Common use of Important Information Regarding HSAs Clause in Contracts

Important Information Regarding HSAs. The PPO Savings Plan is not a “Health Savings Account” or an “HSA”. It is designed as a “high deductible health plan” that may allow Employers, if they are eligible, to take advantage of the income tax benefits available when they establish an HSA for their employees. The money put into the HSA is used to pay for qualified medical expenses subject to the deductibles under this Plan. NOTICE: Blue Shield does not provide tax advice. If Employers intend to purchase this Plan to use with an HSA for tax purposes, they should consult with their tax advisor about whether they are eligible and whether their HSA meets all legal requirements. The HSA is a governmental pilot program that is continued year to year at the discretion of Congress. Blue Shield has designed this Plan to meet government requirements for a high deductible health plan to be used in conjunction with establishing eligibility for HSA tax benefits. Although Blue Shield believes that this Plan meets these requirements, the Internal Revenue Service has not ruled on whether the Plan is qualified as a high deductible health plan. Should an Employer purchase this Plan in order to obtain the income tax benefits associated with an HSA and the Internal Revenue Service were to rule that this Plan does not qualify as a high deductible health plan, the Employer and employees may not be eligible for the income tax benefits associated with an HSA. In this instance, they may have adverse income tax consequences with respect to their HSA for all years in which they were not eligible. However, if there were such a ruling, or if government requirements for a high deductible health plan change, Blue Shield intends to amend the PPO Savings Plan prospectively, if necessary, to meet the requirements of a qualified plan. A change in the Plan's Dues may also be required as a result of a change in the Plan. Subscribers of this Plan may be eligible to establish a tax deductible Health Savings Account (HSA) plan in accordance with the provisions of the Internal Revenue Code, Section 223. This is a Participating Provider Plan. Its Benefits, particularly the payment for Services received from Non- Participating Providers, differ from other Blue Shield plans. Benefits for Services provided by Non-Participating Providers may be substantially reduced, and certain Services are not covered. This Plan is intended to qualify as a “high deductible health plan” within the meaning of Section 223 of the Internal Revenue Code of 1986, as amended. In order to qualify, the calendar year deductible and out-of-pocket maximum amounts may increase annually. In the event that any court, agency, or administrative body with jurisdiction over the matter makes a final determination that this Plan does not qualify, Blue Shield will make efforts to amend this Plan prospectively, if necessary, to meet the requirements of a qualified plan. If Blue Shield determines that the amendment necessitates a change in the Plan provisions, Blue Shield will provide written notice of the change, and the change shall become effective on the first (1st) day of the month following the expiration of 30 days from the date the notice was sent. To learn more about Health Savings Accounts, eligibility and the law's current provisions, the Subscriber can consult with a financial advisor. (GPHSA) TABLE OF CONTENTS PART I. INTRODUCTION 4 PART II. DEFINITIONS 4 PART III. ELIGIBILITY 5

