HomeMy WebLinkAboutC2015-521 - 12/31/2015 - NA AETNA LIFE INSURANCE COMPANY
2016 MEDICARE ADVANTAGE PPO
GROUP AGREEMENT COVER SHEET
Contract Holder: City of Corpus Christi
Contract Holder Number: Group No. TBD
Locations/Eligibility Class TBD
Service Areas TBD
PPO Plan: MEDICARE PPO PLAN Benefits Package
with Medicare Prescription Drug benefits
Effective Date: 12:01 a.m. on January 1, 2016
Term of Group Agreement: This Agreement is for three years
commencing on January 1, 2016 and
continuing through December 31, 2018. The
term includes an option to extend for up to
two additional one-year periods subject to
the approval of the Aetna and the City
Manager.
Premium Due Dates: The Group Agreement Effective Date and
the 1st day of each succeeding calendar
month.
Plan Premium Rates: Please refer to the rate/financial exhibit
and/or final renewal communication (and
any amendments made thereto) issued by
Aetna in connection with this Group
Agreement ("Rate Documents") for
applicable rates.
Term of Rates: During the duration of this agreement, hese
rates are subject to adjustments based on
final regulatory determinations.
Governing Law: Federal law and, to the extent not
preempted,the laws of the State of Texas.
ME PPO GA(Y2016) GRP_GAPPO_2016
2015-521
12/31/15
Aetna Life Insurance Company INDEXED
EXECUTED by the PARTIES, both of which hereby represent that the signatures to this
AGREEMENT, below, are of those persons with the capacity and authority to legally bind the
PARTIES.
CONTRACT HOLDER AETNA LIFE INSURANCE COMPANY
CITY OF CORPUS CHRISTI
.I
By: w�31 :_ �� i� By: _�/
'o .d L.. • son Tami Po . e�i
City k an..-r Sales Director for Public and Labor Sector
J ,J 31 is
Date Date i'll--31/‘'r
APPROVED AS TO LEGAL FORM:
Buck Brice (Date)
Assistant City Attorney
For City Attorney
ME PPO GA(Y2016) GRP_GAPPO_2016
AETNA LIFE INSURANCE COMPANY
TEXAS
MEDICARE ADVANTAGE PPO GROUP AGREEMENT
This Group Agreement is entered into by and between Aetna Life Insurance Company and the
Contract Holder specified in the attached Cover Sheet. This Group Agreement shall be effective
on the Effective Date specified in the Cover Sheet, and shall continue in force until terminated as
provided herein.
In consideration of the mutual promises hereunder and the payment of Premiums and fees when
due, We will provide coverage for benefits in accordance with the terms, conditions, limitations
and exclusions set forth in this Group Agreement.
Upon acceptance by Us of Contract Holder's Group Application, and upon receipt of the
required initial Premium, this Group Agreement shall be considered to be agreed to by Contract
Holder and Us, and is fully enforceable in all respects against Contract Holder and Us.
SECTION 1. DEFINITIONS
1.1 "Aetna Medicare PPO plan" or "Plan" means the Aetna MedicareSM Plan (PPO)
,including Medicare prescription drug benefits„ which is a Medicare Advantage
Preferred Provider Organization Plan offered by Aetna to Contract Holder under this
Group Agreement.
1.2 The terms "Aetna", "Us", "We" or "Our" mean Aetna Life Insurance Company or an
affiliate.
1.3 "CMS" means the Centers for Medicare and Medicaid Services.
1.4 "CMS Contract" means the contract between Aetna and CMS under which Aetna offers
the Plan.
1.5 The terms "Contract Holder", "Effective Date", "Initial Term", "Premium Due Date" and
"Subsequent Terms" will have the meaning set forth in the attached Cover Sheet. If any
of such terms are undefined in the Cover Sheet, such undefined terms shall have the
following meaning:
• "Effective Date" means the date health coverage under this Group Agreement
commences for the Contract Holder.
• "Initial Term" is the period following the Effective Date as indicated on the Cover
Sheet.
ME PPO GA(Y2016) GRP_GAPPO_2016
2
• "Premium Due Date(s)" is the Effective Date and each monthly anniversary of the
Effective Date.
• "Subsequent Term(s)" means the periods following the Initial Term as indicated
on the Cover Sheet.
1.6 "Covered Benefits" is a general term We use to mean all of the health care services and
supplies ,including Medicare Prescription Drug benefits, that are covered by Our Plan,
subject to all of the terms and conditions of the EOC and Schedule of
Copayments/Coinsurance and this Group Agreement.
1.7 "EOC" means the Evidence of Coverage, which is a document outlining coverage for
Members under the Plan, that is issued pursuant to this Group Agreement, and includes
the Schedule of Copayments/Coinsurance and any riders or amendments.
1.8 "ERISA" means the Employee Retirement Income Security Act of 1974, as amended.
1.9 "Grace Period" is defined in the Premiums and Fees section below.
1.10 "Group Agreement" means the Contract Holder's Group Application, this document, the
attached Cover Sheet; the EOC and Schedule of Copayments/Coinsurance issued
hereunder; the Rate Documents issued by Us in connection with this Group Agreement;
the Plan Design and Benefit Summary; and any riders, amendments, inserts or
attachments issued pursuant hereto, all of which are incorporated into or incorporated by
reference into and made a part of this Group Agreement.
1.11 "Mandates" means applicable laws, regulations and government requirements in effect
during the Term of this Group Agreement including, without limitation, applicable
Medicare laws, regulations and CMS requirements.
1.12 "Member" is a Medicare beneficiary who: (1) has enrolled in Our Plan and whose
enrollment in the Plan has been confirmed by CMS, and (2) is eligible to receive
coverage under the Plan, subject to the terms and conditions of the EOC and Schedule of
Copayments/Coinsurance and this Group Agreement.
1.13 "Member Premium(s)" is defined in the Premium and Fees section.
1.14 "Party, Parties" means Aetna and Contract Holder.
1.15 "Premium(s)" is defined in the Premiums and Fees section below.
1.16 "Renewal Date" means the first day following the end of the Initial Term or any
Subsequent Term.
1.17 "Term" means the Initial Term or any Subsequent Term set forth in the Cover Sheet to
this Group Agreement.
