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SECTION 3: ELIGIBILITY, ENROLLMENT, AND DISENROLLMENT <br />A. Eligibility Determination <br />Determination of whether an individual is an Eligible Retiree or Eligible Dependent will be a two-step <br />process: <br />1. You will determine whether the individual is eligible to participate in the retiree group health <br />benefit plan that you sponsor. For individuals meeting your eligibility criteria, you will promptly <br />forward completed applications to us. You are responsible for complying with all applicable laws <br />and regulations, including but not limited to the Employee Retirement Income Security Act <br />(ERISA) and the Internal Revenue Code, in making this eligibility determination. You must also <br />comply with all eligibility guidelines included in the benefit administrative guide and Evidence <br />of Coverage. <br />2. After receiving a complete application, we will process the application in accordance with CMS <br />Requirements. An application must be approved by us and accepted by CMS for an individual to <br />be enrolled in a Medicare Plan. <br />B. Distribution of Enrollment Materials <br />You may only distribute materials describing the Medicare Plan that we have provided to you or that we <br />have approved in writing. You will distribute any pre -enrollment materials that we provide to you to <br />each potential enrollee before collecting enrollment applications. Nothing in this Section will preclude <br />you from making additional disclosures about your group health benefit plan as applicable to comply <br />with ERISA, such as a wrap-around summary plan description or other plan document. If applicable, <br />you are solely responsible for compliance with ERISA disclosure requirements in connection with the <br />Medicare Plan(s). <br />C. Group Disenrollment <br />If you decide to disenroll all Covered Persons from a Medicare Plan, you must: <br />1. Notify all beneficiaries that you intend to disenroll them from the Medicare Plan. You will <br />provide this notice at least twenty one (21) calendar days before the disenrollment. This notice <br />will explain how to contact Medicare for information about other plan options that may be <br />available. You will include language provided by Florida Blue in this notice to meet specific <br />CMS Requirements for notice contents. <br />2. Provide us with all information necessary to submit a complete disenrollment request transaction <br />to CMS in accordance with CMS Requirements. <br />3. In the event of termination of this Agreement, provide advanced notice in accordance with <br />Section 4 of this Agreement. <br />3 <br />