Amendment to the Administrative Services Agreement_Wellmark, Inc. Copyrighted
November 19, 2018
City of Dubuque Consent Items # 14.
ITEM TITLE: Amendment to the Administrative Services Agreement
Between the City of Dubuque and Wellmark, Inc.
SUMMARY: City Manager recommending approval of an amendment to
the Administrative Services Agreement between the City of
Dubuque and Wellmark, Inc. to add telehealth services to
the medical plan.
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Approve
ATTACHMENTS:
Description Type
Amendmentto WellmarkAdministrative Services City Manager Memo
Agreement-NNM Memo
Staff Memo Staff Memo
FirstAmendmenttotheAdministrativeServices SupportingDocumentation
Agreement
Administrati� Services Agreement Supporting Documentation
ExhibitA Supporting Documentation
Insurance Schedule J Supporting Documentation
THE CITY OF Dubuque
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7A13 2017
TO: The Honorable Mayor and City Council Members
FROM: Michael C. Van Milligen, City Manager
SUBJECT: Amendment to the Administrative Services Agreement between the City of
Dubuque and Wellmark, Inc.
DATE: November 13, 2018
Personnel Manager Randy Peck recommends City Council approval of an amendment
to the Administrative Services Agreement between the City of Dubuque and Wellmark,
Inc. to add telehealth services to the medical plan. The telehealth service is a real time
video interaction between a healthcare provider and a member. This service is
provided at no additional cost.
I concur with the recommendation and respectfully request Mayor and City Council
approval.
�� �� ���
Mic ael C. Van Milligen �� �
MCVM:jh
Attachment
cc: Crenna Brumwell, City Attorney
Teri Goodmann, Assistant City Manager
Cori Burbach, Assistant City Manager
Randy Peck, Personnel Manager
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TO: Michael C. Van Milligen, City Manage
FROM: Randy Peck, Personnel Manager �
SUBJECT: Amendment to the Administrative Services Agreement Between the City of
Dubuque and Wellmark, Inc.
DATE: November 1, 2018
This Amendment adds telehealth services to the medical plan. The telehealth service is
a real time video interaction between a healthcare provider and a member. This service
is provided at no additional cost.
The Amendment has been reviewed by the Legal Department. I request that the City
Council pass a motion approving the Amendment and authorizing you to sign the
Amendment.
RP/alk
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FIRST AMENDMENT TO THE
ADMINISTRATIVE SERVICES AGREEMENT
BETWEEN
CITY OF DUBUQUE, IOWA AND WELLMARK, INC.
This First Amendment to the Administrative Services Agreement is made and entered into
effective as of the first day of October, 2018, by and between City of Dubuque, Iowa ("Account")
and Wellmark, Inc., doing business as Wellmark Blue Cross and Blue Shield of Iowa
("Wellmark").
RECITALS
A. Account and Wellmark entered into an Administrative Services Agreement, effective July
1, 2018, (the "Agreement") for Wellmark to furnish certain administrative services to the
Plan.
B. Pursuant to section 10.4 of the Agreement, Wellmark desires to amend the Agreement as
set forth herein.
NOW, THEREFORE, it is hereby agreed as follows:
1. A new definition, 1.35, "Telehealth Services", is added to the Agreement reading as
follows:
"Telehealth Services" means the Covered Services provided to a Member during a
telehealth visit, or virtual visit. A "telehealth visit" is an actual real time video interaction
between a health care provider and a Member in the geographic area served by Wellmark
when an evaluation and management like service is provided.
2. A new section 3.7, Telehealth Services, is added to the Agreement reading as follows:
Telehealth Services. Wellmark has offered to arrange for Telehealth Services for
Members and Account has elected to accept the Telehealth Services as offered by
Wellmark and as described in the Benefits Document. The Telehealth Services will be
provided for no additional administrative fee, although Account shall be responsible for
any and all Claims Paid for Telehealth Services.
3, All other provisions of the Agreement shall remain in full force and effect.
IN WITNESS WHEREOF, Wellrnark has issued and executed this First Amendment to the
Agreement effective as of the date first stated above.
Account Wellmark, Inc., doing business as
Wellmark Blue Cross and Blue Shield of Iowa
Print Name: Michael C. Van Milligen David S. Brown
Executive Vice President, Chief Financial Officer
Title: City Manager and Treasurer
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Form Number: IA WBCBSI LG SF—Custom 8/8/2018 Version: 10/17
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ADMINISTRATIVE SERVECES AGREEMENT ,
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THIS ADMINISI"RATIVE SERVICES AGREEMENT ("Agreement") is made and entered �
into eNective as of the first day of July 2018, ("Effecfiive Date") by and between Welimark, Inc.,
doing business as Wellmark Blue Cross and Blue Shield of lowa, an lowa mutual insurance i
company, (herein "Welimark"), and City of Dubuque, lowa (herein "Account"). %
RECITALS I�
1. Account is the plan sponsor of a self-funded group health plan within the meaning of and
in accordance with applicable federal or state law for its common law employees and other ,
eligible individuals and fihis Agreement is issued to Account as the "group policyholder".
2. The group health plan is sponsored and funded by Account. Account wishes to enter into
a financial arrangement with Wellmark under which Account is solely responsible for the
Claims Paid for Covered Services provided to its Members. Wellmark does not assume
any financial risk or obligation with respect to the Claims Paid for Covered Services
provided to Members of the Plan.
3. Account desires that Wellmark provide administrative services for its self-funded group
health plan and Wellmark agrees to provide such services subject to the terms and
conditions set forth herein.
NOW, THEREFORE, it is hereby agreed as foilows:
ARTICLE 1
AGREEMENT DEFINITIONS
1.1 "Accountable Care Organization or ACO means a group of health care providers who
agree to deliver coordinated care and meet performance benchmarks for quality and
affordability to manage the total cost of care for their mernber populations.
1.2 "Administrative Fee" means an amount or amounts per Plan Member thafi Wellmark
charges the Account for Administrative Services and which includes allocakions for
Wellmark's cost of administering the Plan, general operating costs, and profit margin. The
monthly Administrative Fee is shown on Exhibit "A", Administrative Fees, Network
Access Fees, Other Fees, attached to this Agreement and incorporated by this reference.
1.3 "Administrative Services" means those services to be performed by Wellmark for
Account or the Plan under this Agreement, as described in Article 3 of this Agreement.
Administrative Services expressly exclude any services for the administration of continued
health coverage pursuant to COBRA or any state or federal law relating to continuation
coverage of the Plan, except as may be specified in a COBRA Administrative Services
Agreement or Addendum.
1.A� "Affordabie Care Act" or "ACA►" means the Patient Protection and Affordable Care Act,
enacted March 23, 2010, and the Health Care and Education Reconciliation Act, as
amended, (collectively, "ACA"), including implementing regulations.
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1.5 "Agreement" means this Administrafiive Services Agreement, including all Exhibits,
Benefits Document(s), amendments, Plan Member enrollment form(s), Medical
Management and Well-being Consulting Services Exhibit, and any COBRAAdministrative
Services Agreement or Addendum. This Agresment also incorporates by this reference
the terms of the HIPAA Business Associate Agreement entered into between
Welimark and the Plan and Insurance Schedule "J" completed by Account.
1.6 "Amounts Not Covered" means the amounts that are the liability of the Member under I��
the Plan. These include charges for services that are not covered by the Plan, charges for i
services that are determined to be not medically necessary, reductions in benefits for '
failure to follow notification requirements, and charges for services that have reached a I
Plan maximum.Amounts Not Covered does not include amounts that are the responsibility �
of a health care provider under a provider's contract with Welimark.
1,7 "Benefifis Document" means the written document(s) made available to Members that �
describe and define the terms, benefits, and limitations of the Plan and may.be titled
Benefits Cerfiificate, Coverage Manual, or something similar, Account may at its option
incorporate the Benefits Document into its ERISA Summary Plan Description (SPD).
1.8 "Care Coordinator Fee" means a fixed amount paid by a Host Blue to providers
� periodically for Care Coordination under a Value-Based Program. "Care Coordination" is
organized, information-driven patient care activities intended to facilitate the appropriate �
responses to a Member's health care needs across the continuum of care. �
- �
1.9 "Claims Paid" means the dollar amount of Wellm�rk's payment on behalf of the Account
for Incurred Claims.
1.10 "COBRA" means the group health coverage continuation provisions of the Consolidated
Omnibus Budget Reconciliation Act of 1985, as amended, including implementing
regulations and similar state or federal laws.
1.11 "Confidential Information" means all non-public confidential or proprietary information,
in ,any form, delivered or made available (whether pursuant to this Agreement or
otherwise) by one party or its affiliates, directors, officers, employees and agents (the
"Disclosing Party") to the other party, its affiliates, directors, officers, employees and
agents (the "Receiving Party"). Confidential Information shall include, but not be limited
to, employee, Plan Member, and Member information (including names, addresses and
Social Security numbers), Protected Health Information, personally identifiable
information, medical records, Plan claims data, and payment data, Any information with
respect to Wellmark's systems, procedures, methodologies and practices used by it in
connection with claims processing, claims payment or utilization management, together
with the fees, terms, payment arrangements, discounts with providers, and related
information shall be deemed to be Wellmark Confidential Information. Confidential
Information shall not include information which (a), at the time of disclosure, is available
to the general public; (b) becomes at a later date available fio the general public through
no fault of Receiving Party and then only after such later date; (c) Receiving Party can
demonstrate was in its possession before receipt from Disclosing Party; (d) Receiving
Party can demonstrate was independently developed; or (e) is disclosed to Receiving
Party without restriction on disclosure by a third party who has the lawful right to disclose
such information.
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1.12 "Covered Charges" means the dollar amount a health care provider bills a Member or i
Wellmark for Covered Services in accordance with the terms of the Benefits Document. �
1.13 "Covered Services" means the medically necessary health care services provided to a
Member as described in and covered by the applicable Benefits Document.
1.14 "ERISA" means the Employee Retirement Income Security Act of 1974, as amended, i;
including implementing regulations.
1.15 "Global PaymentlTotal Cost of Care" means a payment methodology that is defined at '
the patient level and accounts for either all patient care or for a specific group of services ,
delivered to the patient such as outpatient, physician, ancillary, hospital services, and
prescripfiion drugs;
1,16 "Grandfathered Health Plarr or Non-Grandfathered Health Plan" mean the same as
such terms are used in ACA. '
1.17 "HIPAA" means the Hea�th Insurance Portability and Accountability Act of 1996, as '
amended, including implementing regulations.
1.18 "Host Blue" means the local Blue Cross and/or Biue Shield plan or licensee in a
geographic area outside of the Wellmark service area.
1.19 "Incurred Claims" means claims for payment of health care services that are provided to
Members pursuant to the Plan with a date of service during the Rating Period.
1.20 "Incurred Date" means the date health care services are provided to Members. With
regard fio inpatient hospital or facility services, the date of the Member's admission to the
facility is considered as the Incurred Date.
1.21 "Maximum Allowable Fee" means a dollar amount Wellmark establishes using various
methodologies for Covered Services and supplies. For medical services, this amount is
developed from various sources, such as charges billed for the same service or supply by
most health care providers within lowa, economic indicators, or relative value indices
developed or approved by Wellmark, and is based on the simplicity or complexity of the
service provided. For medical services received outside of lowa or South Dakota, the
Maximum Allowable Fee is either determined in accordance with the section of this
Agreement entitled Out-of-Area Services or is the amount as described in the preceding
sentence.
For all dental procedures covered under this Agreement, the fee schedule is developed
based on Wellmark's contracts with dentists, input from its dental consultants, and the
charges billed for the same procedure by dentists in lowa.
1.22 "Medical Management and Well-being Consulting Services means health
management and wellness services Wellmark may provide to Members designed to
encourage good health and help them make decisions about health care. These services
may include, but are not limited to, BeWell 24/7, condition support, pregnancy support,
advanced care management, or other programs.
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1.23 "Member" means a person, including a Plan Member's spouse or eligible dependent
children, who is eligible and enrolied to receive health benefits under the terms of the Pian
as determined and identified by Account.
1,24 "Network Access Fee" means the amount charged to Account to gain the collective
advantages of the network of providers with which Wellmark, a Host Biue, or any '
subcontractor of either, has contracfied for the provision of Covered Services. The fee is a ',
monthly amount as shown on Exhibit"A", and may include funding for provider incentives, �,
If the Network Access Fee is expressed as a percentage of Network Savings as shown '
on Exhibit "A", the fee appfies to Incurred Claims regardless of the date the claim is paid. �,,
A portion of the Network Access Fee may include an allocation for administrative '
expenses above the Administrative Fee. I�,
1.25 "Networ{c Savings" ineans fihe amount saved due to payment arrangemenfis between
Welimark or a Host Blue and health care providers. It is generally calculafied as the I
difference between the Covered Charge and the Maximum Allowable Fee. This resuit is �
then added to any other reductions in the liability to a provider pursuant to a contract
between Welimark and the provider, including, but not limited to, reductions for failure to
satisfy any notification requirements and medical necessity determinations. If the amount
paid to a provider on any claim exceeds the Covered Charges, the Network Savings may
be reflected as a negative dollar amount on Account's bill. �
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1.26 "Patient-Cenfiered Medical Home" or "PCMH" means a model of care in which each �
patient has an ongoing relationship with a primary care physician who coordinates a team �
to take collective responsibility for patient care and, when appropriate, arranges for care i
with other qualified physicians,
1.27 "Plan" means the group health plan or plans established, sponsored and maintained by
Account, the terms of which are described in the applicable Benefits Document,
1,28 "Plan Member" means a common law employee or other individual identified by Account i
as a person eligible and enrolled to receive health benefits under the Plan subject to the
terms, conditions, and limitations described in the Plan documenfis and who is the
applicant on a completed enroliment form that has been provided to and accepted by
Wellmark.
