R-12-11-20-G1 - 11/20/2012RESOLUTION NO. R -12-11-20-G1
WHEREAS, the City of Round Rock has previously entered into an Administrative Services
Agreement "(Agreement") with Aetna Life Insurance Company ("Aetna") for stop loss insurance, and
WHEREAS, the City Council desires to renew said Agreement with Aetna, Now Therefore
BE IT RESOLVED BY THE COUNCIL OF THE CITY OF ROUND ROCK, TEXAS,
That the Council hereby authorizes renewal of the Administrative Services Agreement with
Aetna for insurance coverage for the guarantee period of January 1, 2013 through December 31, 2013.
The City Council hereby finds and declares that written notice of the date, hour, place and
subject of the meeting at which this Resolution was adopted was posted and that such meeting was
open to the public as required by law at all times during which this Resolution and the subject matter
hereof were discussed, considered and formally acted upon, all as required by the Open Meetings Act,
Chapter 551, Texas Government Code, as amended
RESOLVED this 20th day of November, 2012.
ALAN MCGRAW, Mayor
City of Round Rock, Texas
ATTEST:
40t, - OM -t7
SARA L. WHITE, City Clerk
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City of Round Rock
Medical Performance Guarantees
General Performance Guarantee Provisions
Guarantees
Aetna Life Insurance Company (ALIC) provides health benefits administration and other
services for the self-funded Aetna Choice POS II. The services set forth in this document will
be provided by ALIC (hereinafter "Aetna").
Performance Objectives
Aetna believes that measuring the activities described below are important indicators of how
well it services City of Round Rock. Aetna is confident that the Plan Administration, Claim
Administration and Member Services provided to City of Round Rock will meet their high
standards of performance. To reinforce City of Round Rock's confidence in Aetna's ability
to administer their program, Aetna is offering guarantees in the following areas:
Performance Category
Minimum Standard
Proposed Penalty
Claim Administration
■ Turnaround Time
90.0% of claims processed
within 14 calendar days
2.0%
■ Financial Accuracy
99.0%
2.0%
■ Payment Incidence Accuracy
96.0%
2.0%
Member Services
■ Average Speed of Answer
30 Seconds
2.0%
■ Abandonment Rate
Can not exceed 2.5%
2.0%
Total
10.0%
7/20/2012 www.aetna.com Page I
City of Round Rock Guarantees
Medical Performance Guarantees
Guarantee Period
The guarantees described herein will be effective for a period of 12 months and will run from
January 1, 2013 through December 31, 2013 (hereinafter "guarantee period").
The performance guarantees shown below will apply to the self-funded Aetna Choice POS II
administered under the Administrative Services Only Agreement ("Services Agreement").
These guarantees do not apply to non -Aetna benefits. In addition, our network guarantees do
not apply to non -Aetna networks.
If Aetna processes runoff claims upon termination of the Services Agreement, performance
guarantees of Turnaround Time, Financial Accuracy, and Payment Incidence Accuracy will
not apply to such claims. Furthermore, performance guarantees described herein will not
apply to the guarantee period claims if termination is prior to the end of the guarantee period.
In addition, performance guarantees will not be reconciled and payouts will not occur until
the full guarantee period administrative service fees have been paid. Failure to remit
applicable service fees within the grace period may invalidate certain guarantees listed below
Aggregate Maximum
The maximum penalty adjustment will be equal to 10.0% of actual base service fees,. In no
event will fees be adjusted by more than 10.0% due to results of this guarantee and all other
guarantees combined.
Administrative Service Fees at risk exclude commissions and charges collected outside of the
monthly billed administrative services fees.
Termination Provisions
Termination of the guarantee obligations shall become effective upon written notice by Aetna
in the event of the occurrence of (i), (ii) or (iii) below:
a material change in the plan initiated by City of Round Rock or by legislative action
that impacts the claim adjudication process, member service functions or network
management;
ii. failure of City of Round Rock to meet its obligations to remit administrative service
fees or fund the City of Round Rock bank account as stipulated in the General
Conditions Addendum of the Services Agreement;
iii. failure of City of Round Rock to meet their administrative responsibilities (e.g., a
submission of incorrect or incomplete eligibility information).
7/20/2012 www.aetna.com Page 2
City of Round Rock
Medical Performance Guarantees
Guarantees
No guarantees shall apply for a guarantee period during which the Services Agreement is
terminated by City of Round Rock or by Aetna.
Refund Process
At the end of each guarantee period, Aetna will compile its Performance Guarantees results.
If necessary, Aetna will provide a "lump sum" refund for any penalties incurred by Aetna.
Measurement Criteria
Aetna's internal quality results for the unit(s) processing City of Round Rock's claims will be
used to determine guarantee compliance for any Financial Accuracy, Payment Incidence
Accuracy, and/or Total Claim Accuracy Guarantees. The results for these guarantees will be
calculated using industry accepted stratified audit methodologies.
7/20/2012 www.aetna.com Page 3
City of Round Rock Guarantees
Medical Performance Guarantees
Claim Administration
Turnaround Time
Guarantee: Aetna will guarantee that the claim turnaround time during the guarantee period
will not exceed 14 calendar days for 90.0% of the processed claims on a cumulative basis
each year.
Definition: Aetna measures turnaround time from the claimant's viewpoint; that is, from the
date the claim is received in the service center to the date that it is processed (paid, denied or
pended). Weekends and holidays are included in turnaround time.
Penalty and Measurement Criteria: If the cumulative year turnaround time (TAT) exceeds
the day guarantee as stated above, Aetna will reduce its compensation by an amount equal to
0.2% of the guarantee period administrative service fees. for each full day that Turnaround
Time exceeds 14 calendar days for 99.0% of all processed claims. There will be a maximum
reduction of 2.0% of the guarantee period administrative service fees.
If City of Round Rock has >3000 enrolled lives, a computer generated turnaround time report
for City of Round Rock's specific claims will be provided on a quarterly basis. If <3000
enrolled lives, results will be reported at the site level. If the customer has multiple products,
the minimum membership requirement will apply to each product.
Financial Accuracy
Guarantee: Aetna will guarantee that the guarantee period dollar accuracy of the claim
payment dollars will be 99.0% or higher.
Definition: Financial accuracy is measured using industry accepted stratified audit
methodology. The results are calculated by calculating the financial accuracy for a subset of
claims (a stratum) and then extrapolating the results based on the size of the population and
combining with the extrapolated results of the other strata. Each overpayment and
underpayment is considered an error; they do not offset each other. Includes both manual
and auto adjudicated claims.
Penalty and Measurement Criteria: Aetna will reduce its compensation by an amount
equal to 0.2% of the guarantee period administrative service fees for each full 1.0% that
financial accuracy drops below 99.0%. There will be a maximum reduction of 2.0% of the
guarantee period administrative service fees.
Aetna's audit results for the unit(s) processing City of Round Rock's claims will be used.
Those results include Aetna's performance in processing ALL customers' claims handled by
7/20/2012 www.aetna.com Page 4
City of Round Rock Guarantees
Medical Performance Guarantees
the unit(s) in question during the Guarantee period, not just your plan's claims. The results
for these guarantees will be calculated using industry accepted stratified audit methodologies.
Payment Incidence Accuracy
Guarantee: We will guarantee that the guarantee period payment incidence accuracy will be
96.0% or higher.
Definition: Payment incidence accuracy is measured by industry accepted stratified audit
methodology. Accuracy in each stratum (a subset of the claim population) is calculated by
dividing the number of claims paid correctly by the total number of claims audited and then
extrapolating the results based on the size of the population and combining with the
extrapolated results of the other strata.
Penalty and Measurement Criteria: Aetna will reduce its compensation by 0.2% of the
guarantee period administrative service fees for each full 1.0% that payment incidence
accuracy drops below 96.0%. There will be a maximum reduction of 2.0% of the guarantee
period administrative service fees.
Aetna's audit results for the unit(s) processing City of Round Rock's claims will be used.
Those results include Aetna's performance in processing ALL customers' claims handled by
the unit(s) in question during the Guarantee period, not just your plan's claims. The results
for these guarantees will be calculated using industry accepted stratified audit methodologies.
Average Speed of Answer
Guarantee: Aetna will guarantee that the average speed of answer for the phone skill(s)
providing City of Round Rock's member services will not exceed 30 seconds.
Definition: On an ongoing basis, Aetna measures telephone response time through
monitoring equipment that produces a report on the average speed of answer. Average speed
of answer is defined as the amount of time that elapses between the time a call is received
into the telephone system and the time a representative responds to the call. The result
expresses the sum of all waiting times for all calls answered by the queue divided by the
number of incoming calls answered. ASA measures the average speed of answer for all
callers answered. Interactive Voice Response (IVR) system calls are not included in the
measurement of ASA.
Penalty and Measurement Criteria: Aetna will reduce its compensation by 0.2% of the
guarantee period administrative service fees for each full second that the average speed of
answer exceeds 30 seconds. There will be a maximum reduction of 2.0% of the guarantee
period administrative service fees. Aetna's results for the phone skill(s) providing member
services for City of Round Rock will be used.
7/20/2012 www.aetna.com Page 5
City of Round Rock
Medical Performance Guarantees
Abandonment Rate
Guarantees
Guarantee: Aetna will guarantee that the average rate of telephone abandonment for the
phone skill(s) providing City of Round Rock's member services will not exceed 2.5%.
Definition: On an ongoing basis, Aetna measures telephone response time through
monitoring equipment that produces a report on the average abandonment rate. The
abandonment rate measures the total number of calls abandoned divided by the number of
calls accepted into the skill.
Penalty and Measurement Criteria: Aetna will reduce its compensation by 0.2% of the
guarantee period administrative service fees for each 1.0% that the average abandonment rate
exceeds 2.5%. There will be a maximum reduction of 2.0% of the guarantee period
administrative service fees. Aetna's results for the phone skill(s) providing member services
for City of Round Rock will be used.
7/20/2012 www.aetna.com Page 6
City of Round Rock
Administrative Services Contract (ASC)
Financial Renewal Overview:
January 1, 2013 through December 31, 2013
Policyholder
Number - 819919
aetna-
tna-
Cassandra
Chapman
Regional Director
Public & Labor
Phone: (860) 273-3294
E-mail: ChapmanC3@aetna.com
Christopher N Blustein
Underwriting Consultant
Public & Labor
Phone: (860) 273-2308
E-mail: BlusteinC@aetna.com
July 20, 2012
Ms. Karin Holland
HR Manager
City of Round Rock
231 Main Street
Round Rock, TX 78664
Dear Ms. Holland:
Thank you for allowing AetnaI to provide health care products and services to City of Round
Rock over the past year. As we approach the January 1, 2013 anniversary of your benefits
program, we are pleased to present your renewal evaluation for the 2013 contract period. We
hope this package provides the information you need to manage both the financial and plan
design aspects of your company's benefits package.
The following provides important information about the cost of your current program,
potential changes you may want to consider and the value that Aetna brings to you and your
company:
1) Fee Schedule — This section contains the administrative service fees exhibit for
the renewal period beginning January 1, 2013. This renewal marks the first year
of a three year guarantee period.
Contracted Services — Aetna utilizes external vendors for claim recovery on
Coordination of Benefits, Retro Terminations, Medical Bill and Hospital Bill
Audits, Workers Compensation, DRG and Implant Audits. For all January 1,
2013 claim recoveries, there will be an additional administrative fee for the
1 Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary
companies, including Aetna Life Insurance Company. Health benefit and health insurance plans contain limitations and
exclusions. Policy form numbers include GR -29, GR -700-W, GR -88435.
collection of these recoveries as a percentage of the amount recovered. The fees
that are outlined in the attached Fee Schedule include Aetna's administrative fee.
2) Renewal Assumptions — Our renewal offer is contingent upon the parameters
outlined in this section. It is important to note that deviations from these
assumptions may result in additional charges and/or adjustments to our
guaranteed fees. Notification of any Aetna initiated changes for the upcoming
contract period are also outlined on this exhibit. Please review this section
thoroughly.
Health Care Reform — This renewal is intended to be compliant with health care
reform. Please refer to the Health Care Reform section in the Renewal
Assumptions for further details.
3) Program Services / Direct Charges — This section outlines the standard
products and services included in your current benefits program. In addition, it
lists examples of non-standard services that are not included and can be added
for an additional fee. Upon Plan Sponsor approval, these non-standard services
will be billed through the claim wire as the services are rendered, using a single
claim account, when applicable. These additional direct charges will be outlined
separately on your monthly Claim Detail Reports.
