HomeMy WebLinkAboutR-2012-109 - Authorized Renewal Agreement with AvMed Health Plan to Provide a Self-Funded Open Access Point of Service Health Plan to Eligible Employees, Retirees or Both RESOLUTION NO. 2012-109
A RESOLUTION OF THE CITY COMMISSION OF THE CITY OF DANIA
BEACH FLORIDA, AUTHORIZING THE PROPER CITY OFFICIALS TO
RENEW AN AGREEMENT WITH AVMED HEALTH PLAN TO PROVIDE A
SELF-FUNDED OPEN ACCESS POINT OF SERVICE ("POS") HEALTH
PLAN TO ELIGIBLE EMPLOYEES, RETIREES OR BOTH; PROVIDING
FOR CONFLICTS; FURTHER, PROVIDING FOR AN EFFECTIVE DATE.
BE IT RESOLVED BY THE CITY COMMISSION OF THE CITY OF DANIA
BEACH,FLORIDA:
Section 1. That the City Commission waives bidding for health administrative
services and authorizes the proper City officials to execute documents pertaining to the renewal
of the AvMed Health Plan a self-funded open access Point of Service "POS" plan afforded to
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eligible employees and retirees. The program shall be inclusive of third party administrative
services, network access services, utilization review services, and organ transplant services
through LifeTrac, at a monthly cost not to exceed $46.77 per employee or retiree beginning
October 1, 2012. The cost of$46.77 represents an adjustment of$1.32 from the current monthly
cost; disease management will be billed separately on a per case basis at an estimated cost of
$5,126.00, based on current enrollment.
Section 2. That funding for the cost of the City's health claims program
administration is planned and shall be charged to the City Health Insurance Fund, Professional
Services Account,Account No. 501-1800-519-31-10.
Section 3. That based on recommendations of the City actuary, the City Commission
approves and adopts the AvMed self-insured health plan for the 2012-2013 fiscal year at a
monthly premium cost for AvMed health care of$684.88 for single coverage and $1,814.92 for
family coverage.
Section 4. That all resolutions or parts of resolutions in conflict with this Resolution
are repealed to the extent of such conflict.
Section 5, That this Resolution shall be in force and take effect October 1, 2012.
PASSED AND ADOPTED on August 28, 2012.
ATTEST:
A
LOUISE STILSON, Ci4C PATRICIA A. FLURY
CITY CLERK MAYOR
's Flits?.
r
APPROVED AS,7p AND CORRECTNESS:
( -1 t
THOMAS J. S RO
CITY ATT RtM Y
2 RESOLUTION#2012-109
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AvMED
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Effective October 1,2012,the Administrative Services Agreement and associated Exhibits have been
amended as follows:
Under Part VII.CLAIMS ADNMgSTRATION,Sections 7.02 and 7.03 have been amended as
follows:
7.02 Employer has delegated claims fiduciary responsibility to AvMed. AvMed, acting as claims
fiduciary to the Plan, retains the authority and responsibility to make a full and fair review of
each claim denial and to notify the claimant in writing of its decision following such review.
Employer acknowledges that this delegation of authority is reflected in the governing
document(s)of the Plan and the Summary Plan Description provided to Plan Participants.
7.03 AvMed will make initial claims determinations pursuant to the Plan terms. AvMed agrees to
notify Plan Participants and beneficiaries of the right to address a final written appeal to AvMed,
as named claims fiduciary. The foregoing is subject to AvMed's retention of full responsibility
as named claims fiduciary for the final review of denied claims appealed in writing by a Plan
Participant or beneficiary holding a valid assignment of benefits under the Plan.
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-Under Part VIII.FUNDING&PAYMENT OF CLAIMS,Section 8.04 has been amended as follows:
----- 8 04 The parties_acknow_ledge that the Employer has paid the sum of$48,000 which is to be used as
follows: - —- I
8.04.01 A working deposit of$1,000 for interest payments to Providers should they be required
- _ -- under the Florida prompt pay legislation;and
8.04.02 A Working deposit of$27,000 for prescription drug coverage offered through AvMed's j
Pharmacy Benefit Manager.
