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CONTRACT ADMIN SERVICES FOR EPO
SELF-INSURED MEDICAL & RX BENEFITS 250006-ITN
This contract is entered into this 26th day of February, 2025 by and between Maricopa County (County), a
political subdivision of the State of Arizona, and Banner Health and Aetna Health Insurance Company dba
Banner|Aetna, an Arizona corporation (Contractor) for the purchase of administrative services for the
Maricopa County Self-Insured Benefits Plan that offer medical, prescription, and behavioral health benefits
to approximately 13,000 employees and their eligible dependents. Services under this contract will include,
but not be limited to claims processing, provider network access services, chronic disease management,
cost management strategies, screening and preventive care, clinical care programs, participant services,
point solutions, strategic planning and consultative services, and reporting and analytics.
1.0
CONTRACT TERM
This contract is for a term of four years, beginning on the 1st day of January 2026 and ending the
31st day of December, 2029.
2.0
OPTION TO RENEW
The County may, at its option and with the concurrence of the Contractor, renew the term of this
contract up to a maximum of five additional years, (or at the County’s sole discretion, extend the
contract on a month-to-month basis for a maximum of six months after expiration). The Contractor
shall be notified in writing by the Office of Procurement Services (OPS) of the County’s intention to
renew the contract term at least 60 calendar days prior to the expiration of the original contract
term.
3.0
CONTRACT COMPLETION
In preparation for contract completion, the Contractor shall make all reasonable efforts for an
orderly transition of its duties and responsibilities to another provider and/or to the County. This
may include, but is not limited to, preparation of a transition plan and cooperation with the County
or other providers in the transition. The transition includes the transfer of all records and other data
in the possession, custody, or control of the Contractor that are required to be provided to the
County either by the terms of this agreement or as a matter of law. The provisions of this clause
shall survive the expiration or termination of this agreement.
4.0
PRICE ADJUSTMENTS
Any requests for reasonable price adjustments must be submitted 180 calendar days prior to
contract expiration for subsequent agreement periods for which the County elects to renew beyond
the initial term. The reasonableness of the request will be determined by comparing the request
with the Consumer Price Index or by performing a market survey. Contractor shall provide the
County with a new Administrative Fee schedule (see Exhibit A – Vendor Information and Pricing)
to replace the schedule in the existing Exhibit A for the successor term. If County agrees to the
adjusted price terms, County will issue written approval of the change and provide an updated
version of the contract. Any such service fee change will become effective the first day of the new
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term. The new change shall not be in effect until the date stipulated on the updated version of the
contract.
Contractor may also request a change to services fees with 60 days’ notice (i) any time there are
changes made to this contract or the Plan, which affect the fees, (ii) when there are changes in
laws or regulations which affect the services Contractor is providing, or will be required to provide,
under this contract, or (iii) if the number of employees covered by the Plan or any Plan option
changes by 15% or more. Any new service fee required by such change will be effective as of the
date the changes occur.
5.0
STANDARD OF CARE
The Contractor shall discharge their obligations under this contract with that level of reasonable
care which a similarly situated services provider or plan administrator, respectively, would exercise
under similar circumstances. County delegates claim fiduciary duties to Contractor and Contractor
shall observe the standard of care and diligence required of a fiduciary under applicable state and
federal law.
6.0
PAYMENTS AND INVOICES
6.1
As consideration for performance of the duties described herein, County shall pay
Contractor the sum(s) stated in Exhibit A – Vendor Information and Pricing.
6.2
Monthly enrollment for billing purposes will be measured based on the enrolled population
on the first day of the month.
6.3
Payment shall be made within 30 days of the County’s receipt of a properly completed
invoice or 30 days from the first day of the month for which it is due, whichever is later.
6.4
The Contractor shall submit one legible copy of their detailed invoice before payment(s)
will be made. Incomplete invoices will not be processed. At a minimum, the invoice must
provide the following information:
•
Company name, address, and contact information
•
Remittance name, address, Tax ID and contact information if different
from the Company name and information
•
County bill-to name and contact information
•
Contract serial number
•
County purchase order number
•
Project name and/or number
•
Invoice number and date
•
Payment terms
•
Date of service or delivery
•
Quantity
•
Contract item number(s)
•
Description of purchase (product or services)
•
Pricing per unit of purchase
•
Total amount due
6.5
A wire request is sent to the County’s bank requesting funds for the total claims from the
previous week. In addition, there will be a month end close out request on the first banking
day of each subsequent month. The cost of this service is included in the Administrative
Service Fee.
6.6
Electronic claims details will be available to the County on a weekly basis.
6.7
Problems regarding billing or invoicing shall be directed to the department as listed on the
purchase order.
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6.8
Payment for administrative service fees or non-claim invoices shall only be made to the
Contractor by Accounts Payable through the Maricopa County Vendor Express Payment
Program. This is an Electronic Funds Transfer (EFT) process. After Contract Award the
Contractor shall complete the Vendor Registration Form located on the County Department
of Finance Vendor Registration Web Site (https://www.maricopa.gov/5169/Vendor-
Information).
6.9
Discounts offered in the contract shall be calculated based on the date a properly
completed invoice is received by the County.
6.10
EFT payments to the routing and account numbers designated by the Contractor shall
include the details on the specific invoices that the payment covers. The Contractor is
required to discuss remittance delivery capabilities with their designated financial institution
for access to those details.
7.0
APPLICABLE TAXES
7.1
It is the responsibility of the Contractor to determine all applicable taxes and include those
taxes in their contract. The legal liability to remit the tax is on the entity conducting business
in Arizona. Tax is not a determining factor in Contract Award.
7.2
The County will look at the price or offer submitted and will not deduct, add, or alter pricing
based on speculation or application of any taxes, nor will the County provide Contractor
any advice or guidance regarding taxes. If County has questions regarding your tax liability,
seek advice from a tax professional prior to submitting your bid. County may also find
information at https://azdor.gov/business. Once your bid is submitted, the offer is valid for
the time specified in this solicitation, regardless of mistake or omission of tax liability. If the
County finds overpayment of a project due to tax consideration that was not due, the
Contractor will be liable to the County for that amount, and by contracting with the County
agrees to remit any overpayments back to the County for miscalculations on taxes included
in a bid price.
7.3
Tax Indemnification: Contractor and all subcontractors shall pay all Federal, State, and
local taxes applicable to their operation and any persons employed by the Contractor.
Contractor shall, and require all subcontractors to, hold Maricopa County harmless from
any responsibility for taxes, damages, and interest, if applicable, contributions required
under Federal and/or State and local laws and regulations, and any other costs including
transaction privilege taxes, unemployment compensation insurance, Social Security, and
workers’ compensation. Contractor may be required to establish, to the satisfaction of
County, that all fees and taxes due to municipality or the State of Arizona for any license
or transaction privilege taxes, use taxes, or similar excise taxes are currently paid (except
for matters under legal protest).
8.0
AVAILABILITY OF FUNDS
8.1
The provisions of this contract relating to payment for services shall become effective when
funds assigned for the purpose of compensating the Contractor as herein provided are
available to County for disbursement. The County shall be the sole judge and authority in
determining the availability of funds under this contract. County shall keep the Contractor
fully informed as to the availability of funds.
8.2
If any action is taken by, any State agency, Federal department, or any other agency or
instrumentality to suspend, decrease, or terminate its fiscal obligations under, or in
connection with, this contract, County may amend, suspend, decrease, or terminate its
obligations under, or in connection with, this contract. In the event of termination, County
shall be liable for payment only for services rendered prior to the effective date of the
termination, provided that such services are performed in accordance with the provisions
of this contract. County shall give written notice of the effective date of any suspension,
amendment, or termination under this section, at least 10 days in advance.
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9.0
POST AWARD MEETING
The Contractor may be required to attend a post-award meeting with the department to discuss the
terms and conditions of this contract. This meeting will be coordinated by the procurement officer of
the contract.
10.0
DUTIES
10.1
The Contractor shall perform all duties stated in the contract, or as otherwise directed in
writing by the procurement officer.
10.2
REQUIRED SERVICES
10.2.1
General Services
10.2.1.1
Contractor shall provide administrative services only (ASO) for a medical
and behavioral health plan and pharmacy benefit manager (PBM)
services. Such services shall include, but not be limited to strategic
planning and consultative services, claims processing, provider network
contracting and access services, chronic disease management, cost
management strategies, screening and preventive care, clinical care
programs, wellness programs that will seamlessly integrate with
County’s existing employee wellness program, participant services
including advocacy and navigation, and reporting and analytics, point
solutions and coordination with other county vendors (e.g., benefits
consultant, EAP, employee wellness program).
10.2.1.2
Contractor shall coordinate case management and care navigation
services as needed so that the right resources are available to treat
participants holistically, including those with a mental health and/or
substance use diagnosis.
10.2.1.3
Contractor shall provide 24/7, HIPAA and ADA compliant, secure
access to an online participant portal for activities such as benefits
overview, claims review and submission, account monitoring,
searchable provider directory, pricing tool for procedures and
medications, access to print and/or request physical ID cards (mailed to
the participant at no charge).
10.2.1.3.1
Contractor’s participant portal shall be accessible and
usable for mobile access.
10.2.1.4
Contractor shall provide a plan sponsor portal to monitor eligibility,
claims, reporting, etc.
10.2.1.5
Contractor shall be expected to coordinate with the County’s third-party
Wellness contractor that provides tools, activities, and support to
employees to help them maintain healthy behaviors. To integrate with
the County’s Wellness plan, contractor shall:
10.2.1.5.1
Provide monthly claims files to Wellness vendor to assist
with tracking participant preventive screenings.
10.2.1.5.2
Establish single sign on functionality with the County’s
contracted Wellness provider or include access to the
Wellness site from the contractor’s participant portal.
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10.2.1.5.3
Provide 24/7 unlimited participant access to telephonic
coaching for healthy living, suicide prevention, chronic
conditions and preventive activities through the third-party
Wellness contractor.
10.2.1.5.4
Provide consultation and annual recommendations of
activities that encourage healthy behaviors and that can be
tracked and incentivized through the third-party Wellness
contractor.
10.2.2
Plan Design and Strategic Planning
10.2.2.1
In collaboration and/or consultation with the County’s benefit consulting
firm, Contractor shall provide ongoing strategic planning and
consultative services to the County’s benefits management staff at
various times during the year, including upon implementation, during the
annual renewal, and periodically to address various topics.
10.2.2.2
Topics include, but are not limited to, plan design, implementation,
network management, formulary management, claims processing,
reporting, rebate management, marketing and communication,
customer service, industry trends, new or emerging initiatives, best
practices, improvement of health outcomes, cost saving measures,
compliance requirements, benchmarking data, point solutions, and
wellness initiatives.
10.2.2.3
Final plan design decisions shall be at the sole discretion of the County
with the Contractor advising the County of its ability to administer the
plan design effectively and efficiently.
10.2.3
Implementation
10.2.3.1
Contractor shall develop a comprehensive implementation plan with the
objective of achieving an effective benefit start date of January 1, 2026.
No later than April 1, 2025 contractor shall complete the following:
10.2.3.1.1
Contractor must affirmatively demonstrate that they are
prepared to provide plan enrollment services for the
County’s open-enrollment period for medical, behavioral
health, and prescription plan.
10.2.3.1.2
Contractor
shall
submit
a
final
itemized,
implementation/open enrollment timeline indicating all 2026
plan design decisions.
10.2.3.1.3
Implementation plan shall consider need to integrate with
Workday.
10.2.3.2
All other implementation/open enrollment activities shall begin no later
than July 1, 2025 and be completed by September 30, 2025 for the
County’s open enrollment period for the 2026 benefit year.
10.2.3.2.1
Contractor shall designate an implementation manager and
implementation team to include persons with expertise in
plan design, benefits and exclusions, account structure,
systems, networks, transition of care, formulary, pharmacy
benefits, eligibility, enrollment services, claims processing,
compliance, best practices, banking and finances, file
integrations, and drafting of plan materials including
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Summaries of Benefits and Coverage (SBCs), Summary
Plan
Descriptions
(SPDs),
and
enrollment/transition
communications.
10.2.4
Annual Enrollment Planning and Responsibilities
10.2.4.1
Annual enrollment planning begins in February, and the employee open
enrollment period begins in October and ends in November with a
January 1 effective date.
10.2.4.2
Contractor shall support annual enrollment by developing a
comprehensive plan to implement any changes to the County’s benefits
program. Such plan shall include a list of all deliverables including
plan/system set-up, system testing, portal updates, pricing tools,
formulary changes, program onboarding/off-boarding, physical ID card
issuance, participant communications, and pre-enrollment customer
service line staffed with representatives ready to answer questions from
prospective participants.
10.2.4.3
After the annual enrollment period, Contractor shall load current year
and annual enrollment eligibility files by the agreed-upon due dates.
10.2.5
Annual Market Check
10.2.5.1
On an annual basis, the PBM agrees to review the financial terms and
other contract provisions as compared to financial offerings presented
to similar collectives, coalitions and/or employers in the marketplace.
The PBM agrees that such comparisons shall be based upon, among
other things, the mail and retail pricing for brand and generic drugs,
pricing for Specialty Drugs, administrative fees and rebates, discounts,
and other contract provisions. The County agrees to provide sufficient
information relating to such financial offerings to allow the PBM to
conduct a fair and adequate review of the marketplace pricing. In the
event that the marketplace pricing, as measured in the aggregate,
would result in at least a two percent savings, in addition to all of the
existing pricing and contract improvements contained in the contract for
the County, the PBM shall renegotiate pricing terms and contract
provisions in good faith. If there are no identified improvements, there
will be no change to the existing pricing.
10.2.5.1.1
Contractor shall provide to the County most favored
customer pricing. Prices and provisions provided to the
County shall be as good or better than prices offered to
other employers, coalitions, collectives, of similar size and
scope.
10.2.6
Account Management
10.2.6.1
Contractor shall provide account management services to the County,
including but not limited to, the following:
10.2.6.2
An account management team that includes:
10.2.6.2.1
The person responsible for the successful management of
the account and who serves as the everyday point of
contact for the County.
10.2.6.2.1.1
A customer service person who is familiar
with the County’s plan design and who can
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quickly handle the day-to-day inquiries that
come
up
(e.g.,
participant
questions,
requests for haste enrollments, handling of
escalations).
10.2.6.2.1.2
Applicable and sufficient clinical experts (i.e.,
Doctor of Medicine (MD), pharmacist,
licensed mental health professional) to
provide clinical information pertaining to drug
performance, trends, population health, cost-
controlling recommendations, and disease
and clinical programs.
10.2.6.2.1.3
A strategic account executive and executive
sponsor assigned to the County to assist with
overall strategy, oversight of administrator
resources, and as needed for escalation
situations.
10.2.6.2.1.4
Contractor shall ensure that all account
management
team
participants
are
preapproved by the County, in writing,
throughout the term of the contract. The
County reserves the right to remove any
team participant the Contractor assigns to
the account.
10.2.6.2.2
Response to inquiries and service requests and completion
of haste enrollments within 24 hours of contact/notification.
10.2.6.2.3
Daily maintenance of the County’s account and weekly
account team meetings.
10.2.6.2.4
Development
of
custom
participant
communication
materials in accordance with the County’s branding
standards.
10.2.6.2.5
Account structure set-up to include actives, COBRA,
surviving spouses, and any other group structure needed
for purposes of claims processing and reporting.
10.2.6.2.6
Electronic invoice submission and payment remittance, with
as much detail as required by the County for ease in
payment processing and reconciliation.
10.2.6.2.7
Access to an employer portal for viewing of coverage
eligibility, claims status, ID card requests, and utilization
reporting.
10.2.6.2.8
Preparation of a customized Summary of Benefits and
Coverage (SBC) for each benefit plan, highlighting the most
utilized services and detailing what the plan pays and what
a participant’s out-of-pocket cost share is expected to be.
The County shall have final approval on the SBCs.
10.2.6.2.9
Contractor shall ensure that SBCs are completed within ten
business days following the date of benefit decisions by the
County.
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10.2.6.2.10 Preparation of a customized Summary Plan Description
(SPD) for each benefit plan detailing plan design, covered
services, limitations and exclusions, information on how the
plan works, drug tiering and participant costs, utilization
management requirements, clinical programs, claims
procedures, coordination of benefits, the appeals process,
and other coverage details. The County shall have final
approval on the SPDs.
10.2.6.2.10.1 Contractor shall ensure that SPDs are
completed within ten business days following
the date of benefit decisions by the County.
10.2.6.2.11 Participation in weekly and semi-annual strategic meetings
with the County benefits staff for purposes of discussing
operational business, problem resolution, customer service
issues, and plan direction.
10.2.6.2.12 Participation in no more than six benefits and wellness fairs,
and educational meetings at different locations and times of
the year as requested by the County with a 30-day notice.
10.2.7
Eligibility and Enrollment Services
10.2.7.1
The County controls eligibility and enrollment. The County uses
Workday for benefit enrollment. Contractor shall integrate with Workday
and shall ensure timely and accurate enrollments in the County’s
medical plan, process eligibility and demographic changes, and manage
disenrollment from the plan.
10.2.7.1.1
Contractor shall support the County with qualified medical
child support orders processing and compliance.
10.2.7.1.2
Contractor shall support the County by determining
continued disability or handicap status of over age
dependents.
10.2.7.1.3
Contractor shall integrate with/accept electronic eligibility
from the County’s third-party COBRA administrator.
10.2.7.2
Contractor must use Electronic Data Interchange (EDI) 834 or another
equally HIPAA-compliant file format, and shall use secure file
transmission methods (e.g., EDI, API, SFTP).
10.2.7.3
Contractor agrees to accept eligibility files at whatever frequency
desired by the County, including accepting daily and weekly files.
Eligibility files will include records of subscribers, spouses, and
dependents in simple structure groups. Contractor agrees to include the
following, throughout the term of the contract, in a service level
agreement or performance guarantee with a portion of fees at risk for
non-performance.
10.2.7.3.1
Contractor must be able to accept and process eligibility
files and generate an electronic exception report within 24
hours of receipt of the eligibility file.
10.2.7.3.2
The County shall have final approval on questions
regarding correction of eligibility errors.
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10.2.7.3.3
Contractor shall work with the County or its designee to fully
resolve errors within 24 hours.
10.2.7.4
Identification (ID) cards shall be produced by Contractor and mailed by
Contractor to the subscriber’s home address within seven calendar days
from submission of enrollment information.
10.2.7.5
Contractor shall grant the County’s benefits staff access to make haste
eligibility updates using the employer portal.
10.2.8
Underwriting Services
Contractor shall provide periodic claims projections and estimated cost impacts of
plan design or related changes. Such services shall include recommended reserve
estimates and year-end claims accounting and reconciliation.
10.2.9
Claims Processing
10.2.9.1
Contractor shall process claims, both in-network and out-of-network, in
accordance with the SPDs and all applicable plan documents and
pricing terms. No subcontracting or use of another’s network shall be
allowed for purposes of claims processing without the express written
consent of the County. Claims processing services shall also include
the following:
10.2.9.1.1
Set up of the Contractor’s claims system to facilitate the
automatic and accurate adjudication of claims submitted by
health care providers. Contractor shall, at a minimum,
include claims system edits that trigger review for the
following:
Total billed charges less than total allowable payment
Potential duplicates
Work-related, auto, and other accidents identified for
potential subrogation
Provider licensing and credentialing matches the type
of services billed
Cross references for providers with multiple locations
to include national provider identifier (NPI) and tax
identification number (TIN)
Potential third-party payor
Under/over payment
Manual claim processing
Pended claims
Unbundled procedure coding
Billing for inappropriate care for stated diagnosis,
age, or gender
Billing for excluded drugs
Over-utilization
Billing for inappropriate site of care
Participant eligibility
Missing prior authorization
10.2.9.1.2
Accurate manual processing of claims submitted via paper
or electronic claims forms within 10 business days of receipt
of request from participants.
10.2.9.1.3
Coordination of benefits with Medicare and other third-party
payers.
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10.2.9.1.4
Production and issuance of electronic and hard-copy
Explanation of Benefits (EOB) for each claim processed.
10.2.9.1.5
Medical and prescription drug claims payment services/run-
out processing services for 18 months upon termination of
the contract at no additional cost to the County.
10.2.9.1.6
Claims audits shall be performed by the Contractor as
requested by the County to confirm whether claims are
processing in accordance with plan design. Reports of
these claim audits shall be provided to the County within 30
days from completion of audit. Any findings requiring
potential correction or re-processing of claims shall be
reviewed with the County and implemented within 30 days.
10.2.9.1.7
Hospital claims and claims greater than $100,000 must
undergo a second level review before payment is issued to
providers.
10.2.9.1.8
A $100,000 allowance shall be furnished to the County by
the Contractor once every two years to be used to fund an
independent claims and billing audit performed by an
independent third-party company designated by the
County. The first external audit shall be performed no earlier
than one-year post implementation. Contractor shall
immediately correct any claims processing discrepancies
identified through the audit process and shall refund the
County any fees or claims dollars paid in error, such as
those resulting from claims processing errors.
10.2.10 Other Claims Management Services
10.2.10.1 Contractor shall provide claims management services to include
recovery services for overpayments, fraud and abuse, third-party
liability, and subrogation matters.
10.2.10.1.1 Overpayments are payments made to a provider more than
what is due based on set plan design, pricing, and other
contractual agreements.
10.2.10.1.1.1 The Contractor shall reprocess any identified
errors in Plan benefit payments (other than
errors the Contractor reasonably determines
to be de minimis) and seek to recover any
resulting overpayment by attempting to
contact the party receiving the overpayment
twice by letter, phone, or email. The County
may direct the Contractor not to seek
recovery
of
overpayments
from
Plan
participants, in which event the Contractor
will have no further responsibility with respect
to those overpayments except to the extent
that the Overpayment was due to the
Contractor’s failure to meet the Standard of
Care. The County shall reasonably cooperate
with
the
Contractor
in
recovering
all
overpayments of Plan benefits.
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10.2.10.1.1.2 If Contractor elects to use a third-party
recovery vendor, collection agency, or
attorney
to
pursue
the
recovery,
the
overpayment recoveries will be credited to
the County net of fees charged by the
Contractor or those entities.
10.2.10.1.1.3 Any requested payment from the Contractor
relating to an overpayment must be based
upon documented findings or direct proof of
specific claims, agreed to by both parties,
and must be due to the Contractor’s actions
or inactions. Indirect or inferential methods of
proof
–
such
as
statistical
sampling,
extrapolation of error rate to the population,
etc. – may not be used to determine
overpayments. In addition, use of software or
other review processes that analyze a claim
in a manner different from the claim
determination and payment procedures and
standards used by the Contractor shall not be
used to determine overpayments.
10.2.10.1.1.4 When seeking recovery of overpayments
from
a
provider,
the
Contractor
has
established the following process: if it is
unable to recover the overpayment through
other means, the Contractor may offset one
or more future payments to that provider for
services rendered to Plan participants by an
amount equal to the prior overpayment. The
Contractor may reduce future payments to
the provider (including payments made to
that provider involving the same or other
health
and
welfare
plans
that
are
administered by the Contractor) by the
amount of the overpayment, and the
Contractor will credit the recovered amount to
the plan that overpaid the provider. By
entering this contract, the County is agreeing
that its right to recover overpayments shall be
governed by this process and that it has no
right to recover any specific overpayment
unless otherwise provided for in this contract.
10.2.10.1.1.5 The County may not seek recovery of
overpayments from network providers, but
the
County
may
seek
recovery
of
overpayments from other third parties once
the County has provided the Contractor
notice that it will seek such recovery and
Contractor has been afforded a reasonable
opportunity to recover such amounts. The
Contractor has no duty to initiate litigation to
pursue any overpayment recovery.
10.2.10.1.2 Third-party liability and subrogation matters refer to
instances where claims for plan benefits were paid but are
recoverable by the plan because a claim was or should have
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been paid by a third party (including in instances of
coordination of benefits with other plans, including
Medicare). The County has unique statutory subrogation
and reimbursement rights under the Arizona Revised
Statute section 12-962, which entitles the County, among
other things, to recover the cost of medical treatment from
the injured party’s net recovery of any third-party recovery.
10.2.10.1.3 Contractor shall be responsible for the negotiation of
reimbursement on subrogation matters, with the Contractor
obtaining the County’s written approval on all settlements in
accordance with the Declaration of Trust for Maricopa
County, Arizona Self-Insured Benefits Trust Fund and
revised and restated from time to time.
10.2.10.1.4 Contractor shall prepare a written summary of each case
detailing pertinent facts of the accident or injury, parties
involved, continuing treatment needs, third-party insurance
bodily injury limits, underinsured motorist coverage, other
liens, and all potential sources of recovery.
10.2.10.1.5 Contractor shall be available to discuss written report.
10.2.10.1.6 Both the County and Contractor shall engage in discussions
regarding strategy and next steps in the recovery process.
10.2.10.2 Contractor shall handle all first and second level claim denials and
appeals including but not limited to those involving prior authorizations,
transition of care, step therapy, formulary exceptions, limitation or
exclusion, or direct participant reimbursements by conducting a
thorough review of information submitted by an appellant or on behalf of
an appellant, along with plan information and in consultation with health
care professionals with the knowledge and expertise to assist with
making a determination to uphold or reverse a denial or appeal.
10.2.10.3 Contractor shall help facilitate an external review process when an
appellant has exhausted the first and second levels of appeals and
remains dissatisfied with the outcome of the first and second level
appeals. Any external review organization with whom the Contractor has
a contract must meet the Patient Protection and Affordable Care Act
(PPACA) requirements to conduct such reviews. Contractor shall
document the claim denials and appeals process, along with timelines
that must be met both by the appellant and the Contractor. All responses
to claims, denials and appeals must be in writing, and quarterly reports
indicating number of appeals, reasons for the appeals, and disposition
of the appeals shall be provided to the County on a quarterly basis.
10.2.10.4 Contractor shall provide the County quarterly reporting of all appeal
metrics and identify areas of opportunity to address common themes
noted in appeal volume.
10.2.11 Utilization Management Services
Contractor shall provide robust utilization management services with a focus on
delivering high quality care and cost/risk management. Such services shall include
decision-making/steerage
tools,
prior
authorizations,
medical
necessity
determinations, case management, step therapy, quantity limits, appropriate site
of care, high-cost claimant care, appropriate level of care education, transition of
care, inpatient admission, skilled nursing facility admission, duration reviews,
SERIAL 250006-ITN
home health visits, and overall cost and risk management. Contractor shall identify
all services that require pre-authorization or pre-certification and manage those
consistently and correctly. Procedures for all utilization management services must
be well-documented and communicated.
10.2.12 Network Access Services
10.2.12.1 Contractor shall provide sufficient access to a network of contracted
providers, as relevant to the medical, behavioral health, and/or PBM
services provided, to address the health needs of County participants,
and such providers shall include primary care, specialty care, ancillary
services, labs and radiology, urgent care, emergency care, out-patient
and in-patient facilities, mental, behavioral and substance abuse
counseling, participating in-network pharmacies, specialty drug
pharmacy, infusion services providers, and other health care and
prescription services.
10.2.12.2 Network providers shall provide care in a variety of sites/modalities,
including but not limited to in-patient, outpatient, in-person in office,
telephonic, videoconference, chat, and text. The adequacy of the size
and range of a contractor’s network, and thus its ability to provide
expansive coverage, will be determined at the start of the contract, and
throughout the term of the contract as requested by the County, in part
by utilizing the County’s employee census whereby the Contractor shall
indicate the number of each contracted provider type and specialty type
including behavioral health providers and participating pharmacies and
prescription services providers operating within a 10-mile radius of each
zip code in which County participants work and reside. The network shall
include a transplant network utilizing centers of excellence and services
necessary to support participants receiving transplants.
10.2.12.3 The network of contracted providers shall be credentialed by the
Contractor upon application to participate in the Contractor’s network,
and current physicians and providers shall be re-credentialed on a
rotating schedule set forth by the Contractor. While it is understood that
the make-up of the network can change at any time, the Contractor shall
provide notice of any such changes to the County’s participants no less
than 30 days in advance of any changes. Contractor should identify to
the County hospital contracts within the County that are up for renewal
in the next three years.
10.2.12.4 Contractor shall exercise oversight of network providers to ensure they
are compliant with administering the County’s plan design and services,
and that they are otherwise compliant with local, state, and federal
regulations. Network providers may direct and/or refer participants to
other network providers when additional services are required. The
County is not liable or responsible for any care, pharmacy, or health
services rendered to participants by network providers.
10.2.12.5 Contractor shall provide access to its electronic provider directory for
purposes of enabling participants to locate participating pharmacies and
in-network providers of their choosing. The provider directory shall be
searchable and clearly designate which providers are high quality
designated, premium, preferred, or those whom the Contractor has
identified as being providers whose care and treatment yields better
health outcomes. The provider directory should include all provider
types, including those outlined in paragraph one of this section, and
must include a listing of inpatient and outpatient facilities. The provider
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directory shall be updated in real time so as to remain accurate and up-
to-date.
10.2.12.6 Contractor
shall
make
membership
eligibility/enrollment,
copayment/coinsurance, and benefit coverage information, supplied by
the County or its designated agent in mutually agreed upon format,
available to network pharmacies at the time of dispensing through the
online electronic transmission link maintained between Contractor and
pharmacies. Subject to Contractor’s responsibility to load all such data
received from County in a timely manner (within 24 hours of receipt),
County is solely responsible for the accuracy, completeness, reliability,
and timeliness of all information provided to Contractor and
acknowledges Contractor’s reliance thereupon.
10.2.13 Participant Services
10.2.13.1 Contractor shall provide the County with a dedicated toll-free number for
participants to seek assistance with questions or to receive support with
service-related issues. The hours of operation for Banner|Aetna’s
Concierge customer service center are Monday through Friday 8:00 AM
to 6:00 PM, member’s local time. Representatives shall be trained to
assist participants with understanding plan coverage and exclusions,
address claims questions, advocate for the participant with providers,
locate in-network providers, resolve problems, explain wellness and
other health programs, and provide exceptional customer service.
