HomeMy WebLinkAboutContract 47547 k
e
EMPLOYEE ASSISTANCE PROGRAM SERVICES AGREEMENT
CITY SECRETA P(
CONTRACT NO.
This Employee Assistance Program Services Agreement(hereinafter, the "Services Agreement") is made and entered into by and
between Aetna Behavioral Health,LLC on behalf of itself and its affiliates (hereinafter "Company"), and City of Fort Worth-TX
(hereinafter"Customer").
WHEREAS,Customer has established an employee assistance program("EAP")for certain eligible individuals;and
WHEREAS, Customer also desires to engage the services of Company to provide EAP services and WorkLife and other
additional EAP services which are defined in this Agreement(the"Services"),
THEREFORE,in consideration of the mutual covenants and promises stated herein and other good and valuable consideration,the
parties hereby enter into this Services Agreement, This Services Agreement includes and incorporates by reference the attached
General Conditions Addendum,Description of EAP Services Addendum,Description of Work/Life Services Addendum,
and Service and Fee Schedule,and the Business Associate Agreement entered into between Aetna Life Insurance Company,on
behalf of itself and its affiliates and Customer,(including Aetna Behavioral Health,LLC)as may be amended from time to time,
and is referred to herein as the"Business Associate Agreement".
Customer hereby elects to receive the Services set forth in the Service and Fee Schedule attached hereto and made a part hereof.
The corresponding Service Fees are specified in the Service and Fee Schedule, which shall be amended for future periods, in
accordance with Section 3 of the General Conditions Addendum,to reflect the Services elected and corresponding Service Fees
for such periods.
This Services Agreement(including incorporated addendums) constitutes the complete and exclusive contract between the parties
and supersedes any and all prior or contemporaneous oral or written communications or proposals not expressly included herein.
Notwithstanding Section 3 of the General Conditions Addendum, no modification or amendment of this Services Agreement
shall be valid unless contained in a writing signed by a duly authorized representative of Company and a duly authorized
representative of Customer. By executing this Services Agreement, Customer acknowledges and agrees that it has reviewed all
terms and conditions incorporated into this Services Agreement and intends to be legally bound by the same.
X234 b6)
Rlr��'VED
OFFICIAL RECORD FEB 2 6 2616 i
CITY OF FORT WORTH
CITY SECRETARY �� CITYSECRETARY .-
FT.WORTH,TX
EAP 8`9 ! b £ Z �v^
EMPLOYEE ASSISTANCE PROGRAM SERVICES AGREEMENT
The initial term of this Services Agreement shall be from 01/01/2016 through 12/31/2018. This Agreement may be executed in
counterparts, each of which when so executed and delivered shall be considered an original, but such counterparts shall together
constitute one and the same instrument and agreement. Any signature delivered by a party by facsimile or other electronic
transmission (including email transmission of a portable document file (pdf) or similar image) shall be deemed to be an original
signature hereto.
IN WITNESS WHEREOF, parties her ave caused this Services Agreement to be executed by their duly authorized
representatives on the �. date of _.
CITY OF FORT WORTH-TX AETNA BEHAVIORAL HEALTH,LLC
Signed By: Signed By:
Susan lan Printed Name: Hyong Un,M.D.
Assists it Mana r Title: Head of EAP and Chief Psychiatric Officer
Date: OP- 2!A0 I 3-p/(e Date• / / 2
of Q2, .
ATTEST: A.�8°
°0
/Milry Kay er ty Werefary ,J•°°°° ,d�° '
0000°°°
Wui�en-no
OVED AS TO FORM AND LEGALITY: �q s
(Will)S.Trevino,Asst.City Attorney 11
CONTRACT AUTHORIZATION:
M&C No.:C-27334
-Fc, I Z 4 5 }Jan No avf
OFFICIAL RECORD
CITY SECRETARY
FT.WORTH,TX
EAP 2
EMPLOYEE ASSISTANCE PROGRAM SERVICES AGREEMENT
GENERAL CONDITIONS ADDENDUM
Definitions: In this General Conditions Addendum and in all attachments to this Services Agreement:
(A) "Employee" means any person eligible to receive Services under this Services Agreement by virtue of being a current
employee of Customer, and not designated a temporary employee, and employees of subsidiaries and affiliates of Customer
who are reported by Customer,in writing,to Company for inclusion in this Services Agreement.
(B) "Dependent"means the eligible family members,including domestic partners,household members,and dependents (including
adult children up to age 26)of an Employee eligible to receive Services under this Services Agreement as a dependent of an
Employee.
(C) If Applicable,the term"EAP Behavioral Health Professional"may mean EAP Network Provider or EAP Staff Clinician.
(D) If applicable, the term"EAP Network Providers"shall mean licensed behavioral health professionals, who meet all Company
credentialing standards,and who are contracted by Company,as independent contractors,to provide counseling to Members.
(E) If applicable, the term "EAP Staff Clinicians" shall mean behavioral health professionals who are licensed in the State in
which they practice and who are employed by Company to provide clinical services to Members. EAP Staff Clinicians may
be part of Company's EAP call center and may provide telephonic clinical services. If applicable,EAP Staff Clinicians may
be located at the Customer site and provide counseling at the Customer's location.
(F) "Members"means Employees and Dependents eligible for Services.
(G) "Payment Due Date"shall mean the date that payment is required as set forth on the Customer's invoice. Payment Due Date
will be 30 days from the invoice generation date for the invoice month(s). Payment is to be made in a form and manner as
reasonably determined by Company.
(H) The term"Service Fees"shall have the meaning set forth in Section 3 of this General Conditions Addendum.
(I) The term"Services"shall have the meaning set forth in Section 1 of this General Conditions Addendum.
The following are the terms and conditions under which Company agrees to perform Services for Customer:
1. Purpose. Customer will purchase and Company will provide to Customer the Services designated in this Services Agreement
and such other services Customer requests of Company and Company agrees in writing to perform, as described in the
Service and Fee Schedule and the Description of Services Addenda(the "Services").
2. Term. The initial term of this Services Agreement shall commence on January 1,2016("Effective Date")and shall expire on
December 31, 2018, unless terminated earlier by either party in accordance with Section 4 of this General Conditions
Addendum. Following the initial term, Customer and Company may renew this Agreement for two (2) additional one-year
terms. If either party desires to exercise an option to renew, the renewing party shall notify the other party in writing of its
intention to renew at least 60 days prior to the end of the then-current term. Compensation to be paid during any option term
shall be the same as that provided for in the Initial Term, unless otherwise agreed to in writing.
3. Service Fees; Renewals. The Service Fees payable by Customer to Company for the Services shall be determined in
accordance with the Service and Fee Schedule. No Services other than those identified in the Service and Fee Schedule are
included in the Service Fees. Both the Services to be provided by Company and the Service Fees may be amended by
Company in accordance with the terms and conditions of the Service and Fee Schedule.
