HomeMy Public PortalAboutRES-CC-2015-03RESOLUTION #03-2015
A RESOLUTION ADOPTING AN EMPLOYER HEALTH INSURANCE AGREEMENT AND THE FIRST
AMENDMENT TO THE AGREEMENT BY AND BETWEEN THE CITY OF MOAB AND THE PUBLIC
EMPLOYEES' HEALTH PROGRAM (PEHP)
WHEREAS, the City of Moab is required to provide health insurance coverage for its employees;
and
WHEREAS, a proposal for health insurance services provided by PEHP was approved by the
Governing Body on November 6, 2014;
NOW, THEREFORE, we, the Governing Body of the City of Moab do herby Adopt the employer
health insurance agreement and first amendment as presented and attached hereto.
FURTHER, the effective date of this contract is January 1, 2015.
Passed and adopted by action of the Governing Body of the Cityf Moab in open session this
13th day of January, 2015.
B
ATTEST: •
Rachel E. Stenta
City Recorder
David L. Sakrison
Mayor
Resolution #03-2015 January 13, 2015
!y
r ,! ,
"' , ,y.
Employer Health Insurance Agreement
Between _City of Moab
and
Utah Retirement Systems Public Employees' Health Program
JANUARY 1, 2015 through DECEMBER 31, 2015
Table of Contents
SECTION 1 — INTRODUCTION 2
SECTION 2 — ELIGIBILITY AND ENROLLMENT 3
SECTION 3 — RESPONSIBILITIES OF EMPLOYER 7
SECTION 4 — RESPONSIBILITIES OF PEHP 9
SECTION 5 — FUNDING 12
SECTION 6 — DATA AND RECORDS 14
SECTION 7 — TERM AND TERMINATION 14
SECTION 8 — GENERAL TERMS 15
SECTION 9 — DEFINITIONS 17
SECTION 10 — SIGNATURE PAGE 20
APPENDIX A 21
SECTION 1- INTRODUCTION
1.1 Contract
1.1.1 This Employer Health Insurance Agreement ("Agreement") is made and entered into, pursuant to
Utah Code Annotated Title 49, Chapter 20, by and between City of Moab ("Employer"), a body
corporate and politic of the State of Utah, and the UTAH RETIREMENT SYSTEMS, by and through
its Employer benefit and insurance division, the PUBLIC EMPLOYEES' HEALTH PROGRAM
("PEHP").
1.1.2 In exchange for Employer's payment of Rates, PEHP provides defined healthcare Benefits to
Members. Any payment of Rates will constitute Employer's agreement to the terms of this Agreement,
regardless of whether Employer has actually signed the Agreement.
1.1.3 NOW, THEREFORE, for and in consideration of the agreements and provisions hereinafter
contained, the parties hereby agree and enter into this Agreement.
1.2 Scope of Agreement
1.2.1 PEHP will make available to Employer's Eligible Employees, Eligible retirees under age 65, and
Eligible dependents, the health and prescription drug plans listed in Appendix A. All terms, definitions,
and conditions of the health and prescription drug plans are hereby incorporated into this Agreement.
1.2.2 Any and all other documents attached hereto are hereby made a part of this Agreement as fully as
though detailed herein.
1.2.3 The parties acknowledge that for purposes of paying fees required by the Affordable Care Act,
PEHP shall act as the plan sponsor of Employer's benefit plans. All programs and plans offered by
PEHP are subject to change in order to adapt to the changes and trends in the health care industry.
Further, the Benefits in this Agreement are not necessarily the benefits of the Employer's previous
insurance carrier. This contract does not guarantee benefits payable under the previous carrier will be
payable under PEHP.
1.2.4 No Member of PEHP has a vested right to any Benefits. Changes to the Agreement may be made
without notification, consultation or the consent of Members. However, material mid -plan year
changes to the Benefits must be made with approval of the Employer and with 60 days notice to the
Members. The rights and interest of Members at any particular time depend on the Agreement terms in
effect at that time.
1.2.5 PEHP may adopt reasonable policies, rules and procedures to help in the administration of the
Agreement. Employer agrees to abide by all such reasonable policies, rules, and procedures that are not
inconsistent with the Agreement.
2
1.2.6 PEHP has discretion to determine Eligibility for Benefits and to interpret the terms and conditions
of the Benefit plan(s). PEHP's determinations under this Section do not prohibit or prevent a Member
from seeking an appeal of claims or an administrative review by following the appeals procedure
established by the Master Policy and Utah Code Ann. § 49-11-613.
SECTION 2 - ELIGIBILITY AND ENROLLMENT
2.1 Eligibility
2.1.1 PEHP shall provide coverage to those Eligible Employees and their Eligible Dependents in
accordance with the terms of the PEHP Master Policy attached as Appendix A.
2.1.2 In consultation with PEHP and within PEHP's stated Eligibility parameters, if Employer has 100
Subscribers or more, Employer shall decide which categories of Employees and Dependents are
Eligible to become Members and establish related Eligibility requirements. Employer agrees to
implement standards that are nondiscriminatory and is solely liable if any standards are determined to
be discriminatory.
2.1.3 Notwithstanding Section 2.1.2, if Employer is community rated or all Employers in Employer's
risk pool are paying the same Rates, then Employer shall be subject to PEHP's Eligibility parameters
and shall not have discretion to set its own standards.
2.1.4 Eligibility standards (including termination standards) determined by Employer must be reported
to and approved by PEHP each plan year, at least ninety (90) days prior to the start of the plan year.
Employer shall inform PEHP of its eligibility standards on the PEHP Benefit Selection Form. If
Eligibility standards vary from plan year to plan year, PEHP may revise Rates correspondingly, in
accordance with sound actuarial principles.
2.1.5 Employer may not change, extend, expand, or waive the Eligibility criteria without first obtaining
the advance, written approval of an officer of PEHP. Eligibility standards may not be changed mid -
plan year.
2.1.6 Employer's Eligibility parameters must meet PEHP's criteria which include the following:
• All retirement -eligible Employees are Eligible;
• Elected and appointed officials, including board members, elected after July 1, 2006 must
meet URS participation guidelines. They earn the minimum salary during the first full
month of the term of the office. ($825.00 effective February 1, 2006)..
• Otherwise Eligible Employees with other coverage may waive coverage with the
Employer under the Plan;
• At least 80% of the above listed Eligible individuals, who have not demonstrated proof of
other coverage, must participate in the Plan, or, if Employer employs fewer than five (5)
individuals, 100% of individuals must participate in the Plan;
• Independent contractors are not Eligible;
3
" R e t i r e e s ( o t h e r t h a n E a r l y R e t i r e e s , a s d e f i n e d b y t h e E m p l o y e r ) a r e n o t E l i g i b l e ;
" T e r m i n a t e d e m p l o y e e s a c t i v e c o v e r a g e s h a l l c e a s e o n o r b e f o r e e i t h e r t h e e n d o f t h e p a y
p e r i o d f o l l o w i n g t e r m i n a t i o n o f e m p l o y m e n t , o r t h e d a t e t h e l a s t p a y c h e c k i s r e c e i v e d b y
t h e E m p l o y e e f r o m E m p l o y e r f o r w h i c h t h e E m p l o y e e w a s e l i g i b l e f o r C o v e r a g e .
