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Home My WebLink AboutPSA - ACA Reporting for IRS Forms - AccordWare LLC.1316 COUNTY -CITY BUILDING] PHONE 574/ 235-9251 227 W. JEFFERSON BOULEVARD I'". ' FAX 574/235-9171 SOI1TH BEND. INDIANA 46601-1830 �� r CITY OF SOUTH BEND PETE BUTTIGIEG, MAYOR BOARDF PUBLIC WORKS November 12, 2019 Mr. Matthew C. Czmer AccordWare LLC. 2250 Butterfield Dr. Troy, MI 48084 RE: Professional Services Agreement Dear Mr. Czmer: The Board of Public Works, at its meeting held on November 12, 2019, approved the above referenced agreement in the amount of $1.40 per 1095-C Form and $1.00 per Employee Reports Fee; plus $1,000 Annual Base Fee. Enclosed please find a copy of the agreement for your records. If you have any further questions regarding this matter, please call this office at (574) 235- 9251. Sincerely, Linda M. Martin, Clerk Enclosure GARY A. GILOT GENEVIEVE E. MILLER ELIZABETH A. MARADIK LAURA L. O'SULLIVAN THERESE J. DORAU 2019 ACA Order Form for City of South Bend This order form, effective October 21, 2019 constitutes a Services Agreement between AccordWare LLC and City of South Bend hereafter referred to as Service Company and Client respectively, for ACA Reporting Services. By executing this order form, Client and Service Company accepts the following: Purpose Client wishes to engage Service Company to assist with fulfillment of its reporting obligations pursuant to the Patient Protection and Affordable Care Act, more specifically, populating and communicating the necessary information to satisfy Section 6055 and 6056 (Forms 1094-C & 1095-C) reporting requirements with regard to the Internal Revenue Service. Obligations & License Client will furnish and manage the necessary data for Service Company to meet this obligation. Client will respond promptly to questions and issues raised by Service Company in the course of fulfilling their reporting obligations and execute any documentation necessary in this regard. Client will retain ownership and control of said data, and Service Company shall use same only as necessary to meet Client's reporting obligations. Service Company shall retain ownership of their methods, software, processes, and any other intellectual property or proprietary items, which shall be licensed to the Client as needed to fulfill the purposes of this Addendum, only. Client acknowledges that entering into a reporting arrangement does not transfer the potential liability of the provider for failure to report information and furnish statements under section 6055. 2019 REPORTING SERVICE FEES Client Service &/or Application Software Title Reporting Service Fees Postage* Annual Base Fee ACA Reporting IRS $1.00 Per Employee Analyzed Forms 1094-C $1.40 TBD $1,000.00 & 1095-C Per 1095-C Form * Postage is billed as an at cost pass through cost to City of South Bend. ADDITIONAL TERMS Ptcadctt AwaiBalility. As provided in Exhibit B below, Client acknowledges that several steps must occur following the execution of this order form to prepare the application software for Client's use. The parties estimate that these steps will be completed, and that the application software will be available for use by Client on or about December 1, 2019 (the "Product Launch Date"); however, the ability to meet this Product Launch Date depends upon the timely actions of the Client, Service Company and external parties (i.e. the US Internal Revenue Service, etc.). Both parties agree to use their best efforts to achieve this Product Launch Date, or if they are unable to do so, to modify this order form to reflect a new launch date as close in time as possible to the Product Launch Date. Any change to this Product Launch Date must be agreed to by both Client and Service Company in writing. l ill ,n =. Billing of the Implementation or Annual Base fee will occur on or about December 1, 2019. Total Reporting Service and Postage Fees under this order form will be billed on or about February 1, 2020. Term. This order form covers the reporting period for the 2019 calendar year. ("Full Agreement Term"). COSB Order Form 5 Confidential Page 1 of 4 4 5 C hanges in Fees and Rates. Service Company agrees to honor the fees and rates provided in this order form through December 20, 2019. Service Company reserves the right to modify said fees and rates if this order form have not been executed by Client by said date. Miscellaneous. Customization, detailed in Exhibit A, including customized data file imports beyond the standard allowable customization will be billed at an hourly rate of $150/hour. Customizations will not be initiated without the written consent of Client. The parties have caused this order form to be executed by their duly authorized representatives as of the date last signed below ("Effective Date"). CITY OF SOUTH BEND By: 04' UMr o Name: Title: Date: ACCORDWARE LLC 0 fj . Name: Matthew C. Czmer Title: Member Date: October 1,, 2019 COSB Order Form 5 Confidential Page 2 of 4 EXHIBIT A Client Setup, Delivery, and Client Support Services