Okaloosa County BOCC — June 17, 2014 — BlueMedicare — reading text

CONTRACT & LEASE INTERNAL COORDINATION SHEET Contract/Lease Number: CH Diop - LIN) Tracking Number: q G | -1 Grant Funded: YES NO x Contractor/Lessee Name: Blige Creede Purpose_{V\g agro | Den pel ~ Date/Term: Cite Nonorin 1. Ml GREATER THAN $50,000 Amount: 2. L] GREATER THAN $25,000 Department: Lan 3. L] $25,000 or Less a L ny ; 4 3 Dept. Monitor Name:_ 7 Veo d aus A Lk, L Document has been reviewed and includes any attachments or exhibits. Purchasing Review cS requirements aré ‘met: Se / oe ly Phechasind Direltor or or Désignee CMayne ki =— Risk Management Review Approved as written: MELE Date: bfef are Risk Manager or designee Gwerf,box, S/S. County Attorney Review Date: [ ~F~1Y 1. unty. a —<prer tnd 7! ie of Com Sau Following Okaloosa County approval: Contracts & Grants Document has been received: Date: Contracts & Grants Manager Florida Blue An Independent Licensee of the Blue Cross and Blue Shield Assaciation BLUEMEDICARE GROUP MASTER AGREEMENT SECTION 1: INTRODUCTION This BlueMedicare Group Master Agreement (this “Agreement") describes the rights and obligations which you and Blue Cross and Blue Shield of Florida, Inc. (“Florida Blue”) have with respect to the group Medicare Advantage, Medicare Advantage Prescription Drug Plan, and/or standalone Medicare Prescription Drug Plan (hereinafter, “Medicare Plan(s)”) coverage to be provided by us to your Covered Retirees and Covered Dependents. References to “we”, “us”, “our,” and Florida Blue throughout this Agreement refer to Blue Cross and Blue Shield of Florida, Inc. In exchange for your payment of the Premium, we agree to provide the coverage and/or benefits specified in the Evidence of Coverage for the Medicare Plan(s) (“Evidence of Coverage”), a copy of which is attached to this Agreement. The coverage to be provided by us under the Group Plan which you have established is described in the Evidence of Coverage. SECTION 2: DEFINITIONS Certain terms defined in the Agreement are also used and defined (for the convenience of Covered Persons) in the Evidence of Coverage. If a word or phrase starts with a capital letter, it is either the first word in a sentence, a proper name, a title, or a defined term. The following defined terms apply to this Agreement: Anniversary Date means the date one year after the Effective Date of coverage and subsequent annual anniversaries or such other date as mutually agreed to in writing by the parties. Appeal means a request submitted by or on behalf of a Covered Person for a review of our decision to deny a request for coverage of health care services or prescription drugs or payment for services or drugs. CMS means the Centers for Medicare and Medicaid Services. CMS Requirements means the provisions of Parts C and D of Title XVIII of the Social Security Act, CMS Medicare Part C and D regulations at 42 C.F.R. Parts 422 and 423, the CMS Managed Care and Prescription Drug Benefit Manuals, other CMS instructions and guidance and the provisions of Florida Blue’s contracts with CMS to offer the Medicare Plans. Late Enrollment Penalty (“LEP”) means an amount added to the Part D Premium of an individual who did not have Part D coverage or other creditable prescription drug plan when the individual first became eligible for Part D or who had a break in Part D or other creditable prescription drug coverage for at least 63 days. Low Income Subsidy (“LIS”) means the premium subsidy amount paid to us by CMS for qualifying Covered Persons with Medicare Part D coverage. Medicare Plan means the group Medicare Advantage Plan, Medicare Advantage Prescription Drug Plan, and/or standalone Medicare Prescription Drug Plan that you select. Premium means the amount required to be paid by the Group to us for coverage under this Agreement. Service Area means a geographic area where a Medicare Plan accepts members. SECTION 3: ELIGIBILITY, ENROLLMENT, AND DISENROLLMENT A. Eligibility Determination Determination of whether an individual is an Eligible Retiree or Eligible Dependent will be a two-step process: 1. You will determine whether the individual is eligible to participate in the retiree group health benefit plan that you sponsor. For individuals meeting your eligibility criteria, you will promptly forward completed applications to us. You are responsible for complying with all applicable laws and regulations, including but not limited to the Employee Retirement Income Security Act (ERISA) and the Internal Revenue Code, in making this eligibility determination. You must also comply with all eligibility guidelines included in the benefit administrative guide and Evidence of Coverage. 2. After receiving a complete application, we will process the application in accordance with CMS Requirements. An application must be approved by us and accepted by CMS for an individual to be enrolled in a Medicare Plan. B. Distribution of Enrollment Materials You may only distribute materials describing the Medicare Plan that we have provided to you or that we have approved in writing. You will distribute any pre-enrollment materials that we provide to you to each potential enrollee before collecting enrollment applications. Nothing in this Section will preclude you from making additional disclosures about your group health benefit plan as applicable to comply with ERISA, such as a wrap-around summary plan description or other plan document. If applicable, you are solely responsible for compliance with ERISA disclosure requirements in connection with the Medicare Plan(s). 1. At least sixty (60) calendar days prior to such Anniversary Date, you notify us that you do not want the Agreement to automatically renew; or 2. It is terminated as permitted by its terms. At least ninety (90) calendar days before each Anniversary Date, we will provide you with notice of changes in Premium and benefits under the Medicare Plan for the upcoming year (the “Renewal Notice”). If this Agreement renews as specified above, all of its terms and provisions (including the Premium due) shall be amended to include the terms of the Renewal Notice, and the amended Agreement shall govern coverage as of the Anniversary Date. Payment of the new charges shall constitute acceptance of the change in Premium rates. This Agreement is conditionally renewable. This means that it automatically renews each year on your Anniversary Date unless terminated earlier in accordance with its terms. B. Termination by Group The Group may cancel this Agreement on its Anniversary Date by giving written notice to us at least sixty (60) calendar days in advance, unless we have initiated a termination for any of the reasons stated below. C. Termination by Florida Blue We may terminate this Agreement or refuse to renew for the following reasons: 1. Failure to Pay Premiums. You do not pay Premiums in accordance with its terms or we have not received timely Premium payments prior to the end of the Grace Period. Termination of this Agreement for failure to pay premiums shall be effective as of the end of the Grace Period. In the event of such termination, you are obligated to pay the following: a. Any portion of the Premium due for coverage provided by us prior to termination; and b. Any amounts otherwise due us. 2. Fraud or Intentional Misrepresentation of Material Fact. You perform an act, or engage in any practice, that constitutes fraud or make an intentional misrepresentation of material fact. 3. Group Contribution and Participation and CMS Rules. You do not comply with: (1) a material provision which relates to rules for Group contributions or Covered Person participation; or (2) any provision in this Agreement which relates to LIS or other CMS Requirements. 4. Service Area. There is no longer any Covered Person who lives, resides, or works in the Service Area. frequency of payment. The Premium is due and payable on or before the first day of each succeeding calendar month to which such payments apply. C. Grace Period This Agreement has a thirty (30) calendar day Premium payment Grace Period, which begins on the date the Premium payment is due. If we do not receive the required Premium payment on or before the date it is due, it may be paid during this Grace Period. Coverage will stay in force during the Grace Period. If Premium payments are not received by the end of the Grace Period, we will terminate this Agreement and proceed with the disenrollment of Covered Persons as described in Section 3 of this Agreement. D. Changes in Premium Premium rates may be changed on your Anniversary Date as described in Section 4.A above regarding renewal. E. Other Rules Regarding the Payment of Premiums 1. CMS rules govern the effective date of any disenrollment of a Covered Person under this Agreement, and we are not required to retroactively terminate this Agreement or coverage for any Covered Person. 2. If full payment of the Premium is not paid when due, this Agreement may be terminated as described in Section 4 of this Agreement. F. Premium Subsidization You may subsidize Premium amounts charged to Eligible Retirees. You are responsible for compliance with all applicable laws and regulations relating to your subsidy of Premiums, including ERISA and CMS Requirements, as applicable. You acknowledge and agree that Premium subsidization may vary for different classes of Eligible Retirees only if such classes are reasonable and based on objective business criteria. You represent and warrant that you will not vary Premium subsidization based on any Covered Person’s eligibility for LIS. Further, you will not vary Premium subsidization for individuals within a given class of Eligible Retirees. In no case will you charge an Eligible Retiree more than the sum of the monthly Premium that we charge you for the Medicare Plan benefits. G. Low Income Subsidy You will comply with the following requirements in connection with LIS: 1. You are required to pass through any LIS payments received from CMS to reduce the Premium amount that the Covered Retiree pays. You will first apply any LIS amounts to a Covered Person’s share of Premium. You may not benefit from any LIS amount until the Premium for a Covered Person (including amounts for the non-drug benefits in a the Medicare Advantage Program policies then in effect. The Medicare Advantage Program available to Covered Persons under this Agreement is described generally below. B. Covered Persons Liability Calculation The cost of the service on which the Covered Person’s liability is based, will be either: 1. The Medicare allowable amount for covered services; or 2. The amount we negotiate with the provider of the Host Blue negotiates with its provider on behalf of our Covered Persons, if applicable. The amount negotiated may be either higher than, lower than, or equal to the Medicare allowable amount. SECTION 7: GENERAL PROVISIONS A. Administration and Record Retention You must provide us with any information we need to administer the coverage and/or benefits to be provided or needed to compute the Premium due. While this coverage is in force, we have the right, at any reasonable time, to examine your records on any issues necessary to verify information provided by you. You must retain all records relating to this Agreement, including but not limited to those relating to LIS administration, for the current calendar year plus an additional ten (10) years. B. Assignment and Delegation You may not assign, delegate or otherwise transfer this Agreement and the obligations hereunder without our written consent. Any assignment, delegation, or transfer made in violation of this provision shall be void. We may assign, delegate, or otherwise transfer this Agreement to our successor in interest or an affiliated entity without your consent at any time. C. Authorization Where this Agreement requires that an act involving the administration of coverage and/or benefits be authorized or