14-Suwannee Cert P60 10-1-25.pdf

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SUWANNEE COUNTY BOCC TAX COLL

215 PINE AVE SW STE A

LIVE OAK FL 32064

Thanks for choosing Florida Blue! See the enclosed Welcome brochure for everything you need to get the most value from your health plan. For plan info on the go, download the Florida Blue app or log in to your account at floridablue.com.

Health Insurance is offered by Blue Cross and Blue Shield of Florida, Inc., D/B/A Florida Blue. HMO coverage is offered by Health Options, Inc., D/B/A Florida Blue HMO, an HMO affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association.

This Master Contract is for SUWANNEE COUNTY BOCC TAX COLL

Group Number 15534

Division(s) Package Division Package C02 01

Blue Cross and Blue Shield of Florida 4800 Deerwood Campus Parkway Jacksonville, FL 32246

Section 1557 Notification: Discrimination is Against the Law

We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, sex, age or disability. We do not exclude people or treat them differently because of race, color, national origin, sex, age or disability.

We provide:

l Free auxiliary aids, reasonable modifications and services to people with disabilities to communicate effectively with us, such as:

l Qualified sign language interpreters l Written information in other formats (e.g., large print, audio, and accessible electronic formats) l Free language assistance services to people whose primary language is not English, such as:

l Qualified interpreters l Information written in other languages

If you need these services, contact:

l Health and vision coverage: 1-800-352-2583 l Dental, life, and disability coverage: 1-888-223-4892 l Federal Employee Program (FEP): 1-800-333-2227

If you believe that we have failed to provide these services or have discriminated in another way on the basis of race, color, national origin, sex, age, or disability, you can file a grievance with:

Health and vision coverage (including FEP members):

Section 1557 Coordinator 4800 Deerwood Campus Parkway, DCC 1-7.

Jacksonville, FL 32246.

1-800-477-3736 x29070.

1-800-955-8770 (TTY).

Fax: 1-904-301-1580.

Section1557Coordinator@bcbsfl.com

Dental, life, and disability coverage:

Civil Rights Coordinator 17500 Chenal Parkway Little Rock, AR 72223.

1-800-260-0331.

1-800-955-8770 (TTY).

civilrightscoordinator@fclife.com

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Section 1557 Coordinator or Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019

1-800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Visit www.floridablue.com/disclaimer/ndnotice to view an electronic version of this notice.

87768 0924R S

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-352-2583 (TTY: 1-877-955-8773). FEP: Llame al 1-800-333-2227

ATANSYON: Si w pale Kreyòl ayisyen, ou ka resevwa yon èd gratis nan lang pa w. Rele 1-800-352-2583 (pou moun ki pa tande byen: 1-800-955-8770). FEP: Rele 1-800-333-2227

CHÚ Ý: Nếu bạn nói Tiếng Việt, có dịch vụ trợ giúp ngôn ngữ miễn phí dành cho bạn. Hãy gọi số 1-800-352-2583 (TTY: 1-800-955-8770). FEP: Gọi số 1-800-333-2227

ATENÇÃO: Se você fala português, utilize os serviços linguísticos gratuitos disponíveis. Ligue para 1-800-352-2583 (TTY: 1-800-955-8770). FEP: Ligue para 1-800-333-2227

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-352-2583（TTY:

1-800-955-8770)。FEP：請致電1-800-333-2227

ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement.

Appelez le 1-800-352-2583 (ATS : 1-800-955-8770). FEP : Appelez le 1-800-333-2227

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-352-2583 (TTY: 1-800-955-8770). FEP: Tumawag sa 1-800-333-2227

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.

Звоните 1-800-352-2583 (телетайп: 1-800-955-8770). FEP: Звоните 1-800-333-2227

ATTENZIONE: Qualora fosse l'italiano la lingua parlata, sono disponibili dei servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-352-2583 (TTY: 1-800-955-8770). FEP: chiamare il numero 1-800-333-2227

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: +1-800-352-2583 (TTY: +1-800-955-8770). FEP: Rufnummer +1-800-333-2227

주의: 한국어 사용을 원하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-352-2583 (TTY:

1-800-955-8770) 로 전화하십시오. FEP: 1-800-333-2227 로 연락하십시오.

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-352-2583 (TTY: 1-800-955-8770). FEP: Zadzwoń pod numer 1-800-333-2227.

સુચના: જો તમે ગુજરાતી બોલતા હો, તો નિ:શુલ્ક ભાષા સહાય સેવા તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-800-352-2583 (TTY:

1-800-955-8770). FEP: ફોન કરો 1-800-333-2227

ประกาศ:ถ้าคุณพูดภาษาไทย คุณสามารถใช้บริการช่วยเหลือทางภาษาได้ฟรี โดยติดต่อหมายเลขโทรฟรี 1-800-352-2583 (TTY: 1-800-955-8770) หรือ FEP โทร 1-800-333-2227

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-352-2583（TTY:

1-800-955-8770）まで、お電話にてご連絡ください。FEP: 1-800-333-2227

Baa ákonínzin: Diné bizaad bee yáníłti'go, saad bee áká anáwo', t'áá jíík'eh, ná hólǫ́. Kojį' hodíílnih 1-800-352-2583 (TTY: 1-800-955-8770). FEP ígíí éí kojį' hodíílnih 1-800-333-2227.

