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HomeMy WebLinkAboutMINUTES - 05041993 - 1.31 TO: BOARD OF SUPERVISORS (�` FROM: Mark Finucane, Health Services Director /, - r Contra By: Elizabeth A. Spooner, Contracts Administrat Costa DATE: April 22, 1993 County SUBJECT: Approval of Standard Agreement #29-768 with the State of California, Major Risk Medical Insurance Board SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION I. RECOMMENDED ACTION: A. Approve Contra Costa Health Plan's participation in the Health Insurance Program of California (California Insurance Code: "Voluntary Alliance for Uniting Employers Purchasing Program") ; and B. Approve and authorize the Health Services Director or his designee (Milt Camhi) , to execute on behalf of the County, Drug Free Workplace Certification and Standard Agreement #29-768 (State #92MN041) , with the State of California, Major Risk Medical Insurance Board, effective May 1, 1993 through June 30, 1995, for participation in the Health Insurance Program of California. II. FINANCIAL IMPACT: Premium revenues from this program are dependent upon the number of participants enrolled in the program. III. REASONS FOR RECOMMENDATIONS/BACKGROUND: The Health Insurance Program of California allows small employers in California to purchase health insurance through a purchasing pool administered by the Major Risk Medical Insurance Board. Approval of Standard Agreement #29-768 will establish the Contra Costa Health Plan as a participating carrier in the pool. CONTINUED ON ATTACHMENT: YES SIGNATURE: Q RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMME ATI N OF BOARD COMMITTEE APPROVE OTHER SIGNATURE(S) ACTION OF BOARD ON fn&Z4APPROVED AS RECOMMENDED OTHER VOTE OF SUPERVISORS UNANIMOUS (ABSENT v� ) I HEREBY CERTIFY THAT THIS IS A TRUE AYES: NOES: AND CORRECT COPY OF AN ACTION TAKEN ABSENT: ABSTAIN: AND ENTERED ON THE MINUTES OF THE BOARD OF SUPERVISOR ON THE DATE SHOWN. Contact: Milt Camhi (313-5604) Health Services (Contracts) CC:c: ATTESTED Auditor-Controller (Claims) State Major Risk Medical Insurance Board Phil Satchel r, Clerk of the Board of $upwvjwts x d Wty AdlninWraW M3e2/7-e3 BY ��� � DEPUTY 57ATE OF C:'!F'ANLA .Ina.NU. STANDARD AGREEMENT APPROVED BY THE ATTORNEY GENERAL 92MV041 STO.2(REV.8-89) CONTRACTORS FEDERAL L D.NUMBER 94-6000509 THIS AGREEMENT, made and entered into this 1st day of May 19 93 In the State of California,by and between State of California,througn its duly elected or appointed,qualified and acting TITLE CF OFrICER ACTING FOR STATE AGENCY Executive Director Ma'or Risk Medical Insurance Board hereafter called the State and Contra Costa County for its Contra Costa Health Plan 2 9 — 768 hereafter called the Contractor. WITNESSETH: That the Contractor for an In consideration of the covenants,conditions,agreements and stipulations of the State hereinafter expressed,does hereby agree to furnish to the State services and materials as follows: (Set forth service to be rendered by Contractor,amount to be paid Contractor,t1me for performance or completion, and attach plane and spec/fkatlons,b any.) I. INTRODUCTION A. Act and Regulation This Agreement is in accord with and pursuant to Sections 10730 et seq., Part 2 of Division 2 of the California Insurance Code, which establishes and sets forth the Voluntary Alliance for Uniting Employers Purchasing Program, which shall hereinafter be called the program. This Agreement is also pursuant to Title 10, Chapter 5.7 of the California Code of Regulations, which are adopted by the Major Risk Medical Insurance Board to implement the program and shall hereinafter be called the program regulations. Terms and conditions used in the program regulations will have their same and identical meanings in this Agreement. This law and these regulations are hereby incorporated by this reference. CONTINUED ON SHEETS,EACH BEARING NAME OF CONTRACTOR AND CONTRACT NUMBER. The provisions on the reverse side hereof constitute a part of this agreement. IN WITNESS WHEREOF.this agreement has been executed by the parties hereto,upon the date first above written. STATE OF CALIFORNIA CONTRACTOR ABY CONTRACTOR(If other than an individual,state whether a corporations,partnership,etc. Major Risk Medical Insurance Board Contra Costa County for its Contra Costa Health Plan BY(AUTHORIZED SIGNATURE) BY(AUTHCRIZED SIGNATURE) PRINTED NAME OF PERSON SGNNVG PR WTED NAME AND TI11 E OF PEASON SIGNW(' John Ramey Milt Camhi, Executive Director TfiLE AODRFSS Executive Director 595 Center Ave., #100, Martinez, CA 94553 4MCLNT ENC1.MBERED BY THIS PROGRAM/CATEGCRY(CODE AND TITLE) FUND Tf1E DEPARTMENT OF GENERAL SERVICES DOCUMENT USE ONLY -0- Local Assistance VALUE EXEMPT FROM DGS 'RORAlko N ENCUMBERED FOR (OPTIONAL USE) APPROVAL PER 'HE 00CLUENT SECTION 10731, 5 INSURANCE CODE OTALAMOlMENCUTABEREDTO REM CHAPTER STATUTE FISCAL YEAR LATE 4280-957 1128 1992 92/93 OBJECT OF EXPENDITURE(CODE AND TITLE) 0100-01400 751 hereby certify upon my own personal knowledge that budgeted funds T.B.A.NO. B.R.NO. to available for the period and purpose of the expenditure sated above GN4TURE CFACCOLKI'M OFFICER DATE ] CONTRACTOR [ ] STATE AGENCY [ ] DEPT.OF GEN.SER. ( ] CONTROLLER 89 54245 STATE CF CAUFORNA , STANDARD AGREEMENT ' STO.2(REV.4-90) 1 . The Contractor agrees to indemnify, defend and save harmless the State, its officers, agents and employees from any and all claims and losses accruing or resulting to any and all contractors, subcontractors, materialmen, laborers and any other person, firm or corporation furnishing or supplying .work services, materials or supplies in connection with the performance of this contract, and from any and all-claims and losses accruing or resulting to any person, firm or corporation who may be injured or damaged by the Contractor in the performance of this contract. 2. The Contractor, and the agents and employees of Contractor, in the performance of the agreement, shall act in an independent capacity and not as officers or employees or agents of State of California- 3. alifornia3. The State may terminate this agreement and be relieved of the payment of any consideration to Contractor should Contractor fail to perform the covenants herein contained at the time and in the manner herein provided. In the event of such termination the State may proceed with the work in any manner deemed proper by the State. The cost to the State shall be deducted from any sum due the Contractor under this agreement, and the balance, if any, shall be paid the Contractor upon demand. 4. Without the written consent of the State, this agreement is not assignable by Contractor either in whole or in part. 5. Time is of the essence in this agreement. 