4. Termination. This Services Agreement may be terminated by Company or the Customer as follows:
(A) Legal Prohibition - If any state or other jurisdiction enacts a law which prohibits the continuance of this Services
Agreement, or an existing law is interpreted to prohibit the continuance of this Services Agreement, this Services
Agreement shall terminate automatically as to such state or jurisdiction on the effective date of such law or interpretation;
EAP 3
EMPLOYEE ASSISTANCE PROGRAM SERVICES AGREEMENT
provided, however, that if only a portion of this Services Agreement is prohibited by such law, only that portion of this
Services Agreement shall be affected,and this Services Agreement shall be construed in all respects as if such invalid or
unenforceable provision were omitted.
(B) Customer Termination - Customer may, with or without cause, terminate this Services Agreement with respect to all
Employees (including their Dependents) or any group of Employees included under this Services Agreement or any
subsidiary or affiliate of Customer that is covered under this Services Agreement by giving Company at least thirty-one
(3 1)days written notice stating when,after the date of such notice,such termination shall become effective.
(C) Company Termination-
(1) Company may terminate this Services Agreement by giving to Customer at least thirty-one (31) days written notice
stating when,after the date of such notice,such termination shall become effective.
(2) Company may terminate this Services Agreement within ninety(90)days of transmitting notice to Customer by mail,
facsimile transmission or other means of communication (including electronic mail) if (a) Customer fails to pay
Service Fees by the Payment Due Date,(b)Customer fails to provide current Employee counts to Company by each
Payment Due Date, (c) Company determines that Customer will not meet its obligation to pay such Service Fees
and/or provide current Employee counts by the Payment Due Date,and/or(d)Company determines that Customer is
in material default,or substantial breach,of one or more of its obligations under this Services Agreement.
(3) Any acceptance by Company of funds or Service Fees described in paragraph 3 above, shall not constitute a waiver
of Company's right to terminate this Services Agreement in accordance with this section with respect to any other
failure of Customer to meet its obligations hereunder.
(D) Non-appropriation of Funds — In the event no funds or insufficient funds are appropriated by Customer in any fiscal
period for any payments due hereunder,Customer will notify Company of such occurrence and this Servicees Agreement
shall terminate on the last day of the fiscal period for which appropriations were received without penalty or expense to
Customer of any kind whatsoever, except as to the portions of the payments herein agreed upon for which funds shall
have been appropriated.
5. Customer's Responsibilities.
(A) Employee Count—If needed and where applicable,on or before the Effective Date,Customer may be requested to furnish to
Company a listing of Employees (by zip code of each Employee's place of residence). Thereafter,Customer shall supply to
Company, on a monthly basis by the Payment Due Date, current Employee counts in a form and manner as reasonably
determined by Company. Company shall not be responsible in any manner for any delay or error in the provision of Services
caused by the Customer's failure to furnish accurate Employee counts in a timely fashion. If Customer fails to provide current
Employee counts with payment by the Payment Due Date, all Employee counts will be updated and reflected in the next
billing and payment cycle. Company will not process Employee counts retroactively nor will Company perform any
retroactive fee adjustments due to Customer submitting inaccurate Employee counts.
(B) Fiduciary Duty — It is understood and agreed that the Customer, as Plan Administrator, retains complete authority and
responsibility for their employee health benefits plan (the "Plan"), its operations, and the benefits provided there under,
including EAP(if applicable)and that Company is empowered to act on behalf of Customer in connection with the Plan only
to the extent expressly stated in this Services Agreement or as agreed to in writing by Company and Customer.
(C) Summary Plan Description (SPD) — If Customer's EAP is part of the Plan, Customer shall provide Company with all Plan
documents at least thirty(30)days prior to the Effective Date or such other date mutually agreed upon by the parties. Absent
the Customer providing Company with an SPD,Company shall automatically apply its internal policies and procedures to all
EAP plans, including but not limited to internal appeals and external review, as applicable. Company does not review
Customer's SPD for compliance with applicable law.
6. Services. Company shall perform the Services set forth in the Service and Fee Schedule and the Description of Services
Addenda. Customer acknowledges that Company may utilize the services of external contractors in performing these
Services. Company and Customer will discharge their obligations under this Services Agreement with that level of reasonable
EAP 4
EMPLOYEE ASSISTANCE PROGRAM SERVICES AGREEMENT
care which a similarly situated EAP Services provider or Plan Administrator under ERISA would exercise under similar
circumstances.
7. Records. Customer acknowledges and agrees that Company or its affiliates or authorized agents shall have the right to use all
documents, records, reports, and data, including data recorded in Company's data processing systems ("Documentation"),
subject to compliance with privacy laws and regulations, including without limitation regulations promulgated pursuant to the
Health Insurance Portability and Accountability Act of 1996. All Documentation is stored in Company's data warehouses,
and may be de-identified as to Members and Customer identity for purposes other than administration of EAP Services, at
Company's discretion. Customer is not compensated for any use of de-identified Documentation maintained in Company's
data warehouse.
8. Indemnification.
(A) Company shall indemnify and hold harmless Customer, its directors, officers, employees (acting in the course of their
employment, but not as Members) for that portion of any third party loss, liability, damage, expense, settlement, cost or
obligation (including reasonable attorneys' fees) caused solely and directly by Company's willful misconduct, criminal
conduct,breach of this Services Agreement, fraud,breach of fiduciary responsibility, or failure to comply with Section 6
above,related to or arising out of the Services provided under this Services Agreement.
(B) Except as provided in (A) above, Customer shall, to the extent allowed by law, indemnify and hold harmless Company,
its affiliates and their respective directors, officers, and employees for that portion of any third party loss, liability,
damage, expense, settlement, cost or obligation (including reasonable attorney's fees): (i) which was caused solely and
directly by Customer's willful misconduct, criminal conduct, breach of this Services Agreement, fraud, breach of
fiduciary responsibility,or failure to comply with Section 6 above, related to or arising out of this Services Agreement or
Customer's role as employer; (ii) resulting from taxes, assessments and penalties incurred by Company by reason of
Services performed hereunder, and any interest thereon, provided that Customer shall not be required to pay any net
income, franchise or other tax, however designated,based upon or measured by Company's net income, receipts, capital
or net worth, (iii) in connection with the release or transfer of Member-identifiable information to Customer or a third
party designated by Customer, or the use or further disclosure of such information by Customer or such third party
designated by Customer;or (iv)resulting from or arising out of claims,demands or lawsuits brought against Company in
connection with Services provided under this Services Agreement,except those claims covered by subsection(A)above.
(C) The party seeking indemnification under(A)or(B)above must notify the indemnifying party within 20 days in writing of
any actual or threatened action, suit or proceeding to which it claims such indemnification applies. Failure to so notify
the indemnifying party shall not be deemed a waiver of the right to seek indemnification to the extent permitted by law,
unless the actions of the indemnifying party have been prejudiced by the failure of the other party to provide notice
within the required time period.
