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<br />GROUP BENEFITS SERVICES AGREEMEN,T <br />NON-PARTICIPATING <br /> <br />This Agreement is between the Employer named in the Schedule and the TML Intergovernmental Employee <br />Benefits Pool, 1821 Rutherford Lane, Suite 300, Austin, Texas 78754 <br /> <br />SCHEDULE <br /> <br />1. Employer: City of San Marcos <br />2. Effective Date: <br />3. Monthly Service Charge per employee per month: <br /> <br />. <br /> <br />Claims Administration <br />Medical <br />Dental <br />Vision <br />Medical Management <br /> <br />5. Optional Services (per employee per month) <br /> <br />o PPN Access Fee using direct contracts <br />o toe Administration PEPM <br />o Section 125 PPPM <br />o HIP AA Compliance Adm.PEPM <br />o Medical Conversion PEPM <br />D Retiree Direct Billing PRPM <br /> <br />HealthChex - Auto Audit <br />Custom Clai~s Reports <br />Rx Card Claims <br />HIP AA Certificates <br />Benefit Booklets (every 2 years) <br />PPO Directories <br />Run-in <br />Outpatient Audits <br />Hospital, Audit <br />Subrogation <br /> <br />Out of State Network <br />Out of Network Claims (Concentra) <br /> <br />DRAFT 6-6-01 <br /> <br />$12.50 <br />$1.10 <br />$0.00 <br />$2.55 <br /> <br />$3.50 <br />$0.50 <br />$5.00 <br />$0.50 <br />$0.40 <br />$1.00 <br /> <br />No Charge <br />$150.00/programming hour <br />$ 0.55/claim until 10/1/01 <br />Included in Medical Admin Fee <br />Included for Number ofEE Plus 10% <br />Included For Number ofEE Plus 10% <br />$12.50 per claim <br />15010 of savings - External Vendor <br />200/0 of savings - External Vendor <br />200/0 of savings - In-House Counsel/External <br />Vendor <br />18010 of savings - External Vendor <br />20010 of savings - External Vendor <br /> <br />Page 1 of5 <br />