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ee r Etta V. j�j/�� F& r 6J i4 a + V An Independent Licensee of the Blue Cross and Blue Shield Association STOP LOSS PROPOSAL FOR Indian River County BOCC initials* BASIS OF OFFER Assumptions • Aggregate coverage is only available when purchased with Specific coverage. • This proposal is subject to revision if there is a change in effective or renewal dates, or a change in the plan of benefits. • This proposal is based on the utilization of the Provider Network(s) and the Utilization Review Vendor(s) listed on this proposal. • This proposal assumes a minimum participation level of 75% applies for all eligible enrollees under a contributory plan, and 100% under a non- contributory plan. • This proposal assumes the plan of benefits 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 HMIG, employee and dependent census data, submission of any requested claim information, plus any other information relevant to the underwriting risk. If any of the information was incorrect or changes the risk involved, the rates and factors will be modified, and the specific and aggregate 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 • Retirees are included in the stop loss coverage. • 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 Specific Benefit Maximum. • The Agent is properly licensed and appointed by HMIG. • The initial rates are guaranteed for the proposed policy period unless otherwise noted. • There are not more than 15% COBRA participants. date sq,°23 i9 Qualifications • Any stop loss insurance requested and requested effective date of that coverage must be approved by us 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 be completed in its entirety. Failure to do so will result in approval being denied or delayed until a later effective date. • 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 and/or by single/family mix. • A signed and dated Plan Document is required within 30 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 and aggregate factors may be subject to re -rating, retro -active to the effective date. • Quote assumes the Plan Document will include traditional industry provisions and definitions including, but not limited to the following: eligibility, HIPAA, termination provisions, extension for leave of absence or disability, FMLA, subrogation, transplants, COB, exclusions for job related injuries, experimental and cosmetic treatment, usual and customary charges, war, not medically necessary, traveling outside of the U.S. solely for 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 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' REB (August 18, 2015) 10445852891-2015-420165-5-4 Page 3 of 4