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Home My WebLink About20101436.tiff RESOLUTION RE: APPROVE EARLY RETIREE REINSURANCE PROGRAM APPLICATION AND AUTHORIZE CHAIR TO SIGN WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with an Early Retiree Reinsurance Program Application from the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Resources, to the U.S. Department of Health and Human Services, commencing January 1, 2010, and ending December 31, 2010, with further terms and conditions being as stated in said application, and WHEREAS,after review, the Board deems it advisable to approve said application, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado,that the Early Retiree Reinsurance Program Application from the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County,on behalf of the Department of Human Resources, to the U.S. Department of Health and Human Services, be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said application. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 7th day of July, A.D., 2010, nunc pro tunc January 1, 2010. BOARD OF COUNTY COMMISSIONERS 76 p _WELD COU LORADO ATTEST: 1861 f`, , ougl Rademac r, Chair ` {{-- WeldCountyClerktoth-�:o- Fcn J !� EXCUSED BY. �/L� �,,•,q/y;�,�. \;,, ✓ Barbara Kirkmeyer, Pro-Tem Deputy Clerk a e Board --�" G '' Sean P. C APPROVED AS T9 FORM i iam . Gar / w� C y Attorney EXCUSED David E. Long Date of signature: 7/..5eO(cm) O n 9 4-o HR C-C HK 2010-1436 i�l�� lo l- a)c-ID PE0027 OMB Approval 0938-1087 ERRP Early Retiree Reinsurance Program Application sl3RvrcEs e 411. coo U.S. Department of Health and Human Services According to the Paperwork Reduction Act of 1995,no persons are required to respond to a collection of Information unless it displays a valid OMB control number.The valid OMB control number for rho information collection is 0938-1087.The time required to complete this information collection for this appliration is estimated to average 35 hours,including the time to review instructions,search existing data resources,gather the data needed,and complete and review the information collection.If you have comments concerning the accuracy of the time estimatefs]or suggestions for improving this form,please write to:CMS.1500 Security Boulevard,Attn:PRA Reports Clearance Officer,Mail Stop C4-26.05,Baltimore,Maryland 21344.1850. HHS Form 4 CMS-10321 '[col 2010-1436 PEooaq OMB Approval 0938-1087 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 promptly report the change or inaccuracy. Send,using the U.S.Postal Service a hardcopy of the signed original ERRP Application(i.e. not a photocopy)and Attachments(if any)to: HHS ERRP Application Center 4700 Corridor Place Suite D Beltsville,MD 20705 Page 2 HHS Form pCM5-10321 TMn OMB Approval 0938-1087 An asterisk(*)identifies a required field. PART I:Plan Sponsor and Key Personnel Information 1)'Organization's Name(Must correspond with the information associated with the Federal Employer Tax Identification Number(EIN): County of Weld,Weld County Colorado 2)*Type of Organization(Check the one category that best describes your organization): ✓❑Government ❑Union ❑Religious ❑Commercial ❑Non-profit 3)'Organization's Employer Identification Number(EIN):84 .6000813 4)'Organization's Telephone Number: 970-356-4000 ext. 234 5)Organization's FAX Number: 970.352.9019 ext • 6)'Organization's Address(must be the address associated with the EIN provided above): *Street Line 1: P 0 Box 758 Street Line 2: 'City: Greeley 'State: Colorado 'Zip Code:80632-0758 7)Organization's Website Address:www.co.weld.co.us B.Authorized Representative Information 1)'First Name:Douglas Middle Initial: 'Last Name: Rademacher 2)'Job Title:Chair,Board of County Commissioners 3)Date of Birth: Do not respond to this item now. To comply with the Application Instructions,you must provide this at a later date if and when the application is approved. • 4)Social Security Number: Do not respond to this item now. To comply with the Application Instructions,you must provide this at a later date if and when the application is approved. 5)'Email Address: drademacher@co.weid.co.us 6)'Telephone Number: 970.356.4000 ext.4207 7)FAX Number: 970.352.0242 ext. 8)'Employer Name: County of Weld.Weld County Colorado ? / Page 3 HHS Form#CMS-10321 '19. OMB Approval 0938-1087 9)*Authorized Representative Business Address: *Street Line 1: P O Box 758 Street Line 2: *City: Greeley *State: Colorado *Zip Code: 80632-0758 C.Account Manager Information 1)*First Name:Jewel Middle Initial: R *Last Name: Vaughn 2)*Job Title:HR Analyst 3)Date of Birth:Do not respond to this item now. To comply with the Application Instructions,you must provide this at a later date if and when the application is approved. 4)Social Security Number:Do not respond to this item now. To comply with the Application Instructions,you must provide this at a later date if and when the application is approved. 5)*Email Address: lvaughn@co.weld.co.us 6)*Telephone Number: 970-356-4000 ext.4231 7)FAX Number: 970-352.9019 ext. 8)*Employer Name: County of Weld,Weld County Colorado 9)*Account Manager Business Address: *Street Line 1: P O Box 758 Street Line 2: *City: Greeley *State:_Colorado *Zip Code: 80632-0758 #.