UHC Contract sig redacted for Extranet.pdf

Contract by Authorized Board

Commodity or Service:

Medicare Advantage Plans for Medicare-Enrolled Participants in the State of Wisconsin Group Health Insurance and Wisconsin Public Employer Programs

Contract No./Request for Proposal No:

ETH0020

Authorized Board: Group Insurance Board

Contract Period: June 1, 2018 – December 31, 2021 with the option for renewal for two (2) additional two (2) year periods.

1. This Contract is entered into by the State of Wisconsin Department of Employee Trust Funds (Department or

ETF) on behalf of the State of Wisconsin Group Insurance Board (Board), and Sierra Health and Life Insurance Company, Inc. dba UnitedHealthcare (Contractor), whose address and principal officer appear below. The Department is the sole point of contact for this Contract.

2. Whereby the Department agrees to direct the purchase and Contractor agrees to supply the Contract requirements in accordance with the Department Terms and Conditions, and the documents specified in the order of precedence below, hereby made a part of the Contract by reference.

3. For purposes of administering this Contract, the order of precedence is:

(a) This Contract;

(b) Exhibit A – Contract Changes;

(c) Exhibit 1 – State of Wisconsin Group Health Program Agreement dated May 16, 2018;

(d) Exhibit 5 – Department Terms and Conditions dated April 17, 2018;

(d) ETF Request for Proposal (RFP) ETH0020 dated October 17, 2017 as revised November 14, 2017; and,

(f) Contractor’s proposal dated November 28, 2017.

State of Wisconsin Department of Employee Trust Funds

4822 Madison Yards Way Madison, WI 53705-9100

P. O. Box 7931 Madison, WI 53707-7931

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ETH0020 Exhibit A

Exhibit A ETH0020 Contract Changes

Changes agreed to by the parties during contract negotiations for Request for Proposal (RFP) ETH0020 – Medicare Advantage Plans for Medicare-Enrolled Participants in the State of Wisconsin Group Health Insurance and Wisconsin Public Employer Programs.

1) Cost: Contractor’s revised cost submission dated April 27, 2018 is made a part of this Contract. Contractor agrees that if Contractor’s Centers for Medicare & Medicaid Services (CMS) Star ratings are lowered, Contractor’s rates quoted to ETF in its cost submission dated April 27, 2018 will not increase. Contractor agrees that the Department will pay Contractor the plan premiums by the first Business Day of the coverage month.

2) RFP Exhibit 3 – Standard Terms and Conditions (DOA-3054) is deleted.

3) RFP Exhibit 4 – Supplemental Standard Terms and Conditions for Procurement for Services (DOA-3681) is deleted.

4) RFP Exhibit 5 – Department Terms and Conditions dated April 27, 2017, is deleted and replaced with the attached, revised Exhibit 5 – Department Terms and Conditions dated April 17, 2018.

5) RFP Exhibit 1 – State of Wisconsin Medicare Advantage Program Agreement revised November 14, 2017, is deleted and replaced with the attached, revised Exhibit 1 – State of Wisconsin Group Health Program Agreement dated May 16, 2018.

6) The following is added to the Contract:

The Department and Contractor shall execute a Certification to Health Insurance Issuer for Disclosure of PHI to Department agreement prior to Contractor providing Services.

7) The following is added to the Contract:

Contractor will provide, at no additional expense to Department, at the Department’s request, a part-time Service Account Manager who will perform duties on-site at ETF.

8) The following is added to the Contract:

Contractor must certify annually that its provider contracts meet the requirements in Section 230 of Exhibit 1 – State of Wisconsin Group Health Program Agreement. If the Department determines it is necessary, and has exhausted all other reasonable alternatives, it will invoke Section 13.0 of Exhibit 5, Department Terms and Conditions, in an effort to obtain agreement that Department can review provider contracts for the purpose of confirming that the provider contracts meet the requirements in Section 230 and validating reported data regarding provider payments. The Department understands that Contractor has stated that it is unable to release provider contracts to the Department without express permission by provider to share the contract. UHC may be allowed to redact proprietary and confidential information from such provider contracts before the Department review, unless such information is imperative to the review.

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ETH0020 Exhibit A

9) The following is added to the Contract:

The Department represents that employer manuals will conform with the Medicare Managed Care Manual Chapter 9 Section 20.4.2 requirements regarding employer conditions in determining plan beneficiary premium subsidy.

Pursuant to the Wisconsin Public Employers’ Group Health Insurance Program Manual, the employer may determine if and/or how much of an annuitant’s plan beneficiary premium they will subsidize, subject to the following conditions in determining the plan beneficiary premium subsidy:

• The employer can subsidize different amounts for different classes of annuitants and employees in the plan provided such classes are reasonable and based on objective business criteria, such as years of service, date of retirement, business location, job category, and nature of compensation (e.g., salaried v. hourly); and

• The employer cannot vary the plan beneficiary premium subsidy for individuals within a given class of annuitants.

10) The following is added to the Contract:

The Department acknowledges that federal law preempts Wis. Stat. § 609.24(1)(e), which requires that provider contracts contain provisions addressing reimbursement rendered under Section 230C of Exhibit 1 – State of Wisconsin Group Health Program Agreement and if provider contracts do not contain such provisions, Contractor is required to reimburse the provider according to the most recent contracted rate.

