HomeMy WebLinkAboutIsland Group AdminRESOLUTION 2013-446
ADOPTED
DOC ID: 8859
THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2013-446 WAS
ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON
JUNE 4, 2013:
RESOLVED that thc Town Board of thc Town of Southold hereby authorizes and directs
Supervisor Scott A. Russell to execute an agreement with Island Group Administration,
Inc. for the administration of the Town of Southold Employee Health Plan for the 2013 calendar
year, said agreement subject to the approval of the Town Attorney.
Elizabeth A. Neville
Southold Town Clerk
RESULT: ADOPTED [UNANIMOUSI
MOVER: Jill Doherty, Councilwoman
SECONDER: Louisa P. Evans, Justice
AYES: Dinizio Jr, Ruland, Doherty, Talbot, Evans, Russell
ORIGINAL
Isfancf roup cfministration, Inc.
Corporate Offices
3 Toilsome Lane, East Hampton, New York 11937
Phone: (631) 324-2306 or 1-800-926-2306
Fax: (631) 324-7021 or 631) 329 0152
ISLAND GROUP ADMZNISTRATION, ~NC. (IGA , a New York Corporation,
with corporate offices located at 3 Toilsome Lane, East Hampton,
New York 11937, agrees to render Health Benefits Services to its
self-insured client:
TOWN OF SOUTHOLD
53095 Main Road
Southold NY 11971
for a period of ONE (1) year, commencing on the 1st day o£
January 2013, and terminating on the 31st c~ay of December 2013.
ISLAND GROUP ADMINISTR3tTION AGREES TO:
1. PROGRAM DEVELOPMENT
A)
Consult with key personnel of your staff on the
necessary procedures, practices and coordination to
meet your summary plan requirements.
B)
Participate in the orientation of all your staff
involved directly or indirectly in the processing of
health related claims.
c)
Provide information on changes in legislation, rules
and regulations affecting the self-insured employer.
D)
Employ an automated claims-processing system. Reports
generated by this system can be customized to meet the
self-insured's needs, if required.
E)
Design and prepare the necessary claims media or assist
in the modification of existing media where required.
Typically, this material consists of: 1) enrollment
cards; 2) identification cards; 3) prescription drug
cards; 4) claim forms; 5)checks; 6)E.O.B.s, 7) PPO
Booklets, etc. The cost of printing the required media
is an expense of the self-insured.
2. ADMINISTRATION
A)
Maintain "hard" claim files, which shall be available
to the self-insured at reasonable times for inspection
iSLAND GROUP
B)
C)
F)
G)
or audit. The self-insured has the right to employ an
independent auditor to perform an audit. All costs
associated with the audit are the financial
responsibility of the self-insured.
Maintain current estimates of the cost of all
anticipated benefits on each case.
Island Group will recommend on behalf of the
self-insured what benefits, if any, should be paid or
rendered in accordance with the summary plan booklet,
and make such payments on behalf of the self-insured
from funds supplied by the self-insured, under a system
agreeable to both the self-insured and Island Group
Administration.
Conduct investigations of cases by our staff as in its
judgment are deemed necessary.
Arrange where necessary for medical evaluation on
behalf of the self-insured by consultants, as the
summary plan will allow. The cost of these consultants
will be borne solely by the self-insured.
Conduct a pre-admission review (PAR) of elective
surgery, if necessary. Findings will be rendered to the
self-insured and covered individuals.
Hospital reviews will be conducted weekly and/or as
necessary. Cases that will be reviewed are as follows:
1) Ail New York hospital billings will be reviewed for
accuracy, coding and pricing.
2) Medicare EOBs will be examined for accuracy and
payment.
3) Charges not justified by length of stay.
Charges unrelated or normally unassociated with
treatment.
5) Charges in excess of Reasonable and Customary, or in
excess of the Medicare allowance for the procedures.
6) Any unusual treatment or charges will be
investigated.
H)
~)
J)
K)
7)
Reports will be rendered monthly, to the
self-insured as to any and all "providers" who
consistently exceed reasonable and customary
charges.
Provide a Participating Provider Network (Physician
PPO) for the benefit of the self-insured and covered
individuals. The listing of Practitioners, Labs, etc.,
will be provided to the self-insured. The listing of
PPO members will be updated as necessary. The cost of
printed media in the form of a PPO Practitioner's
Booklet will be the responsibility of the self-insured.