ME PPO GA(Y2016) GRP_GAPPO_2016
3
1.18 Capitalized terms not defined in this Group Agreement shall have the meaning set forth
in the EOC. In the event of a conflict between the terms of this Group Agreement and
the terms of the EOC, the terms of this Group Agreement shall prevail.
SECTION 2. COVERAGE
2.1 Covered Benefits. We will provide coverage for Covered Benefits to Members subject
to the terms and conditions of this Group Agreement. Coverage will be provided in
accordance with the reasonable exercise of Our business judgment, consistent with
Mandates. Members covered under this Group Agreement are subject to all of the
conditions and provisions contained herein and in the incorporated documents.
2.2 Policies and Procedures. We have the right to adopt reasonable policies, procedures,
rules, and interpretations of this Group Agreement and the EOC in order to promote
orderly and efficient administration of the Plan and/or comply with Mandates ("Policies
and Procedures"). Aetna will provide Contract Holder with advanced written notice if
Contract Holder must comply with any such Policies and Procedures.
SECTION 3. PREMIUMS AND FEES
3.1 Premiums. Members shall pay Us on or before each Premium Due Date a monthly
Member Premium (the "Member Premium") determined in accordance with the Premium
rates and the manner of calculating Premiums specified by Aetna. Member Premiums
rates and the manner of calculating Member Premiums may be adjusted in accordance
with the Changes in Premium and Membership Adjustments sections below. Member
Premiums are subject to adjustment, if any, for partial month participation as specified in
the Membership Adjustments section below. Membership as of each Premium Due Date
will be determined by Us in accordance with Our Member records. A check does not
constitute payment until it is honored by a bank. We may return a check issued against
insufficient funds without making a second deposit attempt. We may accept a partial
payment of Member Premium without waiving Our right to collect the entire amount due.
This Group Agreement is subject to the annual renewal of Aetna's CMS Contract.
Covered Benefits and/or Member Premiums are also subject to change at the beginning
of a Term of this Group Agreement. Increases in Member Premiums and/or decreases in
Covered Benefits are only permitted at the beginning of a Term of this Group Agreement.
Should CMS terminate Our CMS Contract or should We decide not to renew Our CMS
Contract, Members shall be given notice of such termination in accordance with the EOC
and any applicable Mandates.
3.2 Fees. In addition to the Member Premium, We may charge the following fees:
ME PPO GA(Y2016) GRP_GAPPO_2016
4
•
• An installation fee may be charged to Contract Holder upon initial installation of
coverage or any significant change in installation(e.g. a significant change in the
number of Members or a change in the method of reporting Member eligibility to
Us). A fee may also be charged upon initial installation for any custom Plan set-
ups.
• A reinstatement fee as set forth in the Effect of Termination section.
33 Past Due Premiums and Fees. If all Member Premiums are not received from a
Member within three (3) months following the Premium Due Date (the "Member Grace
Period"), the Member's failure to make such payments may result in termination of the
Member's coverage under this Group Agreement (in accordance with the termination
provisions in the EOC), and may result in termination of the Group Agreement pursuant
to the Termination by Us section hereof.
If the Group Agreement terminates for any reason, Member will continue to be held
liable for all Member Premiums due and unpaid before the termination, including, but not
limited to, Member Premium payments for any period of time the Group Agreement is in
force during the Member Grace Period. Members shall also remain liable for Member
cost sharing and other required contributions to coverage for any period of time the
Group Agreement is in force during the Member Grace Period. We may recover from
Contract Holder, Our costs of collecting any unpaid Member Premiums or Fees,
including reasonable attorney's fees and cost of suit.
3.4 Changes in Premium. We may adjust the Member Premium rates and/or the manner of
calculating Member Premiums to reflect changes in Mandates having a material impact
on the cost of providing Covered Benefits to Members. Any changes to Member
Premiums shall be made in accordance with applicable Mandates.
3.5 Membership Adjustments. Retroactive additions of Members will be made at Our
discretion based upon eligibility guidelines, as set forth in the EOC, and are subject to the
payment of all applicable Member Premiums.
3.6 Uniform Premiums and Low Income Subsidy. Contract Holder shall comply with the
following conditions with respect to any subsidization of that portion of Premiums paid
by Contract Holder for the Medicare Prescription Drug benefit ("PD Premium") and any
required PD Premium contribution by the Member:
• Contract Holder may subsidize different amounts of PD Premium for different classes of
Members and their dependents, provided such classes are reasonable and based on
objective business criteria, such as years of service, business location, job category, and
nature of compensation (e.g., salaried vs. hourly). Classes of Members and their
dependents cannot be based on eligibility for the Low Income Subsidy ("LIS").
• PD Premium contribution levels cannot vary for Members within a given class.
• Direct subsidy payments from CMS to Aetna must be passed through to reduce the
amount of any required PD Premium payment by the Member ("Member Contribution")
ME PPO GA(Y2016) GRP_GAPPO_2016
5
so the Member in no event shall be required to pay more than the sum of: a) the standard
Medicare Part D premium, net of the direct subsidy payment from CMS, and b) one
hundred percent(100%) for any supplemental coverage selected by the Member.
Contract Holder shall comply with the following conditions with respect to any LIS
payment received from CMS for any LIS-eligible Member:
• Any monthly LIS payment received from CMS for an LIS-eligible Member shall be used
to reduce any Member Contribution. Any remainder may then be used to reduce the
amount of the Contract Holder's PD Premium contribution. However, if the sum of the
Member Contribution and Contract Holder's PD Premium is less than the LIS payment,
any portion of the LIS payment will be returned to CMS by Aetna.
• If the LIS payment for any LIS-eligible Member is less than the Member Contribution
required by such individual (including the Member Contribution for supplemental
benefits, if any), Contract Holder shall communicate with the LIS-eligible Member about
the cost of remaining enrolled in Contract Holder's Plan versus obtaining coverage as an
individual under another Medicare Part D Prescription Drug plan. ]
• In the event that the LIS-eligible Member is due a refund of the LIS payment (i.e., there
was no upfront reduction of the PD Premium by the LIS amount), such refund shall be
completed by Aetna or Contract Holder, as applicable, within 45 days of the date Aetna
receives the LIS payment for that Member from CMS.
