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HomeMy WebLinkAboutContractOctober 27, 2021 To: HMA From: City of Renton RE: Renewal Notice, 2022 Plan Year Please consider this formal notification of benefit renewal for the City of Renton. If further information is required, please email Gallagher (sarah_bosien@ajg.com). Coverage: Medical, Dental, Vision, COBRA Administration for Active and Retiree Plans Commission: Net of commission Administration Fee: Review HMA Client Intent & Exhibit A Fee Schedule for details CITY OF RENTON By:_____________________________ Armondo Pavone Mayor _____________________________ Date Attest _____________________________ Jason A. Seth City Clerk Approved as to Legal Form By: __________________________ Alex Tuttle Sr. Assistant City Attorney CAG-21-270 (approved via email from Alex Tuttle) 11/29/2021 Proving What’s Possible in Healthcare® HMA CLIENT INTENT & EXHIBIT A SCHEDULE OF FEES 4034 / 5034 City of Renton 1/1/2022 through 12/31/2022 Renewal Account Information Group Name: City of Renton Employee Healthcare Plan Group: #4034/5034 Group Size: 639 Employees Network: HMA Contract Period: 1 Year Enrollment Type: Web How will Open Enrollment be submitted: Changes Only Open Enrollment Dates: November 1 – 30, 2021 Broker (firm): Gallagher Benefit Services - Bellevue Contact Info Name Phone Email Broker Contact: Sarah Bosien (425) 974-3276 sarah_bosien@ajg.com Account Manager: Robert Block 425-289-5173 Robert.Block@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 right column. Description Current Change? Describe changes needed here. Tribal Client No ☐ Balance Billing Protection Act* (Applicable to Washington Headquartered Clients Only) No Domestic Tier? (usually only pertains to medical clients) 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. Please note Washington State is considering sun setting the program for Self-Funded Plans due to the Federal Balance Billing requirements taking effective in 2022. DocuSign Envelope ID: F266C033-4AE0-4A66-98A0-297EDA34DA9E HMA Client Intent & TPA Exhibit A – City of Renton Employee Healthcare Plan Page 2 of 14 4034/5034 City of Renton 2022.01 Client Intent Exhibit A 5.24.2021 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. 4034 – 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): Telemedicine will align with in- person visit costs for same service/treatment Telemedicine will align with in-person visit costs for same service/treatment Telemedicine will align with in-person visit costs for same service/treatment 5034 – LEOFF 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% 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. DocuSign Envelope ID: F266C033-4AE0-4A66-98A0-297EDA34DA9E HMA Client Intent & TPA Exhibit A – City of Renton Employee Healthcare Plan Page 3 of 14 4034/5034 City of Renton 2022.01 Client Intent Exhibit A 5.24.2021 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. All Plans Benefit Preferred (P) Participating (N) Out-of-network (M) Vision Exam 100% 100% $30 copay, then 100% Changes (if any): Hardware 100% 100% 100% 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. All Plans Benefit Preferred (P) Participating (N) Out-of-network (M) Dental Deductible None None None Changes (if any): Dental Maximum $2,000 – Individual Calendar Year Maximum $2,000 – Individual Calendar Year Maximum $2,000 – Individual Calendar Year Maximum Changes (if any): Coinsurance Type I – 100% Type II – 100% Type III – 80% Type I – 100% Type II – 100% Type III – 80% Type I – 80% Type II – 80% Type III – 50% Changes (if any): 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. DocuSign Envelope ID: F266C033-4AE0-4A66-98A0-297EDA34DA9E HMA Client Intent & TPA Exhibit A – City of Renton Employee Healthcare Plan Page 4 of 14 4034/5034 City of Renton 2022.01 Client Intent Exhibit A 5.24.2021 Vendor type Change? Current vendor name & information New vendor name & information Member Advocacy or Concierge Service ☐ Gallagher BAC CDHP* ☐ None COBRA ☐ HMA Internal Provided Dental ☐ HMA Internal Provided Kidney Dialysis ☐ None Maternity ☐ None PBM ☐ Costco Health Solutions (877) 908-6024 Telehealth ☐ MDLive, Inc. (877) 596-8826 Vision ☐ HMA Internal Provided ACA Reporting ☐ HMA/MZQ * 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 ☐ ACTIVE ☐ COBRA Fees Broker Fees These are fees for services provided by the broker or the broker’s contracted partners. HMA will remit fees to the broker only. The broker is responsible for payment of any fees to its own vender partners. Fee Vendor Description Broker Medical commission Broker Dental commission DocuSign Envelope ID: F266C033-4AE0-4A66-98A0-297EDA34DA9E HMA Client Intent & TPA Exhibit A – City of Renton Employee Healthcare Plan Page 5 of 14 4034/5034 City of Renton 2022.01 Client Intent Exhibit A 5.24.2021 Fee Vendor Description Broker Analytic vendor External Vendor Administrative Fees These are fees for services provided by external vendors through a direct or broker contract. Fee Vendor Description 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. 