Extracted text (via pymupdf)
66668 characters
Administrative Service Agreement Amendment (ASA Amendment)
Legal Name of Group: CITY OF CHANDLER
Effective Date: 01/01/2025 - 12/31/2025
Group Number(s): 028399
Current Date: 10/15/2024
Strategic Rel. Executive: Christie Thomas
Funding: 12/24 Incurred ASC with Medical and Pharmacy
Days Notice: 210
Underwriter: Brian Cohen
Total Enrollment: 1,872
Specific Stop Loss Limit: $350,000
Broker: SEGAL COMPANY ARIZONA INC: RACHEL MARIE CALISI
Commission (% of Billed Rate): 0.000%
Aggregate Stop Loss Limit: 125%
Commission: 0.000%
Dental Coverage: No
SOLD BENEFITS
Benefit Descriptions
Grandfathered Status
N: Non-Grandfathered
N: Non-Grandfathered
N: Non-Grandfathered
Red Medical Option
Enrollment
Admin
SSL $350K
ASL 125%
Commission
Other
Fixed Cost
ICAP
Exp Liab
Max Liab
Employee
233
$32.81
$100.72
$2.52
$0.00
$0.00
$136.05
$1,139.39
$1,047.56
$1,275.44
Employee + Spouse
174
$32.81
$100.72
$2.52
$0.00
$0.00
$136.05
$1,964.98
$1,708.03
$2,101.03
Employee + Child(ren)
103
$32.81
$100.72
$2.52
$0.00
$0.00
$136.05
$1,730.87
$1,520.75
$1,866.92
Employee + Family
226
$32.81
$100.72
$2.52
$0.00
$0.00
$136.05
$2,877.58
$2,438.11
$3,013.63
Total Plan 1
736
$24,148
$74,130
$1,855
$0
$0
$100,133
$1,435,997
$1,248,929
$1,536,130
Blue Medical Option
Enrollment
Admin
SSL $350K
ASL 125%
Commission
Other
Fixed Cost
ICAP
Exp Liab
Max Liab
Employee
49
$32.81
$100.72
$2.52
$0.00
$0.00
$136.05
$1,115.89
$1,028.76
$1,251.94
Employee + Spouse
12
$32.81
$100.72
$2.52
$0.00
$0.00
$136.05
$1,924.49
$1,675.64
$2,060.54
Employee + Child(ren)
17
$32.81
$100.72
$2.52
$0.00
$0.00
$136.05
$1,695.22
$1,492.23
$1,831.27
Employee + Family
19
$32.81
$100.72
$2.52
$0.00
$0.00
$136.05
$2,818.32
$2,390.71
$2,954.37
Total Plan 2
97
$3,183
$9,770
$244
$0
$0
$13,197
$160,139
$141,308
$173,336
White Plan
Enrollment
Admin
SSL $350K
ASL 125%
Commission
Other
Fixed Cost
ICAP
Exp Liab
Max Liab
Employee
383
$32.81
$100.72
$2.52
$0.00
$0.00
$136.05
$879.81
$839.90
$1,015.86
Employee + Spouse
143
$32.81
$100.72
$2.52
$0.00
$0.00
$136.05
$1,517.34
$1,349.92
$1,653.39
Employee + Child(ren)
101
$32.81
$100.72
$2.52
$0.00
$0.00
$136.05
$1,336.55
$1,205.29
$1,472.60
Employee + Family
412
$32.81
$100.72
$2.52
$0.00
$0.00
$136.05
$2,222.03
$1,913.67
$2,358.08
Total Plan 3
1,039
$34,090
$104,648
$2,618
$0
$0
$141,356
$1,604,415
$1,424,887
$1,745,771
Sold CDH Account Pricing PEPM (Not Included Above)
PEPM Account Fee
White Plan
$2.70
CDH Annual Account Setup Fee (Not Included Above)
# of Accounts
Annual Fee
Annual account setup fee is billed by CDH and is based on the total number of HRA and FSA plans.
0 - 499
$250
500 - 2,999
$500
3,000 +
$1,500
One-Time Fee /
Sharecare Account Summary
Effective Date
Non-Enrollees
Employee
EE + Spouse
EE + Child(ren)
EE + Family
Non-Enrollees
Basic
1/1/2025
No
$0.00
$0.00
$0.00
$0.00
$0
Premium tax is NOT included in the specific and aggregate charges.
Minimum Monthly Attachment Level: $2,880,496.
White Plan
INET: Ded $1,750/$3,500; 85%; OOP $3,500/$7,000; OV/ER/UC Ded+85%; Rx $10/$30/$50/$100 2x MOD;
ONET: Ded $5,000/$10,000; 60%; OOP $10,000/$20,000
(If the Employer has purchased BCBSAZ stop loss coverage, this ASA Amendment amends Exhibit C and Exhibit C-1 of the Maximum Aggregate and Specific Liability
Agreement. If the Employer has NOT purchased BCBSAZ stop loss coverage, this ASA Amendment amends the ASA.)
Red Medical Option
INET: Ded $500/$1,000; 85%; OOP $2,500/$5,000; OV $25/$40; ER $100 Ded+85%; UC $50; Rx $10/$30/$50/$100 2x MOD;
ONET: Ded $1,000/$2,000; 60%; OOP $5,000/$10,000
Blue Medical Option
INET: Ded $750/$1,500; 80%; OOP $2,750/$5,500; OV/UC Ded+80%; ER $100 Ded+80%; Rx $10/$30/$50/$100 2x MOD;
ONET: Ded $1,750/$3,500; 50%; OOP $6,500/$13,000
Monthly PEPM Fees
Sold Rates Effective 01/01/2025
Health Savings Account
Employers selecting Consumer-Directed Healthcare (CDH) Account Administration (including integration), for account types; HSA, HRA, FSA, DCFSA & LPFSA, hereby direct BCBSAZ to collect the
administration fees and forward the proportional fees to HealthEquity for services, along with the required personal health information. BCBSAZ collects CDH Account administration fees and is not responsible
for any reconciliation, recoupment or adjustments to payments received and forwarded to on behalf of Employer.
Employer agrees to pay for charges for CDH administration services. For HSA and HRAs, these charges apply to all employees enrolled in a health plan the group has paired with a CDH account. For FSAs,
those charges apply to any employee for whom an FSA election has been sent to BCBSAZ by the employer.
Proposed administration assumes BCBSAZ will retain Rx Rebates. In exchange for retaining Rx Rebates, BCBSAZ has adjusted the Admin PEPM by the Rx Rebate Credit. Rx Rebate Credit (PEPM) = $31.00.
In addition to the Rx Rebate Credit (PEPM), BCBSAZ is also providing a rebate share agreement based on utilization of brand name drugs eligible for rebates. Please see the assumptions for details.
Fixed Expenses = Admin Charges + Stop Loss Premium + Commission (if applicable). Exp Liab = Fixed Expenses + ICAP/Aggregate Corridor. Max Liab = Fixed Expenses + ICAP.
Page 1 of 7
028399 - 4
EXHIBIT 1
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
Mayo is not included as an in-network provider.
Consumer-Directed Healthcare (CDH) services were purchased and will be billed as an additional charge to the above premium rates. See the CDH rate exhibit for details.
Out-of-Network Shared Savings: 15% with $10,000 cap per claim.
Sharecare (Basic): included. See Assumptions for details.
Rx coverage through BCBSAZ: Yes. Rx applies to stop loss products: Yes.
Subrogation: Included.
Rx Formulary: Open.
BCBSAZ reserves the right to adjust these premium rates retroactive to the first day of any billing month in which enrollment varies by more than fifteen percent (15%) from that listed above.