>"`""' z:'M1 Page 4 HMS Form#CMS-10321 t OMB Approval 0938-1087 PART II:Plan Information A.Plan Information 1)*Plan Name: Weld County Retiree Health Plan 2)*Plan Year Cycle: Start Month/Day: 01 /01 End Month/Day: 12 /31 B.Benefit Option(s)Provided Under This Plan (If the plan has more than one benefit option for which you intend to seek program reimbursement,please include the information below for each benefit option,on a separate copy of the Attachment below.) la)*Benefit Option Name: Preferred Provider Organization-Choice Plan lb)*Unique Benefit Option Identifier: PPO-00358610-Class 0002 1c)*Benefit Option Type: Self-Funded El Insured❑ Both❑ 1d)*Benefit Administrator Company Name: CIGNA e Page S HHS Form#CMS-10321 OMB Approval 0938-1087 C.'Programs and Procedures for Chronic and High-Cost Conditions A sponsor cannot participate in the Early Retiree Reinsurance Program unless,as of the date of its application for the program is submitted,its employment-based plan has in place programs and procedures that have generated or have the potential to generate cost savings with respect to plan participants with chronic and high cost conditions.The program regulations define"chronic and high cost condition"as a condition for which$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 employment-based plan has such programs and procedures in place,and summarize those programs and procedures,including how it was determined that the identified conditions satisfy the$15,000 threshold. If necessary to provide a complete response,the sponsor may submit additional pages as an attachment to the application. Please reference such attachment in this space. See Attachment A + ' ' Page 6 HHS Form NCMS-103214 Attachment A The Weld County's early retiree benefits plan administered by Connecticut General Life Insurance Company (CIGNA) includes programs designed to promote health and generate savings for Weld County and its early retiree participants — especially those participants with chronic and/or high-cost conditions. Based on CIGNA's review of the claim costs paid by all plans it administered between 2007 to date, CIGNA has determined which conditions are most likely to generate health benefit claims totaling $15,000 or more during a plan year by any one early retiree plan participant, including asthma, cardiac, oncology, catastrophic situations, COPD, transplants, diabetes and maternity. The programs in place on the Weld County's early retiree plan are designed to address those conditions. Accordingly, Weld County believes these programs in place and administered by CIGNA meet the requirements for Weld County to participate in the Early Retiree Reinsurance Program. • CIGNA is a pioneer in the health and disease management fields, with over 10 years' experience addressing the significant cost and health issues that result from chronic conditions. While each of the programs described below has its own individual merits, together they provide a comprehensive suite of health management programs to maximize overall savings. Outlined below are the programs that Weld County includes on its early retiree plan. PHS+: Catastrophic,Oncology,Transplant, High Risk Maternity and NICU • The goal of the Personal Health Solutions Plus (PHS+) medical management model precertification process is to improve clinical outcomes and reduce cost. In addition to inpatient admission notification, CIGNA maintains a standard list of outpatient services and supplies that require precertification of coverage under PHS+. Factors considered in deciding which outpatient supplies and services are included on the precertification list include the potential for over-utilization, specific plan exclusions that may apply, the opportunity for channeling to preferred vendors, the opportunity for potential case management and the overall benefit plan cost savings opportunity. Based on ongoing clinical and financial analysis, the services and procedures that are generally included for review are: procedures that may be considered cosmetic in nature; experimental and/or investigational procedures; high-dollar services that may be associated with over-utilization or inappropriate utilization;selected advanced radiology procedures(e.g., CT, PET scans,MRI); and certain injectable drugs. During an inpatient stay, CIGNA conducts inpatient case management (concurrent stay review). CIGNA's nurse case managers work with the hospitals' utilization review This document is provided by CIGNA for general informational purposes only.Its information is provided"as is"and CIGNA makes no representations or warranties regarding its accuracy or completeness.The information provided should not be construed as legal or tax advice or as a recommendation of any kind.Users should seek professional advice from their own attorneys and tax and benefit plan advisers with respect to their specific circumstances and needs.Users should refer to the Dept.of Health&Human Services'regulations at 45 CPR§149.2 for the definitions of key terms(e.g..health benefits.claims,early retiree,etc.). 