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State of Wisconsin Group Health Insurance Program Agreement

Issued by the State of Wisconsin Department of Employee Trust Funds

On behalf of the Group Insurance Board

Release Date: May 16, 2018

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000 DEFINITIONS 2

(v. 2018-05-16)

TABLE OF CONTENTS

Table of Contents

000 Definitions

100 General

105 Introduction

110 Objectives

115 General Requirements

120 Board Authority

125 Eligibility

125A General

125B Dependent Coverage Eligibility

125C Change to Family Coverage

125D No Double Coverage

125E Local Annuitants

125F Medicare Participants

125G Notice of Qualifying Event

130 Premiums

130A Medicare Participant Premiums

130B Rate-Setting Process

130C Annual Rate-Setting Process for MEDICARE ADVANTAGE CONTRACTOR

130D Medicare Advantage Uniform Premium Requirements

135 Financial Administration

135A Prohibited Fees

135B Included Services

135C Recovery of Overpayments

135D Subrogation and Other Payers

135E Amounts Owed by Contractor

135F Automated Clearinghouse (ACH)

140 Participant Materials and Marketing

140A Informational / Marketing Materials

140B It’s Your Choice Open Enrollment Materials

145 Information Systems

150 Data Requirements

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000 DEFINITIONS 3

150A Data Integration and Technical Requirements

150B Eligibility/834 File Requirements

150C Data Warehouse File Requirements

150D Data Integration and Use

150E Data Submission Requirements

155 Miscellaneous General Requirements

155A Reporting Requirements and Deliverables

155B Performance Standards and Penalties

155C Audit and Other Services

155D Fraud and Abuse

155E Department May Designate Vendor

155F Contract Termination

155G Transition Plan

155H Insolvency

160 Submission of New Proposals

160A Operating Experience

160B Financial Requirements

160C Comprehensive Plans

160D Provider Agreements

160E Capital Equipment and Expenditures

160F Enrollment and Reporting

160G Rate-Making Process

160H Submission of Proposals

160I Implementation

200 Program Requirements

205 Enrollment

205A Identification (ID) Cards

205B Participant Information

205C Disabled Child Eligibility

205D Date of Death

205E Coordination of Benefits (COB)

210 Primary Care Provider or Primary Care Clinic

215 Medical Management

215A Disease Management / Prior Authorizations / Utilization Review

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000 DEFINITIONS 4

215B Department Initiatives

220 Benefits

220A Overview

220B Telehealth / Nurse Line

220C Emergency / Urgent / Catastrophic Care

220D Inpatient When Changing Coverage

220E Federal / State Requirements

220F Out-of-Network Services for Preferred Provider Organization (PPO)

220G Medicare

220H End Stage Renal Disease - Medicare Participants

220I Ancillary Services

220J Transfer of Benefit Maximums / Deductible / Out-of-Pocket Limits

220K Coordination / Non-Duplication

220L Wellness

225 Quality

230 Provider Contracts

230A Provider Access Standards

230B Provider Directory

230C Continuity of Care

230D Provider Contracts Shall Include Compliance Plans

235 Claims

240 Grievances

240A Grievance Process for MEDICARE ADVANTAGE CONTRACTOR

240B Grievance Process Overview

240C Claim Review

240D Participant Notice

240E Investigation and Resolution Requirements

240F Notification of Department Administrative Review Rights

240G External Review

240H Provision of Complaint Information

240I Department Request for Grievance

240J Notification of Legal Action

240K Penalty for Noncompliance

245 Cancellation of Participant Coverage

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000 DEFINITIONS 5

250 Direct Pay Premium Process

255 Continuation

255A Right to Continue Coverage

255B Subscriber Nonpayment of Premiums

255C Conversion / Marketplace

255D Surviving Dependents

260 Miscellaneous Program Requirements

260A Account Management and Staffing

260B Customer Service

260C Contractor Web Content and Web-Portal

260D Patient Rights and Responsibilities

260E Errors

260F Record Retention

260G Disaster Recovery and Business Continuity

260H Other

260I Gifts and/or Kickbacks Prohibited

300 Deliverables

305 Reporting Requirements

310 Deliverables

310A Deliverables to the Department

310B Deliverables to Participants

315 Performance Standards and Penalties

315A Claims Processing

315B Customer Service

315C Data Management

315D Enrollment

315E Other

400 Uniform Benefits

I. Definitions

II. Schedule of Benefits

A. State of Wisconsin:

1) Non-MEDICARE Prime State PARTICIPANTS: DEDUCTIBLES, COINSURANCE and COPAYMENTS as described in this schedule for participants without MEDICARE

B. Local / Wisconsin Public Employers (WPE):

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000 DEFINITIONS 6

3) Program Option (PO) 2/12, and Medicare Prime PARTICIPANTS in PO 6/16 and PO 7/17: DEDUCTIBLES, COINSURANCE and COPAYMENTS as described in this schedule:

III. Benefits and Services

A. Medical/Surgical Services

B. Institutional Services

C. Other Medical Services

D. Prescription Drugs and Other Benefits Administered by the PHARMACY BENEFIT

MANAGER (PBM)

IV. Exclusions and Limitations

A. Exclusions

B. Limitations

V. Coordination of Benefits and Services

A. Applicability

B. Definitions

C. Order of Benefit Determination Rules

D. Effect on the Benefits of THIS PLAN

E. Right to Receive and Release Needed Information

F. Facility of Payment

G. Right of Recovery

VI. Miscellaneous Provisions

A. Right to Obtain and Provide Information

B. Physical Examination

C. Case Management/Alternate Treatment

D. Disenrollment

E. Recovery of Excess Payments

F. Limit on Assignability of Benefits

G. Severability

H. Subrogation

I. Proof of Claim

J. Grievance Process

K. Appeals to the Group Insurance Board

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000 DEFINITIONS 7

000 DEFINITIONS

Unless otherwise defined herein, any term needing definition shall have the definition found in UNIFORM BENEFITS (of this AGREEMENT) or in applicable Wisconsin law. These terms, when used and capitalized in this AGREEMENT are defined and limited to that meaning only:

AGREEMENT means this State of Wisconsin Group Health Insurance Program Agreement, which is the binding agreement between the BOARD and CONTRACTOR for the administration of the HEALTH BENEFIT PROGRAM.

ANNUITANT

When not specified, ANNUITANT means all ANNUITANTS, including state and LOCAL.

STATE ANNUITANT means any retired EMPLOYEE of the State of Wisconsin: receiving an immediate annuity under the Wisconsin Retirement System, a currently insured recipient of a long-term disability benefit under Wis. Adm. Code § ETF 50.40, a currently insured recipient of a disability benefit under Wis. Stat. § 40.65; or a terminated EMPLOYEE with twenty (20) years of creditable service.

LOCAL ANNUITANT means:

1) Any currently insured retired EMPLOYEE of a participating EMPLOYER: receiving an immediate annuity under the Wisconsin Retirement System, or a long-term disability benefit under Wis. Adm. Code § ETF 50.40, or a disability benefit under Wis. Stat. § 40.65, or a person with twenty (20) years of creditable service who is eligible for an immediate annuity but defers application, or a person receiving an annuity through a program administered by the DEPARTMENT under Wis. Stat. § 40.19 (4) (a).

2) A retired public employee under Wis. Stat. § 40.02 (25) (b) 11, who is receiving an annuity under the Wisconsin Retirement System (but not a disability benefit under Wis.

Stat. § 40.65 or Long-Term Disability Insurance (LTDI)), or any DEPENDENT of such an employee, who is receiving a continuation of the employee's annuity, and, if eligible, and who has acted under Wis. Stat. § 40.51 (10) to elect the Local Annuitant Health Program (LAHP).

BALANCE BILLING means an OUT-OF-NETWORK provider’s practice of billing a patient for the difference between the patient’s health plan’s standard reimbursement for a covered service and that provider’s USUAL and CUSTOMARY CHARGES if the health plan’s standard reimbursement is less than the provider’s charge.

BENEFITS means those items and services as listed in UNIFORM BENEFITS. A PARTICIPANT’S right to BENEFITS is subject to the terms, conditions, limitations and exclusions of the HEALTH BENEFIT PROGRAM.

BOARD means the Group Insurance Board.

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000 DEFINITIONS 8

BUSINESS DAY means each calendar DAY except Saturday, Sunday, and official State of Wisconsin holidays (see also: DAY).

CMS means Centers for Medicare & Medicaid Services in the U.S. Department of Health and Human Services.

CONFINEMENT as defined in UNIFORM BENEFITS.

CONTINUANT means any SUBSCRIBER enrolled under the federal or state continuation provisions as described in the HEALTH BENEFIT PROGRAM.

CONTRACT means the contract document signed by the CONTRACTOR/MEDICARE ADVANTAGE CONTRACTOR and the DEPARTMENT, and includes, all exhibits, attachments, supplements, and endorsements or riders made a part thereof, and this AGREEMENT.

CONTRACTOR or HEALTH PLAN means the licensed insurer who is the legal signatory to the

CONTRACT.

DAY means calendar DAY unless otherwise indicated.

DEPARTMENT means the State of Wisconsin Department of Employee Trust Funds.

DEPENDENT as defined in UNIFORM BENEFITS.

EFFECTIVE DATE as defined in UNIFORM BENEFITS.

EMPLOYEE

When not specified, EMPLOYEE means all EMPLOYEES, including state and LOCAL.

STATE EMPLOYEE means an eligible EMPLOYEE of the State of Wisconsin as defined under Wis. Stat. § 40.02 (25) (a), 1., 2., or (b), 1m., 2., 2g., or 8.

LOCAL EMPLOYEE means an eligible EMPLOYEE as defined under Wis. Stat. § 40.02

(46) or 40.19 (4) (a), of an EMPLOYER as defined under Wis. Stat. § 40.02 (28), other than the state, which has acted under Wis. Stat. § 40.51 (7), to make health care coverage available to its EMPLOYEES.

EMPLOYER

When not specified, EMPLOYER means all EMPLOYERS, including state and LOCAL.

STATE EMPLOYER means an eligible State of Wisconsin agency as defined in Wis. Stat.

§ 40.02 (54).

LOCAL EMPLOYER means an employer who has acted under Wis. Stat. § 40.51 (7), to make health care coverage available to its EMPLOYEES.

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000 DEFINITIONS 9

HEALTH BENEFIT PROGRAM means the Group Health Insurance Program that provides group health BENEFITS to eligible State of Wisconsin and participating LOCAL EMPLOYEES, ANNUITANTS, CONTINUANTS and their eligible DEPENDENTS in accordance with Chapter 40, Wisconsin Statutes. The HEALTH BENEFIT PROGRAM is established, maintained and administered by the BOARD.