4) Future Program Costs — This section outlines the projected program costs for
your health plan(s) for the renewal contract period.
5) The Aetna Difference — This sgction outlines additional offerings from the
Aetna portfolio. We hope this information provides a better understanding of the
many ways we are striving to provide quality health care programs, products and
services to our customers and members.
Aetna Pharmacy Management —
Please note that we are providing renewal information regarding your Aetna Pharmacy
Management program under separate cover.
Health Care Reform and Dependant Eligibility Verification (DEV) —
While PPACA has expanded the terms under which a plan will be required to cover children
under age 26, it did not eliminate all reasons dependent children are determined to be
ineligible for coverage
Employers need to vigilant in protecting their plan due to employee confusion regarding
health care reform. We strongly recommend a dependent eligibility verification and
maintenance program. This solution remains one of the most compelling means to obtain
immediate savings and protect your health plan(s) from unnecessary claim expenditures. Our
clients have seen an ineligible results range from 4 percent to 8 percent from our
comprehensive Dependent Eligibility Verification (DEV) services.
Federal Mental Health Parity - The Federal Mental Health Parity and Addiction Equity Act
of 2008 applies to fully insured traditional and HMO Middle Market (MM) & National
Accounts (NA) commercial plans as well as self-funded Traditional and HMO MM & NA
commercial plans for plan years beginning on or after October 3, 2009. This means many
calendar year plans were required to comply with the Act by Jan. 1, 2010. The new Interim
Final Regulations apply to plan years beginning on or after July 1, 2010, so calendar year
plans must comply with the regulations by January 1, 2011. However, given that this is a self
funded plan, it is ultimately up to the plan sponsor to comply with Federal Mental Health
Parity. We can continue to make our recommendation regarding application and how
we think their plan should be designed in order to comply but we are not in the position to
provide self funded plan sponsors legal advice. Therefore, the plan sponsor should speak to
their own legal counsel and make the final determination related to compliance with Federal
Mental Health Parity.
In the absence of any changes impacting the conditions of this renewal as outlined in the
Renewal Assumptions section, the fees, rates and factors presented here will remain in effect
through December 31, 2013.
We are committed to working with you to provide quality products and services that
reinforce your decision to do business with Aetna and help manage your current and future
health care needs.
Please feel free to contact me or Kendra Hoduski, your Aetna Account Executive, if you
have any questions or need additional information.
Sincerely,
Cassandra Chapman Christopher N Blustein
Regional Director Underwriting Consultant
Fee Schedule
City of Round Rock Aetna Life Insurance Company
January 1, 2013 through December 31, 2013 Customer Number - 819919
This exhibit outlines the fees for the contract between City of Round Rock and Aetna Life
Insurance Company (hereinafter "Aetna") for services performed by Aetna under the
Administrative Services Agreement (hereinafter "Agreement") for the Guarantee Period
January 1, 2013 through December 31, 2013. The fees described here replace the Fees
described in the Agreement for the Guarantee Period January 1, 2012 through December 31,
2012.
National Advantage Program TM with Facility Charge Review —
Included 50.0% of savings. In addition, access to Aetna -contracted physicians is $1.75 PEPM
for indemnity coverages (no percentage of savings charged on Aetna contracted physicians).
The $1.75 PEPM is included in the total guaranteed fee.
Contracted Services:
• Aetna Subrogation Program — Aetna has entered into an agreement with the firm of
Rawlings & Associates to provide comprehensive subrogation services. A
contingency fee of 30.0% is retained upon recovery for self-funded customers.
• A contingency fee of 30% is retained upon recovery for self-funded customers on
the following programs:
'Employee' is defined as only those persons in the classes of employee, retiree, COBRA continuee and any other persons
within classes that are specifically described in Appendix I of the Services Agreement, including employees, retirees,
COBRA continuees and any other persons within classes of City of Round Rock subsidiaries and affiliates of who are
reported, in writing, to Aetna for inclusion in the Services Agreement.
Page 5 of 42
Choice POS II
PPO Dental
Vision
2012 Guaranteed Billing Fee
PEPM"
$34.75
$4.43
$1.00
2013 Guaranteed Billing Fee
PEPM"
34.75
$4.43
$1.00
Percentage Chane
0.00%
0.00%
0.00%
2014 Total Guaranteed Billing Fee
PEPM
36.14
$4.43
$1.00
Percentage Chane
4%
0%
0.00%
2015 Total Guaranteed Billing Fee
PEPM"
37.59
$4.43
$1.00
Percenta a Chane
4%
0%
0.00%
National Advantage Program TM with Facility Charge Review —
Included 50.0% of savings. In addition, access to Aetna -contracted physicians is $1.75 PEPM
for indemnity coverages (no percentage of savings charged on Aetna contracted physicians).
The $1.75 PEPM is included in the total guaranteed fee.
Contracted Services:
• Aetna Subrogation Program — Aetna has entered into an agreement with the firm of
Rawlings & Associates to provide comprehensive subrogation services. A
contingency fee of 30.0% is retained upon recovery for self-funded customers.
• A contingency fee of 30% is retained upon recovery for self-funded customers on
the following programs:
'Employee' is defined as only those persons in the classes of employee, retiree, COBRA continuee and any other persons
within classes that are specifically described in Appendix I of the Services Agreement, including employees, retirees,
COBRA continuees and any other persons within classes of City of Round Rock subsidiaries and affiliates of who are
reported, in writing, to Aetna for inclusion in the Services Agreement.
Page 5 of 42
Fee Schedule
o Coordination of Benefits Primary and Secondary Review, Retro Termination,
Medical Bill and Hospital Bill Audit, Worker's Compensation Program
(California, Florida, New York, Ohio and Texas), DRG and Implant Audit.
Guarantee Period
The components of the Fees will be referred to as Guaranteed Fees.
The period January 1, 2013 through December 31, 2013 will be referred to as the
First Guarantee Period, the period January 1, 2014 through December 31, 2014 will
be referred to as the Second Guarantee Period, and the period January 1, 2015
through December 31, 2015 will be referred to as the Third Guarantee Period.
Guaranteed Fees
Self -Funded Fee Guarantee — The fees for the self-funded coverages included in this
renewal for the period January 1, 2013 through December 31, 2013 are guaranteed according
to the PEPM fees provided above. We guarantee that the fees for the Second Guarantee
Period will increase over the fees for the First Guarantee Period by 4.0%. We also guarantee
that the fees for the Third Guarantee Period will increase over the fees for the Second
Guarantee Period by 4.0%.
Run-off Processing Charges
City of Round Rock was sold on an incurred (mature) claim basis, which takes into account
the expenses associated with the processing of run-off claims following cancellation, subject
to the conditions of our financial guarantee.
Additional Services (Direct Charges)
The Guaranteed Fees exclude provisions for certain additional services which may be
requested by City of Round Rock. Please see the attached Services/Direct Charges document
for more information and examples of included and excluded charges. Fees for any additional
services requested by City of Round Rock will be billed as described on the Services/ Direct
Charges section.
Billing of Fees
We will bill and collect your monthly Medical fees as outlined above. At the end of the
Agreement year, Aetna will reconcile the collected fees to those outlined in this exhibit. Any
overage due City of Round Rock, or any shortfall due Aetna, will be payable within the time
frame specified in the Agreement.
Compensation
Page 6 of 42
Fee Schedule
We honor "Agent of Record" or "Broker of Record" letters when an agent, broker, or
consultant takes over an Aetna case from another agent, broker, or consultant. The
notification of this change must be submitted on your organization's letterhead and signed by
an appropriate representative from your organization. The "Agent of Record" or "Broker of
Record" letter that designates a change for commission payment will become effective on the
first day of the month following receipt by our commission unit, unless another future date is
designated in the letter.
We have various programs for compensating agents, brokers and consultants. If you would
like information regarding compensation programs for which your agent, broker, or
consultant is eligible, payments (if any) which Aetna has made to your agent, broker, or
consultant, or other material relationships your agent, broker, or consultant may have with
Aetna, you may contact your agent, broker or consultant, or Kendra Hoduski in our Dallas
field office. Information regarding our programs for compensating agents, brokers and
consultants is also available at www.aetna.com.
National AdvantagJm Program
The National Advantage Program (NAP) offers access to contracted rates for many medical
claims that would otherwise be paid at billed charges under indemnity plans, the out -of -
network portion of managed care plans, or for emergency and medically necessary services
not provided within the standard network. The NAP network consists of many Aetna -
contracted hospitals, ancillary providers, and physicians as well as hospitals, ancillary
providers and physicians accessed through vendor arrangements where we do not have
contractual arrangements.
Standard Facility Charge Review (FCR)
FCR is a feature of NAP. This program provides reasonable charge allowance review for
most inpatient and outpatient facility claims where a National Advantage Program contracted
rate is not available. Without the advantage of this program, these claims are often paid at
billed charges. The program is only available in conjunction with NAP.
Late Payment Charges
If City of Round Rock fails to provide funds on a timely basis to cover benefit payments as
provided in the Agreement, and/or fails to pay service fees on a timely basis provided in such
Agreement, Aetna will assess a late payment charge. The charges for 2013 are outlined
below:
(i) late funds to cover benefit payments (e.g., late wire transfers): 12.0% annual rate
(ii) late payments of Service Fees: 12.0% annual rate
Aetna reserves the right to collect any incurred late payment charges through the claim wire
on a monthly basis provided there are no other special payment arrangements in -force to fund
Page 7 of 42
Fee Schedule
any incurred late payment charges. Plan Sponsor will be notified by Aetna in writing to
obtain approval prior to billing any late payment charges through claim wire.
In addition, Aetna will charge to recover its costs of collection including reasonable
attorney's fees.
We will notify City of Round Rock of any changes in late payment interest rates.
The late payment charges described in this section are without limitation to any other rights
or remedies available to Aetna under the Agreement or at law or in equity for failure to pay.
Page 8 of 42
Renewal Assumptions
City of Round Rock Aetna Life Insurance Company
January 1, 2013 through December 31, 2013 Customer Number - 819919
Services
Choice POS II
PPO Dental
Enrolled Lives
777
798
Projected PCTs per Employee
24.9
3.7
Member to Employee Ratio
2.03
2.03
Retiree Percentage
0.8%
0.8%
Definitions:
AVA Level — Aetna Voice Advantage Level
Level 1.0 — Automated AVA module; no opt out to Customer Services needed (does not
apply to medical)
Level 2.0 — Automated AVA module; member may opt out to Customer Services after
automated services are offered.
Level 3.0 — Initial selection AVA module; member may opt out immediately to Customer
Services
No AVA — Plan Sponsor elects immediate live voice access by member
Navigator Enrollment
Aetna Navigator® allows members online access to member services.
Manual Processed Claim Transaction (PCT) per Employee
Adjustments are applied reflecting the variation in the number of manually processed PCTs
and those auto adjudicated. Claim processing charges increase as manual processing
increases.
Page 9 of 42
Renewal Assumptions
Our guaranteed fees have taken into account the overall business relationship we enjoy with
City of Round Rock and have factored into our pricing the economies of offering multiple
products and services through Aetna. Aetna reserves the right to recalculate the Guaranteed
Fees using its then current book of business formula under the circumstances described
below. In such case, City of Round Rock will be required to pay any difference between the
fees collected and the new fees calculated retroactive to the start of the Guarantee Period.
Aetna may recalculate:
i. If, for any product identified above, there is a:
• 15% decrease in the number of enrolled lives during the guarantee period from the
Guaranteed Fee Assumptions above (such decrease is to be determined in total for
all Medical products combined, or from any reset assumptions (reset if a new Fee is
established).
• 15% increase in the processed claim transactions per employee (PCTs/ee) ratio from
the ratio above, or from any subsequently reset assumptions (reset if a new fee is
established).
• 15% increase in the retiree percentage above, or from any subsequently reset
assumptions (reset if a new fee is established).
• 15% increase in the member to employee ratio above, or from any subsequently
reset assumptions (reset if a new fee is established).
2. If a material change in the plan of benefits is initiated by City of Round Rock or by
legislative or regulatory action.
3. If a material change is initiated by City of Round Rock or by legislative or regulatory
action in the claim payment requirements or procedures, claim fiduciary option, account
structure, or any other change materially affecting the manner or cost of paying benefits.
4. If the National AdvantageTM Program (NAP), Facility Charge Review (FCR) or
Itemized Bill Review (IBR) programs are terminated by City of Round Rock.
