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HomeMy WebLinkAboutContractProving What’s Possible in Healthcare® HMA CLIENT INTENT & EXHIBIT A SCHEDULE OF FEES City of Renton 4034/5034 1/1/2024 through 12/31/2024 Renewal Account Information Group Name: City of Renton Group: # 4034/5034 Group Size: Employees: 636 Network: HMA Contract Period: 1 Year Enrollment Type: Web Enroll Open Enrollment Dates: November 1 – 30, 2023 Broker (firm): Gallagher Benefit Services, Inc. Contact Info Name Phone Email Broker Contact: Aubrey Wheeler (509) 808-3089 Aubrey_Wheeler@ajg.com Account Manager: Robert Block (206) 953-4030 Robert.Block@accesstpa.com Benefit Information and Change Requests Medical Benefits Please review and indicate desired changes in the space provided for each benefit. If there are changes to more than 6 plans, please attach a list to your email when you send this form back to HMA. If you don’t need changes to any of the below benefit levels, skip to the next section. Active Benefit Preferred (P) Participating (N) Out-of-network (M) Current deductible None None None Changes (if any): Current out-of- pocket maximum* 500 – Individual 875 – Family 500 – Individual 875 – Family 500 – Individual 875 – Family Changes (if any): Current copay – doctor’s office visit $ 30 copay, Paid at 100% $30 copay, Paid at 100% $30 copay, Paid at 100% Changes (if any): CAG-23-383DocuSign Envelope ID: D2EAAD65-019C-4123-AED0-DCCEAD46639F HMA Client Intent & TPA Exhibit A – City of Renton 4034/5034 Page 2 of 19 4034_5034 City of Renton 2024.01 Client Intent Exhibit A_V1_Filled in 5.5.2023 Retiree Benefit Preferred (P) Participating (N) Out-of-network (M) Current deductible None None None Changes (if any): Current out-of- pocket maximum* N/A N/A N/A Changes (if any): Current copay – doctor’s office visit Paid at 100% Paid at 100% Paid at 100% Changes (if any): For any change to OOPM where the accumulator is integrated, the PBM will need to be updated with the new OOPM amount to ensure accurate tracking. Vision Benefits Please review and indicate desired changes in the space provide immediately each benefit. If you don’t need changes to any of the below benefit levels, skip to the next section. Active Benefit Preferred (P) Participating (N) Out-of-network (M) Vision Exam Paid at 100% Limited to one exam per calendar year. Paid at 100% Limited to one exam per calendar year. 30 copay, Paid at 100% Limited to one exam per calendar year. Changes (if any): Hardware Paid at 100% Limited to $650 every 2 calendar years. Paid at 100% Limited to $650 every 2 calendar years. Paid at 100% Limited to $650 every 2 calendar years. Changes (if any): Retiree Benefit Preferred (P) Participating (N) Out-of-network (M) Vision Exam Paid at 100% Paid at 100% Paid at 100% Changes (if any): DocuSign Envelope ID: D2EAAD65-019C-4123-AED0-DCCEAD46639F HMA Client Intent & TPA Exhibit A – City of Renton 4034/5034 Page 3 of 19 4034_5034 City of Renton 2024.01 Client Intent Exhibit A_V1_Filled in 5.5.2023 Retiree Benefit Preferred (P) Participating (N) Out-of-network (M) Hardware Paid at 100% Limited to $450 every 2 calendar years. Paid at 100% Limited to $450 every 2 calendar years. Paid at 100% Limited to $450 every 2 calendar years. Changes (if any): Dental Benefits Please review and indicate desired changes in the space provide immediately each benefit. If you don’t need changes to any of the below benefit levels, skip to the next section. Benefit Preferred (P) Out-of-network (M) Dental Deductible None None Changes (if any): Dental Maximum $2,000 – Individual Calendar Year Maximum $2,000 – Individual Calendar Year Maximum Changes (if any): Coinsurance Type I: Paid at 100% Type II: Paid at 100% Type III: Paid at 80% Orthodontia: Paid at 50%, Limited to a 2,000 lifetime maximum. Type I: Paid at 80% Type II: Paid at 80% Type III: Paid at 50% Orthodontia: Paid at 50%, Limited to a $2,000 lifetime maximum. Changes (if any): DocuSign Envelope ID: D2EAAD65-019C-4123-AED0-DCCEAD46639F HMA Client Intent & TPA Exhibit A – City of Renton 4034/5034 Page 4 of 19 4034_5034 City of Renton 2024.01 Client Intent