8.05.02 A working deposit of$20,000 for medical claims coverage administered by AvMed.
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EXHIBIT B
BASIC ADM dSTRATIVE SERVICES&CHARGES
L BASIC ADMIMSIRATiIVE SERVICES
A. CLAIM ADMINISTRATION
1. Preparation and delivery of standard claim forms to the Employer for issuance to eligible
Employees under the Plan(if necessary).
2. Make initial claim determinations and final claim determinations on appeal.
3. Investigation of claims,as necessary. - —
4. Discussion of claims,where appropriate,with providers of health services.
5. Performance of internal audits of claim payments on a random sample basis.
6. Application of claim control procedures necessary to the effective implementation of the
basic principles ofthe Plan.
7. Claim Department consultation,as necessary, with its health care and legal consultants in
handling claims. (The Employer will be responsible for seeking its own advice if more -
specific consultative services are required in a particular case). -
8. Calculation of benefits,check preparation,and issuance.
9. Notification to claimants of denials and the reason for the denial.-
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10. Notification to providers-of_denied claims, if provider submitted claim directly to Plan for
- payment, along with the reason for the denial and whether or not the Participant is
responsible for payment.
11. Issue certificates of creditable coverage pursuant to the requirements of the Health Insurance
Portability and Accountability Act of 1996(HIPAA).
12. Coordination with stop loss carrier on aggregate and/or specific stop loss,if purchased.
13. Standard Claims and Experience Reporting
14. Ad hoc reporting may be available at an additional charge of$125 per hour.
15. Determination of Maximum Allowable Payment schedule for providers who are not under
contract with AvMed based on Employer's election of 215%of AvMed's standard Maximum
Allowable Payment fee schedule.
16. Subrogation Claims Payment(terms described in Part III of this Exhibit).
B. MANCUL
1. Provision of a monthly invoice for services,fees,and premiums.
2. Disbursement of monthly payments for insurance premiums,fees,etc...to enable continuous
provision of services and insurance coverages.
3. Provision of annual year-end accounting consisting of a summary of the amount of paid
claims at the coverage level and a summary of charges paid.
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C. BANXING&ADNIINISTI ATION
I. Furnishing of bank account activity data (to the extent administratively reasonable) to
Employer on a mutually agreed upon frequency.
2. Preparation for Employer of information reports required in connection with claim payments
under the Plan to providers of health care services pursuant to Section 6041 of the Internal
Revenue Code(Form 1099).
3. Provision of data maintained by AvMed for Employer's preparation of required
governmental filings,upon request. i
D. NETWORK ACCESS
1. Access to the AvMed Choice and PHCS national network, which may change from time to
time.
2. Provide Employer a listing of Participating Providers. Such listing shall include the names,
specialties, addresses, and phone numbers of such providers. An updated listing shall be
posted on AvMed's website at www.avmed.org.
3. Access to a Transplant Network.
4. Provide Employer with a Provider Directory for each eligible Covered Employee at the initial
enrollment and provide Employer a reasonable supply of Provider Directories upon each
reprint for distribution to new enrollees in the Plan.
5. Employer understands that AvMed may not contract for all services offered by a Participating
Provider. It is the responsibility of the Employer and the Participant to verify that the
specific services are covered by both the Plan and AvMed's contract with the Participating
Provider.
6. Network Management Services which include credentialing and re-credentialing of providers,
contract negotiations and provider servicing.
7. Provide one identification card for each Participant upon enrollment and subsequently if there
is a material change in benefits. AvMed reserves the right to charge the Plan for reissuing
cards at other times.
E. MEDICAL MANAGEMENT
1. AvMed will provide Utilization Review programs to include: (1) preauthorization of all
inpatient and certain outpatient and office procedures, (2) concurrent review of inpatient
stays,(either on-site or telephonically),(3)Service Plus program which provides nurses and
other medical staff available to all providers 24 hours a day,7 days a week,and(4)discharge
planning.
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2. AvMed will provide: (1)Nurse On Call,which is staffed 24 hours a day,7 days a week to
provide immediate information to the Participant either by talking to a nurse or by listening to
a pre-recorded informational health topic,(2)Complex Case Management,when appropriate.
