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3
CONTRACT NO., 3��$$-_
No. 889000
Amendment 3
Attached to and made a part of the Administrative Services Only Agreement or Contract No.ASA or ASC-889000
(the"Services Agreement/Contract")
between
Aetna Life Insurance Company
(hereinafter referred to as Aetna)
and the Customer or Contractholder(as defined in the applicable services agreement or contract)
City of Fort Worth
(hereinafter defined as"Customer/Contractholder")
It is understood and agreed that the Services Agreement/Contract,as constituted on the effective date of this Amendment,is
changed to reflect that Aetna will provide the following services in addition to those services elected in accordance with the
terms of the Services Agreement/Contract:
Early Retiree Reinsurance Program(ERRP)reporting services as described in the attached Appendix C.
The charge for ERRP reporting services for the period 01/01/10 through 12/31/10 is
• $8,600 per ERRP plan year for Quarterly Reporting
• $1,000 per Direct Data Submission to HHS
• $1,000 per Additional Reports
The charge for ERRP Reporting will be payable as a Direct Billed charge in accordance with the terms of the Services
Agreement/Contract.
The charges may be adjusted annually effective on the anniversary of the Services Agreement/Contract by Aetna in
accordance with the terms of the Services Agreement/Contract.
Nothing contained in this amendment shall be held to alter or affect any of the terms of the contract other than as herein
specifically stated.
rOFFICIAL RECORD
SECRETARYORTH,TX
ERRP—ASC AMENDMENT 1
10-07-11 P02: 22 M
In Witness Whereof,the parties hereto have caused this Amendment to be executed by their duly authorized representatives,
to become effective January 1,2010.
Signed by Aetna,February 3,2011.
CUSTOMER: AETNA LIFE INSURANCE COMPANY:
CITY OF FORT WORTH
By: try By:
Printed Name: SUSo.i\ A10Ws Printed Name: Ronald A.Williams
((���__``.' q� Title: Chairman,Chief Executive Officer and
Title: �SS1S�atR� Ll w� I r�Gl��l�-e r President
Date: ���Ip, I Date: February 3.2011
Financial Verification:
APPROVED AS TO
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ASSI TA ITY ATTORNEY
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IAL RECORD
SECRETARY
ORTH, TX
ERRP—ASC AMENDMENT 2
APPENDIX C
EARLY RETIREE REINSURANCE PROGRAM("ERPP")REPORTING SERVICES
THIS APPENDIX between City of Fort Worth ("Customer/Contractholder")and Aetna Life Insurance Company or any of
its corporate affiliates("Aetna")is an attachment to Administrative Services Only Agreement or Contract No.ASA or ASC-
889000 (the"Services Agreement/Contract")between Aetna and Customer/Contractholder and is incorporated by reference
therein.
It is understood that Customer/Contractholder has applied to participate in the Early Retiree Reinsurance Program("ERRP")
authorized by the Patient Protection and Affordable Care Act(the"Act")and pursuant to which Customer/Contractholder
will request reimbursement for certain health care costs incurred with respect to certain early retirees,as defined under 45
CFR 149.2,who are covered under a certain health benefit plan for which Aetna provides administrative services under the
Services Agreement/Contract(the"Early Retirees"). The Act and regulations promulgated thereunder require that applicants
for participation in the ERRP have a written agreement containing certain terms and conditions in place with vendors that
will assist the applicant in seeking reimbursement under the ERRP. The purpose of this Appendix is to comply with these
written agreement requirements and to specify the services to be provided by Aetna to Customer/Contractholder in
connection with the ERRP and the applicable charges for such services. This Appendix shall supersede and replace any
agreement entered into previously by Aetna and Customer/Contractholder for purposes of Customer/Contractholder's initial
ERRP application.
1. Services—
In support of Customer/Contractholder's ERRP reimbursement requests pertaining to the Early Retirees,Aetna will prepare
the required cost data in support of the ERRP. Such reports will be prepared by Aetna in the form and manner required by
the Department of Health and Human Services("HHS")and will be submitted by Aetna to the Customer/Contractholder
and/or the Customer/Contractholder's third party designee("Designee")so that the Customer/Contractholder and/or the
Designee can consolidate such reports from all of Customer/Contractholder's claims data suppliers and submit the
consolidated reports to HHS.The cost reports prepared by Aetna will be based on eligibility information supplied by
Customer/Contractholder and/or its vendor(s)to Aetna regarding Early Retirees.