6. No alternation or variation of the terms of this contract shall be valid unless made in writing and signed by the parties hereto, and no oral understanding or agreement not incorporated herein, shall be binding on any of the parties hereto. • 7. The consideration to be paid Contractor, as provided herein, shall be in compensation for all of. Contractor's expenses incurred in the performance hereof, including travel and perdiem, unless otherwise expressly so provided. MRMIB/Contra Costa County (CCHP) Page 2 of 20 Agreement #92MV041 B. Health Maintenance Organization This Agreement is entered into by the Contractor and the State for the purpose of providing health insurance coverage for enrollees who pay premiums to the Contractor. The method of delivery of the insured health benefits shall be a health maintenance organization. The Contractor agrees to provide and maintain the health maintenance organization. C. Geographic Areas Covered The Contractor's participation in the Program is limited to enrollment of program enrollees who reside in the Contractor's licensed service area: Contractor agrees to provide service to enrollees residing throughout Contractor's licensed service area. D. Changing.Service Area or Health Care Providers The Contractor's health maintenance organization shall consist of the list of health care providers to be provided to the State. Health care providers shall be deemed added to or deleted from this list as contracts between Contractor and health care providers begin or end, but Contractor shall give not less than sixty (60) days written notice to the state if such contract activity either opens a new region to the coverage contemplated by this Agreement or would materially impair Contractor's capacity to perform under this Agreement. E Term of Aareement The term of this Agreement shall be from May 1, 1993 until June 30, 1995. F. Policy Holder The State is the policy holder for all coverage issued pursuant to this Agreement. C Contractor Cooperation The State has agreement with other participating carriers and an administrator for the purpose of implementing and maintaining the program. The Contractor agrees to cooperate fully, and in a timely manner with the State and any of the State's other contractors involved in implementing and maintaining the program. MRMIB/Contra Costa County (CCHP) Page 3 of 20 Agreement #92MV041 II. ENROLLMENT A eligibility All applicants and dependents who are determined eligible by the State in accordance with the Act and program regulations are eligible to enroll hereunder. The State certifies that its enrollment process will not be prejudicial to the Contractor or other participating health plans. The Contractor may at any time observe the State's enrollment process. B. Conditions of Enrollment 1 . The Contractor agrees to enroll all persons referred by the State on the date specified by the State. 2. The State shall notify the applicant of enrollment with the Contractor and the effective date of coverage by the Contractor. The State shall notify the Contractor no later than 17 calendar days prior to the enrollee's and/or dependent's effective date of coverage. C Disenrollment 1 . Enrollees shall be disenrolled pursuant to Article 2 of the program regulations. The Contractor agrees to disenroll enrollees when notified to do so by the State on the date specified by the State. 2. In no event shall any individual enrollee be entitled to the payment of any benefits with respect to health care services rendered, supplies or drugs received or expense incurred following termination of coverage. For the purposes of this Agreement, a charge shall be considered incurred on the date the service or supply giving rise to the charge is rendered or received. D. Commencement of Coverage Coverage shall commence for a enrollee at 12:01 a.m. on the day designated by the State as the beginning date of coverage. . E Identification Cards. Provider Directory. and Evidence of Coverage The Contractor shall issue to the enrollee an Identification Card, Provider Directory, and Evidence of Coverage booklet setting forth a statement of the services and benefits to which the enrollee is entitled no later than the effective date of coverage. The Evidence of Coverage booklet and Provider Directory shall be updated annually by the Contractor or whenever there is a material change in MRMIB/Contra Costa County (CCHP) Page 4 of 20 Agreement #92MV041 the Contractor's provider network and distributed to each enrollee at the end of each open enrollment period or within 30 calendar days of the material change in the Contractor's provider network. The provider directory shall indicate the language capabilities of providers, if bilingual capability is available. Possession of a contractor Identification Card confers no right to services or other benefits of the program. To be entitled to services or benefits, the holder of the card must, in fact, be a enrollee on whose behalf applicable premiums under this Agreement have actually been paid. Therefore, any person receiving services or other benefits for which he or she is not then entitled pursuant to the provisions of this Agreement is personally responsible for the cost of all medical care. Upon request, the Contractor will provide persons interested in enrollment with the Contractor through the program with a copy on the Contractor's evidence of coverage booklet and Provider Directory within 10 business days of the request. F. Open Enrollment The Contractor agrees to participate in an annual open enrollment process during which enrollees may transfer between health plans. At the State's discretion, the Contractor may be required to participate in up to twelve regional open enrollment meetings. Such meetings shall be organized by the State. 111. CUSTOMER SERVICE A Phone Service For Subscribers 1 . The Contractor agrees to provide a toll free number for enrollee inquiries. This phone service shall be available on regular business days from the hours of 8:30. am to 4:30 pm. Contractor will provide staff bilingual in English and Spanish during all hours of phone service. 2. The Contractor agrees to cooperate with the State in establishing a process by which the State may transfer calls related to benefits and claims administration directly to the Contractor. B. Grievance Procedure The Contractor shall establish a grievance procedure to resolve issues arising between itself and enrollees. :Contractor's process shall provide a written response to enrollee grievances within 10 business days of their receipt by the health plan. This procedure shall be described in the Contractor's Evidence of Coverage booklet. MRMIB/Contra Costa County (CCHP) Page 5 of 20 Agreement #92MV041 C. Calculation of Enrollee Cost Sharing Requirements The Contractor shall establish and maintain a process for accurately calculating enrollee cost sharing requirements at the point of service. D. Assessing Subscriber Satisfaction The Contractor shall establish and maintain a process to measure enrollee satisfaction with Contractor's services. The results of such measurements shall be provided to the State. IV. FISCAL PROVISIONS The Contractor agrees to arrange for the provision of medical benefits and case management services for enrollees in the Program as described in Section V. of this Agreement. A Payments to Contractor 1 . The State agrees to bill , pursue collection, and disenroll enrollees pursuant to Articles 2., 3., and 4. of the program regulations. The amounts collected from small employers will be based on the Contractor's premium rates as described in Attachment A, which is hereby incorporated. 