3. AvMed will provide transplant coordination and management to Participants,upon notice. i
4. Disease management services are available from an AvMed partner as a pass through cost on '
a per participating member per month fee basis. The following table lists the fees associated
with this service:
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The City purchased the Core Conditions at the following rates
Core Conditions
Diabetes $79.00
Heart Failure $116.81 i
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Coronary Artery Disease $71.71
COPD $90.57
Asthma $37.70
Low Risk
(Education only:all conditions) $1.41
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F. COMPREHENSIVE ACCOUNT&MEMBER SERVICES
1. Enrollment and case installation. i
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2. Designated Account Service Team.
3. Member Service staff available Monday through Friday 8:00 am.to 8:00 p.m.and Saturday
9:00 a.m.to 1:00 p.m.via shared toll free telephone number.
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4. Distribution of notices to Participants from time to time to improve Plan administration or as
required by law. Notices specific to the Plan will be submitted to the Employer for review
prior to distribution to Participants.
5. Creation and maintenance of a basic Summary Plan Description for distribution by Employer.
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6. Printing of Member Information Booklets at a cost of$1.25 per Booklet ---- -- - j
G. ELIGIBILIPTY
1. Screening of enrollment requests for dependent coverage in accordance with the Plan. This `
screening may include requests for marriage licenses,adoption papers, and birth certificates,
as well as requests for documentation supporting student status or financial dependency.
2. Screening for continued Covered Dependent eligibility as required.
3. Screening for Pre-Existing conditions for Participants age 19 and over.
4. Performance of COBRA Continuation Coverage administration through an AvMed business
partner.
H, OTHER SERVICES
1. Add Worksite Wellness Program Coordination, upon request from Employer. Employer j
agrees to fund actual cost of delivering the requested services(e.g.massage therapy;flu shot
administration,health screenings,etc.) j
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2. Access to the Healthways WholeHealth Network which provides a list of holistic providers at I
a discounted rate.
3. Upon request from Employer, AvMed agrees to administer the Weight Watchers program I
reimbursement, according to AvMed's standard program criteria. Should any Participant
achieve goal weight, AvMed will include the request for funds on a weekly claim funding
report to the Employer. Once funds are received, AvMed will issue a check for i
reimbursement of a portion of the program fees to the Participant.
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4. AvMed will perform Hospital and Physician bill auditing as part of AvMed's standard f
program for a fee of 25%of savings. I
5. AvMed will make available, on the AvMed website, the Health Risk Assessment tool for
Employer's Participants at a cost of$4.20 per Assessment.
H. CHARGES FOR BASIC ADMINISTRATIVE SERVICES PROVIDED BY AVMED OR A
SUBCONTRACTOR `
A. BASIC ADMINISTRATIVE SERVICES
1. AVMED HEALTH PLANS
Year 1: 10/01/12 through 9/30/13. $46.77 per Covered Employee per month. For purposes I
of this Exhibit, Covered Employee means each active and former employee and COBRA
continuee eligible for Plan benefits in his or her own right and not as the spouse or dependent
8r gh Po 1�
of another person.
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2. CAPITATION FEES BILLED BY AVMED ON BEHALF OF PROVIDER VENDORS
In lieu of medical claims,fixed expenses will include the capitation per Participant per mouth
to provider vendors, as per the terns of the AvMed contract with the provider. Capitation i
vendors, services, and rates may change throughout the contract year (the period of 12
consecutive months commencing on the Effective Date of the Agreement)based on AvMed's
commercial block of business. The rate is subject to change as AvMed's rate is adjusted
throughout the year and is subject to the provisions of Section XU(Modification of Plan and
Administrative Duties and Charges)of this Agreement.
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PARTICIPATING PROVIDERS RATES
Each AvMed Participating Provider in the Self-funded network has agreed to accept
contractual and negotiated rates as payment in full for services rendered to the Employer's
Participants who are covered under the City of Dania Beach Group Health Plan, provided
claims are funded by the Employer as soon as presented for payment. Participating Providers
expect to receive payment of the required Deductibles, Co-payments and Co-insurance, as
outlined in the Schedule of Benefits,from the Participants at the time the service is rendered.
3. PHCS
AvMed has arranged with PHCS (Private Health Can Systems)to serve as a wrap-around
network for medical care provided outside of the AvMed Service Area when Participants who
reside in the AvMed Service Area travel. Therefore,AvMed is making this benefit available
to the City of Dania Beach Group Health Plan for any claims that may fall within the
parameters of AvMed's agreement with PHCS. The fee for this service is 30%of savings
(billed charges less contracted amount). AvMed has also entered into contracts with third
parties that may provide a negotiated savings on Hospital and other Medical Services.Use of
these additional AvMed contractual arrangements will provide additional savings for the City
of Dania Beach Group Health Plan.
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IN WITNESS WHEREOF,the parties hereto have caused this Agreemeat to be executed by their
duly authorized officers.
DATE:
� (�� BY•MED �J�V W0'
ITS: 4 Y r
DATE: ENMD •CI OF DANIA BEACH
BY"
ITS: _
III. CONDITIONAL CLAIM/SUBROGATION RECOVERY SERVICES
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A. ALL CONDITIONAL CLAIM PAYMENT AND/OR SUBROGATION RECOVERIES
UNDER THE PLAN WILL BE HANDLED BY THE ENTITY CHECKED BELOW:
EMPLOYER
AN INDEPENDENT RECOVERY VENDOR i
WHOSE NAME AND ADDRESS FOLLOW: I j
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V AVMED&ITS SUBCONTRACTORS)
B. IF EMPLOYER HAS DESIGNATED AVMED AND ITS SUBCONTRACTORS TO
ACT AS ITS RECOVERY AGENT IN PARAGRAPH A ABOVE;THEN:
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1. Employer hereby confers upon AvMed and its subcontractors discretionary authority to
reduce recovery amounts by as much as(select 50•/.,75% or 100%)of the total amount of
benefits paid on Employer's behalf,and to enter into binding settlement agreements for such
amounts.
In the event a settlement offer represents a reduction greater than the selected percentage
identified above,AvMed and its subcontractors should seek settlement advice from:
NAME:
TITLE:
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ADDRESS:
TELEPHONE:
2. All subrogation and/or reimbursement recovery functions under the Plan will be handled by
AvMed.
3. In accordance with state law restrictions,AvMed shall have no duty or obligation to represent
Employer in any litigation or court proceeding involving any matter which is the subject of
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4. this Agreement,but shall make available to Employer and/or Employer's legal counsel such
information relevant to such action or proceeding as AvMed may have as a result of its
handling of any matter under this Agreement.
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5. All amounts reimbursed to Employer's benefit payment Account shall be net of AvMed's
subrogation administrative fee of 25% of any recovery amount allocable to reimburse the
Plan.
OFT-OUT
Employer does not confer subrogation/reimbursement recovery responsibilities to AvMed.AvMed
will only be responsible for providing the Employer with claims information pertinent to subrogation and
reimbursement cases upon request.Employer will perform all subrogation/reimbursement fimctions.
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EXHIBIT C
FORM OF CLAIM AUDIT AGREEMENT
L WHEREAS,AVMED,INC.DIWA AVMED HEALTH PLANS(-AVMED-)DESIRES TO
COOPERATE WITH REQUESTS BY THE CITY OF DANIA BEACH(-EMPLOYER-)
TO PERM[T AN AUDIT FOR THE PURPOSES SET FORTH BELOW;AND
IL WHEREAS, (-THE AUDITOR-) HAS BEEN RETAINED BY
EMPLOYER FOR THE PURPOSE OF PERFORMING AN AUDIT (-AUDIT-) OF
CLAIMS ADMINLSTERED BY AVMED.