HIGH DEDUCTIBLE HEALTH PLAN (HDHP) as defined in UNIFORM BENEFITS.

HOSPITAL as defined in UNIFORM BENEFITS.

IN-NETWORK refers to a provider who has agreed in writing by executing a participation agreement to provide, prescribe or direct health care services, supplies or other items covered under the policy to PARTICIPANTS. The provider's written participation agreement must be in force at the time such services, supplies or other items covered under the policy are provided to a PARTICIPANT. The CONTRACTOR agrees to give PARTICIPANTS lists of affiliated providers.

Some providers require prior authorization by the CONTRACTOR in advance of the services being provided.

INPATIENT means a PARTICIPANT admitted as a bed patient to a health care facility or in twenty-four (24)-hour home care.

IT’S YOUR CHOICE OPEN ENROLLMENT means the enrollment period referred to in the DEPARTMENT materials as the It’s Your Choice enrollment period that is available at least annually to insured SUBSCRIBERS allowing them the opportunity to change CONTRACTORS and/or coverage and also to eligible individuals to enroll for coverage in any CONTRACTOR offered by the BOARD.

LOCAL means a Wisconsin Public Employer who has acted under Wis. Stat. § 40.51 (7), to participate in the HEALTH BENEFIT PROGRAM for its EMPLOYEES.

MEDICARE ADVANTAGE means a program defined under Title 18, Part C of the U.S. Social Security act of 1965, as amended.

MEDICARE PART A means the hospital insurance program defined under Title 18, Part A of the U.S. Social Security Act of 1965, as amended, and covers inpatient care.

MEDICARE PART B means the medical insurance program defined under Title 18, Part B of the O.S. Social Security Act of 1965, as amended, and covers outpatient care.

MINIMUM PROVIDER ACCESS STANDARDS means those as defined under Wis. Stat. §

609.22 and Wis. Admin. Code INS 9.32.

OUT-OF-NETWORK refers to a provider who does not have a signed participating provider agreement and is not listed on the most current edition of the CONTRACTOR’S professional directory of providers. Care from an OUT-OF-NETWORK provider may require prior-authorization from the CONTRACTOR unless it is an emergency or urgent care.

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000 DEFINITIONS 10

PARTICIPANT means the SUBSCRIBER or any of the SUBSCRIBER'S DEPENDENTS who have been specified by the DEPARTMENT for enrollment and are entitled to BENEFITS.

PHARMACY BENEFIT MANAGER (PBM) as defined in UNIFORM BENEFITS.

PREMIUM means the rates shown in the It’s Your Choice materials that includes the medical, pharmacy, and dental (when applicable) components, and administration fees required by the BOARD. Those rates may be revised by the BOARD annually, effective on each succeeding January 1 following the effective date of this AGREEMENT. The PREMIUM includes the amount paid by the EMPLOYER when the EMPLOYER contributes toward the PREMIUM.

QUARTERLY means a period consisting of every consecutive three (3) months beginning January 2018.

SECURE means the confidentiality, integrity, and availability of the DEPARTMENT’S data is of the highest priority and must be protected at all times. All related hardware, software, firmware, protocols, methods, policies, procedures, standards, and guidelines that govern, store, or transport the data must be implemented in manners consistent with current industry standards, such as, but not limited to the Health Insurance Portability and Accountability Act (HIPAA), Genetic Information Nondiscrimination Act (GINA), National Institute of Standards and Technology (NIST) 800-53, and Center for Internet Security (CIS) Critical Security Controls to ensure the protection of all DEPARTMENT data.

SUBSCRIBER means an EMPLOYEE, ANNUITANT, or his or her surviving DEPENDENTS, who have been specified by the DEPARTMENT to the CONTRACTOR for enrollment and who is entitled to BENEFITS.

UNIFORM BENEFITS means the BENEFITS described in Section 400 that are administered to PARTICIPANTS enrolled in the HEALTH BENEFIT PROGRAM.

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100 GENERAL 11

100 GENERAL

105 Introduction This State of Wisconsin Health Benefit Program Agreement (“AGREEMENT”) is for the purposes of administering the HEALTH BENEFIT PROGRAM. The HEALTH BENEFIT PROGRAM is the umbrella term used to describe the program in whole, including the State of Wisconsin Group Benefits Program and the Wisconsin Public Employers Group Benefits Program, herein referred to as “state” and “LOCAL”, respectively. The HEALTH BENEFIT PROGRAM is administered for the Group Insurance Board (BOARD) by the State of Wisconsin Department of Employee Trust Funds (DEPARTMENT).

By statute, the BOARD has the authority to negotiate the scope and content of the HEALTH BENEFIT PROGRAM for EMPLOYEES and ANNUITANTS of the State of Wisconsin, as well as for local units of government who choose to participate. The DEPARTMENT regularly provides the most current rosters for state agencies and authorities as well as the local employer roster (forms ET-1404 and ET-1407, respectively).

Eligible PARTICIPANTS have the opportunity to choose a benefit plan design. A minimum of two

(2) competing benefit plans is required per Wis. Stat. § 40.51 (6).

110 Objectives The BOARD's objectives of the HEALTH BENEFIT PROGRAM include, but are not limited to the following:

1) Management and delivery of health care services to PARTICIPANTS through contracted networks that provide for high-quality, cost-effective care.

2) To provide excellent customer service to PARTICIPANTS.

3) To offer networks of high value providers, and to incent PARTICIPANTS to choose benefit plan designs with high value providers.