2. The Contractor agrees to accept amounts collected by the State from small employers and forwarded to the Contractor, and any applicable enrollee copayments, as full and complete payment for services provided under this Agreement unless otherwise provided by law or the terms of this Agreement. 3. The State will forward to the Contractor amounts collected from small employers for coverage under this Agreement on the last business day of each week. 4. The Contractor shall establish and maintain, in a manner and format to be specified by the State, the capability to receive electronic_data and electronic fund transfers from the State. B. Premium Rates 1 . The Contractor agrees that the premium rates described in Attachment A will be submitted to the Contractor's licensing entity as the Contractor's standard employee risk rates for the products the Contractor offers MRMIB/Contra Costa County (CCHP) Page 6 of 20 Agreement #92MV041 through the program. These rates shall be in effect from July 1, 1993 through June 30, 1994. 2. The Contractor agrees that the risk adjustment factor which will be applied to all enrollees in the program is 1.0. 3. The Contractor agrees that an enrollee shall be charged for a change in age category beginning July 1 following the enrollee's birthday. 4. The Contractor agrees that an enrollee shall be charged for changes in geographic area or family composition in the premium period following notification of the change of status. 5. The Contractor agrees that all deductibles and copayment maximums as described in Article 3. of the program regulations shall be applied annually and shall be renewed on July 1st of each year. 6. The Contractor agrees that the standard employee risk rates for the products offered through the program shall be no higher than the Contractor's standard employee risk rates for products offered to small employers outside the program which have an actuarial value equal to or higher than the products offered through the pool. C. Annual Rate Adjustments 1 . The Contractor's standard employee risk rates for the products offered through the program may be updated on July 1, 1994. The updated rates will be in effect from July 1, 1,994 through June 30, 1995. 2. The Contractor agrees that the premium rates for enrollees in each risk category (a risk category is a unique combination of an.enrollee's age, geographic area, family grouping and chosen product design) will not increase by more than 17% on July 1, 1994. 3. No later than February 15, 1994, the Contractor will provide the State with its proposed premium rates which will be in effect for the annual period beginning July 1, 1994. These rates will be reviewed and approved or rejected by the State no later than March 15, 1994. The Contractor agrees to submit these premium rates to the Contractor's licensing entity as the Contractor's standard employee risk rates for products sold through the program. MRMIB/Contra Costa County (CCHP) Page 7 of 20 Agreement 1#92MV041 D. Minimum Loss Ratio 1. Contractor agrees that the minimum loss ratio for services provided to enrollees pursuant to this Agreement shall be 80%. Contractor's loss ratio shall be calculated using the following formula: a/b Where "a" is :Total covered benefit and service costs of contractor including incurred but not reported claim completion costs minus enrollee deductible and copayment requirements and amounts recovered pursuant to Item VII. of this Agreement., and . where "b" is : Total premiums received by the Contractor. 2. Contractor's loss ratio shall be calculated by the State, with the assistance of the Contractor, in December of 1994 for costs incurred from July 1, 1993 through June 30, 1994, and in December 1995 for costs incurred from July 1, 1994 through June 30, 1995. The State shall make these calculations using data provided to the program pursuant to Item X1.D. of this Agreement. E Marketing Efforts The Contractor agrees to provide marketing efforts designed to increase public awareness of and enrollment in the program. Contractor's marketing efforts shall be valued at an estimated value of $14,600. The Contractor's proposed plan for expenditure of these funds is described in Confidential Attachment 2, Marketing Efforts, which is hereby incorporated. The Contractor shall report to the State quarterly on its marketing efforts related to the program and the dollar value of such efforts. F. moment Limitation Only enrollees for whom a premium is actually received by the Contractor are entitled to health services and benefits provided hereunder and only for services rendered or supplies received during the period for which such payment is received. G Funding Of Costs The Contractor understands and agrees that this program of the State is funded through premium payments. Contractor understands and agrees that no State funds shall be appropriated for the purposes of this Contract. MRMIB/Contra Costa County (CCHP) Page 8 of 20 Agreement #92MV041 H. Fiscal Solvency The Contractor agrees that it will at all times maintain the reserves required under the Knox-Keene Health Care Service Plan Act of 1975, as amended, and the regulations promulgated thereunder by the Department of Corporations, including the Tangible Net Equity Regulations. The State will recognize for purposes of this section, any waivers granted by the State to the requirements for maintaining reserves and deposits. Evidence of above solvency shall be made available to the State upon request. I. Contractor Performance & Remedy For Non-Performance 1 . The State shall monitor the Contractor's compliance with the terms of this Agreement. The State shall attempt to work with the Contractor to assist the Contractor in fulfilling its obligations under this contract. 2. The following Contractor standards of performance will be monitored by the State: a. Item II.E. Identification Cards, Provider Directory and Evidence of Coverage b. . Item III. A: Phone Service For Subscribers C. Item III.B. Grievance Procedure d Item IV. 3.C. Annual Rate Adjustments e. Item XI. D. Data Elements 3. If, in the State's view, the Contractor has not fulfilled its contractual responsibilities with regard to any of the items identified in 2. above, the State shall notify the Contractor in writing of the Contractor's lack of performance. If the Contractor does not improve performance to an acceptable level within 5 business days,.the State may impose liquidated damages on the Contractor of $.25 per enrollee per day beginning on the sixth business day following notification. If the Contractor's performance does not improve within 15 additional business days from the first day liquidated damages were imposed, the State after written notice to the Contractor, may increase the liquidated damages to $.50 per enrollee per day on the 16th business day following the notification of non- performance until the Contractor is in compliance with the Contract. The State may impose concurrent liquidated damages for each of the items listed in 2. above. MRMIB/Contra Costa County*(CCHP) Page 9 of 20 Agreement #92MV041 4. The State may deduct liquidated damages due from the Contractor from amounts payable to the Contractor pursuant to Item IV-A. of this Agreement. 