HL WHEREAS, THE AUDITOR AND THE EMPLOYER RECOGNIZE AVMED'S
LEGITIMATE INTERESTS IN MAINTAINING THE CONFIDENTIALITY OF ITS
CLAIM INFORMATION, PROTECTING ITS BUSINESS REPUTATION, AVOIDING
UNNECESSARY DISRUPTION OF ITS CLAIM ADMINISTRATION, AND
PROTECTING ITSELF FROM LEGAL LIABILITY;
IV. NOW THEREFORE, IN CONSIDERATION OF THE PREMISES AND THE MUTUAL
PROMISES CONTAINED HEREIN,AVMED,THE EMPLOYER AND THE AUDITOR
HEREBY AGREE AS FOLLOWS:
A. AUDIT SPECIFICATIONS
The Auditor will specify to AvMed in writing at least 30 days prior to the commencement of
the Audit the following"Audit Specifications": f
1. the name,title and professional qualifications of individual Auditors;
2. the Claim Office locations,if any,to be audited;
3. the Audit objectives;
4. the scope ofthe Audit(time period and number of claims);
5. the process by which claims will be selected for audit;
6. the recordstinformation required by the Auditor for purposes of the Audit;and
7. the length of time contemplated as necessary to complete the Audit.
B. REVIEW OF SPECIFICATIONS
AvMed will have the right to review the Audit Specifications and to require any changes in,
or conditions on,the Audit Specifications which may be necessary to protect AvMed's legal
and business interests identified in paragraph C above.
C. ACCESS TO INFORMATION
AvMed will make the records/information called for in the Audit Specifications available to
the Auditor at a mutually acceptable time and place.
D. AUDIT REPORT
The Auditor will provide AvMed with a true copy of the Audit's findings,as well as of the
Audit Report,if any,that is submitted to the Employer. Such copies will be provided to
AvMed at the same time that the Audit findings and the Audit Report are submitted to the
Employer.
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E. COMMENT ON AUDIT REPORT
AvMed.reserve's the right to provide the Auditor and the Employer with its comments on the
findings and,if applicable,the Audit Report.
F. CONFIDENTIALITY
The Auditor understands that AvMed is permitting the Auditor to review the claim
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recordsrutformation solely for purposes of the Audit. Accordingly,the Auditor will ensure
that all information pertaining to individual claimants will be kept confidential in accordance
with all applicable laws and/or regulations. Without limiting the generality of the foregoing,
the Auditor specifically agrees to adhere to the following conditions:
1. The Auditor shall not make photocopies or remove any of the claim records/information
without the express written consent of AvMed;
2. The Auditor agrees that its Audit Report or any other summary prepared in connection with
the Audit shall contain no individually identifiable information as more fully described in
Section 14.15 of the Administrative Service Agreement between Employer and AvMed.
-- G. RESTRICTED USE OF THE AUDIT INFORMATION
With respect to persons other than the Employer,the Auditor will hold and treat information
obtained from AvMed during the Audit with the same degree and standard of confidentiality
owed by the Auditor to its clients in accordance with all applicable legal and professional
standards.The Auditor shall not,without the express written consent of AvMed executed by j
an officer of AvMed,disclose in any manner whatsoever,the results,conclusions,reports or
information of whatever nature which it acquires or prepares in connection with the Audit to
- any party other than the Employer except as required by applicable law. The Employer and
Auditor agree to indemnify and to hold harmless AvMed for any and all claims,costs,
expenses and damages which may result from any breaches of the Auditor's obligations
under paragraphs 6 and 7 of this Agreement or from AvMed's provision of information to the
Auditor.
H. EXPENSES INCURRED
Expenses incurred in performing the Audit will be the responsibility of the Employer.
L TERMINATION
AvMed may terminate this Agreement with prior written notice. The obligations set forth in
Sections 4 through 7 shall survive termination of the Agreement.
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DATE AVMED, Q(
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BY:
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DATE: AUDITOR:
BY:
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DATE: EMP R: OF DANIA CH
BY•
ITS:
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CONFIDENTIALITY AGREEMENT
This Agreement effective the first day of October,2005,is by and between the City of Dania Beach
("Employer")and AvMed,Inc.d/b/a AvMed Health Plans,for itself and its affiliated companies
("AvMed").
