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An Independent Licensee of the STOP LOSS PROPOSAL FOR <br /> Blue cross and Blue shield Association Indian River County Board of County Comm - <br /> BASIS OF OFFER initials* Q'1�date August 16, 201E <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 filing,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 Policy provisions 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 /> Qualifications <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 /> • 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 /> • If the descriptions of the benefits or plan provisions differ from what was initially utilized to underwrite the risk,an updated Plan Document or other <br /> acceptable plan description is required within 30 days of the proposed effective date,and the premium rates and aggregate factors may be <br /> subject to re-rating,retro-active to the effective 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. <br /> • HIPAA Privacy rules permit the release of Protected Health Information(PHI)for the purpose of evaluating and accepting risk associated with the <br /> Plan Sponsor as part of"Healthcare operations" HMIG will use this information solely for the purpose of evaluating and accepting the risk and <br /> will not disclose any PHI collected except to perform this risk evaluation. <br /> Coverage is underwritten by Florida Blue,Jacksonville, FL and is administered by HM Life Insurance Company,Pittsburgh, PA. HM Life Insurance <br /> Company is an independent company providing only administrative services. <br /> Underwriter REB(August 8,2016) 10500541335-2016-503868-6-4 Page 3 of 4 <br />