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 $24.69 Medical Plan Administration PEPM If all documents are signed and returned by 10/04/2022, the new PEPM with -$0.20 discount will be $24.49 $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. DocuSign Envelope ID: F266C033-4AE0-4A66-98A0-297EDA34DA9E HMA Client Intent & TPA Exhibit A – City of Renton Employee Healthcare Plan Page 6 of 14 4034/5034 City of Renton 2022.01 Client Intent Exhibit A 5.24.2021 Fee Product Description $0.45 Federal Transparency Technology Enablement PEPM Effective January 1, 2022, self-funded health plans are subject to seven new transparency-related federal regulatory requirements. At a high- level these include; an advanced EOB, balanced billing protection, new ID cards design and fulfillment of a single issuance of new cards, publically available machine-readable files for the medical plan and HMA preferred PBMs, a consumer price comparison tool, new compliance reporting, and new provider directory requirements. Additional transparency-related requirements are slated for 2023 and 2024. These new requirements represent a massive technology lift and investment. We are passing through only a portion of the real costs of delivering on these new requirements. We will comply with the portions of the new regulations that apply to the products and services covered under our contracts. 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 HMA 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 HMS* *Note, the contingency fee charged by HMS 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 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. DocuSign Envelope ID: F266C033-4AE0-4A66-98A0-297EDA34DA9E HMA Client Intent & TPA Exhibit A – City of Renton Employee Healthcare Plan Page 7 of 14 4034/5034 City of Renton 2022.01 Client Intent Exhibit A 5.24.2021 Continue Add Remove Current Fee Renewal Fee Product Service Description ☒ ☐ ☐ $3.25 $3.25 Dental Plan Administration PEPM Current Product 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 Current Product Access to the National Dental Network. (In addition to the Dental Plan Administration fees) ☒ ☐ ☐ $0.65 $0.65 Vision Hardware Administration PEPM Current Product 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” in previous section. ☐ ☐ ☐ $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. DocuSign Envelope ID: F266C033-4AE0-4A66-98A0-297EDA34DA9E HMA Client Intent & TPA Exhibit A – City of Renton Employee Healthcare Plan Page 8 of 14 4034/5034 City of Renton 2022.01 Client Intent Exhibit A 5.24.2021 Continue Add Remove Current Fee Renewal Fee Product Service Description ☐ ☐ ☐ $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 Current Product 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 11/01/2021 ☐ ☐ ☐ $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 Group or VSP. ☐ ☐ ☐ $2.00 $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. DocuSign Envelope ID: F266C033-4AE0-4A66-98A0-297EDA34DA9E HMA Client Intent & TPA Exhibit A – City of Renton Employee Healthcare Plan Page 9 of 14 4034/5034 City of Renton 2022.01 Client Intent Exhibit A 5.24.2021 Continue Add Remove Current Fee Renewal Fee Product Service Description ☐ ☐ ☐ $1.50 $1.50 Care Navigator PEPM RECOMMEND ADDING HMA’s in-house concierge service engages members and supports them across their health journey. Our team can help members understand their benefits, coordinate care needs, and determine next steps in their personal care plan. ☐ ☐ ☐ $2.00 $2.00 Healthcare Bluebook Cost and Quality PEPM RECOMMEND ADDING 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 protect the Plan from overpaying for health services. Reward range from $25-$100 when a member selects a fair price provider. ☐ ☐ ☐ Healthcare Bluebook Engagement Rewards RECOMMEND ADDING 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 RECOMMEND ADDING 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). ☐ ☐ ☐ $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. DocuSign Envelope ID: F266C033-4AE0-4A66-98A0-297EDA34DA9E HMA Client Intent & TPA Exhibit A – City of Renton Employee Healthcare Plan Page 10 of 14 4034/5034 City of Renton 2022.01 Client Intent Exhibit A 5.24.2021 Continue Add Remove Current Fee Renewal Fee Product Service Description ☐ ☐ ☐ $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 PEPM at Renewal ☐ ☐ ☐ $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 RECOMMEND ADDING 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. DocuSign Envelope ID: F266C033-4AE0-4A66-98A0-297EDA34DA9E HMA Client Intent & TPA Exhibit A – City of Renton Employee Healthcare Plan Page 11 of 14 4034/5034 City of Renton 2022.01 Client Intent Exhibit A 5.24.2021 Continue Add Remove Current Fee Renewal Fee Product Service Description ☐ ☐ ☐ $1.30 $1.30 Medical plus Dermatology PEPM MDLIVE offers access to board-certified dermatologist 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 Current Product 