10/15/2024
BCBSAZ Representative
Date
Group Representative Signature
Group Representative Title
Date
This Rate Acceptance Form must be signed and returned prior to BCBSAZ issuing ID Cards. The Agreement will terminate if this Amendment is not signed and returned prior to the end of your current term. If
any information on this Form is inaccurate, please provide the correct information on this Form.
$80,000 Misc. Trust & Wellness allowance, $100,000 On Site Wellness Consultant allowance, $25,000 General Fund allowance, and $5,000 Audit Allowance allowance are included. See Assumptions for
details.
Administrative rate guarantee is included. Performance Guarantee is included. See Assumptions for details.
Chiropractic Capitation: $2.93 PMPM. UM Services: excluded. Value Based Services: included.
All information from the exhibit Assumptions IASC-2025-028399-4, Administrative Summary, Guarantees and Disclosure of 'Eligible Indirect Compensation' (Exhibit 1) incorporated herein by reference.Employer
acknowledges electronic receipt of the Uniform Summaries of Benefits and Coverage (SBCs) for plans selected and the SBCs are incorporated herein by reference. As of the effective date on page 1, this
amends and is made part of Employer's Administrative Service Agreement (ASA) with BCBSAZ. All provisions in the ASA not modified by this Amendment remain in full force and effect.
The ACA prohibits waiting periods in excess of 90 days. By signing below you represent that you do not impose a waiting period which is longer than 90 days and that you have made all necessary changes to
bring all waiting periods for your plan into compliance with the ACA requirements. You agree to promptly advise BCBSAZ of any change which may impact the accuracy of this representation. You agree to
provide BCBSAZ with timely and accurate information regarding enrollee effective dates and shall ensure such effective dates comply with applicable laws.
Page 2 of 7
028399 - 4
APPROVED AS TO FORM:
By: __________________________________________
City Attorney
ATTEST:
By: __________________________________________
City Clerk
Mayor
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
CITY OF CHANDLER
Group Number(s):
028399
Renewal Period:
01/01/2025 - 12/31/2025
Assumption: IASC-2025-028399-2
GENERAL
* BCBSAZ may adjust rates if the following requirements are not met:
Where the employer does not contribute 100%, BCBSAZ requires 70% of all eligible employees to participate.
BCBSAZ requires a minimum of 50% of all full-time eligible employees in the group to be enrolled in the employer's group plan.
Employer must contribute a minimum of 50% of the employee's health premium.
Payroll deduction for employee contribution is required.
*
* BCBSAZ reserves the right to re-evaluate the rates if there is a significant change in the rating assumptions (e.g. enrollment).
*
*
*
*
*
PHARMACY
*
30 days retail - $50.00 per eligible brand script,
90 day retail - $203.00 per eligible brand script,
Mail Order Delivery - $219.00 per eligible brand script,
Specialty Home Delivery - $881.00 per eligible brand script.
Blue Cross Blue Shield of Arizona (BCBSAZ) Assumptions
Where the employer contributes 100% of the employee cost, BCBSAZ requires 100% participation of all eligible employees, excluding
those with other qualifying medical coverage.
Rates assume BCBSAZ is the sole medical and Rx carrier.
Beginning in 2015 the Affordable Care Act provides that certain large employers will be subject to a penalty if they fail to offer full-time employees and
certain dependents health coverage which satisfies both a 60% minimum value standard and an affordability requirement and a full-time employee obtains
a subsidy on the health insurance marketplace. Groups subject to these requirements and seeking to avoid a penalty are responsible for the ultimate
determination of whether the minimum value and affordability requirements are satisfied. Using the minimum value calculator made available by HHS and
the IRS, BCBSAZ estimates that the minimum value of Red Medical Option, Blue Medical Option, White Plan, plans do meet the minimum value standard.
It is important that you independently review and confirm these results as they may be impacted by information not available to us (for example, benefits not
provided by BCBSAZ, non-standard benefits not suited for the calculator and certain HSA contributions or HRA funds). BCBSAZ has included its
conclusion(s) about minimum value in the plan(s) SBC(s) that BCBSAZ provides to Group. Any changes that Group makes to that conclusion based on
Group’s independent analysis will also affect the minimum value statement(s) in the SBC.
BCBSAZ reserves the right to re-evaluate and change the rates if City of Chandler adds or deletes a benefit eligible class that will have BCBSAZ medical
coverage.
We have not included premium tax on this account, based on the assumption that all premiums are paid with the employer's funds, and the employer is a
municipality.
To view compensation BCBSAZ may receive if you purchase certain third-party products, visit azblue.com/compensation
The Plan Sponsor is responsible for design of the Plan, including any modification or termination of the Plan, and retains sole and complete control to select
and change the formularies for its Plan.
If BCBSAZ receives pharmacy rebates attributable to pharmaceutical products covered under the terms of this Agreement and used by Participants of
Employer’s Plan, BCBSAZ will pay Employer the following amounts for brand prescriptions filled and for which BCBSAZ received a rebate:
Employer acknowledges that it accepts these amounts and that it and its group health plan have no right to, or legal interest in, any rebates provided by
pharmaceutical manufacturers to BCBSAZ.
Notwithstanding anything to the contrary in the Agreement, nothing in this Agreement shall restrict Group’s ability to access or share the information
specified in ERISA Section 724 (commonly referred to as the No Gag Clause provision) for the purposes permitted in ERISA Section 724.
Page 3 of 7
028399 - 2
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
CITY OF CHANDLER
Group Number(s):
028399
Renewal Period:
01/01/2025 - 12/31/2025
Assumption: IASC-2025-028399-2
FUNDING
*
* BlueCard fees are included in the Attachment Point rate (if applicable) and are charged on the monthly invoice as a claim expense.
* The Specific Stop Loss level is $350,000 per person per policy year.
*
*
DISCLOSURE
*
*
* BCBSAZ Value Based Programs
PBM PRICING MODEL: Pharmacy Network discounts are negotiated between BCBSAZ and our pharmacy benefit manager (PBM) over BCBSAZ’s entire
book of business and not on behalf of any group customer. You have selected the pass through PBM pricing model effective 1/1/2025. The pass through
PBM pricing model allows you to pay the same discounted prices for prescription drugs that the PBM actually pays the pharmacies. Prices for the same
drug may differ at different pharmacies. The Pass Through PBM pricing model passes on to you 100% of the specific pharmacies' network discount.
However, it does not allow the PBM to lower the prices for expensive drugs by applying savings realized elsewhere. Any projected savings discussed with
you that may result from this pricing are only estimates. Your actual savings may vary from these estimates.
Rates assume BCBSAZ is the sole Specific and Aggregate Stop Loss carrier.
If the Group Participant with the redacted ID number xxxxxx971-01 terminates coverage under Group's plan (including ceasing any elected COBRA
coverage), BCBSAZ agrees to re-rate Group's specific stop-loss premium for the remaining months of the 2025 policy period to factor in that change.
BCBSAZ will continue to process claims incurred during the renewal term of the Agreement (January 1, 2025 - December 31, 2025 for a period of 24
months after the end of the renewal term. Stop loss coverage will apply to claims incurred during the renewal term and paid during the renewal term or
within 24 months after the end of the Renewal Term. If the Agreement is terminated before December 31, 2025, the foregoing 24 month periods shall start
on the effective date of the termination of the Agreement. BCBSAZ's obligations are contingent upon Employer satisfying its payment obligations.
With respect to BCBSAZ group members residing and receiving Value Based Services in Arizona under a BCBSAZ value based program, BCBSAZ will
estimate at the beginning of the contract year the amount BCBSAZ projects it will pay BCBSAZ’s contracted providers for members who receive Value
Based Services throughout the upcoming year in the form of a PMPM or PEPM charge (“PMPM Charge”). BCBSAZ will charge BCBSAZ’s self-insured
(“ASC”) Groups via the Employer’s Claims Invoice this PMPM Charge beginning January 1, 2016.
