HomeMy WebLinkAboutIsland Group Admin - Caremark PCSRESOLUTION 2011~618
ADOPTED
DOC ID: 7090
THIS IS TO CERTIFY THAT THE FOLLO~NING RESOLUTION NO. 2011-618 WAS
ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON
AUGUST 30, 2011:
RESOLVED that the Town Board of the Town of Southold hereby authorizes and directs
Supervisor Scott A. Russell to execute an Addendum with Carcmark PCS and Island
Group Administration for programming in connection with the federal Early Retiree
Reinsurance Program at no cost to the Town of Southold, all in accordance with the approval of
the Town Attorney.
Elizabeth A. Neville
Southold Town Clerk
RESULT: ADOPTED [UNANIMOUS]
MOVER: Christopher Talbot, Councilman
SECONDER: William Ruland, Councilman
AYES: Ruland, Orlando, Talbot, Krupski Jr., Russell
Early Retiree Reinsurance Program Addendum
THIS Addendum ("Addendum"), is entered into by and among CaremarkPCS Health, L.L.C.
("Caremark"), Island Group Administration, Inc. ("Administrator"), and Southold Town acting
on its own behalf and as plan administrator on behalf of its group health plan ("Client") effective
June 1, 2010.
RECITALS
WHEREAS, Caremark provides prescription benefit management and other related services to
Administrator and Client's health benefit plan(s) in accordance with the terms of the Prescription
Benefit Management Services Agreement entered into with Administrator and/or the related
Caremark Prescription Benefit Services Agreement - Participating Group Agreement, entered
into with Client, or other agreement describing the financial and other terms applicable to the
services Caremark provides to Administrator and Client's plan(s) (each as amended from time to
time, collectively the "Agreement").
WHEREAS, the Department of Health and Human Services ("HHS") has adopted regulations at
45 CFR Part 149 implementing the federal Early Retiree Reinsurance Program ("ERRP") that
provides for reimbursement of certain health costs incurred by sponsors of participating
employment-based plans ("Reimbursement"); and
WHEREAS, Administrator and/or Client has informed Caremark that Client intends to apply for
the Reimbursement payments specified in 45 CFR Part 149 for its prescription drug coverage for
qualifying early retirees as defined in 45 CFR § 149.2 ("Early Retirees"); and
WHEREAS, Administrator and Client desire to have Caremark assist Client with applying for
such Reimbursement and, as mutually agreed, to assist Client with complying with HHS
requirements for obtaining and maintaining such Reimbursement.
Any capitalized terms used but not otherwise defined herein shall have the same meaning as such
terms as defined in the Agreement or, if not defined in the Agreement, in 45 CFR Part 149.
1. Caremark Responsibilities.
1.1 ERRP Reimbursement Services. Caremark will provide Client the services set
forth in this Addendum. Caremark may recommend changes to the services from time to time,
and may use Claims Information and other Protected Health Information (as defined in the
Agreemen0 to improve or recommend additional Services to Client, or suggest alternate drug
coverage options for Early Retirees, so long as such changes are consistent with the requirements
of the ERRP and do not materially alter any of the provisions of this Addendum or the
Agreement. Client, acting on behalf of its Plan, also authorizes Caremark to use and disclose
Protected Health Information as necessary to perform its services and otherwise assist the Plan in
submitting information to HHS on behalf of and as necessary to enable Client to claim the
Reimbursement from HHS.
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1.2 Application. Subject to section 2.2, upon Client's request, Caremark shall
provide the following to Client in support of its ERRP application(s):
a) With respect to those Chronic and High Cost Conditions identified by Client, a
description of Caremark's procedures and programs currently in place for the Client's Plan(s)
under the Agreement that may have generated or have the potential to generate cost savings with
respect to a plan participant with such a condition;
b) A description of Caremark's policies and procedures to protect against, detect and
reduce fraud, waste, and abuse in the Client's Plan as provided in the Agreement. Client
recognizes that Caremark's policies and procedures were not designed for purposed of the
ERRP, and thus, Caremark cannot and does not guarantee the suitability of this information for
purposes of the ERRP requirements.
