HomeMy WebLinkAboutBlue Choice Option Group Master Contracts
Augusta Richmond GA
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DOCUMENT TYPE: Co n+rn.c,-\-s
YEAR: WO ~
BOX NUMBER: 7-\
FILE NUMBER: \ l \ <=6 3
NUMBER OF PAGES:
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BlueChoice Option GROUP MASTER CONTRACT
Underwritten by Blue Cross Blue Shield Healthcare Plan of Georgia, Inc.
(Herein called BCBSHP)
An Independent Licensee of the Blue Cross and Blue Shield Association
IN CONSIDERATION of the Application made by
The Group Applicant identified on the attacbed Group Master Application
(Herein called the Applicant, Group, or employer)
a copy of which is attacbed and made part of this Contract, and in consideration of payment by the
Applicant of the required charges, Blue Cross Blue Sh.ield Healthcare Plan of Georgia, lnc_ hereby agrees
to provide fOT the Employees of the Applicant or Members of the Group, the benefits described in the
Certificate Booklet begIDning at 12:01 a.m. Eastem Standard Time on the Effective Date as shown on the
attacbed Group Master Application, hc:TCin called the Effective Date, for an initial Contract period
eA.-tending for one year unless otherwise designated on the attached Group Master Application and from
year to year thereafter, unless this Contract is tenninated as provided in the attached Group Master
Application. The charges shall be due and payable by the Applicant in advance of the Effective Date and
thereafter as provided herein. .
This Contract is issued and delivered in the State of Georgia, is subject to termS and provisions recited on
subsequent pages hereof, the Group Master Application of the Applicant, the Certificate Booklet, the.
amendments, endorsements and riders, if any, and the notices or election of Employees or the Applicant
indicating their participation in the coverage provided hereunder, all of which are a part of this Contract as
fully as ifrecited over !:he signatures herdo affIXed. .
IN "WITIffiSS 'WHEREOF, Blue Cross Blue Shield Healthcare plan of Georgia, Inc. has caused this
Contract to be signed. . .
President and CEO
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TABLE OF CONTENTS
, ARTICLE 1
CONTRA CT AND BOO nET ..................... ........................ .................. ........ .................. .......... 1
ARTICLE 2
ELI Gmrr,ITY ................ ............................ ......... .... ...................... ................. ...................... ......... 1
ARTICLE 3
BENEFIT S.... ............ ........... ........... ... ...... ...... ...................... ............. .........-......... .........;............... 1
ARTICLE 4
GENERAL PRO '\lISI ONS .......................... .............. ...................... ........; .......... ................ ... .... ... 2
ARTICLE 5
CONDITIONS UNDER 'WHICH BENEFITS sHALL BE RENDERED............................... 5
ARTICLE 6
TERJ\1IN"A TION OF, CO'VERAGE ................................................................ .................. .......... 5
ARTICLE 7
, NO 11 CE.. ................. ... .... .__, ...... _.............. ...... ................. ..........._.n................... .................... .. ~... 6
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ARTICLE 1
CONTRACT AND BOOKLET
INTEGRITY
1.1 Contract and BooWet Wording
Eligibility for coverage, Effective Dates for
any Member, levels of b~nefit payments,
exclusions, termination of coverage
information and other pertinent data arc listed
in depth in the Certificate Booldet and Group
Master Application. These are included and a
part of the entire . BlueChoice Option Group
Master Contract. Those items listed only in the
Certificate Booklet will be controlled by that
document and all rights and obligations related
thereto will be determined by its integrity,
related internal procedures and medical policy
documents.
ARTICLE 2
ELIGIBILTIY
2.1 Requirements "
Requirements for eligibility are shown in the
Group Master Application, which is attaChed
and is a part of this Contract. Any application-
-new group "Subsc:noer, . supplemental
application, or application for change of
coverage-mUSt be received and approved" by
BCBSHP before an Effective Date can be
ass igned..
:\
.1.2 . Late EnroUees
Late Enrollees (otherwise eligible Empioyees "
orDq>end.ents who do not enroll when initially
eligible, or within 31 days of a qualifying event
entitling them to a special enrollroent period)
. may enroU during the annual open enrollment
period.