10.2.13.2 Contactor shall provide navigation assistance and natively connect
participants to other County benefits and point solutions (e.g., disability,
Employee Assistance Program (EAP), telehealth, group legal,
wellness).
10.2.13.3 Contractor shall also provide access to registered nurses 24/7, including
holidays, to answer health care questions and direct participants to
appropriate level of care.
10.2.13.4 Acceptable service levels per the performance guarantees shall always
be maintained to ensure participant satisfaction.
10.2.13.5 Contractor shall not outsource participant services to a third-party
without the expressed written consent of the County.
10.2.13.6 Contractor shall provide other methods for communicating with the
County’s participants including a secure portal (secure portal shall also
be accessible as a mobile application) where participants may view plan
information, claims, request a new ID card (receipt options to include
downloadable or mailed hard copy ID card), and search for in-network
providers. Other methods of communication shall include an online app,
chat option, or other similar technology, along with updated marketing
and informational materials.
10.2.13.7 Contractor shall provide introductory materials for issuance to
participants, via paper and electronic media. This includes prescription
mail service order forms, program brochures, newsletters, mail service
promotional materials, generic usage educational pieces and retail
pharmacy prescription labels. Contractor shall be responsible for all
costs associated with its development, printing, and mailing of standard
marketing and educational materials that Contractor provides to County
participants, unless Contractor obtains written agreement from the
County directing it to develop, print, and mail custom material. This does
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not include the standard materials that the Contractor shall develop for
posting on the County’s benefits website during the annual enrollment
period. The County shall have final approval on all implementation and
annual enrollment communication being provided to its participants.
10.2.13.8 Contractor shall provide County participants with medical procedure and
drug transparency pricing tools for their use to determine the cost of a
procedure or drug. Pricing shall be based on the County’s medical and
prescription plan design, procedure or drug name, site of care, drug
dosage, the delivery method, and fill amount (i.e., 30 day or 90 day).
10.2.13.8.1 Information about lower cost alternatives and comparison of
costs across pharmacy options covered under the County’s
plan shall be available through the pricing tool. Pricing tool
shall include the plan cost share of any procedure or drug
and the participant’s cost share as this will serve as
educational information for participants with the potential to
drive better consumer decisions.
10.2.13.8.2 A similar tool shall be made available during newly eligible
and annual enrollment for prospective enrollees in the plan
to make informed decision when selecting their benefits.
10.2.14 Health Care Management Programs
10.2.14.1 Contractor shall provide programs intended to support participants with
managing care associated with complex, chronic, and/or high-cost
medical conditions including diabetes, cardiac care, cancer, kidney and
other transplants, musculoskeletal and back pain, arthritis and other
inflammatory or pain management care, blood disorders, mental health,
asthma, and COPD. Such programs shall include participant outreach,
engagement strategies, proven steps that lead to better health
outcomes, and measurable improvement results. Most appropriate/least
expensive site of care strategies shall be implemented for specialty
and/or infusion services where evidence exists that driving participants
to such sites is financially advantageous, convenient, and yields the
same or better health outcomes.
10.2.14.2 Contractor shall agree to work cooperatively with other vendors to
provide a holistic approach to managing participants’ health.
10.2.15 Data and Reports
10.2.15.1 Monthly, the Contractor shall securely transmit to the County, or the
County’s third-party data warehouse vendor, de-identified claims
utilization data. On a monthly or as-needed basis, Contractor shall
provide a variety of routine and ad hoc reports to the County to include,
but not be limited to the following:
10.2.15.1.1 Medical and PBM services utilization by participant and by
place/method of service.
10.2.15.1.2 Demographic data.
10.2.15.1.3 Top diagnostic/disease categories.
10.2.15.1.4 Spend per participant per month (PPPM).
10.2.15.1.5 Catastrophic/large dollar claims.
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10.2.15.1.6 In-network versus out-of-network utilization.
10.2.15.1.7 Drug utilization review.
10.2.15.1.8 Top drugs by spend/volume/condition.
10.2.15.1.9 Drug rebates.
10.2.15.1.10 Program performance.
10.2.15.1.11 Health care trends and drivers.
10.2.15.1.12 Number of appeals and their disposition.
10.2.15.1.13 Participant engagement.
10.2.15.2 Reports must be provided electronically and be accessible to the County
through access to the Contractor’s secure portal.
10.2.15.3 On an annual basis, Contractor shall provide Service Organization
Control Reports (SOC 1 and SOC 2) that represent that the Contractor
has been audited during the year and has been deemed to have the
appropriate controls in place for its claims payment and financial system
and other related technology housing County data. Contractor shall also
provide additional reports necessary to assist the County with any
internal or external audit it undergoes.
10.2.16 HIPAA Privacy and Security
10.2.16.1 Contractor shall be considered a business associate and be required to
sign a HIPAA Business Associate Agreement (BAA) and to adhere to
HIPAA privacy and security rules. The successful respondent shall sign
and return the BAA prior to final award of the contract (See
Exhibit E - HIPAA Business Associate Agreement (BAA)).
10.2.16.2 Contractor shall also provide a comprehensive HIPAA Privacy and
Security Policy complete with protocols and procedures for handling
breaches or unauthorized disclosures of varying degrees of
seriousness. If there is a breach or unauthorized disclosure of the
County’s Protected Health Information, Contractor shall notify the
County within 48 hours of the Contractor identifying the breach or
unauthorized disclosure. A detailed report outlining the scope of the
incident and the expected participant impact shall be furnished to the
County, in writing, within five business days of the identification of the
breach or unauthorized disclosure. Contractor shall perform all HIPAA
and security responsibilities required, including notifications to all
required parties. Additionally, upon request, Contractor shall furnish to
the County a detailed remedial plan to prevent such incidents from
reoccurring within 15 business days of such request.
10.2.17 Business Continuity Plan
Contractor shall provide a comprehensive Business Continuity Plan detailing how
business would continue to be conducted accurately and timely in the event of a
natural disaster or an unforeseen event that has the potential to interrupt normal
business operations for longer than one business day. The plan shall include
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detailed steps the Contractor shall take to protect the integrity and privacy of all
data pertaining to the County and its participants.
10.2.18 Compliance
Contractor shall comply with IRS regulations, Health Information Technology for
Economic and Clinical Health Act (HITECH) and Health Insurance Portability And
Accountability Act (HIPAA), Patient Protections and Affordable Care Act (PPACA),
Genetic
Information
Non-Discrimination
Act
(GINA),
the
Consolidated
Appropriations Act (CAA) and its Transparency in Coverage (TIC) rule, and other
Federal, state, and local laws and regulations that govern the administration of a
Self-Insured Government Employee Group Health Plan. This includes advising the
County on actions needed to remain in compliance as legislative changes at all
levels of government are approved and whereas adherence is required. Contractor
shall assist the County in complying with the Mental Health Parity and Addiction
Equity Act (MHPAEA).
10.2.19 Performance Guarantees
10.2.19.1 Contractor shall agree to maintain throughout the term of the contact
performance guarantees wherein Contractor shall put a maximum
percent of fees at risk related to its performance in areas to include, but
not be limited to, system readiness and reliability, claims processing,
claims accuracy, claims cost, health management programs, clinical
services, call center statistics, data integration and customer service.
10.2.19.2 The performance guarantees shall be specific to the Contractor services
being provided (medical and PBM). Performance guarantees shall be
included as part of the Medical Performance Service Level Agreement
and the PBM Performance Service Level Agreement which are included
as a separate exhibit within the contract.
10.2.19.3 Contractor shall not make any changes to any of the Service Level
Agreements, including any changes to performance guarantees, without
prior written consent of the County.
10.2.20 Formulary Management
10.2.20.1 Contractor shall perform formulary management, rebate sharing, and
other clinical services, including self-reporting of adherence to all
guarantees, pricing, discounts, and services. These services shall
include, but are not limited to, prior authorization, step-therapy,
systematic prospective, concurrent, and retrospective drug utilization
review, a pharmacy and therapeutics (P&T) committee or an equivalent
entity, and other measures that are deemed appropriate to effectively
manage a closed, multi-tiered formulary or prescription drug list. While
the Contractor is responsible for managing formulary changes, the
County reserves the right to authorize any and all such changes.
10.2.20.1.1 Contractor shall pass through 100% of drug rebates to the
County and guarantee a minimum amount of rebate in
prescription drug pricing.
10.2.20.1.2 At a minimum, Contractor shall provide the County with self-
reporting, including all reporting on guarantees, pricing,
discounts, and services outlined in Contractor’s response in
attachments/questionnaires/pricing sheets and that are
subsequently included in the contract.
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10.2.20.2 As part of the plan design process, the County will determine the
frequency of formulary changes. Contractor shall provide advance
written notice to the County of any planned formulary changes at least
90 days prior to any such change. Additionally, Contractor shall provide
60-day advance written notice to County participants adversely
impacted by any formulary change, including changes in tier and
exclusions. Additionally, Contractor shall notify participants no later than
60 days in advance, in writing to their home address, of the expiration
date of a prior authorization and for industry changes (e.g., black box
warnings, drug withdrawals when significant impact is expected, etc.).
10.2.21 Mail-Order Pharmacy
Contractor shall offer access to a mail-order pharmacy where participants may
purchase prescription drugs conveniently, with secure and timely delivery, and at
competitively low pricing. Mail-order prescriptions for a 90-day supply of
maintenance medication shall be sent to a participant’s home address, work
address, or to a local network-participating pharmacy (provided the pharmacy is
willing to accept the delivery) via the United States Postal Service, an express
delivery service (e.g., UPS, DHL, FedEx), or any other method that achieves the
goal of secure delivery within 48 hours. Limiting the risk of loss or damage to
covered drugs is the responsibility of the mail-order pharmacy until such drugs
have been delivered to a participant. Contractor shall guarantee that certain
products which require cold-pack shipping methods as recommended by the
manufacturer will be handled appropriately. The mail-order pharmacy is
responsible for the cost of shipping. When placing a new or refill order through the
mail-order pharmacy, participants must pay for their share of the cost (copayment,
coinsurance, or deductible). Additionally, participant will be responsible for paying
or reimbursing the mail-order pharmacy, as applicable, for all additional expenses
due to expedited delivery (e.g., next day) requested by a participant unless such a
request is the result of an error on the part of the pharmacy to ensure a participant
has received a new or re-fill order within 48 hours of being sent. To the extent
Contractor’s shipping costs significantly increase due to rate increases by the
United States Postal Service or any other mail delivery handler after the effective
date of the rates set forth in this agreement, the parties will negotiate in good faith
to reach agreement on an adjustment to the rates to compensate Contractor for its
increased costs.
10.2.22 Specialty Drug Program
10.2.22.1 Contractor shall provide a cost-effective Specialty Drug Program with
either centralized distribution or multi-channel distribution that is
national, convenient, consistent, and flexible. Specialty pharmaceuticals
are generally high-cost medications that are usually prescribed for
people with complex or chronic medical conditions (i.e., multiple
sclerosis, hemophilia, hepatitis, and rheumatoid arthritis) and/or that
require special handling/administration. Medications typically exhibit
one or more of the following characteristics: are injected or infused,
however some may be taken orally; have unique monitoring, storage, or
shipment requirements; require additional education and support from a
health care professional; and are usually not readily available at retail
pharmacies.
10.2.22.2 Contractor must have fully developed Specialty Drug Program services
that meet the unique challenges of dispensing and monitoring specialty
pharmaceuticals. The program must provide cost-effective care and
positive patient outcomes through increased adherence, as well as
provide an enhanced patient experience through the convenience of
scheduled delivery, disease management programs, and compliance
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monitoring employing a care-coordination model. In care coordination,
licensed clinicians (nurses, pharmacists, and physicians) provide
comprehensive clinical management services. Clinical professionals
support patients through education, training, and mental health support
(e.g., behavioral health, case management or disease management
referral). The care plan shall address education, interventions,
compliance, monitoring parameters, and goals and outcomes of
therapy. Non-adherence or non-compliance and the rationale must be
communicated to the prescribing physician.
10.2.22.3 The Specialty Drug Program must contain provisions addressing and
controlling the high cost of preferred specialty medications and
biosimilars, biologics, and gene therapies.
10.2.23 Pharmacy Participant Services
10.2.23.1 Contractor and its providers shall dispense prescription products and
services as follows:
10.2.23.1.1 Dispensed upon presentation by a participant of his/her
identification card, authorized prescription order, and
remittance of any required participant cost share (i.e., co-
insurance, deductible). A pharmacy shall compound and
dispense all qualified prescriptions and covered drugs
pursuant to the pharmacy benefit plan design and eligibility
information provided by the County to the Contractor and
communicated by the Contractor to such pharmacy via the
Online Eligibility and Claim System at the time of dispensing
and subject to legal restrictions and professional ethics and
professional judgment.
10.2.23.1.2 Pharmacy shall collect any applicable co-payment,
coinsurance
and/or
deductible
amount
from
each
participant for each covered prescription, as indicated by
the Online Eligibility and Claims System at the time of
dispensing. When the participating pharmacy’s usual and
customary charge or retail cash price for the prescription is
less than the coinsurance, the participating pharmacy will
collect the lowest amount in lieu of the minimum
coinsurance indicated by the Online Eligibility and Claims
System.
10.2.23.1.3 Pharmacy may withhold prescription services to a
participant for good cause, including, but not necessarily
limited to: 1) the County’s nonpayment for prescription
services provided to participants; 2) the participant’s failure
to pay for products or services (i.e. coinsurance, and/or
deductible); 3) requests by participant for drug quantities in
excess of prescribed amounts or refill limitations pursuant
to the pharmacy benefit information; or 4) where, in the
professional judgment of the dispensing pharmacist, the
prescription should not be filled.
10.2.23.1.4 Pharmacy shall attempt to dispense lowest net cost or tier
drugs in lieu of prescribed non-preferred brand name drugs
if commercially available, meet quality rating standards, and
if consistent with the prescriber’s orders and the dispensing
pharmacist’s professional judgment and state and federal
law.
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10.2.24 Site of Care
10.2.24.1 Contractor will employ processes, procedures, and tools to ensure that
lowest cost, highest quality site of care is utilized most often to
administer medical and prescription drug services.
10.2.24.1.1 Contractor shall pass through 100% of drug rebates to the
County and guarantee a minimum amount of rebate in the
medical pricing for drugs dispensed through the medical
plan rather than the pharmacy plan.
10.2.25 Transition
10.2.25.1 At no cost to the County, the Contractor shall comply with the following
provisions upon receipt of a notice of termination or upon the expiration
of the contract, and at no additional cost to the County:
10.2.25.1.1 The Contractor shall transfer title and deliver to the County
or its designee any and all completed or partially completed
reports, materials, information, data, other work product of
the Contractor that were made under the contract or as part
of the Contractor’s performance of the contract, and all
work-in-progress, including any work covered under the
contract but scheduled for delivery at a future date.
10.2.25.1.2 Provide medical and prescription drug claims payment
services/runout processing services for 18 months upon
termination of contract.
10.2.25.1.3 Provide a minimum of 18 months of historical data upon
termination of contract.
10.2.25.1.4 Make available for a period of 18 months any reports or
other materials pertaining to the administration and
performance of the County’s plans.
10.2.25.1.5 As directed by the County, the Contractor shall terminate or
assign to the County or its designee any outstanding orders
or contracts that relate to the Contractor’s performance
under the contract.
10.2.25.1.6 As directed by the County, the Contractor shall destroy
and/or deliver to the County or its designee all confidential
or proprietary documents, information, and data that the
Contractor has received under the contract and all copies
thereof.
10.2.25.1.7 Upon written request from the County, the Contractor shall
provide to the County or its designee all records,
documents, information, and data reasonably necessary to
allow the County or its designee to continue to provide
and/or administer, without interruption, all health and other
benefit plans to County beneficiaries, and to comply with
Federal, state, and other legal requirements to which the
County is subject. Such records, documents, information,
and data shall include, but not be limited to, eligibility
information and data, claims experience or history data, and
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administrative records. For prescription drug plans, this
shall include, but not be limited to:
10.2.25.1.7.1 All claims files for the entire contract period
10.2.25.1.7.2 Prior authorization files
10.2.25.1.7.3 Exceptions to formulary approvals
10.2.25.1.7.4 True out-of-pocket balances
10.2.25.1.7.5 Medical necessity review files
10.2.25.1.7.6 Quantity limit information by participants and
exceptions
10.2.26 Responsibilities on Termination
10.2.26.1 Upon termination of the contract, for any reason other than default of
payment by the County, Contractor will continue to process runoff claims
for Plan benefits that were incurred prior to the termination date, which
are received by Contractor within 18 months following the termination
date. Runoff claims will be processed and paid in accordance with the
terms of this contract. New requests for benefit payments received after
the 18-month runoff period will be returned to the County or to a
successor administrator at the County’s expense. Claims which were
pended or disputed prior to the start of the runoff period will be handled
to their conclusion by Contractor, as well as provider performance or
incentive payments paid for prior period performance pay outs, and
County agrees to fund such claims or payments when requested by
Contractor.
10.2.26.2 The County shall continue to fund Plan benefit payments and agrees to
instruct its bank to continue to make funds available until all outstanding
Plan benefit payments have been paid or until such time as mutually
agreed upon by Contractor and the County. The County’s wire line and
bank account from which funds are requested must remain open for one
year after runoff processing ends, or two years after termination.
10.2.26.3 Upon termination of the Agreement and provided all Service Fees have
been paid, Contractor will release to the County, or its successor
administrator, all claim data in Contractor's standard format, within a
reasonable period following the termination date.
10.2.27 Additional Contractual Requirements
Contractor shall not require minimum participation requirements, and rates in the
contract shall be guaranteed.
10.3
FIDUCIARY DUTY
It is understood and agreed that the County, as plan administrator, retains complete
authority and responsibility for the Plan, its operation, and the benefits provided there
under, and that the Contractor is empowered to act on behalf of the County in connection
with the Plan only to the extent expressly stated in this contract, including, but not limited
to, as expressly stated in Section 5.0 (STANDARD OF CARE) of this contract or as agreed
to in writing by the Contractor and the County.
10.4
DEFENSE OF CLAIM LITIGATION
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10.4.1
In the event of a legal, administrative or other action arising out of the
administration, processing or determination of a claim for Plan benefits, the
Contractor when having rendered the decision in the appeal last exercised, shall
undertake the defense of such action at its expense and settle such action when
in its reasonable judgment it appears expedient to do so. If the County is also
named as a party to such action, the Contractor will defend the County provided
the action relates solely and directly to actions or failure to act by the Contractor
and there is no conflict of interest between the parties. The County agrees to pay
the amount of Plan benefits included in any judgment or settlement in such action.
The County shall not be liable for any other part of such judgment or settlement,
including but not limited to legal expenses and punitive damages, except to the
extent provided in section 11.1 (Indemnification).
10.4.2
Notwithstanding anything to the contrary in this Section 10.4, in any multi-claim
litigation (including arbitration) disputing reimbursement for benefits for more than
one Plan Sponsor, the County authorizes the Contractor and the Contractor shall
undertake to defend the County, at the Contractor’s expense, and, reasonably
settle the County's benefit claims in such litigation.
11.0
TERMS AND CONDITIONS
11.1
INDEMNIFICATION
11.1.1
To the fullest extent permitted by law, and to the extent that claims, damages,
losses, or expenses are not covered and paid by insurance purchased by the
Contractor, the Contractor shall defend, indemnify, and hold harmless the County
(as Owner), its agents, representatives, officers, directors, officials, and employees
from and against all claims, damages, losses, and expenses (including, but not
limited to attorneys' fees, court costs, expert witness fees, and the costs and
attorneys' fees for appellate proceedings) arising out of, or alleged to have resulted
from, the negligent acts, errors, omissions, or mistakes of the Contractor, a
subcontractor, anyone directly or indirectly employed by them, or anyone for
whose acts they may be liable relating to the performance of this contract.
11.1.2
Contractor's duty to defend, indemnify, and hold harmless the County, its agents,
representatives, officers, directors, officials, and employees shall arise in
connection with any claim, damage, loss, or expense that is attributable to bodily
injury, sickness, disease, death, or injury to, impairment of, or destruction of
tangible property, including loss of use resulting therefrom, caused by negligent
acts, errors, omissions, or mistakes in the performance of this contract, but only to
the extent caused by the negligent acts or omissions of the Contractor, a
subcontractor, anyone directly or indirectly employed by them, or anyone for
whose acts they may be liable, regardless of whether or not such claim, damage,
loss, or expense is caused in part by a party indemnified hereunder.
11.1.3
The amount and type of insurance coverage requirements set forth herein will in
no way be construed as limiting the scope of the indemnity in this section.
11.1.4
The scope of this indemnification does not extend to the sole negligence of County.
11.1.5
The County and the Contractor agree that: (i) health care providers are not the
agents or employees of the County or the Contractor and neither party renders
medical services or treatments to Plan participants; (ii) health care providers are
solely responsible for the health care they deliver to Plan participants, and neither
the County nor the Contractor is responsible for the health care that is delivered
by health care providers; and (iii) the indemnification obligations of (A) or (B) above
do not apply to any portion of any loss relating to the acts or omissions of health
care providers with respect to Plan participants.
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11.1.6
Contractor and the County will discharge their obligations under this contract with
that level of reasonable care which a similarly situated services provider or plan
administrator, respectively, would exercise under similar circumstances.
11.2
INSURANCE
11.2.1
Contractor, at Contractor’s own expense, shall purchase and maintain, at a
minimum, the herein stipulated insurance from a company or companies duly
licensed by the State of Arizona and possessing an AM Best, Inc. category rating
of B++. In lieu of State of Arizona licensing, the stipulated insurance may be
purchased from a company or companies, which are authorized to do business in
the State of Arizona, provided that said insurance companies meet the approval of
County. The form of any insurance policies and forms must be acceptable to
County.
11.2.2
All insurance required herein shall be maintained in full force and effect until all
work or service required to be performed under the terms of the contract is
satisfactorily completed and formally accepted. Failure to do so may, at the sole
discretion of County, constitute a material breach of this contract.
11.2.3
In the event that the insurance required is written on a claims-made basis,
Contractor warrants that any retroactive date under the policy shall precede the
effective date of this contract and either continuous coverage will be maintained,
or an extended discovery period will be exercised for a period of two years
beginning at the time work under this contract is completed.
11.2.4
Contractor’s insurance shall be primary insurance as respects County, and any
insurance or self-insurance maintained by County shall not contribute to it.
11.2.5
Any failure to comply with the claim reporting provisions of the insurance policies
or any breach of an insurance policy warranty shall not affect the County’s right to
coverage afforded under the insurance policies.
11.2.6
The insurance policies may provide coverage that contains deductibles or self-
insured retentions. Such deductible and/or self-insured retentions shall not be
applicable with respect to the coverage provided to County under such policies.
Contractor shall be solely responsible for the deductible and/or self-insured
retention and County, at its option, may require Contractor to secure payment of
such deductibles or self-insured retentions by a surety bond or an irrevocable and
unconditional letter of credit.
11.2.7
The insurance policies required by this contract, except Workers’ Compensation
and Errors and Omissions, shall name County, its agents, representatives, officers,
directors, officials, and employees as additional insureds.
11.2.8
The policies required hereunder, except Workers’ Compensation and Errors and
Omissions, shall contain a waiver of transfer of rights of recovery (subrogation)
against County, its agents, representatives, officers, directors, officials, and
employees for any claims arising out of Contractor’s work or service.
11.2.9
If available, the insurance policies required by this contract may be combined with
Commercial Umbrella Insurance policies to meet the minimum limit requirements.
If a Commercial Umbrella insurance policy is utilized to meet insurance
requirements, the Certificate of Insurance shall indicate which lines the
Commercial Umbrella Insurance covers.
11.2.9.1
Commercial General Liability
SERIAL 250006-ITN
Commercial General Liability (CGL) insurance and, if necessary,
Commercial Umbrella insurance with a limit of not less than $2,000,000
for each occurrence, $4,000,000 Products/Completed Operations
Aggregate, and $4,000,000 General Aggregate Limit. The policy shall
include coverage for premises liability, bodily injury, broad form property
damage, personal injury, products and completed operations and
blanket contractual coverage, and shall not contain any provisions which
would serve to limit third party action over claims. There shall be no
endorsement or modifications of the CGL limiting the scope of coverage
for liability arising from explosion, collapse, or underground property
damage.
11.2.9.2
Workers’ Compensation
11.2.9.2.1
Workers’ compensation insurance to cover obligations
imposed by Federal and State statutes having jurisdiction of
Contractor’s employees engaged in the performance of the
work or services under this contract; and Employer’s
Liability insurance of not less than $1,000,000 for each
accident, $1,000,000 disease for each employee, and
$1,000,000 disease policy limit.
11.2.9.2.2
Contractor, its subcontractors, and sub-subcontractors
waive all rights against this contract and its agents, officers,
directors, and employees for recovery of damages to the
extent these damages are covered by the workers’
compensation and Employer’s Liability or Commercial
Umbrella Liability insurance obtained by Contractor, its
subcontractors, and its sub-subcontractors pursuant to this
contract.
11.2.9.3
Errors and Omissions/Professional Liability Insurance
Contractor shall maintain Professional Liability insurance which will
provide coverage for any and all acts arising out of the work or services
performed by the contractor under the terms of this contract, with a limit
of not less than $2,000,000 for each claim, and $4,000,000 aggregate
claims.
11.2.10 Certificates of Insurance
11.2.10.1 Prior to Contract Award, Contractor shall furnish the County with valid
and complete Certificates of Insurance, or formal endorsements as
required by the contract in the form provided by the County, issued by
Contractor’s insurer(s), as evidence that policies providing the required
coverage, conditions and limits required by this contract are in full force
and effect. Such certificates shall identify this contract number and title.
11.2.10.2 In the event any insurance policy(ies) required by this contract is (are)
written on a claims-made basis, coverage shall extend for two years
past completion and acceptance of Contractor’s work or services and
as evidenced by annual certificates of insurance.
11.2.10.3 If a policy does expire during the life of the contract, a renewal
certificate must be sent to County 15 calendar days prior to the
expiration date.
11.2.10.4 Certificates of Insurance shall identify Maricopa County as the
certificate holder as follows:
SERIAL 250006-ITN
Maricopa County
c/o Risk Management
301 W Jefferson St, Suite 910
Phoenix, AZ 85003
11.2.11 Cancellation and Expiration Notice
Applicable to all insurance policies required within the insurance requirements of
this contract, Contractor’s insurance shall not be permitted to expire, be
suspended, be canceled, or be materially changed for any reason without 30 days
prior written notice to Maricopa County. Contractor must provide to Maricopa
County, within two business days of receipt, if they receive notice of a policy that
has been or will be suspended, canceled, materially changed for any reason, has
expired, or will be expiring. Such notice shall be sent directly to Maricopa County
Office of Procurement Services and shall be mailed, or hand delivered to 301 W.
Jefferson, Suite 700, Phoenix, AZ 85003, or emailed to the procurement officer
noted in the solicitation.
11.3
FORCE MAJEURE
11.3.1
Neither party shall be liable for failure of performance, nor incur any liability to the
other party on account of any loss or damage resulting from any delay or failure to
perform all or any part of this contract, if such delay or failure is caused by events,
occurrences, or causes beyond the reasonable control and without negligence of
the parties. Such events, occurrences, or causes include, but are not limited to,
acts of God/nature (including fire, flood, earthquake, storm, hurricane, or other
natural disaster), war, invasion, act of foreign enemies, hostilities (whether war is
declared or not), civil war, riots, rebellion, revolution, insurrection, military or
usurped power or confiscation, terrorist activities, nationalization, government
sanction, lockout, blockage, embargo, labor dispute, strike, and interruption or
failure of electricity or telecommunication service, and pandemic.
11.3.2
Each party, as applicable, shall give the other party notice of its inability to perform
and particulars in reasonable detail of the cause of the inability. Each party must
use best efforts to remedy the situation and remove, as soon as practicable, the
cause of its inability to perform or comply.
11.3.3
The party asserting Force Majeure as a cause for non-performance shall have the
burden of proving that reasonable steps were taken to minimize delay or damages
caused by foreseeable events, that all non-excused obligations were substantially
fulfilled, and that the other party was timely notified of the likelihood or actual
occurrence which would justify such an assertion, so that other prudent
precautions could be contemplated.
11.4
FINANCIAL SANCTIONS
11.4.1
If Plan benefits provided under this contract violate or will violate any economic or
trade sanctions, such Plan benefits are immediately considered invalid. Contractor
cannot make payments for claims or Services if it violates a financial sanction
regulation. This includes sanctions related to a blocked person or a country under
sanction by the United States, unless permitted under a written office of Foreign
Assets Control (OFAC) license. Contractor shall notify the County in writing within
10 days of notice to Contractor of such violation.
11.5
WAIVER
No delay or failure of either party in exercising any right under this contract shall be deemed
to constitute a waiver of that right.
SERIAL 250006-ITN
11.6
NO MINIMUM OR MAXIMUM PURCHASE OBLIGATION
This contract does not guarantee any minimum or maximum purchases will be made.
Orders will only be placed under this contract when the County identifies a need and proper
authorization, and documentation have been approved.
11.7
BACKGROUND CHECK
Contractor may be required to pass multiple background checks (e.g. Sheriff’s Office,
County Attorney's Office, Courts, as well as Maricopa County general government) to
determine if the respondent is acceptable to do business with the County. This applies to,
but is not limited to, the company, subcontractors, and employees, and the failure to pass
these checks shall deem the respondent non-responsible.
11.8
SUSPENSION OF WORK
The procurement officer may order the Contractor, in writing, to suspend, delay, or interrupt
all or any part of the work of this contract for the period that the procurement officer
determines appropriate for the convenience of the County. No adjustment shall be made
under this clause for any suspension, delay, or interruption to the extent that performance
would have been so suspended, delayed, or interrupted by any other cause, including the
fault or negligence of the Contractor. No request for adjustment under this clause shall be
granted unless the claim, in an amount stated, is asserted in writing as soon as practicable
after the termination of the suspension, delay, or interruption, but not later than the date of
final payment under the contract.