'CIGNA'and the'Tree of Lite'logo are registered service marks of CIGNA Intellectual Property,Inc.,licensed for use by CIGNA Corporation and its operating subsidiaries.All products and services are provided exclusively by such operating subsidiaries and not by CIGNA Corporation.Such operating subsidiaries include Connecticut General Life Insurance Company.Tel-Drug,Inc.and its affiliates, CIGNA Behavioral Health,Inc.,Intracorp,and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health.Inc. 6110©2010 CIGNA June 12, 2010 Page 2 departments to monitor patients and their progress, assess the appropriateness of admission and length of stay, identify any delays in care, and perform initial assessments for possible case management referral. The nurses also have the opportunity to work directly with the patient and the patients physician. All admissions are screened using our Pre*Vue predictive modeling tool to identify potential candidates for CIGNA's case management services. The screening is based on factors that include diagnosis, anticipated length of stay, and previous admission history. Screening occurs while the individual is still an inpatient, before claims have been generated. This screening assesses the probability that a patient will be readmitted to the hospital, and allows CIGNA's case managers or other health advocates to outreach appropriately to eliminate preventable readmissions. Specialty Case Management: Dedicated nurse case managers with special expertise and training, working collaboratively with specialty physician leads and specialized resources on these high impact conditions: Complex and Catastrophic Case Management This program focuses on achieving superior clinical outcomes for the most severely ill individuals and avoiding hospital readmissions whenever possible. It includes helping the individual understand the diagnosis and treatment plan, provides support from a board-certified physician; depression screening and co-management with inpatient case management and specialty case management when an individual is in the hospital or extended care facility. Case management services typically include: • a case management plan that establishes objectives, activities, and anticipated timeframes that take into consideration physical, functional, cognitive, psychosocial, environmental,support system, and economic factors; • coordinating access to health services including acute care,skilled • nursing and/or hospice care, and outpatient or home health care services; • identifying and addressing potential barriers to availability, accessibility, and affordability of treatment; • initiating referrals to other programs, such as disease management programs, when appropriate; During their post-discharge assessments with individuals, CIGNA's case managers use evidence-based assessment tools to address the following topics, all of which are significant in helping individuals to avoid readmissions: follow-up appointments; recognition of signs and symptoms requiring attention; medication compliance; availability of Durable Medical Equipment(DME) or home health services; transition and referral to other programs such as CIGNA's disease management and health advocacy coaching programs. Oncology Case Management This program is focused on helping to improve the quality of care and the quality of life of individuals with cancer who are at the highest risk or have the greatest need. It is designed to reduce avoidable June 12, 2010 Page 3 hospitalizations and emergency room visits due to complications with chemotherapy and inadequate pain management. The specialized nurse case manager can: • provide information and educational tools, as well as resources regarding the condition treatment options and services available • anticipate and plan for potential care needs to minimize avoidable disruptions and delays in accessing care • provide information about CIGNA certified oncology centers • help people navigate the complex health care system and minimize the administrative hassles of claim payment,benefit, and authorization issues • assist in hospice placement,if appropriate Organ Transplants The CIGNA LifeSOURCE Transplant Network® program includes the services of dedicated transplant case managers, who help coordinate all phases of the transplant process, including case referral, planning, concurrent review, and coordination of post-transplant care. This dedicated unit ensures effective and efficient service to both the transplant patient and the health care professional. All services are provided under the support and guidance of a dedicated LifeSOURCE medical director,who is a physician with transplant experience. The case managers maintain regular contact with the facility transplant coordinators and attending physicians, the patient and the family members. Transplant managers help coordinate all post-transplant services including counseling, ancillary in-home care, and the involvement of community resources. High Risk Maternity This program is focused on proactively identifying pregnant women who are at high risk for pregnancy-related complications and prenatal hospitalizations because of co-morbid medical conditions such as hypertension or diabetes. It includes an integrated approach that addresses medical, behavioral, pharmacy, dental, disability and disease management needs; prenatal and postpartum depression and stress screening and management and targeted health education materials for at-risk individuals Highly trained and experienced obstetrical nurses contact participants at least monthly; their outreach is individualized based on the woman's management plan. High-risk maternity case management also includes seamless integration with, and referral to, the NICU specialty case management program. Neonatal Intensive Care Unit(NICU) CIGNA's neonatal