Costs for covered services provided by a chiropractor to PPO, EPO, HMO and indemnity members, including an allowance for BCBSAZ to maintain this
arrangement, will be paid by the Employer to BCBSAZ on a per member per month (PMPM) basis. The PMPM rate each Employer pays BCBSAZ will differ
from the capitated fee BCBSAZ negotiated with the chiropractic administrator. BCBSAZ negotiated the fee that BCBSAZ pays the chiropractic administrator
on the basis of BCBSAZ’s entire book of business, without regard to any individual Plan. The PMPM rate BCBSAZ charges the employer is subject to
change by BCBSAZ upon 60 days prior written notice. The PMPM rate for chiropractic services applicable to this Employer is $2.93 PMPM. Any difference
between this amount and the amount paid to the chiropractic administrator will be reflected on the employers Form 5500 Information (if BCBSAZ provides
one). The fee BCBSAZ pays may be adjusted at any time as a result of modifications to the contract between BCBSAZ and chiropractic provider.
Additionally, the fee may be decreased in a given year if a set claims to capitation ratio is not achieved. Neither of these adjustments to the fee BCBSAZ
pays would result in adjustment to the fee applicable to Employer.
Third Parties: BCBSAZ charges a per member per month (PMPM) or other specified amount for certain services provided by third-parties which includes
an allowance for BCBSAZ to maintain these arrangements. This PMPM or other amount may be different than the amount BCBSAZ pays the third-party
and BCBSAZ will retain any difference as reasonable compensation for services provided. In some cases, the amount retained by BCBSAZ and received
by the third-party is a percentage of the savings or recoveries generated by the third-party services. Certain of these third-party contractual arrangements
may involve reconciliation processes or other adjustments which may further change the amount paid to the third-party or retained by BCBSAZ. The rate
BCBSAZ charges the employer is subject to change by BCBSAZ upon 60 days prior written notice. The fee BCBSAZ pays may be adjusted at any time due
to modifications of the contract between BCBSAZ and the third-party. BCBSAZ negotiates the fees it pays these third-parties on the basis of BCBSAZ’s
entire book of business, without regard to any individual plan.
Value-Based Program (VBP) is outcome-based payment arrangement and/or a coordinated care model facilitated with one or more local providers that is
evaluated against cost and quality metrics/factors and is reflected in provider payment.
LOCAL - BCBSAZ pays some of its contracted medical providers an amount to manage the medical care of members diagnosed with certain medical
conditions if the provider demonstrates to BCBSAZ it has satisfied BCBSAZ’s criteria for effectively managing the care (“Value Based Services”).
Page 4 of 7
028399 - 2
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
CITY OF CHANDLER
Group Number(s):
028399
Renewal Period:
01/01/2025 - 12/31/2025
Assumption: IASC-2025-028399-2
a.
b.
Inter-Plan Arrangements Fees:
BlueCard Program Fees
Access Fees:
·
1.84% in 2025 for 1,000–9,999 Blue PPO, EPO (Self-Funded Group Health Plans Only) or traditional enrolled contracts
·
Professional - $4.00 per claim
·
Institutional - $9.75 per claim
·
Non-Participating Provider $3.00 per claim
·
Medicare related claims $1.00 per claim
·
* Out-of-Network Shared Savings
*
ALLOTMENTS
*
*
On an aggregate basis for the entire Value Based Program, the amounts used to calculate PMPM charge are fixed amounts estimated to be necessary
to finance the cost of a particular Value-Based Program. Because amounts are estimates, there may be positive or negative differences based on actual
experience, and such differences will be accounted for in a variance account maintained by BCBSAZ until the end of the applicable Value-Based Program
payment and/or reconciliation measurement period. The amounts needed to fund a Value-Based Program may be changed before the end of the
measurement period if it is determined that amounts being collected are projected to exceed the amount necessary to fund the program or if they are
projected to be insufficient to fund the program.
On an aggregate basis for the entire Value Based Program, at the end of the Value-Based Program payment and/or reconciliation measurement period
for these arrangements, BCBSAZ will do one of the following:
Use any surplus in funds in the variance account to fund Value-Based Program payments or reconciliation amounts in the next measurement period.
Address any deficit in funds in the variance account through an adjustment to the PMPM billing amount or the reconciliation billing amount for the next
measurement period.
NOTE: If an ASC Group terminates its BCBSAZ contract, that Employer will neither receive a refund nor a charge to reflect any variance between what
BCBSAZ charged the Employer in Value Based Charges and what BCBSAZ paid the providers for Value Based Services.
NATIONAL - Value Based Services will also apply to your members who reside in other states/geographical locations served by other Blue Cross Blue
Shield Plans. A full description of these arrangements will be described in your contract.
BCBSAZ developed and maintains a proprietary fee schedule and utilizes claim editing software to calculate the Allowed Amount. Costs for calculating the
Allowed Amount for Out-of-Network Services will be paid by the Employer to BCBSAZ on a percentage of claims savings basis. The cost for this service is
15% of claims savings with $10,000 cap per claim. This cost will not be applied to Group's ASL and/or SSL. BCBSAZ has hired a third party to attempt
negotiation of reimbursement and member protection from balance billing for Out-of-Network Services. When the third party negotiation is successful,
BCBSAZ will pay the vendor’s fees with no additional charge to the Employer.
Sharecare: For certain Sharecare programs that Employer has specifically elected to purchase, BCBSAZ charges an amount per person which may be
based upon employee count, member count or program participation depending on the specific program purchased. These charges will be included in the
monthly claims invoice and may be different than the amount BCBSAZ pays Sharecare. BCBSAZ will retain any difference as reasonable compensation for
services provided. For the Sharecare Incentive Reward Program, BCBSAZ will charge Employer the amount of the award plus any applicable
administrative fees and include this charge in the monthly claims invoice. The rates BCBSAZ charges Employer for the Sharecare programs are subject to
change by BCBSAZ upon 60 days’ prior written notice. BCBSAZ negotiates fees with Sharecare on the basis of BCBSAZ’s entire book of business, without
regard to any individual plan. The one-time setup fees are built into the admin rate as a PMPM (per member per month) charge.
Reduced Administrative Expense Allowances (AEAs) – To be considered for reduced fees, the Employer must exceed 1,000 PPO, EPO (Self-Funded
Group Health Plans Only) or traditional enrolled Blue contracts:
Non-standard negotiated fees can range from either $5.48 to $15.44 per claim or $8.50 to $21.10 per contract per month depending on the negotiated
arrangement and/or the health plan product.
BCBSAZ's proposal includes a(n) Misc. Trust & Wellness allowance of $80,000 for the 01/01/2025 - 12/31/2025 policy period. Any portion of the misc. trust
& wellness not used during the referenced policy period will be retained by BCBSAZ and applied to misc. trust & wellness programs for subsequent policy
period(s). Upon termination of the group contract, BCBSAZ will pay any unused portion of the misc. trust & wellness allowance to Group. If group terms its
contract prior to 12/31/2025, the group will be required to return a prorated amount of the disbursed funds.
BCBSAZ's proposal includes a(n) On Site Wellness Consultant allowance of $100,000 for the 01/01/2025 - 12/31/2025 policy period. Any portion of the on
site wellness consultant not used during the referenced policy period will be retained by BCBSAZ and applied to on site wellness consultant programs for
subsequent policy period(s). Upon termination of the group contract, BCBSAZ will pay any unused portion of the on site wellness consultant allowance to
Group. If group terms its contract prior to 12/31/2025, the group will be required to return a prorated amount of the disbursed funds.