Specification Customizations• None anticipated Optional Services linitial all that a l z None anticipated COSB Order Form 5 Confidential Page 3 of 4 EXHIBIT B ACA Reporting Lmidellnes The following items detail each of the actions to be completed by Service Company in the administration of the ACA Reporting for Client. • Communicate with Client's reporting team to detail and confirm; o The annual reporting process o Each task to be completed o Assign task responsibilities to the most appropriate parties, and o Develop work schedules. • Communicate with Client's reporting team to review the reporting plan, eligibility (salaried, hourly, project, and variable -hour employees) and "pay or play" issues for employees subject to fines for non - reporting. • Prepare the necessary plan specification documents. • Establish data reporting requirements and processes between Client administrative systems (Benefits management, Payroll, and Human Resource Information System) and BenXpress administrative system. • Establish data reporting requirements and processes between the IRS, insurance providers and/or third party administrators and BenXpress administrative system. • Communicate with Client to establish ongoing administrative processes to be performed upon completion of the annual filings of the 1094-C / 1095-C, including: o Employee additions, terminations, transfers, leaves -of -absence, employment status changes, and changes in family status • Establish Client reporting configuration on BenXpress administrative system in accordance with the plan design, eligibility, rates, pricing, and plan parameters as necessary for reporting, as defined by the agreed - upon specification documents. • Document all administrative work flow and reporting processes to be completed by Service Company • Perform testing and auditing of administrative system functions and reports. Provide reports to Client for internal audit. • Update employee database on BenXpress administrative system and obtain written confirmation from Client of the accuracy of employee data. • Finalize all data on BenXpress administrative system and obtain written confirmation from Client of the accuracy of employee data. • Finalize all data on BenXpress administrative system following any final adjustments from Client. • Provide final data file of reporting results for IRS. • Furnish employee 1095-C statements to all "responsible individuals" on or before January 31 ** following the end of the annual reporting period (January 1 — December 31) Upon final review and approval by Client, electronically file form 1094-C and 1095-C with the IRS on or before March 31 ** following the end of the annual reporting period (January 1 — December 31). • Make available on BenXpress Self -Service, a downloadable PDF copy of the 1095-C for all currently active employees. « Make available on BenXpress Administrator, a downloadable PDF copy for all reported employees ** If the Internal Revenue Service changes any filing dates, Service Company will meet all adjusted filing deadlines. COSB Order Form 5 Confidential Page 4 of 4 BOARD OF PUBLIC WORKS AGENDA ITEM REVIEW REQUEST FORM Date 11/01/2019 Department Human Name Tierra Davis Resources BPW Date 11/12/19 Phone Extension 5510 u w �..... .., xmm :.n�, :,,r�^ r�sv�wxmnxe rv�w� ffmf .yumv mimuuuwti mommi� .. .�.,...�.�.-.. �._._�._.. Re, quired Prior to Submittal to Bo.. and BPW Attorney ® Attorney Name Dept. Attorney, Attorney Name Danielle Weiss Purchasing El Check the Appropriate Item Type _. Professional Services Agreement ® Contract El Open Market Contract El Amendment/Addendum Bid Opening ❑ Bid Award Quote Opening E] Quote Award ❑ Proposal Opening ❑ C/O & PCA No, E] Chg. Order, No. ❑ Traffic Control EJ Other: Company or Vendor Name New Vendor MBE/WBE Contractor Project Name Project Number Funding Source Account No. Amount Information All Submissions Proposal LJ Special Purchase, QPA Req. to Advertise Reject Bids/Quotes PCA Resolution Ease./Encroach ❑ Title Sheet Accordware LLC Yes El If Yes, Approved by Purchasing ® No ❑ MBE Completed E-Verify Form Attached El Yes ❑ WBE ❑ No ACA-R�.. __�._........rn 1095-C e ortm or IRS Forms 1094-C & Health Insu rance Fund 711-0401-671-31-06 $1.40 per 1095-C Form and $1.00 per employee reporting fee; there is a $1 „000 Annual Base Fee Terms of Contract The agreement covers the reporting e �od for themm2019 calendar year, w Purpose/Description Accordware LLC will assist with fulfillment of the Cit 's re orting obligations ursuant to the Patient Protection and Affordable Care Act to sates 1..0...9.4 & 1095 rMqr.in._.g requirements wit_h....r._.e and to the IRS_ .,.... Amount of ❑ Increase $ ❑ Decrease ($ ) Previous Amount $ Increase� %... .....�_ � ....m...�.�-......................._�........__ Current Percent of Change: Decrease %) New Amount $ Increase.....................m.........._..........%...�........_......�....e.. ..— m......�.�.�.�...�..�aa_. �� ... ..... �a. Total Percent of Change: Decrease %) Time Extension Amount: New Completion Date: