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Supplemental Documentation Required for Fiscal Review Committee
Revised April 2014
*Contact Name: Seannalyn Brandmeir, Benefits Administration
*Contact Phone:
615.532.4598
*Presenter’s name(s):
Laurie Lee, Executive Director; Christa Martin, Director of Financial Management and Program Integrity; Seannalyn Brandmeir, Procurement and Contracting Manager
Edison Contract Number: (if applicable)
38894 RFS Number: (if applicable)
*Original or Proposed Contract
Begin Date:
9/30/2013 *Current or Proposed End
Date:
12/31/2018
Current Request Amendment Number: (if applicable)
One
Proposed Amendment Effective Date: (if applicable)
May 1, 2017
*Department Submitting: Finance and Administration *Division: Benefits Administration
*Date Submitted: February 1, 2017 *Submitted Within Sixty (60) days: Yes
If not, explain: *Contract Vendor Name:
*Current or Proposed Maximum Liability: $3,000,000.00 *Estimated Total Spend for Commodities:
*Current or Proposed Contract Allocation by Fiscal Year: (as Shown on Most Current Fully Executed Contract Summary Sheet) FY: 2014 FY: 2015 FY: 2016 FY: 2017 FY: 2018 FY: 2019 $411,292.22 $565,103.39 $565,103.39 $565,103.39 $565,103.39 $328,294.22 *Current Total Expenditures by Fiscal Year of Contract: (attach backup documentation from Edison) FY: 2014 FY: 2015 FY: 2016 FY: 2017 FY FY $259,763.80 $553,312.10 $515,442.72 $178,676.16 $ $
IF Contract Allocation has been greater than Contract Expenditures, please give the reasons and explain where surplus funds were spent:
IF surplus funds have been carried forward, please give the reasons and provide the authority for the carry forward provision:
IF Contract Expenditures exceeded Contract Allocation, please give the
Supplemental Documentation Required for Fiscal Review Committee
Revised April 2014
reasons and explain how funding was acquired to pay the overage: *Contract Funding Source/Amount:
State:
Federal:
Interdepartmental:
$3,000,000.00 Other:
If “other” please define: If “interdepartmental” please define: Public Sector Health Plan funding Dates of All Previous Amendments
or Revisions: (if applicable) Brief Description of Actions in Previous Amendments or Revisions: (if applicable)
n/a
Method of Original Award: (if applicable) RFP *What were the projected costs of the
service for the entire term of the contract prior to contract award?
How was this cost determined?
During the RFP process, Benefits Administration estimated the cost between $3 million to $4 million. Previous contract and a RFI was conducted before the 2013 RFP was released.
*List number of other potential vendors who could provide this good or service;
efforts to identify other competitive procurement alternatives; and the
reason(s) a sole-source contract is in the best interest of the State.
n/a
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Page 10
Amendment Request This request form is not required for amendments to grant contracts. Route a completed request, as one file in PDF format, via e-mail attachment sent to: [email protected]
APPROVED
CHIEF PROCUREMENT OFFICER DATE
Agency request tracking # 31786-00117
1. Procuring Agency Benefits Administration
2. Contractor
3. Edison contract ID # 38894
4. Proposed amendment # One
5. Contract’s Original Effective Date 9/30/2013
6. Current end date 12/31/2018
7. Proposed end date n/a
8. Current Maximum Liability or Estimated Liability $3,000,000.00
9. Proposed Maximum Liability or Estimated Liability n/a
10. Strategic Technology Solutions Pre-Approval Endorsement Request – information technology service (N/A to THDA)
Not Applicable Attached
11. eHealth Pre-Approval Endorsement Request – health-related professional, pharmaceutical, laboratory, or imaging Not Applicable Attached
12. Human Resources Pre-Approval Endorsement Request – state employee training service Not Applicable Attached
13. Explain why the proposed amendment is needed
Legal name change of the company from to
14. If the amendment involves a change in Scope, describe efforts to identify reasonable, competitive, procurement alternatives to amending the contract.
