HomeMy WebLinkAboutHR Employee Assistance Services Prepaid ContractDocuSign Envelope ID: DF2A434A-F9BE-446C-AD27-7EOF4081EB47
CONCERN: EMPLOYEE ASSISTANCE PROGRAM
AGREEMENT FOR EMPLOYEE ASSISTANCE SERVICES
FOR
CITY OF SAN RAFAEL
January 1, 2022 — December 31, 2022
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TABLE OF CONTENTS
I.
Definitions...........................................................................................................................3
2.
Responsibilities of the Plan.................................................................................................5
3.
Responsibilities of The Group.............................................................................................7
4.
Relationship Between the Parties........................................................................................7
5.
Coverage, Obtaining Covered Services, Limitations, and Exclusions................................8
6.
Choice of Plan Providers.....................................................................................................9
7.
Other Charges....................................................................................................................10
8.
Member Liability for Services Rendered..........................................................................10
9.
Reimbursement Provisions................................................................................................10
10.
Term and Termination.......................................................................................................10
11.
Warranty and Indemnification...........................................................................................12
12.
Limitation of Liability.......................................................................................................13
13.
Individual Continuation of Benefits..................................................................................14
14.
Continuity of Care.............................................................................................................14
15.
Second Opinions................................................................................................................16
16.
General Provisions.............................................................................................................16
17.
Dispute Resolution............................................................................................................17
AttachmentA
.................................................................................................................................22
AttachmentB
.................................................................................................................................24
AttachmentC
.................................................................................................................................25
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AGREEMENT FOR EMPLOYEE ASSISTANCE SERVICES
PREPAID CONTRACT
This Agreement for Employee Assistance Services ("Prepaid Contract)" including the Attachments
thereto by and between CONCERN: EAP, a California corporation (hereinafter designated "Plan"
or "The Plan"), and City of San Rafael (hereinafter designated as "Group" or "The Group") is
effective on January 1, 2022 (the "Effective Date").
RECITALS
WHEREAS, The Group wishes to establish an Employee Assistance Program as defined herein, for
the benefit of its employees and their Covered Dependents.
WHEREAS, The Plan is licensed as a specialized health care service plan under the Knox -Keene
Health Care Service Plan Act of 1975, as amended.
WHEREAS, The Plan has experience in providing Employee Assistance Program services and has
established a network of professional providers to render required Employee Assistance Program
services.
WHEREAS, The Group wishes to engage The Plan to provide such services and The Plan wishes to
provide the same on the terms and conditions set forth herein;
NOW, THEREFORE, in consideration of the mutual covenants and agreements contained herein,
the parties agree as follows:
1. Definitions
1.1 "Agreement" means the Agreement for Employee Assistance Services between The
Plan and The Group, including Attachments A, B, and C. Attachments A, B, and C
are incorporated herein by this reference.
1.2 "Covered Dependent" means the Subscriber's household members.
1.3 "Covered Services" means those services, which are provided by The Plan to
Members and set forth in Attachment A to this Agreement.
1.4 "Crisis" means a situation wherein a reasonable person determines there is an
immediate need to assess for the possibility of a Medical Emergency Condition,
Psychiatric Medical Emergency Condition, or to request services from The Plan
relating to an Urgent situation.
1.5 "Crisis Intervention" means the process of responding to a request for immediate
services to determine whether or not a Medical Emergency Condition, Psychiatric
Medical Emergency Condition, or Urgent situation exists, and to otherwise assess the
need for short-term counseling, referrals to community resources, and/or referrals to
Medical Emergency Care.
1.6 "Employee" means a First Responder, as defined by The Group.
1.7 "Employee Assistance Program (EAP) Assessment" means the process of
determining, based upon information provided by a Member, the need for either:
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a. Short-term counseling;
b. Referral(s) to community resources; or
C. Referrals) to Medical Emergency Care services or treatment.
1.8 "Employee Assistance Program (EAP) Benefits" means a systematic program to
help employees resolve personal problems, such as family conflict, drug or alcohol
abuse, stress, marital discord, and other personal problems, and to provide training,
consultation, and other management services relating to the effective utilization of
this benefit by employers and their employees.
1.9 "Grievance" means a written or oral expression of dissatisfaction regarding the Plan
and/or provider, including quality of care concerns, and shall include a complaint,
dispute, request for reconsideration or appeal made by a Member or the Member's
representative. Where The Plan is unable to distinguish between a grievance and an
inquiry, it shall be considered a grievance. Grievances may be communicated to The
Plan via telephone, FAX, e-mail, on-line through the Plan website, or submission of
a written grievance form.
1.10 "Medical Emergency Care" means medical screening, examination, and evaluation
by a physician, or, to the extent permitted by applicable law, by other appropriate
personnel under the supervision of a physician, to determine if a Medical Emergency
Condition or active birthing labor exists and, if it does, the care, treatment, and surgery
by a physician necessary to relieve or eliminate the Medical Emergency Condition,
within the capability of the facility. This definition also includes additional screening,
examination, and evaluation by a physician, or other personnel to the extent permitted
by applicable law and within the scope of their licensure and clinical privileges, to
determine if a Psychiatric Medical Emergency Condition exists, and the care and
treatment necessary to relieve or eliminate the Psychiatric Medical Emergency
Condition, within the capability of the facility.
1.11 "Medical Emergency Condition" means a medical condition manifesting itself by
acute symptoms of sufficient severity (including severe pain) such that the absence of
immediate medical attention could reasonably be expected to result in any of the
following:
a. Placing the patient's health in serious jeopardy.
b. Serious impairment to bodily functions.
C. Serious dysfunction of any bodily organ or part.
1.12 "Member" means a person who is enrolled in The Plan and eligible to receive
Covered Services. Member includes the Subscriber and any Covered Dependents.
1.13 "Plan Provider" means a person who has entered into a Plan Provider contract with
The Plan to provide Covered Services to Members, and who is licensed in the State
they practice in as a psychologist, clinical social worker, or marriage and family
therapist.
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1.14 "Prepayment Fees" means the periodic Prepayment Fees set forth in Attachment B,
which The Group agrees to pay The Plan for Covered Services.
1.15 "Psychiatric Medical Emergency Condition" means a mental disorder that
manifests itself by acute symptoms of sufficient severity that it renders the patient as
being either of the following:
a. An immediate danger to himself or herself or to others.
b. Immediately unable to provide for, or utilize, food, shelter, or clothing,
due to the mental disorder.
1.16 "Subscriber" means an Employee of The Group who: (a) meets all applicable
eligibility requirements as established by The Group; and (b) on whose behalf The
Group has paid, and The Plan has received, any applicable Prepayment Fees in
accordance with section 3.3 of the Agreement.
