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Home My WebLink About2025-163An Independent Licensee of the STOP LOSS PROPOSAL FOR Blue Cross and Blue Shield Association Indian River County Board Sales Representative: George Eppl Proposed Effective Date: 10/01/2025 Broker: LOCKTON COMPANIES LLC Through Date: 09/30/2026 Claims Administrator: Blue Cross Blue Shield of South Carolina RFP Situs State: FL Provider Network(s): Blue Cross Blue Shield of South Carolina Utilization Review Vendor(s): Blue Cross Blue Shield of South Carolina Retirees: Both Medicare Retirees and Under 65 Retirees Included Specific (Check one .. Option 1 Option Specific Deductible (per Covered Participant) $300,000 $300,000 $325,000 $350,000 Policy Year Maximum Specific Benefit Inforce Unlimited Unlimited Unlimited Lifetime Maximum Specific Benefit Inforce Unlimited Unlimited Unlimited Eligible Claims Expenses Med, Rx Med, Rx Med, Rx Med, Rx Specific Premium Composite Rate 1,724 $52.42 $56.67 $50.17 $47.77 Total Lives 1,724 Estimated Policy Term Specific Premium $1,084,465 $1,172,389 $1,037,917 $988,266 Policy Term Aggregating Specific Loss Fund $100,000 $100,000 $100,000 $100,000 Specific Covered Claims Basis 36/12 48/12 48/12 48/12 Commission 0.00% 0.00% 0.00% 0.00% Specific Coverage Features/Options Rate Cap Note: This proposal is not complete unless accompanied by the proposal notes and the basis of offer noted on the following pages. Individual Special Requirements: • Firm through 08/20/2025. Underwriter: KW (July 21, 2025) 11611394256-78346-5-1 Page 1 of 4 An Independent Licensee of the Blue Cross and Blue Shield Association PROPOSAL NOTES STOP LOSS PROPOSAL FOR Indian River County Board • The rates in this proposal are firm. Please provide a signed proposal. • Large claim data must be submitted for any claims that are at or have the likelihood to exceed 50% of the group specific deductible. Large claim data must include age, sex, diagnosis, prognosis, treatment plan, case management notes (if applicable), Pre -Cert and paid/pended claims. • The Specific rates in this proposal are based on an Aggregating Specific arrangement. Maximum Specific Liability includes estimated Policy Term Specific premium and the Aggregating Specific fund. • Human Organ Transplant benefits are payable in accordance with the Covered Underlying Plan and are subject to the proposed Lifetime Maximum Specific Benefit offered within this proposal. • This proposal includes a 40% rate cap on the Specific Premium Rate at the renewal of your Stop Loss Policy. If applicable, this increase also will apply to the Aggregating Specific Loss Fund. The rate cap does not apply to Material Changes including, but not limited to, the following: Covered Underlying Plan, HM's Stop Loss Policy provisions, the PPO network or the Claims Administrator, and the rates may be further adjusted by such changes. The rate cap rider applies to this Policy Term only. It may be offered at subsequent Stop Loss Policy renewals at the discretion of HM Underwriting. • At renewal, We will not apply any new lasers, including but not limited to, an Alternate Specific Deductible or Excluded Claim Expense, within the Special Risk Limitations section of the policy, unless requested. • Lockton's standard required terms will not be automatically accepted. However, a Stop Loss Acknowledgement Form may be requested at the time of sale. • Notwithstanding any other terms or conditions, the following provisions shall apply to gene therapies: No new laser (including, but not limited to, an alternate specific deductibles or excluded claim expenses) will be applied to any individual at the next renewal for gene therapy costs. Rates and aggregate specific deductibles, if applicable, will not increase at renewal due to gene therapy claim costs. Any lasers and/or contingencies in place as of the proposal effective date may be continued on subsequent renewals, subject to the carrier's discretion. The carrier reserves the right to offer, modify, or discontinue these provisions on subsequent renewals. These provisions do not supersede the group's plan documents in determining eligibility for gene therapy coverage and do not apply to gene therapy claims deemed ineligible for coverage. The specific deductible and any pre-existing lasers remain applicable. These provisions apply exclusively to the costs of the gene therapy itself and do not extend to costs associated with underlying conditions, comorbidities, or other medical expenses related to the treatment or management of such conditions. PROPOSAL ACCEPTANCE To consider a group for coverage we will require submission of all underlying documentation regarding member eligibility and termination as well as the group Leave of Absence Policy. If there is no Leave of Absence Policy in place, we will require a statement from the Plan Sponsor stating there is no Leave of Absence available. Additionally, we will require an approved benefit book within 60 days of Benefit Book release by FL Blue for group approval. Please acknowledge acceptance of the terms in this proposal by signing and returning by 08/20/2025. Please also indicate which option is chosen by checking the appropriate box on the previous page. All payments after the effective date of this policy, found on the previous page, must use the rates selected. Any deviation from the rates specified could result in„a!r04rp ent leading to a possible policy cancellation. Failure to remit t e signed greement by 08/20/2025 will resuff ilhvAlt; prppos4gi9jng considered expired. Signature: G` itle: ai rt:m mow. s' cn APPROVED AS TO FORM AND GSUFFICIENCY Accep on the 19th day of August 20 �;�� Coverages underwritten by Florida Blue, .Jacksonville, FL and is administered by HM Life Insu Company is an independent company providing only administrative services. PHER A. HICKS OUNTY ATTORNEY pany, Pittsburgh, PA. HM Life Insurance Underwriter: KW (July 21, 2025) 11611394256-78346-5-1 Page 2 of 4 F&rpl & B&M IOU An Independent Licensee of the STOP LOSS PROPOSAL FOR Blue Cross and Blue Shield Association Indian River County Board AV "Al initials: AFA date: QV_19V 5 BASIS OF OFFER AWW 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. • The premium rates are subject to change should the number of Covered Units change by 10% or more, either in total and/or by singleffamily mix. • If the descriptions of the benefits or plan provisions differ from what was initially utilized to underwrite the risk, an updated Summary Plan Document or other acceptable plan description is required within 60 days of the Effective Date, and 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. • HIPAA Privacy rules permit the release of Protected Health Information (PHI) for the purpose of evaluating and accepting risk associated with the Plan Sponsor as part of "Health Care Operations." HM will use this information solely for the purpose of evaluating and accepting the risk and will not disclose any PHI collected except to perform this risk evaluation. • The rates in this proposal are based on the Disclosure of all individuals considered a special enrollee due to having previously satisfied the plan's lifetime maximum. Written acceptance by HM must be acknowledged before terms of coverage for such individuals are included under HM's Stop Loss Policy. 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: KW (July 21, 2025) 11611394256-78346-5-1 Page 3 of 4 An Independent Licensee of the Blue Cross and Blue Shield Association STOP LOSS PROPOSAL FOR Indian River County Board • Any Stop Loss Policy issued by HM may be rescinded or re -underwritten if any information requested in connection with this proposal was intentionally concealed or misrepresented by or on behalf of the Policyholder and/or the Policyholder's Agent, or if the Policyholder and/or the Policyholder's Agent commits fraud. As used above: An "Agent" is the prospective Policyholder's representative including, but not limited to, the agent, producer or broker of record, or Claims Administrator. A "Claims Administrator" is a third -party administrator (TPA) designated by the Policyholder and approved by Us. Disclosure or Disclosed means to provide Claim Information and any other documentation or data requested by Us including, but not limited to, Census and Demographic Information and the estimated number of Covered Units prior to the beginning of the Policy Term. 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: KW (July 21, 2025) 11611394256-78346-5-1 Page 4 of 4