WHEREAS,AVMED and Employer have entered into an Administrative Services Agreement pursuant to
which AVMED administers claims for benefits under Employer's self-funded employee welfare benefit
plan entitled City of Dania Beach Group Health Plan(the"Plan");and
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WHEREAS,in its role as claim administrator for the Employer,AvMed has come into possession of
certain individually identifiable records and other information including,but not limited to,information j
relating to claims for benefits under the Plan(collectively"Information');and
WHEREAS,Employer desires that Information in the possession of AvMed be made available to it and to
certain designated third parties("Designated Third Parties")who assist it in administering the Plan. Such
parties may include,but are not limited to,third-party administrators,consultants,brokers,auditors,
successor administrators or insurers,and stop-loss carriers.
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WHEREAS,AvMed desires,to the extent allowable by state law and by the Health Insurance Portability
and Accountability Act of 1996,as amended,to accommodate Employer's request;
WHEREAS,Employer recognizes the confidential nature of Information that it has requested;and
WHEREAS,Employer recognizes AvMed's legitimate interest in maintaining the confidentiality of
Information and in protecting itself from any and all legal liability with respect thereto;
NOW,THEREFORE,in consideration of the premises and the mutual promises contained herein,
AVMED and Employer hereby agree as follows:
1. AvMed will provide to Employer Information requested in writing by a person designated in
writing by Employer to receive Information. Employer acknowledges that in receiving
h mmiation under the terms of this Agreement, Employer acts in its capacity as Plan I
Administrator. Information will be used by Employer for the purpose of satisfying its
fiduciary responsibilities with respect to administration of the Plan,and will be handled and
maintained in accordance with all fiduciary obligations owed by Employer to Participants.
Upon Employer's written request, AvMed will provide to Designated Third Parties
Information requested in writing by a person designated in writing by Employer to receive
such Information. Employer acknowledges that in directing AvMed to give information to
Designated Third-Parties,Employer acts in its capacity as Plan Administrator. Information
will be used by Designated Third-Parties for the sole purpose of assisting Employer in
satisfying its fiduciary responsibilities with respect to administration of the Plan,and will be
handled and maintained in accordance with all fiduciary obligations owed by Employer to
Participants. i
2. Employer acknowledges that AvMed is providing Information to Employer or to Designated
Third Parties solely for the purposes stated in paragraphs 1 and 2 above.
3. Employer will not provide access to Information to any employee, agent or other designee
other than an employee, agent or designee on a need-to-know basis who is designated by
Employer to participate in the activities described in paragraph 1 above and who has the
requisite expertise and responsibility to engage in such activities.
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4. Employer will maintain and adhere to a written policy and procedure designed to protect the
confidentiality of Information.
S. Employer agrees to keep all Information that pertains to individual Participants confidential
in accordance with all applicable state and federal laws and regulations.
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6. Employer will defend, indemnify and hold AvMed harmless from and against any and all
claims, suits, expenses (including reasonable attorney's fees and court costs), liabilities or
damages (whether resulting from settlement, judgment, arbitration or otherwise) arising
directly or indirectly from AvMed's provision of Information to Employer or to Designated
Third-Parties,or relating directly or indirectly to the use of Information by the Employer or {
Designated Third Parties,their officers,agents,directors,employees or designees.
7. This Confidentiality Agreement shall remain in force until it is terminated upon 60 days prior
written notice by either party. However,termination shall not in any way affect the parties'
obligations with respect to Information released under this Agreement prior to termination
nor shall it affect the indemnification provision set forth above in paragraph 7, which also
shall survive the termination of this Agreement.
IN WITNESS WHEREOF,the parties hereto have caused this Agreement to be executed by their
duly authorized officers.
DATE- AVMEn,
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DATE: EMPLOO Ft7 BEACH
BY•� �
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CLAIM PAYMENT OR OVERPAYMENT RECOVERY
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If a claim is paid and it becomes necessary to re-claim all or part of the funds from the Participant,AvMed
will contact the Participant in writing to request reimbursement of these fiords. If there is no response
within 30 days AvMed will notify the Employer who will then either handle the recovery themselves OR
allow AvMed to use its contracted collection agency to try to recover fiords on their behalf. The cost of
this collection agency is approximately 25%of collected funds and is the responsibility of the Employer.
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Employer should indicate which method of collection is required:
(a)Employer handles recovery in all cases j
[ (b)AvMed refers all cases to collection
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