5. If the State determines that the Contractor's non-performance was caused in part by the State, the State shall reduce the damages proportionately. V. COVERED SERVICES AND BENEFITS A Covered and Excluded Benefits 1 . Only those benefits described in Article 3. of the program regulations will be covered benefits under the terms of this Agreement. Those benefits excluded in Article 3. of the program regulations will not be covered benefits. The Contractor shall set out the plan of coverage in an Evidence of Coverage booklet. 2. The Contractor shall make benefit and coverage determinations. All such determinations shall be subject to the Contractor's grievance procedures. B. Pre-existing condition Coverage Exclusion Contractor agrees that no pre-existing condition exclusion period or post- enrollment waiting period will be required of subscribers. C. Exercise of Cost Control The Contractor shall enforce all contractual agreements for price and administer all existing utilization control mechanisms for the purpose of containing and reducing costs. Attachment B of this Agreement describes the Contractor's cost control program and is hereby incorporated. D. Copayments and Deductibles 1 . The Contractor shall impose copayments and deductibles for subscribers and enrolled dependents as described in Article 3. of the program regulations. 2. Enrollee copayments and deductibles imposed by the Contractor shall be limited as described in Article 3. of the program regulations. 3. The Contractor shall include in its evidence of coverage booklet and inform enrollees who request such information, the amount the plan will pay for out of network services. MRMIB/Contra Costa County (CCHP) Page 10 of 20 Agreement #92MV041 E Designation of Centers The Contractor shall designate centers which have documented skill, resources, commitment and records of favorable outcomes to provide services related to human organ transplantation as specified in Article 3. of the program regulations. F. COEFA The State agrees to collect premiums from COBRA qualified enrollees. The Contractor agrees to provide coverage for the COBRA eligible enrollee for the premium rates shown on Attachment A: Premium Rates. G. Risk Assessment The State intends to conduct a risk assessment survey of enrollees. The risk assessment tool will be developed by the State in consultation with. the Contractor and all other participating health plans. Contractor agrees to provide technical staff to participate in a workgroup to be convened by the State to review and advise the State on the risk assessment instrument. VI. TERMINATION Either party may terminate this Agreement without cause by giving written notice of termination to the other party not less than ninety (90) calendar days prior to the effective date of the termination. Upon service of notice of termination, the responsibilities of either party shall be as follows: A Enrollment with the contractor by the State will cease immediately. B. The State shall transfer enrollment of enrollees and prior to the effective date of termination, however enrollees in inpatient facilities at the time of termination shall not be transferred until the first day of the month following completion of their inpatient stay. The Contractor agrees to fully cooperate in such transfers. C. The Contractor shall be responsible for covered service costs incurred by enrollees during their period of enrollment with the Contractor. VII. EXCLUSIONS AND LIMITATIONS A Coordination of Benefits The Contractor agrees to coordinate benefits with other group health plans or insurance policies for enrollees in the program. Contractor agrees to work with MRMIB/Contra Costa County (CCHP) Page 11 of 20 Agreement #92MV041 other plans or insurers to provide 100 percent of enrollees' covered medical expenses. Contractor will determine under the Contractor's coordination of benefits rules which coverage is primary, and which coverage is secondary. B. Acts of Third Parties 1 . If an enrollee is injured through the wrongful act or omission of another person, the Contractor shall provide the benefits of this Agreement only on condition that the enrollee shall be deemed: a. To have agreed to reimburse the Contractor to the extent of the reasonable value of services provided, immediately upon collection of damages by him or her, whether by action at law, settlement or otherwise; and b. To have provided the Contractor with a lien to the extent of the reasonable value of services provided by the Contractor. The lien may be filed with the person whose act caused the injuries, his or her agent, or the court. 2. For purposes of Item VII.B.(1) of this Agreement, reasonable value shall be determined to be the allowable amount paid to preferred providers/ contracted providers for services in the geographic area where the services are rendered. a Workers' Compensation Insurance If, pursuant to any Workers' Compensation of Employer's Liability Law or other legislation of similar purpose or import, a third party is responsible for all or part of the cost of health services provided by the Contractor, then the Contractor shall provide the benefits of this Agreement only on condition that the enrollee shall be deemed to have provided the Contractor with a lien to the extent of the reasonable value of the services provided by the Contractor. The lien may be filed with the responsible third party, his or her agency, or the court. For purposes of this subsection, reasonable value shall be determined to be a reasonable charge for services in the geographic area where the services are rendered. D. Use of Subcontractors The Contractor may, in its discretion, use the services of subcontractors to recover on *the liens provided for under Items VII.B. and C. of this Agreement. The subcontractor's compensation may be paid out of any lien recoveries obtained. The State understands and agrees that lien recoveries may be chargeable with a prorata contribution toward the injured person's attorney fees under the MRMIB/Contra Costa County (CCHP) Page 12 of 20 Agreement #92MV041 Common Fund Doctrine. Contractor may compromise liens as may be reasonable and appropriately consistent with normal practices. VIII. WARRANTIES AND CERTIRCATIONS The Contractor warrants and certifies as follows: A Non-Discrimination The Contractor has, unless exempted, complied with the nondiscrimination program requirements of Section 12990 of the Government Code of the State of California and all regulations promulgated thereunder, including Section 8103 of the California Code of Regulations. B. Authorizations The Contractor has or will by the effective date of coverage complete, obtain and perform all registrations, filings, approvals, authorizations, consents or examinations required by any government or governmental authority for its acts contemplated by this Agreement. a Legal Proceedings Except as specifically disclosed in writing to the program by the Contractor prior to the date hereof, and approved by the State in writing, there are no suits, investigations, or other proceedings pending or threatened against the Contractor which would have a material effect on the Contractor's ability to perform under this Agreement. D. Drug Free Workplace The Contractor shall maintain a drug free workplace in accordance with Government Code Section 8355. STD 21, the Drug Free Workplace Certification, signed