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HMA CLIENT INTENT & EXHIBIT A SCHEDULE OF FEES
4034 City of Renton
1/1/2021 through 12/31/2021 Renewal
Account Information
Group Name: City of Renton Group: #4034
Group Size: 658 Employees
1,562 Members
Network: HMA Contract Period: 1 Year
Enrollment Type: Web How will Open Enrollment
be submitted:
Web
Open Enrollment Dates: 11/1 - 11/30
Broker (firm): Gallagher Benefit
Services - Bellevue
Contact Info Name Phone Email
Broker Contact: Nancy Kokenge (425) 974-4465 nancy_kokenge@ajg.com
Account Manager: Cole Harrison (425) 289-5236 Cole.Harrison@accesstpa.com
Client Specific Details
To make changes, check the boxes in the ‘change?’ column. Provide a description of each change needed in the space
provided in the far left column.
Description Describe changes needed here.
Section 1557( (subject to Federal non-
discrimination laws)
Yes
Balance Billing Protection Act*
(Applicable to Washington
Headquartered Clients Only)
No
*Any and all costs attributed to special member communications, negotiations and arbitration, including legal fees incurred by HMA
while supporting the Plan in adhering to the Balance Billing Protection Act program requirements shall be passed through to the Plan
for payment.
HMA Client Intent & TPA Exhibit A – City of Renton Page 2 of 9
4034 City of Renton 2021.01 Client Intent Exhibit A
Benefit Information and Change Requests
Medical Benefits
Please review and indicate desired changes in the space provide immediately each benefit. If you have changes for more
than 6 plans, 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. Pay close attention to the Health & Human Services’ guidance below
regarding annual out-of-pocket maximums for 2021
The current proposed maximum annual limitation on cost sharing for the 2021 benefit year are
(full document):
$8,550 for self-only coverage
$17,100 for family coverage
This represents an approximately 4.9% increase above the 2020 parameters of $8,500 for self-
only and $16,300 for family coverage.
4034 – Active (PPO)
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):
5034 – LEOFF (PPO)
Benefit Preferred (P) Participating (N) Out-of-network (M)
Current deductible None None None
Changes (if any):
Current out-of-pocket
maximum Not Applicable Not Applicable Not Applicable
Changes (if any):
Current copay –
doctor’s office visit Paid at 100% Paid at 100% Paid at 100%
HMA Client Intent & TPA Exhibit A – City of Renton Page 3 of 9
4034 City of Renton 2021.01 Client Intent Exhibit A
5034 – LEOFF (PPO)
Benefit Preferred (P) Participating (N) Out-of-network (M)
Changes (if any):
Vendors
List any vendors the client utilizes for services outside of HMA’s Administation 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
CDHP* None
COBRA HMA Internal Provided
Dental HMA
Kidney Dialysis Covered under HMA Medical Plan
Maternity None
PBM Costco Health Solutions
(877) 908-6024
Stop Loss Symetra
(800) 796-3872
Vision HMA Internal Provided
Telehealth MDLive, Inc.
(877) 596-8826
* 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 Change needed Effective
Date
HMA Client Intent & TPA Exhibit A – City of Renton Page 4 of 9
4034 City of Renton 2021.01 Client Intent Exhibit A
Active
COBRA
Fees
Medicare Part D Testing
Complete Medicare’s Creditable Coverage Requirements. Electing Description Fee
Yes, request NW Actuaries to complete the determination of employer compliance with
Medicare Part D. A finalized SPD is required to complete request.
$385 per plan
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.
Fee Description
$23.70 PEPM for Medical Plan Administration
Includes pharmacy interface + integrated OOP maximum/QHDHP administration
If all documents are signed and returned by 11/2/2020, the new PEPM with $0.20 discount will
be $23.50.
$5.50 HMA PPO Network Access
$3.75 PEPM Care Management base services
30% of savings Claims negotiation, hospital bill audit, and out-of-network claim re-pricing services as outlined
in TPA agreement section 4
27% of recovered funds
Subrogation services as outlined in Section 4(i) of Exhibit B
The plan will receive 73% of recovered funds. Of the remaining, 22% is retained by PHIA, and 5%
is retained by HMA.*
* In the event of litigation to enforce the Plan’s right of recovery, PHIA’s fee will increase to 33.3% and
shall not retain any compensation.