SECTION 4. ENROLLMENT
4.1 Open Enrollment. Contract Holder will offer enrollment in the Aetna Medicare PPO
plan:
• at least once during the term of this Group Agreement during Contract Holder's
annual open enrollment period ("Open Enrollment Period"); and
• Within 31 days from the date an individual or any dependent becomes eligible to
receive coverage under the Plan.
Eligible individuals and dependents who are not enrolled in the Plan within the Open
Enrollment Period or 31 days of becoming eligible may be enrolled during any
subsequent Open Enrollment Period. Coverage under the Plan will not become effective
until confirmed by Us. Contract Holder agrees to hold the Open Enrollment Period
consistent with the open enrollment period applicable to any other group health benefit
plan being offered by the Contract Holder and in compliance with Mandates. The
Contract Holder shall permit Our representatives to meet with eligible individuals and
dependents during the Open Enrollment Period unless the parties agree upon an alternate
enrollment procedure.
ME PPO GA(Y2016) GRP_GAPPO_2016
6
4.2 Eligibility. Actively working employees and their dependents are not permitted to enroll
in the Plan, unless Contract Holder employs between two and nineteen (2-19) employees.
The number of eligible individuals and eligible dependents and composition of the Plan,
the identity and status of Contract Holder, the eligibility requirements used to determine
membership in the Plan, and the participation and contribution standards applicable to the
Plan which exist at the Effective Date of this Group Agreement are material to the
execution and continuation of this Group Agreement by Us. The Contract Holder shall
not, during the Term of this Group Agreement, modify the Open Enrollment Period or
any other eligibility requirements as described in the EOC and on the Schedule of
Copayments/Coinsurance, for the purposes of enrolling Contract Holder's eligible
individuals and eligible dependents under this Group Agreement, unless We agree to the
modification in writing.
SECTION 5. RESPONSIBILITIES OF THE CONTRACT HOLDER
In addition to other obligations set forth in this Group Agreement, Contract Holder
agrees to:
5.1 (A) Records. Furnish to Us, on a monthly basis (or as otherwise required), on Our form
(or such other form as We may reasonably approve) by facsimile (or such other means as
We may reasonably approve), such information as We may reasonably require to
administer this Group Agreement. This includes, but is not limited to, information
needed to enroll Members of the Contract Holder, process terminations, and effect
changes in family status and transfer of employment of Members.
Contract Holder certifies, based on best knowledge, information and belief, that all
enrollment and eligibility information that has been or will be supplied to Us is accurate,
complete and truthful. Contract Holder acknowledges that We can and will rely on such
enrollment and eligibility information in determining whether an individual is eligible for
Covered Benefits under this Group Agreement. To the extent such information is
supplied to Us by Contract Holder (in electronic or hard copy format), Contract Holder
agrees to:
• Obtain from all Members a "Disclosure of Healthcare Information" authorization in
the form currently being used by Us in the enrollment process (or such other form as
We may reasonably approve).
• Maintain a reasonably complete record of such information (in electronic or hard
copy format, including evidence of coverage elections, evidence of eligibility,
changes to such elections and terminations) for at least ten (10) years and to make
such information available to Us upon request, as required under this Section 5.
We will not be liable to Members for the fulfillment of any obligation prior to
information being received in a form satisfactory to Us. Contract Holder must notify Us
ME PPO GA(Y2016) GRP_GAPPO_2016
7
of the date in which a Member's employment/eligibility ceases for the purpose of
termination of coverage under this Group Agreement.
(B) Maintenance of Information and Records. Contract Holder agrees to maintain
Information and Records (as those terms are defined in the Access to Information and
Records Section below) in a current, detailed, organized and comprehensive manner and
in accordance with Mandates, and to maintain such Information and Records for the
longer of: (i) a period of ten (10) years from the end of the final contract period of any
government contract of Aetna to offer an Aetna Medicare PPO plan, (ii) the date the U.S.
Department of Health and Human Services, the Comptroller General or their designees
complete an audit, or (iii) the period required by Mandates. This Provision shall survive
the termination of this Group Agreement, regardless of the cause of the termination.
(C) Access to Information and Records. Contract Holder agrees to provide Us and
federal, state and local governmental authorities having jurisdiction, directly or through
their designated agents (collectively "Government Officials"), upon request, access to all
books, records and other papers, documents, materials and other information (including,
but not limited to, contracts and financial records), whether in paper or electronic format,
relating to the arrangement described in this Group Agreement ("Information and
Records"). Contract Holder agrees to provide Aetna and Government Officials with
access to Information and Records for as long as it is maintained as provided in
"Information and Records" Section above. Contract Holder agrees to supply copies of
Information and Records within fourteen (14) calendar days of Contract Holder's receipt
of the request, where practicable, and in no event later than the date required by
Mandates. This provision shall survive termination of this Group Agreement, regardless
of the cause of termination.
5.2 Forms. If agreed to by both Parties, distribute materials to Aetna Members regarding
enrollment, Plan features, including Covered Benefits and exclusions and limitations of
coverage, as required under Mandates. Contract Holder shall, within no longer than 10
days of receipt from an eligible individual, forward all completed enrollment information
and other required information to Us.
5.3 Policies and Procedures; Compliance Verification. Comply with all Policies and
Procedures, as described in Section 2.2 of this Group Agreement. Contract Holder shall,
upon request, provide a certification to Aetna of its compliance with Mandates applicable
to Contract Holder under this Group Agreement.
5.4 Written Notice to Members. Contract Holder will provide Members with any written
notice required under Mandates or Policies and Procedures. The written notices
described in this Section are hereinafter collectively referred to as the "Written Notices".
If Contract Holder does not distribute Written Notices to Members as required under this
Section 5.4, Contract Holder will be liable for payment of all Premiums or other costs
incurred by Aetna as a result of Contract Holder's failure to distribute the Written
Notices. If Contract Holder does not distribute the Written Notices as required under this
Section , Aetna may, in its discretion, distribute such Written Notices to Members, and
ME PPO GA(Y2016) GRP GAPPO 2016
8 - -
Contract Holder shall reimburse Aetna for any expenses incurred by Aetna in connection
with such distribution.