1.29 "Plan Year" means the year designated by the plan sponsor as the plan year in the plan
document or as set forth on Exhibit "A".
1.30 "Protected Heaith Information" or "PI-11" means the same as the term "protected health
information" in 45 CFR §160,103.
1.31 "Provider Incentive" means an additional amount of compensation paid to a heaith care
provider, based on the provider's compliance with agreed-upon procedural and/or
outcome measures for a particular population of covered persons.
1.32 "Rating Period" means the period of time set forth on Exhibit "A" or the most recent
revision to Exhibit "A".
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1.33 Shared Savin s means a payment mechanism in which the p o _d p y I,
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cost savings achieved against a target cost budget based upon agreed upon terms and ;
may include downside risk.
1.34 "Value-Based Program" means an outcomes-based payment arrangement and/or a '
coordinated care model facilitated with one or more local providers that is evaluafied
against cosfi and quality metrics/factors and is reflected in provider payment. '
ARTICLE 2
RESPONSIBILITIES OF ACCOUNT '
2.1 Group Health Plan Compliance. Account is the plan administrator and plan sponsor of '
the Plan for purposes of fihis Agreement and applicable law, and is responsible for group
health plan design and compliance. Accounfi will exercise its responsibilities in the fiime
required by law and has full responsibility for all of the following:
a. Maintaining the Plan, determining Plan design, and funding payment of Incurred ,
Claims;
b. Determining eligibility criteria for Members subject to certain Wellmark enrollment
and underwriting guidelinea, including the requirements for locations or Members
located outside of lowa; Account is responsible for enrolling and canceling
individuals in the Plan in accordance with such criteria and agrees to terminate
coverage for ineligible individuals;
c. Designating the Plan Year for the Plan;
d. Complying with all applicable laws, reporting �nd disclosure requirements,
including specifically, (i) preparing and furnishing Members with Plan documents
or notices as may be required by law, including the summary of benefits and
coverage ("SBC"), any notice of material modification, employer notice of the
availability of coverage options under the health insurance marketplace, and
applicable �HIPAA notices relating to health coverage portability such as the
Special Enrollment Notice. Account will also make available to Members on
request the uniform glossary of insurance-related terms; (ii) complying with any
applicable non-discrimination laws; and (iii) furnishing any notices and
requirements with regard to COBRA continuation coverage. Account's
responsibilities for COBRA administration requirements may be delegated to
Welimark, but only to the extent expressly specified and agreed upon with
Wellmark in a COBRA Administrative Services Agreement or Addendum;
e. Reviewing and approving promptly templates or drafts of Benefits Document(s)
provided by Wellmark, and delivering or making available Benefits Document(s),
and Provider directories if applicable,to Plan Members. Based on the eligibility and
benefit information Account provides, Wellmark will draft written Benefits
Document(s) stating the benefits, terms and conditions of fihe Plan. Account is
responsible for reviewing fihe draft Benefits Document(s) promptly, typically within
thirty (30) days of receiving the draft document(s), and determining to Account's
satisfaction that the document(s) meet all of AccounYs legal and business
obligations and advising Wellmark of any necessary revisions or approval. The
absence of Account's express timely approval of any Benefits Documents provided
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by Welimark wili be considered Account's approval that the draft documents are
consistent with benefit information provided by Account, and Welimark will
administer the benefits in accordance with the proposed documents;
f. Making final determinations regarding claims, claims internal appeals, or claims
exceptions, except to the extent expressly delegated to, and accepted by,
Wellmark in Sections 3.1 and 3,6 of this Agreemenfi;
g. Providing to Wellmark written notice of benefit selections, limitations, and
exclusions, changes in the benefits at renewal, or material modifications at any
time during the Rating Period. Account shall provide such notice(s) in the time and
manner required by Welimark to fulfill the issuance of SBCs, preparation of
Benefits Document templates, or the issuance of other required notices within the
time required by law;
h. If the coverage of any Plan Member or Member is terminated retroactively,Account ',
represents that it either has not collected any premium contribution from the '�
retroactively terminated Member, or has refunded any premium contribution to the �
retroactively terminated Member, for the period following the effective date of the I'
termination; ���
i. Payment of any state premium tax, use tax, or similar tax, or any similar benefit or
Plan-related charge, tax, surcharge or assessment, however denominated, that I
may be assessed on the Plan or related to the administration of the Plan, including i
any penalties and interest payable with respect thereto;
j. Compliance with any income and employment tax withholding, depositing, and
reporting obligations (including state or federal income tax withholding, FICA tax
withholding, employer, FUTA taxes, and Form W-2 wage reporting) applicable to
rewards incentives or value-added benefits that may be provided under this
employer-sponsored group health plan to Members covered under the Plan,
Account is responsible for including the value of any such incentives or value-
added benefits as reported by Wellmark to Account in the applicable employees'
wages for federal or state income tax, employment fiax, and Form W-2 reporting
purposes;
k, Account shall maintain a process for external review of final internal adverse
benefit determinations as required by ACA, except to the extent expressly
delegated to, and accepted by, Wellmark in fihis Agreement; and
I. Calculating, reporting, and payment of any fees and assessments, however
denominated, required for ail group health plans under ACA, including specifically,
the per Member Patient-Centered Outcomes Research fees,
2.2 Enroilment Information; Social Security Number Reporting; Information
Requirements, Account agrees to furnish Wellmark with reports, data, and information,
including but not limited to, eligibility, enrollment information, physical home address, and
Social Security number for each Member, benefit selection or benefit changes for the Plan,
claims history, and information necessary for the administration of the Plan. Account shall
provide all such information in a time, form, format, and manner required by Wellmark and
is responsible for the timeliness, integrity, retention, and accuracy of information and
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records provided to Wellmark. Wellmark shall be entitled to rely upon such information in ;
determining any person's rights to benefits under the Plan, in making required filings with �
state or federal government agencies, and in discharging ifis responsibilities under this
Agreemenfi. Account recognizes- fihe importance to fihe �uccessful provision- of the �
Administrative Services the timely, accurats, and complete reporting of the information set (
forth in this section and that should reporting be inaccurate, untimely, or incomplete, ,
Wellmark shall not be responsible fior the provision of the Administrative Services affected ;
by such inaccuracy or delay.
Eligibility or enrollment information shall be provided to Wellmark in a standard medium ;
and layout using Wellmark's proprietary format, the HIPAA ANSI 834 standard format, or �
an application such as BluesEnroll, unless the parties agree in writing fio a non-standard �
format or application. Account acknowledges that ifi may be responsible for adcfitional fees
if it uses a non-standard format or if Welimark is required fio pei�form a comparison study �
of the fuil eligibility file. ;
2.3 Account Represenfiation regarding Eligibility; Notice of Persons Eligible for !
Coverage; Changes in Eligibility. Account represents to Wellmark that the terms of any ,
eligibility criteria, conditions, and/or waiting period imposed under the Plan are, and shall ��,
be for so long as fihis Agreement is in effect, in compliance with all applicable laws and I,
regulations, including specifically, the prohibition on excessive waiting periods and ,
applicable provisions on non-discrimination. Account shall enroll persons eligible for
coverage in the Plan in advance of each person's effective date of coverage and shall
provide Wellmark with each person's name, Plan selection, Social Security number, and
other required identifying information. Account shall provide all initial enrollment
information in advance of the Effective Date of this Agreement. As new persons become
eligible,or as eligibility changes occur, including any special enrollment events that require
a person to be offered coverage or changed to a different enrollment status such as
COBRA, Account shall provide Wellmark with updated required information as such
changes occur.Account shall provide Wellmark with enrollment updates no less often than
weekly and in advance of the effective date of the change if possible. Account's delay in
providing eligibility changes more than three (3) months following the effective date of the
change shall delay the requested effective date of coverage for the person and may cause
Incurred Claims not to be paid.
2.4 Notice of Persons 7erminated or No Longer Eligible for Coverage; Accounfi's
Liability for Ciaims Paid for Ineligible Individuals. Account shall notify Wellmark of
each person's termination or ineligibility for coverage under the Plan in advance, but in no
event no later than three (3) months following the requested date of coverage termination.
No requested coverage termination shall be effecfiive any earlier than three (3) months
prior to the date Wellmark receives the required notice from Account. If Incurred Claims
prior to the date Wellmark is notified of the coverage termination have been paid and are
not recouped, Account shall be responsible for the Claims Paid. For Claims Paid prior io
the date Wellmark is notified of the coverage termination, Wellmark shall, at its election,
(a) attempt to recoup such payrnents from the individual or the involved provider, unless
Wellmark determines recoupment is not feasible under the circumstances, or extends
beyond an eighteen (18) month recoupment period; or (b) bill Account for such Claims
Paid and associated Administrative Fee and Account shall pay the amount due to
Wellmark.
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2.5 Medicare Secondary Payer ("MSP"). Federal law mandates coordination of heaith care
benefits in certain instances where a Member is covered under both a group health plan I
and Medicare. Proper coordination of benefits in this context depends on obtaining and
maintaining accur�te and timely information regarding such dual health coverage.
Pursuant to contract and applicable law, Welimark provides information to Centers for
Medicare and Medicaid Services ("CMS") regarding such dual health coverage for
Members and Account enrollment on a quarteriy or more frequent basis.
Account is solely responsible for compliance with MSP laws and other requirements.
Wellmark shall use all information provided by Account to properly coordinate benefits. In
the event Account does not timely provide to Wellmark information requested by Welimark
regarding Account's size and status and Employer ldentification Number ("EIN")(s), or
does not gather and timely provide information to Wellmark concerning the Medic�re
enroliment of Meml�ers, Account enrollment, and related information (including, without
limitation, Member Social Security numbers), or such other information as requested by
Wellmark for inclusion on the Confirmation of MSP form submissions and other
disclosures, Account shail be solely responsible for non-compliance with MSP laws and �
other requirements, including, without limitation, any damages, losses, taxes, interest
charges, and administrative penalties (including, without limitation, any civil money
penalties) fihat may be assessed or otherwise result in connection therewith (including,
without limitation, any claims by Members, providers or other claimants), and mistaken
payments to CMS on behalf of Medicare enrolled Members.
2.6 Stop Loss insurance Coverage, Account is solely responsible for the Claims Paid for
Members of the Plan:Account may at its option separately purchase stop loss insurance
coverage from Wellmark, Inc., which shall be reflected in a separate policy issued by
Wellmark. If Account purchases stop loss insurance coverage from a carrier other than
Wellmark, Account shall advise Wellmark of the terms of such coverage. Account shall be
solely responsible for all reporting, submission of claims, payment of premiums, and any
other obligation required by its stop loss policy with the other carrier, however, upon
request Wellmark will provide Account with standard stop loss reports necessary for
Account to file stop loss insurance claims with its stop loss carrier.
2.7 Outside Services Vendor(s) to the Plan. If Account arranges for health plan
administrafiion services for the Plan from vendor(s) other than Wellmark or a Wellmark-
contracted vendor, such as, for example, pharmacy benefits management services or
telehealth management services, Account shall be responsible for compliance with laws,
the accuracy and submission of reports, claims data reporting, payments, and for any
other oblic�ation required by its vendor agreements. If Account requires its vendor to submit
claims for Covered Services to Wellmark, such vendor shall also enter into an agreement
with Wellmark that requires vendor to comply with Welimark's claims procedures. If
Account or the Plan requires coordination or health plan accumulations between its third
party vendor's administration and the health plan administration provided by Wellmark,
Account shall be responsible for providing Welimark with all enrollment information and
claims or payment data reasonably necessary for Welimark to provide Administrative
Services under this Agreement.
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ARTICLE 3 �
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WELLMARK'S RESPONSIBILITIES
3.1 Determinatian of Claims; Administrafiive Services. During the Term of this Agreement �
and subject to Accouni's payment to Wellmark, when due, of the charges for Claims Paid ;
and other fees specified in this,Agreement,Wellmark shall provide Administrative Services '
as specified in this section as follows: � '
a. Wellmark shall provide Account with a written draft of Benefits Document(s) based
on the plan design and Member eligibility criteria information provided by Account, ,
for Account's review and approval as required by Section 2.1(e), setting forth the �
benefits, terms and conditions of the Plan for delivery to Plan Members; �
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b. Wellmark shall provide access to a network(s) of heaith care providers and shall
make information about the network and network providers available to Members;
c. Wellmark shall prepare, print, and deliver identification cards to Plan Members; '
d. Wellmark will perForm its Administrative Services and retain records regarding i
such Administrative Services in compliance with applicable laws, including, but not
limited to, applicable provisions on non-discrimination; ',
e. Wellmark shall provide or make available to Account forms of ACA or HIPAA I',
required notices, including the summary of benefits and coverage ("SBC') and
applicable HIPAA notices relating to health coverage portability such as fihe
Special Enroliment Notice. Wellmark shall make available the uniform glossary of
insurance-related terms;
f. Subject to Section 6.1(c),Wellmark shall adminisfier benefits and process Incurred
Claims for health care services furnished Members in accordance witfi the terms,
limitations and conditions set 'forth in the Plan, the Benefits Document(s), this
Agreement, applicable laws and regulations, the terms of the applicable provider
agreements, and the claims administration and medical policies of Wellmark, all of
which may be revised from time to time. Processing of claims may include payment
by Wellmark on behalf of Account and reporting of benefits to providers or
Members, coordination of benefits, and the monitoring,detection, and investigation
of potenti�lly abusive or fraudulent claims submitted by providers or Members.
