HomeMy WebLinkAboutPR 15927: APPLICATION TO US DEPT. OF HEALTH AND HUMAN SERVICES - EARLY RETIREMENT REINSURANCE PROGRAMCity of Port Arthur
Memorandum
TO: Stephen B. Fitzgibbons, City Manager DATE: 06/ 10/ 10
FROM: Dr. Albert T. Thigpen, IPMA-CP, Director of Human Resources and Civil Service~~
RE: P. R. No. 15927 A RESOLUTION AUTHORIZING THE CITY MANAGER TO
SUBMIT AN APPLICATION TO THE U. S. DEPARTMENT OF HEALTH AND
HUMAN SERVICES TO PARTICIPATE IN THE EARLY RETIREMENT
REINSURANCE PROGRAM (ERRP)
COMMENT
RECOMMENDATION:
It is recommended that the City Council adopt P. R. No. 15927 which
authorizes the City Manager to submit an application to the U. S. Department
of Health and Human Services t:o participate in the Early Retirement
Reinsurance Program (ERRP).
BACKGROUND:
The City of Port Arthur offers access to its Major Medical Health Insurance Plan to
retirees as apost-retirement benefit. Changes in actuarial standards [GASB No. 45] for
the accounting of the liability for this benefit have resulted in a significant change
(increase) in the dollar amount of the actuarial projection. Changes were approved last
year by City Council to address this area and estimates in the preliminary actuarial report
indicate a reduction of the projected liability from $93,760,224 (10/01/07) to
$68,932,472 (10/0l /09).
The federal government in recognition of~ the referenced liability included as part of the
Patient Protection and Affordable Care Act of 2010 (PPACA) the Early Retirement
Reinsurance Program (ERRP) which will allow the City to be reimbursed for 80
(80%) percent of eligible claim expenses between $15,000 to $90,000 for eligible plan
participants and dependents age 55 to 64 not yet Medicare eligible -for claims filed on
or after June 1, 2010. Reimbursable services include medical claims for medical,
surgical, hospital, and prescription drug costs. Reimbursements can be used to reduce
retiree costs; must generate, or have the potential to, generate savings and cannot be used
to reduce the level of support for the health insurance plan. Key goals of the plan is to
have employers maintain retiree health benefits and to assist retirees with the cost of
health coverage.
Participation in the program will be on a first come first served basis and will require
the submission of an application. However, the final version of the application has not
been released by the federal government. Staff is concerned that the release of the final
version of the application may not allow sufficient time to have a special City Council
meeting for authorization and waiting until the next scheduled City Council meeting
might I>lace the City's application in an unfavorable position relative to timing and the
'`first. come first served" participation review.
The City's participation in the Early Retiree Reinsurance Program will not eliminate the
Ciry's GASB No. 45 liability, but will provide the City with additional tools to address
this financial concern.
BUDGETARY/FISCAL EFFECT:
Approval of P. R. No. 15927 will authorize the City to submit an application to
participate in the U. S. Department of Health and Human Services' Early Retiree
Reinsurance Program which has been funded by the federal government in the amount of
$5 billion dollars and provides reimbursement for eligible claims $15,000 to $90,000
tiled on or after June 1, 2010 by plan participants 55 to 64 not yet Medicare eligible. The
program is funded through January 14, 2010.
There is no cost to participate in the program.
EMPLI~YEE/STAFF EFFECT:
None anticipated.
SUMMARY:
It is recommended that the City Council adopt P. R. No. 15927 which
authorizes the City Manager to submit an application to the U. S. Department
of Health and Human Services to participate in the Early Retirement
Reinsurance Program (ERRP).
P. R. No. 15927
06/09/10 att
RESOLUTION NO.