Contract Holder acknowledges that CMS requires that all Members receive from Aetna a
combined ANOC and EOC no later than the sooner of: (1) fifteen (15) days prior to the
Open Enrollment Period, (2) September 30th of each calendar year, or (3) such shorter
timeframe required under Mandates.
5.5 Member Plan Materials. Contract Holder shall assure that any Member Plan materials
that have not been approved by CMS comply with the following alternative disclosure
standards: "ERISA" or any alternative disclosure standards applicable to state or local
entities that provide retiree benefits.
5.6 ERISA Requirements. Maintain responsibility for making reports and disclosures
required by "ERISA", including the creation, distribution and final content of summary
plan descriptions, summary of material modifications and summary annual reports, unless
Contract Holder's Plan is specifically exempt thereunder.
5.7 Enrollment & Disenrollments Transactions.
(A) Generally. To the extent that Contract Holder directly accepts enrollment and/or
disenrollment requests from Members that Contract Holder forwards to Aetna for
processing and submission to CMS, Contract Holder agrees to comply with all Mandates
that relate to the handling and processing of enrollment and disenrollment requests that
apply to the Plan ("Enrollment/Disenrollment Requirements"), including, without
limitation, all Enrollment/Disenrollment Requirements that relate to the timeframes that
apply to handling, processing and submission of enrollment and disenrollment requests
for the Plan. Contract Holder agrees to forward enrollment and disenrollment forms
completed by Members to Aetna no later than ninety (90) days after the Member's
coverage effective date. Contract Holder acknowledges that if there is a delay between
the time a Member submits an enrollment/disenrollment request to Contract Holder and
when the enrollment/disenrollment request is received by Aetna, the
enrollment/disenrollment transaction may not be processed by CMS, unless Aetna
requests and CMS approves a retroactive enrollment/disenrollment transaction for the
Member. Contract Holder further acknowledges that Aetna, in its sole discretion and
judgment, will determine whether to submit retroactive enrollment and disenrollment
transaction requests to CMS, and will make such determinations in accordance with
Mandates.
Contract Holder acknowledges that, per Enrollment/Disenrollment Requirements, the
effective date of enrollments and disenrollments in the Plan cannot be earlier than the
date the enrollment or disenrollment request was completed by a Member. If approved
by CMS, the effective date of an enrollment or disenrollment may be retroactive up to,
but may not exceed, ninety (90) days from the date that Aetna received the enrollment or
disenrollment request from Contract Holder, and the enrollment or disenrollment form
ME PPO GA(Y2016) GRP_GAPPO_2016
9
must be completed and signed by the Member prior to the requested enrollment or
disenrollment effective date.
Contract Holder acknowledges that CMS does not permit Contract Holder to
retroactively terminate a Member's coverage under the Plan if the Member no longer
meets Contract Holder's eligibility criteria to remain enrolled in the Plan. To meet these
CMS requirements, Contract Holder agrees to provide Aetna with advanced written
notice if Contract Holder chooses to terminate a Member's coverage under the Plan based
on loss of eligibility, and Contract Holder acknowledges that the Member's coverage
termination effective date will be determined in accordance with Mandates.
All of the requirements described in this Section 5.7 also apply equally to any third party
administrator or other entity retained by Contract Holder to accept and/or process
enrollment/disenrollment requests for the Plan from Members on Contract Holder's
behalf.
(B) Notice to Members. CMS requires that Aetna provide written notice to all Members
confirming their enrollment in or disenrollment from the Plan from Aetna. The written
notice sent by Aetna confirming a Member's disenrollment from the Plan must describe
how the Member can contact Medicare for information about other Medicare Advantage
or Medicare Prescription Drug plan options that may be available to the Member.
If Contract Holder elects to change the Plan coverage offered to a Member or terminate a
Member's coverage under the Plan, the Contract Holder must provide written notice to
the Member at least twenty-one (21) calendar days prior to the effective date of the
change in the Member's coverage or disenrollment from the Plan, as applicable. This
written notice to Members must include a description of how the Member can contact
Medicare to obtain information regarding other Medicare Advantage plans or Medicare
Prescription Drug plan options that may be available to the Member.
We reserve the right to notify Members of the involuntary termination of their coverage
under this Group Agreement for any reason.
(C) Electronic Enrollment and Disenrollment. To the extent that the Contract Holder
has elected to electronically enroll eligible retirees and their eligible dependents
("Eligible Party" or Eligible Parties") in the Aetna Medicare PPO plan ("Enroll" or
"Enrollment") and to electronically terminate the coverage of Members under the Aetna
Medicare PPO plan ("Disenroll" or "Disenrollment"), and Aetna has agreed to accept
Enrollment and Disenrollment information from Contract Holder through a roster and
electronically process such Enrollments and Disenrollments, Contract Holder must meet
certain administrative and legal requirements set forth in this section of this Group
Agreement.
Aetna will electronically Enroll Eligible Parties who have elected the Plan coverage
("Electronic Enrollment") and electronically Disenroll Members from the Plan
ME PPO GA(Y2016) GRP_GAPPO_2016
to
("Electronic Disenrollment"), provided Contract Holder meets the following
requirements:
• Uses Aetna Enrollment and Disenrollment forms approved by CMS for Electronic
Enrollments and Disenrollments ("Aetna Enrollment and Disenrollment Forms").
As permitted under Mandates and this Group Agreement, Contract Holder may
permit Eligible Parties to electronically submit an election form to enroll in a Plan
("Online Enrollment Form") to Contract Holder("Online Election Process").
• Confirms that all Aetna Enrollment and Disenrollment Forms and Online
Enrollment Forms contain all data required by CMS, prior to requesting that
Aetna process any Electronic Enrollments or Disenrollments.
• Maintains and provides access to all original Aetna Enrollment and Disenrollment
Forms and Online Enrollment Forms completed by Eligible Parties and Members
in accordance with the Records section of this Group Agreement and all
Mandates.
• Submits Electronic Enrollment and Disenrollments to Aetna timely and accurately
in accordance with Mandates, Aetna policies and procedures, and this Group
Agreement.
