ORDER NO. 31569 KERB COUNTY EMPLOYEE HEALTH BENEFITS INSURANCE CONTRACTS Came to be heard this the 14th day of December, 2009, with a motion made by Commissioner Williams, seconded by Commissioner Oehler, the Court unanimously approved by a vote of 4-0-0 to: Approve the Kerr County Employee Health Insurance Benefits Contracts, and authorize County Judge to sign same, on the basis that the provider network by the Third Party Administrator is the Texas True Choice Network, in lieu of previously agreed Network of UMR. ~,~a COMMISSIONERS' COURT AGENDA REQUEST ,3~Sb ~ PLEASE FURNISH ONE ORIGINAL AND ONE (1) COPY OF THIS REQUEST AND DOCUMENTS TO BE REVIEWED BY THE COURT MADE BY: Eva Hyde OFFICE: Human Resources MEETING DATE: December 14, 2009 TIME PREFERRED: SUBJECT: Consider, discuss and take appropriate action to approve County Employee Health Benefits Insurance contracts and allow County Judge to same. 'EXECUTIVE SESSION REQUESTED: (PLEASE STATE REASON) NAME OF PERSON ADDRESSING THE COURT: Eva Hyde ESTIMATED LENGTH OF PRESENTATION: IF PERSONNEL MATTER -NAME OF EMPLOYEE: Time for submitting this request for Court to assure that the matter is posted in accordance with Title 5, Chapter 551 and 552, Government Code, is as follows: Meeting scheduled for Mondays THIS REQUEST RECEIVED BY: THIS RQUEST RECEIVED ON: 5:00 PM previous Tuesday @ .M. All Agenda Requests will be screened by the County Judge's Office to determine if adequate information has been prepared for the Court's formal consideration and action at time of Court Meetings. Your cooperation will be appreciated and contribute towards your request being addressed at the earliest opportunity. See Agenda Request Rules Adopted by Commissioners' Court. I~~ RetiaStar Life tnsurance Company RE: Group Name: Kerr County Group #: 66792-7 This is to confirm that Kerr County, hereinafter referred to as THE EMPLOYER GROUP, has a Third Party Administrator agreement with UMR, hereinafter referred to as THE TPA, under which the TPA will generate the billing and/or submit payment for insurance coverage on the Employer Group to ReliaStar Life Insurance Company, hereinafter referred to as THE COMPANY. The Employer Group acknowledges that in performing services, the TPA is acting solely on behalf of the Employer Group and not as an agent or Third Party Administrator for the Company. The Employer Group understands and agrees that any payments are not considered received by the Company until they are reconciled by the Company's billing department and that the Company will notify the Employer Group if premiums become delinquent. As such, the Company strongly encourages the Employer Group to verify there are adequate internal controls regarding premium administration at the TPA. Printed Name Pat Tinley Title Kerr County Judge Signature ~ Date December 14, 2009 Cc: Broker/Agent of Record APPLICATION FOR APPOINTMENT ReliaStar Life Insurance Company, Minneapolis, MN I NG ReliaStar Life Insurance Company of New York, Woodbury, NY A member of the iNG family of companies Your future. Made easier.snn Service Office: 909 Locust St, Des Moines, IA 50309 Phone: (888). 238-6297 Option 1, Fax: (515) 698-2037 1. TYPE OF REQUEST ^ Individual (Complete Section 2, 4, 5, 6) ^ Corporate (Complete Section 2, 3, 4, 5, 6) Plan Number 2. INDIVIDUAL PRODUCER APPOINTMENT INFORMATION Producer/Principal Name (First) (Last) (M.l.) Professional Designations Residence Phone Producer Residence Street Address City Business Phone Business Street Address City State ZIP E-mail Address 3. CORPORATION APPOINTMENT INFORMATION Complete this section only if you are the signing officer of the corporation and are appointing both you and your corporation. Name of Corporation TIN 4. ERRORS AND OMISSIONS COVERAGE E&O Coverage Carrier (Required) Policy # (Required) 5. QUESTIONNAIRE (Please respond to all questions for you personally and any organization over which you have exercised control. If you answer "Yes" to any questions, you must attach an explanation with all relevant information and supporting documents.) 1. Are you currently a registered representative with the NASD? ........................................ ^Yes ^ No If yes, please provide C.R.D. Number. 2. Have you ever had an insurance and/or securities license or registration under another name? ............... ^Yes ^ No If yes, please provide that name. 3. Have you ever been discharged or permitted to resign from your employment because you were accused of: a) violating investment- related or insurance-related statutes, regulations, rules, or industry standards of conduct? b) fraud or the wrongful taking of property? c) violating company rules? ........................................................ ^Yes ^ No 4. Within the past 10 years, have you ever initiated bankruptcy proceedings or declared bankruptcy? .......... ^Yes ^ No 5. Do you have any unsatisfied. judgements or liens? ................................................^Yes ^ No 6. Do you have any knowledge of indebtedness to an insurance carrier or financial organization that involves yourself or an organization that you have been associated with? ............................................... ^Yes ^ No 7. Within the past 10 years, has any insurance carrier canceled your contract or appointment for any reason other than lack of production? ............................................................................ ^Yes ^ No Date of Birth SSN State ZIP Business Fax Sex: ^ Male ^ Female Page 1 of 2 (Incomplete without all pages.) Order #139428 05/15!2007 5. QUESTIONNAIRE (continued) 8. Have you ever had your insurance license or securities registration suspended, revoked, investigated, audited or had a license denied ................................................................................ ^ Yes ^ No 9. Within the past 10 years have you ever had a complaint filed against you that resulted in a fine, penalty, cease or desist order, censure or consent order, or disciplinary action? ................................................ ^ Yes ^ No 10.With the exception of routine traffic violations, have you ever been convicted of or pled guilty or nolo contendere (no contest) in a court to a) a misdemeanor? b) a felony? .................................................... ^ Yes ^ No 11. Are you involved in any pending or current litigation, investigations or complaints, or E&O claims? .......... ^ Yes ^ No 12. Within the past 10 years, has any E&0 carrier denied, paid claims, or canceled your coverage? ............. ^ Yes ^ No 13. Have you ever sued or been sued by an insurance company? .................. . ....... . ............ ^ Yes ^ No 14. Have you ever been named as a defendant or co-defendant in a lawsuit? ............................. ^ Yes ^ No 15. Has a bonding company ever denied, paid out on, or revoked a surety or fidelity bond for you or is there any reason you cannot secureabond? ......................................................................... ^ Yes ^ No 16.Have you ever been found guilty or nolo contendere (no contest) in violating state insurance department, federal or state securities. or investment related regulation or statute? ............................................ ^ Yes ^ No 6. CONDITIONS AND AGREEMENTS Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. person (including a U.S. resident alien). INSTRUCTIONS: You must cross out item 2 above if the IRS has notified you that you are currently subject to backup withholding because of underreporting interest or dividends on your tax return and you have not received notice from the IRS advising that backup withholding has terminated. The Internal Revenue Service does not require your consent to any provision of this document other than the certification required to avoid backup withholding. By signing this Application, I acknowledge and represent that: • All information furnished by me in this Application is true, correct and complete. . I understand that no Company has an obligation to approve this Application and I release any Company that does not appoint or contract me from alb liabilities. . I agree nat to solicit or sell, as determined by state law, any business until I have been notified by the appropriate company that I have been contracted and I am authorized to solicit or sell business for it. • I have included. a copy of a current license for each state in which I do business. • I authorize any person or entity that may have knowledge of my employment, financial, criminal or other history to release such information to any Company in connection with this Application; and I authorize each Company to release any information regarding my Debit Balance to Vector One, or any successor organization. A photocopy of this authorization will be as valid as the original, regardless of the date it is signed. • 1 also acknowledge by my signature below that I authorize the Company, now or in the future, to obtain a consumer and/or investigative consumer report on me, and that I have received from the Company all disclosures required by the Fair Credit Reporting Act. Print Producer/Corporate Principal Name (Corporate%4gency Name if applicable) _ Producer/Corporate Principal Signature (CorporatelAgency Officer if applcable) ~ Date December 14 , 2009 Corporate/Agency Contact Name Phone 830-792-2211 Page 2 of 2 (Incomplete without all pages.) Order #139428 05/15/2007 Pat Tinley, Kerr County Judge a7 United Resource Networks ._,~ URN ACCESS AGREEMENT ING Employee Benefits, through your stop loss insurer, ReliaStar Life Insurance Company, has an agreement with United Resource Networks (URN), that gives your self-funded employee benefit plan access to transplant services at negotiated prices. To take advantage of this agreement, you need to agree to several points, as follows: 1. You will be entitled to receive the favorable pricing that URN has with providers and you will pay for services in accordance with the terms of the agreements negotiated with providers. ING Employee Benefits has reviewed these payment terms. 2. ING Employee Benefits will follow the requirements for transplant notifications and approvals of payments. You also agree to pay the URN administrative fees, described below, which will be included as claim payment amounts for purposes of eligibility for reimbursement under ING Employee Benefits' stop- loss policy. For the Transplant Network. the fees are as follows: T e of A roved Trans lant Amount Bone Marrow Autolo ous: Less than 11 Da s $ 5,000 11 or more Da s -breast cancer $10,000 11 or more Da s -all other dia noses $20,000 Allo eneic: related or unrelated $20,000 Heart, Lun , Heart/Lun $10,000 Intestinal, Liver, Intestinal/Liver $20,000 Kidne ,Pancreas, Kidne /Pancreas $ 3,500 3. 4. 5. If, before a member receives a transplant, the member: a) is not accepted to a provider's transplant program, or b) the member dies, or c) the member's coverage ends, you will pay URN 35% of the difference between billed charges and URN's agreed upon charges for the services rendered, capped at the amount of the administrative fee for the corresponding transplant set forth above. Payment to URN under these circumstances is in lieu of the payment specified in the table above and is due within 30 days of the date URN sends the invoice. • For the Transplant Access Program the fees are 15% of savings, calculated as the difference between billed charges and amounts paid pursuant to the applicable provider agreement. The fees shall not exceed the administrative fee for the corresponding transplant set forth in the table above. • For Specialized Physician Review Services the fees are as follows: a) For transplants other than bone marrow transplants, the fee is $1,850 for a written opinion from a single reviewer, or $2,450 for three written opinions, one from each of three reviewers; and b) For bone marrow transplants, the fee is $2,250 for a written opinion from a single reviewer, or $2,700 for three written opinions, one from each of three reviewers. For an expedited review, the fee is an additional $200 for each physician reviewer. An expedited review is the provision of Specialized Physician Review Services within 2 business days of initiation, as described above. The additional fee is not charged if the written opinion is not delivered within this timeframe. If you fonnrard additional information to URN and request additional Specialized Physician Review Services about a previously prepared written opinion, then you will pay URN another fee of $1,000 for an additional written opinion from a single reviewer. Such fee will not apply if the additional information was anticipated and noted by the author of the opinion and received within 4 months of the date of the initial written opinion. • For Extra Contractual services you shall contact URN to initiate an Extra Contractual Agreement and shall provide URN Member specific information relevant to the services being requested. Once URN receives the required information, URN will negotiate the Extra Contractual Agreement on your behalf. The final Extra Contractual Agreement will confirm the understanding between you and your Extra Contractual Provider regarding specific services that the Extra Contractual Provider has agreed to provide to a Member. For URN's service under the Agreement, the fees are as follows: 15% of savings, calculated as the difference between Billed Charges and the amounts paid pursuant to the applicable Participation Agreement. This administrative fee shall not exceed the administrative fee for the corresponding transplant set forth above in the Transplant Network section and shall be billed upon receipt of claims for transplant services. • For Congenital Heart Disease (CHD) Services the fees are 15% of savings, calculated as the difference between billed charges and amounts paid pursuant to the applicable provider agreement. The fees shall not exceed $10,000 and shall be billed to you upon receipt of claims for CHD Services. You have sole responsibility for verifying member benefits or eligibility for transplant coverage, and for any plan coverage dispute that may arise with employees and dependents. You acknowledge that URN will not be deemed or understood to be an ERISA plan administrator or fiducia~~, and that URN has no responsibility of any kind for: a) medical outcomes or the quality or competence of any physician, facility, or provider rendering service; b) payment of any medical, hospital, or other bills resulting from any medical or surgical treatment or confinement; and c) interpretation of any benefit plan contract concerning coverage or denial of benefits. The signed agreement is effective on the day it is received by URN. Upon receipt of this Access Agreement by URN, URN reserves the right to deny you access. Your access to this agreement will end when your stop-loss agreement v~ith ING Employee Benefits terminates or upon 30 days notice by you or by URN. Acknowledged and agreed Employer Name: Kerc County Signature: t ~ Name: Pat Tinley Address: Telephone: Title: Kerr County Judge # of Employees: 700 Main Kerrville, TX 78028 830-792-2211 264 TO ACTIVATE THIS AGREEMENT FAX THIS FORM ING EMPLOYEE BENEFITS AT 612-342-3373 11.11.2004 I T ~..