ERISA/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