87768 0924R

BlueCare Rx® Pharmacy Program

Schedule of Benefits This Pharmacy Program Schedule of Benefits is part of the BlueCare Rx Pharmacy Program described in the PRESCRIPTION DRUG PROGRAM section of your Benefit Booklet, both of which should be reviewed carefully. To find a Participating Pharmacy, you may access the Pharmacy Program Provider Directory on our website at www.floridablue.com or call the customer service phone number on your ID Card.

Pharmacy Deductible (DED) per Benefit Period (BP)........................................................................ $200

BENEFIT DESCRIPTION YOUR COST

Preferred Generic and Covered OTC Drugs purchased from:

Retail Pharmacy – For up to a One-Month Supply $15

Specialty Pharmacy – For up to a One-Month Supply $15

Home Delivery Pharmacy – For up to a Three-Month Supply $30

Preferred Brand Name Drugs or Supplies purchased from:

Retail Pharmacy – For up to a One-Month Supply $30 after DED

Specialty Pharmacy - For up to a One-Month Supply $30 after DED

Home Delivery Pharmacy – For up to a Three-Month Supply $60 after DED

BENEFIT DESCRIPTION YOUR COST

Non-Preferred Prescription Drugs or Supplies purchased from:

Retail Pharmacy – For up to a One-Month Supply $50 after DED

Specialty Pharmacy - For up to a One-Month Supply $50 after DED

Home Delivery Pharmacy – For up to a Three-Month Supply $100 after DED

Important Information affecting what you will pay:

l If you or your provider request a Brand Name Prescription Drug when there is a Generic Prescription Drug available; you will be responsible for:

1. the Cost Share amount that applies to the Brand Name Prescription Drug you received, or in the case of a Non-Preferred Prescription Drug, the Cost Share amount that applies to Non-Preferred Prescription Drugs, as indicated in this Schedule of Benefits; and

2. the difference in cost between the Generic Prescription Drug and the Brand Name Prescription Drug or Non-Preferred Prescription Drug you received, unless the provider has indicated on the

BCR.LG.RXS.OF 0524 1S

Prescription that the Brand Name Prescription Drug or Non-Preferred Drug is Medically Necessary.

Note: The difference in cost described in 2 above is a benefit penalty and therefore does not help to satisfy your Deductible or Out-of-Pocket Maximums.

l Specialty Drugs are only covered when purchased from the Specialty Pharmacy and only up to a One-Month Supply. Certain Specialty Pharmacy products may have unique quantity limits. Specialty Drugs may be dispensed in lesser or greater quantities due to manufacturer package size or FDA-approved dosage requirements for a course of therapy. These unique quantity limits will be indicated in the Medication Guide.

l You can also get up to a Three-Month Supply of a Covered Prescription Drug or Covered Prescription Supply (except Specialty Drugs) purchased at a retail Participating Pharmacy.

l Specialty Drugs, as designated in the Medication Guide, are not covered when purchased through the Home Delivery Pharmacy.

BCR.LG.RXS.OF 0524 2

BlueCare for Large Groups Group Master Policy

BCR.LG.POL 0524 S

Group Master Policy

Jeffrey Goddard Chief Executive Officer

For Customer Service Assistance: 800-FLA-BLUE

BCR.LG.POL 0524

TABLE OF CONTENTS

Administrative Provisions .......................................................................................... GP-1

Payment Provisions................................................................................................... GP-5

General Provisions .................................................................................................... GP-6

Medicare Secondary Payer Provisions.................................................................... GP-12

COBRA Administrative Services Provisions............................................................ GP-15

BlueCard® Program ................................................................................................. GP-17

Benefit Booklet Provisions....................................................................................... GP-19

Table of Contents

ADMINISTRATIVE PROVISIONS

Introduction

Thank you for choosing Health Options, Inc. ("HOI"), a wholly-owned subsidiary of Blue Cross and Blue Shield of Florida, Inc., a leader in health care financing solutions for over 50 years. HOI is a Florida-based Health Maintenance Organization ("HMO") providing comprehensive HMO-type coverage for groups. By purchasing coverage for your employees, and their dependents, you have established an employee welfare benefit plan ("Group Plan"). This Group Master Policy (herein “Policy") is evidence of the existence of the Group Plan and describes the rights and obligations which you and HOI have with respect to the coverage and or benefits to be provided by us.

References to “we”, “us”, and “our” throughout this Policy refer to Health Options, Inc. We may also refer to ourselves from time to time as “HOI”.

In exchange for your payment of the Premium, we agree to provide the coverage and/or benefits specified in the Benefit Booklet, a copy of which is made part of this Policy. The comprehensive health care coverage to be provided by us under the Group Plan which you have established is subject to all the requirements set forth in this Policy including the Benefit Booklet and any amendments or Endorsements issued by us.