O n l y i n d i v i d u a l s w h o c o n t i n u o u s l y s a t i s f y t h e E l i g i b i l i t y c r i t e r i a o f t h e A g r e e m e n t m a y b e e n r o l l e d a n d
c o n t i n u e a s M e m b e r s . E m p l o y e r , S u b s c r i b e r s , a n d t h e i r D e p e n d e n t s a r e r e s p o n s i b l e f o r o b t a i n i n g a n d
s u b m i t t i n g t o P E H P e v i d e n c e o f E l i g i b i l i t y .
2 . 1 . 7 N o t w i t h s t a n d i n g t h i s S e c t i o n 2 , P E H P r e s e r v e s t h e r i g h t t o d e n y c o v e r a g e t o a n o t h e r w i s e E l i g i b l e
E m p l o y e e a n d / o r t h e i r E l i g i b l e D e p e n d e n t ( s ) , i n a c c o r d a n c e w i t h t h e P E H P M a s t e r P o l i c y , i f t h a t
i n d i v i d u a l c o m m i t s f r a u d u p o n P E H P , f o r g e s p r e s c r i p t i o n s , c o m m i t s c r i m i n a l a c t s a s s o c i a t e d w i t h
c o v e r a g e , m i s u s e s o r a b u s e s B e n e f i t s o r b r e a c h e s t h e c o n d i t i o n s o f t h e P E H P M a s t e r P o l i c y .
N o t w i t h s t a n d i n g a n y o t h e r p r o v i s i o n o f t h i s A g r e e m e n t , i f s u c h a n i n d i v i d u a l r e t a i n s C o v e r a g e w i t h
P E H P a t t h e r e q u e s t o f a n E m p l o y e r a f t e r a r e c o m m e n d a t i o n b y P E H P t o a d d r e s s e i t h e r t h e f r a u d ,
c r i m i n a l a c t s a s s o c i a t e d w i t h c o v e r a g e , o r a b r e a c h o f t h e P E H P M a s t e r P o l i c y , E m p l o y e r s h a l l b e s o l e l y
a n d c o m p l e t e l y r e s p o n s i b l e f o r a l l c l a i m s i n c u r r e d f o r t h i s i n d i v i d u a l . I n s u c h a c i r c u m s t a n c e , t h e
i n d i v i d u a l ' s c l a i m s s h a l l b e a d j u d i c a t e d s e p a r a t e l y f r o m t h e E m p l o y e r ' s e x p e r i e n c e , a n d n o c l a i m s f o r t h i s
i n d i v i d u a l , e i t h e r i n s p e c i f i c o r a g g r e g a t e , s h a l l b e e l i g i b l e f o r p a y m e n t b y P E H P r e i n s u r a n c e .
2 . 2 E n r o l l m e n t R e q u i r e m e n t s
2 . 2 . 1 I n o r d e r f o r a n E l i g i b l e i n d i v i d u a l t o r e c e i v e B e n e f i t s , E m p l o y e r m u s t e n r o l l t h e i n d i v i d u a l , P E H P
m u s t a c c e p t t h e i n d i v i d u a l a s a M e m b e r , a n d E m p l o y e r m u s t p a y t h e a p p l i c a b l e R a t e s . E m p l o y e r
a g r e e s t o l i m i t e n r o l l m e n t t o E l i g i b l e E m p l o y e e s a n d t h e i r D e p e n d e n t s .
2 . 2 . 2 A n y E m p l o y e e w h o d o e s n o t e n r o l l i n t h e E m p l o y e r P l a n d u r i n g t h e i r f i r s t 3 0 d a y s o f e m p l o y m e n t
w i t h t h e E m p l o y e r w i l l n o t b e E l i g i b l e t o e n r o l l u n t i l t h e n e x t a n n u a l e n r o l l m e n t p e r i o d .
2 . 2 . 3 E x c e p t a s o t h e r w i s e p r o v i d e d i n t h i s A g r e e m e n t , e n r o l l m e n t a n d e n r o l l m e n t c h a n g e s f o r e x i s t i n g
E m p l o y e e s a n d t h e i r D e p e n d e n t s m a y o n l y b e m a d e d u r i n g a n o p e n e n r o l l m e n t p e r i o d .
2 . 2 . 4 P E H P s h a l l a l l o w f o r a s p e c i a l e n r o l l m e n t p e r i o d f o r s p e c i f i c c i r c u m s t a n c e s l i s t e d i n S e c t i o n 2 . 2 . 5 .
T h e t e r m s g o v e r n i n g s p e c i a l e n r o l l m e n t f o r P E H P a r e a l s o c o n t a i n e d i n t h e M a s t e r P o l i c y a t t a c h e d
h e r e t o a s p a r t o f E x h i b i t A .
2 . 2 . 5 E m p l o y e r m u s t n o t i f y P E H P w i t h i n 3 1 d a y s w h e n e v e r t h e r e i s a c h a n g e i n a M e m b e r ' s f a m i l y a n d
o r e m p l o y m e n t s t a t u s t h a t m a y a f f e c t E l i g i b i l i t y o r e n r o l l m e n t . F a m i l y o r e m p l o y m e n t s t a t u s i n c l u d e s
t h e f o l l o w i n g e v e n t s :
a ) A d o p t i o n o f a c h i l d , b i r t h o f a c h i l d , o r g a i n i n g l e g a l g u a r d i a n s h i p o f a c h i l d ;
b ) C h i l d l o s e s D e p e n d e n t s t a t u s ;
c ) D e a t h ;
4
d) Divorce;
e) Marriage
0 Involuntary loss of other coverage;
g) Member called to active military duty;
h) Member receives a Qualified Medical Child Support Order (QMCSO);
i) Reduction in employment hours;
j) Member takes, returns from, or does not return from a leave of absence; and
k) Termination of employment.
2.2.6 If Employer fails to notify PEHP within 31 days of a Member's termination from employment or
other family and/or employment change that results in the loss of a Member's Eligibility, Employer
agrees to promptly pay PEHP any amounts paid as Benefits for such Member after the Member became
ineligible and before PEHP was notified.
2.2.7 PEHP agrees to supply certification of creditable coverage to all terminated Subscribers and their
Eligible Dependents losing coverage in accordance with federal law. The terms governing certification
and disclosure are contained in the Master Policy attached hereto as part of Exhibit A.
2.2.8 Employer hereby agrees the Effective Date for new Employees is based upon receipt of
enrollment forms by the PEHP enrollment department.