A RESOLUTION AUTHORIZING THE CITY MANAGER TO SUBMIT AN
APPLICATION TO THE U. S. DEPARTMENT OF HEALTH AND HUMAN
SERVICES TO PARTICIPATE IN THE EARLY RETIREMENT
REINSURANCE PROGRAM
WHEREAS, the City of Port Arthur provides access to its
major medical health insurance program as a post-retirement
benefit to qualified retirees; and,
WHEREAS, the actuarial liability of providing this benefit
is ;significant pursuant to changes in general accounting
standards therefor; and,
WHEREAS, the federal government in recognition of the
financial impact of the provision of this benefit especially as
it relates to employees who retire early (retiree age 55 or older
and not yet Medicare eligible) pursuant to the Patient Protection
and Affordable Care Act (PPACA) of 2010 created the Early Retiree
Fei.nsurance Program (ERRP); and,
WHEREAS, participation in said program requires the
submission of an application; which will be processed in the
order received with any deficiency requiring the submission of a
rew application; and,
WHEREAS, the ERRP notice indicates that the application
will be available by the end of June, 2010 and the program will
P. R. No. 15927
06/09/10 att - P.2
bE~ available June 21, 2010; however, said application is
currently only available in draft form; and
WHEREAS, it is deemed prudent to have the City of Port
Arthur's application submitted as timely as practical to provide
the best opportunit:y for the City to be a program participant;
nc~w, therefore,
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF PORT
ARTHUR, TEXAS:
Section l: That the facts and opinions of the preamble are
true and correct.
Section 2: That the City Manager is hereby authorized to
submit an application to the U. S. Department of
Health and Human Services on behalf of the City
of Port Arthur to participate in the Early
Retiree Reinsurance Program (ERRP.) Said
submittal to use the final approved version of
the preliminary application which is shown as
Exhibit '~A" hereto.
Section 3. That Mayor and City Council will be provided a
copy of the final version of the application
submitted to the U. S. Department of Health and
Human Services for the ERRP.
Section 4. That a copy of the caption of the Resolution be
spread upon the Minutes of the City Council.
P. R. No. 15927
06/09/10 att - P.3
READ, ADOPTED, and APPROVED this day of
A.D., 2010, at a _ __ _ Meeting of the City Council of
the City of Port Arthur, Texas, by the following vote:
AYES: Mayor
Councilmembers
NOES::
Deloris ~~Bobbie" Prince
Mayor
P.TTEST
Terr_L Hanks
City Secretary
APPROVED FOR ADMINISTRATION:
Dr. Albert '.C. Thigpen, IPMA-CP
Lirector of Human Resources
~:~ /~ ~ ~~
Deborah Echols, CPA
Director of Finance
Stephen B. Fitzgibbons
City Manager
APPROVED AS TO FORM:
~~~ ~ ~
CITY AT E /
Exhibit ~~A"
OMB Approval
ERRP
Early Retiree Reinsurance Program. Application
gERVICF.,~ , ~
~ S,~
4'
9~'
O
~~~
~~'d~Q
U.S. Department of Health and Human Services
According to the Paperwork Reductlon Act of 1995, no persons are required to rnspond to a collection of Information unless !t displays a valid OMB control
number. The valid OMB control number for this information collection Is }trSf;R~~y11Av~fsiZ:093fi-I u5% . The time required to complete this information
collecion Yo~ this a~nlicatlon !s estimated to average 22~~ hoursi~ a spy>nser's f:+~swea+= h3 ~R-{~'-~'a~;+,-ai'c 3=~~ Y~e'-`r~ Y~~ st}tsseci-:=en-j=tzrs, including
the time to review instructions, search existlng data resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Repor7s Clearance Officer, Mail Stop C4-26-05, Baltimom, Maryland 21244-1850.
HHS Form # ~''iAS-1x321
OMB Approval
Please note that if any information in this Application changes or if the sponsor discovers
that any information is incorrect the sponsor is required to promptlyreport the change or
inaccuracy.
An asterisk (*) identifies a required field.
PART I: Plan Sponsor and Key Personnel Information
A. Plan Sponsor r',r€:c~~-nt .F,eg~4-t> ~ti~;~Y v~_~r_~~i~t_
1) *Organization's Name (Must correspond with the information associated with the Federal Employer
Tax Identification Number (EIN):
2) *Type of Organization (Check thF one c~~rf ~~~, that hest desc_rihP~ gn~i_r nrganizati~~on):
Government
Union
Religious
Commercial
Non-profit
3) *Organization's Employer Identification Number (EIN):
4) *Organization's Telephone Number:.. ext.
5) Organization's FAX Number
6) *OrganizatiOn'S Address (must be the address associated with the EI N provided above):
* Street Line 1:
Street Line 2:
*City:
*State/US Territory:
*Zip Code:
7) Organization's Website Address:
I R n ,r0.., oa na ,ze~r:d .nrit,tien
~T-~}rSt 1V2r3~3e rA,.a~lo Ir„t;~t ~.,~,rc„ ~r~);c3s~ n--«",~-------_--
€~. Authorized Representative Information
Page 2
HHS Form # - _._ .:'~ _.
OMB Approval
1*
~) *First Name: Middle Initial (optional): _ *Last Name:
42) *Job Title:
~3) *Date of Birth(Month/Day/Year):
~4) *Social Security Number:
~5) *Email Address:
B61 *Telephone Number. ext
~~ FAX Number:
~8) *Employer Name:
~9) * Authorized Representative Business Address:
* Street Line 1:
Street Line 2:
*City:
*State/US Territory:
*Zip Code:
'1 '1'~ +~i ~ .. I., Fem..-m •~t...:.
*ino irl. _--_- __-
*~~SSV~ '~' _
*
'-~`Afi3SiNE'fi ~' _
*
r 7. --
19~. Account Manager Information
1}~ ~eati-;mc~-;~c~ }~t~- ~se~~gn~~.e ;'~ ~~va~~e~~-~=-4-Ee~e~~-1'~-+e;~-~ e~ ~+~:~ ~ ~a~tt~? e~~
Z) *First Name: Middle Initial (optional): _ *Last Name:
~Z) *Job Title:
43) *Date of Birth(Month/Day/Year):
~4) *Social Security Number:
g5) *Email Address:
~6) "`Telephone Number: ext
B7) FAX Number:
III) *Employer Name:
x-89) *Account Manager Business Address:
* Street Line 1:
Street Line 2:
*City:
Page 3
HHS Form # ' • •Mti-1U3~'.
OMB Approval
*State/US Temtory:
*Zip Code:
~3SSi~YAr~i
~es~ii~cj-q'ci'e6~i9ir~' -
'Fi nSKLeF i
*~1~swer':
~~*o...... ot,,..,~o.
Al* Dln a' ire rl.o err;.,.. ~~'~_ ~'~ ~:,I~- ' s _.. ~° ~8'.`~;, ~E3?' to._:: c~j?} ~.~~<_ T'i_
''z-,~Eer ~c~-P-ass -phrase: --
* * ,
A l *i.,h T;rle.
~~ *-.ret,v.,.,,o.
Gl *il~r~ .+f 12i..rl, lrA....rL. /P~., 1• _
Zrzcnr r~rj
~~ ,~es~;zber• -
*
~8,~ env ni,,,,.i-,,,,- .
~z-m-r.-~~T .-- --
i iti l*A'~:
* Ci-..oot i i I . _ __
-vaczrarrr~-=~ ---__---- ------.. __-._
*r • r.,.
~;r -
~;~, r.,ao
*~Qg~'-,~- -
- ----
~ee~r'
*insiver ~:
Page 4
HHS Form #,r ___ ~_~_~
OMB Approval
~~ n.~~i.o~~m«r .gill Dri.,or.: llnli~;,
_ .. 's9 a~i-'E-:.-
fC/'1 !DC \A/CD UTC --£~t~+~-E-'-~~*rtt{~i~t!ftfe~'ar:E-i~ftl~t9-f'cr irs.,..t ~f~75"r~~
A..rn., w. ~r.+ ~f +' C +
~ } + rl 4, 1 II rl .J + M 11 + }' Il i~ 6c..cf~r~u:c
_ _
~¢'; s ~ ar=y.,.- ~.o{-
TL. CDDD C.. .. \Aln4. f:+i. .:.J.. I]i-, .y~y;, <-1~?f;'Q+;?.~z~. ; s'~it'Et+'+E'-H'~}I;aP~#~#fl?~:
nt,c.~.~.~'YttYT-tt-£--Fac~i:
?-~=1=~~~~':sr'~~~>-CC-EBfi?~-~-~:: ~}a'c r-.='~.z:
L 1 D +' D r-...r.~ t\.r.e.r-.....~..rrr:L.e~ .