The Policy is divided into two parts. The first part generally contains various administrative and other provisions relating to your agreement with us. You should make sure that you read and understand these provisions as they describe important obligations applicable to you and us. The second part is the Benefit Booklet which describes the coverage, benefits limitations and exclusions under this Policy. The Benefit Booklet includes the Schedule of Benefits, any applicable Enrollment Forms, and any Endorsements to the Benefit Booklet or the Policy. Any Endorsements issued by us to the Benefit Booklet or the first part of this Policy are also part of the Policy.

Definitions

Certain terms defined in the first part of the Policy are also used and defined (for the convenience of Covered Persons) in the Benefit Booklet. If a word or phrase starts with a capital letter, it is either the first word in a sentence, a proper name, a title, or a defined term. In addition to the definitions set forth in the Benefit Booklet, the following terms apply to this Policy:

Anniversary Date means the date one year after the Effective Date stated on the Group Application, and subsequent annual anniversaries or such other date as mutually agreed to in writing by the parties.

Covered Dependent means an Eligible Dependent who continues to meet all applicable eligibility requirements described in the ELIGIBILITY FOR COVERAGE section of the Benefit Booklet and who is enrolled, and actually covered, under the Policy other than as a Covered Employee.

Covered Employee means an Eligible Employee, or other individual, who continues to meet all applicable eligibility requirements described in the ELIGIBILITY FOR COVERAGE section of the Benefit Booklet and who is enrolled, and actually covered, under the Policy other than as a Covered Dependent.

Covered Person means a Covered Employee or a Covered Dependent.

Effective Date for the Group means 12:01 a.m. on the date specified on the Group Application and for Covered Persons means 12:01 a.m. on the date coverage will begin as specified in the ENROLLMENT AND EFFECTIVE DATE OF COVERAGE section of the Benefit Booklet.

Eligible Dependent means an individual who meets and continues to meet all of the eligibility requirements described in the ELIGIBILITY FOR COVERAGE section in the Benefit Booklet.

Group Master Policy GP-1

Eligible Employee means an individual who meets and continues to meet all of the eligibility requirements set forth in the ELIGIBILITY FOR COVERAGE section in the Benefit Booklet and is eligible to enroll as a Covered Employee. An eligible employee is not a Covered Employee until actually enrolled and accepted for coverage as a Covered Employee by us.

Enrollment Forms means those forms, electronic or paper, which are approved by us and used to maintain accurate enrollment files under the Policy.

Grace Period means the ten-day period beginning on the date the Premium is due.

Group means the employer, labor union, association, partnership, corporation, department, other organization or entity through which coverage and benefits are issued by us.

Note: References to "you" or "your" throughout the first part of this Policy also refer to the Group.

References to “you” or “your” in the Benefit Booklet refer to Eligible Employees, Eligible Dependents, Covered Employees and/or Covered Dependents depending on the context and intent of the specific provision.

Group Master Policy or Policy means the written document which is evidence of the entire agreement between the Group and HOI whereby coverage and benefits are provided to Covered Persons. The Policy includes the Benefit Booklet, the Schedule of Benefits, the Group Application, Enrollment Forms and any Endorsements to the Benefit Booklet or this Policy.

Premium means the amount required to be paid by the Group to us in order for there to be coverage under this Policy.

Waiting Period means the period of time specified on the Group Application, if any, which must be met by an individual before that individual is eligible to enroll for coverage under this Policy.

Term of Policy

This Policy shall become effective as of the Effective Date provided that:

1. we accept your Group Application, and

2. that you pay the required initial Premium specified by us.

This Policy shall continue in effect until the first Anniversary Date following the Effective Date unless terminated earlier as permitted by its terms. After the initial term, this Policy shall automatically renew each succeeding year on the Anniversary Date for an additional one-year period unless:

1. at least 45 days prior to such Anniversary Date, you notify us that you do not want the Policy to automatically renew; or

2. it is terminated as permitted by its terms.

If this Policy renews as specified above, all of its terms and provisions (including the Premium due) shall govern coverage as of the Anniversary Date, unless we give written notice of a modification or revision to you at least 45 days prior to the Anniversary Date. In the event we give such written notification, you may elect not to renew this Policy effective as of the Anniversary Date by giving us written notice prior to the Anniversary Date. If you do not give us written notice as required, this Policy shall renew on the Anniversary Date with the modified or revised terms. Nothing in this subsection shall prohibit us from amending, at the time of renewal, the coverage and/or benefits to be provided by us. We may modify the Premium at any time in accordance with the applicable provisions of this Policy.

Group Master Policy GP-2

Prior Carrier Responsibilities under an Extension of Benefits

Your prior carrier, if any, may be required to provide certain benefits to certain individuals covered by this Policy under an extension of benefits provision. We are not responsible for the payment of any claims which are payable under any extension of benefits provision in the prior carrier’s plan.

Commencement of Coverage

Our coverage in accordance with the terms of this Policy begins on the Effective Date (see ENROLLMENT AND EFFECTIVE DATE section in the Benefit Booklet). We are not required to pay for health care expenses incurred prior to the Effective Date.