Wellmark may initiate adjustments to processed claims, generally for a period of
up to eighteen (18) months after the Incurred Claim was first processed, if
Wellmark determines in its sole discretion that such adjustments are necessary
and appropriate. lf a Paid Claim adjustment results in a recovery of a prior
payment, Wellmark shall credit Account for such adjustments to the extent of the
amount recovered. Notwifihstanding the preceding two sentences and except as
provided in Sections 2.3 and 2.4 of fihis Agreement, Wellmark sh�ll not be required
to reprocess claims as a result of any changes made to information relating to a
Member or the Member's benefits unless (i) in addition to submitting changes to
Wellmark, Account expressly requests in wrifiing that Wellmark reprocess specific
Member claims; and (ii) such reprocessing does not extend beyond eighteen (18)
months prior to the date Wellmark receives Account's requesk;
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g. Wellmark shail process clairns for benefits and shall maintain a single-level internal
appeal procedure for Members to appeal adverse benefit determinations each in
accordance with the requirements of the Plan and applicable law, Welimark shall
also maintain a procedure for processing external review requests of final internal
adverse benefit determinations with appropriate independent review
organizations, pursuant to the requirements of the Plan and applicable law. Fees
and costs for external review billed by independent review organizations ("IROs")
will be billed to Account; and
h. To the extent that Account has delegated discretionary authority to Welimark,
Wel�mark shall exercise its discretion to make determinations in connection with
the administration of this Agreement and the Plan including, without limitation,
determinations regarding whether health care services are medically necessary in
accordance with Pian terms or whether charges for heaith care services are
reasonable. Wellmark shall make determinations that are not arbitrary or
capricious and such determinations shall be final and conclusive to the extent
permitted by this Agreement, the terms of the Benefits Document, and by law.
3.2 Medical Management and Well-being Consulting Services. Wellmark may, at its sole
discretion, offer or arrange for various Medical Management and Well-being Consulting
Services to be available to Members or purchased by Account for its Members. Such
services that may be offered are further described in the Medical Management and Well-
being Consulting Services Exhibit, attached to this Agreement and incorporated by this
reference, and including those services, if any, specifically selected or purchased by
Account as shown on Exhibit "A" attached to fihis Agreement. Medical Management and '
Well-being Consulting Services may be changed, replaced, or discontinued from time to �'
time and may be modified or removed in accordance with the Medical Management and
Well-being Consulting Services Exhibit.
3,3 Value-Added Services; Identity Protection. Wellmark, at its sole discretion, may offer I
or arrange for value-added services or benefits for Accounk and its Members, including,
for example, Member ldentity Protection services from a third-party vendor. Identity
Protection services are offered at no additional charge to Account or Members. Account
may at its opfiion accept or reject Identity Protection services for its Members.
3,4 IRS Form 1095-C Reporting. At the written request of Account, Wellmark will provide
certain coverage information for purposes oF Account's Form 1095-C reporting to the
Internal Revenue Service,Welimark does not guarantee the accuracy or completeness of
the information provided, and expressly disclaims any liability for any penalties or costs
that may be incurred due to alleged or actual inaccuracy or incompleteness, including but
not limited to information reporting or other penalties that may be imposed if such
information is relfed upon or used in conjunction with any tax or other regulatory filing.
Wellmark does not provide federal or state legal or tax advice, and does not prepare or
otherwise assist in preparing, in any way, any federal or state tax returns or reports on
behalf of its customers, including but not limited to IRS Form 1095-C, Account assumes
all liability in connection with the preparation of such documents and has the responsibility
to consult with its own legal or tax advisors for information or assistance.
3,5 Subrogation. Wellmark shall provide subrogation recovery service for Claims Paid while
this Agreement is in force, but shall have no obligation to initiate subrogation recovery
services after this Agreement is terminated and shall have no obligation to continue
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subrogation recovery services initiated prior to termination more than twelve (12) months '
following termination of the Agreement. Following the twelve (12) month run-out period, I�
Wellmark will forward any open subrogation files information to Account. The nature and �
extent of efforts to pursue subrogation recovery are within the sole discretion of Wellrnark. i
Such subrogation recovery service may include all sfieps necessary to recover Claims Paid
that may be found fio be the liability of a third party or other insurance carrier. The Account
shall be responsible for all fees or costs, including atfiorney's fees and fihe fees and costs ,'
of any third party utilized by Wellmark to perform subrogation recovery services, incurred i
in the recovery process, with those costs and fees firsfi paid from any funds recovered and ,,
the net amount only credited to Account's Claims Paid amounfis. Account acknowledges
that its stop loss carrier has priority of any recovery in the event the Claims Paid exceed
the stop loss attachment level and there is insufficient recovery to reimburse stop loss ,
carrier and Account in full. If the Claims Paid exc�eds $25,000 for a Member, Welimark
shall nofiify Account prior to settlemenfi anel the Account shall approve, in writing, any
proposed settlement. For all other matters, the Accaunfi shall accept any such recoveries
as negotiated by Wellmark as payment in full and the determination of the recovery
amount is within the sole discretion of Wellmark. To facilitate recoveries for matfiers where
the subrogation amount equals or exceeds $25,000, the Account will make available a
staff person with the authority to provide instruction to Welimark.Welimark can also make
available, upon request, a report, on a quarterly basis, that lists subrogation matters where
the Claims Paid amount exceeds $25,000.
Wellmark has sole discretion with regard to the choice of counsel to pursue subrogation
recovery. Wellmark may choose to allow a Member's counsel to represent the AccounYs
subrogation interest. However, if the fee charged for collection of the subrogation interest
by legal counsel retained by the Member exceeds the prevalent fees for such services,
Wellmark shall not authorize pursuit or settlement of the subrogation claim by said
Member's attorney or payment of that attorney's fee without Account's written
authorization. Further, if in the opinion of Wellmark, recovery of funds shall not offset the
costs associated with such recovery, or recovery of the funds is not otherwise practicable,
Wellmark shall inform the Account in writing of its opinion. Thereafter, uniess the Account
directs otherwise,Wellmark shall not further pursue the claim. In the eventAccount directs
Wellmark to pursue Account's subrogation interest notwithstanding Wellmark's notice to
Account of its opinion that the recovery shall not offset the involved costs, Account shall
be responsible for all attorney's fees and costs incurred by Welirnark to pursue recovery,
including the reasonable cost of Wellmark's staff time as determined by Wellmark.
Wellmark does not guarantee the recovery nf funds and. nothing in this section or
Agreement obligates Welimark to participate in or initiate any subrogation efforts or
litigation to recover Claims Paid.
3.6 Discretionary Authority. Wellmark is delegated the authority to determine claims for
benefits and to determine internal appeals of adverse benefit determinations of Members,
provided such determinations are consisfient with the terms of the Plan as provided by
Account, this Agreement, the applicable Benefits Document, and applicable law, unless
otherwise directed in writing by the Account. In making decisions regarding claims for
benefits and appeals of denied claims,Wellmark shall have discretionary authority only to
the limited extent necessary to construe and interpret the terms of the Plan and to
determine whether a claim is properly payable under the Plan. Notwithstanding anything
in this Agreement to the contrary, Account shall have full responsibility for Plan design, for
making any and all determinations whether an individual has satisfied the Account's
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requirements to be an eligible Member, and for making any determination regarding an
individual's eligibility for continued coverage pursuant to COBRA.
ARTICLE 4
BILLING AND PAYMENT
4.1 Billing; Account's Payment to Weilmark. Account authorizes Welimark and Wellmark
agrees to process Incurred Claims as received, subject to the limitations, conditions, and
exclusions stated in the Benefits Document.
Wellmark shall bill Account for Claims Paid, Network Access Fee, Administrative Fee, and
other fees, based on the billing and payment method set forth on Exhibit"A'', attached to
this Agreement. Any adjustments due to membership or eligibility changes shall be
reflected on the billing for the month in which the mernbership or eligibility change is made.
Adjustments to Network Access Fee, Administrative Fee, and other fees, billed on a per
Plan Member or per Member basis, shall be limited to a period of three (3) months prior
to the date Wellmark processes the Member eligibility change. Wellmark shall provide a
bill to Account that shows the amounts due and, if applicable, the amounts of any weekly
payments received by Wellmark and other credits during the preceding month. Account
shall promptly pay Wellmark at Wellmark's office, the total amount due, no later than the
due date on the bill. Such payment may be made by wire transfer, electronic (ebilling)
payment, or aufiomatic funds withdrawal. If Account elects automatic funds withdrawal, it
shall execute the necessary aufihorization.
If Account elects to authorize automatic funds withdrawal from a deposit account, the
automatic withdrawal will change to correspond with khe applicable billing, including
applicable taxes or fees. Account's�authorization for automatic funds withdrawal shall
include authorization for automatic withdrawai of any changed amount unless Account
calls or provides its bank with written notice not less than three (3) business days before
a scheduled withdrawal to stop the payment. If Account calis its bank to stop payment,
Account may be required to provide a written request within fourteen (14) days after the ',
call. Account will be responsible for any fee assessed by its bank for stop-payment orders '
made by Account. '�
4.2 Late Payments. All payments from Account to Wellmark must be paid on time and when �
due in accordance with Section 4.1. If the Account fails to make payments in full when
due, Welimark may in its discretion do any or all of the following: impose interest or late
fees; setoff late payments from other amounts that may be due to Account under the
Agreement; stop the payment of all ciaims for Members, regardless of the Incurred Date;
require an alternative billing and payment method; or require an alternative financial
arrangement. Payments not made when due shall include an interest charge on the
outstanding amount from the due date until payment is made in full at the then current
prime rate as published in the Midwest edition of The Wall Street Journal plus two percent
(2%), The acceptance by Wellmark of any late payments or partial payments shall not
constitute a waiver of any rights under this Agreement. If Account fails to make payments
when due for two or more consecutive months, Welimark may impose additional late fees
of up to eighteen percent (18%) per annum.
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ARTICLE 5 i
CONFIDENTIAL INFORMATION; REPORTING; EXAMINATION OF RECORDS i
5.1 Protected Health Information.The rights and responsibilities of the parties and permifited �
uses and disclosures with respect to Protected Health Information shall be set forth in the
separately executed Business Associate Agreement. If Account utilizes third-party �
vendors to provide any administrative services to the Plan and directs Wellmark to provide �
or exchange any PHI with such vendors, Account represents it has the legally required
business associate and data security agreements in place with such third-party vendors. %
If Account desires access to mental health information, Account shall file an applicable '
statement with the lowa Insurance Division, as may be required pursuant to lowa Code
Section 228.7. �
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5.2 Non-Disclosure of Confidentiaf fnformafiion. I
a. Subject to the terms of fihe Business Associate Agreement and as permitted by ,,,
applicable law, the Receiving Party will: (i) not disclose Confidential Information to
any third party that is not an agent, consultant or business associate to Wellmark ,
without the written authorization of the Disclosing Party; (ii) restrict disclosure of
Confidential Information only to fihose employees, agents or consultants who have '
a need to know the Confidential Information for purposes related to this Agreement
or the administration of the Plan and who are bound by confidentiality terms
substantially similar to those in this Agreement; (iii) use the same degree of care
as for its own information of like importance, but at least use reasonable care, in
safeguarding against disclosure of Confidential Information; and (iv) without
unreasonable delay and in accordance with applicable law notify the Disclosing
Party of any unauthorized use or disclosure of the Confidential Information and
take reasonable steps to regain possession of the Confidential Information and
prevent further unauthorized actions or other breach of this Agreemenfi.
b. If the Receiving Party is required to disclose Confidential Information pursuant to
applicable law, statute, or regulation, or court order, for a purpose other than
contemplated in this Agreement, the Receiving Party will give to the Disclosing
Party prompt written notice of the request and a reasonable opportunity to object
to such disclosure and seek a protective order or appropriate remedy, If, in the
absence of a protective order, the Receiving Party determines, upon the advice of
counsel, that it is required to disclose such information, it may disclose only
Confidential Information specifically required and only to the extent compelled to
do so.
c. All Confidential Information remains the property of the Disclosing Party and will
not be copied or reproduced without the express written permission of the
Disclosing Party, except for copies that are necessary to fulfill fihe confidentiality
obligations contained in this Agreement, to render the services under this
Agreement, or as otherwise allowed under the Business Associate Agreement or
applicable law. A party may retain Confidential Information when obligated to do
so as a matter of law, and may also retain any Protected Health Information as set
forth in the Business Associate Agreement.
5.3 Wellmark's Right to Use Confidential Information.Wellmark shall have the right fio de-
identify or remove direct identifiers from the Confidential Information so that it no longer
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constitutes Protected Health Information, and so that such Confidential Information is no
longer identifiable with respect to Account, and to aggregate such de-identified
Confidential Information for any purpose whatsoever; provided that such use is in
accordance with all applicable laws, including but not limited fio HIPAA. Such Confidential
Information, after it is de-identified or limited pursuant to HIPAA, shall no longer be subject
to Section 5.2 and shall thereafter be Wellmark's property.
5.4 Right to Examine Records; Audit. Wellmark or its authorized representative may at its
own expense examine the financial, enrollment,and claims records of Account reasonably
related to the adrriinistration of this Agreement, as reasonably often as Wellmark deems
appropriate, to reconcile enroliment information and records, to` determine whether
Account can make the payments required by this Agreement, or to determine payment of
benefits under the Plan. Such examination shall be conducted during regular business
hours, upon reasonable advance written nofiice. The examination period may cover the
most recent twenty-four (24) months .only, if applicable. Upon completion of the
examination, Wellmark shall share its examination findings wlth Account and conduct an
exit conference with Account. Any third party conducting such audit on Weilmark's behalf
must agree in writing to be bound by the terms and conditions of the Business Associate
Agreement between Account and Wellmark.
Account's third-party authorized representative or auditor may, at Account's own expense,
examine Wellmark's records reasonably and necessarily related to Wellmark's discharge
of its responsibilities under this Agreement no more frequently than annually. Account
shall provide Weilmark with written authorization specifying the Account or Plan
information that Wellmark may disclose to the auditor, The auditor must be acceptable to
Wellmark, must not compete direcfily or indirectly wifih Welimark, and must execute a non-
disclosure agreement with Wellmark prior to receiving any Protected Health Information '
or Wellmark Confidential Information. Such examination shall be conducted during regular '
business hours, upon advance written notice reasonable under the circumstances and �'
shall include the following Wellmark records: claims records (but not including individually �,
idenfifiable sensitive diagnosis information unless Account specifically authorizes such 'I
disclosure), third-party explanations of health care benefits, enrollment records, and �'�
coordination of benefits procedures, Any other audifi or examination requesfi must be i
coordinated with Welimark. The examination period may cover the most recenfi twenty- �
' four (24) months only, notwithstanding the period for claim adjustments as may be
specified in Section 3.1. Upon completion of the examinafiion, Account shall share its I
examination findings with Welimark and conduct an exit conference with Welimark. Audits �
conducted by auditors compensated on a contingency fee basis are not permitted by
Wellmark as such compensation arrangements are not consistent with professional
auditing standards. Such standards consider these compensation arrangements to impair
the auditor's or consultant's independence and objecfiivity. Audit practice and procedure
under this Agreement will conform to generally accepted auditing and accounting
principles.
5.5 Website Access and Reporting. Wellmark may provide Account while this Agreement is
in force with secured access to Wellmark's website, web-based applications, or other
electronic databases with respect to the Plan and Members for the purpose of Plan
administration and health care operations, reporting, billing, or for self-service.Web-based
applications or databases with Member and Plan specific Confidential Information may be
hosted or supported by third parties on Wellmark's behalf. If Account or a third party acting
on Account's behalf accesses such websites or information, Account is subject to and
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agrees to all of fihe fierms and conditions, including the confidentiality requirements of this !
Agreement, and security restrictions and user requirements as established by Wellrnarlc !
with respect to such access, as such terms are set forth in a data use agreement and in ,
the applicable Terms and Conditions posted at Wellmark's website (Wellmark,com). ;
5.6 Survival. Any obligations of either party to the ofiher under this Article of fihe Agreemenfi ;
survive any termination of this Agreement. �
ARTICLE 6
PROVIDER PAYMENT ARRANGEMENTS; CL�AIMS RECOVERIES; REBATES; VALUE-
BASED PROGRAMS; DISCLOSURE OF COMPENSATION
6.1 Provider Payment Arrangements. Wellmark will be responsible for negotiating and
entering into separafie payment arrangemenfis with healfih care providers. Such provider
payment arrangements and agreements shall apply to services by such providers for all
Members entitled to benefits under plans insured or administered by Wellmark, including ,
Members under this Plan. '
Wellmark shall determine, in its sole discretion, the paymenfi arrangements with healfih ,
care providers including, without limitation, the Maximum Allowable Fees for Incurred ,
Claims. Without limiting the foregoing, Wellmark may compensate providers pursuant to ,
a variety of payment arrangements, including the following:
a. Fee for service arrangements, including, without limitation, per diem and percent
of charge arrangements; ,
b. Fixed fee or other payment rnethodology that is based on pre-determined criteria;
or
c. Episode of care arrangements under which payment is based on a pre-established
rate for a healfih care encounter, including, without limitation, a hospital stay or
outpatient visit. In the event such an arrangement is utilized, consistent with the
methodology established by Welimark for such arrangement, Wellmark is not
required to impose cost share responsibility on Members for each Covered Service
Members receive. An episode of care arrangement payment may cover both
Covered Services and non-Covered Services that are incidental to the Covered
Services.
6.2 Network Savings Allocations. Any Network Savings amounts allocated to the Account
shall be reflected in the amount of Cl�ims Paid. Based on Wellmark's payment
arrangements with health care providers, and in accordance with Section 6.1, the amounfi
paid on �n individual claim may be more or less than the Covered Charge minus any
applicable Amounts Not Covered, deductible, copayment, and coinsurance amounts. If
the amount paid to a provider on any claim exceeds the Covered Charge, the Network
Savings is reflected as a negafiive dollar amount, Any Network Savings amounts allocated
to Plan Members shall be reflected in the calculation of coinsurance, where applicable.
The calculation of coinsurance depends on the type and location of the services provided
and the contracting status of the health care provider. The calculation of coinsurance is
further described in the applicable Benefits Document.
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6,3 Non-Contracting or Non-Network Providers. If the appiicable Benefifis Document
provides benefits for Covered Services rendered by health care providers that have not
contracted with Wellmark or another Blue Cross and Blue Shield Plan ("Non-Contracting
Providers"), Members may be liable to Non-Contracting Providers for any difference
between the Covered Charges and the Maximum Allowable Fee and Members are
responsible for paying the provider in full,
6,4 Claims Recoveries. From time to time, Welimark, Account, or Plan may receive notice of '
a pending or potential lawsuit (including, without limitation, a class action lawsuit) that �I
seeks recovery of health care claims expenses on behalf of one or more group health ��
plans or payors and that may include Wellmark,Account, or the Plan as a party or potential I
class member (a "Lawsuit"). Notwithstanding any language to the contrary in this �
Agreement, Welimark shall not participate in a Lawsuit on behalf of Account or Plan or
pursue recovery on behalf of Account or Plan uniess Wellmark and Account enter into a i
separate written agreement relating to participation, recovery, and expenses in such ��
Lawsuit. Welimark has no duty to notify Account or Plan of Wellmark's receipt of any
notices in connection with any Lawsuit and each party is free to make its own
determination whether to initiate or participate in any Lawsuit on its own behalf,
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6,5 Value-Based Programs. Wellmark or Host Blues may enter into collaborative
arrangements with Value-Based Programs (as described in Section 9.3 Oufi-of-Area
Services) under which the health care organizations participating in such programs are
eligible for financial incentives relating to quality and cost-effective care of Wellmark
members. Identifiabie Data regarding Account's Members may be included in information
Weilmark or Host Biues provide to Value-Based Programs and used by the Value-Based
Program and its providers. Account has elected not to participate in Welimark's Value-
Based Program, although Account's Members may access Covered Services from
providers that participate in a Host Blue's Value-Based Program as described in Section
.. 9.3.
6.6 Disclosure of Compensation. Wellmark shall comply with Department of Labor
requirements regarding the disclosure of compensation received from all sources in
connection with this Agreement,
ARTICLE 7 I
LIABILITY OF THE PARTiES
7.1 Responsibility for Claims. Account is solely responsible for all Claims Paid for its
Members, including, without limitation, an individual added or deleted as a result of a
retroacfiive eligibility change. Wellmark provides Administrative Services and network
access only and does not assume any financial risk or obligation with respect to claims,
including, without limitation, any Claims Paid. Wellmark has no obligation to pay Incurred
Claims if Account fails to pay or reimburse Wellmark in accordance with this Agreement.
7.2 No Duty to Defend.Wellmark shall have no duty or obligafiion to defend against any action
or proceeding brought against Account or Plan to recover a claim for benefits. Wellmark
shall, however, make available to Account and its counsel, such evidence relevant to such
action or proceeding as Wellmark may have as a result of its administration of the
contested benefit determination.
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7.3 Account's Liability. Except as otherwise explicitly provided in this Agreement, Account
shall accept the tender of defense and have fihe liability for all Plan benefit claims �nd all
expenses incident to the Plan, and agrees to release, hold harmless, and indemnify I�
Wellmark and its employees, officers; and direcfiors against any and all amounts,
expenses, losses, liabilifiy, claims, lawsuits, injuries, damages, taxes, interesfi charges, i
administrative penalties, and other costs or obligations, including reasonable afitorneys' 'I
fees and court costs, for which Wellmark may become liable: �,
a. due to any state premium tax, use tax, or similar tax, or any similar benefit or plan- !
relafied charge, surcharge or �ssessment, federal tax, excise tax, or fee imposed '
on group healfih plans or plan sponsors under ACA, however denominated,
including any penalties and interest payable with respect thereto, assessed against
Wellmark on the basis of and/or measured by the amount of Plan benefits
administered by Wellmark pursuant to this Agreement; '
b. due to any action or proceeding brought by a third party to recover benefits under '
the Plan; '
c. due to any action or proceeding brought by a third party alleging Wellmark provided '�,
significant assistance fio Account to aid or perpetuate any discrimination activity;
d. due to a release of Confidential Information to Account, the Plan, or a third parfiy
at Account's direction or arising out of any improper use of Confidential Information
by Account or such third party;
e. due to Account's failure to timely provide requested information to Wellmark for
inclusion on the Confirmation of MSP form submissions and other disclosures that
relate to Account's size and status, EIN(s), the Medicare enrollment of Members,
Account enrollment, and related information (including,without limitation, Member
Social Security numbers), or such other information requested by Wellmark
resulting in processing of claims not in compliance with MSP laws and other
requirements in accordance with Section 2.5;
f. due to Account's failure to comply with applicable law relating to issuing or failing
to issue the required notices in accordance with Section 2.1(d);
g, due to AccounYs failure or delay in providing accurate reports, data, and
information regarding eligibility, enrollment, and Social Security numbers for each
Member, benefit selection,limitations, exclusions, or benefit changes for the Plan,
claims history, and other information necessary for Wellmark to administer the
terms, coordination of benefits, limitations, and exclusions contained in the Plan;
h. due to the Account's or its employees' or agents' negligence or material breach of
their obligations under this Agreement, except to the extent that any such losses
are caused by the negligence or willful misconduct of Wellmark;
i, arising from any other acts or omissions of Account that constitute a material
breach of an obligation hereunder or which, in the aggregate, constitute a failure
on the part of Account to perform its obligations under this Agreement in
accordance with the provisions of this Agreement; or
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j. due to or arising out of Welimark's adherence with any direction from Account or
decision made by Account with regard to the Plan design, benefits, or eligibility
provisions in the Benefits Document,or the Administrative Services provided under
this Agreement.
7.4 Selection of Counsel. In the event litigation is instituted by a third party against the
Account and/or Wellmark concerning any matter under the Plan, including a suit for Plan
benefits, each party to this Agreement shall,to the extent possible, advise the other of the
legal action, and shall have sole authority to select legal counsel of its choice.
7.5 Wellmark's Liability. In performing its obligations under this Agreement, Wellmark shall
use reasonable diligence and that degree of skill and judgment possessed by one
, experienced in furnishing claim administration services to group health plans of similar
size and characteristics as the Plan, Wellmark.agrees to release, hold harmless, and
indemnify Account and its employees, officers, and directors against any and all amounts,
expenses, losses, liability, claims, lawsuits, injuries, damages, taxes, interest charges,
administrative penalties, and other costs or obligations, including reasonable attorneys'
fees and court costs, for which Account may become liable:
a. arising from any acfis or omission of Wellmark which constitute a material breach
of an obiigation hereunder or which, in the aggregate, constitute a failure on the
part of Wellmark to perform its obligations under this Agreement in accordance
with the provisions of this Agreement; and
b. arising from any allegation of a breach of confidentiality arising out of release of �'�
Confidential Information to Wellmark or a third party at Welimark's direction or '
arising out of any improper use of Confidential Information by Wellmark or such �
third party. II
7.6 Disclaimer of Warranties; Limitation of Liability. EXCEPT AS EXPRESSLY SET
FORTH IN THIS AGREEMENT, WELLMARK DOES NOT MAKE AND HEREBY
DISCLAIMS ANY REPRESENTATION OR WARRANTY OF ANY KIND, EXPRESS OR
IMPLIED, INCLUDING IMPLIED WARRANTIES OF MERCHANTABILITYAND FITNESS
,FOR A PARTICULAR PURPOSE, REGARDING ANY OF THE SERVICES WELLMARK
PROVIDES OR ARRANGES TO PROVIDE UNDER THIS AGREEMENT. IN NO EVENT
SHALL ANY PARTY BE LIABLE FOR INDIRECT, INCIDENTAL, CONSEQUENTIAL,
PUNITIVE, OR SPECIAL DAMAGES, LOSS. OF DATA OR LOST PROFITS, EVEN IF
THAT PARTY HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. THE
FOREGOING LIMITATION OF LIABILITY REPRESENTS THE ALLOCATION OF RISK
BETWEEN THE PARTIES AS REFLECTED IN THE PRICING HEREUNDER AND IS AN
ESSENTIAL ELEMENT OF THE BASIS OF THE BARGAIN BETWEEN THE PARTIES,
ADDITIONAL DISCLAIMER OF WARRANTIES AND LIMITATION OF LIABILITIES
REGARDING MEDICAL MANAGEMENT AND WELL-BEING CONSULTING SERVICES
ARE SET FORTH IN THE MEDICAL MANAGEMENT AND WELL-BEING CONSULTING
SERVICES EXHIBIT.
7.7 Grandfathered Health Plan Disclaimer. Account has the sole obiigation to determine the
status ofi its Plan as either a Grandfathered Health Plan or a Non-Grandfathered Health
Plan and has advised that its Plan is Non-Grandfafihered.
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7,8 No Testing for Healfih Plans. Wellmark will not determine whether coverage is �
discriminatory or otherwise in violation of Internal Revenue Code Section 105(h). �
Wellmark also will not provide any testing for compliance with Internal Revenue Code ;
Secfiion 105(h) and will not be held liable for any penaltiesor other losses resulting from j
Account offering coverage in violation of Section 105(h). �
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7.9 Survival. The indemnities set forth in this Article, including any liability of either party to ;
the other for indemnification shall survive the termination of this Agreement. i
ARTICLE 8 '
TERM AND TERMINATIOiV
8.1 Term of Agreement. This Agreement shall become effecfiive on the Effective Date and ,
shall continue in force through June 30, 2019 (the "�'erm"). Cei�:ain guarantees and '�,
programs as more fully described ir� the Exhibits to this Agreement may be modified or i
terminated on an earlier date as specified in the applicable Exhibit without termination of ,
the entire Agreement.
8.2 Renewat Terms. Upon expiration of the Term, this Agreement shall continue in force from
year to year until replaced by a subsequently executed Agreement, or as amended or
terminated as provided in this Agreement. Welimark shall have the right to change any of
the Administrative Fees or other fees for subsequent Rating Periods (subject to any fee
guarantees set forth on Exhibit"A")or any renewal term upon not less than thirty(30)days
advance written notice. Any such changes shall be reflected on a revised or new Exhibit
"A" issued by Wellmark, to be attached to this Agreement and incorporated by this
reference.
8.3 Termination Notice. Upon expiration of the Term or any renewal term, either party may
terminate this Agreement as of the end of the current Term by giving written notice of
termination delivered t�fihe other party at least sixty (60) days in advance of the effective
date of termination.
8.4 Termination for Nonpayment.Wellmark may terminate this Agreement at any time, upon
ten (10) days written notice to Account, if Account fails to make complete payments,
including late fees, when due in accordance with this Agreement or Wellmark determines
that Account has inadequate funds to make payments required by this Agreement and, in
either case, Account fails to cure such non-payments or cure the inadequacy of funds
within the ten (10) day notice period. Account is solely responsible for notifying its Plan
Members of the termination of this Agreement for nonpayment or for any other reason.
8.5 Effects of Termination. If Wellmark terminates this Agreement for nonpayment,
Wellmark shall not be required to pay on behalf of Account any Incurred Claims beyond
the effective date of the termination and Wellmark reserves all rights to recoup any Paid
Claims for which Account has not paid Wellmark, regardless of when services were
received.
8.6 Termination and Claims Administration. If, following termination of this Agreement for
reasons other than Account's nonpayment, Incurred Claims with Incurred Dates prior fio
the date of termination are submitted to Wellmark in the period specified in the Benefits
Document for timely filing of claims, Wellmark shall pay these claims on behalf of Account
in accordance with this Agreement and submit bills to the Account for the payment of
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Claims Paid for a period of twelve (12) months following termination.The bills shall also I
include a Network Access Fee amount when the Network Access Fee, shown on Exhibit
"A", is reflected as a percentage of Network Savings or when Account makes retroactive
changes to add or delete a Plan Member from coverage during the Rating Period. The
Account shall pay ali bilis in accordance with the procedures set forth in Section 4.1,
Wellmark shall not, on behalf of Account, pay Incurred Claims with dates of service
following the date of termination. Unless Account and Wellmark otherwise agree in writing,
Welimark shall not continue any other services for Account after the effective date of
termination. -
8.7 Availability of Records. Upon written request by the Account, Wellmark will make
available to any successor benefit services administrator, designafied by the Account,
standard reports and materials in its possession at the time of termination that are
reasonably necessary to continue the administration of the Plan, Weilmark shall provide
such materials in its standard format and Account shall pay a reasonable fee for such
services.
8.8 Survival. Any liability of either party to the other for amounts owed or owing under this
Agreement, unless such amounts are de minimus, shall not be extinguished by the
termination of this Agreement.
ARTICLE 9
BLUE CROSS AND BLUE SHIELD DISCLOSURES AND INTER-PLAN ARRANGEMENTS
9.1 Blue Cross and Biue �hield Disclosure �tatement. Account on behalf of itself and its
Members, hereby expressly acknowledges ifis understanding this Agreement constitutes
a contract solely between Account and Welli�iark, w��icf� is ar� ir�ciepe�ic��r�� cc�rpc�ration
operating under licenses from the Blue Cross Blue Shield Association, an association of
independent Blue Cross and Blue Shield Plans (the "Association"), permitting Wellmark
to use the Blue Cross and Blue Shield Service Marks in the state of lowa, and that
Wellmark is nofi contracting as the agent of the Association. Account on behalf of itself and
its Members, further acknowledges and agrees that it has not entered into this Agreement
based upon representations by any person other than Wellmark and that no person, entity,
or organization other than Wellmark shall be accountable or liable to Account for any of
Wellmark's obligations to Account created under this Agreement, This section shall not
create any additional obligations whatsoever on the part of Wellmark other than those
obligations created under other provisions of this Agreement.
9.2 Account Locafiions or Members Outside of lowa.Account understands and agrees that
Welimark defines a National Account as a company headquartered and located in lowa
that also has employees in other states whose claims are processed through Inter-Plan
Arrangements. If Account is headquartered in lowa, any employees or persons associated
with Account are eligible for coverage under the Account's Plan, including those employed
or working at Account locations outside lowa. If Account is not headquartered in lowa,
only fihose employees or individuals associated with the lowa business locations are
eligible for coverage under the Account's Plan, and coverage will be void for any persons
associated with Account locations outside of lowa. Eligibility of persons located outside of
lowa, or associated with Account locations outside of lowa, is subject to applicable law
and Associafiion guidelines.
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9.3 Out-of-Area Services, Wellmark has a variefiy of relationships with ofiher Blue Cross ,
and/or Blue Shield Licensees referred to generally�s"Inter-Plan Arrangements."These ��
Jnter-Plan Arrangements operate under rules and procedures issued by the Blue Cross �
Blue Shield Association("Association").Whenever Members access health care services ;
outside the geogr�phic area Wellmark serves, the claim for those services may be !
processed through one of these Inter-Plan Arrangements. The Inter-Plan Arrangements ;
are described generally below. ,
Typically, when accessing care outside the geographic area Wellmark serves, Members ,
obtain care from health care providers that have a contractual agreement("participating
providers")with the local Blue Cross and/or Blue Shield Licensee in that other geographic ,
area ("Host Blue"). In some instances, Members may obtain care from health care
providers in the Host Blue geographic area that do not have a contractual agreement
("nonparfiicipating providers") with the Host Blue. Wellmark remains responsible for
fulfilling its contractual obligations to Account. Wellmark payment practices in both ,
instances are described below. '
This disclosure describes how claims are administered for Inter-Plan Arrangements and '
the fees that are charged in connection with Inter-Plan Arrangements.
a. BlueCardO Program. The BlueCardO Program is an Inter-Plan Arrangement. '
Under this Arrangement, when Members access Covered Services within the
geographic area served by a Host Blue, the Host Blue will be responsible for '
contracting and handling all interactions with its participating providers. The
financial terms of the BlueCard Program are described generally below.
i. Member Liability Calculation Method Per Claim. Unless subject to a ,
fixed dollar copayment, fihe calculation of the Member liability on claims for '
Covered Services processed through the BlueCard Program will be based '
on fihe lower of the participating provider's billed charges for Covered
Services or.the negotiated price made available to Wellmark by the Host
Blue.
ii. Account-Liability Calculation Method Per Claim. The calculation of
Account's liability on claims for Covered Services processed through the
BlueCard Program will be based on the negotiated price made available to
Wellmark by the Host Blue under the contract between the Hosfi Blue and
the provider. Sometimes, this negotiated price may be greater for a given
service or services than the billed charge in accordance with how the Host
Blue has negotiated with its participafiing provider(s)for specific health care
services. In cases where negotiated price exceeds the billed charge,
Account may be liable for the excess amount even when the Member's
deductible has not been satisfied. This excess amount reflects an amount
that may be necessary to secure (a) the provider's participation in the
network and/or(b)the overall discount negotiated by the Host Blue. In such
a case, the entire contracted price is paid to the provider, even when the
contracted price is greater than the billed charge.
iii. Claims Pricing. Host Blues determine a negotiated price, which is
reflected in the terms of each Host Blue's provider contracts. The
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negotiated price made available to Welimark by the Host Blue may be
represented by one of the foilowing:
a) An actual price. An actual price is a negotiated rate of payment in
effect at the time a claim is processed without any other increases
or decreases; or
b) An estimated price. An estimated price is a negotiated rate of
paymenf in effect at the time a claim is processed, reduced or
increased by a percentage to take into account certain payments
negotiated with the provider and other claim-and non-claim-related
transactions. Such transactions may include, but are not limited to,
anti-fraud and abuse recoveries, provider refunds not applied on a
claim-specific basis, retrospective settlements, and performance-
related bonuses or incentives; or
c) An average price. An average price is a percentage of billed
charges for Covered Services in effect at the time a claim is
processed representing the aggregate payments negotiated by the
Host Biue with all of its health care providers or a similar
classification of its providers and other claim-and non-claim-related
transactions. Such transactions may include the same ones as
noted above for an estimated price.
The Host Blue determines whether it will use an actual, estimated, or
average price. The use of estimated or average pricing may result in a
difference (positive or negative), between the price Account pays on a
specific claim and fihe actual amount the Host Blue pays to the provider.
However, the BlueCard Program requires that the amount paid by the
Member and Account is a final price; no future price adjustment will result
in increases or decreases fio the pricing of past claims,
In some instances federal or state laws or regulations may impose a
surcharge, tax or other fee. If applicable, Wellmark will disclose any such ',
surcharge, tax or other fee to Account, which will be AccounYs liability. I
Any positive or negative differences in estimated or average pricing are
accounted for through variance accounts maintained by the Host Blue and '
incorporated into future claim prices, As a result, the amounts charged to
Account wiil be adjusted in a following year, as necessary, to account for
over- or underestimation of the past years' prices. The Host Blue will not
receive compensation from how the estimated price or average price
methods, described above, are calculated. Because all amounts paid are
final, neither positive variance account amounts (funds available to be paid
in the following year), nor negative variance amounts (the funds neecled to
be received in the following year), are due to or from Account. If Account
terminates, Account will not receive a refund or ch�rge from the variance
account.
Variance account balances are small amounts relative to the overall paid
claims amounfis and wili be liquidated over time. The timeframe for fiheir
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liquidation depends on variables, including, but not limited to, overall ,
volume/number of claims processed and variance account balance. �
Variance account balances may earn infierest. Host Blues may retain ;
interest earned, if any, on funds held in variance accounfis.
iv. BlueCard Program Fees and Compensafiion. Account understands and
agrees to reimburse Welimark for certain fees and compensation which
Wellmark is obligated under the BlueCard Program to pay to the Host �
Blues, to the Association, and/or to vendors of BlueCard Program-related
services. The specific BlueCard Program fees and compensation that are
charged to Account, if any, are set forth in Exhibit "A". BlueCard Program
Fees and compensation may be revised from time to time as described in
subsection f below. All BlueCard Program-relafied fees, including any
Access Fees paid to Host Blues, and Adminisfirative Expense Allowance ,
("AEA") Fees are included in Wellmark's general Administrative Fee as set
forth in Exhibifi "A°. Wellmark has elected to not separately charge any
Inter-Plan Arrangement-related fees to Account.
b. Special Cases: Value-Based Programs. Account's Members may access
Covered Services from providers that participate in a Host Blue's Value-Based
Program. Value-Based Programs may be delivered through the BlueCard
Program. These Value-Based Programs may include, but are not limited to,
Accountable Care Organizations, Giobal Payment/Total Cost of Care
arrangements, Patient Centered Medical Homes, and Shared Savings
arrangements.
i. Value-Based Programs under the BlueCard Program; Program
Adminisfiration. Under Value-Based Programs, a Host Blue may pay
providers for reaching agreed-upon cost/quality goals in the following ways:
retrospective settlements, Provider Incentives, share of target savings,
Care Coordinator Fees and/or other allowed amounts, The Host Blue may
pass these provider payments to Wellmark, which Wellmark will pass
directly on to Account as an amount included in the price of the ciaim.
When such amounts are included in fihe price of the claim, the claim may
be billed using one of the following pricing methods, as determined by the
Host Blue:
a) Actual Pricing; The charge to accounts for Value-Based Programs
incentives/Shared Savings settlements is part of the claim. These
charges are passed to Account via an enhanced provider fee
schedule.
b) Supplemental Factor: The charge to accounts for Value-Based
Programs incentives/Shared Savings settlements is a supplemental
amount that is included in the claim as an amount based on a
specified supplemental factor (e.g., a small percentage increase in
the claim amount). The supplemental factor may be adjusted from
time to time.
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The amounts used to calculate the supplementai factors for estimated
pricing are fixed amounts that are estimated to be necessary to finance the
cost of a particular Value-Based Prograrn. Because amounts are
estimates, there may be positive or negative differences based on actual
experience and such differences will be accounted for in a variance
account maintained by the Host Blue (in the same manner as described in
fihe BlueCard claim pricing section above) untii the end of the applicable
Value-Based Program payment and/or reconciliation measurement period,
The amounts needed to fund a Value-Based Program may be changed
before the end of the measurement period if it is determined that amounts
being collected are projected to exceed fihe amount necessary to fund the
. programs or if they are projected to be insufficient to fund the program.
At the end of the Value-Based Program paymenfi and/or reconciliation
measurement period for these arrangements, Host Blues will take one of
the foliowing actions: ,
a) Use any surplus in funds in the variance account to fund Value- II
Based Program payments or reconciliation amounts in the next �
measurement period.
b) Address any deficit in funds in the variance account through the
reconciliation billing amount for the next measurement period,
The Host Blue will not receive compensation resulting from how estimated
or average price methods, described above, are calculated. If Account
terminafies, Account will not receive a refund or charge from the variance
account. This is because any resulting surpluses or deficits would be
eventually exhausted through prospective adjustment to,the settlement
billings in the case of Value-Based Programs. The measurement period for
determining these surpluses or deficits may differ from the term of this
Agreement.
Variance accounfi balances are small amounts relative to the overall paid
claims amounts and will be liquidated over time. The timeframe for their
liquidation depends on variables, including, but nofi limited to, overall
volume/number of claims processed and variance account balance.
Variance account balances may earn interest. Host Blues may retain
interest earned on funds held in variance accounts,
_ Note: Members will nofi bear any portion of the cost of Value-Based
Programs except when a Hosfi Blue uses either average pricing or actual
pricing to pay providers under Value-Based Programs.
ii. Care Coordinator Fees. Host Blues may also bill Welimark for Care
Coordinator Fees for provider services which Wellmark will pass on to
Account as follows;
Individual claim billings through applicable care coordination codes from
the most current edition of either Current Procedural Terminology (CPT)
pubiished by the American Medical Association (AMA) or Heaithcare
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Common Procedure Coding System_(HCPCS) published bythe Centers for j
Medicare and Medicaid Services (CMS). �
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As part of this Agreement, Wellmark and Account will nofi impose Member �
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cosfi sharing for Care Cnordinator Fees. ,
c. Return of Overpayments. Recoveries of overpayments from a Host Blue or its I
participating providers can arise in several ways including, but not limited to, anti-
fraud and abuse recoveries, health care provider/hospital bill audits, credit balance ,
audits, utilization review refunds, and unsolicited refunds. Recoveries will be
applied in general, on either a claim-by-claim or prospective basis, If recovery '
amounts are passed on a claim-by-claim basis from a Host Blue to Wellmark they
will be credited to Account. In some cases, the Host Blue will engage a third party ,
to assist in identification or collection of overpayments. The fees of such a third i
party may be charged to Account as a percentage of the recovery. ',
d. Nonparticipating Providers Outside Welimark's Service Area.
i. Member Liability Calculation.
a) In General. When Covered Services are provided outside of ',
Wellmark's service area by nonparticipating providers, the ,
amount(s) a Mernber pays for such services will be based on either ',
the Host Blue's nonparticipating provider local payment or the ,
pricing arrangements required by applicable state law. In these
situations, the Member may be responsible for the difference
between the amount that the nonparticipating provider bilis and the
payment Wellmark will make for the Covered Services as set forth
in this paragraph. Payments for out-of-network emergency services
will be governed by applicable federal and state law.
b) Exceptions. In some exception cases, Wellmark may pay claims
from nonparticipating providers for Covered Services outside of
Wellmark's service area based on the provider's billed charge. This
may occur in situations where a Member did not have reasonable
access to a participating provider, as determined by Wellmark or by
applicable law. In other exception cases, Wellmark may pay such
claims based on the payment Wellmark would make if Wellmark
were paying a nonparticipating provider for the same Covered
Services inside of Wellmark's service area. This may occur where
the Host Blue's corresponding payment would be more than
Wellmark's in-service area nonparticipating provider payment.
Wellmark may choose to negotiate a payment with such a provider
on an exception b�sis.
Unless otherwise stated, in any of these exception situations, the
Member may be responsible for the difference between the amount
that the nonparticipating provider bills and the payment Wellmark
will make for the Covered Services as set forth in this paragraph.
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ii, Fees and Compensation. Account understands and agrees to reimburse
Wellmark for certain fees and compensation which Wellmark is obligated
under applicable Inter-Plan Arrangement requirements to pay to the Host
Blues, to the Association, and/or to vendors of Inter-Pian Arrangement-
related services, The specific fees and compensation that are charged to
Account, if any, are set forth in Exhibit "A". Fees and compensation under
applicable Inter-Plan Arrangements may be revised from time to time as
provided for in subsection f below.
e. Biue Cross Blue Shield GlobalT"' Core.
i. General Information. Ifi Members are outside the United States, the
Commonwealth of Puerto Rico, and the U.S. Virgin Islands (hereinafter:
"E31ueCard service area"), they may be able to take advantage of the Blue
Cross Blue Shield Global Core when accessing Covered Services. The
Blue Cross Blue Shield Global Core is not served by a Host Blue.
Inpatient Services. In most cases, if Members contact the Blue Cross Blue
Shield Global Core Service Center for assistance, hospitais will not require
Members to pay for covered inpatient services, except for their cost-share
amounts. In such cases,the hospital will submit Member claims to the Blue
Cross Blue Shield Global Core Service Cenfier to initiate claims peocessing. '
However, if the Member paid in full at the time of service, the Member must I
submif a claim to obtain reimbursement for Covered Services. Members '�
must contact Welimark fia obtain precertification for non-emergency �I
inpatient services. I�
ii, Blue Cross Blue Shield Global Core Related Fees.Account understands j
and agrees to reimburse Wellmark for certain fees and compensation which �
Wellmark is obligated under applicable Inter-Plan Arrangement
requirements to pay to the Host Blues,to the Association, and/or to vendors
of Inter-Plan Arrangement-related services. The specific fees and
compensation that are chargsd to Account under the Bfue Cross Blue
Shield Global Core, if any, are set forth in Exhibit "A", Fees and �
compensation under applicable Inter-Plan Arrangements may be revised
from time to time as provided for in subsection f below. i
f. Modifications or Changes to Inter-Plan Arrangement Fees or Compensation,
Modifications or changes to Inter-Plan Arrangement fees are generally made
effective January 1 of the calendar year but they may occur at any time during the
year. In the case of any such modifications or changes, Wellmark shall provide
Account with at least thirty(30) days' advance written notice of any modification or
change to such Inter-Plan Arrangement fees or compensation describing the
change and the effective date thereof and Account's right to terminate this
Agreement without penalty by giving written notice of termination before the
effective date of the change. If Account fails to respond to the notice and does not
fierminate this Agreement during the notice period, Account will be deemed to have
approved the proposed changes, and Wellmark wiil then allow such modifications
to become part of this Agreement.
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- ARTICLE 10- !
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MISCELLANEOUS ;
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10.1 Change of Agreement. If Account makes changes in the Plan or Benefits Document, ;
Account shall give Wellmark sufficient advance notice of such changes. If Account makes
any material changes in fihe Plan, or if material changes are required by law, inciuding fihe �
addition or deletion of benefits, a mafierial change in group composition or membership or i
eligibility requirements, such as a change in the number of eligible or enrolled individuals �'
of fien percent (10%) or more, percentage of individuals enrolled, types of coverage I
offered, business entities covered, or offerings of other health insurers'coverage to eligible i
individuals, Wellmark shall have the right at its option to amend this Agreement, including
an adjustment to fihe financial fierms shown on Exhibifi"A", or to terminafie this Agreement
in accordance with Section 8.3.
uarial Certification. Nothin contained '
ter 509A Com liance• No Act 9 �
10.2 lowa Code Chap p � ,
in this Agreement or on Exhibit A shall be construed or considered to be an actuarial �
opinion or certification by Wellmark in connection with lowa Code Chapter 509A regarding
the adequacy of reserves, rates, or financial condition of Account or the Plan. Account is
solely responsible for compliance with all provisions of lowa Code Chapter 509A and
implementing regulations and, if applicable, is responsible for reporting any paid losses
for the Account's self-funded operation of the Plan, as required by lowa Code Section
513C.10, and for paying any assessment related to those paid losses.
10.3 Use of Trademarks and Names. Wellmark and Account reserve the right fio control the
use of their respective corporate names and any other respective symbols, assumed
names, trademarks, and service marks, presently existing or subsequently established.
Wellmark and Account agree not to use the corporate name, symbol, assumed names,
trademarks, or service marks of the other in advertising, promotional materials, or
otherwise without the prior written consent of the other. Any previously approved usage
shall cease immediately upon the termination of this Agreement and any materials using
such names or marks are the property of the appropriate namesake and shall be returned
to the appropriate property owner upon request or at the termination of this Agreement.
10.4 Complete Agreement; Amendments. The parties agree that this Agreement, including,
without limitation, any Exhibits or amendments hereto, applicable Business Associate
Agreement, the Medical Management and Well-being Consulting Services Exhibit, and
COBRA Administrative Services Agreement or Addendum, if any, constitute the complete
and exclusive agreement and statement of the relationship between the parties with
regard to the subject matter of this Agreement and supersedes all related discussions,
understandings, proposals, exhibits, amendments, prior and concurrent agreements,
representations and warranties, whether oral or written, and any other communications
between the parties in regard to the subject matter hereof. This Agreement, including,
without limitation, any Exhibits hereto, may be amended from time to time by the parties.
Any amendment to this Agreemenfi, or change, modification, or waiver of any of the terms
or provisions of this Agreement shall be effective only when made in wrifiing and signed
by an authorized representative of each party and delivered in accordance with Section
10.11. This Agreement shall take precedence over any other documents that may be in
conflict with it.
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Notwithstanding the foregoing, if this Agreement supersedes a prior Agreement, health
services with an Incurred Date prior to the Effective Date of this Agreement shall be
processed pursuant to the terms of the applicable superseded Agreement.
10.5 Force Majeure. The parties to this Agreement shall be excused from any performance '
under this Agreement, other than payment of amounts due,for any period and to the extent �I�
they are delayed, restricted, or prevented from performing under this Agreement as a I
result of an act of God, war, civil disturbance, court order, labor dispute, act of terrorism, I
or other cause beyond their reasonable control. I
10.6 Limitation of Action. Notwithstanding Sections 5.6, 7.9, and 8,8, no legal or equitable
action or claim, may be brought against Weilmark for an action or claim arising under or
relating to this Agreement mor� than three (3) years after the cause of action arose.
10.7 Assignment. The Agreement shall be binding on the parties and their respective I
successors and permitted assigns. Neither party may assign this Agreement to any third
party, in whole or in part, without the prior written consent of the other; provided, however,
Welimark may assign this Agreement, in whole or in part, to any entity that controls, is
controlled by, or is under common control with Wellmark. Further, Welimark may, in its
sole and unfettered discretion, contract with a fihird party to per�orm some Administrative
Services or other of Wellmark's duties under this Agreement, including, without limitation,
the subrogation recovery services for Claims Paid. To the extent Wellmark contracts with
a third party to perform any such services or duties, the term "Wellmark" as used in this
Agreement shall be deemed to include the contracfied third party, as the context so
requires,
10,8 Waiver,The failure of any party to enforce any terms or provisions of the Agreement shall
not be deemed or construed to be a waiver of the enforceability of such provision.
Similarly, the failure to enforce any remedy arising from a default under the terms of the
Agreement shall not be deemed or construed to be a waiver of such default. Any waiver
of any provision of this Agreement, and any consent to any departure from the terms of
any provision of this Agreemenfi, shall be effectiv� only in the specific instance and for the
specific purpose for which made or given.
10.9 Nature of Relationship; Authority of Parties. Nothing contained in this Agreement and
no action taken or omitted to be taken by Account or Wellmark pursuant hereto shall be
deemed to constitute Account and Wellmark a partnership, an association, a joint venture
or other entity whatsoever. Wellmark shall at all times be acting as an independent
contracfior under this Agreement. No party has the authority to bind the other in any respect
whatsoever.
10,10 No Third-Party Beneficiaries, This Agreement is for the benefit of Account and Welimark
and not for any other person. It shall not creafie any legal relationship between Welimark
and any employee, Member, or any other party claiming any right, whether legal or
equitable, under the fierms of this Agreement or of the Plan.
10.11 Notices and Communication. The parties shall be entitled to rely upon any
communication or notice from the other in connection with this Agreement to be genuine,
truthful, and accurate, and to have been authorized, signed, or issued by an officer or
agent of such entity empowered to make such representation on behalf of the entity.
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Any notice required or permitted io be given under this AgrE�ment sh�ll be in wrifiing and e 'I
shall b� cleemed �iven when d�livered personally, placed in the U.S, mail (post�ge ,
pr�paid), deliverecl to a recognized courier service for delivery(delivery chargos prepaid}, ; �,
or s�nt by electronic me�ns and addressed io the last �ddress furnished in writing. Untif '
�nother address is furnished in writing, notice to Account m�y be address�d io the address 'i ''i
shown on Exhibifi"A" �ttached fio fihis Agre�ment. � '
Nafiice to Wellm�rk m�y b� �ddressed:
�
Wellmark Blue Cross and Blue Shield of lowa � !
�
Aitention: Procuremenl�nd Contracts ;
' 1331 Grand Avenue i
Qes Moines, lowa 50309-2901 '
10.12 State of Issue; Applicable Law; Venu�; and Waiver a� Jury Trial. This Agreement is
issued �nd delivered in th� state of lowa and is porFarmed in Des Moines, lowa. To fihe
extenfi not superseded by the laws of the United States and withaut regard to any conflict
of law rule, this Agreement shall be construed in accordance with �nd governed by the
laws o�the state of low�.Any action in rogard to this Agreement or arising oufi of the terms ;
of this Agreement sh�ll be institufied and lifiigated in the fow� Disfirict Gourt or fihe United ,
States District Court loc�ted in Des Moines, Polk County, lowa and no ofiher. ACCOUNT
AND WELLMARK WAIVE ANY RIGHT TO A JURY TRIAM,WITH RESPECT TO AND IN
ANY ACTION, PROCEEDING, CLAIM, COUNTERCI.AIM, DCMAND OR OTHER
MATTER WHATSOEVER ARISING OUT OF THIS AGREEM�NT.