~ Important Information About Your Employee Benefits Insurance Thank you for considering ReliaStar Life Insurance Company (the "Company") for your employee benefits insurance needs. We offer various Employee Benefits insurance products that have different features, benefits and costs. We are confident that, working with your professional insurance agent, broker, or consultant you will find that one of our products is right for you. Your agent, broker, or consultant may work with many employee benefits insurance companies, and we are pleased that they are presenting one of our products to you. If you decide to purchase, or offer to your employees or members, a policy from us we would like you to understand how we will pay the selling agent, broker, or consultant. There are generally three types of payments that may be made to agents, brokers and consultants: 1. Commissions: Agents, brokers, or consultants may earn a commission for each Company policy sold. The commission is generally a percentage of the policy premiums paid. The percentage may be higher for agents, brokers, or consultants that sell a larger number of Company policies. The actual percentage and amount of commission paid will vary based on the specific circumstances of the product(s) purchased. 2. Bonuses: Agents, brokers, or consultants may receive additional compensation based on a percentage of policy premiums paid for each year a policy remains in force and as .rewards for things like achieving certain sales volume levels, sales contest objectives, or other measures. We also may .pay for agent, broker, or consultant education, training or attendance at conventions, and may pay bonuses, provide advance commissions and/or loans with an expectation that the advancement and/or loans be repaid as new policies are issued, reimburse expenses or provide other payments or benefits. 3. Administrative/Service Fees: Agents, brokers, or consultants may provide administrative services and marketing support for a flat fee, a percentage of policy premiums paid, or, a fee based on the amount of commissions earned from the initial sale. The agents, brokers or consultants may be associated with other brokers or consultants that may provide administrative services and marketing support for similar fees. This is a general discussion of the compensation we pay for the sale of our policies. We pay commissions and other sales expenses from our general assets and revenues, including amounts we earn from fees and charges under our policies. The price of an insurance policy is set by the Company, and reflects the compensation we pay for the sale of our policies. It also covers other costs to design, manufacture and service our policies, fees associated with the cost of any applicable gi~ara~~tees, the investment management needed to build cash values and pay benefits, and our profits. We are committed to providing top-quality insurance products to our customers and are pleased that your professional insurance agent, broker, or consultant trusts us to deliver on your long term insurance needs. 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I~'~~~, C!~~~at~~!~r rra~~ f c~r~c~~, ,~tr~~t:7t~t ~~'i ,~F~;, •l~r', ~ :`vi~~ F~rrs~uirJe , .,_ : ~ r "~:~,nyee's frri~fa~:te srr ~~ia~3-,G~I i~,~~~~n~.e data. €ur can': pur~csa c~.h~, t~... t. _ ~,.rn -~ti~,n :~f t~e~ Pal ._ ;r~ ,,. ~.~ r~:~ei~°~ ~~~ IhJ~ ~~al tie ~,C,i-,:~ln~t~d °~~+ `~~ >n a~,rar.~f r.c.- ~xitt~ s, ,tun~arri r.;- r~rd ° P~n'~T ~ ,..:_:~~1'es .,n~ t°,'il, t~ r~~in~ac ~y 9P1G~ a~c~rr€trrc~l~r ='~~~cut r~s~~ t~ 1urr~. r ~=t ~~•~ ~f tai r'?~ri;i:l"~~("tf R: tt'd~~ .... -„ ~,tCy.I~::Ii,S. ..._ t .a.;y Integrate ~ irl~y~;' ~ ~ ~::.:.., .:"~~ ether - - ~~5~ rn i~'~~'~; S;~St~~1S i~~ ;>!Wtll~tcl~r..~~I~;a..,cua:tF'r~,.--,i. .,:k°t"191~3}/c'r,,,~::Yar~dr~r:: .-,.. ~.~ what n~ith" party nsx ~~ ~ ~-~„»i~ztr..r it ~.~:_ Provider may ~..~~ r.--, _ , ~ r~ r.~,~,~r~ ~~ll'~:.'t '(~ ~r.,S ,.:,-_~~] C'C C73r1t'Ur~t ~ t~i^:~ ~gfe~(Tc.":`. 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Airy ~ t~C:`.y ~p~'~I~ {'~; -: ~:~ :C1C,~E t7•T ra:p~rts rl;: ~tJ i::' ~!~ ~'Tt N1_j9r' -~ ..., - -s r ~r-i`l , art~..lln,. ~~,~ ~ . rr~"~. ~_ r7U'b, ~ ?~ a~'G,' ~harg~~.. ~.~ 7`',(.'", !. "lc'_.' utlllze ~f~Ctrr~nl~ ,f,'C",'' ' "(' .rl"ir tt~i~tC2t:il ..,.,~ ~C »_~~''-rr7w5 ~f fnr~, ,iur' ~~y':7~~>~rt rn _ aul"£ari~e en i~(~~Sli~`te~ra -- " -_ , _~~ __ G~all~~wt _ . _~ t~t_ t ~v-°lia'n tCr is,,li.~ „1'i=-~s ihz r"s.('pf,r~' .i.' -: F~r~vsder P~ci$ ~) nf~e,g;,d.Cp ;~ ~ ~ - - - -'itered 36" ~:~Fr~ i~='"'~ffar ~,_:~_: _°tLfi ~5 >Cf'.'7 iN~. rwE3 nom, ;at~re ~~i'J"Ce~ F~`rC.,~t 1~ .. `-}' -~' ' - ~~ i '~'-(!~ ~It'et'1~klf , _ _'.~t;., C,tl ~fiGlxa ~f ~~rrrr~e?rcr~n3~rr,~r*,~Irl~:..~' ~ _,":'~~fC~r C'E'1et'~~3y~r[t _,~ c.i:~~ ._.';~~. ~.~ ~'~C'3~$'?SrR ~....,~1r~ed &n tfia~ Lti ~ ~:.,Yl~tlt:S I:'I .:_"_: '~.~ ...c:nFa ~.::. ag€~nt ~If t7~rcl.er "-_::~. s~G(} t~f*I4~E-:'r l~l ~,'~ t s~n ~;F~.ati~n ~er~~s P mvi -~, - : Ite~~rt~-~ .•. ' xi~tinra er ~t~a~s~;ge~i ~~~nt, i;rtakcr, l~r r_ ~_ - ~ rt ~'~ ,~'~ n#, +4ny lhJra' a}ent r b '3t' ar _ " erst wilt C ,~:rne~i :~lely b}r ftte =aim, ~` .'~:~'s. alter,' , _-_r~fr . ,. , ac~ ''~: ff curl ~t,t{J aC.`~.°9~r§ ~': ~. .:~' ~' ~: :~i~r '_~Lli?.~ `t ~h:-:t L'3P~ittf, 'e~t5,°>3 f~.. `u-F'.~ .~r.`t' ~ : ~ti:~' ~. it ~< v ~_r T1~as ;~4~reem~ri4 ~~~( ~~ ~~e~r~~r~ iy f~ ~~4'Y$ u# t~~ ~t~ i~',:~ft?~'~ C.~'iv ~~ii w ~;~ i~ ;r~:~u~~. ~'E'~. .: i~,F~ LI~~ II}J`- !. , .,, _ ~ fit, ~'.~:C~I`r ~, h~J~rre~ Pat Tinle w ~: ~ ;i~,. Kerr County Judge L~.~fe: December 14, 2009 hd~me: ~~~€~t~ire; Tit#e' ~?~t~: E~~,G~S ~-74~ ~ cif 3 ERISA Plan Request for Summary Plan Description Group Policy/Plan Number(s): Group PolicyholderlPlan Sponsor Name: ERISA Plan Name: ERISA Plan Administrator Name and Title: Note: The Plan Administrator may not be the insurance company or any of its employees. ERISA Plan Administrator Address: ERISA Plan Administrator Primary Office Telephone Number: ERISA Plan Trustees: If the Group Policyholder/Plan Sponsor is a Trust, include names, titles and addresses of principal Collective Bargaining or Multiple-Employer Agreements: If the ERISA Plan is established under one or more collective bargaining agreements, indicate place(s) where agreement(s) can be seen and place(s) where a list of employers and employee organizations sponsoring the ERISA Plan can be seen. If fhe ERISA Plan is established under amultiple-employer agreement, indicate place(s) where a list of employers sponsorin the ERISA Plan can be seen. Agent far Legal Process: Plan Administrator Other: ERISA Plan Year: ERISA Plan Number: to Tax ID Number: Premium Payments: Indicate proportions or amounts of premium cost paid by employees and the Group Policyholder/Plan Comments: The ERISA Plan Administrator hereby requests that ReliaStar Life Insurance Company and/or ReliaStar Life Insurance Company of New York provide Summary Plan Descriptions for distribution to eligible plan participants, using the insurance company's standard language and format. If the language/format requested is other than the insurance company's standard, I certify that the Summary Plan Descriptions that are to be provided by the insurance company were developed by the Group Policyholder/Plan Sponsor in cooperation with its legal counsel. ReliaStar L'rfe Insurance Company and ReliaStar Life Insurance Company of New York have given no legal advice as to whether these Summary Plan Descriptions comply with ERISA requirements and assume no responsibility for their style, format or content. ~ Date r S an~inistrator ReliaStar Life Insurance Company and ReliaStar Life Insurance Company of New York assume no responsibility for meeting disclosure requirements imposed by ERISA. (12/06) Golden Triangle Specialty Network Group Access Agreement ReliaStar Life Insurance Company, an ING North American Insurance Company subsidiary ("ING"), has an agreement with Golden Triangle Specialty Network, LLC ("GTSN"), that gives your self-funded employee benefit plan, hereafter refereed to as "Plan," access to a national network of out-patient renal dialysis facilities and providers who offer discounts from charges through their contracts with GTSN. To take advantage of this agreement, you need to sign this Access Agreement and return it to the fax number presented below. GTSN will provide the following Services with respect to renal dialysis management: • Evaluation of claimant treatment costs (itemized bill review); • Access to a comprehensive national network of out-patient dialysis centers providing significant discounts on dialysis and dialysis related services, including medications; • Settlement negotiations for out-of-network dialysis claims, including documentation of settlement. All settlements must include language such that the claimant is not balance billed by any Provider excluding claimant's obligation for co-insurance and deductibles; and • If claimant seeks treatment at a non-GTSN facility, GTSN will attempt to negotiate with said facility to enter the GTSN vendor network to allow for discount access. Service Fee: • GTSN compensation is 25% of the difference between the initial facility charges and the negotiated, billed on a monthly basis. • All invoices include a worksheet which defines cost savings and the invoice itself • Failure to compensate GTSN within 30 days of invoice receipt may cause Payor to lose access to the GTSN renal network. Responsibilities of the Plan: • The Plan has sole responsibility for verifying member benefits or eligibility for coverage, and for any plan coverage dispute that may arise. Plan will provide eligibility within 24 hours of referral and benefit language information related to any patient within 48 hours of the referral. • Plan will notify claimant of access to GTSN Dialysis Services. If claimant agrees to participate, Plan will inform claimant that GTSN Case Manager will contact them. • Plan will make all required payments to the Provider(s) within 30 days of invoice. • GTSN and the Plan agree to keep information confidential, which identifies rate, and proprietary information, and any information regarding covered members in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). • Plan understands and agrees that GTSN will provide ING periodic reports regarding all referrals under this Access Agreement. • The Plan acknowledges that GTSN will not be deemed or understood to be an ERISA plan administrator or fiduciary, and that GTSN has no responsibility of any kind for: 1) medical outcomes of the quality or competence of any physician, facility, or provider rendering service; 2) payment of any medical, hospital, or other bills resulting from any medical or surgical treatment of confinement; and 3) interpretation of any benefit plan contract concerning coverage or denial of benefits. • The signed agreement is effective on the day it is received by GTSN. Your access to the agreement will end when your Excess Risk Policy through ING terminates or upon 90 day written notice by you or by GTSN. Acknowledged and agreed: Employer Name: Kerr County Address: 700 Main Street, Kerrville, TX 78028 Signature: ~ Telephone: 830-792-2211 Name: Pat Tinley # of Employees: Kerr County Judge Date: December 14, 2009 TO ACTIVATE THIS AGREEMENT FAX THIS FORM TO THE ING CLINICAL STAFF AT 612-342-3373 APPLICATION FOR ReliaStar Life Insurance Company GROUP INSURANCE Home Office • Minneapolis, Minnesota 55440 Application is made to ReliaStar Life Insurance Company (we, us, our) for Group Insurance. 