HomeMy WebLinkAboutExcess Loss Agreement
Augusta Richmond GA
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BOX NUMBER: 9
FILE NUMBER } Lj LP J'iS
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EXCESS LOSS AGREEMENT
By and Between
AUGUSTA, GEORGIA
(Herein called the EMPLOYER or Plan Sponsor)
And
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC.
. (Herein called the insurer or BCBSGA)
WHEREAS, the EMPLOYER has adopted for certain of its employees and their
dependents an employee welfare benefit plan (herein called "the Plan" or "Plan Document")
more thoroughly described below and incorporated herein by reference; and
WHEREAS, the EMPLOYER recognizes "the Plan" is an employee welfare benefit
plan and the EMPLOYER, as a named fiduciary with respect to the "the Plan", wishes to
accept liability for direct funding of a certain portion of the claims arising out of some of the
benefits provided by lithe Plan" and covered by this agreement; and
WHEREAS, BCBSGA agrees to provide insurance for a certain portion of the claims
arising out of lithe Plan" and covered by this agreement.
NOW, THEREFORE, in consideration of the mutual covenants contained herein,
including the payment of premiums when due to BCBSGA, the EMPLOYER, and BCBSGA
agree as follows:
SECTION I. THE TABLE
Benefits of lithe Plan" SuQject to This Agreement:
Comprehensive Major Medical Expense Benefits with a Separate Pre~cription Card, if
applicable.
Effective Date: January 1, 2000
Accumulation Period:
Incurred From: January 1, 2000 through December 31, 2000
Paid From: January 1, 2000 through June 30, 2001
OCDSGA Monthly Premium Rates:
Per IndividuaL........ .$11.24
Per Family............. .$32.93
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AUGUSTA, GEORGIA
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SECTION II: BENEFITS
The benefits described in the "Table" are only benefits under "the Plan" affected by this
agreement and are affected only to the extent of the method of funding such benefits.
SECTION III: EFFECTIVE DATE
This agreement will be effective from the Effective Date shown in the Table.
SECTION IV: AGREEMENT YEAR
An agreement year is a period of twelve consecutive months beginning on the Effective
Date of this agreement.
SECTION V. AUGUSTA, GEORGIA
While this agreement is in force, AUGUSTA, GEORGIA agrees to be liable for and to
fund all claims paid on behalf of their employees and/or dependents under the Comprehensive
Major Medical benefits, subject to AUGUSTA-GEORGIA's Individual Stop-Loss Limit
outlined below:
a. $100,000.00 Individual Agr~ment Year Stop-Loss Limit-:Major Medical Paid
Claims in excess of $100,000.00 on an individual during an agreement year will be
the responsibility of BCBSGA during continuance of this agreement. This
$100,000.00 agreement year.deductible will beautomatica1ly reinstated at the
beginning of each subsequent agreement year and will again become the obligation
of the EMPLOYER.
SECTION VI. EXCLUSIVITY OF OBLrGA TrONS AND REIMBURSEMENTS
BCBSGA's LIABILITY for claims for benefits subject to this agreement shall exist
only when the paid claims exceed the EMPLOYER'S Liability set forth in Section V.
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AUGUSTA, GEORGIA
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In no case shall BCBSGA be liable for the payment of benefits in excess of those
payable under the "Plan Document" pursuant to this agreement, nor shall the EMPLOYER be
. liable for any benefits payable by BCBSGA under the "Plan Document" pursuant to this
Agreement, it being understood and agreed that the obligations of the EMPLOYER under their
"Plan Document" and of BCBSGA under the "Plan Document" pursuant to this Agreement are
and shall be mutually exclusive. If the EMPLOYER pays any amount of benefits which is an
obligation of BCBSGA pursuant to this Agreement, BCBSGA shall reimburse the
EMPLOYER for such payment. If BCBSGA pays any amount of benefits which is an
obligation of the EMPLOYER, the EMPLOYER shall reimburse BCBSGA for such payment.
SECTION VII. CLAIMS DETERMINATION AND CLAIMS PAYMENT
BCBSGA shall have the exclusive right to make a final determination of the amount of
benefits, if any, to which any employee and/or.dependent may become entitled under the "Plan
Document" to the extent and for the purpose of establishing BCBSGA's LIABILITY as
outlined in SECTIONS V and VI above the EMPLOYER agrees to accept such determination.
