15-Suwannee Cert P03161 10-1-25.pdf

~~TOD~~

SUWANNEE COUNTY BOCC BOARD O

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 BOARD O

Group Number 15534

Division(s) Package Division Package C24 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

BlueOptions Group Master Policy

60698 0107R SR

Large Group

Group Master Policy

Brian D. Pieninck Chief Executive Officer

For Customer Service Assistance: 800-FLA-BLUE

This Policy Contains Deductible Provisions

60698 0107R SR

Large Group

Table of Contents Group Administrative Provisions .......................................................................... GP-1

Introduction .......................................................................................................... GP-1

Definitions ............................................................................................................ GP-1

Terms of the Group Master Policy ....................................................................... GP-2

Prior Carrier Responsibilities under an Extension of Benefits.............................. GP-3

Commencement of Coverage .............................................................................. GP-3

Voluntary Termination by the Group .................................................................... GP-3

Conditions of Renewal and Termination .............................................................. GP-3

Termination Based on Discontinuation of Form ................................................... GP-4

Termination Based on Discontinuation of all Policies in Large-Group Market ..... GP-4

Termination by Us for Non-payment of Premium................................................. GP-4

Notification of Termination to Covered Employees .............................................. GP-4

Representations Made By, and Obligations of, the Group................................... GP-4

Effective Date for Eligible Employees .................................................................. GP-5

Group Payment Provisions .................................................................................... GP-6

Monthly Invoice .................................................................................................... GP-6

Premium Payment Due Date ............................................................................... GP-6

Grace Period ........................................................................................................ GP-6

Changes in Premium............................................................................................ GP-6

Other Rules Regarding the Payment of Premiums .............................................. GP-7

General Group Provisions ...................................................................................... GP-8

Administration ...................................................................................................... GP-8

Assignment and Delegation ................................................................................. GP-8

Membership Provision.......................................................................................... GP-8

Changes to the Group Master Policy ................................................................... GP-8

Enrollment Records.............................................................................................. GP-8

Entire Agreement ................................................................................................. GP-9

Table of Contents i

Financial Responsibilities of the Group................................................................ GP-9

Indemnification ..................................................................................................... GP-9

Benefit Booklet ..................................................................................................... GP-9

Representations on the Group Application and the Enrollment Forms ................ GP-9

Reservation of Right to Contract .......................................................................... GP-9

Service Mark ........................................................................................................ GP-9

Group Medicare Secondary Payer Provisions.................................................... GP-11

Working Elderly .................................................................................................. GP-11

Individuals With End Stage Renal Disease........................................................ GP-12

Disabled Active Individuals ................................................................................ GP-13

Miscellaneous .................................................................................................... GP-14

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

Your Obligations ................................................................................................ GP-15

Our Obligations .................................................................................................. GP-15

Obligations of the COBRA Administrator ........................................................... GP-16

Obligations of the Covered Persons .................................................................. GP-17

BlueCard® ............................................................................................................... GP-18

Liability Caluculation Method Per Claim............................................................. GP-18

Return of Overpayments .................................................................................... GP-19

Table of Contents ii

Group Administrative Provisions

Introduction

Thank you for choosing Blue Cross and Blue Shield of Florida’s (“BCBSF”) BlueOptions. For over 50 years, BCBSF has been a leader in health care financing solutions. BlueOptions continues this tradition by combining the quality coverage and benefits you have come to expect with an innovative and affordable choice of Providers.

References to “we”, “us”, and “our” throughout this Group Master Policy refer to BCBSF. We may also refer to ourselves from time to time as “BCBSF.”

If you are an employer and have purchased this coverage for your employees, and their covered dependents, you have established an employee welfare benefit plan ("Group Plan"). This document ("Group Master Policy" or “Policy”) is evidence of the existence of the Group Plan and describes the rights and obligations which you and BCBSF have with respect to the coverage and benefits to be provided by

BCBSF.

In exchange for your payment of the Premium, we agree to provide the coverage and benefits specified in the Benefit Booklet which is attached to and made a part of this Group Master Policy. The health care coverage and benefits to be provided under this Group Master Policy will be subject to all the requirements set forth in this Policy, including the Benefit Booklet and any Endorsements issued by

BCBSF.

This Group Master Policy is divided into two parts. The first part 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 of the Group Master Policy is the Benefit Booklet. The Benefit Booklet describes the coverage, benefits, exclusions, and limitations under this Group Master Policy. The Benefit Booklet includes the Schedule of Benefits, any applicable Enrollment Forms, and any Endorsements to the Benefit Booklet or the Group Master Policy. Any Endorsements issued by us modifying the Benefit Booklet or the first part of this Group Master Policy are also part of this Group Master Policy.

Definitions

Certain terms defined in the first part of the Group Master 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 Group Master 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 Employee means an Eligible Employee, or other individual, who meets and continues to meet all applicable eligibility requirements and who is enrolled, and actually covered, under the Group Master Policy other than as a Covered Dependent (See the Eligibility Requirements for Covered Employees subsection of the Eligibility for Coverage section for further information).

Covered Dependent means an Eligible Dependent who meets and continues to meet all applicable eligibility requirements and who is enrolled, and actually covered, under the Group Master Policy other than as a Covered Employee (see the Eligibility Requirements for Dependent(s) subsection of the Eligibility for Coverage section for further information).

Group Administrative Provisions GP-1

Covered Person means a Covered Employee or a Covered Dependent.

Effective Date means, with respect to the Group, 12:01 a.m. on the date specified on the Group Application. With respect to individuals covered under this Policy, 12:01 a.m. on the date the Group specifies that the coverage will commence as specified in the Enrollment and Effective Date of Coverage section of the Benefit Booklet.

Eligible Dependent means a Covered Employee’s:

1. legal spouse under a legally valid, existing marriage; or

2. natural, newborn, Adopted, Foster, or step child(ren); or

3. a child for whom the Covered Employee has been court-appointed as legal guardian or legal custodian;

who meets and continues to meet all of the eligibility requirements set forth in the Eligibility for Coverage section in the Benefit Booklet.

Eligible Dependent also includes a newborn child of a Covered Dependent child. Coverage for such newborn child will automatically terminate 18 months after the birth of the newborn child. Refer to the Eligibility for Coverage section for limits on eligibility.

Eligible Employee for purposes of this Group Master Policy means an individual who meets and continues to meet all of the eligibility requirements set forth in the Eligibility Requirements for Covered Employees subsection of the Eligibility for Coverage section in the Benefit Booklet and is eligible to enroll as a Covered Employee. Any individual who is an Eligible Employee is not a Covered Employee until such individual has actually enrolled and been accepted for coverage as a Covered Employee by us.

Enrollment Forms means those BCBSF forms, electronic (where available) or paper, which are used to maintain accurate enrollment files under the Group Master Policy.

Grace Period means the ten (10) day period beginning on the date the Premium is due.

Group means the employer, labor union, trust, association, partnership, corporation, department, other organization or entity through which coverage and benefits are issued by us, and through which Covered Employees and Covered Dependents become entitled to coverage and benefits for the Covered Services described herein.

Note: References to "you" or "your" throughout the first part of the Group Master 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 means this document which is the agreement between the Group and us whereby coverage and benefits will be provided to Covered Persons. The Group Master Policy includes the Benefit Booklet (including the Schedule of Benefits), the Group Application, Enrollment Forms, and any Endorsements to the Benefit Booklet or the Group Master 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.

Group Administrative Provisions GP-2

Terms of the Group Master Policy

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

1. BCBSF accepts your Group Application; and

2. 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 that we give such written notification, you may elect not to renew this Policy effective as of the Anniversary Date by giving us written notice at least 10 days prior to the Anniversary Date. If you fail to 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 benefits to be provided by us. We may modify the Premium at any time in accordance with the applicable provisions of this Policy.

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 the Enrollment and Effective Date of Coverage 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

The Group 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 section in 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 fail to 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; or

Group Administrative Provisions GP-3

3. you fail to comply with a material provision which relates to rules for Group contributions or Covered Employee participation.

If we decide to either terminate the Policy 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 the Florida Insurance Code;

2. we provide notice to all groups and individuals 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 insurance form currently being offered for purchase 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 Florida Department of Insurance 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.

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 full Premium payment prior to the end of the Grace Period (see the Grace Period subsection of the Payment Provisions section). In the event of such a 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; and

3. any amounts otherwise due us.

We will mail to you a written notification prior to 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 responsibility to immediately notify each Covered Employee of 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 which you made when you applied for coverage with us and your representation that you have authority to act on behalf of all Covered Employees and Covered Dependents with respect to the Group Plan. Consequently, every act by, agreement with, or notice given to you, will be binding on all Covered Persons. You agree that you will offer to all Eligible Employees the opportunity to become a Covered Employee under the Group Plan. While you may require a Covered Employee to pay a portion

Group Administrative Provisions GP-4 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 to Covered Persons the Benefit Booklet (and any Endorsements to it) and other coverage materials.