by the Contractor, is attached as Attachment C, which is hereby incorporated. E National Labor Relations Board Certification It is understood that the Contractor swears under penalty of perjury that no more than one final unappealable finding of contempt of court by a federal court has been issued against the Contractor within the immediately preceding two-year period because of the Contractor's failure to comply with an order of a federal court requiring the Contractor to comply with an order of the National Labor Relations Board. MRMIB/Contra Costa County (CCHP) Page 13 of 20 Agreement #92MV041 IX. REPRESENTATION The Contractor makes the following representations: A. Financial Information All financial information delivered to the State, including, without limit, information relating to the Contractor, its provider network; its parent corporation; its affiliates and subsidiaries; its partners or joint venturers, or any Guarantor, fairly and accurately represents such financial condition and has been prepared in accordance with Generally Accepted Accounting Principles unless otherwise noted in such information. B. Reg Accuracy All reports, documents, instruments, papers, data, information and forms of evidence delivered to the State with respect to this Agreement are accurate and correct, and complete insofar as completeness may be necessary to give the State true and accurate knowledge of the subject matter thereof, and do not contain any misrepresentations or omissions. C Provider Credentialino The Contractor's providers of care are duly licensed or certified, as required by the laws of this State. The Contractor routinely monitors its participating providers' licenses to ensure that they are current. The Contractor's physician providers have no California Medical Board licensing restrictions. D. Provider Insurance The Contractor's participating physician providers are independently insured for malpractice, in a dollar amount sufficient for their practice. The Contractor's participating hospital providers are also insured for each facility's level of care. X AFRRMATIVE COVENANTS A. Maintenance of Insurance 1 . Directors and Officers Liability As a County Agency, the Contractor is self-insured for Director's and officers' liability. This exposure is covered through the Contractor's self-insurance general liability program which is pre-funded to provide MRMIB/Contra Costa County (CCHP) Page 14 of 20 Agreement #92MV041 funds for payment of claims. The Contractor also carries blanket employee dishonesty insurance with a rate of not less than B and Class X by Best Insurance Guide. 2. During the term of this.Agreement, the Contractor shall also offer health insurance coverage to all of Contractor's permanent fulltime employees. 3. Other Insurance During the term of this Agreement, Contractor shall also maintain workers' compensation insurance, employer liability insurance and such other liability or other insurance as reasonably necessary in Contractor's business judgment to provide adequate coverage against losses and liabilities attributable to the acts or omissions of Contractor in performance of this Agreement. Contractor shall, in any event, determine whether or in what amount to purchase and/or maintain insurance using sound business judgment considering its financial circumstance, the extent of risk, and the availability of coverage on commercially reasonable rates. 4. Evidence of Coverage Evidence of above coverage shall be made available to the State upon request. B. Corrective Actions Upon the Contractor's knowledge that any of its representations or warranties regarding a participating provider may be untrue or incorrect, the Contractor will institute any corrective actions necessary to cure the defect in a reasonable time and manner. C. Notice of Chanqes and Enforcement Actions Contractor shall promptly and in any case within forty-five (45) days, notify the State in writing: (1) if any of the representations and warranties of Contractor set forth in the Agreement shall cease to be true at any time during the term of this Agreement; (2) of any enforcement action described in Item VIII.C. of this Agreement; (3) of any change in control of Contractor, or (4) of any other material change in Contractor's business, partnership or corporate organization. MRMIB/Contra Costa County (CCHP) Page 15 of 20 Agreement #92MV041 D. Provider Network The Contractor shall not make any change to its provider network which would impair its ability to meet Federal or State standards on the availability, accessibility and continuity of care. E Notice Regarding Network Changes The Contractor shall notify the State of any pending material change in the composition of its provider network, or its provider network contracts, at least sixty (60) calendar days prior to the implementation of such change or immediately upon the Contractor's knowledge of change if knowledge is acquired in less than sixty (60) calendar days. For the purposes of this provision, a material change shall be one which could reasonably impair Contractor's ability to perform under this Agreement. F. Designated Representatives In order to avoid unreasonable delay in the provision of the services to be rendered pursuant to this Agreement, the Contractor and the State shall each designate a specific representative(s) for purposes of communications between the parties. Such representative(s) may be changed upon written notice to the other party. G Binding Effect This Agreement and the rights, covenants, conditions and obligations of the respective parties hereto and any instrument or agreement executed pursuant hereto shall be binding upon the parties and be binding upon the successors, assignees and legal representatives of the respective parties hereto. Xl. GENERAL PROVISIONS A Quality and Financial Audits 1 . The Contractor shall maintain for three (3) years after final payment of this Agreement adequate books, accounts and records, and prepare all financial statements in accordance with.Generally Accepted Accounting Principles unless otherwise noted in such information, and in compliance with the regulations of any governmental or regulatory authority having jurisdiction over the Contractor, and permit employees or agents of the State at such reasonable times to inspect Contractor's facilities, and to examine, audit and make copies and memoranda of Contractor's books, accounts and records relating to this Agreement. MRMIB/Contra Costa County (CCHP) Page 16 of 20 Agreement #92MV041 2. The Contractor shall submit to the State a copy of its annual Certified Public Accountant (CPA) report and copies of its quarterly unaudited financial statements (balance sheet and income statements). The CPA report shall be submitted to the State within thirty (30) calendar days of its receipt.by the Contractor. The quarterly unaudited financial statements shall be submitted to the program within forty-five (45) calendar days of the end of each calendar quarter. 