11.9
STOP WORK ORDER
11.9.1
The procurement officer may, at any time, by written order to the Contractor,
require the Contractor to stop all, or any part, of the work called for by this contract
for a period of 90 calendar days after the order is delivered to the Contractor, and
for any further period to which the parties may agree. The order shall be specifically
identified as a stop work order issued under this clause. Upon receipt of the order,
the Contractor shall immediately comply with its terms and take all reasonable
steps to minimize the incurrence of costs allocable to the work covered by the order
during the period of work stoppage. Within a period of 90 calendar days after a
stop work order is delivered to the Contractor, or within any extension of that period
to which the parties shall have agreed, the procurement officer shall either:
11.9.1.1
cancel the stop work order; or
11.9.1.2
terminate the work covered by the order as provided in the Termination
for Default or the Termination for Convenience clause of this contract.
11.9.1.3
The procurement officer may make an equitable adjustment in the
delivery schedule and/or contract price, and the contract shall be
modified, in writing, accordingly, if the Contractor demonstrates that the
stop work order resulted in an increase in costs to the Contractor
11.10
TERMINATION FOR CONVENIENCE
Either party may terminate the resultant contract for convenience by providing 180 calendar
days advance written notice to the other party.
11.11
TERMINATION FOR DEFAULT
11.11.1 The County may, by written Notice of Default to the Contractor, terminate this
contract in whole or in part if the Contractor fails to:
SERIAL 250006-ITN
11.11.1.1 deliver the supplies or to perform the services within the time specified
in this contract or any extension;
11.11.1.2 make progress, to endanger performance of this contract; or
11.11.1.3 perform any of the other provisions of this contract.
11.11.2 The County’s right to terminate this contract under these subparagraphs may be
exercised if the Contractor does not cure such failure within 10 business days (or
more if authorized in writing by the County) after receipt of a Notice to Cure from
the procurement officer specifying the failure.
11.11.3 If the County fails to fund benefits payments according to the contract or fails to
pay Service Fees after request by the Contractor, the Contractor has the right to
cease paying claims and suspend Services until the requested funds or Service
Fees have been provided.
11.12
PERFORMANCE
It shall be the Contractor’s responsibility to meet the proposed performance requirements.
Maricopa County reserves the right to obtain services on the open market in the event the
Contractor fails to perform, and any price differential will be charged against the Contractor.
11.13
CONTRACTOR EMPLOYEE MANAGEMENT
11.13.1 Contractor shall not reassign any key personnel identified in their contract without
the express consent of the County. Contractor shall provide a minimum of two
weeks’ notice to the County of any changes to key personnel on the County’s
account.
11.13.2 County reserves the right to request the replacement of any Contractor personnel
at any time, for any reason.
11.14
TRAINING
Contractor shall provide training services to completely train County personnel in the use
of employer and participant portal. All training shall take place on-site in Maricopa County,
unless otherwise negotiated with County.
11.15
WARRANTY OF SERVICES
11.15.1 The Contractor warrants that all services provided hereunder will conform to the
requirements of the contract, including all descriptions, specifications, exhibits, and
attachments made a part of this contract. County’s acceptance of services or
goods provided by the Contractor shall not relieve the Contractor from its
obligations under this warranty.
11.15.2 In addition to its other remedies, County may, at the Contractor's expense, require
prompt correction of any services failing to meet the Contractor's warranty herein.
Services corrected by the Contractor shall be subject to all the provisions of this
contract in the manner and to the same extent as services originally furnished
hereunder.
11.16
REMEDIES
Other than in an action between the parties for third party indemnification, neither party
shall be liable to the other for any consequential, incidental, or punitive damages
whatsoever.
SERIAL 250006-ITN
11.17
USAGE REPORT
The Contractor shall furnish the County a usage report upon request, delineating the
acquisition activity governed by the contract. The format of the report shall be approved by
the County and shall disclose the quantity and dollar value of each contract item by
individual unit of measure at no cost to the County.
11.18
STATUTORY RIGHT OF CANCELLATION FOR CONFLICT OF INTEREST
Notice is given that, pursuant to A.R.S. § 38-511, the County may cancel any contract
without penalty or further obligation within three years after execution of the contract, if any
person significantly involved in initiating, negotiating, securing, drafting, or creating the
contract on behalf of the County is at any time, while the contract or any extension of the
contract is in effect, an employee or agent of any other party to the contract in any capacity
or consultant to any other party of the contract with respect to the subject matter of the
contract. Additionally, pursuant to A.R.S. § 38-511, the County may recoup any fee or
commission paid or due to any person significantly involved in initiating, negotiating,
securing, drafting, or creating the contract on behalf of the County from any other party to
the contract arising as the result of the contract.
11.19
OFFSET FOR DAMAGES
In addition to all other remedies at Law or Equity, the County may offset from any money
due to the Contractor any amounts Contractor owes to the County for damages resulting
from breach or deficiencies in performance of the contract.
11.20
SUBCONTRACTING
11.20.1 The Contractor may not assign to another Contractor or subcontract to another
party for performance of the terms and conditions hereof without the written
consent of the County. All correspondence authorizing subcontracting must
reference the bid serial number and identify the job or project.
11.20.2 The subcontractor’s rate for the job shall not exceed that of the prime Contractor’s
rate, as bid in the pricing section, unless the prime Contractor is willing to absorb
any higher rates. The subcontractor’s invoice shall be invoiced directly to the prime
Contractor, who in turn shall pass-through the costs to the County, without mark-
up. A copy of the subcontractor’s invoice must accompany the prime Contractor’s
invoice.
11.21
AMENDMENTS
All amendments to this contract shall be in writing and approved/signed by both parties.
Maricopa County Office of Procurement Services shall be responsible for approving all
amendments for Maricopa County.
11.22
ADDITIONS/DELETIONS OF REQUIREMENTS
The County reserves the right to add and/or delete materials and services to a contract. If
a service requirement is deleted, payment to the Contractor will be reduced proportionately
to the amount of service reduced in accordance with the bid price. If additional materials
or services are required from a contract, prices for such additions will be negotiated
between the Contractor and the County.
11.23
RIGHTS IN DATA
11.23.1 The County shall have the use of data and reports resulting from a contract without
additional cost or other restriction except as may be established by law or
SERIAL 250006-ITN
applicable regulation. Each party shall supply to the other party, upon request, any
available information that is relevant to a contract and to the performance
thereunder.
11.23.2 Data, records, reports, and all other information generated for the County by a third
party as the result of a contract are the property of the County and shall be provided
in a format designated by the County or shall be and remain accessible to the
County into perpetuity.
11.24
ACCESS TO AND RETENTION OF RECORDS FOR THE PURPOSE OF AUDIT AND/OR
OTHER REVIEW
11.24.1 In accordance with Section MC1-372 of the Maricopa County Procurement Code,
the Contractor agrees to retain (physical or digital copies of) all books, records,
accounts, statements, reports, files, and other records and back-up documentation
relevant to this contract for six years after final payment or until after the resolution
of any audit questions, which could be more than six years, whichever is longest.
The County, Federal or State auditors and any other persons duly authorized by
the department shall have full access to and the right to examine, copy, and make
use of, any and all said materials.
11.24.2 If the Contractor’s books, records, accounts, statements, reports, files, and other
records and back-up documentation relevant to this contract are not sufficient to
support and document that requested services were provided, the Contractor shall
reimburse Maricopa County for the services not so adequately supported and
documented.
11.25
AUDIT DISALLOWANCES
If at any time it is determined by the County that a cost for which payment has been made
is a disallowed cost, the County shall notify the Contractor in writing of the disallowance.
The course of action to address the disallowance shall be at sole discretion of the County,
and may include either an adjustment to future invoices, request for credit, request for a
check, or a deduction from current invoices submitted by the Contractor equal to the
amount of the disallowance, or to require reimbursement forthwith of the disallowed amount
by the Contractor by issuing a check payable to Maricopa County.
11.26
STRICT COMPLIANCE
Acceptance by County of a performance that is not in strict compliance with the terms of
the contract shall not be deemed to be a waiver of strict compliance with respect to all other
terms of the contract.
11.27
VALIDITY
The invalidity, in whole or in part, of any provision of this contract shall not void or affect
the validity of any other provision of the contract.
11.28
SEVERABILITY
The removal, in whole or in part, of any provision of this contract shall not void or affect the
validity of any other provision of this contract.
11.29
RELATIONSHIPS
11.29.1 In the performance of the services described herein, the Contractor shall act solely
as an independent Contractor, and nothing herein or implied herein shall at any
time be construed as to create the relationship of employer and employee, co-
employee, partnership, principal and agent, or joint venture between the County
and the Contractor.
SERIAL 250006-ITN
11.29.2 The County reserves the right of final approval on proposed staff. Also, upon
request by the County, the Contractor will be required to remove any employees
working on County projects and substitute personnel based on the discretion of
the County within two business days, unless a different time period was previously
approved by the County.
11.30
NON-DISCRIMINATION
Contractor agrees to comply with all provisions and requirements of Arizona Executive
Order 2009-09, including flow down of all provisions and requirements to any
subcontractors. Executive Order 2009-09 supersedes Executive Order 99-4 and amends
Executive Order 75-5 and is hereby incorporated into this contract as if set forth in full
herein. During the performance of this contract, contractor shall not discriminate against
any employee, County, or any other individual in any way because of that person’s age,
race, creed, color, religion, sex, disability, or national origin. (Arizona Executive Order
2009-09
can
be
viewed
at
https://apps.azsos.gov/public_services/register/2009/46/governor.pdf)
11.31
WRITTEN CERTIFICATION PURSUANT to A.R.S. § 35-393.01
If Contractor engages in for-profit activity and has 10 or more employees, and if this
agreement has a value of $100,000 or more, Contractor certifies it is not currently engaged
in, and agrees for the duration of this agreement to not engage in, a boycott of goods or
services from Israel. This certification does not apply to a boycott prohibited by 50 U.S.C.
§ 4842 or a regulation issued pursuant to 50 U.S.C. § 4842.
11.32
CERTIFICATION REGARDING DEBARMENT AND SUSPENSION
11.32.1 The undersigned (authorized official signing on behalf of the Contractor) certifies
to the best of his or her knowledge and belief that the Contractor, its current
officers, and directors:
11.32.1.1 are not presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from being awarded any
contract or grant by any United States department or agency or any
state, or local jurisdiction;
11.32.1.2 have not within a three-year period preceding this contract:
11.32.1.2.1 been convicted of fraud or any criminal offense in
connection with obtaining, attempting to obtain, or as the
result of performing a government entity (Federal, State, or
local) transaction or contract; or
11.32.1.2.2 been convicted of violation of any Federal or State antitrust
statutes or conviction for embezzlement, theft, forgery,
bribery, falsification or destruction of records, making false
statements, or receiving stolen property regarding a
government entity transaction or contract;
11.32.1.3 are not presently indicted or criminally charged by a government entity
(Federal, State or local) with commission of any criminal offenses in
connection with obtaining, attempting to obtain, or as the result of
performing a government entity public (Federal, State or local)
transaction or contract;
11.32.1.4 are not presently facing any civil charges from any governmental entity
regarding obtaining, attempting to obtain, or from performing any
governmental entity contract or other transaction; and
SERIAL 250006-ITN
11.32.1.5 have not within a three-year period preceding this contract had any
public transaction (Federal, State or local) terminated for cause or
default.
11.32.2 If any of the above circumstances described in the paragraph are applicable to the
entity submitting a bid for this requirement, include with your bid an explanation of
the matter including any final resolution.
11.32.3 The Contractor shall include, without modification, this clause in all lower tier
covered transactions (i.e. transactions with subcontractors or sub-subcontractors)
and in all solicitations for lower tier covered transactions related to this contract. If
this clause is applicable to a subcontractor or sub-subcontractor, the Contractor
shall include the information required by this clause with their bid.
11.33
VERIFICATION REGARDING COMPLIANCE WITH A.R.S. § 41-4401 AND FEDERAL
IMMIGRATION LAWS AND REGULATIONS
11.33.1 By entering into the contract, the Contractor warrants compliance with the
Immigration and Nationality Act (INA using E-Verify) and all other Federal
immigration laws and regulations related to the immigration status of its employees
and A.R.S. § 23-214(A). The Contractor shall obtain statements from its
subcontractors certifying compliance and shall furnish the statements to the
procurement officer upon request. These warranties shall remain in effect through
the term of the contract. The Contractor and its subcontractors shall also maintain
Employment Eligibility Verification forms (I-9) as required by the Immigration Reform
and Control Act of 1986, as amended from time to time, for all employees performing
work under the contract and verify employee compliance using the E-Verify system
and shall keep a record of the verification for the duration of the employee’s
employment or at least three years, whichever is longer. I-9 forms are available for
download at www.uscis.gov.
11.33.2 The County retains the legal right to inspect documents of Contractor and
subcontractor employees performing work under this contract to verify compliance
with paragraph 10.30.1 of this section. Contractor and subcontractor shall be given
reasonable notice of the County’s intent to inspect and shall make the documents
available at the time and date specified. Should the County suspect or find that the
Contractor or any of its subcontractors are not in compliance, the County will
consider this a material breach of the contract and may pursue any and all remedies
allowed by law, including, but not limited to: suspension of work, termination of the
contract for default, and suspension and/or debarment of the Contractor. All costs
necessary to verify compliance are the responsibility of the Contractor.
11.34
CONTRACTOR LICENSE REQUIREMENT
The Contractor shall procure all permits, insurance, and licenses, and pay the charges and
fees necessary and incidental to the lawful conduct of his/her business, and as necessary
complete any requirements, by any and all governmental or non-governmental entities as
mandated to maintain compliance with and remain in good standing. The Contractor shall
keep fully informed of existing and future trade or industry requirements, and Federal,
State, and local laws, ordinances, and regulations which in any manner affect the fulfillment
of a contract and shall comply with the same. Contractor shall immediately notify both the
Office of Procurement Services and the department of any and all changes concerning
permits, insurance, or licenses.
11.35
INFLUENCE
11.35.1 As prescribed in MC1-1203 of the Maricopa County Procurement Code, any effort
to influence an employee or agent to breach the Maricopa County Ethical Code of
Conduct or any ethical conduct, may be grounds for disbarment or suspension
under MC1-902.
11.35.2 An attempt to influence includes, but is not limited to:
11.35.2.1 A person offering or providing a gratuity, gift, tip, present, donation,
money, entertainment or educational passes or tickets, or any type of
valuable contribution or subsidy that is offered or given with the intent to
influence a decision, obtain a contract, garner favorable treatment, or
gain favorable consideration of any kind.
11.35.3 If a person attempts to influence any employee or agent of Maricopa County, the
chief procurement officer, or his designee, reserves the right to seek any remedy
provided by the Maricopa County Procurement Code, any remedy in equity or in
the law, or any remedy provided by this contract.
11.36
CONFIDENTIAL INFORMATION
11.36.1 Any information obtained in the course of performing this contract may include
information that is proprietary or confidential to the County. This provision
establishes the Contractor’s obligation regarding such information.
11.36.2 The Contractor shall establish and maintain procedures and controls that are
adequate to assure that no information contained in its records and/or obtained
from the County or from others in carrying out its functions (services) under the
contract shall be used by or disclosed by it, its agents, officers, or employees,
except as required to efficiently perform duties under the contract. The Contractor’s
procedures and controls, at a minimum, must be the same procedures and controls
it uses to protect its own proprietary or confidential information. If, at any time
during the duration of the contract, the County determines that the procedures and
controls in place are not adequate, the Contractor shall institute any new and/or
additional measures requested by the County within 15 business days of the
written request to do so.
11.36.3 Any requests to the Contractor for County proprietary or confidential information
shall be referred to the County for review and approval, prior to any dissemination.
11.37
PUBLIC RECORDS
Under Arizona law, all offers submitted and opened are public records and must be
retained by the County at the Maricopa County Office of Procurement Services. Offers shall
be open to public inspection and copying after Contract Award and execution, except for
such offers or sections thereof determined to contain proprietary or confidential information
by the Office of Procurement Services. If an offeror believes that information in its offer or
any resulting contract should not be released in response to a public record request, under
Arizona law, the offeror shall indicate the specific information deemed confidential or
proprietary and submit a statement with its offer detailing the reasons that the information
should not be disclosed. Such reasons shall include the specific harm or prejudice which
may arise from disclosure. The records manager of the Office of Procurement Services
shall determine whether the identified information is confidential pursuant to the Maricopa
County Procurement Code.
11.38
INTEGRATION
This contract represents the entire and integrated agreement between the parties and
supersedes
all
prior
negotiations,
proposals,
communications,
understandings,
representations, or agreements, whether oral or written, expressed, or implied.
11.39
UNIFORM ADMINISTRATIVE REQUIREMENTS
By entering into this contract, the Contractor agrees to comply with all applicable provisions
of
Title
2,
Subtitle
A,
Chapter
II,
Part
200—UNIFORM
ADMINISTRATIVE
REQUIREMENTS, COST PRINCIPLES, AND AUDIT REQUIREMENTS FOR FEDERAL
AWARDS contained in Title 2 C.F.R. § 200 et seq.
11.40
GOVERNING LAW
This contract shall be governed by the laws of the State of Arizona. Venue for any actions
or lawsuits involving this contract will be in Maricopa County Superior Court, Phoenix,
Arizona.
11.41
FORCED LABOR
11.41.1 By submitting a bid for this solicitation and/or entering into a contract as a result of
this solicitation, Contractor agrees to comply with all applicable portions of Arizona
Revised Statutes Section 35-394. Contracting; procurement; prohibition; written
certification; remedy; termination; exception; definitions.
11.41.2 Contractor certifies that it does not currently, and agrees for the duration of the
contract, that it will not use:
11.41.2.1 The forced labor of ethnic Uyghurs in the People’s Republic of China.
11.41.2.2 Any goods or services produced by the forced labor of ethnic Uyghurs
in the People’s Republic of China.
11.41.2.3 Any contractors, subcontractors or suppliers that use the forced labor or
any good or services produced by the forced labor of ethnic Uyghurs in
the People’s Republic of China.
11.41.3 If Contractor becomes aware during the term of the agreement that Contractor is
not in compliance with this paragraph, the Contractor shall notify the County within
five business days after becoming aware of the noncompliance. If the Contractor
fails to provide a written certification to the County that the Contractor has
remedied the noncompliance within 180 days after notifying the County of its
noncompliance, then the agreement terminates, except that if the agreement
termination date occurs before the end the 180-day period, the agreement
terminates on the agreement termination date.
11.42
PRICES
Contractor warrants that prices extended to County under this contract are no higher than
those paid by any other customer for these or similar services.
11.43
ORDER OF PRECEDENCE
In the event of a conflict in the provisions of this contract, the terms of this contract shall
prevail and all exhibits shall be subordinate to the main contract.
11.44
UNIQUE ENTITY IDENTIFIER (UEI) AND SYSTEM FOR AWARD MANAGEMENT
REGISTRATION
All
contractors
that
receive
funding
must
have
a
UEI
number
through
https://sam.gov/content/entity-registration. Contractor must also remain current with the
System for Award Management www.sam.gov throughout the term of the contract.
11.47
CONTRACT DISPUTES
All Contract disputes will be first handled in accordance with the Maricopa County
Procurement Code, MCI-906. If the dispute is not settled as outlined in MC1-906, parties
may mutually agree to arbitrate in accordance with the American Arbitration Association
Commercial Arbitration. The arbitration venue shall be Phoenix, Arizona.
11.45
INCORPORATION OF DOCUMENTS
11.45.1 The following are to be attached to and made part of this Contract:
11.45.1.1
Exhibit A – Vendor Information and Pricing
11.45.1.2
Exhibit B – Implementation Deliverables and Key Dates
11.45.1.3
Exhibit C – Performance Service Level Agreements (Medical and
PBM)
11.45.1.4
Exhibit D – HIPAA Business Associates Agreement (BAA)
11.45.1.5
Exhibit E - Self-Funded Medical Underwriting (UW) Disclosures
11.46
NOTICES
All notices given pursuant to the terms of this contract shall be addressed to:
For County:
Maricopa County
Office of Procurement Services
301 W. Jefferson St. Suite 700
Phoenix, Arizona 85003-1647
For Contractor:
Banner Health and Aetna Health Insurance Company dba Banner|Aetna
Account Director for Maricopa County
9501 East Shea Blvd
Scottsdale, AZ 85260
11.47
INQUIRIES
11.47.1 Administrative telephone/email inquiries shall be addressed to:
ELIZABETH KUTTNER, PROCUREMENT OFFICER
TELEPHONE: (602) 506-0099
elizabeth.kuttner@maricopa.gov
11.47.2 Inquiries may be submitted by telephone but must be followed up in writing. No
oral communication is binding on Maricopa County.
SERIAL 250006-ITN
IN WITNESS WHEREOF, this contract is executed on the date set forth above.
CONTRACTOR
AUTHORIZED SIGNATURE
PRINTED NAME AND TITLE
ADDRESS
DATE
MARICOPA COUNTY
CHAIRMAN, BOARD OF SUPERVISORS
DATE
ATTESTED:
CLERK OF THE BOARD
DATE
APPROVED AS TO FORM:
DEPUTY COUNTY ATTORNEY
DATE
SERIAL 250006-ITN
EXHIBIT A – VENDOR INFORMATION AND PRICING
COMPANY NAME:
Banner Health and Aetna Health Insurance Company
DOING BUSINESS AS (dba):
Banner|Aetna
MAILING ADDRESS:
9501 E Shea Blvd., Scottsdale, AZ 85260
REMIT TO ADDRESS:
9501 E Shea Blvd., Scottsdale, AZ 85260
TELEPHONE NUMBER:
(800) 872 3862
FAX NUMBER:
(860) 273-3382
WWW ADDRESS:
www.aetna.com
REPRESENTATIVE NAME:
Tracey Lyons
REPRESENTATIVE TELEPHONE NUMBER:
602-659-1719
REPRESENTATIVE EMAIL ADDRESS
LyonsT@aetna.com
UNIQUE ENTITY ID (UEI) FROM SAM.GOV
T1N7KK166CM3
YES
NO
REBATE
WILL ALLOW OTHER GOVERNMENTAL ENTITIES TO PURCHASE
FROM THIS CONTRACT:
WILL ACCEPT PROCUREMENT CARD FOR PAYMENT:
NET 30 DAYS
SERIAL 250006-ITN
Administrative Service Fee Schedule
Contact Information/Assumptions
Account Executive:
Tracey Lyons SIC Code: 3542
Email:
LyonsT@aetna.com Mem/EE Ratio: 2.33
Telephone:
480-267-6926
Year 1
Year 2
Year 3
Year 4
Guarantee Period Effective Date
January 01,
2026
January 01,
2027
January
01, 2028
January 1,
2029
Fee Basis
Mature
Mature
Mature
Mature
Medical Fees as Billed (PEPM)*
Estimated
Enrollment
Year 1
Year 2
Year 3
Year 4
Banner|Aetna Open Access EPO Plus -
Performance Network
3,901
$39.89
$39.89
$39.89
$39.89
Plan Year Administrative Service Fees
3,901
$1,867,331
$1,867,331
$1,867,331
$1,867,331
Administrative Service Fee Illustration
(Plan Year)
Year 1
Year 2
Year 3
Year 4
Administrative Service Fees
$1,867,331
$1,867,331
$1,867,331
$1,867,331
Administrative Service Fee Cap % Change*
0.0%
0.0%
0.0%
Administrative Service Fee Credit**
($311,222)
$0
$0
$0
Total Fees (incl Discounts, Credits,
Other Charges)
$1,556,109
$1,867,331
$1,867,331
$1,867,331
Clarifications
• PEPM is defined as Per Employee Per Month.
• Please see Programs and Services for additional information. Some services may come at additional cost to the fees
shown above
• Any plan tear costs are based on the estimated enrollment and subject to change based on actual enrollment.
Prescription Drug Benefits
The Administrative Service Fees assume that prescription drug benefits are included and will be provided by
Contractor.
If prescription drug benefits are terminated prior to the end of the guarantee period, Administrative Service Fees will
be increased in addition to the medical trend assumption used for any applicable claim projections or guarantees.
County will also be subject to additional charges to integrate data with external pharmacy vendors. Refer to the
reporting charges outlined in the Programs and Services section of the contract for more information.
In addition to an increase in the Administrative Service Fees, the Administrative Service Fee Credit will not apply.
*Administrative Service Fee Cap
An Administrative Service Fee cap for the guarantee period January 01, 2026 to December 31, 2029 is also included.
The maximum Administrative Service Fees are listed above. The Administrative Service Fee cap is subject to the terms
and conditions as stated in the caveats and assumptions section of the contract and is contingent upon County
maintaining all lines of business with Contractor.
**Administrative Service Fee Credit
An Administrative Service Fee credit is included. Subject to Section 8.0 (AVAILABILITY OF FUNDS) of this contract,
County agrees to repay a prorated amount of the fee credit issued if the contract is terminated, or pharmacy is carved
out prior to the end of Year 4. Contractor will prorate this amount using the total number of months that the
termination occurs prior to the end of Year 4 (e.g. if the contract is termed on December 31, 2028 the County agrees
to
repay
12/48
or
1/4
of
the
Medical
Service
Administrative
credit
applied
in
year
1).
Refer to the Administrative Service Fee credit assumptions and caveats section of the contract for specific details.
Programs & Services Included in the Service Fee
Program Summary
PRODUCT: Open Access EPO Plus
NETWORK: Performance Network
General Administration
Experienced Account Management Team
Included
Designated Implementation Manager
Included
Designated billing, eligibility, plan set up,
underwriting
Included
Open Enrollment Meeting Preparation
Included
Open Enrollment Marketing Material
(non-customized)
Included
ID Cards
Included
Review and draft Summary Plan Document / Plan
Booklet -
Included
Summary of Benefits and Coverage (SBC)
Included
Claim Fiduciary Option 1 – Full, with Claim Litigation
Included
External Review
Included
Non-ERISA
Included
Claim Administration
Included
Plan Sponsor Liaison
Included
Special Investigations / Zero Tolerance Fraud Unit
Included
Network Services
Joint Venture Network Access
Included
Full National Reciprocity
Included
98Point6®Includes administration fee and all
member visits
Included
Institutes of Excellence™
Included
Institutes of Quality® (IOQ) Network
Included
National Medical Excellence Program®
Included
Network access
Included
Care Management
Aetna Compassionate Care℠
Included
Aetna One® Flex
Included
Aetna Enhanced Maternity Program
Included
Multi-Disciplinary Care Teams (MDCT) - JV
Collaboration
Included
Preventive Care Considerations (Electronic)
Included
Utilization management (Inpatient Precertification,
Concurrent Review, Discharge
Planning, Retrospective Review)
Included
Virta Administration fee
Included
Member Resources
Designated Service Center
Included
Aetna Concierge (includes First Impression
Included
SERIAL 250006-ITN
Treatment)
Provider search (online provider directory)
Included
Health Decision Support - Basic
Included
Member Website and Mobile Experience
Included
MindCheckSM
Included
Member Microsite, Member Web Portal , Member
App
Included
Wellness
24-Hour Nurse Line: 1-800# Only
Included
Aetna Health Your Way™ Health Assessment and
Digital Support
Included
Aetna Health Your Way™ Plus (includes MedQuery
and Personal Health Record)
Included
Allowances
Audit Allowance - $100K every 2 years
Included
Reporting and Integration
Analytic Consultation from Plan Sponsor Insights
(50 Hours)
Included
Clinical Consultation from Plan Sponsor Insights (50
Hours)
Included
ART Reports - New analytic reporting platform
Included
Aetna Health Information Advantage™ (AHIA)
Included
Monthly Financial Claim Detail Reports
Included
Monthly Banking Reports
Included
Monthly Universal File Feed Outbound (12 total
reports)
Included
Monthly 3rd Party Stop Loss Vendor Reports (12
total reports)
Included
Eligibility to 3rd Party Wellness Vendor (12 total
reports)
Included
Behavioral Health
Managed Behavioral Health
Included
Behavioral Health Condition Management Program
- Standard
Included
Applied Behavior Analysis (ABA)
Included
AbleTo Network
Included
Aetna Discount Program
At home products, fitness, hearing, LifeMart®
shopping website, natural products and
services, oral health care, vision, weight
management
Included
Optional Buy-Up Programs & Services (per employee, per month unless otherwise noted)
Program Summary
Banner|Aetna Performance Network
Health and Wellness Programs
LCC Condition Coaching
$2.40
SERIAL 250006-ITN
LCC Lifestyle Coaching
$1.50
Aetna Back and Joint CareTM (per engaged
member, per year)*
$995
Virta Diabetes Reversal Program
$225* per engaged participant per month - first 12 months
$175* per engaged participant per month - month 13 and
beyond.