The Certificate Booklet contains detailed
information regarding this issue.
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2.3 Notice of Status Change
The Group must notify BCBSHP of changes in
coverage status for all affected Members who
change the type of coverage option. If the
Group does not notify BCBSHP of such
changes in coverage within 30 "or 3 1 days, the
Group agrees to repay BCBSHP for all claims
payments legally incurred after a Member's
eligibility has changed. If any claim is
submitted duririg the interim, BCBSHP will
deduct the applicable Premium from any claim
payment.
ARTICLE 3
BENEFITS
3.1 Introduction
BlueChoice Option is a point-of-service plan
providing primary and referral health care
services. Medical care is furnished by
Network Providers, Physicians and specialists
chosen by Members fer primary and specialty
care. Be:neiits are higher when care is provided
by In-Network Providers. The only exceptions
to all services not being rendered by a Network
Provider are:
1. when the service required for treatment of
the covered condition is not available at a
"Network Hospital or from a Network
Physician. .Ill this case prior approval must
be received from the BCBSHP Medical
Director;
2. when a Member needs life-thieatening
emergency care either-inside or outside the
service area; or
3. wheo a Member decides to use an Out-of- "
Network Provider for a pa,rticular service.. "
3.2 Primary Care Physician
AllIn-Network care must be received from.or
coordinated thro~gh a' Primary Care Physician
(PCP). The individual Member must: decide
whether to receive benefits from an In-
Network BlueChoice . Option" Provider
(physician, Hospital or other provider) or from".
an Out-of-Network Provider at the Point of
Service. A Member will pay more for out-of-
pocket expenses if care is received from an"
Out-cif-N etwork Provider.
.1
3
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5-28-02; 2:57PM;BC/85 OF GA
ARTICLE 4
GENERAL PROVISIONS
4.1 Entire Contract and Changes
This document, the certificate Booklet, the
Group Master Application, and any future
changes, attachments or amendments will be
the Entire Contracl No change in this
Contract is valid unless signed by the President
of BCBSHP. No agent or employee of
BCBSHP may change this Contract or declare'
any part of it invalid.
4.2 Applications for Enrollment
Information will be furnished to BCBSHP for
each Employee as follows:
L Enrolling, Dew Members--Application for
Coverage.
2. A pJ"'Jequisite to eligibility for coverage is
that the Employees submirting applications
for coverage must have been continuously
employed for the length of time stipulated
in th~ Group Master Application.
3. If Employees do not elect coverage when
first eligible to apply and later elect to
apply for coverage, a health statement
application must be submitted. A post-
eligible (late entrant) application for
family members also must be in the form
of a health statement application.
4.3 Enrollment and Payment Procedures
. .
1. The employer (Applicant) agrees that
enrollment will be restricted to those on
the employer's payroll, and that each new
Employee will be given an opportunity to
apply for coverage at such time the
Employee becomes eligible. Employees
who do not elect to apply.for coverage
must submit a Waiver of Coverage form.
2. Further, the employer agrees to collect the
amount of the Employee's contribution, if
any, by payroll deduction; and to pay on or
before the due date' to BCBSHP the
employer's conmontion, if any, plus the
Employee's COtlo1'bution. if any, which,
when combined, amounts to the total
ITionthly subscription charges. '
3. ThC!Cshall be an 'annual re-enro llment
period that will precede the other carrier's
(if any) anniversary date by sixty (60)
days. During this time, eligible
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Employees may transfer their membership
from ,other carriers (if any) to BCBSHP.
The Effective Date of these transfers and
eligibility for coverage will be defined in
the change form.
4.4 Subscription Charges
1. Initial charges shall be payable in advance
of the Effective Date, and coverage shall
not be in, effect until such payment is
received by BCBSHP. Subsequent
charges shall be payable monthly on or
before the due date designated on the
Group Master Application. Except for the
initial payltlC11t, a grace period of thirty-
one (31) days beyond the due date shall be
allowed for payment of charges due.
