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(a)

(b)

(c)

(d)

(e)

Drafting or specifying all documents, forms and records to be used
by Contracting Providers for their claims of reimbursement and to be
used by HPHC to reimburse them and also to develop procedures
to be utilized in the adjudication of claims;

Evaluating and processing all claims for payment submitted to
HPHC under the Plan. HPHC shail investigate reported health care
claims in the manner and to the extent necessary and supervise a
settlement of those health care claims and other demands that the
Plan is legally obligated to pay; prepare checks or drafts drawn
again the Purchaser’s funds allocated to the Plan to settle such
claims or demands; and maintain claim files for the Plan; and

Utilization and Peer Review. HPHC shall maintain systems, trained
staff and procedures necessary or appropriate for the operation of a
reasonable and appropriate utilization review and quality assurance
program that meets generally accepted standard and which reviews
services required under the Plan. Utilization/Case Management
Services included but are not limited to: prior authorization,
precertification, concurrent and retrospective utilization review,
discharge planning, physician review of denials and appeals,
specialty case management, and disease management programs.

In all cases, using its best efforts to advise Purchaser of any
disputed health care claims by Members over which litigation has
been commenced or threatened or which is reasonably iikely to
result in litigation, HPHC will follow its standard practices for
resolving such claims. HPHC shall also refer to Purchaser any
other health care claims where the facts available to HPHC do not
provide adequate basis for resolution of the claim by HPHC and
determination of the claim may involve the exercise of discretion. In
all such disputed or unresolved cases, the ultimate authority to
resolve such claims is expressly retained by Purchaser and
Purchaser expressly retains the authority to make the ultimate
decision with regard to such claims. Purchaser also retains the
authority to decide whether an investigation of any disputed claim is
to be conducted and, if so, the extent of that investigation.

HPHC will administer the grievance and appeals procedure for
Members as described in Attachment E.

Lh.

3. Benefits Adminstration. HPHC will appropriately administer the
Purchaser's Benefit Option Code (BOC) as selected by the Purchaser. Any Level 1 or
Level 2 benefit package not covered by an existing BOC will be charged a set up fee of
one hundred dollars ($100.00) per hour for programming costs and seventy-five dollars
($75.00) per hour for installation costs associated with each request

4. Contracting Provider and Member Service Records. HPHC shall design,

implement and maintain the following services related to Contracting Provider and
Member services and records:

FORM# PS_AQ1

05/17/2002

(a)

(b)

(c)

(d)

HPHC shall assist Purchaser in preparing and distributing to
Members appropriate Member identification cards, instructional
brochures, booklets, announcements, and disclosure statements as
may be reasonably necessary and/or required by law, to assure the
availability of accurate and appropriate information regarding the
healih care services to be provided and the administration and
operations of the Pian’s programs. Upon request of the Purchaser,
customized member materials will be charged to the Purchaser at

cost.

HPHC shall develop and provide information for distribution to
Contracting Providers as may be reasonably necessary and/or
required by law to fully describe billing procedures, payment for
services, and the schedule of Covered Services. Such costs, as
well as all costs associated with the development and maintenance
of a network that meets Purchaser’s requirements as specified
herein shail be borne by HPHC:

HPHC shail develop and maintain Member and provider files to
permit eligibility verification, rate and provider compensation
computations, claims adjudication and efficient and timely response
to inquiries from Members and providers. HPHC shall be
responsible for informing Members in a timely fashion of the lapse
or termination of their eligibility to receive Covered Services. tn
accordance with Section 2.6 and 2.7 of the Purchaser Service
Agreement, HPHC may rely on information regarding the eligibility
of Members provided by Purchaser.

HPHC shall provide to the Purchaser a monthly administration bill
with membership roster. HPHC will accommodate billing.
reconciliation requests subject to availiable staffing capacity and will
reserve the right to charge one hundred dollars ($100) per hour for

labor costs.

5, Information Systems. HPHC shall employ an information system
appropriate for the purposes of claims processing, provider compensation computation,
utilization review, quality assessment, eligibility of Members, billing and making required
reports to regulatory agencies. HPHC shail bear all reasonable costs associated with the
acquisition and maintenance of the information system, including purchase or lease of
equipment, hardware and software development, installation, maintenance and
modification, and computer time- sharing and all personnet costs. The system, including
all software programs related thereto, shall be proprietary to HPHC or its contractor,

FORM# PS_A01

08/17/2002

FORM# PS_A0O14

Reports.