The indemnifying party may then take steps to be joined as a party to such proceeding, and the party seeking
indemnification shall not oppose any such joinder. Whether or not such joinder takes place,the indemnifying party shall
provide the defense with respect to claims to which this Section applies and in doing so shall have the right to control the
defense and settlement with respect to such claims.
The party seeking indemnification may assume responsibility for the direction of its own defense at any time, including
the right to settle or compromise any claim against it without the consent of the indemnifying party, provided that in
doing so it shall be deemed to have waived its right to indemnification except in cases where the indemnifying party has
declined to defend against the claim.
(D) Customer and Company agree that, except for counseling services provided by EAP Staff Clinicians: (i) Company does
not render medical services or treatments to Members; (ii) neither Customer nor Company is responsible for the health
care that is delivered by EAP Network Providers; (iii)EAP Network Providers are solely responsible for the health care
they deliver to Members; (iv)EAP Network Providers are not the agents or employees of Customer or Company; and(v)
the indemnification obligations of(A) or (B) above do not apply to any portion of any loss, liability, damage, expense,
settlement,cost or obligation caused by the acts or omissions of EAP Network Providers with respect to Members.
EAP 5
EMPLOYEE ASSISTANCE PROGRAI:.SERVICES AGREEMENT
(E) The indemnification obligations under (A) above shall not apply to that portion of any loss, liability, damage, expense,
settlement, cost or obligation caused by Company's act or omission undertaken at the direction of Customer (other than
Services described in this Services Agreement). The indemnification obligations under(B) above shall not apply to that
portion of any loss, liability, damage, expense, settlement, cost or obligation undertaken by Customer at the direction of
Company.
(F) The indemnification obligations under this Section 8 shall terminate upon the expiration of this Services Agreement,
except as to any matter concerning which a claim has been asserted by notice to the other party at the time of such
expiration or within two(2)years thereafter.
(G) Nothing contained herein shall be construed so as to require the Customer to create a sinking fund or assess, levy and
collect any tax to fund its obligations under this Section 8.
9. Remedies. Other than in an action between the parties for third party indemnification, neither party shall be liable to the
other for any consequential,incidental or punitive damages whatsoever.
10. Binding Arbitration of Certain Disputes. Any controversy or claim arising out of or relating to this Services Agreement or
the breach, termination, or validity thereof, except for temporary, preliminary, or permanent injunctive relief or any other
form of equitable relief,shall be settled by binding arbitration administered by the American Arbitration Association("AAA")
and conducted by a sole arbitrator in accordance with the AAA's Commercial Arbitration Rules ("Rules"). The arbitration
shall be governed by the Federal Arbitration Act, 9 U.S.C. §§ 1-16, to the exclusion of state laws inconsistent therewith or
that would produce a different result, and judgment on the award rendered by the arbitrator may be entered by any court
having jurisdiction thereof. Except as may be required by law or to the extent necessary in connection with a judicial
challenge,or enforcement of an award, neither a party nor the arbitrator may disclose the existence, content,record or results
of an arbitration. Fourteen(14)calendar days before the hearing,the parties will exchange and provide to the arbitrator(a) a
list of witnesses they intend to call (including any experts)with a short description of the anticipated direct testimony of each
witness and an estimate of the length thereof, and (b) premarked copies of all exhibits they intend to use at the hearing.
Depositions for discovery purposes shall not be permitted. The arbitrator may award only monetary relief and is not
empowered to award damages other than compensatory damages.
11. Confidentiality.
(A) Business Confidential Information - Each party acknowledges that performance of this Services Agreement may
involve access to and disclosure of Customer and Company identifiable business proprietary data, rates, procedures,
materials, lists, systems and information of the other (collectively "Business Confidential Information"). No Business
Confidential Information shall be disclosed to any third party other than a party's representatives who have a need to
know such Information in relation to administration of the EAP Services, and provided that such representatives are
informed of the confidentiality provisions hereof and agree to abide by them. All such information must be maintained in
strict confidence. Customer agrees that Company may make lawful references to Customer in its marketing activities and
in informing health care providers (including EAP Network Providers) as to the organizations and plans for which
Services are to be provided.
(B) Company Confidential Information—Any information with respect to Company or any of its affiliate's fees or specific
rates of payment to health care providers (including EAP Network Providers) and any information which may allow
determination of such fees or rates any of the terms and provisions of the health care provider's agreement (including
EAP Network Providers) with Company or its affiliates are deemed to be Company Confidential Information. No
disclosure of any such information may be made or permitted to Customer or to any third party whatsoever, including,
but not limited to, any broker, consultant, auditor, reviewer, administrator or agent unless (i) Company has consented in
writing to such disclosure and (ii) each such recipient has executed a confidentiality agreement in form satisfactory to
Company's counsel.The Customer will not be held liable for any disclosure that is done in accordance with state law or a
court order. In any event, Customer will notify Company in a timely manner of such request for information. This
provision shall survive the termination of.this Agreement.
(C) Member Confidential Information — In addition, each party will maintain the confidentiality of medical records and
confidential Member-identifiable patient information ("Member Confidential Information"), and in accordance with the
terms of the Business Associate Agreement.
EAP 6
EMPLOYEE ASSISTANCE PROGRAM SERVICES AGREEMENT
(D) Upon Termination—Upon termination of this Services Agreement,each party,upon the request of the other,will return
or destroy all copies of all of the other's Confidential Information in its possession or control except to the extent such
Confidential Information must be retained pursuant to applicable law, to the extent such Confidential Information cannot
be disaggregated from the Company's databases, or except as otherwise provided under the Business Associate
Agreement,provided,however,that Company may retain copies of any such Confidential Information it deems necessary
for the defense of litigation concerning the Services it provided under this Services Agreement.
(E) Customer and Company acknowledge that compliance with the provisions of the foregoing paragraphs are necessary to
protect the business and good will of each party and its affiliates and that any actual or potential breach will irreparably
cause damage to each party or its affiliates for which money damages may not be adequate. Customer and Company
therefore agree that if a party or party's representatives breach or attempt to breach paragraphs (A) through (D) hereof,
the other party will not oppose such party's request for temporary, preliminary and permanent equitable relief, without
bond, to restrain such breaches, together with any and all other legal and equitable remedies available under applicable
law or under this Services Agreement. The prevailing party shall, to the extent permitted by law,be entitled to recover
from the non-prevailing party the attorneys' fees and costs it expends in any action related to such breach or attempted
breach.
12. Relationship of the Parties. It is understood and agreed that Company is an independent contractor with respect to all
Services being performed pursuant to this Services Agreement. Company makes no guarantee and disclaims any obligation to
make any specific EAP Network Providers or any particular number of EAP Network Providers available for use by
Members.