5. If Aetna Programs and Services, including but not limited to Aetna Health Connections
(AHC) disease management, Beginning Right(SM) Maternity Program, MedQuery®,
and Informed Health® Line (IHL), are terminated by City of Round Rock.
6. If City of Round Rock terminates any other Aetna products and services not addressed
within this renewal package, including but not limited to Pharmacy and Self Insured
Dental.
Page 10 of 42
Renewal Assumptions
7. If City of Round Rock places the products and service included in this multi-year fee
guarantee out to bid with an effective date prior to January 1, 2016 (end of multi-year
guarantee period), then this guarantee will be nullified.
Health Care Reform
This renewal is intended to be compliant with health care reform.
The Federal government released regulations related to grandfathering of health plans in
existence on March 23, 2010. Under the health care reform legislation, health plans existing
prior to the enactment of the legislation may be "grandfathered" and not subject to some of
the mandated benefits and reform provisions. Changes in your benefit design as well as your
contribution strategy may affect grandfathering. Plan sponsors are required to notify Aetna
if their contribution rate changes for a grandfathered plan at any point during the plan year.
Aetna will administer the plan in compliance with Federal external review process.
This renewal offering assumes your plan is not grandfathered.
As a non -grandfathered plan, the plan will include Preventive care as defined by regulation
without cost sharing on In Network services.
For plan years on/after 8/1/12 this renewal includes the women's preventive care coverage
requirements, e.g., coverage for contraceptive methods and counseling, breastfeeding
support and equipment, and prenatal care.
Certain religious employers may be exempt from contraceptive services coverage
requirements, or may be able to defer until 8/1/13 because of an extension. If you want to
be considered exempt, please work with your Account Manager/Account Executive to
provide the required documentation to Aetna. Aetna has the right to treat fully insured plans
as subject to the ACA contraceptive services coverage requirements without an executed
certification document.
Except for specific and limited scenarios described as transitional rules in the health care
reform legislation, if a plan's grandfathered status has been lost, it cannot be regained. If,
after reviewing the grandfathering rules with your benefit consultant or counsel, City of
Round Rock determines that their coverage could be or is grandfathered, and they want to
retain grandfathered status, they should contact Aetna for further instructions.
The benefits and fees within this proposal are subject to change pending any required
approvals from state or federal regulatory agencies. If you have questions, please contact
your Account Executive.
Any taxes or fees (assessments) applied to self-funded benefit plans related to The Patient
Protection and Affordable Care Act (PPACA) will be solely the obligation of the plan
sponsor. The administrative service fees that Aetna is presenting do not include any such
plan sponsor liability nor the administration of these fees on the plan sponsor's behalf.
Page 11 of 42
Renewal Assumptions
Aetna reserves the right to modify its products, services, rates and fees, in response to
legislation, regulation or requests of government authorities resulting in changes to plan
benefits and to recoup any material fees, costs, assessments, or taxes due to changes in the
law even if no benefit or plan changes are mandated.
Guidance issued by the Internal Revenue Service ("IRS"), Department of Labor ("DOL"),
and Department of Health and Human Services ("HHS") has indicated that "retiree only"
plans are exempt from the new benefit mandates under PPACA including Medical Loss
Ratio ("MLR") and rebate requirements for fully insured plans. In order to demonstrate the
establishment of a retiree only plan, a plan should maintain, separately from the plan for
current (i.e., active) employees, a separate plan document and Summary Plan Description
(SPD) and file a separate Form 5500. If you have a retiree only plan, and want to be
considered exempt, please submit a retiree only certification form and required
documentation to Aetna.
Page 12 of 42
Medical Program Services
City of Round Rock Aetna Life Insurance Company
January 1, 2013 through December 31, 2013 Customer Number - 819919
Services and Programs
We have provided a list, by product, of those services and programs that are included or available to City of
Round Rock.
Page 13 of 42
Choice POS II
Vision
General Administration
Account Management
Included
Included
Customer Team Services
Included
Included
Communication Materials
Included
Included
Eligibility
Included
Included
Customized Forms
Included
Not Included
Printing of Booklets or Certificates
Not Included
Not Included
Claim Fiduciary
Not Included
Not Included
Claim Fiduciary - Option 4
Included
Not Included
External Review
Included
Not Included
HIPAA Certification
Included
Not Included
Claims Subrogation
Included
Not Included
Banking
Banking Method
ACH Aetna Initiated
ACH Aetna Initiated
Funding Basis
Cleared
Cleared
Alternate Stockpiling
Applies
Applies
Seed Money
Applies
Applies
Claim & Member Services
Claim Administration
Included
Included
Member Services
Included
Included
Aetna Voice Advanta e® IVR
Included
Included
Network Administration
Network Management
Included
Included
Provider Relations
Included
Included
Rural PPO Network Program
Not Included
Included
National Advantage" Program
Included
Included
Standard Facility Charge Review
Included
Included
Facility Charge Review Modified
Balance Bill
Not Included
Not Included
Facility Charge Review Fixed
Determination
Not Included
Not Included
Itemized Bill Review
Not Included
Included
Patient Management
Precertification
Included
Included
Radiology Benefit Management
Not Included
Not Included
Case Management
Not Included
Included
Concurrent Review
Included
Included
Discharge Planning
Included
Included
Aetna Compassionate Care
Program
Included
Included
National Medical Excellence
Included
Included
Biometric Screenings
Not Included
Not Included
Aetna Health Connections —
Included
Not Included
Page 13 of 42
Medical Program Services
Page 14 of 42
Choice POS II
Vision
Disease Management
Flexible Medical Management
Model Option 1
Not Included
Not Included
Flexible Medical Management
Model Option 2
Not Included
Not Included
Flexible Medical Management
Model Option 3
Not Included
Not Included
Care Advocate Team
Not Included
Not Included
Healthy Lifestyle Coaching
Not Included
Not Included
Simple Steps To A Healthier Life
or Health Assessment
Included
Not Included
Aetna Healthy Actions
Not Included
Not Included
Member Health Engagement Plan
Not Included
Not Included
MHEP
CareEngineO Personal Health
Record
Not Included
Not Included
Wellness Counseling
Not Included
Not Included
Healthy Body, Healthy Weight
Not Included
Not Included
Program
Beginning Right Maternity
Included
Not Included
Program
Quit Tobacco Program
Not Included
Not Included
Informed Health Line - Nurseline
800 # only
Included
Included
Informed Health Line - Welcome
Not Included
Not Included
Letters
Informed Health Line - Semi-
Annual Reports
Not Included
Not Included
Informed Health Line - Annual
Not Included
Not Included
Survey/Results
MedQueryO with Basic Member
Included
Not Included
Messaging
Aetna Concierge
Not Included
Not Included
Aetna In Touch Care
Not Included
Not Included
- Enhanced Member Messaging
Not Included
Not Included
Customer Specific Network (Acute
Not Included
Not Included
Care Included
Designated Disease Management
Not Included
Not Included
Get Active - Shape up
Not Included
Not Included
Get Active - Shape up & Stay in
Not Included
Not Included
Shape
Get Active - Welcome Kit (720 -ITC
Not Included
Not Included
Pedometer
Get Active - Welcome Kit (HJ -150
Not Included
Not Included
Pedometer
Get Active - Welcome Kit (Std.
Not Included
Not Included
Pedometer
Value Add Programs
Fitness Pro am GlobalFit
Included
Included
Aetna Natural Products &
Included
Included
ServicessM Program
Aetna Weight Management6m
Included
Included
Discount Program
Page 14 of 42
Medical Program Services
Page 15 of 42
Choice POS II
Vision
Aetna HearinAsm Discounts
Included
Included
Aetna Vision Discounts
Included
Included
Standard Behavioral Health
Focused Psychiatric Review
Not Included
Not Included
Managed Behavioral Health
Included
Not Included
Behavioral Health Disease
Management Programs
- Alcohol Disease Management
Not Included
Not Included
- Anxiety Disease Management
Not Included
Not Included
- Depression Disease
Management
Not Included
Not Included
- Med/Psych Program
Not Included
Not Included
Case Management Behavioral
Health Programs
- Intensive Case Management
Included
Not Included
Member Internet Services
Public Sites
DocFindo
Included
Included
Aetna InteliHealth®
Included
Included
Learning Resources
Included
Included
Secure Sites
Staying Healthy
Included
Included
Estimate the Cost of Care Tool
Included
Included
Claim Research/Forms/Contact us
Included
Included
Spanish version
Included
Included
Plan Sponsor Internet Services
e.Plan Sponsor Monitor Reporting
Aetna Integrated Informatics
- Level A Reporting
Included
Included
- Level B Reporting
Included
Included
- Level C Reporting
Not Included
Not Included
- Level D Reporting
Not Included
Not Included
Aetna Health Information
Advanta eTM
Not Included
Included
Aetna Health Information
Advanta eTM Gold
Not Included
Not Included
Online Disease Management
Not Included
Not Included
Aetna Navigator® Re orting
Included
Included
Page 15 of 42
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Experience Analysis
City of Round Rock
January 1, 2013 through December 31, 2013
Aetna Lite Insurance Company
Customer Number - 819919
Summary of Medical - Choice POS H Experience
Recorded
Adjusted'
Recorded
Month Effq3loyees
Claims
Claims
PCTs
Apr -11 756
$ 313,533
$
313,533
1,410
May -11 754
361,539
361,539
1,579
Jun -11 756
393,946
393,946
1,372
Jul -11 751
627,148
627,148
1,318
Aug -11 752
387,351
387,351
1,606
Sep -11 763
434,346
434,346
1,407
Oct -11 776
368,074
368,074
1,411
Nov -11 763
392,777
392,777
1,802
Dec -11 772
338,329
338,329
1,311
Jan -12 777
727,951
727,951
1,842
Feb -12 785
401,034
401,034
1,473
Mar -12 781
291,722
291,722
1,478
Apr -12 780
392,807
392,807
1,435
May -12 778
583,943
583,943
1,458
Jun -12 777
469,127
469,1271
1,479
Totals for Projection 766 Avg.
$ 5,414,609
$
5,414,609
18,020
Annualized Claims
Annualized Claims
Annualized
PEPY
PEPY
PCTsPEPY
Claim Average Latest: 12 months
$ 7,073.30
$
7,073.30
23.54
9 months
$ 6,877.05
$
6,877.05
23.74
6 months
$ 7,391.28
$
7,391.28
23.63
3 months
$ 7,405.26
$
7,405.26
22.39
' There is no benefit adjustment affecting the claims for this experience period.
Derivation of Projected Claims & PCTs
Claims
PCTg
Recorded Claims & PCTs Jul -11 to Jul -12
$
5,414,609
18,020
Less Claim Wire Billed Fees/Charges
-$
0
0
Net Recorded Claims & PCTs
$
5,414,609
18,020
Average Employees Apr -11 to Apt -12
/
766
766
Average Claims & PCTs Per Employee
= $
7,073.30
23.54
Monthly Claims & PCTs (Before Trend)
$
589.44
1.96
Projected Employees at January 1, 2013
x
777
777
Projected Renewal Period
x
12
12
Projected Claims & PCTs (Before Trend)
_ $
5,495,939
18,275
Trend Period
Experience Period Jul l"II to
Jul 1,12
Midpoint>
Jan 1,12
Billing Period Jan 1,13 to
Jan 1,'14
Midpoint>
Jul 1,13
Projected Claims & PCTs
Claims
PCTs
(A) Annual Trend Rate
9.20%
2.30%
(B) Number of Months Between Midpoints
18.0
18.0
(C) Projected Claims & PCTs Before Trend
5,495,939
18,275
(D) Trend Adjustments (((1 + A) ^ (B / 12)) x
C) - C
775,625
634
(E) Expected Claims & PCTs (C + D)
$
6,271,564
18,909
(F) Expected Claims & PCTs Per EE
8,071.51
24.34
Page 22 of 42
Experience Analysis
City of Round Rock
January 1, 2013 through December 31, 2013
Sum -y of Rx Experience
Totals for Projection 770 Avg $ 1,401,987
Aetna Life Insurance Company
Customer Number - 819919
Adjusted'
Claims
$ 141,969
130,729
76,728
115,986
108,741
113,635
87,268
158,117
100,489
117,463
104,610
144,812
94,023
107,181
149.662
$ 1,401,987
Annualized Claims Annualized Claims
PEPY PEPY
Claim Average latest: 12 months $ 1,821.95 $ 1,821.95
9 months $ 1,829.89 $ 1,829.89
6 months $ 1,843.14 $ 1,843.14
3 months $ 1,800.08 $ 1,800.08
There is no benefit adjustment affecting the claims for this experience period.