Eats,-
=.?:.c
rd :r. Cnr}i r.r~~11}i r~t 2~~~~. C'. 3t~.r~Y 'Rst~Y cacSs Sa-.~:ttc.~.~ffa~r,~a
>Qf- - :-r ~.-2,rafj4f?r;,L:.T
~:.. ..
~
~
~
~ „
, ,
- 4, a c";.cS~%-
i..~.E~T. $ 4~p .k ~7L,
~
n'
F
f~1f-
3f F~`2
E'
i f
''
'?F
+`
~
'
!EE c
{4i ~
~i11f
}fE
?'-~ ~- 7
-
~
.
~ r
~ r3
~
? ~t
1 ~ -
.r d
i
i
-'
~3i-1+-~-1-~f'P34'-syY~f~3~
_ "=e'ddf4?£ ,rFr:e,
~'~.- --ilb"~3e"bP kit-
/
IA/F. 4. .+ +L.r nl+ -. n4. ri+n n
r~{i. ::` i' ;_ %.t'£-F e.Yi...~f'ii~1~F3Fi3~d'.'-.. ~f ~ '
~:; F 6?1 t i;='-(#F?i?~?{R?~'~,;: .
Wei .:rlnw" ., n„~, c
~ +L.., rd~+n ,,.a Hw. nf. cir
~ --- }knT~ of tho :..ah ei}n t:ni3 E _ _
IYe .. =4~f f?'>c~R,:r~f'._f~H~T4EE9i~F1`i
-
r4~~ ~ ~ -xa
r~.~.e ..c,~,.^...,~~'~z~~~! t~t717':-~!¢~~?. ~Y:' ~°~'~__1~;L.G
•-.~ xz.~'"~i`°~`~ c"l;:ff)flz3~1i~-~f-ad+'4ti°
;.: ~~a:c'-d•~'t~ ~?~?~f'iI?C~~l~8f P?{~a~l~i~}}~c7~£`?ir}!~PF)Fn4z}o°s"r.cE?'~'s
r 1 ~ ~;a+Hf'-fib-~~1~ ~~}~k~ ~d'E7l'~}}2~~9~f.-~G,~-~..rrco^ ~-~":,c~°r2~1
ii-I}its ~FfiFH WI~7L3=k-~'6'tt6~S"sue iF~~ro'~'r1~~d~~.,
~'YtS~1~~i Z"Y'3f'iCr~ ~':
~i{4'
'
t ~Tl
~:
+
..
~.
' .,
~'
.. ~
} ~ + t ~ .... :.
° }L.'r '..
f
}4,.. C
] 1_p
~?;t
a
~
~ t'.~.""'{~¢asatusa.,,-*~}-£-~'~{~sV._~{-p~apnt
=x§
:_+.~~..~a}
?.~!
?t
r
,
fa .
.
:
-T.
-E-:- v
~
:
6
-
Page 5
HHSForm~iy ,-_ a&:C.r,_ 'u~;
OMB Approval
~~- ~
`
~
-
-
-
`{
-
-
-rr~- c,c'°c
,- ?.._
~'cT
Tr
•c
?--trrr \y
°F'
i-.ffa-~Y~' •~TCrcc~r`
-~bE 'rr.
J~.xd
%.-l~X.~ ~.` ~ ^.. -+~ t :-s i`=4°'_ £-~7 f:i1@F-;1F~~ .,-~~#6~ii~1@f~id~ i31E'sP
~(,.. -. E;~'<-i '4t"Ei: '4f
~-:~ .. '
' 3t ter.::::. - ~. r. ;~ ~r.~s.n:`~~~F-t=i~z~ciC-'i'-~k34iEjf ~d~i~
c-8{~-6~Ei-F~
=
t;
+
.~
yE en;
`
~' ~.EEttFih?-~.~
6f@~ icvczc^~-i~-teL$Fi~E'F}~ 6~.
i1Eif1-
}$-~ge-~3F6Vtfic'si+ rr
,
t-s
ii3 !,t
:0 +t
:
~
'•
a 2 c ..f c.,~r:.... cnD M~o«;4~il;+~, o~.,. ~ ,.. ~;#?F'
~, ~f .~+ ,d t •. L:.. +11 ,',,.