Page 5 of 7
028399 - 2
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
CITY OF CHANDLER
Group Number(s):
028399
Renewal Period:
01/01/2025 - 12/31/2025
Assumption: IASC-2025-028399-2
*
*
BCBSAZ's proposal includes a(n) General Fund allowance of $25,000 for the 01/01/2025 - 12/31/2025 policy period. Any portion of the general fund not
used during the referenced policy period will be retained by BCBSAZ and applied to general fund programs for subsequent policy period(s). Upon
termination of the group contract, BCBSAZ will pay any unused portion of the general fund allowance to Group. If group terms its contract prior to
12/31/2025, the group will be required to return a prorated amount of the disbursed funds.
BCBSAZ's proposal includes a(n) Audit allowance of $5,000 for the 01/01/2025 - 12/31/2025 policy period. Any portion of the audit allowance not used
during the referenced policy period will be retained by BCBSAZ and applied to audit allowance programs for subsequent policy period(s). Upon termination
of the group contract, BCBSAZ will pay any unused portion of the audit allowance to Group. If group terms its contract prior to 12/31/2025, the group will be
required to return a prorated amount of the disbursed funds.
Page 6 of 7
028399 - 2
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
CITY OF CHANDLER
Group Number(s):
028399
Renewal Period:
01/01/2025 - 12/31/2025
Assumption: IASC-2025-028399-2
GUARANTEES
On-site
* BCBSAZ agrees to an administrative rate guarantee for 1/1/2026 - 12/31/2030.
Wellness
Wellness General
Audit
PEPM
Increase
Allowance
Consultant
Fund
Allowance
1/1/2026 - 12/31/2026 Net Administration Rate
$33.79
3.0%
$80,000
$100,000
$25,000
$5,000
1/1/2027 - 12/31/2027 Net Administration Rate
$34.80
3.0%
$80,000
$100,000
$25,000
$5,000
1/1/2028 - 12/31/2028 Net Administration Rate
$35.85
3.0%
$80,000
$100,000
$25,000
$5,000
1/1/2029 - 12/31/2029 Net Administration Rate
$36.92
3.0%
$80,000
$100,000
$25,000
$5,000
1/1/2030 - 12/31/2030 Net Administration Rate
$38.03
3.0%
$80,000
$100,000
$25,000
$5,000
This guarantee is contingent upon BCBSAZ being selected as the sole stop loss carrier (Specific and Aggregate) for the entire policy period 1/1/2026 -
12/31/2030 (5 years).The rate guarantee excludes any Allotments, Claim Deposit Credits, which will be subject to pricing information at the time of each
renewal. This guarantee assumes BCBSAZ retains all Rx rebates during the time of the guarantee. Guaranteed administration rates assume all quoted
benefit plans remain Rx rebate eligible throughout the guarantee period. BCBSAZ reserves the right to change the rate guarantee due to legislative
changes.
Total enrollment changes do not exceed +/-15%. Total enrollment as of Apr 2024 is 1,872 subscribers and 4,701 members.
Page 7 of 7
028399 - 2
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
Vendor Name
Contact Name
Contact Title
Contact Number
Authorized Signature
PERFORMANCE GUARANTEES
(ALL PROPOSERS)
For the following categories, provide the performance standard you
are willing to offer, the financial penalty (maximum dollar amount
or % of administrative fees) you will agree to pay if the standard is
not met, and the method of measuring the penalty.
Measurement
Frequency
Agree to comply with
Performance
Guarantee?
(Y | N)
Dollars at Risk
(% or $)
1.
Vendor attendance at District meetings
Quarterly
See original for signature.
VENDOR RESPONSE
CITY OF CHANDLER
PERFORMANCE GUARANTEES
Blue Cross® Blue Shield® of Arizona (BCBSAZ)
Christie Thomas
Strategic Relationship Executive
(602) 864-5234
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
Attendance by vendor representatives when requested at
meetings scheduled by the City of Chandler during the
contract period and implementation phase.
BCBSAZ Alternative Recommendation: BCBSAZ proposes
the Account Management Performance Guarantee.
Standard: Overall score of 3 (satisfied) or better on the
BCBSAZ Account Management Score Card (annual Group
Benefit Administrator survey) – see attached.
Desired Qualifiers: Categories include: effective support for
open enrollment events, timely client notification of issues
impacting members, response to client issues and questions
in timely, comprehensive manner, effective coordination to
resolve open issues, accessibility, and delivery of agreed-
upon reports on time.
Group specific
Measured annually
Yes
2% of annual
admin fee
2.
Vendor call (or e-mail) return timeliness
Quarterly
City of Chandler or designated consultant’s calls (or e-mails)
to vendor are returned within 48 business hours.
BCBSAZ Alternative Recommendation: BCBSAZ proposes
combining PGs 1 and 2 under the Account Management
guarantee, which guarantees ongoing communication and
support activities, including accessibility.
See #1 above.
Yes
See #1 above.
3.
Processing monthly eligibility updates
Monthly
All updates to eligibility or enrollment records will be made
within three business days after the information is received by
the vendor.
BCBSAZ Alternative Recommendation: Standard: 99% of
valid electronic eligibility files are processed within five
business days of receipt of complete and accurate
information during initial implementation.
Group Specific
Measured quarterly
Yes
2% of annual
admin fee
4.
Telephone call availability & answering speed
Monthly
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
90% of all calls are answered within 30 seconds, and
telephone service is available between 8:00 am and 6:00 pm
Arizona Time Zone on business days.
BCBSAZ Alternative Response: Standard: BCBSAZ
Customer Service calls answered in an average of 45
seconds or less.
Desired Qualifier: Average speed of answer begins once the
caller exits the IVR.1
Non-Group specific
Customer Service hours are 6 a.m. to 6 p.m. (Arizona time),
Monday through Friday.
Measured quarterly
Yes
2% of annual
admin fee
5.
Telephone call on-hold (in-queue) time
Monthly
An average of less than 2 minute(s) on hold before a human
being answers.
BCBSAZ Alternative Recommendation: This guarantee is
combined with PG #4 (telephone call availability and
answering speed).
See #4 above.
Yes
See #4 above.
6. Telephone Abandonment Rate
Monthly
An abandonment rate of less than 3% is maintained during
standard business hours.
BCBSAZ Alternative Recommendation: Less than 5% of
BCBSAZ Customer Service calls abandoned.
Desired Qualifier: Call abandonment rate applies to calls
abandoned once the caller enters the call queue.1
Non-Group specific
Measured quarterly
Yes
2% of annual
admin fee
7.
Claims Processing Accuracy
Quarterly
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
99% of claims dollars submitted for payment will be
accurately processed and paid. Regardless of whether or not
these standards of performance are satisfied, the vendor
must reimburse the City of Chandler for all overpayments that
are not recovered from the recipient within 60 days after the
overpayment is discovered. City of Chandler will assign its
right to recover such overpayments to the vendor.
BCBSAZ Alternative Recommendation: Standard: 98% of
audited1 claims dollars are paid in accordance with benefit
plan designs and in-force provider contracts.
Desired Qualifier: This penalty applies if BCBSAZ fails to
perform in accordance with this standard two (2) consecutive
reporting periods. A penalty pay out of half of the fees at-risk
would occur for results at or below 97.5%.1
Non-Group specific
Measured quarterly
Yes
2% of annual
admin fee
8. Turnaround Time on Claims Payments
Quarterly
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
95% of all claims received will be completely processed
(paid, denied or pended for additional information) within 14
calendar days after they are received. 100% of claims will be
processed within 30 calendar days of receipt.
BCBSAZ Alternative Recommendation: Standard: 90% of
non-investigated clean claims processed (paid or rejected)
within 14 calendar days after receipt of clean claim.1
Desired Qualifier: A claim is defined as a request for a
payment of a plan benefit by a plan participant or health care
provider; a claim is deemed received when it has been time-
stamped by BCBSAZ. Claims pended for missing information
or benefit eligibility will be included as a documented claim.
Non-Group specific.
Claims processing penalties are not applicable on claims
incurred outside of Arizona.