2.2.9 PEHP will enroll Dependents as a result of a valid court order. Any requirement for the Plan to
comply with court orders, including Qualified Medical Child Support Orders (QMCSOs) and/or
Divorce Decrees is Employer's responsibility. When Employer directs PEHP to enroll an individual on
the basis of a court order, PEHP reserves the right to review and confirm that the order is qualified.
2.2.10 PEHP may decline to enroll Employees, former Employees, or Dependents who do not satisfy
the Eligibility criteria of the Agreement. Also, PEHP may initially decline to issue coverage if
Employer fails to meet the minimum enrollment or minimum contribution requirements.
2.3 Continuation of Coverage (COBRA / Mini -COBRA) and Conversion Coverage
2.3.1 Employer's Members who lose coverage under a Plan made available by PEHP may be permitted
to continue such Coverage in accordance with the requirements of the Consolidated Omnibus Budget
Reconciliation Act of 1986 (COBRA), or Utah mini -COBRA, Utah Code Ann. § 31 A-22-722
(collectively, "Continuation Coverage").
2.3.2 Employer agrees to administer Continuation Coverage according to state and federal law. PEHP
agrees to support and assist Employer in the administration of the Continuation Coverage.
Employer agrees to provide sufficient documentation of a Member's Eligibility for Continuation
Coverage. PEHP will determine if the documentation provided is sufficient.
2.3.3 Employer agrees to timely:
5
a) notify PEHP of a Members' death;
b) notify PEHP of a Member's termination of employment or reduction of hours, (Employer
must notify PEHP if a termination is due to gross misconduct);
c) notify PEHP of a Member's entitlement to the benefits under Title XVII of the Social
Security Administration, which would cause the Member to lose coverage;
d) notify PEHP of any other COBRA Qualifying Event that would affect a Member's Eligibility
for coverage.
2.3.4 PEHP agrees that, at enrollment, termination of employment, or upon receipt of written notice of
a COBRA Qualifying Event, in addition to Employer's function as COBRA plan administrator, to
notify Members of their Continuation rights, if such rights exist, in accordance with state and federal
law. PEHP will not be responsible to notify Members of their Continuation rights if PEHP does not
receive notice from Employer of a Qualifying Event, as defined in the PEHP Master Policy, in a timely
manner.
2.3.5 Adult Designees are eligible for Continuation Coverage with PEHP if they would have otherwise
been eligible for COBRA coverage as a Dependent as defined by PEHP and Employer in Appendix A.
2.3.6 PEHP agrees to provide Employer's Members notice of their Conversion rights in accordance
with state and federal law. Employer's Members who lose coverage under a COBRA or a Mini -
COBRA plan made available by PEHP may be permitted to enroll in a Conversion plan, in accordance
with Utah Code Ann. § 31 A-22-723.
2.3.7 PEHP and Employer agree that if this Agreement is terminated, Continuation Coverage with
PEHP will terminate. Employer will be responsible for obtaining alternate coverage for those Members
who are receiving Continuation Coverage.
2.3.8 PEHP agrees to bill and collect Rates from Members for Continuation and Conversion Coverage.
2.3.9 PEHP agrees to provide COBRA, Mini -COBRA, and Conversion Coverage for the minimum
time and only to the minimum extent required by applicable state and federal law. PEHP will not
provide Continuation or Conversion Coverage if Employer or the Member fails to strictly comply with
all applicable notice and other requirements and deadlines.
2.4 Early Retiree Eligibility
2.4.1 Employer, at Employer's sole discretion, may offer the Employer Plan(s) to the Employer's Early
Retirees and their Eligible Dependents according to Eligibility standards adopted by the
Employer and provided to PEHP under the terms of this Agreement and attached in Appendix A.
Employer shall make available to their Eligible Early Retirees copies of any rules, regulations, and
restrictions limiting their options for coverage.
6
2.4.2 Early Retirees and Eligible Spouses, as specified in Appendix A, upon reaching age 65, and no
longer working, will be eligible to convert their Early Retiree coverage to the Public Employees'
Medicare Supplement Plan if they elect to enroll in Medicare Plans A and B.
2.4.3 Early Retirees and Eligible Spouses, as specified in Appendix A, upon reaching age 65, and no
longer working, will be eligible to convert their Early Retiree coverage to Medicare Part D at any time..
2.4.4 The Employer share of Rate payments for Early Retirees shall be at least as much as that of active
Employees.
2.4.5 The rate for Early Retiree coverage may be higher than the rate charged for active Employees.
Specific rates may be included in Appendix A.
2.4.6 Termination of Early Retiree coverage does not constitute a qualifying under COBRA.
If an Employee elects Early Retiree coverage, the Employee is not eligible for COBRA coverage
thereafter.
2.5 Long -Term Disability Continuation of Coverage
2.5.1 Eligible Employees who are approved for long-term disability benefits with PEHP's Long -Term
Disability Program under Utah Code Annotated, Title 49, Chapter 21 ("Disabled Employee"), are
Eligible to continue coverage with PEHP until the earlier of: 1) the Disabled Employee is no longer
receiving long-term disability benefits, 2) the Disabled Employee fails to make the required payment to
PEHP each month as set forth below, 3) Employer cancels medical coverage with PEHP, or 4) the
Disabled Employee or his/her spouse attains the age of 65.
2.5.2 Upon turning age sixty-five (65), the Disabled Employee or his/her spouse will be Eligible to
continue with a PEHP-sponsored Medicare Supplement plan, but will be required to pay the full
monthly Rate. The Disabled Employee or spouse who is younger than 65, or any other Eligible
Dependents covered on the plan younger than 65, will remain Eligible for PEHP coverage until they
meet one of the other criteria listed above or no longer meet Dependent Eligibility criteria.
2.5.3 Each Disabled Employee who qualifies for PEHP coverage must pay a portion of the monthly
PEHP payment to remain Eligible for PEHP Benefits as set by PEHP and outlined in the Master Policy
attached in Appendix A.
SECTION 3 - RESPONSIBILITIES OF EMPLOYER
3.1 In General
3.1.1 In addition to the responsibilities addressed throughout this Agreement, Employer agrees to the
following responsibilities and obligations.
7
3.2 Rate Payments
3.2.1 Employer is responsible to collect and remit Rates to PEHP. By remitting Rates to PEHP,
Employer certifies to PEHP that the Employer/Employee Rate share complies with the affordability
standards of PPACA. Other than as required by state or federal law, nothing contained in this
Agreement shall obligate the Employer to contribute any specific percentage of the contribution, nor to
provide any specified credits for sick leave conversion, etc. to any Employee.
3.2.2 To the extent Employer requires its Employees to contribute to Rates, Employer agrees to collect
those contributions from its Employees and remit the same to PEHP together with a copy of a
remittance report. Such contributions and report will be submitted to PEHP monthly following the
appropriate payroll dates. By remitting Rates, Employer certifies that all Employees meet the
Eligibility requirements agreed upon under this Agreement.
