPA of the same to assure Management, shall have prior written authorization by the that any affected Dependent receives notice of any Plan Sponsor, COBRA rights to which he or she is entitled. 2.5 Third Party Administrator L.icensure. The TPA represents that it Is licensed and/or registered as a third party administrator in the following slates: Montana, California, Colorado, Idaho, Kansas, Nebraska, North Dakota, Oregon, South Dakota, Utah, Washington, Wisconsin, and Wyoming. SECTION 3: Responsibilities of Plan Sponsor 3A Initial Notice: If applicable, Plan Sponsor will notify the TPA within thirty (30) days after employees and/or their dependents enroll in Plan Sponsor's Plan, of such 3.5 SSI Determination Letters: Plan Sponsor will forward copies of any Social Security Disability Determination letters it may receive from COBRA Participants, within 10 days after Plan Sponsor receives the same and has date stamped the letter. 3.6 Plan Sponsor Plan, Changes, and Amendments: Plan Sponsor will notify the TPA of any changes in benefits, eligibility and/or premiums for Plan Sponsor's Plan, in accordance with the terms of the Administrative Service Agreement for the Plan Sponsor's Plan. MEDICAL ASA MED STD SNGL PMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 22 of 42 REV. 10.2022 Packet Pg. 1984 16.E.3.a 3.7 COBRA Premiums: Plan Sponsor will determine the 4.5 Contemplation of Divorce: Upon receipt of notice from the amount to be charged for COBRA premiums and notify Plan Sponsor, the TPA will provide notices to spouses the TPA of the same, in writing, upon execution of this and other Dependents whose coverage is being Agreement. Plan Sponsor will notify the TPA in writing of terminated in contemplation of divorce or legal separation any premium changes at least thirty (30) days prior to the that they may have rights to COBRA continuation effective date of the change or as soon as reasonably coverage when the divorce decree or legal separation is possible thereafter. entered by a court. 3.8 COBRA Election Forms: If Plan Sponsor receives 4.6 requests for COBRA coverage, Plan Sponsor will record on the form the date it was received by Plan Sponsor. Plan Sponsor will fax a copy of the form to the TPA on the date it is received by Plan Sponsor, and will mail a copy of the same to the TPA within five (5) days of receipt by Plan Sponsor. 3.9 Premium Trust Accounts: Plan Sponsor will establish, or cause to be established, a premium trust account at a bank designated by the TPA. Plan Sponsor, and not the 4.7 TPA, will be the owner of such account. Plan Sponsor authorizes the TPA to endorse COBRA premium payments received by stamping the same with "FOR DEPOSIT ONLY" and the applicable premium trust account number and to deposit the payments into the premium trust account. 3.10 Premium Payments Received from COBRA Participants: If Plan Sponsor receives premium payments directly from COBRA Participants, Plan Sponsor will notify the TPA in writing on the date of receipt, or cause the TPA to be notified in writing on the date of receipt, of the premium amount, the name of the COBRA Participant(s) for whom the premium applies, date of receipt, and period for which the premium applies. Plan Sponsor shall forward premium checks received to the TPA for deposit into the premium trust account. 3.11 Initial Grace Period: Plan Sponsor designates that the initial 45 day grace period for the premium payment will begin on the date of COBRA election. 3.12 Other: Plan Sponsor will provide any other information required by the TPA to perform its obligations under this Agreement. SECTION 4: COBRA Services of the TPA Post -Election Notices: The TPA will provide all post election notices to employees and their spouses required by applicable law, including but not limited to notice of ineligibility for COBRA continuation coverage, notice of nonpayment of premium, and notice of termination of COBRA coverage. If the notice of ineligibility is due to the employee's termination of employment for gross misconduct, the Plan Sponsor shall be solely responsible for the determination of gross misconduct, Plan Chan es and Amendments: The TPA will inform COBRA Participants under the Plan of any changes in benefits, eligibility requirements, or premiums of the Plan. The obligations of the TPA under this subsection will be limited to mailing to COBRA Participants, copies of all Plan amendments, changes, modifications, or other notices as received from the Plan Sponsor. 4.8 Customer Service Toll -Free Line: The TPA will provide customer service assistance regarding COBRA issues to Plan Sponsor and beneficiaries under Plan Sponsor's Plan through a toll -free telephone number during regular business hours. 4.9 COBRA Participant Premiums: The TPA will bill COBRA Participants for the premiums as designated by Plan Sponsor and in accordance with applicable law. The TPA will not be required to bill for any premium amount that does not comply with applicable law. 4A Initial Notice. If applicable, within fourteen (14) days of receipt of notice from Plan Sponsor of a newly -enrolled employee and/or spouse, the TPA will mail to the employee and/or spouse an initial notice of COBRA 4.10 continuation coverage rights. 4.2 Enrollment Packet: Within 14 days of receipt of notice from the Plan Sponsor of a Qualifying Event, the TPA will mail to Qualified Beneficiaries a notice of the right to elect 4.11 COBRA continuation coverage. 4.3 Enrollment of Qualified Beneficiaries: The TPA will enroll all Qualified Beneficiaries who elect COBRA continuation coverage within the time permitted by law, 4.4 Notice of Open Enrollment, The TPA will notify COBRA participants of any open enrollment periods held for employees under Plan Sponsor's Plan, The TPA will direct COBRA Participants to make premium payments payable to the Plan Sponsor and to send payments to the TPA for deposit into the premium trust account. If the TPA receives premium checks made payable to the TPA, the TPA will endorse them over to Plan Sponsor, without recourse. The TPA will collect COBRA premiums and deposit them in the Plan Sponsor's premium trust account no less frequently than weekly. The TPA will establish, or cause to be established, a system to credit the premium payments to the appropriate Qualified Beneficiary or COBRA Participant. Late Premium Notices: The TPA will send a reminder notice to Qualified Beneficiaries and COBRA Participants whose premium payment has not been received on or about the twentieth day of the month. Late Premium Payments: If the TPA receives a premium payment past the premium due date (including any grace period provided by law or the Plan), the TPA will return the payment to the sender with a notice that it cannot be accepted. The TPA will return the payment to the sender, with such notice, within five (6) days of receiving the payment. MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 23 of 42 REV. 10-2022 Packet Pg. 1985 16.E.3.a 4.12 COBRA Terminations: The TPA will notify the Plan Sponsor of the date COBRA continuation coverage will expire in the absence of any default, for each COBRA Participant. Such notice will be given in an eligibility report provided by the TPA to the Plan Sponsor on a monthly basis. 4.13 Notice of Default: The TPA will notify each COBRA Participant, in writing, of any default in payment of 7.3 premium, or other default causing loss of coverage, including the date of default and the date COBRA continuation coverage terminated. Notice will be sent by first class mail within five (5) days following receipt of notice from Plan Sponsor and/or Plan Administrator. 4.14 Notice of COBRA Exhaustion: The TPA will notify each COBRA Participant of the date COBRA continuation coverage will expire in the absence of any default. Such 7.4 notice will be sent by first class mail within thirty (30) days of the termination date. 4.15 Conversion Coverage: If applicable, the TPA shall provide notices to eligible COBRA Participants of their rights to obtain conversion coverage. Such notices shall be supplied at the expense of the Plan. The TPA shall administer conversion rights in accordance with the provisions of the Plan document. SECTION 5: Creditable Coverage Certification Services of 8.1 the TPA 5.1 Customer Service Toll -Free Line: The TPA will provide customer service assistance regarding Creditable Coverage to Plan Sponsor and beneficiaries under Plan Sponsor's Plan through a toll -free telephone number during regular business hours. 5.2 Certificates of Credible Coverage: The TPA will provide Certifications of Creditable Coverage as required by law, to employees, dependents and others authorized to 8.2 receive this information. SECTION 6: TPA Compensation Plan Sponsor agrees to pay the TPA its compensation for services provided under this Agreement in accordance with the terms and conditions outlined in Appendix A, "Fee Schedule and Financial Arrangement" in the Administrative Services Agreement between Plan Sponsor and Allegiance Benefit Plan Management. SECTION 7: Limitations on Liability 7.1 Premium Payments/Loss of Coverage: Except as provided for under section 8.1, the TPA will have no liability to any person or entity regarding the processing of premium payments. Provided the TPA acts in accordance with this Agreement, the TPA will have no liability to any person or any entity for loss of COBRA coverage as a result of late or nonpayment of premium. 7.2 Failure of Plan Sponsor to Notify: The TPA will provide all notices to COBRA Participants and Qualified Beneficiaries in accordance with this Agreement. Provided the TPA acts in accordance with this Agreement, the TPA will have no liability to any COBRA Participant or Qualified Beneficiary for failure of the Plan Sponsor to property notify the TPA and provide the information required for the TPA to perform its obligations under this Agreement. The TPA will have no liability for the accuracy of the information provided by the Plan Sponsor and for any actions taken in reliance upon any such information. NSF Checks: This Agreement will not be construed in any manner to require the TPA to collect insufficient funds, "stop -payment" or otherwise dishonored checks, or other negotiable instruments received for premium payments, which are subsequently not paid by the maker. The TPA will not be liable for any losses to Plan Sponsor or Plan Sponsor's Plan as a result of such checks or negotiable instruments. Determinations of Gross Misconduct: The TPA shall not make any determinations of any nature regarding whether a Qualified Beneficiary's termination from employment was due to gross misconduct, The TPA shall be entitled to rely upon any determinations of gross misconduct as made by the Plan Sponsor and shall have no liability for actions taken in reliance upon any such information as provided by the Plan Sponsor. SECTION 8: Indemnification Plan Sponsor Indemnification: The TPA will indemnify, defend, save and hold the Plan Sponsor harmless from and against any and all claims, suits, actions, liabilities, losses, penalties or damages including court costs and attorneys' fees with respect to the Plan to the extent they are caused by the gross negligence, malfeasance, or criminal acts or omissions of the TPA or its employees in the performance of its duties under this Agreement and for any acts taken at the specific direction of the Plan Sponsor. TPA Indemnification: The Plan Sponsor will indemnify, defend, save, and hold the TPA harmless from and against any and all claims, suits, actions, liabilities, losses, penalties or damages, including court costs and attorneys' fees, to the extent that such claims, losses, liabilities, damages and expenses are caused by the gross negligence, malfeasance or criminal acts or omissions of the Plan Sponsor, its agents and employees, in the performance of its duties under this Agreement and in those situations under Section 7 where the TPA is exculpated from liability. To the extent authorized by law, and applicable to contract and indemnity claims the foregoing indemnification shall not constitute a waiver of sovereign immunity beyond the limits set forth in Section 768.28, Florida Statutes. SECTION 9: Term and Termination of Agreement 911 Term and Renewal Term, The term of this Agreement shall commence on January 1, 2023, and end on December 31, 2027, and may be renewed for two (2) additional one (1) year periods as mutually agreed by the parties in writing unless terminated earlier in accordance with the Administrative Services Agreement. 9.2 Termination. This Agreement shall be terminated in accordance with the provisions of Article V: Term and MEDICAL ASA ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 24 of 42 REv, ;o•io22 Packet Pg. 1986 16.E.3.a Termination of the Administrative Services Agreement. 9.3 Survival: The provisions of Sections 2, 7, and 8 shall survive termination of this Agreement. SECTION 10: General Provisions 10.1 Authorization: Plan Sponsor grants to the TPA the authority to do all acts it deems necessary to carry out the terms of this Agreement. 10.2 Waiver: No forbearance or neglect on the part of either party to enforce or insist upon any of the provisions of this Agreement will be construed as a waiver, alteration, or modification of this Agreement. 10.3 Entire Agreement, Amendments, Modification: This Agreement and any attachments constitute the entire agreement between the parties with respect to its subject matter. This Agreement supersedes all existing agreements and all other oral, written or other communications between them concerning its subject matter. This Agreement or any attachment shall not be amended or modified except as agreed upon in writing and signed by the parties. If any such modification or amendment increases the direct costs to the TPA under this Agreement, the Plan Sponsor agrees to pay any increases in direct costs that the TPA reasonably expects to incur as a result of such modification. 10A Severability: If any provision of this Agreement is held to be invalid, illegal, or unenforceable by any court of final jurisdiction, it is the intent of the parties that all other provisions of this Agreement be construed to remain fully valid, enforceable, and binding on the parties. 10.5 Actreement Counterparts; This Agreement may be executed in two or more counterparts, each and all of which will be deemed an original and all of which together will constitute but one and the same instrument. 10.6 Assignment. Neither party shall assign, transfer, or subcontract any portion of this Agreement without the prior written consent of the non -assigning party. 10.7 Notice of Threatened Litigation: The Plan Sponsor will notify the TPA within ten (10) days of any threatened litigation, lawsuits or regulatory complaints or inquiries pertaining to the subject matter of this Agreement, or any inquiry made by any federal or state authority regarding the same. 10.8 Service of Notice. Neither party will be bound by any notice, directive or request unless and until it is received in writing, or by facsimile transmission, or by e-mail address at the addresses in this subsection. All notices given to either party under this Agreement shall, unless otherwise specified in writing, be deemed to have been given three (3) days after deposit in the U.S. Mail, first class postage prepaid, certified mail, return receipt requested.; date of facsimile transmission; or date of e- mail transmission. Notice to the TPA shall be directed to: Stephen A. Tahta, President, Allegiance Benefit Plan Management, Inc., 2806 South Garfield St„ PO Box 3018, Missoula, MT 59806-3018; Phone: (406) 721- 2222; Fax: (406) 721-2252, Email; Ste hen.Tahta askalle iance.com. Notice to the Plan Sponsor shall be directed to: Jeff Walker, Director of Risk Management, Collier County Government, 3311 Tamiaml Trail East, Naples, FL 34112; Phone: (239) 252-8906; Email:. Jeff.WalkerPcolliercountyfl.gov 10.9 Choice of Law and Venue. This Agreement shall be governed and construed in accordance with the laws of the State of Florida, with venue in the State and Federal courts in and for Collier County, Florida. Prior to the initiation of any action or proceeding permitted by this Agreement to resolve disputes between the parties, the parties shall make a good faith effort to resolve any such disputes by negotiation, The negotiation shall be attended by representatives of the TPA with full decision -making authority and by Plan Sponsor's staff person who would make the presentation of any settlement reached during negotiations to Plan Sponsor for approval. Failing resolution, and prior to the commencement of depositions in any litigation between the parties arising out of this Agreement, the parties shall attempt to resolve the dispute through Mediation before an agreed -upon Circuit Court Mediator certified by the State of Florida. The mediation shall be attended by representatives of the TPA with full decision -making authority and by Plan Sponsor's staff person who would make the presentation of any settlement reached at mediation to Plan Sponsor's board for approval. Should either party fail to submit to mediation as required hereunder, the other party may obtain a court order requiring mediation under Section 44,102, Fla. Statutes. Any suit or action brought by either party to this Agreement against the other party relating to or arising out of this Agreement must be brought in the appropriate federal or state courts in Collier County, Florida, which courts have sole and exclusive jurisdiction on all such matters. 10.10 Headings: Section headings are included only for convenient reference and do not describe the sections to which they relate. 10.11 Inter retation of Words: Words denoting the singular include the plural and vice versa. ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 26 of 42 'D SNGL EMP REV. 10-2022Packet Pg. 1987 16.E.3.a APPENDIX D RFP #22-7977 "Group Health & Dental Plan Administration Services" ADMINISTRATIVE SERVICES AGREEMENT SECTION 105 MEDICAL EXPENSE REIMBURSEMENT PLAN This Agreement, effective for the period beginning January 1, 2023, and ending December 31, 2027, and may be renewed for two (2) additional one (1) year periods as mutually agreed by the parties in writing , is entered into by Collier County Government, a political subdivision of the State of Florida (hereinafter referred to as the "Plan Sponsor") and Allegiance Benefit Plan Management, Inc., a corporation duly organized and existing under the laws of the State of Montana (hereinafter referred to as the "TPA"). WHEREAS, the Plan Sponsor sponsors a medical expense reimbursement plan (hereinafter referred to as the health reimbursement arrangement or HRA Plan) which is a healthcare expense reimbursement plan within the meaning of Section 105 of the Internal Revenue Code of 1986, as amended, and regulations issued thereunder, for all employees participating in the Plan Sponsor's health or welfare benefits plan; and WHEREAS, the Plan Sponsor wishes to contract with an independent third -party administrator to perform certain supervisory services with respect to the HRA Plan; and WHEREAS, the TPA desires to contract with the Plan Sponsor to perform such supervisory services with respect to the Plan, as set forth below; and WHEREAS, the parties wish to enter into this Agreement to set forth the obligations and duties of both parties with regard to such supervisory services. THEREFORE, in consideration of the promises and mutual covenants contained herein, the Plan Sponsor and the TPA enter in to this Agreement for administrative services for the HRA Plan. SECTION 1. DEFINITIONS For the purposes of this Agreement the following words and phrases have the meanings set forth below, unless the context clearly indicates otherwise and, wherever appropriate, the singular will include the plural and the plural will include the singular, 1.1 "COBRA" means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended, together with all regulations applicable thereto. 1.2 "Code" means the Internal Revenue Code of 1986, and any applicable amendments and any Treasury regulation applicable to the section or subsection. 1.3 "Covered Person" means any Participant or Dependent of a Participant meeting the eligibility requirements for coverage and properly enrolled for coverage as specified in the Plan. 1.4 "Dependent" means any eligible Dependent who is a Tax Dependent for the tax year during which expenses were incurred. 1.5 "Employee" means an individual that the Employer classifies as a common-law employee and who is paid by the Employer, but does not include any leased employee (including but not limited to those individuals defined in Code 1 414(n)), or any individual classified by the Employer as a contract worker, independent contractor, temporary employee or casual employee, whether or not any such persons are on the employer's W-2 payroll, or any individual who performs services for the Employer but who is paid by a temporary employment agency under a professional employer arrangement or other employment agency, or any employee for whom the terms of a collective bargaining agreement would supersede the terms of this plan. 1.6 "Employer" means the Plan Sponsor and any successor organization or affiliate of such Employer which assumes the obligations of the HRA Plan and this Agreement. 1.7 "ERISA" means the Employee Retirement Income Security Act of 1974, as amended, together with all regulations applicable thereto. 1.8 "Fee Schedule" means the listing of fees or charges for services provided under Appendix A of this Appendix this Agreement. This Fee Schedule may be modified from time to time in writing by the mutual agreement of the parties. The Fee Schedule is contained in Appendix A and is a part of this Agreement. 1.9 "Group Health Plan" means any group health care, disability, #dental or vision care plan provided by premiums to and contract with a third -party insurer that is in force for Employees of the Employer and as may be amended or replaced from time to time at the discretion of the Employer. MEDICAL ASA MEO STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 26 of 42 REV. W-2022 Packet Pg. 1988 16.E.3.a 1.10 "HIPAA" means the Health Insurance Portability and SECTION 2, RELATIONSHIP OF THE PARTIES Accountability Act of 1996, as it may be amended from time to time, and all regulations applicable thereto. 2.1 The Plan Sponsor delegates to the TPA only those powers and responsibilities with respect to 1.11 "Participant" is any employee, retiree or COBRA development, maintenance and administration of the beneficiary who is eligible for, properly enrolled in and HRA Plan that are specifically enumerated in this entitled to benefits from the HRA Plan. Agreement. Any function not specifically delegated to and assumed by the TPA in writing pursuant to this 1.12 "Plan" means the Medical Expense Reimbursement Agreement will remain the sole responsibility of the Plan for the Employees of Plan Sponsor, which is the Plan Sponsor. The Plan Sponsor retains the subject of this Agreement and which the Plan Sponsor responsibility for any obligations under the has established pursuant to the Plan Document, Consolidated Omnibus Budget Reconciliation Act together with any and all amendments, supplements (COBRA) of 1985, as amended, and obligations under and appendices and any other relevant documents the Health Insurance Portability and Accountability Act pertinent to its operation and maintenance. of 1996 (HIPAA) unless this Agreement and the Fee Schedule in Appendix A expressly include language 1.13 "Plan Administrator" means the Employer and/or any and fees for COBRA or HIPAA administrative services person or entity designated by the Plan Sponsor which by the TPA. is responsible to manage the day-to-day functions and management of the HRA Plan and make all 2.2 The TPA is acting as an independent contractor for discretionary decisions regarding Plan terms and purposes of this Agreement. As such, the TPA is not a managing Plan funds. The Plan Administrator may fiduciary and does not assume any liability or employ persons or firms to process premium payments responsibility for any breach of duty or act of omission and perform other Plan -connected services. For the by Plan Sponsor. purposes of the Employee Retirement Income Security Act of 1974, as amended, and any applicable state 2.3 The parties acknowledge that: legislation of a similar nature, the Employer will be deemed to be the Plan Administrator of the Plan unless A. This is a contract for administrative services by action of the Hoard of Directors or equivalent only as specifically set forth herein; and authority the Employer designates an individual or committee to act as Plan Administrator. B. This Agreement will not be deemed a contract of insurance under any laws or regulations. 1.14 "Plan Document" means the instrument or The TPA does not insure, guarantee or underwrite the liability of the Plan Sponsor instruments that set forth and govern the duties of the under the Plan. The Plan Sponsor has total Plan Sponsor and eligibility and benefit provisions of responsibility for payment of contributions for the HRA Plan which provide for reimbursement of out- the employee health and welfare benefits of -pocket healthcare expenses not covered under the reimbursement plan under the HRA Plan and Plan Sponsor's employee health and welfare benefits all expenses incidental to the Plan. plan 1.15 "Plan Sponsor" will be as defined in Section 3(16)(A) 2.4 Except as specifically set forth herein, this Agreement of ERISA and means the entity and any successor will inure to the benefit of and be binding upon the entity or organization, which is responsible for and parties hereto and their respective legal successors which has created, established and maintains an provided, however, neither party may assign this employee health and welfare benefit plan for the Agreement without the prior written consent of the benefit of a group or groups of employees. Plan other, which consent will not be unreasonably withheld. Sponsor includes any successor organization or There are no intended third -party beneficiaries to this affiliate of such Plan Sponsor that assumes the Agreement, and this Agreement will not be construed obligations of the HRA Plan and this Agreement. in any manner as to create same. 1.16 "Plan Year'' means the twelve-month period of time 2.6 Any dispute as to the applicability of this Agreement commencing with the effective date of this HRA Plan or between the parties or the respective rights and the Plan anniversary date, and terminating on the date obligations of the parties under this Agreement which of the next succeeding Plan anniversary date. The Plan the parties are unable to resolve, will be determined by anniversary date will be January 1 st of each year. arbitration. Either party may submit the dispute to arbitration before a single arbitrator and in accordance 1.17 "Plan Summary" means the document that describes with the rules of the American Arbitration Association. the terms and conditions under which the HRA Plan The cost of such arbitration will be paid by the party operates. that does not substantially prevail. The decision of the arbitrator will be final and binding upon the parties and 1.18 "Working Day" means a regular business day that is may be filed with any court of competent jurisdiction not a recognized federal or banking holiday, and and enforced as judgment of that court, specifically excluding any Saturday or Sunday. 2.6 It is agreed by the parties to this Agreement That any cause of action brought by either party to this contract MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC, Page 27 of 42 REV, 50-2022 Packet Pg. 1989 16.E.3.a must be made within two (2) years of the date of 3.6 The TPA will possess throughout the term of this occurrence of any alleged breach, infraction or dispute, Agreement an in -force fidelity bond or other insurance or within two (2) years of the termination date of this as may be required by state and federal laws for the Agreement, whichever occurs first. protection of its clients, Additionally, the TPA agrees to comply with any state or federal statutes or 2.7 The TPA agrees to be duly licensed as a Third Party regulations regarding its operations. Administrator to the extent required under applicable law and agrees to maintain such licensure throughout 3.6 The TPA will maintain information that identifies a the term of this Agreement, Participant in a confidential manner. The TPA agrees to take all reasonable precautions to prevent disclosure 2.8 The parties to this Agreement acknowledge that TPA or the use of premium payment information for a will have no obligation of any sort, express or implied, purpose unrelated to the administration of the Plan. in this contract to provide Plan Sponsor with any proprietary, confidential or trade secret information of 3.7 Plan Sponsor may provide its own Plan Document and TPA. Plan Sponsor is entitled to its claims information Summary Plan Description at its expense, used by and other information which the Plan Sponsor and Plan TPA for review and approval by Plan Sponsor's legal Administrator are required to retain by applicable law, counsel, subject to review and approval by TPA. but any proprietary, confidential or trade secret information of TPA shall be removed from such 3.8 The TPA will provide non-proprietary information and information. TPA will not disclose proprietary, documents as requested by the Plan Sponsor to confidential or trade secret information to Plan Sponsor brokers and agents designated by the Plan Sponsor, without Plan Sponsor first executing a legally binding provided, however, if the Plan Sponsor has entered Confidentiality and Non -Disclosure Agreement into an agent of record agreement with any agent or regarding such information. broker, and the TPA has notice of the same, the TPA will not be required to provide any information or SECTION 3. THE TPA'S RESPONSIBILITIES documentation to other agents or brokers unless or until Plan Sponsor has terminated the agent of record The TPA will provide the following HRA Plan Supervisory agreement and notified the agent of record of the Services for the Plan Sponsor. The fees for these services are termination, The TPA will have the express right to stated in the Fee Schedule In Appendix A. contact any agent of record to verify the agent of record agreement has been terminated. A separate fee will 3.1 The TPA will assist Plan Sponsor in developing and be charged for this service as stated in Appendix A. designing the HRA Plan and any amendments, revisions or modifications, subject to approval by Plan 3.9 The TPA will have no obligation whatsoever with Sponsor or Plan Sponsor's attorney. regard to the Plan Sponsor's obligations and responsibilities under the Consolidated Omnibus 3.2 The TPA will maintain HRA Plan records based on Budget Reconciliation Act (COBRA) of 1986, as information submitted by the Plan Sponsor as to the amended, or the Health Insurance Portability and dates on which the Plan becomes effective. Accountability Act (HIPAA) of 1996, unless specifically requested by Plan Sponsor, in which case TPA's 3.3 The TPA will perform the following specific services for responsibilities for COBRA administration are stated in Plan Sponsor as requested: the COBRA Appendix C attached hereto and made a part hereof by this reference. A. Receive reimbursement requests and supporting documentation (Explanations of 3.10 Upon request of Plan Sponsor, TPA will perform 25% Benefits) from Participants for processing. Key Employee Concentration discrimination testing and/or prepare the IRS Form 5500 for the Plan B. Process Qualifying Expenses and determine referenced in this Agreement. However, by providing Reimbursable Expenses in accordance with these services, TPA is not acting as Plan Sponsor's the terms of the Medical Expense legal counsel or tax advisor. All services provided by Reimbursement Plan Document. TPA under this paragraph should be reviewed by Plan Sponsor's legal counsel and tax advisors. C. Notify Plan Sponsor for funding requirements in order to fully fund and pay claims as SECTION 4. PLAN SPONSOR OBLIGATIONS required by applicable taw. 4.1 Plan Sponsor will furnish to the TPA the following D. Prepare and transmit reimbursement for reports and information to allow effective performance Reimbursable Expenses as defined in the by the TPA: Plan Document. A. Certification of participation in the HRA Plan 3.4 The TPA agrees to be duly licensed as a Third Party and such other information as may be Administrator to the extent required under applicable necessary. law and agrees to maintain such licensure throughout the term of this Agreement. 4.2 Plan Sponsor will give notice of the establishment of the HRA Plan to its employees and will be responsible MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 28 o142 REV. 10.2022 Packet Pg. 1990 16.E.3.a for distributing copies of the Plan Summary to participating employees. 4.3 Plan Sponsor will maintain current and accurate Plan eligibility and participation records, verify Participant eligibility and submit this information if requested by the TPA, to the TPA at its designated mailing address, This information will be provided in a format acceptable to the TPA and will include the following for each Participant: name and address, Social Security number, date of birth, type of coverage, sex, relationship to employee, changes in participation, date participation begins or ends, and any other information necessary to determine eligibility and participation levels under the Plan. 4.4 Plan Sponsor will resolve all Plan ambiguities and disputes relating to the eligibility of a Plan Participant or any other Plan interpretation questions. The Plan Sponsor will respond to any written request made by the TPA within ten (10) working days. 4.5 Plan Sponsor will provide the TPA with copies of any and all revisions or changes to the Plan within five (5) Working Days of the effective date of the changes. 4.6 Plan Sponsor will provide, and timely distribute, all notices and information required to be given to Participants, maintain and operate the Plan in accordance with applicable law, maintain all record keeping, and file all forms relative thereto pursuant to any federal, state, or local law, unless this Agreement specifically assigns such duties to the TPA. 4.13 Plan Sponsor will maintain a supply of election forms and other documents provided by the TPA and will make them available to participating employees. 4.14 Plan Sponsor will provide all reports and documents required from time to time to satisfy governing law or to promote effective HRA Plan operation, including, but not limited to, year-to-date payroll deduction summaries. 4.15 Plan Sponsor retains sole responsibility for Plan Sponsor's obligations and responsibilities under the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, as amended, or the Health Insurance Portability and Accountability Act (HIPAA) of 1996 , unless Plan Sponsor has specifically requested TPA to provide COBRA administrative services, in which case TPA's responsibilities for COBRA administration are stated in the COBRA Appendix C attached hereto and made a part hereof by this reference. 4.16 If the Plan Sponsor elects Set -Up Services only, as shown on the Fee Schedule in Appendix A, and elects not to have the TPA provide Re -Enrollment Services, the TPA will have no responsibility whatsoever for notifying Plan Sponsor of changes in, and required compliance with, the laws applicable to this Plan including Plan Document revisions required for such compliance. The Plan Sponsor will remain solely responsible for remaining apprised of such future changes in laws and required compliance with regard to Plan Documents. 4.7 Plan Sponsor will at all times acknowledge that it is the 4.17 Plan Sponsor, Plan Administrator, and Named Fiduciary, as these terms are defined in ERISA. As such, Plan Sponsor retains full discretionary control and authority and discretionary responsibility in the operation and administration of the Plan. 4.8 Plan Sponsor will pay any and all taxes, licenses, and fees levied, if any, by any local, state, or federal authority in connection with the Plan. 4,9 Plan Sponsor will hold confidential information obtained that is proprietary to the TPA or information or material not generally known by personnel other than management employees of the TPA. Confidentiality is subject to Chapter 119, Florida Statutes, also known as the public Records Law. 4.10 Plan Sponsor will pay, in accordance with the Fee Schedule, the TPA's fees for services rendered under this Agreement. 4.11 Plan Sponsor will maintain any insurance as may be required by state or federal law for the protection of the Plan and Participants. 4.12 Plan Sponsor will notify the TPA of any requests for HRA Plan documents. TPA provides a website to its customers for access to plan information which includes Protected Health Information (PHI) as that term is defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Access to PHI via the website is limited to the person to whom the PHI belongs by use of a unique personal password mailed to that person's known address. Plan Sponsor has requested TPA issue passwords to persons requesting them via the TPA's website. Assuming there are no technological impediments to providing this service to Plan Sponsor, Plan Sponsor and TPA agree to the following: The person requesting a password will certify their identity by using unique identifiers. TPA will not be responsible or liable in any way as the Business Associate of Plan Sponsor for any fraud or identity misrepresentation which causes a password to be issued to the wrong person. SECTION 5. DURATION OF AGREEMENT 511 This Agreement shall commence on January 1, 2023, and end on December 31, 2027 and may be renewed for two (2) additional one (1) year periods as mutually agreed by the parties in writing. MEDICAL ASA MED STD SNGL EMP ALLEGIANCE 13ENEF€T PLAN MANAGEMENT, INC. Page 29 of 42 REV. 10-2022 Packet Pg. 1991 16.E.3.a 5.2 In the event of a change in the Fee Schedule for a provided that an order for relief from subsequent twelve (12) month period, an amendment automatic stay has been obtained, or with shall be issued and signed by the parties. respect to a Chapter 11 proceeding, that the bankrupt or Bankruptcy Trustee fails to 5.3 At any time during the term of this Agreement, either reaffirm this Agreement and provide adequate the Plan Sponsor or the TPA may amend or change assurances pursuant to 11 USC 365. the provisions of this Agreement. These amendments or changes must be agreed upon in advance in writing 5.6 The Plan Sponsor may, at its option, terminate this by both the Plan Sponsor and the TPA. If any such Agreement within sixty (60) days written notice upon amendment increases the TPA's cost of administering the occurrence of any one or more of the following the Plan, the Plan Sponsor agrees to pay any increase events pertaining to the TPA: in funding expenses, as well as increases in administrative fees or other costs which the TPA A. Insolvency; reasonably expects to incur as a result of such modification. B. Court appointment of a permanent receiver for all or substantially all of the TPA's assets; Any amendment which affects only the Fee Schedule, Appendix A, shall be made, in writing signed by all C. A general assignment of the benefit of parties. All fee quotes accepted by Plan Sponsor for creditors by the TPA; renewals of this Agreement will be incorporated into this Agreement as amendments to the Fee Schedule, D. The filing of a voluntary or involuntary petition Appendix A. of bankruptcy, if such petition is not dismissed within forty-five (45) days of the date of filing, 5.4 This Agreement may be terminated by either party at provided that an order for relief from any time upon providing the terminating party with sixty automatic stay has been obtained, or with (60) days prior notice of intent to terminate unless both respect to a Chapter 11 proceeding, that the parties agree to waive such advance notice. At the bankrupt or Bankruptcy Trustee falls to option of the party initiating the termination, the other reaffirm this Agreement and provide adequate party may be permitted a cure period (of a length assurances pursuant to 11 USC 365; determined by the party initiating the termination) to cure any default. E. The TPA engages in any unethical business practice or conducts itself in a manner which 5.5 The TPA may, at its sole option, terminate this in the reasonable judgment of the Plan Agreement within sixty (60) days written notice upon Sponsor may be a violation of any federal, the occurrence of any one or more of the following state, or other government statute, rule, or events pertaining to the Plan Sponsor: regulation; or A. The Plan Sponsor fails to pay administration F. The TPA loses its Iicensure or certification fees or other fees for the TPA's services upon required by law to continue its business or presentation for payment and in accordance continue as third -party administrator. with the Fee Schedule; SECTION 6. LIMITATIONS AND INDEMNIFICATION B, The Plan Sponsor engages in any unethical business practice or conducts itself in a 6.1 manner which in the reasonable judgment of the TPA may be a violation of any federal, state, or other government statute, rule, or regulation; C. The Plan Sponsor, through its acts, practices, or operations, exposes the TPA to any existing or potential investigation or litigation; D. Insolvency; E. Court appointment of a permanent receiver for all or substantially all of the Plan Sponsor's assets; F. A general assignment of the benefit of creditors by the Plan Sponsor; or G. The filing of a voluntary or involuntary petition of bankruptcy, if such petition is not dismissed within forty-five (45) days of the date of filing, In performing its obligations in this Agreement, the TPA is acting only as an independent contractor. Plan Sponsor shall be deemed to be Plan Administrator, unless Plan Sponsor designates an individual or committee to act as Plan Administrator. For purposes of the Employee Retirement Income Security Act of 1974 as amended from time to time and any applicable State legislation of a similar nature, Sponsor will be deemed to be Administrator of the Plan, unless Sponsor designates an individual or committee to act as Administrator. In no instance will the TPA be deemed to be or be, Administrator of the Plan for purposes of the Employee Retirement Income Security Act of 1974, as amended from time to time. 6.2 The TPA will indemnify, defend, save and hold the Plan Sponsor harmless from and against any and all claims, suits, actions, liabilities, losses, penalties or damages including court costs and attorney's fees with respect to the Plan which directly result from or arise out of the dishonest, fraudulent, grossly negligent or criminal acts MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 30 of 42 REV. 10.2022 Packet Pg. 1992 16.E.3.a of the TPA or its employees, except for any acts taken at the specific direction of the Plan Sponsor, 6.3 The Plan Sponsor will indemnify, defend, save, and hold the TPA harmless from and against any and all claims, suits, actions, liabilities, losses, penalties or damages, including court costs and attorney's fees, to the extent that such claims, losses, liabilities, damages and expenses arise out of or are based upon the gross negligence, fraudulent, criminal or dishonest acts of Plan Sponsor, its agents and employees in the performance of their duties, a release of data by the TPA to the Plan Sponsor, or an interpretation of the Plan by the Plan Sponsor on which the TPA acts. To the extent authorized by law, and applicable to contract and indemnity claims the foregoing indemnification shall not constitute a waiver of sovereign immunity beyond the limits set forth in Section 768.28, Florida Statutes, SECTION 7. MISCELLANEOUS 7.1 This Agreement, together with all addenda, exhibits, and appendices supersedes any and all prior representations, conditions, warranties, understandings, proposals, or other agreements between the Plan Sponsor and the TPA hereto, oral or written, in relation to the services and systems of the TPA, which are rendered or are to be rendered in connection with its assistance to the Plan Sponsor in the administration of the Plan. 7.2 This Agreement, together with the aforesaid addenda, exhibits, and appendices constitutes the entire Administrative Services Agreement of whatsoever kind or nature existing between or among the parties. 7.3 The parties hereto, having read and understood this entire Agreement, acknowledge and agree that there are no other representations, conditions, promises, agreements, understandings, or warranties that exist outside this Agreement which have been made by either of the parties hereto, which have induced either party or have led to the execution of this Agreement by either party. Any statements, proposals, representations, conditions, warranties, understandings, or agreements which may have been heretofore made by either of the parties hereto, and which are not expressly contained or incorporated by reference herein, are void and of no effect, 7.4 This Agreement may be executed in two or more counterparts, each and all of which shall be deemed an original and all of which together shall constitute but one and the same instrument 7.5 Except as provided herein, no changes in or additions to this Agreement shall be recognized unless and until made in writing and signed by all parties hereto. 7.6 In the event any provision of this Agreement is held to be invalid, illegal, or unenforceable for any reason and in any respect, such invalidity, illegality, or unenforceability shall in no event affect, prejudice, or disturb the validity of the remainder of this Agreement, which shall remain in accordance with its terms. 7,7 The Plan Sponsor will notify the TPA within ten (10) Working Days of any inquiry made by any Participant or authorized representative of any Participant related to Plan Documents, Plan Records, disputes, threatened litigation, lawsuits pertaining to the Plan or any inquiry made by any federal or state authority regarding the Plan, 7.8 In the event that either party is unable to perform any of its obligations under this Agreement because of natural disaster, labor unrest, civil disobedience, acts of war (declared or undeclared), or actions or decrees of governmental bodies (any one of these events which is referred to as a "Force Majeure Event"), the party who has been so affected shall immediately notify the other party and shall do everything possible to resume performance. Upon receipt of such notice, all obligations under this Agreement shall be immediately suspended. If the period of non-performance exceeds fourteen (14) Working Days from the receipt of notice of the Force Majeure Event, the party whose ability to perform has not been so affected may, by giving ten (10) Working Days written notice, terminate this Agreement. 7.9 All notices required to be given to either party by this Agreement shall, unless otherwise specified in writing, be deemed to have been given three (3) days after deposit in the U.S, Mail, first class postage prepaid, certified mail, return receipt requested, Any official notice to the TPA will be mailed to the attention of the President at 2806 South Garfield Street, Missoula, MT 59801. The TPA will not be bound by any notice, directive or request unless and until it is received in writing at this address. Any official notice to the Plan Sponsor will be mailed to the attention of the Risk Management Director, at 3311 Tamiami Trail East, Naples, Florida 34112. The Plan Sponsor will not be bound by any notice, directive or request unless and until it is received in writing at this address. 7.10 This Agreement shall be interpreted and construed in accordance with the laws of the state of Florida except to the extent superseded by federal law. Venue shall be in the state and federal courts in and for the U.S. Middle District Court, Fort Myers, Florida. 7.11 No forbearance or neglect on the part of either party to enforce or insist upon any of the provisions of this Agreement shall be construed as a waiver, alteration, or modification of the Agreement. MEDICAL ASA MED ST❑ SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 31 of 42 REV. 10.2022 Packet Pg. 1993 16.E.3.a APPENDIX A to APPENDIX D FEE SCHEDULE AND FINANCIAL ARRANGEMENT 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 A. A fee of $4,00 PEPM for HRA reimbursement processing services. E. 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 MER STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 32 of 42 REV. 10.2022 Packet Pg. 1994 16.E.3.a APPENDIX E RFP #22-7977 " Group Health & Dental Plan Administration Services" ADMINISTRATIVE SERVICES AGREEMENT FLEXIBLE BENEFITS PLAN This Agreement, effective for the period beginning January 1, 2023, and ending December 31, 2027, and may be renewed for two (2) additional one (1) year periods as mutually agreed by the parties in writing, is entered into by COLLIER COUNTY GOVERNMENT, a political subdivision of the State of Florida(hereinafter referred to as the "Plan Sponsor") and Allegiance Benefit Plan Management, Inc., a Corporation duly organized and existing under the laws of the State of Montana (hereinafter referred to as the "TPA"). WHEREAS, the Plan Sponsor sponsors a Flexible Benefits Plan (hereinafter referred to as the FLEX Plan) which is a "cafeteria plan" within the meaning of Section 125 of the Internal Revenue Code of 1986 as amended, and regulations issued thereunder, for all employees participating in the Plan Sponsor's health or welfare benefits plan; and WHEREAS, the Plan Sponsor wishes to contract with an independent third party administrator to perform certain supervisory services with respect to the FLEX Plan and to process reimbursement requests submitted under the FLEX Plan; and WHEREAS, the TPA desires to contract with the Plan Sponsor to provide such supervisory and reimbursement services with respect to the FLEX Plan, as set forth below; and WHEREAS, the parties wish to enter into this Agreement to set forth the obligations and duties of both parties with regard to such supervisory and reimbursement services. THEREFORE, in consideration of the promises and mutual covenants contained herein, the Plan Sponsor and the TPA enter in to this Agreement for administrative services for the FLEX Plan, SECTION 1. DEFINITIONS For the purposes of this Agreement the following words and phrases have the meanings set forth below, unless the context clearly indicates otherwise and, wherever appropriate, the singular will include the plural and the plural will include the singular 1.1 "Calendar Year" means January 1 through December 31 of the same year. 1.2 "COBRA" means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended, together with all regulations applicable thereto. 1.3 "Covered Services" means the care, treatments, services or supplies described in the Plan Document as eligible for reimbursement from the FLEX Plan. 1.4 "Employer" means the Plan Sponsor and any successor organization or affiliate of such Employer which assumes the obligations of the FLEX Plan and this Agreement. 1.6 "ERISA" means the Employee Retirement Income Security Act of 1974, as amended, together with all regulations applicable thereto. 1.7 "HIPAA" means the Health Insurance Portability and Accountability Act of 1996, as it may be amended from time to time, and all regulations applicable thereto. 1.8 "Participant" is any employee, retiree or COBRA beneficiary who is properly enrolled for and entitled to participate in the FLEX Plan and who submits expenses for reimbursement from the FLEX Plan. 1.9 "Plan" means the Flexible Benefits Plan for the Employees of Plan Sponsor, which is the subject of this Agreement and which the Plan Sponsor has established pursuant to the Plan Document. 1.10 1.6 "Fee Schedule" means the listing of fees or charges for services provided under this Agreement, This Fee Schedule may be modified from time to time in writing by the mutual agreement of the parties. The Fee 1.11 Schedule is contained in Appendix A and is a part of this Appendix E. "Plan Administrator" means the Employer andlor entity designated by the Plan Sponsor which is responsible to manage the day-to-day functions of the FLEX Plan and make all discretionary decisions regarding Plan terms and managing Plan assets. The Plan Administrator may employ persons or firms to process Reimbursement Requests and perform other Plan - connected services. For the purposes of the Employee Retirement Income Security Act of 1974, as amended, and any applicable state legislation of a similar nature, the Employer will be deemed to be the Plan Administrator of the FLEX Plan unless by action of the Board of Directors or equivalent authority the Employer designates in writing an individual or committee to act as Plan Administrator. "Plan Document" means the instrument or instruments that set forth and govern the duties of the Plan Sponsor and eligibility and benefit provisions of the FLEX Plan MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 38 of 42 REV. 10.2022 Packet Pg. 1995 16.E.3.a which provide for before -tax payment of premiums for the employee health and welfare plan and the reimbursement of Covered Services. 1.12 "Plan Sponsor" will be as defined in Section 3(16)(A) of ERISA and means the entity and any successor entity or organization, which is responsible for and which has created, established and maintains an employee health and welfare benefit plan and/or FLEX Plan for the benefit of a group or groups of employees. Plan Sponsor includes any successor organization or affiliate of such Plan Sponsor which assumes the obligations of the FLEX Plan and this Agreement. 1.13 "Plan Year" means the twelve-month period of time beginning with the effective date of the FLEX Plan as specified in the Plan Document. 1,14 "Reimbursement Account" means an account utilized for reimbursement for Covered Services. For purposes of this Agreement, the Reimbursement Account means the funds deposited for before -tax payment of 2.4 premiums for the employee health and welfare benefits plan and for Reimbursement Requests. 1.15 "Reimbursement Request" means a request by a Participant for reimbursement for Covered Services from the FLEX Plan. 1,16 "Summary Plan Description" means the document required to be provided under Sec. 102 of ERISA that describes the terms and conditions under which the FLEX Plan operates. 1 A 7 "Working Day" will mean a regular business day that is not a recognized federal or banking holiday, and specifically excluding any Saturday or Sunday. SECTION 2. RELATIONSHIP OF THE PARTIES 2.1 The Plan Sponsor delegates to the TPA only those powers and responsibilities with respect to development, maintenance and administration of the FLEX Plan that are specifically enumerated in this Agreement. Any function not specifically delegated to and assumed by the TPA in writing pursuant to this Agreement will remain the sole responsibility of the Plan Sponsor. The Plan Sponsor retains the responsibility for any obligations under the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, as amended, and obligations under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) unless this Agreement and the Fee Schedule in Appendix A to Appendix E expressly include provisions and fees for COBRA or HIPAA administrative services by the TPA. 2.2 The TPA is acting as an independent contractor for purposes of this Agreement. As such, the TPA is not a fiduciary and does not assume any liability or responsibility for any breach of duty or act of omission by Plan Sponsor, 2.3 The parties acknowledge that: A. This is a contract for administrative services only as specifically set forth herein; and B. The TPA will not be obligated to disburse more in payment for Reimbursement Requests or other obligations arising under the FLEX Plan than the Plan Sponsor will have made available In the Reimbursement Account; and C. This Agreement will not be deemed a contract of insurance under any laws or regulations, The TPA does not insure, guarantee or underwrite the liability of the Plan Sponsor under the FLEX Plan. The Plan Sponsor has total responsibility for payment of before -tax premiums for the employee health and welfare benefits plan, for Reimbursement Requests under the FLEX Plan and all expenses incidental to the FLEX Plan. Except as specifically set forth herein, this Agreement will inure to the benefit of and be binding upon the parties hereto and their respective legal successors provided, however, neither party may assign this Agreement without the prior written consent of the other, which consent will not be unreasonably withheld. There are no intended or unintended third -party beneficiaries to this Agreement, and this Agreement will not be construed in any manner as to create same. 2.5 Prior to the initiation of any action or proceeding permitted by this Agreement to resolve disputes between the parties, the parties shall make a good faith effort to resolve any such disputes by negotiation. The negotiation shall be attended by representatives of the TPA with full decision -making authority and by Plan Sponsor's staff person who would make the presentation of any settlement reached during negotiations to Plan Sponsor for approval. Failing resolution, and prior to the commencement of depositions in any litigation between the parties arising out of this Agreement, the parties shall attempt to resolve the dispute through Mediation before an agreed -upon Circuit Court Mediator certified by the State of Florida. The mediation shall be attended by representatives of the TPA with full decision -making authority and by Plan Sponsor's staff person who would make the presentation of any settlement reached at mediation to OWNER'S board for approval. Should either party fail to submit to mediation as required hereunder, the other party may obtain a court order requiring mediation under Section 44.102, Fla. Statutes, Any suit or action brought by either party to this Agreement against the other party relating to or arising out of this Agreement must be brought in the appropriate federal or state courts in and for Collier County, Florida, which courts have sole and exclusive jurisdiction on all such matters. 2.6 It is agreed by the parties to this Agreement that any cause of action brought by either party to this contract must be made within five (5) years of the date of MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 34 of 42 REV. 10-2022 Packet Pg. 1996 1 ti.E.3.a occurrence of any alleged breach, infraction or dispute, these services are stated in the Fee Schedule in Appendix A of or within five (5) years of the termination date of this this Appendix E. Agreement, whichever occurs first, in compliance with Section 95.11, Florida Statutes. SUPERVISORY SERVICES 2.7 The TPA agrees to be duly licensed as a Third Party 3.1 The TPA will assist Plan Sponsor in developing and Administrator to the extent required under applicable designing the FLEX Plan and any amendments, law and agrees to maintain such licensure throughout revisions or modifications, subject to approval by Plan the term of this Agreement. Sponsor or Plan Sponsor's attorney. 2.8 The TPA may secure the services of actuaries, 3.2 The TPA will maintain FLEX Plan records based on computer service firms, insurance consultants, legal eligibility information submitted by the Plan Sponsor as counsel, accountants and any other entities that it to the dates on which a Participant's eligibility deems necessary in performing its duties under this commences and terminates, maintain Plan records of Agreement. At the discretion of the TPA such services Plan elections applicable to each Participant based on may be performed directly by it, wholly or in part, information submitted by the Plan Sponsor, and through a subsidiary or affiliate of the TPA or under an maintain Plan records regarding Reimbursement agreement with an organization, agent, advisor or Requests, denials of Reimbursement Requests, and other person of its choosing. Any such services Reimbursement Requests pended. resulting in a charge not agreed to in the Fee Schedule must first be authorized in writing by the flan 3.3 Upon request of Plan Sponsor, TPA will perform Sponsor, The TPA will be entitled to rely, without twenty-five percent (25%) Key Employee investigation or inquiry, upon any written or oral Concentration discrimination testing for the Plan information or communication of the Plan Sponsor or referenced in this Agreement. However, by providing Agents, including but not limited to: Consultants, these services, TPA is not acting as Plan Sponsor's Actuaries, Attorneys, Accountants, auditors, or Brokers legal counsel or tax advisor. All services provided by retained by the Plan Sponsor. TPA under this paragraph should be reviewed by Plan Sponsor's legal counsel and tax advisors. 2.9 ALLEGIANCE will not be bound by any notice, directive or request unless and until it is received in writing at the 3.4 The TPA will perform the following specific services for mailing address or fax number shown below: Flan Sponsor as requested: 2806 South Garfield Street A. Project estimated costs relating to the FLEX Missoula, MT 59801 Plan. Facsimile: (406) 523-3149 B. Draft and prepare FLEX Summary Plan Neither Plan Sponsor nor Plan Administrator will be Description for review and approval by Plan bound by any written notice, directive or request unless Sponsor's legal counsel. and until it is received in writing at its primary place of business or fax number shown below: C. Assist with the introduction of Plan provisions and procedures to Plan Sponsor's electing 3311 Tamiami Trail East employees through materials and meetings Naples, Florida 34112 arranged by agreement between Sponsor Facsimile: 239-252-8048 and the TPA. 2.10 The parties to this Agreement acknowledge that the D. Prepare reports as required by law for the TPA will have no obligation of any sort, express or financial management and administrative implied, in this contract to provide Plan Sponsor with control of the FLEX Plan for use by Plan any proprietary, confidential or trade secret information Sponsor. of TPA. The Plan Sponsor is entitled to its claims information and other information which the Plan E. Provide to Plan Sponsor, upon request, a Sponsor and flan Administrator are required to retain copy of all Plan documents which employees by applicable law, but any proprietary, confidential or are entitled to examine under ERISA and any trade secret information of the TPA shall be removed other related documents. Said documents from such information. The TPA will not disclose will be limited to insurance contracts, if any, proprietary, confidential or trade secret information to and documents required to be filed with the U. the Plan Sponsor without the Plan Sponsor first S. Department of Labor. There will be a executing a legally binding Confidentiality and Non- fifteen cent ($.15) per page copy charge Disclosure Agreement regarding such information. assessed for all copies produced hereunder, SECTION 3. THE TPA's RESPONSIBILITIES 3.5 The Employer and not the TPA, is responsible for preparing and filing the IRS Form 5500 on The TPA will provide the following FLEX Plan Supervisory and or before the due date. The TPA will provide Reimbursement Services for the Plan Sponsor. The fees for the necessary information to enable the Plan Sponsor to complete and file an IRS form MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT. WC. Pape 35 of 42 REV. 10-2022 Packet Pg. 1997 16.E.3.a 5500 annual report, if requested, at least thirty (30) days prior to the date such filings are due. REIMBURSEMENT PROCESSING SERVICES 3.6 As specified under the FLEX Plan, the TPA will: A. Promptly process and prepare disbursement to pay valid Reimbursement Requests submitted by participating employees, Provide a proper accounting and billing to Plan Sponsor of Reimbursement Requests paid. C. Maintain current and complete records and files of Reimbursement Requests and payments for each participating employee according to the TPA's current practices. 3.7 The TPA will possess throughout the term of this Agreement an in -force fidelity bond or other insurance as may be required by state and federal laws for the protection of its clients. Additionally, the TPA agrees to comply with any state or federal statutes or regulations regarding its operations. 3.8 The TPA will process enrollment forms for Participants in the FLEX Plan and answer enrollment inquiries; create and maintain enrollment records for Participants and distribute FLEX Plan materials supplied by the Plan Sponsor to new Plan Participants. 3.9 The TPA will process Reimbursement Requests incurred by Participants according to the terms of the Plan Document as construed by the Plan Sponsor. The TPA will establish and maintain usual and customary Reimbursement Request review procedures within the usual standard of care in the TPA industry. The TPA will take reasonable measures and precautions to prevent the reimbursement of improper requests. The TPA will not be liable for fraud, misrepresentation or errors by any Participant or for errors in Reimbursements made to Participants in good faith. When all necessary documents and Reimbursement Request form information have been received and the Reimbursement Request has been adjudicated, a Reimbursement check or draft will be remitted on the next Reimbursement disbursal date provided that the Plan Sponsor has provided funds for such Reimbursement. All Reimbursement Requests will remain in a processed but pended status until funded by the Plan Sponsor. Customer Service Representatives of the TPA will inform any Participant who inquires about any Reimbursement Request which is pended for lack of funds that such Reimbursement Request has been received and processed and is pending receipt of funds. No further explanation will be required of the TPA by the Plan Sponsor under such circumstances. 3.10 The TPA will notify Participants in writing of ineligible Reimbursement Requests received. 3.11 The TPA will process, issue, and distribute Reimbursement checks or drafts as instructed by the Plan Sponsor to Participants. The TPA will notify the Plan Sponsor of the Reimbursement Request amount required to be deposited to the Reimbursement Account to pay the Reimbursement Requests as they occur. 3.12 The TPA will maintain local telephone service and toll - free telephone lines for inquiries made by Participants regarding the status of their Reimbursement Requests. The TPA may record such telephone calls. 3.13 The TPA will respond to Reimbursement Request inquiries by a Participant, the estate of a Participant, an authorized member of a Participant's family unit, or the Participant's authorized legal representative. 3.14 The TPA will maintain information that identifies a Participant in a confidential manner. The TPA agrees to take all reasonable precautions to prevent disclosure or the use of premium payment information or Reimbursement Request information for a purpose unrelated to the administration of the FLEX Plan. 3.15 Plan Sponsor may provide its own Plan Document and Summary Plan Description at its expense, used by TPA for review and approval by Plan Sponsor's legal counsel, subject to review and approval by TPA. 3.16 The TPA will maintain a Reimbursement Request file on every Reimbursement Request reported to it by the Participants. Copies of such records will be made available to the Plan Sponsor during a regularly scheduled Working Day at the office of the TPA for consultation, review, and audit upon advance notice of a minimum of fourteen (14) Working Days. The Plan Sponsor will pay for any audit made at its request. A fee of fifteen cents ($.15) per photo copy will be paid by the Plan Sponsor or Plan auditor on behalf of the Plan Sponsor for any Reimbursement Request or other record. The TPA will charge an hourly fee of one hundred dollars ($100.00) for executive or professional time, fifty dollars ($50.00) per hour for department manager time and twenty-five dollars ($25.00) per hour for clerical time spent in cooperation with such consultation, review and audit, 3.17 The TPA will, upon termination of this Agreement, save all records at the TPA's principal administrative office. Reimbursement request files will be kept in secure storage facilities for at least seven (7) years following the termination of a Plan Year or as required by ERISA. Copies of any materials in storage will be available to Plan Sponsor for a copy fee of fifteen cents ($.15) per page copied plus a retrieval fee of ten dollars ($10.00) per box or CD ROM diskette accessed. At the end of the six-(6) year period, the TPA will destroy all records. 3,18 The TPA will perform special Reimbursement Request history research projects upon request by the Plan Sponsor. A separate fee may be required depending upon the complexity of such request. MEDICAL ASA MEo STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 36 of 42 REV, 10-2022 Packet Pg. 1998 16.E.3.a 3.19 The TPA will provide non-proprietary information and documents as requested by the Plan Sponsor to brokers and agents designated by the Plan Sponsor, provided, however, if the Plan Sponsor has entered into an agent of record agreement with any agent or broker, and the TPA has notice of the same, the TPA will not be required to provide any information or documentation to other agents or brokers unless or until Plan Sponsor has terminated the agent of record agreement and notified the agent of record of the termination. The TPA will have the express right to contact any agent of record to verify the agent of record agreement has been terminated. 3.20 The TPA will have no obligation whatsoever with regard to the Plan Sponsor's obligations and responsibilities under the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, as amended, or the Health Insurance Portability and Accountability Act (HIPAA) of 1996, unless specifically requested by Plan Sponsor, in which case TPA's responsibilities for COBRA administration are stated in the COBRA Appendix C attached hereto and made a part hereof by this reference, 3.21 Upon request TPA will provide certain limited bank account management services for the reimbursement Account, for the fees and upon the conditions set out in Reimbursement Account Management Services Appendix D attached hereto and made a part hereof by this reference. SECTION 4. PLAN SPONSOR OBLIGATIONS 4.1 Plan Sponsor will furnish to the TPA the following reports and information to allow effective performance by the TPA: A. Certification of participation in the FLEX Plan and such other information as may be necessary for processing Reimbursement Requests. B. Prompt reconciliation of: (1) The itemized monthly billing provided by the TPA listing employees covered under the FLEX Plan, and; (2) The amount of premiums and contributions elected by each participating employee for the billing period. In the event the Plan Sponsor does not reconcile the contribution listing, the TPA will reconcile the contribution listing at the rates shown in the Fee Schedule in Appendix A to this Appendix E. 4.2 Plan Sponsor will give notice of the establishment of the FLEX Plan to its employees and will be responsible for distributing copies of the Summary Plan Description to participating employees. 4.3 Plan Sponsor will maintain current and accurate Plan eligibility and participation records, verify Participant eligibility and submit this information if requested by the TPA, to the TPA at its designated mailing address. This information will be provided in a format acceptable to the TPA and will include the following for each Participant: name and address, Social Security number, date of birth, type of participation, sex, relationship to employee, changes in participation, date participation begins or ends, and any other information necessary to determine eligibility and participation levels under the FLEX Plan. Plan Sponsor assumes the responsibility for the erroneous disbursement of reimbursements by the TPA in the event of error or neglect on the Plan Sponsor or Employer's part of providing eligibility and participation information to the TPA, including but not limited to, failure to give timely notification of ineligibility or termination of a former Participant. 4.4 Plan Sponsor will resolve all Plan ambiguities and disputes relating to the eligibility of a Participant, Plan participation, denial of Reimbursement Requests or decisions regarding appeal, or denial of Reimbursement Requests, or any other Plan interpretation questions. The Plan Sponsor will respond to any written request made by the TPA within ten (10) working days. The TPA will administer and process Reimbursement Requests in accordance with this Agreement if the Plan Document and Summary Plan Description are clear and unambiguous as to the validity of the Reimbursement Requests and the Participants' eligibility for participation under the FLEX Plan, but will have no discretionary authority to interpret the FLEX Plan or adjudicate Reimbursement Requests. If processing a Reimbursement Request requires interpretation of ambiguous Plan language, and the Plan Sponsor has not previously indicated to the TPA the proper interpretation of the language, then the Plan Sponsor will be responsible for resolving the ambiguity or any other dispute. The Plan Sponsor's decision as to any Reimbursement Request (whether or not it involves a Plan ambiguity or other dispute) will be final and binding unless modified or reversed by a court or regulatory agency having jurisdiction over such matter. 4.5 Plan Sponsor will prospectively fund the Reimbursement Accounts each pay period by depositing funds deducted from Participants' wages into the Reimbursement Account. If additional funding is required to pay claims, Plan Sponsor shall advance funds in a timely manner, but in no event later than thirty (30) days after notice from the TPA of the required funding amount, so pended claims can be released. 4.6 Plan Sponsor will not demand or require the TPA, under any circumstances, to issue checks or drafts for Reimbursement Requests or any other costs arising MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 37 of 42 REV, 10-2022 Packet Pg. 1999 16.E.3.a out of the subject matter of this Agreement, unless the Plan Sponsor has so authorized and has previously deposited sufficient funds to cover such payment(s). 4.7 Plan Sponsor will provide the TPA with copies of any and all revisions or changes to the FLEX Plan within five (5) Working Days of the effective date of the changes. 4.8 Plan Sponsor will provide, and timely distribute, all notices and information required to be given to Participants, maintain and operate the FLEX Plan in accordance with applicable law, maintain all record keeping, and file all forms relative thereto pursuant to any federal, state, or local law, unless this Agreement specifically assigns such duties to the TPA. 4.9 Plan Sponsor will at all times acknowledge that it is the Plan Sponsor, Plan Administrator, and Named Fiduciary, as these terms are defined in ERISA or other applicable law. As such, Plan Sponsor retains full discretionary control and authority and discretionary responsibility in the operation and administration of the FLEX Plan. 4.10 Plan Sponsor will pay any and all taxes, licenses, and fees levied, if any, by any local, state, or federal authority in connection with the FLEX Plan. 4.17 Plan Sponsor will provide all reports and documents required from time to time to satisfy governing law or to promote effective FLEX Plan operation. 4.18 Plan Sponsor retains sole responsibility for Plan Sponsor's obligations and responsibilities under the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, as amended, or the Health Insurance Portability and Accountability Act (HIPAA) of 1996, unless Plan Sponsor has specifically requested TPA to provide COBRA administrative services, in which case TPA's responsibilities for COBRA administration are stated in the COBRA Appendix C attached hereto and made a part hereof by this reference. 4.19 4.11 Plan Sponsor will hold confidential information obtained that is proprietary to the TPA or information or material not generally known by personnel other than management employees of the TPA. Subject to 4.20 Chapter 119, Florida Statutes, also known as the Public Records Law. 4.21 4.12 Plan Sponsor will pay, in accordance with the Fee Schedule, the TPA's fees for services rendered under this Agreement. Unless otherwise agreed, the TPA may withdraw from the applicable account any fee then due to the TPA prior to application of the funds in the applicable account to pay Reimbursement Requests or any other costs arising out of the FLEX Plan or the subject matter of this Agreement. 4.13 Plan Sponsor will maintain any fidelity bond or other insurance as may be required by state or federal law for the protection of the FLEX Plan and Participants. 4.14 Plan Sponsor will notify the TPA of any requests for FLEX Plan documents or written inquiries about Reimbursement Requests processed under the FLEX Plan. 4.15 Plan Sponsor will maintain a supply of election forms, Reimbursement Request forms, Compensation Reduction Agreement forms, and other documents provided by the TPA, and will make them available to participating employees. 4,15 Plan Sponsor will submit timely payment for enrollment services and administrative fees as stated in Appendix A of this Appendix E. If the Plan Sponsor elects Set -Up Services Only, as shown on the Fee Schedule in Appendix A of this Appendix E, and elects not to have the TPA provide Re -Enrollment and Discrimination Testing Services, the Plan Sponsor retains sole responsibility for Discrimination Testing, and the TPA will have no responsibility for the same, Further, if these services are not elected, the TPA will have no responsibility whatsoever for notifying Plan Sponsor of changes in, and required compliance with, the laws applicable to this Plan, including Plan Document revisions required for such compliance. The Plan Sponsor will remain solely responsible for remaining apprised of such future changes in laws and required compliance with regard to Plan Documents. The Plan Sponsor has sole responsibility for preparing and filing IRS Form 5500 if applicable. TPA provides a website to its customers for access to plan information which includes Protected Health information (PHI) as that term is defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Access to PHI via the website is limited to the person to whom the PHI belongs by use of a unique personal password mailed to that person's known address. Plan Sponsor has requested TPA issue passwords to persons requesting them via the TPA's website. Plan Sponsor and TPA agree to the following: The person requesting a password will certify their identity by using unique identifiers. TPA will not be responsible or liable in any way as the Business Associate of Plan Sponsor for any fraud or identity misrepresentation which causes a password to be issued to the wrong person. SECTION 5. DURATION OF AGREEMENT 5.1 This Agreement shall commence on January 1, 2023, and end on December 31, 2027. This Agreement and may be renewed for two (2) additional one (1) year periods as mutually agreed by the parties in writing, under the same terms, conditions and Fee Schedule unless modified or terminated as described below. MEDICAL ASA MEC STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 38 of 42 REV. 10-2022 Packet Pg. 2000 16.E.3.a 5.2 In the event of a change in the Fee Schedule the fee quote described in this subsection must be accepted, D. The Plan Sponsor loses its licensure or in writing, by Plan Sponsor prior to the renewal date for certification required by law to continue the the period to which the fee quote applies. Non FLEX Plan; acceptance of the fee quote prior to such renewal date shall cause this Agreement to lapse and terminate at E. Insolvency; 12:01 o'clock a.m. on that renewal date. F. Court appointment of a permanent receiver 5.3 Either party may terminate this Agreement at any time for all or substantially all of the Plan Sponsor's upon providing the terminating party with sixty (60) assets; days prior notice of intent to terminate unless both parties agree to waive such advance notice. All G. A general assignment of the benefit of obligations of the TPA to process benefits under the creditors by the Plan Sponsor; or FLEX Plan are terminated on the effective date of termination even though a reimbursable expanse H. The filing of a voluntary or involuntary petition arose prior to the termination of this Agreement. At of bankruptcy, if such petition is not dismissed the option of the party initiating the termination, the within forty-five (45) days of the date of filing, other party may be permitted a cure period not to provided that an order for relief from exceed ten (10) business days. automatic stay has been obtained, or with respect to a Chapter 11 proceeding, that the 6.4 Failure of Plan Sponsor to provide funds for bankrupt or Bankruptcy Trustee fails to Reimbursement Requests or to make contributions to reaffirm this Agreement and provide adequate the FLEX Plan will result in the termination of this assurances pursuant to 11 USC 365. Agreement thirty (30) days from the date of written notice to Plan Sponsor of the lack of funds. 5.8 The Plan Sponsor may, at its option, terminate this Agreement with ten (10) days written notice upon the 5.5 Upon termination of this Agreement, the TPA shall occurrence of any one or more of the following events provide an accounting and reconciliation to Plan pertaining to the TPA: Sponsor within sixty (60) days after the effective date of termination. Together with said accounting and A. Insolvency; reconciliation, the TPA shall return to Plan Sponsor all remaining funds of Plan Sponsor and/or its employees B. Court appointment of a permanent receiver held by the TPA. TPA shall forward to Plan Sponsor for all or substantially all of the TPA's assets; all Reimbursement Requests received but not processed by TPA, C. A general assignment of the benefit of creditors by the TPA; 5.6 Any amendment which affects only the Fee Schedule, Appendix A to this Appendix E, shall be made, in D. The filing of a voluntary or involuntary petition writing signed by all parties and approved by the Collier of bankruptcy, if such petition is not dismissed County Board of County Commissioners, All fee quotes within forty-five (45) days of the date of filing, accepted by Plan Sponsor for renewals of this provided that an order for relief from Agreement will be incorporated into this Agreement as automatic stay has been obtained, or with amendments to the Fee Schedule, Appendix A to this respect to a Chapter 11 proceeding, that the Appendix E. bankrupt or Bankruptcy Trustee fails to reaffirm this Agreement and provide adequate 5.7 The TPA may, at its sole option, terminate this assurances pursuant to 11 USC 365; Agreement with ten (10) days written notice upon the 'occurrence of any one or more of the following events E. The TPA engages in any unethical business pertaining to the Plan Sponsor: practice or conducts itself in a manner which in the reasonable judgment of the Plan A. The Plan Sponsor fails to pay administration Sponsor may be a violation of any federal, fees or other fees for the TPA's services upon state, or other government statute, rule, or presentation for payment and in accordance regulation; or with the Fee Schedule; F. The TPA loses its licensure or certification B. The Plan Sponsor engages in any unethical required by law to continue its business or business practice or conducts itself in a continue as third -party administrator. manner which in the reasonable judgment of the TPA may be a violation of any federal, 5.9 In the event this Agreement is terminated for any state, or other government statute, rule, or reason and Plan Sponsor cannot be located following regulation; reasonable efforts by TPA, TPA shall charge a fifty dollar ($50,00) per check administrative charge for its C. The Plan Sponsor, through its acts, practices, efforts to return any stale dated funds defined as a or operations, exposes the TPA to any check with an original issue date greater than one existing or potential investigation or litigation; hundred eighty (180) days belonging to Plan Sponsor MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 39 of 42 REV. 10.2022 Packet Pg. 2001 16.E.3.a or belonging to a plan participant who, likewise, cannot be located. The administrative charge may be paid from any funds of the Plan Sponsor held by TPA, or billed directly to the Plan Sponsor, This provision shall survive termination of this Agreement. 5.10 TPA, in its sole discretion may provide run out services upon the termination of this agreement. The Run out period, not to exceed three (3) months, will be determined by the Plan Sponsor at the time of notification of the termination. If no run out time is specified, the TPA will cease all claims processing on the date of termination. Run out services will consist solely of processing claims incurred by a Participant prior to the date of termination of this Agreement, but submitted no later than the end of the run out period, Run out services will be provided by the TPA only if at the time of termination of this agreement, all fees due the TPA and all plan funding are paid and current. TPA will not provide run out services if the above conditions are not met, or if termination is a result of any of the conditions listed in paragraph 5,7 of this Agreement, The run out fee will be an amount equal to the amount of Plan Sponsor's administrative fees payable to the TPA for the month immediately prior to the date notice of termination multiplied by the run out time in months, Upon determination of the run out period, a run out fee schedule will be issued to the Plan Sponsor as an Appendix F to this agreement. SECTION 6. LIMITATIONS AND INDEMNIFICATION 6.1 In performing its obligations in this Agreement, the TPA is acting only as an independent contractor. Plan Sponsor shall be deemed to be Plan Administrator, unless Plan Sponsor designates an individual or committee to act as Plan Administrator. For purposes of the Employee Retirement Income Security Act of 1974 as amended from time to time and any applicable State legislation of a similar nature, Sponsor will be deemed to be Administrator of the Plan, unless Sponsor designates an Individual or committee to act as Administrator. In no instance will the TPA be deemed to be or be, Administrator of the Plan for purposes of the Employee Retirement income Security Act of 1974, as amended from time to time. 6.2 The TPA will not be liable for, and will not advance its funds for payment of Reimbursement Requests under the FLEX Plan. The TPA will not be considered the insurer or underwriter of the liability of Plan Sponsor to provide benefits for the employees participating under the FLEX Plan. Plan Sponsor will have final responsibility and liability for Reimbursement Requests in accordance with the FLEX Plan. 6.3 The TPA will indemnify, defend, save and hold the Plan Sponsor harmless from and against any and all claims, suits, actions, liabilities, losses, penalties or damages including court costs and attorney's fees with respect to the FLEX Plan which directly result from or arise out of the dishonest, fraudulent, grossly negligent or criminal acts of the TPA or its employees, except for any acts taken at the specific direction of the Plan Sponsor, 6.4 The Plan Sponsor will indemnify, defend, save, and hold the TPA harmless from and against any and all claims, suits, actions, liabilities, losses, penalties or damages, , to the extent that such claims, losses, liabilities, damages and expenses arise out of or are based upon the gross negligence, fraudulent, criminal or dishonest acts of Plan Sponsor, its agents and employees in the performance of their duties, a release of data by the TPA to the Plan Sponsor, or an interpretation of the FLEX Plan by the Plan Sponsor on which the TPA acts. To the extent authorized by law, and applicable to contract and indemnity claims the foregoing indemnification shall not constitute a waiver of sovereign immunity beyond the limit set forth in Section 768,28, Florida Statutes SECTION 7, MISCELLANEOUS 7.1 This Agreement, together with all addenda, exhibits, and appendices supersedes any and all prior representations, conditions, warranties, understandings, proposals, or other agreements between the Plan Sponsor and the TPA hereto, oral or written, in relation to the services and systems of the TPA, which are rendered or are to be rendered in connection with its assistance to the Plan Sponsor in the administration of the FLEX Plan. 7.2 This Agreement, together with the aforesaid addenda, exhibits, and appendices constitutes the entire Administrative Services Agreement of whatsoever kind or nature existing between or among the parties. 7.3 The parties hereto, having read and understood this entire Agreement, acknowledge and agree that there are no other representations, conditions, promises, agreements, understandings, or warranties that exist outside this Agreement which have been made by either of the parties hereto, which have induced either party or have led to the execution of this Agreement by either party. Any statements, proposals, representations, conditions, warranties, understandings, or agreements which may have been heretofore made by either of the parties hereto, and which are not expressly contained or incorporated by reference herein, are void and of no effect. 7.4 This Agreement may be executed in two or more counterparts, each and all of which shall be deemed an original and all of which together shall constitute but one and the same instrument. 7.6 Except as provided herein, no changes in or additions to this Agreement shall be recognized unless and until made in writing and signed by all parties hereto. 7.6 In the event any provision of this Agreement is held to be invalid, illegal, or unenforceable for any reason and in any respect, such invalidity, illegality, or unenforceabifity shall in no event affect, prejudice, or disturb the validity of the remainder of this Agreement, which shall remain in accordance with its terms. MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 40 of 42 REV. W-2022 Packet Pg. 2002 16.E.3.a 7.7 The Plan Sponsor will notify the TPA within ten (10) Working Days of any inquiry made by any Participant or authorized representative of any Participant related to Plan Documents, Plan Records, Reimbursement Requests, disputes, threatened litigation, lawsuits pertaining to the FLEX Plan or any inquiry made by any federal or state authority regarding the FLEX Plan. 7.8 In the event that either party is unable to perform any of its obligations under this Agreement because of natural disaster, labor unrest, civil disobedience, acts of war (declared or undeclared), or actions or decrees of governmental bodies (any one of these events which is referred to as a "Force Majeure Event"), the party who has been so affected shall immediately notify the other party and shall do everything possible to resume performance. Upon receipt of such notice, all obligations under this Agreement shall be Immediately suspended. If the period of non-performance exceeds fourteen (14) Working Days from the receipt of notice of the Force Majeure Event, the party whose ability to perform has not been so affected may, by giving ten (10) Working Days written notice, terminate this Agreement. 7.9 All notices required to be given to either party by this Agreement shall, unless otherwise specified in writing, be deemed to have been given three (3) days after deposit in the U.S. Mail, first class postage prepaid, certified mail, return receipt requested. Any official notice to the TPA will be mailed to the attention of the President at 2806 South Garfield Street, Missoula, MT 59801. The TPA will not be bound by any notice, directive or request unless and until it is received in writing at this address. Any official notice to the Plan Sponsor will be mailed to the attention of the Risk Management Director at 3311 Tamiami Trail East, Naples, Florida 34112. The Plan Sponsor will not be bound by any notice, directive or request unless and until it is received in writing at this address. 7.10 The TPA has adopted an Affirmative Action Policy that is in compliance with Section 49-3-101 to Section 49- 3-303 MCA. Employees hired by the TPA are hired on the basis of merit and qualifications; and there is no discrimination on the basis of race, color, religious creed, political ideas, sex, age, marital status, physical handicap, national origin or ancestry by persons performing this Agreement. Qualifications mean such abilities as are genuinely related to competent performance of the particular occupational task. 7,11 This Agreement shall be interpreted and construed in accordance with the laws of the state of Florida except to the extent superseded by federal taw with venue in the State and Federal courts in and for Collier County, Florida. 7.12 No forbearance or neglect on the part of either party to enforce or insist upon any of the provisions of this Agreement shall be construed as a waiver, alteration, or modification of the Agreement. MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 41 of 42 REV. 10.2022 Packet Pg. 2003 16.E.3.a APPENDIX A to APPENDIX E FEE SCHEDULE AND FINANCIAL. ARRANGEMENT 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 A. A fee of $5.15 PEPM for flexible spending account processing services. 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 $0.25 /participant/month together with 2% of the COBRA fees collected. MEDICAL ASA MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Page 42 of 42 REV. 10-2022 Packet Pg. 2004 16.E.3.a BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement ("Agreement") is entered into between COLLIER COUNTY Government, a political subdivision of the State of Florida (hereinafter referred to as the "Covered Entity") and Allegiance Benefit Plan Management, Inc., a corporation duly organized and existing under the laws of the State of Montana, and registered to do business in the State of Florida (hereinafter referred to as the "Business Associate"), effective as of this day , 2022 (the "Effective Date"). WHEREAS, Covered Entity and Business Associate have entered into, or plan to enter into, an arrangement pursuant to which Business Associate may provide services for Covered Entity that require Business Associate to receive Protected Health Information ("PHI") on behalf of Covered Entity that is confidential under state and/or federal law; and WHEREAS, Covered Entity and Business Associate intend to protect the privacy and provide for the security of PHI disclosed by Covered Entity to Business Associate, or created by Business Associate on behalf of Covered Entity, in compliance with the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 ("HIPAA"), and the regulations promulgated there under, including, without limitation, the Standards for the Privacy of Individually Identifiable Health Information codified at 45 CFR Parts 160 and 164 ("Privacy Rule") and the Security Standards for the Protection of Electronic Protected Health Information at 45 G.F.R. Parts 160 and 164 ("Security Rule") (collectively "HIPAA Regulations"); as amended by the applicable provisions of the Health Information Technology for Economic and Clinical Health Act, as incorporated in the American Recovery and Reinvestment Act of 2009, and its implementing regulations and guidance issued by the Secretary of the Department of Health and Human Services (the "Secretary") (the "HITECH Act"); as amended by the Final HIPAA regulations (collectively the "HIPAA Rules"); and WHEREAS, the HIPAA Regulations require Covered Entity to enter into an agreement with Business Associate meeting certain requirements with respect to the Use and Disclosure of PHI, which are met by this Agreement. NOW, THEREFORE, in consideration of the mutual promises contained herein and the exchange of information pursuant to this Agreement, the parties agree as follows: 1. Definitions. Capitalized terms used herein without definition shall have the meanings ascribed to them in the HIPAA Rules, as applicable unless otherwise defined herein. "Protected Health Information" or "PHI" shall have the same meaning as the term "protected health information" in 45 C.F.R. §160.103 and is limited to the PHI that Business Associate creates or receives from or on behalf of Covered Entity. As used herein, it also includes electronic Protected Health Information. "Electronic Protected Health Information" or "ePHI" shall have the same meaning as the term "electronic protected health information" in 45 C.F.R. § 160.103 and refers to electronic Protected Health Information transmitted by, or maintained in, electronic media for or on behalf of the Covered Entity. 2.Obligations and Activities of Business Associate. Permitted Uses and Disclosures. Business Associate shall Use or Disclose PHI for the Page I of 8 ;-C Packet Pg. 2005 16.E.3.a purposes of (i) performing Business Associate's obligations under the Administrative Services Agreement resulting from Covered Entity's Request for Proposal # 22-7977, "Group Health and Dental Plan Administrative Services" (including all Appendices/Agreements attached to that Administrative Services Agreement); or (ii) as permitted or Required By Law; ar (iii) as otherwise permitted by this Agreement. Business Associate shall not Use or further Disclose PHI other than as permitted or required by this Agreement or as Required By Law. Further, Business Associate shall not Use or Disclose PHI in any manner that would constitute a violation of the Privacy Rule if it were done by Covered Entity, except as set forth below in this Section 2.a, Business Associate may Use PHI: (i) for the proper management and administration of Business Associate; and, (ii) to carry out the legal responsibilities of Business Associate. Business Associate may Disclose PHI for the proper management and administration of Business Associate, to carry out its legal responsibilities or for payment purposes as specified in 45 CFR § 164.506(c)(1) and (3), including but not limited to Disclosure to a business associate on behalf of a covered entity or health care provider for payment purposes of such covered entity or health care provider, provided that with respect to any such Disclosure either: (i) the Disclosure is Required By Law; or (ii) Business Associate shall obtain reasonable assurances from the person to whom the PHI is to be Disclosed that such person will hold the PHI in confidence and will not use and further disclose such PHI except as Required By Law and for the purpose(s) for which it was Disclosed by Business Associate to such person, and that such person will notify Business Associate of any instances of which it is aware in which the confidentiality of the PHI has been breached. Business Associate may de - Identify any and all PHI obtained by Business Associate, and use such de -identified data on Business Associate's own behalf, all in accordance with the dc-identification requirements of the Privacy Rule. The parties acknowledge and agree that de -identified data does not constitute PHI. Business Associate may use PHI to provide Data Aggregation services to Covered Entity as permitted by 45 C.F.R. § 164.504(e)(2)(i)(B). Business Associate may use PHI to report violations of law to appropriate Federal and State authorities, consistent with 45 C.F.R. § 164.5020)(1), Business Associate may use PHI to the extent and for any purpose authorized by an Individual under 45 C.F.R. § 164.508. b. Appropriate Safeguards. Business Associate shall implement administrative, physical and technical safeguards that (i) reasonably and appropriately protect the confidentiality, integrity and availability of electronic PHI that it creates, receives, maintains or transmits on behalf of Covered Entity; and (ii) prevent the Use or Disclosure of PHI other than as contemplated by the Administrative Services Agreement and this Agreement. C. Compliance with Security Provisions. Business Associate shall: (i) implement and maintain administrative safeguards as required by 45 CFR § 164.308, physical safeguards as required by 45 CFR § 164.310 and technical safeguards as required by 45 CFR § 164,312; (ii) implement and document reasonable and appropriate policies and procedures as required by 45 CFR § 164.316; and (iii) be in compliance with all requirements of the Security Rule related to security and applicable to Business Associate. d. Compliance with Privaq Provisions. Business Associate shall only Use and Disclose PHI as permitted in this Agreement or as Required By Law and in compliance with each applicable requirement of 45 CFR § 164.504(e). To the extent Business Associate is to carry out one or more of Covered Entity's obligation(s) under Subpart E of 45 CFR Part 164, Business Associate shall comply with the requirements of Subpart E of 45 CFR Part 164 that apply to Covered Entity in the performance of such obligation(s). e. Duty to Mitigate. Business Associate agrees to mitigate, to the extent practicable, any harmful effect that is known to Business Associate of a Use or Disclosure of PHI by Business Associate in violation of the requirements of this Agreement. Page 2 of 8 Packet Pg. 2006 16.E.3.a f. Enc�ption. To facilitate Business Associate's compliance with this Agreement and to assure adequate data security, Covered Entity agrees that all PHI provided or transmitted to Business Associate pursuant to the Administrative Services Agreement shall be provided or transmitted in a manner which renders such PHI unusable, unreadable or indecipherable to unauthorized persons, through the use of a technology or methodology specified by the Secretary in the guidance issued under section 13402(h)(2) of the HITECH Act. Covered Entity acknowledges that failure to do so could contribute to or permit a Breach requiring patient notification under the HITECH Act and further agrees that Business Associate shall have no liability for any Breach caused by such failure. 3. Reporting. a. Security Incidents and/or Unguthorized Use or Disclosure. Business Associate shall report to Covered Entity a successful Security Incident affecting Covered Entity's PHI or any Use and/or Disclosure of PHI other than as provided for by this Agreement within a reasonable time of becoming aware of such Security Incident and/or unauthorized Use or Disclosure (but not later than five (5) days thereafter), in accordance with the notice provisions set forth herein. Business Associate shall take prompt and reasonable action to cure any such deficiencies. Notwithstanding the foregoing, the parties acknowledge that this Section 3.a constitutes notice by Business Associate to Covered Entity of the ongoing existence and occurrence or attempts of "Unsuccessful Security Incidents" for which no additional notice to Covered Entity shall be required. "Unsuccessful Security Incidents" means, without limitation, pings and other broadcast attacks on Business Associate's firewall, port scans, unsuccessful log -on attempts, denial of service attacks, and any combination of the above, so long as no such incident results in unauthorized access, use or disclosure of PHI. b. Breach of Unsecured PHI. If Business Associate Discovers that a Breach of unsecured PHI has occurred, Business Associate shall notify Covered Entity of such reportable Breach in writing within five (S) days of the date Business Associate Discovers such Breach. Business Associate shall be deemed to have discovered a Breach as of the first day that the Breach is either known to Business Associate, or by exercising reasonable diligence would have been known to any of Business Associate's employees, officers or agents, other than the person who committed the Breach. To the extent the information is available to Business Associate, Business Associate's written notice shall include the information required by 45 CFR § 164.410(c). Business Associate shall promptly supplement the written report with additional information regarding the Breach as it obtains such information. Business Associate shall reasonably cooperate with Covered Entity in meeting Covered Entity's obligations under the HIPAA Rules with respect to such Breach. 4. Business Associate's Agents. To the extent that Business Associate uses one or more subcontractors or agents to provide services under Administrative Services Agreement, and such subcontractors or agents receive or have access to PHI that Business Associate received from, or created or received from or on behalf of Covered Entity, Business Associate shall sign an agreement with such subcontractors or agents containing substantially the same provisions as this Agreement. 5. Rights of Individuals. a. Access to PHI. To the extent that Business Associate maintains a Designated Record Set on behalf of Covered Entity, within ten (10) days of receipt of a request by Covered Entity, Business Associate shall make PHI maintained in that Designated Record Set available to Covered Entity to enable Covered Entity to fulfill its obligations under 45 CFR § 164.524. Subject to Section S.b below, in the event that any Individual requests access to PHI directly from Business Associate, Business Associate shall forward a copy of such request to Covered Entity and Covered Entity shall be responsible for responding to such Page 3 of S (c,( ) Packet Pg. 2007 16.E.3.a request. b. Access to Electronic Health Records. If Business Associate is deemed to use or maintain an Electronic Health Record on behalf of Covered Entity with respect to PHI received from Covered Entity, then, pursuant to 45 CFR § 164.524, Business Associate shall provide Covered Entity with a copy of an Individual's PHI maintained in such Electronic Health Record in an electronic format in order for Covered Entity to comply with 45 CFR § 164.524, provided that it is readily producible in such format; if it is not readily producible in such format, Business Associate will work with Covered Entity to determine an alternative form and format or provide a hard copy form if the Individual declines to accept all readily producible electronic forms. If an Individual requests access to his or her PHI directly from Business Associate, Business Associate shall promptly forward such request to Covered Entity and Covered Entity shall be responsible for responding to such request. C. Amendment of PHI. To the extent that Business Associate maintains a Designated Record Set on behalf of Covered Entity, Business Associate agrees to make any amendment(s) to PHI in that Designated Record Set that Covered Entity directs or agrees to pursuant to 45 CFR § 164.526 at the request of Covered Entity, and in the time and manner mutually agreed. If an Individual requests an amendment of his or her PHI directly from Business Associate, Business Associate shall either (1) promptly forward such request to Covered Entity and Covered Entity shall be responsible for responding to such request or (2) elect to respond directly to the request. d. Accounting Rights. This Section 5A is subject to Section 5.e below. Business Associate shall make available to Covered Entity, in response to a request from an individual, information required for an accounting of disclosures of PHI with respect to the Individual, in accordance with 45 CFR § 164.528, Such accounting is limited to disclosures that were made in the six (6) years prior to the request. Business Associate shall provide such information as is necessary to provide an accounting within ten (10) days of Covered Entity's request, at no cost to the Covered Entity or Individual. e. Accounting of Disclosures of Electronic Health Records. If Business Associate is deeined to use or maintain an Electronic Health Record with respect to PHI maintained on behalf of Covered Entity, then, in addition to complying with the requirements set forth in Section 5.d above, Business Associate shall maintain an accounting of any Disclosures made through such Electronic Health Record. Such accounting shall comply with the requirements of 45 CFR § 164.528. Upon request by Covered Entity, Business Associate shall provide such accounting to Covered Entity in compliance with the HIPAA Rules, provided that it is readily producible in such format; if it is not readily producible in such format, Business Associate will work with Covered Entity to determine an alternative form and format or provide a hard copy form if the Individual declines to accept all readily producible electronic forms. f. Agreement toRestrict Disclosure. If Covered Entity is required to comply with a restriction on the Disclosure of PHI pursuant to 45 C.F.R. § 164,522 or 42 U.S.C. § 17935(a), then Covered Entity shall, to the extent that such restriction may affect Business Associate's use or disclosure of PHI under this Agreement, provide written notice to Business Associate of the name of the Individual requesting the restriction and the PHI affected thereby. Business Associate shall, upon receipt of such notification, not Disclose the identified PHI to any health plan for the purposes of carrying out Payment or Health Care Operations, except as otherwise required by law or unless doing so would unreasonably burden healthcare operations, in which case Business Associate will notify Covered Entity. 6. Remuneration and Marketing. a. Remuneration for PHI. Business Associate agrees that it shall not, directly or Page 4 of S Packet Pg. 2008 1li.E.3.a indirectly, receive remuneration in exchange for any PHI of Covered Entity in compliance with 42 U.S.C. § 17935(d). b. Limitations on Use of PHI for Marketing Purposes. Business Associate shall not make or cause to be made any communication about a product or service that is prohibited by 42 U.S.C. § 17936(a). 7. GGc vernmental Access to Records. Business Associate shall make its internal practices, books and records relating to the Use and Disclosure of PHI received from, or created or received by Business Associate on behalf of Covered Entity available to the Secretary for purposes of determining Covered Entity's compliance with the HIPAA Regulations. Except to the extent prohibited by law, Business Associate agrees to notify Covered Entity of all requests sewed upon Business Associate for information or documentation by or on behalf of the Secretary. Business Associate shall provide to Covered Entity a copy of any PHI that Business Associate provides to the Secretary promptly after providing such PHI to the Secretary. 8. Minimum Necessa . Business Associate shall limit its Use, Disclosure or request of PHI to the minimum necessary to accomplish the intended Use, Disclosure or request, respectively in accordance with 42 U.S.C. § 17935(b). 9. Qblijzations of Covered Entity. (a) Covered Entity shall notify Business Associate of ally limitation(s) in its notice of privacy practices of Covered Entity in accordance with 45 C.F.R § 164.520, to the extent that such limitation may affect Business Associate's use or disclosure of PHI under this Agreement; (b) Covered Entity shall notify Business Associate of any changes in, or revocation of, permission by an Individual to use or disclose PHI, to the extent that such changes may affect Business Associate's use or disclosure of PHI under this Agreement; (c) Covered Entity shall notify Business Associate of any restriction on the use or disclosure of PHI to which Covered Entity has agreed in accordance with 45 C.F.R. § 164.522 or 42 U.S.C. § 17935(a), to the extent that such restriction may affect Business Associate's use or disclosure of PHI under this Agreement; (d) Covered Entity represents that: (i) it is entitled to receive PHI in accordance with 45 C.F.R. § 164.504(f), (ii) it has received a certification from the Plan Sponsor in accordance with 45 C.F.R. § 164.504(f)(2)(ii), and (iii) the Plan documents permit the Plan to received PHI, including detailed invoices, reports and statements from Business Associate; (c) Covered Entity in performing its obligations and exercising its rights under this Agreement shall use and disclose PHI in compliance with the HIPAA Rules and shall not request Business Associate to use or disclose PHI in any manner that would violate this Agreement or the HIPAA Rules. Covered Entity represents that a request for PHI from Business Associate to Covered Entity shall only be the minimum amount of PHI necessary to accomplish the permitted purpose of the applicable request or use. 10. Termination. a. Breach b_y Business Associate. If Covered Entity knows of a pattern of activity or practice of Business Associate that constitutes a material breach or violation of Business Associate's obligations under this Agreement, then Covered Entity shall promptly notify Business Associate. With respect to such breach or violation, Business Associate shall take reasonable steps to cure such breach or end such violation on or before ten (10) days after receipt of such written notice, if possible. If such steps are either not possible or are unsuccessful, upon written notice to Business Associate, Covered Entity may immediately terminate this Agreement with Business Associate. b. Breach by Cov rcd Enti1y. If Business Associate knows of a pattern of activity or practice of Covered Entity that constitutes a material breach or violation of Covered Entity's obligations under this Agreement, then Business Associate shall promptly notify Covered Entity. With respect to such Page 5 of 8 Packet Pg. 2009 16.E.3.a breach or violation, Covered Entity shall take reasonable steps to cure such breach or end such violation on or before ten (10) days after receipt of such written notice, if possible. if such steps are either not possible or are unsuccessful, upon written notice to Covered Entity, Business Associate may immediately terminate this Agreement with Covered Entity. C. Automatic Termination. This Agreement will automatically terminate, without any further action by the parties hereto, upon expiration or termination of the Administrative Services Agreement by and between the parties hereto. d. Effect of Termination. Except as provided in this Section 10.d, upon termination of this Agreement for any reason, Business Associate shall either return or destroy all PHI that Business Associate or its agents or subcontractors still maintain in any form and shall retain no copies of such PHI. If Business Associate determines that return or destruction is not feasible, Business Associate shall continue to extend the protections of this Agreement to such PHI, and limit further uses and disclosures of such PHI to those purposes that make the return or destruction of such PHI not feasible. The parties agree that it would not be feasible for Business Associate to return or destroy the PHI reasonably needed to be retained by Business Associate for its own legal and risk management purposes, including copies of PHI that may be included in information retained for archival purposes. 11 Amendment. The parties acknowledge that federal laws relating to the HIPAA Rules are rapidly evolving and that amendment of this Agreement and the Administrative Services Agreement may be required to ensure compliance with such developments. The parties specifically agree to take such action as is necessary to implement any new or modified standards or requirements of the HIPAA Rules relating to the security or confidentiality of PHI. Upon the request of Covered Entity, Business Associate agrees to promptly enter into negotiation concerning the terms of an amendment to this Agreement and the Administrative Services Agreement incorporating any such changes. 12. No Third -Party Beneficiaries. Nothing express or implied in this Agreement is intended to confer, nor shall anything herein confer, upon any person other than Covered Entity, Business Associate and their respective successors or assigns, any rights, remedies, obligations or Iiabilities whatsoever. 13. Effect on Administrative Services Agreement. In the event of any conflict between this Agreement and the Administrative Services Agreement between Covered Entity and Business Associate, the terms of this Agreement shall control with respect to the subject matter herein. 14. Survival. The rights and obligations of Business Associate under Section 10,d of this Agreement shall survive the termination of this Agreement. 15. Interpretation. This Agreement shall be interpreted as necessary to comply with the HIPAA Rules. The parties agree that any ambiguity in this Agreement shall be resolved in favor of a meaning that complies and is consistent with the HIPAA Rules. 16. Governing Law. Except to the extent not preempted by federal law with respect to the HIPAA Rules, this Agreement shall be construed in accordance with the laws of the State of Florida. Page 6 of S Packet Pg. 2010 16.E.3.a 17. Notices. All notices required or permitted under this Agreement shall be in writing and sent to the other party as directed below or as otherwise directed by either party, from tithe to time, by written notice to the other. All such notices shall be deemed validly given upon receipt of such notice by certified mail, postage prepaid, facsimile transmission, e-mail or personal or courierdelive I y: If to Covered Entity: Collier County Government Center 3311 Tamiami Trail E. Naples, FL 34112 Attn: Risk Management Director Telephone no: 239-252-8966 Email: Jeffigy.Walker@collicrcountyfl.gov If to Business Stephen A. Tahta, President and General Manager Associate: Allegiance Benefit Plan Management, Inc. 2806 South Garfield St. Missoula, MT 59801 Telephone: (406) 721-2222 Email: `fc`?hr� lttitrr)<siclle it.c c„c,c:t� 18, Indemnification. The Business Associate's obligations to indemnify and hold harmless Covered Entity from and against any and all claims, suits, actions, liabilities, losses, penalties or damages, including courts costs and attorneys' fee, relating to a breach of this agreement shall be in accordance with that Administrative Services Agreement entered into between the parties with an effective date of January 1, 2023. 19. Miscellaneous. a. Severah . In the event that any provision of this Agreement is adjudged by any court of competent jurisdiction to be void or unenforceable, all remaining provisions hereof shall continue to be binding on the parties hereto with the same force and effect as though such void or unenforceable provision had been deleted, b. Waiver. No failure or delay in exercising any right, power or remedy hereunder shall operate as a waiver thereof; nor shall any single or partial exercise of any right, power or remedy hereunder preclude any other further exercise thereof or the exercise of any other right, power or remedy. The rights provided hereunder are cumulative and not exclusive of any rights provided by law. C. Entire Agreement. This Agreement constitutes the entire agreement between the parties hereto relating to the subject matter hereof, and supersedes any prior or contemporaneous verbal or written agreements, communications and representations relating to the subject matter hereof. d. Counterparts, Facsimile. This Agreement may be signed in two or more counterparts, each of which shall be deemed an original and all of which taken together shall constitute one and the same instrument. A copy of this Agreement bearing a facsimile signature shall be deemed to be an original. e. Regulatory Reference. Any reference made herein to any provision of law or regulation shall be a reference to such section as fit effect and as same may be amended from time to time. f. Amendment Generally. This Agreement may not be. amended except in a writing signed by both parties hereto. Both parties hereto agree that this agreement shall be amended to comply with any and Page 7 of 8 Packet Pg. 2011 16.E.3.a all state or federal laws rules, or regulations, including without limitation any future laws, rules or regulations. IN W177dESS WHEREOF, the parties hereto have caused this Agreement to be signed as of the date first set forth above. COVERED ENTITY: BOARD OF COUNTY COMMISSIONERS OF COLL113R COUNTY, FLORIDA By: Jeff Walker, Director of Risk Management BUSINESS ASSOCIATE: ALLEGIANCE EPNEFIT PLAN ANAGEMENT, INC. First Witness: By: /7 Print Name: Signature �' ,� Title: f i lad Approved as to farm and regality Print Name Second Witness: Signature Print Name Ptlge 8 of• 8 Scott R, Teach, Deputy County Attorney Packet Pg. 2012 Cole�i-r County Procurement Services Division RFP #: 22-7977 Title: Group Health & Dental Plan Administration Services Selection Committee Final Ranking Mariana St. Karen Final Name of Firm Sonja Sweet Amia Curry Jeff Walker Total Scores Surin Eastman Ranking Allegiance Benefit Plan Management, Inc. 86 65 88 84 87 410.00 1.0000 Meritain Health, Inc. 77 42 41 64 69 293.00 2.0000 Procurement Professional: tiara =a 2awx Date: 9-Jun-22 Page 1 of 1 Packet Pg. 2013 DocuSign Envelope ID: FB98AF8F-76AB-46AB-9634-02E3B9040293 16.E.3.d Corer County Procurement Services Division r L Notice of Recommended Award T E Solicitation: 22-7977 Title: Group Health & Dental Plan Administration Services q Due Date and Time: May 2, 2022 at 3:00 pm Respondents: Company Name City County State Final Ranking Responsive/Responsible Allegiance Benefit Plan Management, Inc. Missoula Missoula MT 1 Yes/Yes Meritain Health, Inc. Hartford Hartford CT 2 Yes/Yes United Concordia Companies, Inc. Camp Hill Cumberland PA Not Ranked No/Yes Utilized Local Vendor Preference: Yes 0 No - Recommended Vendors) For Award: On March 30, 2022, the Procurement Services Division released Request for Proposal ("RFP") No. 22-7977 to twenty-five thousand three hundred ninety-six (25,396) vendors for the Professional Services for Group Health & Dental Plan Administration Services project. Forty-seven (47) bid packages were viewed and three (3) submittals were received by the May 2, 2022, deadline. Allegiant Benefit Plan Management, Inc. and Meritain Health, Inc. were found to be responsive/responsible, while United Concordia Companies, Inc. was deemed non- responsive for not meeting the requirements of the solicitation. Allegiance Benefit Plan Management, Inc. and Meritain Health, Inc. were contacted to resolve minor irregularities due to missing documents. The Selection Committee met on June 9, 2022. After review of the proposals and deliberation, the Committee scored the proposals and ranked the firms as shown above. The Selection Committee reconvened on June 22, 2022 to review the annual cost breakdown by County Consultant Willis Towers Watson (WTW). Committee members reviewed their individual rankings and there were no changes. Staff is recommending award to the top ranked firm Allegiance Benefit Plan Management, Inc. Contract Driven = Purchase Order Driven 0 DocuSigned by: Required Signatures Project Manager: Sonja Sweet I Sb a SW 1C9 0480D49C448... DocuSigned by: Procurement Strategist: Barbara Lance Ba.� otaAtlb 6/23/2022 14490CMM448F... Procurement Services Director: DocuSigned by: H 6/23/2022 S fA9qE@5 Date Packet Pg. 2014 ALLEBEN-01 16.E.3.e 144coRo CERTIFICATE OF LIABILITY INSURANCE F.ATE(MM/DD/YYYY) 022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THI: CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIE! BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE[ to REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. v IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement or to this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Missoula Office PHONE FAX (A/C, No, Ext): (406) 721-1000 (A/C, No):(406) 721-9230 N Paynewest Insurance, a Marsh McLennan Agency LLC Company ADDRESS: P.O. Box 4386 Missoula, MT 59808 INSURERS AFFORDING COVERAGE NAIC # INSURER A: Hartford Fire Insurance Company 19682 Q INSURED INSURER B : R Allegiance Benefit Plan Management, Inc INSURER C : d INSURER D : PO Box 3018 Missoula, MT 59806 INSURER E : C d INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOI INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THI! CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM DD YYY POLICY EXP MM DD YYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR X X 41UUNID8162 9/1/2022 9/1/2023 EACH OCCURRENCE $ 1,000,1 DAMAGE TO RENTED PREMISES Ea occurrence 300,1 $ MED EXP (Any oneperson) $ 10" PERSONAL & ADV INJURY $ 1,000,1 GEN'L X AGGREGATE LIMIT APPLIES PER: POLICYEl PECOT- LOC OTHER: GENERAL AGGREGATE $ 2,000,1 PRODUCTS - COMP/OP AGG $ 2,000,1 $ A AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED L NON -OWNED AUTOS ONLY AUTOS ONLY 41UENAC0956 9/1/2022 9/1/2023 COMBINED SINGLE LIMIT Ea accident 1 000�1 $ X BODILY INJURY Perperson) $ BODILY INJURY Per accident $ PROPERTY DAMAGE Per accident $ $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 41RHUID8186 9/1/2022 9/1/2023 EACH OCCURRENCE $ 5,000,1 AGGREGATE $ DED X RETENTION $ 10,000 Gen Aggregate $ 5,000,1 A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A 41WEAD7Z4X 10/1/2022 10/1/2023 PER OTH- STATUTE ER 1,000,1 E.L. DISEASE - EA EMPLOYEE $ 1,000,1 E.L. DISEASE - POLICY LIMIT 1,000,1 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) contract #11-5729 General Liability Additional Insured Collier County Board of County Commissioners 3295 Tamiami Trail East Naples, FL 34112 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORI THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED It ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE r Q ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION The ACORD name and logo are registered marks of ACORD Packet Pg. 2015 I 16.E.3.e I ACCOR CERTIFICATE OF LIABILITY INSURANCE I DAT11/8/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THI: CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIE! BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE[ REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement oI this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Jean Hynek Ansay & Associates, LLC. PHONE FAX 4712 Expo Drive AIC No Ext : 920-370-4287 AIC No): 920-682-7799 Manitowoc WI 54220 ADDRESS: jean.hynek@ansay.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Travelers Casualty and Surety Company of America 41769 INSURED BENEMAN-01 INSURER B : Benefit Management Corporation 2806 S Garfield Street INSURER C : Missoula MT 59801 INSURER D: INSURER E: COVERAGES CERTIFICATE NUMBER: 1009659182 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIO1 INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THI; CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP MM/DDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE1:1 OCCUR DAMAGE TO PREMISES( a oRENTED cur ence)$ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ❑ PRO - POLICY ❑ LOC PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY L $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A Managed Care E&O Liability 106303196 5/31/2022 5/31/2023 Each Claim 5,000,000 All Claims 5,000,000 Claims -Made Form DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER Collier County Board of County Commissioners 3295 Tamiami Trail E. Naples FL 34112 CANCELLATION ti N N SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORI THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED II d ACCORDANCE WITH THE POLICY PROVISIONS. E t U AUTHORIZED REPRESENTATIVE a+ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Packet Pg. 2016 S L www.askaIlegiance.com Collier County Government 2806 S. Garfield St. I P.O. Box 3018 1 Missoula, MT 59806 Proprietary and Confidential Collier County Government (.,&)A I I e i an ce RFP 22-7977 April 29, 2022 To Whom it May Concern: Allegiance Benefit Plan Management, Inc. is pleased to respond to Collier County Government's request for Group Health and Dental Plan Administration Services. For over forty years, Allegiance has provided our clients with the flexibility and personal service necessary to administer complex health plans, vendor arrangements, and custom networks. We are very proud of our ten year history of working with the County to provide cost-effective Health Benefits and exceptional service to your plan members. As your incumbent administrator, your current Account Management team of Stephanie Kallevig and Kristen Ross will continue to support the County leveraging their built in experience with the County's Health Plans to deliver expert service to the County's Benefits Team. Stephanie and Kristen are supported by a broad team of dedicated and designated subject matter experts from across Allegiance including representatives from Clinical, Accounting, Enrollment, COBRA, and Reimbursement Accounts. Finally, Dr. Stephen Tahta, President, and Aaron Bay, SVP serve as executive sponsors for the County. This level of dedicated service continues through to our member service model providing a dedicated service and claims processing team for the County that is deeply familiar with the specifics of your benefit plan, network arrangements and Community Health Partners partnership. With our highly flexible and adaptive claims system, Allegiance is able to accommodate all aspects of a custom benefits solution including direct contracts with outside providers. Pricing arrangements, fee schedules, benefit tiers, and more can all be built directly into our integrated Claims Processing, Customer Service, & Eligibility system. In order to realize all benefits of self -funding and direct provider contracts, you need an administrator who has the experience and flexibility to administer your plan, your way. At Allegiance, we do not take a "pre-set" approach to administering your health plan. We work with you to determine the best benefit structure and network design for your unique needs. In tandem with the administration of your health plan and provider network, Allegiance offers a unique, integrated team approach to Medical Management that eases the burden of healthcare expenses for employer groups while ensuring plan participants receive optimum care. For Collier County, we deliver a coordinated medical management model in partnership with the County's local vendor, Community Health Partners. In addition to our flexibility in plan design, custom networks and medical management, Allegiance is a wholly -owned subsidiary of Cigna, enabling access the deepest discounts from the Open Access Plus network for the County's members when seeking care outside of the client -specific Collier County network. Your Ben(fils al lVork "m Page 1 Collier County Government — Cover Letter With complete, instant access to your claims data, Collier County and its consultants can run ad -hoc reports directly to support population management programs for your own employees. The County and its consultants will also have access to our data analytics tool, Cedar Gate (formerly Deerwalk), which allows for 24/7 access to utilization, clinical, and financial reports based on incurred or paid dates with customizable report dates, member cohorts, advanced filtering, and Milliman Risk Analysis. Recognizing the longstanding partnership with the County, Allegiance is offering a flat renewal of the Medical Admin fee with a 5% cap to extend the contract through years 4 & 5: • Medical administration fee of $17.70 PEPM for claims, customer service, eligibility, enrollment, COBRA, and more • 2026 renewal capped at $18.59 PEPM • The option to elect Allegiance Medical Management on a PEPM instead of the current hourly charge • Dedicated member service model at no additional charge • Continued support for the County's custom network arrangement and CHP carve -out In reviewing the RFP, we would like to call out the following exceptions to the proposed RFP language: • Recognizing the current contract between Allegiance and the County, Allegiance proposes continued use of this language as an alternative to the proposed Contract included in this RFP. • In response to the Terms & Conditions document, Allegiance requests that indemnification and termination provisions be mutual to both parties. Allegiance is committed to serving Collier County Government as true partners in health plan administration. It is our goal to provide each client with extraordinary levels of service while administering plan designs, network arrangements, and medical management solutions that represent the very forefront of our industry. We look forward to the opportunity to present our strengths at a capabilities presentation. Please contact our RFP team at the below information with any questions you may have. Aaron Bay SVP, Marketing & Client Service (406) 523-3102 Aaron.bay@askallegiance.com RFP Contact: Jake Whitecar Director of Sales Operations 406-523-3515 Jake.whitecar@askallegiance.com Your Be7yils at Ld'orkl'm Page 2 The Allegiance Difference With over 35 years of experience, Allegiance has earned a reputation for quality, service and efficiency that is unmatched. Through our proactive cost management strategies, trend management, technological efficiencies and strong provider relationships, Allegiance leads the way for a new future in employee benefits. OUR CAPABILITIES Cost Management: Effectively manage costs through bundled payments, contracted healthcare providers, reference -based pricing and patient centered medical homes (PCMH) Flexible Administration Cost-effective administrative workaround solutions for unique plan design, benefit and service customization, and high -touch customer and client service Unbundled Products: Cigna's best network discounts and pharmacy programs can be integrated with products from a portfolio of carriers/ vendors (stop loss, PBM, health and wellness, etc.) P10`� U.-O'd Customized Network Design: Comprehensive management and repricing of Client Specific Networks (CSNs) and tiered network options with network contract approval on a case -by -case basis Robust Reporting: Online access to standard and custom reports through Allegiance's business intelligence tool, national benchmarking, gaps in care tracking, provider performance monitoring and predictive analytics 2 www.askallegiance.com ALLEGIANCE ADMINISTRATIVE SERVICES PROPOSAL Collier County Government Date Created: 4/28/2022 Employees 2,174 Rate Guarantee: 5 Years January 1, 2023 through December 31, 2027 Set Up Fee Waived Medical Administration (2023-2025) $17.70 PEPM Medical Administration (2026-2027) $18.59 PEPM Dental Administration (2023-2025) $2.85 PEPM Dental Administration (2026-2027) $2.99 PEPM Utilization Management $1.70 PEPM Case Management $2.45 PEPM National Network Access (Cigna OAP) 2023 $6.00 PEPM National Network Access (Cigna OAP) 2024 $6.50 PEPM National Network Access (Cigna OAP) 2025 $7.00 PEPM National Network Access (Cigna OAP) 2026-2027 $7.15 PEPM 3 1 www.askallegiance.com ALLEGIANCE ADMINISTRATIVE SERVICES (CONTINUED) Standard Services Medical Claims Administration PBM Coordination** Production & Maintenance of Electronic Plan Documents/SPDs Cedar Gate Analytics*** Plan Building Implementation Amendment Production Production of Standard Initial Enrollment Packets Plan Document Compliance HIPAA Compliance ERISA Compliance (if applicable) Expert Medical Reviews Production & Mailing of Health Plan ID Cards Employer's Name & Logo on ID Card Allegiance alphanumeric alternative member ID Enrollment & Eligibility Maintenance CAA & No Surprises Act Compliance COBRA Administration Stop -Loss Reporting & Coordination Standard SBC Development First Level Appeals Administration Run -Out Administration Out -of -Network Savings Program Optional Services Disease Management 24/7 Nurseline 24/7 TeleMedicine WellVia MD -Live Healthcare Blue Book Maternity Management Wellness Programs Custom Ad -Hoc reporting Overpayment recovery Services/HIPDB Fraud Reporting Subrogation Consolidated Billing Employee Assistance Program Third -Party Vendor Integration Cost Comments Included in Admin Fee Included in Admin Fee Required Included in Admin Fee Included in Admin Fee Included in Admin Fee Included in Admin Fee Included in Admin Fee Included in Admin Fee Included in Admin Fee Included in Admin Fee Included in Admin Fee Costs passed through to employer Included in Admin Fee Included in Admin Fee Included in Admin Fee Included in Admin Fee Additional Fees Apply Included for Allegiance coverages Included in Admin Fee Included in Admin Fee Included in Admin Fee Average of Prior 3 Month's Admin Fee 29% of net savings Additional cost applies for printing and distribution Additional cost applies for mailing to employee's home address Additional fees may apply Additional fees for customization Additional cost applies for co - fiduciary Cost $2.85 PEPM Online Services Eligibility Maintenance Cost Included in Admin Fee $0.65 PEPM Eligibility/Claims Lookup Included in Admin Fee Verification of Benefits Included in Admin Fee $0.25 PEPM + Consult Fee Standard Reporting Package Included in Admin Fee $0.25 PEPM + Consult Fee $1.90 PEPM Online Invoice Availability Included in Admin Fee $225 Per Case Online Report Generator Included in Admin Fee Various Options Available Online Enrollment Included in Admin Fee $175 Per Hour Claims Status Included in Admin Fee Provider Directory Included in Admin Fee 25% of Savings Document Library Included in Admin Fee 20% of Net Recoveries $1.00 PEPM Various Options Available $350/File or $3000 annually www.askallegiance.com 1 4 Spending Accounts (options) HSA FSA with Debit Card Dependent Care FSA Transportation FSA HRA HRA with FSA, Transportation & Debit Card Reimbursement Accounts Fee Schedule Monthly Service - Standard Per active employee participant per month ($75 minimum) Monthly Service - Electronic Per active employee participant per month ($75 mimimum) (Email addresses and direct deposit information required for all participants) Health FSA COBRA Administration Other Fees that may apply Additional reimbursement accounts - FSA, HRA, Transportation (Participant maybe enrolled in one or more reimbursement accounts for one fee) Initial set-up and annual re -enrollment Plan document and summary plan description master Mailed check Debit card Replacement/additional cards Data needed to file form 5500 Online limited non-discrimination testing Cost $2.50 PPPM $5.15 PPPM Included in FSA Included in FSA $4.10 PPPM $4.10 PPPM Cost Health Savings Account (HSA) Fee Schedule Cost Monthly Service - Employer $5.25 Per active employee participant per month fee- $2.50 billed to employer Other Fees that may apply Account Establishment/Set-Up Fee $0 $4.25 Overdraft Fee $0 $10%vent Stop Payment Fee $0 Transaction/Disbursement Fee $0 Special Processing Fee (manual withdrawal of $0 $0 excess Contributions/mistaken distributions) Debit Card $0 $0 Additional Cards $0 $0 Replacement of lost debit card $0 Checks $2.00 $0 Monthly paper account statement $2.00 $0 Monthly Service -Inactive employee account holder $3.95 $0 HSA closure fee by member $25.00 $0 $0 Terms & Conditions Actual Enrollment will be at least 90% of current levels Notification of contract award will be provided at least 90 days prior to effective date Proposal will duplicate all current plan designs unless otherwise noted If client terminates the contract prior to the end of the rate guarantee period, client is responsible for the following reimbursement of Credits & Subsidies: • Term within first year of contract:100% of credits & subsidies • Term within second year of contract: 66% of credits & subsidies • Term within third year of contract: 33% of credits & subsidies Implementation/Transition Credits can be used to offset any costs/fees assocaited with the transition of administrators Communication Credits can be used to offset any costs/fees associated with communicating the change in administrators to client's employees Wellness Subsidy can be used to fund any wellness/population health programs as elected by the client Technology Credit can be used to offset any costs/fees associated with upgrades to existing, or implementation of new online, mobile, data, or other related programs Technology Credit can be used to offset any costs/fees associated with upgrades to existing, or implementation of new online, mobile, data, or other related programs The information contained in this response to the request for proposal is considered confidential and proprietary. This proposal assumes all services will be administered according to our standard format and procedures, unless otherwise specified in this proposal. The Plan Sponsor will be responsible for state and/or federal surcharges, assessments, or fess imposed by governmental entities including but not limited to those related to PPACA. Fees assume one billing, reporting, eligibility, stop -loss, and banking arrangement. **PBM coordination fee assessed regardless of PBM vendor. If the client/ consultant selects a PBM vendor with whom Allegiance does not currently interface, there may be additional set-up fees to establish necessary data feeds ***Medical data (24 months historical claims) from prior TPA/Carrier in re- quired format or $2500 mapping fee applies. If data is not available, claims data will be accumulated moving forward using standard file layout. Histori- cal pharmacy data (24 months) can be coordinated with existing PBM if PBM already works with Verscend. If data is not available, we will coordinate with PBM/Verscend to provide future data. If PBM is not currently working with Allegiance, a $1500 mapping fee applies. If format is not exactly as re- quested, a $3500 mapping fee applies. If client purchases DM and wants to upload HRA data, it must be in the required format exactly or a $1500 map- ping fee applies. There is a $1000 fee per upload regardless of file format. Mapping fees are waived for groups with 5000 or more employees enrolled. 5 1 www.askallegiance.com WORKING WITH ALLEGIANCE Your membership will be supported by dedicated customer service advocates and claims examiners who: — Know and understand your plan — Deliver customized greetings — Provide fast access and call resolution the first time a member calls Account Executive Client Account Specialist Vice President, Client Service & Sales Chief Medical Officer Care Management Senior Vice President, Clinical Operations and Analytics Clinical Client Liaison — Assist members with understanding their benefits and answer claim questions — Help find in -network doctors and facilities — Warm transfer to clinical and other resources as appropriate Our Account Service Model Billing COB Cobra Enrollment Reimbursement Accounts Service Team Management Dedicated Onsite Specialist cated Service Team 21 Team members & Team Leader -e President, Health Service Operations www.askallegiance.com 1 6 WORKING WITH ALLEGIANCE Integrated Customer Service The Allegiance customer service team is committed to providing the best possible experience for you and your employees. We consistently monitor and coach our team to ensure that each inquiry is greeted by a knowledgeable and caring specialist, all while providing a simple, seamless interaction for the member. Dedicated Team Pod Structure Uniquely designed for those who require a high -touch model O mica iaisons s Concierge Client & Customer Model Dedicated Service Center 7 www.askallegiance.com WORKING WITH ALLEGIANCE Implementation We understand that transitioning administrators can be stressful and time-consuming, so we have developed a streamlined process to make implementation easier. Dedicated Implementation Team Your Account Executive is with you throughout the process, ensuring all implementation items are thoroughly addressed and that the day-to-day administration team is on board from day one. Guided by: Representatives from: — Implementation Manager — Claims Processing — Customer Service Executive Manager: — Eligibility — Implementation Specialist — Pharmacy — VP, Client Service — Medical Management — Compliance ................................................................................................................................... Kick-off Call and Implementation Checklist We work with you and your consultant to collect basic information about your plan. Ongoing Implementation Calls Our Implementation team will collaborate with your staff to determine an appropriate call schedule, i.e. weekly, bi-weekly, monthly. Open Enrollment Support Your dedicated Customer Service team is available during Open Enrollment to answer questions regarding eligibility and enrollment, benefits, web services, provider networks, and more. — Customized Welcome Booklets are distributed to introduce your members to Allegiance. — We provide on -site assistance for up to two consecutive days of Open Enrollment Meetings. www.askallegiance.com 1 8 CASE AND UTILIZATION MANAGEMENT Allegiance's integrated Case/Utilization Management programs leverage early intervention and acute case management to effectively coordinate and manage your group's most medically challenging cases. These interventions utilize unique resources for creative approaches to maximize appropriate, cost-effective care. Dedicated case managers interact with members and their families, maintaining an ongoing relationship with the patient. Predictive Modeling 02% Uses patterns in data toestimate the probability of a future financial or health outcome Trigger Diagnosis 0. A clinical diagnosis, event, or behavior presents an opportunity nity for case management intervention. Stop Loss Reporting Reveals [rends in health claims that can used to proactively manage costs. 0 = Customer Service One-on-one support allows team to screen for likelihood of high -risk advancement. Self Identification 000 Member communicates a need for support with self -identified medical issuee or behavior. Internal Experts & Management Resources Medical Risk Management Team collaborates in response to high -risk cases to identify ?merging risks and coordinate strategies for managing the cost and course of care for the member. Medical Risk Management Team A Fully Integrated, Multidisciplinary Approach to Managing the Cost of Healthcare Risk CLIENT CASE MANAGEMENT Client . PC W'V ^J& ST & CARE MANAGEMENT Q* Cases are continually monitored to ensure quality and appropriateness of care. 9 1 www.askallegiance.com PROGRAM HIGHLIGHTS: • We provide a team of registered nurses that conduct assessments on complex cases utilizing Milliman Care Guidelines (MCG) to assess the medical appropriateness of inpatient admissions. Outcomes are benchmarked against MCG Health days per 1000 and average length of stay criteria to certify treatments. Continued collaboration throughout the member's treatment, including ongoing assessments of the interventions related to the plan of care, ensures that all members receive the right care at the right time to achieve the best possible outcomes. This integrated care management approach allows for the automatic trigger of a patient identified as high -risk by the utilization nurse to case management. Peer to peer reviews are conducted by the Medical Director as appropriate. Daily call -outs are made based upon last date credited. • Our interdisciplinary Risk Management Team works together to coordinate and communicate all issues surrounding our clients' high -risk cases. Our fully integrated team approach eases the burden of healthcare expenses for employer groups while ensuring plan members receive optimum care. • The Precertification Program also includes the review and assessment of the medical appropriateness of admissions for inpatient, partial hospital, inpatient rehabilitation, residential treatment and subacute care. This review may be a prospective, concurrent or retrospective review. More Better Appropriate3Utilization Outcomes dQ 3.3 % reduction in in -patient length of stay 7.6 % reduction in avoidable admissions 1 O % fewer readmissions 3.4 % reduction in medical costs Higher Engagement 93 identified members receive complex case management outreach 3.2 % reduction of high cost individuals O engaged with case 6.7 % reduction in costs for outpatient management in ER utilization services www.askallegiance.com 1 10 ° REPORTING CAPABILITIES Allegiance offers a comprehensive standard reporting � g� p package that has the ability to generate custom reports. Our standard reporting package contains the following reports: • Executive Summary Refund Report • Claims Cost Analysis Ineligible Code Summary Report • Total Claims Paid/Trend Report Top 30 Providers • Average Cost per Participant per Month/ 25% Report Trend Utilization Statistics for Medical • Number of Participants per Month/Trend Utilization Statistics for Dental • Service Code Analysis for Total Medical Utilization • Service Code Analysis for Medical Medical Utilization Chart • Group Medical Charges/Paid Chart Dental Utilization • Service Code Analysis for Dental Dental Utilization Chart • Dental Charges/Paid Chart Monthly Cost Report • Paid Claims by Diagnosis Group Claims Lag, Medical, Dental & Vision • PPO Network Savings Report Participant Coverage Census Report • Check Register Claims Analysis Report Our full reporting package is available online for quick access by employers. Our claims system, LuminX, provides comprehensive, operational and management reports to measure and control the costs of the claims processing operation and of the healthcare provided. The healthcare management reports provide measurement tools to assist in the creation and monitoring of cost containment strategies. The system includes a user -oriented report generator that satisfies many ad hoc reporting requirements. Collier County Government will also have access to iBiz, a Cognos-based business intelligence tool allowing 24/7, web -based access to standard and customized report formats, as well as cube -based report authorship with drill -down capabilities. The Allegiance programming and analytics team is available to produce custom ad -hoc reporting at an additional cost. 11 1 www.askallegiance.com CEDAR GATE (FORMERLY DEERWALK) ANALYTICS Allegiance provides our customers innovative analytics and reporting tools, from both the clinical and financial perspective, to assist in better managing cost, quality and risk of their health plan. Through our partnership with Cedar Gate, our customers have access to a both an Executive Analytics web -based dash -board with enhanced data visualizations for standard, summary level financial and utilization reporting, as well as a web -based Plan Analytics portal, which provides deeper drill down, ad -hoc reporting capabilities, quality metrics (gaps in care) and MARA risk models to quickly identify high -risk, high - cost members that may benefit from targeted care management intervention. Additional industry standard re -ports focus on utilization and cost for areas such as places of service, diagnoses, procedures, providers and drugs. Our customers leverage these flexible and customizable reporting options to analyze trends in their healthcare spending and utilization by performing streamlined, on -the -fly analysis, from the aggregate level down to the individual member level. These powerful tools allow our customers to optimize medical resources, improve quality, reduce cost, and maximize patient engagement. FINANCIAL DASHBOARD Population: SAMPLE CLIENT Medical Claims Pharmacy Claims I Specialty Drugs Admissions $29,573,477 $4,272,824 $2,315,833 $6,684,662 PMPM $507 PMPM $73 % of Total Rx 54% Benchmark $5,640,771 Claims Claims Claim Count 0 Avg Claim Cost 0 Benchmark Avg Claim Cost 7k 6k 5k 4k 3k 2k 1k 0 Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Cost % Claimants to Members $700 100% $600 Benchmark 93% $500 $400 Avg Claim Cost $498 $300 Benchmark $300 $200 $100 Avg Cost Per Claimant $0 $5,836 Benchmark $3,204 www.askallegiance.com 1 12 Collier County Government (CCG) Appendix D - Questionnaire (Proposer shall not re -format or alter this spreadsheet) Limit each response to 500 words - exhibits can be included Company Name: Allegiance Benefit Plan Management, Inc. A. Implementation and Transition Transitioning from one administrator or insurer to another is a time consuming process that can cause serious service issues. Following is an outline of issues, services, attributes or questions associated with implementation and transition. What would your organization do to ensure a smooth transition? 1 You will be expected to duplicate the current plans in force for the CCG. How do As Allegiance is Collier County Government's incumbent you minimize problems related to "plan interpretation?" The CCG expects you to administrator, minimal implementation work will be required in order to prepare and draft either Master or Summary Plan Documents. What individuals continue our relationship. If Collier County Government (CCG) is within your organization do you involve to make sure that certain claims areas considering any benefit changes, we recommend a 90 day notice so are handled consistent with the prior administrator, and what is the process you changes can be implemented and communicated to members in use? compliance with notification requirements. As the incumbent administrator, we are able to offer CCG complete continuity of client service resources and no instances of member disruption. 2 Do you request and then perform a review, analysis or request information on As your current administrator, Allegiance has long-established individuals who are high users or who are in the midst of complex treatment to processes for managing CCG's claims. see that administration is consistent? Do you make attempts to look at the prior administrator's claims data to identify such individuals? What is your transition of As part of our standard UM/CM services, we perform such reviews. If care process? beginning a new implementation, Allegiance would request a listing of all active cases in case management, disease management and wellness programs from the prior administrator and a two year history of claims for the population health management software. Using these two sources, we would identify cases for immediate follow up and transitional care. If that historical claims information was not available, we would work closely with CCG to identify high -cost and high -risk claimants for outreach and follow-up. If a member is receiving care from a provider that would be out -of - network, the transition of care (TOC)/Continuity of Care (COC) process evaluates requests for reimbursement to a non -participating provider at the in -network level of benefits for services that would be considered covered benefits when provided by a participating provider. Members and/or their current physician may apply in writing for transition of care reimbursement within 30 days of enrollment in the plan (unless a longer period of time is mandated by the applicable state). If approved, a member receiving care for certain conditions or situations from a non -participating provider at the time the plan takes effect may continue to receive services from that provider for a specified period of time, with covered services reimbursed at the in - network benefit level. 3 Do you ask for, and how do you use lists of individuals who are considered key Yes, we do ask for lists of individuals who are considered "key employees for special handling as well as those who have had specific employees" and flag them in our system so that Member Advocates, problems? Claims Specialists, and other applicable staff recognize these individuals and understand the need for increased care or review. We also place customized flags on members requiring special handling to alert any Allegiance employee working with that individual to a specific problem or circumstance. 4 How do you notify providers, especially those most used by employees, about Since there would not be a transition for CCG, there will be no need the change in administrator? Are you able to notify billing departments as well as for specific provider communication unless there are changes in either doctors and facilities? the network or the benefits. Collier County Government (CCG) Appendix D - Questionnaire (Proposer shall not re -format or alter this spreadsheet) Limit each response to 500 words - exhibits can be included Company Name: Allegiance Benefit Plan Management, Inc. 5 How will you handle initial eligibility transfer and verification? A copy of the Well -established processes are already in place with CCG. Allegiance current file formats utilized is attached. Confirm you can work with these file will continue to accept weekly files from CCG or their vendors and formats. pass any required files to current commercial online enrollment vendors, PBMs, etc. 6 Are you able to host an internet site where employees could check the accuracy Confirmed. For CCG, this custom site is already established. of the information you have received on their families (other coverage Allegiance will continue to work with CCG on any updates, changes, or information, address, etc.)? Can they make note of errors or changes and then reformatting. The website allows employees to check coverages, your organization feed that information back to the HR department for benefits, look at EOB's, link to other vendors' sites, etc. Plan verification? members can also make note of errors or changes. In addition, they are able to make inquiries and certain changes via the website. Allegiance can forward corrections and changes to CCG's individual HR departments. 7 The eligibility system will need to house a random number for use on the ID card, Allegiance will continue to use the numbers currently in place for house the social security number internally for CMS reporting purposes and the Collier County. employee number for use by Community Health Partners (CHP) advocacy staff and internal systems. Have you had experience with this with other clients? If so, how do you assign the random numbers? Is it possible to continue using the current numbers? 8 It is required that you provide a staff person on -site to meet with employees and Confirmed. Your onsite staff member, Dan Ross, will remain onsite. assist with claims resolution and plan questions. Confirm you will meet this requirement and how will you involve the CCG in hiring this individual. This individual must be hired and on staff 60 days prior to the implementation. 9 Provide five (5) client references for which you have implemented and provided Naples Community Hospital TPA services during the past three (3) years. Preference should be given to Lorie Darrah including those references most similar to the CCG in terms of size, industry, Director, Total Rewards location and complexity. Include name, address, telephone and email contact 239-624-5945 with your primary client contact at this organization. Iorie.darrah@nchmd.org Humble ISD Tammye Vaughn Board, Business, & Technology Center 281-641-8042 Tammye.vaughn@humbleisd.net City of Bristol Mary Lee Williams Director of Administration 423-989-5525 Integrated Supply Network Rachael Morris Human Resources Supervisor 863-603-0777 ext. 1217 South Illinois Healthcare Amy Niemann Total Rewards Leader 618-457-5200, ext. 67807 amy.niemann@sih.net B. Control over Administration, Service to Employees, Communications, General Service Issues a. Control over Administration Collier County Government (CCG) Appendix D - Questionnaire (Proposer shall not re -format or alter this spreadsheet) Limit each response to 500 words - exhibits can be included Company Name: Allegiance Benefit Plan Management, Inc. The CCG wants comprehensive control over all aspects of its benefit program. Your role as the administrator is critical, both in providing consistent, high quality service and in addressing issues of concern as they emerge. In the experience of the CCG, administrators are eager to learn about concerns and promise to work diligently to deliver appropriate solutions and day to day administration. However, often follow through is not consistent, leading to missed deadlines, inaccurate or missing data or substandard service. Provide information regarding your organization's experience with each of the issues, services, attributes or questions listed. 1 What is the major complaint you get most frequently with your service and what Like many companies across the US, Allegiance has been are you doing to address it? How does your organization identify and address persevering through staffing shortages, which has led to increased service problems on an ongoing basis? wait times for some of our services. We recently have found great hiring success through an employee -based referral program. We have also hired additional recruiting specialists to better identify potential candidates. 2 How are you proactive in your relationship with clients? Do you use regular As discussed throughout this proposal, our trademark high -touch, meetings to identify problems and outline for your client's items of interest in a highly -personalized service is essential to both our clients and their changing environment? Which individuals from what areas within your members. We deploy a comprehensive team -based approach with organization would be assigned to work with the CCG on an ongoing basis? Will each of our clients. Each team of qualified professionals has you meet with the CCG on a quarterly basis to discuss performance? executive level sponsorship and is headed by a designated Account Executive. This structure provides Allegiance with the ability to comprehend the business case and design solutions most appropriate for each client and deliver quick problem resolution. Allegiance has a reputation for taking all necessary steps to help members understand their benefits. Our team -based approach allows for integration, collaboration, and problem solving between claims and customer service, resulting in high customer service resolution and accurate and timely claims processing. Allegiance is also known for our commitment to transparency in all aspects of our operations. We work closely with our clients to ensure that they are fully informed with regard to how their plan is functioning and being administered. We provide clients with open lines of communication, above average access to member and industry data, and willing consultation designed to support client goals for their plan. Upon renewal, you will continue to receive high -quality administration and service from Allegiance, led by your Account Executive, Stephanie Kallevig, and your onsite Member Advocate, Dan Ross. Allegiance will also continue to meet with CCG quarterly to discuss performance. 3 You must agree to the following performance guarantee. The CCG will appoint 3 # or more employees to rate the performance of your organization on a scale of 1- 5, with 1 being failed expectations to 5 being met expectations. Composite scores must be an average of 4 or you will return 20% of your fees at the end of the year. Scoring will occur on a quarterly basis with a final rollup at the end of the year. Collier County Government (CCG) Appendix D - Questionnaire (Proposer shall not re -format or alter this spreadsheet) Limit each response to 500 words - exhibits can be included Company Name: Allegiance Benefit Plan Management, Inc. 4 Do you record telephone conversations with plan members? If yes, describe your Yes, call recording and tracking is integrated as part of the claims system. If not, describe your documents process. system with calls and documentation immediately available to Member Advocates. All calls are logged into our system with the date, time, person taking the call and a synopsis of the call. All calls are recorded and can be retrieved as needed. Member Advocates document the date and reason for the inquiry, the caller's name and the resolution status. In addition to Member Advocates and their managers, Claims Specialists, members of our medical management and appeals and grievances teams can also view the information in the customer service module. Allegiance records all customer service calls for audit, verification and training purposes. 5 Are there any lawsuits pending against your organization with respect to its No outstanding legal actions are pending that would affect our ability service or service delivery? Have you settled any lawsuits with your organization to provide services. The following legal actions have been resolved: with respect to its service or service delivery in the last five years? If so, what was the outcome? Gendron v. Allegiance and the Montana University System, (DV 09- 953B) filed in 2009. The state district court ruled entirely in Allegiance's favor and dismissed the case against Allegiance with prejudice. Fisher v. Montana Association of Counties, Allegiance Benefit Plan Management, Inc. et al. (DV 15 1273), a nuisance complaint filed in state district court in 2015 was settled for nuisance value and dismissed with prejudice. Bailey v. Montana Municipal Insurance Authority, Allegiance Benefit Plan Management, Inc. et al. (CDV-14-881) a complaint for damages filed in state district court in 2016 was settled for nuisance value and dismissed with prejudice. Health Services Inc. v. Allegiance Benefit Plan Management, Inc., Mergenthaler Transfer and Storage (2:16-CV-00001-DBP) a complaint by a provider against a health plan Allegiance provides services to was filed by the provider in 2016 to prompt the health plan to pay the provider charges. The plan paid the provider charges before the complaint was served so the matter was dismissed with no liability to Allegiance. 6 As you will see in the summary plan documents, the employer groups have plan Confirmed. Allegiance currently administers this plan design for Collier designs where individual members can lower their deductibles and out of pocket County and will continue to do so. maximums by completing certain activities. Confirm you will be able to administer these plan design aspects at the member level. For example, an employee and spouse may trigger different qualifiers at different times and therefore their deductible and out of pocket maximums must be tracked at different amounts. Collier County Government (CCG) Appendix D - Questionnaire (Proposer shall not re -format or alter this spreadsheet) Limit each response to 500 words - exhibits can be included Company Name: Allegiance Benefit Plan Management, Inc. 7 What kind of in-house support do you provide to keep employers updated on Although Allegiance does not act as a legal advisor for our clients, we regulatory changes and to identify, evaluate and execute the resulting necessary maintain a department called Client Advisory Services under the changes to their plan design or administration to comply with the regulations? direction of Roger Cowan that researches and provides insight to our clients on all legal and regulatory matters. In addition, as a wholly -owned subsidiary of Cigna, Allegiance has access to and provides clients information from Cigna's compliance resources. Further, Allegiance participates in several industry organizations (the Self Insured Institute of America, the Society of Professional Benefit Administrators, America's Health Insurance Plans, the International Foundation of Employee Benefit Plans, etc.) to ensure we remain fully up to date on all compliance issues. We communicate compliance insights via blast emails, and webinars, and conference calls are available for individual discussion regarding any client's specific plan. In addition, Allegiance prepares draft plan amendments for compliance purposes for each client to review with its legal advisors and consulting advisors. b. Service to Employees 1 What is the location and hours of operation for the customer service center that Live customer support is offered Monday through Friday from 8:00 am will serve the CCG? to 8:00 pm Eastern Standard Time, excluding major holidays. 2 Where is the location of the claims office that will service CCG? The claims office that services Collier County is located in Missoula, MT and your onsite rep, Dan Ross, is also available to assist with claim issues. 3 If not local, where is the location of the customer service office servicing the For CCG we have an on -site representative located in the CCG CCG? Benefits area. The remainder of the claims and calls team is located in Missoula, Montana. 4 Will you provide a dedicated customer service group for the CCG employers? Confirmed. Collier County currently has a dedicated customer service What provisions will be provided to ensure bilingual services are available? staff. We also have bilingual staff that will be able to assist members as needed, and we also employ the services of a translation line. The translation line ensures that dialects and languages can be accommodated that may not be represented in our staff. Collier County Government (CCG) Appendix D - Questionnaire (Proposer shall not re -format or alter this spreadsheet) Limit each response to 500 words - exhibits can be included Company Name: Allegiance Benefit Plan Management, Inc. 5 Provide your internal service standards pertaining to calls, wait time and Our overall performance standards are listed below: resolution of issues. What is your philosophy toward serving members, especially with problems, and how you continually evolve your processes to ensure a high Average Speed of Answer: 75% within 30 seconds of entering the level of satisfaction with your firm? queue. First Call Resolution: 90% Abandoned Calls: 5% or less Using our team pod service model, we provide client -dedicated service teams who are fully trained on all facets of the client's programs and plan design. A client's designated service team will handle 100% of their member inquiries. This means that members will be automatically directed to Member Advocates and claims specialists who are versed in the intricacies of their plan and prepared to address their questions directly. Prior to a new client's effective date, we hold meetings to fully train their designated service team. In the team meeting, Member Advocates are provided the summary plan document, along with group notes covering any details about the plan intent that are not clearly defined in the SPD. These items are reviewed in detail in order to fully establish with Member Advocates the client's plan and benefits intentions. Team meeting notes are documented and emailed to each member of the service team for reference, along with the training materials. Post -implementation, each designated service team meets regularly to discuss any issues, questions, or plan changes. If any plan changes occur, the client's designated service team leader immediately emails the details to the service team and updates any training materials and group notes in accordance. These changes are then reviewed in depth in the next team meeting. Service team members are also included on all communications about the group, in order to keep them up to speed on the specifics of the Plan and allow them to appropriately train any new members. c. Communications Many times, in spite of best efforts, employees are confused about how their plans work and do not respond to inquiries due to overwhelming or confusing communications. 1 What experience do you have with development of personal letters targeted Allegiance has identified specific individuals who may, for example, toward problems unique to the employee or member? have had significant emergency room utilization for non -emergent situations. Working with our clients, we have developed specific communications regarding plan benefits and options for urgent care and sent communications directly to the affected individuals. In addition, through our population health management systems, we have identified individuals with specific gaps in care and developed informational mailings to encourage closing those gaps in care. We have also developed and implemented the means with various primary care practices to provide access to the population health management database and assisted embedded care coordinators with both telephonic and print outreach. Collier County Government (CCG) Appendix D - Questionnaire (Proposer shall not re -format or alter this spreadsheet) Limit each response to 500 words - exhibits can be included Company Name: Allegiance Benefit Plan Management, Inc. 2 How do you ensure your written communication and language are Allegiance retains the services of Ocozzio, a public relaions/marketing understandable? Do you use outside professional writers? team dedicated to the HealthCare marketplace. We utilize Ocozzio's expertise in reviewing and editing messages we send to plan members and to assist with the development of graphics. The Ocozzio team ensures that jargon is either not utilized or is fully explained and that the message is understandable and engaging. 3 Will you translate written materials into Spanish or other languages on an Allegiance employs the services of Language Line Solutions. employee -specific basis? Language Line Solutions provides immediate telephonic interpretation services that we engage when communicating with a plan member while they are on the phone with us. Further, Language Line Solutions offers, and we have utilized, their translation services to prepare print materials in languages other than English. 4 Do you offer employees the choice of whether to receive information via paper, Allegiance offers employees the option to receive information email or via paper and e-mail? (including explanations of benefits and of payment) via email and/or paper. Furthermore, members and providers each have their own portals on Allegiance's website to provide claims status, benefits, accumulators, ID cards, etc. 5 Can you customize your EOBs and remittances for a specific employer? Provide Yes, Allegiance can customize our EOBs for a specific employer. a sample and outline fields that can and cannot be changed. Please see Exhibit #_Sample EOB for a sample. While the data is system generated, we can change format and wording on nearly every section. 6 How did you develop your EOBs and remittance forms? How often do you Allegiance's EOBs and remittance forms have been developed change them and do you make use of user and focus groups with end through feedback from clients, members and providers over time. consumers to ensure information is understandable? They are, so -to -speak, living documents that evolve as requests are made and as we receive feedback from all stake holders. Rather than using specific focus groups, we take real -world feedback on an ogoing basis and make revisions to improve both the message and the look. As with our other communications, we employ Ocozzio, our retained PR and Marketing advisor, to assist with presentation. 7 Can the CCG have its own EOB that could include messages specific to their Yes, CCG can have their own EOB format complete with their logo. organization to further educate employees? For example, one month include a We can also include specific messages either on the EOBs or in message to plan members who are not using the CCHCC's provider partners inserts that accompany the EOBs. Those messages can provide stating "If you would have used a Partner Provider you would have saved $$$." examples of probable savings under specific circumstances, We would not, however, be able to provide specific, individualized examples of savings if another provider had been used. 8 Can you create EOBs in Spanish or other languages for specific individuals? Confirmed. 9 Do you create the annual Summary of Benefits and Coverage (SBC)? Confirmed. SBCs can be produced within 30 days following finalization of the SPD. Collier County Government (CCG) Appendix D - Questionnaire (Proposer shall not re -format or alter this spreadsheet) Limit each response to 500 words - exhibits can be included Company Name: Allegiance Benefit Plan Management, Inc. 10 Do you provide routine email communications to clients providing updates and Depending on the topic, we send out blast email notices to our clients guidance on federal regulations? of pending regulatory changes, we publish a newsletter and for larger scope legal and compliance issues, we present webinars to which our clients are invited. Allegiance creates and provides all required notices to the client for distribution to the client's employees in accordance to HIPAA, ERISA, IRS, COBRA, and PPACA. We can also mail those notices directly to the plan's members for the actual cost of postage and handling. d. General Service Issues 1 What is your turnover rate in the claims examination and customer service roles? Allegiance tracks tenure and turnover for our service teams as a unit, Will your organization need to increase staff to meet the service needs of the which are comprised of both Member Advocates and Claims CCG? If so, to what extent? Specialists. The average tenure of our Member Advocates and examiners over the past 2 years has been 3.75 years. We have reported an 18.8% turnover rate within our service teams over the past 2 years. Allegiance is always hiring to accommodate growth, but we will not need a specific number of new employees to continue to administrate for CCG. 2 How do you provide consistent administration of the plan when you experience Turnover is an on -going fact of life. Allegiance plans for, hires, and staff turnover? trains team members in advance of actual need in order to ensure consistent administration. 3 Many times there are conflicts between the administrator and the UR firm on pre- Allegiance has worked closely with CHP for more than ten years and authorization, benefits, as well as medical necessity. Describe how you would has established protocols for smooth coordination. Claims work with CHP so conflicting interpretations do not occur. administration, at the direction of the clients, follows the decisions of the UR firm, but can also provide additional resources for review by CHP. 4 How will your firm continue relationships with Navitus, CHP and other vendors Allegiance currently works with Navitus and Community Health the CCG may choose to work with? Does your organization have experience Partners on behalf of CCG. In addition, as a TPA, Allegiance is highly working with these organizations? If yes, describe. experienced in working with any and all vendors chosen by our clients. 5 How would you propose to coordinate in such a way as to avoid after -the -fact A report is run every Monday that picks up every trigger diagnosis that problems with stop loss insurance? Outline your process for disclosure and filing came in the prior week. A notification would be submitted to the claims with stop loss carriers. reinsurance carrier the next week. We file off trigger diagnosis so they will receive a notification every time a new trigger diagnosis is received. We also use encounter forms so if anyone in the company receives a telephone call or e-mail if it is a trigger diagnosis a form is completed and sent to Stop Loss and StarPoint. We file stop loss reimbursement requests weekly. A report is run every day of the week when releases have been completed by accounting and a reimbursement would be filed for anyone over $2,000 at that time. We always have two sets of eyes that review every report that is run so that nothing slips through the cracks. 6 Confirm your availability and willingness to participate in person at annual Confirmed. Your onsite staff member, Dan Ross, will remain onsite benefits fairs for any or all of the organizations who purchase services from you, and your Account Executive, Stephanie Kallevig, is available onsite for if required. two consecutive days annually. Collier County Government (CCG) Appendix D - Questionnaire (Proposer shall not re -format or alter this spreadsheet) Limit each response to 500 words - exhibits can be included Company Name: Allegiance Benefit Plan Management, Inc. 7 Does your organization provide an attorney or legal team to provide guidance Yes, through our Client Advisory Services Department and in and interpretation on Plan language and regulations within a 24 hour timeframe? conjunction with the compliance resources of Cigna, we are always available to provide guidance and interpretation to remain in compliance. In addition, we provide template plan amendments when laws and regulations require plan changes. Further, in addition to providing reports, we discuss compliance options in our quarterly meetings with each employer. C. Provider Network 1 What network(s) would you propose for services outside of Collier County or your CCG will continue to have access to Cigna's nation-wide OAP proprietary network, if appropriate? Confirm that you are able to accommodate network, in addition to the client-speicifc network (CSN) that the use of the CHP network within Collier County and your proprietary network Allegiance currently uses for pricing claims. outside of Collier County. Refer to the Network Disruption section of this RFP for instructions on how to complete the required network analysis. 2 If you proposed to use your own network or lease one, how do you ensure on an Our parent company Cigna maintains strict credentialing and selection ongoing basis that providers in it are of high quality? criteria for doctors, hospitals, and other providers. We collect and verify each provider's credentials during initial credentialing and again at recredentialing, which occurs every three years. Through our consistent provider contracting and credentialing standards, which are based on National Committee for Quality Assurance (NCQA) and state -specific requirements, we ensure our members have access to high quality providers. Additionally, clients benefit through healthier, more satisfied employees, and improved productivity. Provider Selection Process Cigna bases our selection process on our national credentialing policy and a network strategy that considers the desired number and locations of participating providers. When selecting a provider, our main considerations are quality of care, practice efficiency, and patient satisfaction. In selecting specialists, we tailor the network to each community. Member density, client need, the percentage of a provider's practice open to new patients, appointment wait times, patient satisfaction, and the availability of providers who meet our requirements determine the ideal structure of a network. In addition, specialists must meet our selection criteria and credentialing. We regularly evaluate our providers' performance and only select those who meet credentialing requirements and fit with our business strategy. 3 Are you able to assist the CCHCC employers in building a proprietary network? Yes, Allegiance has currently developed a proprietary network for Describe your previous experience in doing so. How would you go about doing CCG. Beyond the current network arrangements in place, Allegiance this? What is your turnaround time for inputting provider updates (address currently administers custom, client -specific network (CSN) changes, TIN changes, etc.) once notified? arrangements for over three dozen healthcare and governement sector clients. All aspects of the CSN are built directly into our system including contract and reimbursement arrangements, provider listings, corresponding tiered plan designs, etc. Provider updates can be entered in immediately if received during normal business hours. Collier County Government (CCG) Appendix D - Questionnaire (Proposer shall not re -format or alter this spreadsheet) Limit each response to 500 words - exhibits can be included Company Name: Allegiance Benefit Plan Management, Inc. 4 Does your online provider directory reflect real-time information? How often is the Cigna simplified the search process for members when they need to online directory updated? find a health care provider or compare cost and quality designations for hospitals and doctors. Our interactive online tools offer members the ability to refine their search results by the items important to them, including estimated costs (before benefits are applied), quality, and location. Members may access our online provider directory on myCigna. We pass personalized member information —the member's plan types (i.e., medical, dental, and pharmacy), zip code, and network —to the directory to ensure access to the correct networks and to provide a simplified, accurate process to access doctors and hospitals. Within myCigna, we have seamlessly integrated the cost of an event so the member can see the entire cost for the procedure or service, including doctor, health care facility, and additional service costs included in the event. Each result allows the user to see what his or her estimated costs are before benefits are applied. We also incorporate quality ratings for our participating hospitals and doctors based on information from the Centers of Excellence program and the National Committee for Quality Assurance (NCQA). We also display health care provider —specific costs for more than 600 common medical procedures, which represent 70-80 percent of Cigna's medical costs. These include estimates across the following categories: • inpatient services and surgeries • outpatient diagnostic services and surgeries • radiology services • lab tests • office visits • immunizations Estimates are created based on 12 months of Cigna claim data using the key data element of allowed charge amount (after discount and claim processing rules) by procedure. Truven Health Analytics creates estimates for other types of procedures based on 12 months of Cigna claim data. Claim data is refreshed quarterly. 5 What is your overall approach to provider contracting and how do you see this Contracts across our networks cover standard plan coverage offerings approach evolving over the next two years? and address the legal and contractual relationship with our health care professionals, including duties and expectations of the parties, credentialing, utilization management participation, billing, payment, member hold harmless, dispute resolution, termination, and other terms. Our contracts help develop long-term relationships with doctors by providing fair and equitable payment, appropriate and meaningful performance feedback, and effective support services. Our standard contracts include evergreen clauses, which state that the health care professional will be in our network until either party ends the agreement. Payment rates can remain in effect for the life of the contract, increase at regular intervals, or be updated via a contract amendment. We don't anticipate any change to this approach over the next two years. Collier County Government (CCG) Appendix D - Questionnaire (Proposer shall not re -format or alter this spreadsheet) Limit each response to 500 words - exhibits can be included Company Name: Allegiance Benefit Plan Management, Inc. 6 Do your current provider contracts in Collier County and Florida contain Cigna does not currently have a performance based reimbursement performance based reimbursements? If yes, describe the methodology. Will program for providers and we do not plan to provide this type of these performance based provisions result in any financial impacts to these reimbursement in the future. organizations? Finally, do you have plans to implement or expand performance based reimbursements? Describe your plans and how it might affect each However, for ASO clients using Cigna's Collaborative care value employer. What percentage of your agreements in Collier and Lee Counties are based program, PCP groups in value -based reimbursement programs performance based today and how do you see this percentage changing in the receive a prospective care coordination reimbursement per aligned next two years? patient per month. Claim data is used to determine alignment of members as a basis for the care coordination reimbursement. In the first year, the care coordination reimbursement amount is determined on an individual group basis. The group identifies specific actions that it contractually agrees to complete to help achieve the triple aim. These actions are assigned a per -patient -per -month (PPPM) value, based on anticipated medical cost reductions as a result of taking these actions. Examples of possible efficiencies to lower market costs and increase quality include the health care provider's coordinator making outreach calls to discharged members to coordinate follow-up appointments, calling members with identified gaps in care, extending office hours, and referring to doctors with the Cigna Care Designation and to preferred vendors. Each year, we evaluate the provider groups on how successful they are at delivering value. Groups must maintain quality at or above market average or improve quality as measured by adherence to evidence -based medicine (EBM) standards. If the group does not meet this requirement, there is no financial reward —no matter the impact on medical trend. If the group meets the quality requirement, we evaluate the impact on total medical cost. If the group achieves both quality and cost metrics, it is eligible for an adjustment to the care coordination reimbursement amount on a prospective basis. This only occurs after we recover the care coordination payment amount paid as shared savings. The care coordination reimbursements are considered a claim expense. By design, we pass savings from our initiatives to clients via lower costs and utilization as well as improved quality through better care coordination for members. If there are lower costs through these programs, the claim experience will capture that for every patient, and 7 What is your favored physician reimbursement methodology in Florida, e.g., We offer several methods to pay participating doctors and hospitals discount off of submitted charge? Why do you favor this approach? fairly and to encourage them to provide quality care while managing costs. Our standard payment method for PCPs and specialists is a fee for -service (FFS) arrangement. Hospitals are paid through negotiated per diems, case rates (typically designated by DRGs), or discounts off charges. Hospital contracts may include payment for hospital -based doctors, such as radiologists, assistant surgeons, pathologists, emergency medicine doctors, and anesthesiologists. When a hospital does not employ these doctors as part of its staff, we make every effort to contract with them on a FFS basis. To help reduce variations, we are also offering and expanding our value -based reimbursement models with large doctor groups, hospitals, and specialists and rewarding them for better quality, cost- effective care, enhanced care coordination, and patient satisfaction. 8 What is your favored facility reimbursement methodology in Florida, e.g., See above. discount off charges, DRG, per diem? Why do you favor this approach? Collier County Government (CCG) Appendix D - Questionnaire (Proposer shall not re -format or alter this spreadsheet) Limit each response to 500 words - exhibits can be included Company Name: Allegiance Benefit Plan Management, Inc. 9 Lab tests for the program are performed by Midland Health. Confirm you can Confirmed. process these claims in bulk for payment to Midland and treat them as an in - network provider. 10 Claims within Collier County that are negotiated via the messenger model from Allegiance currently administrates this design for CCG and the fee is CHP require the administration of a provider withhold. When claims are received, paid weekly to the network. Please see Exhibit #_Sample EOB & the TPA must bill the CCG for the negotiated contractual amount. The resulting EOPs for de -identified examples reflecting the withhold. payment is then split into two pieces. A percentage of the payment called the withhold is remitted to CHP and the balance to the provider. Provide an example of an employee EOB and provider remittance, reflecting the withhold. 11 The CCG operates an on -site clinic, which is managed by Millennium Physician Confirmed. Allegiance will continue to suppress EOBs for clinic Group. It is required that encounters at the clinic be processed as zero payment services. claims within the successful vendor's claims processing system. Claims are submitted via a standard HCFA 1500 claim form utilizing a unique provider ID. Will the CCG have the option of suppressing EOBs for clinic services? 12 The CCG utilizes Zelis to audit claims that exceed certain dollar thresholds based Confirmed. on whether the patient was inpatient or outpatient. It is required that you pend and send these claims to Zelis. Zelis then conducts a review of claims, makes any necessary adjustments, and sends the invoice to the employer for approval and payment. Zelis is paid a percentage of the savings. The proprietary network administered by Community Health Partners allows such audits. Would Zelis be allowed to audit claims under your proprietary network? 13 Are you able, on a request basis, to provide reports which calculate the Allegiance utilizes Payer Compass for this report, which has a fee of percentage of Medicare being reimbursed under the current arrangements to $1500. providers within the CCHCC network. If so, would you do this internally or outsource? 14 CHP has retained and credentialed mental health professionals to provide Confirmed. Allegiance will continue to administrate this plan design. services under the plan. These services are processed under the medical plan at 100% of the contracted amount. You must be able to add these providers into your system and pay them at 100%. 15 Confirm you will allow the CCG to stipulate the level of reimbursement for non- Confirmed. CCG currently reimburses OON providers at 100% of network providers within Collier County. Medicare. If desired, this can be changed by communicating with your Account Executive. D. Technology and Data Availability a. Technology How can technology be used to make the claims payment process more efficient? For example, a lot of paper is generated to get information regarding other coverage, accidents, etc. In many instances, employees do not answer these letters, leading to rejected claims, problems and further confusion. Collier County Government (CCG) Appendix D - Questionnaire (Proposer shall not re -format or alter this spreadsheet) Limit each response to 500 words - exhibits can be included Company Name: Allegiance Benefit Plan Management, Inc. 1 What kind of online systems do you have to help employees with claims, benefits Allegiance has developed a comprehensive internet website for and provider questions? Does the site include the ability for employees to get access to claim status, plan information, reimbursement accounts, forms and request duplicate ID cards? provider directories, FAQs and eligibility information for plan participants. We also offer a mobile app that provides for the same access that a plan member would have on a laptop or desktop computer. Online services include: • Benefits at Glance • Claims History: EOBs, accumulator information, running tally of all claims, tally of deductible and out of pocket amounts met • Document Library • Online enrollment capabilities, if offered by employer • Reimbursement Accounts: FSA/HRA EOBs and notebook -style running tally of reimbursement activity • Verification of Benefits • Request additional ID Card, Change of Address • Print temporary ID card, request replacement • Additional Tools: Tie in Rx to do single sign -on or include wellness vendor's website, online COB and Accident questionnaire 2 To what extent have you used e-mail to allow plan members or providers to Allegiance can utilize secure email, telephone, or mail for response respond to information, accident, other coverage or other inquiry letters? from members. 3 To what extent do you use e-mail as mass communication (e.g., e-mail tip -of -the- Allegiance generally uses mass email to communicate compliance month to employees)? notices or pre -scheduled maintenance to web portals. If CCG would like to incorporate educational mass emails, we can likely accommodate. 4 Do you have a mobile app? What functionality is included? What enhancements Confirmed. Allegiance has a mobile app that provides the same are planned for 2022-2023? access that a plan member would have on a laptop or desktop computer. We recently accomplished a full upgrade of our web services, which extends to both our employer and member -facing web portal & moblie app. Our upgraded web tools offer a state-of-the-art, streamlined, user-friendly online experience for our clients and participants. 5 Do you offer online chat with customer service representatives? Allegiance does not currently offer online chat. We take a conservative approach to the available access to these services to ensure maximum information security on all data and documents. 6 Are you able to customize your website for a specific employer? Would the Yes, we customize a special landing page for our employer clients at employer have any administrative rights, such as posting documents? Is there an their request and at no additional charge. Employers may add links or additional cost for this service? post documents through Allegiance to ensure efficiency and testing. 7 Are you willing to allow employees and providers to respond to inquiries via e- As long as emails contain the necessary information and the mail versus written forms? Can documents be uploaded via your website? communications are HIPAA compliant, Allegiance can accept forms and information via email. Allegiance maintains its own secure email service to allow for that. Nevertheless, Allegiance has developed the ability to fill the forms out online and submit them as well. 8 Can you e-mail EOBs or provide access to EOBs via the Internet so that Confirmed. The EOBs that plan members can access via our website participants could look at an EOB they may have lost, check deductible status, are pdf duplicates of the EOBs they may have previously received. In claim history or coinsurance? Is EOB history available on your website? If yes, addition, through the website plan members can check deductible how long is the history available? status, claims history, history out-of-pocket accumulators, etc. Allegiance maintains this history for a minimum of 6 years. Collier County Government (CCG) Appendix D - Questionnaire (Proposer shall not re -format or alter this spreadsheet) Limit each response to 500 words - exhibits can be included Company Name: Allegiance Benefit Plan Management, Inc. 9 The current telehealth vendor is WeIIVia, are you able to facilitate continued use Allegiance will continue to facilitate use of WeIIVia. of that vendor? If not, who would you recommend, why would you recommend them and what is the cost? 10 Do you have, or do you have a partner who offers, price transparency and quality Allegiance currently partners with Healthcare Blue Book (HCBB), a tools? Elaborate on how they might help the CCG. pricing transparency company, to offer participants a tool for comparing price differences in procedures and/or facilities. HCBB helps reduce the cost of healthcare by enabling participants and employers to make better use of the high -value providers within their existing network. Access to the HCBB is an additional $1.90 PEPM. b. Data Availability The CCG realizes that the availability of data to understand the principal factors that are driving costs is a must. However, most data reporting systems produce mounds of paper but little meaningful information. Describe your experience with each of the following. 1 Review and confirm you are able to provide the data extracts in the required Confirmed. format for Cotiviti, DeerWalk and CHP. 2 Would the CCG, their consulting teams and CHP have direct access to your Yes, with appropriate direction and HIPAA compliance, as is currently reporting system to obtain standard and ad hoc reports? Describe how access the case with CCG, employers and their consulting firms will have and security to the reporting tool would be facilitated and controlled. For example, direct access to standard and ad hoc reports. When someone with what would be the process for turning off access for a terminated team member access to the system terminates, the employer notifies Allegiance and or adding access for a new team member? Confirm CHP advocates will be able the access is immediately terminated. For new team members, with to directly access claim history and EOBs. PHI clearance from the Covered Entity, Allegiance provides secure access within two business days. 3 What is the timing for availability of monthly reporting following the close of the For data files and standard reports in the claims system, Allegiance prior month? Would you be able to make reports available by the 5th day of the makes reports available no later than 15 days after the end of the month following the close of the prior month? month. For predictive modeling, the data and reports are updated no later than the 20 days after the end of the month Download claims files are available as often as weekly no later than 3 business days after the claims for that week have been funded by the client. 4 Describe the security systems you have in place for protecting data and ensuring Please refer to Exhibit #_Allegiance_Disaster Recovery Plan - continuation of service in the event of a catastrophic event. Executive Summary. 5 Confirm that you are able to transfer eligibility files from client systems to yours Confirmed. on a nightly basis. 6 CHP must have access to data on as close to a real time basis as possible in CCG will continue to have real-time integration with Cedar Gate, our order to assist them in managing health costs and outcomes. Outline how you analytics platform. will coordinate with them, including systems access, in order to access timely data. E. Service to Providers, FSA and HRA, COBRA, Health Management, General Requirements a. Service to Providers Many times, provider's issues and needs are not directly addressed in the administration of health plans. Provide your thoughts on the following: 1 Identifying and coaching specific providers whose coding or claim submission Allegiance has reached out to providers by telephone to advise of practices are causing problems. Reference how you take steps to ensure that problems with coding submitted by that provider's office. We have had Modifiers and Units are properly used. very good results in clearing up issues by the outreach to the provider. Coding is reviewed in accordance with NCCI standard coding edits. Modifiers and Unit Llmits are reviewed as part of the NCCI edits. Collier County Government (CCG) Appendix D - Questionnaire (Proposer shall not re -format or alter this spreadsheet) Limit each response to 500 words - exhibits can be included Company Name: Allegiance Benefit Plan Management, Inc. 2 Many providers allege that EOBs contain misleading statements such as "not As stated, Allegiance follows the NCCI coding edits and they are filed within AMA guidelines". How do you ensure that coding rules are properly enforced equally across all providers. Yes, Allegiance would be willing and fairly enforced? Would you be willing to work with local provider groups to to work with local provider groups to develop methods to address develop methods to address communication issues such as this? communication issues. However, Allegiance's EOB/EOP comments are designed to relay specific information relative to the issue. 3 Do you provide Internet access to providers to verify plan design, eligibility and Yes, Allegiance not only provides Internet access to providers to deductible and other out-of-pocket history? obtain this information but we strongly encourage providers to utilize this service as it is more efficient for everyone. 4 What do you do to make your firm more provider friendly as compared to your Cigna establishes collaborative working relationships with each of our competitors? contracted network health care providers. We use a suite of analytical tools, evidence -based medicine (EBM) measures, and ETGs to profile doctors, compare practice patterns, and monitor cost and utilization. We can compare single doctors within their specialty groups and geographic areas. These tools account for clinical patient population differences and help identify opportunities for improvement. We consult with doctors on an annual basis to help them understand the results, how they vary from their peers, and how they can improve or where they exceed. Providers participating with the organization undergo a review of their qualifications in accordance with our national credentialing guidelines. Recredentialing occurs every three years in accordance with industry standards. In addition, our Medical Director will conduct Peer -to -Peer reviews with patient's attending healthcare provider concerning the necessity or appropriateness of the healthcare service. b. FSA and HRA 1 List all third party vendors and contractors used to deliver these services. For Allegiance provides reimbursement account administration internally, each third party partner, explain in detail the nature of this relationship, the length including FSA, HRA, and HSA. This is our preferred arrangement, as of the relationship, and the current contract length with the partner. our internal programs are fully -integrated into our claims/medical management systems and allows us to offer seamless administration to our clients and members. See the included Financial Proposal for pricing related to these programs. In addition to offering these programs internally, Allegiance is a highly flexible partner and is able to coordinate with third -party FSA/HRA/HSA vendors. We work closely with our clients and their vendors to develop a clear understanding of their requirements and needs during the implementation process. 2 Confirm that none of the services will be performed offshore (including banking, Confirmed. Allegiance does not conduct any business offshore. member services, claims, data warehousing, etc.). 3 How do you coordinate benefits between an HRA and FSA? Is this fully Claim reimbursement coordination is automatically governed based on automated? If so, through what system? Describe in detail, showing process plan setup within the software platform. Submitted reimbursement maps, demonstrating data and cash flow for all parties (employer, member, requests are reviewed by a claims examiner for eligibility, then provider, and administrator). processed for reimbursement first through the health FSA. If the health FSA is not elected or is depleted, the claim rolls to the HRA and is reimbursed. Please see Exhibit #_Allegiance_Claims flowchart. Collier County Government (CCG) Appendix D - Questionnaire (Proposer shall not re -format or alter this spreadsheet) Limit each response to 500 words - exhibits can be included Company Name: Allegiance Benefit Plan Management, Inc. 4 Can members access their FSA and HRA account information directly through The health plan, FSA, and HRA can be accessed with a single login. their medical portal website or must they login to a separate portal entirely? Links can be posted on the member portal. Describe your ability to post deep links on your member site(s) that will allow members to more easily view comprehensive program information, including information from third party wellness vendor sites. 5 Confirm that you offer a debit card at no cost. Confirmed. 6 Who owns and administers the debit card? If it is an outside firm, indicate your Allegiance serves as the administrator and main contact for all day -to - partner and explain in detail, the nature of this relationship along with the length day HSA operations, such as reordering debit cards, account balance of the relationship. inquiries, claims submission, etc. We partner with WEX INC. as a software provider and the custodian of funds for our HSA program. 7 Is the card stackable so that one card can be issued to a member with an FSA Confirmed. and HRA? 8 What additional fees are charged in relation to the debit card? There are no additional fees in relation to the debit card. 9 Does the card work for dependent care accounts as well? Confirmed. 10 How many cards are provided for one account? For what period of time are cards Each participant receives two cards with an expiration date three valid? years from the date of issue. 11 What methods are available for members to request reimbursement? List the Reimbursement requests with accompanying documentation, as well options by account type and assess how easy it is for members to submit as debit card transaction documentation, can be submitted by mobile receipts and request reimbursement. app, online, by fax, or by mail to Allegiance. Claims are generally reimbursed within a week of Allegiance receiving the claim. 12 Describe your funding requirements? Allegiance does offer investment options (included as Exhibit #_HSA Advantage 2022). The minimum HSA balance required to invest is $2,000. c. COBRA 1 Confirm your ability to administer COBRA for Medical, Dental, Vision and FSA Allegiance provides COBRA administration and reimbursement accounts. Describe the process for administering each. Confirm this processing accounts, including FSA and HSA, internally. This is our preferred is handled in-house versus outsourced. arrangement, as our internal programs are fully -integrated into our claims/medical management systems and allows us to offer seamless administration to our clients and members. COBRA administration for Allegiance administered servies is included for all Allegiance clients. Allegiance is also able to establish regular eligibility data sharing arrangements with your vendor of choice. No additional fee would apply unless the selected vendor cannot use our industry -standard data sharing arrangement. 2 Confirm how file transmissions are handled between vendors? Are requests sent Outside files are placed on our FTP site and routed accordingly to the electronically, faxed, or mailed? appropriate team. If file transmission is not setup, information can be transmitted via fax or secure mail. 3 Describe your process for integrating COBRA election information with the claims Upon COBRA election, members claims are processed accordingly adjudication system for eligibility purposes. based on the current month's paid -through date. 4 Do you have a process with vendors for weekly error reporting? Confirmed. 5 How are payments handled? Can individuals pay via ACH, check, or credit card? Participants will have the options to make their monthly premium payment via check or money order or a monthly ACH. d. Health Management Collier County Government (CCG) Appendix D - Questionnaire (Proposer shall not re -format or alter this spreadsheet) Limit each response to 500 words - exhibits can be included Company Name: Allegiance Benefit Plan Management, Inc. 1 Following are the utilization review and case management services by CHP. Confirmed. Allegiance will continue to administrate UM and CM Confirm you are able to provide similar services in house. internally for CCG. 2 Following are the disease management services offered by CHP, confirm you are Allegiance's standard procedure is to utilize the client's vendor of able to provide similar services in house. choice for disease management. We have considerable experience integrating with disease management vendors to share data and coordinate referrals as needed. We currently work with a number of DM and point -solution vendors and can recommend solutions tailored to best addressing CCG's specific goals. e. General Requirements 1 The CCG does not require the TPA to assist with the placement of medical stop Allegiance confirms and has demonstrated that we are able to work loss. Confirm your ability to work with any stop loss carrier selected. The CCG with stop loss carriers selceted by CCG employers. knows that organizations such as yours may price their services in anticipation that they will receive commissions, overrides, contingent commissions or other Allegiance confirms that all services fees are quoted net of any remuneration from the carriers that they place these coverages with or vendors commissions, overrides, contingent commissions or other who provide services. Your service fee should be quoted as NET of any and all remuneration for any stop loss carriers. forms of remuneration. Allegiance confirms and has demonstrated that we fully disclose any compensation provided to our organization that is not in the quoted prices in advance of placement and annually thereafter. 2 The CCG used Midland Labs for biometric screenings. Confirm that you can Confirmed. suppress claims payments for these services while enabling data transition to CHP to track results. 3 Certain claims for lab work that occur at a Midland or Quest are collected and Confirmed. entered into the claim system by Allegiance as a $0 claim for tracking and continuity of care done by CHP. Confirm you will be able to replicate this process if chosen as the TPA. This is applicable solely to their health and plan design qualification process. 4 Describe the ownership of your organization. In 2008, Allegiance Benefit Plan Management, Inc. became a wholly - owned subsidiary of Connecticut General Life Insurance Company (CGLIC), a subsidiary of Cigna Corporation, when CGLIC purchased Allegiance's holding company Benefit Management Corp. 5 How many clients do you service that are of similar size to the CCG? Including CCG, Allegiance serves 16 similar -sized clients. 6 What is your organization's vision and mission? What steps do you take to Allegiance is committed to transparency in all aspects of our ensure the vision and mission are realized? operations. We work closely with our clients to ensure that they are fully informed with regard to how their plan is functioning and being administered. We provide clients with open lines of communication, above average access to member and industry data, and willing consultation designed to support client goals for their plan. At Allegiance, we recognize the importance of customers and patients having easy access to information that allows them to make better informed decisions around their health care. F. Community Health Partners The following criteria is established by CHP. Confirm your ability to meet the criteria for each area noted below: 1 Provide a dedicated customer service representative for the medical service Rochelle Cole will remain your Clinical Client Liaison. staff. 2 Provide Member services representative to address questions for benefit Dan Ross will remain your on -site representative. coverage. Collier County Government (CCG) Appendix D - Questionnaire (Proposer shall not re -format or alter this spreadsheet) Limit each response to 500 words - exhibits can be included Company Name: Allegiance Benefit Plan Management, Inc. 3 Report availability - either access to their system for reporting/system availability All current reports that are being provided will continue to be available to obtain information. on the current schedule. In addition, Allegiance is willing to review this process during renewal to address any areas that the client would like. 4 Accept data or provide a process to transition any open authorization for surgery, Yes, Allegiance agrees to work with CCG to transition any open procedures, therapy or other situations to ensure continuation of care with a new authorization to insure a smooth transition and continuation of care TPA. CHP will monitor open authorizations and provide listing for any open during implementation and upon the effective date of coverage. authorizations at least 60 days prior to the 1/1/2023 effective date. 5 Provide a dedicated Customer Service Representative for the Provider Relations Confirmed. staff to respond to fee schedule updates/changes on an as needed basis as requested, in a timely manner. 6 Ability to work collaboratively to program claims payments systems to meet the Confirmed. needs of the client and pay according to the plan document and fee schedule 7 Ability to load multiple levels of fee schedules by provider type (Specialty or TIN Confirmed. 8 Provide a customized member ID card to identify employer groups and networks, Confirmed. including CHP logo and secondary network logo as applicable. Do you allow client input into the design of ID cards? 9 Provide Cotiviti, DeerWalk and CHP a monthly file of claims no later than the 5th Confirmed. of every month in the file format required by each. These are internet-based data analytic tools that enable the CHP, CCG, and its consultant to have the access to medical and pharmacy claims. 10 Member information will be transferred in a formatted text date file from the TPA Confirmed. to CHP on a daily basis Monday through Friday. The format of the data file will be variable length character fields with fields pipe delimited ("I"), the fields/format to be provided by CHP. 11 Update of CPT/ICD codes annually. Scheduling of the update of the CPT/ICD9 Confirmed. codes with CHP allowing CHP to complete updated simultaneously, which will prevent system errors. 12 Use a secured FTP site provided by CHP for delivering and retrieving files. Confirmed. 13 How do you set the medical policy for what is considered experimental, Generally speaking, Allegiance uses the Cigna Medical Policy which is investigational or not covered and how will you coordinate this with CHP? routinely updated by experts in the appropriate clinical field. Allegiance also uses client specific medical policies based on a client's plan design or external vendors, such as CHP. FSA & HRA CLAIM PROCESS ICLAIM SUBMITTED I Mobile I I Online I I Fax I I Mail I Distributed to examiners I Reviewed for FSA roved I I Denied 11 Denial statement I Emplover FundinF, I Payment released I Reviewed for HRA I Approved I I Denied I Denial statement I Proprietary and Confidential (A)Allegiancec"' a Cigna Company Allegiance Business Continuity Plan— Executive Summary Following is the Executive Summary for the Allegiance Business Continuity Plan. The detailed implementation plans and protocols are audited annually for AS70 compliance SSAE-16 compliance and are maintained at the Allegiance corporate offices in Missoula, Montana and distributed to appropriate staff for execution in accordance with the plan. Disaster Protocols Level 1 Disaster — Global impact on one or more critical business systems lasting less than 24 hours for mission critical services or 48 hours for non -mission critical services (Refer to Exhibit 1). A Level 1 Disaster includes but is not limited to: Localized, short -duration interruption of utility services (e.g., phone, electricity, heating/cooling, security, water etc.) impacting the entire office; LuminX system crash; Wisdom system crash; e-mail server crash; jukebox failure; IVR failure; web server crash, etc. In the event of a Level 1 Disaster, it is the responsibility of all management and IT Personnel to: • Protect lives and secure property • Determine which ALLEGIANCE -based services are impacted; • Implement orderly shut down of systems to ensure full storage and recovery capabilities of actions performed since the previous back-up; • Communicate problem to appropriate internal management within 15 minutes of event. (Refer to Exhibit 2. Communication Protocols.) • Contact services to diagnosis and help restore system o Local authorities/utilities o System Vendor(s) o Telecom vendors o Etc. • Restore Services • Test for... o Last transactions o Need for restoration from backups • Communicate Status (Refer to Exhibit 2 in Section 6) • Resume Service Level 2 Disaster — Global Impact on one or more critical business systems lasting 25-72 hours for mission critical services or up to 1 week for non -mission critical services, in which the facilities are stable and secure (Refer to Exhibit 1.). A Level 2 Disaster includes but is not limited to: a mid to long-range duration interruption of utility services (e.g., phone, electricity, heating/cooling, security, water, etc.) impacting the entire office; LuminX system crash; Wisdom system crash; e-mail server crash; jukebox failure; IVR failure; web server crash, etc. All of the above (Level 1) protocols apply. Level 2 Disasters call for greater communication and the implementation of localized work -around plans depending on the disaster. This may include ways to provide partial service, the �■� IIegic A c6 a Cigna Company manual "pre-processing" of claims or other modified workflows that will allow for a quicker recovery of business processes upon correction of the problem(s). Level 3 Disaster — Local, regional or national disruption of services due to natural disaster or other acts. Level 3 Disasters are the same as Level 2 that are generally long-range and greatly exacerbated by the fact that physical facilities and/or major IT hardware are required before business recovery can commence. In addition to the Level 1 and Level 2 protocols noted above, the following actions may be required during Level 3 events. • Determine to what extent ALLEGIANCE physical facilities are impacted; • Determine need for relocation of staff and/or equipment to alternative ALLEGIANCE location. • Determine need for contacting business partners to activate outsourcing services until ALLEGIANCE can reassemble staff at normal or alternate location. • Request required contracted equipment and/or services and reconstruct data center. • Arrange transportation and lodging for appropriate individuals to back-up site; • If orderly systems shutdown is not possible, recreate transactions since last back up; • Contact services to diagnosis and help restore facility and systems o Local authorities/utilities o System Vendors, Telecom vendors o Insurance Company(s) o Construction Vendors o Supply Vendors o Etc. • Assess damage and begin replacing servers; workstations; etc. • Restore services Allegianceo a Cigna Company LOOMIS SAYLES GLOBAL ALLOC Y AMER FUNDS CAPITAL INC BLDR F2 DFA US LARGE CAP VALUE PORT I VANGUARD 500 INDEX ADMIRAL AMER FDS GROWTH FND OF AMER F2 VANGUARD MID CAP INDEX ADM JPMORGAN MARKET EXP ENH IDX I NEUBERGER BERMAN MID CAP GR I VANGUARD SMALL CAP INDEX ADM VAN SMALL CAP GROWTH IDX ADM NORTHERN SMALL CAP VALUE VANGUARD TTL INTL STK IND ADM AMERICAN EUROPACIFIC GROW F2 FIDELITY ADV DIVRSFD INTL I VANGUARD EMG MKTS STK IDX ADM VAN TOTAL WORLD STOCK IDX INV NUVEEN REALESTATE SECURITIES I VANGUARD RETIREMENT 2020 INV VANGUARD RETIREMENT 2030 INV VANGUARD RETIREMENT 2040 INV VANGUARD RETIREMENT 2050 INV VANGUARD RETIREMENT 2060 INV VANGUARD TGT RETIREMNT INC INV LORD ABBETT HIGH YIELD I TEMPLETON GLOBAL BOND ADV VAN INFLATION PROTECTED SEC AD VAN INTERM TERM BND IDX ADM PIMCO TOTAL RETURN INST VANGUARD TTL BND MRKT IDX ADM AMERICAN FUNDS BALANCED FUND Mutual funds currently available for savings greater than $2,000. J.P• Morgan Asset Management Ik CAPITAL AMERICAN GROUP" I FUNDS .