*contracted rate through 12/31/2025 and subject to potential
change on 01/01/2026
Required Programs & Services Included/Charged through the Banking the Claim Wire
Refer to Exhibit E – Self-Funded Medical Underwriting Disclosures for Description of programs marked with an
Asterisk (*)
Network Services
Accountable Care Organization Payments* (Per
Attributed Member Per Month)
$3.50
No Surprises Act - Fees*
No Surprises Act (NSA) claim administration fee*
(per NSA eligible claim)
$90
No Surprises Act (NSA) Independent Dispute
Resolution (IDR) initial fee* (per arbitration case)
Applicable fees are as set by law and passed through to the
plan
No Surprises Act (NSA) Independent Dispute
Resolution (IDR) arbitration expenses*
Applicable fees are as set by law and passed through to the
plan
Additional Administrative and Network Services
Institutes of Excellence™ (Transplants)
$2,500 when wait-listed for a transplant
Institutes of Excellence™ (Transplants)
$7,500 when transplant procedure is complete
Subrogation*
30% of savings
Contracted Services* (Coordination of Benefits,
Retro Terminations, Medical Bill and
Hospital Bill Audits, Workers Compensation, DRG
and Implant Audits)
30% of savings
Claim and Code Review Program*
30% of savings
National Advantage™ Program – includes Facility
Charge Review, Itemized Bill Review, and Data
iSight™*
Contractor will retain 30% of savings
National Advantage™ Program Cap – includes
Facility Charge Review, Itemized Bill*
Cap of $50,000 per individual claim
National Advantage™ Program Cap – includes
Facility Charge Review, Itemized Bill*
$3.00 PEPM
Overpayment Recoveries (not resulting from
Contractor’s errors)
15% - 20% of recoveries
PPI Consortium Pharmacy (Rx) Fee
$1.00 PEPM
Care Management
Enhanced Clinical Review Program – High Tech
$0.35
SERIAL 250006-ITN
Imaging (PMPM)
Enhanced Clinical Review Program – Diagnostic
Cardiac (PMPM)
$0.10
Enhanced Clinical Review Program – Sleep
Management (PMPM)
$0.05
Enhanced Clinical Review Program – Cardiac
Implantable Devices (PMPM)
$0.05
Enhanced Clinical Review Program – Interventional
Pain (PMPM)
$0.10
Enhanced Clinical Review Program – Hip and Knee
Arthroplasties (PMPM)
$0.05
Enhanced Clinical Review Program – SmartChoice
(PMPM)
$0.10
Additional Program Details
Claim Wire Billing, ID Cards, Subrogation, Contracted Services, Claim and Code Review
Details can be found in Contractor Self-funded Medical Underwriting Disclosure Document
Claim and Code Review Program
Claim and code review program and capabilities are part of Contractor standard shared savings
arrangement.
No Surprises Act (NSA) - Fees
Refer to the NSA Payment Practices in Underwriting Caveats for information on Contractor payment practices
for NSA eligible claims.
No Surprises Act - IDR Fees
Independent Dispute Resolution (IDR) fees are required by the NSA rules and are payable to the IDR entity.
There is an initial fee to begin an arbitration, which applies to each case. There is also an additional fee for the
arbitration expenses; the losing party within the dispute is liable for this fee. For batch cases, the NSA permits
IDR entities to charge a different arbitration fee based on a set fee range and/or percentage of the batch fee.
The fees are passed through (with no mark up by Contractor) to County based on the number of line items for
their plan that were included in the batch case. The current NSA fees are set by federal agencies. Both the
initial fee and the arbitration expense fee are subject to future adjustments by the agencies (and any such
adjustments shall be passed on to the County).
Aetna Back and Joint Care™
Includes Aetna predictive analytics and care management coordination and digital MSK therapy programs from
Hinge Health. For any single engaged member, the maximum fee per year is $995, regardless of how many
programs the member has engaged in.
For Chronic Care - The fee associated with an enrolled member in the Chronic program and their Cohort will
be paid in accordance with the 3 milestones for member engagement and pain reduction noted below.
"Cohort" means all enrolled members of the County who sign up for the program within any given month.
Milestone Payments
Milestone 1: A member enrolls in the program, receives the kit, and completes at least 1 exercise
therapy session with a Hinge Health coach.
SERIAL 250006-ITN
Milestone 2: Cohort completes at least 4 exercise therapy sessions within the first 30 days of
enrolling in the program and such Cohort achieves at least a 20 percent reduction in pain.
Milestone 3: Cohort completes at least 8 exercise therapy sessions within the first 60 days of
enrolling in the program and such Cohort achieves at least a 30 percent reduction in pain.
With respect to each member enrolled in the program, the Milestone 1 payment of $331 is due once the
member achieves Milestone 1; the Milestone 2 payment of $332 is due when the member’s Cohort achieves
Milestone 2; and the Milestone 3 payment of $332 is due when such Cohort achieves Milestone 3. If the
applicable Cohort does not achieve Milestone 2 or Milestone 3 then payment for such Milestone is not due.
For Acute Care - The fee associated with an enrolled member in the Acute program
is $250 per year. This fee is not subject to Milestone payments.
For Prevention - There is no fee associated with enrolled members in the
Prevention Program.
Enhanced Clinical Review
This fee shall only be charged based for members who fall into service areas where the program is available.
Institutes of Excellence™ (IOE)
This program includes a steerage component by educating members on the benefits of using an IOE
designated facility. However, benefit differential steerage is not supported for IOE Infertility network.
LCC Condition Coaching and LCC Lifestyle Coaching
LCC requires the purchase of Aetna Health Your Way™ Plus (includes MedQuery), Aetna Health Your Way™
Plus (includes MedQuery and Personal Health Record), Aetna Health Your Way™ Elite or Member Engagement
Platform.
National Advantage™ Program (including the Contracted Rates, Facility Charge Review and Itemized Bill
Review Components)
NAP includes a Contracted Rates component and two optional components: Facility Charge Review (FCR) and
Itemized Bill Review (IBR). In addition, some plans also elect Data iSight (DiS) as their out-of-network plan rate
for professional services. NAP's Contracted Rates component offers access to contracted rates for many medical
claims from non- network providers (including claims for emergency services and claims by hospital-based
specialists such as anesthesiologists and radiologists who do not contract with insurers) and ad hoc negotiations
(when a contracted rate is not available). Contractor retains a percentage of savings achieved through NAP,
including savings achieved through FCR, IBR, and DiS, if elected. This NAP retained savings is in addition to the
per employee, per month administrative service fee.
Underwriting Caveats
Contract pricing considers all the products, programs and services with Contractor and will be in effect for the
full 12 months of the plan year. Pricing for some programs and services are amortized over a 12-month period.
Therefore, subject to Section 8.0 (AVAILABILITY OF FUNDS) of this contract, fees will not be reduced if
termination occurs prior to the end of the plan year. Contractor also assumes the contract assumptions below
remain consistent throughout the plan year. Contractor requires notice to properly terminate before the plan
year ends in accordance with the Termination provision in this contract. Otherwise, County may be charged for
the cost until that notice is met.
If any of the changes outlined below occur, Contractor can request an adjustment of fees. Adjustments must be
made by mutual agreement and shall be added through formal amendment to the contract.
SERIAL 250006-ITN
Enrollment
There is a 15 percent change in the total number of enrolled employees.
Member-to-Employee Ratio
The member-to-employee ratio changes by more than 15 percent from 2.33.
Age 65 and Over Enrollment
The number of enrolled employees aged 65 and over (excluding those enrolled on Medicare Direct plans)
exceeds 5 percent of the total enrolled group or changes by more than 15 percent of 209. Management
programs are excluded for Medicare primary members.
Maximum Account Structure
Maximum account structure exceeds the number of units illustrated in the table below. Account structure
determines the reporting format. During the installation process, Contractor shall work with County to finalize
the account structure and determine which report formats will be most meaningful. Maximum total account
structure includes Experience Rating Groups (ERGs), controls, suffixes, billing and claim accounts.
3,000 to 4,999
150
Quoted Benefits and Administration
A material change is initiated by County or by legislative or regulatory action which materially affects the cost of
the plan. This includes, but is not limited to, changes impacting standard contract provisions, claim settlement
practices, plan administration, plan benefits or changes to the programs and services Contractor provides to
County.
National AdvantageTM Program
County changes or terminates the National AdvantageTM Program (NAP), Facility Charge Review (FCR), Itemized
Bill Review (IBR), or Data iSightTM (DiS) programs.
Joint Venture Administrative Fee
Changes to the geographical make-up of the population or changes to the network may result in a request for
revised administrative fee.
Performance Guarantees
If any of the conditions outlined above occur, then any performance guarantees may be changed or terminated
based on the caveats outlined in those guarantee documents with prior written consent of the County.
Plan Design
This contract is based on the current benefit plan designs, plus any noted deviations, subject to the terms of
Contractor Benefit Review document.
Claim Fiduciary - Option 1
This contract assumes Contractor has been delegated claim fiduciary responsibilities. As claim fiduciary,
Contractor shall be responsible for final claim determination and the legal defense of disputed benefit payments.
Contractor appeal administrative services are included.
External Review
External review is included. External review uses outside vendors who coordinate medical review through their
network of outside physician reviewers.
Non-ERISA
Underwriting
Assumptions
Total Employees
(Open Access EPO Plus)
Maximum Total
Structure Per
Product
SERIAL 250006-ITN
For non-ERISA plan, the risk and responsibilities are different from those under ERISA plans, since the ERISA
preemption and ERISA standard of performance do not apply. CMS and State of Arizona standard of performance
do apply to this Self-Funded, Non-Federal Government plan.
Wellness Incentives and Rewards
Contractor offers several different wellness incentives and rewards programs that County may choose from to
offer to members. Contractor, or Contractor’s third-party vendors, will administer and distribute to members
any wellness incentives or rewards earned based on the programs selected by the County. The County is under no
obligation, financial or otherwise, to select a wellness incentive or reward program. If a program is selected, the wellness
incentives and rewards earned through the program may be taxable for members. Contractor shall provide
County with reporting which will identify members who have earned such wellness incentives or rewards. These
reports will provide the data needed for any tax information reporting requirements that County determine
are necessary.
Regarding these wellness incentives and rewards, County has the following responsibilities:
• Ensure any incentives or rewards offered to County’s members comply with applicable law
and any limitations imposed thereunder. This includes but is not limited to, the Health
Insurance Portability Act (HIPAA), the Americans With Disabilities Act (ADA) and the Genetic
Information Nondiscrimination Act (GINA).
• Distribute notices and/or obtain any authorizations required by law.
• Comply with all tax information reporting requirements regarding any wellness incentives or
rewards earned through these programs (cash, cash equivalent, or other tangible property).
• Assume all liability for County’s noncompliance with any tax withholding or information reporting
requirements.
Mental Health/ Behavioral Health/Substance Abuse Benefits
This contract assumes that mental health, behavioral health, and substance abuse benefits are included.
Stop Loss Reporting
Stop loss coverage is not provided by Contractor and reporting to an external vendor, if needed, is included.
Includes 12 monthly reports. If County’s reporting requirements change, Contractor may request an
amendment for additional fees.
Medical Pharmacy Rebates
As requested, Contractor shall remit 100 percent of the medical pharmacy rebates generated under County’s
medical program to the County. Contractor has included the cost for administering this program in County’s
medical administration fee.
Contractor Intellectual Property
Under the contract, County shall have access to certain of Contractor's Plan Sponsor reporting systems.
Contractor represents that it has either the ownership rights or the right to use all the intellectual property used
by Contractor in providing the Services under the contract ("Contractor IP"). Contractor will grant County a
nonexclusive, non-assignable, royalty free, limited right to use certain of the Contractor IP for the purposes
described in the contract. County agrees not to modify, create derivative product from, copy, duplicate,
decompile, dissemble, reverse engineer or otherwise attempt to perceive the source code from which any
software component of the Contractor IP is compiled or interpreted. Nothing in the contract shall be deemed
to grant any additional ownership rights in, or any right to assign, sublicense, sell, resell, lease, rent, or
otherwise transfer or convey, the Contractor IP to County.
Reporting and Data Transfer
SERIAL 250006-ITN
Legislative and Regulatory Requirements
Affordable Care Act (ACA) Taxes and Fees - Notice to Self-Funded Group Health Plan's Financial Liability
The Affordable Care Act (ACA) imposed Patient-Centered Outcome Research Trust Fund fee (PCORI) on the
issuers of specified health insurance policies and plan sponsors of applicable self-insured health plans. The fee
was set to end in 2019, but it was extended for 10 years through 2029. The fee applies to policy or plan years
ending on or after October 1, 2012, and before October 1, 2029.
Any taxes or fees (assessments) related to the Affordable Care Act that apply to the self-insured health plans
are County’s obligation. The Administrative Service Fee does not include any such liability or the remittance of
the fees on County’s behalf.
NSA Payment Practices
The No Surprises Act (NSA) applies to certain out of network claims at participating facilities when the member
doesn’t have a choice or is unaware the provider is out of network. The law protects Plan participants by
limiting cost sharing to the preferred benefit level and prohibits balance billing by out of network providers.
For NSA eligible claims, Contractor will pay the out of network provider an initial payment amount. In most
cases, the initial payment will be an amount equal to the qualifying payment amount as defined in NSA
regulations (generally, the median contracted rate for a specific service in a geographic area). A provider may
choose to go to independent dispute resolution (IDR) if the provider does not accept Contractor payment as
payment in full. During the IDR process, County authorizes Contractor to pay the amount determined by the IDR
entity to settle the claim dispute without mark-up by the Contractor. Contractor shall provide an annual report of
disputes and resolutions that includes the billed and paid amounts and fees.
Administrative Fee Credit Assumptions and Caveats
The administrative fee credit is shown in the chart below*:
Administrative Fee Credit
Year 1
Plan Year Effective Date
01/01/2026
Fee Credit*
2 Months
*Savings are estimated for the Guarantee Period. The calculation is based on Year 1 expected enrollment and the
PEPM administrative fee.
The Administrative Fee credit will be subject to the following provisions:
• Subject to Section 8.0 (AVAILABILITY OF FUNDS) thereof, the contract will remain in effect until
December 31, 2029.
• The County is required to make the Administrative Fee payments in accordance with the contract.
• Standard termination provisions apply.
• All of the plan caveats as stated in the Underwriting Caveat Section of the contract are met.
• Future renewals will be calculated based on the annualized Administrative Fees before giving any effect
to the Administrative Fee credit.
• Contingent upon Contractor being the sole provider for the single healthcare plan covered by this
contract.
County agrees to pay Contractor the prorated amount of the total fee credit issued within 31 days of notice of
non-compliance if any of the following occur:
• Any of the above provisions are not met
• Subject to Section 8.0 (AVAILABILITY OF FUNDS) of the contract, County terminated the contract, or
pharmacy is carved out prior to the end of 2029. Contractor will prorate this amount using the total
number of months the termination occurs prior to the end of the guarantee period. Contractor will
prorate this amount using the total number of months that the termination occurs prior to the end of Year
SERIAL 250006-ITN
4 (e.g. if the contract is termed on December 31, 2028 the County agrees to repay 12/48 or 1/4 of the
Medical Service Administrative credit applied in year 1).
Refer to the Administrative Service Fee credit assumptions and caveats section of the contract for specific
details
The Administrative Fees listed in the Medical Fee Schedule section of the contract are billed every month. The
Administrative Fee credit is shown as a separate line item on the invoice.
Medical Plan Allowances
This contract includes an audit allowance(s) for as outlined in the chart below. Allowance dollars must be used for
the singular healthcare plan administered by the Contractor.
Annual Allowance Type
Year 1
Year 2
Year 3
Year 4
Plan Year Effective Date
01/01/2026
01/01/2027
01/01/2028
01/01/2029
Audit
$100,000
$100,000
Total
$100,000
$100,000
Annual allowance amounts may be adjusted by mutually agreed upon amendment to the contract if actual
enrollment changes by 15 percent or more from Contractor enrollment assumptions.
Audit Allowance
• The Audit allowance can be used to offset reasonable documented expenses incurred from
third-party vendors for auditing Contractor medical claim adjudication and member eligibility.
Expenses must be incurred during the period for which it is offered.
• All allowance submissions, including those submitted by a third-party vendor, must comply with these
conditions.
The above referenced fund(s) will be available during the second year of the period. Only those expenses
performed and billed by a third party are payable. Reimbursement for time and materials incurred directly by the
County (e.g., hours worked by the County's own employees) are not eligible. County’s normal business operation
expenses, including employee salaries and overtime, are not eligible under the allowance. Contractor preferred
method of payment is directly to the third-party vendor. Contractor requires submission of appropriate
documentation detailing charges for the services provided by the vendor. Acceptable documentation includes, but
is not limited to, detailed vendor invoices itemizing services provided, specific cost-elements and associated
line-item charges.
On an exception basis, Contractor can reimburse County directly provided County submit both the detailed invoice
and receipt showing payment to the third-party vendor.
County should submit documentation within 60 days of the invoice date. Contractor must receive all
documentation no later than 60 days following the close of the plan year to be considered for reimbursement.
The allowance amounts indicated above for the following Allowance Type(s) are available for the years indicated
in the chart. These allowances are forfeited at the end of each plan year if not fully utilized. There is no roll over
of unused funds to the next policy year. Any unredeemed wellness incentives that may be offered through a
"reward program" are forfeited at the end of each plan year.
Funding of any allowance dollars is for the exclusive benefit of County’s Plan. County is responsible for
determining that County’s use of allowance dollars is appropriate and legally compliant.
SERIAL 250006-ITN
If County terminates contract prior December 31, 2029, County will be responsible for remitting payment
for any allowance amounts used, subject to Section 8 - Availability of Funds. Payment is due to Contractor
within 31 days of the invoice.
Integrated Pharmacy Offer
The following summarizes pricing effective 1/1/2026 .
RETAIL NON SPECIALTY
Traditional
NATIONAL NETWORK BRAND
01/01/2026 - 12/31/2029: AWP -20.50%
RETAIL 90 DAY NETWORK BRAND
01/01/2026 - 12/31/2029: AWP -20.50%
NATIONAL NETWORK GENERIC
Generic Effective Rate
01/01/2026 - 12/31/2026: AWP -87.00%
01/01/2027 - 12/31/2027: AWP -87.10%
01/01/2028 - 12/31/2029: AWP -87.20%
(MAC & Non-MAC Combined)
RETAIL 90 DAY NETWORK GENERIC
Generic Effective Rate
01/01/2026 - 12/31/2026: AWP -88.50%
01/01/2027 - 12/31/2027: AWP -88.60%
01/01/2028 - 12/31/2029: AWP -88.70%
(MAC & Non-MAC Combined)
DISPENSING FEE NATIONAL NETWORK
Brand & Generic
01/01/2026 - 12/31/2026: $0.20 per Claim
01/01/2027 - 12/31/2027: $0.20 per Claim
01/01/2028 - 12/31/2029: $0.20 per Claim
DISPENSING FEE RETAIL 90 DAY
Brand & Generic
$0.00 per Claim
SPECIALTY AT RETAIL
SPECIALTY AT RETAIL
BRANDS
AWP -18.00%
GENERICS
AWP -50.00%
(MAC & Non-MAC Combined)
Brand & Generic Dispensing Fee
01/01/2026 - 12/31/2026: $0.20 per Claim
01/01/2027 - 12/31/2027: $0.20 per Claim
01/01/2028 - 12/31/2029: $0.20 per Claim
SPECIALTY AT RETAIL
LIMITED DISTRIBUTION DRUGS
(With & Without Access)
AWP -17.00% + dispensing fee
01/01/2026 - 12/31/2026: $0.20 per Claim
01/01/2027 - 12/31/2027: $0.20 per Claim
01/01/2028 - 12/31/2029: $0.20 per Claim
MAIL/MAINTENANCE CHOICE
BRAND
01/01/2026 - 12/31/2029: AWP -20.50%
GENERIC
Generic Effective Rate
01/01/2026 - 12/31/2026: AWP -92.00%
01/01/2027 - 12/31/2027: AWP -92.10%
01/01/2028 - 12/31/2029: AWP – 92.20%
(MAC & Non-MAC Combined)
NON-MAC GENERICS
AWP -20.50%
DISPENSING FEE
Brand & Generic
$0.00 per Claim
SPECIALTY
EXCLUSIVE
SPECIALTY AT CVS SPECIALTY MAIL, INCLUDING
SPECIALTY CONNECT
See Exclusive Specialty Fee Schedule
OED
01/01/2026 - 12/31/2029: AWP -23.50%
SPECIALTY
OPEN
SPECIALTY AT CVS SPECIALTY MAIL, INCLUDING
SPECIALTY CONNECT
See Open Specialty Fee Schedule
ADMINISTRATIVE FEES
ELECTRONIC CLAIM ADMINISTRATION FEE
01/01/2026 - 12/31/2026: $0.00 per Claim
01/01/2027 - 12/31/2027: $0.00 per Claim
01/01/2028 - 12/31/2029: $0.00 per Claim
MANUAL CLAIM ADMINISTRATION FEE
$1.50 per Claim
REBATES – Baseline Tier
STANDARD CONTROL
RETAIL 30
01/01/2026 - 12/31/2026: $520.95 per Brand Drug Claim
01/01/2027 - 12/31/2027: $550.00 per Brand Drug Claim
01/01/2028 - 12/31/2029: $580.00 per Brand Drug Claim
RETAIL 90
01/01/2026 - 12/31/2026: $1,120.05 per Brand Drug Claim
01/01/2027 - 12/31/2027: $1,150.00 per Brand Drug Claim
01/01/2028 - 12/31/2029: $1,180.00 per Brand Drug Claim
SPECIALTY AT RETAIL
(Advanced Control Specialty Formulary)
01/01/2026 - 12/31/2026: $6,100.65 per specialty Brand Drug Claim
01/01/2027 - 12/31/2027: $6,500.00 per specialty Brand Drug Claim
01/01/2028 - 12/31/2029: $6,900.00 per specialty Brand Drug Claim
MAIL/MAINTENANCE CHOICE
01/01/2026 - 12/31/2026: $1,195.96 per Brand Drug Claim
01/01/2027 - 12/31/2027: $1,230.00 per Brand Drug Claim
01/01/2028 - 12/31/2029: $1,260.00 per specialty Brand Drug Claim
SPECIALTY AT AETNA SPECIALTY
(Advanced Control Specialty Formulary)
01/01/2026 - 12/31/2026: $6,100.65 per specialty Brand Drug Claim
01/01/2027 - 12/31/2027: $6,500.00 per specialty Brand Drug Claim
01/01/2028 - 12/31/2029: $6,900.00 per specialty Brand Drug Claim
Note: Capitalized terms in the pricing chart above are not intended to reflect defined terms except where specifically
noted in the contract.
This pricing has an effective date of 01/01/2026 and is contingent upon signing a four-year agreement. For
Contractor to implement the pricing as set forth above by the effective date, acceptance of the pricing must be given
(120) days prior to the effective date. A legal document must be signed by County and returned to Contractor sixty
(60) days prior to the effective date.
SERIAL 250006-ITN
Charges or services not identified in this contract and/or changes in financial terms resulting from a change in the
scope of services shall be quoted upon request.
Discount and dispensing fee guarantees apply to all paid Claims with the exception of the following exclusions: 340B
Claims; Compound drug Claims; Paper or Member submitted Claims; Coordination of Benefits (COB) or secondary
payor Claims; Claims paid at government required amounts; Vaccine and vaccine administration Claims.
Pricing guarantees are measured and reconciled as four separate components with the components defined as retail
network, Aetna mail order pharmacy, CVS Specialty mail pharmacy, and rebates. Pricing guarantees will be
reconciled across all groups within the coalition. Average wholesale price (AWP) discounts and maximum allowable
charge (MAC), if applicable, are managed to achieve pricing guarantees within each component. If selected,
Maintenance Choice will be reconciled as part of the mail pharmacy channel.
Pricing in this contract is based upon Contractor as the exclusive provider to County for each of the Services quoted
in this contract associated with the singular medical plan serviced by this contract, including without limitation, retail
pharmacy network contracting, pharmacy claims processing, mail and specialty pharmacy services, utilization
management and formulary and rebate administration services.
The proposed retail rates do not necessarily reflect the participating pharmacy contracted rates and Contractor shall
retain, and not disclose to any third party, including County, the difference. However, in states requiring a
transparent network, the amount billed to the County will be equal to the amount paid to the participating
pharmacies (i.e., means a Participating Retail Pharmacy, Mail Order Pharmacy or Specialty Pharmacy) and Contractor
will apply a $1.50 Administration Fee per retail Claim in those states.
The pricing in this document assumes the use of the Aetna Cost Saver TM program, under which Contractor may
compare the price available under the Contractor contracted network with the price available through a non-
Contractor contracted network if available for that pharmacy. If the price is lower through a non-Contractor
contracted network (including an administrative fee paid to the third-party that contracts the network), the Claim
will be processed through that network. These Claims are included in the reconciliation of all financial guarantees.
In these instances, the generic drug prescription through retail may be less than the same generic drug, dosage form,
and dose through mail on the same day of adjudication.
NATIONAL NETWORK
The Aetna National Retail Network is a broad, managed network that includes most major chains and independents
and may not include some regional chains. The composition of this network may differ from County's existing
National Network composition. While member disruption is expected to be minimal, if a member disruption report
has not been provided to County, a report can be provided upon request.
RETAIL 90 NETWORK
The Aetna Retail-90 Network is a subset of the National Network which provides the flexible option of a nationwide
network of retail pharmacies that can fill up to a 90 days’ supply of medications. Aetna Retail-90 Network pricing is
applicable for non-specialty claims equal to or greater than an 84 days’ supply filled by a participating Aetna Retail-
90 Network pharmacy. Claims up to the County’s qualified retail days’ supply plan design limits can be filled at any
participating pharmacy. Claims greater than the County’s, qualified retail plan design limits shall only be filled by a
Aetna Retail-90 Network pharmacy. Implementation of Maintenance Choice and/or a mandatory plan design may
limit the implementation of this offering.
MAINTENANCE CHOICE
The voluntary Maintenance Choice Program is a standard program available to Contractor eligible Counties who
elect Contractor as County’s prescription benefit manager. Contractor innovative voluntary Maintenance Choice®
program combines Aetna mail order pharmacy and CVS Pharmacy retail capabilities to provide members improved
choice in how they access and receive maintenance medications (e.g., 84-90 day supplies). The voluntary
Maintenance Choice Program allows members to receive: (i) prescriptions from all participating retail pharmacies
for 30-day maintenance medications; and (ii) 90-day prescriptions of Maintenance Choice prescriptions from CVS
Pharmacy retail locations and Aetna mail service. All 30-day maintenance medications dispensed by participating
retail pharmacies will be charged in accordance with the retail rates set forth in the contract.
SERIAL 250006-ITN
Contractor shall discuss all Maintenance Choice offerings that can further maximize the savings and convenience
that Contractor Maintenance Choice® program offers upon implementation so that the County can make an
educated decision on which one to select.
Maintenance Choice Prescriptions will be treated the same as prescriptions filled at Contractor mail service
pharmacies for purposes of any mail pricing guarantees and generic dispensing rate guarantees set forth in the
contract. Maintenance Choice Prescriptions will be disregarded and therefore excluded for purposes of calculating
all mail service pharmacy non-financial performance guarantees set forth in the contract. The participating pharmacy
may collect from the member the lowest of the discounted cost, applicable cost share, or the participating
pharmacy’s usual and customary price.
REBATE TERMS
County will receive the greater of the aggregate minimum rebate guarantees quoted herein or 100% of total rebates
plus manufacturer administrative fees collected by Contractor in its capacity as a group purchasing organization on
behalf of County, that are attributable to the utilization of prescription drugs by County’s members.
Rebates guarantees are conditioned upon alignment with the Aetna Standard Formulary with Advanced Control
Specialty Formulary and the claims utilization mix and volume available at the time of pricing negotiations remaining
consistent through the term of the agreement. When remitting and reconciling minimum Rebate guarantees,
Contractor may add “Rebate Credit” value to the total Rebates remitted to County for each respective Rebate
component. “Rebate Credits” shall consist of (i) the differential between the Wholesale Acquisition Cost (WAC) of a
lower net cost Brand Covered Product, including but not limited to a Biosimilar (“Low Cost Brand”), claim processed
and the WAC of the reference Brand Drug, subject to the below cap, and/or (ii) the value of price reductions for
rebateable products that have experienced a WAC decrease, measured as the differential between the Baseline WAC
of the product and the WAC of the product when the Claim is adjudicated, subject to the below cap. The “Baseline
WAC” will be the WAC of the product prior to a reduction in WAC or, as applicable, for Biosimilars, the Baseline WAC
will be the WAC of the reference Brand Drug at the time of Claim processing.
In no way will the Rebate Credit exceed the Baseline Rebate less the earned Rebates on either the Low Cost Brand
Claim or the rebateable product that has experienced a WAC decrease. “Baseline Rebate” is calculated as follows: in
the year the price reduction occurred, Baseline Rebate will be the Rebate available for coverage of the product prior
to the WAC reduction or, as applicable, for Low Cost Brands the Baseline Rebate will be the Rebate available for
coverage of the reference Brand Drug on the date of claim processing. For a product experiencing a WAC reduction
in subsequent years, the Baseline Rebate will increase over the prior year Baseline Rebate at the WAC inflation rate
of the GPI subclass (GPI-6) of the applicable product. Contractor will notify County of any applicable Covered Product
that qualifies for Rebate Credits. Contractor shall provide reporting upon County request demonstrating the net-
cost impact in the therapeutic category. A Covered Drug Claim will only be eligible for application of a Rebate Credit
if a minimum Rebate guarantee reduction has not already been made by Contractor for the same WAC reduction or
change in reference Brand Drug placement event.
Rebates are paid quarterly for each channel and reconciled 120 days after year end in the aggregate. Additional 340B
reconciliation and true-up may occur post annual minimum Rebate guarantee reconciliation.
Rebate guarantees will apply to all paid Brand Drug Claims, with the exception of the following exclusions; however,
any Rebates collected by Contractor for such Claims will be passed to County in accordance with the rebate terms
described herein: 340B Claim; Compound drug Claims; Paper or Member submitted Claims; Coordination of Benefits
(COB) or secondary payor Claims; Vaccine and vaccine administration Claims; COVID treatment claims; any other
Claim identified as having received 340B program pricing and therefore ineligible for a Rebate; Over the Counter
(OTC) product Claims; Claims approved by formulary exception; Limited distribution and exclusive distribution drugs.
Rebates are paid quarterly for each channel and reconciled annually in the aggregate across all groups within the
coalition.
The Aetna Standard Formulary with Advanced Control Specialty Formulary that is being used includes certain
preferred brand drugs where the Tier 1 cost share shall be assessed to members.
SERIAL 250006-ITN
CVS Specialty mail pharmacies, including through the Specialty Connect program, will be the exclusive provider of
specialty pharmacy services. Claims for specialty products will not be processed through the retail network, except
for those specialty drugs that CVS Specialty mail pharmacies are unable to dispense.
Contractor reserves the right to request a contract amendment to adjust rebate guarantees if aggregate rebate
performance is less than 7% of Contractor projections on annual basis. This could occur if a subset lives in the
coalition results in significantly different mix than assumed in this RFP.