BCBSHP reserves the right to refuse to
accept any payment of charges after, the
expiration of the grace period. If the
employer fails to pay such charges to
BCBSHP within. the grace period, the
Group Master Contract automatically will
be :erminated as of the end of the grace
petlod; however, the employer still shall
be ~iable ~ BCBSHP in the amDunt of any
claIms patd on behalf of the Group after
the due date, unless proper notice of
termination has been given as provided
below.
2. BCBSHP may change the monthly
subscription charges whenever the benefits
are changed by amendment, or as of any
monthly due date upon giving sixty (60)
days' prior notice to the employer.
BCBSHP may also change the monthly
subscription charges when the emollment
falls below the minimum requirement
agreed to in the Group Master Application ,
or a significant enrollment change is made
through acquisition of a subsidiary' (ies),
the Employees of which are to be added to
this Group. .
4.5 Certificate Booklets, Miscellaneous
Forms and Notices
,1. BCBSHP agrees to provide Employees a
Certificate Booklet outlining the benefits.
Such Certificate Booklet is an integral part
of the Group Master Contract as stated
above.
2. nie employer agrees to receive, on behalf
of its covered, Employees, all notices,
certificates and. identification .cards
4.
5-28-02; 2:57PM;BC/B5 OF GA
delivered by BCBSHP and to forward such
materials to the persons involved..
3, Any notice shall be sufficient if given to
the employer when addressed to its office,
as stated in the Group Master Application;
if given to BCBSHP when addressed to its
offIce; or if given to an Employee, when
addressed to the Employee either his or
her address as it appears on his or her
records at BCBSHP, or in care of the
employer.
4. The Group Master Contract may be
modified from time to' time. BCBSHJ' will
give the employer sixty (60) chlys' notice
prior to the Effective Date of any such
change.
4.6 Effective Date of Coverage
The Effective Date of Coverage i9 stated on the
Group Master Application. The first Contract
lIIUlivcrsary date is also stated on the Group
Master Application; these two dates liD not
have to be separated by twelve (12) months,
we Group Master Contract, if issued, shall
remain in force unless terminated in
accordance with the terms of this Contract
The due date shall be the first of each month.
4.7 Time Limit on Certain Defenses
Two years after this ContraCt is issued, no false
statements which might have been included on
a Subscriber's application can be used to void
the Conn-act. Also, after these same twO ycars
no claim can be deoied because of any fahe
statement on this application. .
4.8 Reinstatement
If a Member's coverage ends in any manner,
'that Member may be considered for
reinstatement.
4.9 pbysical Examinations
If a Member has submitted a claim and
BCBSHP needs more health information,
BCESHP can require a physical examination
as often as is reasonably necessary. BCBSHP
would pay the cost of my such examination,
4.10 UnreIDlonable Fees
If BCBSHP considers a fee unreasonable, it
will determine a Customary Fee. Payment will
be based on the Customary Fee.
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4.11 Compliance with Given Provisions
BCBSFIP has the right to waive any part oftbis
Conn-act for the benefit of the insured, This
waiver in no way affects BCBSHP's right to
apply that pan of the Conu-act in paying a
future claim.
4.12 Contract Administration
1. For proper. adjudication of claims under
this Contract, it is agreed, and the Group
and its Members consent, that all medical
records involving any condition for which
a clilim is presented will be furnished at
BCBSHP's request, and all priv~leges with
respect to such infonnation are waived.
The Group and its Members agree to
participate and cooperate with BCBSHP in
any pre-admission, concurrent or other
medlcal review activity at any Hospital or
medical facility as BCBSHP deems
appropriate. This, information will be kept
confidential to the oxtont provided by law,
Payment "{ill not be provided where
sufficient information cannot be obtained
to properly adjudicate a claim.
2. Any person or entity baving information
about an illness or Injury for which
benefits are c:1aimed may give BCBSI-rf at
its request, any information (including
copies of records) about the illness or
lojury. In addition, BCBSHP may with
the Member's written consent give any
person or entity similar information at
their request if they are providing similar
benefits. .
3_ In maldng a decision on claims involving
payment for services or supplies or days of
care that are detelTl'lined by BCBSHP to be
'medically unnecessary, BCBSHP reserves
the right to obtain advisory opinions from
Physician consultants in the appropriate
specialty under consideration prior to
reaching B decision. On reconsideration of.
denied Medical Necessity claims,
BCB SHP further reserves the right to refer
such cases to an appropriate peer review. .
. committee for an advisory opinion before
BCBSHP renders its final determination
on such claims.
4.13 Employer Declaration
The employer submits eligibility and group
health profile infonnation with the Group
Master Application. The employer
. understands that the information on such forms
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5-28-02; 2:57PM;BC/BS OF GA
will be used by BCBSHP to evaluate the
acroarial risk of the Group and any coverage
which may be issued can b~ rescinded for the
entire Group if this infonnation is incomplere,
misleading or inaccurate.
4.14 Refunds
Refimds with respect to a Group's request,
b!lSed on circumstances including, but not
limited to, retroactive terminations of
Employees from the Group, will be limited to a
maximum period of three months. Any
eligible refunds for the Employee's coverage
will be sent to the Group.
4.15 Unpaid Premium
Upon the payment of a claim under this
Contract, any Premiums thon due and unpaid
OT covered by any note or written order, may
be deducted from that claim payment.
4.16 Applicahle Law
This Contract is governed by the laws and
ret>u1ations of the State of Georgia Nothing in
this Contract shaIl be constrUed so as to be in
violation of any federal or state law or
regulation. In the event of state or federally
mandated benefits, BCBSHP reserves the right
to change the subscription charges (rates) with
sixty (60) days' prior notice.
4.17 Right of Recovery
VI'hen any payment for Covered Services has
been made by BCBSHP in an amount that
exceeds the maumum benefits available for
such services under the Contract, or whenever
payment has been made in error by BCBSHP
for Non-Covered Services, BCBSHP shall
have the right to recover such payment from
the Member or, if applicable, the provider of
Covered Services.
4.18 Limitation of Actions
No lawsuit may be filed by a Member to
recover benefits on a claim made under this
Contract unless commenced at least sixty (60)
days afte:rflling a claim. A Member cannot
file any legal action after tbree(3) yean from
the date of filing a claim.
4.19 Right to Audit
BCBSHP rese\"es the right to audit a Group's
Employee roster to verify enrollment
panicipation and eligibility requirements.
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7/ 1 i
4.20 Non-Duplication
As a condition precedent to the issuance of this
Group Master Contract, the employer agreed
that other similar Group coverage for Hospital
and/or Physician services, if any, which was in
effect, would be. cancelled on or prior to the
Effective Date of this Group Master Contract,
and no otlu:r Group coverage providing
benefits for Hospital and/or Physician services
would be adopted by the employer during the
period of this Contract. In the event the
employer adopts such other coverage, the
employer will terminate this Contract by giving
sixtY (60) days' written notice prior to the
Effcctive Date of the new coverage, except
when such other coverage wit! not duplicare
benefits alrcady provided by BCBSHP. After
notice by the employer, BCBSHP, at its
discretion., may waive this restriction. Such
waiver will be in writing and must be signed
by the PresicL"llt ofBCBSHP.
4.21 Licensed ControHed Affiliate
The Group on behalf of itself and its Members
hereby expressly aclr.nowledges irs
understanding this policy constitutes a Contract
solely between the Group and BCBSHP, which
is an independent corporation operating under
a license from the Blue Cross and Blue Shield
Association, . an association of independent
Blue Cross and Blue Shield Plans (the
Association), pennining Blue Cross and Blue
Shield of Georgia, Inc. to use the Blue Cross
and Bluc Shield Service Marks in the state of
Georgia, and that BCBSHP. is not contracting
as the agent of the Association. Tne Group
further acknowledges and agrees that it has not
entered into this Contract based upon
representations by any person other than
BCBSHP and that no pcrson, entity, or
organization other than BCBSHP shall be held
accountable or liable to the Group for any of
BCBSHP's obligation to the Member created
under this Contrac=t. This paragraph shall not
create any additional obligations whatsoever on
the part of BCBSHP other than those
obligatioIl!l created under other provisions of
this agreement
4.22 Calculation of Coinsurance and Other
Subscriber Liability
The calculation of Member liability for
Covered Services for claims incurred outside
of Georgia and processed through the Program
lYpically will be at the lower of the provider's
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5-28-02; 2:57PM;BC/B5 OF GA
actual billed charges or' the negotiated rate
BCBSHP pays the on-site Blue Cross and/or
Blue Shiold Plan.
Often this "negotiated price" will consist of a
simple discount. But sometimes it is an
estimated final price that factors in expected
settlements or other non~c:laims transactions
with a health care provider or with a specific
group of providers. The negotiated price may
also be a discount from billed charges that
reflects average e.xpected savings. The
estimated or average price may be adjUSted in
the future to correct. for over-or
underestimation of past prices.
In addition, statutes require Blue Cross and/or
Blue Shield Plans in a smaU number of states
to use a basis for calculating Member liability
for Covered Services that docs not reflecr the
entire savings realized on a particular claim.
Thus, when your Members rcceive Covered
Services in these stateS, their Member liability
for Covered Semces will be calculaIed using
these stateS' sramtory methods.
ARTICLE 5
CONDTIJONSUNDER~CH
BENEFITS SHALL BE
RENDERED
5.1 Hospital Inpatient Benefits
1. Hospital Inpatient Benefits are available
only if a Member is admitted as a bed
patient to a Hospital on the order of a
licensed Physician. The Member must be
under the care of this Physician.. The
Physician must be on the staff of, or'
acceptable to, the Hospital at which the
Member is a patient
2. The service which the Member receives at
. a Hospital is subject to all the rules and
regulations of the Hospital selected. Such
rules also control" admission policies,
3. A Member can. choose any legally.
conStinlted and approved Hospital for care.
However, BCBSHP does Dot guarantee
that any particular service or type of room
will be available even if requested by the
Physician.
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:l_
Physician Availability
A Member may go to any physician. BCBSHP
docs not guarantee that any particular
Physician will be available.
Right to Receive Necessary Information
BCBSHP has the right to receive any
information necessary in order to determine
how much to pay on any claims submined by a
Hospital, PhysiCian, or an individual Member.
BCBSHP agrees to hold all such material .
confidential.
5.3
ARTICLE 6
TERMINATION OF COVERAGE
1. Initial charges shall bc payable in advance of the
Effective Date, and coverage shall not be in
effect until such payment is received by
BCBSHP. Subsequent charges shall be payable
monthly on or before the due date designated in
the attacbed Group Master Application. (The
due date is the date on or before which all
subscription charges must be received.)
Grace Period. If the Group has not given
wrinen notice to BCBSHP this Contract. is to be
terminated, a Grace Period of thiny-one (31)
days, during which this Contract shall remain in
effect, will be allowed for the payment of any
subscription charges due after the due date. If nO
subscription charBes are paid within the Grace
Period, this Contract will automatically terminate
without further notice effective as of the end of
the Grace Period; after termination, the Group
shall continue to be liable 'for all unpaid
subscription charges due through and including
the Grace Period. If written notice is given by
the Group to BCBSHP. during the Grace Period
that this Contract is to be '.tenninated, then
termination shaU be effective immediately and
the Group shall be liable to BCBSHP only for.a
pro rata amount for the portion of the month
prior to the receipt of such notice by BCBSHP.
2. If the Group does not pay the subscription
charges for a Member by the end of the Grace
Period, that Member's coverage ends
automatically atthe end of the Grace Period. No
benefits for sucb a Member or covered family
. members will be paid after this date unless the
insured person is on an existing contintilitg
claim. Any Premium due for a Member shall be
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5-28-02; Z:57PM;BC/85 OF GA
deducted froin any Member's claim paid during
the Grace Period.
3. .If a Subscnoer loses eligibility by no longer
. being a member of a particular subclass within
the Group, that Subscriber's coverage ceases
automatically as of the end of the period for
which current subscription cha:rges have been
paid. Coverage also ends for all other family
members covered under this Subscriber's
certificate of coverage.
4_ If this Group ends (or cancels) this Contract for
any reason, coverage for all Members ends
automatically as of the cancellation date. No
benefits will be paid after this date, except as
provided under Extension of Benefits - or
Extended Benefits.
5. The Group may cancel this Contract by giving
wriuen notice to BCBSHP at least sDcry (60)
days in advance. Coverage for all Subscn"bers
ends automatically as of the cancellation date.
Note: None of the above shall prejudice an
existing claim.
6. BCBSHP may cancel this Contract immediately
for fraud.
7. BCBSHP may cancel this Contract for
nonpayment, noncompliance with contribution
or minimum enrollment participation
requiromel1ts, 'market exit, and service area
limitations with thirty (30) days' prior notice to
the Group.
&. At its option BCBSHP may conveI1 the Group to
another category for failure to maintain the
minimum enrollment participation requirement
with thirty (30) days' prior notice to the Group.
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# 9/ 11
ARTICLE 7
NOTICE
Change Notification -Members
Members may notify BCBSHP of any changes which
would affect coverage at BCBSHP' s office:
Blue Cross Blue Shield Healthcarc Plan
of Georgia, Inc.
Post Office Box 9907
Columbus, Georgia 31908
Change Notification -BCBSHP
BCBSHP may notify Members of any changes at the
Member's address as it appears in BCBSHP's
records. Please notify BCBSHP when a change of
address occurs.
8
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5-28-D2; 2:57PM;6C/BS OF GA
+"-
BluecToss:
BlueShield .
ofGeor~a *
. .~
HMO Georgia, Ine.. >I<
*Independent licensees of the Blue Cross and Blue Shield Association
GROUP MASTER APPLICATION
Th:: purposo of this form is fIE HMO Gocrgili.. IDe:.. and Blu e Cro:!s &Jlll Dluo Sbicld of GCCJtEia, lnc:. (B CBS GA) lD ",vnlunLe raring fa tho campanl ~ fCl]w::st fer gnup
inror.1nOl coverage. Pl= ~ all qudUOJl;. ThiB fmm must be lig.n.ec!. ~ dau>d by an offi= of tho comp>UlY.
SEC110N I . EMPLOY'ER INFORMATION
. l.Jop! Na= of Employer A u. 0, u..sla, {b CO r"" I' ~ Grot'l'fl Tekphone Number (7 ~ (p) ~ 2,( - Z 3~.,L
Sm:t:1 AIJMesa .:;-:go ~e.ac. .s-lr"",+. County ,t,c.-h fY\ ~ n cL-- Whatil: th<: naruro of tho businOll::l? C-OLuJ! ( (; 0 II ~"J'Y1 e.....n-f .
City ~1'7~k-..- ..] .S=..a ft Zip c:..orm J 0 911 Numba of r=' in ~ 3crf
Are th= oliler lm:atioDs to be included? Yes _ No ~ If yes, p1ell.'lC provide tbeowne and number of c-mployes 111 each loClilion. The Employer
certifies that (enter' specifIC .nuroba) employees llIC cligible to make. application for coverage on the dace of this Group Appli=ion. and agrees
that orIDDle of ~ eligible empJoye""~ will hnve made application for membership before the. Effective Date of Coverage.. Oti:lerwu:e tbiJ;
Group Appfu:ariOD will be deemed to have been withdrnwn.
SECll0N II - GROUP HEALTH PROFIlE
Has anyone incum:d h~th claimb in exces8 of 51.500 in the past 12 IDanthB end is tilo condition ongoing? Yes - No -
SpecifY: Etnployee, Dependent or COBRA Age Dol1llr lIIIlDuot of. DiagnoililPrognosis D IIU> of Last
Claim Treatment
-
SECTION III _ CURRENT COVERAGE INFO.RMATlON
Cmier Effective Date Type Coverage Type of Funding
5 ItS c2-I- 199/;- ,P/~ 6~/+- F~~
IcwrentRates ~=wBl. Ra1es .. Cmrent Rates .
RATES Renewul. RateJ;
Medical Medical DeD.tll Dental
EE
EE &. SP
BE &; Cbild(I"'..n)
Family :
Total Number of EmploYees'l Total Number of Eligib1e Employees?
Number of Employees emrently Enrolled in the Health PllIn? Nmnher ofEtnployees in Employee Waiting Pe:riod
Numher of CQBI!..A Puticipants
5-26-02; 2:57PM;BC/BS OF GA
;7068558321
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IV - REQUESTED COVERAGE INFORMATION . , , I
.
lA. Coverages Requested: (Enter appropriate coverage pl3n nwnl>c:r and attach benefit 9l.1IIlIDll1Y) lndic:ate Local Sales Office ,-94"i""~---
HM"O Georgia, Inc. HMO Geotgia, Inc. BlueCross BlueShield BlueCross BlueSbield BIDeCroSS BlueShicld BlueCro&s BlucSbield
of Georgia, Inc. of ~rsia, Inc. of Georgia, Inc. of Georgia, Inc.
..3~-- Trarlitional Health Dental Plan
ffivI 0 Plan POS Plan PPO Plan Plan (THP) Repb=ncnt? _ VISion Plan .
R.X Copay HMO Georgia, Inc.
C=:ric $- Gc=i:: $_ Genetic $_ Gc=:ic $~ Blue: Choice Platinum
Brand $_ l'm $- :&md $_ Br.md $_
In FOIIIIubry S- In Pamwlnxy .$- InFormllimy $- InPomwLuy $- Plan
Notlnf'otmu!.ary $_ NOlin Formulmy $- Not InFonnllimy$_ ~otInFonnula~)' $_
PI'D $- PrO $_ PTD $- Pm $-
1 B. ColnrneDIs
-tY :r/t, t-Of~ ~ M-e.d.,~( E JIYl erve.n e.-i cs ...r A-~ cl cJ ""'"'-+-: I .:I=".. j u...vt' ~
,....
{(I/O C-ilfr fr:;r. /1//1') - e.-~e--rJc.:l l..<.Se OJ:. +-A c..> ER.
I
M 0--( lord q fLJ{- jJ ro,j r CJ.. W\. .f /Sj.!!Aj
?. MaIernity coverage is included with HMO and PaS plans, and with PPO and THP plans for groups with 15 ormo~ I
IDlployees. Maternity coverage is optional for gronps with less than 15 employees for PPO and 1HP pilms. If you Yes - No
lave less than 15 employees, do you wish to select maternity coverage! (If rejected, it cannot be adrled at a later date..) -
I. Mental. health/substance abuse options are listed on your group proposal or other supplemenrnl SUnlimiteO $10,000 $15,000
'mms. Please indicate theUfetime Ma:tim1IIIl. ($10,000 and $15,000 choices are ollly available for
'PO and nIP groups 2-50. HMO and POS are tmlimited automatically.)
L Indicate the percentage of the premium to be paid by the employer Employee Bcalth_ % Depcodcnt Health _ 0/0
Employee Dental_% Dependent Dental_ 0/0
i. What pmod of continuous service ( employee waiting p:riod) on a full.time basis must be completed by an employee t Dental
dore becoming eligible for coverage 7 3D
;A, Will the cOYeIage be eftc;;tive on the fi.-:st day following the employee waiting period? Yes_ No V
.:B. Or will the coverage be effedive on the firGtday of the month foDowinS the employee waiting period? Yes--LL No
-
C. Do you wish to waive the employee waiting period at :initial enrollment7 Yes - No V
:FFcCTlVE DATE OF COVERAGE /s+ day of .::rc;:" t.< ~ (I
he profDsocLEficaivc Dam of ihe Group MllBla CmIInlCt, if issued, is U;Ol 8.lII. (Eastem S~ time) OD the (month),
~(year) (
bdim CotIttRCt anniversary due sbllII be It:' "iu~......((month). 2 /)",:::, (year)
hctl= III' oat me two dstcs ~ sep=lCd by twdve (12) months. The Group Master ContrllCl, if issucn, shaI1 rcuwn JIl force unless tcIlDIlWcd.m acoord:mce WIth. the
rIDS of the Group M~ Contract. Th= due dllUI.sMll be !be iir.rtof cadi month.
igned Z1 fftejl/ (-fr., . ~/9- on JQe~ 1 (moa1b, d.!tE), /)DD I (year)
. /
It UjH'~ ~ -cc :rt:. '0-
Agelll. Brou. or ConsulWll of ICCCJni )11= of the Employer (CompallY )
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~lIlliY: orHMO OallCllSOA
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1681.9901/00