Measured quarterly
Yes
2% of annual
admin fee
9.
Timeliness of Claim Reports
Annually
Each report the vendor will supply City of Chandler will be
provided within a mutually agreed upon timeframe but no later
than the 10th of the month following.
BCBSAZ Alternative Recommendation: Standard: Monthly
standard reports will be delivered on time.
Desired Qualifier: Delivery of standard reports: whYzen-
BlueInsightSM, our self-serve online reporting tool is available
online, and updated the 20th of the month.
Group specific
Measured annually
Yes
2% of annual
admin fee
10. Claims Coding
Annually
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
98% of all claims will be coded with no errors.
BCBSAZ Alternative Recommendation: Standard: 95% of
audited claims are processed in accordance with benefit plan
designs.1
Desired Qualifier: Percentage of claims processed
incorrectly vs. correctly, based on BCBSAZ standard auditing
procedures.
Non-Group specific
Measured quarterly
Yes
2% of annual
admin fee
11. Implementation (if appropriate)
Annually
Successful implementation as defined by key milestones.
Include measurable milestones in your proposal.
BCBSAZ Alternative Recommendation: Standard: BCBSAZ
will complete a successful implementation as defined by key
milestones.
Desired Qualifier: BCBSAZ agrees to meet milestones as
outlined on the proposed implementation timeline (See
Section 5). Note: the current proposed implementation
timeline will be agreed upon and finalized during initial
implementation meetings.
Group specific
Measured 90 days
after effective date and
paid out 120 days after
effective date.
Yes
2% of annual
admin fee
12. Data Exchange
Annually
Receive and transmit data with vendors based on a
frequency defined by the business needs of the City of
Chandler.
BCBSAZ Alternative Recommendation: Standard: BCBSAZ
will receive and transmit data with vendors based on a
frequency defined by the business needs of Client.
Desired Qualifier: Should BCBSAZ interface with any
independent vendors to service client, we agree to establish
appropriate mutually agreeable performance standards for
data transmission.
TBD
TBD
Yes
2% of annual
admin fee
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
Unauthorized replication or use of this financial workbook is prohibited.
Copyright © 2022 by Segal. All rights reserved.
Comments
Total of all risk measures cannot exceed 20% (based on administrative fee only).
1 If BCBSAZ fails to perform in accordance with these guarantee(s) for two (2) consecutive reporting periods after the guarantee(s) are
effective, BCBSAZ will refund or credit the group up to the amount at risk per measure during the time period which BCBSAZ did not meet
the performance guarantee(s).
Additional BCBSAZ Notes:
1. The above stated performance guarantees will be effective for the contract period 1/1/2025 to 12/31/2025.
2. The performance guarantee payout does not include stop loss premiums, claims reimbursement amounts, vendor interface fees,
capitated claim payments, etc.
3. Performance guarantees are reported to the client approximately 90 days after the close of the measurement period or plan year. Payout
is made (if applicable) after the reporting of results.
4. BCBSAZ will not be required to pay a penalty for performance guarantees if the group is in default of its contract with BCBSAZ and/or
has not paid all claims and premiums by the date due.
5. BCBSAZ will determine the sample size of audited claims.
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
Administrative Summary
1
Rev: ASC_09.11.2024
Client Information
Effective Date
1/1/2025
Client Name and Group Number
AZBlue Group Number(s)
Legal Account Name
Doing Business As
Legal Entity Type
Type of Business
028399
City of Chandler
City of Chandler, Arizona
Municipality
City
Tax ID Numbers
Federal:
86-6000238
State:
07004582
Headquartered State
Incorporated State
Headquarters State:
Arizona
Incorporated State:
Arizona
Client Address
175 S. Arizona Avenue
Chandler, AZ 85225
Billing Correspondence Address
☐ Same as the client address
☒ Other:
P.O. Box 4008, Mail Stop 703
Chandler, AZ 85244
Group Benefit Administrator (GBA)
Primary GBA
Fernanda Acurio
Benefits and Compensation Manager
480-782-2359
Fernanda.Acurio@chandleraz.gov
Secondary GBA
Rae Lynn Nielsen
Director of Human Resources
480-782-2353
Raelynn.Nielsen@chandleraz.gov
Billing Contact
Denise Hooker
Benefits Analyst
P.O. Box 4008, Mail Stop 703
Chandler, AZ 85244
480-782-2371
Denise.Hooker@chandleraz.gov
Group Executive
Rae Lynn Nielsen
Director of Human Resources
480-782-2353
Raelynn.Nielsen@chandleraz.gov
Chief Financial Officer
Dawn Lang
Deputy City Manager – Chief Financial Officer
480-782-2255
Dawn.Lang@chandleraz.gov
Chief Executive Officer
Joshua Wright
City Manager – CEO
480-782-2211
Joshua.wright@chandleraz.gov
Additional Authorized Group Contact(s)
Rebecca Davis
Human Resources Specialist
480-782-2376
Rebecca.davis@chandleraz.gov
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
Administrative Summary
2
Rev: ASC_09.11.2024
Product Information
Member ID Number Issuance
(Generated by AZBlue; includes alternate ID numbers)
Included
HealthEquity Integration and Sections
Integration with HealthEquity
☒Yes
☐No
Enrollment Section Set up
☒Yes, set up non-
integrated HDHP products
☐No, all HDHP members
will be integrated with
HealthEquity
Summary of Benefits and Coverage
•
Draft Summary of Benefits and Coverage
•
Review initial drafts with the Client and revise as
agreed
•
Member SBCs will be available to members in
their MyBlue portal account.
Included
☒No printing, AZBlue will provide electronic copies to the
Client/Broker and member portal
Benefit Plan Booklets
•
Prepare draft Benefit Plan Booklet(s)
•
Review initial draft(s) with Client
•
Revise the initial draft(s) in response to the
Client’s comments and obtain the Client’s
approval of the second draft
•
Prepare final Benefit Plan Booklet(s).
•
Benefit Plan Booklet(s) will be in English.
Included
☒No printing, AZBlue will provide electronic copies to the
Client/Broker and member portal
Assignability of benefits
•
If a member receives covered services from an
out-of-network provider and the member wishes
to assign the right to payment to the provider, the
member or the provider may submit the
documents requesting assignment to AZBlue.
•
AZBlue, at our sole discretion, will determine
whether to honor the assignment and, if
approved, remit any payment due directly to the
provider.
☒The group has selected this option
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
Administrative Summary
3
Rev: ASC_09.11.2024
Account Management Services
Implementation Meeting Schedule
Included
Ongoing Account Management:
•
Designated account resources
•
Ongoing management and review of
administration, benefits, and data
Included
Open Enrollment Meetings:
•
At locations that meet AZBlue criteria (available
upon request)
•
AZBlue will attend Open Enrollment meetings as
agreed upon
Included
Annual Consultation:
•
Cost impact of benefit design changes
•
Projection of conventional premium equivalent
rates
•
Year-end accounting reconciliation
Included
Annual 1099 filings to the IRS (regarding
payments to providers)
Included
Standard Accounting Structure:
•
Individual group numbers for each member of a
Pool, if applicable
•
Suffixes to accommodate separate claims
reporting for different benefit plans (i.e., PPO
Plan, HSA Plan, Alliance Plan)
•
Claim accounts to accommodate separate
claims data for distinct locations and employee
types (i.e., COBRA, Retiree, School)
Included
Administrative Fee Statements:
•
Statements generated monthly 15 business
days before the due date
•
Due date is the first of the month.
•
The contract has a grace period of thirty-one
(31) days for premium payments. If a premium
is not paid on or before the date it is due, it
may be paid during the grace period.
•
Billed on a prospective basis
•
Option for online or hard copy delivery of
statements
•
Ability to view invoices online & and download
billing information
•
Ability to sort and search member information
•
Ability to remit payment for Charges for
Covered Services, Administrative Fees, Other
Fees, and any other fees due via ACH, EFT, or
check.
