Common use of Collection of PII Clause in Contracts

Collection of PII. Subject to the terms and conditions of this Agreement and applicable laws, in performing the tasks contemplated under this Agreement, EDE Entity may create, collect, disclose, access, maintain, store, and use the following PII from Consumers, Applicants, Qualified Individuals, or Enrollees—or these individuals’ legal representatives or Authorized Representatives— including, but not limited to: • APTC percentage and amount applied • Auto disenrollment information • Applicant name • Applicant address • Applicant birthdate • Applicant telephone number • Applicant email • Applicant Social Security Number • Applicant spoken and written language preference • Applicant Medicaid Eligibility indicator, start and end dates • Applicant CHIP eligibility indicator, start and end dates • Applicant QHP eligibility indicator, start and end dates • Applicant APTC percentage and amount applied eligibility indicator, start and end dates • Applicant household income • Applicant maximum APTC amount • Applicant CSR eligibility indicator, start and end dates • Applicant CSR level • Applicant QHP eligibility status change • Applicant APTC eligibility status change • Applicant CSR eligibility status change • Applicant Initial or Annual Open Enrollment Indicator, start and end dates • Applicant Special Enrollment Period (“SEP”) eligibility indicator and reason code • Contact name • Contact address • Contact birthdate • Contact telephone number • Contact email • Contact spoken and written language preference • Enrollment group history (past six months) • Enrollment type period • FFE Applicant ID • FFE Member ID • Issuer Member ID • Net premium amount • Premium amount, start and end dates • Credit or Debit Card Number, name on card • Checking account and routing number • SEP reason • Subscriber indicator and relationship to subscriber • Tobacco use indicator and last date of tobacco use • Custodial parent • Health coverage • American Indian/Alaska Native status and name of tribe • Marital status • Race/ethnicity • Requesting financial assistance • Responsible person • Dependent name • Applicant/dependent sex • Student status • Subscriber indicator and relationship to subscriber • Total individual responsibility amount • Immigration status • Immigration document number • Naturalization document number

Collection of PII. Subject to the terms and conditions of this Agreement and applicable laws, in performing the tasks contemplated under this Agreement, EDE Entity Web-broker may create, collect, disclose, access, maintain, store, and use the following data and PII from CMS, Consumers, Applicants, Qualified Individuals, or Enrollees, Qualified Employers, and Qualified Employees—or these individuals’ legal representatives or Authorized Representatives— —including, but not limited to: 1. For individual market QHP coverage: • APTC percentage and amount applied • Auto disenrollment information Information • Applicant name • Applicant address • Applicant birthdate • Applicant telephone number • Applicant email • Applicant Social Security Number • Applicant spoken and written language preference • Applicant Medicaid Eligibility indicator, start and end dates • Applicant CHIP eligibility indicator, start and end dates • Applicant QHP eligibility indicator, start and end dates • Applicant APTC percentage and amount applied eligibility indicator, start and end dates • Applicant household income • Applicant maximum APTC amount • Applicant CSR eligibility indicator, start and end dates • Applicant CSR level • Applicant QHP eligibility status change • Applicant APTC eligibility status change • Applicant CSR eligibility status change • Applicant Initial or Annual Open Enrollment Indicator, start and end dates • Applicant Special Enrollment Period (“SEP”) eligibility indicator and reason code • Contact name • Contact address • Contact birthdate • Contact telephone number • Contact email • Contact spoken and written language preference • Enrollment group history (past six months) • Enrollment type period • FFE Applicant ID • FFE Member ID • Issuer Member ID • Net premium amount • Premium amount, start and end dates • Credit or Debit Card Number, name on card • Checking account and routing number • SEP Special Enrollment Period reason • Subscriber indicator and relationship to subscriber • Tobacco use indicator and last date of tobacco use • Custodial parent • Health coverage • American Indian/Alaska Native status and name of tribe • Marital status • Race/ethnicity • Requesting financial assistance • Responsible person • Dependent name • Applicant/dependent sex • Student status • Subscriber indicator and relationship to subscriber • Total individual responsibility amount amount 2. For SHOP QHP coverage: Employee PII Employee Applicant Name Employee Unique Employer Code Employee Home Address Employee Applicant Mailing Address Employee Applicant Birthdate Employee Social Security Number Employee Applicant Telephone Number (and type) Employee Applicant Email Address Employee Applicant Spoken and Written Language Preference Employee Tobacco Use Indicator and Last Date of Tobacco Use Employee Sex Employee Race and Ethnicity Employer Business Name If American Indian/Alaska Native: Name and Location of Tribe Health Coverage Type (Individual or Family, if offered) Health Plan Name and ID Number Dental Plan Name and ID Number Category Description Other Sources of Coverage Accepting or Waiving Coverage Employee PII continued Dependent Information, if applicable, including: • Immigration status Dependent Name • Immigration document Dependent Date of Birth • Dependent Social Security Number • Dependent Relationship to Employee • Dependent Sex • Dependent Spoken and Written Language Preference • Dependent Race and Ethnicity • If American Indian/Alaska Native: Name and Location of Tribe • Dependent Tobacco Use Indicator and Last Date of Tobacco Use • If individual is living outside of home; name of individual, address, phone, email address • Dependent Other Sources of Coverage • Dependent Accepting or Waiving Coverage • Special Circumstances for Employees and Dependents, i.e., marriage, moving, adopting children, losing eligibility for coverage under a group health plan or losing Employer contribution, or giving birth Employer Offering Coverage Information Employer Name/“Doing Business As” Employer Federal Tax ID Number Employer Address Business Type Employer Attestation to SHOP Eligibility Requirements Employer Contact Information Employer Contact Name and Title Employer Contact Mailing Address (if different than employer address) Employer Contact Phone Numbers (and type) Employer Contact Spoken and Written Language Preference Employer Contact Email Address Employer Contact Fax Number Secondary Contact Name (optional) Secondary Contact Phone number (and type) Secondary Contact Fax Number Secondary Contact Email Address Secondary Contact Authorizations Employer Coverage Offered Employer-selected AV Levels (Bronze, Silver, Gold, or Platinum) Benchmark Plan Category Description Offer of Dependent Coverage Employer Offering Coverage Information continued Agent/Broker/Assister/Navigator Name, Organization Name, Contact Information, FFM User ID Employer Contribution Information: • Naturalization document Benchmark Plan ID number-Medical Plan • Benchmark Plan ID number-Dental Plan • Percentage towards Employee-Medical Coverage • Percentage towards Employee Dental Coverage • Percentage towards Dependent Medical Coverage • Percentage towards Dependent Dental Coverage • Employer Offering-Single QHP or Single Metal Level or Single Issuer • Employer Offering-Single Stand-alone Dental Plan (“SADP”) or multiple SADPs Offer of Stand-alone Dental Coverage Desired Effective Date of Coverage Employee Selection Due Date Waiting Period for New Hires to Enroll Employee List, including: • Employee Name • Employee Date of Birth • Employee Age • Employee Social Security Number • Employee Email Address • Employee Employment Status • Employee’s Other Coverage • Number of Dependents • Dependent Information, including Dependent Name • Dependent Date of Birth • Dependent Age • Dependent Social Security Number • Dependent Email Address • Dependent’s Other Coverage Payment Method options, including: • Electronic Funds Transfer Information (Checking Account Number, Routing Number) • Credit Card Information (Credit Card type, Name on Credit Card, Credit Card Number, Expiration Date, Signature, Signature Date) • Checking Information Employer Attestation to Consolidated Omnibus Budget Reconciliation Act (“COBRA”)/Medicare Compliance Questions