Effective Date for Eligible Employees

Subject to the eligibility requirements set forth in the Eligibility for Coverage section in the Benefit Booklet (and any Endorsements), an Eligible Employee becomes eligible for coverage on the next Premium due date following the satisfaction of any Waiting Period established by you, provided the appropriate Enrollment Form is submitted to us within 30 days of the date the Eligible Employee first meets the applicable eligibility requirements. The designated Waiting Period is shown on the Group Application which you submitted to us.

Group Administrative Provisions GP-5

Group Payment Provisions

Monthly Invoice

We will prepare a monthly invoice of the Premium which is due on or before the due date. This monthly Group invoice may also reflect any 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 Group Master Policy.

You must pay the total amount of the Group invoice, minus any deletions for Covered Employees who became ineligible for coverage during the current month. Do not add names to a Group 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 an applicable signed Enrollment Form is on file and submitted to us.

Other than as specifically set forth in this Group Master Policy, BCBSF is not obligated to provide coverage or benefits for any individual(s) for whom Premium has not been received by BCBSF in advance or to refund Premiums paid on behalf of any individual who was then listed on our Enrollment Records as a Covered Person.

Premium 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 Premium 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 Premium payment due date.

Grace Period

This Group Master Policy has a ten (10)-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. 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 any such change. You must immediately notify each Covered Employee of any such change which affects the Covered Employee’s 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

Group Payment Provisions GP-6 granted. The pro-rated credit will apply for the decrease from the date of the decrease to the next Premium payment due date.

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.

Group Payment Provisions GP-7

General Group Provisions

Administration

You must provide us with any information we need to administer the coverage and 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 Group Master 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.

Membership Provision

As a holder of an insurance policy issued by us, you are a member of BCBSF. As such you have all the rights, privileges, and obligations provided in the Articles of Incorporation and our Bylaws currently in force and as may be amended from time to time.

The annual meeting of the members shall be held for the purpose of electing the Board of Directors and transacting such other business as may be properly brought before the meeting.

At all meetings of our members, each member shall be entitled to cast a number of votes equal to the amount of Premiums attributed to such member in the month of record, as determined by us (e.g., a Premium of $27.36 in that month will be equal to 27.36 votes). All proxies shall be filed with our Secretary before the meeting at which the proxy is to be voted.

Changes to the Group Master 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 a 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 BCBSF 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

1. 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 BCBSF, 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.

2. 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

General Group Provisions GP-8 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 Group Master Policy sets forth the exclusive and entire understanding and agreement between the parties and shall be binding upon all Covered Persons, the parties, and any of their subsidiaries, affiliates, successors, heirs, and permitted assignees. 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 the Group Master 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 and support of such recovery efforts is required.

Indemnification

You shall hold harmless and indemnify BCBSF against all claims, demands, liabilities, or expenses (including reasonable attorney’s 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.

Benefit Booklet

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

Representations on the Group Application and the Enrollment Forms

We rely on the information which 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 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.

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 Group Master Policy.

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Service Mark

You, on behalf of the Group and your Covered Employees, hereby expressly acknowledge your understanding that the Group Master Policy constitutes a contract solely between you and us. We are an independent corporation operating under a license with the Blue Cross and Blue Shield Association, an association of independent Blue Cross and/or 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 for 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.

Third Party Beneficiary

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

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Group 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 attorneys' 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 coverage under the Policy be primary for any Covered Person, you MAY NOT offer, subsidize, procure or provide a Medicare supplement policy to such Covered Person. Also, you MAY NOT induce such Covered Person to decline or terminate his or her group health coverage and elect Medicare as primary payer.

Working Elderly

If you employ 20 or more persons for 20 or more weeks of the current or preceding Calendar Year, or if you are a member of a multi-employer group health plan that includes at least one employer with 20 or more employees, the Policy provides primary coverage for employees and/or their spouses, age 65 or older, who are covered under the Policy, pursuant to the following terms:

1. You shall provide us, without delay, the names of employees, age 65 or older:

a) who are covered under the Policy;

b) who are employed (not retired);

c) who have not elected Medicare as primary payer of their health insurance claims; and

d) who are not eligible for Medicare due to end stage renal disease (ESRD).

2. You shall also provide us, without delay, the names of spouses, age 65 or older, of current employees of any age:

a) who are covered under the Policy;

b) who have not elected Medicare as primary payer of their health insurance claims; and

c) who are not eligible for Medicare due to ESRD.