intensive care unit (NICU) case management program is focused on appropriately reducing the length of stay for infants in the NICU by helping to resolve banters to discharge, and facilitating parental education and use of community resources. It focuses on care plan progress and ensuring communications for the transition of care to the receiving pediatrician. Specialized nurses follow infants while in the NICU and after discharge to the home, using specialized support tools and resources,while the need for case management exists. June 12, 2010 Page 4 Candidates for our NICU case management program are primarily identified pre-term by our high-risk maternity case managers. If an infant has been admitted to the NICU and the mother is not in the high-risk maternity case management program, inpatient case managers are the primary source of referrals, identifying admissions via CIGNA's daily census information. Well Aware Programs Asthma Well Aware for asthma is a full-service disease management program that provides customized telephonic counseling from a clinician, education and support, reinforcement of the physician's care plan, and tools that enable participants to manage their conditions more effectively. The program helps participants save money by teaching them to take control of their asthma. Understanding when and how to use their medications results not only in improved health and productivity but also in fewer hospital admissions and emergency room visits. The program delivers up to 3% savings via medical cost reduction. All CIGNA individuals also have access to treatment cost estimators and a provider directory. CIGNA's Centers of Excellence and clearly marked to help individuals find facilities that offer a balance of quality and cost. Heart Disease Well Aware for heart disease is a full-service disease management program that provides customized telephonic counseling from a clinician, education and support, reinforcement of the physician's care plan, and tools that enable participants to manage their condition more effectively. The program helps participants save money by helping them manage their cardiac condition. Increased medication compliance and support in understanding their doctors' care plans results not only in improved health and productivity, but also in fewer hospital admissions and emergency room visits.The program delivers up to 3%savings via medical cost reduction.All CIGNA individuals also have access to treatment cost estimators and a provider directory. CIGNA's Centers of Excellence and clearly marked to help individuals find facilities that offer a balance of quality and cost. COPD Well Aware for COPD is a full-service disease management program that provides customized telephonic counseling from a clinician, education and support, reinforcement of the physician's care plan, and tools that enable participants to manage their condition more effectively. The program helps participants save money by helping them understand and manage their COPD. Increased medication compliance and support in understanding their doctors' care plans results not only in improved health and productivity, but also in fewer hospital June 12, 2010 Page 5 admissions and emergency room visits. The program delivers up to 3% savings via medical cost reduction. All CIGNA individuals also have access to treatment cost estimators and a provider directory. CIGNA's Centers of Excellence and clearly marked to help individuals find facilities that offer a balance of quality and cost. Diabetes Well Aware for diabetes is a full-service disease management program that provides customized telephonic counseling from a clinician, education and support, reinforcement of the physician's care plan, and tools that enable participants to manage their condition more effectively. The program helps participants save money by helping them understand and manage their diabetes. Increased medication and testing compliance and support in understanding their doctors' care plans results not only in improved health and productivity, but also in fewer hospital admissions and emergency room visits. The program delivers up to 3% savings via medical cost reduction. All CIGNA individuals also have access to treatment cost estimators and a provider directory. CIGNA's Centers of Excellence and clearly marked to help individuals find facilities that offer a balance of quality and cost. Low Back Pain Well Aware for low back pain is a full-service disease management program that provides customized telephonic counseling from a clinician, education and support, reinforcement of the physician's care plan, and tools that enable participants to manage their condition more effectively. The program helps participants save money by helping them manage their low back pain. Better understanding how to manage their pain and support in understanding their doctors' care plans results not only in improved health and productivity, but also in fewer doctor visits. The program delivers up to 3%savings via medical cost reduction.All CIGNA individuals also have access to treatment cost estimators and a provider directory. CIGNA's Centers of Excellence and clearly marked to help individuals find facilities that offer a balance of quality and cost. Healthy Pregnancy Healthy Babies CIGNA's Healthy Pregnancies, Healthy Babies program supports individuals who are