R-1948 - 05/25/2021 - PERSONNEL - Resolutions Supporting Documents BlueCross BlueShield
of Illinois
EXHIBIT TO THE
STOP LOSS COVERAGE POLICY
Employer Group Name: Village of Oak Brook
Employer Group Address: 1200 Oak Brook Road
City: Oak Brook State of Situs: IL Zip Code: 60523
Account Number: 019545
Employer Group Number(s): P19545 (Non-Union) P56642 (Police), P56643 (Fire), P19546 (H S
A)
Current Effective Date of Policy 07/01/2021
Current Policy Period: These specifications are for the Policy Period commencing on 07/01/2021 and ending on 07/01/2022
The specifications below shall become effective on the first day of the Policy Period specified above and shall continue in
full force and effect until the earliest of the following dates: (1) The last day of the Policy Period; (2) The date the Policy
terminates; or(3) The date this Exhibit is superseded in whole or in part by a later executed Exhibit.
A. Aggregate Stop Loss Coverage: ® Yes ❑ No
If yes, complete items 1. through 9. below.
1. ❑ New Coverage ® Renewal of Existing Coverage
2. Stop Loss Coverage during the current Policy Period:
❑ New Coverage (Select one from below):
❑ Incurred and paid during the Claims incurred and paid from to
Policy Period:
❑ Run-in coverage: Claims incurred from to
and Claims paid from to
If coverage is for claims incurred prior to the effective date of the Policy and paid by
Policyholder's prior claim administrator, then such claims must be reported by the Policyholder to
the Company (Blue Cross and Blue Shield of Illinois, a Division of Health Care Service
Corporation, a Mutual Legal Reserve Company) and paid by the Policyholder's prior claim
administrator by the end of the current Policy Period.
® Renewal of Existing Coverage:
® Claim Administrator's Claims: Claims incurred on or after the original Effective Date of Policy and paid
during the Policy Period.
3. Aggregate Stop Loss Coverage shall apply to:
® Medical Claims ❑ Vision Claims
® Outpatient Prescription Drug Claims with Company's Pharmacy Benefit Manager ❑ Dental Claims
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company
an Independent Licensee of the Blue Cross and Blue Shield Association
GA-10-4.1 HCSC CARVE OUT APP Rev. 06/17
❑ Outpatient Prescription Drug Claims with Policyholder's Pharmacy Benefit Manager:
❑ For Hospital Employer Groups only: Excludes % of Home Hospital Medical claims
❑ Other (please specify):
4. Average Claim Value: 1,628.95 (per Employee per month)
® Includes Claim Administrator's Provider Access Fee
❑ Excludes Claim Administrator's Provider Access Fee
Attachment Factor: 125% of the Average Claim Value
5. Aggregate Attachment Claim Liability:
a. Employer's Claim Liability for each Policy Period shall be the sum of the Monthly amounts obtained by
multiplying the number of Individual and Family Coverage Units for each Month by the following factor:
$2,036.19 for each Coverage Unit
$ for each Family Coverage Unit
6. Aggregate Stop Loss Coverage includes coverage of Run-Off Paid Claims: ® Yes ❑ No
Run-Off Attachment Claim Liability Factors:
Employer's Run-Off Claim Liability shall be an amount equal to 15% of the annualized Employer Claim Liability
based on the participation of the two (2) calendar months immediately preceding termination Settlement for the
final accounting period will be described in the section of the Policy entitled SETTLEMENTS.
7. Aggregate Stop Loss Claims:
a. The amount of Paid Claims during the current Policy Period, less Individual (Specific) Stop Loss Claims if
any, that exceeds the Aggregate Point of Attachment. The Aggregate Point of Attachment shall equal the
sum of the Employer's Claim Liability amounts calculated Monthly as described in item A.5. above for the
current Policy Period. However, for the current Policy Period the minimum Aggregate Point of Attachment
shall be $2.572,927.
b. The following applies if the answer to item A.6. above is "Yes" (Aggregate Stop Loss Coverage includes
coverage of Run-Off Paid Claims):
In the event of termination at the end of the current Policy Period, Aggregate Stop Loss Coverage shall
equal the amount of Final Settlement Paid Claims that exceed the Final Settlement Aggregate Point of
Attachment. Final Settlement Paid Claims shall equal the sum of the Paid Claims during the Final Policy
Period and the Paid Claims during the Run-Off Period, less Individual (Specific) Stop Loss Claims, if any.
The Final Settlement Point of Attachment shall equal the sum of the Employer's Claim Liability amount for
the Final Policy Period and the Employer's Run-Off Claim Liability calculated as described in items A.5. and
A.6. above. However, for the Final Settlement Period the minimum Aggregate Point of Attachment shall be
the minimum Aggregate Point of Attachment in item A.7.a. above increased by 15%.
c. The amount of"Run-in" Claims that is excluded from Individual (Specific) Stop Loss Coverage in item B.2.
is also not eligible for Aggregate Stop Loss coverage.
8. Stop Loss Premium (Select one):
® Annual Premium (Due on the first day of the current Policy Period): $29,274.
The following applies if the answer to item A.6. above is"Yes" (Aggregate Stop Loss Coverage includes
coverage of Run-Off Paid Claims): In the event of termination at the end of the current Policy Period, an
additional premium amount equal to 15% of the Annual Premium will be due within ten (10) calendar days of
receipt of the billing.
❑ Monthly Premium shall be equal to the amounts obtained by multiplying the number of Individual and Family
Coverage Units for a particular Month by:
$ for each Coverage Unit
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GA-10-4.1 HCSC CARVE OUT APP Rev. 06/17
$ for each Family Coverage Unit
The following applies if the answer to item A.6. above is "Yes" (Aggregate Stop Loss Coverage includes
coverage of Run-Off Paid Claims):
In the event of termination at the end of the current Policy Period, an additional Premium amount equal to
15% of the annualized Premium based on the participation of the two (2) months immediately preceding
termination will be due within ten (10) calendar days of receipt of the billing.
9. The premium is based upon a current membership of 30 Individual Coverage Units and 87 Family Coverage
Units.
B. Individual (Specific) Stop Loss Coverage: ® Yes ❑ No
If yes, complete items 1. through 6. below.
1. ❑ New Coverage ® Renewal of Existing Coverage
2. Stop Loss Coverage during the current Policy Period:
❑ New Coverage (Select one from below):
❑ Incurred and paid Claims incurred and paid from to
during the Policy
Period:
❑ Run-in coverage: Claims incurred from to
and Claims paid from to
If coverage is for claims incurred prior to the effective date of the Policy and paid by Policyholder's prior
claim administrator, then such claims must be reported by the Policyholder to the Company (Blue Cross
and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve
Company) paid by the Policyholder's prior claim administrator by the end of the current Policy Period.
® Renewal of Existing Coverage:
® Claim Administrator's Claims: Claims incurred on or after the original Effective Date of Policy and paid
during the Policy Period.
3. Individual (Specific) Stop Loss Coverage shall apply to:
® Medical Claims ❑ Vision Claims
® Outpatient Prescription Drug Claims with Company's Pharmacy Benefit Manager ❑ Dental Claims
❑ Outpatient Prescription Drug Claims with Policyholder's Pharmacy Benefit Manager:
❑ For Hospital Employer Groups only: Excludes % of Home Hospital Medical claims
❑ Other(please specify):
4. Individual (Specific) Stop Loss Claims
For each other Covered Person:
a. Individual (Specific) Stop Loss Coverage equals the amount of Paid Claims for a Covered Person
during the current Policy Period in excess of the Individual Point of Attachment of$85.000 per Covered
Person. Such amount shall apply for the current Policy Period.
Point of Attachment ® Includes Claim Administrator's Provider Access Fee
❑ Excludes Claim Administrator's Provider Access Fee
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GA-10-4.1 HCSC CARVE OUT APP Rev. 06/17
b. Employer's Claim Liability equals the sum of Paid Claims for a Covered Person during the current Policy
Period up to the Point of Attachment specified in item B.4.a. above.
5. Individual (Specific) Stop Loss Coverage includes coverage of Run-Off Paid Claims: ® Yes ❑ No
The following applies if the answer to item B.5. above is "Yes" (Individual Stop Loss Coverage includes coverage
of Run-Off Paid Claims):
a. In the event of termination at the end of the current Policy Period, Individual (Specific) Stop Loss
Coverage shall equal the amount of Final Settlement Paid Claims that exceed the Point of Attachment
specified in B.4. above. Final Settlement Paid Claims shall equal the sum of Paid Claims for a Covered
Person during the Final Policy Period and the Run-Off Period (beginning on and ending on
b. In the event of termination at the end of the current Policy Period, Employer's Final Settlement Claim
Liability equals the sum of Paid Claims for a Covered Person during the Final Policy Period and Run-
Off Period up to the Point of Attachment specified in item BA.a. above.
Settlement for the final accounting period will be described in the section of the Policy entitled
SETTLEMENTS.
6. Stop Loss Premium (select one):
❑ Annual Premium (Due on the first day of the current Policy Period): $
The following applies if the answer to item B.5. is"Yes" (Individual (Specific) Stop Loss Coverage includes
coverage of Run-Off Paid Claims): In the event of termination at the end of the current Policy Period, an
additional premium amount equal to 20% of the Annual Premium will due within ten (10) calendar days of
receipt of the billing.
® Monthly Premium shall be equal to the amounts obtained by multiplying the number of Individual and Family
Coverage Units for a particular Month by:
$338.33 for each Coverage Unit
$ for each Family Coverage Unit
The following applies if the answer to item B.5. above is"Yes" (Individual (Specific) Stop Loss Coverage
includes coverage of Run-Off Paid Claims): In the event of termination at the end of the current Policy
Period, an additional premium amount equal to 20% of the annualized Premium based on the participation of
the two (2) months immediately preceding termination will be due within ten (10) calendar days of receipt of
the billing.
7. The premium is based upon a current membership of 30 Individual Coverage Units and 87 Family Coverage Units.
Additional Provisions:
Retirees Covered: Yes ® No ❑
The undersigned person represents that he/she is authorized and responsible for purchasing stop loss coverage on behalf
of the Employer. It is understood that the actual terms and conditions of coverage are those contained in this Exhibit and
the Stop Loss Coverage Policy into which this Exhibit shall be incorporated at the time of acceptance by Blue Cross and
Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company ("HCSC"). Upon
acceptance, HCSC shall issue a Stop Loss Coverage Policy to the Employer. Upon acceptance of this Exhibit and
issuance of the Stop Loss Coverage Policy, the Employer shall be referred to as the "Policyholder."
Ruben Mendez
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GA-10-4.1 HCSC CARVE OUT APP Rev. 06/17
4 -
Sales Representative Sirre of Authorize Purch ser
Brian Buzecky &a_4 0
Name of Underwriter Title of Authoi4ed Pur ser
�_Q�e
Signature of Underwriter Date
INTERNAL USE ONLY Date Application approved by Underwriting:
Name of Underwriter:
5
GA-10-4.1 HCSC CARVE OUT APP Rev. 06/17
HCSC GEN ASO Traditional PBM Fee Addendum 6.19
PBM Fee Schedule Addendum to the Benefit Program Application
Term: Employees:
Guaranteed Traditional Aggregate Pricing Arrangement D'*
Traditional Select Network and Basic Drug List
Brand Generic
AWP minus AWP minus
17 25"ti 80.00111
DISPENSING FEE
Brand Generic
5.95 $9. 5
MAIL
Brand Generic
AWP minus AWP minus
20.35° 81.40°x,
DISPENSING FEE: $0.00
EXTENDED SUPPLY NETWORK("ESN")(If Applicable)
Brand Generic
AWP minus AWP minus
19.35% S2 7C'
DISPENSING FEE: $0.00
Aggregate
Pricing based on Employer's use of the Prime Specialty network AWP minus: 18.00%
DISPENSING FEE: $0.00
Rebate Credits to Err
PEPM Rebate Credits to Employer: 'S
Employer
PBM Administration Fees PEPM: $0.00
Additional Provisions:
t Employer will be billed for retail brand and retail generic prescriptions,mail brand and mail generic prescriptions,ESN brand and ESN generic,and Specialty pharmacy claims(excluding compound prescriptions)
based on the lesser of(a)U&C or(b)PBM's adjudication rate schedule(s)that is/are intended to achieve,on an aggregate calendar-year basis,the AWP discounts and Dispensing Fees shown above for all of Claim
Administrator's group customers that have purchased the above specific pricing arrangement("Groups with the Pricing Arrangement")and use the above Network(the"Employer's Contract Rates").
For purposes of setting Employers Contract Rates and calculating whether the AWP discounts and Dispensing Fees have been achieved:
a."Brand"products include"Brand Drugs"as defined in the PBM Exhibit and also include generic products that are available from no greater than three(3)generic
manufacturers;and
b."Generic"products include all products not defined in(a),above,as"Brand"products.
Employer acknowledges and agrees that Employers Contract Rates may vary based on market influences and as necessaryto achieve the AWP discounts and Dispensing Fees shown above,on an aggregate
calendar year basis,for Groups with the Pricing Arrangement that use the above Network.However,such variation for Brand products in each of the Retail,Mail,and ESN categories(on an aggregate annual
basis)may only vary by+/-3%from the applicable AWP discount shown above.
Employer will be billed the above Dispensing Fee(such Fee may be included in the amount billed to Employer)unless the Employer is billed based on the U&C price.If the Employer is billed based on the U&C
price,then the Dispensing Fee is included in such U&C price.
Employer will be billed for Compound Drug claims based on the applicable discounted rate in the Network Contract.
Employer will be billed for Foreign Claims based on an amount equal to the amount billed by the pharmacy.
Employer will be billed for out-of-network claims based on the pricing set forth in the Administrative Services Agreement and/or PBM Exhibit,as applicable.
If the AWP discounts and Dispensing Fees shown above are not achieved for a particular calendar year,for Groups with the Pricing Arrangement that use the above Network,then Employer will be credited,no
later than 180 days after the end of each calendar year during the Term,an amount calculated as follows:
-First,the total aggregate shortfall dollar amount for the calendar year for Groups with the Pricing Arrangement that use the above Network will be calculated by comparing
the actual performance of each of the above categories(Retail,Mail,ESN,and Specialty)with the corresponding AWP discounts and Dispensing Fees shown above for each
category.The amount of any performance in any category that exceeds the above AWP discounts and Dispensing Fees will be used to offset any and all shortfall(s)in any or
all categories.The above aggregate shortfall,if any,is then divided by total claims for Groups with the Pricing Arrangement that use the above Network,and did not
terminate their Addendum prior to their anniversary date,for the calendar year("Per Claim Amount").Then the Per Claim Amount will be multiplied by Employers total
claims for that calendar year to calculate the reconciliation credit.However,if Employer terminates this Addendum prior to its anniversary date and the above Guaranteed
Traditional Aggregate Pricing Arrangement is not achieved,then Employer will not be eligible to receive such credit.
-For purposes of determining if a shortfall exists,claims billed to Employer based on the U&C price will be considered to have$0.00 Dispensing Fees.
-Compound Drug claims,Foreign Claims,reversed claims,and out-of-network claims are excluded from the calculation of whether the AWP discounts and Dispensing Fees shown
above have been achieved and also are excluded from the calculation of any shortfall credit for Employer.
-lithe AWP discounts and Dispensing Fees shown above are exceeded for Groups with the Pricing Arrangement that use the above Network,then Employer will not receive
any credit,and there will not be a year-end settlement.
1
Proprietary and Confidential Information
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third party representatives,except with written permission of Claim Administrator.
HCSC GEN ASO Traditional PBM Fee Addendum 6.19
-Under the Guaranteed Traditional Aggregate Pricing Arrangement any particular group customer's experience relative tot he pricing guarantees will not determine its
eligibility for a credit.Group customers eligibility for a credit is determined based on the aggregate experience of all group customers that have purchased the Pricing
Arrangement and use the above Network.As such,an individual group customer may have experience that does not meet,or exceeds,the AWP discounts and Dispensing
Fees shown above. In addition,when there is a reconciliation credit,it is allocated in a manner described above and not based on any particular group's experience(other
than number of claims).
PBM uses Medi-Span as the pricing source to establish AWP,for purposes of calculating whether the above AWP discounts have been achieved.
Members'cost share is the applicable copayment,deductible,and/or coinsurance,which coinsurance is calculated based on the Employers Contract Rate orthe applicable out-of-network pricing.Zero balance
logic is not employed.
AWP discounts are based on the actual NDC-11 dispensed.
AWP discounts do not include savings from drug utilization review or other clinical or medical management programs.
The above Guaranteed Traditional Aggregate Pricing Arrangement,Rebate Credits and Administrative Fees may be subject to change if the Employers claims include 3406 pricing.
In addition to the rights of the parties under the PBM Exhibit,if changes occur within the pharmacy benefit management marketplace which lead to a significant deviation from the current economic
environment,both parties agree to engage in good faith negotiations to amend this Addendum to make impact on both parties commercially reasonably economically neutral.If the parties cannot agree on the
terms of the amendment,either party shall be allowed to(a)proceed to dispute resolution,as set forth in the Administrative Services Agreement or(b)terminate this Addendum with 90 days'prior written
notice to the other party.Failure to reach agreement on the amendment shall not be a breach of contract.
The above Guaranteed Traditional Aggregate Pricing Arrangement,Rebate Credits and Administrative Fees are based on the Network and Drug List shown above.
Unless otherwise specified in this Addendum,capitalized terms used in this Addendum shall have the meanings set forth in the Administrative Services Agreement or the PBM Exhibit,as applicable.
Employer Payments to Claim Administrator for Covered Services provided by Network Participants are calculated based on the pricing terms set forth in this Addendum which shall remain in effect for the term
of this Addendum to the extent described in the Administrative Services Agreement.Such pricing may or may not equal the amounts actually paid to the Network Participants or received from drug
manufacturers(e.g.,rebates),or the amounts paid or received between Claim Administrator and the PEIM.As a result,the PBM or Claim Administrator may realize positive margin on prescriptions filled at retail,
mail order,ESN or specialty pharmacies or prescrip' wqrug rebates.Employer acknowledges that it has negotiated for the specific traditional pricing terms set forth in this Addendum,and that it and its group
health plan have no right to,or legal interest ,any po ion of y positive margin retained by Claim Administrator or PBM and consents to Claim Administrators and PBM's retention of all such amounts.
e
J
thorized Purchaser
Title
Date
y
2
Proprietary and Confidential Information '
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third party representatives,except with written permission of Claim Administrator.
The HMOs of Blue Cross and Blue
B1llCCPOSS B1UeShield Shield of Illinois, a Division of Health
of Illinois Care Service Corporation, a Mutual
Legal Reserve Company (`BCBSIL")
Benefit Program Application ("BPA")
(All items are applicable to 151-Plus Grandfathered and Non-Grandfathered Insured Group Accounts unless otherwise
specified.)
Employer Account Number: 019545
HMO Illinois Employer Group Number(s):
HMO Illinois Section Number(s):
Blue Advantage HMO'" Employer Group Number(s): 819545
0101 (Village/Non-Union), 0200 {Park District), 0300
Blue Advantage HMO Section Number(s): (Retirees), 0400 (Retirees 65+), 0500 (PSEBA), 0501
(PSEBA), 0600 (Police Union), 8888 (COBRA)
Employer' Legal Name: Village of Oak Brook
(Specify the Employer, the employee trust, or the association applying for coverage. Names of subsidiary or affiliated
companies to be covered must also be included below. An employee benefit plan may not be named.)
Physical Address: City: State: Zip Code:
1200 Oak Brook Road Oak Brook II 60523
Billing Address (if different from above): City: State: Zip Code:
Employer Identification Number("EIN"): 36-6009534 Standard Industry Code (SIC): 8990
Wholly Owned Subsidiaries to be Covered:
Affiliated Companies to be Covered:
(Affiliated Companies must be required or permitted to be aggregated per IRS guidelines. Employer hereby confirms
that Employer, Subsidiaries and Affiliates are treated as a single employer under Internal Revenue Code Section
414(b), or(c), or(m), or(o), or under applicable law.)