4) To provide high-quality services at a competitive price.

5) Accurate, timely and responsive administration of health care claims.

6) Assist the BOARD in achieving strategy goals of:

a) Managing total costs.

b) Supporting PARTICIPANTS by providing them with tools and resources needed to manage their health and health purchasing decisions.

c) Promoting behavior change and accountability.

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100 GENERAL 12

d) Retain managed care elements that provide value.

7) To offer tools for PARTICIPANTS to increase engagement, including:

a) Knowledge of provider cost and quality.

b) Wellness and disease management.

c) Self-responsibility.

8) To ensure quality population health programs, including case management and disease management, which promote proactive management of PARTICIPANT health concerns.

9) To continuously evaluate and incorporate innovative approaches to health care delivery.

115 General Requirements The CONTRACTOR must meet the minimum requirements of Wis. Stat. § 40.03 (6) (a) and this AGREEMENT. The CONTRACTOR must:

1) Share data, claims information and other operational information as necessary for the smooth functioning of the program, for example to the BOARD’S Pharmacy Benefit Manager (PBM), consulting actuary, DEPARTMENT’S data warehouse and the wellness and disease management vendor, using the most recent file and data specifications provided by the

DEPARTMENT.

2) Administer deductibles and out-of-pocket maximums that depend upon information sharing from one CONTRACTOR, or vendor specified by the DEPARTMENT, to another. Also, assist with the transferring of accumulations towards PARTICIPANTS’ meeting deductibles, BENEFIT maximums, and out-of-pocket limits (OOPL).

3) Cooperate with the DEPARTMENT to develop procedures and protocols for sharing information as necessary.

4) Provide, in a format acceptable to the DEPARTMENT, at no cost and in a timely manner, all data and written or recorded material pertaining to this AGREEMENT.

5) Provide the specified level of services as indicated in this AGREEMENT to PARTICIPANTS.

6) MEDICARE ADVANTAGE CONTRACTOR must comply with all CMS MEDICARE

ADVANTAGE and MEDICARE PART D requirements, including provider network access, care utilization review, grievances and appeals, the quality improvement program, eligibility and enrollment, customer service, marketing, and claims processing, except as waived by CMS for EGWP plans. In cases where CMS requirements and the non-Medicare requirements of this AGREEMENT differ, the more rigorous standard shall supersede.

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100 GENERAL 13

7) Assist the DEPARTMENT with the administration of this AGREEMENT, including PARTICIPANT enrollment, record keeping, and general operations.

8) Have a mechanism for accurately maintaining records for a minimum of seven (7) years on each PARTICIPANT, including but not limited to, initial determination of eligibility for DEPENDENTS for disabled and full-time student status.

9) Apply effective methods for containing costs for medical services, HOSPITAL

CONFINEMENTS or other BENEFITS to be provided with effective peer and utilization review mechanisms for monitoring health care costs and the administration of Coordination of Benefit (COB) provisions.

10) Have a mechanism, as approved by the DEPARTMENT, for handling complaints and grievances made by PARTICIPANTS.

a) This includes a formal grievance procedure, which at a minimum complies with applicable federal or state law, whereby the individual is provided the opportunity to present a complaint to the CONTRACTOR and the CONTRACTOR will consider the complaint and advise the PARTICIPANT of its final decision. PARTICIPANTS must be advised of the grievance process when a claim or referral is denied or if the enrollee expresses, in writing, dissatisfaction with the administration or claims practices or provision of services by the CONTRACTOR. In all final grievance decision letters, the CONTRACTOR shall cite the specific Uniform Benefit contractual provision(s) upon which the CONTRACTOR bases its decision and relies on to support its decision.

b) When necessary, the BOARD intends to take a proactive approach in resolving complaints. The CONTRACTOR must cooperate fully with the efforts of the DEPARTMENT in resolving complaints. Adverse decisions are subject to review by the BOARD for contractual compliance if the PARTICIPANT is not satisfied with the CONTRACTOR’S action on the matter.

c) The CONTRACTOR must retain records of grievances and submit an annual summary to the DEPARTMENT of the number, types of grievances received, and the resolution or outcome. The annual summary report will contain data and be in a format established by the DEPARTMENT.

11) Submit to the DEPARTMENT or its designee, as required by the DEPARTMENT, statistical report(s) showing financial and utilization data that includes claims and enrollment information.

12) Have a process for managing services and charges in the event a PARTICIPANT incurs claims in an emergency or urgent situation that results in care from OUT-OF-NETWORK providers.

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13) Comply with state and federal regulations pertaining to mandated or minimum BENEFITS which may be applicable to the CONTRACTOR under insurance statutes or as directed by the BOARD.

14) Provide DEPARTMENT approved materials to PARTICIPANTS as required under this

AGREEMENT.