16-18% of recovered
amount charged as
contingency fee
Overpayment prevention & recovery as outlined in Section 4(i) of Exhibit B
16%-18% recovery fee retained by Accent*
* Note, the contingency fee charged by Accent varies based on the age of the underlying claim.
In no instance will the total fee to the Plan exceed 18% of the amount recovered.
30% of savings charged
as contingency fee
Fraud, waste, and abuse as outlined in Section 4(i) of Exhibit B
o 17.5% of savings retained by Change Healthcare Solutions
o 12.5% administrative allowance retained by HMA
Additional Products and Services
HMA Client Intent & TPA Exhibit A – City of Renton Page 5 of 9
4034 City of Renton 2021.01 Client Intent Exhibit A
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 all of your existing product and services, then
check ‘Continue’ next to all of those services.
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.
Current Plan
Year Continue Add Remove Renewal Plan Year Service Description & Cost
$3.25 $3.25 PEPM for Dental Plan Administration
$1.50 $1.50 PEPM for HMA National Dental Network Access
(In addition to the Dental Plan Administration fees)
$0.65 $0.65 PEPM Vision Hardware Administration
$1.35 PEPM COBRA Services
Medical/Rx
$1.35 Vision
Dental
FSA administered by HMA HealthEquity
Health Reimbursement Account (HRA) administration
$3.95 Per Account Per Month (PAPM)
Visa card: Up to two cards free. Additional or replacement cards are $10 per card.
Annual Fees: see “HealthEquity Annual Fees” in previous section.
Note – 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).
Flexible Spending Account (FSA) administration
$3.95 Per Account Per Month (PAPM)
Visa card: Up to two cards free. Additional or replacement cards are $10 per card.
Annual Fees: see “HealthEquity Annual Fees” in previous section.
Note – 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).
Dependent Care FSA (DC FSA / DCRA) administration
$3.95 Per Account Per Month (PAPM)
Visa card: Up to two cards free. Additional or replacement cards are $10 per card.
Annual Fees: see “HealthEquity Annual Fees” in previous section.
Note – 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).
HMA Client Intent & TPA Exhibit A – City of Renton Page 6 of 9
4034 City of Renton 2021.01 Client Intent Exhibit A
Current Plan
Year Continue Add Remove Renewal Plan Year Service Description & Cost
Health Savings Account (HSA) administration
$2.70 Per Account Per Month (PAPM)
Visa card: Up to three free cards. Additional or replacement cards are $5 per card.
Annual Fees: see “HealthEquity Annual Fees” in previous section.
Note – HSA accounts coupled with an LPFSA will be billed at $4.65 PAPM ($2.70 PAPM
for HSA + $1.95 PAPM for LPFSA)
Limited Purpose FSA (LPFSA)administration
$1.95 Per Account Per Month (PAPM)
Visa card: Up to two free cards. Additional or replacement cards are $10 per card.
Annual Fees: see “HealthEquity Annual Fees” in previous section.
Note – LPFSA accounts coupled with an HSA will be billed at $4.65 PAPM ($1.95 PAPM
for LPFSA + $2.70 PAPM for HSA)
$2.00 PEPM The Plan-appointed claim evaluator “PACE” Fiduciary service
$2.00 PEPM - Healthcare Bluebook, Fair Price, Facility & Doctor Quality transparency
tool, and the cost of the Go Green to Get Green Rewards program
MDLive Telehealth offers four product options:
Choose one product option below and then designate copays, coinsurance, and
deductibles. (Virtual visit claim fee rates subject to change with 30 days notice)
$1.60 PEPM Medical plus Behavioral Health (Counseling & Psychiatry) and
Dermatology
+ $55 per virtual visit claim fee for Medical
+ $80-$260 per virtual visit claim fee for Behavioral Health
+ $60 per virtual visit claim fee Dermatology
(Virtual visit claim fee rates subject to change with 30 days notice)
$1.35 PEPM Medical plus Behavioral Health (Counseling & Psychiatry)
+ $55 per virtual visit claim fee for Medical
+ $80-$260 per virtual visit claim fee for Behavioral Health
(Virtual visit claim fee rates subject to change with 30 days notice)
$1.30 PEPM Medical plus Dermatology
+ $55 per virtual visit claim fee
+ $60 per virtual visit claim fee Dermatology
(Virtual visit claim fee rates subject to change with 30 days notice)
$1.00
$1.00 PEPM Medical Only + $55 per virtual visit claim fee
(Virtual visit claim fee rates subject to change with 30 days notice)
MDLIVE Telehealth copay, coinsurance, and deductibles.