Exhibit A_V1_Filled in 5.5.2023 Pharmacy Benefit Management (PBM) Please confirm any changes to the current PBM vendor. HMA maintains contracts with preferred PBM’s as well as a list of approved PBM’s. Please contact your Account Manager, with questions regarding the approv ed PBM’s. Renew Change Current vendor name & information New vendor* name & information PBM Costco Health Solutions – Client Contract If changing PBM’s provide all benefit set up documentation. HMA will need this information to prepare Summary Plan Description (SPD) and Summary Benefit Comparisons (SBC). For Plans with a separate deductible and/or out of pocket for pharmacy benefits please outline any changes below. Individual Family Current Rx Deductible If separate from medical) --- --- Changes ( if any): Current Rx OOPM If separate from medical) --- --- Changes ( if any): Please review the copays below and detail any changes. Generic Formulary Non-Formulary Current Retail Copay Active: $10 Retiree: $0 Active: $25 Retiree: $0 Active: $50 Retiree: $0 Changes ( if any): Current Mail Order Copay Active: $10 Retiree: $0 Active: $25 Retiree: $0 Active: $50 Retiree: $0 Changes ( if any): Current Specialty Copay Active: $10 Retiree: $0 Active: $25 Retiree: $0 Active: $50 Retiree: $0 Changes ( DocuSign Envelope ID: D2EAAD65-019C-4123-AED0-DCCEAD46639F HMA Client Intent & TPA Exhibit A – City of Renton 4034/5034 Page 5 of 19 4034_5034 City of Renton 2024.01 Client Intent Exhibit A_V1_Filled in 5.5.2023 Also note any additional benefit changes or program implementations below. Any Other Changes: 4034 Active Plan only: Add coverage for Obesity Treatment (Non-Surgical) & Obesity Surgery (Bariatric Surgery) including complications arising from a bariatric (obesity) surgery covered by this Plan as voted by the Renton Employee’s Health Plan Board on 9/14/2023. Utilize standard SPD HMA language for coverage of these services within 2024 Plan documents. Outline of any additional Benefit Changes (Medical, Dental, Vision, Rx) Please use the below section to include other changes to benefits. Client Insight Recommendations HMA continuously strives for innovation and excellence in serving you. Please see your Client Insights PDF for more information on our recommendations for your Plan. Check the corresponding boxes below for the recommendation you want to implement. Remove/Exclude Add/ Accept Benefit Recommendations Wilderness Treatment and Boarding School coverage related to Mental Health or Substance Use Disorders. Requires medical necessity DocuSign Envelope ID: D2EAAD65-019C-4123-AED0-DCCEAD46639F HMA Client Intent & TPA Exhibit A – City of Renton 4034/5034 Page 6 of 19 4034_5034 City of Renton 2024.01 Client Intent Exhibit A_V1_Filled in 5.5.2023 Remove/Exclude Add/ Accept Benefit Recommendations Update SPD language to comply with Mental Health Parity and Addiction Equity Act (MHPAEA) and remove exclusions for Wilderness Treatment and Boarding Schools. Orthotics Must meet medical necessity Update SPD language to cover medically necessary orthotics, routine foot care and exclude over-the-counter devices. Breast Pumps – OON Coverage Allows members the option to purchase at Target or Walmart without barrier to coverage. Allow at billed charges for OON purchase. If you have MDLIVE products and wish to make changes to your copay or coinsurance amounts please make the appropriate updates below. MDLIVE Telehealth – Copay, Coinsurance and Deductible Confirmation Please fill in the blanks for each Plan option. PPO plan member copay amount of $________ per virtual visit, deductible waived PPO plan member copay amount of $________ per virtual visit after deductible met HDHP plan member coinsurance amount of _________% Vendors List any vendors the client utilizes for services outside of HMA’s Administration and include vendor name with contact information. Please note that if you choose to work with a non-preferred vendor, we may not be able to integrate eligibility, claims reporting or accumulators and additional fees may apply. Vendor type Change? Current vendor name & information New vendor name & information Member Advocacy or Concierge Service Gallagher Benefit Service Center CDHP* COBRA Administered by HMA Dental Administered by HMA Kidney Dialysis Covered under HMA Medical DocuSign Envelope ID: D2EAAD65-019C-4123-AED0-DCCEAD46639F HMA Client Intent & TPA Exhibit A – City of Renton 4034/5034 Page 7 of 19 4034_5034 City of Renton 2024.01 Client Intent Exhibit A_V1_Filled in 5.5.2023 Vendor type Change? Current vendor name & information New vendor name & information Vision Administered by HMA ACA Reporting MZQ Fiduciary Nurseline Disease Management Other Vendor Consumer-driven Health Plan (CDHP), e.g. HRA, FSA, HSA, LPFSA, DCRA. Locations Review this list of locations. Check the box to the left if you need to make a change to a location ( example: remove, add new, update name or address). Then, in the ‘change needed’ column, provide a description of the change needed. Change? Location and Description) Change needed indicate add, term) for additions include # and description) Effective Date ACT Active COBR COBRA Claim Administrative Fees Rates for the contracted time period apply to services administered by HMA. Fees for outside vendors are subject to change at any time. HMA fees and commissions may remain in effect beyond the above-stated term until changed by mutual written agreement of the parties. HMA reserves the right to pass through any and all regulatory assessments, fees, or similar financial obligations that are attributable to a client health plan whether known or not during the renewal process or that may become applicable during the term of HMA's services to a client and its health plan. HMA shall use reasonable efforts to identify and communicate to clients about assessments that it will be liable for, but shall bear no liability for such obligations. Fee Product Description 27.23 Medical Plan Administration PEPM 2024 Medical Plan Administration DocuSign Envelope ID: D2EAAD65-019C-4123-AED0-DCCEAD46639F HMA Client Intent & TPA Exhibit A – City of Renton 4034/5034 Page 8 of 19 4034_5034 City of Renton 2024.01 Client Intent Exhibit A_V1_Filled in 5.5.2023 Fee Product Description 5.50 HMA PPO Network Access PEPM HMA Preferred provides access to Regence BlueShield in Western Washington, Asuris NW Health in Eastern Washington, Regence BlueCross BlueShield of Oregon, Regence BlueShield of Idaho and Regence BlueCross BlueShield of Utah. PHCS provides network access in all other states. 3.75 Care Management PEPM Utilization Review and Care Management services. 0.45 Federal Transparency Technology Enablement PEPM In 2023, self-funded health plans are subject to seven new to ongoing and new transparency-related federal regulatory requirements. At a high-level these include; an advanced EOB, balanced billing protection, publically available machine-readable files for the medical plan, a consumer price comparison tool, compliance reporting, and provider directory requirements. Additional transparency-related requirements are slated for 2024.These requirements represent a massive technology lift and investment. We are passing through only a portion of the real costs of delivering on these requirements. We will comply with the portions of the regulations that apply to the products and services covered under our contracts. 30% of savings Hospital bill audit, out-of-network claim re-pricing services and claims negotiation. 30% of savings Electronic review of claims for code edits prior to payment. 27% of recovered funds Subrogation services The plan will receive 73% of recovered funds. Of the remaining, 22% is retained by The Phia Group, and 5% is retained by HMA.* In the event of litigation to enforce the Plan’s right of recovery, The Phia Group fee will increase to 33.3% and HMA shall not retain any compensation. 15%-30% of recovered funds Data Mining and overpayment recovery 15%-17% recovery fee retained by Cotivitii o 15% current claims o 17% aged claims On post-payment COB and Code Edit recoveries identified by Cotiviti, additional 13- 15% retained by HMA. 9.5% of recovered funds Credit balance premier health services partner on site with providers across the country. 30% of savings Fraud, waste, and abuse o 17.5% of savings retained by Change Healthcare Solutions o 12.5% administrative allowance retained by HMA HealthEquity Annual Fees for HMA’s contract. Fees invoiced by and paid directly to HealthEquity. Fee Description 250 HRA / FSA / DCFSA / LPFSA – Plan set up and annual Plan maintenance fee applied per plan type and invoiced annually through the HealthEquity employer portal. DocuSign Envelope ID: D2EAAD65-019C-4123-AED0-DCCEAD46639F HMA Client Intent & TPA Exhibit A – City of Renton 4034/5034 Page 9 of 19 4034_5034 City of Renton 2024.01 Client Intent Exhibit A_V1_Filled in 5.5.2023 Fee Description 1.50 Per Member/ Per Statement Paper statement fee. HealthEquity will directly debit from members’ account balance if they choose a paper statement. Electronic statements are free. HealthEquity additional fee disclosures: Fee Employer fees for atypical transactions 20/ transaction Return Deposit 20/transaction Employer Contribution Refund Request 20 per event Manual Contribution Processing – (no fee if instructions are submitted online or via electronic file) HSA Account Holder Fees Fees subject to change with appropriate advance notice) HealthEquity Visa Card Up to 3 FREE Additional or replacement cards / $5 per card Electronic Statement FREE Paper Statement (avoided with Electronic Statements) $1.50 Monthly Card Transaction FREE Payment to Provider FREE Electronic Payment to Self FREE Paper Check to Self $2.00 Per transaction Investment Trades FREE Investment Account creation (but see other investment related fees below) FREE Note: A cash balance of at least $2,000 is required to invest in mutual funds. Stop Payment Request $20.00 Per request Overdrawn account or Non-Sufficient Funds $20.00 Per transaction Distribution of Excess Contribution (initiated by member) 20.00 Per request Return Deposit $20.00 Per transaction Account Closing $25.00 One-time Investments Related Fees Investor Choice Funds instead of standard HQY fund line up 0.0333% per month on dollars invested in Investor Choice funds (0.40% per year) Advisor GPS Service 0.05% per month on invested dollars (0.60% per year) Advisor Auto Pilot 0.08% per month on invested dollars (0.96% per year) FSA/HRA/LPFSA Account Holder Fees Fees subject to change with appropriate advance notice) HealthEquity Visa Card* Up to 2 FREE Additional or replacement cards / 10 per replacement DocuSign Envelope ID: D2EAAD65-019C-4123-AED0-DCCEAD46639F HMA Client Intent & TPA Exhibit A – City of Renton 4034/5034 Page 10 of 19 4034_5034 City of Renton 2024.01 Client Intent Exhibit A_V1_Filled in 5.5.2023 Paper Statement (avoided with Electronic Statements) $1.50 Monthly Card Transaction FREE Payment to Provider FREE Electronic Payment to Self FREE Paper Check to Self $2.00 Per Transaction Stop Payment Request $20.00 Per Transaction Additional Products and Services Review the buy-up product and service options below. Check the box in the Continue, Add, or Remove columns to indicate your selected action for each item. If you are simply continuing your existing product and services, then check ‘Continue’ next to each service. Some products and services are offered through partners on our contract. Should pricing changes occur during the plan year, we will make every effort to notify you at least 30 days in advance of the price change. Continue Add Remove Current Fee Renewal Fee Product Service Description 3.25 $3. 00 Dental Plan Administration PEPM Dental benefit administrative services through either an indemnity (non- network) platform or adding network access through the National Dental Network. 1.50 $1. 50 HMA National Dental Network Access PEPM Access to the National Dental Network. In addition to the Dental Plan Administration fees) 0.65 $ 0. 65 Vision Hardware Administration PEPM Vision hardware administrative services. 3.95 $ 3. 95 Flexible Spending Account (FSA) PAPM Only one PAPM fee is charged if an individual has more than one (1) FSA and/or HRA. This does not apply to LPFSA and HSA plan type(s). Note – Visa card: Up to two cards free. Additional or replacement cards are $ 10 per card. Annual Fees: see “HealthEquity Annual Fees” in previous section. 