3.2.3 Employer's obligation to pay the full Rates to PEHP is not contingent upon Employer's ability to
collect any percentage of the Rates that Employer requires to be paid by Subscribers.
3.2.4 Rates will be considered late if received more than thirty days after the date of the corresponding
invoice from PEHP.
3.2.5 Notwithstanding any other provision of this Agreement, if Employer is late in any required
payment to PEHP, PEHP shall assess Employer a 5% penalty on late payments.
3.2.5 Notwithstanding any other provision of this Agreement, if Employer fails to pay a required
invoice to PEHP within sixty (60) days after the date of the corresponding invoice from PEHP, PEHP
shall immediately suspend payment of claims until payment is made in full; in such case, the Employer
shall be responsible for any payment to Providers, including any late fees, as applicable; or immediately
terminate this Agreement in accordance with Section 7.2.
3.3 Employment Verification and Status
3.3.1 To the extent Employer is responsible to determine Eligibility standards under this Agreement,
Employer agrees to provide those standards to PEHP at least ninety (90) days prior to the start of the
Plan Year, as provided in Section 2.1.
3.3.2 Employer agrees to verify employment status and date of employment information contained in
any new applications filed by Employees, and Employer agrees to inform PEHP of any change in
Employee or Dependent status or of the termination of coverage of any Employee or Dependent,
including any COBRA Qualifying Events, on a semi-moilthly basis, in accordance with Section 2.4.
3.3.3 It is the responsibility of the Employer to obtain and maintain updated, accurate records
specifying enrollment information, Member files, Eligibility information, Effective Dates, and
Employee status information. Employer agrees, to the extent requested by PEHP, to provide PEHP
8
with current and updated copies of all completed enrollment forms and otherr documentation as deemed
necessary by PEHP.
3.3.4 Payment of Rates shall constitute Employer's certification that Employer and all its Members
meet the Eligibility standards as outlined in Utah Code Annotated Title 49, Chapter 20, and as
established under this Agreement.
3.4 Compliance
3.4.1 Employer is responsible for its own compliance with applicable laws, rules, and regulations,
including requirements to provide information to Members about their coverage. This includes all
applicable requirements under PHSA, HIPAA, PPACA, COBRA, and any other state and federal
requirements that apply to the Plan.
3.4.2 Employer agrees to notify PEHP when Employer receives Medicare secondary payer information.
3.4.3 Employer shall distribute to Employees all forms, documents, and notices as required by law (i.e.
Summary of Benefits and Coverage, Benefit Summaries). In accordance with Section 4.4, PEHP may
assist Employer in the production of such forms, documents and notices. Employer maintains sole
responsibility to ensure compliance with federal law.
3.5 Miscellaneous
3.5.1 Employer certifies it is a political subdivision of the State of Utah and that both Employer and its
Eligible Employees qualify to participate with PEHP, and Employer agrees to notify PEHP prior to its
losing Eligibility to participate with PEHP.
3.5.2 It is Employer's responsibility to provide Subscribers a 30-day written notice of the Agreement's
termination.
3.5.3 Except as modified in this Agreement, Employer shall be responsible for all tax consequences or
penalties resulting from participation in the PEHP plans or programs.
SECTION 4 - RESPONSIBILITIES OF PEHP
4.1 Plan Services
4.1.1 Employer hereby agrees that it is the sole responsibility and right of PEHP to contract with,
negotiate policies, procedures, and plan provisions, in reference to physicians, hospitals, facilities,
corporations, or other service Providers. PEHP agrees to establish and maintain its usual hospital and
physician relations activities, Subscriber service activities, investigative and claim review procedures,
legal review and defense services, and shall take all reasonable measures to prevent the allowance and
payment of improper claims for Employer.
9
4.1.2 PEHP shall provide Employer with all administrative services provided by PEHP to its other
policy holders. A monthly fee for administrative services shall be included in the Rate amount, on a Per
Member Per Month ("PMPM") basis, at the Rate specified in Appendix A.
4.1.3 PEHP shall provide Reinsurance coverage as provided for in Section 5. PEHP will charge a
monthly reinsurance fee, on a PMPM basis, at the Rate specified in Appendix A. The reinsurance fee is
included in the Employer Rate.
4.1.4 At Employer's request, PEHP may facilitate an on site medical clinic for Employer's employees
in accordance with the terms in Appendix B.
4.1.5 PEHP shall make available to Members an electronic enrollment process via the www.pehp.org
website. PEHP shall also furnish to the Employer appropriate enrollment forms for distribution to new
Eligible Employees. Upon receipt and processing of enrollment information, PEHP will distribute
identification/prescription cards and Benefit brochures to Subscribers.
4.2 Reporting
4.2.1 These reporting provisions are subject to the confidentiality provisions of Section 6.
4.2.2 PEHP shall provide Employer with regular reports of the total amount paid to Providers in
Employer's risk pool.
4.2.3 If Employer employs over 100 Subscribers, PEHP shall provide Employer with Employer -specific
quarterly utilization reports. These Employers may request additional ad hoc reports as needed.
However, to the extent that any specific requested reports may be unique and costly to produce,
Employer agrees to pay PEHP the reasonable cost of assembling and preparing such additional
information and reports, so long as the cost of any such report has been made available to Employer in
advance and Employer has agreed in writing to pay such costs. PEHP may decline to produce reports if
PEHP determines that doing so would violate state or federal law.
4.2.4 If Employer employs over 100 Subscribers, Employer and/or its designated Business Associates,
as defined by HIPAA, shall be entitled, upon written request from Employer, to receive a copy of
individual data pertaining to Employer in accordance with Utah Code Ann. § 49-11-618 and applicable
Board resolutions for the sole purpose of reviewing claims and utilization experience for individuals
covered by the program. PEHP shall not provide diagnosis information unless specifically requested by
Employer, and Employer has demonstrated to the satisfaction of PEHP that the individual diagnosis is
essential to the review process, in which case, PEHP may require a separate release statement.
Employer hereby agrees to never share or otherwise divulge this individual data to any other person or
unit of government, unless subpoenaed by a court or governmental entity having proper jurisdictional
authority. When requesting this data, Employer will designate an officer or employee responsible for
receipt and custody of the data and hereby agrees to indemnify and hold PEHP harmless against any
10
claims, loss, damage, injury or other liability resulting from the disclosure of confidential medical data
by any officer or employee of Employer.
4.2.5 Subject to the foregoing provisions, PEHP may provide specialized or additional reports to
Employer, at Employer's request. PEHP may charge a fee to Employer for such special reporting
requests as negotiated between the parties.
4.3 Record Retention and Review
4.3.1 PEHP shall maintain, or cause to be maintained, records covering claims submitted to PEHP
hereunder as well as payment disbursed by it. The records shall be maintained for the same period of
time that PEHP retains like records in connection with its claims administration.