Voluntary Termination by the Group

You may terminate this Policy at any time by giving us at least 45 days prior written notice. Coverage will not be provided on or after such termination date. Nothing in this subsection shall affect a Covered Person’s right to an extension of benefits, if applicable, in accordance with the Extension of Benefits subsection in the CONTINUING COVERAGE section of the Benefit Booklet.

Conditions of Renewal and Termination

This Policy is conditionally renewable. This means that it automatically renews each year on your Anniversary Date unless terminated earlier in accordance with its terms. We may terminate this Policy or refuse to renew it if:

1. You do not pay Premiums in accordance with its terms or we have not received timely Premium payments.

2. You perform an act, or engage in any practice, that constitutes fraud or make an intentional misrepresentation of material fact.

3. You do not comply with a material provision which relates to rules for Group contributions or Covered Person participation.

4. There is no longer any Covered Person who lives, resides, or works in the Service Area.

If we decide to terminate or not renew it based on one or more of the circumstances mentioned above, we will give you at least 45 days advance written notice, except in the case of failure to pay Premiums.

Refer to the Termination by Us for Non-Payment of Premium subsection.

Termination Based on Discontinuation of Form

We may decide to discontinue this form, which means this Policy is terminated, but may do so only if:

1. we cease to offer this form in the large group market in accordance with 641.31074 Florida Statutes;

2. we provide notice to all groups having coverage under this form of the discontinuation of this form at least 90 days prior to the date of non-renewal; and

3. we offer to all groups having coverage under this form the option to purchase any other health maintenance form currently being offered by us in the large group market.

Termination Based on Discontinuation of all Policies in Large Group Market

We may terminate this Policy if we elect to terminate all of the policies we have issued in the large group market in this state. In that case, we will provide notice, at least 180 days prior to the date of non-renewal, to the Office of Insurance Regulation and to all large groups and each Covered Employee.

If we terminate coverage pursuant to this provision, any unused Premium will be returned to you.

Group Master Policy GP-3

Termination by us for Non-payment of Premium

This Policy will automatically terminate as of the applicable Premium due date if we do not receive the Premium payment prior to the end of the Grace Period.

In the event of such termination, you are obligated to pay the following:

1. any portion of the Premium due for coverage provided by us prior to termination;

2. the amount of any payments made by us for health care expenses incurred by persons who were covered under the Policy, as of the termination date; and

3. any amounts otherwise due us.

We will mail to you a written notification within 45 days after the date the Premium is due that this Policy has terminated. This notification will tell you the reasons for termination.

Notification of Termination to Covered Employees

It is your obligation to immediately notify each Covered Person of any such termination of this Policy for any reason.

Representations Made By, and Obligations of, the Group

In agreeing to provide coverage in accordance with the terms of this Policy, we rely on the representations you made when you applied for coverage with us and your representation that you have authority to act on behalf of all Covered Persons with respect to this Policy. Consequently, every act by, agreement with, or notice given to, you will be binding on all Covered Persons. You agree that you shall offer to all Eligible Employees the opportunity to become a Covered Person under this Policy. You must notify persons considering enrollment with us under the Policy that HOI is an HMO and that, in order to obtain HMO-type coverage under the Policy; certain coverage access rules must be followed. (See the COVERAGE ACCESS RULES section of the Benefit Booklet). While you may require a Covered Employee to pay a portion of the Premium due us, you agree that you will contribute toward the cost of coverage which you purchased.

You agree that, if requested by us, you will distribute the Benefit Booklet (and any Endorsements to it) and other coverage materials to Covered Persons.

Your Obligation to Report Contribution Rate and Changes

If one or more of your plans is considered a “grandfathered health plan” as that term is used under the federal law known as the Patient Protection and Affordable Care Act (PPACA), you agree to provide us with the following information regarding each plan:

1. Your current contribution rates by tier of coverage;

2. Your contribution rates by tier of coverage that were effective on March 23, 2010; and

3. Any changes you make to your contribution rates by tier at any time during the term of this Policy.

You must report any such contribution rate change to us with at least 30 days advance written notice.

This information is required by PPACA so that we can verify that you continue to maintain grandfathered status. Remember, any change that results in a reduction in contribution by tier of greater than 5 percentage points will cause a loss in grandfathered health plan status.

Employer agreement to transfer upon termination of grandfathered health plan status

You understand and agree that upon loss of grandfathered health plan status HOI shall, at our sole discretion, either, 1) modify your current health plan to comply with the provisions of PPACA applicable to non-grandfathered health plans; or 2) transfer your health plan to a comparable health plan that is already

Group Master Policy GP-4 non-grandfathered. Such modification or transfer shall take place at the date specified by HOI and may include modified rates.

You agree that any action you take that causes a loss in grandfathered health plan status constitutes automatic consent for HOI to modify your coverage or transfer your group health plan to a comparable group health plan, as described in the paragraph above. You further agree to any rate change associated with the change in your coverage as a result of the loss of grandfathered health plan status.