Administrative Contact: Phone: Fax: Email:
Kathy Vonachen 630-368-5024 630-368-5025 kvonachen a-)oak-brook.org
Blue Access for Employers'" ("BAE'm") Contact:
(The BAE Contact is the employee of the account authorized by the Employer to access and maintain its account via BAE.)
Title: Phone: Fax: Email:
HR Director/ Deputy Village Clerk 630-368-5024 630-368-5025 kvonachen cDoak-brook.org
Policy Effective Date: 07/01/2021 Policy Anniversary Date: 07/01 /2022
Month Day Year
The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets minimum standards for
employee benefit plans in the private industry. In general, all employer groups, insured or ASO, are subject to ERISA
provisions except for governmental entities, such as municipalities and public school districts, and "church plans" as
defined by the Internal Revenue Code.
ERISA Regulated Group Health Plan*: Yes ❑ No
If Yes, specify ERISA Plan Year*: Beginning Date: _/_/_ End Date: _/_/_ (month/day/year)
ERISA Plan Sponsor*:
ERISA Plan Administrator*:
Proprietary and Confidential Information of Blue Cross and Blue Shield of Illinois.Not for use or disclosure outside Blue Cross and Blue Shield of Illinois,
Employer,their respective affiliated companies and third-party representatives,except with written permission of Blue Cross and Blue Shield of Illinois.
Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue
Shield Association
IL-LG-151 PLUS-H-BPA Rev. 06/20 Page 1
ERISA Plan Administrator's Address: City: State: Zip Code:
ERISA Plan Administrator's Email:
Please provide your Non-ERISA Plan Month/Year:
If you contend ERISA is inapplicable to your group health plan, please give legal reason for exemption*:
❑ Federal Governmental Plan (e.g., the government of the United States or agency of the United States)
❑ Non-Federal Governmental Plan (e.g., the government of the State, an agency of the state, or the
government of a political subdivision, such as a county or agency of the State)
❑ Church Plan (complete and attach a Medical Loss Ratio Assurance form)
❑ Other, please specify:
For more information regarding ERISA, contact your Legal Advisor.
*All as defined by ERISA and/or other applicable law/regulations.
1. Eligible Person:
Employer has decided that Eligible Person means a person who resides in the Service Area of a Participating
IPA and is:
❑ A Full-Time Employee of the Employer.
❑ A Full-Time Employee who is a member of(name of union or association):
® Other(please specify): A Full-time non-union or union employee of the employer
Full-Time Employee means:
❑ An Employee of the Employer who is regularly scheduled to work a minimum of 30 hours per week.
❑ Other(please specify):
The term "Employee" shall have the meaning set forth under ERISA and applicable law. BCBSIL reserves the
right to audit Employer's initial and ongoing eligibility determinations.
2. Civil Union Partner Coverage:
A Civil Union partner, as defined in the Policy, and his or her Dependents are automatically eligible to enroll for
coverage and, once enrolled, eligible for continuation of coverage as described in the Certificate Booklet. The
Employer as Policyholder is responsible for providing notice of possible tax implications to those Insureds with
coverage for Civil Union partners.
3. Domestic Partner Coverage: ❑ Yes ® No
If Employer elects "Yes", a Domestic Partner, as defined in the Policy, shall be considered eligible for coverage.
The Employer is responsible for providing notice of possible tax implications to those Insureds with Domestic
Partner Coverage.
Continuation coverage for Domestic Partners: If Employer elects coverage for Domestic Partners, Domestic
Partners are not eligible for continuation coverage under Consolidated Omnibus Budget Reconciliation Act of
1985 (COBRA), but Employer may elect to offer continuation coverage to Domestic Partners similar to that
available to spouses under COBRA continuation.
Domestic Partner Coverage Continuation (only available if Domestic Partners are covered): ❑ Yes ® No
4. The Limiting Age for covered children:
Hereafter, Covered Children means a natural child, a stepchild, an eligible foster child, an adopted child
(including a child involved in a suit for adoption,) a child for whom the Insured is the legal guardian, under
twenty-six (26) years of age, regardless of presence or absence of a child's financial dependency, residency,
student status, employment status (if applicable under the Policy), marital status, or any combination of those
factors. Unless the Employer elects a Limiting Age over twenty-six (26), coverage will terminate at the end of the
month in which the covered child turns age twenty-six (26). If the covered child is eligible military personnel, the
Limiting Age is thirty (30) years as described in the Certificate Booklet.
IL-LG-151 PLUS-H-BPA Rev. 06/20 Page 2
To cover children age twenty-six(26) or over, you may select option (a) or(b) below:
(a) ❑ Limiting Age for covered children age twenty-six (26) or over, ❑ who are married ❑ who are unmarried
❑ regardless of marital status, is years (twenty-seven (27) —thirty (30) are the available options).
If the covered child is eligible military personnel, the Limiting Age is thirty (30) years as described in the
Certificate Booklet.
(b) ❑ Limiting Age for covered children who are full-time students and age twenty-six (26) or over, ❑ who are
married ❑ who unmarried ❑ regardless of marital status, is years (twenty-seven (27) — thirty
(30) are the available options). If the covered child is eligible military personnel, the Limiting Age is thirty
(30) years as described in the Certificate Booklet.
For a covered child who reaches a Limiting Age over twenty-six (26), coverage will terminate:
❑ At the end of the period for which premium has been accepted.
❑ At the end of the month in which the Limiting Age is reached.
❑ At the end of the calendar year in which the Limiting Age is reached.
❑ On the Limiting Age Birthday.
❑ Other(please specify):
However, coverage shall be extended due to a leave of absence in accordance with any applicable federal or
state law.
5. Disabled Dependent: A Disabled Dependent means a dependent child who is medically certified as disabled
and dependent upon the Employee or his/her spouse.
To administer medical certification of disabled Dependents, you may select option (a) Standard Rules or (b)
Custom Rules. If (b) is selected there are additional selections regarding age, proof of prior coverage,
certification review, forms, and previous medical certification approvals.
(a) ❑ Disabled Dependent Administration will follow Standard Rules.
A disabled Dependent may continue coverage beyond the limiting age, provided the disability began
before the child attained the age of 26. A disabled Dependent may add coverage beyond the limiting
age, provided the disability began before the child attained the age of 26, and proof of coverage as a
disabled Dependent is provided.
Administration of Certification Review is handled by BCBSIL; a BCBSIL Disabled Dependent
Certification Form must be submitted to BCBSIL.
(b) ❑ Disabled Dependent Administration will follow Custom Rules. Please make the following sections:
Age: Please select one option regarding age of when the disability began.
❑ The disability must have begun before the child attained the age of 26 or other age permitted by law.
❑ All disabled Dependents are covered regardless of when the disability began.
Proof of Prior Coverage: Please select required or not required below:
When adding coverage, proof of prior coverage as a disabled Dependent is ❑ required ❑ not required.
Certification Review: Please select one option regarding handling of Certification Review.
❑ Certification Review is handled by BCBSIL; a Disabled Dependent Certification Form must be
submitted to BCBSIL.
❑ Certification Review is handled by the Employer; there are no Disabled Dependent Certification
Form requirements.
If Certification Review is selected as handled by BCBSIL, please select one option regarding forms:
❑ The BCBSIL Disabled Dependent Certification Form will be utilized.
❑ A ❑ Custom or❑ Other Disabled Dependent Certification Form will be utilized
If Certification Review is selected as handled by BCBSIL, please select allowed or not allowed below:
A disabled Dependent approved medical certification from a prior carrier is ❑ allowed ❑ not allowed.
A disabled Dependent approved medical certification from a prior BCBS policy is
❑ allowed ❑ not allowed.
6. Total number of Employees: (indicate the total number of actual Employees, not Enrollees)
Of the Employer 400 Illinois Employees 400 National Employees 0
IL-LG-151 PLUS-H-BPA Rev. 06/20 Page 3
7. Eligibility Date: All current and new Employees must satisfy the substantive eligibility criteria and required
waiting period indicated below before coverage will become effective. No waiting period may result in an effective
date that exceeds ninety-one (91) calendar days from the date that an employee becomes eligible for coverage,
unless otherwise permitted by applicable law.
If a person is added to the Policy and it is later determined that the Employer reported a Coverage Date earlier
than what would apply to the Employee or Dependent, based on the Waiting Period and eligibility conditions the
Employer provided to BCBSIL, BCBSIL reserves the right to retroactively adjust the Coverage Date for such
person.
❑ The date of employment.
® The 31st day of employment. Note: This may not exceed ninety-one (91) calendar days.
❑ The day (select 1st or 15th) of the month following month(s) (option of 1 or 2 months) of
employment.
❑ The day (select 1st or 15th) of the month following days (option of up to 60 days) of
employment.
❑ The day of the month following the date of employment.
❑ Other(please specify): Note: This may not exceed ninety-one (91) calendar days.
A full month's premium will be charged for the first month of coverage for those Employees whose Coverage
Dates fall between the first (1st) and fifteenth (15th) day of the Premium Period. No premium will be charged for
the first month of coverage for those Employees whose Coverage Dates fall between the sixteenth (16th) day and
the end of the Premium Period.
Substantive eligibility criteria.
Provide a representation below regarding the terms of any eligibility conditions (other than any applicable waiting
period already reflected above) imposed before an individual is eligible to become covered under the terms of
the plan. If any of these eligibility conditions change, Employer is required to submit a new BPA to reflect that
new information.
Check all that apply:
❑ An Orientation Period that:
1) Does not exceed one month (calculated by adding one calendar month and subtracting one calendar
day from an Employee's start date); and
2) If used in conjunction with a waiting period, the waiting period begins on the first day after the
orientation period.
❑ A Cumulative hours of service requirement that does not exceed 1200 hours
® An hours-of-service per period (or full-time status) requirement for which a Measurement period is used to
determine the status of variable-hour employees, where the measurement period:
1) Starts between the Employee's date of hire and the first day of the following month;
2) Does not exceed 12 months; and
3) Taken together with other eligibility conditions does not result in coverage becoming effective later than
13 months from the Employee's start date plus the number of days between a start date and the first
day of the next calendar month (if start day is not the first day of the month).
❑ Other substantive eligibility criteria not described above; please describe:
8. Special Enrollment: An Eligible Person may apply for coverage, Family coverage or add Dependents within
thirty-one (31) days of a Special Enrollment event if he/she did not apply prior to his/her Eligibility Date or when
eligible to do so. Such person's Coverage Date, Family Coverage Date, and/or Dependent's Coverage Date will
be the effective date of the Special Enrollment event or, in the event of Special Enrollment due to termination of
previous coverage, the date of application for coverage. In the case of a Special Enrollment event due to loss of
coverage under Medicaid or a state children's health insurance program, however, this enrollment opportunity is
not available unless the Eligible Person requests enrollment within sixty (60) days after such coverage ends.
Open Enrollment: Specify Open Enrollment Period:The month of June for a July 1st effective date.. An Eligible
Person may apply for coverage, Family coverage or add Dependents if he/she did not apply prior to his/her
Eligibility Date or did not apply when eligible to do so, during the Employer's Open Enrollment Period. Such
person's Coverage Date, Family Coverage Date, and/or Dependent's Coverage Date will be a date mutually
agreed to by BCBSIL and the Employer. Such date shall be subsequent to the open enrollment period.
IL-LG-151 PLUS-H-BPA Rev. 06/20 Page 4
9. Effective Date of Termination for a person who ceases to meet the definition of an Eligible Person:
® The last day of the calendar month in which such person ceases to meet the definition of an Eligible Person.
❑ Other(please specify):
10. Extension of Benefits due to Temporary Layoff, Disability or Leave of Absence:
Temporary Layoff: 0 days; Disability: Police and Fire by IL Statute: Other 90 days days; Leave of
Absence: 0 days
❑ Other(please specify):
However, benefits shall be extended for the duration of an Eligible Person's leave in accordance with any
applicable federal or state law.
11. Funding Arrangement: ® Premium Prospective (complete section 12.) ❑ Cost Plus (complete section
15.)
12. STANDARD PREMIUM INFORMATION:
The following elections apply to both Grandfathered and Non-Grandfathered Groups:
Premium Period:
❑ The first(1s') day of each calendar month through the last day of each calendar month. (This option applies to
all coverages if the Employer has BlueCare Dental HMO"' Coverage.)
❑ The day of each calendar month through the day of the next calendar month. (This option is not
available for any coverage if the Employer has BlueCare Dental HMO Coverage.)
13. MINIMUM EMPLOYER CONTRIBUTION INFORMATION:
(a) The following elections apply to Grandfathered and Non-Grandfathered Groups:
Employer Contribution:
❑ One hundred percent(100°/x) of the Individual Coverage Premium and an amount equal to one hundred
percent (100%) of the Individual Coverage Premium will be contributed toward the Family Coverage
Premium.
❑ 87.5% of the Individual Coverage Premium, and % of the Family Coverage Premium.
❑ Other(please specify):
(b) The following applies to Grandfathered and Non-Grandfathered Groups:
BCBSIL reserves the right to change premium rates when a substantial change occurs in the number or
composition of Subscribers covered. A substantial change will be deemed to have occurred when the
number of Subscribers covered changes by ten percent (10%) or more over a thirty (30) day period or
twenty five percent(25%) or more over a ninety (90) day period.
(c) The following applies to Non-Grandfathered Groups:
BCBSIL reserves the right to take any or all of the following actions: 1) initial rates will be finalized for the
effective date of the policy based on the Employer contribution levels; 2) after the policy effective date the
group will be required to maintain a minimum Employer contribution of 25%. In the event the group is
unable to maintain the contribution requirements, then the rates will be adjusted accordingly; and/or 3) non-
renew or discontinue coverage unless the 25% minimum Employer contribution is met. Employer will
promptly notify BCBSIL of any change in Employer contribution.
(d) The following applies to Grandfathered Groups:
It is understood that no Policy will be issued or renewed on a contributory basis unless at least 25% of the
Eligible Persons, and for Family Coverage 75% of the Eligible Persons with Eligible Dependents, have
enrolled for coverage.
14. Essential Health Benefits ("EHB") Definition Election:
Employer elects EHBs based on the Illinois benchmark.
IL-LG-151PLUS-H-BPA Rev. 06/20 Page 5
apply)Premium Rates: (indicate "NIA"in any rate field that does not
Health Coverage
1. Employee only HMO Illinois $ Blue Advantage HMO $548.36
2. Employee plus one Dependent (i.e. HMO Illinois $ Blue Advantage HMO $1072.09
Employee plus one spouse or one child)
3. Employee plus two or more Dependents HMO Illinois $ Blue Advantage HMO $1622.70
4. Employee plus Spouse HMO Illinois $ Blue Advantage HMO $
5. Employee plus Child(ren) (i.e. Employee HMO Illinois$ Blue Advantage HMO $
plus one or more children)
6. Family HMO Illinois $ Blue Advantage HMO $
Single Tier rate structure—complete item 1.
Two Tier rate structure—complete items 1. and 6.
Three Tier rate structure—complete items 1., 2., and 3.
Four Tier rate structure—complete items 1., 4., 5., and 6.
Medicare Eligible Rates(When BCBSIL is Secondary Payer)
Single Coverage HMO Illinois $ Blue Advantage HMO $548.36
Family Coverage HMO Illinois $ Blue Advantage HMO $1096.72
15. Cost Plus Program:
a) Service Charges for Claim Payments:
❑ HMO Illinois: % of Claim Payments; $ per Enrollee per month for health Claim Payments.
❑ Blue Advantage HMO: % of Claim Payments; $ per Enrollee per month for health Claim
Payments.
b) Physician's Services Fees:
❑ HMO Illinois: $ per month per single Enrollee; $ per month per Enrollee with one or more
Dependents.
❑ Blue Advantage HMO: $ per month per single Enrollee; $ per month per Enrollee with one or
more Dependents.
c) ❑ HMO Managed Care Fee: $ per HMO Enrollee per month.
d) ❑ Transfer Payment Method:
❑ Wire Transfer ❑ Draft ❑ Electronic Fund Transfer ❑ Other(please specify):
Tentative Final Settlement Period -Transfer payments required after termination for:
❑ 3 months ❑ 6 months ❑ 9 months ❑ 12 months ❑ Other(please specify):
e) ❑ Post Payment Method
f) Payment Period:
❑ Daily ❑ Weekly ❑ Bi-Weekly ❑ Monthly ❑ Other(please specify):
g) Claim Settlement Period:
❑ Monthly ❑ Quarterly ❑ Other(please specify)
h) Excess Loss — Run Off Period: Months (Standard is twelve (12) months.)
IL-LG-151 PLUS-H-BPA Rev. 06/20 Page 6
i) Final Settlement: Final Settlement is to be made within days after end of Excess Loss Run-Off Period.
(Standard is sixty(60) days.)
j) Employer Payments are to be made past the run-off period for all claims and adjustments.
k) Prescription Drug Program:
❑ Yes (the Pharmacy Benefit Manager(s) ("PBM") Fee Schedule Exhibit must be attached and is part of this
BPA.)
❑ No
Rebate Credit for Drugs covered under the Pharmacy Benefit:
$ per Covered Employee per month
HMO Pharmacy Network (Select one):
❑ Traditional Select Network
❑ Network shown on PBM Fee Schedule Exhibit
Other(please specify):
Prescription Drug Program Clinical Management Programs
❑Medication Therapy Management (MTM) (Retrospective) $ per Enrollee per month.
1) Termination Administrative Charge
As applies to the Run-Off Period indicated in the Payment Specifications section below:
i. For service charges (including, but not limited to, access fees) billed on a per Covered Employee
basis at the time of termination of the Policy or partial termination of Covered Employees, the
Termination Administrative Charge will be the amount equal to ten percent (10%) of the annualized
charges based on the service charges in effect as of the termination date or date of partial termination
and the Policy participation of the two (2) months immediately preceding the termination date or date
of partial termination. Such aggregate amount will be due BCBSIL within ten (10) days of BCBSIL's
notification to the Employer of the Termination Administrative Charge described herein.
ii. For service charges (including, but not limited to, access fees) billed on a basis other than per
Covered Employee at the time of termination of the Policy or partial termination of Covered
Employees, the Termination Administrative Charge will be such service charges in effect at the time
of termination of the Policy or partial termination of Covered Employees to be applied and billed by
BCBSIL, and paid by the Employer, in the same manner as prior to termination of the Policy or partial
termination of Covered Employees.
Termination Administrative Charges assume the continuation of the Policy benefit program(s) and the
administrative services in effect prior to termination. Should such Policy benefit program(s) and/or
administrative services change, or in the event the average Policy enrollment during the three (3) months
immediately preceding termination varies by ten percent (10%) or more from the enrollment used to
determine the service charges in effect at the time of termination, BCBSIL reserves the right to adjust the
rates for service charges (including, but not limited to, access fees) to be used to compute the Termination
Administrative Charge.
Changes in state or federal law or regulations or interpretations thereof may change the terms and conditions of
coverage.
The undersigned representative is authorized and responsible for purchasing insurance on behalf of the Employer,
has provided the information requested in this BPA and on behalf of the Employer offers to purchase the benefit
program as outlined in the proposal document submitted to the Employer by the Sales Representative. It is
understood and agreed that the actual terms and conditions of the benefit program are those contained in the Policy.
This BPA is subject to acceptance by BCBSIL. Upon acceptance, BCBSIL shall issue a Policy to the Employer and
this BPA shall be incorporated and made a part of the Policy. Upon acceptance of this BPA and issuance of the
Policy, the Employer shall be referred to as the Policyholder. In the event of any conflict between the proposal
document and the Policy, the provisions of the Policy shall prevail. No coverage will begin until receipt of the first
premium by BCBSIL.
IL-LG-151PLUS-H-BPA Rev. 06/20 Page 7
The undersigned representative acknowledges that any producer is acting on behalf of the Employer for purposes of
purchasing the Employer's insurance, and that if BCBSIL accepts this BPA and issues a Policy to the Employer,
BCBSIL may pay the Employer's producer a commission and/or other compensation in connection with the issuance
of such Policy. The undersigned representative further acknowledges that if the Employer desires additional
information regarding any commissions or other compensation paid to the producer by BCBSIL in connection with the
issuance of a Policy, the Employer should contact its producer.
The undersigned representative hereby acknowledges that the Employee Retirement Income Security Act of 1974, as
amended, ("ERISA"), establishes certain requirements for employee welfare benefit plans. As defined in Section 3 of
ERISA, the term "employee welfare benefit plan" includes any plan, fund or program which is established or
maintained by an employer or by an employee organization, or by both, to the extent that such plan, fund or program
was established or is maintained for the purpose of providing for its participants or their beneficiaries, through the
purchase of insurance or otherwise, medical, surgical or hospital benefits, or benefits in the event of sickness,
accident or disability. The undersigned representative further acknowledges that: (i) an employee welfare benefit plan
must be established and maintained through a separate plan document which may include the terms hereof or
incorporate the terms hereof by reference, and that (ii) an employee welfare benefit plan document may provide for
the allocation and delegation of responsibilities thereunder. However, notwithstanding anything contained in the
employee welfare benefit plan document of the Employer (or any group member if the group is an association), the
Employer agrees that no allocation or delegation of any fiduciary or non-fiduciary responsibilities under the employee
welfare benefit plan of the Employer (or any group member if the group is an association) is effective with respect to
or accepted by BCBSIL except to the extent specifically provided and accepted in this BPA or the Policy or otherwise
accepted in writing by BCBSIL.
The Rebate Credit is a per Enrollee per month credit applied to the monthly billing statement. Rebate Credits shall not
continue after termination of the Prescription Drug Program, except as otherwise set forth in this BPA or the PBM Fee
Schedule Exhibit. (Further information about rebates, the PBM, and the Rebate Credit is included in the governing
Group Administration Document to which this BPA is attached under the section titled "The Plan's Separate Financial
Arrangements Regarding Prescription Drugs.").
OTHER PROVISIONS:
1. Summary of Benefits and Coverage ("SBC"):
The SBC Addendum is attached and made a part of the Policy. BCBSIL will create the SBC (only for benefits
BCBSIL insures under the Policy) and provide the SBC to the Employer in electronic format. If the Employer
approves of the content, Employer will then distribute the SBC to participants and beneficiaries (or hire a third
party to distribute) as required by law. If the Employer would like changes to the SBC, it will promptly notify
BCBSIL. BCBSIL will also distribute the SBC to participants and beneficiaries via regular hardcopy mail or
electronically in response to occasional requests received directly from individuals. All other distribution is the
responsibility of the Employer.
2. BlueEdge FSA" (Vendor: Select Vendor) purchased: ❑ Yes ❑ No
3. Reimbursement: It is understood and agreed that in the event BCBSIL makes a recovery on a third-party
liability claim, BCBSIL will retain twenty five percent (25%) of any recovered amounts, other than recovery
amounts received as a result of, or associated with, any Workers' Compensation Law.
4. Third Party Recovery Vendors and Law Firms Provisions (other than Reimbursement Services):
BCBSIL engages with third party recovery vendors and law firms on a post-pay basis to identify and/or
recover any potential overpayments that may have been made to Providers.
5. Excess Loss Coverage purchased: ❑ Yes ® No
If yes: Complete separate Application for Excess Loss Coverage.
6. Blue Directions for Large Businesss" purchased: ❑ Yes ® No
(If yes, The Blue Directions"' Addendum is attached and made a part of the Policy.)
7. ® Wellbeing Management: The undersigned representative authorizes the provision of alternative
benefits rendered to Covered Persons in accordance with the provisions of the Policy.
IL-LG-151 PLUS-H-BPA Rev. 06/20 Page 8
ADDITIONAL PROVISIONS:
A. Grandfathered Health Plans: Employer shall provide BCBSIL with written notice prior to renewal (and
during the plan year, at least sixty (60) days advance written notice) of any changes in its Contribution Rate
Based on Cost of Coverage or Contribution Rate Based on a Formula towards the cost of any tier of coverage
for any class of Similarly Situated Individuals as such terms are described in applicable regulations. Any such
changes (or failure to provide timely notice thereof) can result in retroactive and/or prospective changes by
BCBSIL to the terms and conditions of coverage. In no event shall BCBSIL be responsible for any legal, tax
or other ramifications related to any benefit package of any group health insurance coverage (each hereafter
a "plan") qualifying as a "grandfathered health plan" under the Affordable Care Act and applicable regulations
or any representation regarding any plan's past, present and future grandfathered status. The grandfathered
health plan form ("Form"), if any, shall be incorporated by reference and part of the BPA and Group Policy,
and Employer represents and warrants that such Form is true, complete and accurate. If Employer fails to
timely provide BCBSIL with any requested grandfathered health plan information, BCBSIL may make
retroactive and/or prospective changes to the terms and conditions of coverage, including changes for
compliance with state or federal laws or regulations or interpretations thereof.
B. Retiree Only Plans and/or Excepted Benefits: If the BPA includes any retiree only plans and/or excepted
benefits, then Employer represents and warrants that one or more such plans is not subject to some or all of
the provisions of Part A (Individual and Group Market Reforms) of Title XXVII of the Public Health Service Act
(and/or related provisions in the Internal Revenue Code and Employee Retirement Income Security Act) (an
"exempt plan status"). Any determination that a plan does not have exempt plan status can result in
retroactive and/or prospective changes by BCBSIL to the terms and conditions of coverage. In no event shall
BCBSIL be responsible for any legal, tax or other ramifications related to any plan's exempt plan status or any
representation regarding any plan's past, present and future exempt plan status.
C. Employer shall indemnify and hold harmless BCBSIL and its directors, officers and employees against any
and all loss, liability, damages, fines, penalties, taxes, expenses (including attorneys' fees and costs) or other
costs or obligations resulting from or arising out of any claims, lawsuits, demands, governmental inquiries or
actions, settlements or judgments brought or asserted against BCBSIL in connection with (a) any plan's
grandfathered health plan status, (b) any plan's exempt plan status, (c) any directions, actions and
interpretations of the Employer, (d) any provision of inaccurate information, (e) the SBC, (f) any plan's design
(including but not limited to any directions, actions and interpretations of the Employer, and/or (g) Employer's
selection of EHB definition for the purpose of the Patient Protection and Affordable Care Act ("ACA").
Changes in state or federal law or regulations or interpretations thereof may change the terms and conditions
of coverage.
The provisions of paragraphs A-C (directly above) shall be in addition to (and do not take the place of) the other terms
and conditions of coverage and/or administrative services between the parties.
Notwithstanding anything in the Policy or Renewal(s) to the contrary, BCBSIL reserves the right to revise our charge
for the cost of coverage (premium or other amounts) at any time if any local, state or federal legislation, regulation,
rule or guidance (or amendment or clarification thereto) is enacted or becomes effective/implemented, which would
require BCBSIL to pay, submit or forward, on its own behalf or on the Employer's behalf, any additional tax,
surcharge, fee, or other amount(all of which may be estimated, allocated or pro-rated amounts).
Renewals Only: If this BPA is blank, it is intentional, and this BPA is an addendum to the existing BPA. In such
case, all terms of the existing BPA as amended from time to time shall remain in force and effect. However,
beginning with the Employer's first renewal date on or after September 23, 2010, the provisions of paragraphs A-C
(above) shall be part of(and be in addition to) the terms of the existing BPA as amended from time to time.
Any reference in this BPA to eligible dependents may include Domestic Partners or Civil Union partners but will
include dependent covered children under the Limiting Age of twenty-six (26), or election made above.
Any reference in this BPA to the Limiting Age for covered children means twenty-six (26) years, or election made
above, regardless of presence or absence of a child's financial dependency, residency, student status, employment,
marital status or any combination of those factors. If the covered child is eligible military personnel, the Limiting Age
is thirty (30) years as described in the certificate booklet.
IL-LG-151 PLUS-H-BPA Rev. 06/20 Page 9
Any reference in this BPA to the "Employee plus one Dependent" rate structure means "Employee plus one spouse
(includes Civil Union partner and/or, if elected, Domestic Partner) or one child."
Any reference in this BPA to the "Employee plus Child(ren)" rate structure means "Employee plus one or more
children."
Renewing with no changes 7/1/2021
IL-LG-151PLUS-H-BPA Rev. 06/20 Page 10
Ruben Mendez
Sales Representative Si ure o uthorized Purc ser
822 630-824-5197
District Phone No. Title
Brian Walsh a I
Producer Representative Date
Signature of Producer Representative Wit ess
VistaNational Insurance Group
Producer Firm
1301 W. 22nd Street
Suite 600
Oak Brook, IL 60523
Producer Address $ Amount Submitted (not required for renewals)
630-468-6503
Producer Number
36-4095485
Producer Tax ID No.
IL-LG-151PLUS-H-BPA Rev. 06/20 Page 11
PROXY
The undersigned hereby appoints the Board of Directors of Health Care Service Corporation, a Mutual Legal Reserve
Company, or any successor thereof ("HCSC"), with full power of substitution, and such persons as the Board of Directors
may designate by resolution, as the undersigned's proxy to act on behalf of the undersigned at all meetings of members of
HCSC (and at all meetings of members of any successor of HCSC) and any adjournments thereof, with full power to vote
on behalf of the undersigned on all matters that may come before any such meeting and any adjournment thereof. The
annual meeting of members is scheduled to be held each year in the HCSC corporate headquarters on the last Tuesday of
October at 12:30 p.m. Special meetings of members may be called pursuant to notice provided to the member not less than
thirty (30) nor more than sixty (60) days prior to such meetings. This proxy shall remain in effect until either revoked in
writing by the undersigned at least twenty (20) days prior to any meeting of members or by attending and voting in person
at any annual or special meeting of members.
From time to time, HCSC pays indemnification or advances expenses to its directors, officers, employees or agents
consistent with HCSC's bylaws then in force and as otherwise required by applicable law.
P19545 By:
(Non- Union)
Group No.: P19546 (H S
A), P56642
(Police),
P56643 (Fire) Cc, q
int Signer's Na er
hAJ
Signature and Title
Group Name: Village of Oak Brook
Address: 1200 Oak Brook Road
City: Oak Brook State: IL ZIP: 60523
Dated this � l day of
M nt Year
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
IL GEN ASO BPA(Rev. 08/20) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, 2
an Independent Licensee of the Blue Cross and Blue Shield Association
PROXY
The undersigned hereby appoints the Board of Directors of Health Care Service Corporation, a Mutual Legal Reserve
Company, or any successor thereof ("HCSC"), with full power of substitution, and such persons as the Board of
Directors may designate by resolution as the undersigned's proxy to act on behalf of the undersigned at all meetings
of members of HCSC (and at all meetings of members of any successor of HCSC) and any adjournments thereof,
with full power to vote on behalf of the undersigned on all matters that may come before any such meeting and any
adjournment thereof. The annual meeting of members is scheduled to be held each year in the HCSC corporate
headquarters on the last Tuesday of October at 12:30 p.m. Special meetings of members may be called pursuant to
notice provided to the member not less than 30 nor more than 60 days prior to such meetings. This proxy shall remain
in effect until revoked either in writing by the undersigned at least 20 days prior to any meeting of members or by
attending and voting in person at any annual or special meeting of members.
HCSC pays indemnification or advances expenses to its directors, officers, employees or agents consistent with
HCSC's bylaws then in force and as otherwise required by applicable law.
Group No(s).: B19545 By:
t Signer's m Here
Group Name: Village of Oak Brook 0 -L
Address: 1200 Oak Brook Road Signature and Title Q
City: /OakBrook State:=t— Zip Code: �V5�24
Dated this:�Co VA0ay of
M Year
Cut along dotted lines
IL-LG-151 PLUS-H-BPA Rev. 06/20 Page 12
Benefit Program Application ("ASO BPA")
Applicable to Administrative Services Only (ASO) Group Accounts
administered by Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,
a Mutual Legal Reserve Company, hereinafter referred to as"Claim Administrator"or"BCBSIL"
Group Status: Renewing ASO Account
Group Number(s): P19545 (Non- Union) P19546 (H S A),
Employer Account Number(6-digits): 019545 P56642 (Police), P56643 (Fire)
Section Number(s): 0100 (Village - Union), 0101 (Village
- Non Union), 0200 (Park District), 0300 (Retirees), 0400
(Retirees over 65), 0500
(PSEBA), 0600
(Police Union), 0800 (Union - Fire), 1000 (PSEBA- Union),
1100 (Police - Union), 8887
(COBRA),
8889 (COBRA), 8900 (COBRA)
Legal Employer Name: Village of Oak Brook
(Specify the Employer or the employee trust applying for coverage. Names of subsidiary or affiliated companies to be
covered must also be named below. AN EMPLOYEE BENEFIT PLAN MAY NOT BE NAMED.)
ERISA Regulated Group Health Plan*: ❑ Yes ® No
Is your ERISA Plan Year*a period of 12 months beginning on the Effective Date of Coverage specified below? ❑ Yes
If not, please specify your ERISA Plan Year*: Beginning Date_/_/_ End Date_/_/_ (month/day/year)
ERISA Plan Administrator*:
Plan Administrator's Address:
If you maintain that ERISA is not applicable to your group health plan, give legal reason for exemption:
Select legal reason ; if applicable, specify other:
Is your Non-ERISA Plan Year* a period of 12 months beginning on the Anniversary Date specified below? ❑ Yes
If not, please specify your Non-ERISA Plan Year*. Beginning Date 07/01/2021 End Date 07 /01/2022
(month/day/year)
For more information regarding ERISA, contact your Legal Advisor.
*All as defined by ERISA and/or other applicable law/regulations
Effective Date of Coverage: (Month/Day/Year) 07/01 /2021
Anniversary Date: (Month/Day/Year) 07/01 /2022
Account Information E] NO CHANGES F-1 SEE ADDITIONAL PROVISIONS
Standard Industry Code (SIC): 8990 Employer Identification Number(EIN): 36-6009534
Address: 1200 Oak Brook Road
City: Oak Brook State: IL ZIP: 60523
Administrative Contact: Kathy Vonachen Title: Human Resources Manager
Fax Number: 630-368-
Email Address: kvonachen@oak-brook.org Phone Number: 630-368-5024 5025
Wholly Owned Subsidiaries to be covered:
Affiliated Companies to be covered: Employer Identification Number (EIN):
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
IL GEN ASO BPA(Rev. 08/20) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association
(If Subsidiaries or Affiliated Companies listed above are to be covered, Employer hereby confirms that Employer and the listed Subsidiaries and/or
Affiliates are treated as a single employer under Internal Revenue Code Section 414(b),(c)or(m).)
Blue Access for Employers (BAE) Contact: Kathy Vonachen
(The BAE Contact is the Employee authorized by the Employer to access and maintain the Employer's account in BAE.)
Email Address: kvonachen@oak-brook.org Phone Number: 630-368-5036 Fax Number: 630-368-
5037
❑ The Employer or other company listed in this BPA is a public entity or governmental agency/contractor
Producer of Record Information E NO CHANGES E] SEE ADDITIONAL PROVISIONS
Effective:
If applicable, the below-named producer(s)or agency(ies) is/are recognized as Employer's Producer of Record (POR)to
act as representative in negotiations with and to receive commissions from Blue Cross and Blue Shield of Illinois, Claim
Administrator's corporate subsidiaries, as applicable, for procuring Claim Administrator's claims administration services
for Employer's employee benefit program(s). This statement rescinds any and all previous POR appointments for the
Employer. The POR is authorized to perform membership transactions on behalf of the Employer. This appointment will
remain in effect until withdrawn or superseded in writing by the Employer.
Are commissions to be paid? ❑ Yes ❑ No
Producer or Agency to whom commissions are to be paid*:
Illinois Producer#:
NPN:
Address:
City: State:
Phone: Fax:
Is Producer/Agency appointed with BCBSIL? ❑ Yes ❑ No
Commissions:
❑ PCPM $ Does a Monthly Cap Apply ❑ Yes ❑ No $ (If cap is annual, divide by twelve)
❑ Flat$ Does a Monthly Cap Apply ❑ Yes ❑ No $ (If cap is annual, divide by twelve)
❑ Percentage of Stop Loss: %
ADDITIONAL COMMISSIONS:
"The Producer or agency name(s)above to whom commissions are to be paid must exactly match the name(s)on the appointment
application(s).
Schedule of Eligibility ■ NO CHANGES ■ SEE ADDITIONAL
PROVISIONS
Employer has made the following eligibility decisions:
1. Eligible Person means:
❑ A full-time employee of the Employer.
❑ A full-time employee of the Employer who is a member of: (name of union)
❑ A part-time employee of the Employer.
❑ A retiree of the Employer. Define criteria:
® Other: Part-time employees that work at least 20 hours per week are enrolled in the Group Health Plan as of
06/30/2006 are eligible for Group Health Coverage under this plan. Part-time employees that are not enrolled as
of 06/30/2006 and future part-time will not be eligible for coverage.
Are any classes of employees to be excluded from coverage? ❑ Yes ❑ No
If yes, please identify the classes and describe the exclusion:
2. Employee definitions:
Full-Time Employee means:
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
IL GEN ASO BPA(Rev. 08/20) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, 2
an Independent Licensee of the Blue Cross and Blue Shield Association
® A person who is regularly scheduled to work a minimum of 30 hours per week and who is on the permanent payroll
of the Employer.
❑ Other:
Part-Time Employee means:
❑ A person who is regularly scheduled to work a minimum of hours per week and who is on the permanent
payroll of the Employer.
❑ Other:
3. The Effective Date of termination for a person who ceases to meet the definition of Eligible Person:
® The date such person ceases to meet the definition of Eligible Person.
❑ The last day of the calendar month in which such person ceases to meet the definition of an Eligible Person.
❑ Other:
4. Select an effective date rule for a person who becomes an Eligible Person after the Effective Date of the Employer's
health care plan (The effective date must not be later than the 91st calendar day after the date that a newly eligible
person becomes eligible for coverage, unless otherwise permitted by applicable law).
❑ The date of employment.
® The 31st day of employment.
❑ The day of the month following month(s) of employment.
❑ The day of the month following days of employment.
❑ The day of the month following the date of employment.
❑ Other:
Is the waiting period requirement to be waived on initial group enrollment? ❑ Yes ❑ No
Are there multiple new hire waiting periods? ❑ Yes ® No
If yes, please attach eligibility and contribution details for each section.
5. Domestic partners covered: ❑ Yes ® No
If yes: a domestic partner is eligible to enroll for coverage.
If yes, are domestic partners eligible for continuation of coverage? ❑ Yes ❑ No
If yes, are dependents of domestic partners eligible to enroll for coverage? ❑ Yes ❑ No
If yes, are dependents of domestic partners eligible for continuation of coverage? ❑ Yes ❑ No
The Employer is responsible for providing notice of possible tax implications to those Covered Employees with coverage
for domestic partners.
6. Civil Union Partners covered:
❑ The Employer is an Illinois county, municipality, the State of Illinois, subject to the Illinois School Code, a church
plan or other non-ERISA plan. For such Employers, a Civil Union Partner and his or her dependents are
automatically eligible to enroll for coverage and, once enrolled, eligible for continuation of coverage as described
in the Employer's Plan.
For all other Employers: ❑Yes ❑ No
If yes:A Civil Union Partner and his or her dependents are eligible to enroll for coverage.
If yes: Are Civil Union Partners and his or her dependents eligible for continuation of coverage? ❑ Yes ❑ No
The Employer is responsible for providing notice of possible tax implications to those Covered Employees with coverage
for Civil Union Partners.
7. Limiting Age for covered children: Twenty-six (26) years, regardless of presence or absence of a child's financial
dependency, residency, student status, employment status, marital status, eligibility for other coverage, or any
combination of those factors. Other:
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
IL GEN ASO BPA(Rev. 08/20) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, 3
an Independent Licensee of the Blue Cross and Blue Shield Association
If Employer is an Illinois county, municipality, the State of Illinois, or subject to the Illinois School Code, this Limiting Age
is extended to thirty (30) years, for unmarried eligible military personnel as described in the Employer's Plan.
8. Termination of coverage upon reaching the Limiting Age:
❑ The last day of coverage is the day prior to the birthday.
® The last day of coverage is the last day of the month in which the limiting age is reached.
❑ The last day of coverage is the last day of the billing month.
❑ The last day of coverage is the last day of the year(12/31) in which the limiting age is reached.
❑ The last day of coverage is the day prior to the Employer's Anniversary Date.
Will coverage for a child who is medically certified as disabled and dependent on the employee terminate upon reaching
the limiting age even if the child continues to be both disabled and dependent on the employee? ❑ Yes ❑ No
However, such coverage shall be extended in accordance with any applicable federal or state law. The Employer will
notify BCBSIL of such requirements.
9. Disabled dependent: A disabled dependent means a dependent child who is medically certified as disabled and
dependent upon the Employee or his/her spouse.
To administer medical certification of disabled dependents, you may select option (a) Standard Rules or (b) Custom
Rules. If(b)is selected there are additional selections regarding age, proof of prior coverage, certification review, forms,
and previous medical certification approvals.
(a) ® Disabled dependent administration will follow Standard Rules.
A disabled dependent is eligible to continue coverage beyond the limiting age, provided the disability began before
the child attained the age of 26. A disabled dependent is eligible to add coverage beyond the limiting age, provided
the disability began before the child attained the age of 26, and proof of coverage as a disabled dependent is
provided. Administration of certification review is handled by BCBSIL; a disabled dependent certification form must
be submitted to BCBSIL.
(b) ❑ Disabled dependent Administration will follow Custom Rules. Please make the following sections:
Age: Please select one option regarding age of when the disability began.
❑ The disability must have begun before the child attained the age of 26.
❑ All disabled Dependents are covered regardless of when the disability began.
Proof of prior coverage: Please select required or not required below:
When adding coverage, proof of prior coverage as a disabled dependent is ❑ required ❑ not required.
Certification review: Please select one option regarding handling of certification review.
❑ Certification review is handled by BCBSIL; a disabled dependent certification form must be submitted to BCBSIL.
❑ Certification review is handled by the Employer; there are no disabled dependent certification form requirements.
If certification review is selected as handled by BCBSIL, please select one option regarding forms:
❑ The disabled dependent certification form will be utilized.
❑ A ❑ custom or❑ other disabled dependent certification form will be utilized.
If Certification Review is selected as handled by BCBSIL, please select allowed or not allowed below:
A disabled dependent approved medical certification from a prior carrier is ❑ allowed ❑ not allowed.
A disabled dependent approved medical certification from a prior BCBS policy is ❑ allowed ❑ not allowed.
10. Will extension of benefits due to temporary layoff, disability or leave of absence apply?
® Yes (specify number of days below) ❑ No
Temporary Layoff: 0 days Disability: Police & Fire by IL Statute; Other 90 days Leave days
Leave of Absence: 0 days
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
IL GEN ASO BPA(Rev. 08/20) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, 4
an Independent Licensee of the Blue Cross and Blue Shield Association
However, benefits shall be extended for the duration of an Eligible Person's leave in accordance with an applicable
federal or state law. The Employer will notify BCBSIL of such requirements.
11. Enrollment:
Special Enrollment: An Eligible Person may apply for coverage, family coverage or add dependents within thirty-one
(31) days of a Special Enrollment qualifying event if he/she did not previously apply prior to his/her Eligibility Date or
when otherwise eligible to do so. Such person's Coverage Date, family Coverage Date, and/or dependent's Coverage
Date will be the effective date of the qualifying event or, in the event of Special Enrollment due to marriage or termination
of previous coverage, then no later than the first day of the Plan Month following the date of receipt of the person's
application of coverage.
An Eligible Person may apply for coverage within sixty (60) days of a Special Enrollment qualifying event in the case
either of a loss of coverage under Medicaid or a state Children's Health Insurance program, or eligibility for group
coverage where the Eligible Person is deemed qualified for group coverage assistance under a state Medicaid or CHIP
premium assistance program.
Open Enrollment: An Eligible Person may apply for coverage, family coverage or add dependents if he/she did not
apply prior to his/her Eligibility Date or did not apply when otherwise eligible to do so, during the Employer's annual
Open Enrollment Period. Such person's Coverage Date, family Coverage Date, and/or dependent's Coverage Date will
be a date mutually agreed to by the Claim Administrator and the Employer. Such date shall be subsequent to the Open
Enrollment Period.
Specify Open Enrollment Period: The month of June for a July 1st effective date
Late Enrollment: An Eligible Person may apply for coverage, family coverage or add dependents if he/she did not
apply prior to his/her Eligibility Date or did not apply when otherwise eligible to do so. Such person's Coverage Date,
family Coverage Date, and/or dependent's Coverage Date will be a date mutually agreed to by the Claim Administrator
and the Employer.
Select one of the provisions below:
❑ Open Enrollment— Late applicants may only apply during Open Enrollment.
❑ Late Entrant— Late applicants may apply at any time—coverage effective date is determined by the receipt date
and the rules governing off-cycle enrollments.
12. * Does COBRA Auto Cancel apply? ® Yes ❑ No
Member's COBRA/Continuation of Coverage will be automatically cancelled at the end of the member's eligibility period.
*Not recommended for accounts with automated eligibility.
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
IL GEN ASO BPA(Rev.08/20) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, 5
an Independent Licensee of the Blue Cross and Blue Shield Association
Lines of Business (Check all applicable F1 NO CHANGES El See Additional Provisions
Medical Plan Services: Consumer Driven Health Plan:
® Participating Provider Option (PPO) ❑ Health Care Account(HCA)Administrative Services
❑ Blue Choice Select PPO (if purchased, complete separate HCA BPA)
❑ Blue Choice Options ® HSA Eligible Health Plan (Vendor: Other)
❑ BlueEdgesm FSA(Vendor: Select Vendor)
Prescription Drugs:
Additional Services: ® Covered under a pharmacy benefit (If selected, the
❑ Wellbeing Management PBM Fee Schedule Addendum must be attached
❑ Wellness Incentives and is part of this BPA.)
❑ Health Advocacy Solutions ❑ Covered under the medical benefit or Blue Script
❑ Mercer Health Advantage
❑ Custom Care Management Unit Pharmacy Network(Select one):
❑ Blue Directionssm (Private Exchange) (If ® Traditional Select Network
selected, the Blue Directions Addendum is
attached and made a part of the parties' Advantage Network
Administrative Services Agreement.) ❑ Preferred Network (Not offered with Blue Script)
❑ Elite Network (Not offered with Blue Script)
❑ Limited Fiduciary Services for Claims and ❑ Network on PBM Fee Schedule Addendum
Appeals ❑ Other(please specify):
❑ Other Select Product PPO Drug List: Basic Drug List
❑ Other Select Product Other(please specify): Enhanced
❑ Other Select Product
❑ Other Select Product PPO/HSA Preventive Drug List:
❑ Other Please specify: Select Option
❑ Other
Other Rx programs:
Please specify: Select Program
Prescription Drug Program Clinical Programs
❑ PCM (Retrospective) (Included with HAS)
Ancillary Services:
❑ Dental Plan Services
❑ Vision Plan Services
® Stop Loss(if selected, complete separate Exhibit to the
Stop Loss Coverage Policy)
❑ Life or Disability Insurance provided by separate
carrier (if selected, complete separate Life
application)
❑ COBRA Administrative Services (if selected,
complete separate COBRA Administrative Services
Addendum to the BPA)
Mercer Health Advantage is offered by Mercer,an independent company,and is administered by Blue Cross and Blue Shield of Illinois
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
IL GEN ASO BPA(Rev.08/20) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, 6
an Independent Licensee of the Blue Cross and Blue Shield Association
FEE SCHEDULE
Employer shall pay amounts Claim Administrator bills Employer for benefit claims Claim Administrator processes on
Employer's behalf as well as administrative fees as set forth in this Fee Schedule.
Payment Specifications M NO CHANGES E] SEE ADDITIONALPROVISIONS
Employer Payment Method: ❑ Online Bill Pay ® Electronic ❑ Auto Debit ❑ Check
Employer Payment Period: ❑ Weekly (cannot be selected if Check is selected as payment method above)
❑ Semi Monthly (cannot be selected if Check is selected as payment method above)
® Monthly
Claim Settlement Period: ® Monthly
Run-Off Period: Employer Payments are to be made for 12 months following end of Fee Schedule Period.
Standard is twelve (12) months.
Fee Schedule Period: To begin on Effective Date of Coverage and continue for 12 months. If other than 12
months, please specify: 60 Months
Administrative Per Employee Per Month F-1 NO CHANGES E SEE ADDITIONAL PROVISIONS
(PEPM) Charges
All Group
Numbers
Administrative Fee $69.59 $ $ $
Dental $ $ $ $
Limited Fiduciary Services $ $ $ $
Health Advocacy Solutions $ $ $ $
Wellbeing Management $ $ $ $
Management of the Virtual Visits Program $ $ $ $
Medical Rebate Credit $-2.10 $ $ $
*Rebate Credit for the Prescription Drug Program $-73.25 $ $ $
PCM (Retrospective) (No cost if both HAS and $ $ $ $
Prescription Drug Program are elected)
Commissions: $ $ $ $
Commissions: $ $ $ $
Commissions: $ $ $ $
Other: Select Service Category
List Service: $ $ $ $
Other: Select Service Category
List Service: $ $ $ $
Other: Select Service Category
List Service: $ $ $ $
Other: Select Service Category
List Service: $ $ $ $
Miscellaneous: $ $ $ $
Miscellaneous: $ $ $ $
Total $-5.76 $ $ $
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
IL GEN ASO BPA(Rev. 08/20) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, 7
an Independent Licensee of the Blue Cross and Blue Shield Association
*The Rebate Credit is a per Covered Employee per month credit applied to the monthly billing statement. The Employer
and Claim Administrator have agreed to the Rebate Credit and Employer agrees that it and its group health plan have no
right to, or legal interest in, any portion of the rebates, either under the pharmacy benefit or the medical benefit, actually
provided by the Pharmacy Benefit Manager("PBM")or a pharmaceutical manufacturer to Claim Administrator and consents
to Claim Administrator's retention of all such rebates. The Rebate Credit will be provided from Claim Administrator's own
assets and may or may not equal the entire amount of rebates actually provided to Claim Administrator or expected to be
provided. Rebate Credits shall not continue after termination of the Prescription Drug Program. Employer agrees that any
Rebate Credit provision in the governing Administrative Services Agreement to the contrary is hereby superseded.
Administrative Line Item Charges
Other: Select Service Category Select Billing Frequency $
List Service: If applicable, describe other:
Other: Select Service Category Select Billing Frequency $
List Service: If applicable, describe other:
Other: Select Service Category Select Billing Frequency $
List Service: If applicable, describe other:
Other: Select Service Category Select Billing Frequency $
List Service: If applicable, describe other:
Miscellaneous: Select Billing Frequency $
If applicable, describe other:
Miscellaneous: Select Billing Frequency $
If applicable, describe other:
Total:
Claim Administrator Provider Access Fee(s) Z NO CHANGES E] SEE ADDITIONAL PROVISIONS
Group Number(s): P19545 (Non- Union) P19546 (H S A), P56642 (Police), P56643 (Fire)
® % of ADP Savings: 2.33%
❑ $ per Covered Employee per month: $
❑ Group with multiple Provider Access Fees by services (e.g., CMM, and/or PPO plans):
Group Number(s):
❑ % of ADP Savings: %
❑ $ per Covered Employee per month: $
BlueCard Program/Network access fees: Available upon request.
i Other Service and/or Program Fee(s) F-1 NO CHANGES [:] SEE ADDITIONAL PROVISIONS
External Review Coordination: ❑ Yes ® No
If yes, coordination fee: $700 for each external review requested by a Covered Person that the Claim Administrator
coordinates for the Employer in relation to the Employer's Plan.
Employer elects the following process:
❑ State of Illinois External Review Process ® Federal Affordable Care Act Process
Reimbursement Service: ® Yes ❑ No
/f yes: It is understood and agreed that in the event Claim Administrator makes a recovery on a third-party liability
claim, Claim Administrator will retain 25% of any recovered amounts other than recovery amounts received as a
result of or associated with any Workers' Compensation Law.
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
IL GEN ASO BPA(Rev.08/20) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, 8
an Independent Licensee of the Blue Cross and Blue Shield Association
Third-Party Recovery Vendors and Law Firms Provisions (other than Reimbursement Services): ❑ Yes ❑ No
Employer will pay no more than 25% of any recovered amount made by Claim Administrator's Third-Party Recovery
Vendor or up to 25% of any recovered amount will be deducted from the amount distributed according to established
allocation processes. Employer will pay no more than 35% of any recovered amount made by Claim Administrator's
third-party law firm or up to 35% of any recovered amount will be deducted from the amount distributed according to
established allocation processes.
Alternative Compensation Arrangements: Employer acknowledges and agrees that Claim Administrator has
Alternative Compensation Arrangements with contracted Providers, including but not limited to Accountable Care
Organizations and other Value Based Programs. Further information concerning Employer's payment for covered
services under such Arrangements is described in the Administrative Services Agreement between the Claim
Administrator and the Employer.
Virtual Visits Program: ❑ Yes ® No
If yes, Covered Persons would be able to obtain certain Covered Services remotely via interactive video and/or
interactive audio/video (where available) capability from Virtual Visits powered by MDLIVE.
Termination Administrative Charge
As applies to the Run-Off Period indicated in the Payment Specifications section above:
L For service charges(including, but not limited to, access fees)billed on a per Covered Employee basis at the
time of termination of the Administrative Services Agreement or partial termination of Covered Employees,
the Termination Administrative Charge will be the amount equal to ten percent(10%)of the annualized charges based
on the service charges in effect as of the termination date or date of partial termination and the Plan participation of
the two (2) months immediately preceding the termination date or date of partial termination. Such aggregate amount
will be due the Claim Administrator within ten (10)days of the Claim Administrator's notification to the Employer of the
Termination Administrative Charge described herein.
ii. For service charges (including, but not limited to, access fees) billed on a basis other than per Covered
Employee at the time of termination of the Administrative Services Agreement or partial termination of
Covered Employees, the Termination Administrative Charge will be such service charges in effect at the time of
termination of the Agreement or partial termination of Covered Employees to be applied and billed by the Claim
Administrator, and paid by the Employer, in the same manner as prior to termination of the Agreement or partial
termination of Covered Employees.
Other Provisions NO CHANGES SEE ADDITIONAL - • •
1. Summary of Benefits & Coverage:
a. Will Claim Administrator create Summary of Benefits and Coverage (SBC)?
® Yes. Please answer question b. The SBC Addendum is attached.
❑ No. If No, then skip question b and refer to the Administrative Services Agreement for further information.
b. Will Claim Administrator distribute the (SBC) to Covered Persons?
® No. Claim Administrator will create SBC (only for benefits Claim Administrator administers under the
Agreement) and provide SBC to Employer in electronic format. Employer will then distribute SBC to Covered
Persons (or hire a third party to distribute) as required by law.
❑ Yes. Claim Administrator will create SBC (only for benefits Claim Administrator administers under the
Agreement) and provide SBC to Employer in electronic format. Employer will then distribute to Covered
Persons as required by law, except that Claim Administrator will send the SBC in response to any request
received directly from Covered Persons.
❑ Yes. Claim Administrator will create SBC (only for benefits Claim Administrator administers under the
Agreement) and distribute SBC to plan participants and beneficiaries via regular hardcopy mail or
electronically. Distribution Fee for hardcopy mail is $1.50 per package. The distribution fee will not apply to
SBCs that Claim Administrator sends in response to any request received directly from a Covered Person.
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
IL GEN ASO BPA(Rev. 08/20) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, 9
an Independent Licensee of the Blue Cross and Blue Shield Association
2. Massachusetts Health Care Reform Act:
Does the Employer direct Claim Administrator to provide written statements of creditable coverage to its Covered
Employees who reside, or have enrolled dependents who reside, in Massachusetts and file electronic reports to the
Massachusetts Department of Revenue in a manner consistent with the requirements under the Massachusetts Health
Care Reform Act? ® Yes ❑ No
If no:The Employer acknowledges it will provide written statements and electronic reporting to the Massachusetts
Department of Revenue if required by the Massachusetts Health Care Reform Act.
3. Alternative Care Management Program (applicable to the purchased medical management program):
® Yes ❑ No
The undersigned representative authorizes provision of alternative benefits for services rendered to Covered Persons
for Utilization Management, Case Management, including but not limited to Behavioral Health, and other health care
management programs.
4. Prior Authorization (applicable to the purchased medical management program): Employer acknowledges and
agrees to utilize Claim Administrator's standard list of services and supplies for which pre-notification or
preauthorization is required: ® Yes ❑ No
If no, Employer authorizes Claim Administrator to post Employer's pre-notification or preauthorization requirements
on Claim Administrator's Website: ❑ Yes ❑ No
5. Essential Health Benefits ("EHB") Election:
Employer elects EHBs based on the following:
1. 0 EHBs based on a Claim Administrator state benchmark:
® Illinois ❑ Montana ❑ New Mexico ❑ Oklahoma ❑ Texas
2. ❑ EHBs based on benchmark of a state other than IL, MT, NM, OK and TX
If so, indicate the state's benchmark that Employer elects: _
3. ❑ Other EHB, as determined by Employer
In the absence of an affirmative selection by Employer of its EHBs, then Employer is deemed to have elected the EHBs
based on the Illinois benchmark plan.
6. This ASO BPA is binding on both parties and is incorporated into and made a part of the Administrative Services
Agreement between the parties with both such documents to be referred to collectively as the "Agreement" unless
specified otherwise.
7. Producer/Consultant Compensation:
The Employer acknowledges that if its POR acts on its behalf for purposes of purchasing services in connection with
the Employer's Plan under the Administrative Services Agreement to which this ASO BPA is attached, the Claim
Administrator may pay the Employer's POR a commission and/or other compensation in connection with such
services under the Agreement. If the Employer desires additional information regarding commissions and/or other
compensation paid to the POR by the Claim Administrator in connection with services under the Administrative
Services Agreement, the Employer should contact its POR.
Additional Provisions: Effective 7/1/21: Group is renewing with no benefit changes.
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
IL GEN ASO BPA(Rev. 08/20) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, 10
an Independent Licensee of the Blue Cross and Blue Shield Association
Signature
Ruben Mendez ,
Sales Representativeure of Authorized Purchaser
822 630-824-5197 -t CG Lirt2t� V �s7lJ
District Phone & FAX Numbers PI ame
Brian Walsh
Producer Representative Title c--
VistaNational Insurance
Producer Firm Date
1301 West 22nd Street Suite 600
Oak Brook, IL 60523
Producer Address
Producer Phone & FAX Numbers
Producer Email Address
36-4095485
Tax I.D. No.
Proprietary and Confidential Information of Claim Administrator
Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except
with written permission of Claim Administrator.
IL GEN ASO BPA(Rev. 08/20) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association