Derivation ojProjected Claims & PCTs
Recorded Claims & PCTs Jul -11 to Jul -12
Less Claim Wire Billed Fees/Charges
Net Recorded Claims & PCTs
Average Employees Jun -11 to Jun -12
Average Claims & PCTs Per Employee
Monthly Claims & PCTs (Before Trend)
Projected Employees at January 1, 2013
Projected Renewal Period
Projected Claims & PCTs (Before Trend)
Trend Period
Experience Period Jul l"II to Jul 1,12
Billing Period Jan 1,'13 to Jan 1,14
Projected Claina & PCTs
(A) Annual Trend Rate
(B) Number of Months Between Midpoints
(C) Projected Claims & PCTs Before Trend
(D) Trend Adjustments (((1 + A) ^ (B / 12)) x C) - C
(E) Expected Claims & PCTs (C + D)
(F) Expected Claims & PCTs Per EE
Recorded
PCTs
1,251
1,641
1,257
1,211
1,658
1,329
1,318
1,598
1,484
1,844
1,561
1,466
1,455
1,774
1A20
18,118
Annualized
PCTs PEPY
23.55
23.95
24.45
23.85
Claims
Recorded
Month
Employees
Claims
Apr -11
756
$ 141,969
May -11
754
130,729
Jun -11
756
76,728
Jul -11
751
115,986
Aug -11
752
108,741
Sep -11
763
113,635
Oct -11
776
87,268
Nov -11
763
158,117
Dec -11
772
100,489
Jan -12
777
117,463
Feb -12
785
104,610
Mar -12
781
144,812
Apr -12
780
94,023
May -12
778
107,181
Jun -12
777
149.662
Totals for Projection 770 Avg $ 1,401,987
Aetna Life Insurance Company
Customer Number - 819919
Adjusted'
Claims
$ 141,969
130,729
76,728
115,986
108,741
113,635
87,268
158,117
100,489
117,463
104,610
144,812
94,023
107,181
149.662
$ 1,401,987
Annualized Claims Annualized Claims
PEPY PEPY
Claim Average latest: 12 months $ 1,821.95 $ 1,821.95
9 months $ 1,829.89 $ 1,829.89
6 months $ 1,843.14 $ 1,843.14
3 months $ 1,800.08 $ 1,800.08
There is no benefit adjustment affecting the claims for this experience period.
Derivation ojProjected Claims & PCTs
Recorded Claims & PCTs Jul -11 to Jul -12
Less Claim Wire Billed Fees/Charges
Net Recorded Claims & PCTs
Average Employees Jun -11 to Jun -12
Average Claims & PCTs Per Employee
Monthly Claims & PCTs (Before Trend)
Projected Employees at January 1, 2013
Projected Renewal Period
Projected Claims & PCTs (Before Trend)
Trend Period
Experience Period Jul l"II to Jul 1,12
Billing Period Jan 1,'13 to Jan 1,14
Projected Claina & PCTs
(A) Annual Trend Rate
(B) Number of Months Between Midpoints
(C) Projected Claims & PCTs Before Trend
(D) Trend Adjustments (((1 + A) ^ (B / 12)) x C) - C
(E) Expected Claims & PCTs (C + D)
(F) Expected Claims & PCTs Per EE
Recorded
PCTs
1,251
1,641
1,257
1,211
1,658
1,329
1,318
1,598
1,484
1,844
1,561
1,466
1,455
1,774
1A20
18,118
Annualized
PCTs PEPY
23.55
23.95
24.45
23.85
Page 23 of 42
Claims
PCTs
$
1,401,987
18,118
$
0
0
$
1,401,987
18,118
/
770
770
_ $
1,821.95
23.55
$
151.83
1.96
x
777
777
x
12
12
_ $
1,415,663
18,275
Midpoint>
Jan 1,'12
Midpoint>
Jul 1,'13
Claims
PCTs
11.25%
2.81%
18.0
18.0
1,415,663
18,275
245,491
776
$
1,661,154
19,051
2,137.91
24.52
Page 23 of 42
Experience Analysis
City of Round Rock
January 1, 2013 through December 31, 2013
Summary of Dental Experience
Aetna Life Insurance Company
Customer Number- 819919
Page 24 of 42
Recorded
Adjusted'
Recorded
Month Employees
Claims
Claims
PCTs
Apr -11 777
$ 29,249
$
29,249
199
May -11 776
29,715
29,715
211
Jun -11 778
28,913
28,913
189
Jul -11 772
29,176
29,176
195
Aug -11 776
31,237
31,237
212
Sep -11 789
33,173
33,173
231
Oct -11 801
25,602
25,602
221
Nov -11 788
26,496
26,496
199
Dec -11 798
25,785
25,785
205
Jan -12 800
43,051
43,051
307
Feb -12 809
44,495
44,495
296
Mar -12 806
49,092
49,092
296
Apr -12 804
38,280
38,280
228
May -12 798
41,633
41,633
232
Jun -12 798
42,892
42,8921
233
Totals for Projection 791 mg
$ 430,912
$
430,912
2,855
Annualized Claims
Annualized Claims
Annualized
PEPY
PEPY
PCTsPEPY
Claim Average Latest: 12 months
$ 544.48
$
544.48
3.61
9 months
$ 564.48
$
564.48
3.71
6 months
$ 647.93
$
647.93
3.98
3 months
$ 609.20
$
609.20
3.44
' There is no benefit adjustment affecting the claims for this
experience period.
Derivation of Projected Claims & PCTsIC
airts
PCTs
Recorded Claims & PCTs Jul -11 to Jul -12
$
430,912
2,855
Less Claim Wire Billed Fees/Charges
$
0
0
Net Recorded Claims & PCTs
$
430,912
2,855
Average Employees May -11 to May -12
/
791
791
Average Claims & PCTs Per Employee
= $
544.48
3.61
Monthly Claims & PCTs (Before Trend)
$
45.37
0.30
Projected Employees at January 1, 2013
x
798
798
Projected Renewal Period
x
12
12
Projected Claims & PCTs (Before Trend)
_ $
434,463
2,873
Trend Period
Experience Period Jul 1,'11 to
Jul 1,'12
Midpoint>
Jan 1,12
Billing Period Jan 1,'13 to
Jan 1,'14
Midpoint>
Jul 1,13
Projected Claims & PCTs
Claims
PATS
(A) Annual Trend Rate
7.00%
1.75%
(B) Number of Months Between Midpoints
18.0
18.0
(C) Projected Claims & PCTs Before Trend
434,463
2,873
(D) Trend Adjustments (((1 + A) ^ (B / 12)) x
C) - C
46,408
76
(E) Expected Claims & PCTs (C + D)
S
480,871
2,949
(F) Expected Claims & PCTs Per EE
602.60
3.69
Page 24 of 42
Experience Analysis
City of Round Rock
January 1, 2013 through December 31, 2013
Summary of Vision Experience
Aetna Lite Insurance Company
Customer Number - 819919
Page 25 of 42
Recorded
Adjusted"
Recorded
Month Employees
Claims
Claims
PCTs
Apr -11 772
$ 3,939
$
3,939
33
May -11 771
5,328
5,328
43
Jun -11 774
6,085
6,085
38
Jul -11 768
5,247
5,247
38
Aug -11 772
8,321
8,321
59
Sep -11 785
7,260
7,260
61
Oct -11 799
7,109
7,109
52
Nov -11 786
6,190
6,190
51
Dec -11 796
6,281
6,281
47
Jan -12 801
12,861
12,861
118
Feb -12 810
15,512
15,512
108
Mar -12 807
5,857
5,857
41
Apr -12 804
4,211
4,211
34
May -12 802
7,722
7,722
59
Jun -12 803
6,705,
6,7051
51
Totals for Projection 792 Mg
$ 93,276
$
93,276
719
Annualized Claims
Annualized Claims
Annualized
PEPY
PEPY
PCTsPEPY
Claim Average Latest: 12 months
$ 117.77
$
117.77
0.91
9 months
$ 120.91
$
120.91
0.94
6 months
$ 131.62
$
131.62
1.02
3 months
$ 92.69
$
92.69
0.72
" There is no benefit adjustment affecting the claims for this experience period.
Derivation of Projected Claims & PCTs
Claims
PCTs
Recorded Claims & PCTs Jul -11 to Jul -12
$
93,276
719
Less Claim Wire Billed Fees/Charges
-$
0
0
Net Recorded Claims & PCTs
$
93,276
719
Average Employees Jun -11 to Jun -12
/
792
792
Average Claims & PCTs Per Employee
= $
117.77
0.91
Monthly Claims & PCTs (Before Trend)
$
9.81
0.08
Projected Employees at January 1, 2013
x
803
803
Projected Renewal Period
x
12
12
Projected Claims & PCTs (Before Trend)
_ $
94,529
771
Trend Period
Experience Period Jul 1,'11 to
Jul 1,'12
Midpoint>
Jan 1,'12
Billing Period Jan 1,13 to
Jan l,'14
Midpoint>
Jul 1,'13
Projected Claims & PCTs
Claims
PCTs
(A) Annual Trend Rate
3.00%
0.75%
(B) Number of Months Between Midpoints
18.0
18.0
(C) Projected Claims & PCTs Before Trend
94,529
771
(D) Trend Adjustments (((1 + A) ^ (B / 12)) x
C) - C
4,286
9
(E) Expected Claims & PCTs (C + D)
S
98,815
780
(F) Expected Claims & PCTs Per EE
123.06
0.97
Page 25 of 42
The Aetna Difference
City of Round Rock Aetna Life Insurance Company
January 1, 2013 through December 31, 2013 Customer Number - 819919
Smarter is healthy
And with rising health care costs, smarter is necessary.
Aetna connects plan sponsors with programs, services, technology and tools that help
educate employees about their health and drive costs down. Smarter is giving your
employees the tools to make good health decisions. Your employees face many choices
about their health care and health care costs. They need help finding information,
understanding it, and then making decisions they can feel good about. Our online tools and
other resources help your employees get the most from their health plan. And, by the way,
we're always working on more ways we can help.
Payment estimator
Our member payment estimator tool lets your employees get an idea of what they'll pay
before they access health care. That way there are no surprises when the bill comes. Smart,
right?
Mobile App
In response to the growing popularity of smartphone technology, Aetna has created a free
mobile application (app) for the Whonea, Wod touch®, iPad®, BlackBerry Curve and
Android phones.
Our app includes advanced features, such as the following available for the Whone:
Find a Doctor, Dentist, Hospital, or Urgent Care Center
Our Aetna app provides on -the -go capabilities and lets employees and their families:
• Search for a doctor, dentist, hospital or urgent care facility based on current location
and get turn -by -turn directions with the Whone's built-in global positioning system
(GPS)
• Call the doctor's office with the tap of a finger
• View a map of the office location
• Transfer the doctor's contact information right to their address books
View Member ID Cards
View their member ID card information.
Members can also access our most popular mobile web features from the app, including:
Page 26 of 42
The Aetna Difference
• Claims View
Members can click on Claims View to quickly see the status of their five most
recent claims. With one more click, members can get a detailed view of each claim,
or search specifically for additional claims by member name or date.
• Personal Health Record (PHR)
Members with a PHR know how helpful it is for storing and organizing all of the
important information they need to manage their health. Now members can easily
view sections of their PHR — like Activities & Alerts, Emergency Information,
Medications, and Tests & Procedures — when they're on the go.
Check drug prices
Depending on the member's plan, this feature can be used to get an estimate of their
drug cost before filling a prescription. Members can view prescription costs from
both Aetna Rx Home Delivery and their local retail pharmacy based on their
coverage and benefit levels. They can even find money -saving alternatives listed
where available.
• Check coverage and benefits
Members can view their plan's deductible and coinsurance information, including
limits, amounts applied to date and balances. A member can also view flexible
spending account balances.
To use the Aetna mobile app, members must be registered for the secure member site and
have a username and password. If an Aetna member has not registered for access to the
secure member website, they can type "aetna.com" into their mobile Internet browser and
follow the directions to register.
MindBloom
We have teamed up with Mindbloom, Inc., a Seattle -based technology company
specializing in online social gaming. The relationship is driven by the desire to provide a
fun, simple and effective way for individuals to improve their overall health and well-being.
We will begin offering Mindbloom's Life Game- to select customers in the fall of 2011.