13. Subcontractors. The work to be performed by Company under this Services Agreement 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.
Company will remain liable for Services under this Services Agreement.
14. Communications. Company and Customer shall be entitled to rely upon any communication believed by them to be genuine
and to have been signed or presented by the proper party or parties.
Neither party shall be bound by any notice, direction, requisition or request unless and until it shall have been received in
writing at(i) in the case of Company,4300 Centreway Place,Mail Code: 756, Arlington,TX 76018,Attention: Head of EAP
and Chief Psychiatric Officer, (ii) in the case of the Customer, at the address shown below, or (iii) at such other address as
either party specifies for the purposes of this Services Agreement by notice in writing addressed to the other party. Notices or
communications shall be sent by certified mail,return receipt requested.
City of Fort Worth—TX
Attn.Vickie Tieszen
1000 Throckmorton
Fort Worth,TX 76102
With copy to City Attorney's Office at same address.
15. Force Majeure. Company shall not be liable for any failure to meet any of the obligations or provide any of the Services or
benefits specified or required under this Services Agreement where such failure to perform is due to any contingency beyond
the reasonable control of Company, its employees, officers or directors. Such contingencies include, but are not limited to:
acts or omissions of any person or entity not employed or reasonably controlled by Company, its employees, officers or
directors;acts of God; fires; wars;accidents;labor disputes or shortages;governmental laws,ordinances,rules,regulations,or
the opinions rendered by any Court,whether valid or invalid.
16. Compliance. Customer and Company shall remain, throughout the term of this Services Agreement, in compliance with all
applicable federal and state laws and regulations, including HIPAA,related to this Services Agreement and the Services to be
provided hereunder. Accordingly,the parties agree to the terms of the Business Associate Agreement.
17. Audit Rights. Until the expiration of two (2) years after final payment under this agreement, Customer may perform audits
of Company's EAP processes only,during normal business hours upon reasonable written notice. A process audit may not be
EAP 7
EMPLOYEE ASSISTANCE PROGRAM SERVICES AGREEMENT
conducted more than once annually and will not include access to individually identifiable Member information. Any
requested payment from Company resulting from the audit must be based upon documented findings, agreed to by both
parties,and must be solely due to Company's actions or inactions.
18. Insurance. Company shall maintain general, professional, and cyber liability insurance with policy limits of not less than
$1,000,000 per occurrence and in the aggregate with a company that is licensed to do business in Texas or otherwise
approved by the City of Fort Worth,A copy of the policy and certificate is also attached hereto as Exhibit A and incorporated
herein by reference for coverage for claims arising out of the performance of its services under this Services Agreement
18, Miscellaneous. The Services Agreement shall be governed by and interpreted in accordance with applicable federal law,
including but not limited to ERISA. To the extent such federal law does not govern, this Services Agreement shall be
governed by the laws of the State of Texas and the courts in such state shall have sole and exclusive jurisdiction of any
dispute related hereto or arising hereunder. No delay or failure of either party in exercising any right hereunder shall be
deemed to constitute a waiver of that right. It is further understood and agreed that by execution of this Agreement,Customer
does not waive or surrender any of its governmental powers. There are no intended third party beneficiaries of this Services
Agreement. This Section and Sections 3 through 7 and 9 through 11 shall survive termination of the Services Agreement.
The provisions of Section 8 shall survive termination only to the extent stated therein. The headings in this Services
Agreement are for reference only and shall not affect the interpretation or construction of this Services Agreement.
EAP 8
EMPLOYEE ASSISTANCE PROGRAM SERVICES AGREEMENT
DESCRIPTION OF EAP SERVICES ADDENDUM
Subject to the terms and conditions of this Services Agreement,the EAP Services selected by Customer and provided by Company
are reflected in this Description of EAP Services Addendum and the Service and Fee Schedule(as modified by Company from
time to time pursuant to Section 3 of the General Conditions Addendum). Additional EAP Services may be provided at
Customer's written request under the terms of this Services Agreement. All Services described in this Services Agreement are
available within the United States only. International EAP Services are only available if specifically described and priced
separately.
1. UNLIMITED TELEPHONIC ASSESSMENT AND REFERRAL: Unlimited telephonic access to the Company EAP
call center staff, available 24 hours per day, 7 days per week, 365 days per year for purposes of assessing Member need
and referring to appropriate EAP Services.
2. COUNSELING SESSIONS: A clinical session with an EAP Network Provider or EAP Staff Clinician. Sessions are
intended to assist with emotional,family,personal,or work related behavioral health issues.
• COUNSELING SESSIONS WITH EAP NETWORK PROVIDERS AND CONTRACTED TELEVIDEO
PROVIDERS: Counseling sessions can be provided face-to-face, telephonically, or via televideo (when
appropriate). Face-to-face or telephonic sessions are provided by an EAP Network Provider. Televideo
sessions are provided by one of our specialty telepsychiatry vendors. Each member is entitled, on a contract
year, up to the number of counseling sessions per problem as set forth herein in the Service and Fee Schedule
(e.g., up to three counseling sessions per member per problem under the 3-Session EAP Model), unless a State
regulation requires otherwise. All counseling sessions require prior authorization. The member must contact
Company to receive referrals and authorizations for all counseling sessions whether face-to-face, telephonic, or
televideo. Marital and/or family sessions are considered one problem for the couple or family and sessions are
not authorized individually for each attendee. Face-to-face, telephonic, and televideo counseling sessions count
toward the number of counseling sessions per member per problem.
3. EAP PROVIDER NETWORK: A nationwide network of licensed behavioral health professionals, who meet all
Company credentialing standards, and who are contracted by Company, as independent contractors, to provide
counseling to Members. EAP Network Providers include, but are not limited to: social workers, licensed professional
counselors,marriage and family therapists,master's level psychiatric nurses and psychologists.
4. TRAINING AND EDUCATION: The term "Training and Education" refers to training, provided by Company, or a
Company Contracted educator to the Customer,concerning general behavioral health and work/life issues. This includes
Employee Orientation Meetings and Supervisor Orientation Trainings. This training may be provided in different ways,
i.e. in-person, telephonically, or web-based. Additional fees apply to web-based training over 25 participants
(Participants is defined as unique phone lines calling into the webinar). Department of Transportation (DOT) services
are excluded from standard Training and Education services. For specialized DOT training,see separate definition under
Drug Free Workplace Services. Mental Health First Aid trainings are excluded from standard Training and Education
services. For specialized Mental Health First Aid training,see separate definition under Mental Health First Aid.
