Okaloosa County BOCC — August 16, 2016 — Enrollment Summary with Benefit Changes 10-1-2016 Okaloosa County BCC — reading text

ENROLLMENT SUMMARY For Groups with 51+ Eligible Employees Medicare Secondary Payor Compliance Multiple Employer Plan: a plan sponsored by more than one employer. Multi-employer plan: a plan jointly sponsored by employers and unions. If you are a single employer plan: ✔ Yes No Our Company employed 20 or more employees** each working day in 20 or more calendar weeks during the current or preceding calendar year. If you are a single employer, multiple employer, or multi-employer plan: ✔ Yes No Our Company employed 100 or more employees** on 50 percent or more of the business days during the preceding calendar year. If you are a multiple employer or a multi-employer plan: All employers in our Group Health Plan (GHP) employed 20 or more employees** for 20 or more weeks in either the current or Yes No proceding calendar year. Yes No At least one of the employers in our GHP employed 20 or more employees** for 20 or more weeks in either the current or preceding calendar year. Yes No All employers in our GHP employed fewer than 20 employees** for 20 or more weeks in either the current or preceding calendar year. **"Employees" includes all full and/or part time employees Common Ownership/Controlled Group Compliance Yes ✔ No Our Company is part of a common ownership or Controlled Group as defined by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") states that all persons treated as a single employer under subsection (b), (c), (m), or (o) of section 414 of the Internal Revenue Code of 1986 shall be treated as one employer. General Information Group Name Okaloosa Co Bd of Co Commissioners 59-6000765 Tax ID # Group Number 41954 Group Sales Rep/Agent Dave Sanna/Glenn Little Effective Date Oct 1, 2016 Employer Contribution Toward Employees Premium (50% recommended for groups with 51+ employees) 100 What was the average total number of all employees (full-time, part-time, and seasonal) in the previous calendar year? 1,076 II. Recap of Employee Participation Participation must be collected in certain scenarios. Please use the drop down and select the option that most fits your company. Renewal w/76 or more Enrolled with Benefit Changes Provide information regarding the questions listed below in the right hand column. Some cells are auto-calculated and can not be typed within. 1. How many TOTAL EMPLOYEES ON PAYROLL do you have? 824 2. How many TOTAL COBRA CONTINUANTS are currently enrolled in your Group Health Plan (GHP)? 3 3. The form will calculate the TOTAL INELIGIBLE EMPLOYEES according to answers in 3A through 3C below. 118 A. How many Total Part Time and Seasonal Employee(s) do you have currently have? 93 B. How many Total New Employees (in Waiting Period) do you currently have? 25 C. How many Total Other Employee(s) are not eligible or accounted for in 3A & 3B? 0 4. The form will calculate the TOTAL ELIGIBLE EMPLOYEES according to above answers to determine Group size. 709 A. How many Total Employees with Other Coverage are not enrolling in this GHP? 124 B. Indicate Other employee(s) totals not accounted for above that are eligible. 0 C. How many employees are Not Covered by BCBSF/HOI? (Provide Total from Common Ownership Groups.) 0 5. The form will calculate the TOTAL ELIGIBLE FOR PARTICIPATION according to the above answers. 585 A. Enter the number of Total Refusals. This represents employees refusing coverage without other 0 coverage. 6. The form will calculate the TOTAL ENROLLED according to the answers provided above. 585 7. The form will calculate the total EMPLOYEE PARTICIPATION using the answers provided. (65% Recommended) 100% 8. The form will calculate the ENROLLED PERCENT OF TOTAL (6/4) (50% RULE) using the answers provided. 83% Page 1 of 2 Enrollment Summary Form 7823SR (Rev 0613) Last Revised 09/16/2013  ENROLLMENT SUMMARY For Groups with 51+ Eligible Employees Please read the information below and provide electronic signatures when the document is completed. I certify that the above information is correct to the best of my knowledge. I understand that this information will be used to determine my company's compliance with Blue Cross Blue Shield of Florida, INC. and/or Health Options, INC. eligibility and Underwriting Guidelines, as well as the applicability of State and Federal laws relating to my company and plan. Blue Cross Blue Shield of Florida INC. and/or Health Options, INC. reserves the right to request a UCT-6 or other documentation as evidence of business activity at any time and from time to time in order to validate my compliance with eligibility and Underwriting Guidelines, as well as validate the applicability of State and Federal laws. I certify that the applicant is a single employer under section 414 of Internal Revenue Code of 1986 (26 U.S.C. 414 (b), (c), (m), or (o)), and under any applicable state law. I understand that any person who knowingly and with intent to injure, defraud, or deceive any insurer, files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Charles K. Windes, Chairman Date/Time Field Page 2 of 2 Enrollment Summary Form 7823SR (Rev 0613) Last Revised 09/16/2013