Ordinance No. 8,98920000914 -7
ORDINANCE NO. 8989
AN ORDINANCE AUTHORIZING AND DIRECTING THE CITY MANAGER TO
® EXECUTE AND THE CITY CLERK TO ATTEST TO A RENEWAL OF THE
PROFESSIONAL SERVICES CONTRACT WITH INTERFACE EAP, INC.;
AUTHORIZING PAYMENT BY THE CITY OF BAYTOWN, THE SUM OF NINETEEN
THOUSAND ONE HUNDRED SIXTEEN AND NO /100 DOLLARS ($19,116.00); AND
PROVIDING FOR THE EFFECTIVE DATE THEREOF.
BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF BAYTOWN, TEXAS:
Section 1: That the City Council of the City of Baytown, Texas, hereby authorizes and directs
the City Manager and the City Clerk of the City of Baytown to execute and attest to a renewal of the
professional services contract with Interface EAP, Inc. A copy of said contract is attached hereto, marked
Exhibit "A," and made a part hereof for all intents and purposes.
Section 2: That the City Council of the City of Baytown authorizes payment to Interface EAP,
Inc., of the sum of NINETEEN THOUSAND ONE HUNDRED SIXTEEN AND NO /100 DOLLARS
($19,116.00), pursuant to the Agreement.
Section 3: That the City Manager is hereby granted general authority to approve any change
order involving a decrease or an increase in costs of TWENTY -FIVE THOUSAND AND NO /100
DOLLARS ($25,000.00) or less; however, the original contract price may not be increased by more than
twenty -five percent (25 %) or decreased by more than twenty -five percent (25 %) without the consent of the
contractor to such decrease.
Section 4: This ordinance shall take effect immediately from and after its passage by the City
Council of the City of Baytown.
INTRODUCED, READ and PASSED by the affirmative vote of the City Council of the City of
Baytown this the 14`h day of September, 2000.
PETE C. ALFARO, Mayor
ATTEST:
�t
,— W/ City Clerk
APPROVED AS TO FORM:
ACIO RAMIREZ, S ty Attorney
c: \MyD ocuments \Counci] \99 -00 \S eptember\EAPcontract00 -01
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0
CONTRACT
for
CITY OF BAYTOWN
MANAGED MENTAL HEALTH PL US
and
EMPLOYEE ASSISTANCE PROGRAM
Provided
by
Interface EAP, Inc.
49 7670 Woodway, Ste 350 * Houston, Texas 77063 * (713) 781 -3364 * 1- 800 - 324 -4327
This contract is between CITY -OF BAYTOWN and Interface EAP, Inc. for Managed Mental
Is Health Plus (MMHP), supported by an Employee Assistance Program (EAP).
I. EAP Services
The services to be provided by Interface EAP, Inc. are as follows:
1. 24 hour telephone service with both a local Houston and toll free national number for
employees and family members to use for any personal problem. As used in this Contract
"family member" shall include an employee, as well as the employee's spouse and dependent
eligible children
2. Diagnosis, assessment, initial treatment planning, and referral if necessary for
personal problems, particularly those with the potential for affecting work performance. This
includes consultation with our professionals until an accurate diagnosis and initial treatment plan
is reached for each client of the EAP.
3. Supervisory/Management training will be provided upon initiation of the program.
This will include training on recognizing, documenting, and referring a troubled employee to the
EAP as well as information on all services provided by the EAP.
4. Employee orientation to familiarize all employees with the services provided by the
EAP and the process for utilizing the program.
NOTE: Both supervisory training and employee orientations will be presented by a Program
0 1
Coordinator either in person or via video and will include printed material.
5. Ongoing program awareness in the form of posters, handouts and pay stuffers for
distribution and display.
6. Assistance in establishing a clear policy letter in regards to CITY OF BAYTOWN's
position on employees who use the EAP.
7. Quarterly utilization review. This will include nature of the contract, referral source
and demographics of employees, providing that certain information will not jeopardize
confidentiality. Annual reports for both the EAP and MMHP will be provided with a
breakdown of cost and the number of persons referred for treatment under the health plan.
8. Critical Incident Stress Debriefing to take place between 24 and 72 hours after a
traumatic event.
9. A total of four Brown Bag hours will be available per plan year.
II. Managed Care Services
1. Interface will provide access to hospitals and other treatment facilities with which it
has Preferred Provider Agreements (PPA's), thus allowing discounts for treatment to your health
,1S plan. ,
2
2. Interface EAP will serve as the gatekeeper for the mental health and substance abuse
portion of your health plan. Through plan design, all covered persons will have a financial
incentive to contact Interface before seeking treatment.
3. Interface will review, along with your Administrator, your health plan design for
mental health and substance abuse coverage and recommend any changes that will enhance
Interface's ability to direct cost effective treatment.
4. MMHP will provide individual case management to insure cost containment and
quality service provided by referral resources. This continues after discharge to insure a quality
after -care program.
5. To insure negotiated discounts are received by your TPA, Interface will receive for
review and/or repricing, bills for treatment from facilities with which Interface has a PPA.
Interface will then forward the bills to your Administrator for processing and payment within
three business days.
III. Procedures
An employee /family member will have initial contact with a clinically trained case
manager at Interface. A case will be opened and they will be referred to a professional counselor
in Interface's network. This will be a licensed counselor established in private practice with
experience in the area of the presenting problem. The employee /family member may request
another counselor, for any reason, after their first session without losing that session as one of
their allotted sessions for that problem. Contact with the EAP may be initiated by the employee,
a supervisor, or both. A family member may be referred to the program by their own call or by a
referral of the employee. On a case by case basis Interface will evaluate the need to cover
extended family members who live within the household of the covered employee. EAP benefits
will only be available to those extended family members if deemed clinically appropriate in
resolving the problem(s) presented by the employee or the immediate family member.
When an employee or family member contacts the EAP they will be directed to the most
convenient office location, in their area, where a professional counselor will be assigned to
diagnose, assess, formulate an initial treatment plan, and if necessary refer for additional
treatment. In all instances the need and/or problem will be addressed. The goal of the
counseling process for an employee will be his/her effective return to full productivity.
IV. Publicity of Services
CITY OF BAYTOWN will inform its employees of the service provided by Interface
with at least a letter advising the program is confidential, and that any employee seeking
assistance will not jeopardize his/her position with CITY OF BAYTOWN.
Interface will provide literature in the form of brochures describing the EAP, and all
services included in Section I of this contract.
"a V. Reporting
When the initial contact is the result of a supervisory referral in regards to job
performance, the supervisor will be informed by the EAP counselor: 1) whether the employee
3
has contacted the Employee Assistance Program; 2) whether treatment goals have been
established (without identification of those goals); 3) whether there is progress (but not the
nature of that progress) toward treatment goals. Interface provides an employee authorization
form for the release of pertinent information to the supervisor regarding the progress of
treatment and encourages this release if the employee has been referred by a supervisor.
Employees who make their own contact (self - referrals) with the EAP will be encouraged
to share information with supervisors if deemed appropriate by the counselor. No reports will be
made to CITY OF BAYTOWN concerning self - referrals other than the agreed upon reports in
Section L
Neither the purpose nor content of the contact by an employee or family member will be
revealed to any representative of the City.
CITY OF BAYTOWN will provide a list of employees including their social security
number to Interface for the purpose of verifying employment. An updated list will be provided
as employment changes.
Agreed upon analysis are dependent on the existence of data to be provided by CITY OF
BAYTOWN in a relatively accessible form with all due regard for the confidentiality of
employees.
Except as provided herein, or by law, the identity of the employee or family member, the
nature of the contact, treatment progress and prognosis, will be confidential and reported to no
one without the written consent of the employee or family member.
VI. Consultation
An EAP professional will be available to employees and family members 24 hours a day
via the national toll free number to set up a counseling appointment. The EAP may also be
called upon by supervisors to assist in problem identification, documenting impaired job
performance, intervention with a problem employee, or other concerns.
Sessions with a counselor will be on an as needed basis, and will be free of charge to the
employee and/or family member as described herein. The EAP will be used first to obtain an
assessment of the problem. If the problem is short term, additional EAP sessions will be
available for the person(s) seeking help. If the problem is long term, a referral to the appropriate
program(s) shall be made prior to exhausting the full 6 sessions. During the term of this
Contract, Interface EAP, Inc. shall provide free of charge six counseling sessions per problem.
per year for each family member. If further treatment is needed that is not covered under
insurance, Interface will work to make available that treatment at a reduced cost to the family.
Referrals for legal problems are provided through Law Phone. Provided -is one phone
consultation per problem, with a maximum of three uses per plan year. Additionally, a local
referral with one 30 minute session at no charge to determine the situation or problem is
provided. Additional services with the attorney are provided at a reduced rate. Employees will
have 2 Financial Planning sessions per family, per year. All services are provided via telephone.
L,
is
E7
VII. Hold Harmless Clause
Interface EAP, Inc. will indemnify and hold CITY OF BAYTOWN harmless from any
and all claims, actions, liability and expenses including costs of judgements, settlements, court
costs, and attorney fees, regardless of the outcome of such claim or action, caused by, resulting
from or alleging negligent or intentional acts or omissions or any failure to perform any
obligation undertaken or any covenant in this agreement, whether such act, omission or failure
was that of Interface EAP or that of any person providing services thereunder through or for
Interface EAP. Upon notice from CITY OF BAYTOWN, Interface EAP, Inc. will resist and
defend at Interface EAP's own expense, and by counsel reasonably satisfactory to CITY OF
BAYTOWN any such claim or action.
VIII. Program Cost
The monthly retainer charge for the services of Interface EAP, Inc. is as follows:
$2.70 per employee per month
The above charge is to be paid in quarterly installments based on the number of covered
employees at the beginning of each month. The first being due on October 1, 2000.
IX. Term of Contract
The term of this contract shall be from October 1, 2000 through September 30, 2001.
X. Exhibit
Additional terms of this contract are contained in Exhibit "A" which is attached hereto
and incorporated herein by this reference for all intents and purposes.
AGREED TO AND EXECUTED THIS
CITY OF BAYTOWN
Title:
Print name:
E
DAY OF 2000.
INTERFACE EAP, INC.
own t . J
Print name: d uZs TO a0 - -J--
AGREEMENT TO AMEND PLAN DESIGN
CITY OF BAYTOWN agrees that their plan design will be amended as of October 1, 2000 to
reflect the following:
• Interface EAP will provide precertification and utilization review for all mental/nervous
and substance abuse treatment covered under the medical plan.
• All providers in Interface EAP's provider network will be recognized as a PPO provider
for reimbursement under the medical plan for all mental /nervous and substance abuse
treatment covered under the plan.
Signed this day of , 2000.
(Print or type name)
•
2
�J
Exhibit "A"
These Exhibit "A" shall supersede and control over the terms and conditions contained in
the Contract for Managed Mental Health Plus and Employee Assistance Program provided by
Interface EAP, Inc., for the City of Baytown dated the day of September, 2000 to the
extent that there is conflict.
* Interface EAP, Inc., shall comply with all rules, regulations and laws of the United
States of America, the State of Texas, and all laws, regulations and ordinances of the
City of Baytown as they now exist or may hereafter be enacted or amended.
* It is expressly agreed and understood by all parties hereto that Interface EAP, Inc., is an
independent contractor in its relationship to the City. Nothing herein contained at any
time or in any manner shall be construed to effect a contract of partnership or joint
venture or render any party hereto the employer or master of any other party and/or its
employees, agents or representatives. All necessary personnel shall be deemed
employees of Interface EAP, Inc.
* The City, besides all other rights or remedies it may have, shall have the right to
terminate this contract with or without cause upon thirty (30) days written notice from
the City Manager to Interface EAP of the City's election to do so. Furthermore, the City
may immediately and without notice terminate this Contract if Interface EAP breeches
this Contract. A breech of this contract shall include, but not be limited to, the following:
1. failing to pay any payments due the City, State or Federal Government from
Interface EAP, Inc., or its principals, including, but not limited to, any taxes, fees,
assessments, liens, or any payments identified in this contract;
2. the institution of voluntary or involuntary bankruptcy proceeding against
Interface EAP;
3. the dissolution of Interface EAP;
4. the violation of any provision of this contract; and/or
5. the abandonment for the Contract or any portion thereof and discontinuance of
Interface EAP's services or any portion thereof.
Upon delivery of any notice of termination required herein, Interface EAP, Inc., shall
discontinue all services in connection with the performance of the Contract. Within thirty (30)
days after receipt of the notice of termination, Interface EAP, Inc., shall refund any monies
prepaid by he City prorated to the date of the termination.
7
Interface's Initials L= ,,
City's Initials
1
* All notices required to be given hereunder shall be given in writing either by telecopier,
overnight, or facsimile transmission, certified or registered mail at the respective addresses of
the parties set forth herein or at such other address as may be designated in writing by either
party. Notice given by mail shall be deemed given three (3) days after the date of mailing thereof
to the following addresses:
Interface EAP, Inc.
Interface EAP, Inc.
Attn: Executive Director
7670 Woodway, Suite 350
Houston, TX 77063
Fax: (713) 784 -3241
CITY
City of Baytown
Attn: City Manager
PO Box 424
Baytown, TX 77522
Fax: (281) 420 -6586
* Interface EAP shall not sell, assign, or transfer any of its rights or obligations under this
Contract in whole or in part without prior written consent of the City, nor shall Interface
EAP assign any monies due or to become due to it hereunder without. the previous
consent of the City.
* Failure of either party hereto to insist on the strict performance of any of the agreements
herein or to exercise any rights or remedies accruing thereunder upon default or failure of
performance shall not be considered a waiver of the right to, insist on and to enforce by an
appropriate remedy occurring as a result of any future default or failure of performance.
* This contract shall in all respects be interpreted and construed in accordance with and
governed by the laws of the State of Texas, regardless of the place of its execution or
performance. The place of making and the place of performance for all purposes shall be
Harris County.
Interface's Initials G
City's Initials
0
C!
* All parties agree that should any provision of this Contract be determined to be invalid or
unenforceable, such determination shall not affect any other term of this Contract, which
shall continue in full force and effect.
* This Contract contains all the agreements of the parties relating to the subject matter
hereof and is the full and final expression of the agreement between the parties. This
contract shall not be amended or modified without the express written consent of both
parties hereto.
* The officers executing this Contract on behalf of the parties hereby represent that such
officers have full authority to execute this contract and to bind the party he /she
represents.
E
Interface's Initials G .-T
City's Initials
I _� .
INTERFACE EAP, INC. (IEAP) EMPLOYER FACT SHEET
IEAP Employer #: 106
Employer Name: City of Baytown
Other DBA's:
Address: 2401 Market Other Locations:
Baytown, TX 77520
Phone: (281) 420 -6521
Fax: (281) 420 -6586 E -mail address:
Would you prefer to be contacted via:, e -mail phone fax mail
Contact(s): Carol Berg
# of employees covered by the EAP: 570
Are there employees not covered by the EAP? No
If yes, give that number:
Number of EAP sessions per year: 6 sessions
Is Managed Mental Health Care Plus (MMHP) provided? Yes
If yes, list # of employees under the health plan: 570
Are COBRA participants covered under MMHP? Yes No
Contract starting Date: October 1, 2000
Contract ending Date: September 30, 2001
Per employee, per month charge(s): EAP/MMHP: $2.70
Other services provided? Four Brown Bag hours per plan year.
Does IEAP invoice: Yes
If yes, whom: Carol Berg
Address: 2401 Market
Baytown, TX 77520
Is a Purchase Order (PO) number needed: Yes No
Billing cycle: Quarterly
Form completed by: Chip Melvin Title: Client Services Date: 08/08/00
The information stated on this document is accurate and correct.
Employer signature: Date:
s:lwordlma rketin \EmployersVormslfacts het. doc
August 7, 2000 8:56:45 AM
FOR MANAGED MENTAL HEALTH EMPLOYERS ONLY
Section I•
IEAP Employer #: 106
TPA Group #:
TPA Name: Intercare Health Plans
TPA Address: P.O. Box 3.559
Inglewood, CO 80155 -3559
TPA Phone: (800) 426 -7453 Fax: (303) 770 -5928
TPA Contact(s): Patty Ninneman
Who are claims sent to: Claims Department
Refer claims questions to: TPA
Section II:
Are all Interface EAP, Inc.'s providers approved for payment under the benefit plan?
Yes
If no, please state plan limitations:
What are the annual dollar limits on:
mental nervous benefits: $
substance abuse benefits: $
combined benefits: $10,000
What are the lifetime dollar limits on:
mental nervous benefits: $
substance abuse benefits: $
combined benefits: $50,000
Is there a precertification penalty? No
If yes, what is it?
Is Employer Initials:
s:\ word\ marketiMEmployers \formslfactshet.doc Z
August 7, 2000 8:56:45 AM
L]
CPrtinn IM
Please complete Section III for Mental & Nervous benefits or Mental & Nervous benefits
combined with Chemical Dependency, Drug &Substance Abuse (isf combined). Please fill out
Section V if Substance Abuse Benefits are separate from Mental & Nervous Benefits.
In- Network Benefits:
Plan pays: 90 % to an annual maximum of (please make any changes):
Inpatient Acute
Days
Inpatient Sub -acute
Days
Day Treatment/PHP
Days
Residential
Days
Outpatient
Sessions
IOP
Weeks
Are out -of- network benefits provided? Yes
If yes, please complete Section IV. If no, go to Section V.
Certinn TV-
Out -of- Network Benefits:
Plan pays: 50 % to an annual maximum of (please make any changes):
Inpatient Acute Days
Inpatient Sub -acute Days
Day Treatment/PHP Days
Residential Days
Outpatient Sessions
IOP Weeks
Are out -of- network claims repriced per IEAP's non - network fee schedule? No
NOTE: Although LEAP can precertify out -of- network outpatient counseling IEAP does not
provide on -going authorization for non - network outpatient treatment.
Does IEAP rp ecert out -of- network outpatient counseling? Yes
Notes or special instructions:
s:l wordlmarketin \Employerslformslfactshet.doc 3
August 7, 2000 8:56:45 AM
Employer Initials:
Please skip this section if the Mental Nervous and Substance Abuse benefits are combined.
Section V•
Chemical Dependency, Drug & Substance Abuse Plan Design:
In- network:
Plan pays % to an annual maximum of (please make any changes):
Inpatient Acute
14 Days or
Days
Inpatient Sub -acute
14 Days or
Days
Day Treatment/PHP
28 Days or
Days
Residential
40 Days or
Days
Outpatient
50 Sessions or
Sessions
IOP
6 Weeks or
Weeks
Out -of- Network Benefits:
Plan pays: % to an annual maximum of (please make any changes):
Inpatient Acute
14 Days or
Days
Inpatient Sub -acute
14 Days or
Days
Day Treatment/PHP
28 Days or
Days
Residential
40 Days or
Days
Outpatient
50 sessions or
Sessions
IOP
6 Weeks or
Weeks
C!
Are out -of- network claims repriced per IEAP's non - network fee schedule? No
NOTE.- Although IEAP can precertify out -of- network outpatient counseling, IEAP does not
provide on- ,coinc authorization for non - network outpatient treatment.
Does IEAP rp ecert out -of- network outpatient counseling? Yes
Please return a copy of your Mental Nervous plan design from the pages of your benefit book.
Notes or Special Instructions:
s: \word\marketin\Employers \forms \factshet.doc 4
August 7, 2000 8:56:45 AM
Employer Initials:
CONTRACT
for
CITY OF BAYTOWN
MANAGED MENTAL HEALTH PLUS
and
EMPLOYEE ASSISTANCE PROGRAM
Provided
by
Interface EAP, Inc.
7670 Woodway, Ste 350* Houston,Texas 77063 * (713)781-3364 * 1-800-324-4327
Exhibit "A"
These Exhibit "A" shall supersede and control over the terms and conditions contained in
the Contract for Managed Mental Health Plus and Employee Assistance Program provided by
Interface EAP, Inc., for the City of Baytown dated the day of September, 2000 to the
extent that there is conflict.
Interface EAP, Inc., shall comply with all rules, regulations and laws of the United
States of America, the State of Texas, and all laws, regulations and ordinances of the
City of Baytown as they now exist or may hereafter be enacted or amended.
It is expressly agreed and understood by all parties hereto that Interface EAP, Inc., is an
independent contractor in its relationship to the City. Nothing herein contained at any
time or in any manner shall be construed to effect a contract of partnership or joint
venture or render any party hereto the employer or master of any other party and/or its
employees, agents or representatives. All necessary personnel shall be deemed
employees of Interface EAP, Inc.
The City, besides all other rights or remedies it may have, shall have the right to
terminate this contract with or without cause upon thirty (30) days written notice from
the City Manager to Interface EAP of the City's election to do so. Furthermore, the City
may immediately and without notice terminate this Contract if Interface EAP breeches
this Contract. A breech of this contract shall include, but not be limited to, the following:
1.failing to pay any payments due the City, State or Federal Government from
Interface EAP, Inc., or its principals, including, but not limited to, any taxes, fees,
assessments, liens, or any payments identified in this contract;
2.the institution of voluntary or involuntary bankruptcy proceeding against
Interface EAP;
3.the dissolution of Interface EAP;
4.the violation of any provision of this contract; and/or
5.the abandonment for the Contract or any portion thereof and discontinuance of
Interface EAP's services or any portion thereof.
Upon delivery of any notice of termination required herein, Interface EAP, Inc., shall
discontinue all services in connection with the performance of the Contract. Within thirty (30)
days after receipt of the notice of termination, Interface EAP, Inc., shall refund any monies
prepaid by he City prorated to the date of the termination.
Interface's Initials L_T •
City's Initials ,17,0
7
All notices required to be given hereunder shall be given in writing either by telecopier,
overnight, or facsimile transmission, certified or registered mail at the respective addresses of
the parties set forth herein or at such other address as may be designated in writing by either
party. Notice given by mail shall be deemed given three (3) days after the date of mailing thereof
to the following addresses:
Interface EAP, Inc.
Interface EAP, Inc.
Attn: Executive Director
7670 Woodway, Suite 350
Houston, TX 77063
Fax: (713) 784-3241
CITY
City of Baytown
Attn: City Manager
PO Box 424
Baytown, TX 77522
Fax: (281)420-6586
Interface EAP shall not sell, assign, or transfer any of its rights or obligations under this
Contract in whole or in part without prior written consent of the City, nor shall Interface
EAP assign any monies due or to become due to it hereunder without the previous
consent of the City.
Failure of either party hereto to insist on the strict performance of any of the agreements
herein or to exercise any rights or remedies accruing thereunder upon default or failure of
performance shall not be considered a waiver of the right to insist on and to enforce by an
appropriate remedy occurring as a result of any future default or failure of performance.
This contract shall in all respects be interpreted and construed in accordance with and
governed by the laws of the State of Texas, regardless of the place of its execution or
performance. The place of making and the place of performance for all purposes shall be
Harris County.
Interface's Initials G 77.
City's Initials//
8
r►
All parties agree that should any provision of this Contract be determined to be invalid or
unenforceable, such determination shall not affect any other term of this Contract, which
shall continue in full force and effect.
This Contract contains all the agreements of the parties relating to the subject matter
hereof and is the full and final expression of the agreement between the parties. This
contract shall not be amended or modified without the express written consent of both
parties hereto.
The officers executing this Contract on behalf of the parties hereby represent that such
officers have full authority to execute this contract and to bind the party he/she
represents.
Interface's Initials C•T•
City's Initials.o14
9
r r
INTERFACE EAP, INC. (IEAP) EMPLOYER FACT SHEET
IEAP Employer#: 106
Employer Name: City of Baytown
Other DBA's:
Address:2401 Market Other Locations:
Baytown, TX 77520
Phone: (281) 420-6521
Fax: (281) 420-6586 E-mail address:
Would you prefer to be contacted via: e-mail phone fax mail
Contact(s): Carol Berg
of employees covered by the EAP: 570
Are there employees not covered by the EAP? No
If yes, give that number:
Number of EAP sessions per year: 6 sessions
Is Managed Mental Health Care Plus (MMHP)provided? Yes
If yes, list# of employees under the health plan: 570
Are COBRA participants covered under MMHP? Yes No
Contract starting Date: October 1, 2000
Contract ending Date: September 30, 2001
Per employee, per month charge(s): EAP/MMHP: $2.70
Other services provided? Four Brown Bag hours per plan year.
Does IEAP invoice: Yes
If yes, whom: Carol Berg
Address: 2401 Market
Baytown, TX 77520
Is a Purchase Order(PO) number needed: Yes No
Billing cycle: Quarterly
Form completed by: Chip Melvin Title: Client Services Date: 08/08/00
The information stated on this document is accurate and correct.
Employer signature:ny Date: O c,.\-C L 2-0100
s:\word\marketin\Employers\forms\factshet.doc 1
August 7,2000 8:56:45 AM
FOR MANAGED MENTAL HEALTH EMPLOYERS ONLY
Section I:
IEAP Employer#: 106
TPA Group #:
TPA Name: Intercare Health Plans
TPA Address: P.O. Box 3559
Inglewood, CO 80155-3559
TPA Phone: (800)426-7453 Fax: (303) 770-5928
TPA Contact(s):Patty Ninneman
Who are claims sent to: Claims Department
Refer claims questions to: TPA
Section II:
Are all Interface EAP, Inc.'s providers approved for payment under the benefit plan?
Yes
If no, please state plan limitations:
What are the annual dollar limits on:
mental nervous benefits: $
substance abuse benefits:$
combined benefits: 10,000
What are the lifetime dollar limits on:
mental nervous benefits: $
substance abuse benefits: $
combined benefits: 50,000
Is there a precertification penalty? No
If yes, what is it?
Employer Initials: ,47/14
s:\word\marketin\Employers\forms\factshet.doc 2
August 7,2000 8:56:45 AM
Section III:
Please complete Section III for Mental & Nervous benefits or Mental & Nervous benefits
combined with Chemical Dependency, Drug & Substance Abuse (if combined). Please Jill out
Section V if Substance Abuse Benefits are separate from Mental&Nervous Benefits.
In-Network Benefits:
Plan pays: 90 %to an annual maximum of(please make any changes):
Inpatient Acute Days
Inpatient Sub-acute Days
Day Treatment/PHP Days
Residential Days
Outpatient Sessions
IOP Weeks
Are out-of-network benefits provided? Yes
Ifyes,please complete Section IV If no, go to Section V.
Section IV:
Out-of-Network Benefits:
Plan pays: 50 %to an annual maximum of(please make any changes):
Inpatient Acute Days
Inpatient Sub-acute Days
Day Treatment/PHP Days
Residential Days
Outpatient Sessions
IOP Weeks
Are out-of-network claims repriced per IEAP's non-network fee schedule?No
NOTE: Although LEAP can precertifv out-of-network outpatient counseling LEAP does not
provide on-going authorization for non-network outpatient treatment.
Does IEAP precert out-of-network outpatient counseling? Yes
Notes or special instructions:
Employer Initials: Mil
s:\word\marketin\Employers\forms\factshet.doc 3
August 7,2000 8:56:45 AM
r . .
Please skip this section if the Mental Nervous and Substance Abuse benefits are combined.
Section V:
Chemical Dependency, Drug & Substance Abuse Plan Design:
In-network:
Plan pays to an annual maximum of(please make any changes):
Inpatient Acute 14 Days or Days
Inpatient Sub-acute 14 Days or Days
Day Treatment/PHP 28 Days or Days
Residential 40 Days or Days
Outpatient 50 Sessions or Sessions
IOP 6 Weeks or Weeks
Out-of-Network Benefits:
Plan pays: to an annual maximum of(please make any changes):
Inpatient Acute 14 Days or Days
Inpatient Sub-acute 14 Days or Days
Day Treatment/PHP 28 Days or Days
Residential 40 Days or Days
Outpatient 50 sessions or Sessions
IOP 6 Weeks or Weeks
Are out-of-network claims repriced per IEAP's non-network fee schedule?No
NOTE: Although lEAP can precertifv out-of-network outpatient counseling, lEAP does not
provide on-going authorization for non-network outpatient treatment.
Does IEAP precert out-of-network outpatient counseling? Yes
Please return a copy of your Mental Nervous plan design from the pages of your benefit book.
Notes or Special Instructions:
Employer Initials: XX
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August 7,2000 8:56:45 AM