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2021-074B
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Last modified
6/22/2021 12:13:29 PM
Creation date
6/11/2021 3:23:37 PM
Metadata
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Template:
Official Documents
Official Document Type
Agreement
Approved Date
05/11/2021
Control Number
2021-074B
Agenda Item Number
12.D.1.
Entity Name
Employer Direct Healthcare, LLC
Subject
Surgeryplus Services Agreement
Addition of SurgeryPlus Benefit as Optional Benefit
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DocuSign Envelope ID: 29EAB906-1936-4BAB-83BE-97C974F00293 <br />REGULATORY ADDENDUM <br />This Regulatory Addendum shall apply only if, to the extent, and for so long as, EDH or its successor <br />is subject to state insurance laws applicable to third party administrators and to the extent that any of the <br />administrative services provided by EDH to Sponsor are subject to such laws. The provisions of this <br />Regulatory Addendum are only applicable if, and to the extent that, EDH is performing services under the <br />Agreement that apply to that particular provision. If EDH shall not perform services that apply to a given <br />provision, then such provision shall have no force or effect. (For example, if EDH does not collect <br />premiums or contributions, then any provisions specifying requirements related to premium collection <br />would not be applicable, and EDN would not be obligated to establish a fiduciary account to hold <br />premiums collected.) Additionally, if EDH is not licensed as a producer, then EDH shall not perform <br />services as a producer, and no provision referring to such services, to insurance commissions, or referring <br />to payment of insurance commissions herein shall apply to EDH. <br />1. Georgia. If Sponsor authorizes EDH to receive premiums or contributions, Sponsor shall <br />follow all the Georgia applicable third party administrator laws regarding receipts and disbursements of <br />premiums and contributions. <br />2. Florida. Sponsor's payments to health care providers must include an explanation of <br />services being reimbursed, which includes, at a minimum: (1) for payments to non -capitated providers, <br />the patient's name, the date of service, the procedure code, the amount of reimbursement, and the <br />identification of the plan on whose behalf the payment is being made; and (2) for capitated providers, the <br />number of patients covered by the contract, the rate per patient, the total amount of the payment, and <br />the identification of the plan on whose behalf the payment is being made. <br />3. Kansas. To the extent applicable if the services specified in the Agreement provide for <br />payment of claims, all claims paid by EDH from funds collected on behalf of or for Sponsor shall by paid <br />only as authorized by the Sponsor. Payments from a claims paying account maintained or controlled by <br />EDH may be made forthe following purposes including the payment of claims: (1) Payment of valid claims; <br />(2) payment of expenses associated with the handling of claims to EDH or to other service providers <br />approved by the Sponsor; (3) remittance to the Sponsor, or transfer to a successor administrator as <br />directed by the Sponsor, for the purpose of paying claims and associated expenses; and (4) return of funds <br />held as collateral or prepayment, to the person entitled to those funds, upon a determination by the <br />Sponsor that those funds are no longer necessary to secure or facilitate the payment of claims and <br />associated expenses. <br />4. Michigan. The Parties desire to supplement the Agreement to specifically reference certain <br />provisions of Michigan law applicable to third party administrators and to comply with those laws to the extent <br />applicable and not preempted by federal law, as follows: In Michigan, Sponsor shall provide written notice <br />to each individual covered by the Plan of the following information with respect to services provided by <br />EDH in relation to the Plan: (a) what benefits are being provided; (b) of changes in benefits; (c) the fact <br />that individuals covered by the Plan are not insured or are only partially insured, as the case may be; (d) if <br />the Plan is not insured, the fact that in the event the Plan or Sponsor does not ultimately pay medical <br />expenses that are eligible for payment under the Plan for any reason, the individuals covered by the plan <br />may be liable for those expenses; (e) the fact that the EDH or any third party administrator merely <br />processes claims and does not insure that any medical expenses of individuals covered by the Plan will be <br />paid; (f) the fact that complete and proper claims for benefits made by individuals covered by the Plan <br />will be promptly processed but that in the event there are delays in processing claims, the individuals <br />4 <br />
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