The determination of the BCBSGA' s LIABILITY, as outlined in SECTIONS V and. VI above,
shall be made in the same manner as such determination would be made under the "Plan
Document" in the absence of this agreement.
Payment of benefits which are the obligation of the EMPLOYER shall be paid from
funds provided by the EMPLOYER.
Payment of claims which are the obligation of BCBSGA will be paid from funds
provided by BCBSGA.
- SECTION VIII. LITIGATION
In the event of litigation. with respect to any claim for benefits which are the liability of
BCBSGA pursuant to this agreement, BCBSGA will, at its option, undertake the defense of
such suit and will have the right to settle any such suits when, in its sole judgement, settlement
appears to be advisable. BCBSGA agrees to provide periodic reports to the EMPLOYER at
reasonable intervals of any such claims/litigation.
SECTION IX. BCBSGA INDEMNIFICATION OF THE EMPLOYER
BCBSGA will indemnify the EMPLOYER and hold it harmless against any claims,
lawsuits, settlements, judgement, costs, penalties and expenses, including attorney's fees, with
respect to this agreement resulting from or arising out of the dishonest, fraudulent, negligent
or criminal acts of BCBSGA or BCBSGA's employees, acting alone or in collusion with
others.
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AUGUSTA, GEORGIA
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SECTION X. THE EMPLOYER INDEMNIFICATION OF BCBSGA
The EMPLOYER will indemnify BCBSGA and hold it harmless against any claims,
lawsuits, settlements, judgement, costs, penalties and expenses, including attorney's fees, with
respect to this agreement resulting from or arising out of the dishonest, fraudulent, negligent
or criminal acts of EMPLOYER or EMPLOYER's employees, acting alone or in collusion
with others.
SECTION XI. NOTICE TO EMPLOYEES
Within 30 days of the date this agreement becomes effective as to each employee, the
EMPLOYER will furnish all employees covered by "the Plan" a written notice that the
EMPLOYER is liable for funding a portion of the benefits described in the "Plan Document."
The EMPLOYER will indemnify BCBSGA for losses incurred by BCBSGA as a result of any
failure by the EMPLOYER to furnish such notice in the time and manner prescribed.
SECTION XII. SEVERABILITY_
In the event any provision of this Agreement shall be held invalid or illegal for any
reason by law or by a court of competent jurisdiction, said. invalidity or illegality shall not
affect the remaining parts of this Agreement, and this Agreement shall be construed and
enforced as if its said invalid or ill~gal provisions had not been included in this Agreement;
provided the basic purposes of this Agreement can be effectuated through the remaining valid
and legal provisions.
SECTION XIII. ADDITIONAL COSTS
In the event that for any reason by law, regulation, or decision of any administrative
body or court of competent jurisdiction, additional cost shall be determined to be due in
connection with this Agreement, or the "Plan Document", such additional costs shall be the
responsibility of the EMPLOYER. . NothIng contained in this paragraph changes the
obligations set out in SECTIONS IX and X herein.
SECTION XIV. CONTRACT COMPLIANCE:- NON-WAIVER
Failure by the EMPLOYER or by, BCBSGA to insist upon. compliance with any
provision of this agreement at any given time or under any given set of circumstances shall not
operate to waive or modify such provision orin any manner render to unenforceable, as to any
other time or as to any other occurrence, whether the circumstances are or are not the same,
and no waiver of any of the terms or conditions of this Agreement shall be valid or of any
force or effect unless in each instance it is communicated in writing expressing such alternation
or modification and executed for the EMPLOYER and for BCBSGA pursuant to the provision
of SECTION XVII of this Agreement.
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AUGUSTA, GEORGIA
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SECTION XV. RIGHT TO CONTRACT
BCBSGA may with reasonable notice to the EMPLOYER contract with another
organization to perform all or part of its duties under this Agreement. However, any such
action on the part of BCBSGA will not relieve BCBSGA of its duties and obligations under
this Agreement.