PAYMENT PROVISIONS

Monthly Invoice

We will prepare a monthly invoice of the Premium due on or before the due date. This monthly invoice will also reflect any pro-rated charges and credits resulting from changes in the number of Covered Persons and changes in the types of coverage that took place in the previous or current month.

If you become aware that a Covered Person will become ineligible, you must provide us with written notice of such ineligibility on or before the date that the individual is, or will become, ineligible. If a Covered Person becomes ineligible for coverage for any reason, you are specifically required to provide written notice to us of such ineligibility no later than 10 days after such ineligibility. In the event that you do not comply with the notice requirements, you shall be liable to us for the Premium due for any individual for which we make claims payments under this Policy.

You must pay the total amount of the invoice, minus any deletions for Covered Employees who became ineligible for coverage during the current month. Do not add names to an invoice, change coverage or pay for an employee whose name does not appear on the invoice. No changes can be made to a Group invoice unless a signed application form is on file and submitted to HOI. Payment shall be for the total amount of the Group invoice, minus any employee deletions for the current month only.

Other than as specifically set forth in this Policy, we are not obligated to provide coverage or benefits for any individual for whom Premium has not been received by us in advance. In addition, we are not obligated to refund Premiums paid on behalf of any individual who was then listed on our enrollment records as a Covered Person.

Payment Due Date

The first Premium payment is due before the Effective Date of the Policy. Each following Premium payment is due monthly unless you agree with us on some other method and/or frequency of payment.

The Premium is due and payable on or before the first day of each succeeding calendar month to which such payments apply, unless you agree with us to have the 15th day of each month as the payment due date.

Grace Period

This Policy has a ten-day Premium payment Grace Period, which begins on the date the Premium payment is due. If we do not receive the required Premium payment on or before the date it is due, it may be paid during this Grace Period. Coverage will stay in force during the Grace Period. If Premium payments are not received by the end of the Grace Period, coverage will automatically terminate effective as of the applicable due date.

Changes in Premium

We may modify the amount of Premium at any time after the initial term. However, if the benefits or the composition of the Group are changed, we may modify the Rates during the initial 12-month period. We shall provide at least 45 days prior written notice to you of any such change. Premium payments submitted to us following receipt of any such written notice of change constitutes your acceptance of such

Group Master Policy GP-5 change. You must immediately notify each Covered Employee of any such change that affects his or her financial contribution requirement.

If an increase in Premium takes place on a date other than the Premium payment due date, a pro-rated increase will be applied from the date of the increase to the next payment due date. If a decrease in Premium takes place on a date other than the Premium payment due date, a pro-rated credit will be applied from the date of the decrease to the next Premium payment due date.

Incorrect Premium Payment

Any Premium adjustment made due to the correction of an error in the Premium payments will be made without interest after the facts are made known to us.

Other Rules Regarding the Payment of Premiums

1. In the event we do not receive Premium payment prior to the applicable due date, we reserve the right to suspend payment of claims for Health Care Services rendered to a Covered Person, on or after the applicable Premium due date.

2. We are not required to retroactively terminate this Policy or coverage for any Covered Person.

3. If full payment of the Premium is not paid when due, this Policy will automatically terminate as of the applicable Premium payment due date provided notification is sent to you within 45 days after the date the Premium is due.

GENERAL PROVISIONS

Administration

You must provide us with any information we need to administer the coverage and/or benefits to be provided or needed to compute the Premium due. While this coverage is in force, we have the right, at any reasonable time, to examine your records on any issues necessary to verify information provided by you.

Assignment and Delegation

You may not assign, delegate or otherwise transfer this Policy and the obligations hereunder without our written consent. Any assignment, delegation, or transfer made in violation of this provision shall be void.

We may assign, delegate or otherwise transfer this Policy to our successor in interest or an affiliated entity without your consent at any time.

Authorization

Where this Policy requires that an act involving the administration of coverage and/or benefits be authorized or approved by us, such authorization or approval shall be considered given when provided in writing by a duly authorized officer of HOI or his or her designee.

Benefit Booklet

We will provide a Benefit Booklet and ID Card for each Covered Employee. The Benefit Booklet will describe the coverage and benefits to be provided to Covered Persons by us.

You agree that, if requested by us, you will distribute the Benefit Booklet (and any Endorsements to it) and other coverage materials to Covered Persons.

Group Master Policy GP-6

Complaint and Grievance Process

We have established and will maintain a process for hearing and resolving Complaints and Grievances raised by Covered Persons. Details regarding the Complaint and Grievance process are provided in the Benefit Booklet.

Changes to the Policy

No person may change, modify, or revise the written terms or provisions of this Policy unless such change is made by a written Endorsement signed by one of our duly authorized officers. This is the only manner in which a change may be made to this Policy. For example, no employee or agent of HOI or the Group can change or waive the written terms or provisions of this Policy except as stated in the first sentence of this paragraph.