The names required to be provided as set forth above, along with any other identifying information requested by us, shall be provided to us on or before the 65th birthday of the employee or spouse or on or before such later date when the individual enrolls with us.

3. For an enrolled individual who meets one of the descriptions set out in paragraph 1 or 2 directly above, we will provide group health coverage, as set forth in the Benefit Booklet, on a primary basis beginning with the first day of the month in which the individual attains age 65 or the date of enrollment, if the individual is 65 or over at the time of enrollment.

4. Individual entitlement to primary coverage under this subsection will terminate automatically:

a) for a current employee, age 65 or older, when he or she elects Medicare as the primary payer or when he or she becomes eligible for Medicare due to ESRD;

b) for the spouse, age 65 or older, of a current employee of any age, when the spouse elects Medicare as the primary payer or when the spouse becomes eligible for Medicare due to ESRD.

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You are required to provide us, without delay, the names of any current employees or spouses of such employees, age 65 or older, who choose Medicare as primary payer of their health insurance claims or who become eligible for Medicare due to ESRD.

Under Medicare, you MAY NOT offer, subsidize, procure or provide a Medicare supplement insurance policy to such individual. Also, you MAY NOT induce such individual to decline or terminate his or her group health coverage and elect Medicare as his or her primary payer.

5. Entitlement of the employee and/or spouse to primary coverage under this subsection will terminate automatically when:

a) the employee retires; or

b) the employee no longer meets the employer eligibility requirements.

You are required to notify us, without delay, of the retirement or reduction to a part-time schedule of any employee who has received primary coverage pursuant to this subsection or whose spouse has received primary coverage pursuant to this Working Elderly subsection.

6. The primary coverage described in this subsection will not be provided in the case of a group that is a member of a multi-employer group health plan where that group has fewer than 20 employees and the plan has elected treatment of that group's employees under the exception for small employers described at 42 U.S.C. §1395y(b)(1) (A)(iii).

Note: You must immediately report to us changes in the number of employees to fewer than 20 employees or from fewer than 20 employees to 20 or more employees, including pertinent changes in multi-employer group health plans.

Individuals With End Stage Renal Disease

Primary coverage is provided for your current and former employees and/or their dependents who are covered under this Policy and who are entitled to Medicare coverage because of end stage renal disease (“ESRD”), pursuant to the following terms:

1. You are required to provide us, without delay, information, including, but not limited to, the following:

a) the names of any individuals who are or will be undergoing a regular course of renal dialysis;

b) the names of any individuals who will receive or already have received a kidney transplant;

c) the beginning date of such dialysis or the date of such transplant;

d) the individual's date of birth, sex, and social security number;

e) health insurance claim number;

f) relationship of each individual covered to the employee (i.e., employee, employee's spouse, or employee's dependent child);

g) reason for Medicare entitlement;

h) Medicare Part A effective date;

i) employee's social security number;

j) contract number;

k) current employment status;

l) coverage Effective Date;

m) coverage termination date;

n) group number;

Group Medicare Secondary Payer Provisions GP-12

o) benefits provided (i.e., hospital benefits only, medical benefits only, or all other); and,

p) type of coverage provided (i.e., self, family, etc.).

2. For an enrolled individual who is entitled to Medicare coverage because of ESRD, we will provide group health coverage, as set forth in the Benefit Booklet, on a primary basis for 30 months beginning with the earlier of:

a) the month in which the individual became entitled to Medicare Part A ESRD benefits; or

b) the first month in which the individual would have been entitled to Medicare Part A ESRD benefits if a timely application had been made.

If Medicare was primary prior to the individual becoming eligible due to ESRD, then Medicare will remain primary (i.e., persons entitled due to disability whose employer has less than 100 employees, retirees and/or their spouses over the age of 65). Also, if group health coverage was primary prior to ESRD entitlement, then the Group will remain primary for the ESRD coordination period. For individuals eligible for Medicare due to ESRD, BCBSF will provide group health coverage, as set forth in the Benefit Booklet, on a primary basis for 30 months.

Under Medicare, you MAY NOT offer, subsidize, procure or provide a Medicare supplement policy to such individual or induce such individual to decline or terminate his or her group health coverage and elect Medicare as his or her primary payer.

Disabled Active Individuals

We provide primary coverage to Covered Persons who are covered under this Policy if:

1. you are a part of a health plan that has covered employees of at least one employer of 100 or more full-time or part-time employees on 50 percent or more of its regular business days during the previous Calendar Year; and

2. the Covered Persons are entitled to Medicare coverage because of disability (unless they have

ESRD).

Primary coverage, if any, under this subsection of this Policy is also subject to the following terms:

1. You are required to provide us, without delay, with the names of any Covered Persons covered under this Policy, who are entitled to Medicare coverage because of disability (other than those with ESRD), and who have not elected Medicare as primary payer of their health insurance claims, along with any other identifying information requested.

2. For such a Covered Person, we will provide group health coverage, as set forth in the Benefit Booklet, on a primary basis during any month in which that individual meets the description set out in paragraph 1 directly above.

3. Individual entitlement to primary coverage under this subsection will terminate automatically when:

a) the individual turns 65 years of age; or

b) the individual no longer qualifies for Medicare coverage because of disability; or

c) the individual elects Medicare as the primary payer. Coverage will terminate as of the day of such election.

You are required to notify us, without delay, of the occurrence of any of the above events.

Under Medicare, you MAY NOT offer, subsidize, procure or provide a Medicare supplement policy to such individual or induce such individual to decline or terminate his or her group health coverage and elect Medicare as his or her primary payer.

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Entitlement of the Covered Person to primary coverage under this subsection will terminate automatically if the Covered Employee no longer qualifies as such under applicable Medicare regulations and instructions.

You shall notify us, without delay, of any such change in status.

Note: You must immediately report to us changes in the number of employees to fewer than 100 employees or from fewer than 100 employees to 100 or more employees.

Miscellaneous

1. This Medicare Secondary Payer Provisions section shall be subject to, modified if necessary to conform to or comply with, and interpreted with reference to, the requirements of federal statutory and regulatory Medicare Secondary Payer provisions as those provisions relate to Medicare beneficiaries who are covered under this Policy.

2. We will not be liable to you or to any individual covered under this Policy due to any nonpayment of primary benefits resulting from any failure of performance of your obligations as set forth in this section.

3. If we should elect to make primary payments covering services rendered to Covered Persons described in this section in a period prior to receipt of the information required by the terms of this section, we may require you to reimburse us for such payments. Alternatively, we may require you to pay as additional Premium the rate differential that resulted from your failure to provide us with the required information in a timely manner.

4. You shall indemnify and hold us harmless to the extent of any liability that we may be charged with on account of improper primary Medicare payments that were made as a result of any failure of performance of your obligations as set forth in this section.

Note: You are subject to the federal laws described in this section. Individuals with questions regarding their rights under those laws should direct their questions to you.

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COBRA Administrative Services Provisions

The following rules apply if the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, apply to you.

Your Obligations

1. You are responsible for all aspects of the administration of COBRA with respect to the group health coverage provided by the Group Plan.

2. You specifically delegate to us the right to designate an administrator (COBRA Administrator) to perform COBRA administration responsibilities as provided in the Obligations of the COBRA Administrator subsection set out below.

3. You delegate the COBRA administration responsibilities to the COBRA Administrator designated by us as specified in such Obligations of the COBRA Administrator subsection.

4. You retain responsibility for the following COBRA administrative duties:

a) You will complete and provide all notices and Enrollment Forms to the Covered Persons (including the initial notice of COBRA rights) required under COBRA, using forms or sample forms provided by the COBRA Administrator.

b) You will provide a copy of the Enrollment Form to the COBRA Administrator at the same time that it is sent to the beneficiary(ies).

c) You will determine the applicable Premium for qualified beneficiaries in accordance with this Policy with us.

d) You will remit Premiums to us on behalf of the qualified beneficiary until we receive notice from the Group that such beneficiary is no longer entitled to COBRA coverage.

5. By entering into the Policy, you agree to indemnify and hold us and the COBRA Administrator, including any directors, officers, employees, and agents harmless against any and all claims, lawsuits, settlement, judgments, costs, taxes, and expenses, including reasonable attorneys' fees directly resulting from or arising out of your failure to perform COBRA administration responsibilities not delegated to the COBRA Administrator.

6. Upon receipt of notice from us that a COBRA Administrator is not designated pursuant to the Obligations of the COBRA Administrator subsection to then perform COBRA administration for the Group, you shall resume responsibility for all COBRA administration.

Our Obligations

1. On behalf of the Group, we may designate a COBRA Administrator to perform the COBRA administration responsibilities specified in the Obligations of the COBRA Administrator…