• Submits to Aetna all data elements that are required by CMS and Aetna with
respect to each Electronic Enrollment and Disenrollment, including, but not
limited to, the following data elements:
o Name
o Permanent Address (When a Member submits a Post Office (PO) box as
their permanent address, CMS requires direct verification with the
Member that he/she resides in the Plan's service area. To ensure
compliance with this CMS requirement, if a Member submits a PO box as
their permanent address, Contract Holder agrees that it will verify with the
Member that they reside in one of the Plan's Service Areas (as identified
on the Cover Sheet to this Group Agreement) and retain evidence of such
verification, which Contract Holder will supply to Aetna, upon Aetna's
request.)
o Medicare Claim Number(HICN)
o End Stage Renal Disease (ESRD)
o Gender
o Date of Birth
o Plan Selection
o Provider Selection(if applicable)
o Group Number
o Class Code
o Plan ID
o Effective Date
Contract Holder agrees to be bound by all Mandates applicable to Electronic Enrollment
and Disenrollment. If Aetna determines, in its sole discretion and judgment, that the
Electronic Enrollment or Disenrollment information provided by Contract Holder is
incomplete, the Electronic Enrollment or Disenrollment will not be processed.
ME PPO GA(Y2016) GRP_GAPPO_2016
11
Electronic Enrollments deemed by Aetna to be complete will be processed by Aetna for
the first of the month following receipt of the electronic file from Contract Holder.
Electronic Enrollments may be processed 90 days retroactively from the current CMS
effective cycle date when the following conditions apply:
• The requested effective date is indicated on the Aetna Enrollment Form or Online
Enrollment Form completed by an Eligible Party, and on the electronic file
transmitted by Contract Holder to Aetna; and
• The Aetna Enrollment Form is signed or the Online Enrollment Form is received by
an Eligible Party prior to the requested effective date or prior to the date the Aetna
Enrollment Form or Online Enrollment Form was completed by the Eligible Party.
Electronic Disenrollments deemed by Aetna to be complete will be processed by Aetna
for the first of the month following receipt of the electronic file. Aetna will only process
Electronic Disenrollments where an Eligible Party has voluntarily elected to Disenroll
from a Plan by submitting a fully completed Aetna Disenrollment Form to Contract
Holder. Aetna will not process Electronic Disenrollments where Contract Holder has
elected to Disenroll an Eligible Party from a Plan due to Eligible Party's failure to pay
Plan premium or any other basis.
Contract Holder will produce, at Aetna's request, the original copy of any Aetna
Enrollment or Disenrollment Form or record of the Online Enrollment Form completed
by an Eligible Party.
Contract Holder agrees that it will transmit to Aetna only that information which is
reflected on an Aetna Enrollment or Disenrollment Form or Online Enrollment Form that
is completed and signed, as required,by an Eligible Party.
Contract Holder agrees to obtain from Eligible Parties information, including
authorizations, reasonably necessary for Aetna to perform its obligations under the
arrangements set forth in this Group Agreement.
Contract Holder agrees to indemnify and hold Aetna harmless for any costs, expenses,
claims or judgments, including attorney's fees that Aetna incurs as a result of Contract
Holder's failure to comply with the terms of this provision.
SECTION 6. TERMINATION
6.1 Termination by Contract Holder. The Parties acknowledge the CMS requirement that
Aetna provide Members with a minimum of 30 days' advance written notice prior to
termination of their coverage under the Plan. To allow Aetna to comply with this CMS
requirement, this Group Agreement may be terminated by Contract Holder by providing
Us with a minimum of 60 days prior written notice ("Notice of Termination"). The
Notice of Termination shall specify the effective date of such termination, which shall be
ME PPO GA(Y2016) GRP_GAPPO_2016
12
on the 1st day of a calendar month and may not be less than 60 days from the date of the
notice, and including the following information: Contract Holder's name, Contract
Holder's Group Number, Service Area(s) (if Contract Holder elects to terminate the Plan
in some, but not all, Service Areas covered under this Group Agreement), Plan name, and
the effective date of termination of the Group Agreement.
6.2 Renewal of Group Agreement. This Agreement is for three years commencing on
January 1, 2016 and continuing through December 31, 2018. The term includes an option
to extend for up to two additional one-year periods subject to the approval of the Aetna
and the City Manager.This Group Agreement is renewable, unless Aetna will no longer
offer any Aetna Medicare PPO plan in any Service Areas covered under this Group
Agreement, because: (1) CMS terminates or otherwise non-renews the Aetna's CMS
Contract, or (2) We terminate Our CMS Contract or reduce the service areas referenced
in Our CMS Contract.
6.3 Termination by Us. This Group Agreement may be terminated by Aetna by providing
Contract Holder with 30 days' prior written notice if the Member Premiums owed by ten
percent (10%) or more of Members remain unpaid at the end of the applicable Grace
Period. The notice of termination shall specify the effective date of such termination.
This Group Agreement may also be terminated by Us as follows:
• Immediately upon notice to Contract Holder if Contract Holder has performed
any act or practice that constitutes fraud or made any intentional
misrepresentation of a material fact relevant to the coverage provided under this
Group Agreement;
• Immediately upon notice to Contract Holder if Contract Holder no longer has any
Member under the Plan who resides in the Service Area;
• Upon 30 days' written notice to Contract Holder if Contract Holder (i) breaches a
provision of this Group Agreement and such breach remains uncured at the end of
the notice period; (ii) fails to meet Our contribution or participation requirements
applicable to this Group Agreement that are set forth in the Rate Documents; (iii)
fails to provide the compliance certification required under Section 5.3 of this
Group Agreement within a reasonable period of time specified by Us; (iv)
provides written notice to Members stating that coverage under this Group
Agreement will no longer be provided to Members; (v) changes its eligibility or
participation requirements without Our consent or (vi) ceases to meet any
Mandates applicable to offering the Plan to Contract Holder;
• Upon 180 days' written notice to Contract Holder (or such shorter notice as may
be permitted by Mandates, but in no event less than 30 days) if We cease to offer
a product or coverage in any market in which Members covered under this Group
Agreement reside;
ME PPO GA(Y2016) GRP_GAPPO_2016
13
• Upon 30 days' written notice to Contract Holder for any other reason which is
acceptable to CMS and consistent with the Health Insurance Portability and
Accountability Act of 1996 ("HIPAA") or other Mandates ; or
• Immediately upon notice to Contract Holder if Contract Holder is a member of an
employer-based association group, and the Contract Holder's membership in the
association ceases.