1. Narne of Group Applicant Kerr Count (use exact legal name of organization) 2. Address 700 Main (number & street) Kerrville TX 78028 (city, state, zip code) 3. Types of insurance desired: Does the Group Applicant pay 100% of the premium? ® Basic Life Insurance ..............................................................................:......................... Yes ® Supplemental Life Insurance ........................................................................................... No ^ Basic Dependent Life Insurance ...................................................................................... n/a ® Supplemental Dependent Life Insurance ........................................................................ No ^ Paid Up Life Insurance .................................................................................................... n/a ® Basic Accidental Death & Dismemberment Insurance (AD&D) ....................................... Yes ® Supplemental Accidental Death & Dismemberment Insurance (AD&D) .......................... No ^ Basic Dependent Accidental Death & Dismemberment Insurance (AD&D) ..................... n/a ^ Supplemental Dependent Accidental Death &Dismemberment .........................:............ n/a Insurance (AD&D) ^ Survivor Income Benefit (Life Insurance) ........................................................................ n/a ^ Weekly Disability Income Insurance ................................................................................ n/a ^ Monthly Disability Income Insurance ............................................................................... n/a ^ Employee Dental Insurance ............................................................................................. n/a ^ Dependent Dental Insurance ........................................................................................... n/a ^ Other Personal Accident Insurance-Employee ................................................................ n/a ^ Other Personal Accident Insurance-Dependent .............................................................. n/a 4. This insurance is to become effective on (date) January 1, 2010 at the Group Applicant's place of business, only if the first month's premium is paid in full, and we accept this application. 5. The writing agent on the insurance applied for is: (The agent must be duly licensed as required bylaw) Alamo Insurance Group _Hilb Rogal and Hobbs of San Antonio. Inc. Group Applicant Kerr County BY ~- ~ ~5 S -' ---- Title .Pat Tinley, Kerr County Judge Date December 14, 2009 See reverse side for Fraud Warnings GrpAppStnd 1 of 2 Fraud Warnings Standard: Any person who knowingly and with intent to defraud, submits an application or files a claim containing any materially false or misleading information, commits a fraudulent act, which is a crime. Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. District of Columbia: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Louisiana: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Oregon: Any person who knowingly and with intent to defraud submits an application or files a statement of claim containing any materially false or misleading information, may be guilty of insurance fraud. Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Tennessee: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines and denial of coverage. GrpAppStnd 2 of 2 HEMOPHILIA HEALTH SERVICES ...for the human factor. Hemophilia Health Services Access Agreement Your stop loss insurer ReliaStar Life Insurance Company ("ING"), has an agreement with Hemophilia Health Services ("HHS") that gives your self-funded employee benefit plan, hereafter referred to as "Plan", access to certain hemophilia therapy risk management consulting services. To take advantage of this agreement, you need to agree to the terms of this Access Agreement by signing below and faxing it to the numbers below. HHS will perform the following Services with respect to hemophilia therapy management and maximize cost avoidance for hemophilia claims: • 'Contact Payor and/or their third party administrator to determine strategy for supply of hemophilia Factor drug(s) to claimant. • Guarantee performance for assay matching within 2% of the prescribed dose for factor dispensed by HHS. • 'Bill the Payor or Payor's third party administrator directly for provision of HHS Services. • Conduct a RN home visit for initial evaluation along with infusion training and administration of services to Participant as needed • Provide without cost any necessary safety equipment including but not limited to helmets, knee and elbow pads, Cryocuff®, and travel packs. • provide Factor in a timely manner along with supplies necessary for the administration of same including but not limited to sterile syringes, tourniquets, port-a-cath supplies, butterfly needles, alcohol wipes, latex gloves and bandaging materials customized to the Participant's needs. • Provide emergency delivery of Factor (same day) if necessary. Service fees: • HHS service costs for Hemophilia Therapy Management are included in the purchase price of the Factor drug(s) payable by Payor. Reimbursement for Factor products will be agreed upon by HHS and Payor. Negotiated agreements are Participant ,specific and signed apart from this Agreement. HHS shall require payment by the Payor or its third parry administrator within 30 days of its invoice. Responsibilities of the Plan: • The Plan has sole responsibility for verifying member benefits or for eligibility for coverage and for any plan coverage dispute that may arise. Plan will provide eligibility verification with referral. Plan will provide HHS with administrative requirements, a listing of all pharmacy/medical providers related to each referral. • HHS and the Plan agree to provide notification to each other if a complication occurs v~ith financial, compliance or quality assurance issues. • .Plan understands and agrees that HHS will provide ING periodic reports regarding all referrals under this Access Agreement. • Plan acknowledges that neither HHS nor ING is deemed, understood to be, or agrees to be an ERISA plan administrator or .fiduciary, and that HHS has no responsibility of any kind for 1) medical outcomes or the quality or competence of any physician, facility or provider rendering service; 2) payment of any bills resulting from treatment or confinement; and 3) .interpretation of any benefit plan contract concerning coverage or denial of benefits. HHS' and the Plan agree to keep information confidential that identifies rate and proprietary information, and any information regarding covered members in accordance with the Health Insurance Portability Act of 1996. The signed agreement is effective on the day it is received by HHS. Your access to this agreement will end when your Excess Risk coverage with ING terminates or upon 30 days written notice by you or by HHS. HHS is not obligated to accept any participant who does not meet its standards for compensation and compliance. Acknowledged and agreed: Employer Name: Kerr County Address: 700 Main _ ~ Kerrville, TX 78028 Signature: phone: Pat Tinle~~ Name: Kerr County Judge # of Employees Title: Date: ember 14, 2009 TO ACTIVATE THIS AGREEMENT FAX TO ING EMPLOYEE BENEFITS AT 612-342-3373 830-792-2211 264 09.02.2005 ~ - ' INTERLINK '~- ~i ~ ~- EIEALTH SERVICES l~_ ~ 1% ~-- INTERLIIVK ACCESS AGREEMENT ING Employee Benefits, through your stop loss insurer, ReliaStar Life Insurance Company ("ING"), has an agreement with INTERLINK Health Services, Inc., that gives your self-funded employee benefit plan, hereafter referred to as "Plan", access to transplant services at negotiated prices. To take advantage of this agreement, you need to sign this Access Agreement and return it to the fax number presented below. 1. You will be entitled to receive case rntes and other preferential pricing that INTERLINK has negotiated with providers and you will pay for transplant services in accordance with the Memorandum of Understanding which provides specific payment terms. Once the Access Agreement is signed, rates can be accessed by plan-authorized representatives, which may include the Plan's case manager and/or TPA administrator. 2. Case rates and access to INTERLINK negotiated rates require benefit payment levels ample enough to pay providers in accordance to negotiated rntes. If the Plan knows, or suspects, that the plan payment or the plan covernge will not cover the case rate payment, procurement, acquisition or any procedure related to the transplant, the Plan shall contact INTERLINK for clarification. 3. For transplants occurring at network facilities, INTERLINK agrees to confirm the network contract rate is reserved for the transplant candidate and that Plan receives a Memorandum of Understanding detailing the contracted terms. INTERLINK shall be compensated for network transplant program services as outlined inthe access fee table presented below. For transplants occurring at non-network facilities, INTERLINK, at the request of the Plan, agrees to determine if a fixed rate agreement is available through various relations it has established. If a fixed rate agreement is not available, INTERLINK shall attempt to negotiate a rate acceptable to the Plan. INTERLINK shall discuss the proposed rate with the Plan's contact person, and if agreeable, shall secure the agreed upon rate in a Memornndum of Understanding. INTERLINK shall be compensated for non-network transplant program services as outlined in the access fee table presented below. Preferred INTERLINK access fees* areas follows: T e~ofComletedTranslan~ Amount, Kidn $ 3,000 Pancreas $ 7,000 Kidn & Pancreas $ 7,000 Heart $ 10,000 Heart & Lun $ 10,000 Lun $ 10,000 Autolo ous Bone Marrow $ 10,000 Related Donor, Allo eneic Bone Marrow $ 10,000 Unrelated Donor, Allo eneic Bone Marrow $ 13,000 Liver $ 12,000 Negotiated Cases Without Case rates $ 25% of savings with cap accordin to access fees * As part of the transplant program services with ING, access fees are only due if and only if the candidate receives a transplanted organ or has marrow/stem cell reinfused. Access fee invoices must be paid within thirty (30) days from the date they are received. 4. Provider bills shall be repriced to terms outlined in the Memorandum of Understanding and sent to the Plan's claims payer for payment. 5. INTERLINK and the Plan agree to provide notification to each other if a complication occurs with a transplant financial agreement, member access problems, or quality assurance issues. Plan agrees to provide INTERLINK early notification of potential transplants. Notifications after admission may not be eligible for fixed rate transplant services. 6. INTERLINK and the Plan agree to keep information confidential, which identifies rate and proprietary information, and any information regarding covered members in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 7. The Plan understands and agrees that INTERLINK shall provide ING periodic reports regarding all Plan candidates referred under this Access Agreement whether or not such candidate(s) underwent a transplant or had marrow/stem cell reinfused. 8. INTERLINK agrees to provide the Plan an ongoing claims audit process for all candidates referred under this Access Agreement which is the same or more favorable to the Plan as INTERLINK's audit process currently in place at the time this Access Agreement is signed. 9. Plan acknowledges that INTERLINK will not be deemed or understood to be an ERISA plan administrator or fiduciary, and that INTERLINK has no responsibility of any kind for: 1) medical outcomes or the quality or competence of any physician, facility, or provider rendering service; 2) payment of any medical, hospital, or other bills resulting from any medical or surgical treatment or confinement; and 3) interpretation of any benefit plan contract concerning coverage or denial of benefits. 10. The signed agreement is affective on the day it is received by INTERLINK. Upon receipt of this Access Agreement INTERLINK reserves the right to deny you access. Your access to this agreement will end when your Excess Risk Policy agreement through ING terminates or upon 30 days written notice by you or by INTERLINK. Acknowledged and agreed: Employer Name: _ Ken County Address: 700 Main Kerrville. TX 78028 Name of Signatory: Pat Tinley Title: Kerr County Judge Signature: ~ # ofEmployees: 64 Date: December 14 , 2009 TO ACTIVATE THIS AGREEMENT FAX THIS FORM TO ING EMPLOYEE BENEFTI'S AT 612-342-3373 10.06.2004 LONDON MEDICAL MANAGEMENT ACCESS AGREEMENT ReliaStar Life insurance Company ("ING"), has an agreement with London Medical Management, Inc. ("London Medical Management") that gives your self-funded employee benefit plan, hereafter referred to as "Plan", access to medical cost negotiation services. To take advantage of this agreement, you need to sign this Access Agreement and return it to the fax number presented below. London Medical Management will perform the following Services with respect to financial management of claims: • Bill review for determination of fair and reasonable charges and/or opportunity to obtain reduction of billed charges; • If a claim is deemed negotiable, London Medical Management agrees to meet specific service standards regarding reviews including but not limited to; • Initial contact with provider(s) will occur within 2 business days of receipt of complete claim information from Plan; • Provision of negotiation progress every 14 days from the time of London Medical Management's initial receipt of document to settlement of claim; and • Documentation of settlement. All settlements must include language such that the Participant is not balance billed by any Provider excluding Participant's obligation for co-insurance and deductibles. It must also protect the Payor and ING from future billing or other attempts at financial recourse from all providers. Service Fee: • Bill review for charges deemed fair and reasonable is done at no charge to the Plan; • Plan agrees to pay London Medical Management twenty percent (20%) of the difference between the initially billed rate for Provider services and the negotiated rate for each claim processed by London Medical Management; • Payor agrees to pay London Medical Management twenty-five percent (25%) of the difference between the initially billed rate for Provider services and the lower negotiated rate for each claim processed by London Medical Management when the Payor validates that the account was contracted with the network on a per employee per month basis or that the cost of accessing the network is included in the administration fee charged to the client. This Service Fee shall apply to the difference between the savings available through the contracted network and the additional amount of savings London Medical Management is able to obtain. If a claim is in the network contracted as a secondary network on a percentage of savings and this network is noted as coverage on the claimant's medical card, it will be treated as in network. If there is no secondary network listed on the claimant's card and a payment has not been made, then regardless of Payor history, this secondary network claim is considered out of network. • London Medical Management will invoice Plan on a monthly basis for the Service Fee. If Plan does not pay Service Fee within 30 days, unpaid balance will bear interest at the rate 1.5% per month until paid; and • London Medical Management fees are reimbursed by ING for eligible claims which exceed stop loss specific deductible. Responsibilities of the Plan: • Plan has sole responsibility for verifying member benefits or eligibility for coverage, and for any plan coverage dispute,that may arise. Plan will provide eligibility verification with referral. Plan will provide London Medical Management with administrative requirements, a listing of physicians, hospitals and ancillary providers related to each referral; • London Medical Management and the Plan agree to provide notification to each other if a complication occurs with a financial agreement or quality assurance issues; • Plan has sole responsibility to pay all service fees stated herein; • Plan will make all required payment to the Provider(s) within 10 business days of receipt of settlement notice from London Medical Management; • The Plan understands and agrees that London Medical Management will provide ING periodic reports regarding all referrals under this Access Agreement; and • Plan acknowledges that neither London Medical Management nor ING is deemed, understood to be, or agrees to be an ERISA plan administrator or fiduciary, and that London Medical Management has no responsibility of any kind for: 1) medical outcomes or the quality or competence of any physician, facility, or provider rendering service; 2) payment of any medical, hospital, or other bills resulting from any medical or surgical treatment or confinement; and 3) interpretation of any benefit plan contract concerning coverage or denial of benefits. London Medical Management and the Plan agree to keep information confidential, which identifies rate and proprietary information, and any information regarding covered members in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The signed agreement is affective on the day it is received by London Medical Management. Your access to this agreement will end when your Excess Risk Policy agreement through ING terminates or upon 30 days written notice by you or by London Medical Management. Acknowledged and agreed: Employer Name: Kerr Count Signature: ~~, Pat Tinley, Kerr County Judge Title: Address: 700 Main Kerrville. TX 78028 830-792-2211 Telephone: Date: December 14, 2009 # of employees: 264 TO ACTIVATE THIS AGREEMENT FAX THIS FORM TO ING EMPLOYEE BENEFITS AT 612-342-3373 RELIASTAR LIFE INSURANCE COMPANY Home Office, Minneapolis, Minnesota 55440 EXCESS RISK APPLICATION The Plan Sponsor hereby applies for the Excess Risk Insurance coverage as now in effect or later modified. Name of Plan Sponsor (exact legal name) Kerr County Address (number and street, city, state, zip code) 700 Main Kerrville, TX 78028 ^ Corporation ^ Partnership ^ Sole Proprietorship ® Other (specify) Public Group Nature of Plan Sponsor's Business: SIC Code: 9120 Are Associated Organizations to be included? ® No ^ Yes (If "yes," give names.) Number of Eligible Individuals: Employee Only Coverage: 264 Employees with Dependent Coverage: 98 Number of Enrolled Individuals: Employee Only Coverage: Employees with Dependent Coverage: Number of Individuals Covered Elsewhere: Employee Only Coverage: Employees with Dependent Coverage: Claim Administrator for coverages checked below for the Employee Benefit Plan: Name of Claim Administrator*(exact legal name of entity) UMR Address of Claim Administrator (number and street, city, state, zip code) 12668 Silicon Drive San Antonio, TX 78249 *Claim-Administrator must be approved by ReliaStar Life prior to acceptance of this Application AGGREGATE EXCESS RISK ® YES ^ NO BENEFITS TO BE COVERED: ® Medical ^ Vision ®Prescription Drugs ^ Weekly Disability Income ^ Dental ^ Other (specify) II~IITIAL CONTRACT BASIS: ^ Incurred and paid in 12 months ^ Incurred in 12 months and paid in 15 months ® Incurred in 15 months and paid in 12 months ^ Incurred in months and paid in months ^ Paid in 12 months ^ Other: Actively at Work requirement ® Waive ^ Do not Waive Deductible Adjustment Factor: 125% Minimum Aggregate Deductible: See Excess Risk Schedule/Current Premium Rate Not cation ReliaStar Life's Limit of Liability: $1,000,000 per contract period Optional: ^ Terminal Liability RL-SL-APP-08 INDIVIDUAL EXCESS RISK ® YES ^ NO BENEFITS TO BE COVERED: ® Medical ®Other (please specify) Prescription Drues INITIAL CONTRACT BASIS: ^ Incurred and paid in 12 months ® Incurred in 15 months and paid in 12 months ^ Paid in 12 months Actively at Work requirement ® Waive ^ Incurred in 12 months and paid in 15 months ^ Incurred in months and paid in months ^ Other: ^ Do not Waive Individual Deductible: Individual Deductible: $60,000 per Individual True Family Deductible: $ per family Lasered Individuals as identified in the disclosure process: none Claims for Lasered Individuals are excluded under Aggregate Excess Risk Insurance, if any. Aggregating Individual Deductible: $n/a (Individual Excess Risk must be elected) Benefit Percentage: 100% ReliaStaz Life's: Maximum Individual Contract Period Benefit: $N/A Maximum Individual Lifetime Benefit: $2,000,000 minus the individual deductible Optional: ^ Terminal Liability ^ Immediate Reimbursement Are retirees covered? ®Yes ^ No Are retirees age 65 and over covered? ®Yes ^ No If so, is Medicare Primary? ®Yes ^ No Attached to and incorporated in this Application is a copy of the Employee Benefit Plan currently in effect for the provision of benefits by the Plan Sponsor to its eligible employees or members. The initial Contract Period is from January 1, 2010 to December 31, 2010. The Producer/Agent of Record (provided he/she is duly licensed as required by law) is: Hilb Roeal and Hobbs of San Antonio, Inc.. This insurance is to be effective on January 1, 2010 at 12:01 a.m. Standard Time at the Plan Sponsor's place of business, provided that the first premium is paid in full and that the Claim Disclosure Statement and. this Application are accepted by ReliaStaz Life. An advance deposit of $26,176.80 is attached. (The deposit is to equal the first premium.) The deposit will be applied toward payment of the premiums on the insurance requested if the application is accepted by ReliaStaz Life. If not accepted, the deposit will be refunded to the Plan Sponsor Applicant. PLAN SPONSOR APPLICANT Kerr County Witness December 14, 2009 Date By Pat Tinley Name of signer (please print) Kerr County Judge Title RL-SL-APP-08 PRELIMINARY STATEMENT OF AGREEMENT Effective 1-1-2010, UMR, Inc. ("UMR") and Kerr County ("Plan Sponsor") agree that UMR shall provide certain third party administrative services for the Plan Sponsor's self-funded employee benefit plans. The intent of the parties is to establish a formal Administrative Services Agreement that fully discloses each party's duties, rights and obligations, and that discloses applicable fees for services being purchased by the Plan Sponsor. It is understood, however, that before the Administrative Services Agreement can be prepared, a series of transition meetings need to take place between UMR and the Plan Sponsor to make final decisions regarding services to be provided. In the interim, this Preliminary Statement of Agreement will reflect the intent of both parties to begin providing services. Covered Plans UMR shall provide certain mutually agreed upon administrative services for the following employee benefit plans of the Plan Sponsor: 501 Medical Plan Fees During the course of the transition meetings described above, Plan Sponsor will finalize decisions regarding the services that it will purchase from UMR. Fees for those services will be reflected in the actual Administrative Services Agreement that will be sent to the Plan Sponsor within a reasonable amount of time after the transition meetings have been completed. The anticipated base administrative fee(s) that UMR will charge Plan Sponsor to process claims is listed below, however this could change if Plan Sponsor makes changes during the transition meetings. All other fees including the base fee will be listed in the Administrative Services Agreement to reflect the decisions that the Plan Sponsor makes during the transition meetings. The Plan Sponsor agrees to pay UMR the applicable service fees in a timely manner so that UMR receives the payment on or before the last day of each calendar month for which services are rendered. Add Base Fee information for those products that were purchased, and delete those that were not purchased. Medical Plan Base Fee: $16.50 per employee per month. All other fees will be listed in the Administrative Services Agreement. III. Relationship of Parties Both parties agree that UMR is not providing an insurance policy or an indemnity agreement, and that Plan Sponsor is simply purchasing administrative services from UMR. It is further understood and agreed that the relationship between UMR and Plan Sponsor is that of independent contractor. IV. Run-In Claims Processing: It is understood and agreed that should UMR be requested to process run-in claims for Plan Sponsor, Plan Sponsor shall .assume responsibility and liability for complying with ERISA and the Department of Labor's claims regulations, if applicable. Plan Sponsor is fully and solely responsible for any risks associated with stop loss carriers as it relates to run-in claims, and holds UMR harmless with respect to such stop loss problems. Plan Sponsor further agrees to supply UMR with all pertinent eligibility, benefit and other information that UMR deems necessary to process run-in claims. V. Termination and Definitive Agreement: Either party may terminate this Preliminary Statement of Agreement upon written notice to the other. This Preliminary Statement of Agreement will expire ninety (90) days after the first effective date of the Plan Sponsor with UMR. The parties agree to negotiate in good faith to attempt to reach a final definitive Administrative Services Agreement within the ninety (90) day period. This Preliminary Statement of Agreement will automatically terminate in the event that Plan Sponsor fails to provide sufficient funds with which to pay claims or other liabilities under the Plan(s), or a petition is filed by or with respect to the Plan Sponsor under the Federal Bankruptcy Act or any state insolvency law. Agreed to on behalf of UMR By: Jay Anliker, President and CEO Date Signed: Agreed to on behalf of Kerr County Legal name of Customer/Plan Sponsor) By: Print Name: Pat Tinley Title: Kerr County Judge Date Signed: December 14, 2009 Revised 10/31/08 Yc~r~C urc~r ,~~U ~~ ~.~." P i _ ..~ ~. E}PTIaN I UMR Administration of New York Surcharge w ~,UnitedHealthua*e Company UMR will file HCRA reports and submit payments to the Public Goods Pool on your behalf when you return signed New York Dept. of Health forms to UMR. Retroactive elections for New Payors are not allowed. Per HCRA regulations, New Payor Elections can only be effective on the first of the month following the Pool's receipt of the election form. UMR will file forms related to Payor surcharge obligations and covered lives assessment as required. OPTIQN II I am waiving New York Surcharge administrative services. UMR waives all responsibility for filing and reporting. New York Surcharge liability and administration will be the sole responsibility of the Plan. Note: Should the Plan decide to change their election, Federal Identification number, or Legal name completion of a new form is required. Signature: Name (print): Title: Plan Sponsor Legal Name, or DBA ("doing business as") Date: Group Number: Policy Effective Date: Pat Tinley Kerr County Judge December 14, 2009 Golden Triangle Specialty Network Group Access Agreement ReliaStar Life Insurance Company, an ING North American Insurance Company subsidiary ("ING"), has an agreement with Golden Triangle Spedalty Network, LLC ("GTSN"), that gives your self-funded employee benefit plan, hereafter refereed to as "Plan," access to a national network of out-patient renal dialysis fadlities and providers who offer discounts from charges through their contrails with GTSN. To take advantage of this agreement, you need to sign this Access Agreement and return it to the fax number presented below. GTSN will provide the following Services with respell to renal dialysis management: • Evaluation of daimant treatment cests (itemized bill review); • Access to a comprehensive national network ofout-patient dialysis centers providing significant discounts on dialysis and dialysis related services, including medications; • Settlement negotiations for out-of-network dialysis claims, including documentation of settlement. All settlements must include language such that the daimant is not balance billed by any Provider excluding claimant's obligation for co-insurance and deductibles; and • If daimant seeks treatment at a non-GTSN fadiity, GTSN will attempt to negotiate with said fadlity to enter the GTSN vendor network to allow for discount access. Service Fee: • GTSN compensation is 25% of the difference between the initial fadlity charges and the negotiated, billed on a monthly basis. • All invoices include a worksheet which defines cost savings and the invoice itself • Failure to compensate GTSN within 30 days of invoice receipt may cause Payor to lose access to the GTSN renal network. Responsibilities of the Plan: • The Plan has sole responsibility for verifying member benefks or eligibility for coverage, and for any plan coverage dispute that may arise. -Plan will provide eligibility within 24 hours of referral and benefit language information related to any patient within 48 hours of the referral. • Pian will notify daimant of access to GTSN Dialysis Services. If daimant agrees to participate, Plan will inform daimant that GTSN Case Manager will contail them. • Plan wil(make alt required payments to the Provider(s) within 30 days of invoice. • GTSN and the Plan agree to keep information confidential, which identifies rate, and proprietary information, and any informaton regarding covered members in akxordance with the Health Insurance Portability and Accountability Ad of 1996 (HIPAA). • Plan understands and agrees that GTSN will provide ING periodic reports regarding all referrals under this Access Agreement. • The Plan acknowledges that GTSN will not be deemed or understood to be an ERISA plan administrator or fidudary, and that GTSN has no responsibility of any kind for: 1) medical outcomes of the quality or competence of any physidan fadlity, or provider rendering service; 2) payment of any medical, hospital, or other bills resulting from any medical or surgipl treatment of confinement; and 3) interpretation of any benefit plan contred concerning coverage or denial of benefits. • The signed agreement is effective on the day it is received by GTSN. Your access to the agreement will end when your Excess Risk Policy through ING terminates or upon 90 day written notice by you or by GTSN. Acknowledged and agreed: Employer Name: Kerr County Address: 700 Main Street, Kerrville, TX 78028 ~ 830-792-2211 Signature: /~' ~ Telephone: Name: Pat Tinley # of Employees: Title: Kerr County Judge Date: December 14, 2009 TO ACTIVATE THIS AGREEMENT FAX THIS FORM TO THE ING CLINICAL STAFF AT 612-342-3373 ERISA Plan Request for Summary Plan Description Policy/Plan Number(s): Policyholder/Plan Sponsor Name: Plan Name: Plan Administrator Name and Title: Note: The Plan Administrator may not be the insurance company or any of its employees. Plan Administrator Address: ERISAY Plan Administrator Primary Office Telephone Number: ERISA Plan Trustees: If the Group Policyholder/Plan Sponsor is a Trust, include names, tifles and addresses of princip lace `of business of all Trustees. '. Collective Bargaining or Multiple-Employer Agreements: If the ERISA Plan is established under one or more collects e bargahing agreements, indicate place(s) where agreement(s) can be seen and place(s) where a list of employers and em organ rations sponsoring the ER/SA Plan can be seen. if the ERISA Plan is established under amultiple-employer agree ; loyee ant, iodic a laces where a list of em !o ers s onsorin the ERISA Plan can be seen. Agen~f egalProcess: ~j ~PlanAdministrator Other: ERISIl* Plan Year: to ERIS~ Plan Number: Tax ID Number: Premium Payments: Indicate proportions or amounts of premium cost paid by employees and the Group Policyholder/P n S on r. Com' ants: i The ~RISA Plan Administrator hereby requests that ReliaStar Life Insurance Company and/or ReliaStar Life In rance Com pny of New York provide Summary Plan Descriptions for distribution to eligible plan- participants, using the in rance compny's standard language and format If thelanguagelformat requested is other than the insurance company's standard, I certify that the Summary Plan Des `. thate to be provided by the insurance company were developed by the Group Policyholder/Plan Sponsor in cooperati its I I counsel. ReliaStar Life Insurance Company and ReliaStar Life Insurance Company of New York have given advic4i3 as to whether these Summary Plan Descriptions comply with ERISA requirements and assume no responsibility style,'i~ormat con nt. R 'ptions n with legal r their Z 1 05 n..a,. R n inistrator va~a ~., _.~.._._. _ _.. .~...._ Relia~tar Life Insurande Company and ReliaStar Life Insurance Company of New York assume no responsibility for meet. g disc) Sure requirements imposed by ERISA. 12/06) APPLICATION FOR ReliaStar Life Insurance Coml G RO U P L N S U RAN C E Home Office • Minneapolis, Minnesota Applid8tion is made toReliaStar Life Insurance Company (we, us, our) for Group Insurance. 1. Name of Group Applicant Kerr Coun (use exact legal name of organization) 2. Address 700 Main (number & street) Kerry' a TX 78028 (city, state, zip code) 3. Tykes of insurance desired: Does the Group Applicant pay 00% of the premium? ® Ba~6ic Life Insurance ..............................................................................:.........................Yes ® St.~Plemental Life Insurance ...........................................................................................No ^ Basic Dependent Life Insurance ..................:...................................................................n/a ® Supplemental Dependent Life Insurance ........................................................................No ^ Paid Up Life Insurance ....................................................................................................n/a ®B ~' is Accidental Death & Dismemberment Insurance (AD&D) .......................................Yes ®S elemental Accidental Death & Dismemberment Insurance (AD8~D) ..........................No ^ B is Dependent Accidental Death 8~ Dismemberment Insurance (AD&D) .....................n/a ^ S4pplemental Dependent Accidental Death &Dismemberment .................:.......:............n/a Insurance (AD8~D) ^ Survivor Income Benefit (Life Insurance) ........................................................................n/a ^ I~ekly Disability Income Insurance ................................................................................n/a W ^ Monthly Disability Income Insurance ...............................................................................n/a ^ ErtlPloyee Dental Insurance .............................................................................................n/a ^ Dependent Dental Insurance ....................................................................:......................n/a ^ O ~ er Personal Accident Insurance-Emolovee ................................................................n/a ..................................... n/a ^ Oer Personal Accident Insurance-Dependent ......................... 4. Th;~s insurance is ~o become effective on (date) Janua 1 2010 at'~the Group. Applicant's place of business, only if the first month's premium is paid in full, and we acc %pt this aplplication. ~: 5. TNe writing agent!on the insurance applied for is: (The agent must be duly licensed as required `law) Applicant I' Title ~"' Pat Tinhy, Kerr County Judge Date's December 14, 2009 See reverse side for Fraud Warnings 1 of 2 LONDON MEDICAL MANAGEMENT ACCESS AGREEMENT ReliaStar Life~lnsurance Company ("ING"), has an agreement with London Medical Management, Inc. ("London Medical Man gement") that gives youlr self-funded employee benefit plan, hereafter referred to as "Plan", access to medical cost negotiation services. To take advantage of t~is agreement, you need to sign this Access Agreement and return it to the fax number presented below. London Medir$al Management will perform the following Services with respect to financial management of claims: • Bill review for determination of fair and reasonable charges and/or opportunity to obtain reduction of billed charges, • If a c~aim is deemed negotiable, London Medical Management agrees to meet specific service standards regarding r views including but not limited to; • initial contact with provider(s) will occur within 2 business days of receipt of complete claim information from Pla ; • ~'rovision of negotiation progress every 14 days from the time of London Medical Management's initial receipt o document to settlement of claim; and • ocumentation of settlement. All settlements must include language such that the Participant is not balance bill by any rovider excluding Participant's obligation for co-insurance and deductibles. It must also protect the Payor and G from uture billing or other attempts at financial recourse from all providers.. Service Fee: • -Bill r~view for charges deemed fair and reasonable is done at no charge to the Plan; • Plan agrees to pay London Medical Management twenty percent (20%) of the difference between the initially billed ra a for Provider serv~Ces and the negotiated rate for each claim processed by London Medical Management; • Payctt agrees to pay London Medical Management twenty-five. percent (25%) of the difference between the initially, billed rate for Prov(tler services and the lower negotiated rate'for each claim processed by London Medical Management when the yor validates that ~e account was contracted with the network on a per employee per month basis or that the cost of accessing ; he network is incl ed in the administration fee charged to the client. This Service Fee shall apply to the difference between the sa; ings available thro `ugh the contracted network and the additional amount of savings London Medical Management is able to obtain. ' If a claim is in the etwork contracted as a secondary network on a percentage of savings and this network is noted as coverage onthe claimant's mad ' 1 card, it will be treated as in network. If there is no secondary network listed on the claimant's card and a pa' ment has not bee ';made, then regardless of Payor history, this secondary network claim is considered out of network. • Lonn Medical Management will invoice Plan on a monthly basis for the Service Fee. If Plan does not pay Service ee within 30 day ;unpaid balance will bear interest at the rate 1.5% per month until paid; and • Lon~on Medical Management fees are reimbursed by ING for eligible claims which exceed stop loss specific deduct le. ponsibiliti~s of the Plan: Pla Chas sole responsibility for verifying member benefits or eligibility for coverage, and for any plan coverage dispu that may aris ;Plan will provide eligibility verification with referral. Plan will provide London Medicaf Management with admin trative req rements, a listing of physicians, hospitals and ancillary providers related to each referral; • Lon on Medical Management and the Plan agree to provide notification to each other if a complication occurs with 'financial agreement or quality assurance issues; • Plar( has sole responsibility to pay all service fees stated herein; • Plar~lwill make all required payment to the Provider(s) within 10 business days of receipt of settlement notice from L `ndon Medical Thelplan understands and agrees that London Medical Management will provide ING periodic reports regarding all fen'als under this Access Agreement; and • Pla}- acknowledges that neither London Medical Management nor ING is deemed, understood to be, or agrees to b' an ERISA plar~'administrator orlfiduciary, and that London Medical Management has no responsibility of any kind for: 1) medic I outcomes or the quality or competence of any physician, facility, or provider rendering service; 2) payment of any medical, hospit I, or other billsi esufGng from any medical or surgical treatment or confinement; and 3) interpretation of any benefit plan contra t concerning coverage or denial of benefits. London Medil~al Management and the Plan agree to keep information confidential, which identifies rate and proprietary info ation, and any information regarding covered members in accordance with the Health Insurance Portability and Accountability Act of 19 6 (HIPAA). The signed ` reement is affective on the day it is received by London Medical Management. Your access to this agreement ill end when your Excesstisk Policy agreement through ING terminates or upon 30 days written notice by you or by London Medical Ma gement. Acknowledged and agreed: ;, Employer Nakne: Kerr County Address: 700 Main ~"`~ ~ Signature: I 1 ' > > -.