Loading...
HomeMy WebLinkAboutBlue Choice Option Group Master Contracts Augusta Richmond GA DOCUMENTNAME1)\Ue. Choice O\:*iO() GV-Ou-p \-J\cxs-\-er- CDn+YUG-\- DOCUMENT TYPE: Co n+rn.c,-\-s YEAR: WO ~ BOX NUMBER: 7-\ FILE NUMBER: \ l \ <=6 3 NUMBER OF PAGES: Cl ~ .; 706855832 i # 2/ i j 5-28-02; 2:57PM;BC/8S OF GA 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 5-28-02; Z:57PM;BC/BS OF GA ;7068558321 ;;: 31 11 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 , , 2 1 " ~-Z8-D2; 2:57PM;BC/B5. OF GA 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. ;7068558321 # 4/ i i 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 . 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 ;7068558321 #- 51 11 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. ; 7068558321 ... ... 6/ 11 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 5 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. ;7065558321 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 6 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. ;7068558321 # 81 11 -') :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 7 , 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. ; 7068558321 # 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 ;7068558321 ;;: 101 11 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 # 11/ 11 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 ) .~~<:o. ,~-r~ ~. . _~"'-t&"'" . ~lIlliY: orHMO OallCllSOA J.I, I n.." ~ /<t:sOWC eJ {),'re.c. b't- 1681.9901/00