6.4 Effect of Termination. No termination of this Group Agreement will relieve either
Party from any obligation incurred before the date of termination. When terminated, this
Group Agreement and all coverage provided hereunder will end at 12:00 midnight on the
effective date of termination. We may charge the Contract Holder a reinstatement fee if
coverage is terminated and subsequently reinstated under this Group Agreement.
6.5 Notice to Members. It is the responsibility of Contract Holder to notify Members of the
termination of the Group Agreement in compliance with all Mandates and Policies and
Procedures (if any). However, We reserve the right to notify Members of termination of
the Group Agreement for any reason, including non-payment of Premium. In accordance
with the EOC and applicable CMS requirements, Contract Holder shall provide written
notice to Members of their rights upon termination of coverage under the Plan.
6.6 Auto-Enrollment Upon Termination of Plan. If this Group Agreement is terminated,
certain Mandates permit Aetna to disenroll Members from the Plan and automatically
enroll such Members in a comparable individual Medicare plan offered by Aetna("Aetna
Individual Medicare Plan"), unless the Member opts out or makes another health plan
choice.
Contract Holder agrees that if it establishes a Health Reimbursement Account("HRA")
and provides a subsidy for use by Members to pay health insurance premiums for
individual health insurance policies, Contract Holder will allow Members who are
automatically enrolled in an Aetna Individual Medicare Plan as described in this Section
6.6 to continue to receive the same level of subsidy and use such HRA to pay the health
insurance premium for the Aetna Individual Medicare Plan. Contract Holder will not
limit such Members' use of the HRA solely to health insurance policies issued through a
public or private exchange in which Contract Holder participates.
SECTION 7. PRIVACY AND SECURITY OF INFORMATION
7.1 Compliance with Privacy and Security Laws. We and Contract Holder will abide by
all Mandates regarding the confidentiality and the safeguarding of individually
identifiable health and other personal information, including the privacy and security
requirements of HIPAA.
7.2 Disclosure of Protected Health Information. We will not provide protected health
information ("PHI"), as defined in HIPAA, to Contract Holder, and Contract Holder will
ME PPO GA(Y2016) GRP_GAPPO_2016
14
not request PHI from Us, unless Contract Holder has provided the certification required
by 45 C.F.R. § 164.504(f) and amended Contract Holder's Plan documents to incorporate
the necessary changes required by such rule.
7.3 Brokers and Consultants. To the extent any broker or consultant receives PHI in the
underwriting process or while advocating on behalf of a Member, Contract Holder
understands and agrees that such broker or consultant is acting on behalf of Contract
Holder and not Us. We are entitled to rely on Contract Holder's representations that any
such broker or consultant is authorized to act on Contract Holder's behalf and entitled to
have access to the PHI under the relevant circumstances.
SECTION 8. INDEPENDENT CONTRACTOR RELATIONSHIPS;
INDEMNIFICATION
8.1 Relationship Between Us and Network Providers. The relationship between Us and
providers contracted with Aetna to participate in the Plan's provider network ("Network
Providers") is a contractual relationship among independent contractors. Network
Providers are not agents or employees of Us nor are We an agent or employee of any
Network Provider.
Network Providers are solely responsible for any health services rendered to their
Members . We make no express or implied warranties or representations concerning the
qualifications, continued participation, or quality of services of any Network Provider. A
Network Provider's participation in the provider network for the Plan may be terminated
at any time without advance notice to the Contract Holder or Members, subject to
Mandates. Network Providers provide health care diagnosis, treatment and services for
Members. We administer and determine Plan benefits.
8.2 Relationship Between the Parties. The relationship between the Parties is a contractual
relationship between independent contractors. Neither Party is an agent or employee of
the other in performing its obligations pursuant to this Group Agreement.
8.3 Standard of Care. Aetna and Contract Holder will discharge their obligations under the
Group Agreement with that level of reasonable care which a similarly situated services
provider or plan sponsor, as applicable, would exercise under similar circumstances. In
connection with fiduciary powers and duties hereunder, if applicable and if delegated by
Contract Holder to Aetna, Aetna shall observe the standard of care and diligence required
of a fiduciary under ERISA Section 404(a)(1)(B).
ME PPO GA(Y2016) GRP_GAPPO_2016
15
8.4 Indemnification. Aetna shall indemnify and hold harmless Contract Holder, its directors,
officers, and employees (acting in the course of their employment, but not as Members)
for that portion of any third party loss, liability, damage, expense, settlement, cost or
obligation (including reasonable attorneys' fees) caused solely and directly by Aetna's
willful misconduct, criminal conduct, breach of the Group Agreement, fraud, breach of
fiduciary responsibility, failure to comply with Section 8.3 above or infringement of any
U.S. patent, copyright, trademark or other intellectual property right of a third party,
related to or arising out of the services provided under the Group Agreement.
The party seeking indemnification must notify the indemnifying party within 20 days in
writing of any actual or threatened action, suit or proceeding to which it claims such
indemnification applies. Failure to so notify the indemnifying party shall not be deemed a
waiver of the right to seek indemnification, unless the actions of the indemnifying party
have been prejudiced by the failure of the other party to provide notice within the
required time period.
The indemnifying party may then take steps to be joined as a party to such proceeding,
and the party seeking indemnification shall not oppose any such joinder. Whether or not
such joinder takes place, the indemnifying party shall provide the defense with respect to
claims to which this section applies and in doing so shall have the right to control the
defense and settlement with respect to such claims.
The party seeking indemnification may assume responsibility for the direction of its own
defense at any time, including the right to settle or compromise any claim against it
without the consent of the indemnifying party, provided that in doing so it shall be
deemed to have waived its right to indemnification, except in cases where the
indemnifying party has declined to defend against the claim.