Mindbloom's Life Game inspires and engages people to grow the life they want by creating
a Life Tree where the branches represent areas of life that matter most to them. By defining
and completing small steps towards their goals on a regular basis, people grow a healthy
Mindbloom tree and earn virtual rewards that allow users to unlock additional features.
Mindbloom's Life Game focuses on:
• Achievement and reward: a simple, intuitive daily action tracker
• Motivation: an inspiration system providing rich, multimedia, and inspirational
entertainment
• Healthy competition: a seamless interface with other social network that allows
users to post their Mindbloom success stories on Facebook/Twitter
Page 27 of 42
The Aetna Difference
Fun and engagement around content: customizable messaging and content
management systems for enterprise clients.
Community support and self-expression: a buddy support system that includes
journaling and messaging capabilities.
Our relationship includes working with the Mindbloom team to collaborate on the creation
of Version II of the Life Game and a greater mobile presence. Some enhancements include:
• Bloom — a Mindbloom inspirational reminder app
• Enhancement of overall usability and performance
• Additional social game rewards
• An optimized first day experience
iTriage
In 2011, we acquired Healthagen, the developer of iTriage®. Recently named one of "10
Apps That Could Save your Life" in Parade magazine, iTriage is a free mobile health care
application for iOS® and Android devices.
It offers a symptom checker to help people answer the two most common medical
questions: "What condition could I have?" and "Where should I go for treatment?"
The app provides consumers with comprehensive health care information on the go and
helps them determine what type of health care provider and treatment they need. Through
the "Symptom -to -Provider" pathway, users can:
Look up symptoms and find possible causes
Based on the causes, guide the consumer to the most appropriate treatment path
Locate the closest appropriate health care by location
In addition to the "Symptom -to -Provider" pathway, the iTriage application provides
consumers:
• A nationwide directory of hospital ERs, physicians, urgent care centers and retail
clinics
• Turn -by -turn directions to all provider facilities using either GPS, IP address or any
specified location
• Information on nurse advice lines
• Hospital emergency room wait times and a pre -registration feature in select parts of
the country
Page 28 of 42
The Aetna Difference
Nearly 5 million consumers around the globe have downloaded iTriage on their mobile
devices and thousands of health care providers use the app to deliver facility and service
information to their patients.
Smarter is providing your employees with access to the right health care, the right
way, at the right time.
Personalized care management programs can mean lower costs — for you and your
employees.
Aetna's care management services focus on each person as an individual
There's no set action plan that we give based on a certain medical condition. We find out
each person's wants and needs and coordinate with their physician, so each solution is
different.
Motivational interviewing to encourage lig behavior change
Your employees need someone who can listen, understand their motivations and their
personal preferences. Our nurses and other clinical staff can do that because we have real
conversations and don't rely on scripting. We work to find out what motivates your
employees and help them discover answers on their own. That's what drives lasting
behavior change.
Data and technology combine help employees get quality, access to affordable health care
and save costs
Our technologies use evidence -based medical guidelines to help your employees and their
doctors make thoughtful decisions about their health care, maximizing savings for both of
you.
In the Included Programs and Services document, we have outlined the products and
services included in your current benefit pricing. The following provides a description of
additional offerings from Aetna's entire portfolio which are designed to complement your
current benefits.
At Aetna, we are committed to making high quality health care more affordable for your
employees and their families. We are constantly reviewing our current offerings and coming
up with innovative ideas to provide your employees with the most for their health care
dollars. We believe in empowering our members to make informed health care decisions
through the use of information. Our Aetna Navigator® website assists members by providing
online access to personal health and benefit information. Registered members can view their
claim explanation of benefits to quickly and securely communicate with Aetna. In addition,
this site contains interactive tools including Aetna InteliHealth®, Healthwise®
Knowledgebase, Estimate the Cost of Care, Find Health Care in DocFind®, Rate Your
Medical Professional, Price-A-DrugsM and the Hospital Comparison Tool. These tools allow
members to find credible and easy to understand information about the treatment and
management of common diseases and conditions, research the cost of care, find health care
professionals in their area, provide feedback about their doctors, estimate drug costs and
Page 29 of 42
The Aetna Difference
compare hospitals to determine
which is right for their particular needs.
To further assist you in reaching this goal, we are providing this brief overview of additional
products and services Aetna has to offer. For more information and current pricing, please
contact your Account Executive, Kendra Hoduski.
Products and Services to complement your current benefits:
• Aetna OnesM
The Aetna One suite of integrated health and productivity solutions offers an innovative
approach that seamlessly integrates medical, disability and other benefits into one
coordinated, streamlined system that helps increase your employees' health, engagement
and productivity - and helps lower your benefit trend over time.
Core - Aetna One Core/IHD is automatically included at no additional cost when you
have both an Aetna medical benefits/insurance plan and an Aetna disability insurance
plan/policy. Aetna One Core is a case management process that helps employees on
disability get back to health and work sooner. It gives disability case managers access
to member -specific Aetna medical claims information to help identify the best
opportunities for care.
Enhanced - Aetna One Enhanced/IHS is a program that builds on Aetna One Core. It
integrates health services and data across multiple benefits and wellness programs to
help improve employee productivity and reduce health care and disability costs. It
provides a complete picture of the true drivers of direct and indirect health care costs,
including presenteeism, absenteeism, and workforce productivity.
Premier - Aetna One Premier expands on both Aetna One Core and Aetna One
Enhanced by adding additional program components, as well as enhanced
technologies and more closely integrated clinical and customer service models. From
medical and disability to behavioral health and pharmacy Aetna One brings together
all the benefits your employees need - and makes them available through one single
source, the health concierge, who can see the complete picture of a member's health
at all times. A health advocate is also on hand to guide employees through the wide
expanse of clinical resources and to make sure critical connections are made to help
employees achieve better health.
Online Disease Management
We offer online disease management as a personalized and convenient way to help members
manage their chronic conditions. Members can take advantage of all six online programs
including:
CareTM for Your Health - Chronic condition management
AchieveTM - Cholesterol control
• CareTM for Diabetes - Diabetes management
Page 30 of 42
The Aetna Difference
ControlTM - Blood pressure control
CareTM for Pain - Pain management
CareTM for Your Back - Lower back pain treatment
In addition, members can access our online wellness programs at no additional cost:
• Relax — Focuses on stress management
• Balance — Focuses on weight management
• Nourish — Focuses on nutrition
• Breathe — Focuses on smoking cessation
• Depression — Focuses on overcoming depression
• Insomnia — Focuses on overcoming insomnia
Members receive "personalized messaging" e-mails (if the program is offered with a health
assessment), tailored program plans (based on the completion of the online disease
management program assessment), program specific tools and resources, and evaluations to
gauge the programs impact.
• Aetna Health Connections - Get Active!
Aetna Health Connections Get Active! is a great way for plan sponsors to help employees
of all health and fitness levels get and stay motivated to improve their fitness and well-
being. It features an online fitness and nutrition tracker, team -based challenges, social
networking, emails, newsletters, activity tracking, full reporting capabilities, and the
option to purchase a welcome kit that includes a pedometer and reminder wristband.
• Radiology Benefit Management
High-tech radiology represents an area of significant medical cost. While the clinical
benefits of these services are valuable, this is also an area that is seeing cost trends in
excess of 20 percent a year. This is a major driver of overall medical cost increases,
outpacing prescription drug cost trends, and is far above overall general inflation trends.
We believe there are ways to better manage this expense in a way that offers access to
these valuable services, but improves the cost management of this rapidly increasing cost
category.
Our Radiology Benefit Management program focuses exclusively on high-tech radiology,
including MRI / MRA, CT scans, coronary CTA scans, PET scans and nuclear imaging.
We have contracted with three vendors, known as radiology management service
organizations, to assist in managing the program. In addition to assessing the
appropriateness of the recommended test, these vendors look to ensure members are
using network facilities. While we encourage the adoption of our Radiology Benefit
Management program, it is optional for self-funded plans.
Page 31 of 42
The Aetna Difference
• Healthy Lifestyle Coaching
Aetna Healthy Lifestyle Coaching (HLC) is a high -touch, relationship -based program
designed to help members reach their personal health and wellness goals. HLC is
designed to target risk factors that employees and their families can change before
disease develops or complications arise. Reducing the incidence of chronic conditions
promotes employee wellbeing, increases workplace productivity and reduces overall
medical costs over time.
According to a 2011 Aetna Informatics study, among members participating in HLC
(weight management focus), 54 percent reported weight loss, 55 percent exercised more,
and 51 percent reported a lower stress level.
HLC support success on every level through:
• Proactive outreach
• One-on-one telephonic coaching sessions
• Unlimited inbound calls
• Educational materials
• Web -based interactive tools
• Program -based rewards
HLC offers a powerful, personalized approach based on the member's goals. We include
comprehensive lifestyle modification programs that address the interrelationship
between lifestyle choices and common risk factors for chronic disease. Coaches use
techniques such as Prochaska to assess readiness to change, along with co -active
coaching and motivational interviewing to help encourage members to achieve their
goals.
• Aetna Personal Health Record
Our Personal Health Record (PHR) offers members a consolidated resource to access
detailed and comprehensive health records, and sends them targeted alerts and messages
to help improve their health.
According to a 2011 Aetna Informatics study, 30 percent of our members utilize their
PHR, 10 times the industry average. Additionally, PHR users generate 33 percent more
alerts, and resolve 68 percent more care gaps.
We use our CareEngine technology to identify member care gaps and populate the PHR.
The online record also combines detailed, claims -driven information gathered from
across the health care spectrum — such as physician offices, labs, diagnostic treatment and
pharmacies — with user -entered information such as family history or allergies.
Page 32 of 42
The Aetna Difference
Additionally, the PHR supports incentives as part of a larger wellness strategy. Activity
related to tracking bio -metric indicators such as weight, exercise, blood pressure, and
review of PHR contents by member can be used for member rewards and other customer
reporting.
• Performance Networks
AexceM is an enhanced network option and is based on the designation of specialists.
By leveraging our health information resources to identify specialists from our broader
networks, we have developed a network option that aims to provide access to cost-
effective care based on a balance of clinical performance and cost efficiency measures.
In selected markets, our Performance Network features a subset of our current network
of specialists focused on physicians within 12 medical specialty categories. Savings will
vary based on location, plan design, utilization and disease prevalence. For a savings
analysis, please contact your Aetna Account Executive.
• Employee Assistance Program
At Aetna, we believe in an integrated total health focus where an Employee Assistance
Program (EAP) and other benefits are part of a continuum of care. Together they help
you improve productivity, increase employee satisfaction and better manage health costs.
We also believe that an EAP can serve as the early point of intervention for many
problems and issues. For an EAP to be most effective, employees should use the
program to help manage work and life issues before they become unmanageable. That's
why Aetna has taken the traditional EAP one step further and put an emphasis on
motivating employees to use this important benefit.
• COBRA & Retiree Direct Administration
Individual Billing Administration is an employer's alternative to billing COBRA and
other off -payroll employees themselves. We offer the easiest, most efficient way to bill
group insurance premiums to COBRA continues, retirees, surviving spouses and
employees on leave or medical continuation — essentially any off -payroll employee who
receive benefits from the employer's group insurance plan.
With IBA, we can bill both Aetna coverages, as well as premiums from other carriers
(e.g. Blue Cross).
• Dependent Eligibility Verification
Dependent Eligibility Verification (DEV) validates all dependents enrolled in a health
care benefits plan. Over time, an employee may forget to remove a dependent that
becomes ineligible after a divorce or at the end of a domestic partner relationship or after
a child is offered access to their own employer's benefit plan. DEV gives an employee
the opportunity to update changes in status that have ended the dependent's eligibility
Page 33 of 42
The Aetna Difference
under the terms of your plan, and allows you to lower costs by removing ineligible
dependents from your benefits plan.
DEV can help you control your health care costs by managing eligibility more
effectively. DEV audits typically find that up to 4 percent to 8 percent of dependents
currently enrolled are not eligible for benefits coverage, according to the guidelines
established by the plan sponsor.* By ensuring that your plan is covering dependents as
intended, you may be able to lower your health care costs, without impacting valuable
benefits offerings for your eligible plan members.
Aetna offers DEV services through ACS, a subcontractor of Aetna.
• Care Advocate Team (CAT)
The Care Advocate Team model is comprised of a group of dedicated nurses and
supervisors, designated medical director, and support staff who provide precertification,
concurrent review, case management and standardized and customized outreach to a plan
sponsors membership. This includes clinical support to members with acute and chronic
medical conditions, and those in need of support while exploring treatment options and
working through the recovery process. In addition, the dedicated unit has its own option
off the 1-800 number allowing direct access to the CAT team for providers and
members. The goal and focus of the Care Advocate model is to provide the highest plan
sponsor/member experience while working with the membership and plan sponsor to
improve the health and outcomes of the members.