CDDD 5A/eL. fite~~~-~,~R2-~~~~~vv}f~~~-.~~St~ t ,,t
Wa.~~1~§E~-~Yii~c~~6F~
i
~ ~~1ec.'
_ ~ ~'~~/
dfi~
- fi i i /
~-+efi~rta~~lPk?.b1~s-~€ifle~-i~#ate-~Rea!t"?t~
r: '
~~:~~~~€e-per~~f~+t~, ~~~
TiTFeca~wi f~nvi n~n'ti+`'r -'~c
TL. ['ODD 5A/ k C+.. -. ,-.... ,:
TOIC
'
~„ ..r k-i ~ `. ~ - -~-~Ct'tr .-F v Fem.. .,+' :, + !C
f'+
-
°
F. ~.: ~ ~.r ~ , -. -' -. ~. ~^-...
~CTT
V
TiTC'L~TT'~TC9 ~CC ~
ru~ T
CC DI ] ~T
~
1
.... .. a].A~j+C.C':.~--~~~Ci6?3 +.J.."~",~~~~/~AI~F_~',~-~A14y.[1k']1"
T' 1 ~T'JC{TAF~~
Page 7
HHS Form # _ ~ :-~ ,
OMB Approval
PART II: Plan Information
A. Pian Information
1) *Plan Name:
2) *Plan Year Cycle: Start Month/Day: End Month/Day:
B. Benefit Option(s) Provided Under This Plan of tl~e plan has more tl;a~~ c;p.E bEi~efit optioi~ f::s
which you Intend to seek~ro_grarn reianh«rsement. please include the_inform_a_tic?n below for
each benefit option. on a separate copy of the Attachment below,
1a) *Benefit Option Name:
lb) *Unique Benefit Option Identifier:
lc) *Benefit Option Type: Self-Funded Insured Both
ld) *Benefit Administrator Company Name:
C. *Programs and Procedures for Chronic and High-Cost Conditions
Dl° °;.7°.,r;f,> ri,°,.1,.-^ .~ l,' 1, f ~ a"t' F.,r..,l,;~l, +L,° °.T,.,lr,.:.~.,~t_F,~~°rl .,1~., 4.-,.-
a ~p~
1 r .i .d .,.a,. ~ r., ter., of o nc~:~M .•r r., -, «r;.. „ram .,~ ::fi' c
r o r v
.a'~' Dl
~~^~° *~-° ~-^^-'-•:c ~^d ^r^^°a~~-'°~A sponsor cannot participate in the Earle
Retiree Reinsurance Program unless. as of the date of its application for the program is submi ttecs. its
employment-based plan has in~lace programs and procedures that have generated or have tl~r
potential to generate cost savings with respect to plan participarts witl•. chronic and high cos':
conditions The program regulations define "chronic and high cost condition" as a condition fa~_ aaj:_;_~ ~-,
$15.000 or more in health benefit claims are likely to be incurred during a plan year by one plan
participant Please identify the chronic and high cost conditions for which the empiaYrnent-based Ulan
has such programs and procedures in .place and summarize those programs and procedures incl;:ui ~.
how it waS determined that the identified conditions satisfy the $15 000 threshold. If necessan~ tr;
provide a complete response the sponsor may submit additior~d ~ ~;a~es as a;rr attachment- t~ the
~" t r, iSc . i'i cPACE ~u~`_-. i ;": i;' ti ~5.5'~CE,
D. *Estimated Amount of Early Retiree Reinsurance Program Reimbursements
Please estimate the projected amount of proceeds you expect to receive under the Early Retiree
Reinsurance Program for the plan identified in this application, for each of the first two plan year cycles
identified in this application. ~~-}ri~~.eli veil ti>.~isl"~, yptl_>l~_pr°ov~de ~, p%~~:e c~i exie~:tf~~ r~rn~ra,~n
-ceeas that ~ncludes_~ a Govb~-end estimate of exnectedprogram proceeds (2 i an estimate tn~;_.