5. MANAGEMENT SERVICES:
• MANAGEMENT CONSULTATION: A telephonic resource for managers, supervisors, and human resources
professionals to assist in identifying and resolving workplace issues and promoting a productive workforce. Issues
may include but are not limited to employee personal and family issues, behavioral health concerns, workplace
conflict, workplace crisis and other disruptions, substance abuse, threats of violence and employee performance
concerns. This includes the provisions of guidance to the Customer in making voluntary referrals for employees to
the EAP. EAP will coordinate with specialty providers as needed(SAP,DOT,FFD).
• MANDATORY REFERRALS: Case management to assist Customer and employees in addressing significant
workplace performance issues. Mandatory referrals are used to monitor compliance with the EAP Behavioral Health
EAP 9
EMPLOYEE ASSISTANCE PROGRAM SERVICES AGREEMENT
Professional's recommendations, wherein the EAP,with appropriate executed release of information forms,confirms
the employee's participation in and compliance with the Program.
• DRUG FREE WORKPLACE SERVICES: Suite of services to assist Customer in managing workplace related
employee substance mis-use and/or disclosure of substance abuse in the workplace. Services for general employer
industries include Company EAP case management of mandatory referrals related to workplace impacted substance
abuse, as well as management consultation services as described above. Services for transportation related
industries, such as employers who are regulated by DOT, FMCSA, FAA, FRA, FTA, PHMSA, etc., include
substance abuse case management by a Substance Abuse Professional (SAP) for Department of Transportation
regulation compliance. Additional service for transportation regulated employees includes DOT training to meet
Drug-Free Workplace regulations regarding drug and alcohol awareness available through American Substance
Abuse Professionals (ASAP)or comparable SAP provider. A variety of training formats are available, including on-
site,on-line or video.
• FITNESS FOR DUTY (FFD) CONSULTATION AND COORDINATION: A Fitness for Duty Evaluation is a
forensic evaluation completed by a specially trained psychologist, psychiatrist, outside the EAP, for the purpose of
evaluating an employee's ability to safely perform the functions of their job, assess organizational and behavioral
risk, and provide a report recommending steps needed to be taken to minimize Customer risk in returning the
employee to work. Fitness for Duty Evaluations are outside the scope of EAP, and as such the EAP does not
conduct Fitness for Duty Evaluations. Upon specific request,the EAP may assist Customer with locating companies
or providers external to the EAP who are capable of performing FFD Evaluations. At all times the Customer is
responsible for working directly with the identified FFD provider as well as directly making payment arrangements
with that provider for the FFD Evaluation. All decisions, regarding returning to work, retaining or dismissing
employees remain with the Customer.
• SUBSTANCE ABUSE PROFESSIONAL (SAP) CONSULTATION AND CONTACT INFORMATION: Upon
request of Customer, for drug and alcohol cases that fall under the Department of Transportation(DOT) guidelines,
Company shall provide initial and ongoing management consultation on DOT issues. Company will further provide
contact information of local providers in our specialized network of qualified Substance Abuse Professionals. The
Customer is responsible for choosing and working directly with the SAP, as well as performing Follow-up,
Compliance and Aftercare attendance monitoring. The Customer is responsible for payment of the SAP and
determines whether the employee or employer pays SAP fees as well as recommended treatment costs.
• MENTAL HEALTH FIRST AID: An educational program offered to Customers to help managers and employees
recognize and respond to mental health issues in the workplace. The curriculum includes an overview of mental
health and provides education about Anxiety,Depression,Suicide,Trauma,Psychosis,and Substance Use Disorders,
along with videos, interactive exercises and practice scenarios. Courses must be taught onsite. The eight hour course
provides all participants with Mental Health First Aid Certification for three years. A four-hour option is available
for a general overview of the topic. The four-hour class does NOT provide participants with a Mental Health First
Aid Certification.Courses are limited to 30 participants per course.
6. CRITICAL INCIDENT SUPPORT (Crisis Support/Management Services/Critical Incident Stress De-Briefing (CISD)
Services): An array of services offered by the EAP that helps an organization to prepare for, prevent, or respond to
traumatic events. Acts of war are excluded from on-site CISD Services.
• ON-SITE STANDARD CRITICAL INCIDENT SUPPORT: On-site attendance response time in greater than
two hours for hourly onsite crisis support and Critical Incident Stress De-Briefing (CISD) Services at Customer
sites to help an organization prepare for,prevent,or respond to traumatic events.
• ON-SITE IMMEDIATE CRITICAL INCIDENT SUPPORT: On-site attendance response time in less than two
hours for hourly onsite crisis support and Critical Incident Stress De-Briefing(CISD)Services at Customer sites
to help an organization prepare for,prevent,or respond to traumatic events.
7. REDUCTION IN FORCE: The process by which a work organization reduces its work force by eliminating jobs, such
as closing subsidiaries or departments.
EAP 10
EMPLOYEE ASSISTANCE PROGRAM SERVICES AGREEMENT
8. COMMUNICATION AND PROMOTIONAL MATERIALS: Information provided to Employees and management
about EAP Services, including, in part, how EAP Services can be accessed for consultation and assistance. The
communications and promotional resources may include template e-mails, letters, flyers, wallet cards, and posters for
Employees and management. Company will provide reasonable quantities of printed materials in support of
implementation and/or on an annual basis at Customer's request at no cost. Reasonable quantities are defined as up to
120% of the number of eligible Employees for items such as flyers or brochures; a quantity up to 5% of the number of
eligible Employees for items such as posters; and a quantity of up to 20%of anticipated attendees at health fairs for other
promotional items. Requests exceeding these quantities may incur an additional fee.
9. MANAGEMENT REPORTS: A specific collection of data and narrative information designed to inform the Customer
about the overall utilization of the program. Customer may receive reports on a quarterly electronic basis. If for any 2
consecutive reporting periods there is less than 1%utilization,reporting frequency will default to annual reporting.
10. INTAKE MODEL:
• STANDARD MODEL: Initial intake calls answered by a care service associate/customer service representative.
11. EAP EXCLUSIONS: The following services are outside the scope of the EAP:
• Counseling services beyond the allowed number of sessions covered by the EAP benefit.
• Court ordered treatment or therapy,or any treatment or therapy ordered as a condition of parole,probation,custody,
or visitation evaluations,or paid for by Workers' Compensation.
• Formal psychological evaluations which normally involve psychological testing and result in a written report.
• Diagnostic testing and/or treatment.
• Visits with psychiatrist,including medication management.
• Prescription medications.
• Services for remedial education.
• Inpatient,residential treatment,partial hospitalizations,intensive outpatient.
• Ongoing counseling for a chronic diagnosis that requires long term care.
• Biofeedback.
• Hypnotherapy.
• Aversion therapy.
• Examination and diagnostic services required to meet employment,licensing, insurance coverage,travel needs.
• Services with a non-contracted EAP provider.
• Fitness for duty evaluations.
• Legal representation in court,preparation of legal documents,or advice in the areas of taxes,patents,or immigration,
except as otherwise described in this document.