1.17 "Urgent" means a situation in which it is determined that no Medical Emergency
Condition or Psychiatric Medical Emergency Condition exists, however, the Member
is in need of immediate telephone support and/or an appointment with a Plan Provider
within 24-48 hours to get support for a Serious Personal Problem.
1.18 "Visit" means a session between a Plan Provider and Member of approximately 45-
50 minutes wherein the Member, individually or with others, discusses problems with
a Plan Provider in order to work on or resolve the problem.
2. Responsibilities of the Plan
2.1 Covered Services: The Plan shall provide to The Group those benefits set forth in
Attachment A, which is appended hereto. Said benefits shall be provided through Plan
Providers who have agreed to enter into a written contract with The Plan.
a. All Plan Providers shall be appropriately licensed and shall comply
with professionally recognized standards of practice and all applicable
state and federal laws.
b. The Plan shall not decrease in any manner the Covered Services set
forth in the Attachment(s) except after notifying The Group at least
sixty (60) days in advance by means of a postage paid mailing, or by
any electronic means, which will be deemed to have the same effect as
physical delivery of the paper document. Compensation to The Plan
shall be reduced commensurate to any reduction in services.
2.2 Quality Assurance: The Plan shall establish and maintain a quality assurance review
program throughout the term of this Agreement. A standing Quality Improvement
Committee meets on a quarterly basis, and is chaired by the Plan Medical Director.
The Committee consists of two providers for the Plan and two staff positions. The
Committee reports directly to the Board of Directors. The Quality Improvement
Committee serves as an oversight of the Quality Management Committee, and as
such, regularly reviews the reports compiled by the Quality Management Committee,
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as well as provides feedback and recommendations regarding potential performance
improvement projects.
2.3 Confidentiality of Records: The Plan shall comply at all times with the California
Confidentiality of Medical Information Act (California Civil Code section 56 et seq.)
and any other state or federal law applicable to the services provided under this
Agreement. Compliance to Health Insurance Portability and Accountability Act of
1996 (HIPAA) guidelines will be maintained in regard to confidentiality of all
records. Information related to the identity, medical diagnosis, or treatment provided
to any Member shall be kept confidential and shall not be disclosed by The Plan or
any Plan Provider to The Group without the prior written consent of the person who
is receiving care (or the legal representative of such person). Prior to the release of
any confidential information, record, documentation or the like, the Member shall
provide to The Plan a signed Release of Information form. The Release of Information
form describes in full the extent and scope of information to be released. If a Member
has any questions regarding the Release of Information form, he or she should contact
The Plan. All records, files or other materials obtained in connection with this
Agreement (including those related to individual employees of The Group or their
families) shall be the property of The Plan.
2.4 Medical Emergency Care: If a Member feels the situation constitutes a Medical
Emergency Condition or Psychiatric Medical Emergency Condition, the Member
should seek care at the nearest hospital emergency room (or trauma center), or
immediately call the 911 operator for emergency assistance. The Plan does not pay
for Medical Emergency Care. Medical Emergency Care treatment is a non -
Covered Service. A Plan Provider can assist the Member in accessing Medical
Emergency Care services.
2.5 Crisis Intervention, Urgent and Routine Appointments
a. The Plan arranges for the provision of Crisis Intervention 24 hours a
day, seven days a week, to all Members. Members must contact The
Plan at 1-800-344-4222 for Crisis Intervention services. Crisis
Intervention is the process of responding to a request for immediate
services in order to determine whether or not a Medical Emergency
Condition, Psychiatric Medical Emergency Condition, or Urgent
situation exists and to otherwise assess the needs for short term
counseling, referrals to community resources, and/or referrals to
Medical Emergency Care or treatment.
b. Urgent services: Members or a Plan Provider may contact The Plan at
any time (24 hours a day) to obtain an EAP Assessment or referrals for
care. A Member will be referred to a Plan Provider so that care is
provided within 24 to 48 hours in urgent cases.
C. Routine appointment: Offered within 3-5 days.
2.6 Access to Plan's Processes, Criteria and Procedures for Claim Review: The
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processes, criteria and procedures that The Plan uses to authorize, modify, or deny
employee assistance services under the benefits provided by The Plan are available to
the Member, Plan Providers, and the public upon request. Members, Plan Providers
and the public may contact The Plan at 1-800- 344-4222 to obtain a copy of the
processes, criteria and procedures that The Plan uses to authorize, modify, or deny
employee assistance services under the benefits provided by The Plan.
2.7 Family Health Insurance Notification: A non-custodial parent of a Covered
Dependent child is entitled to inspect the child's Plan Membership, Combined
Evidence of Coverage and Disclosure Form, and all other information provided to the
covered parent about the child's coverage. The Plan will also notify both parents
(including the non -covered custodial parent) if a Covered Dependent child's coverage
is terminated, provided that the parent has provided The Plan with a medical child
support order. Lastly, The Plan will respond to telephone or written inquiries from a
non -covered custodial parent concerning a child's health coverage.
3. Responsibilities of The Group
3.1 Information to Members: The Group shall provide Members with information
concerning this Agreement, including making copies available of the combined
evidence of coverage and disclosure form, which shall be furnished to The Group by
The Plan.
3.2 Provide Headcounts: The Group will provide an accurate headcount of all
employees covered by The Plan at the beginning of each contract year.
3.3 Prepayment Fees: The Group shall pay The Plan the Prepayment Fees set forth in
Attachment B, which is appended hereto and incorporated by this reference. The Plan
shall not increase the amount set forth in Attachment B, except after notifying the
Group at least sixty (60) days in advance of the rate change by means of a postage
paid mailing or by any electronic means, which will be deemed to have the same
effect as physical delivery of the paper document.
4. Relationship Between the Parties
4.1 Independent Contractor: The Plan shall perform its duties under this Agreement as
an independent contractor. Nothing contained in this Agreement shall be construed to
create the relationship of principal and agent, employer and employee, partners or
joint venture between the parties.
4.2 Each Party Responsible for its Own Acts: The Plan and The Group are each
responsible for their own acts and/or omissions and are not responsible for the acts
and/or omissions of the other party, its employees, independent contractors, directors,
officers, agents or representatives.
4.3 Insurance: The Plan is covered by professional liability insurance. The coverage is
$10,000,000 per claim or $20,000,000 aggregate. A copy of the Certificate of
Insurance is attached (Attachment Q. The Plan will notify The Group if there is any
change in coverage. The Plan also has a Workers' Compensation Certificate of
Consent to Self -Insure.
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5. Coverage, Obtaining Covered Services, Limitations, and Exclusions
5.1 Eligibility: An individual is eligible to receive Covered Services under this
Agreement if he or she is an Employee who works or resides in the Plan's service
area and meets any additional eligibility requirements as established by The Group,
or a Covered Dependent of the Employee.
5.2 Coverage: The Plan covers assessments, referrals, crisis intervention and short-term
counseling. A Member is entitled to a defined number of visits with a counselor, as
set forth in the Covered Services, Attachment A. The Plan can assist with most
personal problems including marital and family problems, difficulty with
relationships, emotional distress, job stress, communications or conflict issues,
substance abuse issues and loss and death.
5.3 Obtaining Covered Services: The Plan does not distribute identification cards to its
Members. In order to access care, Members should contact The Plan at 1-800-344-
4222 and a Plan representative will direct the Member to an appropriate Plan Provider.
5.4 Limitations: Unless otherwise authorized by The Plan, all Covered Services must be
performed by a Plan Provider. The number of visits to a member is limited, specified
in Attachment A.
5.5 Exclusions: The following services are specifically excluded from Covered Services
provided under this Agreement. All denials, modifications, and delays of requested
services are subject to The Plan's grievance review process. (See Section 17 for the
Grievance Procedure.)
a. Services not listed as Covered Services.
b. Medical Emergency Care.
C. Acupuncture.
d. Aversion therapy.
e. Biofeedback and hypnotherapy.
f. Services required by court order, or as a condition of parole or
probation, not, however, to the exclusion of services to which the
Member would otherwise be entitled.
g. Services for remedial education including evaluation or medical
treatment of learning disabilities or minimal brain dysfunction;
developmental and learning disorders; behavioral training; or
cognitive rehabilitation.
h. Medical treatment or diagnostic testing related to learning disabilities,
developmental delays, or educational testing or training.
Experimental or investigational procedures.
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j. Services for the medical treatment of mental retardation or defects and
deficiencies of functional nervous disorders, including chronic mental
illness.
k. Services received from a non -Plan Provider, unless pre -approved by
The Plan.
I. Psychological testing. (psychological testing is not necessary to
determine an appropriate referral to a Plan Provider to receive Covered
Services, or alternatively, to determine appropriate referrals to
community resources for non -covered services)
in. Sleep therapy.
n. Examinations and diagnostic services in connection with the
following: obtaining or continuing employment; obtaining or
maintaining any license issued by a municipality, state or federal
government; securing insurance coverage; foreign travel or school
admissions.
o. Medical treatment of congenital and/or organic disorders associated
with permanent brain dysfunction, including without limitation,
organic brain disease, Alzheimer's disease and autism.
p. Medical treatment for speech and hearing impairments. (A speech or
hearing impaired Member is entitled to Covered Services. Treatment
for speech and hearing impairment is not necessary to determine an
appropriate referral to a Plan Provider to receive Covered Services, or
alternatively, to determine appropriate referral to community
resources for non -covered services.)
q. IQ testing. (IQ testing is not necessary to determine an appropriate
referral to a Plan Provider to receive Covered Services, or
alternatively, to determine appropriate referral to community
resources for non -covered services.)
Medical treatment for chronic pain.
Services involving medication management or medication
consultation with a psychiatrist.
6. Choice of Plan Providers
The Plan will assign a Plan Provider who will deliver services to a Member. In assigning a
Plan Provider to a Member, The Plan will consider where the Member lives and works in
relationship to a Plan Provider's office. Naturally, Plan Providers will be matched with a
Member who lives or works in close proximity to a Plan Provider's office. If the Member
prefers to select his or her own Plan Provider, the Member may choose from any available
Plan Provider. The Member must state during the initial contact to The Plan representative
that he or she prefers to select his or her own Plan Provider, in which case The Plan
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representative shall provide a list of all Plan Providers that have offices in the geographic
area where the Member desires to be seen. If the Member is assigned a Plan Provider or
selects one he or she is dissatisfied with, the Member may contact The Plan and request to be
reassigned a new Plan Provider or inform the Plan of his or her intent to select a new Plan
Provider from the Plan Provider list.
7. Other Charges
No Member shall be obligated in any way to pay for services rendered by The Plan in
accordance with the terms of this Agreement, including the payment of any Prepayment Fees,
deductibles, copayments, or co-insurance.
Member Liability for Services Rendered
By statute, every contract between The Plan and its Plan Providers provides that in the event
that The Plan fails to pay the Plan Provider, the Member shall not be liable to that Plan
Provider for any sums owed by The Plan. If The Plan fails to pay a non -Plan Provider, the
Member could be liable to the non -Plan Provider for the cost of services.
9. Reimbursement Provisions
Covered Services are provided by The Plan at no cost to the Member. In the event that a Plan
Provider, or a non -Plan Provider who has been authorized by The Plan to provide the Member
with Covered Services, charges a Member for Covered Services and the Member has paid
the provider, the Member will be reimbursed by The Plan. For reimbursement, contact The
Plan at 1-800-344-4222.
10. Term and Termination
10.1 Term: This Agreement shall become effective at 12:01 a.m. on the Effective Date.
This Agreement shall continue to remain in full force and effect for a period of one
(1) year from the Effective Date unless renewed pursuant to section 10.7 of this
Agreement (the "Term").
10.2 Group Termination: The Group shall have the right to terminate this Agreement
immediately upon notice to The Plan in the following circumstances:
a. Application for or appointment of a receiver, trustee in bankruptcy or
liquidator of The Plan;
b. The Plan's loss of licensure as a specialized health care service plan
pursuant to the provisions of the Knox -Keene Act; or
C. Upon 30 days prior written notice in the case The Plan breaches this
Agreement and fails to cure within the 30 days written notice period.
The Group shall have the right to terminate this Agreement for any other reason by
sending written notice of such termination to the Plan. Such termination shall be
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effective 120 days after the date on which The Group has sent the notice or the date
specified in such notice, whichever is later.
10.3 Plan Termination: The Plan shall have the right to terminate this Agreement in the
following circumstances:
a. Failure to Pay the Prepayment Fees: The Plan shall send a Notice of
Consequences for Nonpayment of Prepayment Fees with the billing
invoice, which shall include the Prepayment Fee due date, a
description of the consequences for failure to pay Prepayment Fees by
the due date, and a statement that The Plan will continue to provide
coverage during a 30 -day grace period that begins on the first day after
the last day of paid coverage. If Prepayment Fees are not received by
The Plan by the due date stated in the billing invoice, The Plan shall
send The Group a Notice of Termination for Nonpayment of
Prepayment Fees and Grace Period no later than five (5) business days
after the last day of paid coverage. The Notice of Termination for
Nonpayment of Prepayment Fees and Grace Period will include the
reason for termination, the date of the last day of paid coverage, the
effective date of termination, the dollar amount due to The Plan, a
description of the duration and effect of the grace period, the date the
grace period begins and ends, any obligations of The Group, and an
explanation of the right to request a review from the Director of the
Department of Managed Health Care. Within five (5) business days of
the effective date of termination, The Plan will send The Group a
Confirmation Notice confirming such termination. The Plan shall
reinstate coverage after termination of this Agreement if payment of
the required Prepayment Fees is received within 15 days from the date
of Confirmation Notice.
Grace Period: The Plan shall provide The Group with a thirty
(30) day grace period that begins on the first day after the last
date of paid coverage to make payment of overdue Prepayment
Fees to The Plan. During the grace period, coverage will
continue. If The Group has not made payment to The Plan by
the end of the grace period, The Plan may terminate this
Agreement effective on first day after the end of the thirty (30)
day grace period.
b. The Plan demonstrates fraud or intentional misrepresentation of
material fact under the terms of this Agreement by The Group.
Termination shall be effective on the 31 st day from the date of notice
of cancellation or on the date stated in the notice, whichever is later.
C. Upon 30 days prior written notice in the case The Group breaches this
Agreement and fails to cure within the 30 days written notice period.
d. Upon termination, the respective responsibilities of the parties shall be
as follows:
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The Plan shall pay Plan Providers for Covered Services
authorized by The Plan prior to termination of this Agreement
and rendered after such termination.
ii. As requested in the event of Agreement termination, The Plan
shall use its best efforts to assist Members in the transfer of
care from Plan Providers to the new plan's contracted
providers.
10.4 Payments Due after Termination: In the event of termination of this Agreement by
either The Plan (except in the case of fraud or deception in the use of services or
facilities of The Plan or knowingly permitting such fraud or deception by another) or
The Group:
a. The Plan shall return to The Group, within thirty (30) days, the pro
rata portion of the money paid to the Plan which corresponds to any
unexpired period for which payment has been received together with
amounts due on claims, if any, less any amounts due the Plan.
The Group shall make payment of any Prepayment Fees for any period
remaining unpaid prior to the effective date of such termination.
10.5 Notice of Termination: Upon receipt of any notice of termination from The Plan,
The Group shall inform Subscribers of the termination of this Agreement. The Group
shall promptly mail to each Subscriber a legible, true copy of a notice of cancellation
and shall provide promptly to The Plan proof of that mailing and the date thereof.
10.6 Notice of Plan Provider Termination: The Plan shall provide written notice to The
Group within 30 days in the event that a Plan Provider ceases to be a Plan Provider
for The Plan or otherwise becomes unable to provide services, or breaches a contract
with The Plan, if The Group might be materially or adversely affected thereby.
10.7 Renewal: This Agreement shall automatically renew for successive one (1) year
periods, unless: (1) The Group notifies The Plan in writing ninety (90) days before
the end of the contract year of its intent not to renew, or (2) The Group and The Plan,
by mutual consent, modify or alter this renewal provision of this Agreement . The
Plan shall not increase the amount paid by The Group, nor decrease in any manner
the benefits stated in the Agreement, unless written notice of such change has been
delivered no less than ninety (90) days prior to this Agreement's renewal effective
date.
10.8 Response to Notice of Plan Termination: If The Group alleges that the Agreement
has been or will be improperly canceled, rescinded or not renewed, The Group may
request a review by the director of the Department of Managed Health Care.
11. Warranty and Indemnification
11.1 Responsibility for Own Acts. Each party shall be responsible for its own acts or
omissions and for any and all claims, liabilities, injuries, suits, demands and expenses
of all kinds which may result or arise out of any alleged malfeasance or neglect caused
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or alleged to have been caused by that party or its employees or representatives in the
performance or omission of any act or responsibility of that party under this
Agreement.
TO THE MAXIMUM EXTENT PERMITTED BY APPLICABLE LAW, EXCEPT
AS EXPRESSLY PROVIDED IN THE AGREEMENT, NEITHER PARTY
MAKES ANY WARRANTY OF ANY KIND, WHETHER EXPRESS, IMPLIED,
STATUTORY OR OTHERWISE, AND EACH PARTY SPECIFICALLY
DISCLAIMS ALL IMPLIED WARRANTIES, INCLUDING ANY IMPLIED
WARRANTY OF MERCHANTABILITY, FITNESS FOR A PARTICULAR
PURPOSE OR NON -INFRINGEMENT. COVERED SERVICES ARE PROVIDED
"AS IS" "WHERE IS" EXCLUSIVE OF ANY WARRANTY WHATSOEVER.
11.2 The Group agrees to indemnify, defend, and hold harmless The Plan, its agents,
officers, and employees from and against any and all liability expense including
defense costs and legal fees incurred in connection with claims for damages of any
nature whatsoever, including but not limited to, bodily injury, death, personal injury,
or property damage arising from The Group's performance or failure to perform its
obligations hereunder.
11.3 The Plan agrees to indemnify, defend, and hold harmless The Group, its agents,
officers, and employees from and against any and all liability expense, including
defense costs and legal fees incurred in connection with claims for damages of any
nature whatsoever, including but not limited to, bodily injury, death, personal injury,
or property damage arising from The Plan's performance or failure to perform its
obligations hereunder.
11.4 Section 11.2 and 11.3 states the indemnifying party's sole liability to, and the
indemnified party's exclusive remedy against, the other party for any type of claim
described in this Section.
12. Limitation of Liability
12.1 Limitation of Liability. IN NO EVENT WILL EITHER PARTY OR ITS
AFFILIATES HAVE ANY LIABILITY ARISING OUT OF OR RELATED TO
THIS AGREEMENT FOR ANY LOST PROFITS, REVENUES, GOODWILL, OR
INDIRECT, SPECIAL, INCIDENTAL, CONSEQUENTIAL, COVER, BUSINESS
INTERRUPTION OR PUNITIVE DAMAGES, WHETHER AN ACTION IS IN
CONTRACT OR TORT AND REGARDLESS OF THE THEORY OF LIABILITY,
EVEN IF A PARTY OR ITS AFFILIATES HAVE BEEN ADVISED OF THE
POSSIBILITY OF SUCH DAMAGES OR IF A PARTY'S OR ITS AFFILIATES'
REMEDY OTHERWISE FAILS OF ITS ESSENTIAL PURPOSE. THE
FOREGOING DISCLAIMER WILL NOT APPLY TO THE EXTENT
PROHIBITED BY LAW. NOTWITHSTANDING ANYTHING TO THE
CONTRARY IN NO EVENT SHALL THE AGGREGATE LIABILITY OF
EITHER PARTY ARISING OUT OF OR RELATED TO THIS AGREEMENT,
INCLUDING ITS RESPECTIVE AFFILIATES, EXCEED THE TOTAL AMOUNT
PAID FOR COVERED SERVICES IN THE TWELVE (12) MONTHS
PRECEDING THE FIRST INCIDENT OUT OF WHICH THE LIABILITY AROSE.
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THE FOREGOING LIMITATION WILL APPLY WHETHER AN ACTION IS IN
CONTRACT OR TORT AND REGARDLESS OF THE THEORY OF LIABILITY,
BUT WILL NOT LIMIT PAYMENT OBLIGATIONS OF GROUP AS SET FORTH
HEREIN.
13. Individual Continuation of Benefits
13.1 If a Subscriber terminates his or her employment with The Group for any reason
(including death), the Subscriber and the Subscriber's spouse or domestic partner and
his or her Covered Dependents are eligible to receive Covered Services from a Plan
Provider from whom they are currently receiving care for up to the maximum amount
of Visits to which they are entitled, as set forth in the Benefit Schedule set forth in
Attachment A. If a Subscriber terminates his or her marriage, and a court of law grants
such divorce by issuing a divorce decree, the Subscriber's former spouse is entitled
to receive Covered Services from the Plan Provider from whom he or she is currently
receiving care for up to the maximum amount of Visits to which he or she is entitled,
as set forth in the Benefit Schedule set forth in Attachment A.
13.2 Subscribers and their Covered Dependents are entitled to receive Covered Services
following the Subscriber's termination of employment if the Member elects to
continue coverage through the Consolidated Omnibus Budget Reconciliation Act
(COBRA) or California COBRA (Cal- Cobra), as appropriate. Covered Services
under COBRA or Cal -Cobra do not include Work/Life services (parenting and
childcare resources, adult care resources, financial services, or legal consultations);
these are not ERISA -regulated benefits and are provided for The Group's
convenience by The Plan.
14. Continuity of Care
14.1 New Members who were receiving otherwise Covered Services from a non -Plan
Provider at the time his or her employer changed EAP plans may request completion
of Covered Services with the non -Plan Provider at the Plan's cost and at no cost to
the Member, if the Member notifies The Plan no later than forty-five (45) days after
the effective date of coverage.
a. The Plan will allow the new Member a reasonable transition period or
allot a reasonable number of transitional visits to continue his or her
course of treatment with the non -Plan Provider prior to transferring to
a Plan Provider. The non -Plan Provider must provide all services on a
timely, appropriate, and medically necessary basis.
b. In determining the length of the transition period or number of
transitional visits, The Plan will take into account on a case-by-case
basis, the severity of the Member's condition, the amount of time
reasonably necessary to effect a safe transfer, and the potential clinical
effect of a change of provider on the Member's treatment for the
condition.
C. The Plan may require non -Plan Providers whose services are
continued pursuant to The Plan's Continuity of Care policy to agree in
CONCERN Form version 20211012
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writing to the same contractual terms and conditions that are imposed
upon Plan Providers, including reimbursement methodologies and
rates of payment. If the non -Plan Provider does not agree to such
contractual terms and conditions, The Plan is not required to provide
continuation of the non -Plan Provider's services.
d. If The Plan determines that a Member's treatment should temporarily
continue with the Member's existing provider who is a non -Plan
Provider, The Plan is not liable for actions resulting solely from the
negligence, malpractice, or other tortious or wrongful acts arising out
of the provision of services by the existing provider.
e. All requests for continuity of care and notifications by Members of
care being provided by a non -Plan Provider shall be made to The Plan
office or by calling 1-800-344-4222. All continuity of care requests
are forwarded to one of The Plan's Clinical Managers or Supervisors
for action, and reviewed in consultation with the Medical Director, as
appropriate. The Clinical Manager or Supervisor shall respond to the
Member within an appropriate period of time depending on the
assessed severity of the condition involved to ensure safety, and in no
event more than five (5) days after submission of the request to The
Plan.
14.2 In the event a Plan Provider terminates from The Plan and a Member was receiving
Covered Services from such terminated Plan Provider at the time of termination, The
Plan will allow the Member to continue to receive such Covered Services from the
terminated Plan Provider at The Plan's cost and at no cost to the Member until services
being rendered are completed, unless The Plan makes reasonable and medically
appropriate arrangements to transfer care to a current Plan Provider. If for any other
reason the terminated Plan Provider is unavailable or unable to continue care of the
Member, The Plan will make immediate arrangements to transfer care to a current
Plan Provider.
This provision does not apply to providers who were terminated as a Plan Provider
for reasons related to medical disciplinary cause or reason, as defined in Section
805(a)(6) of the California Business and Professions Code, or fraud or other criminal
activity.
14.3 The Plan shall pay the non -Plan Provider up to the maximum number of Visits the
Member is entitled to under the Benefits Schedule set forth in Attachment A.
14.4 Continuity of Care provisions apply to any covered condition, whether or not acute,
serious or chronic in nature.
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15. Second Opinions
15.1 Plan Members or Plan Providers providing Covered Services to Members may request
second opinions from another appropriately qualified Plan Provider by calling the
Plan and requesting a second opinion.
15.2 The Plan will provide an authorization or denial in an expeditious manner appropriate
for the nature of the Member's condition.
15.3 Reasons for a second opinion to be provided or authorized include, but are not limited
to, the following:
• The reasonableness or necessity of recommendations made is questioned by
the Member.
• The indications for treatment are sufficiently complex or confusing that
second opinion may enhance the development of an effective treatment plan.
• The Member has questions about his or her EAP Assessment.
• The Plan Provider is unable to make, or would like additional assistance in
making, an EAP Assessment.
15.4 Second opinion consultations are provided at no cost to the Member.
16. General Provisions
16.1 Notice: All notices required by this Agreement shall be in writing. Notices shall be
sent by either United States mail, certified or registered, or by electronic means, which
will be deemed to have the same effect as physical delivery of the paper document, to
The Plan or The Group at their respective addresses set forth on the signature page of
this Agreement. If mailed in accordance with the above, such notice shall be deemed
to be received three business days after mailing. The Group or The Plan shall notify
the other party in writing within thirty (30) days of a change of address to which
notices are to be sent.
16.2 Member Non -Liability: Pursuant to the provisions of the Knox -Keene Act, in the
event that The Plan fails to pay a Plan Provider for any sums owed for Covered
Services rendered to a Member, the Member shall not be liable in any way to the Plan
Provider. In the event The Plan fails to pay a non -Plan Provider for services rendered
to a Member, the Member may be liable to the non -Plan Provider for the cost of the
services received.
16.3 Plan Subject to the Provisions of Knox -Keene Act: The Plan is subject to the
requirements of Chapter 2.2 of Division 2 of the Health and Safety Code and Title 28
of the California Code of Regulations, and any provisions required to be in this
Agreement by either of the above shall bind The Plan whether or not provided in this
Agreement.
16.4 Review by the Director of the Department: If any person believes that a
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Membership has been improperly canceled, rescinded, or not renewed, or a Member
has been denied eligibility or services under the Agreement because of a Member's
health status or requirements for EAP benefits, he or she may request a review by the
Director of the Department of Managed Health Care of the State of California under
section 1365(b) of the California Health and Safety Code.
16.5 Amendments: This Agreement may be modified or amended only by a written
amendment signed by both parties.
16.6 No Assignment: Neither party may assign its rights or delegate its duties under this
Agreement without the other party's prior written approval.
16.7 Attachments and Interpretation: All Attachments are incorporated into this
Agreement at the point of their reference.
16.8 Governing Law: This Agreement shall be governed by the laws of the State of
California and in particular the Knox -Keene Act and accompanying regulations but
without regard to its conflicts of law provisions. Each party agrees that,
notwithstanding terms and conditions for Dispute Resolution set forth herein, the
exclusive venue for all legal actions related to this Agreement shall be the federal or
state court of competent jurisdiction located in Santa Clara County, California.
16.9 Non -Discrimination: Neither party may discriminate in any way against any person
on the basis of age, sex, race, color, creed, ancestry, physical or mental impairment
or handicap, marital status, sexual orientation, or national origin in connection with
or related to the performance of this Agreement.
16.10 Entire Agreement, Prior Agreements: This Agreement including its Attachments
and documents referred to therein represents the entire understanding and agreement
of the parties as to those matters contained in it. No prior oral or written understanding
shall bring any force or effect with respect to such matters.
16.11 Severability: If any provision of this Agreement is determined to be illegal or
unenforceable, that provision shall be severed from this Agreement, and the
remaining provisions shall remain enforceable between the parties.
16.12 Waiver: No waiver of any provision of this Agreement shall be effective against
either party unless it is in writing and signed by the party granting the waiver. Failure
to exercise any rights shall not operate as a waiver of such right.
16.13 Authority to Execute: By their signature below, each of the following persons
represent that they have the authority to execute this Agreement and to bind the party
on whose behalf their execution is made.
17. Dispute Resolution
17.1 Grievance Procedure: The Plan shall establish and maintain grievance procedures,
and shall provide The Group with said procedures for dissemination to Members.
Those procedures shall include the current address and telephone number for
registering grievances with The Plan, including the availability of a grievance form
CONCERN Form version 20211012
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and a description of procedures for filing a grievance online through the Plan's
website. For purposes of this section, complaint shall have the same meaning as
grievance.
a. The Plan maintains a Quality Improvement Committee comprised of
the Medical Director, who chairs it, two Plan Providers and two staff.
The Committee shall provide supervision over, and review grievances
not resolved by, The Plan's Medical Director and Clinical Manager.
The Committee shall have primary responsibility for the review of the
grievance procedures, and for the analysis of any patterns that could
impact policy changes and procedural improvements in The Plan's
administration.
b. A Member may file a complaint form about The Plan's services or that
of a Plan Provider by appearing in person or writing or calling The
Plan, at:
(800) 344-4222
Clinical Manager
CONCERN: Employee Assistance Program
2490 Hospital Drive, Suite 310
Mountain View, CA 94040
info@concernhealth.com
Grievances may also be filed through the Plan's website at
www.concernhealth.com, or faxed to the Plan at 650-934-2310.
Complaint forms and copies of the grievance procedure shall be
available at The Plan's office and at each Plan Provider office as well
as on the Plan's website. In addition, complaint forms shall be sent to
Members on request. Completed forms should be submitted to the
above address or through procedures noted on the website. Assistance
will be provided by a Plan representative to anyone attempting to file
a grievance in person or by telephone.
Members will receive a written response within five (5) calendar days
acknowledging receipt of the complaint, and within thirty (30)
calendar days a written notice describing the Plan's resolution of the
complaint. Grievances that require expedited review will be resolved
within three (3) calendar days. The details of these processes will be
outlined in the Evidence of Disclosure and Coverage Form (EOC).
A written record shall be made of all grievances received,
whether in person, by mail or email, by fax or by telephone, or
through the website, including the date, the name of the person
recording the complaint, a summary describing the grievance,
and the resolution. The Clinical Manager will tabulate the
types and numbers of grievance received for periodic review
by The Plan's Board of Directors, the Public Policy
CONCERN Form version 2021 1012
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Committee, the Quality Improvement Committee and Chief
Executive Officer in connection with their consideration and
formation of The Plan's policy. The Quality Improvement
Committee shall include in its periodic reports recommended
corrective actions to be taken in light of the pattern of
grievances received.
ii. The Plan will assure that a Member is not discriminated against
for having filed a complaint. The Quality Improvement
Committee will investigate any alleged retaliation and take
appropriate action.
17.2 Independent Medical Review: If a Member believes that health care services have
been improperly denied, modified, or delayed by The Plan or by a Plan Provider, the
Member has the right to request an independent medical review. To initiate a request,
the Member must complete an application. The California Department of Managed
Health Care will review the application and determine whether the request qualifies
for an independent medical review. For more information and application forms,
Members may contact The Plan at 1-800-344-4222 or the California Department of
Managed Health Care at 1-888-466-2219 (TDD at 1-877-688-9891) or visit
http://www.dmhc.ca.gov.
17.3 Review by the Department of Managed Health Care: The California Department
of Managed Health Care is responsible for regulating health care service plans. If you
have a grievance against your health plan, you should first telephone your health plan
at 1-800-344-4222 and use your health plan's grievance process before contacting the
department. Utilizing this grievance procedure does not prohibit any potential legal
rights or remedies that may be available to you. If you need help with a grievance
involving an emergency, a grievance that has not been satisfactorily resolved by your
health plan, or a grievance that has remained unresolved for more than 30 days, you
may call the department for assistance. You may also be eligible for an Independent
Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an
impartial review of medical decisions made by a health plan related to the medical
necessity of a proposed service or treatment, coverage decisions for treatments that
are experimental or investigational in nature and payment disputes for emergency or
urgent medical services. The department also has a toll-free telephone number (1-
888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech
impaired. The department's Internet Web site http://www.dmhe.ca.gov has
complaint forms, IMR application forms and instructions online.
17.4 Arbitration of Disputes:
a. In addition to the Grievance Procedure, a Member may also seek
redress by submitting the dispute to binding arbitration in accordance
with the Commercial Arbitration Rules of the American Arbitration
Association. Binding arbitration is the final process for resolution of
any dispute described in section 16.4.b. below. Under binding
arbitration, both parties give up their rights to have the dispute decided
by jury in a court of law.
CONCERN Form version 20211012
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b. Each and every unresolved disagreement, dispute or controversy
arising out of or relating to Covered Services under this Agreement or
the construction, interpretation, performance or breach of this
Agreement, between a Member or personal representative of such
persons, as the case may be, and The Plan shall be submitted to binding
arbitration in accordance with this section whether such dispute
involves a claim in tort, contract or otherwise, and whether or not other
parties (e.g., Plan Providers or their partners, agents, or employees) are
involved. This Arbitration section does not include disputes involving
medical malpractice. If you have a dispute involving medical
malpractice, you should consult a lawyer to assist you in determining
your legal rights. It does include any act or omission which occurs
during the term of this contract but which may give rise to a claim after
the termination of this contract.
C. The Member seeking binding arbitration shall send a written notice to
The Plan. The notice shall contain a demand for binding arbitration
and a statement describing the nature of the dispute, including the
specific issue(s) involved, the amount involved, the remedies sought
and a declaration that the party seeking binding arbitration has
previously attempted to resolve the dispute with The Plan. For further
assistance, the Member may also write to the AAA at 3055 Wilshire
Blvd., 7th Floor, Los Angeles, CA 90010-1108, or telephone (213)
383-6515.
d. In the case of extreme economic hardship, a Member may request from
The Plan information on how to obtain an application for full or partial
assumption of the Member's share of fees and expenses incurred by
the Member in connection with the arbitration proceedings.
e. For all claims or disputes for which the total amount claimed is
$200,000 or less, the parties shall select a single neutral arbitrator who
shall have no jurisdiction to award more than $200,000. This provision
is not subject to waiver, except nothing in this section shall prevent the
parties from mutually agreeing, in writing, after a case or dispute has
arisen and a request for arbitration has been submitted, to use a
tripartite arbitration panel which includes two party -appointed
arbitrators or a panel of three neutral arbitrators, or another multiple
arbitrator system mutually agreeable to the parties. The agreement
shall clearly indicate, in boldface type, that "A case or dispute subject
to binding arbitration has arisen between the parties and we mutually
agree to waive the requirement that cases or disputes for which the
total amount of damages claimed is two hundred thousand dollars
($200,000) or less be adjudicated by a single neutral arbitrator." If the
parties agree to waive the requirement to use a single neutral arbitrator,
the Member or Subscriber shall have three business days to rescind the
agreement. If the agreement is also signed by counsel of the Member
or Subscriber, the agreement shall be binding and may not be
rescinded. If the parties are unable to agree on the selection of a neutral
CONCERN form version 20211012
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arbitrator, The Plan shall use the method provided in section 1281.6 of
the Code of Civil Procedure to select the arbitrator.
f. The parties agree that the arbitrator(s) shall issue a written opinion,
and the award of the arbitrator shall be binding and may be enforced
in any court having jurisdiction thereof by filing a petition of
enforcement of said award. The findings of the arbitrator and the award
of the arbitrator issued thereon shall be governed by the applicable
state and federal statutory and case law. The arbitrator's award shall be
accompanied by a written decision explaining the facts and reasons
upon which the award is based, including the findings of fact and
conclusions of law made and reached by the arbitrator(s). The decision
shall be signed by the arbitrator(s) in order to be effective.
g. The declaration of a court or other tribunal of competent jurisdiction
that any portion of this contract to arbitrate is void or unenforceable
shall not render any other provision hereof void or unenforceable.
h. The arbitrator(s) shall make the necessary arrangements for the
services of an interpreter upon the request of any party, which party
shall assume the cost of such services.
The arbitration shall take place in the largest city or town in the county
where the services were provided, unless some other location is
mutually agreed upon by the parties, and shall be governed by the rules
of the American Arbitration Association. The expenses of the
arbitrator(s) shall be shared equally by the parties.
IN WITNESS WHEREOF, the parties have executed this Agreement as of the Effective Date set
forth above.
CONCERN: Employee Assistance Program
CONCERN: EAP Headquarters
2490 Hospital Drive, Suite 310
Mountain View, CA 94040
(800)344-4222
CONCERN Form version 20211012
City of San Rafael
Name Sign: X-S&q&—
Name Print: Jim Schutz
Title:
City Manager
Date: 12/16/21
City of San Rafael
1400 Fifth Avenue, Room 210
San Rafael, CA 94901
r-Do-c-uSign/ed by:
C[6 (- �tr
Name Sign:
Name Print:
DFC544DF1FBA4FD
Cecile Currier
Title:
CEO
Date:
12/15/2021
CONCERN: EAP Headquarters
2490 Hospital Drive, Suite 310
Mountain View, CA 94040
(800)344-4222
CONCERN Form version 20211012
City of San Rafael
Name Sign: X-S&q&—
Name Print: Jim Schutz
Title:
City Manager
Date: 12/16/21
City of San Rafael
1400 Fifth Avenue, Room 210
San Rafael, CA 94901
DocuSign Envelope ID: DF2A434A-F9BE-446C-AD27-7EOF4081 EB47
Attachment A
COVERED SERVICES
BENEFIT SCHEDULE
The Plan shall provide the following Covered Services:
A. EAP Assessment, referral to community resources and Medical Emergency Care, and short-
term counseling. The Plan offers counseling services for a wide range of personal problems
and immediate response for Crisis situations. Each First Responder Member and his or her
Covered Dependents shall be limited to a maximum of Ten (10) Visits for each problem.
Counseling for First Responders will be provided by counselors on a First Responder
Specialty Panel. Counseling for Covered Dependents of First Responders will be provided
from our standard panel of counselors or by counselors on a First Responder Specialty Panel
when appropriate. For the purpose of this provision, the word "problem" means a specific
type of matter, situation or issue of concern to a Member for which the Member requests
EAP services for purposes of obtaining assistance in arriving at a solution. If a Member is
referred for unsatisfactory work performance by means of a Supervisor Referral, or if a
Member or Covered Dependent is assessed as having a chemical dependency problem, the
maximum number of visits shall be Ten (10). The Plan provides counseling for "problem"
issues including but not limited to:
(i) marital and family problems,
(ii) difficulty with relationships,
(iii) emotional distress,
(iv) job stress,
(v) communications or conflict issues,
(vi) substance abuse issues and
(vii) loss and death issues.
B. The Plan provides a problem -focused form of individual or family outpatient counseling that
(i) seeks resolution of problems in living rather than basic character changes;
(ii) emphasizes the Member's skills, strengths and resources;
(iii) involves setting and maintaining realistic goals that are achievable in a one to five
month period; and
(iv) encourages the Member to practice behavior outside the counseling Visits to promote
therapeutic goals.
C. The Plan's EAP services will provide Members with confidential EAP Assessment, Crisis
Intervention, short-term counseling and referral to community resources. The Plan can also
CONCERN Form version 20211012
DocuSign Envelope ID: DF2A434A-F9BE-446C-AD27-7EOF4081 EB47
refer Members to individuals who provide parenting and childcare resources, adult care
resources, legal consultations, and financial services.
D. Upon reaching the maximum number of Visits, a Member may continue to receive services
by the Plan Provider, but at the Member's expense. Upon each case opening, The Plan shall
inform the Member of the number of Visits he or she is entitled to receive.
E. A Plan Provider will also refer a Member to community resources for assistance for non -
Covered Services. In the event of such referral, the Member shall be advised by The Plan
and the Plan Provider that the Member is responsible for payment of costs and fees for
services provided.
F. The Plan Provider shall also obtain from a Member a consent form prior to the release of any
information concerning said Member, except as required by law. A Plan Provider shall
explain such form to each Member.
G. Upon request, The Plan shall provide three (3) hours per contract year of on-site or virtual
educational seminars and crisis response. Seminars are to be selected from a list of topics
provided by The Plan. Cancellations of educational seminars within three business days of
their scheduled time shall be counted as used on-site or virtual hours, or subject to a late
cancellation billing of Four Hundred Dollars ($400), whichever applies. Additional on-site
or virtual hours may be purchased by The Group at current pricing.
H. The Plan shall conduct management orientation sessions for The Group's management and
supervisory personnel and employee orientation sessions for The Group's personnel at such
times and locations as are mutually agreed upon by The Plan and The Group.
I. Upon request, The Plan shall consult with The Group's Human Resources staff and
individual supervisors and managers regarding potential or actual supervisory referrals and
Employee performance issues.
J. The Plan shall provide semiannual and annual reports. Such reports shall include statistics
on number of Employees using The Plan, demographics, referral sources, services used and
problem types.
K. Facilities: The Plan's Provider's offices are located close to where member work or live, and
are available during regular business hours. To find out the exact address and hours of
operation of a Plan Provider's office, contact The Plan at (800) 344-4222. Member will be
asked to provide either the city or zip code where member would like to receive care.
L. The Plan shall provide members with access to the digital platform, a digital guide to
customized care recommendations that include; an online assessment, triage to appropriate
level of care based on risk, a personalized dashboard, client -counselor matching for face-to-
face or video counseling, work/life referrals and resources, self -guided content, and digital
therapeutics.
CONCERN Form version 20211012
DocuSign Envelope ID: DF2A434A-F9BE-446C-AD27-7EOF4081 EB47
Attachment B
PREPAYMENT FEES
B.1 Prepayment Fees. The Group will pay an annual fee of Fourteen Thousand Five Hundred
Twenty -Five Dollars and Zero Cents ($14,525.00), based on a group size of up to 175 First
Responders. Pricing changes based on utilization will be determined each contract year. Pricing
for the next year will decrease/increase to the rate stated below if the utilization rate falls below or
exceeds the expected utilization range of (8-10%). A review of utilization will be conducted at the
end of each contract year based on projected annual utilization; the projection relies on actual
utilization at the time of the review projected through the end of the contract year.
Initial Base Rate for Expected
8-10% Annual Utilization
<8% Utilization
>15% Utilization
$14,525.00
$13,555.00
$15,530.00
B.2 Invoices. The Group will be billed the annual fee at the start of the contract year. All
amounts due under this Agreement shall be paid to The Plan within 30 days of invoice date. In the
event that payment is not received within 30 days of invoice date, a finance charge of 1.5% (18%
annually) will be applied. Payment shall be remitted to:
CONCERN: EAP
P.O. Box 883079
Los Angeles, CA 90088-3079
Tax I.D. number for The Plan is 77-0528349.
For questions or changes, please contact the Plan at billing@concemhealth.com
CONCERN Form version 20211012
DocuSign Envelope ID: DF2A434A-F9BE-446C-AD27-7EOF4081 EB47
Attachment C
.? BETA
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CERTIFICATE- OF COVERAGE
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CONCERN dorm version 20180822
EAP Agreement for City of San Rafael
Final Audit Report 2021-12-16
Created: 2021-12-16
By: Jennifer Alcantara Qennifer.alcantara@cityofsanrafael.org)
Status: Signed
Transaction ID: CBJCHBCAABAAb-yl_bQaO2MULYQZh9hWYH8RxFOLwvEK
"EAP Agreement for City of San Rafael" History
Document created by Jennifer Alcantara Oennifer.alcantara@cityofsanrafael.org)
2021-12-16 - 8:34:47 PM GMT- IP address: 199.88.89.34
' Document emailed to Jim Schutz aim.schutz@cityofsanrafael.org) for signature
2021-12-16 - 8:35:38 PM GMT
Email viewed by Jim Schutz Qim.schutz@cityofsanrafael.org)
2021-12-16 - 10:15:41 PM GMT- IP address: 199.88.89.34
Document e -signed by Jim Schutz aim.schutz@cityofsanrafael.org)
Signature Date: 2021-12-16 - 10:16:07 PM GMT - Time Source: server- IP address: 199.88.89.34
O' Agreement completed.
2021-12-16 - 10:16:07 PM GMT
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CONTRACT ROUTING FORM
INSTRUCTIONS: Use this cover sheet to circulate all contracts for review and approval in the order shown below.
TO BE COMPLETED BY INITIATING DEPARTMENT PROJECT MANAGER:
Contracting Department: HUMAN RESOURCES
Project Manager: CARMEN VALDEZ Extension: x3069
Contractor Name: Concern Health
Contractor's Contact: Ann Wagner Contact's Email: Ann-Wagner@concernhealth.com
❑ FPPC: Check if Contractor/Consultant must file Form 700
Step
RESPONSIBLE
DESCRIPTION
COMPLETED
REVIEWER
DEPARTMENT
DATE
Check/Initial
1
Project Manager
a. Email PINS Introductory Notice to Contractor
Click here to
❑
enter a date.
b. Email contract (in Word) and attachments to City
12/3/2021
Attorney c/o Laraine.Gittens@cityofsanrafael.org
❑x
2
City Attorney
a. Review, revise, and comment on draft agreement
12/13/2021
® LG
and return to Project Manager
12/13/2021
® LG
b. Confirm insurance requirements, create Job on
(n/a)
PINS, send PINS insurance notice to contractor
3
Department Director
Approval of final agreement form to send to
12/14/2021
❑ _cv_
contractor
4
Project Manager
Forward three (3) originals of final agreement to
12/16/2021
contractor for their signature
5
Project Manager
When necessary, contractor -signed agreement
❑ N/A
agendized for City Council approval *
*City Council approval required for Professional Services
❑
Agreements and purchases of goods and services that exceed
Or
$75,000; and for Public Works Contracts that exceed $175,000
Click here to
Date of City Council approval
enter a date.
PRINT
CONTINUE ROUTING PROCESS WITH HARD COPY
6
Project Manager
Forward signed original agreements to City
City Attorney
Attorney with printed copy of this routing form
7
Review and approve hard copy of signed
agreement
8
City Attorney
Review and approve insurance in PINS, and bonds
(for Public Works Contracts)
9
City Manager/ Mayor
Agreement executed by City Council authorized
official
10
City Clerk
Attest signatures, retains original agreement and
forwards copies to Project Manager