��IUc �g�,y • FRANKLIN ®TEMPLETON NORTHERN 19 1V TRUST 2806 S. Garfield St. P.O. Box 3018 1 Missoula, MT 59806-3018 1 www.askallegiance.com Sample EOB & EOPs (*)Allegiance Member EOB: Claim- 2022D1i3AME IdemterlU=� Patient: DOB:= Treahnem Procedure Biled Indyb6e errceAdlusvreer 6edtcuUe C�-pay �Insuranae Paid Payr m Dates Amxxust Amo.rrt Cade Arre-yunt Arr3ount At lXJ n011rt 0111MV1d12M atTioarart}ry.t twisitnew $3czm 30-00 14150 $134-41 SO.DD SMOG 50-0O 100% $182-59 01I1D-0111012D22 electrccardtog complete 1MDO °FPO.00 41150 $mAm TO-DO $0.00 SD-04 1DD% $1D-20 Column Totals $3B&00 $0.00 $151.21 SC_Li7 5M.03 S&n0 $2d1.79 Other Irmuranoe Credits $D-DO aGO Adjusted Payment $201-79 +* r tr Code description 1415D Provider discount through Qxnmunity Health Partriers. Appeal proced ures are pri med as 4he last page of this document Patient not res port5ible for thr5 amourlR_ Rendering Provider EOP: PT: PT. DOE � MiH: PLAN ID: 2DD302112421 PT. ACCT. � CLAIM #: 2a220113AA4F cuaff: COLUERCOUNTY GrOVERN W-WF CLAW ID: 20DW21 Billed PP() -Non Other Deductible Patient MLLof5erwine Procedure Paid Ref Amount Discount Covered Coverage Co -Pays 4esp- 992(M:officeopnew c 0111D22-0111022 4&N rnn S352.90 $134.41 SO.Oa 80.90 sat.:: 335A0 S179.5 CCPAKK150.14151 0111u122-0111u1L2 cMM ue ectr, -.ardiegrar• SMOG S16.80 SO.00 Su.=ti :3 SOA9 318.91 4150.14151 Totals: 5386.00 5151.21 50.04 $0.04 535.v; 53&04 1'198-76 Reference: COPAM Co -payment Arnount 1415a Provider discount through Community HeaFth Partners. Patient not responsible for tNs amount. 14151 Community Healith Partners contracted withhoid. Patient is not responsible for this wwunt. CHP Payment EOP: PT; PT, DOR PT. ACCP CUENr, COLu ER COUNTY G-DJERNI ENT MDR: PLAN ID. 200302112421 CLAIM 4: 20220113AA4E WENT ID: 2003021 Dave of Serr-ce Procedure Billed PPO Han Other Deductible Patient Paid Re€- Amouni discount Covered Coverage Co -Pays Resp. OWI 22-OWO22 D02u4:office&pnearmod45-59 $ r .Oa 1134.41 SO.00 50AO S35.49 Wim $2-74 C-OPAM.14,d0 0111 OM-0111 GM 93010 - elecutr�rdicgram compleke MOO 50.00 #a.0: ::: SOAO 5023 14750 Totals: 538B.00I $151.2" U.00 UM $35 vv W-00 Reference: COPAM Co -payment Amount 14150 Provider discount through Community Health Partrsars. Patient not responsible for this amount. Pour Benefits at Work TM Page 1 O�,&,)Allegianc6 Cigna Company Claims Analysis (By Division) GROUP NAME Medical Paid Date Between Jun 1, 2021 and May 31, 2022 IParticipant/Dependent Claim No Charges Ineligible Amounts Discount Amounts Deductible Amounts Coinsurance Out Of Pocket COB Savings Total Paid Claim Count Lines I Group Division Plan GROUP NAME COBN PLAN NAME --Plan Totals-- $268.15 $0.00 $0.00 $0.00 $164.36 $0.00 $103.79 2 2 --Division Totals-- $268.15 $0.00 $0.00 $0.00 $164.36 $0.00 $103.79 2 2 Group Division Plan GROUP NAME COBR PLAN NAME --Plan Totals-- $167,063.61 $2,426.93 $36,407.13 $343.48 $2,651.80 $0.00 $125,234.27 247 394 Plan NA -NA --Plan Totals-- $15.00 $15.00 $0.00 $0.00 $0.00 $0.00 $0.00 1 1 --Division Totals-- $167,078.61 $2,441.93 $36,407.13 $343.48 $2,651.80 $0.00 $125,234.27 248 395 Group Division Plan GROUP NAME NON PLAN NAME --Plan Totals-- $2,856.50 $0.00 $0.00 $0.00 $1,009.91 $0.00 $1,846.59 10 10 --Division Totals-- $2,856.50 $0.00 $0.00 $0.00 $1,009.91 $0.00 $1,846.59 10 10 Group Division Plan GROUP NAME RETR PLAN NAME --Plan Totals-- $584,042.32 $76,525.34 $118,985.87 $2,634.94 $15,686.34 $10,247.01 $359,962.82 1053 1685 Plan NA -NA --Plan Totals-- $424.93 $424.93 $0.00 $0.00 $0.00 $0.00 $0.00 9 10 --Division Totals-- $584,467.25 $76,950.27 $118,985.87 $2,634.94 $15,686.34 $10,247.01 $359,962.82 1062 1695 GROUP NAME $754,670.51 $79,392.20 $155,393.00 $2,978.42 $19,512.41 $10,247.01 $487,147.47 1322 2102 Run Date - Time:Aug 10, 2021-12:41:13 PM Pagel Allegiance a Cigna Company Claims Analysis GROUP NAME Medical Paid Date Between Jun 1, 2021 and May 31, 2022 Participant/Dependent Claim No Charges Ineligible Amounts Discount Amounts Deductible Amounts Coinsurance Out Of Pocket COB Savings Total Paid Claim Count Lines I Group Division Plan GROUP NAME COBN PLAN NAME --Plan Totals-- $268.15 $0.00 $0.00 $0.00 $164.36 $0.00 $103.79 2 2 --Division Totals-- $268.15 $0.00 $0.00 $0.00 $164.36 $0.00 $103.79 2 2 Group Division Plan GROUP NAME COBR PLAN NAME --Plan Totals-- $167,063.61 $2,426.93 $36,407.13 $343.48 $2,651.80 $0.00 $125,234.27 247 394 Division Plan COBR NA - NA --Plan Totals-- $15.00 $15.00 $0.00 $0.00 $0.00 $0.00 $0.00 1 1 --Division Totals-- $167,078.61 $2,441.93 $36,407.13 $343.48 $2,651.80 $0.00 $125,234.27 248 395 Group Division Plan GROUP NAME NONM PLAN NAME --Plan Totals-- $2,856.50 $0.00 $0.00 $0.00 $1,009.91 $0.00 $1,846.59 10 10 --Division Totals-- $2,856.50 $0.00 $0.00 $0.00 $1,009.91 $0.00 $1,846.59 10 10 Group Division Plan GROUP NAME RETR PLAN NAME --Plan Totals-- $584,042.32 $76,525.34 $118,985.87 $2,634.94 $15,686.34 $10,247.01 $359,962.82 1053 1685 Division Plan RETR NA - NA --Plan Totals-- $424.93 $424.93 $0.00 $0.00 $0.00 $0.00 $0.00 9 10 --Division Totals-- $584,467.25 $76,950.27 $118,985.87 $2,634.94 $15,686.34 $10,247.01 $359,962.82 1062 1695 Group Name $754,670.51 $79,392.20 $155,393.00 $2,978.42 $19,512.41 $10,247.01 $487,147.47 1322 2102 Run Date - Time:Aug 10, 2021-11:59:03 AM Page:1 M Allegiance a Cigna Company Paid Claims by Network Status & Relationship In -Network Paid Jun 1, 2021 through May 31, 2022 Out -Network All Providers Relationship I Male Female I Male Female I Total Male Total Female Total Group: 1234567- GROUP NAME Division: COBN - COBRA (Plan Name) M Employee $103.79 $0.00 $0.00 $0.00 $103.79 $0.00 $103.79 Total Division: $103.79 $0.00 $0.00 $0.00 $103.79 $0.00 $103.79 Total Group: $293,469.44 $167,710.00 $18,523.15 $7,444.88 $311,992.59 $1755154.88 $487,147.47 Run Date: Aug 12, 2021-10:00:04 PM Page:1 Allegiance a Cigna Company Paid Claims by Network Status & Relationship Paid Jun 1, 2021 through May 31, 2022 In -Network Out -Network All Providers Relationship I Male Female I Male Female I Total Male Total Female I Total Division: COBR - COBRA _ Employee $179.98 $122,819.76 $0.00 $2,234.53 $179.98 $125,054.29 $125,234.27 Total Division: $179.98 $122,819.76 $0.00 $2,234.53 $179.98 $125,054.29 $125,234.27 Total Group: $293,469.44 $167,710.00 $18,523.15 $7,444.88 $311,992.59 $1755154.88 $487,147.47 Run Date: Aug 12, 2021-10:00:04 PM Page:2 Allegiance a Cigna Company Paid Claims by Network Status & Relationship Paid Jun 1, 2021 through May 31, 2022 In -Network Out -Network All Providers Relationship I Male Female I Male Female I Total Male Total Female Total Group: 1234567- Group Name Division: NOW - NON MEMBER M2 Employee $1,846.59 $0.00 $0.00 $0.00 $1,846.59 $0.00 $1,846.59 Total Division: $1,846.59 $0.00 $0.00 $0.00 $1,846.59 $0.00 $1,846.59 Total Group: $293,469.44 $167,710.00 $18,523.15 $7,444.88 $311,992.59 $1755154.88 $487,147.47 Run Date: Aug 12, 2021-10:00:04 PM Page:3 Allegiance a Cigna Company Paid Claims by Network Status & Relationship Paid Jun 1, 2021 through May 31, 2022 In -Network Out -Network All Providers Relationship Male Female Male Female I Total Male Total Female Total Group: 1234567- Group Division: RETR - RETIREE Name ME Employee $290,620.95 $4,728.16 $18,452.86 $0.00 $309,073.81 $4,728.16 $313,801.97 Spouse $718.13 $40,162.08 $70.29 $5,210.35 $788.42 $45,372.43 $46,160.85 Total Division: $291,339.08 24 = $5,210.35 50,100.59 $359,962.82 Total Group: 1 $293,469.44 $167,710.00 $18,523.15 $7,444.88 $311,992.59 $175,154.88 $487,147.47 Run Date: Aug 12, 2021-10:00:04 PM PageA 09/01/21 Allegiance Benefit Plan Management, Inc. PAGE: 175 LXPYCHEK CHECK REGISTER BY RANGE OF DATES DATES SELECTED: 08/01/2021 through 08/31/2021 Check Date 165089 12/18/20207 167153 12/28/2020 167155 12/28/2020 167238 12/28/2020 202104 05/14/2021 202559 05/14/2021 211028 06/18/2021 212730 06/25/2021 213069 06/25/2021 217983 07/16/2021 222891 08/06/2021 222892 08/06/2021 222893 08/06/2021 222894 08/06/2021 222895 08/06/2021 222896 08/06/2021 222897 08/06/2021 222951 08/06/2021 222952 08/06/2021 222953 08/06/2021 222954 08/06/2021 222955 08/06/2021 222956 08/06/2021 222957 08/06/2021 222958 08/06/2021 222959 08/06/2021 222960 08/06/2021 222961 08/06/2021 222962 08/06/2021 222963 08/06/2021 222964 08/06/2021 222965 08/06/2021 222966 08/06/2021 222967 08/06/2021 222968 08/06/2021 222969 08/06/2021 222970 08/06/2021 222971 08/06/2021 222972 08/06/2021 222973 08/06/2021 222974 08/06/2021 222975 08/06/2021 GROUP NAME GROUP NUMBER ACCOUNT: BANK Payee Payee Name Amount -3.88 -2.66 -141.24 -196.60 -45.00 -40.00 -95.00 -95.00 -224.00 -223.00 17.15 215.18 2.66 196.60 141.24 21.62 179.75 257.60 505.10 474.20 20.27 51.33 66.44 134.58 157.75 1276.26 289.60 129.10 36.18 971.20 1095.82 149.36 83.00 53.98 196.00 313.79 16.17 161.11 152.07 362.33 13096.79 292.00 R R R R 09/01/21 Allegiance Benefit Plan Management, Inc. PAGE: 191 LXPYCHEK CHECK REGISTER BY RANGE OF DATES DATES SELECTED: 08/01/2021 through 08/31/2021 Check 0003P50525 0003P50526 0003P50527 0003P50528 0003P50529 0003P50530 0003P50531 0003P50532 0003P50533 0003P50534 0003P50535 0003P50536 0003P50537 0003P50538 0003P50539 0003P50540 0003P50541 0003P50542 0003P50543 0003P51465 0003P51466 PPS TOTAL * CHECKS PAID Date Payee 08/27/2021 08/27/2021 08/27/2021 08/27/2021 08/27/2021 08/27/2021 08/27/2021 08/27/2021 08/27/2021 08/27/2021 08/27/2021 08/27/2021 08/27/2021 08/27/2021 08/27/2021 08/27/2021 08/27/2021 08/27/2021 08/27/2021 08/27/2021 08/27/2021 $347,185.67 _> Totals for Bank: 8301 FUND TOTAL * CHECKS PAID $751,070.71 FUND TOTAL * CHECKS VOIDED: $1,066.38- FUND TOTAL ** NET DISBURSED: $750,004.33 PPS TOTAL * CHECKS PAID $347,185.67 GROUP NAME GROUP NUMBER ACCOUNT: BANK Payee Name NUMBER OF CHECKS: 683 NUMBER OF VOIDS : 10 Amount 180.04 100.00 91.13 183.27 302.97 1309.50 448.63 118.66 1377.43 88.75 40.86 347.30 476.00 58.47 134.44 114.56 126.00 112.00 168.30 57.33 1761.55 09/01/21 Allegiance Benefit Plan Management, Inc. PAGE: 192 LXPYCHEK CHECK REGISTER BY RANGE OF DATES DATES SELECTED: 08/01/2021 through 08/31/2021 GROUP NAME GROUP NUMPER ACCOUNT: BANK Check Date Payee Payee Name Amount GROUP TOTALS TOTAL CHECKS PAID $751,070.71 TOTAL CHECKS VOIDED: $1,066.38- NET DISBURSED $750,004.33 Aging Report A AII I'1 Group Name a Cigna company as of Jul 31, 2021 Group 1234567 - Group Name Division COBR - COBRA Claim Status 0-7 8-14 15-21 22-28 29-45 46+ 2 - On System Hold I 10 11 0 0 10 0 3- Manual User Hold 0 26 0 0 0 0 5- Waiting Review 2 13 1 1 0 0 6- Ready to Pay 0 3 0 0 0 7 V- Voided 0 0 0 0 0 317 Z- DEACTIVATED/SPLIT PAY 0 0 0 0 0 84 Division Totals: COBRA 12 53 1 1 10 408 Group Totals: Group Name Claim Status 0-7 8-14 15-21 22-28 29-45 46+ V- Voided 0 0 0 0 0 10 Division Totals: NON MEMBER 0 0 0 0 0 10 Amm��A== Division RETR - Claim Status 0-7 8-14 15-21 22-28 29-45 46+ 2 - On System Hold 42 26 5 11 2 0 3- Manual User Hold 0 0 0 1 11 77 4- History/Pre-Treatment 0 0 0 0 0 20 5- Waiting Review 7 23 2 7 4 1 6- Ready to Pay 14 13 0 0 2 8 V- Voided 0 0 0 0 0 1,106 Z- DEACTIVATED/SPLIT PAY I 0 0 0 0 0 231 Division Totals: 63 62 7 19 19 1,443 19 19 1 1,443 Run Date: Aug 8, 2021 - 5:30:05 PM Page: 1 04/18/14 Allegiance Benefit Plan Management, Inc. PAGE: 1 LXSLREGR STOP LOSS SPECIFIC DETAIL REGISTER GROUP XXXXXXX ABC COMPANY CARRIER 00001-0109 COMPANION LIFE INS COMPANY RENEWAL 03 07/01/2013 to 06/30/2014 INCLUDES ALL CLAIMANTS 25% OF SPECIFIC LIMIT ----------------------------------------------------------------------------------------------------------------------------------------------- GROUP: XXXXXXX SSN: *********** SEQ: ** DIV: ACTV RELAT: Spouse EFF: ********** DOB: ********** TERM: ********** LEVEL: FOO PLAN: PARTICIPANT ID & NAME DEPENDENT SPEC LMT % OF SPEC PAID YTD OVER SPEC REIMBURSED PENDING UNREPORTED (ID Suppressed) 01-* 25000.00 48.25 12061.32 .00 .00 .00 .00 _______=====Diagnosis Recap=====_______ Year Month Amount Code Description February 2014 Total $18.27 October 2013 Total $10,619.75 September 2013 Total $98.26 August 2013 Total $680.39 July 2013 Total $644.65 Total Paid ----------------------------------------------------------------------------------------------------------------------------------------------- $12,061.32 Diagnosis Summary for *************************** Amount Paid Last D.O.S. DRUGS PRESCRIPTION DRUGS 1153.96 09/26/2013 714.0 RHEUMATOID ARTHRITIS 285.70 09/25/2013 719.49 PAIN IN JOINT INVOLVING MULTIPLE SITES 06/28/2013 V58.69 LONG-TERM (CURRENT) USE OF OTHER 06/28/2013 355.8 MONONEURITIS OF LOWER LIMB, UNSPECIFIED 157.02 07/09/2013 703.8 OTHER SPECIFIED DISEASES OF NAIL 86.48 07/09/2013 735.2 HALLUX RIGIDUS 9580.05 09/25/2013 244.9 UNSPECIFIED ACQUIRED HYPOTHYROIDISM 09/20/2013 788.30 URINARY INCONTINENCE NOS 09/20/2013 726.91 EXOSTOSIS OF UNSPECIFIED SITE 567.29 09/25/2013 729.5 PAIN IN LIMB 127.88 09/23/2013 727.1 BUNION 09/23/2013 355.6 LESION OF PLANTAR NERVE 70.27 09/25/2013 716.97 UNSPECIFIED ARTHROPATHY INVOLVING ANKLE 32.67 09/25/2013 735.8 OTHER ACQUIRED DEFORMITIES OF TOE 09/25/2013 ----------------------------------------------------------------------------------------------------------------------------------------------- 729.90 Disorders of soft tissue, unspec 09/25/2013 GROUP: SSN: *********** SEQ: ** DIV: ACTV RELAT: Spouse EFF: ********** DOB: ********** TERM: ********** LEVEL: F00 PLAN: PARTICIPANT ID & NAME DEPENDENT SPEC LMT % OF SPEC PAID YTD OVER SPEC REIMBURSED PENDING UNREPORTED (ID Suppressed) 01-* 25000.00 86.95 21737.21 .00 .00 .00 .00 _______=====Diagnosis Recap=====_______ Year Month Amount Code Description January 2014 Total $10.75 December 2013 Total $449.74 November 2013 Total $12.00 October 2013 Total $2,653.87 September 2013 Total $3,937.64 August 2013 Total $13,107.78 July 2013 Total $1,565.43 Total Paid ---------------------------------------------------------------------------------------------------------------------------------------- $21,737.21 Diagnosis Summary for *************************** Amount Paid Last D.O.S. V43.3 HEART VALVE REPLACED BY OTHER MEANS 996.03 06/05/2013 420.91 ACUTE IDIOPATHIC PERICARDITIS 366.60 06/27/2013 715.92 OSTEOARTHROSIS, UNSPECIFIED WHETHER GENE 202.80 06/05/2013 719.52 STIFFNESS OF JOINT, NOT ELSEWHERE CLASSI 996.72 08/21/2013 V67.00 FOLLOWING SURGERY, UNSPECIFIED 77.70 07/29/2013 786.05 SHORTNESS OF BREATH 210.66 07/29/2013 DRUGS PRESCRIPTION DRUGS 710.40 12/26/2013 726.91 EXOSTOSIS OF UNSPECIFIED SITE 8786.74 07/26/2013 718.52 ANKYLOSIS OF UPPER ARM JOINT 07/26/2013 718.12 LOOSE BODY IN UPPER ARM JOINT 07/26/2013 726.39 OTHER ENTHESOPATHY OF ELBOW REGION 4285.75 07/26/2013 718.42 CONTRACTURE OF UPPER ARM JOINT 1457.50 07/26/2013 719.42 PAIN IN JOINT INVOLVING UPPER ARM 202.80 08/21/2013 716.92 UNSPECIFIED ARTHROPATHY INVOLVING UPPER 07/24/2013 V54.9 UNSPECIFIED ORTHOPEDIC AFTERCARE 08/21/2013 338.18 OTHER ACUTE POSTOPERATIVE PAIN 1045.00 07/26/2013 790.92 ABNRML COAGULTION PRFILE 2398.51 07/29/2013 515 POSTINFLAMMATORY PULMONARY FIBROSIS 07/29/2013 ---------------------------------------------------------------------------------------------------------------------------------------- GROUP: SSN: *********** SEQ: ** DIV: ACTV RELAT: Spouse EFF: ********** DOB: ********** TERM: ********** LEVEL: P00 PLAN: PARTICIPANT ID & NAME DEPENDENT SPEC LMT % OF SPEC PAID YTD OVER SPEC REIMBURSED PENDING UNREPORTED (ID Suppressed) O1-* 25000.00 90.52 22630.69 .00 .00 .00 .00 _______--===Diagnosis Recap=====_______ Year Month Amount Code Description February 2014 Total $235.68 January 2014 Total $2,916.26 December 2013 Total $610.63 November 2013 Total $11,018.60 October 2013 Total $1,737.28 September 2013 Total $2,189.34 August 2013 Total $3,705.71 July 2013 Total $217.19 Total Paid ---------------------------------------------------------------------------------------------------------------------------------------- $22,630.69 Diagnosis Summary for *************************** Amount Paid Last D.O.S. DRUGS PRESCRIPTION DRUGS 1184.43 11/26/2013 427.31 ATRIAL FIBRILLATION 297.76 11/21/2013 V58.61 LONG-TERM (CURRENT) USE OF ANTICOAGULANT 27.00 11/15/2013 999 COMPLICATIONS OF MEDICAL CARE, NOT ELSEW 21.32 07/03/2013 425.4 PRIMARY CARDIOMYOPATHIES 952.05 10/28/2013 V45.02 CARDIAC DEVICE IN SITU;AUTO IMPLANTABLE 10/28/2013 847.2 LUMBAR SPRAIN 957.21 06/25/2013 721.3 LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPAT 07/22/2013 401.9 UNSPECIFIED ESSENTIAL HYPERTENSION 07/03/2013 272.4 OTHER AND UNSPECIFIED HYPERLIPIDEMIA 07/03/2013 724.3 SCIATICA 3538.23 09/04/2013 753.10 CYSTIC KIDNEY DISEAS NOS 09/11/2013 724.02 Stenosis, spinal, lmbr, no neuro cl 4855.55 11/11/2013 V58.83 ENCOUNTER/THERAPEUTIC DRUG MONITORING 70.60 07/31/2013 427.32 ATRIAL FLUTTER 48.00 10/28/2013 V49.89 OTHER SPECIFIED CONDITIONS INFLUENCING 1215.52 09/11/2013 562.10 DIVERTICULOSIS OF COLON 09/11/2013 751.5 OTHER CONGENITAL ANOMALIES OF INTESTINE 09/11/2013 737.30 SCOLIOSIS (AND KYPHOSCOLIOSIS), IDIOPATH 09/11/2013 V53.32 CARDIAC DEVICE; AUTO IMPLANTABLE CARDIAC 09/11/2013 724.2 LUMBAGO 11/11/2013 729.5 PAIN IN LIMB 09/04/2013 785.0 TACHYCARDIA, UNSPECIFIED 09/11/2013 745.5 OSTIUM SECUNDUM TYPE ATRIAL SEPTAL DEFEC 09/11/2013 786.05 SHORTNESS OF BREATH 09/11/2013 729.2 NEURALGIA, NEURITIS, AND RADICULITIS, UN 1170.03 10/22/2013 724.00 SPINAL STENOSIS OF UNSPECIFIED REGION 08/02/2013 722.6 DEGENERATION OF INTERVERTEBRAL DISC, SIT 08/02/2013 780.79 OTHER MALAISE AND FATIGUE 6371.91 10/16/2013 780.57 UNSPECIFIED SLEEP APNEA 10/16/2013 724.4 THORACIC OR LUMBOSACRAL NEURITIS OR RADI 1090.50 10/02/2013 790.99 OTH NSPCF FINDING BLOOD 148.43 10/22/2013 VO4.81 NEED FOR PROPHYLACTIC VACCINATION/ 25.00 10/30/2013 V64.3 PROCEDURE NOT CARRIED OUT FOR OTHER REAS 188.19 09/11/2013 722.4 DEGENERATION OF CERVICAL INTERVERTEBRAL 210.33 11/11/2013 721.0 CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY 11/11/2013 723.4 BRACHIAL NEURITIS OR RADICULITIS NOS 11/11/2013 724.1 PAIN IN THORACIC SPINE 95.76 11/11/2013 723.1 CERVICALGIA 11/11/2013 782.0 DISTURBANCE OF SKIN SENSATION 11/11/2013 211.3 BENIGN NEOPLASM OF COLON 162.87 03/22/2013 V12.72 ------------------------------------------------------------------------------------------------------------------------- Hx, prsnl, colonic polyps 03/22/2013 GROUP: SSN: *********** SEQ: ** DIV: ACTV RELAT: Participant EFF: ********** DOB: ********** TERM: ********** LEVEL: P00 PLAN: PARTICIPANT ID & NAME DEPENDENT (ID Suppressed) 00- ------------ Diagnosis Recap =====___-_-_ Year Month Amount Code April 2014 Total $892.80 March 2014 Total $1,459.99 February 2014 Total $1,672.96 January 2014 Total $105.75 December 2013 Total $1,403.68 November 2013 Total $1,565.48 October 2013 Total $1,134.20 September 2013 Total $1,092.60 SPEC LMT % OF SPEC PAID YTD OVER SPEC REIMBURSED PENDING UNREPORTED 25000.00 50.37 12592.78 .00 .00 .00 .00 Description August 2013 Total $556.01 July 2013 Total $2,709.31 Total Paid $12,592.78 ----------------------------------------------------------------------------------------------------------------------------------------------- Diagnosis Summary for *************************** Amount Paid Last D.O.S. 577.2 CYST AND PSEUDOCYST OF PANCREAS 82.75 06/20/2013 787.20 DYSPHAGIA, UNSPECIFIED 1602.90 02/10/2014 793.6 NONSPECIFIC ABNORMAL FINDINGS ON RADIOLO 06/20/2013 562.10 DIVERTICULOSIS OF COLON 275.81 06/04/2013 789.06 OTHER SYMPTOMS INVOLVING ABDOMEN AND 1140.30 06/27/2013 V12.79 Hx, prsnl, digestive disease NEC 06/27/2013 DRUGS PRESCRIPTION DRUGS 2161.43 03/20/2014 528.9 OTHER AND UNSPECIFIED DISEASES OF THE OR 95.50 07/09/2013 789.00 OTHER SYMPTOMS INVOLVING ABDOMEN AND 07/09/2013 327.23 OBSTRUCTIVE SLEEP APNEA (ADULT) 1004.98 03/28/2014 496 CHRONIC AIRWAY OBSTRUCTION, NOT ELSEWHER 724.50 08/20/2013 793.19 Othr nonspecfc abnorml finding/lung 08/20/2013 787.3 FLATULENCE, ERUCTATION, AND GAS PAIN O1/22/2014 478.5 OTHER DISEASES OF VOCAL CORDS 1229.70 01/31/2014 493.00 EXTRINSIC ASTHMA, UNSPECIFIED O1/31/2014 472.0 CHRONIC RHINITIS 09/25/2013 558.3 ALLERGIC GASTROENTERITIS AND COLITIS 95.50 01/31/2014 787.91 OTHER SYMPTOMS INVOLVING DIGESTIVE 570.14 02/10/2014 478.79 OTHER DISEASES OF LARYNX 110.50 12/05/2013 V72.31 ROUTINE GYNECOLOGICAL EXAM 187.00 10/16/2013 VO4.81 NEED FOR PROPHYLACTIC VACCINATION/ 25.00 10/25/2013 729.5 PAIN IN LIMB 94.98 03/25/2014 728.71 PLANTAR FASCIAL FIBROMATOSIS 195.52 11/12/2013 V57.3 Speech -language therapy 549.05 12/05/2013 362.51 NONEXUDATIVE SENILE MACULAR DEGENERATION 90.78 12/04/2013 530.81 ESOPHAGEAL REFLUX 95.50 12/05/2013 493.10 INTRINSIC ASTHMA WITHOUT MENTION OF STAT O1/22/2014 530.13 Eosinophilic esophagitis 01/31/2014 530.10 ESOPHAGITIS, UNSPECIFIED 1334.61 02/10/2014 558.9 OTHER AND UNSPECIFIED NONINFECTIOUS GAST 536.85 03/18/2014 458.9 HYPOTENSION, UNSPECIFIED 02/19/2014 V70.0 ROUTINE GENERAL MEDICAL EXAMINATION AT A 219.00 03/21/2014 780.94 SYMPTOM, EARLY SATIETY 85.50 03/18/2014 700 CORNS AND CALLOSITIES 84.98 03/25/2014 733.0 HALLUX VALGUS (ACQUIRED) 03/25/2014 ----------------------------------------------------------------------------------------------------------------------------------- GROUP: SSN: *********** SEQ: ** DIV: ACTV RELAT: Participant EFF: ********** DOB: ********** TERM: ********** LEVEL: F00 PLAN: PARTICIPANT ID & NAME DEPENDENT SPEC LMT % OF SPEC PAID YTD OVER SPEC REIMBURSED PENDING UNREPORTED (ID Suppressed) 00-* 25000.00 79.03 19757.44 .00 .00 .00 .00 -_-_-_-=====Diagnosis Recap =====_______ Year Month Amount Code Description April 2014 Total $85.50 March 2014 Total $31.95 January 2014 Total $1,560.20 December 2013 Total $1,444.30 November 2013 Total $982.95 October 2013 Total $1,003.73 September 2013 Total $977.50 August 2013 Total $664.50 July 2013 Total $13,006.81 Total Paid ----------------------------------------------------------------------------------------------------------------------------------------------- $19,757.44 Diagnosis Summary for *************************** Amount Paid Last D.O.S. 172.6 MALIGNANT MELANOMA OF SKIN OF UPPER LIMB 5236.68 12/23/2013 216.5 BENIGN NEOPLASM OF SKIN OF TRUNK, EXCEPT 03/13/2014 305.1 TOBACCO USE DISORDER 06/19/2013 786.50 UNSPECIFIED CHEST PAIN 05/20/2013 216.6 BENIGN NEOPLASM OF SKIN OF UPPER LIMB, I 207.83 03/13/2014 170.6 MALIGNANT NEOPLASM OF PELVIC BONES, SACR 884.00 06/20/2013 171.2 MALIGNANT NEOPLASM OF CONNECTIVE AND OTH 8142.00 06/20/2013 DRUGS PRESCRIPTION DRUGS 877.60 12/27/2013 238.2 NEOPLASM OF UNCERTAIN BEHAVIOR OF SKIN 3516.30 12/23/2013 V10.82 Hx, prsnl, malignant skin melanoma 596.65 03/13/2014 958.3 POSTTRAUMATIC WOUND INFECTION NOT ELSEWH 104.88 09/01/2013 709.2 SCAR CONDITIONS AND FIBROSIS OF SKIN 12/23/2013 172.9 MELANOMA OF SKIN, SITE UNSPECIFIED 159.55 12/23/2013 702.19 OTHER DERMATOSES;OTHER SEBORRHEIC 31.95 03/13/2014 ----------------------------------------------------------------------------------------------------------------------------------------------- 216.7 BENIGN NEOPLASM OF SKIN OF LOWER LIMB, I 03/13/2014 GROUP: SSN: *********** SEQ: ** DIV: ACTV RELAT: Spouse EFF: ********** DOB: ********** TERM: ********** LEVEL: F00 PLAN: PARTICIPANT ID & NAME DEPENDENT SPEC LMT % OF SPEC PAID YTD OVER SPEC REIMBURSED PENDING UNREPORTED (ID Suppressed) 01-* 25000.00 100.00 48051.32 23051.32 22741.37 .00 309.95 _______--===Diagnosis Recap=====_______ Year Month Amount Code Description April 2014 Total $96.09 February 2014 Total $57.90 January 2014 Total $155.96 December 2013 Total $5,525.35 November 2013 Total $2,185.69 October 2013 Total $5,953.94 September 2013 Total $7,893.98 August 2013 Total $26,182.41 Total Paid ----------------------------------------------------------------------------------------------------------------------------------------------- $48,051.32 Diagnosis Summary for *************************** Amount Paid Last D.O.S 724.5 BACKACHE, UNSPECIFIED 1857.52 07/23/2013 805.4 CLOSED FRACTURE OF LUMBAR VERTEBRA WITHO 21822.55 11/15/2013 825.21 FRACTURE OF ASTRAGALUS, CLOSED 805.46 11/15/2013 729.5 PAIN IN LIMB 177.66 01/16/2014 DRUGS PRESCRIPTION DRUGS 1108.39 03/24/2014 729.81 SWELLING OF LIMB 180.70 08/06/2013 257.2 OTHER TESTICULAR HYPOFUNCTION 1022.53 09/03/2013 269.2 UNSPECIFIED VITAMIN DEFICIENCY 08/06/2013 V54.89 OTHER ORTHOPEDIC AFTERCARE;AFTERCARE FOR 08/06/2013 V58.61 LONG-TERM (CURRENT) USE OF ANTICOAGULANT 60.00 12/18/2013 V12.51 Hx, prsnl, yens thrombosis/embolism 36.00 09/20/2013 453.9 EMBOLISM AND THROMBOSIS OF UNSPECIFIED S 70.60 08/11/2013 824.8 UNSPECIFIED FRACTURE OF ANKLE, CLOSED 07/27/2013 305.1 TOBACCO USE DISORDER 07/22/2013 780.2 SYNCOPE AND COLLAPSE 07/22/2013 V15.88 Hx, prsnl, fall 08/09/2013 959.19 OTHER INJURY OF OTHER SITES OF TRUNK 2588.29 07/22/2013 959.7 OTHER AND UNSPECIFIED INJURY TO KNEE, LE 182.70 07/23/2013 E884.9 OTHER ACCIDENTAL FALL FROM ONE LEVEL TO 07/22/2013 E849.9 ACCIDENTS OCCURRING IN UNSPECIFIED PLACE 07/22/2013 924.20 CONTUSION OF FOOT 07/27/2013 401.9 UNSPECIFIED ESSENTIAL HYPERTENSION 100.20 12/19/2013 999 COMPLICATIONS OF MEDICAL CARE, NOT ELSEW 479.17 10/25/2013 453.41 Acute embl/thrmb dp vsl lwr ext prx 9815.97 08/09/2013 453.42 Acute emb/thrb dp vsl lwr ext dst 08/09/2013 V54.19 AFTERCARE FOR HEALING TRAUMATIC FRACTURE 08/09/2013 796.2 ELEVATED BLOOD PRESSURE READING WITHOUT 08/09/2013 823.80 CLOSED FRACTURE OF UNSPECIFIED PART OF T 113.90 08/20/2013 E881.1 ACCIDENTAL FALL FROM SCAFFOLDING 08/20/2013 724.2 LUMBAGO 2292.14 10/24/2013 268.9 UNSPECIFIED VITAMIN D DEFICIENCY 09/03/2013 721.3 LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPAT 09/03/2013 V76.44 SPECIAL SCREENING FOR MALIGNANT NEOPLASM 08/06/2013 733.90 DISORDER OF BONE AND CARTILAGE, UNSPECIF 45.45 08/06/2013 V72.83 OTH SPCF PREOP EXAM 50.00 07/23/2013 719.47 PAIN IN JOINT INVOLVING ANKLE AND FOOT 10/24/2013 719.57 STIFFNESS OF JOINT, NOT ELSEWHERE CLASSI 10/24/2013 728.87 MUSCLE WEAKNESS (GENERALIZED) 10/24/2013 V54.16 AFTERCARE FOR HEALING TRAUMATIC FRACTURE 163.80 11/15/2013 V54.17 AFTERCARE FOR HEALING TRAUMATIC 11/15/2013 451.19 PHLEBITIS AND THROMBOPHLEBITIS OF OTHER 295.25 10/11/2013 453.40 Acute emblsm/thrmb dp vsl lwr extrm 51.00 12/18/2013 272.4 OTHER AND UNSPECIFIED HYPERLIPIDEMIA 143.16 12/19/2013 790.21 IMPAIRED FASTING GLUCOSE 12/02/2013 794.31 NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM ( 3946.96 12/11/2013 V16.0 FAMILY HISTORY OF MALIGNANT NEOPLASM OF 140.25 11/21/2013 V72.84 PREOP EXAM UNSPCF 401.47 11/26/2013 V17.49 FAMILY HISTORY OF OTHER CARDIOVASCULAR 11/26/2013 414.00 CORONARY ATHEROSCLEROSIS OF UNSPECIFIED 100.20 12/19/2013 ----------------------------------------------------------------------------------------------------------------------------------------------- GROUP: 0010723 SSN: *********** SEQ: ** DIV: ACTV RELAT: Participant EFF: ********** DOB: ********** TERM: ********** LEVEL: F00 PLAN: 723MED-HDHP PARTICIPANT ID & NAME DEPENDENT SPEC LMT % OF SPEC PAID YTD OVER SPEC REIMBURSED PENDING UNREPORTED (ID Suppressed) 00-* 25000.00 38.77 9693.38 .00 .00 .00 .00 -_-_-_-=-=-=Diagnosis Recap =====_______ Year Month Amount Code Description April 2014 Total $6,637.17 March 2014 Total $322.35 February 2014 Total $338.01 January 2014 Total $214.50 December 2013 Total $381.49 November 2013 Total $419.59 October 2013 Total $11.70 September 2013 Total $110.70 August 2013 Total $553.79 July 2013 Total $704.08 Total Paid ----------------------------------------------------------------------------------------------------------------------------------------------- $9,693.38 Diagnosis Summary for *************************** Amount Paid Last D.O.S. DRUGS PRESCRIPTION DRUGS 1285.07 12/17/2013 238.2 NEOPLASM OF UNCERTAIN BEHAVIOR OF SKIN 428.40 07/16/2013 709.2 SCAR CONDITIONS AND FIBROSIS OF SKIN 07/16/2013 695.3 ROSACEA 07/16/2013 454.8 VARICOSE VEINS OF LWR EXTREMITIES W/ 314.94 08/15/2013 448.9 OTHER AND UNSPECIFIED CAPILLARY DISEASES 08/15/2013 782.3 EDEMA 08/15/2013 VO4.81 NEED FOR PROPHYLACTIC VACCINATION/ 25.00 10/15/2013 999 COMPLICATIONS OF MEDICAL CARE, NOT ELSEW 127.94 12/03/2013 V76.12 OTHER SCREENING MAMMOGRAM 214.50 01/14/2014 V72.31 ROUTINE GYNECOLOGICAL EXAM 308.31 02/10/2014 V76.41 SCREENING FOR MALIGNANT NEOPLASMS OF THE 29.70 02/10/2014 611.72 LUMP OR MASS IN BREAST 322.35 03/06/2014 793.99 OTHER NONSPECIFIC ABNORMAL FINDINGS ON 03/06/2014 V70.0 ROUTINE GENERAL MEDICAL EXAMINATION AT A 50.00 03/21/2014 611.1 HYPERTROPHY OF BREAST 412.25 03/06/2014 ----------------------------------------------------------------------------------------------------------------------------------------------- 610.2 FIBROADENOSIS OF BREAST 6174.92 03/06/2014 GROUP: SSN: *********** SEQ: ** DIV: ACTV RELAT: Participant EFF: ********** DOB: ********** TERM: ********** LEVEL: P00 PLAN: PARTICIPANT ID & NAME DEPENDENT SPEC LMT % OF SPEC PAID YTD OVER SPEC REIMBURSED PENDING UNREPORTED (ID Suppressed) 00-* 25000.00 100.00 64983.25 39983.25 39983.25 .00 .00 _______--===Diagnosis Recap=====_______ Year Month Amount Code Description February 2014 Total $200.84 January 2014 Total $1,824.66 December 2013 Total $59,425.77 November 2013 Total $1,566.33 October 2013 Total $588.39 September 2013 Total $1,263.88 August 2013 Total $113.38 Total Paid ----------------------------------------------------------------------------------------------------------------------------------------------- $64,983.25 Diagnosis Summary for *************************** Amount Paid Last D.O.S. DRUGS PRESCRIPTION DRUGS 700.99 12/18/2013 719.46 PAIN IN JOINT INVOLVING LOWER LEG 2309.91 12/02/2013 715.36 OSTEOARTHROSIS, LOCALIZED, INVOLVING 48514.14 10/29/2013 713.96 OSTEOARTHROSIS, UNSPECIFIED, INVOLVING 10627.19 10/25/2013 V43.65 JOINT;KNEE 200.84 12/02/2013 702.0 ACTINIC KERATOSIS 615.40 08/26/2013 702.19 OTHER DERMATOSES;OTHER SEBORRHEIC 08/26/2013 228.01 HEMANGIOMA OF SKIN AND SUBCUTANEOUS TISS 08/26/2013 216.5 BENIGN NEOPLASM OF SKIN OF TRUNK, EXCEPT 08/26/2013 401.9 UNSPECIFIED ESSENTIAL HYPERTENSION 518.16 11/14/2013 250.00 DIABETES MELLITUS WITHOUT MENTION OF 10/29/2013 780.57 UNSPECIFIED SLEEP APNEA 10/10/2013 VO4.81 NEED FOR PROPHYLACTIC VACCINATION/ 25.00 10/02/2013 V58.66 LONG-TERM (CURRENT) USE OF ASPIRIN 10/10/2013 V58.69 LONG-TERM (CURRENT) USE OF OTHER 10/10/2013 V54.81 AFTERCARE FOLLOWING JOINT REPLACEMENT 56.96 10/18/2013 278.00 OBESITY, UNSPECIFIED 10/29/2013 999 COMPLICATIONS OF MEDICAL CARE, NOT ELSEW 460.00 12/25/2013 427.32 ATRIAL FLUTTER 10/29/2013 V85.42 BMI 45.0-49.9, adult 10/29/2013 401.1 BENIGN ESSENTIAL HYPERTENSION 66.50 11/21/2013 V54.89 OTHER ORTHOPEDIC AFTERCARE;AFTERCARE FOR 646.77 11/14/2013 278.01 MORBID OBESITY 11/14/2013 303.90 OTHER AND UNSPECIFIED ALCOHOL DEPENDENCE 11/14/2013 V67.09 FOLLOWING OTHER SURGERY 241.39 12/13/2013 V72.83 OTH SPCF PREOP EXAM 10/21/2013 GROUP: SSN: *********** SEQ: ** DIV: ACTV RELAT: Spouse EFF: ********** DOB: ********** TERM: LEVEL: F00 PLAN: PARTICIPANT ID & NAME DEPENDENT SPEC LMT % OF SPEC PAID YTD OVER SPEC REIMBURSED PENDING UNREPORTED (ID Suppressed) 01-* 25000.00 42.55 10637.02 .00 .00 .00 .00 -_____-=-=-=Diagnosis Recap ______ Year Month Amount Code Description April 2014 Total $3.42 February 2014 Total $298.50 January 2014 Total $71.85 December 2013 Total $1,301.27 November 2013 Total $962.81 October 2013 Total $3,614.71 September 2013 Total $6.00 August 2013 Total $551.96 July 2013 Total $3,826.50 Total Paid $10,637.02 ----------------------------------------------------------------------------------------------------------------------------------------------- Diagnosis Summary for *************************** Amount Paid Last D.O.S 414.00 CORONARY ATHEROSCLEROSIS OF UNSPECIFIED 3646.50 10/18/2013 433.10 OCL CRTD ART WO INFRCT 180.00 06/26/2013 DRUGS PRESCRIPTION DRUGS 435.89 03/24/2014 272.4 OTHER AND UNSPECIFIED HYPERLIPIDEMIA 121.20 10/18/2013 300.00 ANXIETY STATE, UNSPECIFIED 10/18/2013 274.9 GOUT, UNSPECIFIED 07/12/2013 681.10 UNSPECIFIED CELLULITIS AND ABSCESS OF TO 287.12 08/14/2013 401.9 UNSPECIFIED ESSENTIAL HYPERTENSION 08/14/2013 300.09 OTHER ANXIETY STATES 08/14/2013 V12.59 Hx, prsnl, circulatory syst ds NEC 08/14/2013 277.7 DYSMETABOLIC SYNDROME X 08/14/2013 377.30 OPTIC NEURITIS, UNSPECIFIED 4165.88 02/03/2014 784.2 Symptom, swelling in head/neck 464.56 10/02/2013 V71.89 OTHER SPECIFIED SUSPECTED CONDITION 34.20 10/02/2013 VO4.81 NEED FOR PROPHYLACTIC VACCINATION/ 25.00 10/10/2013 401.1 BENIGN ESSENTIAL HYPERTENSION 10/18/2013 999 COMPLICATIONS OF MEDICAL CARE, NOT ELSEW 421.67 11/25/2013 348.89 Other conditions of brain 790.00 11/18/2013 377.41 ISCHEMIC OPTIC NEUROPATHY 11/18/2013 V70.0 ROUTINE GENERAL MEDICAL EXAMINATION AT A 65.00 12/23/2013 ----------------------------------------------------------------------------------------------------------------------------------------------- GROUP: SSN: *********** SEQ: ** DIV: ACTV RELAT: Participant EFF: ********** DOB: ********** TERM: ********** LEVEL: F99 PLAN: PARTICIPANT ID & NAME DEPENDENT SPEC LMT % OF SPEC PAID YTD OVER SPEC REIMBURSED PENDING UNREPORTED (ID Suppressed) 00-* 25000.00 100.00 46801.61 21801.61 21329.67 .00 471.94 _______=====Diagnosis Recap=====_______ Year Month Amount Code Description April 2014 Total $5.25 January 2014 Total $445.09 December 2013 Total $5,629.76 November 2013 Total $1,081.55 October 2013 Total $2,453.48 September 2013 Total $2,765.94 August 2013 Total $2,856.38 July 2013 Total $31,564.16 Total Paid ----------------------------------------------------------------------------------------------------------------------------------------------- $46,801.61 Diagnosis Summary for *************************** Amount Paid Last D.O.S. 813.05 FRACTURE OF HEAD OF RADIUS, CLOSED 38250.01 10/18/2013 813.02 FRACTURE OF CORONOID PROCESS OF ULNA, CL 05/30/2013 729.3 PAIN IN LIMB 05/30/2013 812.40 FRACTURE OF UNSPECIFIED PART OF LOWER EN 202.50 05/21/2013 719.42 PAIN IN JOINT INVOLVING UPPER ARM 240.45 10/18/2013 477.9 ALLERGIC RHINITIS, CAUSE UNSPECIFIED 491.25 03/28/2014 E881.0 ACCIDENTAL FALL FROM LADDER 06/03/2013 V43.62 JOINT;ELBOW 31.71 06/03/2013 V67.09 FOLLOWING OTHER SURGERY 94.50 06/07/2013 338.18 OTHER ACUTE POSTOPERATIVE PAIN 1178.00 06/03/2013 719.53 STIFFNESS OF JOINT, NOT ELSEWHERE CLASSI 10/18/2013 728.87 MUSCLE WEAKNESS (GENERALIZED) 10/18/2013 477.0 ALLERGIC RHINITIS DUE TO POLLEN 950.40 11/21/2013 DRUGS PRESCRIPTION DRUGS 452.44 12/30/2013 V54.12 AFTERCARE FOR HEALING TRAUMATIC 146.80 10/15/2013 300.00 ANXIETY STATE, UNSPECIFIED 155.40 10/21/2013 VO4.81 NEED FOR PROPHYLACTIC VACCINATION/ 34.20 11/04/2013 470 DEVIATED NASAL SEPTUM 182.10 11/04/2013 780.53 HYPERSOMNIA WITH SLEEP APNEA, 631.80 11/04/2013 780.79 OTHER MALAISE AND FATIGUE 77.70 11/06/2013 786.09 OTHER DYSPNEA AND RESPIRATORY ABNORMALIT 11/06/2013 780.54 HYPERSOMNIA, UNSPECIFIED 11/06/2013 327.23 OBSTRUCTIVE SLEEP APNEA (ADULT) 3682.35 12/03/2013 ************** GROUP TOTALS ************** Division Break Down ------------------- ACTV 10 $268,946.02 Total 10 $268,946.02 PAID YTD OVER SPEC REIMBURSED PENDING UNREPORTED 268946.02 84836.18 84054.29 .00 781.89 TOTAL OF PRINTED CLAIM DETAIL: 268946.02 Proprietary and Confidential Collier County Government Repricing Summary Cigna OAP - 2023 3-DIGIT ZIP PROVIDER SPECIFIC Network Charges Network Discount % Network Discount Network Allowed Network Charges Network Discount % Network Discount Network Allowed 22 703 968 58.1 % $13,193,833 $9,510,135 $22,703,968 52.3% $11,863,193 $10,840,775 28 380 708 69.0% $19,581,362 $8,799,347 $28,380,708 61.9% $17,581,305 $10,799,403 18 065 716 60.3% $10.896.329 $7,169,388 $18,065,716 59.0% $10,653,458 $7.412.259 2 153 416 55.6% $1,197,611 $955,805 2,153,416 55.3% $1,190,076 $963,341 5 088 258 57.3% $2,913,092 $2,175,165 $5,088,258 77.3% $3,932,507 $1,155,750 3 210 071 59.1 % $1,898,253 $1,311,818 $3,210,071 63.1 % $2,024,798 $1,185,273 852 158 58.5% $498,723 $353,435 $852,158 59.0% $502,QAQ, 349 192 80 454 296 62.4% 50 179 203 30 275 093 80 454 296 59.3% 47 748 303 32 705 993 1 912 110 62.4% 1 192 579 719 530 1 912 110 59.3% 1 134 806 777 304 $82 366 406 62.4% $51 371 782 $30 994 624 $82 366 406 59.3% $48 883 108 $33 483 297 $2 364 575 47.8% $1 129 208 $1 235 367 $2 364 575 47.8% $1 129 208 $1 235 . Healthcare Common Procedure Codinq Svstem (HCPCs) claims include transportation, medical supplies/materials, and hearing. Collier County Government Repricing Summary.xlsx - Summary 11/4/2022 2:42 PM Steerage of Non -Preferred Lab/Rad/ER-UC and Estimated Medical Management Savings --Illustrative Only Charges Type Option 1 60% Network 1Chg Opt Option 2 75% Network 2Chg Opt Option 3 100% Network 3Chg Op Preferred Lab 60% $ 27,238 75% $ 34,048 100% $ 45,397 Preferred Radiology 60% $ 317,547 75% $ 396,934 100% $ 529,246 ER to UC Saving 60% $ - 75% $ - 100% $ - Heath Matters Care Management 60% $ 784,944 75% $ 981,180 100% $ 1,308,240 Your Health First Disease Managerneril 60% $ 588,708 75% $ 735,885 100% $ 981,180 Personal Health Team 60% $ 196,236 75% $ 245,295 100% $ 327,060 Cigna Onsite Health Centers 60% $ 19,624 75% $ 24,529 100% $ 32,706 ACO Programs - Facility and Professio 60% $ 660,404 75% $ 825,505 100% $ 1,100,673 Tele Health 60% $ 58,871 75% $ 73,588 100% $ 98,118 Dial sis Lock -in Benefit 60% $ 39,247 75% $ 49,059 100% $ 65,412 Delivery system non -par management 60% $ 98,118 75% $ 122,647 100% $ 163,530 vs NetworK L;riarqe 1 $80.454296 Savings Savings Opt 1 Savin s Opt 2 1 Savings Opt 3 Repriced In Network Discount 59.3% $ 47,748,303 59.3% $ 47,748,303 59.3% $ 47,748,303 Additional Savings: Lab and Rad 0.1 % $ 64,239 0.1 % $ 80,299 0.1 % $ 107,065 ER to UC Saving 0.0% $ - 0.0% $ - 0.0% $ - Revised Savings Amount 59.4% 47,812,542 59.4% 47,828,601 59.50/6 47,855,368 Heath Matters Care Management $ 784,944 $ 981,180 $ 1,308,240 Your Health First Disease Management $ 588,708 $ 735,885 $ 981,180 Personal Health Team $ 196,236 $ 245,295 $ 327,060 Cigna Onsite Health Centers $ 19,624 $ 24,529 $ 32,706 ACO Programs - Facilityand Professio $ 660,404 $ 825,505 $ 1,100,673 Tele Health $ 58,871 $ 73,588 $ 98,118 Dialysis Lock -in Benefit $ 39,247 $ 49,059 $ 65,412 Delivery system non -par management $ 98.118 $ 122,647 $ 163,530 Estimated Additional Savings 1 $2,510,3901 1 $3,137,9881 1 $4,183,984 Collier County Government Repricing Summary 2.xlsx - Potential Savings Summary 11/4/2022 2:43 PM Repricing Summary - IP/OP/Physician 3-DIGIT ZIP PROVIDER SPECIFIC State Total Claim Charges Network Charges Network Discount % Network Discount $ Network Allowed Network Charges Network Discount % Network Discount $ Network Allowed Totals 1 $82,786,2331 $80,454,2961 62.4%1 $50,179,2031 $30,275,093 $80,454,2961 59.3%1 $47,748,3031 $32,705,993 AL $1,771 $1,771 57.8% $1,024 $747 $1,771 58.3% $1,032 739 AZ $9,592 $6,539 61.4% $4,017 $2,522 $6,539 66.3% $4,335 $2,204 CA $675,069 $512,506 56.5% $289,390 $223 116 $512,506 76.9% $394,360 $118,146 CO 32 652 $30,634, 50.0% $15,306 $15,328 $30,634 41.7% $12,768 $17,866 CT 10 690 $10,690, 62.3% $6,663 $4,027 $10,690 72.0% $7,697 $2 993 DC 27 997 $27,997, 52.7% $14,764 $13,233 $27,997 62.9% $17,611 $10 386 DE $2,458 $2,458 59.3% $1,457 $1,001. $2,458 40.6% 998 $1 460 FL $68,890,807 $67,014,197 63.2% $42,348,207 $24,665,990 $67 014 197 56.9% $38,137,061 $28,877,136 GA $5,596,758 $5 594 406 56.7% $3,174,476 $2 419 930 $5 594 406 62.6% $3 504 514 $2 089 892 IA 846 846 32.2% 272 573 846 24.5% $207 $638 ID 655 0 0.0% $0 0 $0 0.0% $0 0 IL $212,771 $162,052 62.2% $100,833 $61,219 $162,052 59.9% $97 033 $65 019 IN $6,799 280 57.8% 162 $118, 280 55.4% 155 $125 KY 360 360 42.6% 153 207 360 50.2% 181 179 MA $46,056 $46,056 49.6% $22,864 $23,192 $46,056 54.9% 25 288 $20 768 MD $31,357 $12,581, 57.0% $7,176 $5,406 $12,581 66.1 % $8,314 $4 268 ME $309,468 $309,468 52.6% $162,641 $146,827 $309,468 71.6% $221,678 $87,790 M 31 566 $29,941 40.2% $12,040 $17,901 $29,941 37.7% $11,292 $18,649 MN $131,989 $131,989 42.7% $56,303 $75 685 $131,989 46.4% $61,216 $70,772 MO $1,289 $1,289 56.3% 725 563 $1,289 46.1% 593 695 MS 200 200 65.5% 131 69 $2001 63.9% 128 72 MT 565 565 32.3% 183 383 $565 24.80/6 140 425 NC $1,056,071 $1,046,188 51.7% $540,667 $505,521 $1 046 188 82.5% $863,410 $182,778 NH $1,150 $1,150 56.0% 644 506 $1,150 45.7% $525 625 NJ $100,410 $37,160 65.00/6 $24,172 $12,988 $37,160 81.9% $30,428 $6,733 NM $300 $300 51.7% $155 $145 $300 62.0% $186 $114 NY $39 607 $34 017 62.5% $21 266 $12 752 $34 017 66.0% $22 468 $11 550 OH $379 874 $364 524 55.3% $201 721 $162 803 $364 524 58.6% $213 765 $150 759 OR $319 $319 43.5% $139 $180 $319 42.0% $134 $185 PA $3 130 272 $3 090 990 58.7% $1 815 918 $1 275 072 $3 090 990 85.5% $2 641 560 $449 430 RI $1 722 $1 722 58.0% $998 $724 $1 722 57.0% $982 $740 SC $33 560 $23 750 57.9% $13 749 $10 001 $23 750 67.7% $16 072 $7 677 TN $1 400 859 $1 400 859 74.7% $1 046 294 $354 565 $1 400 859 82.2% $1 152 167 $248 692 TX $219 045 $166 756 66.3% $110 612 $56 144 $166 756 63.4% $105 730 $61 026 UT $51 387 $50 670 53.4% $27 070 $23 600 $50 670 70.8% $35 879 $14 791 VA $45 490 $34 615 66.1 % $22 884 $11 731 $34 615 79.0% $27 343 $7 272 WA $3 200 $3 200 47.4% $1 515 $1 685 $3,2001 27.2% $869 $2 331 W I 1 $294 905 1 $294,9051 43.9% $129 521 $165 385 3 351 43.1 % $126 992 $167 913 WV $6,348 $6,348 48.7% $3,091 $3,257 $6,348 50.3% $3,194 $3,154 Collier County Government Repricing Summary 2.xlsx - IP-OP-Phys Subtotal 11/4/2022 2:43 PM Repricing Summary - Inpatient 3-DIGIT ZIP PROVIDER SPECIFIC State Total Claim Char es I Network I Char es Network Discount % I Network Discount Network Allowed Network Char es Network Discount % Network Discount Network Allowed Totals 1 $22,887,9081 $22,703,9681 58.1%1 $13,193,8331 $9,510,135 $22,703,9681 52.3%1 $11,863,1931 $10,840,775 FL $22,159,249 $21,975,309 58.2% $12,792,816 $9,182,493 $21,975,309 51.9% $11,404,316 $10,570,993 GA $340,929 $340,929 50.7% $172,728 $168,201 $340,929 72.1 % $245,784 $95,145 OH $179,019 $179,019 54.0% $96,676 $82,343 $179,019 52.8% $94,478 $84,541 PA $151,425 $151,425 66.7% $101,067 $50,358 $151,425 60.6% $91,818 $59,607 MN $22,718 $22,718 42.9% $9,747 $12,971 $22,718 47.2% $10,714 $12,004 TN $22,440 $22,440 60.1 % $13,494 $8,946 $22,440 60.6% 13 606 $8,834 IL $12,1281 $12,1281 60.2%1 $7,3041 $4,8241 $12,1281 20.4%1 $2,4761 $9,652 Collier County Government Repricing Summary 2.xlsx - Inpatient 11/4/2022 2:43 PM Repricing Summary - Outpatient 3-DIGIT ZIP PROVIDER SPECIFIC State Total Claim I Charges Network Charges Network Discount % Network Discount Network Allowed Network Char es Network Discount % Network Discount Network Allowed Totals $28,855,865 $28,380,7081 69.0%1 $19,581,3621 $8,799,347 $28,380,7081 61.9%1 $17,581,3051 $10,799,403 FL $25,255,268 $24,843,361 68.7% $17,067,237 $7,776,125 $24,843,361 59.5% $14,780,678 $10,062,683 GA $1,559,627 $1,559,627 69.8% $1,089,133 $470,494 $1,559,627 81.9% $1,277,796 $281,831 TN $1,364,109 $1,364,109 75.1 % $1,025,035 $339,074 $1,364,109 82.8% $1,128,944 $235,166 CA $184,571 $184,571 74.8% $138,141 $46,430 $184,571 76.5% $141,248 $43,323 OH $84,415 $84,415 61.3% $51,710 $32,705 $84,415 69.4% $58,550 $25,866 MN $75,254 $75,254 47.2% $35,511 $39,743 $75,254 46.8% $35,208 $40,046 NJ $63,862 612 72.6% 444 168 612 72.6% 444 168 TX $57,703 $57,703 72.2% $41,637 $16,065 $57,703 57.2% $33,008 24 695 IL $56,705 $56,705 69.5% $39,383 $17,322 $56,705 49.1 % $27,865 $28,840 NC $50,517 $50,517 62.8% $31,712 $18,805 $50,517 79.7% $40,245 $10,273 VA $24,012 $24,012 69.7% $16,743 $7,268 $24,012 87.0% $20,897 $3,114 CO $13,301 $13,301 41.3% $5,487 $7,815 $13,301 19.1 % $2,545 $10,756 PA $13,064 $13,064 73.8% $9,640 $3,424 $13,064 60.3% $7,883 $5,181 W I $12,761 $12,761 43.4% $5,538 $7,223 $12,761 20.2% $2,572 $10,188 NY $11,110 $11,110 62.3% $6,916 $4,193 $11,110 69.2% $7,682 $3,427 CT $10,690 $10,690 62.3% $6,663 $4,027 $10,690 72.0% $7,697 $2,993 MA 8,2771 8 277 53.9% $4,463 $3,814 $8,277 36.3% $3,002 $5,276 MD $2,966 $2,966 58.9% $1,746 $1,221 $2,966 59.8% 1 772 $1,194 SC 1965 $1,965 63.9% $1,255 710 $1,965 58.4% $1,147 18181 WV $1,317 $1,317 50.0% 658 659 $1,317 34.2% 450 1867 DE 1 224 $1,224 57.8% 708 516 $1,224 32.1 % 393 1831 RI 775 775 58.5% 453 322 7751 50.4% 391 384 NH 681 681 58.6% 399 282 681 53.4% 364 317 MT 565 565 32.3% 183 383 565 24.8% 140 425 MIMMAOSI 540 540 58.3% 315 225 540 28.3% 153 387 337 337 27.6% 93 244 337 22.8% 77 260 200 200 65.5% 131 69 63.9% 128 72 $48 $48 54.7% $27 $22 $48 54.7% $27 $22 Collier County Government Repricing Summary S.xlsx - Outpatient 11/4/2022 2:44 PM Repricing Summary - Physician 3-DIGIT ZIP PROVIDER SPECIFIC State Total Claim Charges Network Charges Network Discount % Network Discount Network Allowed Network Char es Network Discount % Network Discount Network Allowed Totals $19,083,229 $18,065,7161 60.3%1 $10,896,3291 $7,169,388 $18,065,7161 59.0%1 $10,653,4581 $7,412,259 FL $16,123,584 $15,128,933 61.9% $9,362,980 $5,765,953 $15,128,933 58.6% $8,872,625 $6,256,308 GA $1,486,121 $1,485,236 51.8% $769,081 $716,155 $1,485,236 51.7% $768,471 $716,765 NC $705,448 $705,448 51.2% $361,129 $344,319 $705,448 81.3% $573,387 $132,061 PA $197,254 $197,254 53.9% $106,396 $90,858 $197,254 53.6% $105,732 $91,522 OH $103,395 $88,345 52.3% $46,183 $42,162 $88,345 57.6% $50,910 $37,435 CA $86,525 $84,554 55.4% $46,819 $37,734 $84,554 61.3% $51,869 $32,685 IL $73,618 $73,618 57.9% $42,612 $31,006 $73,618 72.4% $53,323 $20,295 TX $71,144 $70,388 63.3% $44,535 $25,853 $70,388 68.3% $48,108 $22,281 ME $34,347 $34,347 52.6% $18,051 $16,296 $34,347 53.8% $18,468 $15,879 MA $29,978 $29,978 47.9% $14,353 $15,625 $29,978 59.6% $17,871 $12,107 MN $28,843 $28,843 32.9% $9,483 $19,361 $28,843 43.9% $12,665 $16,178 DC $27,984 $27,984 52.7% $14,757 $13,227 $27,984 62.9% $17,606 $10,378 SC $20,157 $20,157 57.6% $11,601 $8,556 $20,157 69.2% $13,944 $6,213 NY $20,147 $18,449 62.4% $11,521 $6,929 $18,449 63.5% $11,711 6 738 MI $16,499 $14,874 38.6% $5,748 $9,127 $14,874 37.4% $5,570 $9,304 CO $15,083 $15,083 56.6% $8,543 $6,540 $15,083 60.1 % $9,066 $6,017 VA 0,411 0,411 57.9% $6,029 $4,382 $10,411 61.1 % $6,360 $4,051 W I 7,7441 7,7441 43.0% $3,331 $4,413 $7,744 46.2% $3,575 $4,169 TN 4,9401 4,940 53.9% $2,663 $2,276 $4,940 49.7% $2,456 $2,484 AZ $4,918 $4,758 61.5% $2,927 $1,831 $4,758 63.8% $3,035 $1,723 MD $4,631 $4,631 56.4% $2,613 $2,018 $4,631 57.0% $2,640 $1,991 WA $3,200 $3,200 47.4% 1 515 1 685 3 200 27.2% 869 2 331 WV 2117 2117 50.4% 1067 1050 2117 50.2% 1062 1055 DE 1234 1234 60.7% 749 485 1234 49.0% 605 629 RI 732 732 57.5% 421 311 732 57.8% 423 309 UT 717 0 0.0% 0 0 0 0.0% 0 0 NH 469 469 52.3% 245 224 469 34.4% 161 308 MO 410 410 57.2% 234 176 410 57.6% 236 174 KY 310 310 42.6% 132 178 310 50.2% 156 154 NM 300 300 51.7% 155 145 300 62.0% 186 114 OR 299 299 43.5% 130 169 299 42.0% 126 173 AL 291 291 58.0% 169 122 291 52.0% 151 140 IA 274 274 35.2% 97 177 274 14.0% 38 236 IN 1 $104 $1041 57.1% $59 $45 $104 50.6% $53 $51 Collier County Government Repricing Summary 5.xlsx - Physician 11/4/2022 2:44 PM Repricing Summary - Injectables, Lab, Radiology 3-DIGIT ZIP PROVIDER SPECIFIC State Total Claim Charges Network Charges Network Discount % Network Discount Network Allowed Network Char es Network Discount % Network Discount Network Allowed Totals $10,767,277 $10,451,7451 57.5%1 $6,008,9561 $4,442,789 $10,451,7451 68.4%1 $7,147,3811 $3,304,364 FL $4,634,641 $4,525,345 61.6% $2,789,008 $1,736,337 $4,525,345 60.6% $2,741,049 $1,784,296 PA $2,733,902 $2,694,652 58.6% $1,580,318 $1,114,334 $2,694,652 89.7% $2,417,402 $277,250 GA $1,992,005 $1,990,598 51.8% $1,030,667 $959,931 $1,990,598 55.1 % $1,096,169 $894,429 NC $296,721 $287,313 50.9% $146,335 $140,977 $287,313 86.3% $248,082 $39,231 CA $295,201 $237,994 42.7% $101,545 $136,449 $237,994 83.3% $198,332 $39,662 W I $274,401 $274,401 44.0% $120,653 $153,748 $274,401 44.0% $120,845 $153,556 ME $255,912 $255,912 52.6% $134,495 $121,417 $255,912 76.3% $195,270 $60,642 TX $74,446 $35,204 63.1 % $22,213 $12,991 $35,204 64.0% $22,538 12 665 UT $50,670 $50,670 53.4% $27,070 $23,600 $50,670 70.8% $35,879 $14,791 IL $39,752 $15,567 58.8% $9,147 $6,421 $15,567 70.8% $11,027 $4,540 NJ $30,962 $30,962 65.4% $20,236 $10,726 $30,962 85.6% $26,501 $4,460 MD $22,960 4,1841 56.4% $2,360 $1,825 $4,184 87.2% $3,650 534 OH $12,745 2,745 56.1 % $7,151 $5,594 $12,745 77.1 % $9,827 2 918 SC $11,438 1628 54.8% 893 735 1628 60.3% 981 646 TN 8 947 8 947 54.5% 4 872 4 075 8 947 77.4% 6 926 2 021 MI 8 157 8 157 38.8% 3 163 4 994 8 157 31.8% 2 592 5 565 MA 4 596 4 596 52.0% 2 392 2 204 4 596 54.7% 2 515 2 081 CO 3,981 2 250 56.7% 1 277 973 2 250 51.4% 1 156 1 094 NY 3 658 3 658 63.9% $2,337 $1,321 $3,658 74.3% $2,720 939 IN $3,461 6 58.2% 3 3 6 58.2% 3 3 MN $2,887 $2,887 24.6% 710 $2,177 $2,887 56.6% $1,633 $1,254 WV $2,007 $2,007 46.8% 939 $1,068 $2,007 48.2% 968 $1,039 AZ $1,443 335 62.6% 210 125 335 70.5% 236 99 AL 900 900 57.2% 515 385 900 64.6% $582. $318 ID $6551 $0 0.0% 0 0 0 0.0% 0 0 MO 339 339 52.1 % 176 162 339 60.3% 204 134 RI 215 215 57.5% 124 91 215 78.2% 168 47 VA 192 192 58.0% 111 81 192 44.6% 86 106 Collier County Government Repricing Summary S.xlsx - Hospital Based 11/4/2022 2:44 PM Repricing Summary - HCPCs 3-DIGIT ZIP PROVIDER SPECIFIC State Total Claim Charges Network Charges Network Discount % Network Discount Network Allowed Network Char es Network Discount % Network Discount Network Allowed Totals $1,191,954 $852,1581 58.5%1 $498,7231 $353,435 $852,1581 59.0%1 $502,9661 $349,192 FL $718,065 $541,248 62.1 % $336,166 $205,082 $541,248 62.5% $338,393 $202,855 GA $218,076 $218,016 51.8% $112,867 $105,149 $218,016 53.3% $116,294 $101,722 CA $108,772 $5,387 53.5% $2,885 $2,503 $5,387 54.0% $2,911 $2,476 PA $34,627 $34,595 53.5% $18,497 $16,098 $34,595 54.1 % $18,725 $15,870 IL $30,568 $4,033 59.2% $2,387 $1,646 $4,033 58.1 % $2,341 $1,692 ME $19,209 $19,209 52.6% $10,095 $9,114 $19,209 41.3% $7,940 $11,269 TX $15,751 $3,461 64.3% $2,226 $1,235 $3,461 60.0% $2,076 $1,385 VA $10,875 0 0.0% 0 0 0 0.0% 0 0 MI $6,861 $6,861 45.2% $3,103 $3,758 $6,861 45.2% $3,103 $3,758 NJ $5,587 $5,587 62.5% $3,492 $2,095 $5,587 62.3% $3,482 $2,105 NY $4,692 800 61.4% 492 308 800 44.3% 355 445 NC $3,385 $2,910 51.2% $1,491 $1,419 $2,910 58.3% $1,696 $1,214 IN $3,234 170 58.2% 99 71 170 58.2% 99 71 AZ $3,231 $1,446 60.9% 880 565 $1,446 73.6% $1,064 382 MA $3,205 $3,205 51.7% $1,655 $1,550 $3,205 59.3% $1,901 $1,304 MN $2,286 $2,286 37.3% 853 $1,433 $2,286 43.6% 996 $1,290 WV 907 $907, 47.0% 426, $4801 $907, 78.7% $714, 193 MD 8001 $8001 57.2% 458 3421 $8001 31.4% 251 549 Collier County Government Repricing Summary S.xlsx - HCPCs 11/4/2022 2:44 PM Data Issues - Claims Excluded from Analysis Comments Claim Types Percent of Total Total Charges 3-DIGIT ZIP PROVIDER SPECIFIC Dental 3.9% $75,861 62.4% 59.3% Assume these claims are similar to the repriced ones Dietitian 0.1% $1,638 62.4% 59.3% Equipment/Supplies 13.5% $262,237 62.4% 59.3% Holistic 0.1% $2,650 62.4% 59.3% Home Health 24.8% $482,064 62.4% 59.3% Limited Benefit 1.5% $29,815 62.4% 59.3% Nursing 32.5% $632,267 62.4%1 59.3% Pharmacy 18.5% $359,850 62.4%1 59.3% Vision 1 5.1% $98,366 62.4%1 59.3% Grand Totals 1 100.0% $1,944,748 62.4%1 59.3% Collier County Government Repricing Summary 5.xlsx - Data Issues 11/4/20222:45 PM Reconciliation to Source Data Comments Source File Source Table/Tab Grouper (optional) Total Source File 84,730,981 Total on Source File 84,730,981 Total on Summary Page 84,730,981 Difference Were these totals taken from the phvsical file provided? © Yes 0 No If not, what processing was done prior to these totals? Summary by Rating Area Nate: The totals in row 6 coincide with the Repricing Summary, Summary tab, IP/OP/Phys Subtotal row $80.454.296 62.4% 59.4% Product Rating Area -NEW Rating_Area_Name_N EW Charge 3DZ Discount PS Discount OAP FLOAPW FL, NAPLES $42,852,933 61.7% 55.9% OAP FLOAPF FL, FORT MYERS $12,498,985 65.2% 58.3% OAP GAOAPA GA, ATLANTA $5,587,061 56.7% 62.7% OAP OAP OAP OAP FLOAPJ FL, DADE $3,323,739 66.7% 57.2% FLOAPH FL, TAMPA $2,789,593 66.9% 65.1% PAOAPB PA, PHILADELPHIA ME $2,708,613 58.7% 89.5% FLOAPA FL, ORLANDO $1,913,402 63.5% 54.7% OAP TNOAPI TN, NASHVILLE INNER, $1,379,537 74.9% 82.6% OAP FLOAPR FL, SOUTH BROWARD $1,169,516 72.7% 70.8% OAP FLOAPC FL, OCALA/GAINESVILL $875,441 59.9% 58.5% OAP NCOAPB NC, CHARLOTTE $846,220 51.7% 81.8% OAP FLOAPM FL, MONROE $504,488 73.8% 25.3% OAP FLOAPK FL, PALM BEACH $338,494 69.8% 59.7% OAP PAOAPD PA, PITTSBURGH CORE $321,610 57.8% 55.4% OAP MEOAPH ME, BANGOR $309,468 52.6% 71.6% OAP WIOAPA WI, MILWAUKEE $285,589 44.1% 43.8% OAP FLOAPI FL, NORTH BROWARD $251,629 66.4% 72.3% OAP CAOAPG CA, SAN MATEO $214,023 41.5% 86.0% OAP OAP OAP OAP OAP OAP OHOAPA OH, CLEVELAND $201,903 58.0% 57.5% NCOAPC NC, TRIAD $181,432 50.8% 89.2% FLOAPS FL, SARASOTA $179,253 65.9% 56.2% CAOAPQ CA, VENTURA $157,683 74.2% 77.7% ILOAPB IL, CHICAGO NORTH $113,021 60.6% 57.7% MNOAPA MN, TWIN CITIES - HEA $110,280 46.8% 45.5% OAP OAP OAP OHOAPD OH, CINCINNATI $99,840 53.4% 66.1% FLOAPG FL, POLK $97,718 61.5% 28.4% FLOAPV FL, VOLUSIA $72,999 62.6% 66.3% OAP OAP FLOAPD FL, JACKSONVILLE CEr $67,508 61.2% 55.7% TXOAPH TX, HOUSTON $64,212 65.8% 61.9% OAP TXOAPD TX, DALLAS $53,892 66.1% 65.2% OAP OHOAPF OH, COLUMBUS $52,654 48.0% 48.6% OAP CAOAPK CA, NORTH LA $52,267 68.2% 70.0% OAP PAOAPS