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TRUE COPY r:ERTIFICATION ON LASTPAGE <. SMITH, CLERK You will determine whether the individual is eligible to participate in the retiree group health benefit plan that you sponsor. For individuals meeting your eligibility criteria, you will promptly forward completed applications to us. You are responsible for complying with all applicable laws and regulations, including but not limited to the Employee Retirement Income Security Act (ERISA) and the Internal Revenue Code, in making this eligibility determination. You must also comply with all eligibility guidelines included in the benefit administrative guide and Evidence of Coverage. 2. After receiving a complete application, we will process the application in accordance with CMS Requirements. An application must be approved by us and accepted by CMS for an individual to be enrolled in a Medicare Plan. B. Distribution of Enrollment Materials You may only distribute materials describing the Medicare Plan that we have provided to you or that we have approved in writing. You will distribute any pre -enrollment materials that we provide to you to each potential enrollee before collecting enrollment applications. Nothing in this Section will preclude you from making additional disclosures about your group health benefit .plan as applicable to comply with ERISA, such as a wrap-around summary plan description or other plan document. If applicable, you are solely responsible for compliance with ERISA disclosure requirements in connection with the Medicare Plan(s). C. Group Disenrollment If you decide to disenroll all Covered Persons from a Medicare Plan, you must: 1. Notify all beneficiaries that you intend to disenroll them from the Medicare Plan. You will provide this notice at least twenty one (21) calendar days before the disenrollment. This notice will explain how to contact Medicare for information about other plan options that may be available. You will include language provided by Florida Blue in this notice to meet specific CMS Requirements for notice contents. 2. Provide us with all information necessary to submit a complete disenrollment request transaction to CMS in accordance with CMS Requirements. 3. In the event of termination of this Agreement, provide advanced notice in accordance with Section 4 of this Agreement. D. Individual Covered Person Disenrollment Covered Persons may be disenrolled from a Medicare Plan by Florida Blue if they become ineligible for continued enrollment. Covered Persons may also be disenrolled if this Agreement terminates or if you inform us that they are no longer eligible to participate in your retiree group health plan. If Florida Blue determines that a Covered Person is ineligible for continued enrollment or if you instruct us to disenroll an individual, you must: 1. Provide us with at least thirty (30) calendar days advanced notice of the ineligibility or disenrollment election of an individual; and