~"~~ ' Kenville. TX 78028 P!,at Tinley, Kerr County Judge 830-792-2211 .Title: Telephone: Date: D~cember 14 , 2009 # of employees: 264 TO ACTIVATE THIS AGREEMENT FAX THIS FORM TO ING EMPLOYEE BENEFITS AT 612-342-3373 RISK ® YES ^ NO ®Other (please specify) Prescription Drues red and paid 12 months red in 15 mo the and paid in 12 months in 12 months i ~elv at Work #equirement ® V~aive Individua --Deductible: Indi dual Deductible True ' amily Deducti~ Lasered ~ ividuals as ide. Claims fo ' Lasered Indivic Aggregating Individual De Benefit Percentage: 100% i ReliaStar ~,ife's: ~~a 1 Are reti Are reti If so, is covered? age 65 and :o and incorpi ~f benefits by ^ Incurred in 12 months and paid in 15 months ^ Incurred in months and paid in ^ Other: ^ Do not Waive $60.000 per Individual $ per family d in the disclosure process: none are excluded under Aggregate Excess Risk Insurance, if any. ible: $n/a (Individual Excess Risk must be elected) Contract Period Benefit: $N/A Lifetime Benefit: $2 000.000 minus the individual deductible ® Yes ^ No r covered? ®Yes ^ No ® Yes ^ No ated in this Application is a copy of the Employee Benefit Plan currently in effect for ~e Plan Sponsor to its eligible employees or members. The initi 'Contract Perio is from January 1.2010 to December 31, 2010. The Prod 'cer/Agent of R cord (provided he/she is duly licensed as required by law) is: Hilb Rogal and Hobbs of San E Inc.. This ins ce is to be eff ctive on January 1.2010 at 12:01 a.m. Standard Time at the Plan Sponsor's place of busines that the st premium is p id in full and that the Claim Disclosure Statement and this Application are accepted by Relic An adv '', a deposit of $2 176.80 is attached. (The deposit is to equal the first premium.) The deposit will be applied payments' f the premiums on the insurance requested if the application is accepted by ReliaStar Life. If not accepted, tl will be re~'unded to the Pl Sponsor Applicant. i Witness ''; `ecember 14 2009 Date I I I RL-SL- PLAN SPONSOR APPLICANT Kerr Countx_ J Pat Tinley Name of signer (please print) Kerr County Judge Title 2 ~_ Life. deposit y I CE COMPANY A ~ r ~ N LIASTAR LIFE INSUR ~,~ ' I Home Office, Minneapolis, Minnesota 55440 ~, , ~ ' II , ~, EXCESS RISK APPLICATION The Plan ponsor hereby ~pplies for the Excess Risk Insurance coverage as now in effect or later modified. Name of lan Sponsor (exact legal name) Kerr Co ~ ty ' I Address ( t, city, state, zip code) "umber and stre 700 Ma' '' Kerrville,'>jX 78028 ^ Corp~ _ pration ^~I Partnership ^ Sole Proprietorship ® Other (specify) Public Group Nature o , lan Sponsor's usiness: SIC Cod ' 9120 ', Are Asso ''ated Organiza ', ns to be included? ® No ^ Yes (I ~' "yes," give names.) Number o 'Eligible Individu s: Employee Only Coverage: 264 Employees with Dependent Coverage: 98 Number o Enrolled Individ s: Employee Only Coverage: Employees with. Dependent Coverage: Number o Individuals Cov d Elsewhere: Employee Only Coverage: Employees with Dependent Coverage: Claim A 'nistrator for overages checked below for the Employee Benefit Plan: Name of aim Administrat *(exact legal name of entity) tJMR Address o Claim Adminis for (number and street, city, state, zip code) ..12668 Sili ' n Drive San tonio TX 78249 *Claim-A ' 'nistrator must a approved by ReliaStar Life prior to acceptance of this Application AGG GATE EXCE~S RISK ® YES ^ NO BENEFI S TO BE COV RED: ® edical I, ^ Vision ®Prescription Drugs ^ I ' eekly Disability Income ^ Dental ^ Other (specify) INITIAL ONTRACT B SIS: ^ ' curved and paid' in 12 months ^ Incurred in 12 months and paid in 15 months ® curved in 15 moths and paid in 12 months ^ Incurred in months and paid in mon ^ id in 12 month ^ Other: c6vely at World requirement ® aive '~ ^ Do not Waive Deductib ctor: I25% a Adjustment F~ Minim II '' Aggregate Ded~ZCtible: See Excess Risk Schedule/Current Premium Rate Notification ReliaStar ~Life's Limit of ~.iability: $1,000,000 per contract period Optionala I ^ ~ ,erminal Liabilit~ ' i I I '~ y I RL-SL- ~~ P-08 1 I ' !, "HEMOP~HIL HEALTH S RVIC ..for e human factor. .~ Hemophilia Health Services Access Agreement stop loss insurReliaStar Life Insurance Company ("ING"), has an agreement with Hemophilia Health Services ("HHS")1 your self-?und employee benefit plan, hereafter referred to as "Plan", access to certain hemophilia therapy risk manage ~Ifing services. take advantage of this agreement, you need to agree to the terms of this Access Agreement by signing v and faxing it to',the numbers below. H $ will perform the ~ollowing Services with respect to hemophilia therapy management and maximize cost avoidance for he ophilia claims: • ', Contact Payor a~d/or their third party administrator to determine strategy for supply of hemophilia Factor drug(s) to claimant • ~' Guarantee performance for assay matching within 2% of the prescribed dose for factor dispensed by HHS. • '~ Bill the Payor or Payor's third party administrator directly for provision of HHS Services. • ~{ Conduct a RN home visit for initial evaluation along with infusion training and administration of services to Participant as ~' needed • Provide without host any necessary safety equipment including but not limited to helmets, knee and elbow pads, Cryocuff®, and travel packs • ~'' provide Factor i~ a timely manner along with supplies necessary for the administration of same including but not limited to , sterile syringesoumiquets, port-a-oath supplies, butterfly needles, alcohol wipes, latex gloves and bandaging materials customized to Participant's needs. • ~ Provide emergency delivery of Factor (same day) if necessary. S ~i ce fees: . HHS service cots for Hemophilia Therapy Management are included in the purchase price of the Factor drug(s) payable by { Payor. Reimbu ement for Factor products will be agreed upon by HHS and Payor. Negotiated agreements are Participant'. specific and signed apart from this Agreement. HHS shall require payment by the Payor or its third party administrator withi ';'i 30 days of its iny~oice. wnsibilities of th Plan: The Plan has s e responsibility for verifying member benefits or for eligibility for coverage and for any plan coverage dispu that may arise. Ian will provide eligibility verification with referral. Plan wilt provide HHS with administrative requirements, listing of all pha acy/medical providers related to each referral. HHS and the Pl~n agree to provide notification to each other if a complication occurs with financial, compliance or quality assurance issuels. Plan understands and agrees that HHS will provide ING periodic reports regarding all referrals under this Access Agreemei Plan acknowledges that neither HHS nor ING is deemed, understood to be, or agrees to be an ERISA plan administrator or fiduciary, and th t HHS has no responsibility of any kind for 1) medical outcomes or the quality or competence of any physician, facilit~ or provider rendering service; 2) payment of any bills resulting from treatment or confinement; and 3) interpretation of zany benefit plan contract concerning coverage or denial of benefits. and the Plan ag ee to keep information confidential that identifies rate and proprietary information, and any information rding covered m tubers in accordance with the Health Insurance Portability Act of 1996. signed agreeme t is effective on the day it is received by HHS. Your access to this agreement will end when your Excess F ;rage with ING te~rninates or upon 30 days written nofrce by you or by HHS. Hf~S is not obligated Ito accept any participant who does not meet its standards for compensation and compliance. and mployer Name: !, Kerr County Address: ignature: "g~elephone: Pat T_ i n1 _v ame: !i # of Employees: Kerr County Judge itle: ~ Date: 700 Main Kerrville, TX 78028 830-792-2211 264 09.02.2005 INT INK I, 2iFST, SERVICES ', ~,, ;~i INTERLINK ACCESS AGREEMENT i ING Employ ,Benefits, through your stop loss insurer, ReliaStar Life Insurance Company ("ING"), has an agreement with INTERLINK Health Servic ,Inc., that gives your sel ..,funded employee b~Tiefit plan, hereafter referred to as "Plan", access to transplant services at negotiated prices. To take advantage of this greement, you need to si ' this Access Agreement and return it to the fax number presented below. 1. You wi be entitled to receivee case rates and other preferential pricing that INTERLINK has negotiated with providers and you will pay for Mans lant services in acco ce with the Memorandum of Understanding which provides specific payment terms. Once the Access Agreement is signed, rates can b accessed by plan-au 'rued representativ ,which may include the Plan's case manager and/or TPA administrator. 2. Case rat¢~ S and access to INT~RLINK negotiated rates require benefit payment levels ample enough to pay providers in accordance to negotiated tes. If the Plans, or suspects, that) the plan payment or the plan coverage will not cover the case rate payment, procurement, acquisition or any proc related to the lant, the Plan shall contact 1NTERLINK for clarification. i 3. For traT-.~lants occurring at twork f cilities, INTERLINK agrees to confirm the network contract rate is reserved for the transplant candidate that Plan receives', Memorandum of nderstanding detailing the contracted terms. INTERLINK shall be compensated for network transplant programs ces as outlined ~- the access fee table presented below. For lams occurring at on-T twork fa iliti INTERLINK, at the request of the Plan, agrees to determine if a fixed rate agreement is av ble through various ' lations it has estab hed. If a fixed rate agreement is not available, INTERLINK shall attempt to negotiate a rate acceptable to the Plan. ERLINK shall di uss the proposed i}ate with the Plan's contact person, and if agreeable, shall secure the agreed upon rate in a Memorandum of U deistanding. INTE K shall be compensated fornon-network transplant program services as outlined in the access fee table presented below. TNTFRT.TIJK'ar~exa free arr ae fnllnwc• `t' of C .. _. ~ ant ~ Auttnlu~ Ki $ 3,000 P ' reas $ 7,000 I{i & Pancreas $ 7 000 H $ 1Q000 H & Lun $ 10 000 $ 1Q000 A to ous Bone M w $ 1Q000 Re ted Donor, Allo eic Bone Marrow $ 10 000 U ', lated Donor Allo eic Bone Marrow $ 13 000 Li er $ 12,000 N otiated Cases Wi ut Case rates $ 25% of savings with cap accordin to access fees * s part of the transplant program services with ING, access fees are only due if and only if the candidate receives a transplanted o nor has m row/stem cell rein used. Access fee invoices must be paid within thirty (30) days from the date they are received. 4. Providei~bills shall be repriced to teems outlined in the Memorandum of Understanding and sent to the Plan's claims payer for payment. . I 5. INTE K and the Plan aglree to provide notification to each other if a complication occurs with a transplant financial agrcement, member acces problems, or quali 'assurance issues. Elan agrees to provide INTERLINK early notification of potential transplants. Notifications after admission may not "eligible for fixed rat transplant services.'',. 6. INTER)~K and the Plan agree to keep information confidential, which identifies rate and proprietary information, and any information regarding overed member' in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 7. The Plait. ~derstands and agrees that INTERLINK shall provide ING periodic reports regarding all Plan candidates referred under this Access Agr ~ ent whether °~br not such candidate(s) underwent a transplant or had marrow/stem cell reinfused. y' ~i 8. INTE ~ K agrees to provi~e the Plan an ongoing claims audit process for all candidates referred under this Access Agreement which is the sam or more favorabl ' to the Plan as INT>~RLINK's audit process currently in place at the time this Access Agreement is signed. 9. Plan ac owledges that RLINK will not be deemed or understood to be an ERISA plan administrator or fiduciary, and that INTE INK has no responsi ility of any kind fo i 1) medical outcomes or the quality or competence of any physician, facility, or provider rendering service; 2) p ent of acry medical' !hospital, or other b' s resulting from any medical or surgical treatment or confinement; and 3) interpretation of any benefit plan con concerning coverag 'or denial of benefits. 