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An Independent Licensee of the Blue Cross and Blue Shield Association PROPOSAL NOTES STOP LOSS PROPOSAL FOR Indian River County Board of County Comm • The rates and factors in this proposal are firm. Please provide a signed proposal. • Large claim data must be submitted for any claims that are at or have the likelihood to exceed 50% of the group specific deductible. Large claim data must include: age, sex, diagnosis, prognosis, treatment plan, case management notes (if applicable), Pre -Cert and paid/pended claims. • The specific rates in this proposal are based on an aggregating specific arrangement. Total Specific Liability includes estimated contract specific premium and the aggregating specific fund. • Human Organ Transplant benefits are payable in accordance with the underlying plan and are subject to the proposed Lifetime Maximum Specific Benefit offered within this proposal. PROPOSAL ACCEPTANCE Leave of Absence (LOA) Policy for eligible employees is: Days or Weeks or ✓ Other and it is to be applied once per plan year per member and only after FMLA allowance is exhausted. Leave Of Absence allowance need not be used in consecutive days, but total time not actively at work during the plan year as a whole must not exceed the above outlined allowance plus the 90 day FMLA allowance. In the absence of Leave of Absence language in the group plan document, the above will be considered as the LOA policy as it relates to Stop Loss Eligibility and continuation of coverage only. Any subsequent changes must be approved by Florida Blue at least 30 days in advance of the effective date of the change. Failure to notify Florida Blue of your company's policy changes for Leave of Absence may result in a possible Stop Loss claim denial. Upon exhaustion of LOA benefits as described above, to continue Stop Loss eligibility members must be offered COBRA as outlined in the "Continuation of Coverage Under Cobra" section in your Group Benefit Book. All other eligibility requirements beyond the LOA allowance described here are outlined in the Group Benefit Book and apply to the Stop Loss in their entirety. Please acknowledge acceptance of the terms in this proposal by signing and returning by 09/22/2017 (no signed proposal will be accepted after the effective date). Please also indicate which option is chosen and whether Aggregate is to be included, by checking the appropriate boxes on the previous page. Failure to remit the signed agreement within the same period will result in updated large claim disclosure (and claims) being required for our review. All payments after the effective date of this policy, found on the previous page, must use the rates selected. Any deviation from the rates specified could result in an underpayment leading to a possible policy cancellation. o..iSY•Cp4f��, ass/oA /Slacpn: Signature: 1/ Title: Chairman sep Fle c er Accepted o e 19th day of SeptembpYO 17 •�a;`9'' ...... '��o•' • �OUNTY. W0 .• ATTEST: Jeffrey R. Smith, Clerk of Court and APPROVED AS TO FORM Comptroller AN'SO L.EGAL SUFFICIE C%v—, BY: By Deputy Clerk DYLAN REINGOLD COUNTY ATTORNEY Underwriter: REB (September 1, 2017) 10533093820-2017-531476-3-4 Page 2 of 4