PA, SCRANTON AND W $50,827 66.2% 66.1% OAP UTOAPA UT, SALT LAKE CITY $50,670 53.4% 70.8% OAP FLOAPT FL, TALLAHASSEE $40,697 56.7% 48.7°% OAP MAOAPD MA, BOSTON $38,496 48.4% 57.1% OAP CAOAPJ CA, CENTRAL LA $35,831 56.8% 57.8% OAP VAOAPA VA, FAIRFAX $34,303 66.2% 79.5°% OAP ILOAPC IL, CHICAGO SOUTH $33,941 68.1% 64.8°% OAP CAOAPI CA, SAN DIEGO $31,194 51.8% 64.9% OAP NJOAPN NJ, NORTHEAST $30,844 65.2% 79.9% OAP DCOAP1 DC, WASHINGTON DC $27,997 52.7% 62.9% OAP TXOAPV TX, SOUTHERN VALLEI $26,893 70.5% 59.7% OAP FLOAPE FL, COCOA BEACH $24,501 61.7% 72.9% OAP MNOAPB MN, OTHER MN - HEAL- $21,708 21.5% 51.1% OAP NCOAPA NC, TRIANGLE $17,677 59.6% 51.3% OAP TNOAPJ TN, NASHVILLE INNER $15,840 60.0% 60.0% OAP MIOAPB MI, DETROIT, ANN ARB $14,158 45.2% 45.2% OAP ILOAPA IL, CHICAGO METRO $13,999 61.7% 64.2% OAP SCOAPC SC, FLORENCE MYRTLI $13,976 58.9% 72.1% OAP COOAPJ CO, RURAL SOUTHWE: $12,897 39.5% 17.1% OAP NYOAPM NY, METRO MANHATTP $12,859 65.0% 68.6% OAP COOAPH CO, BOULDER $11,416 56.9% 65.0% OAP CTOAPA CT, HARTFORD $10,690 62.3% 72.0% OAP MIOAPA MI, DETROIT SUBURBS $10,366 40.9% 40.9% OAP FLOAPN FL, PENSACOLA $9,983 68.3% 74.1 % OAP MDOAPA MD, BALTIMORE CITY $9,827 56.4% 68.3% OAP WIOAPB WI, MADISON $9,316 37.4% 19.6% OAP OHOAPB OH, AKRON $9,087 59.9% 63.0% OAP NYOAPL NY, METRO LONG ISLAI $8,316 67.0% 69.8% OAP CAOAPE CA, OTHER NORTHERN $8,207 63.7 % 26.9% OAP TXOAPM TX, LUBBOCK $7,864 58.6 % 77.6% OAP CAOAPA CA, SAN FRANCISCO $7,110 44.5% 46.6% OAP PAOAPL PA, LEHIGH VALLEY $6,344 51.0% 42.8% OAP NJOAPC NJ, CENTRAL $6,316 64.2% 91.4% OAP NYOAPQ NY, METRO KINGS/QUE $6,138 65.5% 73.4% OAP MAOAPE MA, SOUTHEAST $5,560 57.4% 37.4% OAP MIOAPF MI, NORTHERN MI $5,416 26.0% 12.2% OAP TXOAPR TX, NORTH CYPRESS $5,370 70.3% 61.0% OAP AZOAPP AZ, PHOENIX IPA $4,642 63.4% 72.2% OAP COOAPA CO, DENVER $4,593 60.0% 53.5% OAP SCOAPJ SC, ROCK HILL $4,400 53.7% 69.1% OAP NYOAPU NY, MVP-SYRACUSE $4,117 48.9% 49.9% OAP TXOAPS TX, SAN ANTONIO $4,024 65.2% 69.6% OAP GAOAPJ GA, SOUTH GEORGIA $3,914 60.1% 49.3% OAP WVOAPN WV, NORTH $3,848 50.2% 45.6% OAP CAOAPB CA, SACRAMENTO $3,801 44.8% 89.9% OAP WAOAPE WA, EAST SEATTLE $3,200 47.4% 27.2% OAP TNOAPU TN, KNOXVILLE INNER $2,699 52.4% 42.5% OAP TXOAPX TX, DFW OUTLYING $2,523 63.4% 52.7% OAP WVOAPP WV, PHCS $2,500 46.4% 57.6% OAP SCOAPH SC, CHARLESTON $2,471 62.6% 58.7% OAP DEOAP1 DE, DELAWARE $2,458 59.3% 40.6% OAP PAOAPA PA, PHILADELPHIA SUE $2,325 58.7% 81.3% OAP CAOAPT CA, EAST LA $2,240 57.2% 57.2% OAP MAOAPB MA, ESSEX $2,000 52.3% 61.4% OAP AZOAPT AZ, TUCSON METRO $1,842 56.7% 51.3% OAP MDOAPE MD, FREDERICK $1,754 60.5% 69.2% OAP RIOAP1 RI, RHODE ISLAND $1,722 58.0% 57.0% OAP SCOAPB SC, COLUMBIA INNER $1,633 55.3% 57.3% OAP FLOAPB FL, LAKE $1,551 62.4% 48.6% OAP NYOAPN NY, METRO NORTH/WE $1,444 55.8% 51.8% OAP COOAPC CO, CO SPRINGS/EL P $1,431 55.0% 35.9% OAP TXOAPA TX, AUSTIN $1,329 59.7% 69.4% OAP ALOAPB AL, BIRMINGHAM - ME $1,321 57.8% 58.3% OAP SCOAPI SC, GREENVILLE $1,270 55.5% 44.8% OAP GAOAPS GA, ATLANTA SOUTH $1,207 53.2% 54.0% OAP NHOAPK NH, SOUTHERN $1,150 56.0% 45.7% OAP TNOAPV TN, KNOXVILLE EAST $1,073 57.3% 58.7% OAP FLOAPL FL, MARTIN $980 64.7% 60.9% OAP GAOAPO GA, SAVANNAH OUTER $818 61.9% 41.5% OAP MDOAPB MD, BALTIMORE OUTEI $800 57.2% 31.4% OAP FLOAPP FL, JACKSONVILLE OU $787 58.4% 55.7% OAP NCOAPF NC, WILMINGTON $690 55.7% 20.6% OAP TNOAPX TN, TRI CITIES SOUTH $686 52.8% 55.9% OAP TXOAPQ TX, ABILENE $650 62.3% 58.4% OAP IAOAPD IL, ROCKFORD $646 57.6% 82.3% OAP TNOAPA TN, MEMPHIS $636 62.5% 82.0% OAP OHOAPN OH, RURAL COLUMBU $628 52.0% 54.2% OAP GAOAPV GA, GAINESVILLE INNE $624 55.4% 49.0% OAP GAOAPE GA, SE GEORGIA $589 57.1% 22.8% OAP PAOAPH PA, HARRISBURG $570 52.3% 54.0% OAP MTOAP1 MT, ALLEGIANCE OAP 1 $565 32.3% 24.8% OAP MOOAPK MO, NEVADA $540 58.3% 28.3% OAP PAOAPC PA, LANCASTER $530 56.8% 56.8% OAP IAOAPD IA, DES MOINES - MIDL $509 35.2% 25.6% OAP ALOAPH AL, HUNTSVILLE $450 58.1% 58.1% OAP ILOAPH IL, SOUTHERN $445 52.8% 80.8% OAP MOOAPA MO, ST. LOUIS $435 57.2% 57.6% OAP NYOAPW NY, WESTERN PHCS $420 36.2% 36.2% OAP NYOAPO NY, MVP -BUFFALO $414 43.0% 62.8% OAP KYOAPT KY, WESTERN CENTER $360 42.6% 50.2% OAP IAOAPQ IA, CEDAR RAPIDS ANC $337 27.6% 22.8% OAP OROAPA OR, PORTLAND $319 43.5% 42.0% OAP MOOAPN MO, SPRINGFIELD $314 51.7% 60.6% OAP NYOAPE NY, MVP -NORTHEAST f $310 55.0% 39.6% OAP NMOAPA NM, ALBUQUERQUE 1 $300 51.8% 62.1 % OAP TNOAPL TN, NASHVILLE INNER 11 $238 56.3% 46.0% OAP INOAPA N, INDIANAPOLIS $2161 58.2% 53.6% OAP OHOAPC OH, YOUNGSTOWN $210 58.4% 30.7% OAP OHOAPE OH, DAYTON $202 54.0% 21.1% OAP MDOAPD MD, SUBURBAN MARY $200 56.9% 68.7% OAP MSOAPT MS, JACKSON MHP TP\ $200 65.5% 63.9% OAP GAOAPI GA, SAVANNAH INNER $193 61.8% 41.1% OAP COOAPG CO, GREELEY $172 55.3% 47.9% OAP PAOAPF PA, PITTSBURGH OUR $170 53.6% 45.6% OAP NCOAPH NC, WEST $170 56.1% 60.4% OAP VAOAPD VA, ROANOKE $165 53.0% 21.2% OAP CAOAPH CA, CENTRAL VALLEY $150 52.7% 52.7% OAP TNOAPR TN, CHATTANOOGA S $150 57.3% 57.3% OAP VAOAPE VA, RICHMOND OUTER $147 54.0% 26.2% OAP JCOOAPF ICO, FORT COLLINS $1251 64.5% 70.6% OAP JINOAPB JIN, RURAL 1 $641 56.5% 61.2% OAP JAZOAPR JAZ, PHOENIX RURAL 1 $551 58.8% 67.7% Proprietary and Confidential Question Combined File CHPNetwork - 1 Prov Type I rov Type I III Frov I ype I Claim Count Hospital 28871 ital 20061 7Other Hospital 8810 Physic Pwysic Phy ian 63065 19121 Otherian 24812 Otherian 87877 2 Prov Type a I Claim Count rov Type Clai Hospital 28556 Hospital 19946 Hospital 8610 Physician 78551 Physician 60482 Physician 18069 Other 84698 Other 62425 Other 22273 3 Claim Count Claim Count Claim Count 10824 7033 3791 4 Charges Charges Charges $82,366,405.72 $55,458,402.81 $26,908,002.91 5 Charges $2,364,575.06 6 Unique Members Non Network 1076 '121 member ids in both provider networks Charges $898,945.47 Unique Members Non Network 594 Charges $1,465,629.59 Unique Members Non Network 603 7 Prov Type I Claim Count I Billed I Discount $ I Discount % I Prov Type Claim Count I Billed Discount $ I Discount % Prov Type Claim Count Billed I Discount $ Discount Hospital 285561 51,084,676 29,444,498 57.6% Hospital 19946 34472,060 19,034,255 55.2% Hospital 8610 16,612,616 10,410,243 62.7% Physician 78551 18,065,716 10,653,458 59.0% Physician 60482 12:135,605 7142984 58.9% Physician 18069 5,930,112 3,510,473 59.2% Other 84698 13,216,013 8,785,153 66.5% Other 624251 8,850,738 6:075:629 68.6% Other 22273 4,365,275 2,709,524 62.1% Total 191805 82,366,406 48,883,108 59.3% Total 142853 55,458,403 32,252,868 58.2% Total 48952 26,908,003 16,630,240 61.8% Proprietary and Confidential Cigna. A Medical Disruption Analysis completed for: Account Name: Collier County Government Date of Completion: 4/11/2022 Reporting Options: Option 1 Data Elements Provided Total Number Records Provider Tax ID 203133 Provider CPF ID 0 Provider NPI 0 Provider Name 203151 Provider Address 0 Provider City 203151 Provider State 200234 Provider Zip 0 Provider Specialty 0 Par/Non-Par Indicator 0 Total Records on file 203151 Best results will be generated when all of the following data elements are provided: • Cigna CPF ID — for existing Cigna accounts — must be 7 digits • National Provider Identification (NPI) — must be 10 digits • Provider Tax Identification Number (TIN) — must be 9 digits • Provider Name (first, last) • Provider Address (number, street) • Provider City (optional) • Provider State • Provider Zip Code — required for Local Plus and SureFit markets • Par/Non-Par indicator — indicates whether or not provider participates in the current carrier's network • Provider Specialty (Cardiology, etc.) • Measure of utilization (paid claims, submitted claims, number of claims, etc.) All reasonable efforts have been used to ensure that this report is accurate based on the data and methodology used. However, Cigna does not guarantee accuracy. Match results are based on contract status and is not a indication of how claims will be paid and/or processed. Please note that the address provided may not reflect the actual practice location and may impact match results. Geography based products depend on service location zip codes. If billing zip codes are provided instead of physical service location, your match may be understated. LCP Only: All National Ancillary Vendors are included in the LocalPlus network but due to some data challenges, not all National Ancillary Vendors will return a Yes match in the results. In some LocalPlus markets, the risk of returning false/positive matches is greater when using the Low Confidence Matches due to the structure of the network where not all providers with the same TIN are participating. "Cigna" is a registered service mark, and the "Tree of Life" logo is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries, including Connecticut General Life Insurance Company and Cigna Health and N.& Cigna. Disruption Standard Reporting Rules Choosing the correct report option is critical to ensure you receive the best results for your needs or broker/client expectations. The option you choose can vary with each request. Disruption analysis results will differ based on specialty between the three report options as identified below. Provider Specialty Category Reporting Option 1 Reporting Option 2 Reporting Option 3 Highest overall % result - non -medical May result in lower overall % than Lowest overall match results - "Yes/No" specialties are excluded from overall Option 1 because non -medical match for each record - no exclusions or General Description of disruption. Hospital based are defaulted to specialties are included in results. defaults based on specialty are used. methodology Yes. Hospital based are defaulted to Yes. Preferred option for repricing, Hospital Based Providers not identified Hospital Based Providers Defaulted to "Yes'. Defaulted to "Yes". or defaulted - "Yes/No" contract match for each record. and Senefuts nC U e - Yesmo contract nC U e - YevNo contract matt linvand Limited or Not Covered Excluded from disruption results match results. results. REPORT OPTIONS 1 & 2 REPORT OPTION 1 ONLY Hospital Based Ambulance Neonatologist Invalid (specialties not considered part Acu uncture Home Health Anesthesi0lo Patholo Assistant Midwife Provider Specialties of a medical or behavioral facility, (specialties considered as par due to type of specialty regardless of the contract status when services are rendered by Emer enc Radiology represent ancillary services covered under national vendor contracts). Excluded from overall disruption results for option 1. Dental DDS Misc Hos italist Surgical Assistant Dietician No Provider DME Nurse EDD Pharmacy Holistic Telemedicine an in -network facility). Benefits Limited or Not Covered Match results defaulted to "Yes". (specialties that typically have low affinity and/or represent limited or non- covered services under the plan Audiology Vision design). Excluded from overall disruption results for option 1. REPORT OPTIONS 1, 2 & 3 Excluded - Invalid - No Records that do not provide enough information to validate a match or are not an actual provider of service. For example, records without a valid TIN or Name ("No Provider", "Unknown Provider"), Provider government agencies, foreign providers, etc. These records are not included in the overall disruption results. Out of Date Range Effective Date is taken into consideration when determining whether or not the provider is contracted. If a record shows a match of NO with a match type of Out of Date Range, either the provider contract data is after the effective date of the case or the provider voll term prior to the case effective date. This match type will only be reflected on the detail report. BH Only Identified that a contract match has been found for the behavioral network only. Contract match was not found for medical network. Match Type For standard disruption analysis requests, a mixture of high, middle and low confidence match types will be used unless specific match types are requested. To identify the match types used for this disruption analysis, refer to the "Yes" Breakdown section of the Summary page(s). Confidence Level Data Elements/Match Type Examples Description/Risks not all inclusive High CPF only For existing clients only, the internal Cigna Provider ID is utilized for a match Compound Match on 3 or 4 Data Elements: Cigna applies "Compound Matching Methodology" by combining multiple High NPI + Name + Address + State data elements from the incoming data to match the same Cigna record thereby TIN + Name + Address+ State increasing the match confidence and accuracy. NPI + Name + State QR Quality Review - indicates that match has been manually reviewed to validate match results. Compound Match on 2 or 3 Data Elements: Medium Limited unique compound data elements could result in false/positive matches NPI + State Tin + Name due to shared TINS and shared address or do not include name in the match. Tin + Name + Address Compound Match on 2 Data Elements: Could result in false/positive matches due: • TIN + State Shared TIN, and addresses • TIN + Address Name rovided on file was not matched to other data elements • Name + State Common names or misspelled names/abbreviations Shared states • Provider Group Affiliation (previously Identifies an incumbent/Cigna provider match when — 50 % of providers in an association are contracted with Auto a.. na. Does not guarantee that all affiliated providers within the group are contracted or that there is a contract with Cign Single Data Element Match that is not unique Could result in false/positive matches due: or exclusive to aproviders: • TIN only Shared TIN' • Name only Name rovided on file was not matched to other data elements 1 I I• Common names or misspelled names/abbreviations I �a. 0gna. Medical Disruption Overall Summary Combined overall summary percentages by product requested Open Access Plus Option 1 In Network? ITotal Records % Total Records Billed Amount % Billed Amount YES , 9439% 8,85. 97.15% N 104 2.86% Excluded Records 1 8,9141 1 $1,897,539.78 Total Records in File 1 203,1511 1 $84,730,980.78 Total Records % Billed Amount 94.39% 97.15% �5.61% i �2.86% I..�, % Cigna. How to Read Summary Reports The summary report will provide, at a minimum, the number of total records by Yes and No match results. Total records are the total number of records on the file submitted. A separate summary section for the following categories will be provided: • YES Breakdown — summary of all Yes matches by match type • NO Breakdown - summary of all No matches by state and/or specialty if provided in the data elements (not available for standard Local Plus summary report) • Behavioral Health Providers - summary of Yes/No match results for providers that have been identified as Behavioral Providers (included in overall disruption results). Note: The behavioral provider summary section may not provide an accurate portrayal of the Cigna/Evernorth Behavioral Network compared to a competitor, if provider specialty is not provided. The identification of behavioral providers is dependent on the specialty information from the incumbent file. Missing or inaccurate specialty information, could impact the behavioral provider summary analysis section. • Hospital Based Providers - summary of Yes match results for providers that are identified as Hospital Based Providers (included in overall results). Reporting Options 1 & 2 only. • Non -Par Providers - summary of Yes and Non -Par providers - if the file contains incumbent par/non-par information, this section will identify those providers who were "non -par" for the incumbent but returned a "Yes" match for Cigna. It will also show the "non -par" providers for the incumbent that are also "non -par" for Cigna. The non -par providers for both the incumbent and Cigna are not included in the overall disruption analysis results. • Tiered Benefits (18) or (21) - If Tiered Benefits is requested, the disruption analysis results will provide the providers in the Tiered benefits. The Tiered Benefits section on the Summary will show the total "yes" matches for Tiered Benefits 18 and Tiered Benefits 21 (if requested). The Providers must be contracted for the main product (i.e., OAP or PPO) in order to be designated as a Tiered Benefits Provider for that network. Tiered Benefits 18 and Tiered Benefits 21 are not available for LocalPlus, HMO, Select, Value or SureFit products. • Collaborative Accountable Care (CAC) - identifies Providers who have a Collaborative Accountable Care designation. Reporting is only available at the physician level and the disruption results may underestimate the impact of Cigna Collaborative Care physician group programs (aka Cigna Accountable Care, CACs). Facilities, Ancillaries and Associations are not identified at the CAC level and therefore the disruption report cannot return CAC results for these types of providers. Cigna. Cigna SUMMARY REPORT Collier County Government Open Access Plus Ontinn 1 Total Recortls 183,346 %Total Records 94 Billed Amount $80,468,865.94 %Billed Amount 97.15% 10,891 5.61%$2,364,575.02.86% 7Rec-d2m 194,237 $82,833,441.008914 $1,897,539.78ile 1 203,1511 1$84,730,980.781 Yes Breakdown Total Records %Total Records Billed Amount % Billed Amount NAME -BH ONLY 1 0.00% $1,134.00 0.00% NAME+STATE - BH ONLY 7 0.00% $1,236.00 0.00% Provider Gmy Affiliation 94 0.05% 140112.38 0.17% TIN-BH ONLY 141 0.08% $24763.76 0.03% TIN+NAME -BH ONLY 153 0.08% $33651.81 0.04% TIN+NAME+STATE -BH ONLY 1062 0.58% $254,811.63 0.32% TIN+STATE -BH ONLY 2046 1.12% 503521.26 0.63% TIN+NAME+STATE 112868 61.56% $51795776.20 64.37% T1N+NAME 31713 17.30% 5691917.23 7.07% TIN+STATE 20918 11,41% $17219849.51 21.40% NAME+STATE 4659 2.54% 1785927.53 2.22% TIN 4200 2.29% 560336.05 0.70% NAME 2 003 1.09 % 297 326.26 0.37% Hospital -Based 3481 1.90% 2158502.32 2.68% Total Yes 183,346 $80 468 865.94 20 No Breakdown - STATE FL Total Records 10,598 %Total Records 97.31% Billed Amount $2,300,375.94 % Billed Amount 97.29% NA 145 1.33% $49593.39 2.10% MN 66 0.61% $7.495.00 0.32% AZ 36 0.33 % $3.053.69 0.13% MI 25 0.23% $1,625.00 0.07% NV 9 0.08% 1,220.00 0.05% OH 6 0.06 % $983.00 0.04 MO -KS 4 0.04% $40.00 0.00% TN 2 0.02% $189.04 0.01% Total No 10 891 2 364 575.06 BEHAVIORAL HEALTH Providers (included in above results): In Network? Total Records Impact on Disruption Billed Amount Impact on Disruption VES 3,438 $814,930.16 NO 711 O.G4%1 $10,210.001 0.01% Total 1 3,5091 1 $825,140.16 Hr1RPITAI .RA-Fn Prnvia- rinfh - in ah- recnitcl- Provider Tyse I Total Records I I Billed Amount Ambulance 312 $133,186.64 Anesthesiology 404 $689,707.74 Emer enc 20 $10.695.94 Pathol 294 $50,989. 17 Radiol 2,444 1 268 962.83 Sur Assistant 7 4960.00 Total 3,481 158 502.32 2158, Provider Type Total Records Billed Amount Audiology 12 $29,815.00 Vision 326 $51,387.21 Acupuncture 26 $2,650.00 Assistant 1,589 $232,916.84 Dental 70 $75,631.00 Dietitians 5 $1,637.75 DME 1,471 $262,237.46 Home Health 760 $482,063.99 Midwife 47 $9,978.61 Nurse 4,478 $389,371.46 Pharmacy 130 $359,850.46 Total 1 8,9141 1 $1,897,539.78 Collaborative Accountable Care (CAC): M 1 Total Records % Total Records Bill Amount % Billed Amount Yes 34,736 18.95% $3,521,642.92 4.38% This report may underestimate the impact of Cigna Collaborative Care physician group programs (aka Ciqna Accountable Care, CACs) as it reports at the physician level only. Facilities, Ancillaries, and Associations are not identified at the CAC level and therefore this report does not contain CAC results for these types of providers. Collier C014-nty Administrative Services Department Procurement Services Division Vendor Check List IMPORTANT: Please review carefully and submit with your Proposal/Bid. All applicable documents shall be submitted electronically through BidSync. Vendor should checkoff each of the following items: ® General Bid Instructions has been acknowledged and accepted. ® Collier County Purchase Order Terms and Conditions have been acknowledged and accepted. ® Form 1: Vendor Declaration Statement ® Form 2: Conflict of Interest Certification ® Proof of status from Division of Corporations - Florida Department of State (If work performed in the State) - bl p://dos.myflorida.com/sunbiz/ should be attached with your submittal. ® Vendor MUST be enrolled in the E-Verify - https://www.e-verify.gov/ at the time of submission of the proposal/bid. ® Form 3: Immigration Affidavit Certification MUST be signed and attached with your submittal or you MAY be DEEMED NON -RESPONSIVE ® E-Verify Memorandum of Understanding or Company Profile page should be attached with your submittal. ® Form 4: Certification for Claiming Status as a Local Business, if applicable, has been executed and returned. Collier or Lee County Business Tax Receipt should be attached with your submittal to be considered. Not Applicable ® Form 5: Reference Questionnaires form must be utilized for each requested reference and included with your submittal, id applicable to the solicitation. ® Form 6: Grant Provisions and Assurances package in its entirety, if applicable, are executed and should be included with your submittal. All forms must be executed, or you MAY be DEEMED NON -RESPONSIVE. Not Applicable ® Vendor W-9 Form. As the client's current Administrator, a copy of Allegiance's W9 is on file with the County. ® Vendor acknowledges Insurance Requirements and is prepared to produce the required insurance certificate(s) within five (5) days of the County's issuance of a Notice of Recommend Award. ® The Bid Schedule has been completed and attached with your submittal, applicable to bids. ® Copies of all requested licenses and/or certifications to complete the requirements of the project. ® All addenda have been signed and attached, or you MAY be DEEMED NON -RESPONSIVE. ® County's IT Technical Architecture Requirements has been acknowledged and accepted, if applicable. Not Applicable ® Any and all supplemental requirements and terms has been acknowledged and accepted, if applicable. Not Applicable DocuSign Envelope ID: 261774CD-063E-4123-AD07-B96F966F79C3 Collier County Administrative Services Department Procurement Services Division Form 1: Vendor Declaration Statement BOARD OF COUNTY COMMISSIONERS Collier County Government Complex Naples, Florida 34112 Dear Commissioners: The undersigned, as Vendor declares that this response is made without connection or arrangement with any other person and this proposal is in every respect fair and made in good faith, without collusion or fraud. The Vendor hereby declares the instructions, purchase order terms and conditions, requirements, and specifications/scope of work of this solicitation have been fully examined and accepted. The Vendor agrees, if this solicitation submittal is accepted by Collier County, to accept a Purchase Order as a form of a formal contract or to execute a Collier County formal contract for purposes of establishing a contractual relationship between the Vendor and Collier County, for the performance of all requirements to which this solicitation pertains. The Vendor states that the submitted is based upon the documents listed by the above referenced solicitation. The Vendor agrees to comply with the requirements in accordance with the terms, conditions and specifications denoted herein and according to the pricing submitted as a part of the Vendor's bids. Further, the Vendor agrees that if awarded a contract for these goods and/or services, the Vendor will not be eligible to compete, submit a proposal, be awarded, or perform as a sub -vendor for any future associated work that is a result of this awarded contract. IN WITNESS WHEREOF, WE have hereunto subscribed our names on this 27th day of April 20 2 2in the County of Mi ssoul a , in the State of Montana Firm's Legal Name Address: City, State, Zip Code: Florida Certificate of Authority Document Number Federal Tax Identification Number *CCR # or CAGE Code *Only if Grant Funded Telephone: Email: Signature by: (Typed and written) Title: Allegiance Benefit Plan Management, Inc. 2806 S. Garfield Street, P.O. Box 3018 Missoula, MT 59806-3018 No. 12-810400550 TIN 81-0400550 N/A 406-721-7222 rfpteam@askallegiance.com DocuSigned by: Stephen A. Tahta �� \-1 President & General Manager DocuSign Envelope ID: 261774CD-063E-4123-AD07-B96F966F79C3 Additional Contact Information Send payments to: Allegiance Benefit Plan Management, Inc. (required if different from Company name used as payee above) Contact name: Stephanie Kallevig Title: Client Account Executive Address: 2806 S. Garfield Street, P.O. Box 3018 City, State, ZIP Missoula, MT 59806-3018 Telephone: 406-721-7222 Email: Stephanie.Kallevig@askallegiance.com Office servicing Collier County to place orders (required if different from above) Contact name: Title: Address: City, State, ZIP Telephone: Email: COXY coHnty Administrative Services Departrnent Procurement Services Division Form 2: Conflict of Interest Certification Affidavit The Vendor certifies that, to the best of its knowledge and belief, the past and current work on any Collier County project affiliated with this solicitation does not pose an organizational conflict as described by one of the three categories below: Biased ground rules - The firm has not set the "ground rules" for affiliated past or current Collier County project identified above (e.g., writing a procurement's statement of work, specifications, or performing systems engineering and technical direction for the procurement) which appears to skew the competition in favor of my firm. Impaired objectivity - The firm has not performed work on an affiliated past or current Collier County project identified above to evaluate proposals / past performance of itself or a competitor, which calls into question the contractor's ability to render impartial advice to the government. Unequal access to information -The firm has not had access to nonpublic information as part of its performance of a Collier County project identified above which may have provided the contractor (or an affiliate) with an unfair competitive advantage in current or future solicitations and contracts. In addition to this signed affidavit, the contractor / vendor must provide the following: 1. All documents produced as a result of the work completed in the past or currently being worked on for the above -mentioned project; and, 2. Indicate if the information produced was obtained as a matter of public record (in the "sunshine") or through non-public (not in the "sunshine") conversation (s), meeting(s), document(s) and/or other means. Failure to disclose all material or having an organizational conflict in one or more of the three categories above be identified, may result in the disqualification for future solicitations affiliated with the above referenced project(s). By the signature below, the firm (employees, officers and/or agents) certifies, and hereby discloses, that, to the best of their knowledge and belief, all relevant facts concerning past, present, or currently planned interest or activity (financial, contractual, organizational, or otherwise) which relates to the project identified above has been fully disclosed and does not pose an organizational conflict. State of YY\ �Yl��✓� County of The foregoing instrument was acknowledged before of (month), ;2 oaa (year), by Personally Known OR Produced Identification Type of Identification Produced Allegiance Benefit Plan Management, Inc. C any Name 1 Signature Stephen Tahta, President & General Manager by means of 46hysical presence or 0 online notarization, this ::�D day l9- -r A4rn (name of person acknowledging). (Signature of Notail6j Public) (Print, Type, or Stamp Commissioned Name of Notary Public) yNi RAYNI LENZ �Po.AR� tir NOTARY PUBLIC for the -�` State of Montana A SEAL $ Residing at Missoula, M1 ��oFMo�`r M Commission Expires July 31, 2023. FLORIDA OFFICE OF INSURANCE REGULATION ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC, , Has duly qualified pursuant to Chapter 626.88-- 626.894, Florida Statutes for a Third Party r Certificate Of Authority and is entifie �. Administrator to transact business in accordance with their: authorization cited above. Original Issuance-: January44, 2012 12 - 810400550 Kevin M. McCarty CommGsWner Office of Insurance Regulation Collier County Administrative Services Department Procurement Services Division 00 ier County Administrative Services Department Procurement Services Division Form 3: Immigration Affidavit Certificatioli This Affidavit is required and should be signed, by an authorized principal of the firm and submitted with formal solicitation submittals. Further, Vendors are required to be enrolled in the E-Verify program (hgps://www.e-verify.govn, at the time of the submission of the Vendor's proposal/bid. Acceptable evidence of your enrollment consists of a copy of the properly completed E- Verify Company Profile page or a copy of the fully executed E-Verify Memorandum of Understanding for the company which will be produced at the time of the submission of the Vendor's proposal/bid or within five (5) day of the County's Notice of Recommend Award. FAILURE TO EXECUTE THIS AFFIDAVIT CERTIFICATION AND SUBMIT WITH VENDOR'S PROPOSAL/BID MAY DEEM THE VENDOR'S AS NON -RESPONSIVE. Collier County will not intentionally award County contracts to any Vendor who knowingly employs unauthorized alien workers, constituting a violation of the employment provision contained in 8 U.S.C. Section 1324 a(e) Section 274A(e) of the Immigration and Nationality Act ("INA"). Collier County may consider the employment by any Vendor of unauthorized aliens a violation of Section 274A (e) of the INA. Such Violation by the recipient of the Employment Provisions contained in Section 274A (e) of the INA shall be grounds for unilateral termination of the contract by Collier County. Vendor attests that they are fully compliant with all applicable immigration laws (specifically to the 1986 Immigration Act and subsequent Amendment(s), that it is aware of and in compliance with the requirements set forth in Florida Statutes §448.095, and agrees to comply with the provisions of the Memorandum of Understanding with E-Verify and to provide proof of enrollment in The Employment Eligibility Verification System (E-Verify), operated by the Department of Homeland Security in partnership with the Social Security Administration at the time of submission of the Vendor's proposal/bid. Allegiance Benefit Plan Management, Inc. C� ompany Name Signature Stephen Tahta, President & General Manager State of County of The foregoing instrument was acknowledged before me by means of fib physical presence or ❑ online notarization, this day of (month), (year), by A �(name of person acknowledging). (Signature of Not Public) Personally Known OR Produced Identification Type of Identification Produced (Print, Type, or Stamp Commissioned Name of Notary Public) tai cF RAYNI LENZ PPy �TARI N NOTARY PUBLIC for the _ _L State of Montana SEAL r Residing at Missoula, MT MY Commission Expires July 31, 2023. � sect v- orE-Verif Company ID Number: 1824823 THE E-VERIFY MEMORANDUM OF UNDERSTANDING FOR EMPLOYERS ARTICLE I PURPOSE AND AUTHORITY The parties to this agreement are the Department of Homeland Security (DHS) and the Allegiance Benefit Plan Management, Inc. (Employer). The purpose of this agreement is to set forth terms and conditions which the Employer will follow while participating in E-Verify. E-Verify is a program that electronically confirms an employee's eligibility to work in the United States after completion of Form 1-9, Employment Eligibility Verification (Form 1-9). This Memorandum of Understanding (MOU) explains certain features of the E-Verify program and describes specific responsibilities of the Employer, the Social Security Administration (SSA), and DHS. Authority for the E-Verify program is found in Title IV, Subtitle A, of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (IIRIRA), Pub. L. 104-208, 110 Stat. 3009, as amended (8 U.S.C. § 1324a note). The Federal Acquisition Regulation (FAR) Subpart 22.18, "Employment Eligibility Verification" and Executive Order 12989, as amended, provide authority for Federal contractors and subcontractors (Federal contractor) to use E-Verify to verify the employment eligibility of certain employees working on Federal contracts. ARTICLE II RESPONSIBILITIES A. RESPONSIBILITIES OF THE EMPLOYER 1. The Employer agrees to display the following notices supplied by DHS in a prominent place that is clearly visible to prospective employees and all employees who are to be verified through the system: a. Notice of E-Verify Participation b. Notice of Right to Work 2. The Employer agrees to provide to the SSA and DHS the names, titles, addresses, and telephone numbers of the Employer representatives to be contacted about E-Verify. The Employer also agrees to keep such information current by providing updated information to SSA and DHS whenever the representatives' contact information changes. 3. The Employer agrees to grant E-Verify access only to current employees who need E-Verify access. Employers must promptly terminate an employee's E-Verify access if the employer is separated from the company or no longer needs access to E-Verify. Page 1 of 17 E-Verify MOU for Employers I Revision Date 06/01/13 � sect v- orE-Verif Company ID Number: 1824823 4. The Employer agrees to become familiar with and comply with the most recent version of the E-Verify User Manual. 5. The Employer agrees that any Employer Representative who will create E-Verify cases will complete the E-Verify Tutorial before that individual creates any cases. a. The Employer agrees that all Employer representatives will take the refresher tutorials when prompted by E-Verify in order to continue using E-Verify. Failure to complete a refresher tutorial will prevent the Employer Representative from continued use of E-Verify. 6. The Employer agrees to comply with current Form 1-9 procedures, with two exceptions: a. If an employee presents a "List B" identity document, the Employer agrees to only accept "List B" documents that contain a photo. (List B documents identified in 8 C.F.R. § 274a.2(b)(1)(B)) can be presented during the Form I-9 process to establish identity.) If an employee objects to the photo requirement for religious reasons, the Employer should contact E-Verify at 888-464-4218. b. If an employee presents a DHS Form 1-551 (Permanent Resident Card), Form 1-766 (Employment Authorization Document), or U.S. Passport or Passport Card to complete Form 1-9, the Employer agrees to make a photocopy of the document and to retain the photocopy with the employee's Form 1-9. The Employer will use the photocopy to verify the photo and to assist DHS with its review of photo mismatches that employees contest. DHS may in the future designate other documents that activate the photo screening tool. Note: Subject only to the exceptions noted previously in this paragraph, employees still retain the right to present any List A, or List B and List C, document(s) to complete the Form 1-9. 7. The Employer agrees to record the case verification number on the employee's Form 1-9 or to print the screen containing the case verification number and attach it to the employee's Form 1-9. 8. The Employer agrees that, although it participates in E-Verify, the Employer has a responsibility to complete, retain, and make available for inspection Forms 1-9 that relate to its employees, or from other requirements of applicable regulations or laws, including the obligation to comply with the antidiscrimination requirements of section 274B of the INA with respect to Form 1-9 procedures. a. The following modified requirements are the only exceptions to an Employer's obligation to not employ unauthorized workers and comply with the anti -discrimination provision of the INA: (1) List B identity documents must have photos, as described in paragraph 6 above; (2) When an Employer confirms the identity and employment eligibility of newly hired employee using E-Verify procedures, the Employer establishes a rebuttable presumption that it has not violated section 274A(a)(1)(A) of the Immigration and Nationality Act (INA) with respect to the hiring of that employee; (3) If the Employer receives a final nonconfirmation for an employee, but continues to employ that person, the Employer must notify DHS and the Employer is subject to a civil money penalty between $550 and $1,100 for each failure to notify DHS of continued employment following a final nonconfirmation; (4) If the Employer continues to employ an employee after receiving a final nonconfirmation, then the Employer is subject to a rebuttable presumption that it has knowingly Page 2 of 17 E-Verify MOU for Employers I Revision Date 06/01/13 � sect v- orE-Verif Company ID Number: 1824823 employed an unauthorized alien in violation of section 274A(a)(1)(A); and (5) no E-Verify participant is civilly or criminally liable under any law for any action taken in good faith based on information provided through the E-Verify. b. DHS reserves the right to conduct Form 1-9 compliance inspections, as well as any other enforcement or compliance activity authorized by law, including site visits, to ensure proper use of E-Verify. 9. The Employer is strictly prohibited from creating an E-Verify case before the employee has been hired, meaning that a firm offer of employment was extended and accepted and Form 1-9 was completed. The Employer agrees to create an E-Verify case for new employees within three Employer business days after each employee has been hired (after both Sections 1 and 2 of Form 1-9 have been completed), and to complete as many steps of the E-Verify process as are necessary according to the E-Verify User Manual. If E-Verify is temporarily unavailable, the three-day time period will be extended until it is again operational in order to accommodate the Employer's attempting, in good faith, to make inquiries during the period of unavailability. 10. The Employer agrees not to use E-Verify for pre -employment screening of job applicants, in support of any unlawful employment practice, or for any other use that this MOU or the E-Verify User Manual does not authorize. 11. The Employer must use E-Verify for all new employees. The Employer will not verify selectively and will not verify employees hired before the effective date of this MOU. Employers who are Federal contractors may qualify for exceptions to this requirement as described in Article II.B of this MOU. 12. The Employer agrees to follow appropriate procedures (see Article III below) regarding tentative nonconfirmations. The Employer must promptly notify employees in private of the finding and provide them with the notice and letter containing information specific to the employee's E-Verify case. The Employer agrees to provide both the English and the translated notice and letter for employees with limited English proficiency to employees. The Employer agrees to provide written referral instructions to employees and instruct affected employees to bring the English copy of the letter to the SSA. The Employer must allow employees to contest the finding, and not take adverse action against employees if they choose to contest the finding, while their case is still pending. Further, when employees contest a tentative nonconfirmation based upon a photo mismatch, the Employer must take additional steps (see Article III.B. below) to contact DHS with information necessary to resolve the challenge. 13. The Employer agrees not to take any adverse action against an employee based upon the employee's perceived employment eligibility status while SSA or DHS is processing the verification request unless the Employer obtains knowledge (as defined in 8 C.F.R. § 274a.1(1)) that the employee is not work authorized. The Employer understands that an initial inability of the SSA or DHS automated verification system to verify work authorization, a tentative nonconfirmation, a case in continuance (indicating the need for additional time for the government to resolve a case), or the finding of a photo mismatch, does not establish, and should not be interpreted as, evidence that the employee is not work authorized. In any of such cases, the employee must be provided a full and fair opportunity to contest the finding, and if he or she does so, the employee may not be terminated or suffer any adverse employment consequences based upon the employee's perceived employment eligibility status Page 3 of 17 E-Verify MOU for Employers I Revision Date 06/01/13 � sect v- orE-Verif Company ID Number: 1824823 (including denying, reducing, or extending work hours, delaying or preventing training, requiring an employee to work in poorer conditions, withholding pay, refusing to assign the employee to a Federal contract or other assignment, or otherwise assuming that he or she is unauthorized to work) until and unless secondary verification by SSA or DHS has been completed and a final nonconfirmation has been issued. If the employee does not choose to contest a tentative nonconfirmation or a photo mismatch or if a secondary verification is completed and a final nonconfirmation is issued, then the Employer can find the employee is not work authorized and terminate the employee's employment. Employers or employees with questions about a final nonconfirmation may call E-Verify at 1-888-464- 4218 (customer service) or 1-888-897-7781 (worker hotline). 14. The Employer agrees to comply with Title VI of the Civil Rights Act of 1964 and section 274B of the INA as applicable by not discriminating unlawfully against any individual in hiring, firing, employment eligibility verification, or recruitment or referral practices because of his or her national origin or citizenship status, or by committing discriminatory documentary practices. The Employer understands that such illegal practices can include selective verification or use of E-Verify except as provided in part D below, or discharging or refusing to hire employees because they appear or sound "foreign" or have received tentative nonconfirmations. The Employer further understands that any violation of the immigration -related unfair employment practices provisions in section 274B of the INA could subject the Employer to civil penalties, back pay awards, and other sanctions, and violations of Title VI could subject the Employer to back pay awards, compensatory and punitive damages. Violations of either section 274B of the INA or Title VII may also lead to the termination of its participation in E-Verify. If the Employer has any questions relating to the anti -discrimination provision, it should contact OSC at 1-800-255-8155 or 1-800-237-2515 (TDD). 15. The Employer agrees that it will use the information it receives from E-Verify only to confirm the employment eligibility of employees as authorized by this MOU. The Employer agrees that it will safeguard this information, and means of access to it (such as PINS and passwords), to ensure that it is not used for any other purpose and as necessary to protect its confidentiality, including ensuring that it is not disseminated to any person other than employees of the Employer who are authorized to perform the Employer's responsibilities under this MOU, except for such dissemination as may be authorized in advance by SSA or DHS for legitimate purposes. 16. The Employer agrees to notify DHS immediately in the event of a breach of personal information. Breaches are defined as loss of control or unauthorized access to E-Verify personal data. All suspected or confirmed breaches should be reported by calling 1-888-464-4218 or via email at E-Verify(@dhs.gov. Please use "Privacy Incident — Password" in the subject line of your email when sending a breach report to E-Verify. 17. The Employer acknowledges that the information it receives from SSA is governed by the Privacy Act (5 U.S.C. § 552a(i)(1) and (3)) and the Social Security Act (42 U.S.C. 1306(a)). Any person who obtains this information under false pretenses or uses it for any purpose other than as provided for in this MOU may be subject to criminal penalties. 18. The Employer agrees to cooperate with DHS and SSA in their compliance monitoring and evaluation of E-Verify, which includes permitting DHS, SSA, their contractors and other agents, upon Page 4 of 17 E-Verify MOU for Employers I Revision Date 06/01/13 � sect v- orE-Verif Company ID Number: 1824823 reasonable notice, to review Forms 1-9 and other employment records and to interview it and its employees regarding the Employer's use of E-Verify, and to respond in a prompt and accurate manner to DHS requests for information relating to their participation in E-Verify. 19. The Employer shall not make any false or unauthorized claims or references about its participation in E-Verify on its website, in advertising materials, or other media. The Employer shall not describe its services as federally -approved, federally -certified, or federally -recognized, or use language with a similar intent on its website or other materials provided to the public. Entering into this MOU does not mean that E-Verify endorses or authorizes your E-Verify services and any claim to that effect is false. 20. The Employer shall not state in its website or other public documents that any language used therein has been provided or approved by DHS, USCIS or the Verification Division, without first obtaining the prior written consent of DHS. 21. The Employer agrees that E-Verify trademarks and logos may be used only under license by DHS/USCIS (see M-795 (Web)) and, other than pursuant to the specific terms of such license, may not be used in any manner that might imply that the Employer's services, products, websites, or publications are sponsored by, endorsed by, licensed by, or affiliated with DHS, USCIS, or E-Verify. 22. The Employer understands that if it uses E-Verify procedures for any purpose other than as authorized by this MOU, the Employer may be subject to appropriate legal action and termination of its participation in E-Verify according to this MOU. B. RESPONSIBILITIES OF FEDERAL CONTRACTORS 1. If the Employer is a Federal contractor with the FAR E-Verify clause subject to the employment verification terms in Subpart 22.18 of the FAR, it will become familiar with and comply with the most current version of the E-Verify User Manual for Federal Contractors as well as the E-Verify Supplemental Guide for Federal Contractors. 2. In addition to the responsibilities of every employer outlined in this MOU, the Employer understands that if it is a Federal contractor subject to the employment verification terms in Subpart 22.18 of the FAR it must verify the employment eligibility of any "employee assigned to the contract" (as defined in FAR 22.1801). Once an employee has been verified through E-Verify by the Employer, the Employer may not create a second case for the employee through E-Verify. a. An Employer that is not enrolled in E-Verify as a Federal contractor at the time of a contract award must enroll as a Federal contractor in the E-Verify program within 30 calendar days of contract award and, within 90 days of enrollment, begin to verify employment eligibility of new hires using E-Verify. The Employer must verify those employees who are working in the United States, whether or not they are assigned to the contract. Once the Employer begins verifying new hires, such verification of new hires must be initiated within three business days after the hire date. Once enrolled in E-Verify as a Federal contractor, the Employer must begin verification of employees assigned to the contract within 90 calendar days after the date of enrollment or within 30 days of an employee's assignment to the contract, whichever date is later. Page 5 of 17 E-Verify MOU for Employers I Revision Date 06/01/13 � sect v- orE-Verif Company ID Number: 1824823 b. Employers enrolled in E-Verify as a Federal contractor for 90 days or more at the time of a contract award must use E-Verify to begin verification of employment eligibility for new hires of the Employer who are working in the United States, whether or not assigned to the contract, within three business days after the date of hire. If the Employer is enrolled in E-Verify as a Federal contractor for 90 calendar days or less at the time of contract award, the Employer must, within 90 days of enrollment, begin to use E-Verify to initiate verification of new hires of the contractor who are working in the United States, whether or not assigned to the contract. Such verification of new hires must be initiated within three business days after the date of hire. An Employer enrolled as a Federal contractor in E-Verify must begin verification of each employee assigned to the contract within 90 calendar days after date of contract award or within 30 days after assignment to the contract, whichever is later. c. Federal contractors that are institutions of higher education (as defined at 20 U.S.C. 1001(a)), state or local governments, governments of Federally recognized Indian tribes, or sureties performing under a takeover agreement entered into with a Federal agency under a performance bond may choose to only verify new and existing employees assigned to the Federal contract. Such Federal contractors may, however, elect to verify all new hires, and/or all existing employees hired after November 6, 1986. Employers in this category must begin verification of employees assigned to the contract within 90 calendar days after the date of enrollment or within 30 days of an employee's assignment to the contract, whichever date is later. d. Upon enrollment, Employers who are Federal contractors may elect to verify employment eligibility of all existing employees working in the United States who were hired after November 6, 1986, instead of verifying only those employees assigned to a covered Federal contract. After enrollment, Employers must elect to verify existing staff following DHS procedures and begin E-Verify verification of all existing employees within 180 days after the election. e. The Employer may use a previously completed Form 1-9 as the basis for creating an E-Verify case for an employee assigned to a contract as long as: i. That Form 1-9 is complete (including the SSN) and complies with Article II.A.6, ii. The employee's work authorization has not expired, and iii. The Employer has reviewed the Form 1-9 information either in person or in communications with the employee to ensure that the employee's Section 1, Form 1-9 attestation has not changed (including, but not limited to, a lawful permanent resident alien having become a naturalized U.S. citizen). f. The Employer shall complete a new Form 1-9 consistent with Article II.A.6 or update the previous Form 1-9 to provide the necessary information if: i. The Employer cannot determine that Form 1-9 complies with Article II.A.6, ii. The employee's basis for work authorization as attested in Section 1 has expired or changed, or iii. The Form 1-9 contains no SSN or is otherwise incomplete. Note: If Section 1 of Form 1-9 is otherwise valid and up-to-date and the form otherwise complies with Page 6 of 17 E-Verify MOU for Employers I Revision Date 06/01/13 � sect v- orE-Verif Company ID Number: 1824823 Article II.C.5, but reflects documentation (such as a U.S. passport or Form 1-551) that expired after completing Form 1-9, the Employer shall not require the production of additional documentation, or use the photo screening tool described in Article II.A.5, subject to any additional or superseding instructions that may be provided on this subject in the E-Verify User Manual. g. The Employer agrees not to require a second verification using E-Verify of any assigned employee who has previously been verified as a newly hired employee under this MOU or to authorize verification of any existing employee by any Employer that is not a Federal contractor based on this Article. 3. The Employer understands that if it is a Federal contractor, its compliance with this MOU is a performance requirement under the terms of the Federal contract or subcontract, and the Employer consents to the release of information relating to compliance with its verification responsibilities under this MOU to contracting officers or other officials authorized to review the Employer's compliance with Federal contracting requirements. C. RESPONSIBILITIES OF SSA 1. SSA agrees to allow DHS to compare data provided by the Employer against SSA's database. SSA sends DHS confirmation that the data sent either matches or does not match the information in SSA's database. 2. SSA agrees to safeguard the information the Employer provides through E-Verify procedures. SSA also agrees to limit access to such information, as is appropriate by law, to individuals responsible for the verification of Social Security numbers or responsible for evaluation of E-Verify or such other persons or entities who may be authorized by SSA as governed by the Privacy Act (5 U.S.C. § 552a), the Social Security Act (42 U.S.C. 1306(a)), and SSA regulations (20 CFR Part 401). 3. SSA agrees to provide case results from its database within three Federal Government work days of the initial inquiry. E-Verify provides the information to the Employer. 4. SSA agrees to update SSA records as necessary if the employee who contests the SSA tentative nonconfirmation visits an SSA field office and provides the required evidence. If the employee visits an SSA field office within the eight Federal Government work days from the date of referral to SSA, SSA agrees to update SSA records, if appropriate, within the eight -day period unless SSA determines that more than eight days may be necessary. In such cases, SSA will provide additional instructions to the employee. If the employee does not visit SSA in the time allowed, E-Verify may provide a final nonconfirmation to the employer. Note: If an Employer experiences technical problems, or has a policy question, the employer should contact E-Verify at 1-888-464-4218. D. RESPONSIBILITIES OF DHS 1. DHS agrees to provide the Employer with selected data from DHS databases to enable the Employer to conduct, to the extent authorized by this MOU: a. Automated verification checks on alien employees by electronic means, and Page 7 of 17 E-Verify MOU for Employers I Revision Date 06/01/13 � sect v- orE-Verif Company ID Number: 1824823 b. Photo verification checks (when available) on employees. 2. DHS agrees to assist the Employer with operational problems associated with the Employer's participation in E-Verify. DHS agrees to provide the Employer names, titles, addresses, and telephone numbers of DHS representatives to be contacted during the E-Verify process. 3. DHS agrees to provide to the Employer with access to E-Verify training materials as well as an E-Verify User Manual that contain instructions on E-Verify policies, procedures, and requirements for both SSA and DHS, including restrictions on the use of E-Verify. 4. DHS agrees to train Employers on all important changes made to E-Verify through the use of mandatory refresher tutorials and updates to the E-Verify User Manual. Even without changes to E-Verify, DHS reserves the right to require employers to take mandatory refresher tutorials. 