10. The si agreement is affe~tive on the day it is received by INTERLINK. Upon receipt of this Access Agreement INTERLINK reserves the ri to deny you access. our access to this agreement will end when your Excess Risk Policy agreement through ING terminates or upon 30 days written notice y you or by and agreed: Employer Nadte: ~Cerr Count} Name of Si a o I'at T rY~ Title: 9, Kerr Judge Signature: # of Employees: i D ce ember 14, 209 Fraud Warnings Any person who. knowingly and with intent to defraud, submits an application or files a claim I any materially false or misleading information, commits a fraudulent act, which is a crime. Colo ' do: It is umlawful to knowingly provide false, incomplete, or, misleading facts or information to an insur ''nce company ~or the purpose of defrauding or attempting to defraud the company. Penalties may i clude impri onment, fines,) denial of insurance, .and civil damages. Any insurance company or agent of an ins rance com ' ny who knov~ingly provides false, incomplete or misleading facts to a policyholder or claimant r the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or ward pays le from insurad~ce proceeds shall be reported to the Colorado Division of Insurance within the Dep , ment of Rulatorv Agencies. Distr ' of Columb a: It is a crime to provide false or misleading information to an insurer for the pur ; se of defra' ding the insurfrr or any other person. Penalties include imprisonment and/or fines. In addition, an `; surer may ' eny insurance',benefits if false information materially related to a claim was provided by the applicant' Loui liana: Any pe son who knowingly presents a false or fraudulent claim for payment of a loss or be efit or know ugly presents ~alse information in an application for insurance is guilty of a crime and may be su ect to fines hand confinement in prison. Ma ' nd: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a ss or bene or who knowingly and willfully presents false information in an application for insurance is guilty of crime and r~;~ay be subject to fines and confinement in prison. New' erse Any ~erson who includes any false or misleading information on an application for an ins rance polic is subject to c~iminal and civil penalties. Any pers~n who knowingly and with intent to defraud submits an application or files a stateent of containing any., materially false or misleading information, may be guilty of insurance fraud. Penr>ylvania: Anyi person who knowingly and with intent to defraud any insurance company or other erson fifes ~n application ~or insurance or a statement of claim containing any false information or conceals r the purp se of misleading, information concerning any fact material thereto commits a fraudulent insuran a act, whichi' is a crime and) subjects such person to criminal and civil penalties. Tenn ' see: It is ~ crime to knowingly provide false; incomplete or misleading information to an ins' rance com ' ny for the pulrposes of defrauding the company. Penalties include imprisonment, fines and d ial of 2 of 2 .~ ~, :. 't,~ ~~. 1{ a~ ~~.- ~~ ~` ~'~ ReliaStar Life'; Insurance +Campany RE: Group ~~Name: Kerr County Group ~: 66792-7 This is to cgnfirm that Kerr County, hereinafter referred to as THE EMPLOYER GROUP, has a Third Party Administrator agreement with UMR, hereinafter referred to as THE TPA, finder which the TPA will generate the billing and/or submit payment for insurance overage on the 1mployer Group to ReliaStar Life Insurance Company, hereinafter deferred to as THE COMPANY. The Emplo er Group acknowledges that in performing services, the TPA is acting solely on behalf o~the Employer Group and not as an agent or Third Party Administrator for the Company. ',The Employer Group understands and agrees that any payments are not considered ~eceived by the Company until they arereconciled by the Company's billing department end that the Company will notify the Employer Group if premiums become delinquent. '~, As such, the Company strongly encourages the Employer Group to verify there are adequate internal controls regarding premium administration at the TPA. Printed Naxz2e Pat Tinley Title Kerr County Judge Signature ! ~ ~ Date ~~ December 14, 2009 Cc: Broker/Aeenti of Record Q ut :fits, through your stop loss insurer, ReliaStar Life Insurance Company, has an agreement with United Resource Networks URN), that gives pioyee benefit flan access to transplant services at negotiated prices. To take advantage of this agreement, you need t agree to several URN ACCESS AGREEMENT ING Employee E your self-funded points, as follow 1. You will bE agreement; 2. ING Emplo fees, descr loss policy. • For the Tr entitled to receive the favorable pridng that URN has with providers and you will pay for services in accordance wi negotiated with p eiders. ING Employee Benefits has reviewed these payment terms. f;e Benefits will fo~ow the requirements for transplant notifications and approvals of payments. You also agree to pay-the led below, which rill be included as claim payment amounts for purposes of eligibility for reimbursement under ING Empl Network) the fees are as follows: S of "roved Tra s lant Amount Bo 'Marrow Autolo ous: Less than 11 Da $ 5,000 11 or more Da -breast cancer $10,000 11 or more Da -all other dia noses $20,000 Allo eneic: relat or unrelated $20,000 He ' , Lun Heart/Lu $10,000 Inte final, Liver, Intesti al/Liver $20,000 Kid ,Pancreas, Kid a /Pancreas $ 3,500 Networks If, before a 'ember receives coverage. a ds, you will pay l amount of 'e administrative spedfied in ' e table above ai • For the Tr ' spfant Access applicable eider agreemen • For Speci 'Jized Physician written opin ' n from a single r is $2,250 fo ' a written opinion For an exp ' ited review, the Services wi in 2 business d timeframe. ~ If you fonnratd adc opinion, th you will pay Uf information ' s antidpated ai • For Extra ontractual serv relevant to a services bein behalf. Th 'final Extra Conti that the Ext Contractual Prc calculated the difference I shall not ex ed the administ of daims fo '#transplant servio • For Cong nitai Heart Dise pursuant to' a applicable pro 3. You have " le responsibility employees 'nd dependents. 4. You adcno ,edge that URN ~ kind for. a) medical outcome: other bills r ulting from any i of benefits. 5. The signed ' greement is effe access. Y ' r access to this by URN. Acknowledged a~1d agreed: Employer Signature: Name: Title: transplant, the member: a) is not accepted to a provider's transplant program, or b) the member dies, o N 35% of the difference between billed charges and URN's agreed upon charges for the services render for the corresponding transplant set forth above. Payment to URN under these circumstances is in lie is due within 30 days of the date URN sends the invoice. ogram the fees are 15% of savings, calculated as the difference between billed charges and amounts pa The fees shall not exceed the administrative fee for the corresponding transplant set forth in the table abc eview Services the fees. are as follows: a) For transplants other than bone marrow transplants, the fi fewer, or $2,450 for three written opinions, one from each of three reviewers; and b) For bone marrow tc ~m a single reviewer, or $2,700 for three written opinions, one from each of three reviewers. s is an additional $200 for each physician reviewer. An expedited review is the provision of Specialized' 's of initiation, as described above. The additional fee is not charged if the written opinion is not de onal information to URN and request additional Specialized Physician Review Services about a previousE another fee of $1,000 for an additional written opinion from a single reviewer. Such fee will not app) noted by the author of the opinion and received within 4 months of the date of the initial written opinion. :s you shall .contact URN to initiate an Extra Contractual Agreement and shall provide URN Member s~ requested. Once URN receives the required information, URN will negotiate the Extra Contractual A~ ual Agreement wilt confirm the understanding between you and your Extra Contractual Provider regarding ier has agreed to provide to a Member. For URN's service under the Agreement, the fees are as follow! Iween Billed Charges and the amounts paid pursuant to the applicable Parficipation Agreement. This' :ive fee for the corresponding transplant set forth above in the Transplant Network section and shall be I terms of the administrative Benefits' stop- c) the member's ;d, capped at the u of the payment d pursuant to the ve. e is $1,850 for a rnspiants, the fee 'hysician Review leered within this prepared written r if the additional :cific information ~eement on your specific services 15% of savings, dministrative fee Iled upon receipt (CHD) Services the fees are 15% of savings, calculated as -the difference between billed charges nd amounts paid :r agreement. The fees shall not exceed $10,000 and shall be billed to you upon receipt of claims for C D Services. verifying member benefits or eligibility for transplant coverage, and for any plan coverage dispute t t may arise with II not be deemed or understood to be an ERISA plan administrator or fidudary, and that URN has nor ponsibility of any or the quality or competence of any physican, fadlity, or provider rendering service; b) payment of any m ical, hospital, or edical or surgical treatment or confinement; and c) interpretation of any benefit plan contract concerning verage or denial on the day it is received by URN. Upon receipt of this Access Agreement by URN, URN reserves thright to deny you ment will end when your-stop-loss agreement with ING Employee Benefits terminates or upon 30 da , notice by you or ey Kern County Address: TX 78028 Telephone: # of Employees: 830-792-2211 11.11.2004 ING Thank you f r considering ReliaStar Life Insurance Company (the "Company") for your employ benefits insu~ance needs. ~1le offer various Employee Benefits insurance products that have differ features, benefits and costs. We are confident that, working with your professional insurance age broker, or consultant you will find that one of our products is right for you. Your agent, broker consultant may work with. many employee benefits insurance companies, and we are pleased 1 ~I' they are presenting one of our products to you. If you decide to purchase, or offer to your employ ~!, or members,', a policy from us we would like you to understand how we will pay the selling age ~I' broker, or consultant. There are geherally three types of payments that may be made to agents, brokers and consultants 1. Commissions: Agents, brokers, or consultants may earn a commission for each Comp. polic~r sold. The commission is generally a percentage of the policy premiums paid. percentage may be higher for agents, brokers, or consultants that sell a larger numbe Company policies. The actualpercentage and amount of commission paid will vary basec j the specific circumstances of the product(s) purchased. 2. Bon~lses: Agents, brokers, or consultants may receive additional compensation based o percentage of policy premiums paid for each year a policy remains in force and as rews for things like achieving certain sales volume levels, sales contest objectives, or of mea$ures. We also may .pay for agent, broker, or consultant education, training attendance at conventions, and may pay bonuses, provide advance commissions any toan~ with an expectation that the advancement and/or loans be repaid as new policies issued, reimburse expenses or provide other payments or benefits. or gat es nt, ny he of on is ~ds ier or 3. Administrative/Service Fees: Agents, brokers, or consultants may provide administra ive servi~Ces and marketing support for a flat fee, a percentage of policy premiums paid, or, a ee based on the amount of commissions earned from the initial sale. The agents, broker or conslultants may be associated with other brokers or consultants that may pro de administrative services and marketing support for similar fees. I~ This is a g !' commission 'earn from i 'Company, ' costs to de: guarantees, profits. ' We are con your profes insurance n Feral discussion of the compensation we pay for .the sale of our policies.. We and other sales expenses from-our general assets and revenues, including amounts s .and charges under our policies. The price of an insurance policy is set by d reflects the compensation we pay for the sale of our policies. It also covers o1 fin, manufacture and service our policies, fees associated with the cost of any applic~ he investment management needed to build cash values and pay benefits, and to providing top-quality insurance products to our customers and are pleased insurance agent, broker, or consultant trusts us to deliver on your long Name(s) Group Group Basic Life/ADi4~D, Supplemental Life/AD8~D, Dependent Life, Individual and Aggregate Excess Risk ___ Account Name Kerr Cou ponsonng Signature Printed Name Pat Ti Title Kerr County Judge Date December 14, 2009 Revised: ti !, ~.I~GTRt)1tiiIC t~~L~l'A'~'tCfht AGREt4[Ei~T ~'h~s lP(t~tmn~'r' Iitat~n Agreement ~''eerrten{°~ is k~t~veert f~$iEa~taf t~3fe lnsurart C~mpa~ra~+ a€r~tt its a~t?~it~ ReliaStar Life Ir~~nce ~ormpany rtst Ycss~ ktara€~gt~ its fN~ Empt~yee t3+sraefts CYl~ri~ion rA"l*'~~", ~ ~ fr ~ 0v~ ~ ~°Er-lplo~'er"~r 'I e~~~dr~~s ~ Empt~ye~ eith~eC directly ~° through ~ thud party, ~ttiSilt3$ t0 xcsnge with ~r vFev,~ rr,ateraig ~rr~ lrtforrttatl~ar slertrer~ically ~v~h 1~:~_ _ 1N ~t~~; ~mpl~y~r v~sh to, coopt~rate to achieve ef~ncies in the adrnintsiratkc~ft sst Ernplayef's t~raefi~ p9a~s, '~ ttVG Clbl~patiinne~ artct the EMer~fanic Facititatiorx Manual ~i t,1 thlG v¢itl feC91VB ar~d process eta#~ and updates @I~t4vi11C3Id~'~t~tf lrl~ pfEJrt'„ ~tS i~slled to Efasp(~y~l t.~ Itt11~ agrees 4o use reasonable etf~rts t4 operate ~~r~th sny third party application s~r~°iG~s g~r,~~id~~ 'Ap{alication Services Pravrder" ar "ASP"~ appoint~*d by Emp`ayer provided that ?hdG has had the cpp~*tunity Iv Eew and approve the clectraniy data transmission methods utilized try the Application Services Prc;~iel€r ~mployAr rues #a require the Application ~uer~ic~5 #'rovides to Operate ivtith any reasonable It*s review, acrd '1N{;~`s r~ppr~va uri11 ntat be unreasanatrly ~~nthtsekd, . 3.3 ING wi11 pro~vde Emplmyef with an Electfr~ni~c Facilitation hllanual rAh,tanua€", des~'bir~g 1N ~iPctronic protocols and requiremeht3. The tvlanual sra~rpiements other administrative manuals ardor u+ri~ instructions that ING may prouide f=mp9tryef. The h±tansal tfiscuss~s all ot~lint and data r~xchanr~€~ ~rtrst~ts o~ ~sraugh 1N~ ~mptoyee benefits artd covered b~Y thin Agreemerti hrtwever this Agrearr~en{ is not inteett#~ trr irnp~ any abigatians upon ~rnpioyer pertaining to etectronie services that. E~t?plflyer is not qualified #vr a~rsdlsx has chosen to tatilize, Specific topics addressed in the Manual ~,ctude; t'~nlarse services inc:udrg vievsirsg ~fnplt~yer sp~ec~c intttfmaticrt and materral~ Internet Security anti Fide `t~ra~sfer {!''CF'j T~r~ss Fide Forrttats far Electronic Bata Tr~ansrrrission Formals o~t Fleci~an3c C~ata ACCeptingfSer€ding Data Frarri an C3utsida Source d7PA err Rl'~ Filed Pcrrms Paper arir3 Eleetroric} Pasting Electronic Foram nn a Ntrn-lPt ~fn{pyee Ber~hts W~bsite Farm Types Ele~ctr~nic Sirgnaturgs _ lrksc~rance CErtificates Recd ItiAaintenarec~e i 2.i rnployer agars tta operate in arce~dance swith the Atlanual and cxth~r reasanat~le 1t~G, atitr8 guidelines I 2.2 i=mpioyer shalt use besi ends tar maintain anri transmit. at~ura#e u~a>a tc~ iN and update sucf~ i~r;€aatign en a regular basis, including provirirng general updates at least ~r~onthly fcrr empti~yee eGg~b[laty ~I ~•ranathsr< Specific ~2tigihlti€}~ event data that is 2wailable through the ete~ctrorric processes used kryP i^rnployer or its ii ,~pplicaldcsss Services Prcv~der +t~itl be transmitted tar II~G as soon as tfie infGrrnali€~n is avaslat~le. P ~~~ Fmplpyer agrees to prouide tNG twiilt at least sixty f~a~ Sys notice Qt any proposed ~ang~ in atr~+ pplicatrsn 5s~i~s Provider that rrsay ~be utiiized by ~n?Rloyer. 2.d ~rr~ptatrer uwiil provet~_b~ertefr{ da~scriptions to employees €n accarddar~e.~ wiitr ING's rnaterlal~ andl u'sdetines; Ii~G must have {he opparlu~#y to review in advance arFy ~rroposed plan desrgns etectirgnec data exchange t4rnaats, and any forms ter materia~Is pertaining to iN~ insurance coverage. tt~G's insurance obligatit~ns wil! ~e ~'~~ ~".'~rrrair~ed s€stety by the torrrrs of ifis €rrstrranct policies, any! If•1G assumes €~o tesp©nsik~tEity +~r d'€abit~ty fir any t~tts~r ~l communrcataaras to err~ployees made by ~mploy~er ar a~n P.pplicafaun services Provider. Employ~:r, Itl~, ar,d ~nY ~I p~plieatlt~rt S~~i~ Pt~YidefS agree tp cA~7~?L~rdt9 t~ Lek td avoid Sr1}~ i~ic+~n;~l~tencieS in ccarr~m~uriica4ion ~AO~C[3~, R~{le 1 of 2 ~ ~mpfoyer w11C regu+r~ any l+pplicatit ~~e€rric~s iproerider to act try a;„eat°dance with i=rxrplayer's rig}ats obt€~ratt,rs~ u'rad~r this At~rf;en~ent. I~tG ma°ar provide a co~ay of ttai~ Agreomertt to an A,ppiicatirn S~rvi ider appr~irsted by ~mp(~oyer Land apprrnred fey 1Pd~ in arc~rd;~e€: with ~ctio~n 1,3 afica~r~~, urhi~:h d~ntl serve as ~~yer"~ awthot'izatior~ tc fhe Appt~ation Services Provider to apt i~ acc©rdance 4Yrth ~~S ~greemer?i. ~i. foal Qbligdtions -Both .Parties Agree: Id ~,i 1~Ca ~rrtply wrfh all applicable laves and c~ufatican~-. 3.2 i ~ provide artd utilize data in a ttmety manner. 3 3 -la respect the privacy tat aN ind~v3dwalty identifiable data Brad to take reasonable steps tc prc~teot the' I~~ nfider~tiality and security of ss~ch data during e9ectresntc transmisaiors grad vievrirtg~ tr~1G wall :neat c'ez:tr'onie data i€t_ same manner as hard Grapy data if receives. Tcs th€ ext€~t~t r~gt,irod by applicable law, ~r~play~r may rsot dir~tly,; r through a~ R~ls~ati[~n Services f'rouider, tstitize er~r~toy~er:'s private or persorrai snst~rant:e data far any purpc~e i~thra° than the adrninistrat~n of the f~olioy(s~. till data recoived by (N~ wii( lee maintained by tN~ sn ac~ccrrdanc~ witht its standard r~c~rd keepirsg pr~~ura;~r anti wilt tae retained b,y 1N~ accordingly. vvitht~ut rest2e~ fe' teirnitaa~taora of this. ~,greem?rrt or iNC, sn~~ra~ce ~+cr(icies. t?~~, may integratra ~rnplo+~e€'s cerasvs ar3d ca4h~r ltatotr3aatao~ rn 14+D's syst~~a,s to erradle tN~ to ~'ovid~ ratir;g and prcapasals der employer palrc€es and renevdals. ~~ 3.4 "What n~,ther Party ncrr any APp;ication ~erurces Provider rrt~y make any p~sblic a~€ararrece€ne-;si ~~~bDUt flee exist€rtlcx~ cr conte[r# of this Agreeament without the other party's praor written conse'~~ Ire ~rdditic~rr, neitl~rrr~ ae~y nor any .~{~pfieatis~~ Seratis~ Psw'vider may use the o#~er's nanaert toga ar trasieraaarks rn written ~> e6rpnic farm. ~xcep~t as Q~~erwisa prc~.~irf~d tOtn without the prier writt~r* abns~nt s~~t##t~ owner in aadh tnsane~. 3. i a generally cooperate to at~rieue the objectives tat this Agreement. Gaineral 4e'1 ~acfa party is res~acar?sttrte far fts rrw,7 aaligatit~nso ~rrp-ta}rar ts~ ra~pcanstbtu #c7r its tat~rnn r~si?awr~es! a and da#a a~(atsctiora functions, ;end may dt=t~;gat~ sarrai~ cr all sucfi~ duties to ars A~,plicstian Seeviwes Provider ?a tt:~~ pxi+~nt E(alayrrr acts as IP~~~s agent. under the law of the state where the Potieyis) is issued, then Er~spiayer agrees ~ La perform such duties in accordance ~.vith 1NG's guidelirses, as may be updated from trrr:rw to tirrat, and Errtplt~y?,° ~~<<;II carasa any Applir„aticn entices Prt~vider appointed by FmpPCyer tv da sta as well. 1T~~ reserves the right to ct?r'i~vct teasos~atale audits upon reasar~able notice to l=mpl~ayert vrsth respect to these servicce~. f~1~ remarins r~sptana=ble f~~.r~ its at~tigations under the terms of its p~alicie~, and nc,tfting in this Flgreemerst is int~raded ttr moc#if}~ or aff~~t tt~~ s~ r€ghrs and ol~tigaticFns under the Policies. ~~ ~€_2 t4~4~ i~ rrrtt responsible for ~~ny data inaccurately provided byBrrrplt~yer r~r an ~'~ppLcatt~an SereiCe~ ~ccsvider, rear #ar gray data ipsf or dt~lay~l dt>rr utilized by Err:pl~yer 4~ This Agreemi?rst shaft be effectisle wpon sigrsirsg by both parties, but ~ is aEso apptaabfe fa ary' tectror?ic rnft~rrsr2rtron exchange taking place prtar to the exec~ion date It remains i~ effect for as long as 1N~~s~ ~rbirgatlos~s under the Policy{s) remain in effect.. Alr rights ar~d obligations irac~rred prier to terrrainatic>n wi9t survi~~+e~ ~rrrriraatirin rf t#se A.greert~er~t. Both parties agree to r~pe~te weth r+~SpeGt tai data exGttange asisirag frpm', ~errtslnatio~n of this Agreemerst ar the Folicy(s~. I~ny special data exch.arage ar reports regwested by E€nptoyer dwrin~g' this Agrr~rraerrt or fr3tlowing terminataon may be sub;~c? to additic,nao charges ~E.S ~ra~playsr golf tt~~ may utilize etectrcrnic wire frarrsfer ar other electronic means: fe~r~ rr~.~r~Psases tat? remiurn rsaym.. ~rnlatoyer may n>at authorize an ~.ptpli~fic~rt Ser~it;es Pcovd~r to coAeet and €rar7sra'ait Prerniurn to N~ unless the Appticati~an Servir,,es Provider has alt necessary licenses and has entered into an agreeine~rt far such '3ervit"es with tN~. An P~pllcatitxn Services Pro~iitler is not restnet~i fr©m facit~ating prenriuna cc~@~tiohon beha?f ofl mptoye~r and arranging for efactrarr~ic or a9her paymt:nt ~m ~mplt~yer dite~tty to iN~. , 4:~i t~othin r~cataitaed in this A reerr,ent is intended fir create art a ent ar brakef reEatso€~st;ip t~tween~ g 9 g ~hlG and an Appli~:ation Services Rrovirder, oar to interfere wrt#a any existing ar propcaed agent, LrQker, ar e>ansuttr~gi, arrangement. Arty 1NG agent sar braiter arsangerrsant will f~ gc,verned sAftrly ay the #urms of t~s~'s agon€ or hrok~ri grc$merrts= if an ,~ppliCBtresrs Serva~s Provider shouls~ act in that capacity, then these separate agreements u~;ll', ~overtt tai re~~iorrshtp wtttr tt~~~ ~A~~Q~a Pale ~ ~+f ~ 4.i Tti~s A~reetnrrt s~~l be t~~u~,=nod tar the'ia~s~ tri tt~e ~t~te wh'~ t?~e 4~c~li~.p'~~ is ~s:.u~tl. ~APGY RIAS~"~a~t LIFE ~NSU~h~t~~ ~~t4~~?,N ~E.LiA~T,4R 1_I~ If~S~,~Rt~t~C~ CCtV4~.~~J~~ G NE~`r{ Y(~t~K lame Pat ' Tinle Neat. E~~e• Ker~ County Judge -~31 ante: Dec tuber 14, 2009 C~~t~ a 3 of 3 .Administrative Service Fee Disclosure Form UMR receives .a service fee from ReliaStaz Life Insurance Company ("ReliaStaz") in the amount bf 3% of adjusted gross premium that each Plan Sponsor pays to ReliaStaz for insurance provided under new or renewed stop loss policies provided to Plan Sponsors with self-inured groups that have a contractual relationship with UMR for third party administrative services. This 3% payment from ReliaStaz to UMR shall be based on the amount of premium ReliaStaz receives directly relating to the stop loss policy that UMR '~ administers ion behalf of the Plan Sponsor. This document serves to disclose these fees to the customer. UMR I PLAN SPONSOR /POLICYHOLDER Company Its ~~I ~AT~2..t c.K. ~t N t..E~ ~~-BIZ-~AU~Z Authorized Representative (Printed) Date , (Signature) I ~a to Date ~~ ~1 ~H~~ ~~~~~~ ~ ~~~ ~~ ~vfJU~~ i `Administrative Service Fee Disclosure Form UNIR rec~ives.a service fee from ReliaStar Life Insurance Company ("ReliaStar") in the amount~,of 3% of adjusted gross premium that. each Plan Sponsor pays to ReliaStar for insurance provided under new or renewed stop loss policies provided to Plan Sponsors with self-inured groups that have a contractual relationship with UMR for third party administrat#.ve services.. This 3% payment from ReliaStar to UMR shall be based on the amount of remium ReliaStar receives directlyrelating to the stop loss policy that tTMR 'administer~on behalf of the Plan Sponsor. This docu~erit serves to disclose these fees to the customer. Ulm By - Its Date PLAN SPONSOR !POLICYHOLDER ~~ ~ ~ ..Company - ~ATY2.t c..K. l t tit t...E+~ ~~-(Z(Z- CflU ~U (~ C~C.~ Authorized Representative (Primed) ut orize'~ Representative (Signature) ~ ~a l D Date ~,~..~1 ~H DE/ l~tl2~ CD ~>~ ~ ~u~,,~- 1 ~. t~~~~~o 12668 Silicon Dr San Antonio, TX 78249 January 2~, 2010 Attn: Eva (Hyde Kerr County 700 Main ~BA-104 Kerrville, ~~,TX 78028 Dear Evaa !, Enclosed~s the countersigned Preliminary Statement of Agreement effective January 1, 2010 for }dour records. Thank yo~ for your business. ~Q~tl li`.0~- Patricia arza on behalf of Ke li Merchant cc Grey Malek, Wi11isHRH t 6 10.270.4865 (1) 866.898.4878 (F~ www.umr.com Patricia.Garca@UMR.com i '' PRELIMINARY STATEMENT OF AGREEMENT Effective 1-1-010, UMR, Inc. ("UMR")and Kerr County ("Plan Sponsor") agree that UMR shad provide certai~ third party administrative services for the Plan Sponsor's self-funded employee) benefit plans.'The intent of the parties is to establish a formal Administrative Services Agreement tf~at fully discloses each party's duties, rights and obligations, and that discloses applicable fe s for services being purchased by the Plan Sponsor. It is understood, however, j that before th Administrative Services Agreement can be prepared, a series of transition meetings nee to take place between UMR and the Plan Sponsor to make final decisions regarding se ices to be provided. In the interim, this Preliminary Statement of Agreement will reflect the int nt of both parties to begin providing services. Plans UMR emgl~ I provide certain mutually agreed upon administrative services for the followi benefit plans of the Plan Sponsor: 501 '' Medical Plan Fees Durin decis will b Plan been Spon make be lis Spor the a tMe course of the transition meetings described above, Plan Sponsor will finaliz~'' ns regarding the services that it will purchase from UMR. Fees for those service' reflected in the actual Administrative Services Agreement that will be sent to they','', ponsor within a reasonable amount of time after the transition meetings have !''~ ompleted. The anticipated base administrative feels} that UMR will charge Plarij ~!~~ x to process claims is listed below, however this could change if Plan Sponsor j',', changes during the transition meetings. All other fees including the base fee wll~ :d in the Administrative Services Agreement to reflect the decisions that the Plar~ '~,', ~r makes during the transition meetings. The Plan Sponsor agrees to pay UMRI ' ~licable service fees in a timely manner so that UMR receives the payment on o~l'~ the fast day of each calendar month for which services are rendered: I,!, Add Base Fete information for those products that were purchased, and delete those that were' no~ purchase'd. Medi I Plan Base Fee: $16.50 per employee per month. All of er fees will be listed in the Administrative Services Agreement. 'I III. Relationship of Parties Both ~ arties agree that UMR is not providing an insurance policy or an indemnity agre~ment, and that Plan Sponsor is simply purchasing administrative services from UMR It is further understood and agreed that the relationship between UMR and Plan,' Sponsor is that of independent contractor. ~'. ,, IV Run-fin Claims Processing: It is nd~rstood and agreed that should UMR be requested to process run-in claims fo ~'~' Plan~pbnsor, Plan Sponsor shall assume responsibility and liability for complying wit '~~' ERISIq and the Department of Labor's claims regulations, if applicable. Plan Sponsor ,. fully a~d solely responsible for any risks associated with stop loss carriers as it relates t~# run-in laims, and holds UMR harmless with respect to such stop loss problems. Plan '' Sponsor further agrees to supply UMR with all pertinent eligibility, benefit and other information that UMR deems necessary to process run-in claims. V. Termination and Definitive Agreement: Either~party may terminate this Preliminary Statement of Agreement upon written notic~al to the ether. This Preliminary Statement of Agreement will expire ninety (90) days after',', the fir$t effective date of the Plan Sponsor with UMR. The parties agree to negotiate in'~~I good ith to attempt to reach a final definitive Administrative Services Agreement within, the nirjlety (90) day period. This Plreliminary Statement of Agreement will automatically terminate in the event that I',,~!~ Plan ~ponsor fails to provide sufficient funds with which to pay claims or other liabilities under Ithe Plan(s), or a petition is filed by or with respect to the Plan Sponsor under the!' Federal Bankruptcy Act or any state insolvency law. I Agreed to on behalf of UMR Jay Anliker, President and CEO Date Signed: I ~ ~ A~reed to on behalf of Kerr County Le al name of Customer/Plan Sponsor) B' Print Name: P'-~' I N~ /; Y Title: '~ -` Date Signed: ~~ f ~ ~ ,2~ ~-ly~ c~ ~~ ' Revised 10/31~IID8