The Overall Effective Discount (OED) offer is conditioned on Contractor being the exclusive provider of Specialty
Services and County implementing and maintaining a generics first plan design for specialty. Contractor may request
to amend the individual Specialty Drug discounts to manage the financial guarantee. The financial guarantee is
measured and reconciled annually across all Specialty Drugs dispensed from CVS Specialty mail pharmacy, including
through the Specialty Connect program, except for the following exclusions (in addition to the discount and
dispensing fee exclusions). Note: New to market and existing Biosimilars are included in the discount guarantees.
• New to Market Brand Drugs
For the items notes here, the following quoted rates shall apply.
• New to Market Brand Drugs: AWP -15.00%;
• New to Market Generic Drugs: AWP -15.00%;
• New to Market Limited and exclusive distribution drugs: AWP -10.00%.
It is the intention of the parties that, for purposes of the Federal Anti-Kickback Statute, the following credit(s) shall
constitute and shall be treated as a discount against the purchase price of drugs dispensed under the contract
within the meaning of 42 U.S.C. §1320a-7b(b)(3)(A).
General Credit
Contractor agrees to provide County an annual credit in the amount up to $3.00 per member which will be available
during the term of the contract. The number of members shall be based on the information provided by County
during this process. This credit may be used to offset certain expenses incurred by County in the administration of
County’s prescription benefit plan or the services provided by Contractor during the term. The credit, for example,
may be applied to offset legitimate implementation expenses, communication expenses, member I.D. cards,
postage, special programming charges, or applied to clinical programs offered by Contractor. County will be
requested to provide reasonable documentation of expenses incurred that are to be applied to this credit. If County
terminates this contract prior to the expiration of its Initial Term for any reason other than Contractor breach, or if
Contractor terminates the contract as a result of County’s breach, County shall repay Contractor a pro rata portion
of the applied general credit amount based upon the number of months remaining in the original contract term.
Implementation Credit
Contractor shall provide County with a one-time implementation credit up to $5.00 Per Net New Member to defray
certain transition costs associated with moving County’s business to Contractor. This credit can be used to offset
typical and/or mutually agreed upon implementation costs in transferring from the current provider to Contractor.
County shall be responsible for all transition and implementation expenses more than the implementation credit
provided to County as set forth above. Examples of transition and implementation expenses include costs of
customized Member I.D. cards, postage expense for direct mail of I.D. cards and other communication materials to
Members, and special programming required by Contractor or County’s prior prescription benefit manager to
provide data to Contractor. Identification of the costs shall occur no later than six (6) months after the effective date
of the contract. County shall provide Contractor with documentation of eligible expenses directly incurred by County
in the form of an invoice, an account statement, or other detailed documentation. For agreed upon implementation
or transition services provided by Contractor towards this credit, Contractor shall provide expense detail for such
items. If County’s contract with Contractor is terminated prior to the expiration of the original contract term for any
reason (other than Contractor's uncured breach), or if Contractor terminates the contract as a result of County’s
uncured breach, and subject to Section 8.0 (AVAILABILITY OF FUNDS) of this contract, County will repay Contractor
a pro rata portion of the applied implementation credit amount based upon the number of months remaining in the
SERIAL 250006-ITN
original contract term. The parties acknowledge and agree that the implementation credits provided by Contractor
are commercially reasonable and necessary services related to the implementation of this contract and represent
fair market value for the services provided.
Third Party Payment
Contractor will bill the County an administrative fee of $2.00 per paid claim (i.e. any electronic or paper request for
payment or reimbursement arising from a participating pharmacy providing covered services to a member in
accordance with the terms of this contract in connection with the County’s plan) and will collect and remit this
amount to the Coalition, (i.e. National Association of Counties Public Promise Insurance Agency – “PPI Coalition”),
after the effective date of the contract.
General Audit Credit
Contractor shall provide County with an annual audit credit of up to $30,000, available for use during the contract
year in which it was provided. This credit can be applied to offset costs incurred by County in the administration of
an audit pursuant to the terms of the contract. This audit credit will be credited to County’s monthly invoices.
Identification of the expenses attributable to this audit credit shall be mutually agreed upon. County shall provide
Contractor with documentation of expenses actually incurred in the form of an invoice, an account statement, or
other detailed documentation. Expenses applied to this credit will not exceed fair market value of such expenses. It
is the intention of the parties that, for purposes of the Federal Anti-Kickback Statute, this credit shall constitute and
shall be treated as discounts against the price of drugs within the meaning of 42 U.S.C. §1320a-7b(b)(3)(A). If County
terminates this contract prior to the expiration of its original contract term for any reason other than Contractor’s
uncured breach, or if Contractor terminates the agreement as a result of County’s uncured breach, subject to Section
8.0 (AVAILABILITY OF FUNDS) of this contract, County shall repay Contractor a pro rata portion of the applied credit
amount based upon the number of months remaining in the original contract term.
Shipping Fees
Shipping fees and/or postage may not be increased if Contractor's third-party carrier increases its charges to
Contractor.
Financial Provisions
The financial provisions in the contract are based upon information available to Contractor during the pricing request
process. Contractor reserves the right to request in writing to modify or amend the financial provisions in the
contract in a manner designed to account for the impact of events identified below. Such request will include
Contractor’s explanation of the way the requested modification accounts for the impact of the event.
1.
Greater than 15% change in total membership in the PPI Coalition or claims volume (83,000 members will
be used as the baseline member count for total membership);
2.
County-initiated change to pharmacy benefit program, plan design, or formulary alignment. Adding,
deleting, or modifying member choice or incentives to enroll in pharmacy benefit options (e.g., Exchanges,
Medicare Part D plans);
3.
Product offering decisions by drug manufacturers that result in a reduction of rebates, including the
introduction of a lower cost alternative product which may replace an existing rebateable brand product;
an unexpected launch of an interchangeable version of a brand product; or a branded product converted
to OTC status, recalled or withdrawn from the market; or a material reduction in Wholesale Acquisition
Cost (WAC); or
4.
Any government imposed or industry-wide change, including any prohibition or restriction on Contractor’s
ability to receive rebates or discounts from pharmaceutical manufacturers; changes to methodology,
availability, or publication of AWP; changes to tax laws; or changes in CMS guidelines for government
regulated programs, if applicable.
Contract Confidentiality
By accepting this contract, County acknowledges and agrees that the information included is confidential,
proprietary and trade secret to Contractor and, unless otherwise required by applicable law or by a court order from
a court with competent jurisdiction, will agree to protect the information from disclosure.
SERIAL 250006-ITN
AETNA PHARMACY PROGRAM SUMMARY
Aetna Pharmacy Program summary – CORE SERVICES
Unless otherwise specified, the services outlined below are available at no additional cost for Contractor’s
Customers and Members.
PBM Services
Included in Core Services
PBM Benefit Administration
Member Services
Maintenance Choice
Member Services Call Center – Available 24/7
Aetna Standard Preventive Drug List (HDHP)
Real-Time Benefits
Aetna Standard Preventive Drug List (ACA)
Aetna Health Mobile App and Internet Tools
Integrated retail, mail and specialty claims with medical
benefit claims in real-time
Benefit Automation
Loading Client Benefit Plan
RxSavingsPlus Savings Program
Generic Substitution/DAW Penalties
Price-A-Drug Tool available at aetna.com or through
our mobile app, Aetna Health
Member Communication Materials
Customer Services
Initial Implementation benefits communication materials,
printed and online support
Claim funding and banking arrangements integrated
with County’s Aetna medical plan
Member specific e-mail communications
Consultative services
Aetna Integrated Pre- and Post-enrollment materials
Education materials on key healthcare topics
Clinical program member letters, including transition
letters for formulary changes/updates
Implementation support including eligibility loading
and ongoing additions/deletions
Informational brochures for using the CVS Caremark Mail
Service Pharmacy, including order forms
Regulatory and compliance support by specific line of
business
Member-specific formulary and plan design
Meetings to discuss program performance
Aetna Health website and app brochures
Account Management
Client Authorized Override
Member Satisfaction Surveys
Post Rejection Communications (PRC)
Proactive Retail Refill Notice
Claims Processing Services
Mail Service Pharmacy
Online, Point-of-Service (POS) claims adjudication with
real-time integration with medical claims
Use of CVS Caremark Mail Service Pharmacies
Information System Infrastructure & Maintenance
Profile/order form and return envelope
Member counseling labels – drug specific
First time fill prescription processing
Online Customer Access
Online Services (on-site eligibility maintenance and prior
authorization overrides-viewing member claims history
Website Access allowing customized dashboard creating
for members--keep
Clinical Programs and Utilization Management Edits
Included in Core Services
Clinical Solutions
Clinical Solutions cont.
Diabetic Meter Program
Standard Utilization Management edits, including quantity
limits and step therapy
Pharmacy Advisor Support – Automatic refill and renewal
programs
Dose Optimization
Core Medication Management: Closing Gaps in
Medication Therapy
Retrospective Safety Review
Point of Sale (POS) Drug Safety Alerts
Pharmacy Advisor Support – Adherence to Drug Therapy
Member and Physician clinical education
Smart Edit overrides
Global safety edits
Opioid safety edits
Compound drugs management
Maximum pay edits
Mail Order DAW Solution
Select OTC Coverage
Analytics and Reporting
Included in Core Services
Analytic Support
Analytic Support cont.
Aetna Report Rx self-service reporting tool suite for up to
10 Customer users
RxNavigator Self-Service Reporting Tool Suite
E Tool Access (Self Service for Rx Insight Reports)
Claim detail reporting combined with medical reporting
through the new reporting tool, ART
Account Team Supported Reporting
Clinical Program Opportunity Analysis
Quarterly clinical and financial reports based on
aggregate customer utilization
Formulary
Included in Core Services
Standard Formulary Administration
Standard Formulary Administration cont.
Formulary maintenance
Rebate administration
Formulary exclusions lists
Point of Sale (POS) Rebates Type 3
Hyperinflation management
Compound Management
Specialty
Included in Core Services
Specialty Clinical Solutions
Specialty Support cont.
Specialty Expedite
Specialty Connect
Digital - Secure Messaging
First time fill prescription processing
Specialty CareTeam
Patient Assistance Program
Specialty Starter Fill
AccordantCare Specialty
Proactively supports and empowers Members with rare
conditions to manage their whole condition, not just
adherence to their medication (beyond traditional
specialty pharmacy care). Members identified by Aetna
Specialty dispense for nine (9) specialty conditions.
Available to Customers who use the Aetna Specialty
Performance Network.
Specialty Benefit Administration
Specialty Pharmacy
SERIAL 250006-ITN
Mandatory Fees
The services outlined below are associated with meeting federal, state, and local regulatory compliance
requirements
Regulatory Programs
Member Threshold, if any
Fee
Basis
State Regulatory Impact Assessment1
$0.30
Per Retail Claim Only
Traditional Pricing Auxiliary Fee2
$1.50
Per Retail Claim Only
Retail Network Pharmacy Third Party Appeal
Pass through Fees Per Review
1Applies to claims in select states with relevant regulatory requirements. The current list of states includes AL, AR, AZ, CO, DE, FL, GA, IA,
LA, MD, MI, ND, NM, OK, SD, MS, NJ, TN, VA, TX, WA, WV, WY and is subject to change
2Applicable to clients under Traditional pricing arrangements only. Applies to claims in states with extraterritorial regulations requiring
transparent pricing. The current list of states includes AR, FL, OK, TN, WV and is subject to change.
Aetna Pharmacy Program summary – ADDITIONAL SERVICES
Custom Formulary
Fee
Custom Formulary and Maintenance, including services such as:
Custom UM Criteria
Custom Exclusion Lists
Custom Preventive Lists
Hyperinflation Management
Compound Management
Net Cost Analysis and Consultation
$100,000
Specialty Guideline Management (SGM) – criteria
development and maintenance
Use of the CVS Specialty Pharmacy network with full
integration of retail, mail and specialty claims
Information System Infrastructure & Maintenance
Specialty Copay Card Plan Designs
Standard Specialty Product List
Member Onboarding
Member counseling label – drug specific
Exclusive Specialty Grace Fill Member Letter (Under
Member Communication Materials)
Supply Management Optimization (SMO (Exclusive and
Preferred Specialty Customers)
Specialty Connect
Digital Secure Messaging
Specialty Expedite
Specialty CareTeam
Digital
Included in Core Services
Standard Digital Services
Standard Digital Services cont.
Open enrollment links
Single Sign on (SSO)
Aetna.com configurations
Integrated medical and pharmacy websites
Enhanced Safety, Adherence and Gaps in Care Programs
Fee
Basis*
Pharmacy Advisor Counseling at CVS Pharmacy 1
$0.25**
PMPM
Pharmacy Advisor Counseling All Channels1
$0.60**
PMPM
Pharmacy Advisor Counseling Retail All Channels1
$0.60**
PMPM
Integrated Fraud and Safety Solutions
$0.06
PMPM
Drug Savings Review (DSR) (2:1 ROI over 1 year)2
$0.30
PMPM
Precertification
Fee
Basis
Clinical and Non-Clinical Review
Precertification
$45.00
Per review
Formulary Exceptions
$45.00
Per review
Wegovy Cardiovascular
$45.00
Per review
Specialty Precertification
Fee
Basis
Specialty Guideline Management (SGM) Precertification
$45.00
Per review
Vendor Transition Files
Fee
Basis
Termination files for all open mail service and specialty pharmacy
refill files (one test and two production files)
$5,200
As listed
Specialty User Report (SUR) – specialty pharmacy file
$1,500
Per file
Precertification history
$3,500
Per file
Accumulator files
$1,000
Per file
Historical claims data
$1,000
Per file
Additional Services
Fee
Basis
Custom programming (includes customer-specific data file formats,
reporting, or IT systems work)
$150
Per Hour
Standard on-going claim files to third-parties (includes Universal
Pharmacy Claim File)
$500
$500 for initial set up and $500
per file for ongoing frequencies.
Aetna Report Rx Self-Service Reporting Tool License over 10
Customer users
$1,500
Per License
Caremark Cost SaverTM 3
$0.00
Optional
Vaccine Program Management Fee
$0.05
PMPM
Shipping and Handling of Temperature Sensitive Products
$22.00
Per Non-Specialty Mail Rx
Temperature Sensitive
Additional Specialty Programs
Fee
Basis
Custom Specialty Network - When Accreditation Support is
Required
Quoted Upon Request
Charges for services not identified above and/or changes in financial terms resulting from a change in the scope of
services shall be quoted upon request.
Pricing noted above for programs not implemented within twelve (12) months from the time of pricing negotiations
is subject to change.
NOTES:
1 Pharmacy Advisor Counseling Additional Terms:
(a) Customer may terminate the Pharmacy Advisor Counseling program by providing Contractor at least
60-days prior written notice.
(b) The pricing described above for Pharmacy Advisor Counseling program is based on the following conditions:
SERIAL 250006-ITN
(i)
In the event Customer desires to include additional lines of business, implement a portion of the Plan
Participants, or reduces the Plan Participants participating in the Pharmacy Advisor program,
Contractor may revise pricing for the program.
(ii)
Customer agrees to implement all the current conditions in Pharmacy Advisor Counseling:
Asthma/COPD, Breast Cancer, Depression, Diabetes, Cardiovascular conditions, and Osteoporosis.
(iii)
The above pricing reflects the current program and future program expansions may require an
additional fee.
2 Drug Savings Review Additional Terms:
Contractor guarantees that the gross Customer savings realized from DSR Program over the first Clinical
Program Year shall be 200% of the DSR Program fees paid by Customer during the first Clinical Program
Year. For the subsequent Clinical Program Years, Contractor guarantees that the gross Customer savings
realized from DSR Program shall be 300% of the DSR Program fees paid by Customer during subsequent
Clinical Program Years. “Clinical Program Year” means the twelve (12) month period commencing on the
start date of the Drug Savings Review Program and each full consecutive twelve (12) month period
thereafter that the Drug Savings Review program is provided. In the event contractor fails to meet the
targeted savings, Customer shall be credited for any guaranteed savings short-fall following the end of the
applicable Clinical Program Year, up to the amount of fees paid by Customer for the Drug Savings Review
Program during the Clinical Program Year. Reconciliation will occur during the quarter after the conclusion
of Clinical Program Year.
Contractor may revise the performance guarantee at time of reconciliation in a manner designed to
account for membership shifts of 20% or more during the Clinical Program Year. The performance
guarantee offered for the Drug Savings Review Program is conditioned on (1) Customer maintaining a
monthly average of at least 1,500 Members throughout the Clinical Program Year and (2) Customer
participating in the Drug Savings Review Program for the entire Clinical Program Year.
3 Caremark Cost SaverTM : The pricing in the Pharmacy Service and Fee Schedule assumes the use of the Caremark
Cost SaverTM program, under which Contractor may compare the price available under the Aetna contracted
network with the price available through a non-Aetna contracted network if available for that pharmacy. If the price
is lower through a non-Aetna contracted network (including an administrative fee paid to the third-party that
contracts the network), the Claim will be processed through that network. These Claims are included in the
reconciliation of all financial guarantees. In these instances, the prescription through retail may be less than the
same Drug, dosage form, and dose through mail on the same day of adjudication.
*DEFINITIONS:
PMPM = Per Member Per Month
PEPM = Per Employee Per Month
**if retiree membership is over 15%, referral needed to review for custom pricing.
Aetna Pharmacy Program summary – Third-Party Services
The services outlined below are provided by third party providers.
Optional Third-Party Services
Fee
PrudentRx Copay Optimization
The PrudentRx offering minimizes the impact of manufacturer copay cards,
targeting all Specialty Drugs, including highly utilized classes such as hepatitis C,
autoimmune, oncology and multiple sclerosis, to drive maximum value for
Customers while providing Members with $0 out-of-pocket costs.
County contracts directly with PrudentRx for this service.
Program costs are a percentage of shared savings billed monthly by PrudentRx.
Contractor does not charge any fees to County to support the PrudentRx Copay
Optimization services.
Quoted by Prudent Rx upon request
SERIAL 250006-ITN
ADDITIONAL PHARMACY LANGUAGE AND DEFINITIONS
“Single Source Generics” means those generics having fewer than two FDA-approved Abbreviated New
Drug Application (ANDA) manufacturers (not including any "authorized generics"), or alternatively generic
drugs for which there is insufficient inventory and/or competition to supply market demand.
“Rebates” means the pharmaceutical manufacturer revenue shared with Aetna (Contractor) by CVS
Caremark and/or any of their respective affiliates (i) pursuant to the terms of an agreement with
a pharmaceutical manufacturer, (ii) in consideration for the inclusion of such manufacturer’s Prescription
Drugs on Contractor’s Formulary and (ii) which are directly related and attributable to, and calculated
based upon, the specific and identifiable utilization of certain Prescription Drugs by Plan participants.
Rebates shall not include any fees or other compensation paid, credited, or owing by a pharmaceutical
manufacturer to Aetna (Contractor) or CVS Caremark or any of their respective affiliates, as applicable, in
exchange for the performance or provision of front-end pharmacy or clinical services or activities,
including any of the following services and activities: (i) Plan participant adherence or compliance services,
(ii) nursing or other Plan participant support, (iii) physician or member communication services, (iv) Plan
participant assistance and referrals, (v) product launch and similar support, (vi) equipment replacement
services, (vii) clinical and other research or studies, (viii) data and analytics, and (ix) services to ensure the
appropriate distribution of high risk biopharmaceuticals.
“Specialty Products” means those injectable and non-injectable Prescription Drugs, other medicines,
agents, substances and other therapeutic products that are designated in the Pharmacy Service and Fee
Schedule and modified by Contractor from time to time in its sole discretion as Specialty Products on
account of their having particular characteristics, including one or more of the following: (i) they address
complex, chronic diseases with many associated co-morbidities (e.g., cancer, rheumatoid arthritis,
hemophilia, multiple sclerosis), (ii) they require a greater amount of pharmaceutical oversight and clinical
monitoring for side effect management and to limit waste, (iii) they have limited pharmaceutical supply
chain distribution as determined by the drug’s manufacturer and/or (iv) their relative expense.
“Brand Drug” shall mean drugs or devices for which the Medi-Span Multisource Code field contains “M”
(co-branded product), or “N” (single source brand), or “O” (originator). In limited circumstances,
Contractor may override the M, N, or O indicators and deem the drug to be a Generic Drug through review
of additional information including other Medi-Span data, FDA application data (NDA/ANDA) and price.
“Generic Drug” shall mean drugs or devices for which the Medi-Span Multisource Code field contains a
“Y” (generic). In addition, Claims with DAW 5 code (“House Generics”) shall be classified as Generic Drug
Claims. In limited circumstances, Contractor may override the M, N, or O indicators and deem the drug
to be a Generic Drug after a review of additional information including other Medi-Span data, FDA
application data (NDA/ANDA) and price.
For purposes of reconciliation of financial guarantees, including generic dispensing rates, “Brand Drug”
shall mean drugs or devices for which the Medi-Span Multisource Code field contains “M” (co-branded
product), or “N” (single source brand), or “O” (originator). For purposes of claim adjudication, in limited
circumstances, Contractor may override the M, N, or O indicators and deem the drug to be a Generic Drug
SERIAL 250006-ITN
after a review of additional information including other Medi-Span data, FDA application data
(NDA/ANDA) and price.
For purposes of reconciliation of financial guarantees, including generic dispensing rates, “Generic Drug”
shall mean drugs or devices for which the Medi-Span Multisource Code field contains a “Y”
(generic). Claims with DAW 5 code (“House Generics”) shall also be classified as Generic Drug Claims. For
purposes of claim adjudication, in limited circumstances, Contractor may override the M, N, or O
indicators and deem the drug to be a Generic Drug after a review of additional information including other
Medi-Span data, FDA application data (NDA/ANDA) and price.
We provide one claim data file per month to County for accounting purposes. Additional Pharmacy
Universal Claim Data files for third party vendors are available for an additional fee with signed
confidentiality agreement in place. Fees are as follows: One time $500 initial set up. Each subsequent file
cost $500, regardless of frequency. Frequencies include monthly, quarterly, semi-annually, annual or
irregular.
Customers Right to Pharmacy Claims Audit
Contractor shares information with a qualified auditor under a strict confidentiality agreement that
prohibits disclosure of this information to any third party. In addition, no party may use this information
for any purposes other than the audit. Auditors must not have a conflict of interest, past business or other
relationships which would prevent the auditor from performing a complete independent audit. A conflict
of interest includes, but is not limited to, a situation in which the audit agent:
Is employed by an entity, or any affiliate of the entity, which is a competitor to our benefits or claims
administration business or our mail service and specialty pharmacy businesses.
Is affiliated with a vendor we subcontract with to adjudicate claims or provide services in connection with
our administration of benefits or provision of mail service and specialty pharmacy services.
County has the right to have one pharmacy claims audit per year. This includes the pharmacy claims that
Contractor has processed on behalf of County’s plan. These are claims for County’s population and
submitted by participating pharmacies or a pharmacy benefits manager under contract with Contractor
in accordance with this contract. Pharmacy audits may be performed at Contractor’s Minnetonka, MN or
Hartford, CT location. Contractor defines an “audit” as performing a review of claim transactions for
assessing the accuracy of benefit determinations.
Contractor asks that County will begin any claims audit within two (2) years following the period County
wishes to audit. While Contractor provides a full data file of all claims processed for the audit period, the
size of the audit sample may not exceed 250 claim transactions, without Contractor’s mutual written
consent.
In the case of electronic Claim audits that follow standard pharmacy benefit audit practices where
electronic re-adjudication of Claims is requested and processed off-site, County may elect to audit
Contractor is not responsible for paying County’s audit fees or County’s costs associated with the audit.
Audit of Rebate Contracts
Coalition, through a mutually agreeable independent third party retained by Coalition, may conduct an
annual Rebate audit for the prior Contract Year for those participating groups, including the County. This
audit shall also include the minimum rebate guarantee reconciliation for the participating groups that
SERIAL 250006-ITN
have coalition minimum rebate guarantee. Such audit shall be limited to a review of up to ten (10)
pharmaceutical company contracts directly related to participating groups’ rebates as selected by
Coalition. Such review of pharmaceutical company contracts may include formulary and Rebate
provisions to the extent permitted by such contracts and shall be limited to information necessary for
validating the accuracy of the Rebate amounts remitted to the County by Contractor. The scope and
procedures of the Rebate audit shall be in accordance with the procedures set forth in this Audit section.
The same time period and data may only be audited once.
Confidentiality Agreement
Any mutually agreed upon third party auditor engaged by the Coalition or the County shall execute
Contractor’s form confidentiality agreement prior to conducting a Rebate audit ensuring that all
information reviewed during such audit and all details and terms of any pharmaceutical company contract
reviewed will be treated as confidential and will not be revealed in any manner or form by or to any third
party, including participating groups.
Additional Claim and Rebate Audit Terms and Conditions
Contractor and the County agree the following guidelines shall apply to any audit described by this
contract.
1.
Audit Notification Letter
A County request for an audit of Contractor will be directed to the County’s account manager either
in writing on the County’s letterhead or by e-mail. Audits require thirty (30) days prior written
notice, including receipt of fully executed confidentiality agreement by the County’s auditor and
Contractor, detailed audit scope document, and a complete Claims sample, if applicable. A new
audit may not be started until the prior audit, if any, is closed.
2.
Teleconference
Upon Contractor’s receipt of a request for an audit, Contractor will organize and conduct an initial
teleconference between the County and Contractor. This teleconference will address the following:
Individual audit participants
Requirement and purpose of an approved confidentiality agreement (for use with outside
audit firms or other Participating Group representatives, as applicable)
Onsite requirements
Mutually established timelines
Claims tape needs and costs
Prescription copies: timelines, availability and cost
Guidelines for acceptable verification of audit questions
Contractor’s right to respond within a reasonable time after questions arise and before
audit results are disseminated by the auditor to Participating Group
Audit process confirmation letter
Other appropriate issues.
3.
Mutually Agreed Timelines
SERIAL 250006-ITN
County and Contractor will mutually agree upon an audit timeline, taking into consideration
individual circumstances and constraints.
An example of a standard timeline is as follows (from the time a signed confidentiality agreement
is secured):
•
Claim tape request – two (2) weeks
•
Standard screen prints – fourteen (14) business days
•
Mail service prescription copies – six (6) weeks (cost is typically $5.00 per script copy)
•
Audit report reply – the County or the County’s auditor may review the entire prior
Contract Year’s Claims data. Contractor will review a maximum of 250 Claims from the
County or County Auditor’s fall out report related to such claims and will respond within
thirty (30) business days.
4.
Response to Sampling Questions
The County can submit to Contractor questions related to provided claim samples. Answers to
generic questions are normally provided within fourteen (14) business days after the questions have
been presented. Answers to claim level questions are normally provided within thirty (30) business
days for a maximum of 250 Claim sample from the County or County Auditor’s fall out report.
5.
Claims Tape Requests
Claims tape specifications shall be clarified during the initial teleconference and processed following
Contractor’s receipt of a signed confidentiality agreement from any third party auditor. Delivery to
the specified party normally takes place within two (2) weeks for the prior Contract Year of data and
at Contractor’s standard data fees (($125 per month of data). Audits requiring more than a prior
Contract Year of data, and/or multiple Contract Years during a single audit, may be conducted at
Contractor’s standard audit cost plus additional data fees ($5,000 per year of data) and a mutually
agreed upon timetable.
6.
Audit Report
In the event of an audit by a third party, the third-party auditor and County shall provide Contractor
with a copy of any proposed audit report, and Contractor will have a reasonable opportunity to
comment on any such report before it is finalized.
7.
Close of Audit
Upon finalization of audit results and agreement between the County and Contractor on any
identified financial discrepancies, the audit period under review will be closed. Any adjustments,
payments and/or reimbursements determined to be necessary as a result of any examination or
audit shall be paid by the appropriate party within thirty (30) days of execution of an appropriate
release document covering the audit period. The County is responsible for requesting and
performing a comprehensive audit regularly. To enable the parties to close their financial records
in a timely manner, once a Contract Year has been audited, no further auditing activity for the
Contract Year may be performed, notwithstanding that an issue arises in a future period that dates
back to the previously audited period. In the event that no prior audits have occurred, any audit
findings and adjustments will be limited to a maximum timeframe of three (3) Contract Years (i.e.,
the Contract Year being audited and up to the preceding two (2) Contracts Years).
SERIAL 250006-ITN
8.
Audit Costs
County shall be responsible for all their expenses of the audit. Audit requests beyond those defined
within this section of the Agreement is subject to payment of an audit support charge.
The audit rights herein are valid during the term of the contract and through one (1) year of termination.
Any audit ask after one (1) year of termination will be at Contractor’s standard audit fee.
INTEGRATED PHARMACY – SPECIALTY PHARMACY SCHEDULE
Due to frequency of updates, County will not include the Specialty Pharmacy Schedule or amend
the contract with the Specialty Pharmacy Schedule; the initial schedule and any subsequent
approved updates to the Specialty Pharmacy Schedule shall be saved to file.
NOTES:
The Overall Effective Discount (OED) offer is conditioned on Contractor being the exclusive provider of
Specialty Services and County implementing and maintaining a generics first plan design for specialty for
the single health plan covered by this contract . The rates quoted herein apply to specialty products
dispensed from CVS Specialty mail pharmacies, including through the Specialty Connect program.
Contractor may amend the individual Specialty Drug to manage the financial guarantee. The financial
guarantee is measured and reconciled annually across all Specialty Drugs dispensed by Aetna Specialty
pharmacy, including through the Specialty Connect program, with the exception of the following
exclusions (in addition to the discount and dispensing fee exclusions). Note: New to market and existing
Biosimilars are included in the discount guarantees.
New to Market Brand Drugs
For the items noted here, the following quoted rates shall apply.