1.3 Claims Cost Reporting. Caremark agrees to provide Claims costs incurred by
Client's Participants that am potentially Early Retirees based on date of birth of the primary
cardholder as of the effective date of the ERRP, as determined from Client's PBM eligibility
files (including the Client hierarchy) provided to Caremark ("Claims Report"). Caremark shall
include such Claims costs as Caremark reasonably believes meets the definition of a "health
benefit" cost as defined in 45 CR 149.2, net of any known Negotiated Price Concessions
provided by Caremark with respect to such Claims as required by 45 CFR 149.110 in sufficient
time to allow Client to submit such information to HHS within the time periods specified by
HHS. Client shall be responsible for combining such cost data with any medical cost data for
Client's Plan's Early Retirees, and for applying the cost threshold and limit as required by 45
CFR 149.100. Negotiated price concessions that are not included in the Claims Report because
they were not known at the time the report is provided to the Client will be reported to Client
within a reasonable period after the actual Negotiated Price Concessions become known to
Caremark, and Client shall be responsible for reporting these Negotiated Price Concessions to
HHS. Caremark agrees to respond to requests by Client with respect to records returned to it
from HHS related to the submission of the Client's Claims cost data. Client shall be responsible
for reviewing the Claims Report to determine whether Participants listed qualify as Early
Retirees and that the cost data meet HHS requirements before including the data from the Claims
Report in its submissions to HHS, including for purposes of reporting any data inaccuracies as
required by 45 CFR 149.600.
1.4 Supplemental Customized Reporting. Client may request customized reports
which will be subject to an additional fee as referenced in Attachment A. Client authorizes
Caremark to provide such customized reports as requested by Client consultant(s), which reports
shall be paid for by Client unless paid for by such consultant(s).
1.5 Non-Eligible Claims. In accordance with guidance provided by HHS, Caremark
will use its reasonable best efforts to include Claims for items eligible for coverage under
Medicare Parts A, B or D, using a list developed based on guidance provided by CMS. Client
acknowledges and agrees that it is ultimately responsible for determining which Claims costs to
submit for reimbursement under the ERRP, and for complying with the laws governing
determination of whether a Claim cost is eligible for reimbursement under the ERRP.
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NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND
CONSTITUTES TRADE SECRETS OF CAREMARK
2. Client Responsibilities.
2.1 Early Retiree Determination and List. Client shall be solely responsible for
determining whether a Plan Participant is an Early Retiree in accordance with 45 CFR 149.2 and
HHS guidance. Caremark shall have no responsibility to determine or confirm whether a
particular Plan Participant is an Early Retiree. Client shall be solely responsible for preparing
and submitting to HHS the Early Retirees list(s) for each reporting period as required by HHS.
2.2 Application. Client will be solely responsible for preparing and submitting ERRP
application(s) in order to be certified by HHS for participation in the ERRP.
2.3 Payments. Client shall receive all ERRP Reimbursements from HHS directly, and
Caremark shall have no responsibility for claiming, receiving or handling such payments.
2.4 Appeals. In the event that HHS makes an adverse reimbursement determination
with respect to Client, Caremark shall not be responsible for asserting an appeal request on
Client's behalf. Caremark will provide Client with such information concerning Claims costs as
retained by Caremark on Client's behalf under the Agreement as reasonably requested by Client
to exercise its appeal rights, but Client shall be solely responsible for submitting any request for
appeal or reopening in accordance with 45 CFR Part 149, Subpart F.
4. General Provisions.
4.1 Books and Records. Caremark shall maintain documentation of all Claims
processed for six (6) years. In addition, Caremark shall maintain, for a period of six (6) years, or
such longer period as may be required pursuant to 45 CFR § 149.350, books, records, documents
and other evidence of accounting procedures and practices directly related to the financial and
other aspects of its administration of the Plan consistent with 45 CFR §149.350. Subject to this
Section, all such records, while maintained by Caremark, shall be accessible by Client for
examination and audit during the term of and in accordance with the Agreement.
