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HomeMy WebLinkAboutCoresouce Third Party ProviderCoreSource Plan Supervisor - 1999 Human Resources AGKEEMENT FOR PROFESSIONAL SERVICES APPROVEDi FORM BY: THIS AGREEMENT FOR PROFESSIONAL SERVICES ("Agreement"), is made effective the first day of Februa~, 1999, by and between the City of Carmel, Indiana, acting by and through its Board of Public Works and Safety, Indiana, hereinafter referred to as "City", and. CoreSource, Inc., a Delaware Corporation, hereinafter referred to as "CoreSource" and/or "Plan Supervisor". RECITALS WHEREAS, the City has developed the City of Carmel Employee Health Benefit Plan, as amended from time to time (the "Plan"), a copy of which has been previously provided to CoreSource; and WHEREAS, the City requires assistance in the implementation and administration of the Plan; and WHEREAS, CoreSource is experienced in providing the professional services required of a plan supervisor, which assists in the implementation and administration of a health'benefit plan; and WHEREAS, the City desires to engage CoreSource as an independent contractor to provide the professional services of a plan supervisor. NOW THEREFORE, in consideration of the foregoing recitals and the mutual covenants and conditions set forth herein, the City and CoreSource mutually agree as follows: SECTION 1. iNCORPORATION OF RECITALS The foregoing recitals are hereby incorporated into this Agreement and made a part hereof. SECTION 2. SCOPE OF SERVICES A. Plan Supervisor 1. The Plan Supervisor shall have certain duties for the proper administration of the Plan. In performing its duties under this Agreement, the Plan Supervisor shall act solely as an independent contractor of the City. 2. The Plan Supervisor shall arrange for payment of approved claims under the Plan by providing written orders and authorizations delivered to a person authorized to disburse funds of the Plan for payment of said claims. 3. The Plan Supervisor shall, as directed by the City, arrange for the purchase of policies of insurance to provide any of the benefits provided for in the Plan, or policies of stop-loss or aggregate deductible or a similar type of insurance to protect the Plan. 4. The Plan Supervisor shall issue a written order to a person with authority to disburse funds of the Plan to pay all expenses of the operation of the Plan. · CoreSource Plan Supervisor - 1999 Human Resources 5. The Plan Supervisor shall assist the City in the enrollment of eligible employees and their covered beneficiaries for Participation in the Plan. 6. The Plan Supervisor shall provide the City with monthly reports. Such monthly reports shall include: (a) the amounts of any premiums collected or charges made for stop loss coverage for the Plan; (b) receipts of the Plan; (c) all written authorizations made by the Plan Supervisor to persons authorized to disburse funds of the Plan in payment of claims or operation expenses of the Plan, including, but not limited to, a detailed explanation of any claim or series of claims with respect to an individual in excess of Fifty Thousand Dollars ($50,000.00) per family; and (d) an itemized statement of fees due the Plan Supervisor. 7. The Plan Supervisor shall maintain a fidelity bond in the amount set forth in Appendix B, covering the Plan Supervisor and any of its agents or employees who may collect, disburse or otherwise handle or have possession of any funds of the Plan or who may have authority to authorize or order disbursements of claims or operation expenses on behalf of the Plan. 8. The Plan Supervisor shall accept any claim for benefits made in the appropriate manner, and after due review, investigation and verification of the statements contained in the claim application, determine the eligibility of the applicant for benefits. 9. If the facts of any claim, or those facts as determined by the Plan Supervisor in its investigation of the claim, entitle the claim applicant to receive payment of benefits from the Plan, the Plan Supervisor shall arrange for the proper payment of such claim from the Plan. 10. If the facts of any claim, or those facts as determined by the Plan Supervisor in its investigation of the claim, do not entitle the applicant to receive payment of benefits from the Plan, the Plan Supervisor shall deny the claim for benefits. If appealed, the Plan Supervisor shall refer the denied claim to the City with the Plan Supervisors reasons for the denial. The City shall be solely responsible for determining an individual's entitlement to benefits under the Plan. 11. The City shall, upon written request of the claimant, review any previously denied claim in accordance with the claims appeal procedure of the Plan. The City shall be responsible for the review of all denied claims for benefits which are requested to be reviewed. ' 12. The Plan Supervisor shall not be liable for, nor advance any funds on account of, any failure or refusal to pay any claim for benefits made according to the terms of the Plan, nor shall the Plan Supervisor be considered in any way an insurer or underwriter of any liability of the City to provide benefits. CorcSourcc Plan Supervisor - 1999 Human P~esourccs B. COBRA Administration 1. CoreSource shall assist the City in the day-to-day requirements of the Public Health Service Act, hereinafter referred to as COBRA. Specific functions to be performed by CoreSource for the City will include the following: (a) distributing COBRA Notification of Election Right offers based on information supplied by the City; such notices shall be distributed such that a Certificate of Mailing is provided to document compliance with regulations; tracking all COBRA Notice of Election Rights offers and terminating offers as appropriate; (c) tracking all payments made by COBRA recipients and terminating or extending coverage as appropriate; (d) generating past due notices and termination notices when appropriate, applicable to payments; (e) funding the City's claim/expense account with premium checks received from COBRA recipients; and (f) processing and payment of claims for COBRA recipients. C. HIPAA Administration 1. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) imposed certain administrative requirements upon the City as the sponsor of an Employee Benefit Plan. It is the intent of the Plan Supervisor to assist the City with compliance with the provisions of HIPAA by providing services as outlined below: (a) issuing Certificates of Creditable Coverage based upon information regarding terminated employees and dependents supplied by the City and covered employees for terminations from June 1, 1997 through the termination of this Agreement; such Certificates of Creditable Coverage shall be in a format prescribed by federal regulations; (b) reviewing Certificates of Creditable Coverage or other forms of acceptable evidence regarding creditable coverage which are submitted with enrollment forms by the City for employees hired from June 1, 1997 through the termination of this Agreement; (c) determining whether the City's pre-existing condition elimination periods have been satisfied by previous creditable coverage of new hires based upon infomration submitted; (d) advising new hires if pre-existing condition limitations or exclusions contained within the City's benefit plan will apply to them and for how long; and CoreSource Plan Supervisor - 1999 Human Resources (e) maintaining documentation files of evidence of creditable coverage and any correspondence with employees. 2. City responsibilities include: (a) reporting terminations from the benefit plan to the Plan Supervisor in a timely manner; (b) reporting any other terminations that may necessitate the production of a Certificate of Creditable Coverage to the Plan Supervisor in a timely manner; (c) obtaining information regarding previous creditable coverage from newly hired employees; the City shall work directly ~vith the employee to obtain any information required and/or requested by the Plan Supervisor in order to demonstrate creditable coverage; (d) timely forwarding any such information received to the Plan Supervisor; (e) advising new hires of their enrollment rights as mandated by HIPAA and their options for special enrollments if they waive coverage; and maintaining documentation of enrollment information, including any Certificates of Creditable Coverage or other evidence of previous coverage. The City shall be responsible for any expenses incurred in obtaining information regarding creditable coverage for a newly hired employee. D. Utilization Review 1. Utilization review is a program designed to help ensure that individuals enrolled in the Plan receive necessary and appropriate health care while avoiding um~ecessary expenses when a hospital confinement, home health care or the use or purchase of durable medical equipment is proposed. CoreSource will provide: (a) pre-certification of the medical necessity for all non-emergency hospital admissions, home health care and services for durable medical equipment before medical services are provided; (b) retrospective review of the medical necessity for all emergency hospital admissions; (c) concurrent review, based on the admitting diagnosis, of the number of days of hospital confinement requested by the attending physician; and (d) certification of the length of confinement and discharge plarming. CoreSourc¢ Plan Supervisor - 1999 Human Resources 2. This program is not designed to be the practice of medicine or to be a substitute for the medical judgment of the attending physician or other health care provider. If a particular course of treatment is not certified, it means that the Plan will not consider that course of treatment appropriate for the maximum reimbursement under the Plan. If a particular course of treatment is certified, it means only that the course of treatment is deemed to have met all criteria. E. Subrogation 1. The