3.95 $ 3.95 Dependent Care FSA ( DC FSA / DCRA) PAPM Only one PAPM fee is charged if an individual has more than one (1) FSA and/or HRA. This does not apply to LPFSA and HSA plan type(s). Note – Visa card: Up to two cards free. Additional or replacement cards are $ 10 per card. Annual Fees: see “HealthEquity Annual Fees” DocuSign Envelope ID: D2EAAD65-019C-4123-AED0-DCCEAD46639F HMA Client Intent & TPA Exhibit A – City of Renton 4034/5034 Page 11 of 19 4034_5034 City of Renton 2024.01 Client Intent Exhibit A_V1_Filled in 5.5.2023 Continue Add Remove Current Fee Renewal Fee Product Service Description 3.95 $ 3. 95 Health Reimburseme nt Account HRA) PAPM Only one PAPM fee is charged if an individual has more than one (1) FSA and/or HRA. This does not apply to LPFSA and HSA plan type(s). Note – Visa card: Up to two cards free. Additional or replacement cards are $ 10 per card. Annual Fees: see “HealthEquity Annual Fees” in previous section. 2.70 $ 2. 70 Health Savings Account (HSA) PAPM HSA accounts coupled with an LPFSA will be billed at $4.65 PAPM ($2.70 PAPM for HSA + 1.95 PAPM for LPFSA) Note – Visa card: Up to three free cards. Additional or replacement cards are $ 5 per card. Annual Fees: see “HealthEquity Annual Fees” in previous section. 1.95 $ 1.95 Limited Purpose FSA LPFSA) PAPM LPFSA accounts coupled with an HSA will be billed at $4.65 PAPM ($1.95 PAPM for LPFSA + 2.70 PAPM for HSA) Note – Visa card: Up to two free cards. Additional or replacement cards are $ 10 per card. Annual Fees: see “HealthEquity Annual Fees” in previous section. 1.35 $ 1.35 COBRA Services PEPM HMA will notify participants of COBRA continuation coverage rights upon the occurrence of a qualifying event and collect premiums for continuation of coverage with distribution to vendors. All COBRA eligible benefits (Medical, Dental, Vision, FSA, EAP) are included in the administration. Please provide COBRA renewal rates by 11/1/2023) 2.00 $ 2.00 Consolidated Billing PEPM - Option 1 Premium Remittance only, NO Eligibility Administration. 3.00 $ 3.00 Consolidated Billing PEPM - Option 2 Premium Remittance AND Eligibility Administration $3.00 PEPM and $0. 50 PEPM for any vendor(s) other than WDS, Willamette Dental DocuSign Envelope ID: D2EAAD65-019C-4123-AED0-DCCEAD46639F HMA Client Intent & TPA Exhibit A – City of Renton 4034/5034 Page 12 of 19 4034_5034 City of Renton 2024.01 Client Intent Exhibit A_V1_Filled in 5.5.2023 Continue Add Remove Current Fee Renewal Fee Product Service Description 2.10 $ 2. 10 PACE Fiduciary PEPM The PACE Fiduciary Service provides final appeal determination decisions on behalf of the plan. The Fiduciary Service is provided by the Phia Group, an expert in self- funded legal services. With PACE, Phia reviews adverse benefit decisions made by the plan and acts as the plan’s fiduciary to make final appeal determination on the plan’s behalf. In addition, the Phia Group takes on liability for damages that may result from an arbitrary or capricious claims determination. 1.50 $ 2. 00 Care Navigator PEPM Care Navigator is our legacy concierge service that supports members across their health journey. Our team acts on certain prior authorization requests to steer planned out-of-network care in-network, makes pre- and post-procedure calls, monitors utilization trends to identify opportunities for ER diversion, and educates members on plan benefits to promote utilization and support the health DocuSign Envelope ID: D2EAAD65-019C-4123-AED0-DCCEAD46639F HMA Client Intent & TPA Exhibit A – City of Renton 4034/5034 Page 13 of 19 4034_5034 City of Renton 2024.01 Client Intent Exhibit A_V1_Filled in 5.5.2023 Continue Add Remove Current Fee Renewal Fee Product Service Description 4.00 Care Navigator Plus PEPM Our new Care Navigator Plus identifies at-risk members, engages them early in their care journey, and pairs them with a Care Navigator who may guide them to high- quality, high-value sites of care for surgeries and imaging, in-network primary care, and partner