IN WITNESS WH�REOF, the parties h�ve executed this Agre�ment as of the Effective Date first '
stated above.
City of Dubuque, lowa Welim�rk, Fna, doing business as
, Wellmark Blue Cross and Blue Shield of lowa
�_ DocuSigned by:
By; gY ��-��w--�—�� —
� �8E531 A8388684BE...
Print Nam�: i�'1ic.���e �-� v��► �'�4�� ���,►'� David S. Brown
� Executive Vice Presidont, Chief Financial Officer
Title; �.i�4� i �. �c,� and Treasurer
e
IA WBCBSI LG SF 29 Version: 10117
DocuSign Envelope ID:3D1467FA-AAE2-4FAA-BC3E-35FCEC2F5218
Wellmark Blue Cross and Blue Shield of lowa
Administrative Services Agreement
Exhibit A
Administrative Fees, Network Access Fees, Other Fees
Account Full Legal Name and Legal Address:
City of Dubuque, lowa
50 West 13th St
Dubuque, IA 52001
Benefit Plan(s)Administered By:
Wellmark Blue Cross and Blue Shield of lowa
Ratinc� Period:
The Rating Period begins on 7/01/2018 and ends on 6/30/2019.
Plan Year:
The Plan Year begins on 07/01 and ends on 06/30,
Administrative Fee:
Health: $35.06 per Plan Member per month based on active Plan Members on
last day of billing month(subject to limitations listed under Billing
and Payment Method below).
Pharmacy Administrative Fee:
$2.00 per Plan Member per month based on active Plan
Members on last day of billing month (subject to
fimitations listed under Billing and Payment Method
Network Access Fee: $8.03 per Plan Member per month based on active Plan Members on
last day of billing month (subject to limitations listed under Billing
and Payment Method below).
Externa! Review:
External review fees for Independent Review Organizations QROs), if applicable,will be on a per case �I
or per external review basis and all such fees attributable to Members under the Plan shall be billed to
Account in the amount billed to Wellmark by the IRO.
Subrogation Vendor Fees:
The subrogation recovery vendor(s)retain a service fee calculated as a percentage of the recovered
amount after deductions for attorneys'fees and costs. For subrogation cases initiated on or after July 1,
2016,the subrogation recovery vendor's service fee is 19.5%of the recovered amount. This fee is
subject to change. The final recovered amount received from the vendor is credited to Account.
Wellmark's agreement with the subrogation recovery vendor may from time to time allow for the
application of no vendor service fees to amounts recovered during that period of time. Any subrogation
recovery amount obtained by the vendor on behalf of the Account during such time period will be provided
to Account without application of the vendor service fee.
Page 1 of 2 A51
Confidential&Proprietary—Confidential Treatment Requested-lowa Code§22.7
a
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DocuSign Envelope ID:3D14B7FA-AAE2-4FAA-BC3E-35�CEC2F5218 i
I
Wellmark Blue Cross and Blue Shield of lowa ��
Administrative Services Agreemenfi ��
Exhibit A �
Administrative Fees, Network Access Fees, Other Fees �
;
Accounfi Full Le�al Name and Legal Acldress: �
City of Dubuque, lowa ��
50 West 13th St i
Dubuque, lA 52001 �I
BlueCard Program-related Fees: I
All BlueCard Program-related fees, including any Access Fees paid to Host Blues and Administrative '!
Expense Allowance("AEA")Fee, are included in Welimark's general Administrative Fee stated above. !
Wellmark has elected to not separately charge any Inter-Plan Arrangement-related fees to Account. The '
general Administrative Fee encompasses fees Wellmark charges to Account for administering Account's
benefit plan. Fees may include both local and Inter-Plan fees. Other BlueCard Program-related fees
included in the general Administrative Fee include the Central Financial Agency Fee, ITS Transaction '
Fee, Toll-Free Number Fee, PPO Provider Directory Fee, and the Blue Cross Blue Shield Global Coverage
Fees, if applicable.
Biliing and Payment Method:
Wellmark shall notify Account weekly of the total Claims Paid amounfi for the week. Account shall
make payment to Wellmark within forty-eight hours of receipt of the notification. Wellmark shall bill
Account monthly for Claims Paid (if any),Administrative Fee, other fees, and refiect the
payments/credits received.
Limitations: Any adjustments to Administrative Fee, Network Access Fee, and other fees due to
membership or eligibility changes shall be reflected on the billing for the month in which the
membership or eligibility change is made and shall be limited to a period of three(3)months prior to
the date Wellmark processes the Member eligibility change.
Exhibit A Issue Date: 6/29/2018
Page 2 of 2 A51
Confidential&Proprietary—Confidential Treatment Requested-lowa Code§22.7
DocuSign Envelope ID:3D14B7FA-AAE2-4FAA-BC3E-35FCEC2F5218
MEDICAL NIANAGEM�NT AND`VELL-BEING CONSULTING SERVIC�S�YHIBIT
THIS EXHIBIT ("�shibiY') is 1ttiched to and constittrtes a plrt of the Administrative Services ',
Agreement by and bet�veen Wellmark ancl Account (the "Aclministr�tive Services Agree�nent"). Any ,
capitllized term not otherwise clefinecl herein sh�ll have the me�ning lscribed to it in the Administrative �i,
Services Agreement. '
I.RECITALS ,
A. Pursuant to the Administrati.ve Services Agreement,Wellmark provicies certain claims administration, I
enrolhnent, �nd medical manlgement�nd�vell-being consulting services for Account.
B. Wellmark delivers these various medicll management and well-.being consulting services described in �
Section II of this Exliibit ("Medic�l M�n�gement �ncl We1l-being Consulting Sei•vices") to Wellzllarlc's
MemUers and other eligible individulls, either directly or througli �greenieiits with thircl-plrty vendors (the
"Venclors"� �eaC�l,1"Vendor Agreement"�,
I
C. Account desires to obtain, and �Vellmark desires to provide, Medical Management and Well-being
Consulting Services all as further described herein.
II. S�RVICES
Wellmark may,at its sole discretion,make certain Medical M�nagement and Well-being Consulting Ser�ices
available to Account, the cost for which is included in the Aclministrative Fee. Wellmark inay, at its sole
discretion, make certlin other Medical Management and Well-being Consulting Services availlble for
Accottnt's purchase at a fee in addition to the Adininistrative Fee, Account h1s signified �vhich Medical
Management and tiVell-being Consulting Services it wishes to purchase and such services and fees �re stated ,
in �shibit "A", Administrative Fees, Network Access Fees, Other Fees, to the Administrative Services
Agreement. In consideration of the Medicll Management and Well-being Consulting Services to be received
by Account from`Vellmlrk,Account shall pay to Wellmark the fees, if any, set forth on Eskibit "A" Co the
Administrltive Services Agreement. Account acknowledges the fees n11y chinge from time to time.
BE`VELL 24/7. BeWell 24/7 is generally comprised of a dedicated to11-free telephone ntunbar, available
twenty four hours per day,seven days per�veek, three hundred sixty-five days per year,that will be staffed by
1 registered mirse, licensed practical nurse or non-niuse personnel, who assist Members by providing I
infonnation,eclucation, decision-making assistance, �dvocacy�nd help in navigating the he�lth c�re system.
ADVANCED CARE MANAG�MENT. Advanced C�re Management is generally comprised of
individualized coaching and support to Members�vith severe or complex conditions.
W�LLNESS SERVIC�S. If Account's election includes `Vellness Services, �vhich m1y inclucle 1ny of the
following: Online tiVellness Center and Wellness Assessment;Paper Wellness Assessment;Telephonic Health
Coaching; Wellness Screenings (biometrics); Tobacco Cessltion Coaching, Wellness Challenges; Health
Program Referr�ls;or Debit Card Redemption,the follo�ving provision 1pplies:Wellness Services are designed
to help Members reduce liFestyle-rel�tted health rislc factors and develop healthy behaviors.`Vellness Services
include assessments and beh�vior ch�nge tools meant to help individulls improve health,increase productivity,
and clecre�se absenteeism.
CONDITION SUPPORT. If Account's election inchides Condition Support, �vhich may include 1ny of the
follotiving:Astlunl,Coronary Artery Disease("CAD"),or Diabetes Condition Support Services,the following
provision applies: Condition Support Services 1re generally comprised of the identi�cation of Members tivith
Medical Nianagement and tiVell-being Constilting Services Exhibit—SF Version:O1/O1/2018
1
DocuSign Envelope ID:3D�14B7PA-AAE2-4FAA-BC3E-35FCEC2F5218 I
i
I
conciitions that reqtiire signific�nt self-care ancl the rendering of support ttuough coordinatecl interventions and �
i
communicltions. �
i
P12EGNANCY SUPPORT. If Account's election includes Pregnancy Support("Pi•egn��ncy Support"), the !,
following provision applies: Pregnancy Support offers maternity educ�tion 1nd personal support for pregnant '
woinen, 1nd assesses and identifies 1t-risk or high-rislc pregnancies. The goal is for particip�nts to better II�
understand and malce medical and lifestyle choices that reduce the incidence of pre�term deliveries,low birth- '�
weight babies, and other pregnlncy-related complications. Particip�nts receive educational m�teri�ls �nd '�
telephone-based counseling with 1 registered nurse during pregnancy�nd up to six vveel<s postpartum,
W�LL-BEING CONSULTING S�RVIC�S. If Account elects tiVell-being Consulting Services j
("Consulting Services"), which may include 1�y of the following: Worlcplace Assessment; Well-being �
Communication Strategy; Well-being Comiilittee Development; Vending and Clfeteria Audit; Employer
Incentive Design; Custonzized Well-being DashUoard 1nc1 Metrics; Couununity Based Vendor 5election;
Worlcsite Policy 1nd Practice Review; Well-being Certification/Accreditation; or Worksite Well-being
ConsulCing, the following provision applies: Consulting Services are gener�lly comprised of lssisting
employers with creating well-being solutions or wellness programs at their worksites for their workforce. '
TERMS AND CONDITIONS '
l. Term �nd Termin�tion. This Exhibit 2. Represent�tions �nd W�rr�►nties of
shall cover the Medical Management and Well- Account. Aecount hereby represents and
being Consulting Services provided to Account warrants to Wellmark as follows:
as set forth in Exhibit "A" to the Administrative
Services Agreement, effective as of the effective 2.1 In the performance of its obligations under
date set forth therein. this Exhibit, Account has the responsibility for
the design and implementation of its employer-
l.l Wellmarlc may tenninate this Exhibit or sponsored wellness program and shall comply
any Medical Management and Well-being with all applicable federal,state or local laws and
Consulting Services iimnediately by written regulations, including, without limitation,
notice to AccoLtnt upon the terinination or HIPAA, as modi�ed by the Health Infonnation
expiration of the Administr�tive Services Technology for Economic and Clinical Health
Agreament or any Vendor Agreement or any Act ("HITECH" Act), as incorporated in the
attachment thereunder. Ainerican Recovery and Reinvestment Act of
2009, and as inodified by the ACA, the
1.2 Wellmark m1y, at any time, in its Atnericlns with Disabilities Act, as �mended by
discretion, tenninite this Exhibit in the event of the Atnericlns with Disabilities Ainendments
Account's failttre to p�y when due the fees and Act,the Genetic Infonnation Non-Discrimin�tion
other lmounts payable to �Vellm�rk under this E1ct, laws �nd regulations regarcling employer-
Exhibit,where such failure is not cured�vithin ten sponsored wellness progrlms, �nd the laws and
(10) d�ys following Wellmarlc's written notice to regul�tions reglyding the maintenance and
Account specifying such failure. confidentiality of hellth, fin�ncial and other
information and records. Account will only
1.3 This Exhibit m�y be terminaCed by lccess, use and disclose health, �n�nci�l and
Welhnarlc or by Account at any time, with or other infonnation and records in accord�nce with
without c�use, for 1ny reason or no relson, 111 applicable laws.
effective thirty (30) days following the
tenniniting party giving written notice to the 2.2 Account will not describe, discuss or
other party of its intent to terminate this Exhibit. promote the web portal used in connection with
the Medicll Mlnagement and Well-being
Consulting Services (the "Web Port�l") in any
Medical Nianagement and Well-being Consulting Seivices Exhibit—SF Version; O1/O1/2018
2
DocuSign Envelope ID:3D1467FA-AAE2-4FAA-BC3E-35FCEC2F5218
way that is inconsistent with,or would add to,the such Medical Man�tgement and Well-being
terins 1nd conditions of use set forth on the Web Consulting Services, inchtding, without
Portal. limitation, educlCionll inaterials, software,
source code, h�rd�vare, technology, content,
3. Performance Level Snecifications, informltion, know how, forms, policies,
`Vellmark inay provide or the Vendor procedures, manuals, specifications, service
Agreements may contain certain performance models, and designs, or any confidentill
guarantees obligating Wellmlrk or its Vendors to informltion belonging to Wellmark or the
meet the attributes of perfonnance that the Vendors or their respective affiliates or suppliers,
Meclic�l Management and Well-being Consulting and that all such right, title �nd interest is and
Services shall achieve, all as set forth in detail in shall remain owned by Welhnark, Vendors, or
the respective Vendor Agreement or perfoi7n�nce their respective affiliates or suppliers, as
level gu�r�ntee schedule, if applicable (the 1pplicable.
"Perform��uce Level Specific�tions"or"PLS").