5. DHS agrees to provide to the Employer a notice, which indicates the Employer's participation in E-Verify. DHS also agrees to provide to the Employer anti -discrimination notices issued by the Office of Special Counsel for Immigration -Related Unfair Employment Practices (OSC), Civil Rights Division, U.S. Department of Justice. 6. DHS agrees to issue each of the Employer's E-Verify users a unique user identification number and password that permits them to log in to E-Verify. 7. DHS agrees to safeguard the information the Employer provides, and to limit access to such information to individuals responsible for the verification process, for evaluation of E-Verify, or to such other persons or entities as may be authorized by applicable law. Information will be used only to verify the accuracy of Social Security numbers and employment eligibility, to enforce the INA and Federal criminal laws, and to administer Federal contracting requirements. 8. DHS agrees to provide a means of automated verification that provides (in conjunction with SSA verification procedures) confirmation or tentative nonconfirmation of employees' employment eligibility within three Federal Government work days of the initial inquiry. 9. DHS agrees to provide a means of secondary verification (including updating DHS records) for employees who contest DHS tentative nonconfirmations and photo mismatch tentative nonconfirmations. This provides final confirmation or nonconfirmation of the employees' employment eligibility within 10 Federal Government work days of the date of referral to DHS, unless DHS determines that more than 10 days may be necessary. In such cases, DHS will provide additional verification instructions. ARTICLE III REFERRAL OF INDIVIDUALS TO SSA AND DHS A. REFERRAL TO SSA 1. If the Employer receives a tentative nonconfirmation issued by SSA, the Employer must print the notice as directed by E-Verify. The Employer must promptly notify employees in private of the finding and provide them with the notice and letter containing information specific to the employee's E-Verify Page 8 of 17 E-Verify MOU for Employers I Revision Date 06/01/13 � sect v- orE-Verif Company ID Number: 1824823 case. The Employer also agrees to provide both the English and the translated notice and letter for employees with limited English proficiency to employees. The Employer agrees to provide written referral instructions to employees and instruct affected employees to bring the English copy of the letter to the SSA. The Employer must allow employees to contest the finding, and not take adverse action against employees if they choose to contest the finding, while their case is still pending. 2. The Employer agrees to obtain the employee's response about whether he or she will contest the tentative nonconfirmation as soon as possible after the Employer receives the tentative nonconfirmation. Only the employee may determine whether he or she will contest the tentative nonconfirmation. 3. After a tentative nonconfirmation, the Employer will refer employees to SSA field offices only as directed by E-Verify. The Employer must record the case verification number, review the employee information submitted to E-Verify to identify any errors, and find out whether the employee contests the tentative nonconfirmation. The Employer will transmit the Social Security number, or any other corrected employee information that SSA requests, to SSA for verification again if this review indicates a need to do so. 4. The Employer will instruct the employee to visit an SSA office within eight Federal Government work days. SSA will electronically transmit the result of the referral to the Employer within 10 Federal Government work days of the referral unless it determines that more than 10 days is necessary. 5. While waiting for case results, the Employer agrees to check the E-Verify system regularly for case updates. 6. The Employer agrees not to ask the employee to obtain a printout from the Social Security Administration number database (the Numident) or other written verification of the SSN from the SSA. B. REFERRAL TO DHS 1. If the Employer receives a tentative nonconfirmation issued by DHS, the Employer must promptly notify employees in private of the finding and provide them with the notice and letter containing information specific to the employee's E-Verify case. The Employer also agrees to provide both the English and the translated notice and letter for employees with limited English proficiency to employees. The Employer must allow employees to contest the finding, and not take adverse action against employees if they choose to contest the finding, while their case is still pending. 2. The Employer agrees to obtain the employee's response about whether he or she will contest the tentative nonconfirmation as soon as possible after the Employer receives the tentative nonconfirmation. Only the employee may determine whether he or she will contest the tentative nonconfirmation. 3. The Employer agrees to refer individuals to DHS only when the employee chooses to contest a tentative nonconfirmation. 4. If the employee contests a tentative nonconfirmation issued by DHS, the Employer will instruct the Page 9 of 17 E-Verify MOU for Employers I Revision Date 06/01/13 � sect v- orE-Verif Company ID Number: 1824823 employee to contact DHS through its toll -free hotline (as found on the referral letter) within eight Federal Government work days. 5. If the Employer finds a photo mismatch, the Employer must provide the photo mismatch tentative nonconfirmation notice and follow the instructions outlined in paragraph 1 of this section for tentative nonconfirmations, generally. 6. The Employer agrees that if an employee contests a tentative nonconfirmation based upon a photo mismatch, the Employer will send a copy of the employee's Form 1-551, Form 1-766, U.S. Passport, or passport card to DHS for review by: a. Scanning and uploading the document, or b. Sending a photocopy of the document by express mail (furnished and paid for by the employer). 7. The Employer understands that if it cannot determine whether there is a photo match/mismatch, the Employer must forward the employee's documentation to DHS as described in the preceding paragraph. The Employer agrees to resolve the case as specified by the DHS representative who will determine the photo match or mismatch. 8. DHS will electronically transmit the result of the referral to the Employer within 10 Federal Government work days of the referral unless it determines that more than 10 days is necessary. 9. While waiting for case results, the Employer agrees to check the E-Verify system regularly for case updates. ARTICLE IV SERVICE PROVISIONS A. NO SERVICE FEES 1. SSA and DHS will not charge the Employer for verification services performed under this MOU. The Employer is responsible for providing equipment needed to make inquiries. To access E-Verify, an Employer will need a personal computer with Internet access. ARTICLE V MODIFICATION AND TERMINATION A. MODIFICATION 1. This MOU is effective upon the signature of all parties and shall continue in effect for as long as the SSA and DHS operates the E-Verify program unless modified in writing by the mutual consent of all parties. 2. Any and all E-Verify system enhancements by DHS or SSA, including but not limited to E-Verify checking against additional data sources and instituting new verification policies or procedures, will be covered under this MOU and will not cause the need for a supplemental MOU that outlines these changes. Page 10 of 17 E-Verify MOU for Employers I Revision Date 06/01/13 � sect v- orE-Verif Company ID Number: 1824823 B. TERMINATION 1. The Employer may terminate this MOU and its participation in E-Verify at any time upon 30 days prior written notice to the other parties. 2. Notwithstanding Article V, part A of this MOU, DHS may terminate this MOU, and thereby the Employer's participation in E-Verify, with or without notice at any time if deemed necessary because of the requirements of law or policy, or upon a determination by SSA or DHS that there has been a breach of system integrity or security by the Employer, or a failure on the part of the Employer to comply with established E-Verify procedures and/or legal requirements. The Employer understands that if it is a Federal contractor, termination of this MOU by any party for any reason may negatively affect the performance of its contractual responsibilities. Similarly, the Employer understands that if it is in a state where E-Verify is mandatory, termination of this by any party MOU may negatively affect the Employer's business. 3. An Employer that is a Federal contractor may terminate this MOU when the Federal contract that requires its participation in E-Verify is terminated or completed. In such cases, the Federal contractor must provide written notice to DHS. If an Employer that is a Federal contractor fails to provide such notice, then that Employer will remain an E-Verify participant, will remain bound by the terms of this MOU that apply to non -Federal contractor participants, and will be required to use the E-Verify procedures to verify the employment eligibility of all newly hired employees. 4. The Employer agrees that E-Verify is not liable for any losses, financial or otherwise, if the Employer is terminated from E-Verify. ARTICLE VI PARTIES A. Some or all SSA and DHS responsibilities under this MOU may be performed by contractor(s), and SSA and DHS may adjust verification responsibilities between each other as necessary. By separate agreement with DHS, SSA has agreed to perform its responsibilities as described in this MOU. B. Nothing in this MOU is intended, or should be construed, to create any right or benefit, substantive or procedural, enforceable at law by any third party against the United States, its agencies, officers, or employees, or against the Employer, its agents, officers, or employees. C. The Employer may not assign, directly or indirectly, whether by operation of law, change of control or merger, all or any part of its rights or obligations under this MOU without the prior written consent of DHS, which consent shall not be unreasonably withheld or delayed. Any attempt to sublicense, assign, or transfer any of the rights, duties, or obligations herein is void. D. Each party shall be solely responsible for defending any claim or action against it arising out of or related to E-Verify or this MOU, whether civil or criminal, and for any liability wherefrom, including (but not limited to) any dispute between the Employer and any other person or entity regarding the applicability of Section 403(d) of IIRIRA to any action taken or allegedly taken by the Employer. E. The Employer understands that its participation in E-Verify is not confidential information and may be disclosed as authorized or required by law and DHS or SSA policy, including but not limited to, Page 11 of 17 E-Verify MOU for Employers i Revision Date 06/01/13 E-Verifv- Company ID Number: 1824823 Congressional oversight, E-Verify publicity and media inquiries, determinations of compliance with Federal contractual requirements, and responses to inquiries under the Freedom of Information Act (FOIA). F. The individuals whose signatures appear below represent that they are authorized to enter into this MOU on behalf of the Employer and DHS respectively. The Employer understands that any inaccurate statement, representation, data or other information provided to DHS may subject the Employer, its subcontractors, its employees, or its representatives to: (1) prosecution for false statements pursuant to 18 U.S.C. 1001 and/or; (2) immediate termination of its MOU and/or; (3) possible debarment or suspension. G. The foregoing constitutes the full agreement on this subject between DHS and the Employer. To be accepted as an E-Verify participant, you should only sign the Employer's Section of the signature page. If you have any questions, contact E-Verify at 1-888-464-4218. Page 12 of 17 E-Verify MOU for Employers I Revision Date 06/01/13 riE-Vefv— or �y�N� Company ID Number: 1824823 Approved by: Employer Allegiance Benefit Plan Management, Inc. Name (Please Type or Print) Title Krystal Plantz Signature Date Electronically Signed 04/21/2022 Department of Homeland Security — Verification Division Name (Please Type or Print) Title USCIS Verification Division Signature Date Electronically Signed 04/21/2022 Page 13 of 17 E-Verify MOU for Employers I Revision Date 06/01/13 � sect v- orE-Verif Company ID Number: 1824823 Information Required for the E-Verify Program Information relating to your Company: Company Name Allegiance Benefit Plan Management, Inc. Company Facility Address 2806 S Garfield St Missoula, MT 59801 Company Alternate Address County or Parish MISSOULA Employer Identification Number 810400550 North American Industry Classification Systems Code 524 Parent Company Number of Employees 500 to 999 Number of Sites Verified for 2 Page 14 of 17 E-Verify MOU for Employers I Revision Date 06/01/13 E-Verifv- Company ID Number: 1824823 Are you verifying for more than 1 site? If yes, please provide the number of sites verified for in each State: MONTANA 1 site(s) TEXAS 1 site(s) Page 15 of 17 E-Verify MOU for Employers I Revision Date 06/01/13 E-Verifv- Company ID Number: 1824823 Information relating to the Program Administrator(s) for your Company on policy questions or operational problems: Name Valerie Chase Phone Number (406) 523 - 3177 Fax Number (406) 523 - 3182 Email Address valerie.chase@askallegiance.com Name James Burkhart Phone Number (406) 523 - 3145 Fax Number (406) 523 - 3182 Email Address james.burkhart@askallegiance.com Name Krystal Plantz Phone Number (406) 523 - 3184 Fax Number (406) 523 - 3182 Email Address krystal.plantz@askallegiance.com Page 16 of 17 E-Verify MOU for Employers I Revision Date 06/01/13 E-Verifv- Company ID Number: 1824823 Page intentionally left blank Page 17 of 17 E-Verify MOU for Employers I Revision Date 06/01/13 collier County Administrative Services Department Procurement Services Division Form 4: Vendor Submittal — Local Vendor Preference Certification *Not Applicable to this Proposal* (Check Appropriate Boxes Below) State of Florida (Select County if Vendor is described as a Local Business) ❑ Collier County ❑ Lee County Vendor affirms that it is a local business as defined by the Procurement Ordinance of the Collier County Board of County Commissioners and the Regulations Thereto. As defined in Section Fifteen of the Collier County Procurement Ordinance: Local business means the vendor has a current Business Tax Receipt issued by the Collier County Tax Collector prior to bid or proposal submission to do business within Collier County, and that identifies the business with a permanent physical business address located within the limits of Collier County from which the vendor's staff operates and performs business in an area zoned for the conduct of such business. A Post Office Box or a facility that receives mail, or a non -permanent structure such as a construction trailer, storage shed, or other non -permanent structure shall not be used for the purpose of establishing said physical address. In addition to the foregoing, a vendor shall not be considered a "local business" unless it contributes to the economic development and well-being of Collier County in a verifiable and measurable way. This may include, but not be limited to, the retention and expansion of employment opportunities, support and increase to the County's tax base, and residency of employees and principals of the business within Collier County. Vendors shall affirm in writing their compliance with the foregoing at the time of submitting their bid or proposal to be eligible for consideration as a "local business" under this section. A vendor who misrepresents the Local Preference status of its firm in a proposal or bid submitted to the County will lose the privilege to claim Local Preference status for a period of up to one year under this section. Vendor must complete the following information: Year Business Established in ❑Collier County or ❑ Lee County: Number of Employees (Including Owner(s) or Corporate Officers): Number of Employees Living in ❑ Collier County or ❑ Lee (Including Owner(s) or Corporate Officers): If requested by the County, Vendor will be required to provide documentation substantiating the information given in this certification. Failure to do so will result in vendor's submission being deemed not applicable. Sign and Date Certification: Under penalties ofperiury, I certify that the information shown on this form is correct to my knowledge. Company Name: Address in Collier or Lee County: Date: Signature: Title: DocuSign Envelope ID: 8C23C9CC-BD96-4691-A25C-99D6F6845A9F co per County Procurement Services Division Date: April 14, 2022 Email: Barbara.Lance@colliercountyfl.gov Telephone: 239.252.8998 ADDENDUM # 1 From: Barbara Lance, Procurement Strategist To: Interested Bidders Subject: Addendum # 1 — 22-7977 Group Health & Dental Plan Administration Services This Addendum has been issued for the following items identifying clarifications, changes, deletions, and/or additions to the scope of work, solicitation documents and/or bid schedule for the above referenced solicitation: BIDSYNC QUESTIONS/ANSWERS QUESTION 2 : Question: Who is the current Dental carrier? What was the effective date with the current carrier? Answer: We have a self -funded dental plan and we pay a fee to utilize the CIGNA Dental Network. We have had self -funded plan since l/1/2016, prior to that we were fully insured with CIGNA for more than 10 years. Question: What is the current plan design? Is the current booklet (SPD) available? Answer: The complete SPD is necessary to properly understand the current plan provisions and details including frequencies and limitations. Dental SPD link: htips://www.colliercogptyfl. gov/home/shonublisheddocument/66120/6359865942667700 00 Question: Are there currently multiple plan options for employees to choose from? If yes, how may plans are offered? Please provide the plan design for each of the options. Answer: 2 plans outlined in the SPD link above Question: How are the out -of -network claims reimbursed? Negotiated fee schedule or R&C? If R&C, which percentile? Answer: 951h percentile, no penalty for non -network usage. See page 7 of SPD Question: What is the current level of employer contribution toward the cost of coverage by tier (by plan)? Is this expected to change? Answer: Link to Rates - hiips://www.colliercountyfl.gov/government/county-manager- operations/divisions/collier-county-employee-health-benefits/benefit-rates DocuSign Envelope ID: 8C23C9CC-BD96-4691-A25C-99D6F6845A9F Question: What is the current financial arrangement? Answer: Self funded with $2000 calendar year max Question: What, if any, changes to the current financial arrangement are being requested? Answer: No changes expected Question: Please include plan election on census. Answer: Census was provide in Appendix B. Question: Are three years of monthly premium, enrolled lives, and paid claims available (by plan)? Answer: I'm sure we can provide if requested. Question: Is a recent billing invoice available? Answer: Since we are self -funded, it would not be appropriate to share that invoice since it has the rate of our current provider. Question: What are the current rates (by plan)? Answer: Link to rates: https://www.colliercouptyfl.gov/government/county-manager- onerations/divisions/collier-county-employee-health-benefits/benefit-rates Question: Are the historical rates available to correspond to the experience? Answer: The current rates have been in place since 1/1/2016 Question: Are the renewal rates available (by plan)? Answer: No plans at this time to increase employee rates. Question: Have there been any plan design changes over the past 3 years? If so, please provide the details and dates of any change(s). Answer: No plan design changes in the last 3 years. Question: Is dental coverage bundled with the medical? Answer: It is not bundled. If you require additional information please post a question on our Bid Sync (www.bidsync.com) bidding platform under the solicitation for this project. Please sign below and return a copy of this Addendum with your submittal for the above referenced solicitation. (Signature) Allegiance Benefit Plan Management, Inc. (Name of Firm) 4/27/2022 Date DocuSign Envelope ID: 8C23C9CC-BD96-4691-A25C-99D6F6845A9F co per County Procurement Services Division Date: April 15, 2022 Email: Barbara.Lance@colliercountyfl.gov Telephone: 239.252.8998 ADDENDUM #2 From: Barbara Lance, Procurement Strategist To: Interested Bidders Subject: Addendum # 2 — 22-7977 Group Health & Dental Plan Administration Services This Addendum has been issued for the following items identifying clarifications, changes, deletions, and/or additions to the scope of work, solicitation documents and/or bid schedule for the above referenced solicitation: ADDITION: A follow-up to the question below, document 22-7977 Addendum 2 — Medical and Dental Claims 3 years has been uploaded to BidSync. Question: Are three years of monthly premium, enrolled lives, and paid claims available (by plan)? Answer: I'm sure we can provide if requested. If you require additional information please post a question on our Bid Sync (www.bidsypc.com) bidding platform under the solicitation for this project. Please sign below and return a copy of this Addendum with your submittal for the above referenced solicitation. 4/27/2022 (Signature) �-2E60BA06857843Fv Date Allegiance Benefit Plan Management, Inc. (Name of Firm) DocuSign Envelope ID: 8C23C9CC-BD96-4691-A25C-99D6F6845A9F co per County Procurement Services Division Date: April 20, 2022 Email: Barbara.Lance@colliercountyfl.gov Telephone: 239.252.8998 ADDENDUM #3 From: Barbara Lance, Procurement Strategist To: Interested Bidders Subject: Addendum # 3 — 22-7977 Group Health & Dental Plan Administration Services This Addendum has been issued for the following items identifying clarifications, changes, deletions, and/or additions to the scope of work, solicitation documents and/or bid schedule for the above referenced solicitation: CLARIFICATION: In response to Question 13 in BidSync: What is the current pricing for administrative services? Answer: Please see below. A. Administration fees are guaranteed from January 1, 2019 through December 31, 2020, as follows: 2019 2Q20'• $17.26 1 S17.70 The above fees shall include services For production and maintenance of Plan DocumentslSummary Plan Description, plan building, amendment production, plan document compliance, and MIPAA 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 _,�_ PPG Management and Provider Network Coordination Predictive Modeling Disease Management Data Extracts Consolidated Billing Di: 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 (PEM) 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 Parttelpants, except for Welcome Packets and identification cards. " Fees for 2020 are also guaranteed for two (2) additional one (1) year renewals. For Vision RA services, a fee of D.35 Iper Errifteg, per Month. DocuSign Envelope ID: 8C23C9CC-BD96-4691-A25C-99D6F6845A9F C- If elected by the Plan Sponsor during the teen of this Agreement or any renewal thereof, Dental claims processing services per Employee per Month: 2019 2020 " $2.75 $2.35 " Fees for 2020 are also guaranteed for two (2) additional one (1) year renewals. 1, FEE SCHEDULE The Plan SpurnorandiheTPA hereby agree to Ihecompensal on schedulessetforth belawas heklgthe wlaPump anaeffan to We7PAfor anyorimwrwloeawh-c reiatntothe:Se Ion 105HRAPlan. Mm%lyfee earebased upon PranPurii4ipmYtenr❑IlmenlesOfrheheglnning oiihe month. AN feer} stated heiow are aubject tp Cheater 246, Florlda Slatulea, alas Unown r}a ;he ' Load Gov wnmenl Prompt Pevrnent Acr'. Plan 8penrnr rhaE!I pay THE TPA the falrowlrg fear as indicated SERVICE AMOUKT DUE 20H 2019 20M T` tk MDnthly SevvIce Fee HM l'er FartkIpant per Month I S4,0d $4,00 " Foes for =0 era slea guaraneed fGr tw (2) Wdfenal a u (1) yip-pr renuwpP4, FEE SCHEDULE The Plan Sponaorand Ut9TPAherebyagraeto tt~e componsallon schedula!�setforth;belawasbaing the salavomperh48tiontolhe7PAfor any of 1tS eervtces whloh redabo t-0 the FLEX Plan, Monthly Rues Wo balled upon Plan participant enrollment as of flm beginning of the month. P0lees staled befm ern suWnt lc? Chapler 71$1 Florida 5tatutea, also known as lho-'L-aw Govemment Prompt Payment Ad', Plan Sponsor snarl pay THE TPA the following fees as indlwted: SERVICE A. Monthly Service fee FSA including EletlrWIC Payment Card Service: AMOUNT OUE 2018 1 2019 1 2020 r• Rer}'articl rrt perMonth 1 $5.00 $S.t7t3 55.15 " Fees for =0 ere also guaranteed for two (2) additlanel one (1) Mr remewels. E, Foe for FSJ+ OOeFA eerwIm5: $.25 1pmIkIpardM nth togglmr with 2% of the C08RA [am uAacted. If you require additional information please post a question on our Bid Sync (www.bidsypc.com) bidding platform under the solicitation for this project. Please sign below and return a copy of this Addendum with your submittal for the above referenced solicitation. (Signature) Allegiance Benefit Plan Management, Inc. (Name of Firm) 4/27/2022 Date DocuSign Envelope ID: 8C23C9CC-BD96-4691-A25C-99D6F6845A9F INSURANCE AND BONDING REQUIREMENTS Insurance / Bond Type Required Limits 1. ® Worker's Compensation Statutory Limits of Florida Statutes, Chapter 440 and all Federal Government Statutory Limits and Requirements Evidence of Workers' Compensation coverage or a Certificate of Exemption issued by the State of Florida is required. Entities that are formed as Sole Proprietorships shall not be required to provide a proof of exemption. An application for exemption can be obtained online at hLtps://oj2s.fldfs.com/bocexempt/ 2. ® Employer's Liability $_1,000,000_ single limit per occurrence 3. ® Commercial General Bodily Injury and Property Damage Liability (Occurrence Form) patterned after the current $_1,000,000_single limit per occurrence, $2,000,000 aggregate for Bodily Injury ISO form Liability and Property Damage Liability. This shall include Premises and Operations; Independent Contractors; Products and Completed Operations and Contractual Liability. 4. ® Indemnification To the maximum extent permitted by Florida law, the ContractorNendor shall defend, indemnify and hold harmless Collier County, its officers and employees from any and all liabilities, damages, losses and costs, including, but not limited to, reasonable attorneys' fees and paralegals' fees, to the extent caused by the negligence, recklessness, or intentionally wrongful conduct of the Contractor/ Vendor or anyone employed or utilized by the ContractorNendor in the performance of this Agreement. 5. ® Automobile Liability $_1,000,000_ Each Occurrence; Bodily Injury & Property Damage, Owned/Non-owned/Hired; Automobile Included 6. ® Other insurance as noted: ❑ Watercraft $ Per Occurrence ❑ United States Longshoreman's and Harborworker's Act coverage shall be maintained where applicable to the completion of the work. $ Per Occurrence ❑ Maritime Coverage (Jones Act) shall be maintained where applicable to the completion of the work. $ Per Occurrence ❑ Aircraft Liability coverage shall be carried in limits of not less than $5,000,000 each occurrence if applicable to the completion of the Services under this Agreement. $ Per Occurrence ❑ Pollution $ Per Occurrence ® Professional Liability $ _1,000,000_ Per claim & in the aggregate ❑ Project Professional Liability $ Per Occurrence ❑ Valuable Papers Insurance $ Per Occurrence ® Cyber Liability $ 1,000,000 Per Occurrence ❑ Technology Errors & Omissions $ Per Occurrence 7. ❑ Bid bond Shall be submitted with proposal response in the form of certified funds, cashiers' check or an irrevocable letter of credit, a cash bond posted with the County Clerk, or proposal bond in a sum equal to 5% of the cost proposal. All checks shall be made payable to the Collier County Board of County Commissioners on a bank or trust company located in the State of Florida and insured by the Federal Deposit Insurance Corporation. DocuSign Envelope ID: 8C23C9CC-BD96-4691-A25C-99D6F6845A9F 8. ❑ Performance and Payment For projects in excess of $200,000, bonds shall be submitted with the executed Bonds contract by Proposers receiving award, and written for 100% of the Contract award amount, the cost borne by the Proposer receiving an award. The Performance and Payment Bonds shall be underwritten by a surety authorized to do business in the State of Florida and otherwise acceptable to Owner; provided, however, the surety shall be rated as "A-" or better as to general policy holders rating and Class V or higher rating as to financial size category and the amount required shall not exceed 5% of the reported policy holders' surplus, all as reported in the most current Best Key Rating Guide, published by A.M. Best Company, Inc. of 75 Fulton Street, New York, New York 10038. 9. ® Vendor shall ensure that all subcontractors comply with the same insurance requirements that he is required to meet. The same Vendor shall provide County with certificates of insurance meeting the required insurance provisions. 10. ® Collier County must be named as "ADDITIONAL INSURED" on the Insurance Certificate for Commercial General Liability where required. This insurance shall be primary and non-contributory with respect to any other insurance maintained by, or available for the benefit of, the Additional Insured and the Vendor's policy shall be endorsed accordingly. 11. ® The Certificate Holder shall be named as Collier County Board of County Commissioners, OR, Board of County Commissioners in Collier County, OR Collier County Government, OR Collier County. The Certificates of Insurance must state the Contract Number, or Project Number, or specific Project description, or must read: For any and all work performed on behalf of Collier County. 12. ® On all certificates, the Certificate Holder must read: Collier County Board of County Commissioners, 3295 Tamiami Trail East, Naples, FL 34112 13. ® Thirty (30) Days Cancellation Notice required. 14. Collier County shall procure and maintain Builders Risk Insurance on all construction projects where it is deemed necessary. Such coverage shall be endorsed to cover the interests of Collier County as well as the Contractor. Premiums shall be billed to the project and the Contractor shall not include Builders Risk premiums in its project proposal or project billings. All questions regarding Builder's Risk Insurance will be addressed by the Collier County Risk Management Division. GG — 3/15/22 Vendor's Insurance Statement We understand the insurance requirements of these specifications and that the evidence of insurability may be required within five (5) days of the award of this solicitation. The insurance submitted must provide coverage for a minimum of six (6) months from the date of award. Allegiance Benefit Plan Management, Inc. 4/27/2022 Name of Firm 9 9 Date Vendor Signature Print Name Insurance Agency Agent Name Stephen A. Tahta Insurance specifics can be provided upon contract award per the RFP. Telephone Number HN Collier County Administrative Services Department Procurement Services Division Form 5 Reference Questionnaire (USE ONE FORM FOR EACH REQUIRED REFERENCE) Solicitation: 22-7977 Reference Questionnaire for: Allegiance Benefit Plan Management (Name of Company Requesting Reference Information) Jake Whitecar (Name of Individuals Requesting Reference Information) Name: Rachael Morris (Evaluator completing reference questionnaire) Email: com Company: Integrated Supply Network (Evaluator's Company completing reference) FAX: 863.616.5406 Telephone: 863.603.0777 xt 1217 Collier County has implemented a process that collects reference information on firms and their key personnel to be used in the selection of firms to perform this project. The Name of the Company listed in the Subject above has listed you as a client for which they have previously performed work. Please complete the survey. Please rate each criteria to the best of your knowledge on a scale of 1 to 10, with 10 representing that you were very satisifed (and would hire the firm/individual again) and 1 representing that you were very unsatisfied (and would never hire the firm/indivdival again). If you do not have sufficient knowledge of past performance in a particular area, leave it blank and the item or form will be scored "0." Project Description: Project Budget: Completion Date: Project Number of Days: Item Criteria Score (must be completed) 1 Ability to manage the project costs (minimize change orders to scope). 8 2 Ability to maintain project schedule (complete on -time or early). 8 3 Quality of work. 9 4 Quality of consultative advice provided on the project. 9 5 Professionalism and ability to manage personnel. 10 6 Project administration (completed documents, final invoice, final product turnover; invoices; manuals or going forward documentation, etc.) 9 7 Ability to verbally communicate and document information clearly and succinctly. 10 8 Abiltity to manage risks and unexpected project circumstances. 10 9 Ability to follow contract documents, policies, procedures, rules, regulations, etc. 8 10 Overall comfort level with hiring the company in the future (customer satisfaction). 9 TOTAL SCORE OF ALL ITEMS 90 MN Collier County Administrative Services Department Procurement Services Division Form 5 Reference Questionnaire (USE ONE FORM FOR EACH REQUIRED REFERENCE) Solicitation: 22-7977 Reference Questionnaire for: Allegiance Benefit Plan Management (Name of Company Requesting Reference Information) Jake Whitecar (Name of Individuals Requesting Reference Information) Name:Julie Neubig Company:SIH (Evaluator completing reference questionnaire) (Evaluator's Company completing reference) Email: julie.neubig@sih.net FAX: 618-529-0574 Telephone: 618-457-5200 ext. 67807 Collier County has implemented a process that collects reference information on firms and their key personnel to be used in the selection of firms to perform this project. The Name of the Company listed in the Subject above has listed you as a client for which they have previously performed work. Please complete the survey. Please rate each criteria to the best of your knowledge on a scale of 1 to 10, with 10 representing that you were very satisifed (and would hire the firm/individual again) and 1 representing that you were very unsatisfied (and would never hire the firm/indivdival again). If you do not have sufficient knowledge of past performance in a particular area, leave it blank and the item or form will be scored "0." Project Description: Project Budget: Completion Date: Project Number of Days: Item Criteria Score (must be completed) 1 Ability to manage the project costs (minimize change orders to scope). 10 2 Ability to maintain project schedule (complete on -time or early). 10 3 Quality of work. 10 4 Quality of consultative advice provided on the project. 10 5 Professionalism and ability to manage personnel. 10 6 Project administration (completed documents, final invoice, final product turnover; invoices; manuals or going forward documentation, etc.) 10 7 Ability to verbally communicate and document information clearly and succinctly. 10 8 Abiltity to manage risks and unexpected project circumstances. 10 9 Ability to follow contract documents, policies, procedures, rules, regulations, etc. 10 10 Overall comfort level with hiring the company in the future (customer satisfaction). 10 TOTAL SCORE OF ALL ITEMS 100 HN Collier County Administrative Services Department Procurement Services Division Form 5 Reference Questionnaire (USE ONE FORM FOR EACH REQUIRED REFERENCE) Solicitation: 22-7977 Reference Questionnaire for: Allegiance Benefit Plan Management (Name of Company Requesting Reference Information) Jake Whitecar (Name of Individuals Requesting Reference Information) Name: Mary Lee Williams Company: City of Bristol Tennessee (Evaluator completing reference questionnaire) (Evaluator's Company completing reference) Email: mlwilliams@bristoltn.org FAX: 423-968-7197 Telephone: 423-989-5525 Collier County has implemented a process that collects reference information on firms and their key personnel to be used in the selection of firms to perform this project. The Name of the Company listed in the Subject above has listed you as a client for which they have previously performed work. Please complete the survey. Please rate each criteria to the best of your knowledge on a scale of 1 to 10, with 10 representing that you were very satisifed (and would hire the firm/individual again) and 1 representing that you were very unsatisfied (and would never hire the firm/indivdival again). If you do not have sufficient knowledge of past performance in a particular area, leave it blank and the item or form will be scored "0." Project Description: Services Project Budget: Third Party Administrator Completion Date Current Project Number of Days: 3 years/36 months Item Criteria Score must be completed) 1 Ability to manage the project costs (minimize change orders to scope). 10 2 Ability to maintain project schedule (complete on -time or early). 10 3 Quality of work. 10 4 Quality of consultative advice provided on the project. 10 5 Professionalism and ability to manage personnel. 10 6 Project administration (completed documents, final invoice, final product turnover; invoices; manuals or going forward documentation, etc.) 10 7 Ability to verbally communicate and document information clearly and succinctly. 10 8 Abiltity to manage risks and unexpected project circumstances. 10 9 Ability to follow contract documents, policies, procedures, rules, regulations, etc. 10 10 Overall comfort level with hiring the company in the future (customer satisfaction). 10 TOTAL SCORE OF ALL ITEMS 100 collier county Administrative Services Department Procurement Services Division Form 5 Reference Questionnaire (USE ONE FORM FOR EACH REQUIRED REFERENCE Solicitation: 22-7977 Reference Questionnaire for: Allegiance Benefit Plan Management (Name of Company Requesting Reference Information) Jake Whitecar (Name of Individuals Requesting Reference Information) Name: Tammye Vaughn Company: Humble ISD (Evaluator completing reference questionnaire) (Evaluator's Company completing reference) Email: FAX: 281-446-2312 Telephone: 281-641-8042 Collier County has implemented a process that collects reference information on firms and their key personnel to be used in the selection of firms to perform this project. The Name of the Company listed in the Subject above has listed you as a client for which they have previously performed work. Please complete the survey. Please rate each criteria to the best of your knowledge on a scale of 1 to 10, with 10 representing that you were very satisfied (and would hire the firm/individual again) and 1 representing that you were very unsatisfied (and would never hire the firm/individual again). If you do not have sufficient knowledge of past performance in a particular area, leave it blank and the item or form will be scored "0." Project Description: Project Budget: Completion Date: Project Number of Days: Item Criteria Score must be completed) 1 Ability to manage the project costs (minimize change orders to scope). BROKER MANAGES PROJECT COST. 2 Ability to maintain project schedule (complete on -time or early). 10 3 Quality of work. 10 4 Quality of consultative advice provided on the project. 10 5 Professionalism and ability to manage personnel. 10 6 Project administration (completed documents, final invoice, final product turnover; invoices; manuals or going forward documentation, etc.) STILL ACTIVE WITH TPA. 7 Ability to verbally communicate and document information clearly and succinctly. 10 8 Ability to manage risks and unexpected project circumstances. 10 9 Ability to follow contract documents, policies, procedures, rules, regulations, etc. 10 10 Overall comfort level with hiring the company in the future (customer satisfaction). 10 TOTAL SCORE OF ALL ITEMS 80 MN Collier County Administrative Services Department Procurement Services Division Form 5 Reference Questionnaire (USE ONE FORM FOR EACH REQUIRED REFERENCE) Solicitation: 22-7977 Reference Questionnaire for: Allegiance Benefit Plan Management (Name of Company Requesting Reference Information) Jake Whitecar (Name of Individuals Requesting Reference Information) Name:Lorie Darrah Company:NCH Healthcare System (Evaluator completing reference questionnaire) (Evaluator's Company completing reference) Email: lorie.darrah@nchmd.org FAX: 239-624-4501 Telephone: 239-624-5945 Collier County has implemented a process that collects reference information on firms and their key personnel to be used in the selection of firms to perform this project. The Name of the Company listed in the Subject above has listed you as a client for which they have previously performed work. Please complete the survey. Please rate each criteria to the best of your knowledge on a scale of 1 to 10, with 10 representing that you were very satisifed (and would hire the firm/individual again) and 1 representing that you were very unsatisfied (and would never hire the firm/indivdival again). If you do not have sufficient knowledge of past performance in a particular area, leave it blank and the item or form will be scored "0." Project Description: Project Budget: Completion Date: Project Number of Days: Item Criteria Score (must be completed) 1 Ability to manage the project costs (minimize change orders to scope). 10 2 Ability to maintain project schedule (complete on -time or early). 10 3 Quality of work. 10 4 Quality of consultative advice provided on the project. 10 5 Professionalism and ability to manage personnel. 10 6 Project administration (completed documents, final invoice, final product turnover; invoices; manuals or going forward documentation, etc.) 10 7 Ability to verbally communicate and document information clearly and succinctly. 10 8 Abiltity to manage risks and unexpected project circumstances. 10 9 Ability to follow contract documents, policies, procedures, rules, regulations, etc. 10 10 Overall comfort level with hiring the company in the future (customer satisfaction). 10 TOTAL SCORE OF ALL ITEMS 100 6/13/22, 11:46 AM Detail by Entity Name DIVISION OF CORPORATIONS rill (1Jflr/u[ - 'wie Uj'I [urlr r wb-'if? Department of State / Division of Corporations / Search Records / Search by Entity Name / Detail by Entity Name Foreign Profit Corporation ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. Filing Information Document Number F11000002516 FEI/EIN Number 81-0400550 Date Filed 06/16/2011 State MT Status ACTIVE Principal Address 2806 S GARFIELD ST MISSOULA, MT 59801 Mailing Address 2806 S GARFIELD ST MISSOULA, MT 59801 Registered Agent Name & Address C T CORPORATION SYSTEM 1200 SOUTH PINE ISLAND ROAD PLANTATION, FL 33324 Officer/Director Detail Name & Address Title CEO, Chairman VISSER, DIRK C 2806 S GARFIELD ST MISSOULA, MT 59801 Title Director JAMESON, WILLIAM S 400 N BRAND BLVD GLENDALE, CA 91203 Title President TAHTA, STEPHEN A https://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=EntityName&directionType=ForwardList&searchNameOrder=ALL... 1 /3 6/13/22, 11:46 AM 2806 S GARFIELD ST MISSOULA, MT 59801 Detail by Entity Name Title VP, CFO DANIELS, RICHARD K 2806 S GARFIELD ST MISSOULA, MT 59801 Title Secretary STADELMAN, JILL 1601 CHESTNUT ST TL71-0 PHILADELPHIA, PA 19192 Title Director DeRosa, Christopher 26 Executive Park Irvine, CA 92614 Title Director TUTWILER, JESSICA 900 Cottage Grove Rd. Wilde Bloomfield, CT 06002 Title Director NOVACK, RICHARD 3500 PIEDMONT RD N.E. SUITE 200 ATLANTA, GA 30305 Annual Reports Report Year Filed Date 2020 03/25/2020 2021 03/26/2021 2022 04/01 /2022 Document Images 04/01/2022 -- ANNUAL REPORT View image in PDF format 03/26/2021 -- ANNUAL REPORT View image in PDF format 03/25/2020 -- ANNUAL REPORT View image in PDF format 04/01/2019 -- ANNUAL REPORT View image in PDF format 03/26/2018 -- ANNUAL REPORT View image in PDF format 03/15/2017 -- ANNUAL REPORT View image in PDF format 02/03/2016 -- ANNUAL REPORT View image in PDF format 03/24/2015 -- ANNUAL REPORT View image in PDF format https://search.sunbiz.org/Inquiry/CorporationSearch/Search ResultDetai I?inqu irytype=EntityName&di rectionType=Forward List&searchNameOrder=ALL... 2/3 6/13/22, 11:46 AM 03/19/2014 -- ANNUAL REPORT View image in PDF format Detail by Entity Name 01/24/2013 --ANNUAL REPORT View image in PDF format 01/10/2012 -- ANNUAL REPORT View image in PDF format 06/16/2011 -- Foreign Profit View image in PDF format Florida Department of State, Division of Corporations https://search.sunbiz.org/Inquiry/CorporationSearch/Search ResultDetai I?inqu irytype=EntityName&di rectionType=Forward List&searchNameOrder=ALL... 3/3 ADMINISTRATIVE SERVICES AGREEMENT THIS Administrative Services Agreement (hereinafter "Agreement'), effective for the period beginning ### and ending ###, and continuing thereafter for additional twelve (12) month periods as provided by this Agreement, is entered into by ###, a legal entity, duly organized and existing under the laws of the State of ### (hereinafter referred to as the "Plan Sponsor"), and ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC., a corporation duly organized and existing under the laws of the State of Montana (hereinafter referred to as the "TPA"). WHEREAS, the Plan Sponsor sponsors a self -funded employee welfare benefit plan (the "Plan"); WHEREAS, the Plan Sponsor desires to make available a program of health care benefits under the Plan; WHEREAS, the Plan Sponsor wishes to contract with an independent third party administrator to perform certain administrative services with respect to the Plan as described herein; WHEREAS, the TPA desires to contract with the Plan Sponsor to perform certain administrative services with respect to the Plan as described herein; and THEREFORE, in consideration of the promises and mutual covenants contained herein, the Plan Sponsor and the TPA enter into this Agreement for administrative services for the Plan. ARTICLE I: DEFINITIONS Health Care Provider or the Covered Person, void of any omissions of pertinent information, coordination of For the purposes of this Agreement, the following words and benefits or liability issues, in a form satisfactory to TPA phrases have the meanings set forth below, unless the context and with sufficient documentation to substantiate the clearly indicates otherwise and, wherever appropriate, the singular claim for benefits under the Plan that is necessary or shall include the plural and the plural shall include the singular. required according to industry standards or requirements in order for the TPA to make a determination of benefits 1.1 "Claim" means each bill, invoice, claim form or other under the Plan. document representing a request for payment for medical, dental or vision services, which is received by 1.7 "Covered Person" is a person who is properly enrolled the TPA. Each such document will be considered to be and entitled to benefits from the Plan. one "claim", regardless of the number of itemized lines on the document and regardless of whether the document is 1.8 "Covered Services" means the care, treatments, services a duplicate of previous documents or whether the or supplies described in the Plan Document as eligible for services indicated on the document are eligible for payment or reimbursement from the Plan. coverage under the applicable Plan. 1.9 "Employer' means the Plan Sponsor and any successor 1.2 "Claimant' means a Covered Person or entity on behalf organization or affiliate of such Employer which assumes of a Covered Person, submitting expenses for payment the obligations of the Plan and this Agreement. or reimbursement from the Plan. 1.10 "ERISK means the Employee Retirement Income 1.3 "Claims Payment Account' means an account utilized by Security Act of 1974, as amended, together with all the Plan Sponsor for payment or reimbursement for regulations applicable thereto. Covered Services, which account balances shall constitute assets of the Plan Sponsor and not the Plan. 1.11 "Fee Schedule" means the listing of fees or charges for services provided under this Agreement. This Fee 1.4 "COBRA" means the Consolidated Omnibus Budget Schedule may be modified from time to time in writing by Reconciliation Act of 1985 or the Public Health Service the mutual agreement of the parties. The Fee Schedule Act, as amended, together with all regulations applicable is contained in Appendix A and is a part of this thereto. Agreement. 1.5 "COBRA Participant' means any person who is properly 1.12 "Health Care Providers" means physicians, dentists, enrolled for and entitled to benefits from the Plan policy, hospitals, or other health care practitioners or health care pursuant to COBRA continuation coverage. facilities that are duly licensed and authorized to receive payment or reimbursement for Covered Services in 1.6 "Complete Claim" means a claim for benefits for a accordance with the terms of the Plan. Covered Person that has been submitted by a licensed MEDICAL ASA - ERISA Page 1 of 14 MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. REV.05-2019 1.13 "HIPAK means the Health Insurance Portability and Accountability Act of 1996, as amended, together with all applicable regulations thereto. 1.14 "Paid Claims" means claims for benefits under the Plan which have been processed for payment by the TPA, have been funded in U.S. Dollars by the Plan or the Plan Sponsor, and for which payment or electronic payment has been issued and transmitted to the Claimant or assignee. 1.15 "Plan" means the self -funded health and welfare benefit plan which is the subject of this Agreement and which the Plan Sponsor has established pursuant to the Plan Document. 1.16 "Plan Administrator" means the person or entity, including an insurance company, designated by the Plan Sponsor to manage the Plan and make all discretionary decisions regarding Plan terms and managing Plan assets. 1.17 "Plan Document" means the instrument or instruments that set forth and govern the duties of the Plan Sponsor and eligibility and benefit provisions of the Plan, which provide for the payment or reimbursement of Covered Services. 1.18 "Plan Participant" is any employee, retiree or COBRA beneficiary who is properly enrolled and eligible for benefits under the Plan. 1.19 "Plan Year" means the twelve-month period of time beginning with the effective date of the Plan as specified in the Plan Document. 1.20 "Qualified Beneficiary" means a Covered Person under the Plan Sponsor's Plan, who is eligible to continue coverage under the Plan policy in accordance with the applicable provisions of Title X of COBRA or §609(a) of ERISA regarding Qualified Medical Child Support Orders, or in accordance with any similar applicable state law. Qualified Beneficiary also means a child born to, adopted (b) With respect to covered Dependents 1. Death of the covered Participant; 2. Termination of the covered Participant's employment; 3. Reduction in hours of the covered Participant's employment causing the Participant to become ineligible for coverage; 4. The divorce or legal separation of the covered Participant from his or her spouse; 5. The covered Participant's entitlement to Medicare; or 6. A covered Dependent child ceases to be a Dependent as defined by the Plan. (c) Qualifying Events for retired Participants, for purposes of this section, are: 1. Bankruptcy, if the covered Participant retired on or before the date of any substantial elimination of group health coverage due to bankruptcy. (d) Qualifying Events for the Dependents of retired covered Participants, for purposes of this section, are: 1. Bankruptcy, if the Dependent was a covered Dependent of a covered retiree on or before the day before the bankruptcy Qualifying Event. 1.22 "Stop Loss or Excess Loss Insurance" means an insurance policy obtained by the Plan or the Plan Sponsor to provide coverage for individual claims at a specified stop loss limit and/or group claims at an aggregate stop loss limit that are incurred and paid during a defined period of time by the insurance policy. 1.23 "Summary Plan Description" means the document that describes the terms and conditions under which the Plan operates. or placed for adoption with a Participant or former 1.24 "Utilization Management" means the evaluation of Participant, who is a COBRA participant, at any time medical necessity and appropriateness of the use of during active COBRA continuation coverage of that health care services, procedures, and facilities utilized by Participant or former Participant. a Covered Person under the terms of the Plan. 1.21 "Qualifying Event" means: (a) With respect to an eligible Participant: 1. The termination (other than by reason of gross misconduct) of the covered Participant's employment; or 2. The reduction in hours of the covered Participant's employment causing the Participant to become ineligible for coverage. 1.25 "Working Days" shall mean a regular business day, which is not a recognized federal or banking holiday, and specifically excluding any Saturday or Sunday. ARTICLE II: RELATIONSHIP OF THE PARTIES 2.1 The Plan Sponsor acknowledges that the TPA is an independent contractor for purposes of this Agreement. As such, the TPA is not an agent or employee of the Plan Sponsor and does not assume any liability or responsibility for any breach of duty or act of omission by MEDICAL ASA - ERISA Page 2 of 14 MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. REV.05-2019 the Plan Sponsor. The Plan Sponsor delegates to the 2.6 The Plan Sponsor acknowledges and agrees that the TPA only non -discretionary authority with respect to TPA will not be deemed to be a legal or tax advisor for assisting Plan Sponsor in the development, maintenance the Plan or the Plan Sponsor as a result of the and administration of the Plan as specifically described in performance of its duties under this Agreement. The TPA this Agreement. Any function not specifically delegated makes no representation to the Plan Sponsor concerning by Plan Sponsor to, and agreed to be assumed by the federal, state, or local laws, rules or regulations TPA in writing pursuant to this Agreement shall remain applicable to the Plan. Company must seek its own the sole responsibility of the Plan Sponsor. The Plan counsel for legal advice and guidance. In no event shall Sponsor shall retain all discretionary authority, control the TPA be liable for special or consequential and responsibility for the operation and administration of damages, even if the TPA was advised of the the Plan. possibility of such damages. 