programs. Care Navigator Plus supports the financial health of your organization by lowering overall spend on high-cost care and improves health outcomes by empowering members at important moments in their health journeys. Lyn Health and Healthcare Bluebook Cost and Quality data are bundled into this product at no additional cost. Clients choose between reducing the member health plan contributions or digital gift cards as an incentive for those members who complete their health questionnaire within the specified timeframe determined by the Plan. Please select one of the options below: Employee Contribution Reduction (HMA will provide reporting of members qualifying for the incentive, employer executes employee health plan contribution reduction) 25 digital gift card sent to member-provided email (employer will be invoiced for value of gift card plus administrative fees) 50 digital gift card sent to member-provided email (employer will be invoiced for value of gift card plus administrative fees) 2.00 $ 2.25 Healthcare Bluebook Cost and Quality PEPM A transparency digital tool that makes it easy for members to find the fair price for medical procedures and the nearest and best quality providers that offer fair prices. Bluebook empowers members with greater visibility on cost and quality variance and protects the Plan from overpaying for health services. Rewards range from $25-$100 when a member selects a DocuSign Envelope ID: D2EAAD65-019C-4123-AED0-DCCEAD46639F HMA Client Intent & TPA Exhibit A – City of Renton 4034/5034 Page 14 of 19 4034_5034 City of Renton 2024.01 Client Intent Exhibit A_V1_Filled in 5.5.2023 Continue Add Remove Current Fee Renewal Fee Product Service Description Healthcare Bluebook Engagement Rewards For no additional admin fee, incent members with higher reward amounts ranging from up to $350 for outpatient procedures to a max of $1500 for inpatient procedures for a selection of 420 procedures when a member logs into HCBB and selects a fair price provider. Requires client to provide email addresses of all eligible employees. Healthcare Bluebook Care Connect Concierge service for joints, spine, and women’s surgical procedures health including finding the right provider, scheduling appointment and facilitating medical record transfer. Case rates apply for each successful steerage amounts ranging from $ 700-$5,500. Only available with Engagement Rewards). Omada for Musculoskelet al Omada for Musculoskeletal is digital physical therapy that pairs members with a physical therapist and leverages Advanced Computer Vision. By shifting care upstream in a member’s care journey, providing clinical quality at a lower cost, and driving clinically meaningful member behaviors, Omada for MSK improves health and cost outcomes for members and employers. Self-guided preventive program available at no cost to members. 200 initial consultation 550 case rate for Recovery Phase ( covers 12 months) Billed as medical claims. Member cost share applies. No DocuSign Envelope ID: D2EAAD65-019C-4123-AED0-DCCEAD46639F HMA Client Intent & TPA Exhibit A – City of Renton 4034/5034 Page 15 of 19 4034_5034 City of Renton 2024.01 Client Intent Exhibit A_V1_Filled in 5.5.2023 Continue Add Remove Current Fee Renewal Fee Product Service Description 318 per case 318 per case Lyn health Polychronic Care Management and Advocacy Program Lyn provides human- centric healthcare created for people with multiple chronic conditions, delivering clinical, advocacy and care coordination services via a single point of contact, 24/7. Leveraging virtual capabilities and in-person resources, Lyn improves quality of care and lowers cost for the polychronic population. For adults 18 & older. Participating plans must waive cost share on a monthly $318. 00 care coordination cost and is captured in claim fee requests. Full fee schedule for additional psychiatric diagnostic evaluation, psychotherapy, and outpatient medical condition management services captured as claim fee requests available to plans upon opt-in. requires client to provide email address of all eligible employees. 1.50 $1. 