Enrollment Records

Furnishing and Maintaining Enrollment Records

You must provide any information required by us for the purpose of creating and maintaining enrollment records, processing terminations, and recording changes in family status. In addition, you and each Eligible Employee must submit accurate and complete Enrollment Forms on a timely basis. You are responsible for collecting the Enrollment Forms, reviewing them for accuracy and completeness, and forwarding them to us, along with the applicable Premium payment. All enrollment record information which is relevant to the eligibility or coverage status of any individual must be made available to us for inspection and copying upon request.

Errors or Delays

Clerical errors or delays by us in maintaining enrollment records regarding Covered Persons will not invalidate coverage which would otherwise be validly in force or continue coverage which would otherwise be validly terminated, provided you have furnished us with timely and accurate enrollment information.

Errors or delays by you in furnishing accurate enrollment information to us will not affect our right to strictly enforce any and all eligibility requirements. You are liable to us for any claims payments made by us on behalf of any individual who was not eligible for coverage at the time the Health Care Service was rendered.

Entire Agreement

This Policy sets forth the exclusive and entire understanding and agreement between the parties and shall be binding upon the Covered Persons, the parties, and any of their subsidiaries, affiliates, successors, heirs, and permitted assigns. All prior negotiations, agreements, and understandings are superseded hereby. No oral statements, representations, or understanding by any person can change, alter, delete, add or otherwise modify the express written terms of this Policy, which includes the terms of coverage and/or benefits set forth in the Benefit Booklet, the Schedule of Benefits, and any Endorsements.

Financial Responsibilities of the Group

We reserve the right to recover any benefit payments made to or on behalf of any individual whose coverage has been terminated. Our recovery efforts may relate to benefit payments made for Health Care Services rendered subsequent to the Covered Person's termination date and prior to the date notice of coverage termination is required to be made by you. Your cooperation with and support such recovery efforts is required.

In the event that you do not comply with the notice requirements set forth in the Monthly Invoice subsection, you shall be solely liable to us, to the extent of any payment made on behalf of such individual, for Health Care Services rendered subsequent to the date notice of a Covered Person's termination was due.

Group Master Policy GP-7

Grandfathered Health Plan Indemnification

There are certain actions that are solely within your control, as the employer, that can cause a loss in grandfathered health plan status. As such, if you wish to retain grandfathered health plan status, please recognize that we make no representations that your group health plan will retain grandfathered health plan status where you take unilateral action that may cause a loss in grandfathered health plan status.

For example, if you:

1. Reduce your contribution percentage by more than 5%;

2. Acquire another corporation, or merge another corporation into your health plan solely to add enrollees to your health plans; and/or

3. Transfer employees from one health plan to another with no bona fide employment-based reason for the transfer;

you will likely lose your grandfathered health plan status. Since we have no control over the above actions and other such unilateral actions identified in the grandfathering health plan interim final regulations found at 75 FR 34537 (June 17, 2010), as may be amended from time to time, we disclaim all responsibility for compliance with grandfathering health plan rules for such unilateral actions.

You agree to indemnify HOI for any and all penalties and/or fines and costs associated therewith for such unilateral actions taken by you that cause a loss in grandfathered health plan status. We encourage you to read the grandfathering health plan rules and work with your attorney to ensure compliance with such rules.

Indemnification

You shall hold harmless and indemnify HOI against all claims, demands, liabilities, or expenses (including reasonable attorney fees and court costs), which are related to, arise out of, or are in connection with any of your acts or omissions, or acts or omissions of any of your employees or agents, in the performance of your obligations under this Policy. We are not your agent, nor are you our agent, for any purpose.

Medical Loss Ratio Rebates

Federal law requires that HOI return that portion of premiums where HOI’s claims and quality improvement costs fall below a specified minimum Medical Loss Ratio (MLR) for the entire large group market. This return of premium is known as a “rebate”. MLR is determined by the federal government and sets a minimum percentage of total premiums that must be attributed to claims and quality improvement expenses. This is calculated in accordance with Section 2718 of the Public Health Services Act ("PHSA"), as added by the Patient Protection and Affordable Care Act (the "ACA" or the "Act") and any promulgated regulations. While we make every effort to meet such MLR, there may be times when we will rebate a portion of the Premium amount to you and/or your Covered Employees in accordance with federal law. Currently, such rebates, if any, are payable by the date specified by the federal government of the year following the Calendar Year in which our MLR exceeds the then current federal threshold required by Section 2718 of the Act.

In order to properly rebate that portion of Premiums due under federal law you and/or your Covered Employees agree to the following:

1. You, or your authorized representative (e.g., agent, broker, etc.), shall timely cooperate with us in determining that portion of rebate due you and provide all required information for determining your employer size under federal law. This may require you, or your authorized representative, to complete written or electronic questionnaires and report on amounts you may be required to rebate to Covered Employees under paragraph 3, below. Required information may include, but is not limited

Group Master Policy GP-8 to, your employee and former employee addresses, whether Premium contributions are collected pre or post tax, and employee social security numbers.

2. You agree that we have the sole right to determine to whom rebates are due and how such rebates shall be provided, e.g., in the form of future Premium credits, by check, or debit card.