Aetna Concierge Program Overview
The Aetna Concierge will simplify and personalize the member experience through high -
touch, consultative service. Aetna Concierge team members will serve as advocates who
support Aetna members in navigating the health care system through the use of Aetna tools,
resources, and benefit programs to improve satisfaction and increase engagement.
In Touch Care
Our Aetna In Touch CaresM model is a new and innovative approach to managing members
through better prediction, personalization, and participation. It is based on a nurse model that
designates a true single -point of contact offering a 360 degree view of each member's needs.
This approach provides an alternative to traditional case management and/or disease
management. Nurses develop trusting and meaningful relationships to better support
members as they manage their health issues.
The model also features the following key elements:
• Holistic Approach — Sees the whole person and passionately supports their efforts to
achieve optimal health
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The Aetna Difference
• Integrated Medical Services — Evaluates more data points about each individual to
determine an appropriate level of support
• Multi -Modal Support — Engages members through our virtual support channels who
have less urgent care and to supplement the one-on-one support.
The model also leverages an enhanced clinical algorithm that effectively identifies and
engages members earlier while capturing preferences around programs and services
Additional Products and Services
Dental
Aetna Dental offers a broad product spectrum to meet employers' varied needs, including:
Dental Maintenance Organization (DMO®) — With the Aetna Dental Maintenance
Organization (DMO) plan, members are covered for a broad range of covered services
with no deductibles or annual maximums to meet (Copays may apply). To take advantage
of covered benefits, members must select a participating primary care dentist. Each
family member can select a different participating primary care dentist who is the key to
the member's dental care. The primary care dentist provides and coordinates the
member's care, referring members to participating dental specialists as appropriate under
the terms of the plan.
The DMO can be offered as either a coinsurance or fixed dollar co -payment plan.
Voluntary (employee -pay -all) plans are also available. The DMO can also be packaged in
a variety of ways:
➢ Dual Option — packages our DMO plan with one of our Indemnity or PPO plan
options. Members choose between the plans at annual enrollment.
➢ Dual Choice — packages our DMO plan with another company's dental plan.
Members choose between the plans at annual enrollment.
➢ Freedom -of -Choice — packages our DMO plan with one of our Indemnity or
PPO plan options. Members may switch between the plans as often as monthly.
Employers pay one blended rate.
Aetna Dental® PPO II — Aetna Dental is pleased to offer over 12,000* available dental
PPO practice locations, doubling the size of the program. This vendor based network is
called Aetna Dental PPO II. In combination with our standard dental PPO network, there
are over 130,000* available dental practice locations. With the inclusion of Aetna Dental
PPO II, you and your employees may save on dental costs through access to more
dentists providing services at contracted rates! Program highlights are:
➢ No cost to you — there is no impact to your self funded per -employee -per -
month (PEPM) administration fee
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The Aetna Difference
➢ Claim Savings — You retain 60% of the negotiated Aetna Dental PPO II
savings (Aetna will retain 40% of the negotiated Aetna Dental PPO II
savings)
➢ More participating dental locations for your employees
➢ Lower out-of-pocket costs to your employees
Aetna DentalFund® — Like Aetna HealthFund®, Aetna DentalFund offers the
comprehensive coverage of a traditional dental plan, plus a unique dental fund benefit,
which allows members to choose any licensed dentist to provide covered dental services.
At the employer's discretion, this plan also provides first -dollar coverage for preventive
services, such as routine oral exams and cleanings, not subject to the annual deductible
or deducted from the dental fund. Any unused dollars in the fund can be carried over to
provide additional plan coverage the following year. The plan offers a wide variety of
deductible and coinsurance options to provide additional flexibility in dental benefits to
employers.
Indemnity — Members can choose any licensed dentist for services and pay deductibles
and coinsurance up to an annual maximum. Members can be balanced bill and may be
required to file claims.
Vital Savings by Aetna® - A program that provides access to discounts for dental
services from participating dental providers, as well as access to discounted fees for
vision services and supplies through the Aetna Vision sM discount program. These dental
discounts are the same as Aetna's Dental PPO discounts (average 30% nationally). This
program is NOT an insurance plan. Participants simply present their Vital Savings ID
card when they visit a participating dental office. Participants are responsible for payment
of 100 percent of the fee directly to the dentist at the time services are rendered. There are
no claims with this program.
• Vital Savings provides access to a network of 64,700+ dental office locations
nationwide and it targets the 40 percent of Americans who currently lack dental
insurance.
• The Vital Savings Program is currently available to plan sponsors with 51+
employees who perform traditional benefit administration functions such as
collection of enrollments, payroll deduction of fees and remittance of fees via
Service Fee Billing.
• There are two main options available for Vital Savings - a group billing option and
an individual billing option.
• In addition, Vital Savings fees are eligible for pre-tax payroll deductions for
employees/retirees under age 65.
Page 36 of 42
The Aetna Difference
Medicare Related Plans
Medicare Advantage Plans
Aetna Medicare Advantage plans provide more comprehensive coverage than Original
Medicare, routine services not covered by Medicare, and maximum out-of-pocket limits on
member cost sharing. Each Aetna Medicare Advantage plan also includes best in class
medical management programs.
Aetna Medicare sM Plan (HMO
Aetna Medicare HMO plans offer a network of doctors, medical specialists, and hospitals
for members to choose from. Plan features include low monthly premiums, no deductibles,
and virtually no paperwork. Members must select a primary care doctor to coordinate care.
Covered services must be provided by doctors and hospitals within the network except with
emergency, urgent care, out -of -area kidney dialysis and some direct access care.
Aetna Medicare sM Plan (PPO)
Aetna Medicare PPO plans provide all the benefits of HMOs, but also allow the member to
visit doctors or hospitals that are in or out of Aetna Medicare network. Members may seek
care from any provider that is licensed, eligible to receive Medicare payment and willing to
accept the plan. Generally, members will pay higher cost sharing when accessing care
from non -network providers. No referrals or pre -certification is required.
Aetna Medicare SM Plan (PPO) with Extended Service Area*
The Aetna Medical PPO -with Extended Service Areas (ESA) is a Medicare Advantage
(MA) PPO plan design in which the in -network and out -of -network benefits and cost
sharing are identical. A CMS group waiver allows Aetna to enroll retirees who do not
reside within the Aetna Medicare PPO network service area into a MA PPO plan when the
majority of the plan sponsor's retirees (more than 50%) reside within the Aetna Medicare
PPO network service area. Aetna has several standard MA PPO Plans and MA PPO with
ESA plans available within the Medicare Advantage Group Portfolio for plan sponsors who
meet the requirements of the CMS waiver eligibility.
CMS Enrollment Waiver for Medicare Advantage Employer Group Plans
CMS allows Medicare Advantage Organizations (MAO) offering group Medicare
Advantage PPO plans to apply for a waiver to the standard group eligibility guidelines.
This waiver permits Medicare Advantage PPO plans to enroll retirees who do not reside
within a service area where the MA PPO network meets CMS requirements, so long as the
Page 37 of 42
The Aetna Difference
majority of the employer's retirees (50.1%) reside within a service area where the MA PPO
plan's network meets CMS requirement ("MA PPO network service area). In this situation
MAOs must provide group members residing outside of the MA PPO network service area
the same in -network cost sharing as those who reside within the MA PPO network service
area. This enables the MAO to offer consistent benefits to all of the employer's retirees
enrolled in the MA PPO plan, regardless of where the retirees may reside. Any plan
offering this waiver must ensure that the group members who do not have access to
network providers receive the in -network level of cost sharing. The MAO is also required
to facilitate access to care by conducting provider education efforts, encouraging providers
to participate in medical management programs and assisting members with locating
providers.
Medicare Advantage Prescription Drue (MA -PD) Plans
By integrating our Medicare Advantage plans with our Medicare prescription drug coverage
(known as an "MA -PD plan"), we offer a complete health coverage solution. With an MA -
PD plan, we have access to both medical and pharmacy claim data, which allows us to
better evaluate each member's health situation and enhance the coordinated medical
management programs provided to our members. MA -PD integration can also simplify
enrollment, billing, administration, and communications, since the medical and pharmacy
benefits are all coordinated by one source.
Standalone Aetna Medicare Rx SM Plans (PDP)
Aetna offers both basic and enhanced Medicare Part D prescription drug plans in all 50
states and the District of Columbia as part of our standard group plan portfolio. These PDPs
include an array of plan designs with different levels of coverage and premium. There are
currently more than 60,000 participating pharmacies in the Aetna Medicare Pharmacy
Network nationwide, including Aetna RX Home Delivery, our convenient mail-order
pharmacy.
Limited Benefits - Strategic Resource Company (SRC)
Aetna offers an innovative solution for unbenefitted employees (i.e. Part-time, waiting
period, seasonal, temporary, per diem, etc.) Through SRC, we can offer quality, affordable
coverage to this important segment of the workforce, which provides significant value to
these individuals and plan sponsors as well. Specifically' our experience shows that offering
these benefits reduces turnover in this population and therefore, positively impacts
acquisition, hiring and training costs.
Leader in Consumer Directed Healthcare
With the launch of the Aetna HealthFund® Health Reimbursement Arrangement (HRA) in
September 2001, Aetna became the first national, full-service health insurer to offer one-
stop shopping for a consumer -directed plan without reliance on additional third -party
vendors.
Page 38 of 42
The Aetna Difference
The Aetna Healthfund family of products has expanded to include a wide variety of fund
and account options to meet the unique needs of employers of all sizes. These choices
include the Aetna HealthFund Health Savings Account (HSA), Aetna HealthFund Retiree
Reimbursement Account (RRA), and Aetna HealthFund Flexible Spending Account (FSA).
Aetna Healthfund leverages our unique resources, including one of the largest networks of
physicians, dentists, hospitals, pharmacies and health professionals; our extensive
experience in claims payment and administration of innovative health benefits; and our
powerful online resources and self-service tools, which we continue to enhance to support
the Aetna HealthFund family of products.
Provider Price Transparency Model
In an industry-leading initiative, we now provide our members with the ability to know a
doctor's actual rates before they go for a visit. For the first time ever, consumers can better
gauge their out-of-pocket health care expenses by having online access to the actual
discounted rates for up to 25 of the most common office -based services offered by their own
primary care or specialist physician. Due to the success of the pilot, the program has been
expanded to several additional major metropolitan areas. Members can access price
transparency information through Aetna Navigator.
Retiree Drug Subsidy Support Services
If a plan sponsor's existing retiree drug plan qualifies under CMS regulations, the plan
sponsor can apply to receive the 28 percent Retiree Drug Subsidy (RDS) from CMS.
Aetna's dedicated RDS team can help to provide support for the enrollment, claim and
rebate reporting requirements.
Consumer -Directed Health Care
With the launch of the Aetna HealthFund® Health Reimbursement Arrangement (HRA) in
September 2001, Aetna became the first national, full-service health insurer to offer one-
stop shopping for a consumer -directed plan without reliance on additional third -party
vendors.
The Aetna HealthFund family of products has expanded to include a wide variety of fund
and account options to meet the unique needs of employers of all sizes. These choices
include the Aetna HealthFund Health Savings Account (HSA), Aetna HealthFund Retiree
Reimbursement Account (RRA), and Aetna HealthFund Flexible Spending Account (FSA).
Aetna HealthFund leverages our unique resources, including one of the largest networks of
physicians, dentists, hospitals, pharmacies and health professionals; our extensive
experience in claims payment and administration of innovative health benefits; and our
powerful online resources and self-service tools, which we continue to enhance to support
the Aetna HealthFund family of products.
Page 39 of 42
The Aetna Difference
Customized Communications Group
Aetna Customized Communications Group (CCG) is available to partner with customers to
develop and deliver customized materials. CCG, our strategic communications consulting
group, has more than 25 years of experience in customized benefit communications and
offers a broad range of products and services to meet customer needs.
CCG works directly with customers to create and deliver targeted, integrated and
compelling communication programs that educate, engage and motivate employees to take
action. CCG's customized approach supports the customer's specific objectives and reflects
their unique employee population, culture and brand. Communication programs developed
by CCG help employees understand their health care options, make informed decisions and
get the most value from their benefit plan.