Contract Holder and Aetna agree that: (i) Aetna does not render medical services or
treatments to Members; (ii) neither Contract Holder nor Aetna is responsible for the
health care that is delivered by contracting health care providers; (iii) health care
providers are solely responsible for the health care they deliver to Members; (iv) health
care providers are not the agents or employees of Contract Holder or Aetna; and (v) the
indemnification obligations above do not apply to any portion of any loss, liability,
damage, expense, settlement, cost or obligation caused by the acts or omissions of health
care providers with respect to Members.
The indemnification obligations of Aetna above shall not apply to that portion of any
loss, liability, damage, expense, settlement, cost or obligation caused by any act
undertaken by Aetna at the direction of Contract Holder, or by any failure, refusal, or
omission to act, directed by Contract Holder (other than services described in the Group
Agreement).
The indemnification obligations under this Section 8.4 shall terminate upon the expiration
of this Group Agreement, except as to any matter concerning which a claim has been
ME PPO GA(Y2016) GRP_GAPPO_2016
16
asserted by notice to the other party at the time of such expiration or within two (2) years
thereafter.
SECTION 9. MISCELLANEOUS
9.1 Delegation and Subcontracting. Contract Holder acknowledges and agrees that We
may enter into arrangements with third parties to delegate functions hereunder such as
utilization management, quality assurance and provider credentialing, as We deem
appropriate in Our sole discretion and as consistent with Mandates. Contract Holder also
acknowledges that Our arrangements with third party vendors (i.e. pharmacy, behavioral
health) are subject to change in accordance with Mandates.
9.2 Accreditation and Qualification Status. We may from time to time obtain voluntary
accreditation or qualification status from a private accreditation organization or
government agency.
9.3 Prior Agreements; Severability. As of the Effective Date, this Group Agreement
replaces and supersedes all other prior agreements between the Parties as well as any
other prior written or oral understandings, negotiations, discussions or arrangements
between the Parties related to matters covered by this Group Agreement or the documents
incorporated herein. If any provision of this Group Agreement is deemed to be invalid or
illegal, that provision shall be fully severable and the remaining provisions of this Group
Agreement shall continue in full force and effect.
9.4 Amendments. This Group Agreement may be amended as follows:
• This Group Agreement shall be deemed to be automatically amended to conform
with all Mandates promulgated at any time by any state or federal regulatory
agency or authority having supervisory authority over Us;
• B y written agreement between both Parties; or
• By Us upon 30 days' written notice to Contract Holder.
The Parties agree that an amendment does not require the consent of any Member or
other person. Except for automatic amendments to comply with Mandates, all
amendments to this Group Agreement must be approved and executed by Us. No other
individual has the authority to modify this Group Agreement; waive any of its provisions,
conditions, or restrictions; extend the time for making a payment; or bind Us by making
any other commitment or representation or by giving or receiving any information.
9.5 Clerical Errors. Clerical errors or delays by Us in keeping or reporting data relative to
coverage will not reduce or invalidate a Member's coverage. Upon discovery of an error
or delay, an adjustment of Premiums shall be made. We may also modify or replace a
Group Agreement,EOC or other document issued in error.
ME PPO GA(Y2016) GRP_GAPPO_2016
17
9.6 Claim Determinations and Administration of Covered Benefits. We have complete
authority to review all claims for Covered Benefits as defined in the EOC and Schedule
of Copayments/Coinsurance under this Group Agreement. In exercising such
responsibility, We shall have discretionary authority to determine whether and to what
extent eligible individuals and beneficiaries are entitled to coverage and to construe any
disputed or doubtful terms under this Group Agreement, the EOC and Schedule of
Copayments/Coinsurance or any other document incorporated herein. We shall be
deemed to have properly exercised such authority unless We abuse Our discretion by
acting arbitrarily and capriciously. Our review of claims may include the use of
commercial software (including Claim Check) and other tools to take into account factors
such as an individual's claims history, a provider's billing patterns, complexity of the
service or treatment, amount of time and degree of skill needed and the manner of billing.
The administration of Covered Benefits and of any appeals filed by Members related to
the processing of claims for Covered Benefits shall be conducted in accordance with the
EOC and any Mandates.
9.7 Misstatements. If any fact as to the Contract Holder or a Member is found to have been
misstated, an equitable adjustment of Premiums may be made. If the misstatement
affects the existence or amount of coverage, the true facts will be used in determining
whether coverage is or remains in force and its amount.
9.8 Incontestability. Except as to a fraudulent misstatement, or issues concerning Premiums
due:
• No statement made by Contract Holder or any Member shall be the basis for
voiding coverage or denying coverage or be used in defense of a claim unless it is
in writing.
• No statement made by Contract Holder shall be the basis for voiding this Group
Agreement after it has been in force for two years from its effective date.
9.9 Assignability. No rights or benefits under this Group Agreement are assignable by
Contract Holder to any other Party unless approved by Aetna.
9.10 Waiver. Our failure to implement, or insist upon compliance with, any provision of this
Group Agreement or the terms of the EOC incorporated hereunder, at any given time or
times, shall not constitute a waiver of Our right to implement or insist upon compliance
with that provision at any other time or times. This includes, but is not limited to, the
payment of Premiums or benefits. This applies whether or not the circumstances are the
same.
9.11 Notices. Any notice required or permitted under this Group Agreement shall be in
writing and shall be deemed to have been given on the date when delivered in person; or,
if delivered by first-class United States mail, on the date mailed, proper postage prepaid,
and properly addressed to the address set forth in the Group Application or Cover Sheet,
ME PPO GA(Y2016) GRP_GAPPO_2016
18
or to any more recent address of which the sending Party has received written notice or, if
delivered by facsimile or other electronic means, on the date sent by facsimile or other
electronic means.
9.12 Third Parties. This Group Agreement shall not confer any rights or obligations on third
parties except as specifically provided herein.
9.13 Non-Discrimination. Contract Holder agrees to make no attempt, whether through
differential contributions or otherwise, to encourage or discourage enrollment in the
Aetna Medicare PPO plan of eligible individuals and eligible dependents based on health
status or health risk.
9.14 Compliance with Law. Aetna and Contract Holder shall comply with all Mandates
applicable to the performance of their respective obligations under this Group
Agreement.