pregnant or considering pregnancy, whether they need information about pregnancy and babies, or are identified as high-risk and need specialized case management. The primary focus of the program is helping the mother understand the importance of prenatal care and healthy habits during pregnancy to mitigate the risk, and cost, of pre-term labor. Women receive educational materials and telephonic support during and after their pregnancies. By participating in the program, women decrease their risk of pregnancy complications and pre-term labor in addition to the high cost of neonatal intensive care for a pre-term infant. June 12, 2010 Page 6 Cancer Care Support CIGNA Cancer Support provides online cancer prevention materials,access to the Cancer Support program webpage,coaching from experienced oncology nurses,guidance on preferred cancer and hospice networks, and coaching for those individuals in an active stage of cancer. Through enhanced predictive modeling for Oncology, along with additional identification methods utilizing inpatient claim data,approximately eight times as many individuals are identified and targeted by the program. Coaching and support is not only provided to those individuals in an active stage of cancer but those in a maintenance or remission stage. By reaching out to members at all levels we are acting on the warning signs, creating awareness and making suggestions to individuals before cancer develops or becomes acute and even more costly. Coaches focus on discussing healthy lifestyles,educating individuals on reducing health risks, and reinforcing the importance of cancer screenings and follow-up appointments. CIGNA, a global health service company, is dedicated to helping people improve their health, well being and sense of security. CIGNA Corporation's operating subsidiaries provide an integrated suite of medical, dental, behavioral health, pharmacy and vision care benefits, as well as group life, accident and disability insurance, to approximately 46 million people throughout the United States and around the world. OMB Approval 0938-1087 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.If you wish,you may provide a range of expected program proceeds that includes:(1)a low-end estimate of expected program proceeds,(2)an estimate that represents your most likely amount of program proceeds,and(3)a high-end estimate of expected program proceeds. For purposes 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.If necessary to provide a complete response,the sponsor may submit additional pages as an attachment to the application. Please reference such attachment in this space. Early Retiree Reinsurance Estimated Valuation Plan Year High Estimate Mid Estimate Low Estimate 2010$ 203,000 $ 135.333 $ 121.800 2011$ 348,000 $ 232,000 $ 208,800 Total$ 551.000 $ 367,333 $ 330,600 Based on actuarial assessment of CIGNA HealthCare book of business data on early retiree plan participants Page 7 HHS Form#CMS-10321 OMB Approval 0938-1087 E.*Intended Use of Early Retiree Reinsurance Program Reimbursements 1) Please summarize how your organization will use the reimbursement under the Early Retiree Reinsurance Program to reduce health benefit or health benefit premium costs for the sponsor of the employment-based plan(i.e.,to offset increases in such costs);or reduce,or offset increases in, premium contributions,copayments,deductibles,coinsurance,or other out-of-pocket costs(or combination of these)for plan participants;or reduce a combination of any of these costs(whether offsetting increases in sponsor costs or reducing,or offsetting increases in,plan participants'costs). If necessary to provide a complete response,the sponsor may submit additional pages as an attachment to the application.Please reference such attachment in this space. Weld County intends to use the reimbursement funds from the Early Retiree Reinsurance Program to offset increases in the sponsor's health benefit premiums or health benefit costs. S. Page 8 HHS Form MOMS-10320 ?Y OMB Approval 0938-1087 E.Intended Use of Early Retiree Reinsurance Program Reimbursements(continued) 2) If a sponsor decides to apply the reimbursement for its own use,it may only use the reimbursement to offset increases in its health benefit premium costs,if an insured plan,or its health benefit costs, if 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 participants'costs),please summarize how program funds,as a result of being used by your organization for such purposes,will relieve your organization of using its own funds to subsidize such increases,thereby allowing your organization to instead use its own funds to maintain its level of financial contribution to the employment-based plan.