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

terminated, provided you have furnished us with timely and accurate enrollment information. Errors or delays by you in furnishing accurate enrollment information to us will not affect our right to strictly enforce any and all eligibility requirements. 1. Entire Agreement This Agreement sets forth the exclusive and entire understanding and agreement between the parties and shall be binding upon the Covered Persons, the parties, and any of their subsidiaries, affiliates, successors, heirs, and permitted assigns. All prior negotiations, agreements, and understandings are superseded hereby. No oral statements, representations, or understanding by 10 any person can change, alter, delete, add or otherwise modify the express written terms of this Agreement, which includes the terms of coverage and/or benefits set forth in the Evidence of Coverage, the Schedule of Benefits, and any other attachments, amendments or riders. J. Financial Responsibilities of the Group We reserve the right to recover any benefit payments made to or on behalf of any individual whose coverage has been terminated. Our recovery efforts may relate to benefit payments madc for health care services rendered subsequent to the Covered Person's termination date and prior to the date notice of coverage termination is required to be made by you. Your cooperation with and support such recovery efforts is required. In the event that you do not comply with the notice requirements set forth in Subsection 5.A (Monthly Invoice), you shall be solely liable to us for Premium due until the effective date established by CMS for a Covered Person’s disenrollment. K. Indemnification You shall hold harmless and indemnify Florida Blue, against all claims, demands, liabilitics, or expenses (including reasonable attorney fees and court costs), which are related to, arise out of, or are in connection with any of your acts or omissions, or acts or omissions of any of your employees, retirees or agents, in the performance of your obligations under this Agreement. Wc are not your agent, nor are you our agent, for any purpose. This paragraph shall only apply to the extent allowed under Florida Statutes § 768.28. L. Representations on the Group Application and the Enrollment Forms We rely on the information you and your Eligible Retirees provide to determine whether to issue coverage; the appropriate Premium and financing method; and eligibility for coverage. All such information must be accurate, truthful, and complete. Statements made on the Enrollment Forms are representations and not warranties. We may cancel, terminate, or void this Agreement if the information which you provide is fraudulent, or if you make an intentional misrepresentation. M. Reservation of Right to Contract We reserve the right to contract with any individuals, corporations, associations, partnerships, or other entities for assistance with the servicing of coverage and benefits to be provided by us or obligations due, under this Agreement. N. Service Mark You, on behalf of the Group and its Covered Retirees, hereby expressly acknowledge your understanding that this Agreement constitutes a contract solely between you and Florida Blue. We are an independent corporation operating under a license with the Blue Cross and Blue 1] J Shield Association, an association of independent Blue Cross and Blue Shield Plans, (the "Association") permitting us to use the Blue Cross and Blue Shield Service Mark in the state of Florida and that we are not contracting as the agent of the Association. You further acknowledge and agree that you have not entered into this contract based upon representations by any person other than us and that no person, entity, or organization other than us shall be held accountable or liable to you for any of our obligations created under this Agrecment. This paragraph shall not create any additional obligations whatsoever on our part other than those obligations created under other provisions of this Agreement. O. Third Party Beneficiary This Agreement was entered into solely and specifically for the benefit of Florida Blue and the Group. The terms and provisions of the Agreement shall be binding solely upon, and inure solely to the benefit of, Florida Blue and the Group, and no other person shall have any rights, intercst or claims under this Agreement, including the Evidence of Coverage, or be entitled to sue for a breach thereof as a third-party beneficiary or otherwise. Florida Blue and the Group hercby specifically express their intent that health care providers that have not entered into contracts with Florida Blue to participate in Florida Blue’s provider networks shall not be third-party beneficiaries under this Agreement, including the Evidence of Coverage. P. Inspection and Audit You shall permit CMS, The U.S. Department of Health and Human Services, the Comptroller General, or their designees, to inspect, evaluate, and audit any of your books, contracts, medical records, patient care documentation, documents, papers, and other records pertaining to coverage by providing records to Florida Blue, which will submit the records to CMS. This right to inspect, evaluate, and audit shall extend ten (10) years from the expiration or termination of the Agreement or completion of final audit, whichever is later, unless otherwise required by applicable law. Q. Benefit Administrator Guide We will provide you with a Benefit Administrator Guide, which provides details related to how your plan is administered and your responsibilities as a benefit administrator. R. Member Communications and Campaigns We may send CMS required or Florida Blue member communications without your consent. Samples of all required materials are available upon request for informational purposes. We may also contact Covered Persons by telephone regarding any Florida Blue campaign and any campaign approved by the Florida Office of Insurance Regulation and/or CMS, as applicable. We will notify you of the campaign prior to making contact with members. 12 S. COBRA You are solely responsible for determining when individuals arc cligible for coverage under a Medicare Plan pursuant to the Consolidated Omnibus Budget Reconciliation Act (“COBRA”). You will notify us promptly of any COBRA elections. For more information on your COBRA responsibilities refer to the Benefit Administrator Guide. In consideration of the payment of Premiums when due and subject to all of the terms of this Agreement, Blue Cross Blue Shield of Florida, Inc. hereby agrees to provide each enrollee of Okaloosa County Board of County Commissioners the benefits of this Agreement as set forth in the attached Evidence of Coverage beginning on each enrollee’s effective date. The Group has selected the following plan and premium: BlueMedicare Group PPOIRx2 at $275.90 per member, per month and Rx2-Only at $137.48 per member, per month. The Group’s Agreement is effective as of October 1, 2013. IN WITNESS WHEREOF, the parties have executed this Agreement as of Benny lege | 4 Blue Cross Blue Shield of Florida, Inc. Okaloosa Co Board of County Commissioners By: & Kt rcilorn By: f (Signature) v (Signature) Name: Elizabeth Strombom Name: kK i LorG aw (Please Print or Type) (Please Print or Type) Title: Senior Vice President, Title: . Medicare Solutions (Yarra BCC 13