Customer/Contractholder shall have an ongoing responsibility to ensure that Aetna is furnished with timely updates to Early
Retiree eligibility information including any changes required as a result of any Customer/Contractholder appeal of an
adverse reimbursement determination. In connection with any report furnished by Aetna hereunder,Aetna shall not be
responsible for any delay or inaccuracies caused by Customer/Contractholder's and/or its vendor(s)' and/or claim data
suppliers'(as the case may be)failure to furnish accurate eligibility information with all data fields required by HHS in a
timely fashion.
2. Records Retention-Aetna shall maintain the ERRP-related records delineated in 45 CFR Section 149.350 and any
other record specified by the Secretary of HHS for six(6)years after the expiration of the plan year in which the costs were
incurred,or longer if otherwise required by law.
3. Disclosure to Department of Health and Human Services-Aetna agrees to disclose to HHS,on behalf of
Customer/Contractholder,in a time and in a manner specified by the Secretary,the information,data,documents,and records
necessary for Customer/Contractholder to comply with the requirements of the ERRP.
4. Policies and Procedures to Detect Fraud,Waste,and Abuse—Aetna shall have policies and procedures in place to
detect and reduce fraud,waste,and abuse.Upon request by HHS and the Office of the Inspector General("OIG"),Aetna will
produce to HHS and OIG such policies and procedures and any necessary documents or data to substantiate the
implementation of the policies and procedures and their effectiveness.
5. False Claims Act Acknowledgement—Customer/Contractholder and Aetna acknowledge that the data provided
hereunder in support of Customer/Contractholder's application and participation in ERRP is used for the purpose of obtaining
federal funds.
6. Disclosure of Confidential Early Retiree Health Data—Customer/Contractholder acknowledges that the reports and
other information provided to HHS pursuant to this Appendix will include confidential health data pertaining to Early
Retirees subject to certain state and federal laws protecting the privacy and confidentiality of such confidential health data
ERRP—ASC AMENDMENT
(the"Confidential Information"). Customer/Contractholder further acknowledges that Aetna is authorized to disclose the
Confidential Information on the Customer/Contractholder's behalf to HHS and/or to the Customer/Contractholder and/or
Designee without obtaining specific authorization from the affected individuals.
7. Standard of Care/Indemnification-The parties acknowledge that federal laws related to the ERRP are new and
evolving,and that the ERRP requirements and procedures are not yet fully defined and developed. As a result,HHS may
provide subsequent guidance or requirements that may alter the manner in which the services contemplated by this Appendix
are to be provided. Aetna shall carry out its obligations hereunder in accordance with its best understanding and
interpretations of the requirements of the ERPP. Aetna specifically acknowledges that,in performing its responsibilities
under this Appendix,it shall be subject to the standard of care and indemnification obligations contained in the Services
Agreement. Customer/Contractholder acknowledges and agrees that(i)Aetna is providing services hereunder for the sole
purpose of supporting Customer/Contractholder's request to HHS for reimbursement under the ERRP,and(ii)Aetna makes
no guarantee,representation or warranty that Customer/Contractholder will receive any reimbursement under the ERRP.
8. Compliance with Applicable Law—Customer/Contractholder and Aetna will abide by all applicable Federal laws and
regulations,including not limited to,all requirements pertaining to the ERRP and all applicable State and Federal privacy and
security requirements with respect to the Confidential Information.
9. Audits-Upon Customer/Contractholder's request,Aetna shall make records maintained or produced on behalf of
Customer/Contractholder with respect to the ERRP available to Customer/Contractholder and/or its Designee for audit or
inspection,subject to mutually acceptable audit guidelines,applicable state and federal laws protecting the privacy and
confidentiality of the Confidential Information,and the execution of a mutually acceptable confidentiality agreement.
10. Appeals—It shall be Customer/Contractholder's sole responsibility to decide whether to acceptor appeal any adverse
reimbursement determination with respect to the ERRP and to pursue any appeal thereof under 45 CFR 149.500.
11. Subcontractors. The work to be performed by Aetna under this Appendix may,at its discretion,be performed directly
by it or wholly or in part through a subsidiary or affiliate or under a contract with an organization of its choosing. Aetna will
remain liable for services under this Appendix.
ERRP--ASC AMENDMENT 2