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Fkllftw& B&C 0 9 An Independent Licensee of the Blue Cross and Blue Shield Association BASIS OF OFFER STOP LOSS PROPOSAL FOR Indian River County Board initis ate: Q9 10 /2024 Assumptions • This proposal is subject to revision if there is a change in Proposed Effective or Renewal Dates or a change in the Covered Underlying Plan. • This proposal is based on the utilization of the Provider Network(s) and the Utilization Review Vendor(s) listed in this proposal. • This proposal assumes a minimum participation level of 50%. • This proposal assumes the Covered Underlying Plan includes a pre -certification, utilization review and large case management program. • This proposal is based on a description of the employee benefit plan(s) provided and approved by HM; employee and dependent census data; submission of any requested claim information; and any other information relevant to the underwriting risk. If any of the information was incorrect or changes the risk involved, the rates will be modified, and the Specific claims will be adjusted accordingly. • Surcharges (including the bad debt and charity surcharge portion of the New York Reform Act applicable to services are rendered in New York State), pool charges, and/or covered lives assessments may be covered under the Stop Loss Policy if such charges are considered a claim cost. 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 Hampshire Vaccine Assessment as modified by NH HB 664. • All standard policy provisions apply. The laws of the state where the policy is issued will apply. Certain exclusions and limitations may apply. • The terms of this proposal are subject to revision by HM if there is a change in any state law or regulation between the date of this proposal and the effective date of the proposed Stop Loss coverage if HM deems such change to have a material effect on the risk being assumed. Such a revision can be made even if the proposal has already been accepted. • This proposal will expire on the Proposed Effective Date. • Unless otherwise limited or excluded by the Stop Loss Policy or under the Individual Special Requirements, Eligible Claim expenses under the Stop Loss Policy will follow the Covered Underlying Plan, up to the proposed Maximum Specific Benefit. • The Agent is properly licensed and appointed by HM. • The initial rates are guaranteed for the proposed Policy Term unless otherwise noted. • There are no more than 15% COBRA participants. Qualifications • Any Stop Loss insurance requested and the Proposed Effective Date of that coverage must be approved by HM under Our current rules and practices. • Our approval is subject to receipt of Disclosure, Claim Information and any other information requested in connection with this proposal including, but not limited to, a completed Disclosure Form, Application, first month's premium check, signed proposal, final census, and any other required information as stated under the Assumptions or Individual Special Requirements. Such information must be received prior to the Proposed Effective Date. Information contained on the Disclosure Form should be current up to the date of signature and completed in its entirety. Failure to do so will result in approval being denied or delayed until a later effective date. The premium rates are subject to change should the number of Covered Units change by 10% or more, either in total and/or by single/family mix. • A signed and dated Summary Plan Document is required within 60 days of the Effective Date. If the descriptions of the benefits or plan provisions differ from what was initially utilized to underwrite the risk, the premium rates may be subject to re -rating, retro -active to the Effective Date. • This quote assumes the Covered Underlying Plan will include standard industry provisions and definitions including, but not limited to, eligibility, HIPAA, termination, leave of absence or disability, FMLA, subrogation, transplants and COB and exclusions for job-related injuries, treatments that are experimental and/or investigational, cosmetic, not medically necessary, war, felonies, charges in excess of usual and customary, and foreign medical care when traveling outside of the U.S. solely for the purpose of receiving medical care. In the event that a Summary Plan Document is not available within 60 days from the Proposed Effective Date, We reserve the right to issue the policy assuming standard exclusions will apply. Coverage is underwritten by Florida Blue, Jacksonville, FL and is administered by HM Life Insurance Company, Pittsburgh, PA. HM Life Insurance Company is an independent company providing only administrative services. Underwriter: TLR (August 15, 2024) 11391839286-37516-2-2 Page 3 of 4