Okaloosa County BOCC — February 4, 2014 — BlueMedicareContract — reading text

CONTRACT #C14.2126-RM BLUE MEDICARE MEDICARE FOR RETIREES EXPIRES: 9/30/2014 WITH | AUTO REN Flovida “ms Blue OG 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 agrec 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. SIL fj Covered Dependent means an Eligible Dependent who continucs to mect all applicable eligibility requirements described in the Evidence of Coverage and who is enrolled, and actually covered, under the Agreement other than as a Covered Retiree. Covered Person means a Covered Retiree or a Covered Dependent. Covered Retiree means an Eligible Retiree, who continues to meet all applicable eligibility requirements described in the Evidence of Coverage and who is enrolled, and actually covcred, under the Agreement other than as a Covered Dependent. Effective Date for the Group means 12:0] a.m. on the date specified on the last page of this Agreement and for Covered Persons means 12:0] a.m. on the date coverage will begin as specified in the Evidence of Coverage. Eligible Dependent means an individual who meets and continues to meet all of the cligibility requirements described in the Evidence of Coverage. Eligible Retiree means an individual who meets and continues to meet all of the eligibility requirements set forth in the Evidence of Coverage and is eligible to enroll as a Covered Retirce. An Eligible Retiree is not a Covered Retiree until actually enrolled and accepted for coverage as a Covered Retiree by us. Enrollment Forms means those forms, electronic or paper, which are approved by us and used to maintain accurate enrollment files under the Agreement. Grace Period means the sixty (60) calendar day period beginning on the date the Premium is due. Grievance means a type of complaint submitted by a Covered Person (or other person eligible under CMS Requirements to submit a Grievance) about us or one of our network providers or pharmacies, including a complaint concerning the quality of care. This type of complaint docs not involve coverage or payment disputes. Group means the employer, labor union, association, partnership, corporation, department, other organization or entity through which coverage and benefits are issued by us. Note: References to "you" or "your" throughout the first part of this Agreement also refer to the Group. References to “you” or “your” in the Evidence of Coverage refer to Eligible Retirees, Eligible Dependents, Covered Retirees and/or Covered Dependents depending on the context and intent of the specific provision. Group Master Agreement or Agreement means the written document which is evidence of the entire agreement between the Group and Florida Blue whereby coverage and benefits arc provided to Covered Persons. 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). AL JN C. Group Disenroliment If you decide to disenroll all Covered Persons from a Medicare Plan, you must: 1. Notify all beneficiaries that you intend to disenroll them from the Medicare Plan. You will provide this notice at least twenty one (21) calendar days before the disenrollment. This notice will explain how to contact Medicare for information about other plan options that may be available. You will include language provided by Florida Blue in this notice to meet specific CMS Requirements for notice contents. 2. Provide us with all information necessary to submit a complete disenrollment request transaction to CMS in accordance with CMS Requirements. 3. In the event of termination of this Agreement, provide advanced notice in accordance with Section 4 of this Agreement. D. Individual Covered Person Disenrollment Covered Persons may be disenrolled from a Medicare Plan by Florida Blue if they become ineligible for continued enrollment. Covered Persons may also be disenrolled if this Agreement terminates or if you inform us that they are no longer eligible to participate in your retiree group health plan. If Florida Blue determines that a Covered Person is ineligible for continued enrollment or if you instruct us to disenroll an individual, you must: |. Provide us with at least thirty (30) calendar days advanced notice of the ineligibility or disenrollment election of an individual; and 2. Provide the Covered Person(s) who will be disenrolled with at least twenty one (21) calendar days advanced notice of the termination and of other insurance options that are available to them. You will include language provided by Florida Blue in this notice to meet specific CMS Requirements for notice contents. The Covered Person will have the opportunity to elect another plan offered by us or by you, join Original Medicare, or join another carrier’s Medicare Plan (by submitting an enrollment request to that organization). SECTION 4: TERM AND TERMINATION A. Term of Agreement and Renewal Process This Agreement shall become effective as of the Effective Date provided: (1) that we accept your Group Application; and (2) that you pay the required initial Premium specified by us. This Agreement shall continue in effect until the first Anniversary Date following the Effective Date unless terminated earlier as permitted by its terms. After the initial term, this Agreement shall automatically renew each succeeding year on the Anniversary Date for an additional onc- year period unless: I. 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. Itis 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 ates. 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