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 renewal for pricing. ☐ ☐ ☐ $2.00 $2.00 ID re-card fee per employee Incidental individual card replacement or reissue available upon member request through our portal at no cost Not adding except where required by law **HMA reserves the right to invoice cost 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. Stop Loss Services In compensation for the work HMA does to support stop loss carriers, HMA requires a 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. Change Current vendor name & information New vendor name & information Excess Loss Carrier ☐ Symetra (800) 796-3872 Decision not yet final. HMA will be notified of changes if they occur. Add Term Change Current vendor name & information New vendor name & information MGU, GA, Captive ☐ ☐ ☐ N/A DocuSign Envelope ID: F266C033-4AE0-4A66-98A0-297EDA34DA9E HMA Client Intent & TPA Exhibit A – City of Renton Employee Healthcare Plan Page 12 of 14 4034/5034 City of Renton 2022.01 Client Intent Exhibit A 5.24.2021 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 include other notes or comments. Change below for the Active 4034 medical plan:  Vision therapy added when medically necessary as prescribed by a physician. Covered at 100% in -network. 24 visit lifetime max.  Knee injection coverage added when medically necessary, with coverage at 100% in-network. Requires prior authorization.  Ambulance reimbursed at 100% of billed charges out-of-network  Hearing aid frequency limit to be reduced to every 3 years. Maximum benefit to remain at $4,000 in that time.  Schick Shadel added to PPO network, no change needed at the City-level. Kidney dialysis and telemedicine addressed in subsequent pages. Change below for the Retiree 5034 medical plan:  Hearing aid frequency limit to be reduced to every 3 years. Maximum benefit to remain at $5,600 in that time. 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 _________% DocuSign Envelope ID: F266C033-4AE0-4A66-98A0-297EDA34DA9E HMA Client Intent & TPA Exhibit A – City of Renton Employee Healthcare Plan Page 13 of 14 4034/5034 City of Renton 2022.01 Client Intent Exhibit A 5.24.2021 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 Gene & Cellular Therapies (Requires Pre-Authorization): Choose one of the two coverage options below if accepting this recommendation: (Current plan exclusion language: “Gene Therapy - Charges for gene therapy or adoptive cellular therapy”) ☒ ☐ In-network 100% coverage, deductible applies, and no coverage out-of-network, or ☒ ☐ In-network coinsurance _________%, deductible applies, and no coverage out-of-network If accepting the Gene & Cellular Therapies benefit recommendation, confirm whether to include or exclude travel benefits. If the boxes below are not marked we will assume benefits are excluded. ☒ ☐ Coinsurance _________% of billed charges, and ☒ ☐ Define maximum allowable travel benefit $___________ (only if you desire to limit the benefit) ☐ ☒ Kidney Dialysis Benefit Design Update The Plan will cover kidney dialysis the same as all other out-of-network claims and will no longer cover Part B premium reimbursement. *If you decline the recommendation we will require a hold harmless agreement. Current benefit structure (2021): KIDNEY DIALYSIS (OUTPATIENT SERVICES)  Basic Coverage - Initial Benefit Period: 100% - Preferred/Participating / 100% - OON  Supplemental Coverage - Out-of-Network services are payable at 150% of the Medicare allowable rate: 100% - Preferred/Participating / 100% - OON ☒Maintain 100% deductible waived benefit ☐Update coinsurance amount to _________% ☐ deductible waived or ☐ deductible applies ☐ ☒ Telemedicine: Coverage for virtual visits to community providers (example Swedish, Everett Clinic, Primary Care Provider, etc...) Pay the same as an in-person visit. For example a virtual preventive visit will be paid at the Preventive benefit level. Conversely a diagnostic virtual visit will be paid at the Doctor Office Visit benefit level. Current benefit structure (2021): Paid at 100% (Preferrred, Participating & OON) DocuSign Envelope ID: F266C033-4AE0-4A66-98A0-297EDA34DA9E HMA Client Intent & TPA Exhibit A – City of Renton Employee Healthcare Plan Page 14 of 14 4034/5034 City of Renton 2022.01 Client Intent Exhibit A 5.24.2021 Remove/Exclude Add/ Accept Benefit Recommendations ☒ ☐ Complications from Bariatric Surgery: Add coverage for Obesity Treatment complications / Cover complications from Bariatric Surgery when medically necessary (Current plan exclusion language: “Obesity (and Morbid Obesity) - Treatment for obesity (excessive weight and morbid obesity) including surgery or complications of such surgery, wiring of the jaw or procedures of similar nature, diet programs and/or other therapies, except as provided herein.”) 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: Wendy Rittereiser Name: Title: HR Benefits Manager Title: Date: 9/28/2021 Date: DocuSign Envelope ID: F266C033-4AE0-4A66-98A0-297EDA34DA9E Lindsay Harris October 1, 2021 | 8:28 AM PDT President