(In other words,please explain how your organization will continue to maintain the level of support for this plan,and if it applies the reimbursement for its own use,will use the program reimbursement to pay for increases in health benefit premium costs or health benefit costs,as applicable).If necessary to provide a complete response,the sponsor may submit additional pages as an attachment to the application.Please reference such attachment in this space. Weld County is committed to continuing support of the Weld County Retiree Health Plan. Page 9 HHS Form#CMS-10321 OMB Approval 0938.1087 PART III:Banking Information for Electronic Funds Transfer 1)*Bank Name:SSA 2)'Bank Address: 'Street Line 1: 2164 35th Avenue Street Line 2: *city: Greeley 'State: Colorado 'Zip Code: 80634 3)'Account Number: 4)'Name of Organization Associated with Account: County of Weld,Weld County Colorado 5)'Account type:(Checking or Savings Account) Ching 6)'Bank Routing Number: 7)'Bank Contact Name: 'First Name: Ray Middle Initial: 'Last Name:Ulibarrl 8)'Email address: Raymond.O.Ulibard@wellsfargo.com 9)'Telephone Number: 870-336-6236 ext. i Page 10 11145 Form MCMS-10131 t OMB Approval 0938-1087 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(Pt.111-148)and 45 C.F.R.Part 149 and in other guidance issued by the Secretary of the U.S.Department of Health& Human 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 be given the opportunity to identify one or more Designees(i.e.,individuals the Sponsor will authorize to perform certain functions on behalf of the Sponsor related to the Early Retiree Reinsurance Program,such as individual(s)who will be involved in making program reimbursement requests). Plan Sponsor certifies that all individuals that will be identified as Designees will 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 Program,including but not limited to the Sponsor's reimbursement under,the program. 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 employment-based plan regarding disclosure of information,data,documents,and records to HHS,and the issuer or plan agrees to disclose to HI-IS,on behalf of the Plan Sponsor,at a time and in a manner specified by the HHS Secretary in guidance, the information,data,documents,and records necessary for the Plan Sponsor to comply with the requirements of the Early Retiree Reinsurance Program,as specified in 45 C.F.R.149.35. 4. Use of Records:Plan Sponsor understands and agrees that the Secretary 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 Section 1102 of the Patient Protection Act(P.L.111-148)and 45 C.F.R.Part 149 including,but not limited to,determining reimbursements and reimbursement- related oversight and program integrity activities,or as otherwise allowed by law. Nothing in this section limits the U.S.Department of Health&Human Services'Office of the Inspector General's authority to fulfill the Inspector General's responsibilities in accordance with applicable Federal law. S. 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 a 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 the Secretary.Plan Sponsor will promptly update any changes to the information submitted in its Plan Sponsor application.If Plan Sponsor becomes aware that information in this application is not(or is no longer)true,accurate and to ' Page 11 HHS Form#CMS-10321J�C2(+ OMB Approval 0938-1087 complete,Plan Sponsor agrees to notify the Secretary 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 C.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 appropriate safeguards in regard to PHI.Any and all Plan Sponsor personnel interacting with PHI shall be advised of:(1)the confidential nature of the information;(2)safeguards required to protect the information;and(3)the administrative,civil and criminal penalties for noncompliance contained in applicable Federal laws. 7. Depository Information:Plan Sponsor hereby authorizes the Secretary 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 (Pl.111-148)and 45 C.F.R Part 149 and applicable provisions of 45 C.F.R.Part 30,to the account at the financial institution(hereinafter the"Depository")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 the 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. The Plan Sponsor attests that,as of the date this Application is submitted,has in place policies and procedures to detect and reduce fraud,waste,and abuse related to the Early Retiree Reinsurance Program.The Plan Sponsor will produce the policies and procedures,and necessary information,records and data,upon request by the Secretary,to substantiate existence of the policies and procedures and their effectiveness,as specified in 45 C.F.R.Part 149. 9. Change of Ownership;The Plan Sponsor shall provide written notice to the Secretary at least 60 days prior to a change in ownership,as defined in 45 C.F.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.I declare that I have examined this Plan Sponsor Application and Plan Sponsor Agreement.My signature legally and financially binds the Plan Sponsor to the statutes,regulations,and other guidance applicable to the Early Retiree Reinsurance Program including,but not limited to Section 1102 of the Patient Protection Act(P.L.111-148)and 45 C.F.R. Part 149 and applicable provisions of 45 C.F.R.Part 30 and all other applicable statutes 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 the Secretary to verify this information.I understand that,because program Page 12 HHS Form MCMS-1032] OMB Approval 0938-1087 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. 'Signature: Page 13 HHS Form#CMS-10321 = !Y OMB Approval 0938-1087 Attachment:Additional Benefit Options (Complete this form for each unique benefit option not already specified above in Part II.B) la)'Benefit Option Name: Preferred Provider Organization-Standard Plan lb)'Unique Benefit Option Identifier:PPO-00358610-Class 0002 I 1c)'Benefit Option Type: Self-Funded El Insured❑ Both l El Id)"Benefit Administrator Company Name:CIGNA Page 14 HHS Form#CMS-10321 ;1Ty' Hello