50 Wellness Hub PEPM Features a customizable online wellness incentive tracker, a personal health assessment, extensive health library, and wellness challenges with popular fitness device and app integration. 125 $ 125 Incentive Administration per hour Available only in combination with the Wellness Hub. Administrative support for Wellness Hub incentives, customized incentive campaign design, creation, management, tracking. Standard reporting is available. 5 hours are included, additional hours are available for $ 125 per hour. 2.50 $ 2. 50 Wellness Coaching PEPM Includes unlimited health coaching via phone and email for help with wellness goals such as stress management, tobacco cessation, eating healthier and being more physically active. Health coaches will help members seeking lasting lifestyle changes to adopt healthy habits and prevent the risk of chronic conditions. 3.00 $ 3. 00 Disease Management PEPM Includes nurse coaching and outreach for six major chronic conditions: asthma, back pain, cancer, depression, diabetes, coronary artery disease (CAD), congestive heart failure (CHF), end stage renal disease (ESRD), chronic obstructive pulmonary disease ( COPD), and hypertension. 3.00 PEPM First Year Only Discount 3.50 DocuSign Envelope ID: D2EAAD65-019C-4123-AED0-DCCEAD46639F HMA Client Intent & TPA Exhibit A – City of Renton 4034/5034 Page 16 of 19 4034_5034 City of Renton 2024.01 Client Intent Exhibit A_V1_Filled in 5.5.2023 Continue Add Remove Current Fee Renewal Fee Product Service Description 350 $ 350 Maternity per case MommyTrax.com is a maternity and new parent benefit package that features both evidence-based health content and telehealth case management with maternity nurses. Includes a welcome kit (prenatal vitamins and a parenting book) and a $50 gift card upon program completion as incentives for participation. 0.65 $0.65 24 Hour Nurse Line CareNet provides 24/7 access to nurses via telephone for member counseling or advice. 1.60 $1. 60 Medical plus Behavioral Health and Dermatology PEPM Combines all of the MDLive Telehealth benefits described for Medical, Behavioral Health, and Virtual Dermatology. A claim cost also applies and is captured in claim fee requests. See admin renewal for pricing. 1.35 $1. 35 Medical plus Behavioral Health PEPM MDLIVE provides access to a network of licensed therapists and board- certified psychiatrists in addition to board-certified doctors. Each provider is credentialed according to NCQA guidelines and trained on best practices in online therapy. A claim cost also applies and is captured in claim fee requests. See admin renewal for pricing. 1.30 $1. 30 Medical plus Dermatology PEPM MDLIVE offers access to board-certified dermatologists through secure website or mobile device in addition to base Medical services. Patients receive a full consultation, complete with a diagnosis, personalized treatment plan, and appropriate prescriptions. A claim cost also applies and is captured in claim fee requests. See admin renewal for pricing. 1.00 $1. 00 Medical Only PEPM MDLIVE offers members access to board-certified doctors via secure online video or phone via our portal, the web, or the MDLIVE app – anytime, anywhere- 24/7/365. A claim cost also applies and is captured in claim fee requests. See admin DocuSign Envelope ID: D2EAAD65-019C-4123-AED0-DCCEAD46639F HMA Client Intent & TPA Exhibit A – City of Renton 4034/5034 Page 17 of 19 4034_5034 City of Renton 2024.01 Client Intent Exhibit A_V1_Filled in 5.5.2023 Continue Add Remove Current Fee Renewal Fee Product Service Description 2. 15 Virtual Behavioral Health Product Option A PEPM By election Virtual Health Option, A or B, any exclusions within the SPD will be updated to align with Virtual Behavioral Health product offerings) 6 counseling + 6 coaching sessions per enrolled employee/ family unit, per incident, per year HMA’s new innovative behavioral health product offers fast speed to appointment and therapy for conditions often excluded from health plans such as marital conflict and grief. Easy to use technology, with a personal touch. Highlights include: Behavioral Telehealth Live Video Sessions Instant Chat and Text with a counselor Cognitive behavioral therapy Behavioral coaching, Digital mental health tools. Online Scheduling Form Extensive reporting 3. 