15) Provide notification of all significant events:

a) Each CONTRACTOR shall notify the BOARD in writing of any "Significant Event" within ten (10) calendar DAYS after the CONTRACTOR becomes aware of it. (In the event of insolvency, the BOARD must be notified immediately.) As used in this provision, a "significant event" is any occurrence or anticipated occurrence that might reasonably be expected to have a material effect upon the CONTRACTOR’S ability to meet its obligations under this AGREEMENT, including, but not limited to, any of the following:

disposal of major assets; loss of fifteen percent (15%) or more of the CONTRACTOR’S membership; termination or modification of any contract or subcontract if such termination or modification will have a material effect on the CONTRACTOR’S obligations under this AGREEMENT; the imposition of, or notice of the intent to impose, a receivership, conservatorship or special regulatory monitoring; the withdrawal of, or notice of intent to withdraw, dissolution of existing relationship, state licensing or certification, United States Department of Health and Human Services (HHS) qualification or any other status under state or federal law; default on a loan or other financial obligations; strikes, slow-downs or substantial impairment of the CONTRACTOR’S facilities or of other facilities used by the CONTRACTOR in the performance of this AGREEMENT.

b) In addition, any change in the ownership of or controlling interest in the CONTRACTOR, any merger with another entity or the CONTRACTOR’S acquisition of another organization that participates in the HEALTH BENEFIT PROGRAM is a "significant event." A change in ownership or controlling interest means any change in ownership that results in a change to or acquisition of majority (fifty-one percent (51%)) interest in the CONTRACTOR or any transfer of ten percent (10%) or more of the indicia of ownership, including but not limited to shares of stock. The CONTRACTOR agrees to provide to the BOARD at least sixty (60) DAYS advance notice of any such event. The BOARD may accept a shorter period of notice when it determines the circumstances so justify.

c) The BOARD requires the information concerning any change in ownership or controlling interest, any merger or any acquisition of another entity in order to fulfill the BOARD's responsibility to assess the effects of the pending action upon the best interests of the HEALTH BENEFIT PROGRAM and its PARTICIPANTS. The BOARD agrees to keep the information disclosed as required under paragraph (b) above, confidential under Wis. Stat.

§ 19.36 (5) of the Wisconsin Public Records Law until the earliest of one of the dates noted below unless the CONTRACTOR waives confidentiality or a court orders the DEPARTMENT or BOARD to disclose the information or the DEPARTMENT or BOARD determines that under the particular circumstances, any harm to the public interest that

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100 GENERAL 15

would result from permitting inspection is outweighed by the public interest in immediate inspection of the records.

The BOARD also agrees to notify the CONTRACTOR of a request to disclose the information as a public record prior to making such disclosure, so as to permit the CONTRACTOR to defend the confidentiality of the information. Information disclosed by a CONTRACTOR concerning any change in ownership or controlling interest, any merger or any acquisition of another entity will be disclosed by the BOARD as a public record beginning on the earliest of the following dates:

i) The date the pending change in ownership or controlling interest, any merger or any acquisition of another entity becomes public knowledge, as evidenced by public discussion of the action including but not limited to newspaper accounts.

ii) The date such action becomes effective.

iii) Sixty (60) DAYS after the BOARD receives the information.

d) The BOARD shall reserve the right to institute action as it deems necessary to protect the interests of the PARTICIPANTS of the HEALTH BENEFIT PROGRAM as the result of a "significant event."

16) Agree to utilize identification numbers (group and SUBSCRIBER) according to the system established by the DEPARTMENT. Identification numbers must not correlate to Social Security numbers. Social Security numbers may be incorporated into the SUBSCRIBER’S data file and may be used for identification purposes only and not disclosed or used for any other purpose. CONTRACTORS must always keep record of Social Security numbers for providing data and other reports to the DEPARTMENT or its authorized vendors and track the eight (8)-digit unique member identification number that is assigned by the DEPARTMENT.

Any costs incurred by the DEPARMENT because of CONTRACTOR’S failure to comply with this requirement shall be paid by the CONTRACTOR.

17) Comply with the provider network access standards set forth in WI Adm. Code § INS 9.32., if not preempted by federal law.

18) Provide coverage for both state and LOCAL PARTICIPANTS deemed eligible and enrolled by the DEPARTMENT.

19) Have legal and technical staff available to the DEPARTMENT for consultation as needed for program administration, and for assistance with any appeals processes. The CONTRACTOR shall monitor the development of and provide notification and information to the DEPARTMENT in a timely manner concerning state or federal regulations or legislation that may affect the HEALTH BENEFITS PROGRAM.

20) Shall not use or disclose names, addresses, or other data for any purpose other than specifically provided for in the CONTRACT.

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100 GENERAL 16

21) Comply with all applicable requirements and provisions of the Americans with Disabilities Act

(ADA) of 1990. Evidence of compliance with ADA shall be made available to the DEPARTMENT upon request.

120 Board Authority

1) Wis. Stat. § 40.03 (6) (a), provides authority for the BOARD to enter into contracts with insurers authorized to transact insurance business in the state of Wisconsin for the purpose of providing the group insurance plans, or, provide any group insurance plan on a self-insured basis in which case the BOARD shall approve a written description setting forth the terms and conditions of the plan, and may contract directly with providers of HOSPITAL, medical or ancillary services to provide eligible and enrolled EMPLOYEES with the BENEFITS.

2) The BOARD shall establish enrollment periods, known as the IT’S YOUR CHOICE OPEN ENROLLMENT period, which shall permit eligible EMPLOYEES, ANNUITANTS, and CONTINUANTS to enroll or transfer coverage to any benefit plan offered by the BOARD as required by Wis. Stat. § 40.51. Unless otherwise provided by the BOARD, the IT’S YOUR CHOICE OPEN ENROLLMENT period shall be held once annually in the fall of each year with coverage effective the following January 1.

3) The BOARD reserves the right to change to a fiscal year or to some other schedule that it deems appropriate.