• Investment advice(nor does plan loan money or pay bills).
EAP 11
EMPLOYEE ASSISTANCE PROGRAM SERVICES AGREEMENT
DESCRIPTION OF WORKLIFE SERVICES ADDENDUM
Subject to the terms and conditions of this Services Agreement,the WorkLife Services selected by Customer and provided by
Company are reflected in this Description of WorkLife Services Addendum and the Service and Fee Schedule,(as modified by
Company from time to time pursuant to Section 3 of the General Conditions Addendum). Additional WorkLife Services may be
provided at Customer's written request under the terms of this Services Agreement.
L UNLIMITED TELEPHONIC ACCESS: Unlimited telephonic access to the call center staff,available 24 hours per day,7
days per week,365 days per year.
2. CAREGIVING SERVICES: Services that include consultation,information,education and referral services in connection
with,in part,adoption,child care,parenting, temporary back-up care,summer care,special needs,high-risk adolescents,academic
services,education loans,grandparents as parent,adult care,elder care,and disaster resources. Carekits may be included with this
service.
3. PERSONAL SERVICES:Free educational materials,personalized referrals,and interactive web tools to assist with:
A. Health&Wellness--Children's health;women's health;men's health;seniors' health;weight loss and nutrition;fitness
and exercise programs;general health;safety;stress management;information on diseases and conditions;and more.
B. Daily Life--Home improvement;pet care;consumer information;automotive services;relocation;travel; time
management;cleaning services;and more.
4.LEGAL SERVICES: Services provided through the EAP that include:
A. LEGAL SERVICES:
a. '/z hour Initial Consultation with selected participating attorney on an unlimited number of new Legal
Topics (each plan year). Certain topic areas are excluded, including employment law. Also excluded are
matters that, in the attorney's opinion, lack merit. Court costs, filing fees and fines are the responsibility of
the member. If members choose to continue with the participating attorney and hire that attorney on their
own, they will receive 25% off of the fees for services beyond the initial consultation (excluding flat legal
fees,contingency fees,and plan mediator services).
b. Mediation Services—Each member is entitled to one(1)initial thirty minute office or telephone
consultation per separate legal matter at no cost with a participating mediator. In the event that the member
wishes to retain a participating mediator after the initial consultation,they will be provided with a preferred
rate reduction of 25%from the mediator's normal hourly rate. Typical matters may include divorce and
child custody,contractual and consumer disputes,real estate and landlord tenant,car accidents and
insurance disputes.
c. Document Preparation: Members have access to telephonic document preparers and an on-line assisted
process to complete their own legal document preparation. Member's will receive a preferred discount of
10%off and the types of forms include,divorce,wills, living wills,powers of attorney, immigrations and
others.
d. Simple Will Preparation: Members receive resources to complete one Simple Will.
e. All initial consultation(and discounted consultations)must be for legal matters related to the Employee and
eligible household members.
5. FINANCIAL SERVICES: Services provided through the EAP that include:
A. FINANCIAL SERVICES:
a. '/z hour Initial Consultation with the selected participating financial counselor on an unlimited number of
new Financial Counseling Topics each plan year.
b. Financial counseling topics include Budgeting,Credit,Debt,Retirement,College Planning,Buying vs.
Leasing,Mortgages/Refinancing,Financial Planning,Tax Questions,Tax Preparation,IRS Matters,Tax
Levies and Garnishments,Consumer Credit Counseling,and Community Services.
c. A discount of 25%off the tax preparation services.
d. Individual Employees may have the option to purchase additional services for a monthly nominal fee.
6. IDENTITY THEFT SERVICES: Services provided through the EAP that include:
A. IDENTITY THEFT SERVICES:
a. 1-hour telephonic fraud resolution consultation for Identity Theft.
EAP 12
EMPLOYEE ASSISTANCE PROGRAM SERVICES AGREEMENT
b. Coaching and direction on prevention and restoring credit for victims of Identity Theft.
c. Free Identity Theft Emergency Response Kit for victims of Identity Theft.
d. Individual Employees may have the option to purchase additional services for a monthly nominal fee.
7. MEMBER WEBSITE:
A. CORE MEMBER WEBSITE: Access to customizable member website for free webinars,online worklife searches,
concierge database,discount program,thousands of articles, videos,and tools on worklife and behavioral health topics.
EAP 13
EMPLOYEE ASSIST ANCE PROGRAM SERVICES AGREEMENT
DOMESTIC EAP SERVICE AND FEE SCHEDULE
Customer hereby elects to receive the Services designated below. The below Service Fees shall be in effect for three(3)years of
this Services Agreement, beginning upon the Effective Date of this Services Agreement, and, thereafter, if this Services
Agreement is extended by the parties for any additional successive one year term(s), such Service Fees may be revised for each
such successive term. Notwithstanding the immediately preceding sentence, the below Service Fees shall be amended by
Company, from time to time during the first three (3) years of this Services Agreement and for any future period(s) thereafter, in
accordance with the terms of this Service and Fee Schedule.
Services Service Fees
EAP Session Model
Unlimited Telephonic Access $ 1.39 PE/PM
with
Up to Six counseling sessions with an EAP
Network Provider or televideo provider,
delivered via face-to-face,telephonically,or
televideo per problem per contract year
with
Worklife Services,including Caregiving
Services,Personal Services,Legal and
Financial Services,Identity Theft
Services,Core Member Website
EAP 14
EMPLOYEE ASSISTANCE PROGRAM SERVICES AGREEMENT
Services Service Fees
Critical Incident Support/Critical Incident Stress Fee for Service Standard CISD Pricing: $250.00 per hour plus
De-Briefing(CISD)Services—Standard Services travel and preparation expenses reimbursed at a flat rate of$150.00
(On-site attendance response time in greater than per location.
2 hours)
CISD hours used,whether fee for service and/or within the bank of
standard hours,are calculated based upon the combined total number
of hours all clinicians are on-site.
If Customer requests a specific crisis counselor,or a counselor with
specific qualities,including but not limited to specialized
certifications,experience,or language,Customer will be billed the
applicable hourly rate"door-to-door"which will include the
specialist's travel time. This is in lieu of the flat travel fee.
If Customer requests on-site crisis response services in a location
which is further than 50 miles from a town with a population of at
least 25,000 people,Customer will be billed the applicable hourly rate
"door-to-door"which will include the specialist's travel time. This is
in lieu of the flat travel fee.
If Customer requests on-site support services in response to a large
scale disaster area affecting the transportation infrastructure of that
area,and/or the availability of local providers,necessitating the
assistance of providers from outside the affected areas,Customer will
be billed the current hourly rate plus$50 per hour for each on-site
hour. In addition,Customer will be billed$200 per travel hour from
the command center to the intervention site. This is in lieu of the flat
travel fee.