3. You agree that HOI has the sole right to choose to whom the rebate will be paid. As such, we may rebate the entire amount due to you or choose to rebate the entire amount to your Covered Employees, including your portion of the rebate based upon your contribution toward coverage.

Should we choose to rebate the entire amount due to you, you agree to the following:

a. If the Group Plan is subject to the Employee Retirement Income Security Act of 1972 (“ERISA”), then you will use the rebate in accordance with the terms of your Plan Document as that term is defined in ERISA, and treat the rebated amount as a Plan Asset as that term is defined in ERISA;

b. If the Group Plan is not subject to ERISA, you attest, acknowledge and agree that you shall use the rebates for the benefit of the Covered Employees of your Group Plan. You agree to use the rebates in one of the following three ways:

i. To reduce subscribers’ portion of the annual premium for the subsequent policy year for all subscribers covered under any group health plan offered by the group;

ii. To reduce subscribers’ portion of the annual premium for the subsequent policy year for only those subscribers covered by the group health plan on which the rebate was based; or

iii. To provide a cash refund only to subscribers that were covered by the group health plan on which the rebate is based.

c. You shall timely cooperate with any data reporting requirements that we may have for reporting to the federal government the amounts rebated to you and your employees.

4. If we choose to rebate to your Covered Employees directly, you agree that you shall not contest in any formal way, e.g. litigation, our choice to rebate to employees directly. Furthermore, you agree that HOI may, in its sole discretion, choose to treat amounts that may be due you as “unclaimed” as that term is defined under any promulgated regulations related to Section 2718 of the Act. If we choose to treat the amount due as “unclaimed”, you shall have the right, at any time prior to escheat to the state, to provide the information in paragraph 1 to allow for proper return of such amounts as required by Section 2718 of the Act.

5. You acknowledge and agree that you, or your authorized representative, shall certify all information as true and correct as may be required by us on any forms provided for provision of the requested information in paragraphs 1 through 4 above.

You recognize and agree that this section shall apply to all rebates returned to you on or after June 1, 2012, regardless of which Calendar Year the rebate reflects.

You recognize that appropriately rebating amounts due you and your employees under this section is both complex and requires significant support from you. Failure to correctly rebate may result in fines and/or other penalties being imposed on us. If we are fined for failure to provide rebates, failure to provide rebates in a timely fashion, or failure to provide the appropriate rebates and such fines and/or penalties result from your failure to comply with the provisions of paragraphs 1 through 4, above, you agree to indemnify HOI for any such fines, penalties, interest or other amounts due, including any additional rebates due as a result of improper rebating based upon information you provided or failed to provide in accordance with this process. You agree to provide such amounts to us in accordance with any required timeframe imposed upon us by the government for such failure.

Representations on the Group Application and the Enrollment Forms

We rely on the information you and your Eligible Employees provide to determine whether to issue coverage; the appropriate Rate and financing method; and eligibility for coverage. All such information

Group Master Policy GP-9 must be accurate, truthful, and complete. Statements made on the Group Application and the Enrollment Forms are representations and not warranties.

We may cancel, terminate, or void this Policy if the information which you provide is fraudulent, or if you make an intentional misrepresentation.

Rescissions

You represent that any eligibility and status changes you request are compliant with and permissible under applicable state and federal law, including the Patient Protection and Affordable Care Act (“ACA”) and subsequent regulations. For example, Section 2712 of the Public Health Services Act (“PHSA”), as added by the ACA prohibits canceling the policy of an employee and/or their dependent(s) for any period during which a premium was collected from the employee and/or their dependent.

You hereby agree not to collect any premium from an employee and/or their dependent(s) for a coverage period occurring after the date their policy terminates. When submitting cancellation requests to us, you represent that you have not collected any premium from the canceled employee(s) and/or their dependent(s) for coverage after the requested termination date.

Reservation of Right to Contract

We reserve the right to contract with any individuals, corporations, associations, partnerships, or other entities for assistance with the servicing of coverage and benefits to be provided by us or obligations due, under this Policy.

Service Mark

You, on behalf of the Group and its Covered Employees, hereby expressly acknowledge your understanding that this Policy constitutes a contract solely between you and HOI. We are an independent corporation operating under a license with the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans, (the "Association") permitting us to use the Blue Cross and Blue Shield Service Mark in the state of Florida and that we are not contracting as the agent of the Association. You further acknowledge and agree that you have not entered into this contract based upon representations by any person other than us and that no person, entity, or organization other than us shall be held accountable or liable to you for any of our obligations created under this Policy.

This paragraph shall not create any additional obligations whatsoever on our part other than those obligations created under other provisions of this Policy.

Special Federal Reporting and Disclosures

Transparency in Coverage – Machine Readable Files

HOI will produce the data required at 45 CFR 147.212(b) to the extent that HOI processes this data and will publish this information on its website. The group health plan may link to this data at https://www.floridablue.com/members/tools-resources/transparency/machine-readable-files.

Prescription Drug and Health Care Spending (RxDC) Reporting

HOI will produce the data and perform the reporting required by 45 CFR 149.720(a) to the extent that HOI processes this data on behalf of the Group during the time period for which the reporting is required. In addition, HOI will perform the reporting of the data in support of employer / employee share of premium only to the extent that the Group has supplied the information needed for HOI to perform this reporting.