9.15 Applicable Law. This Group Agreement shall be governed and construed in accordance
with applicable federal law and the applicable law, if any, of the state specified in the
Cover Sheet or, if no state law is specified, Our domicile state.
9.16 Inability to Arrange Services. If due to circumstances not within Our reasonable
control, including but not limited to major disaster, epidemic, complete or partial
destruction of facilities, riot, civil insurrection, disability of a significant part of Our
Network Providers or entities with whom We have contracted for services under this
Group Agreement, or similar causes, the provision of medical or hospital benefits or
other services provided under this Group Agreement is delayed or rendered impractical,
We shall not have any liability or obligation on account of such delay or failure to
provide services, except to refund the amount of the unearned prepaid Premiums held by
Us on the date such event occurs. We are required only to make a good-faith effort to
provide or arrange for the provision of services, taking into account the impact of the
event.
9.17 Use of the Aetna Name and all Symbols, Trademarks, and Service Marks. We
reserve the right to control the use of Our name and all symbols, trademarks, and service
marks presently existing or subsequently established. Contract Holder agrees that it will
not use such name, symbols, trademarks, or service marks in advertising or promotional
materials or otherwise without Our prior written consent and will cease any and all usage
immediately upon Our request or upon termination of this Group Agreement.
9.18 Dispute Resolution. Any controversy, dispute or claim between Aetna and Contract
Holder arising out of or relating to the Group Agreement, whether stated in tort, contract,
statute, claim for benefits, bad faith, professional liability or otherwise("Claim"), shall be
settled by confidential binding arbitration administered by the American Arbitration
Association ("AAA") before a sole arbitrator ("Arbitrator"). Judgment on the award
rendered by the Arbitrator ("Award") may be entered by any court having jurisdiction
thereof. If the AAA declines to administer the case and the parties do not agree on an
ME PPO GA(Y2016) GRP_GAPPO_2016
19
alternative administrator, a sole neutral arbitrator shall be appointed upon petition to a
court having jurisdiction. We and Contract Holder hereby give up our rights to have
Claims decided in a court before a jury.
Any Claim alleging wrongful acts or omissions of Network Provider or a provider that
does not participate in the provider network for the Plan("Non-Network Providers") shall
not include Us. Contract Holder may not recover any damages arising out of or related to
the failure to approve or provide any benefit or coverage beyond payment of or coverage
for the benefit or coverage where (i) We have made available independent external
review and (ii) We have followed the reviewer's decision. Contract Holder may not
participate in a representative capacity or as a member of any class in any proceeding
arising out of or related to the Group Agreement. This agreement to arbitrate shall be
specifically enforced even if a Party to the arbitration is also a Party to another
proceeding with a third party arising out of the same matter.
9.19 Workers' Compensation. In accordance with 42 C.F.R. Section 422.108, as may be
amended from time to time, and other Mandates, Contract Holder is responsible for
protecting Our interests in any Workers' Compensation claims or settlements with any
Member. We shall be reimbursed for all paid medical expenses which have occurred as a
result of any work related injury that is compensable or settled in any manner.
Upon Our request, Contract Holder shall also submit a monthly report to Us listing all
Workers' Compensation cases for Members who have outstanding Workers'
Compensation claims involving the Contract Holder. Such list will contain the name,
social security number, date of loss and diagnosis of all applicable Members.
9.20 Medicare Secondary Paver Requirements.
• Generally. Aetna and Contract Holder agree to comply with all Medicare Secondary
Payer ("MSP") Mandates that apply to Contract Holder, the Plan and Aetna ("MSP
Requirements").
• MSP Requirements Applicable to Medicare Beneficiaries Diagnosed with End Stage
Renal Disease ("ESRD"). Aetna and Contract Holder agree to comply with all MSP
Requirements applicable to Contract Holder's active employees and retirees and their
dependents who are Medicare beneficiaries diagnosed with ESRD ("ESRD
Beneficiaries" or "ESRD Beneficiary"), including, without limitation, those MSP
Requirements set forth in 42 U.S.C. § 1395y(b)(1)(C), 42 C.F.R. §§ 411.102(a),
411.161, and 411.162 and 42 C.F.R. §§ 422.106 and 422.108 ("ESRD MSP
Requirements").
• Contract Holder acknowledges and agrees that if an ESRD Beneficiary is eligible for
or entitled to Medicare based on ESRD, the MSP Requirements require the
commercial group health plan offered by Contract Holder ("GHP") to be the primary
payer for the first thirty (30) months of the ESRD Beneficiary's Medicare eligibility
or entitlement ("30-month coordination period"), regardless of the number of
ME PPO GA(Y2016) GRP_GAPPO_2016
20
.
employees employed by Contract Holder and regardless of whether the ESRD
Beneficiary is a current employee or retiree.
• In furtherance of Aetna's and Contract Holder's compliance with ESRD MSP
Requirements, Contract Holder agrees to confirm to Aetna whether ESRD
Beneficiaries are in their 30-month coordination period, and not seek to enroll ESRD
Beneficiaries in the Plan during their 30-month coordination period unless coverage
under the GHP is maintained for such ESRD Beneficiaries for that period. If
Contract Holder seeks to enroll an ESRD Beneficiary in the Plan, Contract Holder
agrees to provide Aetna, upon request, with information or documentation to verify
compliance with ESRD MSP Requirements, including any MSP reporting or other
requirements established by CMS.
9.21 Disease Management/Care Management Programs. From time to time, Aetna may offer
and administer programs for Members that are designed to improve quality of care,
ensure access to Covered Benefits and/or coordinate care delivered to Members under the
Plan ("Disease/Care Management Programs"). Aetna will administer Disease/Care
Management Programs consistent with Mandates and monitor the performance of
Disease/Care Management Programs on an ongoing basis. Contract Holder
acknowledges that Aetna may determine, in its sole discretion and judgment, to
discontinue offering a Disease/Care Management Program to Members at any time,
consistent with Mandates.
9.22 Office of Foreign Asset Control. If coverage provided by this Group Agreement
violates or will violate any economic or trade sanctions, the coverage is immediately
considered invalid. For example, Aetna cannot make payments for health care or other
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 Asset Control (OFAC) license.
ME PPO GA(Y2016) GRP_GAPPO_2016
21