Access fees for Hospital Discount Networks, for
example, Galaxy Inc., Peconic Services, Inc., etc, and
non Island Group Practitioner PPOs are the
responsibility of the self-insured. The cost(s) of
accessing the Island Group practitioner PPO is included
in the capitated service fee expressed in this contract
in Section 5.
Perform the necessary functions to satisfy the dictates
of the Federal Statutes regarding C.O.B.R.A., ERISA and
all other applicable statutes that govern self insured
Employee Health Plans.
Island Group Administration, Inc., agrees to maintain
professional liability insurance coverage of an amount
not less than $1,000,000, and to additionally maintain
fidelity bond coverage on all Island Group employees,
in the amount of $75,000. The amount of the fidelity
bond shall be determined by the self-insured as of the
effective date of this agreement and shall be subject
to change as of each anniversary of this agreement, or
more frequently if the self-insured deems there has
been a significant change in the total amount of funds
handled by Island Group. The fidelity bond shall state
that loss, if any, involving money or the property
belonging to the self-insured shall be payable to the
Town, as its interest may appear. The bond shall also
contain a statement that if the bond is cancelled,
written notice shall be given to the self-insured,
thirty (30) days prior to such cancellation.
Island Group will segregate the Town's claims
reimbursement funds in a separate bank account. Funds
on deposit will be collateralized in accordance with
the recommendations on investment issued by the
3
L)
M)
N)
Comptroller of the State of New York. It is agreed
that Island Group will be deemed to be in full
compliance with this requirement as long as the total
funds on deposit do not exceed $100,000 and are held in
a bank account with FDIC insurance. When funds on
deposit exceed the FDIC limits, 102% collateral is to
be deposited into a third party custodial account to be
established by, and on behalf of the Town, written
notice given to the self-insured.
Island Group agrees to take such measures as may be
necessary to protect the confidentiality of claims and
records.
Island Group will maintain and process claims on behalf
of the Town at the level of benefits determined by the
self-insured. Island Group will institute benefit
revisions to the summary plan of benefits for the self
insured as those benefits are amended by the self-
insured. Revisions to the benefits will be made only
with the prior written authorization of the Town
unless such change is mandated by law. Revision of the
benefits as instituted by the self insured will subject
the service fees to be amended based upon any
additional service responsibilities that must be
assumed as a result of these amendments by Island Group
Administration, Inc.
Island Group Administration, Inc., in order to
facilitate thorough and efficient plan administration,
shall provide the following additional services:
1) Toll-free "800" telephone access to plan
administrators;
2) Ease of access to claims service representatives,
or their superiors;
3)
Timely response to inquiries or need for
assistance regarding the plan or their individual
claims;
4) Expeditious claims processing and turnaround time
on appropriately submitted claims.
3. REPORTING
A)
We will provide reports for the self-insured on a
weekly, monthly, and annual basis. Our reports
generally consist of check registers, E.O.B.s, drafts,
and an analysis of what each particular component
benefit costs the self-insured.
B)
A census report listing all enrollees and their
dependents covered shall be provided to the
self-insured on a monthly basis.
c)
Per diem hospital costs will be established and
tracked.
D)
Special reports can be made available should the
self-insured desire. Our automated system can interface
with available health management reports and be made
available to the self-insured. A comprehensive listing
of all "special" reports will be provided upon request.
The cost of reports that require custom programming to
prepare will be at the expense of the self-insured.
The self-insured's approval for said costs, will be
required prior to the preparation of these special
reports.
4. INS~CE SERVICES AND CONSULTING
A)
Insurance- We will review annually the specific and
aggregate insurance with the self-insured, including
coverage and premium charges.
B)
We will discuss with your personnel the impact of
changes in the summary plan, as it may affect
reinsurance costs.
c)
We will assist in securing the health reinsurance for
the self-insured after reviewing the marketplace, and
determining which carrier is offering the best coverage
and terms for the premium dollar. The self-insured's
approval is required prior to securing the reinsurance.
D)
Island Group Administration, Inc. shall bill the Town
for reinsurance premiums and shall remit said payments
to the reinsurance carrier.
5
o
RETIREE DRUG SUBSIDY/M~DICAR~ PART D
Island Group Administration can provide complete
administration of a client's Medicare eligible retiree Part D
Drug reimbursement through RDS Medicare. This administrative
function is optional, and services and fees will be added to
this contract by the attached addendum and mutual agreement.
6° SERVICE FEE
A)
This agreement is in the nature of a service agreement,
and does not constitute, nor is it meant to be, an
insurance policy, an agreement of insurance, or an
agreement to provide insurance.
B)
The fees billable by I.G.A.I. shall be based upon a
capitated rate of $23.00 per eligible employee and or
retiree. Additional eligible individuals and spouses
shall be included at the per month capitated rate of
$23.00 each. Additions and deletions to the eligible
census shall be included for billing purposes on the
1st calendar day of the month following such
addition(s) and deletion(s) to the eligible census.
c)
Island Group Administration, Inc., shall bill the
Town on or before the 1st day of each month
for services to be rendered on behalf of the Town
for that month. Payments shall be received by the 15th
day of the month.
D)
The costs and expense of any litigation or dispute
between the Town and/or Island Group Administration, as
agent for the Town, and a covered individual under the
health plan shall be the responsibility of the self-
insured, except if the litigation is the result of, or
in connection with the negligence, willful misconduct,
or fraud of Island Group Administration, Inc, its
agents, servants and/or its employees.
7. TERMINATION
A)
This agreement may be terminated by the self insured
upon 90 days prior written notice, and by Island
Group Administration, Inc., with 90 days prior written
notice, to the addresses indicated herein by regular
mail or certified mail, return receipt requested.
B)
Upon the termination of this agreement by either party,
Island Group shall within 30 days after the date of
termination, deliver to the Town a complete and final
accounting report as of the date of termination of this
agreement. All books and records in its possession and
control relating to the administration of the plan,
except any records that Island Group is required by law
to retain, if any, shall be returned within 30 days of
the effective date of this termination.
c)
In the event of a breach of any material term of this
agreement, the self-insured may terminate this
agreement immediately, without any further
responsibility. The unprocessed and unpaid claims held
by I.G.A.I., and those claims that are received after
such termination by I.G.A.I., will be returned to the
self-insured. The processing and payment of these
claims will become the responsibility of the self-
insured.
8. MISCELLANEOUS PROVISIONS
A) If any provision of this agreement is not immediately
enforced or is held invalid or unenforceable, such lack
of enforcement or unenforceability shall not weigh
future enforcement nor affect any of the other
provisions. If any provision is unenforceable, this
agreement shall be construed and enforced as if such
provision had not been included.
B)
This agreement may be amended by the parties at any
time by mutual written consent provided, however, that
this agreement may not be amended to reduce any
benefits which might be paid for any claim prior to the
amendment or in any way prejudice such a claim.
IN WITNESS WHEREOF, the following affix their signatures:
ISLANDG~~INISTRATION, INC. TOWNO~OUTHO£D
/ ~//~TITLE} t ~ . . ~ ~(TITLE)/ ~
WITNESS:
7
Island Grou~ Administration~ Inc
A~nistrative Service Agreement
Supplemental Services
Medicare Part D A~nistration
Island Group Administration, Inc. (administrator) agrees to
provide the following additional services for the Town of
Southold in conjunction with the client's pharmacy benefit
manager for an additional service fee as expressed below, for
the period 1/1/13-12/31/13:
1. Satisfying Creditable Coverage Notice Requirements under
Medicare Part D.
2. Preparing Medicare Part D subsidy application(s),
· Assessing drug coverage funding and relevant
options".
including:
"benefit
As your authorized representative to register at the
Retiree Drug Subsidy web page maintained by CMS
(Medicare), obtain a logon ID, and establish an
electronic signature.
· Serving as the Account Manager for the Subsidy
Application, performing the following tasks within the
Retiree Drug Subsidy ("RDS") secure web site maintained
by CMS:
- Obtain unique Plan Sponsor ID number
- Obtain unique application ID number
- Provide secure, dedicated e-mail address for CMS
communications
- Complete all portions of the Application Form,
including General Contact Information, Qualified
Basic Plan Information, Actuary Assignment,
Electronic Fund Transfer, Payment Frequency
arrangements, Retiree List Submission with 12
fields of formatted demographic and other
information for each Medicare Eligible
Individual.
· Assist plan actuary in providing electronic actuarial
attestation
· As your authorized representative provide electronic
signature of the Subsidy Application.
3. Receiving and electronically responding to any CMS partial
or complete rejections of the Subsidy Application within the
required period.
4. Electronically updating the Retiree file on an ongoing
basis, including during Subsidy Payment process, using the
RDS Medicare format.
5. Work with your Pharmacy Benefit Manager in the preparation
and filing of quarterly Subsidy Payment Requests, which
entail the following tasks:
· Identifying and adjusting for non-Part D drugs.