You agree that your group will provide any needed supplemental data requested by HOI to support RxDC Reporting upon request, in a timely manner. If your group does not supply the information needed to support the RxDC Reporting upon request, HOI will not perform the reporting for which we do not have the information, and HOI does not take responsibility for this reporting as defined in 45 CFR 149.720(d).

Group Master Policy GP-10

Gag Clause Attestation

A Gag Clause Prohibition Compliance Attestation (GCPCA) is an attestation of compliance with Internal Revenue Code (Code) section 9824, Employee Retirement Income Security Act (ERISA) section 724, and Public Health Service (PHS) Act section 2799A-9, as added by section 201 of Title II (Transparency) of Division BB of the CAA, as applicable.

HOI will produce the data and perform the Gag Clause Attestation to the extent that HOI manages the network of Providers for medical Services, behavioral health Services, and / or Pharmacy Benefit Manager (PBM) services on behalf of the Group during the time period for which the attestation is applicable.

Summary of Benefits and Coverage

Section 2715 of the Public Health Services Act (“PHSA”), as added by the Patient Protection and Affordable Care Act and any promulgated regulations and guidance (“SBC Rules”) require group health plans, group health plan administrators, and health insurers offering group health coverage to provide a Summary of Benefits and Coverage (“SBC”). An SBC must be provided to your employees and their dependents, at the following times, and under the following circumstances:

1. upon application for coverage;

2. by the first day of coverage (if there are changes to the SBC after application);

3. to special enrollees;

4. upon renewal; or

5. upon request for an SBC or summary information about health coverage.

Additionally, when a material modification (as defined under section 102 of ERISA) is made to the terms of a plan or coverage occurring outside a renewal or reissuance that would affect the most recently provided SBC, notice must be provided to each person covered under such plan 60 days in advance of the change.

HOI will provide you or your designated representative or agent with an SBC for each HOI benefit plan you offer for you to distribute to your Eligible Employees and their dependents in accordance with the following:

1. You agree to provide an SBC to your Eligible Employees and their dependents as required by the SBC Rules, within the required time frames, and in compliance with the delivery rules including electronic delivery requirements. The SBC Rules only require providing an SBC to dependents if they live at a different address than the employee.

2. You agree to distribute the SBC in the manner and appearance as specified in the SBC Rules. For example, the SBC must be provided either (1) as a stand-alone document; or (2) in combination with other summary materials (such as a Summary Plan Description (SPD)). The SBC must be intact and prominently displayed at the beginning of any other summary materials (such as immediately after the table of contents in an SPD).

3. You agree to provide a complete and accurate SBC with respect to each benefit plan you offer to your Eligible Employees and their dependents. For example, you are responsible for creating an SBC for any benefits not covered by HOI. To the extent the SBC Rules require you to incorporate such information into a single SBC document you are responsible for incorporating all such information into a single SBC and providing it to your Covered and Eligible Employees and their dependents.

4. You agree to provide notice to your Covered Employees and their dependents 60 days prior to a material modification that affects the most recently provided SBC.

5. You agree to retain records related to the delivery of the SBCs and compliance with the SBC Rules.

These records must be made available to HOI for inspection and copying upon request.

Group Master Policy GP-11

6. You agree to indemnify and hold HOI harmless from any damages, loss, action, claim or suit, including court costs and attorney’s fees, arising from, or related to, your failure to provide a complete, accurate and timely SBC to your covered and Eligible Employees and their dependents in accordance with the SBC Rules.

Third Party Beneficiary

This Policy was entered into solely and specifically for the benefit of HOI and the Group. The terms and provisions of the Policy shall be binding solely upon, and inure solely to the benefit of, HOI and the Group, and no other person shall have any rights, interest or claims under this Policy, including the Benefit Booklet, or be entitled to sue for a breach thereof as a third-party beneficiary or otherwise. HOI and the Group hereby specifically express their intent that health care Providers that have not entered into contracts with HOI to participate in HOI’s Provider networks shall not be third-party beneficiaries under this Policy, including the Benefit Booklet.

Time Limit on Certain Defenses

Relative to a misstatement in the application, after 2 years from the issue date, only fraudulent misstatements in the application may be used to void the policy or deny any claim for loss incurred or disability starting after the 2-year period.

MEDICARE SECONDARY PAYER PROVISIONS

In order to ensure compliance with the applicable Medicare laws, you are required to advise us, without delay, of any Covered Person who will be, or is, covered under Medicare prior to or immediately following the date such Covered Person becomes so covered (e.g., prior to the Covered Person’s 65th birthday).

Additionally, you are required to advise us, without delay, of the Medicare status of any Medicare beneficiary who applies for coverage, prior to such individual's Effective Date. You shall indemnify and hold us harmless to the extent of any liability, including attorney fees and costs, that results directly or indirectly from your failure to so advise us.

In any circumstances under which the Medicare statute requires that the Covered Services under this Policy be primary for any…