2.2 The parties acknowledge that: 2.7 The TPA may secure the services of actuaries, computer software companies, computer service firms, insurance (a) This is a contract for administrative services consultants and producers, legal counsel, accountants, only as specifically set forth herein; utilization management consultants, pharmacy benefit (b) The TPA shall not be obligated to disburse more management companies, preferred provider in payment for Claims or other obligations organizations, claims negotiation companies, arising under the Plan than the Plan Sponsor subrogation firms, and any other entities that it deems shall have made available in the Claims necessary in the performance of its obligations under this Payment Account; Agreement. At the discretion of the TPA, such services (c) This Agreement shall not be deemed a contract may be performed directly by the TPA, wholly or in part, of insurance under any laws or regulations. The through a subsidiary or affiliate of the TPA or under an TPA does not insure, guarantee or underwrite agreement with an organization, agent, advisor or other the liability of the Plan Sponsor under the Plan. person of its choosing. Any such services resulting in a The TPA has no responsibility and the Plan fee not agreed to in the Fee Schedule, Appendix A, must Sponsor has total responsibility for payment of first be authorized in writing by the Plan Sponsor. Claims under the Plan and all expenses incidental to the Plan; and 2.8 The TPA agrees to be duly licensed as a Third Party (d) The TPA is not the plan administrator, plan Administrator to the extent required under applicable law sponsor or plan fiduciary and the Plan Sponsor and agrees to maintain such licensure throughout the will not identify the TPA or any of its affiliates as term of this Agreement. such. The Plan Sponsor acknowledges and agrees that it is the plan sponsor, plan 2.9 The TPA will possess through the term of this Agreement administrator and named fiduciary as such an in -force fidelity bond or other insurance as may be terms are defined by ERISA. required by state and federal laws for the protection of its clients. Additionally, the TPA agrees to comply with any 2.3 Except as specifically set forth herein, this Agreement state or federal statutes or regulations regarding its shall inure to the benefit of and be binding upon the operations. parties hereto and their respective legal successors provided, however, that neither party may assign this 2.10 The TPA shall be entitled to rely upon, without Agreement without the prior written consent of the other, investigation or inquiry, any written or oral information or which consent shall not be unreasonably withheld. communication of the Plan Sponsor or agents, including but not limited to consultants, actuaries, attorneys, 2.4 Any controversy or claim arising out of or relating to this accountants, auditors, managed care organizations, Agreement, or the breach thereof, shall be settled by preferred provider organizations, pharmacy benefit arbitration administered by the American Arbitration management companies, mental health care Association in accordance with its Commercial Arbitration management companies or brokers retained by the Plan Rules, unless otherwise stated in this provision, and Sponsor. judgment upon the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. The 2.11 The TPA will indemnify, defend, save and hold the Plan locale for arbitration under this provision shall be Sponsor harmless from and against any and all claims, Missoula, MT, unless otherwise agreed by the parties. suits, liabilities, losses, penalties or damages including court costs and attorneys' fees with respect to the Plan 2.5 It is agreed by the parties to this Agreement that any which directly result from or arise out of the dishonest, cause of action brought by either party to this contract fraudulent, grossly negligent or criminal acts of the TPA must be made within two (2) years of the date of or its employees, except for any acts taken at the specific occurrence of any alleged breach, infraction or dispute, direction of the Plan Sponsor. or within two (2) years of the termination date of this Agreement, whichever occurs first. MEDICAL ASA - ERISA Page 3 of 14 MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. REV.05-2019 2.12 The Plan Sponsor will indemnify, defend, save and hold the TPA harmless from and against any and all claims, suits, actions, liabilities, losses, penalties or damages, including court costs and attorneys' fees to the extent that such claims, losses, liabilities, damages and expenses arise out of or are based upon the gross negligence, fraudulent, criminal or dishonest acts of the Plan Sponsor, its agents or employees, in the performance of their duties, a release of Claims data by the TPA to the Plan Sponsor, or an interpretation of the Plan by the Plan Sponsor on which the TPA acts. The Plan Sponsor will further indemnify and hold the TPA harmless for any attorneys' fees, costs fine civil penalties or any other damages of any kind whatsoever in the event that TPA has advised the Plan Sponsor that any act or omission of the Plan Sponsor may be non -compliant or a violation of any known law or regulation, and the Plan Sponsor continues with such act or omission contrary to TPA's advice and such act or omission results in any attorneys' fees, costs fine civil penalties or any other damages of any kind being assessed to or incurred by TPA. ARTICLE III: THE TPA'S RESPONSIBILITIES The TPA will provide the following Plan Administrative services for the Plan Sponsor: 3.1 Maintain Plan records based on eligibility information submitted by the Plan Sponsor as to the dates on which a Covered Person's coverage commences and terminates. Maintain Plan records of Plan coverage applicable to each Covered Person based on information submitted by the Plan Sponsor. Maintain Plan records regarding payment of Claims, denial of Claims, and Claims pended. 3.2 Administer enrollment of Covered Persons, create and distribute enrollment forms and answer inquiries, create and maintain enrollment records for Covered Persons, and distribute identification cards to the Plan Sponsor in accordance with Appendix A, the Fee Schedule. 3.3 Process Complete Claims submitted by Covered Persons or Health Care Providers according to the terms of the Plan Document as construed by the Plan Sponsor. These Claims will be processed in accordance with prevailing industry practices and the TPA will use an industry -recognized method of determining usual, customary, and reasonable charges or the prevailing fee allowance as determined by the Plan Sponsor in the Plan. The TPA will not be required by the Plan Sponsor to alter its standard claims processes, procedures or regular mail dates to manipulate the Paid Claims date for any purpose. The TPA will process claims received on a basis consistent with prevailing industry practice for timeliness and accuracy, in accordance with the terms of the Plan Document as construed by the Plan Sponsor, and consistent medical information forms, pre-existing conditions requirements, disability determinations and coordination of benefits situations. Unless specifically agreed by the parties in writing, the TPA's duties with respect to subrogation situations shall be limited to informing the Plan Sponsor that subrogation rights may exist. The terms, conditions and fees for any additional agreement regarding subrogation are as stated in the attached Subrogation and Reimbursement Services Appendix, if applicable. The TPA will process Claims or request additional information in order to be able to process a Complete Claim within an average of fourteen (14) Working Days from the date the Complete Claim is received by the TPA. If additional information is needed for a Complete Claim, the TPA will send through the U.S. Mail to the appropriate persons (with a copy to the Plan Participant) a follow-up request for the required information for a Complete Claim requesting a response to the request for additional information for a Complete Claim within a maximum of forty-five (45) days. The follow-up request will indicate that no additional requests for information will be sent and the file will be closed, and the initial incomplete claim will be denied, if the requested information is not provided within the specified time. When all necessary documents and Claim information have been received to constitute a Complete Claim and the Complete Claim has been approved, a Claim check or draft will be remitted on the next Paid Claims batch disbursal date provided that the Plan Sponsor has provided funds for such Complete Claims or advance funding has been provided by the Stop Loss or Excess Loss insurance company. All Complete Claims will remain in a processed but pended status until funded by the Plan Sponsor or its Stop Loss or Excess Loss insurance company. The Plan Sponsor must provide funding of all Complete Claims within five (5) Working Days of receipt of request for funding from the TPA. Customer Service Representatives of the TPA will inform any Plan Participant or Health Care Provider who inquires about any Claim which is pended for lack of funds that such Claim has been received and processed and is pending receipt of funds. No further explanation will be required of the TPA by the Plan Sponsor under such circumstances. Unless otherwise advised by the Plan Sponsor, the Plan Sponsor agrees that the order of claims payment by TPA of new claims submitted under the Plan shall be based on processing first the oldest claims with complete medical, repricing/discount, and other necessary information with permitted exceptions for those claims identified with excess loss insurance reimbursement MEDICAL ASA - ERISA Page 4 of 14 MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. REV.05-2019 potential or which face loss of any available discounts for the medical services so rendered. Any payment by TPA is contingent upon the availability of adequate funding by the Plan Sponsor. If the funds provided by the Plan Sponsor are insufficient to pay all adjudicated claims, then, at the specific direction of Plan Sponsor, the funds will be applied to pay claims as noted above to the extent funds are available except that large claims that cannot be funded by the then available funding will be skipped in favor of more recent claims that can be covered with then available funding. Further, all claims for a participant and his or her covered dependents subsequent to the first claim that cannot be funded due to insufficient funding from the Plan Sponsor shall be skipped in favor of more recent claims from other participants and/or their dependents if the Plan Sponsor funding is not sufficient to cover all adjudicated claims for the participant and/or his or her dependent. 3.4 After a preliminary review to determine that the Claim was correctly processed, the TPA will refer any doubtful, disputed or appealed Claims to the Plan Sponsor for a final decision. The TPA will provide initial claims adjudication and assist the Plan Administrator with appeals. The Plan will pay the actual cost of any expert medical consultation required to determine claims eligibility under the Plan as a claims cost. 3.6 Notify Covered Persons in writing through the U.S. Mail of ineligible Claims received. The computerized Explanation of Benefits form (EOB) shall indicate the general reason why such Claim is ineligible for payment. The EOB shall also contain notice of the written Claims review and appeal procedure in the Plan. This notification will be made within an average of fourteen (14) Working Days of the date the TPA receives the Complete Claim documentation and any Plan interpretations by the Plan Sponsor. 3.7 Respond to Claims inquiries by a Covered Person, the estate of a Covered Person, an authorized member of a Covered Person's family unit, the Covered Person's authorized legal representative or an authorized Health Care Provider. 3.8 Maintain local telephone service and toll -free telephone lines during regular business hours for inquiries made by Covered Persons regarding the status of their Claims. Such telephone lines may be recorded by the TPA. 3.9 Maintain an Internet Inquiry site for Paid Claims, processed claims and related information. Maintain an interactive voice response system and fax back service for the convenience of Covered Persons and Health Care Providers for Claim or coverage inquiries. 3.5 Process, issue and distribute Claims checks, drafts or 3.10 electronic funds transfers, as instructed by the Plan Sponsor to Plan Participants, Health Care Providers, or others as may be applicable. Every week the TPA will notify the Plan Sponsor of the Claims batch amount required to be prospectively deposited to the Claims Payment Account to pay the Claims liability after these Claims are processed for payment. The TPA shall establish and maintain customary investigative benefit and Claims review procedures within the prevailing standard of care in the TPA industry. The TPA shall take reasonable measures and precautions to prevent the allowance and payment of improper benefits and Claims. The TPA shall not be liable for fraud by any Health Care Provider or Covered Person or for errors in Claim payment made to Covered Persons or designated assignees in good faith. The TPA shall not be liable for any loss of discount or increase in charges arising from a Claim due to a delay in the payment of a Claim. If a Claim payment error is discovered, the Health Care Provider or Covered Person will be notified and requested to refund payment. In the event that the Covered Person or his/her assignee does not respond to the refund request or refuses payment, the Plan Sponsor will be notified. The Plan Sponsor shall have the right to bring action against any employee or provider of service who does not voluntarily agree to repay the Plan for payments made in error. The TPA shall not be liable for misrepresentations, inflated charges, omissions, errors or fraud by any Health Care Provider or Covered Person which may result in any ineligible or excessive Claim payments. Maintain information that identifies a Covered Person in a confidential manner. The TPA agrees to take all reasonable precautions to prevent disclosure or use of Claims information for a purpose unrelated to the administration of the Plan. TPA shall not be liable for fraud, deceit, misrepresentation or any other false, misleading or erroneous representations made by the Plan Sponsor, any Covered Person, any Health Care Provider or any other person pertaining to any confidential, personal or protected health information or claim request. The TPA will only release non -protected health or Claims information for certificate of need reviews; for medical necessity determinations; to set uniform data standards; to update relative values scales; to use in claims analysis; to further cost containment programs; to verify eligibility; to comply with federal, state or local laws; for coordination of benefits; for subrogation; in response to a civil or criminal action upon issuance of a subpoena, or with the written consent of the Covered Person or his or her legal representative. 3.11 Provide and maintain a specimen Plan Document and Summary Plan Description in a format acceptable to the TPA for review and final approval by the Plan Sponsor and the Plan Sponsor's legal counsel. Upon approval of the Plan Document from the Plan Sponsor, the TPA will forward copies of plan document and amendments, if any, to the Stop Loss or Excess Loss insurance company. The TPA will furnish a master Summary Plan Description to the Plan Sponsor, either electronically (PDF format), or in printed form, and Summary Plan Description booklets in TPA's format for the fees stated in Appendix A. MEDICAL ASA - ERISA Page 5 of 14 MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. REV.05-2019 The TPA will maintain an electronic Claims file on every Claim reported to it by the Covered Persons. The TPA shall retain such files and all Plan -related information for a period of six (6) years. Copies of such records shall be made available to the Plan Sponsor for inspection during a regularly scheduled Working Day at the office of the TPA for consultation, review and audit upon advance notice of a minimum of fourteen (14) Working Days. The Plan Sponsor shall pay for any audit made at its request. In the event this Agreement is terminated, the Plan Sponsor shall have a continuing obligation and liability to pay the TPA for all costs and professional, executive, managerial and clerical time expended by the TPA and its employees for any audit conducted by the Plan Sponsor or its Stop Loss or Excess Loss insurance company, and this obligation and liability shall survive and continue beyond the termination of this Agreement. The Plan Sponsor shall pay an advance retainer to the TPA for any audit assistance at any time the TPA receives notice from the Plan Sponsor or its Stop Loss or Excess Loss insurance company of an audit to be conducted after the termination date of this Agreement. The advance retainer shall be in an amount to be determined by the TPA in estimation of the extra time required for the scope of the audit that is requested. In no event shall the audit retainer fee be less than Two Thousand Five Hundred and no/100 Dollars ($2,500.00). The TPA will not be required by the Plan Sponsor to provide access to its records, nor will any of the TPA's employees provide assistance to any auditor until receipt by the TPA of the required audit retainer fee. Any audit shall be conducted by an auditor mutually acceptable to the Plan Sponsor and the TPA and the audit shall include, but not necessarily be limited to, producing photocopies of Claims and funding information in the TPA's existing format(s), a review of procedural controls, a review of system controls, a review of Plan provisions, a review of sampled Claims, and comparison of results to TPA industry performances standards or any statistical models previously agreed to by the Plan Sponsor and the TPA in writing. Nothing in this Agreement, expressed or implied, shall require the TPA to disclose any proprietary information, including, but not limited to, file layout or record formats of its Claims processing system or procedures, providing records or information in a format not in use by the TPA, or creating unique information formats solely for the use of the auditor(s), consultant(s), agent(s) or broker(s) for the Plan Sponsor. 3.12 Upon request of the Plan Sponsor, provide COBRA continuation coverage services through a related corporation, Allegiance COBRA Services, Inc. (ACSI). A separate fee will be charged for COBRA continuation services, which fee is set out in a COBRA Services Agreement. If the Plan Sponsor does not request COBRA continuation services from ACSI, all responsibility and liability for administration of COBRA continuation shall remain with the Plan Sponsor, and neither the TPA nor ACSI will have any obligation or responsibility for providing such services or consultation regarding such services. 3.13 Provide all reports available through TPA's Ibiz reporting program and through Cedar Gate Technologies reporting. 3.14 If requested by Plan Sponsor, procure, through Intermountain Underwriters, Inc., an affiliated company of TPA, Stop Loss or Excess Loss (specific and aggregate) insurance proposals and policies for the Plan Sponsor's consideration and selection, which Excess Loss or Stop Loss insurance will be an asset of the Plan Sponsor and not of the Plan. Intermountain Underwriters, Inc., may act as agent of record for the Plan Sponsor in placing Stop Loss or Excess Loss for the Plan Sponsor. 3.15 If applicable (a) Notify the Stop Loss or Excess Loss insurance company of any potential large Claims, which may become a Claim under the Stop Loss or Excess Loss coverage. (b) On behalf of the Plan Sponsor, the TPA will file with the insurance company or its designee any Complete Claims for consideration for reimbursement under the Stop Loss or Excess Loss policies. (c) Promptly forward to the Plan Sponsor any premium, claim reimbursement, Stop Loss or Excess Loss or other notices received from the Stop Loss or Excess Loss insurance carrier concerning the policy. 3.16 If applicable, conduct utilization review for the Plan, including pre -certification of hospital stays, concurrent review of hospital stays, discharge planning, preliminary review for potential hospital bill audits, large case management or any other managed care programs as agreed to between the Plan Sponsor and the TPA. A separate fee will be charged for these services as stated in Appendix A. Specific to these services, the Plan Sponsor adopts for the Plan all screening criteria used by TPA and its affiliated companies including, but not limited to: • 16th Edition of the Milliman USA Optimal Recovery Guidelines for medical/surgical inpatient reviews, and all Addenda • Acuity Assessment Tools for Rehabilitation and Skilled Nursing Level of Care Solucient Length of Stay Guidelines Medicare Guidelines Milliman USA Behavioral Health Guidelines American Society of Addiction Medicine (ASAM), Patient Placement Criteria-2R, 2001, for Substance -Related Disorders. MEDICAL ASA - ERISA Page 6 of 14 MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. REV.05-2019 3.17 Maintain working relationships with networks of Health Agreement, the TPA will automatically perform run -out Care Providers through Preferred Provider Organizations services for a period of three (3) months after the date of (PPO) contracted by the Plan Sponsor or arranged by the such termination for such designated subsidiary, division TPA. The TPA shall be entitled to rely upon any and all or member employer, unless directed not to do so by the representations made by Health Care Providers/PPO Plan Sponsor in writing. The fee for each month of run - regarding their qualifications as Health Care Providers, out services will be equal to the claims processing fee(s) and shall have no obligation or liability to obtain, verify or stated in Appendix A, based upon the designated monitor such qualifications or credentials. subsidiary's, division's or MEWA member employer's number of enrolled Plan Participants for the month If applicable, a separate fee will be charged for PPO immediately prior to the date of termination of coverage. network services, TPA coordination and system Plan Sponsor will also pay the TPA run -out services fees maintenance for PPO networks, as stated in Fee for any enrolled Plan Participants who were laid -off or Schedule, Appendix A. otherwise terminated from the rolls of the Plan during the term of this Agreement if the total number of such laid -off The TPA will not be responsible for any services provided or terminated Plan Participants exceeds five (5%) (or any failure to provide services) by a participating PPO percent of the total number of enrolled Plan Participants or Health Care Providers and specifically makes no during the first month of this Agreement. Final representation, warranty or guarantee whatsoever reconciliation of run -out services fees will be made within regarding any such PPO, Health Care Providers, or their ninety (90) days of the end of this Agreement. representations, qualifications or credentials. 3.22 Fees for the services described in Article III are set out in 3.18 Provide, within thirty (30) days after termination of this Appendix A hereto. Such fees are fixed for the initial term Agreement, a summary paid Claim report of all Claims of this Agreement except that the fees are subject to paid twenty-four (24) months prior to the date of change under the following conditions: termination, copies of any governmental reports, and other plan documentation to the Plan Sponsor. Until that (a) if the Plan Sponsor's census of enrolled time, these records will be maintained at the TPA's employees increases or decreases by more principal administrative office. Claim files will be kept in than ten (10%) percent from the number of secure storage facilities or electronic media for at least employees that were enrolled upon the six (6) years following the termination of the Plan Year. commencement of this Agreement; Copies of any materials in storage will be available to the (b) if the Plan Sponsor significantly alters the Plan Sponsor for a copy fee of fifteen ($0.15) cents per design or complexity of its health benefit plan; or page copied plus a retrieval fee of Ten Dollars ($10.00) (c) regularly requesting and obtaining extra - per box or electronic media access. At the end of the six contractual services from the TPA. (6) year period or termination of this Agreement, if earlier, the TPA shall notify the Plan Sponsor that these records 3.23 The TPA will comply with the applicable laws and rules will be destroyed. for the storage, transmission and release of any "protected health information" (used herein as such 3.19 Provide Medicare, MSP, and §111 reporting services. defined in HIPAA). Notwithstanding any other provision of this Agreement, the TPA shall not be required to do any 3.20 Provide non-proprietary information and documents as act which in its judgment violates HIPAA. requested by the Plan Sponsor to brokers and agents designated by the Plan Sponsor. However, if the Plan 3.24 The TPA will provide consolidated billing services if Sponsor has entered into an agent of record agreement checked as an included service in Appendix A. with any new agent or broker, and the TPA has notice of Specifically, the TPA will bill fees and premiums for other the same, the TPA shall not be required to provide any employee benefits including, but not limited to, group life, information or documentation to other agents or brokers group AD&D and/or group short term and long term unless or until the Plan Sponsor has terminated the disability to the Plan Sponsor, and will remit the premium original agent of record agreement and notified the collected to the applicable carrier. original agent of record of the termination. The TPA shall have the express right to contact any agent of record to 3.25 TPA will provide administrative interface services for the verify the agent of record agreement has been plan sponsor with the Plan's Pharmacy Benefit Manager terminated. A separate fee will be charged for this service including but not limited to census reconciliation and as stated in Appendix A. claims information transfer, and dispersal and distribution of any pharmacy rebates due to the Plan Sponsor. With 3.21 For Plan Sponsors which have designated subsidiaries, regard to any pharmacy rebates due the Plan Sponsor, divisions, or which are a Multiple Employer Welfare Cigna PBM will transfer the entire amount of any rebate Arrangement (MEWA): when any designated subsidiary, to the TPA and the TPA will distribute the rebate to the division or member employer of a MEWA terminates Plan Sponsor or its designee, after deducting an amount coverage under the plan that is the subject of this for the fees due the TPA for providing the interface services described above. The amount deducted by the TPA shall be as stated in Appendix A of this agreement. MEDICAL ASA - ERISA Page 7 of 14 MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. REV.05-2019 ARTICLE IV: THE PLAN SPONSOR'S RESPONSIBILITIES The Plan Sponsor or Employer will: 4.1 Establish the Plan together with a framework of policies, interpretations and rules, which shall be the basis for the TPA's performance of its duties under this Agreement. Maintain current and accurate Plan eligibility and coverage records, verify Covered Person eligibility and submit eligibility and coverage information monthly, or more often if requested by the TPA, to the TPA at its designated electronic or postal address. 4.3 This information shall be provided in a format acceptable to the TPA and shall include the following for each Covered Person: name and address, Social Security number, date of birth, type of coverage, sex, relationship to employee, changes in coverage, date coverage begins or ends, and any other information as necessary to determine eligibility and coverage under the Plan. The Plan Sponsor assumes the responsibility for and will hold the TPA harmless from the erroneous disbursement of benefits by the TPA in the event of error or neglect by the Plan Sponsor or Employer in providing eligibility and coverage information to the TPA, including, but not limited to, failure to give timely notification of ineligibility or termination of a former Covered Person, or fraudulent enrollment and/or continuation of coverage. 4.2 The TPA shall make recommendations regarding Claims determinations. The Plan Sponsor shall have the sole authority to resolve all Plan ambiguities and interpretations, questions and disputes relating to the Plan eligibility of a Covered Person, Plan coverage and denied Claims. The Plan Sponsor shall have the sole authority to make determinations regarding appeal of denied Claims. The Plan Sponsor will respond to any written request for information made by the TPA within ten (10) Working Days of receipt of the request. Resolve all Plan ambiguities, questions and disputes relating to the Plan eligibility of a Covered Person, Plan coverage, denial of Claims or decisions regarding appeal or denial of Claims, or any other Plan interpretation questions. The Plan Sponsor will respond to any written request made by the TPA within ten (10) Working Days of receipt of the request. The TPA will administer and process Claims in accordance with Article III if the Plan Document and Summary Plan description are clear and unambiguous as to the validity of the Claims and the Covered Person's eligibility for coverage under the Plan. The TPA will have no discretionary authority to interpret the Plan or adjudicate Claims. If processing a benefit Claim requires interpretation of ambiguous Plan language, and the Plan Sponsor has not previously indicated to the TPA the proper interpretation of the language, then the Plan Sponsor will be responsible for resolving the ambiguity or any other dispute. In any event, the TPA shall rely upon the Plan Sponsor's decision as to any Claim (whether or not it involves a Plan ambiguity or other dispute) and such decision by the Plan Sponsor shall be final and binding unless modified or reversed by a court or regulatory agency having jurisdiction over such Claim matter. Fully fund the Claims Payment Account every week based upon the Claims batch report provided by the TPA. 4.4 Set funding levels for the Plan at a minimum level necessary to cover the expected Claims costs, administrative expenses and incurred but not reported Claims liability and fund the Plan at such level. 4.5 Not request or require the TPA, under any circumstances, to issue Claims drafts for Claims, stop loss or excess loss insurance premiums, or any other costs arising out of the subject matter of this Agreement, unless the Plan Sponsor has so authorized and has previously deposited sufficient funds to cover such Complete Claims or other Plan expense obligations and payment(s). 4.6 Provide the TPA with copies of any and all revisions or changes to the Plan at least five (5) Working Days prior to the effective date of the changes. Failure to provide timely notice may result in additional claims processing fees as set forth in Appendix A. 4.7 Provide, and timely distribute, all notices and information required to be given to Covered Persons, including Summary Annual Reports. Maintain and operate the Plan in accordance with applicable law. Maintain all recordkeeping and file all forms relative thereto pursuant to any federal, state or local law, unless this Agreement specifically assigns such duties to the TPA. 4.8 Acknowledge that it is the Plan Sponsor, Plan Administrator, and Named Fiduciary. As such, the Plan Sponsor retains full discretionary control and authority and discretionary responsibility in the operation and administration of the Plan. 4.9 Pay or reimburse TPA for any taxes, assessments for fees arising solely out of the operations of the Plan or the services provided under this Agreement that are levied against the Plan or against the TPA by any governmental entity whether federal, state or local, or any political subdivisions or instrumentality thereof. Taxes based on TPA's net income or licenses TPA is required to maintain to provide the services under this Agreement shall be the sole responsibility of TPA. MEDICAL ASA - ERISA Page 8 of 14 MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. REV.05-2019 4.10 Hold confidential information that is proprietary to the TPA or information or material not generally known by personnel other than management employees of the TPA. The Plan Sponsor agrees not to use or disclose proprietary information of the TPA. Such proprietary information includes, but is not limited to, information designated as "trade secrets" under the Montana Uniform Trade Secrets Act, Title 30, Chapter 14, Part 4 of the Montana Code Annotated and any other constitutional protections. The Plan Sponsor acknowledges that such proprietary information shall include all financial information, PPO network or provider contracting arrangements, reasonable and customary Claims levels, fee schedules, conversion factors and Claims administration guidelines or procedures of the TPA or its affiliates or subcontractors. 4.11 Pay, in accordance with the Fee Schedule, Appendix A, the TPA's fees for services rendered under this Agreement. The TPA is expressly directed by the Plan Sponsor to pay any excess loss insurance premiums (where applicable), fee, cost or charge then due to the TPA prior to application of funds to payment of Claims or any other costs arising out of the Plan or subject matter of this Agreement. The Plan Sponsor specifically directs that all funds provided to TPA under this Agreement will be disbursed in the following order: First to pay excess loss insurance premiums where applicable, claims administration fees, costs and related expenses incurred by TPA and, second, to pay benefit claims arising under the Plan. 4.12 4.13 Maintain any fidelity bond or other insurance as may be requested by state or federal law for the protection of the Plan and Covered Persons. other individually identifiable health care information to Plan Sponsor, its agents and designees if such authorizations and/or releases are not provided. 4.16 Have the sole responsibility for reporting and disclosure, including but not limited to plan documents, summary plan descriptions, summaries of material modifications, participant communications, pre -retirement counseling to participants, bonding filings or other compliance required of, by or for the Plan, their participants and beneficiaries, or the Plan Sponsor by ERISA, the Internal Revenue Code, or any other related and/or applicable federal, state or local laws, rules or regulations. Plan Sponsor shall indemnify and hold harmless TPA from any claim or expense incurred as a result of the Plan Sponsor's failure to comply with the requirements or provisions of applicable, federal, state, and local laws, rules and regulations. 4.17 Shall be solely responsible for paying all fees, expenses, or costs attributable to any legal action or proceeding brought to recover a claim for benefits under the Plan. TPA shall, however, make available to the Plan Sponsor and its counsel, such evidence which relates to or is relevant to such action or proceeding as TPA may have as a result of the performance of the services set forth in this Agreement. TPA shall promptly notify the Plan Sponsor in writing of any legal actions of which it becomes aware that involve the Plan or the Plan Sponsor. Any legal fees incurred by TPA in connection with any legal action or proceeding brought to recover a claim for benefits under the Plan shall be the responsibility of the Plan Sponsor. Maintain Stop Loss or Excess Loss insurance with an 4.18 admitted insurance company in the minimum amount set forth in the Fee Schedule, Appendix A. 4.14 Promptly notify the TPA of any termination notice, expiration lapse, or modification of Stop Loss or Excess Loss insurance, life insurance, disability insurance, conversion insurance or any other insurance purchased in conjunction with the Plan. 4.15 Ensure that there is adequate release and authorization from each participant and/or beneficiary under the Plan permitting Health Care Providers to share with TPA and TPA to share with Health Care Providers and other service providers to the Plan any and all information, whether protected or individually identifiable, which may be necessary to perform the services anticipated by this Agreement and any Appendices hereto. TPA may in its sole discretion, require participants and/or beneficiaries of the Plan to execute additional releases and authorizations for the use and disclosure of such information. TPA may refuse to release protected or Provide timely, accurate and complete information required by TPA to provide the services that TPA has agreed to perform under this Agreement. TPA shall have the right to rely on such information. Such information shall include but not be limited to all necessary eligibility enrollment and participant data; and copies of all governing documents of the Plan and any amendments thereto, including any written policies, interpretations, rules, practices or procedure(s) concerning same. Such information shall be provided upon execution of this Agreement and immediately following modification or amendment. TPA shall have the right to assume that all such information is accurate and complete and TPA shall be under no duty to question such information. Plan Sponsor shall reimburse TPA at its standard hourly rates for TPA's costs incurred for efforts expended to remedy data or information inaccuracies as were provided by the Plan Sponsor. 4.19 File and timely pay all applicable PCORI fees and file and distribute to employees all applicable IRS Form 1094 and 1095 forms. Upon request, TPA will provide census information that is stored in TPA's data systems to assist with this reporting. MEDICAL ASA - ERISA Page 9 of 14 MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. REV.05-2019 4.20 Premier Joint Replacement Provider Benefit Shared 5.3 Either the Plan Sponsor or the TPA may terminate this Savings: Agreement at any time, by giving sixty (60) days advance written notice to the other party unless both parties agree If Plan Sponsor has adopted a Premier Joint to waive such advance notice. At the option of the party Replacement Provider Benefit in its Plan Document, Plan initiating the termination, the other party may be Sponsor agrees to share the savings realized under such permitted a cure period (of a length determined by the benefit with the hospital providing such services under party initiating the termination) to cure any default. this benefit. Such savings will be shared on a 50% / 50% basis between Plan Sponsor and the applicable hospital. 5.4 The TPA may, at its sole option, terminate this Agreement with ten (10) days written notice upon the occurrence of Such savings shall be calculated as follows: any one or more of the following events pertaining to the Plan Sponsor: (a) Professional charges (doctors, assistant surgeons, and anesthesiology) will be deducted (a) The Plan Sponsor fails to fund the Claims from the Maximum Benefit Amount stated in the Payment account; Plan Document. (b) The Plan Sponsor fails to pay administration (b) The hospital's contractually agreed upon base fees or other fees for the TPA's services upon rate shall be subtracted from the remaining presentation for payment and in accordance balance after subtraction of (a) above. with the Fee Schedule, Appendix A; (c) The remaining balance, if any, shall be divided (c) The Plan Sponsor fails to comply with any equally between the Plan Sponsor, as a credit federal, state or other government statute, rule to claims experience, and to the hospital as an or regulation; additional payment. (d) The Plan Sponsor, through its acts, practices, or operations, exposes the TPA to any existing or The shared savings shall be distributed by the TPA on a potential investigation or litigation. per surgical event basis. ONLYMONTANA GROUPS (e) The Plan Sponsor permits its stop loss or excess loss insurance to lapse, whether by ARTICLE V: DURATION OF AGREEMENT failure to pay premiums or otherwise; (f) The Plan Sponsor loses its licensure or 5.1 This Agreement shall commence and end on the dates certification, if required by law, to continue the first written above, unless terminated earlier in Plan; accordance with this Article. This Agreement shall (g) Insolvency of the Plan; automatically renew at the end of each term for an (h) Court appointment of a permanent receiver for additional twelve (12) month period pursuant to receipt of substantially all of the Plan Sponsor's assets; a fee quote from the TPA for the succeeding twelve (12) (i) A general assignment of the benefit of credits by month period, or unless modified or terminated as the Plan Sponsor; or described below. The fee quote in this subsection must Q) The filing of a voluntary or involuntary petition of be accepted, in writing, by the Plan Sponsor prior to the bankruptcy, if such petition is not dismissed renewal date for the period to which the fee quote applies. within forty-five (45) days of the date of filing, Non -acceptance of the renewal fee quote shall cause this provided that an order for relief from automatic Agreement to lapse and terminate at 5:00 P.M. on the last stay has been obtained, or with respect to a Working Day of this Agreement. Chapter 11 proceeding, that the bankrupt or Bankruptcy Trustee fails to reaffirm this 5.2 At any time during the term of this Agreement, either the Agreement and provide adequate assurances Plan Sponsor or the TPA may amend or change the pursuant to 11 USC 365. provisions of this Agreement. These amendments or changes must be agreed upon in advance in writing by 5.5 The Plan Sponsor may, at its option, terminate this both the Plan Sponsor and the TPA. If any such Agreement with ten (10) days written notice upon the amendment increases the anticipated Claims experience occurrence of any one or more of the following events under the Plan or the TPA's cost of administering the pertaining to the TPA: Plan, the Plan Sponsor agrees to pay any increase in Claims expenses, as well as increases in administrative (a) Court appointment of a permanent receiver for fees or other costs which the TPA reasonably expects to all or substantially all of the TPA's assets; incur as a result of such modification. (b) A general assignment of the benefit of credits by the TPA; Any amendment which affects only the Fee Schedule, (c) The filing of a voluntary or involuntary petition of Appendix A, may be made, in writing, signed by all bankruptcy, if such petition is not dismissed parties, and without other formal amendment of this within forty-five (45) days of the date of filing, Agreement. All fee quotes accepted by the Plan Sponsor provided that an order for relief from automatic for renewals of this Agreement will be incorporated into stay has been obtained, or with respect to a this Agreement as amendments to the Fee Schedule, Chapter 11 proceeding, that the bankrupt or Appendix A. Bankruptcy Trustee fails to reaffirm this MEDICAL ASA - ERISA Page 10 of 14 MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. REV.05-2019 Agreement and provide adequate assurances 5.9 In the event this Agreement is terminated for any reason pursuant to 11 USC 365; and Plan Sponsor cannot be located following (d) The TPA loses its licensure or certification reasonable efforts by TPA, TPA shall charge a $50.00 required by law to continue its business or per check administrative charge for its efforts to return continue as third party administrator; or any stale dated funds (defined as a check with an original (e) The TPA fails to comply with any federal, state issue date greater than 180 days) belonging to Plan or other governmental statute, rule or regulation. Sponsor or belonging to a plan participant who, likewise, cannot be located. The administrative charge may be 5.6 At the written request of the Plan Sponsor and subject to paid from any funds of the Plan Sponsor held by TPA, or the Plan Sponsor's continuing obligation to fund the billed directly to the Plan Sponsor. This provision shall Claims Payment Account, and to timely pay any survive termination of this Agreement. outstanding amounts due and payable to the TPA under the terms of this Agreement, the TPA may, at its sole 5.10 The Plan Sponsor specifically acknowledges that the discretion, agree to process incurred but not reported TPA incurs ongoing costs for staffing, long term planning, Claims after the termination of this Agreement (Run -Out maintenance of customer service support and other costs Services). The written request of the Plan Sponsor must connected with providing services to Plan Sponsor's be received simultaneously with the notice of termination Plan, and that the notice of termination and terminate required by subsection 5.3 of this Agreement. Such date provisions of this Agreement provide adequate agreement (Run -Out Services Agreement), if any, shall notice to the TPA so that unnecessary costs are not be in writing and a separate fee will be charged for this incurred by the TPA if the Plan Sponsor terminates this service. Agreement. In that regard, it is specifically agreed by the Plan Sponsor that in the event that the Plan Sponsor 5.7 If this Agreement terminates for any reason and no Run- either fails to provide the advance notice for termination Out Service Agreement is requested, or if the TPA required by this Agreement, or terminates this Agreement declines to provide Run -Out Services, the TPA shall have other than on its express expiration date, the Plan no obligation to: Sponsor shall pay to the TPA a fee equal to two times the amount of Plan Sponsor's administrative fees payable to (a) Complete the processing of any claim requests the TPA for the month immediately prior to the date notice that were pending or otherwise not Complete of termination is received. The amount payable under Claims or complete the processing of any this provision shall be as liquidated damages incurred by Complete Claims if the Plan Sponsor has failed the TPA for the costs recited in this subsection, in lieu of to provide funds for the payments of any specific calculation of the same, and not as a penalty. benefits due; The liquidated damages will be in addition to any other (b) Accept or process requests for claim payments fees required under this Agreement or any subsequent presented to it after termination of this Run -Out Services Agreement between the parties. Agreement irrespective of when such claim was incurred; ARTICLE VI: MISCELLANEOUS (C) Issue claims checks after the termination date of this Agreement for any request for claims 6.1 This Agreement, together with all addenda, exhibits and payments relative to conditions existing before, appendices, supersedes any and all prior on or after such a date. representations, conditions, warranties, understandings, (d) Provide ongoing customer service to Plan proposals or other agreements between the Plan Participants or Health Care Providers; or Sponsor and the TPA hereto, oral or written, in relation to (e) Perform any other task or requirement of this the services and systems of the TPA, which are rendered Agreement, except for those requirements that or are to be rendered in connection with its assistance to specifically survive termination of this the Plan Sponsor in the administration of the Plan. Agreement. 6.2 This Agreement, together with the aforesaid addenda, 5.8 If the Plan Sponsor terminates this Agreement on or exhibits, and appendices, constitutes the entire before the expressed expiration date of this Agreement, Administrative Services Agreement of whatsoever kind or but after such termination date becomes entitled to any nature existing between or among the parties. reimbursement(s) pursuant to the provisions of the Plan Sponsor's Stop Loss or Excess Loss insurance policy 6.3 The parties hereto, having read and understood this aggregate or specific loss reimbursement provisions, and entire Agreement, acknowledge and agree that there are no separate Run -Out Services Agreement is executed, no other representations, conditions, promises, the Plan Sponsor shall pay to the TPA an hourly fee of agreements, understandings or warranties that exist One Hundred and no/100 Dollars ($100.00) per hour for outside this Agreement which have been made by either all services rendered by the TPA after termination of this of the parties hereto, which have induced either party or Agreement regarding such reimbursement(s) request have led to the execution of this Agreement by either made to or claims paid by a Stop Loss or Excess Loss party. Any statements, proposals, representations, insurance company. MEDICAL ASA - ERISA Page 11 of 14 MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. REV.05-2019 conditions, warranties, understandings or agreements 6.9 which may have been heretofore made by either of the parties hereto, and which are not expressly contained or incorporated by reference herein, are void and of no effect. 6.4 Except as provided in Article V, no changes in or additions to this Agreement shall be recognized unless and until made in writing and signed by all parties hereto. 6.5 In the event any provision of this Agreement is held to be invalid, illegal or unenforceable for any reason and in any respect, such invalidity, illegality or unenforceability shall in no event affect, prejudice or disturb the validity of the 6.10 remainder of this Agreement, which shall remain in accordance with its terms. 6.6 The Plan Sponsor will notify the TPA within ten (10) Working Days of any inquiry made by any Covered Person or authorized representative of any Covered Person related to Plan Documents, Plan Records, Claims, Claims Appeals, Claims Disputes, threatened litigation, lawsuits pertaining to the Plan or any inquiry made by federal or state authority regarding the Plan. 6.7 In the event that either party is unable to perform any of its obligations under this Agreement because of natural disaster, fire, flood, wind storm, power outage, labor unrest, civil disobedience, acts of war (declared or undeclared), or actions or decrees of governmental bodies or any event which is referred to as a "Force Majeure Event", the party who has been so affected shall immediately notify the other party and shall do everything possible to resume performance. Upon receipt of such notice, all obligations under this Agreement shall be immediately suspended. If the period of non-performance exceeds fourteen (14) Working Days from the receipt of notice of the Force Majeure Event, the party whose ability to perform has not been so affected may terminate this Agreement by giving ten (10) Working Days' written notice. The TPA has adopted an Affirmative Action Policy which is in compliance with §49-2-101, Montana Code Annotated. Employees hired by the TPA are hired on the basis of merit and qualifications, and there is no discrimination on the basis of race, color, religious creed, political ideas, sex, age, marital status, physical handicap, national origin or ancestry by persons performing this Agreement. Qualifications mean such abilities as are genuinely related to competent performance of the particular occupational task. This Agreement shall be interpreted and construed in accordance with the laws of the state of Montana except to the extent superseded by federal law. 6.11 The parties agree to use and disclose protected health information about a Covered Person in accordance with the terms of a separately provided Business Associate Agreement. 6.12 The TPA shall comply with the Montana Workers' Compensation Act while performing its obligations under this Agreement in accordance with §§39-71-120, 39-71- 401 and 39-71-405, Montana Code Annotated. Proof of compliance shall be in the form of workers' compensation insurance, an independent contractor's exemption or documentation of corporate officer status. Such insurance/exemption shall be valid and in force for the duration of this Agreement. 6.13 6.8 All notices required to be given to either party by this Agreement shall, unless otherwise specified in writing, be deemed to have been given three (3) days after deposit in the U.S. Mail, first class postage prepaid, certified mail, return receipt requested. 6.14 Any official notice to the TPA will be mailed to the attention of: President, Allegiance Benefit Plan Management, Inc., 2806 South Garfield St., Missoula, MT 59801. 6.15 Any official notice to the Plan Sponsor will be mailed to the attention of: ###. The TPA may enter into arrangements with a Health Care Provider or group of Health Care Providers to obtain discounts in charges for Covered Services. The TPA makes no representations that such discounts will continue for any period of time or will apply in any particular factual context. Plan Sponsor agrees to pay such discounted charges based upon the terms of the arrangement, the terms of the contract between the arrangement and the Health Care Provider(s) or the terms of the contract between the TPA and the Health Care Provider(s). In no event will TPA be responsible for the loss of any such discounts except in the sole event that such loss is directly caused by commissions or omissions of the TPA which constitute gross negligence. No forbearance or neglect on the part of either party to enforce or insist upon any of the provisions of this Agreement shall be construed as a waiver, alteration or modification of the Agreement. Should the TPA's performance of its duties under this Agreement be made materially more burdensome or expensive due to an increase in US Postal Service rates or due to a change in federal, state or local laws or imposition of fees there under, any such additional fees shall be paid by Plan Sponsor. MEDICAL ASA - ERISA Page 12 of 14 MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. REV.05-2019 6.16 The TPA and the Plan Sponsor specifically state, acknowledge and agree that it is their intent that no other parties including, but not limited to, all persons eligible for benefits under the Plan, all covered employees, and their assignees shall be third party beneficiaries of this Agreement. The parties further agree that nothing herein shall be deemed to impose on the TPA any obligation to any other party including, but not limited to, all persons eligible for benefits under the Plan, all covered employees, and their assignees. 6.17 The Plan Sponsor acknowledges that the TPA shall have no responsibility or liability for any fines or penalties assessed by the Internal Revenue Service as a result of the issuance of annual 1099 forms to medical service providers so long as the TPA has issued the 1099 to the same name, address and TIN as billed by the medical services provider at the point of claim submission. IN WITNESS WHEREOF, the parties have caused this Agreement to be executed on their behalf by their duly authorized representatives' signatures, effective as of the date first written above. By: _ By: _ Date (Name/Title) (Signature) ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. 2806 S. Garfield St. Missoula, MT 59801 By: Stephen A. Tahta President & General Manager By: (Signature) Date: MEDICAL ASA - ERISA Page 13 of 14 MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. REV.05-2019 MEDICAL ASA - ERISA Page 14 of 14 MED STD SNGL EMP ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC. REV.05-2019