Check the boxes that apply for your Plan(s) and fill in the blanks for each checked
option.
PPO plan member copay amount of $________ per virtual visit, deductible waived
HMA Client Intent & TPA Exhibit A – City of Renton Page 7 of 9
4034 City of Renton 2021.01 Client Intent Exhibit A
Current Plan
Year Continue Add Remove Renewal Plan Year Service Description & Cost
PPO plan member copay amount of $________ per virtual visit after deductible met
$1.50 PEPM - Care Navigator
$6.50 PEPM - Disease Management, Wellness Hub & Wellness Coaching
* Incorporates $1.00 PEPM discount for buying all three services in a bundle.
$3.00 PEPM First Year Only Discount
$3.50 PEPM at Renewal - Disease Management – Includes nurse coaching and outreach
for six major chronic conditions—diabetes, asthma, coronary artery disease (CAD),
congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and
depression.
$2.50 PEPM - Wellness Coaching - Includes unlimited inbound health coaching via
phone, email, or video conferencing for working on wellness goals such as stress
management, tobacco cessation, eating healthier and being more physically active.
$1.50 PEPM -Wellness Hub - includes a personal health assessment, individual and
company challenges, fitness device and app integration, health decision support tools,
and a customizable wellness incentive tracker.
Incentive Administration – Available only in combination with the Wellness Hub.
Incentive administration support is available for outcomes-based incentives and
includes 5 hours of customized incentive campaign design, creation, management, and
tracking.
Standard reporting is available.
Additional Wellness Program or custom reporting hours are available for $125 per
hour.
$350.00 Per Case - Maternity Program (MommyTrax)
$0.65 PEPM - 24 Hour Nurse Line (CareNet)
ID re-card fee - $2.00 per employee
(Incidental individual card replacement or reissue available upon member request
through our portal at no cost)
Excess Loss Services
In compensation for the work that HMA does to support excess loss carriers, HMA receives an administrative allowance of
2.5% from most of our preferred carriers. If you are using a non-preferred carrier, there will be an interface fee of 3.0% of
excess loss premium that is assessed to the group in lieu of the administrative allowance. These excess loss fees will be
reflected on the invoice on a PEPM basis.
HMA reserves the right to decline to work with non-preferred excess loss carriers. If we agree to administer a plan with
an excess loss carrier that is not preferred, we will charge an interface fee of 3.0% of excess 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.
HMA Client Intent & TPA Exhibit A – City of Renton Page 8 of 9
4034 City of Renton 2021.01 Client Intent Exhibit A
For new groups, the interface fee for non-preferred carriers is based on the carriers projected enrollment and premium
rates.
For renewing groups, 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 include other notes or comments.
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
Leave of Absence Due to Furlough
Automatically trigger extended eligibility when Plan is subject to state or federal mandates due to a
declared emergency, includes built-in and automatic sunset provision when the emergency ends.
Gene & Cellular Therapies (Requires Pre-Authorization):
Choose one of the two coverage options below if accepting this recommendation:
In-network 100% coverage, deductible applies, and no coverage out-of-network, or
Insert desired in-network coinsurance _________%, deductible applies, and no coverage out-of-
network
HMA Client Intent & TPA Exhibit A – City of Renton Page 9 of 9
4034 City of Renton 2021.01 Client Intent Exhibit A Remove/Exclude Add/ Accept Benefit Recommendations
If accepting the Gene & Cellular Therapies benefit recommendation, confirm whether to include or
exclude travel benefits, then
Insert desired coinsurance _________%, or
Define maximum allowable travel benefit $___________ (only if you desire to limit the
benefit)
Genetic Testing:
Currently covered under the laboratory benefit. HMA built a separate benefit to better track
utilization.
Insert desired coinsurance 100% if accepting this recommendation, and
Choose one option below if choosing this recommendation:
Deductible waived, or
Deductible applies
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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: 4034 City of Renton
X
By: Healthcare Management Administrators
X
Name: Name:
Title: Title:
Date: Date:
10-27-2020
Attest:
_______________________________
Jason Seth, City Clerk, MMC
Mayor
Armondo Pavone