Offering a unique combination of benefits knowledge and communication expertise, CCG
develops open enrollment campaigns, launches and sustains wellness initiatives, promotes
and administers incentive strategies, and educates employees about appropriate utilization
of the programs and services that encompass their overall benefits program. CCG will
prepare detailed proposals outlining recommendations, specifications and associated costs.
All materials are developed according to a customer's plan design, style, tone, philosophy
and employee audience.
Backed by an experienced staff of project managers, writers, graphic designers, print
production managers, web developers and distribution center specialists, CCG has the
expertise and technical resources to produce a broad range of materials and manage benefit
communications of any size and level of complexity from start to finish, including collation
and mailing through CCG's in-house distribution center.
CCG has been awarded many communications awards including The Communicator's
prestigious Award of Excellence in the category of employee publication/benefits. The
Award of Excellence is presented to those entrants whose ability to communicate elevates
them above the best in the field.
CCG services include:
• Strategic communications consulting
• Project planning and management
• Theme development, creative writing and graphic design
• Website development and multi -media presentations
• Print production management
• Collation, bulk shipping and mass mailings
• Customized fulfillment and distribution
• Ongoing administration of incentive programs and campaigns
CCG designs and develops:
Page 40 of 42
The Aetna Difference
• Enrollment brochures, kits and campaigns
• New hire, welcome and retiree kits
• Health and wellness communications
• Personalized employee benefit communications
• Special benefit announcements and newsletters
• Video and audio benefit presentations and employee meeting scripts
• Customized benefit websites
• Customized plan comparison charts
• Summary plan descriptions (SPDs)
• Postcards and flyer announcements
CCG can combine benefit information from multiple sources including Aetna, the customer,
another carrier or vendor. A sampling of the CCG portfolio of projects can be found at
www.aetnaccg.com. There is an additional charge for CCG services. CCG will develop
proposals and price estimates for recommended solutions for each customer's unique
communication needs.
Comprehensive Group Insurance Portfolio
Aetna offers a broad portfolio of group insurance products and services that are affordable,
easy -to -administer, and available on a stand-alone basis or bundled with your Aetna health
plan. We will help you choose the right plan at the right price, and provide you with the
value-added services and consultative account management expertise to bring it all together.
■ Group Life Insurance - We offer employer -paid basic and employee -paid voluntary life
insurance plans with no -cost features that expand protection and enhance value. Most Aetna
Group Life Insurance plans provide a guaranteed issue benefit and AD&D coverage, family
protection features, the waiving of premiums during total disability, a living benefit option,
and more.
■ Group Disability Insurance - We offer short- and long-term disability plans available
on a combined or stand-alone basis, as well as voluntary group employee -paid and buy -up
plans. Aetna offers a wide variety of funding options — from insured and administrative
services contracts, to advice -only and benefit -determination -only plans.
Page 41 of 42
The Aetna Difference
Voluntary Products Marketplace
Our new Aetna Benefits Advisor (ABA) Marketplace provides a broad selection
of employee -paid voluntary insurance plans and allows your employees the
flexibility to purchase plans that best fit their unique lifestyle and budget. ABA
Marketplace and Voluntary benefits will offer the following advantages to you
and your employees:
• Improved employee morale/satisfaction
• Simplified administration for the employer
• Single consolidated bill to customer for all products
• Customize plan selection support for employees
• An interactive online benefits advisor
• No added direct cost to the company
• Ability to attract and retain employees
• Group rate discounts for employees
• A wider array of benefits for employees
• A strong worksite marketing strategy aimed at educating and engaging your
employees
Marketplace includes:
• Aetna Benefits Advisor
• Aetna Voluntary Hospital Plan
• Life Insurance
• Short Term Disability Insurance
• Long Term Disability Insurance
• Dental PPO Plans
• Vision Plans
• Pet Insurance
• Dental Discount Program
Page 42 of 42
Aetna Resources For Living
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Table of Contents
Page
Why Aetna Resources For Living? ...................................................... 2
EmployeeAssistance Program.......................................................... 5
Organizational Development............................................................ 7
WorklifeBalance............................................................................... 8
WebResources.................................................................................11
Pricing.............................................................................................. 13
Note: This proposal and the information contained are proprietary, and as such, the property o/Aetna. Any use of this information outside of
the specific intent of this sales proposal is prohibited.
aetna-
Why Aetna Resources For Living?
Building on over thirty years of experience in EAP, Aetna Behavioral Health presents Aetna
Resources For Living (Aetna RFL), a suite of lifestyle engagement solutions for workplace and
life needs. Built on the foundational strengths of an EAP model, Aetna Resources For Living
combines behavioral expertise with an outcomes -based approach to problem solving.
At Aetna Resources For Living, we understand how to help individuals make lasting changes in
their lives. Our proprietary assessment and technology tools guide our EAP specialists in
determining the best way for us to help each individual member. Our depth of expertise gives
us the ability to provide the right help at the right time, whether a single resource request or
on-going clinical coaching.
What Makes Aetna Resources For Living Different: Our Approach & Thought Leadership
As a leader in behavioral health, EAP and thought leadership in the field, we are well-positioned
to respond to the new landscape facing companies and individuals. We combine EAP and
behavior change expertise to impact a defined group of at risk employees, improve overall well-
being and your bottom line. We:
• Provide programs customized to our customers' needs, work culture and employee
population
• Maximize engagement through proactive outreach, one-on-one coaching with an EAP
health expert and a motivating approach
• Enlist specialty support and resources as needed to support lasting lifestyle changes
• Systematically gauge participant engagement and level of change within each session
• Serve as integrator and connector for medical, behavioral, wellness and prevention benefits
—regardless of platform
Our focus has changed from mental health, clinically -based, reactive service to:
• General problem resolution and life resiliency
• Advocacy and proactive benefit integration and coaching
• Targeted, proactive engagement capabilities that address everyday well-being
K
Member Experience: Member Driven, Outcomes Informed
Aetna Resources For Living is committed to truly engaging
people in overall well-being. The member experience will be
member driven and outcomes informed. What this means is
that we will meet every caller where they are and provide the
most appropriate service for their individual need.
Our multidisciplinary team of well-being coaches are trained in
motivational techniques and are uniquely qualified to support
needed lifestyle modifications. We deliver behavioral science interventions necessary for
improved member health engagement and more meaningful and sustained health behavior
change. Moreover, current research supports behavioral approaches to well-being. Research
into neuroscience of change has demonstrated the dynamic nature of the brain and its
capability to accommodate the active shaping of emotion, feeling and thinking —all needed to
successfully address the psychosocial determinants of health and improve well-being
outcomes'.
Aetna Resources For Living's SIGNAL System statistically identifies when an intervention
provided is not required or is not working by flagging the level of member distress and how well
the member is engaged in the coaching process. SIGNAL provides our EAP clinical staff with
ongoing and real-time indicators specific to the intensity and pace of intervention that is
needed. This system offers a state-of-the-art platform for focus and accuracy in addressing
emotion, thinking and feeling in order to deliver highly effective behavioral change
interventions.
Finally, Aetna Resources For Living is highly focused on automated engagement strategies that
leverage new technology, such as self-directed online well-being modules and smart technology
for engaging self-service benefits information. We are also developing a strategy regarding
mobile technology, including texting, mobile web and app development for the areas most
highly used by our membership.
What Is Driving Our Strategy?
Several factors are influencing the behavioral health and EAP industry, including:
Current trends and research, such as the increasing cost of healthcare; behavioral factors at
the root of 50 percent of all medical issues; the prevalence of stress and financial concerns;
and the mental health focus and low utilization of traditional EAP models
1 Example references: Gordon E. Barnett KJ, Cooper NJ, Tran N Williams LM (2008). An "Integrative Neuroscience"
platform. Application to profiles of negativity and positivity bias. Journal of Integrative Neuroscience, 7, 345-366.
Other references at httos://www.mvbrainsolutions.com/Pages/BrainResourceScience.aspx
• Business needs of organizations to retain and recruit great talent; respond to demographic
needs; and withstand business changes and reorganization
• Legislation such as Mental Health Parity and Healthcare Reform, highlighting the
importance of quality of care and integration
• Continuing developments in technology, and in our industry specifically to drive, measure,
and track change
Future Vision
At Aetna Resources For Living, we believe that all behaviors can be improved and that
proactive, targeted engagement of individuals is the key to individual and organizational well-
being. We apply evidenced -based strategies to help individuals make immediate and long-term
changes in their lives. By positioning our EAP specialists at the gateway for all lifestyle
management programs, we integrate our behavioral expertise with an outcomes -based
approach to problem solving — resulting in healthier people and a real return on investment to
our client companies.
Aetna Resources For Living is committed to providing real solutions to its members. To achieve
maximum effectiveness, we believe our interventions must be "member driven" to result in
real impact.
This member -driven approach dictates that the caller comes first. Our clinicians thoroughly
assess the needs of every supervisor, member or eligible household member who contacts us.
Since most calls involve several issues, the specialist assumes a central role in directing the
member to the array of solutions we provide. Member driven also means offering access
through the channel that best suits and is most convenient for the member: online,
telephonically or in person.
And last but not least, member driven means the provision of services to meet the needs of the
organization, bringing initiatives such as Return to Work, absence management and case
management programs to bear in meeting those needs.
H
Employee Assistance Program
Aetna Resources For Living has taken traditional EAP services to a new level combining best
practices, clinical excellence and exceptional client care and support. Our EAP services offer a
full continuum: from the traditional assess -and -refer model to an integrated telephonic
coaching model with reportable outcomes. Select the model which best fits your workforce —
or provide a hybrid model combining both. This gives your people a choice of delivery channels
and allows you to manage your costs and outcomes most effectively.
We offer goal -focused counseling designed to address the presenting issue, whether the issue
pertains to behavioral or physical health, substance abuse, legal or financial matters or a
work/life challenge — or a combination of several challenges. The type of service and its
duration depends upon several factors, including but not limited to: type of presenting
problem, severity and length of symptoms, risk of harm and other complicating factors.
Aetna Resources For Living has found that 80 percent of all issues can be resolved within the
EAP, with the remaining 20 percent being referred out to the health plan or community
resources. The flexibility of our short-term counseling model ensures all members and eligible
household members will receive appropriate counseling, avoiding the unnecessary use of
health insurance benefits, thus saving both the member and the organization time and money.
Our proprietary SIGNAL system reports that at Aetna Resources For Living, 80 percent of
members with multiple sessions report improvements in their emotional well-being.
On-going Counseling with an EAP Provider
From the first call, a member is connected to the resources needed for their individual need.
Our members can engage immediately in confidential telephone consultation and referral for
emotional, family, personal, work or any issues limiting the member's personal and professional
effectiveness. Members can call for 'in the moment' telephonic support and consultation or
the Aetna Resources For Living specialist can refer the member to a face-to-face provider from
its national network when appropriate or desired by the member.
Telephonic Consultation and Referral
For support with immediate needs or to access a coach for individualized help from the comfort
of their own homes, telephonic counseling is provided. The need to miss work is eliminated, as
are fears concerning privacy or embarrassment. Supported by the SIGNAL System`, we can also
report back to the member and plan sponsor that what we are doing is working.
Our assessment and referral model includes an assessment, a consultation to address
immediate needs and referral to appropriate services.
We have licensed Master's -level clinicians available 24 hours per day, 365 days a year. If a
member requests a clinical consultation, or it is determined that there is risk, we refer the
member to a clinician who provides immediate support, additional assessment and any needed
referrals. If a risk is identified, we take steps to ensure that the member is safe and provide
appropriate follow-up and referrals.
The initial assessment includes basic demographics, assessment of presenting request/issue,
assessment of imminent risk, and referrals. If we identify the need for further intervention,
requiring face-to-face counseling service, the clinician will arrange referrals to an affiliate EAP
network provider.
Face -To -Face Counseling
For those situations when face-to-face counseling is appropriate, Aetna Resources For Living
provides customers access to one of the largest EAP/mental health databases for professional
face-to-face counseling. All network providers are licensed and credentialed at the highest
industry standards and are monitored regularly to maintain that credentialing. After an initial
assessment, the EAP specialist determines whether the issue can be resolved within the scope
of EAP services or if a behavioral health benefit referral is clinically indicated. Should face-to-
face services be deemed appropriate, a local provider is identified to meet the specific need
and any other specifications, such as location, gender or language.
Our EAP network includes providers with specific expertise in home and work-related issues.
We offer the member a choice of several providers. If requested, the EAP clinician will schedule
the appointment on behalf of the member.