•
Includes a full listing of each enrollee,
summary, and total by section
•
Discrepancies can be addressed with an AZBlue
representative
Included
Premium Statements Delivery:
Included
☐AZBlue will mail hard copies
☒Hard copies will be suppressed, and the group will utilize the
Portal to obtain Premium Statements
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
Administrative Summary
4
Rev: ASC_09.11.2024
Group Administration, Eligibility and Open Enrollment Services
Employee Effective Date
☒First of the month
Employee Termination Date
☒End of the month
Dependent Birthday Termination (Age 26)
☒End of the month
Newborn/Adoptions/ Processing Options
☐
Newborn automatically added; member must request
disenrollment.
☒
Newborns are automatically added for the first 31 days
after birth; the member positively enrolls the newborn on
the plan for coverage after 31 days
Newborn Letters
☐Standard Newborn letter will be sent
☒Custom Newborn letter
Newborn Deductible
☐Newborn deductible applies
☒Newborn deductible waived
Domestic Partnership
☐Same-Sex Only
☐Opposite Sex Only
☐Both
☒Not covered
Domestic Partnership Criteria
☐AZBlue Standard Criteria
Criteria will be published in the Benefit Plan Booklet
☐Client Specific Criteria (or Other)
Client specific criteria will not be printed in the benefit
booklet; Employees will be referred to the Group Benefit
Administrator
Retiree Coverage
☒Yes ☐No
If Yes:
☒Under 65 ☒65 and older
Retiree dependents coverage
☒Yes ☐No
As of January 1, 2024, the City mandates Medicare
enrollment for retirees and their dependents who become
Medicare-eligible in order to remain eligible for continued
coverage under the City of Chandler medical plan. Retirees
and their dependents who became Medicare-eligible before
January 1, 2024, but did not enroll in Medicare are
grandfathered and remain eligible for medical plan
coverage.
Retroactive Termination
Retroactivity is limited to thirty-one (31) days from the date
notice provided to AZBlue for terminations, changes, and
reinstatements.
Leave of Absence
☐90 days
☒Other: Please refer to City of Chandler Statement of
Eligibility as approved by Resolution No. 4995
Enrollment Eligibility Submission
☒ (834) Electronic file submission via secure file transport
☐ Excel (AZBlue will provide the required format)
☐Portal
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
Administrative Summary
5
Rev: ASC_09.11.2024
Eligibility Vendor details
Vendor: City of Chandler
Contact Phone: Primary: Denise Hooker
480-782-2371
Secondary: Rebecca Davis
480-782-2376
Contact email: Denise.hooker@chandleraz.gov
Rebecca.davis@chandleraz.gov
Ongoing Eligibility updates/ files- Type
☐AZBlue Employer Portal Submissions
☐Excel (AZBlue will provide the required format)
☐Paper Applications
☒ (834) Electronic file submission via secure file transport
Frequency of files or Portal Updates
☐Portal Updates
☒Full File
☐Change Only file
☐Maintenance File
☐Daily
☒Weekly
☐Bi-Weekly
☐Monthly
Who should receive the Discrepancy reports?
Name:
Title
Phone:
Email:
benefits@chandleraz.gov
Open Enrollment Eligibility Transmission
Method:
834
Date:
11/22/2024
*Enrollment must be received no later than November 26,
2024, to ensure ID cards are delivered by January 1, 2025*
COBRA Vendor Contact
Name of Vendor:
Alight
Contact Name:
Shaun Smith
Phone:
410-568-2351
Email:
Shaun.smith.3@alight.com
COBRA Processing
In the event the Client has future COBRA enrollees, the
Client will provide one of the following:
1. A Blanket Guarantee letter that includes a
guarantee of payment for the Client’s first
month’s premium for all employees?
2. A Guarantee letter for specific members at the
time of COBRA?
Will the COBRA submission be a paper application or on the
file?
Letter selection:
☐Blanket Guarantee
☐Specific member letter
Not Applicable- members come
on 834 file transmission
COBRA submission:
☐Cobra Election Form or Paper
Application
☒Transmitted via file
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
Administrative Summary
6
Rev: ASC_09.11.2024
Coordination of Benefits (COB)
Commercial:
The combined payments by the primary payer and AZBlue
will not exceed the greater of the primary payer or AZBlue
allowed amount.
Medicare:
AZBlue pays up to the Medicare-allowed amount except if
the provider does not accept Medicare assignment, in
which case AZBlue pays up to the billed charges.
When your group health plan is the secondary payer,
BCBSAZ utilizes the COB methodology that applies to your
group health plan (and not the ACA methodology) to
adjudicate claims for emergency services provided by non-
contracted providers.
As of January 1, 2024, the City mandates Medicare
enrollment for retirees and their dependents who become
Medicare-eligible in order to remain eligible for continued
coverage under the City of Chandler medical plan. Retirees
and their dependents who became Medicare-eligible before
January 1, 2024, but did not enroll in Medicare are
grandfathered and remain eligible for medical plan
coverage.
Appeals
AZBlue administers Level 1, Level 2, and External Review
appeals.
Included
☒AZBlue administers Levels 1, 2, and external.
Arizona Senate Bill 1305 ARS 35-196.02
☒The group must comply with SB1305 ARS 35-196.02;
prescribed abortion benefits will be administered
☐The group is not subject to SB1305 ARS 35-196.02
Abortion*
*Benefits are available for elective and non-elective
abortions, if legal where performed*
☒Non-elective abortions covered
☐Elective abortions covered
☐Elective and Non-elective abortions are covered
☐All abortions excluded
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
Administrative Summary
7
Rev: ASC_09.11.2024
Massachusetts Employees
Plan Sponsor will timely provide any authorizations required
by Massachusetts law or by Massachusetts regulators to
enable AZBlue to perform the mailing and/or electronic
filing(s). If the Plan Sponsor fails to timely provide such
authorization(s), AZBlue will have no duty to make the filing
and/or mailing.
If in AZBlue’s opinion, the Employer’s coverage meets the
Massachusetts Minimum Creditable Coverage (MMCC)
requirements, AZBlue agrees to reflect the coverage as
creditable in its electronic filing and 1099-HC mailings. If in
AZBlue’s opinion, the Employer’s coverage does not meet
the MMCC requirements, the Employer may choose to
either: (a) state the coverage is not creditable in its
electronic filing and 1099-HC mailings; or (b) direct AZBlue
to not make the electronic filing and provide the
uncompleted 1099-HC forms to Employer.
☒AZBlue will not issue 1099HC or complete electronic filing
with MA
☐AZBlue will prepare and distribute annual 1099-HC forms
to Participants who are Massachusetts residents and make
the electronic filing with Massachusetts regulators.
NYHCRA
AZBlue will complete the required filing upon submission of
the required forms. Current or prior elector status with the
NY Pools may impact which documentation is required to
elect and provide AZBlue with consent to perform this
action on behalf of an elector.
☒Elect
☐Non-elect
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
Administrative Summary
8
Rev: ASC_09.11.2024
Plan Compliance with Mandates – AZBlue Support Services
AZBlue will support the Plan’s compliance with the following federal mandates for coverage it administers on behalf of
the Plan Sponsor:
•
Affordable Care Act Transparency in Coverage rule issued in November 2020 (“Transparency Rule”)
•
Certain health plan provisions of the Consolidated Appropriations Act of 2021 (“CAA”).
•
Additional services will be mutually agreed upon in writing by AZBlue and Plan Sponsor.
CAA Provider Directory Requirements
•
Publish a contracted provider directory on
AZBlue’s website
•
Update and verify the Provider directory every
90 days
•
Remove providers whose information cannot
be verified
•
Indicate an “accurate as of” date on printed
directories and direct Plan participants to the
online directory.