3. The State may make periodic audits at its expense regarding the quality of medical and hospital care rendered pursuant to this Agreement. The State may also audit and examine records and accounts which pertain, directly or indirectly, to the Contractor (including its parent corporation). The Contractor shall cooperate with such auditors; however, such audit shall not interfere with the administration of the Contractor, nor with the delivery of health care services by participating providers of the Contractor. 4. Contractor agrees to make available to the State the results of audits performed by the California Department of Insurance or California - Department of Corporations. 5. Audit review may be undertaken directly by the State, or by the Office of the State Auditor General, or by third parties engaged by the State, including accountants, consultants and physicians. The Contractor shall cooperate fully with the State or any such third party in connection with such audit review. 6. Any third party auditor shall not be involved in or be subsidiary to a business engaged in activities competitive to Contractor. The State and the State's auditor shall maintain the confidentiality of any trade secret or proprietary information that may be disclosed or uncovered_during the course of an audit. 7. Contractor shall have the opportunity, prior to the.release of the audit report, to review the draft and to include in the report its responses to issues raised by the report. B. Review of Materials 1 . The Contractor agrees that the State will review and approve all marketing materials, Evidence of Coverage, Provider Directory and correspondence related to the program between the Contractor and enrollees. The State agrees to review, approve or reject all materials submitted by the Contractor within 10 business days of submittal by the Contractor. MRMIB/Contra Costa County (CCHP) Page 17 of 20 Agreement #92MV041 2. The Contractor agrees to provide the State with a copy of all marketing , application, public rate information and the Contractor's summary brochure which the Contractor uses in the small group market in California. The Contractor shall submit these materials to the State on a quarterly basis. C. Right to Receive and Release Information For the purpose of enforcing or interpreting this Agreement, or participating in resolving any matter in dispute in regard to this Agreement, the Contractor and the State agree subject to statutory requirements, to share all relevant information. Each party shall protect proprietary trade secret information of the other from unauthorized use or disclosure. D. Data Elements The Contractor agrees to collect necessary data and provide such data to the State. 1 . Confidentiality of Enrollee Data The State and Contractor agree to protect the confidentiality of data on individual enrollees. 2. Data Elements The Contractor shall provide the data elements in a manner and format to be specified by the State, and agreed to by the Contractor. Data shall be provided quarterly. The first data submission will be for the quarter ending 9/30/93 and will be submitted no later than sixty (60) days following the end of the quarter. The data elements are contained in Attachment D, which is hereby incorporated into this Agreement. The State may make changes to the data elements contained in Attachment D with the mutual consent of the Contractor. The State intends to assess performance and outcome measures through the use of an instrument such as the Health Maintenance Organization Employer Data Information Set (HEDIS) and the National Committee for Quality Assurance (NCQA) indicators. The State will provide the Contractor the opportunity to provide assistance in selection of the assessment instrument. MRMIB/Contra Costa County (CCHP) Page 18 of 20 Agreement #92MV041 3. Electronic Data Transfer The Contractor shall establish and maintain, in a manner and format to be specified by the State, the capability to transmit data to the State using electronic media. E. Contractor's Summary Brochure The Contractor agrees to include a description of and the Contractor's standard employee risk rates for the Contractor's products offered through this program in the Contractor's summary brochure prepared pursuant to Section 1357.14 (h) of the Health and Safety Code or Section 10705(d) of the Insurance Code. The description of the products offered through the pool shall be reviewed and approved by the State prior to its use by the Contractor. F. Plan Responsibility The Contractor acknowledges that the State is not responsible for the decisions of the Contractor's managed care staff, including any aspect of the Contractor's utilization review or cost control programs. G Nondiscrimination Addendum Reference The Nondiscrimination Clause OCP-1 (STD 17A) is attached as Attachment E, which is hereby incorporated. H. Disclosure of Contractor Records and Rates of Payment 1 . In accordance with Section 6254(x) of the Government Code, the State and the Contractor shall protect from public disclosure all program records related to the deliberative process, discussions, communications or negotiations over the development of this Agreement. This Agreement and its terms shall remain confidential and the terms of Agreement may be disclosed by the State and the Contractor only in accordance with the time limits and other conditions set forth in Government Code Section 6254(x). For the purposes of this Agreement, disclosure shall be as follows: a. This Agreement itself, with the exception of Confidential Attachment 1 and Confidential Attachment 2, shall be open to disclosure one year after full execution. b. Confidential Attachment 1 and Confidential Attachment 2 shall be open to public inspection four years after the Agreement has been MRMIB/Contra Costa County (CCHP) Page 19 of 20 Agreement #92MV041 fully executed. All documents and reports held by the State which refer to rates of payment shall also be kept from public inspection until four years after this Agreement has been fully executed. C. The entire Agreement, or amendments to this Agreement, or other records pertaining to the rate of payment, shall be open to inspection by the Joint Legislative Audit Committee and its authorized auditors. The Joint Legislative Audit Committee is bound by confidentiality requirements of Government code Section 6254. CL The State shall also allow its own authorized auditors, whether public or private, to have access to the Agreement, its amendments, the payment rates, and records containing payment rates. However, the State shall bind its auditors to the confidentiality requirements of Government Code Section 6254. I. Contractor Federal Employer/Contractor ID Number The Contractor is hereby notified of its responsibility to use the assigned Contractor Federal Identification Number contained on the front page of the Agreement on each subsequent contract entered into with the State of California. J. Copyright Protection Contractor agrees to grant to the State a royalty-free, nonexclusive and irrevocable license to publish, translate, reproduce, deliver, perform, dispose of and to authorize others to do so, all data, electronic data processing software, and all program forms and public informational materials, which are covered by copyright and were specifically developed by the Contractor for the implementation of this Agreement and funded by the State. Such license shall be effective only to the extent that the