30 Virtual Behavioral Health Product Option B PEPM By election Virtual Health Option, A or B, any exclusions within the SPD will be updated to align with Virtual Behavioral Health product offerings) 12 counseling + 12 coaching sessions per enrolled employee/ family unit, per incident, per year Doubles the sessions for the above product description. A $2.00 per card ID Card Fee applies when changes are made to the template, for example, deductible and out-of-pocket or Pharmacy Benefit Manager changes. Incidental individual card replacement or reissue available upon member request through our portal at no cost. HMA reserves the right to invoice costs plus 20% of printing and mailing charges for member materials. Printing and mailing member materials and other collateral, including but not limited to SBCs, Member Guides, product flyers, etc. HRIS vendor change requests within-3 years of initial set-up incur a charge DocuSign Envelope ID: D2EAAD65-019C-4123-AED0-DCCEAD46639F HMA Client Intent & TPA Exhibit A – City of Renton 4034/5034 Page 18 of 19 4034_5034 City of Renton 2024.01 Client Intent Exhibit A_V1_Filled in 5.5.2023 Stop Loss Services In compensation for the work HMA does to support stop loss carriers, HMA requires payment either directly from our preferred stop loss carrier partner, Managing General Underwriter (MGU), General Agent (GA), Captive or client. Preferred stop loss carriers pay an administrative allowance to HMA for the support and services as part of the override agreements. If you are using a non-preferred carrier, MGU, GA or Captive there will be a stop loss service support fee of 3% of stop loss premiums assessed. The stop loss service support fee will be reflected on the invoice as a PEPM. Renew Change Current vendor name & information New vendor name & information Excess Loss Carrier Symetra Add Term Change Current vendor name & information New vendor name & information MGU, GA, Captive N/A Please note, if the client changes stop loss carriers or desires to implement a third-party service during the course of this renewal term which is not currently included in our preferred carrier list, notification is required to HMA. HMA reserves the right to decline to work with non-preferred stop loss carriers, MGU’s, GA’s or Captives. If we agree to administer a plan with a stop loss carrier, MGU, GA or Captive that is not preferred, we will charge an interface fee of 3.0% of stop loss premium and will ask for a signed waiver of liability from the group. For carriers where we are not an approved benefit administrator, HMA reserves the right to decline to proceed with the approval process at our discretion. The interface fee for non-preferred carriers is calculated based on the final stop loss renewal premium rates and enrollment for the last month of the prior contract period. The rates are calculated as follows: 03 x (single Specific Stop Loss Premium Rate x single enrollment) + (family Specific Stop Loss Premium Rate x family enrollment) + (Aggregate Stop Loss Premium Rate x total enrollment)] / Total Enrollment I’ve read and accept the above terms regarding Excess Loss Services. Other Comments Please use the below section to DocuSign Envelope ID: D2EAAD65-019C-4123-AED0-DCCEAD46639F HMA Client Intent & TPA Exhibit A – City of Renton 4034/5034 Page 19 of 19 4034_5034 City of Renton 2024.01 Client Intent Exhibit A_V1_Filled in 5.5.2023 Acceptance IN WITNESS WHEREOF, the parties have caused this Agreement to be executed by their duly authorized representatives on the respective dates set forth below, effective as of the day and year first above written. By: City of Renton X By: Healthcare Management Administrators X Name: Name: Title: Title: Date: Date: Mayor Armondo Pavone Mayor 10-24-2023 Attest: Jason A. Seth, City Clerk DocuSign Envelope ID: D2EAAD65-019C-4123-AED0-DCCEAD46639F Lindsay Harris President & CEO October 27, 2023 | 2:19 PM PDT