•
Respond within 1 business day to Participant
telephone inquiries regarding provider
contractual relationship with AZBlue
•
Retain responses in the Plan Participant’s file
for two years.
•
Apply in-network cost share to covered
services provided in reliance on incorrect
provider network information (if required by
CAA).
Included
Transparency Rule Machine Readable Files
•
Publish legally required machine-readable files
that disclose the Plan’s:
in-network rates paid to providers
historical out-of-network allowed
amounts paid to providers
negotiated rates and historical net
prices for covered prescription drugs
•
Make files accessible to both Plan Participants
and Plan Sponsor.
Included
Transparency Rule Cost Tool
•
Make available a cost-sharing liability tool
consistent with the Transparency-in-Coverage
final rule for the 500 shoppable services
identified by the Centers for Medicare and
Medicaid Services (“CMS”)
•
Effective 1/1/23 or the end of any deferred
enforcement period issued by federal
regulators
Included
CAA ID Card Requirements
•
AZBlue will issue physical or electronic
insurance ID cards w/ deductibles, out-of-
pocket maximums, & telephone number and
website address for individuals to seek
consumer assistance
•
Issue to all Plan Participants
Included
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
Administrative Summary
9
Rev: ASC_09.11.2024
Billing Model Notice
•
Inform Plan Participants about the Plan’s
balance billing protections by providing the
Billing Model Notice to the Plan Sponsor and
posting it to its public website.
Included
Continuity of Care
•
Apply continuity of care protections when
provider contractual relationships are
terminated.
Included
Prescription Data Reporting
•
Submit to CMS specified files for the
Prescription Drug Data Collection (RxDC)
required by the CAA and implementing
regulations
•
If AZBlue administers the Plan Sponsor’s
prescription drug benefit, submit the following
files:
o
P1 Individual and Student Market Plan
List OR P2 Group Health Plan List
o
D1 Premium and Life Years
o
D2 Spending by Category
o
D3 Top 50 Most Frequent Brand Drugs
o
D4 Top 50 Most Costly Drugs
o
D5 Top 50 Drugs by Spending
Increase
o
D6 Rx Totals
o
D7 Rx Rebates by Therapeutic Class
o
D8 Rx Rebates for the Top 25 Drugs
o
Narrative Response
•
If AZBlue does not administer the Plan
Sponsor’s prescription drug benefit, submit
the following files:
o
P1 Individual and Student Market Plan
List OR P2 Group Health Plan List
o
D1 Premium and Life Years
o
D2 Spending by Category
o
Narrative Response (if applicable)
Included
AZBlue’s obligations to submit any files for the Plan Sponsor
are contingent upon the Plan Sponsor providing AZBlue all
information AZBlue requests by the dates and in the formats
AZBlue’s specifies in its information collection materials.
AZBlue will not provide any RxDC information for the Plan for
any period of time during the applicable calendar year that the
Plan Sponsor was not a Client of AZBlue. AZBlue reserves the
right to modify supported reporting upon sixty (60) days’ prior
written notice to Plan Sponsor.
Other
•
For coverage it administers for the Plan
Sponsor, AZBlue will submit to HHS air
ambulance claim data consistent with the CAA
and implementing regulations.
•
For coverage it administers for the Plan
Sponsor, AZBlue will submit an annual Gag
Clause Prohibition Compliance Attestation
consistent with CAA requirements
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
Administrative Summary
10
Rev: ASC_09.11.2024
IMPORTANT - READ CAREFULLY
As the authorized representative of Plan Sponsor, I certify and agree to the following:
•
Information provided in this Administrative Summary and all other applicable documents
submitted in connection with this Administrative Summary are complete and accurate.
•
If the information contained in the Administrative Summary or other supporting
documentation is incomplete, inaccurate, materially misleading, false, or fraudulent, AZBlue
has the right to:
retroactively adjust the Plan Sponsor’s Administrative Fees or Other Fees if such
information would have affected the Fee calculation;
invalidate, or withdraw any Fee proposal, or terminate coverage to the extent
permitted by the Agreement or applicable federal or state law.
•
This Administrative Summary is not accepted until approved by AZBlue and AZBlue’s
acceptance shall be based on information supplied by the Plan Sponsor, the requested
benefits, and any other information obtained from outside sources.
•
This Administrative Summary shall become binding upon AZBlue and the Plan Sponsor. Upon
acceptance, this Administrative Summary shall be attached to and shall become a part of the
Agreement.
•
By including my e-mail address in the Administrative Summary, I authorize AZBlue to send
information to the Plan Sponsor via e-mail. I also understand I may change the e-mail address
or rescind this permission at any time by contacting AZBlue through azblue.com.
City of Chandler
By:
Title: ___ _ MAYOR
Date: ________________________________
Accepted and Agreed
BLUE CROSS AND BLUE SHIELD OF
ARIZONA, INC.
By:
Print Name:
Title: _______________________________
Date: ________________________________
Date Prepared
10/04/2024
Final
APPROVED AS TO FORM:
By: __________________________________
City Attorney
ATTEST:
By: __________________________________
City Clerk
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
Michael Groeger
Vice President, Commercial Sales
October 25, 2024
For informational Purposes Only - NO Action Required
Re: 2024 Form 5500 Schedule C Service Provider Information
Dear Sir or Madam:
Blue Cross Blue Shield of Arizona (“BCBSAZ”) is providing this information to you to support any
Form 5500 reporting obligations your group health plan has to the U.S. Department of Labor.
A.
Blue Card Program
Under your contract with BCBSAZ, one of the benefits your employees and their dependents
("Participants") receive is access to healthcare services outside the geographic area BCBSAZ
serves under a program known as BlueCard. Typically, in that situation, Participants obtain care
from healthcare providers that have a contractual agreement with the local Blue Cross and/or Blue
Shield Licensee in that other geographic area (the "Host Blue"). Within that arrangement, BCBSAZ
is referred to as the "Home Blue."
Below is a list of indirect compensation that has been and/or is likely to be received in connection
with the BlueCard Program. Note that the fees and compensation subject to disclosure under the
Department of Labor rules include amounts that are not necessarily passed on to your ERISA Plan
or your Participants. The financial terms of the BlueCard Program passed on to your ERISA plan,
and additional details about the BlueCard Program, are described in your Administrative Services
Agreement with BCBSAZ.
1.
BlueCard Access Fees: The Access Fee is charged by the Host Blue to us for making its
applicable provider network available to your members. The Access Fee will not apply to
nonparticipating provider claims. The Access Fee is charged on a per-claim basis and is
charged as a percentage of the discount/differential we receive from the applicable Host
Blue subject to a maximum of $2,000 per claim. When charged, we pass the Access Fee
directly on to you.
2.
Administrative Expense Allowances (AEA): The AEA is a fixed per-claim dollar amount
charged by the Host Blue to us for administrative services the Host Blue provides in
processing claims for your members. The dollar amount is normally based on the type of
claim (e.g. institutional, professional, international, etc.) and can also be based on the size
of your group enrollment. When charged, we pass the AEA fee directly on to you.
Note: To be considered for reduced BlueCard PPO fees, the claim must be for an account
whose total Blue PPO enrollment exceeds 1,000 contracts
3.
Use of Estimated or Average Pricing by Host Blues. As described in your administrative
service agreement, some Host Blues use estimated or average prices to determine the
negotiated price that is made available to BCBSAZ when plan participants access the Host
Blue's participating provider network. This may result in a difference (positive or negative)
between the price you pay on a specific claim and the actual amount paid to the provider
by the Host Blue.
The following describes the formulas used for determining an estimated or average price:
Estimated: A percentage is used to modify the claim price for covered services.