4.2 Audit Services. Caremark agrees to make available for audit by HHS or its
designee the Claims data and such other data in Caremark's possession concerning its Services
under the Agreement as required to be retained by the Agreement and disclosed pursuant to 45
CFR §149.350 for HHS to verify the Reimbursement requests made by Client.
4.3 Federal Funds. Pursuant to 45 C.F.R. §149.40(f)(4)(ii), Caremark acknowledges
that information it provides to Client pursuant to this Addendum may be used by Client for the
purpose of obtaining Federal Funds, as that term may be further described in the ERRP
application. Client is solely responsible for determining which Claims costs, if any, are eligible
for reimbursement under the ERRP.
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NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND
CONSTITUTES TRADE SECRETS OF CAREMARK
4.4 Regulatory Changes. The parties recognize that the ERRP and the ERRP
requirements and procedures are complex, and that subsequent administrative guidance or
requirements from HHS may materially alter the scope of services or manner in which the
services contemplated by this Addendum are to be provided. If either party believes that
subsequent guidance or requirements from HI-IS has materially altered the scope or manner in
which the services contemplated by this Agreement are to be provided, the rights or obligations
hereunder, or that any provision of this Addendum is inconsistent with ERRP requirements, that
party shall promptly notify the other party in writing, and the parties shall negotiate in good faith
to amend this Addendum.
4.5 Data Used and Submitted. The parties recognize that in satisfying its obligations
under this Addendum, Caremark may utilize and/or obtain and/or provide data that is developed
and maintained by third parties or Client, and that Caremark shall not be responsible for the
accuracy and completeness of such data provided to it. The parties also recognize that
Caremark's existing data sources, and those of its subcontractors, were not designed for
purposed of the ERRP. Thus, Caremark cannot and does not guarantee the accuracy of such
information and data for purposes of the ERRP.
4.6 Cooperation. The parties recognize that they must mutually cooperate to perform
the services required under this Addendum, and that Caremark is not responsible if it is unable to
complete any tasks because Client, or any third party contracted or designated by Client, fails to
meets is obligations, including providing required data.
All other terms and conditions of the Agreement shall remain in full force and effect.
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NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND
CONSTITUTES TRADE SECRETS OF CARE MARK
IN WITNESS WHEREOF, the parties hereto have caused this Addendum to be executed by their
respective duly authorized officers or agents as of the effective date first above written.
CAREMARKPCS HEALTH, L.L.C.
By:
Title:
Date:
ISLAND GROUP ADMINISTRATION, INC.
By:.
SOUTHO~OWN
Title:
Date:
Title:
Date:
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NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENT1AI~ PROPRIETARY AND
CONSTITUTES TRADE SECRETS OF CAREMARK
ATTACHMENT A
Fee Schedule
The fees set forth in this Attachment A are in addition to any fees set forth in the Agreement and
any Addendums or other Attachments thereto.
1. ERRP claims support - If standard reporting is requested by the Client, Caremark shall
provide the following services at no additional charge:
a. Prepare Claims Report (described in section 1.3) in standard layout consistent
with ERRP requirements, and up to the frequency specified by HHS.
b. Store Claims cost data in accordance with HHS record retention guidelines.
c. Provide Claims and support during HHS audits and Client appeals.
d. Account services team to review ERRP guidance and instructions and work
directly with Client on ERRP application, assistance with Early Retiree list,
responding to HHS queries and other ERRP issues.
~l'ated costs to 'produ'ug'ammfng fee of $5,600-
ce cost reports in addition
to-m~rm'e'-~~s under t~e g37g'~m~RRP
requirements.
Note: Above fees are contingent upon final HHS requirements. All reporting deliverables are
provided to the Client and not to HHS.
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NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND
CONSTITUTES TRADE SECRETS OF CAREMARK