4) In cases where data submitted by the CONTRACTOR is deemed to be inadequate by the

BOARD, DEPARTMENT, or the BOARD’S consulting actuary, the BOARD may take any action up to and including limiting new enrollment into the benefit plan administered by the

CONTRACTOR.

5) In the event a CONTRACTOR becomes or is at risk for becoming insolvent, experiences a significant event or significant loss of primary providers and/or HOSPITALS, or no longer meets the MINIMUM PROVIDER ACCESS STANDARDS in this AGREEMENT, or if the BOARD so directs due to a significant event as described in Section 115, the BOARD may do any of the following, including any combination of the following:

a) Terminate the CONTRACT upon any notice it deems appropriate, including no notice.

b) Authorize a special enrollment period and require that each SUBSCRIBER enrolled in a benefit plan administered by the CONTRACTOR change to another benefit plan.

c) Authorize a special enrollment period so that a SUBSCRIBER enrolled in a benefit plan administered by the CONTRACTOR may voluntarily change to another benefit plan.

d) Close the benefit plan administered by the CONTRACTOR to any new enrollments for the remainder of the CONTRACT period.

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e) Require that prior to making a selection between benefit plans, prospective SUBSCRIBERS be given a written notice describing the BOARD'S concerns.

f) Take no action.

6) The BOARD may forfeit a SUBSCRIBER'S rights to the HEALTH BENEFIT PROGRAM if a

PARTICIPANT fraudulently or inappropriately assigns or transfers rights to an ineligible individual(s), or aids any other person in obtaining BENEFITS to which they are not entitled, or otherwise fraudulently attempts to obtain BENEFITS. The DEPARTMENT may at any time request such documentation as it deems necessary to substantiate SUBSCRIBER or DEPENDENT eligibility. Failure to provide such documentation upon request shall result in the suspension of BENEFITS.

7) The BOARD may initiate disenrollment efforts in situations where a PARTICIPANT has committed acts of physical or verbal abuse, or is unable to establish/maintain a satisfactory physician-patient relationship with the current or alternate primary care provider. The SUBSCRIBER'S disenrollment is effective the first of the month following completion of the grievance process and approval of the BOARD. The BOARD may limit re-enrollment options in the HEALTH BENEFITS PROGRAM.

8) The BOARD shall determine all policy for the HEALTH BENEFIT PROGRAM. In the event that the CONTRACTOR requests, in writing, that the BOARD issue program policy determinations or operating guidelines required for proper performance of the CONTRACT, the DEPARTMENT shall acknowledge receipt of the request in writing and respond to the request within a mutually agreed upon time frame.

9) The BOARD must be notified of any major system changes to the CONTRACTOR’S administrative and/or operative systems.

125 Eligibility 125A General For HEALTH BENEFIT PROGRAM purposes, eligible EMPLOYEES include:

1) General state EMPLOYEES: active state and university EMPLOYEES participating in the

Wisconsin Retirement System (WRS), as described in Wis. Stat. § 40.02 (25) (a).

2) Elected state officials (Wis. Stat. § 40.02 (25) (a) 2).

3) Members or EMPLOYEES of the legislature (Wis. Stat. § 40.02 (25) (a) 2).

4) Any blind EMPLOYEES of the Beyond Vision (aka WISCRAFT) authorized under Wis. Stat.

§ 40.02 (25) (a) 3.

5) Any EMPLOYEE on leave of absence who has chosen to continue their insurance, as described in Wis. Stat. § 40.02 (40).

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http://docs.legis.wisconsin.gov/document/statutes/40.02(25)(a)3.

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100 GENERAL 18

6) Any EMPLOYEE on layoff whose PREMIUMS are being paid from accumulated unused sick leave as described in Wis. Stat. § 40.02 (40).

7) The following in the University of Wisconsin (UW) System and UW Hospital and Clinics

Authority (Wis. Stat. § 40.02 (25) (b)):

a) Any teacher (employment category 40) who is employed by the university for an expected duration of not fewer than six (6) months on at least a one-third (33%) full-time appointment.

b) Any teacher who is a participating EMPLOYEE and who is employed by the UW System for an expected duration of not fewer than six (6) months on at least a one-third (33%) full-time appointment.

c) Certain visiting faculty members in the UW System.

d) Graduate student assistants (research assistants, fellows, advanced opportunity fellows, scholars, trainees, teaching assistants and project/program assistants) holding a combined one-third (33%) or greater appointment of at least one (1) semester per academic year (nine month) appointments or six (6) months for annual (twelve month) appointments.

e) Employees-in-training (research associates, post-doctoral fellows, post-doctoral trainees, post-graduate trainees 1 through 7, interns (non-physician), research interns, and graduate interns/trainees) holding a combined one-third time (33%) or greater appointment of at least one (1) semester for academic year (nine (9) month) or six (6) months for annual (twelve (12) month) appointments.

f) Short-term academic staff who are employed in positions not covered under the Wisconsin Retirement System (WRS) and who are holding a fixed-term terminal, acting/provisional or interim appointment of twenty-eight percent (28%) or more with an expected duration of at least one (1) semester but less than one (1) academic year if on an academic year (nine (9) month) appointment or have an appointment of twenty-one percent (21%) or more with an expected duration of at least six (6) months but fewer than twelve (12) months if on an annual (twelve (12) month) appointment.

g) Visiting appointees (e.g., visiting professors, visiting scientists, visiting lecturers) may be eligible.

h) Any person employed as a graduate assistant and other employees-in-training as designated by the board of directors of the UW Hospital and Clinics Authority who are employed on at least a one-third full-time appointment with an expected duration of employment of at least six (6) months.

8) LOCAL EMPLOYEES as described in Wis. Stat. § 40.02 (46) or 40.19 (4) (a).

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100 GENERAL 19

9) ANNUITANTS and CONTINUANTS (Wis. Stat. § 40.02 (25) (b)), which include the following:.

ANNUITANTS and CONTINUANTS listed below who are enrolled in MEDICARE PARTS A and B are eligible for enrollment in the MEDICARE ADVANTAGE plan for individual coverage.

To enroll in family MEDICARE ADVANTAGE coverage, an ANNUITANT or CONTINUANT and their DEPENDENTS must be enrolled in MEDICARE PARTS A and B. ANNUITANT and CONTINUANT family contracts that include a PARTICIPANT who is not enrolled in MEDICARE PARTS A and B are not eligible to enroll in the MEDICARE ADVANTAGE plan.

a) Any covered EMPLOYEE who is retired on an immediate annuity or disability annuity, or who receives a lump sum payment under WRS which would have been an immediate annuity if paid as an annuity under Wis. Stat. § 40.25 (1).

b) The surviving spouse of a SUBSCRIBER.

c) The surviving insured domestic partner of a SUBSCRIBER.

d) Covered EMPLOYEES who terminate employment, have attained minimum retirement age (fifty (50) for protective services or fifty-five (55) for all other categories), have twenty

(20) years of WRS creditable service and defer their annuity are eligible to continue in the HEALTH BENEFIT PROGRAM if a timely application is submitted.

e) Any participating STATE EMPLOYEE who terminates employment after attaining twenty

(20) years of WRS creditable service, remains an inactive WRS participant and is ineligible for an immediate annuity (that is, under the minimum retirement age) may enroll in the HEALTH BENEFIT PROGRAM at a later date. Enrollment is restricted to the IT’S YOUR CHOICE OPEN ENROLLMENT period in the fall for coverage effective the following January 1, unless there is a HIPAA qualifying event.

f) Any rehired ANNUITANT electing to return to active WRS participation is immediately eligible to apply for coverage through the EMPLOYER.

g) Any retired LOCAL EMPLOYEE under Wis. Stat. § 40.02 (25) (b) 11, who is receiving an annuity under the Wisconsin Retirement System (but not those only receiving a duty disability benefit under Wis. Stat. § 40.65 or Long Term Disability Insurance (LTDI)), or any DEPENDENT of such an employee, who is receiving a continuation of the employee's annuity, and, if eligible, and who has acted under Wis. Stat. § 40.51 (10) to elect the Local Annuitant Health Program (LAHP).

h) Any LOCAL ANNUITANT receiving an annuity through a program administered by the

DEPARTMENT under Wis. Stat. § 40.19 (4) (a).

i) PARTICIPANTS who meet federal or state continuation provisions. See Section 260.

10) Disabled persons entitled to benefits under Wis. Adm. Code § ETF 50.40 or Wis. Stat. §

40.65 include:

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100 GENERAL 20

a) Insured EMPLOYEES or former EMPLOYEES who choose to continue coverage when the EMPLOYEE’S Long-Term Disability Insurance (LTDI) benefit under Wis. Adm. Code § ETF 50.40 or a duty disability benefit under Wis. Stat. § 40.65 is approved.

b) Previously insured EMPLOYEES or former EMPLOYEES whose coverage lapsed and who are eligible and apply for an LTDI benefit under Wis. Adm. Code § ETF 50.40, or a duty disability benefit under Wis. Stat. § 40.65.

125B Dependent Coverage Eligibility Individual coverage covers only the SUBSCRIBER. All eligible DEPENDENTS listed on the application are covered under a family contract. A SUBSCRIBER cannot choose to exclude any eligible DEPENDENT from family coverage, unless that DEPENDENT is already covered under the HEALTH BENEFIT PROGRAM. Also see 125A 9.

125C Change to Family Coverage An EMPLOYEE eligible for and enrolled in individual coverage only may change to family coverage effective on the date of change to family status, including transfer of custody of eligible DEPENDENTS, if an application is received by the EMPLOYER within thirty (30) DAYS after the date of the change to family status. The difference in PREMIUM between individual and family coverage for that month shall be due only if the change is effective before the 16th of the month.

ANNUITANTS and CONTINUANTS shall be subject to this provision, except that those ANNUITANTS and CONTINUANTS for whom the EMPLOYER makes no contribution toward PREMIUM shall submit the application to the DEPARTMENT.

Notwithstanding the paragraph above, the birth or adoption of a child to a SUBSCRIBER under an individual benefit plan, who was previously eligible for family coverage, will allow the SUBSCRIBER to change to family coverage if an application is received by the EMPLOYER within sixty (60) DAYS of the birth, adoption, or placement for adoption. Also see 125B.

125D No Double Coverage A DEPENDENT or SUBSCRIBER cannot be covered at the same time by two separate SUBSCRIBERS of the HEALTH BENEFIT PROGRAM (including state and LOCAL). In the event it is determined that a DEPENDENT is covered by two (2) separate SUBSCRIBERS, the SUBSCRIBERS will be notified and will have thirty (30) DAYS to determine which SUBSCRIBER will remove coverage of the DEPENDENT and submit an application to remove the DEPENDENT.

The…