represents your most liked amount of program proceeds and (3) a high-end estimate of expectrei
Page 8
HHS Form #._ ; ,;_
OMB Approval
program~roceeds, For lru~~lgses of this estimate only, please assume for each of those plan year cycles
that there will be sufficient program funds to cover all claims submitted by the Plan Sponsor that
comply with program requirements; ~~n'~k-~1~':~rd~i-~~ ;~:s~:, l f n~c_:>s~~ ~o~c_=iw~r
CQP? Mete resnrl? ~~ . Llle SDOI1SOr IIaV SLlbmlt r~C'rir inn2'. ~~=a_~`c ~~ 2~1 =?=t?C~1ITleiil C', 1:hE_=1~~3~!C~~?C?Yi
Pie = r~e~,>> :~ ~~c'~ ~t, achmen~lo~thisspa~_~
E. *Intended Use of Early Retiree Reinsurance Program Reimbursements
1) *Please summarize how your organization will use p~se~s? he reimt;urser?, fit,, under the Early
Retiree Reinsurance Program to reduce health benefit or health benefit premium costs for the
sponsor of the employment-based plan;-j ~.e.~tn offset increases ?n such cr~sts~, or reduce premium
contributions, copayments, deductibles, coinsurance, or other out-of-pocket costs (or combination
of these) for plan participants or reduce a coribinat~on of any of these costs (whether offsetting
creases in sponsor costs or offsetting or reducing plan participants' costsl. If necessary to provide.
a complete response. the sponsor may submit <~??±*;or~_':_>,~~~e_s as an attachrnerl to thP_ a~,~1_'c~ ~~c~-=.
Please reference such attachment in this spat : .
~D7.,., n.~;..0 1,.,.s. tl,e Dlr., C.,.,,.~~.-..,; 11 „c ~ 1 ~"=3i'r ~,:lr,,'?..li k: ?'si~`'~lE?-FPS--~£s$~-'sub-'. F~~c4~fi-1-~.-~-i €.',~j.~.., ,,,
~ ~<
~ ~~,:~ l:'l_;i,: ii, np7 1 V ~ ! ~.., ~:1;;F(; its' 11S O~C1 Uti~ Il_l]'la~' OIl~' USe ~ilE' i~itlliius ~f=YTie3i~
' ~ _,,.~
to offset increases in its health benefit premium costs if an insured klan or its health benefit costs,
;f it is self-funded If any amount of the reimbursement is used to offset increases in health benefit
premium or health benefit costs of your organization (as opposed to offsetting increases to. or
reducing~plan~articipants' costs please summarize how program funds as a result of being _~se~i
byy4ur ororganization for such~urposes will relieve your organization of using its own funds
Suhsidize such increases thereby allowi~ your organization to instead use its own funds to
maintain its level of financial contribution to the employment-based man (In other words pieese
explain howhow your organization will continue to maintain the level of support for this plan and if i?
applies the reimbursement for its own use will use the program reimbursement to pav for increases
in health benefit premium cost; or health benefit costs as applicable) If necessary to provide a
complete response the sponsor may submit adr~tional pales as an attachment to the ap~Iication,
P~caca raFerl'?iCe Sl]Ch attachment i13 tl?iS S a
- -p- ~,.
Page 9
HHS Form #,t, ~ - ;_-i .~ s..
OMB Approval
PART Ill: Banking Information for Electronic Funds Transfer
1) *Bank Name: _
2) *Bank Address:
*Street Line 1:
Street Line 2:
*City:
*State/US Territory:
*Zip Code:
3) *Account Number:
4) *Name of Organization Associated with Account:
S) *Account type: (Checking or Savings Account)
6) *Bank Routing Number.
7) *Bank Contact First Name: Middle Initial (optional): _ *Last Name:
8) *Email address:
9) *Telephone Number:
Page 10
HHS Form #~~+:-:-~ ~% "~i~ iii3~i
OMB Approval
PART IV. Plan Sponsor Agreement
1. Compliance: In order to receive program reimbursement(s), Plan Sponsor agrees to comply with
all of the terms and conditions of Section 1102 of the Patient Protection Act (P.L. 111-148) and
45 F_ER ~_.F.R .Part 149 and in other guidance issued by >~1~S;t~e Secre*ar,~_of the U.S. Department
of Health & Humaru Services-the Secretary;: including, but not limited to, the conditions for
submission of data for obtaining reimbursement and the record retention requirements.
