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Home My WebLink AboutERISA/HRA/o. o,1. THIRD AMENDMENT TO THE PLAN SUPERVISORY AGREEMENT FOR CITY OF CARMEL APPl~rr~, AS lO APPENDIX A ADMINISTRATIVE AND ADDITIONAL SERVICE FEES Effective for Renewal Period from February 1, 2002 through January 31, 2003 The following information is being provided to the undersigned pursuant to Prohibited Transaction Class Exemption 84-24 issued by the U.S. Deparmaent of Labor in order to exempt the proposed transactions between the Plan, the Employer and Plan Supervisor from any applicable prohibited transaction or provisions of ERISA. The following information is being provided to permit the Employer, as Plan Administrator to determine the compensation received _by the Plan Supervisor in the form of commissions, se~ic~ £ees and other similar payments is reasonable, that the services provided are necessaw for-the operation of the Plan and the provision of services by the Plan Supervisor is in the best interest of the Plan. The commission, service fees, compensation arrangements and other similar payments to be provided under the Agreement are as set forth below. It is understood, however, that PPO Access Fees and other vendor fees, if applicable, are subject to the terms and conditions of the underlying agreement and may be subject to change at times other than the renewal date of this agreement. I. Pursuant to the Agreement for Plan Supervisor, the Employer shall remit to Plan Supervisor the following administrative fees and other costs: Description of Service * Medical Administration Fee · Dental Administration Fee $12.00 per employee per month $2.00 per employee per month II. In addition to the basic administrative services listed above, the Employer has agreed that the following services (i.e., those for which the box has been checked) are to be performed by the Plan Supervisor pursuant to the terms and conditions set forth in the Agreement. COBRA Addendum Description of Fee · COBRA Administration Fee $1.00 per employee per month ~' HIPAA Addendum Description of Fee · HIPAA Administration Fee $.50 per employee per month Health Care Management Addendum Description of Fee · Inpatient Utilization Review & & Large Case Management Fee $2.90 per employee per month Flexible Benefits Addendum Description of Fee · Flex Administration Fee $4.25 participant per month Preferred Provider Arrangement Addendum (CoreSource Contracts) Description of Fee · Sagamore Access Fee $3.06 per participant per month Preferred Provider Arrangement Addendum (Employer Contracts) Description of Fee · N/A Subrogation Services Addendum Description of Fee · Subrogation Fee See Attached Addendum Prescription Drug Card Administration Addendum Description of Fee · Per Transaction Charges $.50 per prescription Other Services and Expense Reimbursements Description of Fee · PPO Interface Fee · Broker Fee · Re-enrollment Fee · Hospital Bill Audits Size of Original Hospital Bill $0- $20,000 $2o,ool-$5o ooo Over$50,O00 · Physician Reviews $.25 per participant per month $2.50 per employee per month $350.00 annual fee Actual Cost Amount of Fee $14.30 per thousand of original bill $13.20 per thousand of original bill $12.10 per thousand of original bill Actual Cost · Medical Records Fees · Printing Costs · Directory Costs · Other Miscellaneous Expenses · Plan Amendments · Restatement of Plan Document · Standard Reporting Package Actual Cost Actual Cost Actual Cost Actual Cost $50.00 per amendment $500.00 Included in medical administrative fee III. Commissions on insurance policies, as described in the attached Renewal Acceptance Confu'mation, if applicable, are payable as set forth below. Specific Stop Loss Single Specific Stop Loss Family Aggregate Stop Loss Other Insured Coverages Premium Commission Payable To: CoreSource Broker $26.97 0% 15% $65.151- 0% 15% $6.01) 0% 15% Life AD&D VSP $.23 0% 15% $.04 0% 15% Refer to contract for applicable rates [The next page is a signature page] 3 ACKNOWLEDGMENT AND APPROVAL The undersigned Plan Administrator hereby certifies that he (1) is authorized to sign on behalf of the Employer and the Plan, (2) acknowledges receipt of the foregoing explanation of services and fees and has read and understands it, and (3) approves the purchase of such insurance (if applicable) and the payment to Plan Supervisor of such sales commissions, service fees and other compensation arrangements as listed. EMPLOYER PLAN ADMINISTRATOR Signature Signature Print Name Print Name Title: Title: Date: Date: CORESOURCE, INC. Signature J Sue Kauth Print Name Title: Vice President, Operations Date: ~t ~ ,~ ~ City Signature Page Attached 4 Subrogation Services Addendum 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 Agreement equal to twenty-five percent (25%) of the gross amount recovered for such claim. 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 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. RENEWAl, ACCEPTANCE CONFIRMATION Please respond with the information that corresponds with the renewal conditions accepted by your Company and return an endorsed copy to CoreSource, Inc. SPECIFIC STOP LOSS COVERAGE 1. Contract Basis X Paid (Phoenix American Life) For a claim to count towards the reinsurance cap, a claim only needs to be paid within the reinsurance year, but the date of service is limited to the original inception date of the contract. No claim received by CoreSouree, Inc. in the last 10 business days of the reinsurance year will be counted towards the cap. __ Incurred in 24 months; Paid in 12 months ~: _ (ABC Stop loss) For a claim to count towards the reinsurance cap, a claim needs to be paid within the reinsurance year and the date of service can be 365 days prior to the reinsurance year. No claim received by CoreSource, Inc. in the last 10 business days of the reinsurance year will be counted towards the cap. For CoreSource, Inc. to be able to pay a claim, all necessary information must be received by CoreSource, Inc. before the last 10 business days of the year for us to process and pay the claim. No claim received by CoreSource, Inc. in the last 10 business days of the reinsurance year will be counted towards the cap. 2. Specific Stop-Loss Deductible (Indicate level that has been accepted) $ 70,000 AGGREGATE STOP LOSS COVERAGE X Yes __ No Stop Loss Carrier Chosen: Phoenix American Life Specific Stop Loss commissions of 15% are payable to DeTmde & Company and commissions of 0% are payable to CoreSouree, Inc. Aggregate Stop Loss commissions of 15% are payable to DeTrude & Company and 0% are payable to CoreSource, Inc. It is understood that the Aggregate Factor stated in the Renewal Cost Summary and quote in conjunction with the Specific Deductible indicated above is applicable on the renewal date. It is also understood that any increase in CoreSouree, Inc. administrative fees as stated in the Renewal Cost Summary are effective on the renewal date. Renewal Date: 2/1/02 Company: City of Carmel By: Date: CITY OF CARMEL, INDIANA By and through its Board of Public Works and Safety J~l~e's Brainard, Presiding Office nn~u~ke, Board Member Date Date Board Member Date ATTEST: Diana Cordra~y,~vlC, C4[~rk-T-r~asu~[r Date