This percentage (either positive or negative) allows Host Blues to incorporate
adjustments and actuarial projections prospectively into the final price. The
percentage is determined by calculating the aggregate cost to the Host Blue over
a look-back period less any initial payments made to providers divided by the total
payments initially made to providers. The aggregate cost in the numerator includes
all provider retrospective settlements, anti-fraud and abuse recoveries, provider
refunds not applied on a claim-specific basis, performance-related bonuses or
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
For informational Purposes Only - NO Action Required
incentives, interest, other non-claim transactions and any positive or negative
balance in the variance account. The percentage is then actuarially adjusted for
anticipated changes in claims expenses for the prospective period. As of
December 31, 2023, the modifying percentage applied to claims from those Host
Blues that use estimated pricing ranged from (0.42%) to +9.50% the rate of
payment to the provider at the point of the claims. The modifying percentages
applied to claims from those Host Blues that will be used for estimated pricing have
not been calculated as of the date of this letter.
Average: An average price is determined for a defined category of provider (e.g.,
institutional, professional, etc.) of a Host Blue in a given geographic area. The
average is determined as follows:
Total amount paid to such providers over a look-back period, including
initial payments as well as applicable claim and non-claim related
transactions, which may include but are not limited to provider
retrospective settlements, anti-fraud and abuse recoveries, provider
refunds not applied on a claim-specific basis, performance-related
bonuses or incentives, interest, etc., and any positive or negative balance
in the variance account
divided by
Total amount of such providers' corresponding charges for covered
services over the same look-back period (claims for non-covered services
are not included in the calculation)
This result is an average price that is applied to each claim for the defined category
of provider of the Host Blue in the geographic area and presented as the negotiated
price.
The Host Blue determines whether it will use an actual, estimated or average price. The
use of estimated or average pricing may result in a difference (positive or negative)
between the price you pay on a specific claim and the amount the Host Blue pays to the
provider. However, the BlueCard Program requires that the amount paid by the member
and you is the final price; no future price adjustment will result in increases or decreases
to the pricing of past claims.
Any positive or negative differences in estimated or average pricing are accounted for
through variance accounts maintained by the Host Blue and are incorporated into future
claim prices. As a result, the amounts charged to you will be adjusted in a following year,
as necessary, to account for over- or underestimation of the past years’ prices. The Host
Blue will not receive compensation from how the estimated price or average price
methods, described above, are calculated. Because all amounts paid are final, neither
positive variance account amounts (funds available to be paid in the following year), nor
negative variance amounts (the funds needed to be received in the following year), are
due to or from you. If you terminate, you will not receive a refund or charge from the
variance account.
Variance account balances are small amounts relative to the overall paid claims amounts
and will be liquidated or drawn down over time. The timeframe for their liquidation
depends on variables, including, but not limited to, overall volume/number of claims
processed and variance account balance. Variance account balances may earn interest
at the federal funds or similar rate. Host Blues may retain interest earned on funds held in
variance accounts.
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
For informational Purposes Only - NO Action Required
4.
BlueCard Global Core Program. The BlueCard Global Core Program provides members
with access to an international network of inpatient, outpatient and professional providers.
The Blue Cross and Blue Shield Association (BCBSA) utilizes GeoBlue for Medical
Assistance and Claims support Services. The fees paid by the Home Blue are as
follows:
Medical Assistance
Fee (in dollars)
General Inbound Calls
$28.45 / Call
Provider Inquiry/Referral (non-medical situation)
$22.35 / Call
Cashless access/Guarantee of Payment (GOP)
$111.76 / GOP
Telephone Translation
$63.50 / Call
Fulfillment
$9.65 / Call
Provider/medical assistance information provided by a
nurse
$96.52 / Call
Misrouted Calls
$22.35 / Call
Medical Monitoring
$294.64 / Case
Claims Support Services
Fee (in dollars)
Claim preparation, processing and/or payment (includes
translation, coding, currency conversion)
$39.62 / Claim
Misrouted claim (for example, domestic)
$9.65 / Claim
Claim Status inquiry
$22.35 / call/member ID
Medical records translation
At Cost
Currency conversion gains/losses
At Cost
Wire/ACH fees
At Cost
Additional Services
Fee (in dollars)
Medical Evacuation coordination
$1,270.00 / Case
Medical Repatriation coordination
$1,270.00 / Case
Repatriation of Remains coordination
$609.60 / Case
Medical travel coordination
$294.64 / Case
Assistance Partner Engagement (limited to ONLY
countries where vendor is restricted from conducting
business)
Ranging from $100-500 per
Direct Pay Letter (DPL)
Ad hoc UCR claim research, claim line-item audit and
case negotiation
As agreed upon by Home Plan
and GeoBlue
5. Negotiated Arrangements: With respect to one or more Host Plans, instead of using the
BlueCard Program, BCBSAZ may process your Participant claims for Covered Services
through Negotiated Arrangements.
Non-Standard negotiated AEA fees for 2023/2024:
Non-standard negotiated fees can range from either $5.48 to $17.00 per claim, or
$8.50 to $28.33 per contract per month depending on the negotiated arrangement
and/or the health plan product
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F
For informational Purposes Only - NO Action Required
B. Other Services
Under regulations related to the 2009 Form 5500 Schedule C - Service Provider Information,
BCBSAZ is required to provide information regarding certain indirect compensation paid by
BCBSAZ to other Service Providers during 2023 related to your contract with BCBSAZ.
Company Name: Exela Technologies
Address: 369 Inverness Parkway, Suite 300, Englewood, CO 80112
Service Provided: Claims Edit Resolution
Basis of Compensation: $0.396 per Claim Edit for low complexity, $0.448 for medium complexity, and
$0.614 for high complexity.
Company Name: Smart Data Solutions
Address: 960 Blue Gentian Rd., Eagan, MN 55121
Service Provided: Claims Edit Resolution
Basis of Compensation: $0.71 - $1.67 per Claim Edit for low complexity, $0.85 - $2.29 for medium
complexity, and $1.00 - $3.20 for high complexity.
Company Name: Cobalt MedPlans
Address: 10740 Nall Ave., Overland Park, KS 66211
Service Provided: Claims Edit Resolution
Basis of Compensation: $1.87 per Claim Edit for low complexity, $2.88 for medium complexity, and $4.13
for high complexity.
Company Name: Sutherland Global Services, Inc.
Address: 2 Brighton Rd., Suite 300 Clifton, NJ 07012
Service Provided: Data entry for provider data, assistance with credentialing
Basis of Compensation: $8.10 per provider recredentialing completed and $27.61 per initial credentialing
unit completed
Company Name: Change Healthcare
Address: P.O. Box 572490, Murray Utah 84157-2490
Service Provided: Fee for the Recovery of Overpayments
Basis of Compensation: 16% of the Realized Savings for Diagnostic Related Group (DRG) and Hospital
Billing Validation audits and 20.5% of the Realized Savings for Hospital Charge Audits.
Company Name: OptumRx.1
Address: 1600 McConnor Parkway, Schaumburg, IL 60173-6801
Service Provided: Pharmacy Claims Processing and select PBM services
Basis of Compensation: for electronic claims only
Pass-Thru Pricing Model = $0.75 per net paid claim
1 BCBSAZ paid compensation to OptumRx.only for groups who used BCBSAZ to manage their pharmacy
benefits.
Pharmacy Rebates – BCBSAZ receives rebates from certain Pharmaceutical Manufacturers for certain
drugs. Subject to the terms of your BCBSAZ Administrative Services Agreement your Group may be eligible
for a Pharmacy Rebate. BCBSAZ may earn interest income on Pharmacy Rebates during the period after
the Rebate is paid to BCBSAZ and prior to payment to your Group.
If you have any questions, please contact your BCBSAZ Account Manager.
Sincerely,
Alan Lunde
Alan Lunde
Financial Reporting
Docusign Envelope ID: 3C1A9EA0-4B44-43D6-8DAB-C33683F9F60F