Plan is generally entitled to be reimbursed for medical claims paid by it which arise due to accidents that are the responsibility of another party due to that party's negligence or other wrongful acts: i.e., a right of subrogation. The City wishes CoreSource to include as part of its services the identification and pursuit of certain of the City's subrogation claims. CoreSource will: (a) determine if subrogation is an issue by using its best efforts to identify claims in which the City may have a subrogation interest and reviewing provider's bills and claim forms to determine if the medical diagnosis indicates treatment may be due to an accident; (b) place the Covered Person who has filed a claim for benefits in which the City has a subrogation interest on notice of the City's interest and request information regarding the claim, the accident giving rise to the claim, the party or parties responsible for the Covered Person's injury and the name of the Covered Person's attorney or other representative (if applicable); (c) if applicable, put the Covered Persons attorney or other representative on notice regarding the City's subrogation claim; (d) research and investigate the information obtained from the Covered Person and other sources reasonably available to it necessary to pursue the City's subrogation claim; (e) pursue subrogation claims through negotiations with the Covered Person, the Covered Person's attorney or other representative and/or the party responsible for the Covered Person's injury and, if necessary, coordinate litigation to pursue the City's subrogation claims with an attorney of the City's choice; (f) obtain authorization from the City prior to settlement of any subrogation claim; (g) remit to the City, or to a claims account on behalf of the City, funds recovered through its pursuit of subrogation claims, less the amount payable to CoreSource pursuant to paragraphs 2 and 3 below; and report to the City on a regular basis, as the City directs, the status of open subrogation claims. 2. In the event CoreSource collects a subrogation claim for the City without retaining an attorney to represent the interests of the City, the City will pay CoreSource a fee for its services under this CoreSource Plan Supervisor - 1999 Human l~esources Agreement equal to twenty-five percent (25%) of the gross amount recovered for such claim. CoreSource' fee is payable xvithin thirty (30) days after CoreSource remits the recovered mounts to the City or to the claims account. 3. In the event CoreSource collects a subrogation claim of the City's, but such collection requires retaining an attorney to represent the interests of the City, the City will pay CoreSource a fee for its services under this Agreement, not to exceed fifty percent (50%) of the gross amount recovered for such claim, which includes all litigation expenses, if any, and attorney's fees. CoreSource will consult with City on the selection of an attorney to represent the City's interests. CoreSource and the City will agree, in writing, at the time an attorney is retained to represent the interests of the City, on the fee to be paid for the collection of such claim. CoreSource' fee is payable within thirty (30) days after CoreSource remits the recovered amounts to the City or to the claims account. F. Flexible Spendin~ Account Administration 1. The City offers Flexible Spending Accounts to eligible employees on an optional basis. CoreSource shall assist in the administration of such accounts, to include the following services: (a) administering Flexible Spending Accounts in compliance with Section 125 of the Internal Revenue Code ("Section 125") in order to maintain the preferred tax status of such accounts; (b) reimbursing ali expenses of participating City employees as are authorized by Section 125 provisions for Flexible Spending Accounts, and for which funds have been or are being deferred by the employee, upon presentation of a claim and required documentation; (c) printing and mailing reimbursement checks on a weekly basis for all claims processed the preceding week; and (d) printing and mailing a Flexible Spending Activity Statement to each participating employee three (3) months prior to the end of each Plan year. 2. City responsibilities include: (a) scheduling enrollment meetings and forwarding enrollment forms to the Plan Supervisor on a timely basis; (b) explaining Flexible Spending Accounts and offering enrollment options to new hires; (c) updating enrollments annually in November, to be effective January 1 of the following year; (d) making payroll deductions as requested by participating employees, and forwarding monies so collected to the Plan Supervisor on a timely basis; and Plan Supervisor- 1999 Human Resources (e) serving as liaison between the Plan Supervisor and participating City employees, as necessary, for the purpose of explaining Flexible Spending Accounts and gathering and disbursing relevant information. G. Other Services CoreSource shall prepare monthly billing statements and arrange for the City's payment of its group life insurance and vision insurance, as mutually agreed upon by the City and CoreSource. SECTION 3. COMPENSATION OF THE PLAN SUPERVISOR 3.1 CoreSource shall be entitled to compensation for its services to the Plan and the City under this Agreement. Compensation shall be paid on a monthly basis from the Plan assets or paid directly by the City. For the Term hereof, the amount of the fees shall be determined as set forth in the fee schedule attached hereto as Appendix A. 3.2 The City shall have the sole authority to purchase any insurance contract or armuity policy to provide benefits or compensate the City under the Plan. The City acknowledges that CoreSource may be compensated by an insurance company on the basis of a commission paid on each sale of such insurance contract or annuity policy and that any sales commission will be expressed as a percentage of gross annual premium payments. The City also acknowledges that CoreSource may receive additional compensation from an insurance company for administrative services rendered by it on behalf of the insurance company. 3.3 The City acknowledges, by the execution of this Agreement, that it has read this Agreement and approves it. In addition, the City acknowledges it will read any policy or transaction involving the Plan and CoreSource, prior to the execution of any such policy or transaction. The execution of any such policy or transaction by the City shall signify its acceptance of such policy or transaction. SECTION 4. DUTIES AND RESPONSIBILITIES OF THE CITY 4.1 Upon the request of the Plan Supervisor, the City shall provide the Plan Supervisor with a complete list of ail employees (and their covered dependents) of the City xvho are eligible for benefits from the Plan and for group life insurance and vision insurance. The City shall notify the Plan Supervisor of all changes to the list of eligible employees (and their covered dependents), whether by reason of termination, change in classification or otherwise as they occur. 4.2 The City shall be responsible for notifying the Plan Supervisor of the date an employee ceases to be "actively at work" by reason of a disability, whether short-term, long-term or permanent. If a disabled employee returns to active work, the City shall notify the Plan Supervisor of the date of his or her return. 4.3 The City shall collect the premiums and/or contributions, if any, made by the members of the Plan in the manner it may deem appropriate and shall transfer the funds it collects to the Plan on a monthly or more frequent basis as it determines necessary or advisable. 4.4 The City shall assist in the enrollment of the eligible employees in the Plan. 4.5 The City shall cooperate with the Plan Supervisor with regard to the proper settlement and review of claims for benefits and shall transmit any inquiries pertaining to the Plan to the Plan Supervisor. CoreSource Plan Supervisor - 1999 Human Resources 4.6 The City shall cooperate with the Plan Supervisor in the preparation and distribution of all documents to the eligible employees (and their covered dependents), including the Employee Plan Booklet, claim forms, enrollment cards, reports to eligible employees and other documents as may be necessary or convenient for the proper administration of the Plan or to satisfy legal requirements. 4.7 All documents prepared for distribution to the eligible employees shall be prepared and appropriately distributed at the expense of the City. 4.8 The City shall authorize payment of such expenses as are properly due in connection with the Plan. 4.9 The City shall be solely responsible for funding the payment of benefits and expenses under the Plan, either through: (a) the collection of premiums or contributions from covered employees or dependents, (b) the purchase of insurance; (e) payment from the City of Carmel Medical Escrow Fund; or (d) a combination thereof. The Plan Supervisor shall notify the City as needed of the dollar amount necessary to satisfy the Plan's benefit and expense obligations, and the City shall remit to the Plan Supervisor the amount necessary to satisfy this obligation within ten (10) days of its receipt of notice from the Plan Supervisor. To the extent that Plan benefits and expenses are payable solely from the City of Carmel Medical Escrow Fund, the City shall remit amounts under this Section 4.9 to a common claims account maintained by the Plan Supervisor. Any amount so remitted shall remain the sole and exclusive property of the City until paid from the common claims by the Plan Supervisor, and neither the Plan, nor its participants or beneficiaries, shall have any interest in such common claims account. Earnings, if any, on the common claims account shall be used to offset the expenses of maintaining and admirfistering the conunon claims account. Any earnings remaining after the application of the preceding sentence shall be allocated pro rata among all employers on whose behalf the common claims fund is maintained. Nothing in this Section 4.9 shall require the Plan Supervisor to advance funds for the payment of benefits under the Plan. In the event the City fails to satisfy its funding obligation as provided in this Section 4.9, the Plan Supervisor shall suspend payment of benefits until the City remits sufficient funds to pay such benefits. Absent a good faith dispute or termination of the Plan, if the City does not remit to the Plan Supervisor the amount necessary to satisfy the City's funding obligation within forty-five (45) days of its receipt of notice from the Plan Supervisor, the Plan Supervisor shall notify the Plan's participants and beneficiaries in writing of such failure. The City shall hold harmless the Plan Supervisor for any liability resulting from the Plan Supervisor's duties and obligations under this Section 4.9. Plan Supervisor ~ I999 4.10 With respect to subrogated claims, the City will: (a) identify for CoreSource a person or persons that CoreSource can communicate with to resolve issues with respect to the City's subrogation claims and whose decisions will be binding on the City; (b) assist CoreSource as reasonably necessary for CoreSource to carry out its duties and obligations under this Agreement; and (c) notify CoreSource of any inquiries it receives regarding the activities undertaken by CoreSource under this Agreement. SECTION 5. MISCELLANEOUS 5.1 Term Subject to the termination provisions set forth in Section 5.3 hereinbelow, this Agreement shall be in effect from February 1, 1999 through January 31, 2001, and shai1, on the first day of each February thereafter, automatically renew for a period of two (2) calendar years, unless otherwise agreed by the parties hereto. 5.2 Approval Date The Approval Date is the date on which the last of the parties hereto approves and executes this Agreement. 5.3 Termination The obligation to provide the Services under this Agreement may be terminated by the City or Plan Supervisor without cause upon sixty (60) days written notice to the other party and with cause upon receipt of notice to terminate the Agreement. Ail duties and responsibilities of the Plan Supervisor shall terminate as of the effective date of termination given on the written notice, except with respect to any claims for benefits received by the Plan Supervisor prior to the termination of this Agreement. Upon termination of this Agreement by either party, the Plan Supervisor, within thirty (30) days after the date of termination and the date of completion of all claims activities, shall deliver to the City, or its designee, all books and records in its possession and control regarding the administration of the Plan, all claim files, all reports and other papers pertaining to the Plan. 5.4 Binding Effect City and Plan Supervisor and their respective partners, successors, executors, administrators, assigns and legal representatives of each are bound by this Agreement to the other party to this Agreement, and to the partners, successors, executors, administrators, assigns and legal representative of such other party in all respects of all covenants, agreements and obligations of this Agreement. CoreSource Plan Supervisor - 1999 Human Resources 5.5 No Third Party Beneficiaries Nothing contained herein shall be construed to give any rights or benefits hereunder to anyone other than the City or Plan Supervisor. 5.6 Relationship The relationship of the parties hereto shall be as provided for in this Agreement, and the Plan Supervisor shall in no fashion be deemed to be an employee of the City. In that regard, the Plan Supervisor and all of its employees shall not be employees of the City. Furthermore, the Plan Supervisor shall have all responsibility to pay to or for its employees all statutory benefits and obligations and any other benefits or obligations at its discretion. 5.7 Insurance. The Plan Supervisor shall procure and maintain with an insurer licensed to do business in Indiana reasonably acceptable to the City, insurance ("Insurance"), for protection from claims for damages because of errors and omissions, and from claims or damages because of criminal acts or activities resulting from the actions of its employees. The Plan Supervisor shall secure and maintain Professional Liability Insurance and such insurance as will protect the Plan Supervisor and the City from claims resulting from the Plan Supervisor's errors and omissions. The coverage mounts shall be no less than those amounts set forth in Appendix B which is attached hereto. The Plan Supervisor shall cause its insurers to name the City as an additional insured on ail insurance policies and to provide that such policies will not be canceled without thirty (30) days prior notice to the City. The Plan Supervisor shall submit a certificate to the City evidencing the insurance coverages required hereunder. 5.8 Indemnification City shall indemnify and hold harmless the Plan Supervisor and its respective officers, employees and agents from all loss, liability, claims, judgments and liens, includi.ng costs and expenses and attorney fees, arising out of any act other than an act of gross negligence or willful misconduct of the Plan Supervisor or any of its colleagues, associates, agents, employees or subcontractors in the performance of this Agreement. The failure to do so shall constitute a material breach of this Agreement. Notwithstanding anything to the contrary, the City's liability with respect to its obligation to indemnify and hold CoreSource/Plan Supervisor harmless shall be limited to the maximum of the lesser of (a) the amount of insurance coverage for such claim and in effect at the time of the claim or (b) the amount allowed under the Indiana Tort Claims Act, as amended, at the time of the claim. The Plan Supervisor shall indemnify and hold harmless the City and its respective officers, employees and agents from all loss, liabihty, claims, judgments and liens, including costs and expenses and attorney fees, arising out of any act, other than an act of gross negligence or willful misconduct of the City or any of its colleagues, associates, agents, employees or subcontractors in the performance of this Agreement. The failure to do so shall constitute a material breach of this Agreement. 5.9 Discrimination Prohibition Plan Supervisor represents and warrants that it and its professionals shall comply with all existing laws of the United States and the State of Indiana prohibiting the discrimination against any employee or CoreSource Plan Supervisor - 1999 Human Resources applicant for employment or subcontract work in the performance of any project contemplated by this Agreement with respect to hire, tenure, terms, conditions or privileges of employment or any matter directly or indirectly related to employment or subcontracting because of race, religion, color, sex, handicap, national origin, ancestry, age, disabled veteran status or Vietnam era veteran status. The City reserves the right to collect a penalty as provided in IC 5-16-6-1 for any person discriminated against. 5.10 Severability If any provision of this Agreement is held to be invalid, illegal or unenforceable by a court of competent jurisdiction, the provisioff shall be stricken, and all other provisions of this Agreement which can operate independently of such stricken provision shall continue in full force and effect. 5.11 Notice Any notice, invoice, order or other correspondence required to be sent under this Agreement shall be in writing and either hand delivered or sent by first-class U. S. mail addressed to the parties at the following addresses: CITY: City of Carmel One Civic Square Carmel, IN 46032 Attention: James Brainard, Mayor PLAN SUPERVISOR: CoreSource, Inc. PO Box 879 Anderson, IN 46015 Attention: Sue Kanth, Vice President Operations 5. I2 Governint Law This Agreement shall be governed by and construed in accordance with the laws of the State of Indiana and all municipal ordinances and codes of the City of Carmel, Indiana, as the same shall be in full force and effect upon the Approval Date. 5.13 Waiver The delay or partial inaction on the part of the City or Plan Supervisor in exercising or pursuing its fight and remedies provided hereunder or by law shall not operate to waive any such rights or remedies. 5.14 Appendices All appendices and/or exhibits referenced herein, whether marked "Appendix", "Exhibit", or some other title, shall be considered part of this Agreement. 5.15 Prior Agreements This Agreement contains all of the agreements of the parties hereto with respect to the subject matter hereof, and no prior agreement, understanding or representation regarding same shall be effective Plan Supervisor - 1999 Human Resources for any purpose. No provision of this Agreement may be amended or added to except by an agreement in writing signed by the parties hereto or their respective successors in interest. 5.16 Representation and Warranties Parties represent and warrant that they are authorized to enter into this Agreement and the party executing the Agreement has the authority to bind the party which they represent. 5.17 Entire Agreement This Agreement represents the entire understanding bet~veen the Plan Supervisor and the City with respect to the subject matter hereof and supersedes all prior negotiations, representations and/or contracts either oral or written regarding same. 5.18 Headints All heading and sections of this Agreement are inserted for convenience only and do not form part of this Agreement or limit, expand or otherwise alter the meaning of any provisions hereof. 5.19 Assi~nent In the event of the resignation of the Plan Supervisor or its inability to serve, the City may appoint a successor to the position. 5.20 Taxes If at any time during the operation of the Plan, the federal government or any state or any political subdivision of any instrumentality of either shall assess any tax against the Plan, or any trust related to the Plan in any way, and the Plan Supervisor is required to pay such tax, the Plan Supervisor shall report the payment of the tax to the City and make a charge against the Plan and the City for reimbursement of such payment. 5.21 Modification of Agreement This Agreement may be amended by the City and the Plan Supervisor at any time by mutual written consent of both parties and as set forth in written form. Remainder of page is intentionally left blank. Apr-27-99 09:16A carmel city 317 571 2409 P.14 CorcSourc¢ Plan Supervisor - 1999 Human Resources IN WITNESS WHEREOF, the parties hereto have made and executed this agreement on the day and year first written above. CITY OF CARMEL, INDIANA by and through its Board of Public Works and Safety CORESOURCE, INC. BY: rainard, Presiding~ ~a~An~nn~urk~M~mhar Date: ~'Z ~ Billy V~atke~:, Member Date: t~tg~z'-z~ BY: Signature Printed Name: Title: Date: "J- ~ ATTEST: ~) }~e ,.a Cord?/~I~Treasurer CoreSource Plan Supervisor - [999 Human Resources APPENDIX A FEE SCHEDULE For the period February 1, 1999 through January 31, 2001. Medical and Rx Administrative Fees Dental Administrative Fees Utilization Review Fees Sagamore PPO PPO Interface Fee Broker Fee C OBP,& Administration HIPAA Administration Flexible Spending Administration (U~eimbursed Medical Expense and Dependent Care Accounts) Section 125 Plan Documentation Preparation 1. Booklets Professional Services - Compliance consultation for non-routine matters - Actuarial - Benefit Consulting - Computing Services $10.25 per employee per month $1.00 per employee per month $1.95 per employee per month $2.75 per employee per month $.25 per employee per month $2.50 per employee per month $.60 per employee per month $.25 per employee per month $4.25 per employee per month (only for employees electing to participate) $150.00 COSTS FOR OTHER PRODUCTS AND SERVICES Provided at cost; minimum order of 50 Charged on an hourly rate in accordance with the current published fee schedule at the time requested 3. Medical claim forms after initial 4. Dental claim forms after initial Provided at cost; minimum order of 1,000 Provided at cost; minimum order of 500 APPENDIX A (continued) ComSource Phn Supervisor - t999 Human Resources 5. Plan amendments 6. Summary Plan Description 5-year update (incorporated amendments only) 7. Plan Document Restatement Month-End Reports (included in Administration Fees) - Fund Account Statement - Monthly Check Register - Claim Void Audit - Benefit Analysis - Coverage Analysis - Paid Claims Analysis - Paid Claims Register - Specific Analysis - Group Aggregate Analysis - Membership List 9 9. Quarterly Reports (included in Administration Fees) - Contracted Savings - Utilization Savings 10. Ad-Hoc Reports (up to a total of 4 reports) Each additional ad-hoc report request Cost Containment Reports (minimum 3 day turnaround) Including but not limited to: - Average Length of Stay by Hospital - Claim Lag Study - Excess Dollar Analysis - Individual Payment - Claim Detail Analysis - Procedure Code Analysis - Paid Benefit Analysis 11. Custom Reports (minimum 1 week turnaround) Requires special programming $50.00 per amendment Quoted basis; $150.00 minimum plus printing costs $500 minimum No Charge No Charge No Charge $50.00 per request $75.00 per hour CorcSourc4 Plan Supervisor - 1999 Human Resources APPENDIX B INSURANCE COVERAGES Worker's Compensation & Disability Statutory Limits Employer's Liability: Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease $100,000 each accident $ 500,000 policy limit $100,000 each employee Property damage, contractual liability, products-completed operations: General Aggregate Limit (other than Products/Completed Operations): $2,000,000 Products/Completed Operations: $2,000,000 Personal & Advertising Injury Limit: Each Occurrence Limit: Fire Damage (any one fire): Medical Expense Limit (any one person): Comprehensive Auto Liability Owned, hired and non-owned Bodily Single Limit: Injury and property damage $1,000,000 $1,000,000 $ 50,0O0 $ 5,000 Each accident $1,000,000 Umbrella Excess Liability Each occurrence and aggregate Maximum Deductible $5,OOO,O0O $ 10,000 Owner's Protective Insurance Per Occurrence: Aggregate: $5,000,000 $5,000,000 Professional Liability Insurance: Aggregate Per incident Deductible $2,000,000 $2,000,000 $ 100,000 Fidelity Bond $1,000,000 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A City of Carmel May7,1999 Sue Kauth, Vice President Operations CoreSource, Inc. P.O. Box 879 Anderson, Indiana 46015 Ms. Kauth: On May 5, 1999, the Board of Public Works and Safety approved a contract to do business with your company. Enclosed is a copy of the signed agreement. Please call Clerk-Treasurer Diana Cordray at 571-2414 if you have any questions. Sincerely, Rebecca L. Martin Deputy Clerk cc: file, dept ONE CIVIC SQUARE CARMEL, INDIANA 46032 317/57 D2400