n/a
Page 11
Agency request tracking # 31786-00117
Signature of Agency head or authorized designee, title of signatory, and date (the authorized designee may sign his or her own name if indicated on the Signature Certification and Authorization document)
Page 12
C O N T R AC T A M E N D M E N T C O V E R S H E E T
Agency Tracking # Edison ID Contract # Amendment #
31786-00117 4354 38894 1
Contractor Legal Entity Name Edison Vendor ID
4354
Amendment Purpose & Effect(s) Legal Name Change to
Amendment Changes Contract End Date: YES NO End Date: 12/31/2018
TOTAL Contract Amount INCREASE or DECREASE per this Amendment (zero if N/A): $ 0
Funding — FY State Federal Interdepartmental Other TOTAL Contract Amount
2014 $411,292.22 $411,292.22
2015 $565,103.39 $565,103.39
2016 $565,103.39 $565,103.39
2017 $565,103.39 $565,103.39
2018 $565,103.39 $565,103.39
2019 $328,294.22 $328,294.22
TOTAL: $3,000,000.00
American Recovery and Reinvestment Act (ARRA) Funding: YES NO
Budget Officer Confirmation: There is a balance in the appropriation from which obligations hereunder are required to be paid that is not already encumbered to pay other obligations.
CPO USE
Speed Chart (optional) Account Code (optional)
Page 13
AMENDMENT ONE OF CONTRACT 38894
This Amendment is made and entered by and between the State of Tennessee, State Insurance Committee, Local Education Insurance Committee, and Local Government Insurance Committee, hereinafter referred to as the ‘State” and , hereinafter referred to as the “Contractor”. For good and valuable consideration, the sufficiency of which is hereby acknowledged, it is mutually understood and agreed by and between said, undersigned contracting parties that the subject contract is hereby amended as follows:
Contractor Name. All references to “ .” shall be deleted and replaced with .
Iran Divestment Act. The requirements of Tenn. Code Ann. § 12-12-101 et.seq., addressing contracting with persons with investment activities in Iran, shall be a material provision of this Contract. The Contractor agrees, under penalty of perjury, that to the best of its knowledge and belief that it is not on the list created pursuant to Tenn. Code Ann. § 12-12-106.
Required Approvals. The State is not bound by this Amendment until it is signed by the contract parties and approved by appropriate officials in accordance with applicable Tennessee laws and regulations (depending upon the specifics of this contract, said officials may include, but are not limited to, the Commissioner of Finance and Administration, the Commissioner of Human Resources, and the Comptroller of the Treasury).
Amendment Effective Date. The revisions set forth herein shall be effective May 1, 2017. All other terms and conditions of this Contract not expressly amended herein shall remain in full force and effect.
IN WITNESS WHEREOF,
:
SIGNATURE DATE
PRINTED NAME AND TITLE OF SIGNATORY (above)
STATE INSURANCE COMMITTEE, LOCAL EDUCATION INSURANCE COMMITTEE, LOCAL GOVERNMENT INSURANCE COMMITTEE:
LARRY B. MARTIN, CHAIRMAN DATE
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New Window | Help | Customize Page |
Document Approval Status
SetID: Contract ID: SHARE 0000000000000000000038894 Vendor ID: 0000004354
Review/Edit Approvers
Stage 1 DOC approval
:Approved View CommentsFinal Approval
Approved
Mitzi R Hale Document Approval 1 11/4/2013 - 10:33 AM
Approved
James R Hamdorff Document Approval 2 11/4/2013 - 11:09 AM
Approved
Andrew Kidd Document Approval 3 11/5/2013 - 10:52 AM
Approval Comment History
Mary Anne J Queen at 11/20/2013 - 2:56 PM Response accepted. Approval of the DGS CPO approved document is on behalf of the Comptroller pursuant to current signature authorization. The record is now set to On Hold. The record should remain On Hold until DGS CPO sets to Approved.