4.4 Claims Payment, Customer Service and Appeals
4.4.1 PEHP shall adjudicate claims within forty-five (45) days upon receipt of all information necessary
to accurately make a claim determination pursuant to PEHP's policies and procedures. Necessary
information to adjudicate claims shall include, but is not limited to, information regarding coordination
of benefits ("COB") from the primary insurance carrier, if applicable.
4.4.2 PEHP shall notify Members of paid or rejected claims and the reason for the rejection through an
explanation of benefits, which shall be sent within one (1) week of PEHP's adjudication of the claim.
4.4.3 PEHP shall advise and aid claimants in meeting requirements for additional information and
proper completion of claim forms.
4.4.4 PEHP shall maintain customer service staff and telephone numbers to provide information and
response to inquiries of Members regarding program coverage and Benefits as well as specific
information concerning claims, such as: status of claim, date paid/denied, amount, and Provider.
4.4.5 PEHP shall provide a website with general Plan information, specific claims information, and cost
tools for evaluating and finding Providers.
4.4.6 PEHP shall discuss claims, where applicable, with physicians and other Providers of services.
4.4.7 PEHP shall obtain and furnish information, as necessary, regarding non -duplication of payment or
COB.
4.4.8 PEHP will correct payment of claim en -ors for up to 12 months following the adjudication of a
claim. For claims involving COB, PEHP will have up to 15 months following the adjudication of such
claims to make adjustments. These time frames will not apply in instances where PEHP determines
that the claims were paid due to fraud.
11
4.4.9 PEHP shall provide a claims adjudication and appeals process to resolve any disputes regarding
Benefits under this Agreement. Members and Providers are required to cooperate with this process in
any dispute with PEHP as outlined in the Master Policy attached in Appendix A.
4.4.10 PEHP shall provide additional Member Services, including Case Management, Disease
Management, and Wellness Programs.
4.4.11 If Employer requests for correctly -paid claims to be reprocessed, Employer agrees to pay the
administrative costs of reprocessing in accordance with PEHP's policies and procedures.
4.5 Information for Members
4.5.1 Employer, with cooperation from PEHP, shall produce any required forms or documents required
by law to be distributed to Employees. Employer shall bear the responsibility to distribute such
documents, in accordance with Section 3.4. PEHP may assist Employer with creation and production
of documents, as specified in this Section.
4.5.2 PEHP shall assist Employer in its distribution by making available Plan -specific Benefits
Summaries, Master Policies, Rates, forms and documents online at www.pehp.org, which will include
the ability for Members to check status of claims and other information.
SECTION 5 - FUNDING
5.1 Self -Funded Status
5.1.1 Employer acknowledges and agrees that through this Agreement Employer participates in a self -
insured plan, and that plan is part of a self -insured risk pool. Employer maintains the financial risk
associated with that plan and the risk pool. Such risk includes, but is not limited to claims expenses for
covered Benefits and any interest required to be paid.
5.1.2 Risk pool reserves held by PEHP are owned by, returned to, and credited for interest earnings to
Employer in accordance with Section 5.3 and Appendix A.
5.2 Establishment of Rates
5.2.1 PEHP shall have sole discretion to determine Rates. The Rates will remain the same until the end
of the plan year. However, upon notice to Employer, PEHP may reasonably modify the Rates mid -year
if federal or state laws or regulations mandate an adjustment of Benefits under the Agreement, or if
contingency reserves fall below the level required by the PEHP actuary.
5.2.2 It is understood and agreed that Appendix A outlines the Rates to be paid by Employer for the
Plan(s) in which Employer participates during the current term. Rates include administrative fees and
reinsurance fees as determined necessary by PEHP, and as listed in Appendix A. Rates do not include
12
broker/consultant fees, if any. Rates include, but are not limited to the health experience of Employees
and their Dependents, Early Retirees, LTD Participants, and Members covered under COBRA and/or
Conversion Coverage.
5.2.3 It is further understood and agreed that PEHP will provide notice to Employer of estimated
regular Rate changes ninety (90) days prior to the end of the contract term, with the Rate change to be
effective on the date of renewal of the plan year.
5.2.4 Notice of Rate increases relating to Medicare Supplement programs offered by PEHP will be
provided by PEHP unless Medicare benefits change information has not yet been made available to
PEHP by the Medicare authorities. All changes will become effective on January 1 of each year.
5.3 Reserves
5.3.1 Pursuant to Utah Code Annotated § 49-20-301, PEHP plans "shall be maintained on a financially
and actuarially sound basis by payments from covered employers and covered individuals." Utah Code
Annotated § 49-20-402(1) provides, "The reserves in a risk pool in a given fiscal year shall be
maintained at the level recommended by the program's consulting actuary and approved or ratified by
the Board. If the reserves drop below that level, covered employers in the risk pool are required to cure
any deficiency in the reserve."
5.3.2 PEHP shall provide Employer with reserve recommendations from its consulting actuary upon
request from Employer. PEHP shall provide Employer with financial statements regarding the level of
reserves in Employer's risk pool.
5.3.3 If the reserves in Employer's risk pool drop below the recommendation of the consulting actuary,
Employer shall be responsible to pay the difference (or the pro-rata difference if Employer is in a multi -
Employer risk pool) to PEHP within fifteen (15) days following the request. In the case of a deficit in
reserves, Employer agrees to pay PEHP interest of 1 % per month for each month after the end of the
month in which Employer maintains a deficit.
5.3.4 PEHP, upon recommendation of its consulting actuary, shall determine when "substantial excess
reserves" have been accrued in accordance with Utah Code Annotated § 49-20-402. In such a case, and
upon Board approval, PEHP shall refund reserves to Employer (on a pro-rata basis if Employer is in a
multi -Employer risk pool) in a manner approved by the Board.
5.4 Claims Reinsurance
5.4.1 All Employers participating in the PEHP health plans shall participate in a self -funded
Reinsurance Plan governed by the Utah State Retirement Board (the 'Board"), as described in
Appendix A. 5.4.2 As outlined elsewhere in this Agreement, the Employer self -funded Rate includes
both a specific stop loss and aggregate reinsurance cost. The Reinsurance cost is set forth in Appendix
13
A. Reinsurance fees are not self -insured, and Employer shall have no recourse to recover any of these
amounts paid.
5.5 Administrative Costs
5.5.1 Employer is responsible to pay its share of administrative costs on a PMPM basis. The
administrative fee is included in the Employer Rate, according to the schedule in Appendix A.
Administrative fees are not self -insured, and Employer shall have no recourse to recover any of these
amounts paid.
SECTION 6 - CONFIDENTIALITY
6.1 HIPAA. The parties agree that the acts, duties and obligations required by this Agreement shall be
performed in compliance with the Privacy and Security Rules as promulgated under HIPAA.
6.2 Utah Law. Employer understands that under Utah Code Annotated § 49-11-618, "All data in the
possession of [PEHP] is confidential, and may not be divulged by [PEHP] except as permitted by board
action." Employer acknowledges and agrees that this Agreement is subject to this rule of confidentiality.
6.3 Definition of Data. For the purpose of this Agreement, "data" means any information pertaining to
Employer's participation with PEHP, Plan Rates, this Agreement, PEHP or its business practices, or the
personal health information (as defined by federal law) of any individual participating in the Plan
administered by PEHP.
SECTION 7 - TERM AND TERMINATION
7.1 Term of Agreement
7.1.1 Unless sooner terminated as herein provided, this Agreement shall be effective for a one year term
and pertain to claims incurred during the period January 1, 2015 through December 31, 2015.
7.1.2 This Agreement shall be renewed automatically for one year terms unless Employer notifies
PEHP of its intent to terminate as provided herein.
7.2 Termination
7.2.1 This Agreement, and coverage for all Members under this Agreement, can terminate for the
reasons listed below.
7.2.2 This Agreement may be terminated by Employer by providing PEHP with written notice at least
ninety (90) days prior to the end of the current one year term. PEHP will not accept retroactive
termination dates.
14
7.2.3 PEHP may immediately terminate Employer's coverage upon written notice if PEHP determines
that Employer is in breach of this Agreement. The following circumstances constitute a breach:
a. Employer fails to pay the required Rates in accordance with this Agreement;
b. Partial payment will be treated as nonpayment unless PEHP, at its sole discretion, indicates
otherwise in writing;
c. Employer performs an act or practice that constitutes fraud or makes an intentional
misrepresentation of material fact under the terms of the coverage;
d. Employer's status changes to an entity that is not a political subdivision of the State of Utah;
e. Employer's membership in an entity through which this Agreement was made available
ceases; or
f. Employer fails to satisfy PEHP's minimum contribution requirement, which is 100% of
single coverage or 50% of family coverage.
g. Employer fails to satisfy the minimum Employer participation requirements in Section 2.1.6
of this Agreement.
7.2.4 Employer agrees that if proper written notice of termination is not given within the designated
time parameters, a penalty of up to one percent (1 %) of total annual Rate may be assessed on Employer
at the sole discretion of PEHP.
7.2.5 It is Employer's responsibility to provide Subscribers a 30-day written notice of the Agreement's
termination. PEHP will provide a sample notice upon request.
7.2.6 Upon termination or expiration of this Agreement, PEHP shall continue to process and pay claims
for services obtained or charges incurred by Employer's Members prior to the date of termination or
expiration of this Agreement for a period of 12 months after the date of termination ("Run -Out
Period"). PEHP shall not pay for Services obtained or charges incurred after the date of termination,
regardless of when a condition arose and despite care or treatment anticipated or already in progress.
7.2.7 If Employer breaches this Agreement in accordance with Section 7.2.3 of this Agreement, which
results in termination of this Agreement, PEHP shall pay no further claims, regardless of the date
incurred. Employer shall be responsible for any such claims. Employer shall be responsible to pay
PEHP for all reinsurance and administrative costs due prior to the date of termination, regardless of any
other provision in this Agreement.
7.2.8 Upon termination of this Agreement, Employer shall be responsible for any deficits in the risk
pool as determined by PEHP.
SECTION 8 - GENERAL TERMS
8.1 Interpretation. The attached Appendices are complementary to this Agreement and what is called
for by any one of them shall be binding as if called for by all. In the event of any inconsistency between
the provisions of the Agreement and the documents accompanying this Agreement, the inconsistency
shall be resolved by giving precedence first to the Appendices and then to this Agreement. This
15
Agreement will be interpreted and enforced according to the laws and regulations of the State of Utah and
any applicable federal laws or regulations. If an inconsistency exists between the Agreement and any
applicable law, this Agreement will be construed to include the minimum requirements of the applicable
law.
8.2 Indemnification. PEHP agrees to indemnify Employer from and against any claims or other liability,
including attorney fees, based upon PEHP's failure to comply with its obligations under the Agreement.
Employer agrees to indemnify PEHP from and against any claims or other liability, including attorney
fees, based upon Employer's failure to comply with its obligations under the Agreement.
8.3 Amendment and Assignment. This Agreement may be modified or amended only by a written
instrument executed by duly authorized officers of the parties hereto. This Agreement may not be
assigned by either party without the written consent of the other party.
8.4 Default. If either party defaults in the performance of this Agreement or any of its obligations
hereunder, the defaulting party shall pay all costs and expenses, including reasonable attorney's fees,
which may arise or accrue from enforcing the Agreement or from pursuing any remedy provided
hereunder.
8.5 Force Majeure. Neither party will be responsible for a delay in performing its obligations under the
Agreement due to circumstances reasonably beyond its control, such as natural disaster, epidemic, riot,
war, terrorism, or nuclear release.
8.6 Dispute Resolution. This Agreement is entered into in the State of Utah and shall be governed by the
laws of said state, notwithstanding any conflicts of laws principles. Any dispute arising out of this
Agreement will be subject to the exclusive jurisdiction of the administrative hearing process found in
Utah Code Annotated § 49-11-613.
8.6 Conflict of Interest. PEHP represents that it has not knowingly influenced, and hereby promises that
it will not knowingly influence, an Employer officer or employee, or former Employer officer or
employee, to breach any ethical standards applicable to Employer. Employer represents that it has not
knowingly influenced, and hereby promises that it will not knowingly influence any PEHP officer or
employee or former PEHP officer or employee to breach any ethical standard applicable to PEHP.
8.7 Severance. In the event any portion of this Agreement is determined to be unconstitutional, unlawful
or otherwise unenforceable in the State of Utah, only the unconstitutional portion of the Agreement will
be severed and the remaining portion of the Agreement will continue in effect and be binding on the
Parties, provided that such holding of invalidity or unenforceability does not materially affect the essence
of the Agreement.
16
8.8 Notice.
8.8.1 Any notice required herein of PEHP shall be addressed to Employer at the address listed in
Appendix A, and when required of Employer, shall be addressed to PEHP, Marketing Department,
Public Employees' Health Program, 560 East 200 South, Salt Lake City, Utah 84102-2004, or
kurt.murray@pehp.org (or current Marketing Manager).
8.8.2 All required notices shall be sent by at least first class mail or electronic mail.
8.8.3 Any notice PEHP is required to send will be sufficient if
a. For notice to Employer, notice is sent to the address listed in Appendix A;
b. For notice to a Subscriber, notice is sent to the address PEHP has on record; and
c. For notice to a Dependent, notice is sent to the Subscriber.
8.8.4 Any notice Employer is required to send will be sufficient if sent to the address listed above.
8.9 Waiver. Failure by either party to insist upon strict compliance with any part of this Agreement or
with any procedure or requirement will not result in a waiver of its right to insist upon strict compliance
in any other situation.
8.10 Workers' Compensation Insurance. The Agreement does not provide or replace workers'
compensation coverage for Employer's Employees. Employment -related injuries are not covered under
the Agreement.
8.11 Relationship of the Parties. This Agreement is a contract for services and does not create an
agency relationship. Employer does not have the authority to act as PEHP's agent. PEHP is not
Employer's agent for any purpose.