2. Reimbursement-Related and Other Representations Made by Designees: Plan Sponsor may
itier,_r~EOi~cr'~r,,itt~ tc; identiy_ol~c:.or mole i~es~:,ees; ~., ir;di~-i~ud;s t11e S ons!~~%il;
;rl
,
authorize to~erform certain functions on behalf of the Sponsor rela*ed to the Earle Retiree
Reinsurance Program such as individual(s) who will be involved in makine nroeram
reimbursement req_uestsL Plan S~onsor_certifies that all individuals that will be identified as
Desr res • ^:,, ~-:~t>t:~ r~r +irf~ ~f tit 1'~-~,~~~.t~ _se~~j~ tt l~~t~->.,_~.; ~ a ~ have
first been given authority by the Plan Sponsor to perform those respective functions on behalf of
the Plan Sponsor. Plan Sponsor understands that it is bound by any representations such
individuals make with respect to the Sponsor's involvement in the Early Retiree Reinsurance
}wag-r,Fro ra~~ including but not limited to the Sponsor's a~li~ai+~a,-+~~-tftifa~~t ~+,-any
reimbursement under, the 1?~egra~rprp~ran;.
3. Written Agreement: Plan Sponsor certifies that, prior to submitting a Reimbursement Request,
it has executed a written agreement with its health insurance issuer or n~.:}~ h~-'-~e~'=~!oylY~ir=t
based plan regarding disclosure of informations data. documents and_rec+_erds to HHS, and the
issuer or plan agrees to disclose to HHS, on behalf of the Plan Sponsor, at a time and i~7 a manner
sy;e~ifird by tine HHS Secretary in guidancz the information, ~~~a duc urnents. and records
necessary for the Plan Sponsor to comply with the requirements of the Early Retiree Reinsurance
Program. , as :Yt?ecified in 45 C.F.R 14ti.35
4. Use of Records: Plan Sponsor understands and agrees that c~ , ° ^~^;'°°° '"`~ ~ -- ~*,~"r°
e#-t}~~~~pa~}~e~e1#ealt~~a-Hu~a?~~~ Teesthe-Secretar/ may use data and information
collected under the Early Retiree Reinsurance Program only for the purposes of, and to the extent
necessary in, carrying out t+~i€~er+~i `l~:;fti~~ ~~e~Section 1102 of the Patient Protection Act
(P.L. 111-148)_and 45 6F#tC.F.R. Part 149 including, but not limited to, ''~~~~~~_~!
efdeterminina reimbursements and reimbursement-related oversight and program integrity
activities, or as otherwise wallowed bylaw. Nothing in this section limits the iJ_S.
Dekartment Of Health Sz Human Services' Office of the Inspector General's ~1~}-authority to
fulfill the 81sY'sInsnector General's responsibilities in accordance with applicable Federal law.
5. Obtaining Federal Funds: Plan Sponsor acknowledges that the information furnished in its Plan
Sponsor application is being provided to obtain Federal funds. Plan Sponsor certifies that it
requires all subcontractors, including plan administrators, to acknowledge that information
provided in connection with ~± subcontract is used for purposes of obtaining Federal funds.
Plan Sponsor acknowledges that reimbursement of program funds is conditioned on the
submission of accurate information. Plan Sponsor agrees that it will not knowingly present or
cause to be presented a false or fraudulent claim. Plan Sponsor acknowledges that any excess
reimbursement made to the Plan Sponsor under the Early Retiree Reinsurance Program, or any
debt that arises from such excess reimbursement, may be recovered by l~-H-Sahe Secretant. Plan
Page 11
HHS Form
OMB Approval #'"'~~DT "n~"eo°00938-1087
Sponsor will promptly update any changes to the information submitted in its Ytan Sponsor
application. If Plan Sponsor becomes aware that information in this application is not (or is no
longer) true, accurate and complete, Plan Sponsor agrees to notify I~?~-St~:e_Secret~~ promptly of
this fact
6. Data Security: Plan Sponsor agrees to establish and implement proper safeguards against
unauthorized use and disclosure of the data exchanged under this Plan Sponsor application. Plan
Sponsor recognizes that the use and disclosure of protected health information (PHI) is governed
by the Health Insurance Portability and Accountability Act (HIPAA) and accompanying
regulations. Plan Sponsor certifies that its employment-based plan(s) has established and
implemented appropriate safeguards in compliance with 45 ~l~tC.F.R Parts 160; ~~ and 164
(HIPAA administrative simplification, privacy and security rule) in order to prevent unauthorized
use or disclosure of such information-~~. Sponsor also agrees that if it participates in the
administration of the plan(s), then it has also established and implemented t~:~~a~Qa_~,~?:o 'r"t_e
safeguards in llam,e-~v~-tt~ ~#~ea~~-~I-kA~~ataA-~I~?~ara «PN,R. Any and all Plan Sponsor
personnel interacting with PHI shall be advised of; (1) the confidential nature of the information;
(Z) safeguards required to protect the information„ and (3) the administrative, civil and criminal
penalties for noncompliance contained inapplicable Federal laws.