Any other Customer requested services wherein the crisis counselor
incurs non-standard travel(e.g.having to fly to accompany employees
affected by a crisis) will be billed at the exact travel costs in addition
to the hourly fees.
Critical Incident Support/Critical Incident Stress Fee for Service Immediate CISD Pricing: $350.00 per hour plus
De-Briefing(CISD)Services—Immediate Services travel and preparation expenses reimbursed at a flat rate of$150.00
(On-site attendance response time in 2 hours or per location.
less)
CISD hours used, whether fee for service and/or within the bank of
standard hours,are calculated based upon the combined total number
of hours all clinicians are on-site.
If Customer requests a specific crisis counselor,or a counselor with
specific qualities,including but not limited to specialized
certifications,experience,or language,Customer will be billed the
applicable hourly rate"door-to-door"which will include the
specialist's travel time. This is in lieu of the flat travel fee.
If Customer requests on-site crisis response services in a location
which is further than 50 miles from a town with a population of at
least 25,000 people,Customer will be billed the applicable hourly rate
"door-to-door"which will include the specialist's travel time. This is
in lieu of the flat travel fee.
EAP 15
EMPLOYEE ASSISTANCE PROGRAM SERVICES AGREEMENT
Services Service Fees
If Customer requests on-site support services in response to a large
scale disaster area affecting the transportation infrastructure of that
area,and/or the availability of local providers,necessitating the
assistance of providers from outside the affected areas,Customer will
be billed the current hourly rate plus$50 per hour for each on-site
hour. In addition,Customer will be billed$200 per travel hour from
the command center to the intervention site. This is in lieu of the flat
travel fee.
Any other Customer requested services wherein the crisis counselor
incurs non-standard travel(e.g.having to fly to accompany employees
affected by a crisis)will be billed at the exact travel costs in addition
to the hourly fees.
Critical Incident Support/Critical Incident Stress Whenever possible,Customer agrees to provide Company with 24
De-Briefing(CISD)Cancellation Fee hours advance notice of cancellation of any requested Workplace
Crisis Response Services. Failure to provide Company with 24 hours'
notice of cancellation of any services:
• Fee for Service CISD Cancellation Fee: Services which
are provided on a fee for service basis and which are subject
to the hourly rate will result in a charge of$375.00 per
incident.
Reduction in Force Fee for Service Reduction in Force Pricing: $250.00 per hour plus
travel and preparation expenses reimbursed at a flat rate of$150.00
per location.
Reduction in Force Cancellation Fee Reduction in Force Cancellation Fee: $375.00 per incident charge
for failure to provide Company with 24 hour notice of cancellation of
Reduction in Force service.
EAP 16
EMPLOYEE ASSISTANCE PROGRAM SERVICES AGREEMENT
Services Service Fees
Training and Education Bank of Training Hours: 16 hours of Training and Education are
included in the EAP Session Model PE/PM Rate.Training and
Education services may be on-site,or for web-based seminars up to 25
participants. For webinars with more than 25 participants,an
additional charge of$50.00 applies for each additional 25 participants
up to a maximum of 200 participants. Additional Training and
Education sessions are$250.00 per hour for the total amount of time
that the educator is on site,plus a$150.00 per location charge for
travel and preparation time.If training is not scheduled consecutively
or multiple topics are scheduled,additional travel and preparation
costs may apply or additional hours may be deducted from the bank.
These capitated hours will be used for the total amount of time that the
educator is on site.
Sessions less than one(1)hour in duration will count as one(1)hour
of Training and Education.
If Customer requests a specific educator,or an educator with specific
qualities,including but not limited to specialized certifications,
experiences or language,Customer will be billed any additional
incurred fees beyond the hourly fee above or have hours deducted
from bank.
In addition,if Customer cannot accommodate the schedule/availability
of a local Company contracted educator,requiring that the services of
an educator 50 miles away or greater from the Customer location is
necessary,then Customer will be billed any additional incurred fees
beyond the hourly fee above or have hours deducted from bank.
Training and Education Cancellation Fee Failure to provide Company three(3)business days' notice of
cancellation of a previously scheduled training program may result in
a charge of:
• Bank of Training Hours Training Cancellation Fee:
Services which are included in the bank of capitated hours
described above,will result in the deduction of a number of
hours from the bank,equal to the number of cancelled hours.
When the bank of hours has been exhausted,fee for service
training cancellation fee of$375.00 per hour applies.
Mental Health First Aid—8-Hour Course $7,200.00
This option provides eight(8)hours of standard Mental Health First
Aid curriculum.Fee includes all instructor fees,travel,and
customization
Mental Health First Aid-4-Hour Course $5,700.00
This option provides four(4)hours of standard Mental Health First
Aid curriculum.Fee includes all instructor fees,travel,and
EAP 17
� r
EMPLOYEE ASSISTANCE PROGRAM SERVICES AGREEMENT
Services Service Fees
customization
Mental Health First Aid Cancellation Fee If the Customer cancels for any reason within 30 days from the
Schedule training date,the Customer will be responsible for cancellation fees
as follows:
• 50%of the total fee 15-30 days prior to the scheduled date of
training.
• 100%of the total fee 0-14 days prior to the scheduled date of
training.
Drug Free Workplace Services
Substance Abuse Case Management by a $750.00 per case
Substance Abuse Professional(SAP)and/or
for Department of Transportation regulation
compliance
and and
DOT training to meet Drug-Free Workplace DOT Alcohol and Drug-Free Workplace for Supervisors Training to
regulations regarding drug and alcohol meet Drug-Free Workplace regulations regarding drug and alcohol
awareness use.Additional fees may be added on to the base rate for DOT
training.These fees will be assessed on a case-by-case basis and are
dependent upon travel expenses and for classes that exceed 50
participants.
•DOT Supervisor Training-2 hours at $800
DOT Alcohol and Drug-Free Workplace for Employees Awareness
Training(Note:this training does not meet Drug-Free Workplace
regulations regarding drug and alcohol use.)Additional fees may be
added on to the base rate for DOT training.These fees will be
assessed on a case-by-case basis and are dependent upon travel
expenses and for classes that exceed 50 participants.
•DOT Employee Training- 1 hour at$400
Company also may adjust Service Fees effective as of the date on which any of the following occurs,provided thirty (30) days'
written notice is first given to Customer.
(1)If,for any Service,there is a 20%change in the number of Employees from the number of Employees assumed in Company's
quotation as of the Effective Date of this Services Agreement.
(2) Change in Services—A material change in Services is requested or initiated by the Customer or by legislative action.
(3) Premium Taxes or Assessments—If legislative or regulatory action results in the assessment of premium taxes or other like
charges as it concerns those Services provided under the terms of this Agreement.