SECTION 9 - DEFINITIONS
9.0 In General. This Agreement contains certain defined terms that are capitalized in the text and
described in this Section. Words that are not defined have their usual meaning in everyday language.
9.1 Adult Designee. If Employer accepts Adult Designees as Dependents, the qualifications agreed upon
by Employer and PEHP will be included in Appendix A.
9.2 Agreement. This Employer Health Insurance Agreement, including the Employer Application and all
other documents expressly referred to and incorporated by reference.
9.3 Benefit(s). The payments and privileges to which Members are entitled by this Agreement.
17
9.4 Continuation or COBRA Coverage. Coverage required by the Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA) and/or coverage allowed under Utah Code Annotated § 31 A-22-
722 (Mini -COBRA).
9.5 Conversion Coverage. Coverage provided under Utah Code Annotated § 31 A-22-723.
9.6 Dependent(s). An Employee's lawful spouse (or Adult Designee if allowed by Employer) and any •
child who meets the Eligibility criteria under this Agreement.
9.7 Early Retiree. A former Employee of Employer who is under age 65 and who meets Employer's
Eligibility criteria as defined by Employer in Appendix A.
9.8 Effective Date. The date on which coverage for a Member begins.
9.9 Employee. An individual employed by Employer.
9.10 Employer Plan (or "Plan(s)"). The group health and/or other Benefit plan(s) elected and sponsored
by Employer under this Agreement and attached in Appendix A.
9.11 Eligible, Eligibility. The criteria or standards, established by Employer and/or PEHP under this
Agreement and Appendix A, in order to participate in a PEHP health plan.
9.12 HIPAA. The Health Insurance Portability and Accountability Act found at 45 C.F.R. §§ 160 and
164, as amended.
9.13 Master Policy. The document(s), considered part of this Agreement, which describe(s) the terms
and conditions of the health insurance Benefits with PEHP, including the Benefit Summary, and which is
available online at the address listed in Appendix A, or by request.
9.14 Member. As defined in the Master Policy attached in Appendix A, a Subscriber, including an
Employee, Early Retiree, LTD Participant, COBRA Participant, Conversion Coverage Participant, and
any Dependent, when properly enrolled in the Plan and accepted by PEHP.
9.15 PHSA. The Public Health Service Act of 1944, codified in United States Code, Title 42, as
amended.
9.15 PPACA. The Patient Protection and Affordable Care Act, Pub. L. No. 111-148, as amended,
including the Health Care Education Reconciliation Act of 2010, Pub. L. No. 111-152, as amended.
9.16 Provider. A vendor of healthcare Services as defined in the Master Policy.
9.17 Rate(s). The amount paid periodically by Employer and/or Subscribers to PEHP as consideration
for providing Benefits under the Plan. The Contribution rate is specified in Appendix A.
18
9.18 Service(s). Services provided by a Provider, including medical practices or care, treatment, tests,
supplies, equipment, devices, or drugs.
9.19 Subscriber. An Employee that enrolls with PEHP, as defined in the Master Policy.
SECTION 10 - SIGNATURE PAGE
EXECUTED this day of , 20_.
EXECUTED this 1 3-day of
UTAH RETIREMENT SYSTEMS
PUBLIC EMPLOYEES HEALTH PROGRAM
By
Chet Loftis
Director, Public Employees Health Program
zo]�S
[Employe�ame]
By
[Name]
[Title]
AlrEsT cLLat.e,0
C t 4-y �
20
APPENDIX A
Plan Year: January 1, 2015 — December 31, 2015
A-1 Benefits
A Employer Plans/Programs
Master Policy & Benefit Grid — members can access at www.pehp.org or on Employer's
website.
Summary of Benefits & Coverage (SBC) — members can access at www.pehp.org or on
Employer's website.
Provider Directory - Provider directories for the Employer plans are found online at
www.pehp.org. Provider directories are subject to change without notice. PEHP shall
make reasonable efforts, as determined by PEHP, to inform Employer and Members if a
material disruption shall occur to provider networks during the term of this Agreement.
Wellness Programs
PEHP offers the Healthy Utah wellness program for Employer. If Employer elects to
offer additional wellness programs to employees, Employer shall be solely responsible
for any federal law compliance related to such additional program, included taxability of
rebates and tracking applicable wellness limits for employees.
Adult Designee
Employer has elected to provide coverage to Employer adult designees.
Adult designee means a person selected by an employee and meets the following criteria:
1. Resides in the same domicile with the employee for the past 12 consecutive months
and intends to remain so;
2. Is at least 18 years of age;
3. Is not related to the employee in a way that would disqualify the individuals from
being legally married under Utah law; and
4. Provides evidence to the employer that the adult designee is dependent upon, or is
mutually dependent with the employee.
Acceptable evidence shall include either: a) Any Internal Revenue Service form defining
the Adult Designee as a dependent; or b) Any three of the following four documents:
(i) A joint loan obligation, mortgage, lease or joint ownership of a vehicle;
(ii) A life insurance policy, retirement benefits account, mutually granted power of
attorney for healthcare or financial management, or a Will designating the Adult
Designee as beneficiary thereto, or Will of the employee or the Adult Designee
which designates the other as executor;
(iii) Proof showing that the employee or Adult Designee is authorized to sign for
purposes of the other's bank or credit account;
(iv) Proof of a joint bank or credit account.
21
5. Employer shall be solely responsible for determining the eligibility of adult designees
in accordance with this Agreement. Employer must maintain sufficient evidence of
records to show eligibility for adult designees.
6. Employer shall be solely responsible to PEHP for any amounts incurred by ineligible
adult designees which were not eligible under this Agreement.
7. Employer acknowledges that it shall be solely liable for any tax consequences related
to adult designees, and that PEHP maintains no responsibility or any kind for any
taxes which may be owed.
8. Adult designee rates are included in the rate section of this Appendix.
Early Retiree
Employer may elect to provide Early Retiree benefits to its Early Retirees. PEHP shall
only enroll Employer's retirees if the following conditions are met:
1. Employer takes official action (i.e. City Council resolution; board action; etc) to
adopt an early retiree benefit policy and provides such policy to PEHP. Such policy
shall define the eligibility standards for early retirees, including the time frames
associated with early retiree coverage.
2. PEHP shall accept early retirees prospectively from the date of the official action
forward. Employer acknowledges that early retirees are not eligible for continuing
benefits (COBRA or mini -COBRA) after their early retiree period.
a. Early retiree rates shall be 102% of the active employee monthly rate prior to
18 months.
b. 130% of the active employee monthly rate after 18 months.
3. Employer shall pay all rates associated with early retirees. Any amounts owed by
early retirees for coverage, shall be collected by Employer.
B Vesting Standards for LGRP
1. Employer hereby acknowledges that it participates in the Local Governments Risk
Pool ("LGRP") sponsored by PEHP, which is a multi -employer self -funded risk pool.
