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1154* BC/BS Addendum AgrmtTo: City Clerk RE: Request for Services The item(s) noted below is/are attached and forwarded to your office for the following action(s): Development Order Final Plat (original mylars) Letter of Credit Maintenance Bond Ordinance Performance Bond Resolution Once completed, please: ❑ Return original ❑ Return copy ❑ Special Instructions: ❑ Mayor's signature ❑ Recording ❑ Rendering ® Safe keeping (Vault) ❑ Record Custodian Please maintain this original copy of Blue Cross Blue Shield Addendum Agreement this is effective January 1, 2016. Please advise if you have any questions regarding the above. Thaq you! rom T:\Dept_forms\City Clerk Transmittal Memo - 2009.doc Date AMENDMENT TO ADMINISTRATIVE SERVICES AGREEMENT THIS AMENDMENT, entered into on—tZ;, 17 , 2015 is by and between Blue Cross and Blue Shield of Florida, Inc. d/b/a Florida Blue (hereinafter called "Florida Blue") and City of Sanford (hereinafter called the "Employer"). In consideration of the mutual and reciprocal promises herein contained, the Administrative Services Agreement between Florida Blue and the Employer (hereinafter "Agreement") effective October 1, 2004 is amended as follows: Section I, subsection 1.1, is hereby amended to extend the term of the Group Health Plan until December 31, 2018 unless the Agreement is terminated earlier in accordance with the terms of the Agreement. 2. Exhibit B to the Agreement is hereby amended, effective January 1, 2016. The revised Exhibit B is attached to this Amendment and replaces the Exhibit B previously attached to the Agreement. 3. Except as otherwise specifically noted in this Amendment, all other terms and conditions of the Agreement shall remain unchanged and in full force and effect. IN WITNESS WHEREOF, this Amendment has been executed by the duly authorized representatives of the parties. ATTEST.- ATTEST.- Orwk City ClerkCfet- BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC. DIB/A FLORIDA BLUE Y' Title: Date: a % 11 CITY OFFSANFOR 4 By: Jeff-r-imp{ett Ve Ir ra w' � i i►c �+ns Vice- Mayor Date: For the use and reliance of City of Sanford only. Approved as to form and legal sufficiency. William L. Colbert, City Attorney EXHIBIT "B" to the ADMINISTRATIVE SERVICES AGREEMENT between BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC. D/B/A FLORIDA BLUE and CITY OF SANFORD FINANCIAL ARRANGEMENTS I. Effective Date The effective date of this Exhibit is January 1, 2016. II. Monthly Payments. A. Each month, Florida Blue will notify the Employer of the amount due to satisfy the previous month's paid claims liability. Florida Blue also will provide the Employer with a detailed printout of the previous month's claims payments. The Employer agrees to pay the full amount of the bill within ten (10) days of the written notification. If the payment is not received by Florida Blue by the payment due date, the payment will be considered past due and subject to a late payment charge, as set forth below. Additionally, Florida Blue will immediately suspend claims until payment is received by Florida Blue. B. The Employer agrees to pay to Florida Blue, each month during and after the term of this Agreement, an administrative fee, as set forth below. The Employer agrees to pay to Florida Blue, each month, the administrative fee within ten (10) days of the written notification of the amount due. If payment is not received by Florida Blue by the due date, the payment will be considered past due and subject to a late payment charge, as set forth below. Additionally, Florida Blue will immediately suspend claims until payment is received by Florida Blue. III. Funding Information A. Method of Funding Transfer: ACH IV. Administrative Fees: A. Administrative fees during the term of the Agreement: $49.95 per enrolled employee per month from January 1, 2016 through December 31, 2017. $51.50 per enrolled employee per month from January 1, 2018 through December 31, 2018. B. Administrative fees after the termination of the Agreement: 15% of claims paid. This should not exceed seven months of the current administration fee, times the current enrollment, at time of cancellation. C. Florida Blue will pay Employer a $75,000 wellness contribution in 2015, upon Employer execution of the Amendment. This is to be utilized by the Employer for any wellness related initiatives or activities. D. If the Employer terminates the Agreement prior to December 31, 2018, Employer will pay Florida Blue a termination fee of $75,000. V. Late Payment Penalty A. A daily charge of .00038 times the amount of overdue payment. The provisions of the Prompt Payment Act shall apply to this Agreement. VI. Expected Enrollment A. The administrative fees referenced above are based on an expected enrollment of: 400. B. If the actual enrollment is materially different from this expected enrollment, Florida Blue reserves the right to adjust the administrative fees as set forth in the Agreement. Administrative fees will be charged based on actual enrollment.