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<br /> An independern Licensee of thv ST OP LOSS PROPOSAL FOR
<br /> eit,e c_'t,_s and r,it Shield Associate'" Indian River County BOCC
<br /> BASIS OF OFFER initials- date.
<br /> Assumptions
<br /> • Aggregate coverage is only available when purchased with Specific coverage.
<br /> • This proposal is subject to revision if there is a change in effective or renewal dates,or a change in the plan of benefits.
<br /> • This proposal is based on the utilization of the Provider Network(s)and the Utilization Review Vendor(s)listed on this proposal.
<br /> • This proposal assumes a minimum participation level of 75%applies for all eligible enrollees under a contributory plan,and 100%under a non-
<br /> contributory plan.
<br /> • This proposal assumes the plan of benefits includes a pre-certification,utilization review and large case management program.
<br /> • This proposal is based on a description of the employee benefit plan(s)provided and approved by HMIG,employee and dependent census data,
<br /> submission of any requested claim information,plus any other information relevant to the underwriting risk. If any of the information was incorrect
<br /> or changes the risk involved,the rates and factors will be modified,and the specific and aggregate claims will be adjusted accordingly
<br /> • Surcharges(including the bad debt and charity surcharge portion of the New York Reform Act applicable to services are rendered in New York
<br /> State),pool charges,and/or covered lives assessments may be covered under the stop loss policy if such charges are considered a claim cost.
<br /> HM is not responsible for the fling,and/or payment of any assessment for which HM is not directly liable including but not limited to the New
<br /> Hampshire Vaccine Assessment as modified by NH HB 664.
<br /> • All standard Poli provisions Policy p apply. The laws of the state where the policy is issued will apply. Certain exclusions and limitations may apply.
<br /> Retirees are included in the stop loss coverage.
<br /> • This proposal will expire on the proposed effective date.
<br /> • Unless otherwise limited or excluded by the stop loss policy or under the Individual Special Requirements,eligible claim expenses under the stop
<br /> loss policy will follow the covered underlying plan,up to the proposed Specific Benefit Maximum.
<br /> The Agent is property licensed and appointed by HMIG.
<br /> The initial rates are guaranteed for the proposed policy period unless otherwise noted.
<br /> • There are not more than 15%COBRA participants.
<br /> Qualthcations
<br /> • Any stop loss insurance requested and requested effective date of that coverage must be approved by us under our current rules and practices.
<br /> • Our approval is subject to receipt of Disclosure,Claim Information and any other information requested in connection with this proposal-including
<br /> but not limited to a completed Disclosure Form,Application,first month's premium check,signed proposal,final census,and any otherrequired
<br /> information as stated under the Assumptions or Individual Special Requirements. Such information must be received prior to the proposed
<br /> effective date. Information contained on the Disclosure Form should be current up to the date of signature,and be completed in its entirety.
<br /> Failure to do so will result in approval being denied or delayed until a later effective date.
<br /> • Both the premium rates and the aggregate factors are subject to change should the number of employees change by 10%or more,either in total
<br /> and/or by single/family mix.
<br /> A signed and dated Plan Document is required within 30 days of the effective date. If the descriptions of the benefits or plan provisions differ from
<br /> what was initially utilized to underwrite the risk,the premium rates and aggregate factors may be subject to re-rating,retro-active to the effective
<br /> date.
<br /> • Quote assumes the Plan Document will include traditional industry provisions and definitions including,but not limited to the following: eligibility,
<br /> HIPAA,termination provisions,extension for leave of absence or disability,FMLA,subrogation,transplants,COB,exclusions for job related
<br /> injuries,experimental and cosmetic treatment,usual and customary charges,war,not medically necessary,traveling outside of the U S.solely for
<br /> the purpose of receiving medical care. In the event that a Plan Document is not available within 30 days from the proposed effective date,we
<br /> reserve the right to issue the Policy assuming standard exclusions will apply.
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