HomeMy WebLinkAboutEarly Retiree Reinsurance ProgramRESOLUTION 2010-465
ADOPTED
DOC ID: 6001
THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2010-465 WAS
ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON
JUNE 29, 2010:
RESOLVED that the Town Board of the Town of Southold hereby authorizes and directs
Supervisor Scott A. Russell to execute an authorization letter in connection with the
administration of the U.S. Department of Health and Human Services Early Retirement
Reinsurance Program for the Town of Southold Employee Health Benefit Plan in accordance
with the approval of the Town Attorney.
Elizabeth A. Neville
Southold Town Clerk
RESULT: ADOPTED [UNANIMOUS]
MOVER: Vincent Orlando, Councilman
SECONDER: Albert Krupski Jr., Councilman
AYES: Ruland, Orlando, Talbot, Krupski Jr., Russell
ABSENT: Louisa P. Evans
'~ Ju,,J7, 2010 1:28PM ISLAND GROUP ADMINISTRATION No, 8395
,[s[anaC roup.gaCministratzon, Inc.
Corporate Offices
3 Toilsome Lone, East Hampton, New York 1 i 937
Phone: (631) 324-2306 or 1-800-926-2306
Fax: (631) 324-7021 or (631) 32%0152
TO: John Cushman
Southold Town
June 17,2010
FROM: Alan Kaplan
President
SUBJECT: Early Retiree Reinsurance Program
This is to inform you ora new federal program we have researched that may be of
interest to you. The Early Retiree Reinsurance Program will bo established by the U.S.
Department of Health and Human Services sometime within the next 3 months
(documentation entailed to you today). This program will provide reimbursement to
employment based plans for a portion of the cost of health benefits for early retirees and
their spouses, surviving spouses and dependents that are not eligible for Medicare. The
government has limited the funding for this program m $5 billion so it seems that the
sooner an application is submitted, the better chance you will have for admission into the
pro gram.
Since the application process fro. this program appears to be similar to the Retiree Drug
Subsidy Program, Island Group would be willing to assist in the application and claims
filing process and monetar~ recoveries on thc similar basis of compensation as the RDS
program. If you would like Island Group to administer this program, please sign below
and return this memo via fax to our office as soon as possible,
If Island Group will be assisting you in this process, we must ask that you look over the
emailed documentation regarding the program. Please c~oomplete as much information
as possible on the draft apnlieation and forward a copy to our office by Monda¥~ Juno
21.2010, We do not anticipate changes to the application and therefore would like to
have it ready for submission as the deadline approaches.
If you have any questions, please do not hesitate to contact our office,
Island Group Administration, Inc. Is hereby authorized to administer the U.S.
Department of Health and Human Servtces Early Retiree Reinsurance Program for
Southold Town.
Authorized Signature
Sonthold Town
Date
P, 1/1
'FO: John Cushman
Southold Town
June 17, 2010
FROM: Alan Kaplan
President
SUBJECT: Early Retiree Reinsurance Program
This is to inform you of a new federal program we have researched that may be of
interest to you. The Early Retiree Reinsurance Program will be established by the U.S.
Department of Health and Human Services sometime within the next 3 months
(documentation emailed to you today). This program will provide reimbursement to
employment based plans for a portion of the cost of health benefits for early retirees and
their spouses, surviving spouses and dependents that are not eligible for Medicare. The
government has limited the funding for this program to $5 billion so it seems that the
sooner an application is submitted, the better chance you will have for admission into the
program.
Since the application process for this program appears to be similar to the Retiree Drug
Subsidy Program, Island Group would be willing to assist in the application and claims
filing process and monetary recoveries on the similar basis of compensation as the RDS
program. If you would like Island Group to administer this program, please sign below
and return this memo via fax to our office as soon as possible.
If Island Group will be assisting you in this process, we must ask that you look over the
emailed documentation regarding the program. Please complete as much information
aS possible on the draft application and forward a copy to our office by Monday~ June
21, 2010. We do not anticipate changes to the application and therefore would like to
have it ready for submission as thc deadline approaches.
If you have any questions, please do not hesitate to contact our office.
Island Group Administration, Inc. is hereby authorized to administer the U.S.
Department of Health and Human Services Early Retiree Reinsurance Program for
SouthoM Town.
A orized Signature
Southold Town
OMB Approval 0938-1087
ERRP
Early Retiree Reinsurance Program Application
~ sggVlc~ ·
U.S. Department of Health and Human Services
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0 MB control
number. The valid OM B control number for this information collection la 0938-10BT. The time required to complete this information collection for this
write to: CMS. 7500 Security Boulevard, Atrn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore. Maryland 21244-lBS0.
HHS Form # CMS-10321
OMB Approval 0938-1087
Please note that if any information in this Application changes or if the sponsor discovers
that any information is incorrect, the sponsor is required to promptly report the change or
inaccuracy.
Send, using the U.S. Postal Service. a hardcopy of the signed original ERRP Application (i.e.
not a photocopy) and Attachments [if any) to:
HHS ERRP Application Center
4700 Corridor Place
Suite D
Beltsville, MD 20705
HHS Form #CMS-10321
Page 2
An asterisk I*/ identifies a required field.
PART i: Plan Sponsor and Key Personnel Information
OM[5 Approval 0938-1087
1) *Organization's Name (Must correspond with the information associated with the Federal Employer
Tax Identification Number (EIN): Town of $outhold
2) *Type of Organization (Check the one category that best describes your organization): [] Government
[] Union
[] Religious
[~] Commercial
[] Non-profit
3) *Organization's Employer Identification Number [E1N): 11 . 6001939
4) *Organization's Telephone Number: 631. 765.4333 ext..
5) Organization's FAX Number: 631. 765. 1366 ext.
6) *Organization's Address (must be the address associated with the EIN provided above):
* Street Line 1:53095 Route 25
Street Line 2: P- O. Box 1179
*City: Southold
*State: New York
*Zip Code: 11971
7) Organization's Website Address: southoldtown.northfork.net
B. Authorized Representative Information
1) *First Name: John Middle Initial:
*Last Name: Cushman
2l *Job Title: Town Comptroller
3) Date of Birth: Do not respond to this item now. To comply with the Application Instructions, you must provide this
at a later date if and when the application is approved.
4) Social Security Number: Do not respond to this item now. To comply with the Application Instructions, you must
provide this at a later date if and when the application is approved.
5) *Email Address: john.cushman@town.southold.ny.us
6) *Telephone Number: 631.765.4333 ext.
7) FAX Number: 631. 765~1366 ext.
8) *Employer Name: Town of Souihold
HHS Form #CMS-10321
Page 3
OMB Approval 0938-1087
9) * Authorized Representative Business Address:
· Street Line 1: §309§ Route 26
Street Line 2: ?. O. Box 1179
· City: Southold
*State: New York
*Zip Code: 11971
C. Account Manager Information
1) *First Name: Alan Middle Initial: D
*Last Name: Kaplan
2) *lob Title: President
3) Date of Birth: Do not respond to this item now. To comply with the Application instructions, you must provide this
at a later date if and when the application is approved.
4) Social Security Number: Do not respond to this item now. To comply with the Application Instructions, you must
provide this at a later date if and when the application is approved.
5) *Email Address: adkl@optonline.net
6) *Telephone Number: 631.324.2306 ext.
7) FAX Number: 631 - 324- 7021 ext.
B) *Employer Name: Island Group Administration, Inc.
9} *Account Manager Business Address:
* Street Line 1:3 Toilsome Lane
Street Line 2:
*City: East Hampton
*State:. New York
*Zip Code: 11937
HHS Form #CMS-10321
Page 4
OM8 Approval 0938-1087
PART II: Plan Information
A. Plan Information
*Plan Name: Town of Southold
2) *Plan Year Cycle: Start Month/Day: ~ / ~ End Month/Day: 12 / 31
B. Benefit Option(s) Provided Under This Plan {lf the plan has more than one benefit option for
which you intend to seek program reimbursement, please include the information below for
each benefit option, on a separate copy of the Attachment below.}
la) *Benefit Option Name: Town of Southold Retirees
lb) *Unique Benefit Option Identifier: TOS Retiree
lc) *Benefit Option Type: Self-Funded ~-] Insured [~ Both[---]
ld) *Benefit Administrator Company Name: Island Group Administration, Inc.