Contractor has the right to grant such license without becoming liable to pay compensation to others because of such grant. K. Contract Modification This Agreement may be amended by mutual consent of both parties in writing. L. Resolution of Dis uR tes The State and the Contractor shall each designate a person who is entitled to deal with any disputes. MRMIB/Contra Costa County (CCHP) Page 20 of 20 Agreement #92MV041 M. Reverse Side The reverse of STD 2, Standard Agreement, is hereby incorporated by this reference. MRMIB/Contra Costa Health Plan ATTACHMENT A Agreement #92MV042 Page 1 of 2 ATTACHMENT ,q-: PREMIUM RATES Using the risk categories described in Article 4. of the program regulations health plans will be asked to provide their standard employee risk rates for the products to be offered through the pool. The products are described in Article 3. of the program regulations. GEOGRAPHICAL AREA 3 STANDARD PIAN 30 30-39 40-49 SO- S4 55- 59 60- 64 65+ m Employee Only 92.00 99.00' 111.00 145.00 183.00 232.00 367.00 Employee&Spouse 183.00 198.00 222.00 290.00 367.00 464.00 734.00 Employee and Dependents�2, 168.00 175.00 188.00 221.00 260.00 308.00 443.00 Employee, Spouse &Dependents 330.00 345.00 369.00 436.00 514.00 610.00 881.00 (1) Over age 65 rate assumes that there is no medicare coverage ( ) Dependents are assumed to be chiid or children MRM18/Contra Costa Health Plan ATTACHMENT A Agreement #92MV042 Page 2 of 2 GEOGRAPHICAL AREA 3 PREFERRED PLAN 30 30-39 40-49 50- 54 55- 59 60- 64 65+ (n Employee Only 109.00 118.00 132.00 172.00 218.00 276.00 437.00 Employee & Spouse 218.00 236.00 264.00 345.00 437.00 552.00 873.00 Employee and Dependents m 2CO.00 209.00 223.00 263.00 309.00 367.00 528.00 Employee, Spouse & Dependents 393.00 410.00 439.00 519.00 611.00 726.00 1,048.00 (1) Over age 65 rate assumes that there is no medicare coverage (2) Dependents are assumed to be child or children MRMIB/Contra Costa Health Plan ATTACHMENT B 'Agreement #92MV042 Page 1 of 2 HNIENT The Health Plan has a number of mechanisms designed to control use of services as well as the cost per unit of service provided: 0 HOSPITAL REIIVIBURSEN'TENT - As a staff model HMO, 85% of the care to Plan members is provided by our own Hospital and Clinics. Payments to contract hospitals are on a per diem basis. Because of our public nature, rate negotiations begin with the Medi-Cal level of payment. 6 PHYSICIAN PAYMENTS - The physicians on our staff are salaried. All contract physicians a-re paid on a fee-for-service basis at Medi-Cal rates. Only 15 c, of services are provided by contract physicians. ® PHARMACY COSTS - Per unit costs are controlled through the use of County owned and operated pharmacies, and a contract for phaxmaceutical serAces administration through Pliarinaceutical Care Network (PCN). Pharmacy utilization is controlled through use of a plan formulary, a generic substitution policy, and retrospective drug utilization review. 0 UTILIZATION CONTROL: _UTILIZATION REVIEW - Plan staff review both concurrent and retrospective utilization review to ensure that the appropriate level of care is provided and that the care provided is medically necessary. Inappropriate care is avoided by denying prior authorization,and physician counseling. ® PRIOR AUTHORIZATTON - Out of Plan referrals for procedures and consultations are-prior authorized by one of the following: the Plan's Medical Director, specialists who are on staff at Merrithew Memorial Hospital, or Plan staff working with authorization procedures' approved by the Plan. Medical Director. Prior authorization ensures that out-of-Plan services are appropriate and medically necessary. ADVICE NURSE - The Plan's 24-hour advice nurse program is available to assist members in accessing the appropriate level of care. The advice nurse can provide medical advice in lieu of a clinic visit or make urgent care appointments to avoid emergency room services. The advice nurse can also authorize emergency or urgently needed services whenever appropriate. MRMIB/Contra Costa Health Plan ATTACHMENT B Agreement #92MV042 Page 2 of 2 PRENATAL PROGRAM - All pregnant women in Contra Costa Health Plan are eligible for the Healthy Start Program which is a comprehensive perinatal services program. Healthy Start patients receive their case from a team of providers that includes a doctor, dietician, public health burse, and medical social worker. Care is coordinated and referrals made to special services (e.g. alcohol and drug intervention, health education, smoking cessation, etc.) as the need for them is identified through a psychosocial assessment done early in the pregnancy. TARGETED CASEINIANAGEMENT-The Plan's Targeted Case hlanagtment Program uses nurses to assist patients to access care appropriately and avoid unnecessary use of services. The members in the program are identified by several means: utilization studies, by referral from their primary care provider, or the advice nurse w•no has identified a member who is having difficulty getting the appropriate level of care. Case management nurses use social assessments, education, and services available in the cornmunity to help mernbers be more appropriate. in the use of the Health Plan's resources. PROVIDER PRACTICE PATTERNS - Provider pracdce patterns are monitored through the use of utilization review processes and quality assurance audits. As a staff model HMQ our physician's practice patterns are not scrutinized as they might be in another model of care. However, deviations from normal patterns are disciplined through the peer review process or more informally through physician counseling. 42:sbp MRMIB/Contra Costa County (CCHP) Attachment C Agreement #92MV041 Page 1 of 1 State of California DRUG-FREE WORKPLACE CERTIFICATION STD 21 (NEW 11-90) COMPANY/ORGANIZATION NAME Contra Costa County (CCHP) The contractor or grant recipient named above hereby certifies compliance with Government Code Section 8355 in matters relating to providing a drug-free workplace. The above named contractor or grant recipient will: 1 . Publish a statement notifying employees that unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance is prohibited and specifying actions to be taken against employees for violations, as required by Government Code Section 8355(a). 2. Establish a Drug-Free Awareness Program as required by Government Code Section 8355(b), to inform employees about all of the following: (a) The dangers of drug abuse in the workplace, (b ) The person's or organization's policy of maintaining a drug-free workplace, (c) Any available counseling, rehabilitation and employee assistance programs, and (d) Penalties that may be imposed upon employees for drug abuse violations. 