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HMA Client Intent & TPA Exhibit A – City of Everett 020188 Page 5 of 8 <br />020188 City of Everett 2025.01 Client Intent Exhibit A_Single Year 5.14.2024 <br />Products and services offered through partners on our contract may experience price/fee changes or terminate during <br />the Plan Year. Plan Sponsor acknowledges and agrees that the fees quoted below for such services are not <br />guaranteed. In the event of a pricing change during the term, HMA will make every effort to notify you at least 30 days <br />in advance of such changes. Add Renewal Fee Product <br />☐ $3.95 Flexible Spending Account (FSA) PAPM <br />Only available with a PPO or non-Qualified Plan. <br />☐ $3.95 Dependent Care FSA (DC FSA / DCRA) PAPM <br />☐ $3.95 Health Reimbursement Account (HRA) PAPM <br />☐ $2.70 Health Savings Account (HSA) PAPM <br />☐ $1.95 Limited Purpose FSA (LPFSA) PAPM <br />Only available with a qualified HDHP. <br />☐ $1.35 COBRA Services PEPM <br />☐ $2.00 Consolidated Billing PEPM - Option 1 <br />Premium Remittance only <br />☐ $3.00 Consolidated Billing PEPM - Option 2 <br />Premium Remittance AND Eligibility Administration <br />☐ $2.10 PACE Fiduciary PEPM <br />☐ $2.00 Care Navigator PEPM <br />☐ $4.00 Care Navigator Plus PEPM <br />Clients choose between reducing the member health plan contributions or digital gift <br />cards as an incentive for those members who complete their health questionnaire within <br />the specified timeframe determined by the Plan. <br />Please select one of the options below: <br />☐ Employer Managed Incentive: We will provide reporting of members qualifying for <br />the incentive via BenefitFocus, employer assumes all liability for the incentive design <br />and execution. <br />☐ $25 digital gift card automatically sent to member-provided email from Tango <br />Platform upon employer funding of Tango account. <br />☐ $50 digital gift card automatically sent to member-provided email from Tango <br />Platform upon employer funding of Tango account. <br />☐ $2.25 Healthcare Bluebook Quality + Go Green Rewards PEPM <br />Rewards range from $25-$100 when a member selects a fair price provider. <br />☐ Healthcare Bluebook Engagement Rewards (Client Funded) <br />Add to HCBB Quality + Go Green as an enhanced and tiered incentive for members with an <br />expanded selection of over 400 procedures and higher reward amounts ranging from up to <br />$350 for outpatient procedures to a max of $1000. <br />Requires client to provide email addresses of all eligible employees. <br />Docusign Envelope ID: CC50B3B8-52FD-4DD0-8AA5-5843B00BE3B8