(a)

(b)

(d)

(a)

(a)

HPHC shall assist Purchaser, upon Purchaser’s request, in
providing such reports as may be required by any regulatory agency
having jurisdiction over the operations of the Plan including, to the
extent applicable, the U.S. Department of Labor (including Form
5500 and Summary Annual Report), the Internal Revenue Service,
and state governmental agencies. HPHC shall, upon Purchaser's
request, comply on Purchaser's behalf, with the New York Health
Care Reform Act reporting requirements.

HPHC shall report, at Purchaser's request, concerning the activities
of the Plan as shall be reasonably necessary for Purchaser, its
officers and directors, to fulfill their corporate or governmental
responsibilities.

HPHG shall provide reports to Purchaser, upon Purchaser’s request ”
on a schedule as indicated below:

HPHC will provide reinsurance notifications and filings as outlined in
the HPHC Reinsurance Guidelines to the reinsurance carrier as
noted in the Purchaser’s Stop Loss Policy (Attachment G). HPHC
will accommodate non standard requests subject to available
capacity and will reserve the right to charge one hundred dollars
($100.00) per hour for labor costs and a set up fee of one hundred
dollars ($100) per hour for programming costs and seventy-five
dollars ($75.00) per hour for installation costs associated with each

request.

Monthly

A monthly paid claims report including member identification
number, incurred date or date of service, service paid date/monih,
type of claims (hospital, medical or drug), type of service
description, provider number, total amount paid. All claims, including
prescription drug claims, shail be included. This report shall be
provided in an accepted electronic media format to the Purchaser or
its Designee, which acceptance shall not be unreasonably withheld,

Quarterly

On a quarterly basis or when reasonably requested by Purchaser,
HPHC shall furnish Purchaser with reports regarding the utilization
and cost of health services and supplies rendered to Members by
providers of these services. Such reports shall include, but not be
limited to, eligibility data and information regarding the types and
costs of services rendered and the frequency with which each type
of service was performed. HPHC will accommodate non standard
requests subject to available staffing capacity and will reserve the
right to charge one hundred dollars ($100) per hour for labor costs

05/17/2002

7.

(b)

(a)

and a set up fee of one hundred dollars ($100.00) for programming
costs and seventy-five dollars ($75.00) per hour for installation costs
associated with each request.

A quarterly report of enrollment status and activity by individual and
family subscriber, by group (may be provided in the form of a
monthly invoice for administration fees).

Annually

At least sixty (60) days prior to renewal, HPHC shall present to
Purchaser or its Designee a renewal package that contains: (a) a
detailed claims projection by plan type for the next policy period and
(b) proposed fully incurred administrative fees. Any affect ofthe
renewal package on the Funding of Covered Services (see
Attachment D) will be communicated to Purchaser or its Designee
after Purchaser’s annual open enrollment period.

Government Regulation. HPHC shall use reasonable efforts, within the

scope of its authority and responsibilities hereunder, to ensure that the Plan complies
with the requirements of any applicable state or federal statute, ordinance, law, rule, ’
regulation, or order of any governmental or regulatory body having jurisdiction over the
Plan. The Plan itself, however, is responsible for compliance with all applicable laws.

8.

FORM# PS_A01

(a)

(b)

(c)

Deposit and Disbursement of Funds.

HPHC shall maintain an accouniing of all monies received from
Purchaser or otherwise arising from the operation of the Plan and
shall make disbursements on behalf of the Plan in such amounts
and at such times as the same are required. HPHC shall maintain
and retain records clearly reflecting all transactions made for the
Plan and shall furnish such records to Purchaser, at Purchaser's

request.

HPHC shail serve as Purchaser's true and lawful attorney-in-fact to
bill and collect such amounts as may be payable to the Purchaser
for the Plan; to collect in the Purchaser's name accounts receivable
generated by such billing; and to take possession of and endorse in
Purchaser's name any cash, notes, checks, money orders,
insurance payments, and any other instruments received in
payment.

Upon termination of this Agreement, HPHC will continue to pay
claims (not including taxes or other governmental obligations as
described in section 10(c) below) incurred through the effective date
of termination, for a period not to exceed twelve (12) months (the
“run-out period”) on the condition that Purchaser continue to provide
funding for such claims payments in the same manner as is required
during the contract period. HPHC may charge interest in the
amount of fifteen percent (15%) annually on amounts which

05/17/2002

10.

Purchaser:

FORM# PS_AO1

Purchaser fails to pay within fifteen (15) days of the due date, Within
thirty (30) days after the run-out period ends, HPHC will return the
remainder of the balance of the Plan Working Deposit to Purchaser.
HPHC will subsequently request instruction from Purchaser as to
how future additional payable claims, if any, should be paid. Due to
the nature of the data on which the Massachusetts Uncompensated
Care Pool surcharge amounts are calculated, the final billing for this
charge will take place following the end of the run out period.
Similarly, the final billing for charges incurred under the New York
Health Care Reform Act will occur following the run out period.

Excluded Expenses and Services. Expenses incurred by the Plan, or by
HPHC on behalf of the Plan, for the following services shall be the sole responsibility of

(a)

(b)

(c)

(e)

(f)

(g)

All direct and indirect costs for the providers and suppliers in
connection with the delivery of health care services and supplies to
Members, including all compensation and reimbursement paid to
medical and paramedical personnel and health care facilities;

All insurance costs, including professional liability/malpractice,
general liability and all reinsurance and stop-loss, which may be
purchased for Purchaser or the Plan;

Taxes or other governmental obligations of the Plan or Purchaser,
including without limitation, surcharges assessed on paymenis to
health care providers for the funding of uncompensated care pools
or similar arrangements.

Purchaser’s annual corporate financial audit, and such other audits
and financial statements required by state or federal law and costs
associated with preparation of Purchaser’s corporate tax returns.

Costs of legal services for the Plan which arise in the normal course
of the Plan’s operations, including HPHC’s provision of services for
the Plan, except as otherwise provided in section 1.13 of the
Purchaser Service Agreement.

Filing fees and penalties and other fees associated with annual and
other reports required by federal and state statutes and regulations
applicable to the Plan; and

f&xpenses for independent legal, independent accounting and
independent actuarial services of Purchaser or the Plan.

05/17/2002

©P9 Harvard Pilerim
iy HealthCare’

Tlarvard Pilurim Wealth Care includes Harvard Pilgrim Health Care,
Harvard Pilgrio Health Care of Connecticut, Harvard Pilgrim
Tealth Care of New England and HPIIC Insurance Company.

RATE PROPOSAL

Company Name: City of Nashua
Group Number: 027219

Effective Date: 07/01/2016 - 06/30/2017
Plan ID :MD0000014789/RX0000011897
Product: NH HMO-Best Buy Plan Year Stand Alone Option

-T
Subtotal: Admin & Reinsurance

CAR Total (Claims & Admin &

PURCHASED OPTION * FEES

Fitness Club Reimbursement Program $0.00 PEPM Flat Fee
Fitness Reimbursement Max $150.00 PSPCY Level
BENEFITS SUMMARY (Refer to the Schedule of Benefits for benefit details)
Office Visit $20

Emergency Room $100

Inpatient Services DED

Day Surgery DED

Coinsurance In-Network None

Coinsurance Out of Network NA

Deductible In-Network Individual $250 PPY

Deductible Out of Network Individual NA

Deductible In-Network Family $500 PPY

Deductible Out of Network Family NA

Gut of Pocket Maximum In-Network Individual $6,450 PPY

Out of Pocket Maximum Out of Network Individual | NA

Out of Pocket Maximum In-Network Family $12,900 PPY

Out of Pocket Maximum Out of Network Family NA

Chiropractic Care 12 visits PPY

Rx Copay 30 Days $5/$15/$35/NA/NA
Rx Copay Mail Order $5/$30/$70/NA/NA
Cross Accumulation Cross Accumulated
Rx Copay Deductible N/A

OOP Max Individual Rx $6450

OOP Max Family Rx $12900

Formulary Premium

* In the event that you purchase or have purchased a specialty care and disease management program, please note that specialty care and
disease management program Service Fees must be paid for minimum onc-year periods and no retroactive termination of members is permitted.

*Deductibles and Out of Pocket Maximums are Per Calendar Year (PCY) unless otherwise indicated to be Per Plan Year (PPY)

Max OOP=Maximum Out of Pocket, Chiro=Chiropractic Rider, Rx=Prescription, PCY=Per Calendar Year, OV=Office Visit, IN=In Network,
OON=Out of Network, ER=Emergency Room, PMPM=Per Member Per Month, PEPM=Per Employee Per Month, PDMPM=Per Diseased
Member Per Month, PSPC Y=Per Subscriber Per Calendar Year

Form No. 1207 Printed Date: 03/29/16

] Harvard Pilgrim Harvard Pilgrim Health Care includes Harvard Pilgrim Llealth Care,

’ HealthCare Hath Care of ow Engin nd HE mete Cpe

RATE PROPOSAL
Company Name: City of Nashua Effective Date: 07/01/2016 - 06/30/2017
Group Number: 027219 Plan ID : MD0000014789/RX0000011897
Product: NH HMO-Best Buy Plan Year Stand Alone Option

Rate Proposal terms and conditions

lf applicable, please review the detailed caveats page(s) released by the Stop-loss Carrier.
Preferred Drug List Rebates - Harvard Pilgrim Health Care will retain 30% of any net preferred
drug list rebate recovery attributable to prescription drug products utilized by participants.

3. The customer will retain 70% of that rebate recovery amount.

These figures are approximate based upon 315 subscribers.

5. You may request a fully insured quote, which could provide greater savings (e.g., reduced
HIPAA compliance, avoidance of stop loss volatility and enhanced discounts reflected in fully
insured rates).

Noo

-

Tam authorizing Harvard Pilgrim Health Care (including its affiliates) to proceed with the account setup of the benefit package and fees in this rate proposal,
which is subject to the execution of Harvard Pilgrim's Administrative Service Agreement (ASA) or an applicable amendment to the ASA.

Signature of Company Official/Broker/Consultant Title Date
Form No.1207 Printed Date: 03/29/16

rg4 :
HE

HARTFORD

AMENDMENT TO GROUP POLICY GL-207759 PROCESSED ON FEBRUARY 24, 2015. ANY CHANGES

BETWEEN THIS POLICY AND THE PREVIOUSLY ISSUED POLICY ARE EFFECTIVE FEBRUARY 1,
2015. ALL OTHER TERMS, CONDITIONS AND DATES REMAIN UNCHANGED.

Name of Policyholder: CITY OF NASHUA, NEW HAMPSHIRE

Policy Number: Effective Date: Place of Delivery:
GL-207759 January 1, 1997 New Hampshire
Anniversary Dates: Premium Due Dates:

January 1 of each year, beginning in 2016. Monthly, on the first day of each policy month.

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY
200 Hopmeadow Street, Simsbury, Connecticut 06089

(A stock insurance company, herein called Hartford Life)

Agrees with the Policyholder to insure certain persons who are entitled to the insurance provided by this policy. This
policy is issued in consideration of the application of the Policyholder, and the payment of the first premium. The
first premium is due and payable on the effective date of the policy. Subject to the policy's grace period provision, all
premiums after the first must be paid when or before they are due.

Signed for Hartford Life:
/. wtgtinominn fell et a 5 : + 4 tl trench
Terence Shields, Secretary Michael Concannon, Executive Vice President

Table of Contents
Agreement to Insure
Participant Employers
Incorporation Provision
Schedule of Insurance 3
Premiums
Policy Provisions

NY BeE WP Re

GR-11383-HLA(1) PI-1.00

PARTICIPANT EMPLOYERS

An employer may be included as a Participant Employer if the Policyholder and Hartford Life so agree. Hartford Life
will keep a list of accepted Participant Employers and the effective dates of coverage for each.

The Policyholder may act for or on behalf of all Participant Employers in all matters of the policy. The following will
be binding on all Participant Employers:

e all agreements between Hartford Life and the Policyholder;

e all notices from Hartford Life to the Policyholder; and

e all notices from the Policyholder to Hartford Life.

An employee of a Participant Employer will be deemed to be an employee of the Policyholder for insurance purposes.

Coverage for a Participant Employer wil! terminate on the first to occur of:

« the date his premium is due, but not paid; or

e the date on which the Policyholder wants the employer to be removed from the policy. Such date must be stated
in written notice to Hartford Life, and must be after the date of the notice.

GR-11383-HLA(@) PI-2.00

Booklet-Certificate
The Booklet-certificate(s), and the endorsement form(s) enclosed therein, attached to this Policy are hereby
incorporated in, and made a part of, this policy.

Booklet Form(s):
207759GL)1.18

207759(GL)10.4
207759(GL)11.3
207759(GL)12.3
207759(GL)13.3
207759(GL)14.3
207759(GL)15.3
207759(GL)16.3
207759GL)17.3
207759(GL)18.3
207759(GL)1L9.3
207759(GL)20.2
207759(GL)21.3
207759(GL)22.2
207759(GL)23.2
207759(GL)24.2
207759(GL)4.17
207759(GL)5.12
207759(GL)6.5

207759GL)7.3

207759(GL)8.3

207759(GL)9.3

The terms found in the Booklet-certificate(s) will control:

e = the benefit plan provisions;

the eligibility and effective date of insurance rules;

the termination of insurance rules;

exclusions; and

other general policy provisions pertaining to state insurance law requirements.

INCORPORATION PROVISION

GR-11383-HLA(3)

PI-3.19