If a Vendor does not achieve a speci�c PLS, 5. Ch�n�es in L�ry �nd ReQul�tions. 'I
pursuant to th�t Vendor Agreement, �ellmark Notwithstanding any other provision of this I
shall be entitled to reimbursement of� specit"iecl Exhibit, if any federal, stlte or local �
percentage of the fees rellting to the Medical govermnentll agency or court of competent
Mlnagement ancl tiVell-being Consulting Service jurisdiction passes, issues, interprets or
at issue that are earned by that Vendor undar the promulgltes.any law, rule, regulation, standard,
Vendor Agreement (the "PLS Fees"). To be decision or interpretation(collectively,an"Aet")
eligible to receive its pro-rata share of PLS Fees, at any time while this Exhibit is in effect that
Account must (i) have purchased the relevant prohibits the performance of, or materially �
Medical Management and Well-being Consulting enlarges, Wellmlrk's obligations hereunder, or �
Service for all 12 months of the relevant program other�vise impairs, restricts, limits or otherwise
year, and (ii) remain a customer of Wellmlrk materially and adversely affects `Vellmark's
through the date Wellinark receives PLS Fees for rights, benefits, or obligations hereuncler,
the applicable time period from its Vendors. Wellinarlc may give Account notice of intent to
Account �vill not receive any PLS Fees for any amend this Exhibit to the reasonable satisfaction
Medical Management and�Vell-being Consulting of Welhnark in order to comply with any such
Services it dicl not purchlse 1nd Account will not Act.
receive PLS Fees for any Consulting 5ervices
ptu•chased hereuncler. 6. Disclaimer of Wnrr�nties; Limit�tion of
Lilbilitv. THE MEDICAL MANAGEMENT
4. Ownershin of Meclicai Man��ement nnd AND WELL-BEING CONSULTING
`Vell-bein� Consultina Services. The Medical SERVICES ARE EDUCATIONAL AND
Mlnagement �nd �Vell-being Consulting INFORMATIONAL TOOLS ONLY AND DO
Services �ncl their content are proprietary to NOT CONSTITUTE CLINICAL S�RVICES.
Wellmark, the Vendors and their respective EXCEPT AS EXPRESSLY SET FORTH IN
af�liates or suppliers, as the case may be. Except THIS EXHIBIT, WELLMARIC DOES NOT
as expressly set foi•th in this Exhibit, the Medical MAKE AND HEREBY DISCLAIMS ANY
Manlgetnent 1nd �Vell-being Consulting REPRESENTATION OR WARIZANTY OF
Services may not be duplic�ted, modifiecl, ANY ICIND, EXPR�SS OR INIPLI�D,
reproduced, or used for the benefit of any third INCLUDING IMPLIED WARRANTIES OF
p1rty, Account acknowledges and agrees that it MERCHANTABILITY AND FITNESS FOR A
does not now own, nor by virtue of this Exhibit PARTICULAR PURPOSE, REGARDING THE
or the Medical Management and `Vell-being MEDICAL MANAGEMENT AND `VELL-
Consulting Services rendered hereunder shlll it BEING CONSULTING SERVICES, THEIR
acquire, any right, title or interest in or to the ABILITY TO REDUCE COSTS OR IMPROVE
Medical Management�tnd�Vell-being Consulting OUTCOMES. WELLMARK IS NOT
Services or the intellectual property underlying RESPONSIBLE FOR DATA INACCURACIES
Medical Management and�Vell-being Consulting Services Exhibit—SF Version: O1/O1/2018
3
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DocuSic�n Envelope ID:3D'14B7FA-AAE2-4FAA-BC3E-35FCEC2F52�18 i
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1N TH� SOURCE DATA PROVIDED BY THE RESULTS OF ITS MEMBERS' US�_OP I
ACCOUNT OR MEMB�RS. 1N NO EV�NT SUCH INFORMATION, 1NCLUDING, BUT
SHALL WELLMARIC BE LIABL� I'OR NOT LIMIT�D TO, MEMBERS CHOOSING
1NDIRECT, 1NCIDENTAL, TO SEEK ORNOT TO SEEK PROFESSIONAL i
CONS�QUENTIAL,PUNITIV�, OR SPECIAL MEDICAL CARE, EM�RGENCY CARE, OR i
DAMAGES, LOSS OF DATA OR LOST MEMBERS CHOOSING OR NOT CHOOSING !
PROFITS, EVEN IF WELLMARK IIAS BEEN SP�CIFIC TR�ATMENT. �
ADVISED OF THE POSSIBILITY OF SUCH i
DAMAG�S. �V�LLMARIC'S AGGR�G�ITE
MONETARY LIABILITY TO ACCOUNT OR • '
ITS M�MBERS OR AFFILIATES UND�R
THIS EXHIBIT AND WITH RESPECT TO �.
THE MEDICAL MANAG�MENT AND ,
W�LL-BE1NG CONSULTING S�RVICLS ',
FURNISHED HEREUNDER (WHETHER
UNDER CONTRACT, TORT, OR ANY ',
OTHER T�IEORY OF LAW OR EQUITY) ',
SHALL NOT EXCE�D, UNDER ANY ,
CIRCUMSTANC�S, THE FEES PAID BY '
ACCOUNT TO WELLMARK FOR THE '
MEDICAL MANAG�MENT AND WELL-
BElNG CONSULTING SERVICES UNDER
THIS EXHIBIT DURING THE ONE (1) YEAR
PERIOD PRECEDING THE CLAIM, LESS
TH� AMOUNT OF ANY PLS FEES
REIMBURSED TO ACCOUNT DURING
THAT TIME. THE FOREGOING
LIMITATION OF LIABILITY REPRESENTS
THE ALLOCATION OF RISIC BETWEEN THE
• PARTIES AS REFLECTED 1N THE PRICING
HEREUNDER AND IS AN ESSENTIAL
EL�MENT OF THE BASIS Or THE BARGAIN
BETWEEN THE PARTIES.
HEALTH 1NFORMATION PROVIDED BY
WELLMARK OR THROUGH ITS VENDORS
OR THEIR AI'FILIATES IS BASED ON
MEDICAL LITERATURE. HOWEVER, USE
OF SUCH 1NFORMATION IS NOT
1NTENDED TO R�PLACE PROFESSIONAL
M�DICAL ADVICE AND CARE rROM A
HEALTH CARE PROFESSIONAL. THE
HEALTH INFORMATION IS 1NTEND�D TO
HELP PEOPLE MAICE BETTER HEALTH
CARE DECISIONS AND TAKE GREATER
RESPONSIBILITY FOR THEIR OWN
HEALTII, BUT MAY NOT RESULT 1N
ACTUAL ACHIEVEMENT OF TH�SE
GOALS. ACCOUNT EXPRESSLY
ACKNO�VLEDG�S AND AGREES THAT
�VELLMARIC IS NOT RESPONSIBLE FOR
Medical Management and Well-being ConsuLting Services Exhibit—SF Version: O1/O1/2018
4
DocuSign Envelope ID:3D1467FA-AAE2-4FAA-BC3E-35FCEC2F5218
City of Dubuque Insurance Requirements for Professionai Services
INSURANCE SCHEDULE J
1. Wellmark Blue Cross and Blue Shield of lowa shall furnish a signed certificate of Insurance to the City of Dubuque,
lowa for the coverage required in Exhibit I prior to commencing work and at the end of the project ifthe term
of work is longer than 60 days. Contractors presenting annuai certificates shall present a certificate atthe end
of each project with the final bil�ing, Each certificate shall be prepared on the most current ACORD form
approved by the lowa Department of Insurance or an equivalent approved by the Finance Director, Each
certificate shall include a statement under Description of Operations astowhythecertificatewas issued,Eg: ',
Project# or Project Location at or construction of '�
2. Ali policies of Insurance required hereunder shall be with an insurer authorized to do business In lowa and all I
Insurersshall havea ratingofAorbetterinthecurrentA.M.Best's Rating Guide. ',
3. Each certificate shall befurnished toihe Personnei Department of the City of Dubuque. ,
4. Failure to provide coverage required by this Insurance Schedule shall not be deemed a waiver of these I'�,
requirementsbytheCityofDubuque. Failuretoobtainormaintaintherequiredlnsurance shall beconsidered ''
a material breach of this agreement, I
5, Contractors shail require all subconsultants and sub-subconsultants to obtain and maintain during the I�
performance of work Insurance for the coverages described in this Insurance Schedule and shall obtain
certificates of insurances from all such subconsultants and sub-subconsultants. Contractors agree that they
shall beliableforthefailureofa subconsultantand sub-subconsultant to obt�in and maintain such coverages.
The City may request a copy of such certificates from the Contractor.
6. All required endorsements shall be attached to certificate of Insurance. I
I
7, Whenevera specific ISOform is listed,required thecurrentedition oftheform mustbe used,or an equivalent ;
form maybesubstituted ifapproved bythe Finance Directorandsubjecttothe contractor identifying and listing i
in writing ail deviations and exclusions from the ISOform,
8. Contractors shall be required to carry the minimum coverage/limits, or greater If required by law or other legal
agreement, In Exhibit I. If the contractor's limits of liability are higherthan the required minimum limits then the
provider's limits shall be this agreement's required limits.
Page 1 of 4 Schedule J Professional Services July 2017
DocuSign Envelope ID:3D14B7FA-AAE2-4FAA-BC3E-35FCEC2F5218 I
City of Dubuque Insurance Requirements for Professional Services
IN�URANCE SCHEDULE J (continued)
Exhibit I
A) COMMERCIAL GENERAL LIABILITY ,
General Aggregate Limit $2,000,000
Products-Completed Operations Aggregate Limit $1,000,000
Personal and Advertising Injury Limit $1,000,000
Each Occurrence $1,000,000 ,
Fire Damage Limit (any one occurrence) $50,000
Medical Payments $5,000
1) Coverage shall be written on an occurrence, nofi claims made, form. The general liability '
coverage shall be written in accord with ISO form CG0001 or business owners form BP0002.
All d�viations from the standard ISO commercial general liability form CG 0001, or business
owners form BP 0002, shall be clearly identified.
2) Include ISO endorsement form CG 25 04 "Designated Locafiion(s) General Aggregate Limit"
or CG 25 03 Designated Construction Project (s) General Aggregate Limit" as appropriate.
3) Include endorsement indicating that coverage is primary and non-contributory.
4) Include Preservation of Governmental Immunities Endorsement. (Sample attached).
5) Include an endorsement that deletes any fellow employee exclusion.
6) Include additional insured endorsement for:
The City of Dubuque, including all its elected and app�inted officials, all its employees and
volunteers, all its boards, commissions and/or authorities and their board members,
employees and volunteers. Use ISO form CG 2026.
7) Policy shall include Waiver of Right to Recover from Others endorsement.
B) AUTOMOBILE LIABILITY
Combined Single Limit $1,000,000
C) WORKERS' COMPENSATION & EMPLOYERS LIABILITY
Statutory benefits covering all employees injured on the job by accident or disease as prescribed
by lowa Code Chapter 85 as arnended.
Coverage A Statutory— State of lowa
Coverage B Employers Liability -
Each Accident $100,000
Each Employee-Disease $100,000
Policy Limit-Disease $500,000
Policy shall include Waiver of Right to Recover from Others endorsement.
Nonelection of Workers' Compensation or Employers' Liability Coverage under lowa Code sec.
87.22
_ yes _ form attached
Page 2 of 4 Schedule J Professional Services July 2017
DocuSign Envelope ID:3D14B7FA-AAE2-4FAA-BC3E-35FCEC2F5218
City of Dubuque Insurance Requirements for Professional Services
INSURANCE SCHEDULE J (continued)
D) UMBRELLA/EXCESS LIABILITY $1,000,000
Umbrella/excess liability coverage must be at leastfollowing form with the underlying policies Included herein,
E) PROFESSIONAL LIABILITY $1,000,000
Provide evidence of coveragefor5 years aftercompletion of project.
F) CYBER LIABILITY $1,000,000
X yes no
Coveragefor FirstandThird Partyliabilityincludingbutnotlirriitedtolostdataand restoration, loss ofincome
and cyber breach of Information.
Page 3 of 4 , Schedule J Professional Services July 2017
DocuSign Envelope ID:3D14B7FA-AAE2-4FAA-BC3E-35FCEC2F5218
City of Dubuque Insurance Requirements for Professional Services
Pi�ESERV�ATION O� GOVEF�NMEP�TAL INfI'�IIU(�IT9E� ENCDOR�EMENT
1. Nonwaiver of Governmental Immunity. The insurer expressly agrees and states that the purchase '
of this policy and fihe including of the City of Dubuque, lowa as an Additional Insured does not waive any of
the defenses of governmental immunity available to the City of Dubuque, lowa under Code of lowa Section
670.4 as it is now exists and as it may be amended from time to time.
2. Claims Coverage. The insurer further agrees that this policy of insurance shall cover oniy those
claims not subject to the defense of governmental immunity under the Code of lowa Section 670.4 as it now
exists and as it may be amended from time to time. Those claims not subject to Code of lowa Section 670.4
shall be covered by the terms and conditions of this insurance policy.
3. Assertion of Government Immunitv. The City of Dubuque, lowa shall be responsible for asserting
any defense of governmental immunity, and may do so at any time and shall do so upon the timely written
request of the insurer.
4. Non-Denial of Coveraqe. The insurer shall not deny coverage under this policy and the insurer shall
not deny any of the rights and benefits accruing to the City of Dubuque, lowa under this policy for reasons
of governmental immunity unless and until a court of competent jurisdiction has ruled in favor of the ',
defense(s) of governmental immunity asserted by the City of Dubuque, lowa. '
No Other Chanqe in Policy.The above preservation of governmental immunities shall not otherwise change
or alter the coverage available under the policy.
(DEPARTMENT MANAGER: FILL IN ALL BLANKS AND CHECK BOXES)
Page 4 of 4 Schedule J Professional Services July 2017