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05/11/2021
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05/11/2021
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Last modified
8/16/2021 10:57:56 AM
Creation date
8/16/2021 10:54:54 AM
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Meetings
Meeting Type
BCC Regular Meeting
Document Type
Agenda Packet
Meeting Date
05/11/2021
Meeting Body
Board of County Commissioners
Board of County Commissioners
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PLAN AGREEMENT <br />This Plan Agreement (this "Agreement") is made effective as of February 1, 2021 (the "Effective Date") by <br />and between Employer Direct Healthcare, LLC, a Delaware limited liability company with its principal place of <br />business located at 2100 Ross Avenue, Suite 550, Dallas, Texas 75201 ("EDH") and the City of Sebring, a Florida <br />municipal corporation, with its principal place of business located at 368 South Commerce Avenue, Sebring, Florida <br />33870 ("Sponsor"). EDH and Sponsor are referred to collectively as the "Parties" and individually as a "Party." <br />RECITALS <br />EDH has a contracted network of physicians, hospitals, and other healthcare providers and facilities which <br />provide non -emergent, planned surgical and medical procedures according to rates and terms negotiated <br />by EDH. <br />EDH's contracted network of providers is made available to individuals through self-funded health benefit <br />plans that incorporate EDH's network offering. <br />III. As part of EDH's network offering, EDH assists the individuals electing to utilize EDH's network with <br />administrative, settlement, case management, and travel and logistics services relating to the individuals' <br />medical procedures. <br />IV. Sponsor has established a self-funded health benefit plan for the benefit of Sponsor's employees, <br />employees' dependents, and retirees. <br />V. Sponsor wishes to engage EDH so that EDH's network offering may be incorporated into Sponsor's health <br />benefit plan and made available to the eligible participants enrolled in such plan. <br />follows: <br />Accordingly, in consideration of the promises and mutual covenants contained herein, the Parties agree as <br />ARTICLE 1. <br />DEFINITIONS <br />Except as otherwise specifically indicated, the following terms shall have the following meanings in this <br />Agreement (such meanings to be equally applicable to both the singular and plural forms of the terms defined): <br />1.1 "Accompanying Person" means an individual utilizing Travel Services other than a Participant. <br />1.2 "Case Rate" means the pre -determined charge for an Episode of Care which includes the total of <br />all technical, professional, facility, and other medical services billed by Providers and associated with a Diagnosis <br />Case Code. <br />1.3 "Convenience Item" means a service, supply, or otherwise which is not considered necessary for a <br />Participant's medical care, "Convenience Items" may include, without limitation, telephone use, premium television <br />access, and guest meals. A Participant shall have sole financial responsibility for any Convenience Item. <br />1.4 "Diagnosis Case Code" means the code, determined by a Provider, identifying the anticipated <br />Episode of Care for a Participant. In the case of an inpatient procedure, the ,"Diagnosis Case Code" will be the <br />Medicare: Severity Diagnosis Related Group ("MS -DRG") and/or the Current Procedural Terminology Codes ("CPT <br />Codes") associated with the procedure which may be further modified to identify the specific care protocol. <br />1.5 "Episode of Care" means the collective services rendered by any Provider and/or any Provider's <br />professional and medical staff relating to a Diagnosis Case Code. An "Episode of Care" begins on the day a Participant <br />first. receives services from a Provider related to such Diagnosis Case Code and ends when the Participant is <br />discharged from the hospital or other healthcare facility to return or travel home. Services provided and expenses <br />-1- 52 <br />
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