7. Depository Information: Plan Sponsor hereby authorizes I~I~ t::":e Secretar~~ to initiate
reimbursement, credit entries and other adjustments, including offsets and requests for
reimbursement, in accordance with the provisions of Section 1102 of the Patient Protection Act
(P.L. 111-148) and 45 61iFcC.r.R Part 149 and applicable provisions of 45 C~L.F.R, Part 30, to the
account at the financial institution (hereinafter the "Depositor}') indicated under the Electronic
Funds Transfer (EFT) section of the Plan Sponsor application. Plan Sponsor agrees to
immediately pay back any excess reimbursement or debt upon notification from 1-il~ttie
Secretary of the excess reimbursement or debt Plan Sponsor agrees to promptly update any
changes in its Depository information.
8.
Policies and Procedures to Detect Fraud Waste and Abuse `I'he Pian Sponsor attests tr~~_t~ as;
of the date this Application is submitted has in place policies and procedures to detect anc
reduce fraud waste and abuse related to the Earl} Retiree Reinsurance Program. The Plar.
Sponsor will produce the~olicies and~rocedures and necessary information records ano data,
>~on request by the Secretary to SubStandate existence of the nr~licies and nrpcedures and their
effectiveness as specified in 45 C.F.R Part 149.
may, Change of Ownership: The Plan Sponsor shall provide written notice to ##Sthe Secreta~ at
least 60 days prior to a change in ownership, as defined in 45 ~F~artC.r•R 149.700. When a
change of ownership results in a transfer of the liability for health benefits costs, this Plan
Sponsor Agreement is automatically assigned to the new owner, who shall be subject to the terms
and conditions of this Plan Sponsor Agreement
Signature of Plan Sponsor Authorized Representative
I, the undersigned Authorized Representative of Plan Sponsor, declare that I have legal authority
to sign and bind the Plan Sponsor to the terms of this Plan Sponsor Agreement, and I have or will
provide evidence of such authority.l declare that I have examined this Plan Sponsor Application
and Plan Sponsor Agreement My signature legally and financially binds the Plan Sponsor to the
kv-~stat~,ate ;regulations, and other guidance applicable to the Early Retiree Reinsurance
Page 12
HHS Form CNiS-103li
OMB Approval
Program {including, but not limited to Section 1102 of the Patient Protection Act (P.L. 111-148)
and 45 ~C_F.I<; Part 149 and applicable provisions of 45 ~~`~C.~_fi Part 30 and all other
applicable ~ ~:st~tutes and regulations. I certify that the information contained in this Plan
Sponsor Application and Plan Sponsor Agreement is true, accurate and complete to the best of my
knowledge and belief, and I authorize ###Sche Secretark to verify this information. l understand
that, because program reimbursement will be made from Federal funds, any false statements,
documents, or concealment of a material fact is subject to prosecution under applicable Federal
and/or State law.
13}ee~e~t: Signature
Page 13
HHS Form #-+~b1~+i+-S~#4~~MS-103ll
OMB Approval •a' 0938-1007
- ~., ?.~~snal Benefit Options
~Com_•plete this form for each unique benefit optionl
lal *Benefit Option Name•
1h~ *Unique Benefit O~,tion Identifier:
lc1 #Benefit O-ption Ty_pe• Self-Ftmded Insured Both
~dj "Benefit Administrator Company Name•
Page 14
HHS Form #+ + . +~:_.__ i ~: