Ordinance No. 9,219ORDINANCE NO. 9219
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 FOUR HUNDRED FORTY AND NO / 100 DOLLARS
($19,440.00); 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 FOUR HUNDRED FORTY AND NO /100
DOLLARS ($19,440.00), 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
N01100 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 13`" day of September, 2001.
PETE C. ALFARO, ayor
ATTEST:
G W. MI'TH, City Clerk
APPROVED AS TO FORM:
ACIO RAMIREZ, W., City Attorney
d AMyDocuments \Council \00 -01 \S eptemberTAPcontract0 1 -02
E
CONTRACT
for
CITY OF BAYTOWN
MANAGED MENTAL HEALTH PLUS
and
EMPLOYEE ASSISTANCE PROGRAM
Provided
by
Interface EAP
0 7670 Woodway, Ste 350 * Houston, Texas 77063 * (713) 781 -3364 * 1 -800- 324 -4327
ti A
This contract is between CITY OF BAYTOWN and Interface EAP for Managed Mental Health
® Plus (MMHP), supported by an Employee Assistance Program (EAP).
1. EAP Services
The services to be provided by Interface EAP 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
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 seminars 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
® 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.
® 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. Interfdce 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 I.
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 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 Legal Access. Each covered family
has a maximum of 3 consultations with an attorney per plan year. The consultations with an
attorney may be either in person or via telephone with the first 30 minutes at no charge.
Additional services with the attorney are provided at a reduced rate. Employees will have 2
0 Financial Planning sessions per family, per year. All services are provided via telephone.
4
VII. Hold Harmless Clause
Interface EAP will indemnify and hold CITY OF BAYTOWN harmless from any and
all claims, actions, liability and expenses including costs of judgments, 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 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 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, 2001.
IX. Term of Contract
The term of this contract shall be from October 1, 2001 through September 30, 2002.-
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 DAY OF
CITY OF BAYTOWN
I
Title:
Print name:
r:
5
INTERFACE EAP
2001.
Title: or 0042 ,- J-i6As
Print name: S kiw'o-1 E 11-e �'b v1
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, for the City of Baytown dated the day of September, 2001 to the extent
that there is conflict.
* Interface EAP, 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, 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.
* 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, 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, 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, shall refund any monies prepaid by he City
prorated to the date of the termination.
n
Interface's Initials
City's Initials
* 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
Interface EAP
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.
7
Interface's Initials
City's Initials
* 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
City's Initials
CONTRACT
for
CITY OF BAYTOWN
MANAGED MENTAL HEALTH PLUS
and
EMPLOYEE ASSISTANCE PROGRAM
Provided
by
Interface EAP
7670 Woodway, Ste 350* Houston,Texas 77063 * (713)781-3364 * 1-800-324-4327
fr
This contract is between CITY OF BAYTOWN and Interface EAP for Managed Mental Health
Plus (MMHP), supported by an Employee Assistance Program(EAP).
I. EAP Services
The services to be provided by Interface EAP 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
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 seminars 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
plan.
2
2. Interface EAP will serve as the f rgatekeepero 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.
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 I.
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 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 Legal Access. Each covered family
has a maximum of 3 consultations with an attorney per plan year. The consultations with an
attorney may be either in person or via telephone with the first 30 minutes at no charge.
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.
4
VII. Hold Harmless Clause
Interface EAP will indemnify and hold CITY OF BAYTOWN harmless from any and
all claims, actions, liability and expenses including costs of judgments, 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 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 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, 2001.
IX. Term of Contract
The term of this contract shall be from October 1, 2001 through September 30, 2002.
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.
thAGREEDTOANDEXECUTEDTHISI ?DAY OF `" he( 2001.
CITY OF BAYTOWN INTERFACE EAP
By: By: AS4-44- "1/4- 629.-LC)C15)"\
Title: C -k.\ fl'\j y . Title: D; C O r' -Y'0-14 otA.S
Print name: m 0 n I ex cex' Print name: 5VAcKlv kbr1
5
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, for the City of Baytown dated the Igo day of September, 2001 to the extent
that there is conflict.
Interface EAP, 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, 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.
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, 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, 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, shall refund any monies prepaid by he City
prorated to the date of the termination.
Interface's Initial
City's Initials 44
6
t , ,
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
Interface EAP
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
City's Initials, (f
7
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 YL-
City's Initials/WA,
8
C
INTERFACE EAP (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
Contact(s): Alison F. Smith
Number of employees covered by the EAP: 570
Number of employees under the health plan: 570
Are there employees not covered by the EAP? Yes No
If yes,how many&what type of employees are not covered(i.e.part-time,seasonal etc.):
Number of EAP sessions per year: 6 Sessions
Are COBRA participants covered under the MMHP? Yes No
Are COBRA participants covered under the EAP? Yes No
Contract starting Date: October 1,2001
Contract ending Date: September 30,2002
Per employee,per month charge(s) EAP: $2.20 MMHP: $0.50
Other services provided? 2 one-hour brown bag seminars per plan year
Would you like your quarterly handouts via email?Yes No*
If no, then you will receive them quarterly via the United States Post Office.
Does IEAP invoice? ® Yes No
Do you want the invoices emailed? Yes* No
If yes,email address to send them to:
If invoices are to be mailed,please state the address and person to mail them to:
Alison F. Smith
2401 Market
Baytown,TX 77520
Is a Purchase Order(PO)number needed: Yes No
Billing cycle: Quarterly
Who will receive your original reports(utilization etc.)? Alison F. Smith-City of Baytown
Who will receive copies of those reports(brokers,TPA etc.)?
Who will receive the contract renewals? Alison F. Smith-City of Baytown
Form completed by: Chip Melvin
Title: Client Services
Date: Augusr 3,2001
Please sign and return this entire document within 2 weeks. This will ensure that Interface EAP has the most current
information on your company.
The information stated on docum acc rate and correct:
Employer signature:
Title: City Manager
Date: 18 September 2001
Notes or special instructions:
1
S:\WORD\Client Services\Employer Documents\Factsheet-pending\F106.doc
August 9,2001 1:22:52 PM
s•
FOR MANAGED MENTAL HEALTH EMPLOYERS ONLY
Section I:
IEAP Employer#: 106
TPA Group#:
TPA Name:Intercare Health Plans
TPA Address: PO Box 3559
Inglewood, CO 80155-3559
TPA Phone: 800-426-7453 Fax: 303-770-5928
TPA Contact(s): Patty Ninneman
Where are claims sent: Intercare Health Plans
PO Box 3559
Inglewood, CO 80155-3559
Refer claims questions to:Claims Department
Section II:
Are all Interface EAP's providers approved for payment under the benefit plan?
Yes No
If no, please state plan limitations:
What are the annual dollar limits on:
Mental nervous benefits:
Substance abuse benefits:
Combined benefits: 10,000.00
What are the lifetime dollar limits on:
Mental nervous benefits:
Substance abuse benefits:
Combined benefits: 50,000.00
Is there a precertification penalty? Yes No
If yes,what is it?
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Section III:
Please complete Section III for Mental & Nervous benefits or Mental & Nervous benefits combined with
Chemical Dependency, Drug&Substance Abuse (if 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 No
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? Yes ® No
NOTE: Although LEAP can precertify 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 No
Notes or special instructions:
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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 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
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? Yes ® No
NOTE: Although LEAP canprecertifv out-of-network outpatient counselinc, LEAP does not provide
on-oinji authorization for non-network outpatient treatment.
Does IEAP precert out-of-network outpatient counseling? ® Yes n No
Please return a copy of your Mental Nervous plan design from the pages of your benefit book.
Notes or special instructions:
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