Pursuant to this Agreement, BCBSGA has designated Southern Administrative Services
(SAS), Post Office Box 8069, Columbus, Georgia 31908-8069, to perform certain duties more
specifically described (and incorporated herein by reference) in the Administrative Services
Agreement between AUGUSTA, GEORGIA, and Southern Administrative Services effective
February 1, 1997.
SECTION XVI. "PLAN DOCUMENT" AMENDMENT.
No amendment, rider, or endorsement of the "Plan Document" effective subsequent to
the Effective Date of this agreement shall change any provision or operation of this Agreement
except as may be specifically provided in such amendment, rider, or endorsement and agreed
to in writing by BCBSGA.
SECTION XVII. AMENDMENT
This Agreement may be amended at any time by written agreement between the
EMPLOYER and BCBSGA executed by their authorized officers. However, any change in
Monthly Premium Rates may be effected by a 60 day advance written notice from BCBSGA to
the EMPLOYER of the change.
SECTION XVIII. TERMINATIONS
This Agreement may be terminated in the following manner:
1. By either party hereto giving 60 days written notice of the intent to terminate;
2. By either party if the other violates any terms or conditions of this agreement;
3. By BCBSGA if the EMPLO.YER fails to make any and all premium payments when
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4. If the "Plan Document" terminates, this Agreement will automatically terminate.
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AUGUSTA, GEORGIA
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SECTION XIX. THE EMPLOYER'S LIABILITY UPON TERMINATION
In the event of the termination of this Agreement or the termination of the "Plan
Document" whichever occurs first, the EMPLOYER immediately becomes liable for all
payable and unpaid claims on and after the effective date of the termination, regardless of the
date such chum was incurred and regardless of the EMPLOYER having exceeded the
EMPLOYER's liability as set forth in SECTION V. In addition if any Extended Benefits are
provided under the "Plan Document" the EMPLOYER shall pay all claims arising out of the
Extended Benefit coverage on or after the date of termination.
SECTION XX. SUBROGATION
In the event the EMPLOYER recovers damages, expenses or benefits from a third
party relating to claims covered by this Agreement, BCBSGA will not reimburse the
EMPLOYER for the recovered amount. If BCBSGA has reimbursed the EMPLOYER for all
or part of a particular payment and that payment is later recovered from a third party, the
EMPLOYER must repay BCBSGA to the extent of the reimbursement (regardless of whether
this Agreement is still in force). Repayment may be reduced by any reasonable and necessary
expenses incurred by the EMPLOYER in recovering from the third party. The EMPLOYER
agrees to enforce its right to subrogation relating to any benefit and agrees to diligently
prosecute all claims arising out of such right. If the Employer is unwilling, unable, or
neglects to enforce this right, BCBSGA is hereby empowered and authorized to instigate
appropriate action in the name of the EMPLOYER. The subrogation provision of this
SECTION XX and BCBSGA's rights shall survive the termination of this Agreement. The
EMPLOYER shall notify BCBSGA of any third party action or obligation that affects or may
affect the EMPLOYER's obligation under this Agreement.
For the purposes of this Agreement, subrogated claim recoveries will be applied first to
reduce BCBSGA's liability in full, if any, before being applied to reduce the EMPLOYER's
liability, the liability of BCBSGA and the liability of the EMPLOYER's being mutually
exclusive.
SECTION XXI. W AGE OR PROFIT EXCLUSION
. No payment will be made for or in connection with any expenses arising out of, or in
the course of, any employment for wage or profit.
SECTION XXII. REMEDIES
It is the clear intent of the parties to this Agreement that the Employer shall have the
primary liability for funding the payment of claims which may arise in connection with this
Agreement. If the EMPLOYER does not make funds available as required hereunder, and
BCBSGA should pay claims from its funds, BCBSGA in addition to any other remedies
available to it, shall have the right to bring an action to recover such amounts paid by it and to
recover all of its costs and attorneys' fees incurred in connection with such action.
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AUGUSTA, GEORGIA
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IN WITNESS WHEREOF, AUGUSTA, GEORGIA AND BLUE CROSS AND BLUE
SIllELD OF GEORGIA, INC. have caused this Agreement to be executed in their names by their
undersigned officers, the same being duly authorized to do so, on the date and in the year
designated below.
BY
q4J TIhE
f1'~ DATE
1 ATTEST:
BLUE CROSS AND BLUE SIllELD OF
GEORGIA, INC.
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TITLE
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DATE
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APPENDIX A
To be attached to and made a part of the Administrative Services
Agreement by and between' AUGUSTA, GEORGIA (Client) and Southern
Administrative Services (Administrator), a division of Blue Cross
and Blue Shield of Georgia, Inc. Effective JANUARY 1, 2000, the
following schedule of reimbursements is set:
I. For Services Provided by the Administrator
The Administrator shall provide all materials and administrative
services necessary for the proper implementation and maintenance of
the benefit program(s) as proposed, to include the following
specific services:
a. claims adjudication;
b. explanations of benefits,provided or claims denied;
c. eligibility maintenance and monthly list of covered employees;
d. identification cards;
e. claim forms, enrollment forms and other necessary forms;
f. data for the Client's preparation of Form 5500;
g. 1099 forms for providers;
h. drafts and initial supply of employee benefit booklets;
2. master contract or plan document revisions;
j. check writing services; checks mailed weekly;
k. annual claim reports and projections;
1.' customer service, including state and national WATS service;
m. periodic standard reports.
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In consideration of these services, the Administrator shall be
reimbursed as follows:
Payment Schedule
Claims Administration Fee, Medical
(Per employee per month, composite)
$ 6.11*
Claims Administration Fee, Dental
(Per employee per month, composite)
$ 1. 51 *
Administrative Fee, Pre-Admission Certification
(Per employee, composite)
$ 1. 80*
*Rates guaranteed not to increase by more than 7% for the Plan Year
beginning January I, 2001.
II. For Other Services Coordinated and Billed by the Administrator
*Specific Excess Loss Premium
($100,000 Per individual contract per month)
$ 11. 24
*Specific Excess Loss Premium
($100,000 Per family contract per month)
$ 32.93
*Underwritten by:
Excess Reinsurance thru Blue Cross Blue Shield
of Georgia, Inc.
*PPO Access Fee
(Per employee per month, composite)
$
.15
HIPAA Administration
(Per employee per month, composite)
$
.30
COBRA Solutions Administration $ .50
(Per employee per month, composite to include HMO employees)
III. For Services Provided Outside This Aqreement
The Client may at any time request changes, special services or
Plan-related reports outside the parameters of this Agreement from
the Administrator. The Administrator will be compensated for these
requests in the following manner:
i) If the request is fora non-recurring service, an estimate
will be prepared for a single charge to be included on the monthly
bill; or
ii) If the request requires a revision or addition to the Plan or
to this Administrative Agreement .which requires an increase in
labor or complexity of administration, an estimate wi~l be prepared
for revision of the monthly administrative charge per employee per
month, to be made effective upon the first monthly billing
subsequent to the change.
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IV. For Services Provided After Termination of This Aqreement
The Administrator agrees to provide for the transition of services
rendered to the Client subsequent to termination of this Agreement
in the following manner, at the discretiori of the Client:
i) All materials on hand subsequent to or received on or after
the date of termination relative to the administration of the Plan
shall be r.eturned to the Client by courier for their proper
dispensation, or
ii) A magnetic tape containing employee eligibility records may be
provided at the time of termination; the cost of this service will
be based on charges for time and materials, or
iii) Subsequent to the termination date, the Administrator will
process all claims incurred on or prior to the termination date but
not received or processed by the termination date. The monthly fee
for services provided shall be $500.00 or 5%, whichever is greater,
of the amount of claims payments, to be billed in conjunction with
the weekly payment; however, this fee shall not exceed the maximum
of the average monthly admi~istrative fee for the current or prior
Plan Year, whichever is in effect and shall not be less than one-
half of the aforementioned average. monthly administrative fee,
regardless of volume. The length of this "run-out'" period shall be
negotiated at the time of termination. All materials relating to
the administration of the Plan which are received on or after the
termination of all services shall be returned to the Client.
iv) provisions may be negotiated, upon mutual agreement of the
Client and Administrator, and made a part of this Agreement, which
provide for an alternate termination arrangement.
Services Cl~ GEORGIA
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W.itnessed. by:
t!4i .to.A._
Corp8rfr ejAssistant Secretary
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Date