Mary Anne J Queen at 11/13/2013 - 2:05 PM Perfunctory approval to move record to CPO - Section E.18 of the contract is the ¿California Accountancy Act¿ and states that for engagements where services will be provided by the contractor at offices in California, the State acknowledges that certain of the contractor¿s personnel may not be licensed as certified public accountants. What accounting services would the contractor be providing that would otherwise require a licensed CPA to perform?
Mitzi R Hale at 11/4/2013 - 10:33 AOnly two proposals were received; Benefit was disqualified.
Sylvia D Chunn at 10/25/2013 - 4:48 PM Contract procured by RFP submitted for approval with all supporting documentation. Contract is submitted after start date due to approval by CPO on language change and F&A legal opinion of contractor changes requested. The period of implementation is from 9/30 - 12/31 and is covered by a one-time fee upon implementation and testing. Fee for services does not begin until 1-1-14.
Budget Office
:Approved View Comments
Budget Threshhold
Approved
Amy Miller Con - Budget Office Approval 11/5/2013 - 1:21 PM
Approval Comment History
Mary Anne J Queen at 11/20/2013 - 2:56 PM Response accepted. Approval of the DGS CPO approved document is on behalf of the Comptroller pursuant to current signature authorization. The record is now set to On Hold. The record should remain On Hold until DGS CPO sets to Approved.
Mary Anne J Queen at 11/13/2013 - 2:05 PM Perfunctory approval to move record to CPO - Section E.18 of the contract is the ¿California Accountancy Act¿ and states that for engagements where services will be provided by the contractor at offices in California, the State acknowledges that certain of the contractor¿s personnel may not be licensed as certified public accountants. What accounting services would the contractor be providing that would otherwise require a licensed CPA to perform?
Mitzi R Hale at 11/4/2013 - 10:33 A Only two proposals were received; Benefit was disqualified.
Sylvia D Chunn at 10/25/2013 - 4:48 PM Contract procured by RFP submitted for approval with all supporting documentation. Contract is submitted after start date due to approval by CPO on language change and F&A legal opinion of contractor changes requested. The period of implementation is from 9/30 - 12/31 and is covered by a one-time fee upon implementation and testing. Fee for services does not begin until 1-1-14.
Post Budget
:Approved View CommentsPost Budget
Approved
Mary Anne J Queen Document Approval - Comptrolle 11/13/2013 - 2:06 PM
Approved
Andrew Kidd Inserted Approver 11/19/2013 - 8:33 AM
Approved
Mary Anne J Queen Inserted Approver 11/20/2013 - 2:56 PM
Approved
Sharon L Whitby Document Approval 3 11/21/2013 - 10:41 AM
Approval Comment History
Mary Anne J Queen at 11/20/2013 - 2:56 PM Response accepted. Approval of the DGS CPO approved document is on behalf of the Comptroller pursuant to current signature authorization. The record is now set to On Hold. The record should remain On Hold until DGS CPO sets to Approved.
Mary Anne J Queen at 11/13/2013 - 2:05 PM Perfunctory approval to move record to CPO - Section E.18 of the contract is the ¿California Accountancy Act¿ and states that for engagements where services will be provided by the contractor at offices in California, the State acknowledges that certain of the contractor¿s personnel may not be licensed as certified public accountants. What accounting services would the contractor be providing that would otherwise require a licensed CPA to perform?
Mitzi R Hale at 11/4/2013 - 10:33 AOnly two proposals were received; Benefit was disqualified.
Sylvia D Chunn at 10/25/2013 - 4:48 PM Contract procured by RFP submitted for approval with all supporting documentation. Contract is submitted after start date due to approval by CPO on language change and F&A legal opinion of contractor changes requested. The period of implementation is from 9/30 - 12/31 and is covered by a one-time fee upon implementation and testing. Fee for services does not begin until 1-1-14.
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