Exhibit 17c - Cal Yr 2025 City of Miami CIGNA Healthcare Massachusetts Rider for OAP Plans HC-RDR1.pdf

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Attached to
RFP No. 2130386 - Employee Health Benefits Plan
Solicitation number
RFP No. 2130386 - Employee Health Benefits Plan
Issued by
Florida

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This document is a Certificate Rider issued by Cigna Health and Life Insurance Company for the City of Miami, specifically for employees residing in Massachusetts. The certificate rider is effective January 1, 2025, and covers an Open Access Plus Medical Benefits health plan that meets Minimum Creditable Coverage standards for Massachusetts residents. The policy numbers are 3202272-OAPAE, OAPCE, OAPCX, and OAPNX, and the rider is designed to ensure that employees become insured on the date they become eligible, even if they are not in Active Service due to health status.

The document details the Massachusetts Health Care Reform Law requirement that residents 18 years and older must have health coverage meeting specific standards set by the Commonwealth Health Insurance Connector. The Cigna plan satisfies the statutory requirement for health insurance, and residents are advised to review their health plan material annually to ensure continued compliance with the latest coverage standards. The rider provides information on how to contact the Connector for more details and emphasizes the importance of maintaining minimum health insurance coverage.

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myCigna.com1

Home Office: Bloomfield, Connecticut

Mailing Address: Hartford, Connecticut 06152

CIGNA HEALTH AND LIFE INSURANCE COMPANY

a Cigna company (hereinafter called Cigna)

CERTIFICATE RIDER

No. CR7MNASO67-1

CR7MNASO68-1

CR7MNASO69-1

CR7MNASO70-1

Policyholder: City of Miami

Rider Eligibility: Each Employee who resides in Massachusetts

Policy No. or Nos. 3202272-OAPAE, OAPCE, OAPCX, OAPNX

EFFECTIVE DATE: January 1, 2025

You will become insured on the date you become eligible if you are in Active Service on that date or if you are not in Active Service on that date due to your health status. If you are not insured for the benefits described in your certificate on that date, the effective date of this certificate rider will be the date you become insured.

This certificate rider forms a part of the certificate issued to you by Cigna describing the benefits provided under the policy(ies) specified above.

HC-RDR1 04-10

V1

EXHIBIT 17c myCigna.com2

The pages coded HC-MACR1V1 and HC-MACR2 V12 attached to this certificate rider are added to your certificate.

myCigna.com3

Notice To Massachusetts Residents This Open Access Plus Medical Benefits health plan meets Minimum Creditable Coverage standards and will satisfy the individual mandate that you have health insurance. For additional information, please see the section “Massachusetts Requirement to Purchase Health Insurance,” immediately preceding the Schedule.

HC-MACR1V1

myCigna.com4

Massachusetts Requirement To Purchase Health Insurance:

As of January 1, 2009, the Massachusetts Health Care Reform Law requires that Massachusetts residents, eighteen

(18) years of age and older, must have health coverage that meets the Minimum Creditable Coverage standards set by the Commonwealth Health Insurance Connector, unless waived from the health insurance requirement based on affordability or individual hardship. For more information call the Connector at 1-877-MA-ENROLL or visit the Connector website (www.mahealthconnector.org).

This Open Access Plus Medical Benefits health plan meets Minimum Creditable Coverage standards that are effective January 1, 2025 as part of the Massachusetts Health Care Reform Law. If you purchase this plan, you will satisfy the statutory requirement that you have health insurance meeting these standards.

THIS DISCLOSURE IS FOR MINIMUM COVERAGE STANDARDS THAT ARE EFFECTIVE JANUARY 1, 2025.

BECAUSE THESE STANDARDS MAY CHANGE, REVIEW YOUR HEALTH PLAN MATERIAL EACH YEAR TO

DETERMINE WHETHER YOUR PLAN MEETS THE LATEST STANDARDS.

HC-MACR2 01-25

V12

File details come from the government source that posted it. Updated .