Participation in the LGRP requires meeting PEHP's vesting requirement, which
include:
a. An Employer is vested with PEHP when either:
i. the Employer provides two years of specific plan benefits and claims
costs to PEHP to appropriately determine rates; or
ii. the Employer continuously participates with PEHP in the LGRP for
three years.
b. If an Employer is vested with PEHP, the Employer may terminate this
agreement with no further obligation to LGRP. At the time of termination,
22
the Employer shall not receive any LGRP reserve funds, and shall not pay
any deficits incurred or paid by Employer to LGRP.
c. If Employer is not vested with PEHP and terminates this Agreement before
becoming vested, Employer will immediately pay PEHP for any deficits
incurred during its participation with LGRP. Deficits mean the difference
between claims paid by PEHP, including administrative costs, and the rates
paid by Employer, including all Employer allocated investment earnings or
deficits. Deficits shall be solely determined by PEHP. Any calculations
regarding deficits will include Employer's claims presented and paid by
PEHP over the 12 months following Employer's termination of this
Agreement.
d. Any surpluses attributable to the Employer (when rates exceed premiums),
whether vested or non -vested, will remain with PEHP for the benefit of the
Employers participating in the LGRP.
2. Employer IS NOT deemed vested by PEHP.
C Reinsurance
1. Each Employer shall participate in the PEHP Reinsurance Risk Pool and pay the
applicable rates for such services. Reinsurance rates are included in rates found
in Appendix Section A-2. The Reinsurance Plan covers:
A. Specific stop loss coverage (large medical claims exceeding $100,000
annually) calculated on an incurred in 12 months and paid in 15 months
basis; and
B. 120% to 135% of aggregate stop loss coverage of expected claims.
2. The PEHP Reinsurance Risk Pool specifically excludes coverage for any claims
incurred:
A. Outside of the eligibility standards of this agreement or the Master
Policy; or
B. For benefits not specifically covered by the Master Policy.
If Employer approves claims or benefits not covered by this Agreement or the Master Policy,
Employer shall be responsible for all claims expenses associated with such charges.
Notwithstanding any other provision of this Agreement, PEHP shall have no liability to pay any
claims, benefits or make other payments that are not specifically stated in this Agreement or the
Master Policy.
A-2 Additional Terms
A Following termination of this Agreement, PEHP shall pay claims incurred prior to
termination of this Agreement for 12 months.
23
B Conflict of Interest — Employer acknowledges that PEHP is a public employer, and that
no employee or officer is related to any employee or officer of PEHP within two degrees
of consanguinity except as has been previously disclosed to PEHP.
C Additional Reporting Requests - PEHP shall provide regular reports to Employer as
described in the Agreement. PEHP may provide additional reports to Employer as
negotiated between Employer and PEHP. If such additional reports are agreed upon and
authorized by PEHP, Employer agrees to pay PEHP the reasonable costs of producing
such reports at the rate of $20/hour and $.10/page for printed reports.
24
FIRST AMENDMENT TO THE
PUBLIC EMPLOYEES' HEALTH PROGRAM
EMPLOYER HEALTH INSURANCE AGREEMENT
This Amendment ("Amendment") is made and entered into as of the 13t day of January,
2015 ("Effective Date"), by and between City of Moab , a Utah public employer
("Employer"), and the Public Employees' Health Program ("PEHP"), as a program of the
Utah Retirement Systems, an independent state agency created under Utah Code Title 49.
WITNESSETH
WHEREAS, the parties have entered into an Employer Health Insurance Agreement
("Agreement"), and
WHEREAS, the Agreement allows for an amendment to the terms through a written
instrument executed and authorized by the parties, and
WHEREAS, the Section 6055 and 6056 of the 2010 Patient Protection and Affordable
Care Act ("ACA") requires applicable large employers to make certain reports to the IRS
and notifications to employees on a yearly basis; and
WHEREAS, federal regulations regarding such reporting requirement allow for a
governmental entity to designate another governmental entity to file Section 6056 reports
on its behalf; and
WHEREAS, the parties hereby designate PEHP to be the designated government entity
responsible for filing the applicable tax forms to comply with the reporting requirements
of Sections 6055 and 6056 of the ACA.
NOW THEREFORE, in consideration of the foregoing, the parties hereto agree that:
1. Nothing in the Agreement is deleted.
2. The following provisions are added to Appendix A-1:
D. IRS Reporting
1. Employer hereby asserts to PEHP that it is an "applicable large employer" as
defined by federal law for ACA reporting purposes.
2. Employer hereby designates PEHP as the designated government entity
responsible for filing the applicable tax forms to comply with the reporting
requirements of Sections 6055 and 6056 of the ACA and their applicable
regulations.
3. Employer agrees to provide PEHP with the necessary information, as solely
determined by PEHP, and in a manner approved by PEHP, to accurately and
timely comply with the above federal law reporting requirements. Such
information may include, but is not limited to,
a. The employment status of full-time employees;
b. A designation of whether an employee is full-time employee as
determined by federal law;
c. The eligibility for health coverage for full-time or non -full-time
employees;
d. The amount of premium share the eligible employee would have to pay
for the lowest cost single health coverage plan;
e. Social security numbers for dependents enrolled in the health coverage.
4. PEHP shall inform Employer of the reporting requirements and provide
Employer a format and time deadline in which Employer must provide the
necessary information to PEHP.
5. PEHP agrees to file all required reports under ACA Section 6055 and 6056 to
the IRS, as well provide Employer's full-time employees with the required
notification.
6. The parties understand and agree that PEHP shall file these notifications and
reports based on the information Employer provides to PEHP. Under no
circumstances shall PEHP be responsible for any liability, penalty or damages
of any kind or imposed by any entity for the Employer's failure to provide
timely, accurate or complete information to PEHP. PEHP's liability in
producing these reports is solely and strictly limited to those penalties imposed
by federal law for reporting violations. As required by federal law, Employer
shall be solely liable for any tax penalties imposed under IRC Section 4980H.
PEHP shall never be liable to Employer for any damages, penalties or any other
available remedy for a violation(s) of the ACA reporting requirements.
7. Failure by the Employer to provide timely or accurate information to PEHP as
PEHP reasonably requests may, at PEHP's sole discretion, void the obligations
of PEHP under this Appendix A-1, D. In such a case, Employer shall remain
responsible for any and all reporting requirements under federal law.
All other provisions of the Agreement shall remain unchanged and in full force and effect
for the remainder of the term of the Agreement as set forth herein.
This Amendment may be executed in counterparts, each of which shall constitute an
original and which taken together shall constitute one Amendment.
2
IN WITNESS WHEREOF, the parties hereto have executed this Amendment as of the
Effective Date.
Utah State Retirement Office
Public Employees' Health Program [Empiric,
By: By:
Name: Name: 40;6 dePeei3e6A-)
Title: Title: it fr
Date: Date: / s
3
Ater:
�- � � TrL