New to Market Brand Drugs: AWP -15.00%
New to Market Generic Drugs: AWP -15.00%
New to Market Limited and exclusive distribution drugs: AWP -10.00%
The exclusive specialty offer includes the provision by Contractor of nurse-based rare condition care
management services for Engaged Members (defined below) with the following rare conditions pursuant
to the AccordantCare Specialty program established by Contractor , as may be amended by Contractor
from time to time: Crohn’s Disease, Cystic Fibrosis, Gauchers Disease, Hemophilia, Lupus, Multiple
Sclerosis, Rheumatoid Arthritis, Ulcerative Colitis, and Hereditary Angioedema (the 'AccordantCare
Specialty Program'). Pursuant to the AccordantCare Specialty Program, County acknowledges that
Contractor will utilize those Specialty Drug Claims that are filled by Aetna specialty pharmacy, including
Specialty Connect, to identify and outreach to Members that Contractor determines are likely to have
one of the above listed rare conditions (each an "Eligible Member"), and Contractor may communicate
with medical and other healthcare providers and any health plans providing benefits to Engaged Members.
County acknowledges that the AccordantCare Specialty Program is intended solely to provide education
of, and support to, Engaged Members in the diagnosis and treatment provided by their healthcare
providers. "Engaged Member" means an Eligible Member who elects to receive and receives
AccordantCare Specialty Program services.
SERIAL 250006-ITN
MAC: Certain dosage forms and strengths may not be included on the MAC list and shall be priced at the
specialty default rate.
PER DIEMS, NURSING & EQUIPMENT:
* Remodulin, Veletri, Flolan, Epoprostenol, Treprostinil Sodium, & Zulresso for Injection: $75 per day
**Ventavis: County acknowledges and agrees an I-Neb is necessary for the administration of Ventavis. For
each I-Neb provided to Member, upon the initiation of therapy or in the event a replacement I-Neb is
necessary, County shall reimburse Contractor $1,811 for each I-Neb.
Nursing Charges: $225.00 per visit up to 2 hours,
$110.00 for each hour thereafter. Alternatively,
Contractor can refer any medically necessary nursing services to the County's contracted nursing agency,
in which case nursing services will be billed separately by those agencies.
In further consideration of the fees and charges to be paid to Contractor under the contract, Contractor
will bill any applicable nursing and equipment charges and per diems to the Member’s medical benefit. In
the event it is not possible to bill such nursing and equipment charges and per diems to the Member’s
medical benefit or it is determined there is no coverage, Contractor shall bill County directly for any
nursing and equipment charges and per diem associated with Specialty Drugs.
Routine ancillary supplies (e.g., syringes, alcohol swabs, cotton balls) are included in the Specialty Drug
prices set forth in the Specialty Fee Schedule, unless otherwise indicated in the Specialty Fee Schedule as
being charged separately as part of an equipment fee or per diem.
NON-SPECIALTY CLAIMS:
Non-Specialty Claims dispensed by a CVS Specialty Pharmacy will price as a Retail Non-Specialty Claim.
PRODUCT SHORTAGE:
In the event of an industry-wide product shortage, Contractor reserves the right to request an adjustment
to pricing upon notice to the County.
CONFIDENTIALITY:
County acknowledges and agrees that the information included is confidential, proprietary and trade
secret to Contractor and will, unless otherwise required by applicable law or by a court order from a court
with competent jurisdiction, agree to protect the information from disclosure.
*** Unless otherwise stated above: $75 per dose
EXHIBIT B - IMPLEMENTATION DELIVERABLES AND KEY DATES
Medical Implementation
Due Date
Deliverable
Task Information
Responsible
Party
02/26/2025
Official Contract Award
By approval of the Board of County
Supervisors
County
03/14/2025
Final Account Structure
County to provide approved
structure document to B|A.
Current Cigna structure will be
mirrored upon request
County
04/01/2025
Finalize Detailed Plan Benefit Summary
Document
B|A and County to review and
finalize plan benefits for system
build and SBC/SPD creation
County &
Contractor
04/01/2025 – 04-11-2025
Microsite
Begin build of County’s benefit plan
offering microsite
Contractor
04/11/2025*
SBC
Finalize & post to microsite
Contractor
07/15/2025 – 07/29/2025
Eligibility File
Test file creation
County
09/01/2025
Eligibility File Testing
Continue testing
County &
Contractor
10/20/2025*
Summary Plan Description/Plan
Booklets
Final PDF document due
Contractor
10/20/2025 – 11/07/2025*
Open Enrollment
B|A to assist with needed
employee meetings
Concierge customer service lines
available
County
10/31/2025 – 11/07/2025
Eligibility File Testing
Conduct final file testing and
approval
County &
Contractor
12/04/2025*
Eligibility File Transmission
EDI file to Contractor
County
12/04/2025 – 12/08/2025
Eligibility File Load
Loading of open enrollment
eligibility (viable file)
Contractor
12/12/2025
ID Cards
ID cards sent to USPS mail
Contractor
01/01/2026*
Effective Date
All systems live and functioning
Contractor
02/13/2026
Final Implementation Activities
Conduct post-implementation
meeting and sign-off
County &
Contractor
Pharmacy Implementation
03/03/2025 – 12/31/2025
Pharmacy Implementation Milestones:
1.
Deliver Baselined Project Plan
2.
Set up Account Structure or
Confirm Carrier Build
3.
Load Production Eligibility File
4.
Set up Prior Authorization
Complete
5.
Complete Benefit Requirements
Document
6.
Load Approved Custom Formulary
to Production
7.
Establish Integrated Accumulation
Connectivity
The implementation project plan
will be baselined within a
reasonable time following the
implementation kickoff and at that
time the milestones for the
pharmacy implementation
guarantee will be agreed to from
this list of major milestones
County &
Contractor
SERIAL 250006-ITN
8.
Provide Customer Information
Form for Review
9.
Commence Customer Service Calls
10.
Mail Member Consolidated
Disruption Letters
11.
Load Historical Prior Authorization
File(s)
12.
Load Accumulator File(s)
13.
Load Claims History File(s)
14.
Load Mail Order Open Refill File(s)
15.
Load Specialty Open Refill File(s)
16.
Provide Testing Results for Review
and Approval
17.
Send Network Pharmacy
Notifications
18.
Deliver Production Claims File
19.
Deploy Custom IT Project(s) in
Production
20.
Deploy Encounter File in
Production
21.
Complete Pre-Implementation
Audit
22.
Complete Customer System
Provisioning
23. Complete Customer System
Training (CCA/COS)
*(hard due date)
SERIAL 250006-ITN
EXHIBIT C – MEDICAL AND PHARMACY SERVICE AND PERFORMANCE GUARANTEES
The service and performance guarantee(s) described herein will terminate if the contract is terminated prior to
the end of the calendar year. In addition, all included service and performance guarantee(s) are subject to
enrollment requirements as outlined in the financial conditions of each included guarantee.
Aggregate Maximum
The maximum payout for all medical service and performance guarantees referenced in this exhibit combined
is 40 percent of the fees at risk based on the calculation as noted in the provisions below.
General Medical Guarantee Provisions
1. Fees at risk are calculated at the calendar year-end reconciliation, using the paid medical administrative
service fees for employees covered under each guarantee for the calendar year and excludes:
• Allowance(s)
• Any charges for services performed which are not included on the monthly administrative service fee bill
2. Results are estimated to be available at the end of the quarter noted below, following the close of the calendar
year:
Second Quarter
• Service Guarantee
Third Quarter
• Discount Guarantee
3. If the guarantee(s) have not been met, Contractor will either:
• Provide reimbursement to County for the amount due, or
• Reduce future administrative fee payment(s) by the amount due to County.
4. Contractor reserves the right to revise or remove these guarantee(s) by amendment to this contract if a
material change to the plan is initiated by County or legislative or regulatory action which:
• Impacts Contractor’s standard claim adjudication process, member services functions,
medical management or network management
• Changes the products, programs and services Contractor provides to County
5. The guarantee(s) are considered met if:
• County terminates participation in products, programs and services tied directly to guarantee(s), prior to
the end of the guarantee period.
• Enrollment falls below 50% of the target enrollment of 3,901 prior to the end of the multi-year
Guarantee Period, December 31, 2029.
• County fails to meet obligations under the Agreement (for example, a submission of incomplete
eligibility or failure to fund claim payments)
• Contractor does not receive all the necessary information in the allotted timeframe, as outlined in this Exhibit.
Medical Service Guarantees
Contractor guarantees the administration of its medical and behavioral health product(s) in the following areas:
Service Category
Minimum Standard
Fees at Risk
Implementation
Implementation (Includes Delivering the Summary Plan
Description PDF Document)
Average score of 3.0
3.00%
ID Card Production & Distribution
98% within 12 calendar
days
1.00%
Account Management
Overall Account Management
Average score of 3.0
1.00%
Non-Open Enrollment Eligibility Files
97% of files updated in 1
business days
3.0%
Claim Administration
Turnaround Time (TAT)
12 days for 92 .0%
2.50%
Financial Accuracy
99.0%
3.0%
Total Claim Accuracy
97.0%
3.0%
Member Services
Phone Average Speed of Answer
30 seconds
1.0%
Phone Abandonment Rate
3%
1.0%
Customer Satisfaction Score (CSAT)
95.0%
1.50%
Total
20.00%
Discount Guarantee
Contractor guarantees that the County’s in-network discount for the guarantee period will be 69.1 percent or
better, assuming current enrollment and book-of-business service mix. In other words, the discount guarantee is
based on expected discounts in areas where County membership resides. If this changes, Contractor may request
a change to the guarantee. The illustrative composite discounts are below.
Illustrative Inpatient
Hospital
Discount
Illustrative
Outpatient
Hospital Discount
Illustrative
Physician/Other
Discount
Illustrative Composite
Target Discount
% of Fees at
Risk
66.62%
74.56%
61.78%
69.14%
30.0%
SERIAL 250006-ITN
Medical Service Guarantees:
Category
Measurement Method
Fees at Risk
Criteria
Implementation
An average score of 3.0 on the
Implementation Evaluation
Tool survey(s). Each question
has a rating scale of 1 to 5 (1 =
lowest, 5 = highest).
The implementation period
begins at the initial
implementation meeting and
runs through the
implementation sign-off.
If the Implementation
Evaluation Tool is not
completed and returned
within 30 days of receipt, it is
assumed that the service
provided to County is
satisfactory and the
guarantee is deemed met
with the exception that if SPDs
are not delivered to County by
Contractor by the date agreed
to in the Implementation Plan
the average score on this
category will be automatically
deemed a ”1” and the 3%
reimbursed to the County.
3.0%
Measurement basis
Customer specific
Measurement period
Annually
Reporting period
Annually
Open Enrollment ID
Card Production &
Distribution
If less than the 98% of ID cards
are mailed within 12 calendar
days of receipt of a clean OE
eligibility file, the fee for this
category will be reimbursed.
98% of Open Enrollment ID
cards will be produced and
mailed within 12 calendar days
following the receipt of
complete, accurate and viable
electronic enrollment files
1.0%
Measurement basis
Customer specific
Measurement period
Annually
Reporting period
Annually
SERIAL 250006-ITN
Overall Account
Management
An average score of 3.0 on the
semi-annual surveys for on-
going account management,
financial, eligibility, drafting
and benefit administration. The
average is based on 24
questions with a rating scale of
1 to 5 (1 = lowest, 5 = highest).
If the online surveys are not
completed within 30 days of
receipt, it is assumed that the
service provided to County is
satisfactory and the guarantee
is deemed met.
1.0%
Measurement basis
Customer specific
Measurement period
Annually
Reporting period
Annually
Non-Open Enrollment
Eligibility Files
97% of Non-Open Enrollment
eligibility updates (defined as
the number of electronic
eligibility files updated) are
processed within 2 business
days of receipt of complete,
accurate and viable data
(Contractor will send a
confirmation email to the
County within 24 hours of
receipt of the file. Contractor
will send a feedback file with all
required adjustments and any
warnings or comments within 2
business days of the receipt of
complete, accurate and viable
data file.)
Complete eligibility data is
defined as employee name,
address, DOB, SSN, and
covered dependent
information (if applicable) as
well as mutually agreed upon
eligibility specifications. This
guarantee is contingent upon
the file being transmitted
successfully to Contractor (files
received after noon ET will be
considered as having been
received on the next business
day). Any eligibility file received
which must be adjusted by
Contractor using a file fix will
not be included in the
reconciliation. The Electronic
Report (ELR) is used to
1.0% for each full
1.0% that eligibility
updates drop below
97% within 2
business days, up to
a maximum of 3.0%.
Measurement basis
Customer specific
Measurement period
Annually
Reporting period
Annually
SERIAL 250006-ITN
determine the completeness of
the data provided by County
Turnaround Time (TAT)
12 calendar days for 92.0% of
the processed claims on a
cumulative basis.
Contractor measures TAT from
the date the claim is received in
the service center to the date
that it is processed (paid,
denied or pended). TAT
excludes those claims identified
as rework. Weekends and
holidays are included in
turnaround time.
0.50% for each full
day that the TAT
exceeds 12
calendar days for
92.0% of the
processed claims,
up to a maximum
of 2.5%.
Measurement basis
Customer specific:
Measurement period
Annually
Reporting period
Quarterly
Financial Accuracy
99.0%
Financial accuracy is measured
using industry accepted
stratified audit methodology.
The results are determined by
calculating the financial
accuracy for a subset of claims
(a stratum). Contractor
extrapolates the results based
on the size of the population
and combines them with the
extrapolated results of the
other strata. Each overpayment
and underpayment is
considered an error; they do
not offset each other. Financial
accuracy includes both manual
and auto adjudicated claims.
0.50% for each full
1.0% that financial
accuracy drops
below 99.0%, up to
a maximum of
3.0%.
Measurement basis
Unit(s) processing
County claims (all
customers’ claims
handled in that unit,
not just County plan’s
claims)
Measurement period
Annually
Reporting period
Quarterly
Total Claim Accuracy
97.0%
Total claim accuracy is
measured using industry
accepted stratified audit
methodology. Contractor
extrapolates the results based
on the size of the population
and combine them with the
extrapolated results of the
other strata. Accuracy in each
stratum (a subset of the claim
population) is calculated by:
Number of claims processed
correctly
Total number of claims audited
0.50% for each full
1.0% that total
claim accuracy
drops below 97.0%,
up to a maximum
of 3.0%.
Measurement basis
Unit(s) processing
County claims (all
customers’ claims
handled in that unit,
not just County plan’s
claims)
Measurement period
Annually
Reporting period
Quarterly
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Phone Average Speed of
Answer
Inbound calls to Contractors
toll-free customer service lines
shall be answered within an
average time of thirty (30)
seconds or less.
1.0%
Measurement Period
Annually
Phone Abandonment
Rate
Inbound calls to Contractor’s
toll-free customer service lines
shall be answered with an
abandonment rate of 3% or
less. The result is calculated as
follows:
Total number of calls
abandoned divided by the
number of calls accepted
1.0%
Measurement Period
Annually
Customer Satisfaction
(CSAT)
Positive response rate of 95.0%
or better on the following
statement "On a scale of 1 to 5,
with 1 being the least likely and
5 being the most likely, please
indicate if the following is true:
"I was satisfied with the service
I received today".
The survey assumes a 5-point
scale with the top 2 responses
viewed as positive. The result is
based on a member completing
an interactive survey that is
offered at the end of the call.
0.50% for each full
1.0% that our
positive response
rate falls below
95.0%, up to a
maximum of 1.5%.
Measurement basis
Accountable unit or
the business segment
level that services
County plan in effect at
the time of the
member’s call
Measurement period
Annually
Reporting period
Annually
General Medical Service and Performance Guarantee Provisions
For purposes of the performance guarantees, the term “Business Day” is defined as Contractor’s normal
business hours on any day other than a Saturday or Sunday or a day on which Contractor is closed for general
business purposes.
This contract does not contemplate significant changes in volume of claims and calls that may occur with novel
conditions or circumstances affecting broad populations that place a significant strain on the health care
system and/or County plan. These conditions include but are not limited to COVID-19. Contractor reserves the
right to request an adjustment to the terms and factors of this guarantee in response to these conditions
and/or circumstances, if necessary.
If there is an outage or when experiencing peak volumes, calls may be transferred to other Contractor call
centers.
When Contractor processes runoff claims upon termination of the contract, the Turnaround Time, Financial
Accuracy, and/or Total Claim Accuracy performance guarantee(s) will not apply to runoff claims.
Medial Discount Guarantee
Calendar year: January 01, 2026 through December 31, 2026
County in-network discount will be 69.1 percent or better*
*Assuming current enrollment and book‐of‐business service mix The discount guarantee is based expected discounts in areas where County membership
resides. If this changes, Contractor may request a change to the guarantee.
Product: Banner|Aetna Open Access EPO Plus on the Banner|Aetna Performance Network Guarantee:
The Medical Discount Guarantee Illustration below shows:
• Contractor’s guaranteed network contracted discounts by market, for each of the following three service
types:
– Inpatient hospital
– Outpatient hospital
– Physician/other
• Illustrative aggregate guaranteed network contracted discount based on a weighting of:
– Projected, County enrollees by market
– Book-of-business weighting by service type
Contractor finalizes the discount target during the reconciliation process. The final aggregate guaranteed discount
will be determined by weighting the discounts by the actual aggregate billed eligible charges by product and
service type. The reconciliation will be completed before the end of the Third Quarter following the end of the
calendar year.
How discounts are calculated:
The achieved discount percentage is calculated using the following calculation:
In-network provider discounts in dollars
Total in-network billed eligible charges*
Contractor calculates the discount using data from Contractor’s Aetna Informatics® data warehouse. Three months
of runout data will be included in the calculation. The guarantee reconciliation excludes each medical case where
the claims in that medical case exceed $300,000.
A medical case summarizes clinical events by linking or associating all the claims submitted for a member during
the same treatment (i.e., all claims associated with an Inpatient Acute hospital stay or an Outpatient Facility based
procedure).
The guarantee results combine the Open Access EPO Plus on Banner|Aetna Performance Network product(s)
and Contractor reports in aggregate for purposes of this guarantee reconciliation.
*Billed eligible charges are charges prior to application of plan design, discounts and member cost
sharing (copays and deductibles). Billed eligible charges exclude the following:
• Duplicate or other ineligible/not covered/denied claims
• Claims paid by coordination of benefits where Contractor is not primary (e.g., Medicare)
• Claims on members aged 65 and over
• Claims incurred in passive or custom networks
• Behavioral health claims
• Non-medical claims (e.g. dental and vision hardware claims, pharmacy and specialty pharmacy claims,
SERIAL 250006-ITN
including some of those specialty pharmacy claims paid under the medical plan)
• Charges where the provider billed at or below the allowed amount
• All pay for performance payments, including but not limited to, accountable care payments (ACP) and
coordination of care (COC) payments.
Guarantee reconciliation
Contractor compares the guaranteed discount against the total achieved discount. The guaranteed discount is
based on the actual enrollment by product and market and billed eligible charges by product and service type.
Based on the outcome of the comparison, Contractor will make any applicable fee adjustments as shown in the
table below.
Fee Adjustment
Max Calendar year Adjustment
2.0% fee reduction for each full 1.0% the achieved discount falls
below the risk-free corridor
30.0%
There is a risk-free corridor of 3.0 percentage points.
• A fee reduction occurs when the achieved discount falls below the difference of the guaranteed discount
minus the risk-free corridor by a full percentage point or greater.
Conditions for the guarantee
Contractor relies on information from County and County representatives in creating and reconciling the terms
of this guarantee. If any of this information is inaccurate, it may have an impact on the guaranteed network
discounts. Any revision to the guarantee must be made by mutually agreed upon amendment to the contract.
Revisions may be requested if any of the following conditions are met.
Group Composition
County closes any acquisitions or divestitures during the calendar year.
Minimum Enrollment
County does not enroll a minimum of 300 subscribers and enrollment changes by more than 15 percent of
Contractor’s assumed enrollment of 3,901.
Pharmacy claims
Pharmacy and specialty pharmacy claims, including those paid under the medical plan, are excluded.
In-Network Claim Utilization
Less than 80 percent of claims paid are in-network.
Networks
This guarantee includes networks as outlined in Attachment A to Exhibit C, based on where the County
membership resides
Medical Discount Savings Illustration
Illustrative Inpatient
Hospital
Discount (1)
Illustrative Outpatient
Hospital
Discount (1)(3)
Illustrative Physician/Other
Discount (1)(3)
Illustrative Composite
Target
Discount (2)
66.62%
74.56%
61.78%
69.14%
(1) These discounts are illustrative only.
(2) This composite target is illustrative only. The final guaranteed target will depend on actual enrollees by network
and claim service mix known at the end of the calendar year. For purposes of this illustration, the service mix of
network billed eligible charges prior to discount is based on network level assumed utilization of hospital
inpatient, hospital outpatient, and physician/other.
(3) Charges where the provider billed at or below the allowed amount
Discounts by Location
Contractor considers information concerning fees negotiated with providers to be proprietary, commercially
valuable information, which is not in public domain. Consequently, the information contained herein is to be
maintained in a confidential manner, and used solely for the purposes of the performance of this contract,
however, if a Public Records Request is received by Maricopa County Office of Procurement Services (OPS), OPS
will review and respond to that request in accordance with MC1-104.
Product
Market
Name
Rating Area
Employees
Within
Hospital
Inpatient
Hospit
al
Outpat
ient
Physici
an/
Other
Banner|Aetna
Performance
Network
Arizona
Banner|Aetna
AZ - Northern
5
53.06%
55.06%
61.68%
Banner|Aetna
Performance
Network
Arizona
Banner|Aetna
AZ - Phoenix
3,826
66.64%
74.59%
61.78%
Banner|Aetna
Performance
Network
Arizona
Banner|Aetna
AZ - Tucson
1
73.60%
77.50%
64.00%
Banner|Aetna
Broad Network
West Washington
(Seattle)
WA - Washington
1
61.60%
57.00%
51.00%
Total Subscribers
3,833
SERIAL 250006-ITN
Integrated Pharmacy Performance Guarantees
The guarantees described herein will be effective for a period of 12 months and starting January 1, 2026, through
December 31, 2026. The performance guarantees shown below will apply to the self-funded pharmacy benefit plan
administered by Contractor under the contract.
The maximum amount that Contractor will have at risk for any calendar year will be $150,000 for ongoing
guarantees. The total amount at risk may be allocated at the County’s discretion provided 1) no more than 20% and
no less than 1% of the amount at risk will be allocated to any one guarantee; 2) the total amount allocated equals
100% of the total amount at risk; 3) changes to the allocations must be made by amendment to the Contract at least
30 days prior to the effective date or contract anniversary. Contractor is offering a one-time implementation
guarantee of $30,000. The total amount at risk for implementation guarantees will be allocated as indicated below.
Implementation Guarantees:
(40%) Implementation Timeline. Contractor guarantees the County’s Prescription Drug Program will be live and
processing claims as of the effective date. If the plan is unable to go-live on the effective date the penalty at risk for
this Timeline guarantee will be credited to County. Additionally, Contractor shall provide County an initial
implementation project plan (Refer to Exhibit B-Implementation Deliverables and Key Dates) for review and approval
which highlights tasks, dependencies, milestones, and responsibilities.
The implementation project plan will be baselined within a reasonable time following the implementation kickoff
and at that time the milestones for this guarantee will be agreed to from the list of major milestones outlined in
Exhibit B. After initial baseline, the implementation project plan will be updated as needed with Contractor providing
updates reflecting any changes mutually agreed upon via a change control process. In the event of an approved
change control the milestone date will be measured against the updated date from the mutually approved change
control. Contractor shall not be liable for any missed milestone date in the event County, any third party engaged
on behalf of County, or a regulatory agency fail to provide the necessary information or other dependent tasks as
agreed to in the implementation project plan. This guarantee is measured based on each missed milestone date
within Contractor’s sole and direct control due to its own failure to complete such milestone. Each applicable
milestone will be equally weighted across all the pharmacy milestones listed in Exhibit B with Contractor crediting
County the weighted amount for each missed milestone, up to the total amount at risk for this guarantee.
(40%) Benefits Set up. Contractor guarantees that County's plan will be implemented with 98.5% or greater accuracy
based on Contractor and County’s documented and jointly approved benefit requirements. Accuracy will be
determined by accumulating any errors reported that present an access to care or significant financial impact to the
County and/or member. Should either Contractor or County become aware through the course of business of a
benefit set up error in production that impacts claims for the County’s members that event and the associated
impact when known shall be reported to the other party. This guarantee will be determined based on all errors
identified within 90 days following the plan effective date and will be measured based on the total number of claims
impacted from all identified errors divided by the total number of claims processed for the County for the same time
period rounded to the nearest tenth of a percent. Contractor shall credit the County 20% of the total amount at risk
for the Benefits Set up guarantee for each 1% below the target, up to the total amount at risk for this guarantee.
(20%) Implementation Satisfaction. A satisfaction survey shall be conducted among County’s primary transition
team within 45 days following the effective date. Overall satisfaction with the implementation process with a rating
of 3 or higher on a 5-point scale (5 is best rating) shall be guaranteed, provided responses are received by 100% of
County’s primary transition team that is surveyed and returned within 30 days from their receipt of the survey. Any
issue(s) that would cause the County to rate the Implementation less than 3 must be submitted, in writing, to
Contractor implementation and/or account management leadership in advance to allow for corrective action steps
to be taken. For the purposes of this guarantee, satisfaction shall be defined as Satisfied or better on the following
5-point scale; Completely Satisfied, Very Satisfied, Satisfied, Dissatisfied, Very Dissatisfied. The rating will be
calculated based on the average score of all respondents from County. Contractor shall be responsible for survey
design, data collection, analysis and all costs associated with conducting the surveys.
SERIAL 250006-ITN
ONGOING GUARANTEES:
#
Category
Guarantee
Measurement
Basis
Reporting
Frequency
Measurement
Frequency
Fees at Risk
1
Account
Management
Performance
A survey shall be conducted
annually. Overall performance
ratings of at least 4 on a 5-point
scale (5 is best rating) shall be
guaranteed. For the purposes of
this guarantee, performance shall
be defined as Very Good or
Excellent on the following 5-point
scale; Excellent, Very Good,
Good, Fair, Poor. Contractor shall
be responsible for survey design,
data collection, analysis and all
costs associated with conducting
the surveys.
Annual
Annually
Annually
1%
2
System
Availability
Contractor’s online Claims
processing system will be
available for access by
Contractor’s contracted
pharmacies no less than 99.5% of
the time, excluding normal
scheduled maintenance. This
standard will not apply when
Contractor does not have total
control over the environment or
communication links that impact
the Claims adjudication process
due to third-party involvement.
Scheduled maintenance will not
be performed during routine
pharmacy business hours.
Book of
Business
Annually
Annually
1%
3
All Claims
Accuracy
Contractor shall have a Claims
accuracy rate of at least 98%.
Claims accuracy is calculated as
the total number of Claims
adjudicated without financial
error in the measurement period
divided by total number of Claims
adjudicated in the measurement
period. Contractor shall pay
County 0.50% up to the total
amount at risk for each full
percentage point below 98%.
County Specific
Annually
Annually
5%
4
Mail
Turnaround
Time (Clean)
Within an average of two (2)
Business Days of receipt,
Contractor shall dispense all
clean (not requiring intervention
or clarification) mail service
pharmacy prescriptions. The
average calculation is determined
by taking the total number of
By April of 2026
- no longer
needed for
implementation
to move
forward.
Don’t
understand
Annually
Annually
3%
SERIAL 250006-ITN
prescriptions metered (as
recorded by Contractor's systems
standard practices) multiplied by
the number of days these
prescriptions took to meter
divided by the total number of
metered prescriptions.
why, when, etc.
this is needed
5
Mail
Turnaround
Time (Non-
Clean)
Mail Turnaround Time (Requiring
Intervention). Within an average
of four (4) Business Days of
receipt, Contractor shall dispense
all non-clean (requiring
intervention or clarification) mail
service pharmacy
prescriptions. The average
calculation is determined by
taking the total number of
prescriptions metered (as
recorded by Contractor's systems
standard practices) multiplied by
the number of days these
prescriptions took to meter
divided by the total number of
metered prescriptions.
Participating
Group Specific
A minimum of
1,000 mail
claims is
required
otherwise this
will be
measured book
of business
Annually
Annually
3%
6
E-mail
Inquiries
Contractor guarantees 95% of e-
mail inquiries received by
Contractor’s Customer Care
Department from all members
will be responded to within 48
hours following the Business Day
on which such inquiry was
received.
County Specific
Annually
Annually
1%
7
Prior
Authorization
Contractor guarantees that it will
respond to non-urgent prior
authorization requests within an
average of two (2) Business Days
once all clinical information is
received and Urgent prior
authorization requests within an
average of one (1) Business Day
once all clinical information is
received.
Coalition in
Aggregate
Annually
Annually
3%
8
Mail Service
Prescription
Accuracy
Contractor’s accuracy in
dispensing prescriptions from its
mail service pharmacy (correct
drug, correct strength, correct
dosage form and correct
members) shall be at least
ninety-nine and ninety-five
hundredths of a percent
(99.95%), as measured on a
Contract Year and Coalition’s
book of business.
County Specific
Annually
Annually
3%
SERIAL 250006-ITN
For Participating Groups with
more than twenty thousand
(20,000) mail service
prescriptions per year:
Contractor’s accuracy in
dispensing prescriptions from its
mail service pharmacy (correct
drug, correct strength, correct
dosage form and correct
members) shall be at least
ninety-nine and ninety-nine five
thousandths of a percent
(99.95%), as measured on a
Contract Year and Participating
Group basis.
CONDITIONS:
Contractor’s offer assumes 3,901 subscriber lives. Contractor reserves the right to revisit the guarantees and request
an amendment be made to the contract by the County if there is a change in enrollment of more than 15%.
For purposes of the performance guarantees, the term “Business Day” will mean Contractor’s normal business hours
on any day other than a Saturday or Sunday or a day on which Contractor is closed for general business purposes.
Subjection to Section 11.3 (FORCE MAJEURE ) of the contract, the proposed performance guarantees will be adjusted
equitably by the parties to the extent that Contractor has suffered a force majeure event during the applicable
measurement period.
Contractor will diligently attempt to maintain its performance so that failure to achieve or maintain those levels does
not constitute a default for purposes of the termination provisions set forth in the contract.
Contractor will not be liable to County for any failure to satisfy a performance guarantee during any time that no
contract existed between Contractor and County, even if a subsequent contract between the parties provides that
the effective date of the contract is prior to the time at which the written agreement actually was executed by the
parties.
If any period covered by the contract is less than the period covered by the performance guarantee, and Contractor
has not met such performance guarantee for such period, the amount at risk associated with such failure will be
prorated to reflect the actual period during which the contract was in effect.
In the Contractor fails to meet the proposed guarantees, the amount at risk described above will be the sole and
exclusive financial remedy available to County for such failure which shall not relieve the Contractor from the
obligation to improve performance in areas where it has failed.
Termination Provisions
Termination of the guarantee obligations shall become effective upon written request for contract amendment by
Contractor in the event of the occurrence of (i), (ii) or (iii) below:
i.
a material change in the plan initiated by County or by legislative action that impacts the claim adjudication
process, member service functions, pharmacy network management or rebates;
ii.
failure of County to meet its obligations to remit administrative service fees or fund the County bank
account;
SERIAL 250006-ITN
iii.
failure of County to meet their administrative responsibilities (e.g., a submission of incorrect or incomplete
eligibility information).
No guarantees shall apply for a calendar year during which the contract is terminated by County or by Contractor.
SERIAL 250006-ITN
EXHIBIT D – MARICOPA COUNTY HIPAA BAA
HIPAA BUSINESS ASSOCIATE AGREEMENT (BAA)
This BUSINESS ASSOCIATE AGREEMENT (“Agreement”) is effective [insert effective date] (“Effective
Date”) and is entered into by MARICOPA COUNTY, by and through its HIPAA-covered component, County,
and Banner Health and Aetna Health Insurance Company dba Banner|Aetna (“Business Associate” or
“Associate”). This Agreement sets out the responsibilities and obligations of Business Associate, as a
Business Associate of Maricopa County, a hybrid entity with covered components governed by the Health
Insurance Portability and Accountability Act (“HIPAA”) and the Health Information Technology for Economic
and Clinical Health (“HITECH”) Act.
RECITALS
This Agreement is made a part of the parties’ contract or engagement letter for services (the “Contract”),
pursuant to which Business Associate provides services to Maricopa County that involve the use or
disclosure of Protected Health Information (“PHI”) that Maricopa County may transfer to Business
Associate.
AGREEMENT
Business Associate and Maricopa County agree to the terms and conditions of this Agreement in order to
comply with the rules on handling of PHI under the HIPAA Regulations for Privacy of Individually Identifiable
Health Information, 45 C.F.R. Part 160 and Part 164, Subpart E (“Privacy Rule”), the HIPAA Security Rule,
45 C.F.R. Part 160 and Part 164, Subpart C (“Security Rule”), and the HIPAA Breach Notification
Regulations, 45 C.F.R. Part 164, Subpart D (“Breach Notification Rule”), all as amended from time to time.
Business Associate and Maricopa County will comply with the terms of this Agreement for the duration of
the Contract and for such other continuing periods as provided in this Agreement.
1.
Definitions
a.
Unless otherwise provided in this Agreement, all capitalized terms in this Agreement will have the
same meaning as provided under the Privacy Rule, Security Rule, and the Breach Notification Rule.
b.
“Protected Health Information” or “PHI” means PHI as defined in 45 C.F.R. Part 160 and 164, that
is received from Maricopa County, or created, maintained, or transmitted on behalf of Maricopa
County, by Business Associate.
2.
Uses and Disclosure of PHI
a.
Except as otherwise provided in this Agreement or by law, Business Associate may use or disclose
PHI only for those purposes necessary to perform the services described in the Contract.
b.
Business Associate may use PHI for the proper management and administration of Business
Associate’s business, or to carry out its legal responsibilities. Business Associate may disclose PHI
to a third party for such purposes only if:
i.
the disclosure is required by law; or
ii.
Business Associate obtains written assurances, prior to making any disclosure to a third party
that the third party will (a) hold the PHI confidentially; (b) used or disclose the PHI only as
required by law or for the purpose for which it was disclosed to the third party; and (c) notify
Business Associate of any other use or disclosure of PHI.
c.
In accordance with 45 C.F.R. § 164.502(e)(1), if Business Associate’s subcontractor creates,
receives, maintains, or transmits PHI on behalf of Business Associate, Business Associate will
enter into a written agreement with such subcontractor that contains the same restrictions and
conditions on the use and disclosure of PHI as contained in this Agreement.
SERIAL 250006-ITN
d.
Business Associate may use and disclose de-identified health information, if (i) the use is disclosed
to Maricopa County and permitted by Maricopa County in its sole discretion, (ii) that the de-
identification is in compliance with 45 C.F.R. § 164.502(d), and (iii) the de-identified health
information meets the standard and implementation specifications for de-identification under 45
C.F.R. § 164.514(a) and (b). Business Associate may perform data aggregation services as
permitted by 45 C.F.R. § 164.504(e)(2)(i)(B).
e.
To the extent Business Associate is to carry out Maricopa County’s obligations under the Privacy
Rule, Business Associate will comply with the requirements of the Privacy Rule that apply to
Maricopa County’s compliance with such obligations.
3.
Safeguards
a.
Business Associate will implement and maintain appropriate safeguards to prevent the use or
disclosure of PHI other than as provided by this Agreement including administrative, physical, and
technical safeguards to protect the confidentiality, integrity, and availability of the electronic PHI
that Business Associate creates, receives, maintains, and transmits on behalf of Maricopa County.
b.
Business Associate agrees to take reasonable steps, including providing adequate training to its
employees to ensure compliance with this Agreement and to ensure that the actions or omissions
of its employees or agents do not cause Business Associate to breach the terms of this Agreement.
c.
Upon request of Maricopa County, Business Associate will provide evidence to Maricopa County
that these safeguards are in place and are properly managed.
d.
Business Associate will comply with the HIPAA Security Rule.
4.
Reporting Improper Use or Disclosure of PHI, Security Incidents, and Breaches
a.
Business Associate will report to Maricopa County in writing any use or disclosure of PHI not
provided for by this Agreement within 48 hours of when it becomes aware of such.
b.
Business Associate will report to Maricopa County in writing any Security Incident involving
unsecured PHI of which Business Associate becomes aware. Specifically, Business Associate will
report to Maricopa County any successful unauthorized access, use, disclosure, modification, or
destruction of electronic PHI, or interference with system operations in an information system
containing electronic PHI, of which Business Associate becomes aware within 48 hours of Business
Associate learning of such Security Incident. Business Associate will also report the aggregate
number of unsuccessful, unauthorized attempts to access, use, disclose, modify, or destroy
electronic PHI or interfere with system operations in an information system containing electronic
PHI, of which Business Associate becomes aware, provided that:
i.
such reports will be provided only as frequently as the parties mutually agree, but no more than
once per month; and
ii.
if the definition of “Security Incident” under the Security Standards is amended to remove the
requirement for reporting “unsuccessful” attempts to use, disclose, modify, or destroy e-PHI,
the portion of this Section 4 addressing the reporting of unsuccessful, unauthorized attempts
will no longer apply as of the effective date of such amendment.
c.
Business Associate will report in writing to Maricopa County any Breach of unsecured PHI, as
defined in the Breach Notification Rule, within 48 hours of Business Associate’s learning of such
Breach. Business Associate will provide such information to Maricopa County as required in the
Breach Notification Rule. Business Associate will reimburse Maricopa County for all reasonable
expenses incurred in notifying individuals of a Breach caused by Business Associate or Business
Associate’s subcontractors or agents, and for reasonable expenses incurred in mitigating harm to
those individuals. Business Associate will also defend, hold harmless, and indemnify Maricopa
County and its employees, agents, officers, directors, and affiliated entities, from and against any
claims, losses, damages, liabilities, costs, expenses, penalties, or obligations (including attorneys’
fees), which Maricopa County may incur due to a Breach caused by Business Associate or
Business Associate’s subcontractors or agents.
d.
Business Associate will report in writing to Maricopa County within 48 hours of learning of any
potential unauthorized use or disclosure, Security Incident, or Breach that may contain PHI and
that would take more than 48 hours to determine whether PHI was actually involved.
SERIAL 250006-ITN
5.
Mitigation of Disclosures of PHI
Business Associate will take reasonable measures to mitigate, to the extent practicable, any harmful
effect that is known to Business Associate of any use or disclosure of PHI by Business Associate or its
agents or subcontractors in violation of the requirements of this Agreement.
6.
Obligations Regarding Business Associate Personnel
Business Associate will inform all of its employees, agents, and subcontractors (“Business Associate
Personnel”) who will be involved in providing services related to the Contract, of the Business
Associate’s obligations under this Agreement. Business Associate represents and warrants that the
Business Associate Personnel are under legal obligation to Business Associate, by contract or
otherwise, sufficient to enable Business Associate to fully comply with the provisions of this Agreement.
Business Associate will maintain a system of sanctions for any Business Associate Personnel who
violates this Agreement.
7.
Audit Report
a.
Upon request, Business Associate will provide Maricopa County, with a copy of its most recent
independent HIPAA compliance report (AT-C 315), HITRUST certification, or other mutually agreed
upon independent standards based third party audit report.
b.
Maricopa County agrees not to re-disclose Business Associate’s audit report.
8.
Access to PHI
a.
Within five business days of a request by Maricopa County for access to PHI, Business Associate
will make the requested PHI available to Maricopa County and will provide copies upon request.
b.
If an individual requests access to an individual’s PHI directly to Business Associate, Business
Associate will within five business days forward that request in writing to Maricopa County.
Maricopa County will be responsible for making all determinations regarding the grant or denial of
an individual’s request for PHI and Business Associate will make no such determinations. Maricopa
County will release PHI to an individual pursuant to such a request, or direct Business Associate
in writing to make the disclosure.
9.
Amendment of PHI
a.
Within five business days of a request and instruction from Maricopa County, Business Associate
will amend PHI or a record about an individual that is maintained by, or otherwise within the
possession of, Business Associate in accordance with procedures established by 45 C.F.R. §
164.526.
b.
If an individual requests that Business Associate amend an individual’s PHI, Business Associate
within five business days will forward this request to Maricopa County. Any decision to amend PHI
will be the sole responsibility of Maricopa County.
10. Accounting of Disclosures of PHI
a.
Business Associate will document any disclosures of PHI made by it to account for such disclosures
as required by 45 C.F.R. § 164.528. Business Associate also will make available information related
to such disclosures as would be required for Maricopa County to respond to a request for an
accounting of disclosures in accordance with 45 C.F.R. § 164.528. Business Associate will maintain
its record of disclosures for six years from the termination of this Agreement.
b.
At a minimum, Business Associate will record the following information:
i.
the date of disclosure of PHI;
ii.
the name of the entity or person who received PHI, and, if known, the address of such entity or
person;
iii.
a description of the PHI disclosed; and
iv.
a brief statement of the purpose of the disclosure that includes the basis for such disclosure.
c.
Within five business days of receiving a written request from Maricopa County, Business Associate
will provide Maricopa County its records of disclosures.
d.
If an individual requests an accounting of disclosures directly from Business Associate, Business
Associate will within five business days forward the request and its records of disclosures to
Maricopa County. Maricopa County will be responsible for preparing and delivering the accounting
to the individual, and Business Associate will not provide an accounting of its disclosures directly
to any individual.
SERIAL 250006-ITN
11. Availability of Books and Records
a.
Business Associate will within five business days of Maricopa County’s written request, make
available during normal business hours at Business Associate’s offices, or otherwise mutually
agreed upon location, all its internal practices, books, agreements, records, and policies and
procedures relating to the use and disclosure of PHI for purposes of allowing Maricopa County or
its agents or auditors to determine Business Associate’s compliance with HIPAA and this
Agreement.
b.
Business Associate will make its internal practices, books, and records relating to the use and
disclosure of PHI available to the Secretary of the Department of Health and Human Services to
the extent required for determining compliance with the Privacy Rule, or the Breach Notification
Rule.
c.
No attorney-client, accountant-client, or other legal privilege will be deemed waived by Business
Associate or Maricopa County because of this Section.
12. Restrictions on Use of Disclosure of PHI
If Maricopa County advises Business Associate of any changes in, or restrictions to, the permitted use
or disclosure of PHI, Business Associate will restrict the use or disclosure of PHI consistent with
Maricopa County’s instructions.
13. Data Return or Destruction of PHI
a.
Business Associate’s data stewardship does not confer data ownership rights on Business
Associate with respect to any data shared with it under this Agreement, including all forms thereof.
b.
Within 30 days of termination of the Contract or this Agreement, Business Associate will return to
Maricopa County all PHI that Business Associate and its subcontractors and agents maintain in
any form or format. Alternatively, Business Associate may, upon Maricopa County’s consent,
destroy all such PHI and provide Maricopa County with written documentation of such destruction.
Business Associate will be responsible for recovering any PHI from its subcontractors and agents,
or documenting their destruction of such PHI, consistent with this section.
c.
If Business Associate believes that returning or destroying PHI at the termination of this Agreement
is infeasible, it will provide written notice to Maricopa County within 30 days from the termination of
this Agreement explaining its circumstances. Maricopa County will promptly respond wither it
agrees. If Maricopa County agrees, then Business Associate may keep the PHI and will extend all
protections, limitations, and restrictions of this Agreement to the PHI, and will limit the use and
disclosure of the PHI to only those circumstances that make return or destruction infeasible.
Business Associate will ensure the same protections and limitations are followed by its agents and
subcontractors. If Maricopa County does not agree that that return or destruction of PHI is
infeasible, Maricopa County will notify Business Associate, and Business Associate and its agents
and subcontractors will return or destroy the PHI within 30 days.
d.
The obligations of Business Associate and contractors or agents of Business Associate under this
Section shall survive the termination of this Agreement.
14. Term and Termination
a.
This Agreement will become effective on the date first written above and will continue in effect until
all obligations of the Parties have been met under the Contract and under this Agreement.
b.
Maricopa County may terminate immediately this Agreement, the Contract, and any other related
agreements if Maricopa County makes a determination that Business Associate has breached this
Agreement and Business Associate has failed to cure that breach to Maricopa County’s reasonable
satisfaction within 30 days after written notice from Maricopa County. Maricopa County may report
the problem to the Secretary of HHS if termination is not feasible.
15. General Provisions
a.
Amendments. The parties agree to take such action as is necessary to amend this Agreement
from time to time as is necessary for Maricopa County and Business Associate to comply with the
requirements of applicable federal and state law. All amendments to this Agreement shall be in
writing and signed by both parties.
b.
Construction of Terms. The terms of this Agreement will be construed considering any applicable
interpretation or guidance on the Privacy Standards and Security Standards issued by the
Department of Health and Human Services and other applicable state or federal laws, rules, and
regulations as amended from time to time.
SERIAL 250006-ITN
c.
No Third-Party Beneficiaries. Nothing in this Agreement will confer upon any person other than
the parties and their respective successors or assigns, any rights, remedies, obligations, or
liabilities, whatsoever.
d.
Assignment of Rights and Delegation of Duties. This Agreement is binding upon and inures to
the benefit of the parties and their respective successors and permitted assigns. However, neither
party may assign any of its rights or delegate any of its obligations under this Agreement without
prior written consent of the other party, which consent shall not be unreasonable withheld or
delayed.
e.
No Waiver. Failure or delay on the part of either party to exercise any right, power, privilege, or
remedy shall not constitute a waiver. No provision of this Agreement may be waived by either party
except by a writing signed by an authorized representative of the party making the waiver.
f.
Severability. The provisions of this Agreement shall be severable, and if any provision of this
Agreement shall be held or declared to be illegal, invalid, or unenforceable, the remainder of this
Agreement shall continue in full force and effect.
g.
Entire Agreement. This Agreement constitutes the entire agreement between the parties with
regard to the Privacy Rule, Security Rule, and the Breach Notification Rule. There are no
understandings or agreements relating to this Agreement that are not fully expressed in this
Agreement and no change, waiver, or discharge of obligations arising under this Agreement will be
valid unless in writing and executed by the party against whom such change, waiver, or discharge
is sought to be enforced.
h.
Written Agreement. This Agreement is considered as an integral part of the underlying Contract
and is incorporated as though fully set forth within the Contract. This Agreement will govern in the
event of conflict or inconsistency with any provision of Contract.
i.
Venue and Choice of Law. Any suit, action, or other legal proceeding arising out of, or relating to,
this Agreement shall be brought in the venue designated in the Contract or, if no designation is
made, either in Maricopa County Superior Court or in the United States District Court for the District
of Arizona, sitting in Phoenix, Arizona. This Agreement and the rights and obligations of the parties
shall be governed by the laws of the State of Arizona, without regard to applicable conflict of law
principles.
j.
Counterparts. This Agreement may be executed in two or more counterparts, each of which shall
be deemed an original and when taken together shall constitute one agreement.
k.
Facsimile and Electronic Signatures. Facsimile and electronic signatures shall be deemed to be
original signatures for all purposes of this Agreement.
l.
Notices. For purposes of this Agreement and complying with all of its provisions, including all
reporting, notification, and disclosures required in this Agreement or in accordance with applicable
law, all notices shall be sent in accordance with the notice provisions under the Contract.
m. Relationship of the Parties. In the performance of the Contract and the duties and obligations
described in this Agreement, each party is at all times an independent contractor and at no time
shall the relationship between the parties be construed as a partnership, joint venture, employment,
or agency relationship.
Agreed to by Business Associate and Maricopa County: Banner Health and Aetna Health Insurance
Company dba Banner|Aetna.
MARICOPA COUNTY
BANNER HEALTH AND AETNA HEALTH
INSURANCE COMPANY DBA BANNER|AETNA
By:
By:
Chairman, Board of Supervisors
Name:
Date:
Title:
ATTEST:
Date:
Clerk of the Board
SERIAL 250006-ITN
Date:
APPROVED AS TO FORM:
Attorney for Maricopa County
Date: ___________________________
Exhibit E Page 1
EXHIBIT E –SELF-FUNDED MEDICAL UNDERWRITING DISCLOSURES
TABLE OF CONTENTS
Billing of Fees .................................................................................................................................................................2
Monthly Self-Funded billing..........................................................................................................................................2
Claim Wire Billing .........................................................................................................................................................2
Subrogation.............................................................................................................................................................2
Contracted Services ................................................................................................................................................3
PrudentMed®.........................................................................................................................................................4
Claim and Code Review Program .........................................................................................................................4
Producer Compensation................................................................................................................................................5
Claim and Member Services .........................................................................................................................................5
Alternate Office Processing (AOP)...............................................................................................................................5
Medical Explanation of Benefits (EOB) Suppression...............................................................................................5
Eligibility Transmission .................................................................................................................................................6
Member ID Cards.........................................................................................................................................................6
Network Services..................................................................................................................................................................6
Delegated Relationships..................................................................................................................................................6
Network Provider Arrangements .................................................................................................................................6
Value-Based Contracting...............................................................................................................................................6
Subcontractors.................................................................................................................................................................8
Out-of-Network Benefits and National AdvantageTM Program Description ......................................................8
National AdvantageTM Program (NAP) ....................................................................................................................9
Facility Charge Review (FCR)......................................................................................................................................9
Itemized Bill Review (IBR)............................................................................................................................................9
Data iSight (DiS)..........................................................................................................................................................10
Primary Care Physician Referrals for Gated Products ..........................................................................................10
Primary Care Physician Referrals for Gated Products with membership in California....................................10
Other Payments..................................................................................................................................................................10
Relationship Advisor ....................................................................................................................................................10
Specialty Pharmaceuticals Program..........................................................................................................................10
Reporting......................................................................................................................................................................10
States’ All payer Claims database (APCD) reporting.............................................................................................10
New Hampshire (for customers with a business or branch location in New Hampshire)................................11
Utah (for customers with a business or branch location in Utah) ........................................................................11
Federal Mandates...............................................................................................................................................................12
Health Care Reform...................................................................................................................................................12
Federal Mental Health Parity ...................................................................................................................................13
European Union: General Data Protection Regulations (GDPR)........................................................................14
State Mandates ...................................................................................................................................................................14
Illinois Registration of Business Entities..................................................................................................................14
Exhibit E Page 2
New Jersey A-4 Surcharge.........................................................................................................................................14
New Jersey Out-Of-Network Consumer Protection, Transparency, Cost Containment and Accountability
Act.................................................................................................................................................................................14
New York Dependent Age 30................................................................................................................................14
Accessing Assistance for People with Disabilities …………………………………………………………………... 14
This supplemental underwriting disclosures document (the “Supplement Document”) provides additional
information regarding your programs and services and is intended to be used in conjunction with your new business
proposal or renewal letter. The Supplemental Document applies to our Large Group and Public & Labor self-
funded medical relationships administered by Aetna Life Insurance Company and its affiliates, including
Innovation Health Insurance Company, Texas Health + Aetna Health Insurance Company, Banner Health and
Aetna Health Insurance Company, Allina Health and Aetna Insurance Company and Sutter Health and Aetna
Administrative Services, LLC. For purposes of this document, Banner|Aetna is referred to using ‘Contractor and
Maricopa County is referred to using ‘County’.
Disclosure language in this document that applies to Maricopa County plan is indicated with an asterisk (*).
Billing of Fees
Monthly Self-Funded billing*
Contractor will reconcile the collected fees at the end of the Guarantee Period. Any surplus or shortfall due, will be
payable within the timeframe specified in the Agreement for the payment of service fees.
Claim Wire Billing*
Claim wire billing fees refers to the portion of the total administrative expenses charged through the claim wire as the
services are rendered and are subject to any future fee increases independent of any changes to the base per employee,
per month (PEPM). Fees charged through the claim wire include those described on the financial exhibit as well as
those fees that the parties may subsequently agree to add to the claim wire from time to time. Programs or services
charged through the claim wire are excluded from the monthly Guaranteed Fees as outlined in the financial exhibit
and will not appear on the monthly billing statement. Claim wire charges will appear in the claim detail report separated
by unique Claim Reporting System (CRS) draft accounts and other monthly reports.
Subrogation*
This recovery program involves analyzing trauma-related claim data when the health plan has incurred medical
expenses on behalf of a plan participant associated with an accident, injury, or medical condition (typically due to
some form of third-party liability, such as a motor vehicle accident, slip and fall on another person’s property, etc.).
Proprietary algorithms are applied to adjudicated claim data to identify a potential recoverable opportunity. Identified
opportunities are investigated and negotiated for potential recovery. Any recoveries that are obtained are credited to
the customer on a [quarterly] basis.
Calculation of Shared Savings
Contractor calculates savings as the actual amount recovered. Contractor will retain the percentage of savings
specified in County’s service and fee schedule as compensation for the services provided under the program. These
fees are primarily to support vendor costs and/or internal administrative costs of Contractor or its affiliates associated
with the program. The following is an example of a savings calculation (using a 30% fee for illustrative purposes
only):
Calculation Example
Total amount paid by Plan for participant’s case
$ 57,000
Total subrogation lien settlement
$ 8,333
Total Administrative Fee (30%)
$ 2,500
Total Net Credit to Customer
$ 5,833
Out of the subrogation lien settlement, the customer will receive a total net credit of $5,833 and Contractor will retain
$2,500 (30%) as compensation for the services provided by Contractor, its affiliates and/or a vendor with respect to
Exhibit E Page 3
the program. These amounts will be charged and credited to County on a quarterly basis and disclosed in the claim
detail report.
Contracted Services*
This recovery program is intended to locate overpayments that might not have otherwise been discovered utilizing
specialized methods and applications. The following reviews are conducted on certain inpatient, outpatient, and
professional claims submitted by in- network and out-of-network providers:
Coordination of Benefits (COB). This review Identifies other primary insurance in situations in which
Contractor has already paid as primary, assigns the correct COB order of primacy, updates our COB data
stores to reflect the determination and recovers overpayments.
Retroactive Terminations. This review identifies overpayments that occur where the claim was
processed after the member's termination date.
Hospital and outpatient bill review A hospital bill onsite chart review is conducted for eligible claims
over $10,000. This review compares the patient medical records to the itemized bill to determine the
integrity of the billed charges and the actual paid amount for claims paid using a fee for service
reimbursement methodology.
Outpatient Coding Audits. These audits are performed by clinical coders to verify the code
assignment and reimbursement using medical records.
Workers Compensation. This review includes a comparison member data to the state workers
compensation database. The benefits are coordinated, and funds are recovered from Workers
Compensation carriers.
DRG (Diagnosis Related Grouper) and Implant Audits. DRG audits identify claims with DRG
payment methodology which have a high recovery potential to ensure that diagnosis and procedure codes
are assigned accurately. A short stay DRG audit is a post service, post payment review of participating
and non-participating Medicare Risk inpatient claims paid under a DRG methodology to validate that it
was medically appropriate for the patient to be treated and billed as inpatient rather than outpatient. This
program also identifies potential implant and high- cost drug overpayments to ensure providers are
complying with the contract cost limitation language on implant and high-cost drug reimbursement. Both
medical chart audits are based on a comprehensive review of physician documentation within the medical
chart.
These services may be performed by Contractor and/or its affiliates and/or an external vendor. Overpayments
identified through this program are pursued for reimbursement from the provider and/or member. Any recoveries
that are obtained are credited to the customer on a [quarterly] basis, along with the applicable contingency fee for
the savings.
Calculation of Shared Savings
Contractor calculates the savings achieved through the program as the actual amount recovered. Contractor will retain
the percentage of savings specified in your service and fee schedule as compensation for the services provided under
the program. These fees are primarily to support vendor costs and/or internal administrative costs of Contractor or
its affiliates associated with these programs. The following is an example of a savings calculation (using a 30% fee
for illustrative purposes only):
Calculation Example
Amount paid on claim
$ 1,500
Amount recovered
(via pursuit of other primary coverage)
$ 1,000
Total Administrative Fee (30%)
$
300
Total Net Credit to Customer
$
700
Out of the amount recovered, the customer will receive a total net credit of $700 and Contractor will retain a fee of
$300 (30%) as compensation for the services provided by Contractor, its affiliates and/or a vendor with respect to the
program. These amounts will be credited and charged to County on a daily basis and are disclosed in the claim detail
report.
PrudentMed®
Exhibit E Page 4
The PrudentMed® program, offered by PrudentRx, assists County plan’s members in securing available third-party
copayment assistance for certain specialty drugs through the various programs funded by pharmaceutical
companies.
Calculation of Shared Savings
Contractor calculates savings as the dollar amount of financial assistance County’s eligible members receive through
programs sponsored by pharmaceutical companies that provide financial assistance for payment of the member’s cost
share. In addition to benefiting County members, the plan will realize savings by increasing the member cost share
(which increase in member cost share is offset by the manufacturer programs). A percentage of the savings generated
will be charged as compensation for the services provided under thePrudentMed® program, as specified in your
service and fee schedule. The following is an example of a savings calculation (using a 25% fee for illustrative
purposes only):
Calculation Example
Generated Savings from Pharma Copayment Assistance Programs
$ 10,000
Less Discount Factor (1%)
$ 9,900
Total Administrative Fee (25%)
$ 2,475
Net Savings
$ 7,425
In this example, PrudentMed® was able to generate savings by utilizing $10,000 in manufacturer funds.
PrudentRx will receive $2,475 (25%) as compensation for the services provided under the PrudentMed® program.
PrudentRx may share a portion of the service fee with third parties, including Contractor and/or its affiliates for
services rendered in connection with the PrudentMed® program. This service fee will be charged to County on a
monthly basis through claim wire billing.
Claim and Code Review Program*
This program includes several components that apply additional layers of review to certain inpatient, outpatient, and
professional claims submitted by in-network and out-of-network providers using claim editing and clinical coding
validation capabilities that are integrated with our claims processing systems. Utilizing proprietary algorithms and
claim editing solutions, these reviews ensure claims are properly coded and validated, compliant with Contractors’s
policies and provider contracts and clinically appropriate and consistent. These additional reviews may include:
Edits to enhance accuracy and consistency of claims payments in accordance with Aetna’s clinical,
payment and coding policies identify claims subject to the Clinical Review Program and manage policies
targeting billing errors as well as waste and abuse scenarios
Evaluation of the clinical accuracy of claims
Identification of inappropriate billing and procedures on certain medical, diagnostic and surgical claims
Management of complex billing scenarios for medical injectables, which includes authorization support as
well as compliance of FDA-recognized dose and frequency limits
Reviews performed by specialized nurse coders to ensure accuracy of certain complex claims at
risk of improper payment
Enhanced claim editing for certain services
Medical record reviews for claims meeting certain criteria that includes requesting medical records as
needed
These reviews are applied to submitted claims and adjustments or denials are made for charges that are determined
not authorized or not allowed. Examples of adjustments include: unbundling or mutually exclusive coding
scenarios, experimental & investigational or cosmetic services, billing errors involving excessive number of units
or billable thresholds, duplicate claims, multiple charges for the same procedure, billing errors, insufficient
information regarding a service, non-covered services or supplies, services determined not medically necessary or
not pre-authorized. Also included are services that may require clinical review such us level of care and DRG
audits. The provider is paid the allowed amount, after application of any appropriate adjustments identified through
the program.
These services may be performed by Contractor and/or its affiliates and/or an external vendor.
Exhibit E Page 5
Calculation of Shared Savings
Contractor calculates the savings achieved through the program as the difference in the paid amount. Savings is the
difference between the amount that would have paid before review under the program and the amount paid after the
claim was reviewed and adjusted. Contractor will retain the percentage specified in County’s service and fee schedule
as compensation for the services provided under the program.
The following is an example of a savings calculation (using a 30% fee for illustrative purposes only):
Calculation Example
Program Adjustments/Denials
Denied for specialty drug quantity limit
$ 500.00
Denied per specialized nurse coders
$ 500.00
Total disallowed charges
$1000.00
Shared Savings Retained by Aetna (30%)
$ 300.00
Net Plan Sponsor Savings
$ 700.00
Contractor will receive $300 (30%) of the total savings as compensation for the services provided by Contractor, its
affiliates and/or a vendor with respect to the program and the customer received a net savings of $700 on these claims.
The charge will be applied on a quarterly basis and disclosed in the customer’s Claim and Code Review Report,
which details savings on a claim-by-claim basis.
Producer Compensation
Contractor will honor “Agent of Record” or “Broker of Record” letters when an agent, broker or consultant sells
new business or takes over one of its customers from another agent, broker or consultant. Please have an appropriate
representative from your company sign such a letter using your County’s letterhead. The change will become
effective on the first day of the month following the date the payment unit receives the “Agent of Record” or “Broker
of Record” letter unless another future date is designated in the letter. Contractor has various programs for
compensating agents, brokers and consultants. If your company would like information regarding commission and
additional bonus programs for which County’s agent, broker, or consultant may be eligible for, payments (if any)
which Contractor has made to your agent, broker, or consultant (including commission and applicable bonus
payments), or other material relationships County’s agent, broker, or consultant may have with Contractor, County
may contact County’s agent, broker, or consultant, or County’s Aetna Account Executive. Information about
Contractor’s programs for compensating agents, brokers and consultants is also available at www.aetna.com.
Claim and Member Services
Alternate Office Processing (AOP)
Contractor regularly uses both internal and external claim adjudication services to meet service requirements of its
business. These services may be located inside or outside of the United States. Contractor’s quality standards and
controls apply to all claims regardless of where they’re processed. Standard pricing assumptions are in effect based
on type of product, auto-adjudication, plan design and customer specific requirements. Contractor may adjust
service fees based on the above factors and/or where County wishes to limit use of Alternate Office Processing
(AOP). County’s claims will be processed inside of the United States and cost for this onshore service is included
in the Medical Administrative Service Fee
Medical Explanation of Benefits (EOB) Suppression*
Contractor doesn’t produce paper EOBs for members registered through our member website. Contractor doesn’t
produce EOBs for claims when there is no member liability. EOBs are always available electronically through our
secure member website. Members can visit www.banneraetna.com to register and sign into their account.
Eligibility Transmission*
Contractor assumes County will submit eligibility information once a week, from the customer’s location(s) and/or
by the County’s designated vendor. The preferred method of submission is via electronic connectivity. Contractor
doesn’t charge for the first four Electronic Reporting (ELRs)/segments whether associated with one transmission or
by multiple methods. Costs associated with more than four ELRs/segments or with any custom programming
Exhibit E Page 6
necessary to accept County’s eligibility information and/or information coming from a designated vendor aren’t
included in this proposal/renewal and will be assessed separately. During the installation, Contractor will review all
available methods of submitting eligibility information and identify the approach that best meets County’s needs or
the needs of County’s designated vendor.
Member ID Cards*
Contractor’s standard is to provide County with physical ID cards for the family (“family
style”) except where individual ID cards are mandated by state law. The number of cards mailed is dependent on the
type of coverage and state laws. For existing customers at renewal, digital ID cards are issued to members with an
email address on file when changes are minor. If County requests a reissue of ID cards without a business reason may
incur an additional charge. Examples of a business reason for reissuing physical ID cards where charges will be
waived include, but are not limited to:
Key Benefit Plan Changes
New Hires/Rehires
Member elects a different benefit plan option
Member calls to request a replacement/additional ID card
ID cards and member plan details which include plan deductibles and out of pocket limits are always available
electronically through the Aetna secure member website. Members can visit www.aetna.com to register and sign
into their account.
Network Services
Delegated Relationships*
In some circumstances, Contractor engages third parties to perform certain operations. A few examples of functions
that are “delegated” in this manner include claims management, utilization management, credentialing and call center.
Contractor is ultimately responsible for these functions and exercise oversight over the delegated activities. In some
cases, Contractor will enter into these delegated arrangements with participating providers and provider organizations,
including ACOs, network vendors, specialty groups and medical service organizations.
Under some of these arrangements, the vendor bills Contractor for the health care services performed by the vendor’s
network of providers, as well as for the other administrative/delegated services performed by the vendor. In those
situations, Contractor determine the allowed amount, based on the vendor’s contracted rate with Contractor, which may
include fees supporting the administrative/delegated services. For claims that are billed through these arrangements,
the amount charged by or paid to the underlying provider who rendered the health care services may be higher or
lower than the allowed amount used to determine what the plan and plan participant owes because the allowed amount
under the plan will be Contractor’s contracted rate with the vendor, and not the contracted amount between the vendor
and the underlying provider who rendered the health care services. Accordingly, in this scenario, the allowed amount
under the plan for purposes of determining what the plan and participant owes will include fees paid to the vendor for
administrative or delegated services (or both) and will not be limited to amounts related to medical services.
Network Provider Arrangements*
Certain network providers require payment of claims that might otherwise be denied, such as those not medically
necessary or experimental or investigational (but does not require payment for services County expressly exclude from
coverage, such as for cosmetic surgery). Contractor will charge County for these claims in order to be able to continue
providing members with access to services on an in-network basis. County agrees to comply with such applicable
provisions of Contractor’s network provider contracts.
Value-Based Contracting*
Introduction
Contractor has a variety of different value-based contracting (VBC) arrangements with many of our in-network
providers. These arrangements compensate providers to improve indicators of value such as, effective population
health management, efficiency and quality care.
Contracting Models
Exhibit E Page 7
Contractor has VBC arrangements ranging from bundled payments and pay-for-performance approaches to more
advanced forms of collaborative arrangements that include integrated technology and case management, aligned
incentives and risk sharing. Contractor’s VBC models include:
(A) Pay for Performance (P4P). Under P4P programs, Contractor works together with providers (doctors
and hospitals) to develop and agree to a set of quality and efficiency measures and their performance impacts
their total compensation.
(B) Bundled Payments. In a Bundled Payment model, a single payment is made to doctors or health care
facilities (or jointly to both) for all services associated with an episode-of- care. Bundled payment rates are
determined based on the total expected costs for a particular treatment, including pre- and post-treatment services,
and are set to incentivize efficient medical treatment.
(C) Patient Centered Medical Home (PCMH). In a PCMH, a primary care doctor leads a clinical team that
oversees the care of each patient in a practice. The medical practice receives data about their patients’ quality
and costs of care in order to improve care
delivery. Financial incentives can be earned based upon performance on specific quality and efficiency measures.
(D) Accountable Care Organizations (ACOs). In an ACO, Contractor teams up with systems of doctors,
hospitals and other health care providers to help these organizations manage risk, improve clinical care
management, and implement data and technology to connect providers, health plans and patients. The ACO
arrangements include financial incentives for the organization to improve the quality of patient care and health
outcomes, while controlling costs.
Contractor will continue to evolve our value-based contracting arrangements over time. Contractor employs a broad
spectrum of different reimbursement arrangements with providers to advance the goals of improving the quality of
patient care and health outcomes, while controlling costs.
Example Calculations
A customers’ financial responsibility under many VBC arrangement is determined based on provider performance,
using an allocation method appropriate for each particular performance program. These methods include:
A.
Percentage of allowed claims dollars;
B.
Percentage of member months;
C.
Number of members.
Examples
A.
P4P. Percentage of allowed claims dollars:
Achieving agreed upon clinical and efficiency performance goals by comparing performance year end to
performance year baseline or an industry standard.
i.
Provider earns $100,000 performance-based compensation for the 12-month period January to
December;
ii.
All Customers combined, incurred $8,500,000 in claims with the provider for the 12-month
period January to December;
iii. Customer incurred $150,000 in claims with the provider for the 12-month period January to
December;
iv. Customer’s share of claims costs is ($150,000/$8,500,000) = 1.7647 %. Formula:
(Customer incurred claims/All Customers incurred claims);
v.
Customer’s share of the $100,000 performance-based compensation is 1.7647
% * $100,000) = $1,764.70, which would be processed as a claim through ordinary self-funded banking
channels.
B.
PCMH and ACO. Percentage of member months:
Achieving agreed upon clinical and efficiency goals as measured by performance year end to performance
year baseline or an industry standard.
Exhibit E Page 8
i.
Provider earns $100,000 performance-based compensation for the 12-month period January to
December;
ii.
All Customers combined, had 100,500 member months with the provider for the 12-month period
January to December;
iii. Customer had 9,500 member months (for 850 unique members) attributed to the provider for the
12-month period January to December;
iv. Customer’s share of the member months is (9,500/100,500) = 9.4527%. Formula:
(Customer member months/All Customers member months)
v.
Customer’s share of the $100,000 performance-based compensation is (9.4527% *
$100,000) = $9,452.73, which would be processed as a claim through ordinary self-funded
banking channels.
C.
PCMH and ACO. Number of Members:
In addition to Example B above, a quarterly Accountable Care Payment (ACP) may be made to the
provider to fund activities necessary to meet the financial and clinical objectives. These are paid quarterly
either during, or after the end of each quarter. The financial impact is considered in the total financial
package negotiated with the provider.
i.
We determine the attributed patients for the provider for the quarter April through June;
ii.
Customer had 850 members attributed to the provider for the quarter April through June;
iii. ACP and FFS payments are incorporated into the final analysis of provider performance against
the medical claims target;
iv. We apply the agreed upon rate to the attributed patients; i.e. $2.00 per- member, per-month
(PMPM) = $6.00 per quarter per member, to determine funding to the provider;
v.
Customer’s calculated share is $5,100 ($6.00 * 850), which would be processed as a claim through
ordinary self-funded banking channels.
General
Contractor will process any payments in accordance with the terms of each VBC arrangement. In each of the VBC
models, self-funded County reimburse Contractor for any payment attributable to their plan when the payments are
made. County’s results will vary. It is possible that payments paid to a particular provider or health system may be
required even if the County’s own population did not experience the same financial or qualitative improvements. It
is also possible that payments will not be paid to a provider even if the County’s own population did experience
financial and quality improvements. A report of VBC charges to County will be available on a quarterly basis. Upon
request, Contractor will provide additional information regarding the VBC arrangements.
Subcontractors
The work to be performed by Contractor under the Services Agreement may, at Contractor’s discretion, be performed
directly by Contarctor or wholly or in any part through a subsidiary, an affiliate, or under a contract with an
organization of Contractor’s choosing. Contractor will remain liable for Services under the Services Agreement.
Out-of-Network Benefits and National AdvantageTM Program Description*
Contractor networks help save money for County and County’s employees. However, Contractor knows that
sometimes members receive care out-of-network. Not all out-of-network claims are the same. Sometimes members
need care when an in-network provider is not available and sometimes they go out-of-network voluntarily if they have
a plan that is not limited to in- network only options.
Involuntary:
Emergency services: This often happens when a member gets care outside of our network for
emergency care.
Out-of-network specialists: This can also happen when members get care in a network hospital
from out-of-network specialists like radiologists or anesthesiologists.
Contractor always covers involuntary out-of-network claims and make sure the member pays at their in-
network benefit level.
Voluntary:
This is when a member chooses to get treatment from outside of our network. An example would be
when a member could have reasonably utilized a participating surgeon but instead elected to go to a
Exhibit E Page 9
non-participating surgeon. This can also happen when members seek a second opinion consult with an
out-of-network specialist. In these situations, the member’s contractual plan benefits apply.
National AdvantageTM Program (NAP)*
NAP includes a Contracted Rates component and two optional components: Facility Charge Review (FCR) and
Itemized Bill Review (IBR). In addition, some plans also have Data iSight (DiS) if warranted based on their out-of-
network plan rate. NAP’s Contracted Rates component offers access to contracted rates for many medical claims
from non- network providers (including claims for emergency services and claims by hospital-based specialists such
as anesthesiologists and radiologists who do not contract with insurers) and ad hoc negotiations (when a contracted
rate is not available). We retain a percent of savings achieved through NAP, including savings achieved through
FCR and IBR, if elected, and DiS, if applicable. This NAP Fee is in addition to the per-employee, per-month
administrative service fees.
Facility Charge Review (FCR)*
FCR is an optional NAP component. FCR applies to inpatient and outpatient out-of- network facility claims for
which a contracted rate or facility plan rate is not applicable and for which the claim amount exceeds a certain
threshold as determined by Contractor. Through the FCR component, Contractor establishes a reasonable charge
for a plan benefit in the geographic area where such benefit was provided to the member (“Recognized Charge”).
The Recognized Charge is based on the provider’s estimated cost, including an anticipated profit margin. The claim
will be paid based on the Recognized Charge.
Out-of-network facilities may balance bill the member for any amount above the Recognized Charge. We offer
three different types of FCR – Standard, Modified Balance Bill and Fixed Determination, which provide a range
of options regarding how member balance billing will be handled through negotiations with the facility. Even with
FCR, if a provider refuses to agree to a negotiated rate, claims may be paid at billed charges in certain
circumstances. For claims eligible under the No Surprises Act (NSA), FCR pricing will not apply.
Standard FCR
In the event a member is balance billed, we have a Patient Advocacy reconsideration process which will attempt to
negotiate with the facility to try to come to a mutually agreeable settlement amount. For claims that are to be paid at
the preferred/in-network level under the terms of the member’s plan of benefits, we’ll negotiate with the facility so
that the member isn’t responsible for any covered charges in excess of any applicable deductible and
coinsurance/copayments. However, for non-preferred out-of-network
services, if we can’t negotiate a mutually acceptable rate, the member may be responsible for charges in excess of the
Recognized Charge.
Modified Balance Bill FCR
In the event a member is balance billed or the facility requests a reconsideration, we have a Patient Advocacy
reconsideration process which will attempt to negotiate with the facility to try to come to a mutually agreeable
settlement amount. We’ll negotiate with the facility so that the member is not responsible for any covered charges
in excess of any applicable deductible and coinsurance/copayments.
Fixed Determination FCR
In the event a member is balance billed, there is no Patient Advocacy reconsideration process for voluntary out-of-
network claims. The member is responsible for charges in excess of the Recognized Charge for voluntary out-of-
network claims. For claims that are to be paid at the preferred/in-network level, we will negotiate with the facility so
that the member isn’t responsible for any covered charges in excess of any applicable deductible and
coinsurance/copayments.
Itemized Bill Review (IBR)*
IBR is an optional NAP component. IBR applies to inpatient facility claims submitted by Aetna network providers
(directly contracted) if (a) the submitted claim amount exceeds a certain threshold as determined by Contractor; and
(b) Contractor’s contracted rate with the provider uses a “percentage of billed charges” methodology. Contractor
refers to these as “IBR Claims.”
Contractor will forward IBR Claims to a vendor to review and identify any billing inconsistencies and errors. The
vendor reports back the amount of eligible charges after adjusting for any identified inconsistencies and errors.
Contractor then pays the claim based on the adjusted bill.
Exhibit E Page 10
Data iSight (DiS)*
DiS applies to plans with certain out-of-network rates. MultiPlan, one of Contractor’s external pricing vendors under
NAP, uses the DiS patented methodology to price certain out-of-network claims, based on typical competitive
charges and/or payments for a service, adjusted for the geography in which the service was provided. In the event
a member receives a balance bill from a provider for an out-of-network service, patient advocacy services are
available to assist the member. The DiS patient advocacy program gives members the ability to have an advocate
from the vendor negotiate with providers on their behalf.
DiS will contact the provider to start negotiations on a mutually agreeable payment amount with no member
balance billing. For claims that are to be paid at the preferred/in-network level under the terms of the member’s
plan of benefits, DiS will negotiate with the provider so that the member is not responsible for charges in excess
of any applicable deductible and coinsurance/copayments. However, for voluntary out-of- network services, if
DiS can’t negotiate a mutually acceptable rate, the member may be responsible for charges in excess of the
DiS out-of-network plan rate. Data iSight does not apply to NSA eligible claims.
Primary Care Physician Referrals for Gated Products
Because of certain provider contractual arrangements with some Independent Provider Associations (IPAs) and
medical groups, Aetna will permit specific exemptions to the requirement that a member obtain a referral from their
primary care physician (PCP) before receiving care from other providers.
Primary Care Physician Referrals for Gated Products with membership in California
Given the unique nature of the health care system in California, referral registration for members in California is
generally not required. The delegated model in place in the state already encourages providers to make appropriate
referral decisions for our members.
Contractor believes this decision is in the best interests of customers, members and providers. However, please note
that referral registration is required in California in the event that the servicing provider is not in the same network
area (e.g., Los Angeles, Northern California, San Diego and Central Valley) as the member or the member's PCP. In
addition, PCP selection is required. Par provider claims for members that do not select a PCP will be processed at the
par non-authorized level.
Other Payments
Relationship Advisor
At times , Contractor secures the assistance of third parties in support of procuring business and responding to RFPs.
Any payments to such third parties will be disclosed to County in case County choose to include such information
in the schedule 5500.
Specialty Pharmaceuticals Program
Rebates for specialty pharmaceuticals that are administered and paid through the Plan Participant’s medical benefit
rather than the Plan Participant’s pharmacy benefit will be retained by Contractor as compensation for Contractor’s
efforts in administering the preferred specialty pharmaceuticals program.
Reporting
States’ All payer Claims database (APCD) reporting*
Certain state regulations require insurance carriers to supply data relating to their fully insured products to that
state’s all payer claims database (APCD). As a result of a recent US Supreme Court ruling, and as a TPA for a self-
funded plan, Contractor is no longer required to submit self-funded plan health care claims data to states with
APCDs.
However, in some states, the law indicates that providing the data for self-funded plans is voluntary. In these
circumstances, Contractor won’t provide your self-funded plan data to these states unless County informs us in
writing that County wish us to do so.
Exhibit E Page 11
New Hampshire (for customers with a business or branch location in New Hampshire)
Many states have passed laws requiring disclosure of health care claims data to all payer claims databases (APCDs).
The data is used by the states for a variety of analytical purposes. You can find more information on APCDs at the
APCD Council website at http://www.apcdcouncil.org/
In 2016, the U.S. Supreme Court ruled in Gobeille v. Liberty Mutual Insurance Co., that the Employee Retirement
Income Security Act of 1974 (ERISA) prevents states from requiring self-insured customers to submit data to
APCDs. As a result of this ruling, Contractor will not automatically submit the self-funded plan data to any state
APCDs. If County wishs to have its plan’s date submitted to state APCDs, County will need to affirmatively opt
into this process by notifying the Aetna account manager. Please read the New Hampshire Department of Insurance
specific message to companies with a business location including a branch location in New Hampshire.
NHID Opt-In Form
All-Payer Claims Database Indication of Intent for Private employers Offering Self-Funded Health Coverage in New
Hampshire
You are receiving this form under a 2016 New Hampshire law allowing a self-funded private employer to direct its
claims administrator to include the health care claims data of its employees and covered dependents in the state’s All-
Payer Claims Database (APCD) (NH RSA 420-G:11, V).
•
In response to rising health care costs, the New Hampshire Insurance Department has, since 2003, collected
health care claims data from insurers and third-party
administrators in an APCD. To protect privacy, under state law the database “shall not include or disclose any
data that contains direct personal identifiers”. (NH RSA 420- G:11-a, I).
•
The APCD enhances transparency, providing employers, policymakers, payers, and health care providers
with vital information about the factors contributing to rising health care costs in New Hampshire. In
addition, the Insurance Department uses the
•
database to provide health cost information to the public, including employers and their employees, through
the NH HealthCost website: http://nhhealthcost.nh.gov/.
•
New Hampshire’s database has always included data from self-funded employers, because the accuracy of
information derived from the database increases when more claims are included. In 2016, the U.S. Supreme
Court ruled that Vermont could not require self-funded private employers to submit data to the state’s APCD.
To clarify New Hampshire law after that ruling, the legislature required the creation of this form to allow self-
funded private employers to direct their claims administrators to include their data.
If County elects to participate, please contact your claims administrator. If County have questions about New
Hampshire’s APCD or the department’s efforts to improve health care cost transparency, contact the NH Insurance
Department at 603.271.2261 or requests@ins.nh.gov, or visit http://www.nh.gov/insurance/.
Utah (for customers with a business or branch location in Utah)
VALUE OF PARTICIPATING IN THE UTAH APCD
•
Data in the Utah APCD has supported a statewide coordination of benefits effort to reduce double payment
and ensure that the responsible party is the one that pays.
•
Patient privacy is taken very seriously and is protected by Utah and federal law.
•
This initiative was created by the Utah State Legislature and is supported by the
Governor’s Office and key members of the business and health care communities.
•
Prior to 2016, the APCD was receiving data for over 90% of Utah’s population with private health care
coverage. If employers do not opt in, that number could fall by as much as 40%, greatly affecting the ability
to monitor trends and identify cost drivers.
Exhibit E Page 12
Federal Mandates*
Health Care Reform*
Contractor believes this new business proposal or renewal letter is compliant with health care reform.
For customers with Grandfathered and Non-Grandfathered plans.
For County’s company’s plans that are currently certified as grandfathered, in order to retain grandfathered status,
the plan must meet all grandfathering criteria and must have done nothing to cause the loss of grandfathered status
in relation to the benefits in place on March 23, 2010. It is County’s responsibility to inform Contractor whether
changes to the plan have resulted in a loss of grandfathered status. Contractor recommend that County seek the
advice of legal counsel in making this determination and/or before making changes to the medical plan or the business
that might defeat grandfathered status.
County is also required to notify Contractor if contribution rate changes for a grandfathered plan at any point during
the plan year. By accepting each renewal, County represents that the contribution rate towards the cost of coverage
for the upcoming plan year has not decreased by more than 5 percentage points below the contribution rate that was
in effect on March 23, 2010.
Except for specific and limited scenarios described as transitional rules in the health care reform legislation, if a plan’s
grandfathered status has been lost, it cannot be regained. If, after reviewing the grandfathering rules with your benefit
consultant or counsel, County determine that your coverage could be or is grandfathered, and County want to retain
grandfathered status, County should contact the Aetna Account Executive for further instructions.
For customers claiming religious exemption
Certain employers and organizations with a religious or moral objection, may claim an exemption from ACA
contraceptive services coverage requirements, or request an accommodation. If County qualifies and wants to claim
an exemption or request an accommodation, please work with your Aetna Account Executive to submit the required
Certification so Contractor can handle accordingly. Contractor will treat the plan as subject to the ACA contraceptive
services coverage requirements without an executed Certification on file.
HCR Dependent to Age 26
Source documentation of the dependent limiting age is required for plan installation. In the absence of documentation
from the current carrier(s). the fee and Stop Loss rates consider the dependent limiting age is up to age 26/26
student/non-student based on health care reform legislation. The expected claims and, if applicable, the resultant Stop
Loss factors (and claim target factors) contemplate the change to a dependent limiting age of up to 26/26 student/non-
student and may be amended upward upon receipt of the dependent eligibility.
Customers with Retiree Only Plans
Guidance issued by the Internal Revenue Service (IRS), and the U.S. Department of Labor (DOL), and Department
of Health and Human Services (HHS) has indicated that “retiree- only” plans are exempt from the benefit mandates
under the ACA (though retiree-only plans are subject to certain ACA fees and assessments). In order to demonstrate
the establishment of a retiree-only plan, a plan should maintain, separately from the plan for current (i.e., active)
employees, a separate plan document and Summary Plan Description (SPD) and file a separate Form 5500. If County
has a retiree-only plan, and wants to be considered exempt, County may be asked to submit a retiree-only certification
form and required documentation by the Aetna Account Executive.
The benefits and fees within the new business proposal or renewal letter are subject to change pending any required
approvals or future guidance from state or federal regulatory agencies. If County has questions, please contact the
Aetna Account Executive.
Support for summaries of benefits and coverage (SBC) draft documents
At the customer's request, we will provide assistance in connection with the preparation of draft Summary of Benefits
and Coverage (SBCs), subject to the direction, review and final approval of the customer. The development of draft
SBCs by us will be based on the benefits information the customer has provided and existing plan information from
our benefit source system. Contractor will include plan design information in the draft SBC relating to products or
services administered under the system. Contractor will include plan design information in the draft SBC relating to
products or services administered under the Services Agreement as well as any additional pharmacy or behavioral
health carve out information provided by the Customer or its delegate. SBCs are not required for
Exhibit E Page 13
“retiree-only plans” as defined by the Affordable Care Act (ACA) and Contractor will not be supporting generation of
SBCs for “retiree-only plans.”
The customer has the responsibility to review and approve any SBCs and revisions hereto and to consult with their
legal counsel, at their discretion, in connection with said review and approval, as well as to disseminate the final SBC
to Plan participants. Contractor have no responsibility or liability for the content or distribution of any of the
customer's SBCs, regardless of the role Contractor may have played in the preparation of the documents. The
production of SBCs will not be subject to Service or Performance Guarantees.
For applicable plans and policies, the SBC must include statements about whether the plan or coverage provides
minimum essential coverage (MEC) and if the coverage meets minimum value (MV) requirements. Under the
Affordable Care Act (ACA), minimum value and minimum essential coverage determinations are associated with
the employer's shared responsibility provisions. Contractor will include the MV and MEC statements in SBCs that
are produced for plans with effective dates of January 1, 2014, and later. However, Contractor will not make the
MV or MEC determinations. Although it will indicate whether the plans meet or do not meet the minimum value
standard, Contractor do not assume any responsibility regarding determination.
Contractor will provide the SBC in editable format so customers for self-funded plans can update MV and MEC
statements within the document to appropriately reflect their determination for each respective plan. Contractor do
not provide legal or tax advice and recommend that customers consult with their own legal and tax counselors
when making MEC and MV determinations. Contractor have no responsibility or liability regarding the minimum
value or minimum essential coverage evaluation, regardless of the role Contractor may have played in
reviewing/producing the SBC documents. Contractor will review the minimum value standard for the plans based
on the minimum value calculator criteria provided by the Department of Health and Humans Services (HHS).
Employer Reporting Requirements
Under Internal Revenue Code (IRC) Section 6055 health insurance issuers, certain employers, government agencies
and other entities that provide Minimum Essential Coverage (MEC) to individuals must report to the IRS information
about the type and period of coverage and furnish related statements to covered individuals. This information is used
by the IRS to administer the individual shared responsibility provision and by individuals to show compliance with the
individual shared responsibility provision.
IRC Section 6056 requires large employers (those having employed an average of 50 or more full-time employees
during the preceding calendar year) to report to the IRS information about the health care coverage they have offered
and also furnish applicable statements to employees. The purpose is to allow the IRS to enforce the employer
responsibility provisions. Self-funded employers are responsible for collecting and reporting the information to both
the IRS and its employees pursuant to their obligations under both Sections 6055 and 6056. For the collection they
may use a combined form for their 6055 and 6056 reporting. Entities must file returns under the 6055 and 6056
requirements with the no later than February 28 of the year following coverage (if filing on paper) or March 31 if filing
electronically. A statement must be furnished to individuals by January 31 of the year succeeding the calendar year to
which the return relates.
Federal Mental Health Parity*
For self-funded plans, it is the customer’s responsibility to ensure its plan complies with Federal Mental Health Parity
and Addiction Equity Act of 2008 (MHPAEA), including
any and all regulations, amendments, and regulatory guidance. Contractor cannot provide a self-funded Customer
legal advice on the application of MHPAEA (or any other law) to its plan. Where appropriate, Contracotor can share
its determinations concerning the scope and applicability of MHPAEA to our fully-insured plans for illustrative and
informational purposes only. Therefore, the County should consult with its legal counsel to determine compliance
with MHPAEA.
European Union: General Data Protection Regulations (GDPR)
Aetna International has implemented a framework to follow the General Data Protection Regulation (GDPR), which
became law in all European Union (EU) and European Economic Area (EEA) countries on May 25, 2018. This law
gives people greater protection over their personal data, with the potential for significant fines for privacy breaches.
GDPR includes requirements related to data collection, storage and usage among the companies and organizations
that process personal data of individuals in the European Union.
Our domestic plans are not in scope. To help support operational requirements of GDPR, members based in the EU
and EEA must be enrolled in Aetna International plans.
Exhibit E Page 14
State Mandates
Illinois Registration of Business Entities
Contractor will comply with Section 20-160 of the Illinois Procurement Code. If Contractor fails to comply with
Section 20-160 of the Illinois Procurement Code, any contract between parties shall be voidable under Section 50-60
of the Illinois Procurement Code. Contractor has registered as a business entity with the State Board of Elections and
our registration certificate is enclosed. Contractor acknowledges that Contractor has a continuing duty to update the
registration in compliance with applicable Illinois law.
New Jersey A-4 Surcharge
Chapter 8, Public Law 1993, requires health plans of school districts that do not participate in the State Health Benefits
Program (SHBP) to pay an annual surcharge to the program. Referred to as A-4 , the surcharge is determined by the
State Treasurer and is based on a percentage of the total claims paid for the coverage of employees of the
nonparticipating school districts. Plan Sponsors subject to the surcharge are responsible for compliance and payment
in accordance with applicable law. To assist Plan Sponsors in meeting their obligation, on an annual basis, Aetna will
remit payment of the A-4 surcharge on behalf of the Plan Sponsor. Aetna will collect payment from the Plan Sponsor
through the claim wire on an annual basis. The surcharge will appear as a separate line item in the claim wire. Once
an annual reconciliation has been completed, any adjustments required to equal the actual A-4 payment to the State
will be submitted through the claim wire.
New Jersey Out-Of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act
Important information for Customers that have voluntarily elected to participate in the New Jersey Out-Of-Network
Consumer Protection, Transparency, Cost Containment and Accountability Act (The Act). The Act requires employers
sponsoring self-funded health benefits plans to make a voluntary election annually to participate in the Act’s arbitration
program for New Jersey residents’ inadvertent and emergency care claims involving New Jersey out of network
providers. Contact the Aetna account manager if County have
questions.
New York Dependent Age 30
New York law requires that Contractor offers County the option to provide dependent coverage to age 30 or to allow
dependents who reach the maximum age to continue his or her coverage to age 30 under certain conditions. Please
reach out to the Aetna Account Representative for the offer letter.
ACCESSING ASSISTANT FOR PEOPLE WITH DISABILITIES
If you are a person with a disability who needs assistance using our websites (or mobile apps), our Customer Service
Representatives can assist you. Please call them at the number on your member ID Card or at 1-855-401-5713 from
9 a.m. to 5 p.m. ET Monday-Friday. Persons with a hearing or speech disability can use 711 for
Telecommunications Relay Service (TRS). Additional information can be found on the following URL:
https://www.aetna.com/accessibility/accessibility-services.html.