3. Provide as required by Government Code Section 8355(c), that every employee who works on the proposed contract or grant: (a) Will receive a copy of the company's drug-free policy statement, and (b) Will agree to abide by the terms of the company's statement as a condition of employment on the contract or grant. CERTIFICATION I, the official named below, hereby swear that I am duly authorized legally to bind the contractor or grant recipient to the above described certification. I am fully aware that this certification, executed on the date and in the county below, is made under penalty of perjury under the laws of the State of California. OFFICIAL'S NAME Milt Camhi DATE EXECUTED EXECUTED IN THE COUNTY OF Contra Costa CONTRACTOR or GRANT RECIPIENT SIGNATURE TITLE Executive Director FEDERAL I.D.NUMBER 94-6000509 MRMIB%Contra Costa Health Plan Attachment D 92MV041 Page 1 of 2 The Health Insurance Plan of California (HIPC) Data File Record Layout* T S K Y Length R E P or Field Name C Y E Format Field Description/Definition Gri 1 7 Joiaim Document control numoer. A unique clairrvrecora U numoer. SEC TYPE CD Y A 3 JCccle indicating type of data record (eg. Claim, Encounter, Prov Cap ....) ER ID(Tax ID) AA Y A 10 1 Unique identifier assigned to any employer who applies to HIPC by the state/HIPC administrator. This ID remains with that employer Ino matter how many tines they enter or exit HIPC. (Going to use Tax ID) EE ID(SSN) AA Y A 9 Unicue identifier assi5red to any employee who appiies to HIPC by the state/HIPC administrator. This ID remains with that Employee no matter how many times they enter or exit HIPC. (Going to use SSN) DEPN SSN AA Y A 9 Social Security Number of Dependent d service is provided to Delon. MEMBER CODE CD Y A 3 Two digit number indicating type of subscriber or Dependent. LNAME EE Y A 15 Last name of subscriber under whose policy service is rendered. CONT PAT ID EC Y A 17 If a health contractor uses an unique patient identifier other than SSN or EE ID, then this Patient ID must be coded here. CONT ER ID EC Y A 17 Contractor issued ER/Grcup ID (if applicable). CCNTCODE CD Y A 3 Code corresponding to nealth contractor subscriber enrolled with. PLAN CODE CD Y A 3 Code = specific plan (N/A unless carrier mkiing more than one HIPC plan) BIRTHDAY EE N D MM/DD/YY Date of birth of person to whom services provided. SEX EE N A M or F JSax of person to whom service provided. BEG DOS EC N D MM/DD/YY Beg. date of service for outp. sys (code only this date 4 sys for 1 day) END DOS EC N D MM/DD/YY Enc date of serv. for outp. sys (eg. outp. sys provided over several days) INP ADMIN DT EC N D MM/DD/YY Date of inpatient admission. DOD EC N D MM/DD/YY Date of inpatient discharge. DISCHRGCODE EC N A 3 jCoce corresponding to type of discnarge (OSHPD codes to be provided.) NUM INP DAYS EC N II Numoer of days for inpatient stay when services on claim provided. xatr PRIMDIAG CODE EC N A 6 Primary diagnoses cote (ICD9 CODE) SCNDDIAG CODE EC N A 6 Secondary diagnoses coce(ICD9 CODE) PRIM PROC-C EC N A 6 Primary procedure code - CPT4 code Only one procedure PRIM PROC-I EC N A 6 Pnmary procedure coce - IC09 procedure code code req. Use PRIM PROC-H EC N A 6 Primary procedure code - HCPCS Code applicable code PRIM UOS EC N I ##* Units of service provided of primary procedure listed. DAG EC N A 5 If computed - the DRG code associated with the services provided. PLTREAT CD N A 3 Code corresponding to place of treatment (see table provided.) COORSENE EC N 6 True/False Is there a coordination of benefits? COB AMT EC N R ####.## Dollar amount of any coordination of benefit. AMT BILLED EC N R ####.## Total dollar amount billed. AMT ALLOWED EC N R ####.## Total dollar amount allowable. CO PAY AMT EC N R ####.## Dollar amount of any subscriber co-pay. AMT PAID EC N R ####.## Tot. amount paid or, tot. of adj., or tot. value of sys (eg. encounter data) PROV PMNTAUT EC N R ####.## Total amount of non-claim provider payment (eg. capitation payment) DATE PAID EC N D MM/DD/YY Date claim paid, adjustment made, or provider payment made. PATIENTZIP EE N A 5 Zip Code of patient. PROV 71P EC N A 5 Zip code of provider. PROV TX ID EC N A 10 Providers federal tax ID. MOD DATE EC N D MM/DD/YY Date claim/record last modified. ADJ FLAG EC N A 3 Code flagging claim as an adjustment claim. of claim w icn is being adjusted. 0 4/1/93 MRMIB/Contra Costa Health Plan Attachment D 92MVO41 Page 2 of 2 Summary of Compliance with HIPC Request for Data Contra Costa Health Plan Field Name Comments COGV 1 Provide as request REC TYPE Provide as requested. ER ID(Tax ID) Provide as requested. EE ID(SSN) Provide as requested. DEPN SSN Provide as requested. MEMBER CODE Provide if possible. LNAME Provide if possible. CONT PAT ID j0ptional-will not be Rrovided. CONT ER ID Provided as requested. CONTCODE Provide as requested. PLAN CODE N/A-will not be coded. SIR 71 HDAY I Provide as requested. SEX I Provide as requested. BEG DOS Provide as requested. END DOS Provide as requested. INP ADMIN DT Provide as recuested. DOD Provide as requested. DISCHRG CODE Provide if possibie. NUM INP DAYS Provide as requested. PRIMOIAG CODE jProvide as recuested. SCNDOIAG CODE jProvide as requested. PRIM PROC-C 10ptional-wiil not be provided. PRIM PROC-I Provided as requested. PRIM PROC-H Optional-will not be provided. PRIM UOS jProvide if possible. DRG Optional-will not be provided. PLTREAT Provide it possible. COCRBENE Provide if possible. COB AMT Provide if possible. AMT BILLED Provide if possible. AMT ALLOWED N/A-will not be provided. CO PAY AMT Provide if possible. AMT PAID Provided as requested. PROV PMNT AMT N/A-will not be provided. DATE PAID I Provide as requested. PATIENT 23P Provide as requested. PROV ZIP Provide as requested. PROV TX ID Provide as requested. MOO DATE Provide as requested. AOJ FLAG Provide if possible. ORIG COGV jVrovide it possible. Additional Notes: •HIPC will receive COBRA member service data .Quarterly Submissions:initial submission will be for the first quarter and include all HIPC member service data available. Subsequent submissions will be incremental and include all new and modified data records occurring since the end of the previous quarter. Quarterty submissions should be received no later than 60 days after the close of the quarter. 4/2/93 10:47 AM MRMIB/Contra Costa County (CCHP) Attachment E Agreement #92MV041 Page 1 of 1 NONDISCRIMINATION CLAUSE (OCP - 1) 1 . During the performance of this contract, contractor and its subcontractors shall not unlawfully discriminate against any employee or applicant for employment because of race, religion, color, national origin, ancestry, physical handicap, medical condition, marital status, age (over 40) or sex. Contractors and subcontractors shall insure that the evaluation and treatment of their employees and applicants for employment are free of such discrimination. Contractors and subcontractors shall comply with the provisions of the Fair Employment and Housing Act (Government Code, Section 12900 et seq.) and the applicable regulations promulgated thereunder (California Administrative Code, Title 2, Section 7285.0 et seq.). The applicable regulations of the Fair Employment and Housing Commission implementing Government Code, Section 12990, set forth in Chapter 5 of Division 4 of Title 2 of the California Administrative Code are incorporated into this contract by reference and made a part hereof as if set forth in full, Contractor and its subcontractors shall give written notice of their obligations under this clause to labor organizations with which they have a collective bargaining or other agreement. 2. This contractor shall include the nondiscrimination and compliance provisions of this clause in all subcontractors to perform work under the contract.