EAP 18
M&C Review Page 1 of 2
Official site of the City of Fort Worth,Texas
CITY COUNCILAGENDA FORTIr—
WoRT y
COUNCIL ACTION: Approved on 6/16/2015
DATE: 6/16/2015 REFERENCE NO.: **C-27334 LOG NAME: 14EAP16
CODE: C TYPE: CONSENT PUBLIC HEARING: NO
SUBJECT: Authorize Execution of a Three-Year Contract with Aetna Life Insurance Company for the
Administration of the City's Employee Assistance Program in the Amount of Up to
$325,260.00 (ALL COUNCIL DISTRICTS)
RECOMMENDATION:
It is recommended that the City Council authorize the execution of a three-year contract with Aetna Life
Insurance Company for the administration of the City's Employee Assistance Program in the amount of up
to $325,260.00.
DISCUSSION:
The purpose of this Mayor and Council Communication is to seek authorization from the City Council to
enter into a contract with Aetna Life Insurance Company for the administration of the City's Employee
Assistance Program. The total cost of the three-year contract will not exceed the amount of
$325,260.00. Aetna's subsidiary that will conduct the administration is Resource For Living.
Staff determined it would be in the City's best interest to ensure that it was getting the best overall product
and price by going out to the market and giving all providers the opportunity to compete for the City's
business. On February 17, 2015, a Request for Proposal (RFP) was issued requiring interested vendors to
submit proposals by April 2, 2015. The RFP was designed to solicit proposals for the following services
individually or in combination with each other: (1) Third Party Administrator(TPA) for the City's self-funded
Medical and Disease Management Program; (2) Pharmacy Benefit Management(PBM); (3) Flexible
Spending Account(FSA), Health Saving Accounts (HSA) and COBRA administration; (4) Employee
Assistance Program; and (5) Medicare Advantage.
In April 2015, an Ad Hoc Selection Committee (Committee)was formed that included one retiree, five active
employees-one from the Water Department, two from the Health Benefits Advisory Committee (HBAC)
and two from the Human Resources Department. The Committee was active in the analysis of the
proposals. Human Resources staff and the City's benefits consultant, A.J. Gallagher Benefits Services,
facilitated the RFP review and Committee meetings. Thirty-four vendors were solicited from the Purchasing
Division database system; five vendors responded representing five proposals.
After a lengthy review process, the Committee by consensus agreed that the City's current vendor, Aetna's
Resource For Living, provided the best overall quality of service and pricing. The services available are a
minimum of six face-to-face visits to assist employees in addressing personal issues, make referrals to
qualified professionals for specialized issues such as mental health and stress, parenting, midlife and
retirement, disability, financial issues, addictive behaviors, education, caring for older adults, health and
wellness, and legal issues. Welcome packet for all new employees and unlimited 24/7/365 telephonic
support services are included.
The associated cost and fee is $1.39 per employee per month. Average number of employees (actives
only) is 6,500. The average annual cost (Calendar Year) is$108,420.00. The proposed Fiscal Year 2016
budget includes funds for this contract through September 2016. An appropriation request for the
remainder of Calendar Year 2016 will be included as part of the Fiscal Year 2017 budget
process. Authority for the remaining fiscal years that are encompassed by the contract will be requested
annually as part of the overall budget process and the contract will include a standard fiscal funding out
clause that would comply with state law requirements by allowing the City to terminate the Agreement
without penalty, if in the future, the Council elects not to appropriate funds for the City's Employee
Assistance Program to continue.
http://apps.cfwnet.org/council_packet/mc_review.asp?ID=21207&councildate=6/16/2015 2/25/2016
M&C Review Page 2 of 2
AGREEMENT TERMS - Upon City Council approval, the three-year term of this contract shall begin on
January 1, 2016 and expire on December 31, 2018. The total cost of the three-year contract will not
exceed the amount of$325,260.00. The contract may be renewed for up to two successive one-year terms
at the City's option. This action does not require specific City Council approval, provided that the City has
appropriated sufficient funds to satisfy the City's obligations during the renewal term.
M/WBE OFFICE -A waiver of the goal for MBE/SBE subcontracting requirements was requested by the
Department and approved by the M/WBE Office, in accordance with the M/WBE or BDE Ordinance,
because the purchase of goods or services from source(s)where subcontracting or supplier opportunities
are negligible.
FISCAL INFORMATION/CERTIFICATION:
The Financial Management Services Director certifies that funds will be included in the City Manager's
proposed budget for Fiscal Years 2015-2016 for the Group Health and Life Insurance Fund. Upon
approval of the above recommendations and upon the adoption of the Fiscal Year 2015 -2016 Budget by
the City Council to include the above recommendations, funds will be available in the Fiscal Year 2016
operating budget, as appropriated. Prior to expenditure being made, the Human Resource Department has
the responsibility to validate the availability of funds.
TO Fund/Account/Centers FROM Fund/Account/Centers
60109 5310101 0148520 $108,420.00
Submitted for City Manager's Office by: Susan Alanis (8180)
Originating Department Head: Brian Dickerson (7783)
Additional Information Contact: Margaret Wise (8058)
ATTACHMENTS
http://apps.cfwnet.org/council_packet/mc_review.asp?ID=21207&councildate=6/16/2015 2/25/2016
CERTIFICATE OF INTERESTED PARTIES 2 FORM 1295
Cr�7-3 1011
Complete Nos I-a and 6 If there are interested parses OFFICE USE ONLY
Cottpiete NOS 1,2,3.S.and 6 it these are no interested parties. CERTIFICATION OF FILING
1 Name of busksess entity filing form,and the city,state and country of the business entity's place Certificate Number.
of business. 2016-9117
Aetna aeahavimal Health LLC
HardoFd,CT tlnded StateS tate Fated:
2 governmental ertttty or state agency t at is a party tot the contract for which the form is 02!04/1016
being filed,
City of Fon worth-Tx oar� "f
3 ProvWe the Identification number used by the governmental entity or state agency to track or Identify the contract,and provide a
d-—iplion of the goods or services to be provided under the contract.
15-0222
Employee Assurance Program Services
4 Name of Interested Parry City,Sate,Country(place of bushness) Controlling ( tk app!ca
5 Check only H there is NO Interested Parry. ❑
X
6 AFFIDAVIT I swear.dal em,underd
penalty ptnftrry,that the above disclosure M true and correct.
p�James Lewis
�..t� j0 2018 ._-
"'s Oa- Sgriature of auhonzed agent of contracting business enmy
AFfU NOTARY STAMP!SEAL ABOVE
2:71 Wand subscnmante
bed before e.by said r � ISA T 5 A .this the n day of
0 L--,lo am*wh+dt rinses mpr hard and seal d office.
b,/,T.+) 1.0"P5 VP T#>e
Signature of ofhcer administering oath Printed name of offKer adritanterng oath Title ok-ninisle ring oaih
Forms provWed by Texas Ethos Comnussion www ethics state tx us Version VI 0 349M