HHS Form #CMS-10321
Page S
OMB Approval 0938-1087
C. *Programs and Procedures for Chronic and High-Cost Conditions
A sponsor cannot participate in the Early Retiree Reinsurance Program unless, as of the date of its
application for the program is submitted, its employment-based plan has in place programs and
procedures that have generated or have the potential to generate cost savings with respect to plan
participants with chronic and high cost conditions. The program regulations define "chronic and high
cost condition" as a condition for which $15,000 or more in health benefit claims are likely to be
incurred during a plan year by one plan participant. Please identify the chronic and high cost conditions
for which the employment-based plan has such programs and procedures in place, and summarize
those programs and procedures, including how it was determined that the identified conditions satisfy
the $15,000 threshold. If necessary to provide a complete response, the sponsor may submit additional
pages as an attachment to the application. Please reference such attachment in this space.
Wellness Program
Diabetic Management Program
Medical Management Program
Annual Physical
Annual Lab Evaluation
Annual Mammography
Rx Drug Management Program
Medical Review/Evaluation provided by Plan Administrator
le Programs cited above are all in effect and are designed to reduce or control costs via wellness programs
advocacy programs.
HHS Form #CMS-10321
Page 6
OMB Approval 09B8-1087
D. *Es~mated Amount of Early Retiree Reinsurance Program Reimbursements
Please estimate the projected amount of proceeds you expect to receive under the Early Retiree
Reinsurance Program for the plan identified in this application, for each of the first two plan year cycles
identified in this application. If you wish, you may provide a range of expected program proceeds that
includes: (1) a low-end estimate of expected program proceeds, (2) an estimate that represents your
most likely amount of program proceeds, and (3) a high-end estimate of expected program proceeds.
For purposes of this estimate only, please assume for each of those plan year cycles that there will be
sufficient program funds to cover all claims submitted by the Plan Sponsor that comply with program
requirements. If necessary to provide a complete response, the sponsor may submit additional pages as
an attachment to the application. Please reference such attachment in this space.
Low $30,000 Medium $45,000 High $50,000
This information was compiled on the period of review 711109-6130110 of actual utilization of the health program
! early retirees.
HH$ Form #CMS-10321
Page 7
OMB Approval 0938-1087
E. *Intended Use of Early Retiree Reinsurance Program Reimbursements
1) Please summarize how your organization will use the reimbursement under the Early Retiree
Reinsurance Program to reduce health benefit or health benefit premium costs for the sponsor of
the employment-based plan (i.e., to offset increases in such costs); or reduce, or offset increases in,
premium contributions, copayments, deductibles, coinsurance, or other out-of-pocket costs (or
combination of these) for plan participants; or reduce a combination of any of these costs (whether
offsetting increases in sponsor costs or reducing, or offsetting increases in, plan participants' costs).
If necessary to provide a complete response, the sponsor may submit additional pages as an
attachment to the application. Please reference such attachment in this space.
1. To maintain highest level of benefits
2. To reduce and/or offset retiree contributions
3. To minimize changes in deductibles, co-insurance and co-pays
4. To reduce the cost to the town of maintaining a self-funded retiree health plan.
HHS Form #CMS-10321
Page 8
OMB Approval 0938-1087
E. *Intended Use of Early Retiree Reinsurance Program Reimbursements {continued)
2)
Ifa sponsor decides to apply ~he reimbursement for its own use, it may only use the reimbursement
to offset increases in its health benefit premium costs, if an insured plan, or its health benefit costs,
if it is self-funded. If any amount of the reimbursement is used to offset increases in health benefit
premium or health benefit costs of your organization {~as opposed to offsetting increases to, or
reducing, plan participants' costs), please summarize how program funds, as a result of being used
by your organization for such purposes, will relieve your organization of using its own funds to
subsidize such increases, thereby allowing your organization to instead use its own funds to
maintain its level of financial contribution to the employment-based plan. (In other words, please
explain how your organization will continue to maintain the level of support for this plan, and if it
applies the reimbursement for its own use, will use the program reimbursement to pay for
increases in health benefit premium costs or health benefit costs, as applicable). If necessary to
provide a complete response, the sponsor may submit additional pages as an attachment to the
application. Please reference such attachment in this space.
The reimbursement will be utilized as stated in E.1. above and will be used to defray increases to retiree
contributions and as an offset to cost of paying for claims in excess of $15,000,
HHS Form #CMS-~t0321
Page 9
OMB Approval 0938-1087
PART III: Banking Information for Electronic Funds Transfer
1) *Bank Name: Capitol One Bank
2) *Bank Address:
* Street Line 1:40 Newtown Lane
Street Line 2:
*City: East Hampton
*State: New York
*Zip Code: 11937
3} *Account Number: 1724018443
4} *Name of Organization Associated with Account: Island Group Administration, Inc,
5) *Account type: [Checking or Savings Account) Checking
6) *Bank Routing Number: 021407912
7) *Bank Contact Name:
*First Name: Noe[le
*Last Name: Bass
8) *Email address: BranchO17@capitolonebank.com
9} *Telephone Number: 631.324.7230 ext.
Middle Initial:
HHS Form #CMS-10321
Page 10
OMB Approval 0938-1087
PART IV. Plan Sponsor A§reement
L Compliance: In order to receive program reimbursement(s), Plan Sponsor agrees to comply with
all of the terms and conditions of Section 1102 of the Patient Protection Act (P.L. 111-145) and 45
CF.R .Part 149 and in other guidance issued by the Secretary of the U.S. Department of Health &
Human Services (the Secretary), including, but not limited to, the conditions for submission of data
for obtaining reimbursement and the record retention requirements.
2. Reimbursement-Related and Other Representations Made by Designees: Plan Sponsor may be
given the opportunity to identify one or more Designees 0.e., individuals the Sponsor will authorize
to perform certain functions on behalf of the Sponsor related to the Early Retiree Reinsurance
Program, such as individual(s) who will be involved in making program reimbursement requests).
Plan Sponsor certifies that all individuals that will be identified as Designees will have first been
given authority by the Plan Sponsor to perform those respective functions on behalf of the Plan
Sponsor. Plan Sponsor understands that it is bound by any representations such individuals make
with respect to the Sponsor's involvement in the Early Retiree Reinsurance Program, including but
not limited to the Sponsor's reimbursement under, the program.
3. Written Agreement: Plan Sponsor certifies that, prior to submitting a Reimbursement Request, it
has executed a written agreement with its health insurance issuer or employment-based plan
regarding disclosure of information, data, documents, and records to HHS, and the issuer or plan
agrees to disclose to HHS, on behalf of the Plan Sponsor, at a time and in a manner specified by the
HHS Secretary in guidance, the information, data, documents, and records necessary for the Plan
Sponsor to comply with the requirements of the Early Retiree Reinsurance Program, as specified in
45 C.F.R. 149.35.
4. Use of Records: Plan Sponsor understands and agrees that the Secretary may use data and
information collected under the Early Retiree Reinsurance Program only for the purposes of, and to
the extent necessary in, carrying out Section 1102 of the Patient Protection Act (P.L 111-148] and
45 C.F.R. Part 149 including, but not limited to, determining reimbursements and reimbursement-
related oversight and program integrity activities, or as otherwise allowed by law. Nothing in this
section limits the U.S. Department of Health & Human Services' Office of the Inspector General's
authority to fulfill the Inspector General's responsibilities in accordance with applicable Federal
law.
5. Obtaining Federal Funds: Plan Sponsor acknowledges that the information furnished in its Plan
Sponsor application is being provided to obtain Federal funds. Plan Sponsor certifies that it
requires all subcontractors, including plan administrators, to acknowledge that information
provided in connection with a subcontract is used for purposes of obtaining Federal funds. Plan
Sponsor acknowledges that reimbursement of program funds is conditioned on the submission of
accurate information. Plan Sponsor agrees that it will not knowingly present or cause to be
presented a false or fraudulent claim. Plan Sponsor acknowledges that any excess reimbursement
made to the Plan Sponsor under the Early Retiree Reinsurance Program, or any debt that arises
from such excess reimbursement, may be recovered by the Secretary. Plan Sponsor will promptly
update any changes to the information submitted in its Plan Sponsor application. If Plan Sponsor
becomes aware that information in this application is not (or is no longer) true, accurate and
HHS Form #CMS-10321
Page 11
OMB Approval 0938-1087
complete, Plan Sponsor agrees to notify the Secretary promptly of this facL
6. Data Security: Plan Sponsor agrees to establish and implement proper safeguards against
inauthorized use and disclosure of the data exchanged under this Plan Sponsor application. Plan
Sponsor recognizes that the use and disclosure of protected health information (PHI) is governed
by the Health Insurance Portability and Accountability Act (HIPAA) and accompanying regulations.
Plan Sponsor certifies that its employment-based plan(s) has established and implemented
appropriate safeguards in compliance with 45 C.F.R. Parts 160 and 164 (HIPAA administrative
simplification, privacy and security rule) in order to prevent unauthorized use or disclosure of such
information. Sponsor also agrees that if it participates in the administration of the plan(s), then it
has also established and implemented appropriate safeguards in regard to PHI. Any and all Plan
Sponsor personnel interacting with PHI shall be advised of: (1) the confidential nature of the
information; (2} safeguards required to protect the information; and (3) the administrative, civil
and criminal penalties for noncompliance contained in applicable Federal laws.
7. Depository Information: Plan Sponsor hereby authorizes the Secretary to initiate
reimbursement, credit entries and other adjustments, including offsets and requests for
reimbursement, in accordance with the provisions of Section 1102 of the Patient Protection Act
(P.L. 111-148} and 45 C.F.R Part 149 and applicable provisions of 45 C.F.R. Part 30, to the account at
the financial institution (hereinafter the "Depository") indicated under the Electronic Funds
Transfer (EFT} section of the Plan Sponsor application. Plan Sponsor agrees to immediately pay
back any excess reimbursement or debt upon notification from the Secretary of the excess
reimbursement or debt. Plan Sponsor agrees to promptly update any changes in its Depository
information.
8. Policies and Procedures to Detect Fraud, Waste and Abuse. The Plan Sponsor attests that, as of
the date this Application is submitted, has in place policies and procedures to detect and reduce
fraud, waste, and abuse related to the Early Retiree Reinsurance Program. The Plan Sponsor will
produce the policies and procedures, and necessary information, records and data, upon request by
the Secretary, to substantiate existence of the policies and procedures and their effectiveness, as
specified in 4[; C.F.R. Part 149.
9. Change of Ownership: The Plan Sponsor shall provide written notice to the Secretary at least 60
days prior to a change in ownership, as defined in 45 C.F.R, 149.700. When a change of ownership
results in a transfer of the liability for health benefits costs, this Plan Sponsor Agreement is
automatically assigned to the new owner, who shall be subject to the terms and conditions of this
Plan Sponsor Agreement.
Signature of Plan Sponsor Authorized Representative
I, the undersigned Authorized Representative of Plan Sponsor, declare that 1 have legal authority to
sign and bind the Plan Sponsor to the terms of this Plan Sponsor Agreement, and I have or will
provide evidence of such authority. 1 declare that I have examined this Plan Sponsor Application
and Plan Sponsor Agreement. My signature legally and financially binds the Plan Sponsor to the
statutes, regulations, and other guidance applicable to the Early Retiree Reinsurance Program
including, but not limited to Section 1102 of the Patient Protection ACt (P.L. 111-148) and 45 C.F.R.
Part 149 and applicable provisions of 45 C.F.R. Part 30 and all other applicable statutes and
regulations. I certify that the information contained in this Plan Sponsor Application and Plan
Sponsor Agreement is true, accurate and complete to the best of my knowledge and belief, and 1
authorize the Secretary to verify this information. I understand that, because program
HHS Form #CMS-10321
Page 12
OMB Approval 0938-1087
reimbursement will be made from Federal funds, any false statements, documents, or concealment
ora material fact is subject to prosecution under applicable Federal and/or State law.
Signature: ~.~ C.~o~--
HHS Form #CMS-10321
Page 13
OMB Approval 0938-1087
Attachment: Additional Benefit Options
{Complete this form for each unique benefit option not already specified above
in Part II.B)
la) *Benefit Option Name:
lb) *Unique Benefit Option Identifier:
lc) *Benefit Option Type: Self-Funded[--~ Insured[~
ld) *Benefit Administrator Company Name:
Both []
HHS Form #CM5-10321
Page14