If inpatient treatment is indicated, the EAP specialist assists with placement, in direct
coordination with the medical or behavioral health carrier, to ensure the appropriate
authorization of care. If a member exhibits signs of acute mental illness or poses a risk to self or
others, the specialist provides the services necessary via immediate assistance and a referral to
behavioral health benefits.
6
Training
Aetna Resources For Living can provide a wide range of training to introduce managers and
employees to their benefit or to expand on specific needs you may have. Our goal is to take a
fresh look at typical topics, such as stress and change management, and make those trainings
more engaging and relevant.
Our training and curriculum specialists have created a library of presentations and topics.
"Coping with Change", "Adopting a Healthy Lifestyle", "Building Successful Teams", and
professional development seminars are only a few of those available.
Organizational Development
Aetna Resources For Living's Organizational Risk Management Center (ORMC) is a unique
service offered to those at the administrative, supervisory and executive level. With the ORMC,
your workers and supervisors are never alone. This unique center dedicated to management
issues offers your supervisors and managers immediate access to Management Consultants
(MCs) — experienced, licensed, Master's -level clinicians who are available to consult on such
issues as performance concerns, inappropriate behavior, alcohol or drug violations and
emotional instability.
Crisis Resources and Support
The ORMC provides expert crisis response
services and support. A crisis is any
occurrence in which a person or group
experiences a trauma — an unexpected
and unnatural event where employees
feel overwhelmed by a sense of personal
vulnerability and/or lack of control.
Examples of crisis situations include
natural disasters, serious workplace
accidents, a hostage situation or violence
in the workplace. Performed properly,
Crisis Response Management can prevent
personal trauma, reduce disability claims
and quickly return an organization to a
normal level of functioning.
Our Organizational Risk Management Center ultimately provides you with the tools to increase
employee productivity, retain and develop top talent and decrease workplace inefficiencies.
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Worklife Balance
Most people juggle a myriad of tasks associated with
daily living, from household chores to caring for aging
parents. For some, tending to those duties can spill
over into work time, resulting in lost productivity and
absenteeism. Aetna Resources For Living's unique
Worklife Services offer personal assistance to help
your employees and members juggle their work and
personal lives.
Our worklife consultants have degrees in the fields of
early childhood development, geriatrics, education, social work, developmental disabilities,
counseling or social services. Many consultants even have a master's degree in their field and
licensing in social work. In addition, consultants have at least three years of experience in a
child, elder and/or other counseling field.
Professional experience covers a broad range including work as a child care provider, elder care
case manager or social services counselor. All consultants are highly skilled listeners who
provide individualized, detailed intake interviews. Each consultant is also familiar with a wide
range of care resources and is adept at conducting customized searches for the best possible
solutions for worklife problems.
The Intake Assessment: Dependent Care
When a member calls with a dependent care need, a worklife consultant skilled in the specific
area of need assists the member, covering all of the details of their care needs. The consultant
takes as much time as needed with the caller to fully understand all care concerns.
Together, they may find care options of which the member hadn't been aware. Because of
their expertise, our worklife consultants are often able to educate and inform members about
the many services available to help solve problems.
Once the concerns and goals are clarified, the employee goes back to work, calmed by the
worklife consultant's assurance of help and confident that care issues are being pursued by a
professional. From an organization's point of view, the member has now been relieved of the
immediate worry of at-home or family issues and is able to concentrate on work.
The worklife consultant begins the legwork of calling and identifying resources — a task which
would be distracting, time-consuming and stressful for the member to do on his or her own.
The consultant assures the member that all information exchanged strictly confidential, and all
referral services are free. The consultant has also explained that Aetna Resources For Living
makes referrals, not recommendations, and that all final decisions rest with the member.
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Calling & Identifying Worklife Referrals
After the intake call, the worklife consultant starts the legwork on behalf of the member. The
worklife consultant calls prospective providers to verify the currency and accuracy of the
contact and regulation data. They find out whether or not the provider offers services that
meet the needs of the member, and whether there is an opening when the member needs it.
Often, the worklife consultant will call over 50 providers to find 3-5 that fit the family's need.
Referral is only made if the consultant can contact the provider
first to pre -qualify the provider as licensed, matching the
employee's requirements and having an opening in the
employee's time frame. The worklife consultant provides
referrals to the member within days of the request — or
immediately in urgent situations. Referrals are provided
telephonically, via e-mail or fax and/or in hard copy. Along with
the referrals, the worklife consultant may also provide
applicable articles and guidebooks to help the family with their
worklife issue and make a decision about care.
Convenience Services
Convenience Services, a core service included in worklife, provide information and contacts to
meet the everyday needs of members. From finding help at home to planning a night out,
members can get fast, expert assistance.
As part of your core benefits, we will help you locate resources to assist with those day-to-day
chores that can eat away at valuable time. For many, these services are more than just a
convenience. They are necessary to maintain independence.
Convenience Services begin by addressing chores inside the home. This can include various
property maintenance, skilled labor and repairs. The focus is on services that keep
surroundings functional, safe and hospitable for members and loved ones. Examples of home-
based Convenience Services include referrals for:
• Home cleaning
• lawn and landscape
• Appliance and electrical
• Home security
• Roofing and siding
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Our services also enhance travel and entertaining with over
10,000 online recommendations in over 75 destinations
worldwide, in the categories of:
• Dining
• Entertainment
• Tourist and city
• Sports and recreation
• Shopping
• Travel
This proprietary database includes vetted recommendations by city, giving a greater depth and
breadth of information than others in the convenience industry. Information is updated by our
city specialists on a monthly basis to ensure it is timely and valid. These web -based services
also are included at no additional cost in your EAP benefit.
Members may access all services through the self-service website or by calling to speak with a
worklife consultant. Once the requested resources are identified, it is the member's
responsibility to make a reservation or book an appointment for the needed services.
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Web Resources
People face the challenge of
balancing their professional and
family lives every day — and
they need answers fast.
My Life Values provides those
answers through its web -
enabled EAP and worklife
platform. Beyond just helping to locate child care, our website
offers employees and members easy, online access to a
proprietary database of over one million worklife providers,
useful and compelling research and information on health and
wellness, robust concierge resources, and discounts at a
network of national vendors.
Using the site, employees and members can gather information
and make important decisions about family, health, leisure time
and how to get "the most for their money" — all through one
web tool that they can use at their pace and when their
schedule permits.
We encourage you to visit our website at your convenience:
www.mylifevalues.com
Username: aetnaeapmeddemo
Password: demo
Topics have been assembled after careful research into the
issues most important to most working people and are grouped
into the categories of My Family, My Health, My Time, My
Money, My Workplace and Management Services.
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LifeMorte Discount services
Through Aetna Resources For Living's online LifeMarte Discount Services, your employees will
save an average of 25 percent on over 3.5 million products. Employees and family members
can shop online with ease for savings on everything from movie tickets and travel to electronics
and major appliances.
LifeMart is a private shopping site available to members at work or home. Employees can save
money and time while shopping, and in the process, explore the many EAP and worklife
content and tools available to them. LifeMart provides:
• More than 3.5 million discounted products and services
• National and local discounts
• Deals you won't find elsewhere
• Friendly customer service available to help you
Savings are available on:
• Computers and electronics
• Theme parks
• Travel, car rentals and hotels
• Gifts and retail shopping
• Child and elder care products and services
• Movie tickets and video rentals
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Pricing
1-5-Session—Consultation and resource services with up to five face-to-face assessment and
counseling sessions per issue. Unlimited 24/7/365 Telephonic Support Services Included. $1.72
Telephonic Worklife—Comprehensive worklife consultation and referral services, specializing
in child care, elder care, care for persons with disabilities, convenience services, pet care and
other needs that meet challenges faced by our members each day at home and work. Members $0.25
have access to Worklife specialists around the clock, seven days a week.
Pool of Eight (8) on-site hours that can be used for orientation, training and workshops.
Additional hours are available on a PEPM or Fee for Service basis. $0.22
Online Worklife—Web access to information and self-directed resources to assist with child care, home
health care, assisted living facilities, schools, colleges, health clubs, pet services and more.
Unlimited Management Referral—Our Organizational Risk Management Center is staffed by licensed
clinicians who are specially trained in resolving workplace issues. When an employee's situation mandates
a formal management referral, we can help your managers and supervisors through every step of the
referral process.
Unlimited Supervisor Consultation—Our Account Managers, Management Consultants, and training
consultants maintain a broad base of knowledge to help formulate and update corporate policies.
Communication and Promotional Materials—Information provided to Employees and management about
EAP Services, including, in part, how EAP Services can be accessed for consultation and assistance. The
communications and promotional resources may include template e-mails, letters, flyers, wallet cards, and
posters for employees and management. Certain of these materials can be customized by the customer.
We will provide reasonable quantities of printed materials in support of implementation and/or on an
annual basis at customer's request at no cost. Reasonable quantities are defined as up to 120% of the
number of eligible employees for items such as flyers or brochures; a quantity up to 5% of the number of
eligible employees for items such as posters; and a quantity of up to 20% of anticipated attendees at health
fairs for other promotional items. Requests exceeding these quantities may incur an additional fee.
Reporting—We provide quarterly utilization reports at no additional fee. With our specialized EAP system,
all identified data elements entered into our system are tracked and analyzed. EAP management reports
include overall utilization numbers, rates and patterns, percent of conversion into benefits plans, and
results from satisfaction surveys. Reports give you a comprehensive overview of your EAP program and its
impact.
Unlimited Crisis Response Services—Customized and designed to meet organizational and individual
needs to minimize damage and return people to previous levels of productivity as soon as possible. An
unlimited number of on-site incidents up to 20 hours per incident. The unlimited Crisis Response Services'
apply to only true emergencies and will be delivered in a centralized location. Issues concerning
downsizing, mergers, acquisition activities, natural disasters, acts of war and terrorism are subject to the
hourly rate.
Aetna Resources For Living Page 13
Workplace Seminars/Brown Bag Training—A full slate of workshops and seminars to meet
your organization's training needs. $275 Per Hour
RIF Groups are provided for companies that request onsite support due to having to reduce their
workforce. $325 Per Hour
Substance Abuse Professional (SAP) Services—The EAP shall provide initial and ongoing
management consultation and referral for drug and alcohol cases that fall under the Department
of Transportation (DOT) guidelines. We will refer the employee to a qualified SAP to conduct
initial assessment and provide additional services as required. Services can include treatment $750 Per Case
recommendations, referral to an education/treatment program, compliance monitoring, SAP re-
evaluation, and follow-up testing recommendations once the employee has been cleared to
return to work.
Awareness Training is available for substance abuse prevention, maintaining a drug-free workplace and other topics
promoted through the DOT and other professional organizations. Should Compliance training be required, we will
refer you to a licensed provider.
• DOT Supervisor Training - 2 hours at $800
• DOT Employee Training -1 hour at $400
EAP Pricing Assumptions
A one-year minimum contract
All employees, dependents and immediate household members are eligible for services
Sessions counted on a per issue basis rather than a per year
Rates are good for 60 days
36 month rate guarantee from case effective date
Rates are dependent on employee population within 20% (+/-) of that quoted
Fee for Service Rates are per clinician
Fee for Service Rates include travel to and from the site charged at a rate of $50 per hour
Cancellation fees apply to crisis services, training and other on-site benefits per contract terms
Aetna Resources For Living Page 14
XTEXAS City Council Agenda Summary Sheet
( PROSPERITY.
Agenda Item No. G1.
Consider a resolution authorizing renewal of Administrative Services Agreement with
Agenda Caption: Aetna, for insurance coverage.
Meeting Date: November 20. 2012
Department: Human Resources Department
Staff Person making presentation: Valerie Francois
Human Resources Director
Item Summary:
Consider a resolution authorizing the Mayor to renew the current stop loss contract with Aetna. The current
agreement will expire December 31, 2012.
We are recommending that the specific deductible (specific reinsurance) be raised from $125,000 to $200,000. The
reason for the increase is based on the proposed premium increase for continuing coverage at the same level of
$125,000. The increase is due to claims experience that resulted in Aetna reimbursing almost $900,000 for claims in
2012.
As an added benefit, Aetna will be providing an Employee Assistance Program (EAP) which includes Department of
Transportation regulated services (e.g. substance abuse testing, certification to return to work, etc.) at no additional
costs and will replace our current EAP program. This will result in a annual savings of approximately $25,000.
Cost: Approximately $ 680,851
Source of Funds: Self-funded Health Insurance
Recommended Action: Approval