· Calculating the subsidy amount for each covered person.
· Aggregating the individual covered person's subsidy
calculations.
Electronically submitting cost data for all of the
qualifying covered individuals in each Benefit Option
(multiple submissions if multiple Benefit Option('s),
including:
- Aggregate gross retiree costs (drug only)
Aggregate threshold ($250) reduction
- Aggregate limit ($5,000) reduction
- Estimated cost adjustments
- Reconciling any changes for the previous payment
requests.
· Providing electronic confirmation to CMS that cost data
is to be included in the subsidy payment request.
· Reviewing any and all subsidy payment rejections and
making any appropriate appeals.
· Electronically submitting payment request on behalf of
the Plan Sponsor.
· Confirming receipt of Electronic Funds Transfer deposit
with plan sponsor.
· Responding to any questions, demands or denials issued
by CMS, which may include;
- Filing a 15-day appeal of a denied subsidy
payment
- Requesting a hearing within 15 days of a denied
appeal
- Requesting a reopening of a denial
6. Working with your Pharmacy Benefit Manager in performing the
annual subsidy reconciliation as required by CMS within 15
months after the end of the plan year. This task includes
the electronic filing of the following data for each covered
individual for each month
Subsidy application number
- Unique benefit option identifier applicable to
that covered individual for that month
- Covered individuals Social Security number
- Amount of drug costs incurred each month during
the plan year
- Covered individual's name, date of birth, and
gender
- 12 months' gross retiree costs, threshold
reduction, limit reduction, and actual cost
adjustments
- Date and time of data file creation
7. Responding to any questions, demands or denials issued by
CMS in connection with annual subsidy reconciliation. These
responses may include:
Filing a 15-day Appeal of a denied payment
Requesting a hearing within 15 days of a denied
Appeal
8. Providing Plan Sponsor upon request with the data and
information necessary to assist in the event the Plan
Sponsor is selected by CMS for audit during the six-year
period following receipt of a subsidy payment.
The fee for the aforementioned services will be set at a
maximum of 20% o_f/~he gross recovery from Medicare RDS. This fee
will be a~~a~ the time the subsidy is r~/ived from RDS.
~ G~dministration~Inc. Town of Southold
Prescription Drug Administration
Addendum to administrative service contract
1. Island Group Administration (IGA) will assist the Town of
Southold in the choice of a Pharmacy Benefit Manager (PBM).
2. IGA will provide the necessary and required information to
the Town's PBM to properly install and provide the program
of benefits as chosen by the Town of Southold.
3. IGA will provide to the PBM any changes in enrollment in the
prescription plan, which would include enrollment updates
for newly enrolled individuals, as well as individuals whose
coverage has been terminated.
4. IGA will provide to the PBM the necessary information
required to properly and accurately administer the Town's
chosen prescription drug benefit.
5. IGA will recommend, on an as needed or required basis,
prescription plan changes and modifications in an effort to
assist the Town in controlling the financial integrity of
the prescription drug plan.
6. IGA will provide to the Town periodic reports and supporting
documentation detailing the plan utilization costs and
reimbursements received from the PBM or any other
manufacturer or provider as the information becomes
available.
7. IGA, in conjunction with the PBM, will provide oversight and
review of the pharmacy program.
8. IGA will maintain ~real-time" computer review of the usage
of the pharmacy benefits, provided the necessary computer
access is available from the PBM.
9. IGA will review the PBM's submitted billings made to the
Town's Health Plan to ensure that only agreed to charges and
plan compliance are correct prior to any reimbursement to
the PBM. The PBM's billings will be reviewed for accuracy
and covered lives information as provided by the PBM in
accordance with the Town's prescription benefit and census.
10.IGA will provide telephone access, during normal business
hours, to staff who will assist covered individuals, their
doctors and pharmacies, with the resolution of any
prescription issues including overrides and plan
interpretation and compliance.
ll. IGA will provide prior authorizations and utilization
management for regular retail pharmacy, mail order pharmacy
and specialty pharmacy transactions. This shall include
formulary medications, high dollar medications, quantity
limits, safety, medical necessity, early refills, lost,
stolen or vacation drug supplies.
12.IGA will review all review and administer all formulary
changes with the PBM as required by the plan and applicable
laws.
13.IGA shall maintain a business associate relationship with
the PBM.
14.IGA shall maintain all protected information as required by
HIPAA.
Town of Southold