Important Information Regarding HSAs. The PPO Savings This Plan is not a “Health Savings Account” or an “HSA”. It , but is designed as a “high deductible health plan” that may allow Employersyou, if they you are eligible, to take advantage of the income tax benefits available to you when they you establish an HSA for their employees. The and use the money you put into the HSA is used to pay for qualified medical expenses ex- penses subject to the deductibles under this Plan. NOTICE: Blue Shield does not provide tax advice. If Employers intend to purchase this Plan to use with an HSA for tax purposes, they should consult with their tax advisor about whether they are eligible and whether their HSA meets all legal requirements. The HSA is a governmental pilot program that is continued year to year at the discretion of Congress. Blue Shield has designed this Plan to meet government requirements for a high deductible health plan to be used in conjunction with establishing eligibility for HSA tax benefits. Although Blue Shield believes that this Plan meets these requirements, the Internal Revenue Service has not ruled on whether the Plan is qualified as a high deductible health plan. Should an Employer purchase this Plan was selected in order to obtain the income tax benefits associated with an HSA and the Internal Revenue Service were to rule that this Plan does not qualify as a high deductible health plan, the Employer and employees you may not be eligible for the income tax benefits associated with an HSA. In this instance, they you may have adverse income tax consequences with respect to their your HSA for all years in which they you were not eligible. HoweverNOTICE: Blue Shield does not provide tax advice. If you intend to purchase this Plan to use with an HSA for tax purposes, if there were such you should consult with your tax advisor about whether you are eligible and whether your HSA meets all legal requirements. This Evidence of Coverage and Disclosure Form (EOC) constitutes only a ruling, or if government requirements for a high deductible summary of the Health Plan. The health plan change, contract must be consulted to determine the exact terms and conditions of coverage. Notice About This Group Health Plan: Blue Shield intends makes this Health Plan available to amend Employees through a contract with the PPO Savings Plan prospectivelyEmployer. The Group Health Service Contract includes the terms in this EOC, if necessary, to meet the requirements of a qualified planas well as other terms. A change in copy of the Contract is available upon request. A Summary of Benefits is pro- vided with, and is incorporated as part of, the EOC. The Summary of Benefits sets forth the Member’s share-of-cost for Covered Services under the benefit Plan's Dues may also be required as a result of a change in . Please read this EOC carefully and completely to understand which services are Covered Services, and the limitations and exclusions that apply to the Plan. Subscribers Pay particular attention to those sections of the EOC that apply to any special health care needs. For questions about this Plan, please contact Blue Shield Customer Service at the address or telephone number provided on the back page of this Plan may be eligible to establish a tax deductible Health Savings Account (HSA) plan in accordance with the provisions of the Internal Revenue Code, Section 223. This is a Participating Provider Plan. Its Benefits, particularly the payment for Services received from Non- Participating Providers, differ from other Blue Shield plans. Benefits for Services provided by Non-Participating Providers may be substantially reduced, and certain Services are not covered. This Plan is intended to qualify as a “high deductible health plan” within the meaning of Section 223 of the Internal Revenue Code of 1986, as amended. In order to qualify, the calendar year deductible and out-of-pocket maximum amounts may increase annually. In the event that any court, agency, or administrative body with jurisdiction over the matter makes a final determination that this Plan does not qualify, Blue Shield will make efforts to amend this Plan prospectively, if necessary, to meet the requirements of a qualified plan. If Blue Shield determines that the amendment necessitates a change in the Plan provisions, Blue Shield will provide written notice of the change, and the change shall become effective on the first (1st) day of the month following the expiration of 30 days from the date the notice was sent. To learn more about Health Savings Accounts, eligibility and the law's current provisions, the Subscriber can consult with a financial advisor. (GPHSA) TABLE OF CONTENTS PART I. INTRODUCTION 4 PART II. DEFINITIONS 4 PART III. ELIGIBILITY 5EOC.

Important Information Regarding HSAs. The Shield PPO Savings Plan is not a “Health Savings Account” or an “HSA”. It is designed as a “high deductible health plan” that may allow Small Employers, if they are eligible, to take advantage of the income tax benefits available when they establish an HSA for their employees. The money put into the HSA is used to pay for qualified medical expenses subject to the deductibles under this Plan. NOTICE: Blue Shield does not provide tax advice. If Small Employers intend to purchase this Plan to use with an HSA for tax purposes, they should consult with their tax advisor about whether they are eligible and whether their HSA meets all legal requirements. The HSA is a governmental pilot program that is continued year to year at the discretion of Congress. Blue Shield has designed this Plan to meet government requirements for a high deductible health plan to be used in conjunction with establishing eligibility for HSA tax benefits. Although Blue Shield believes that this Plan meets these requirements, the Internal Revenue Service has not ruled on whether the Plan is qualified as a high deductible health plan. Should an a Small Employer purchase this Plan in order to obtain the income tax benefits associated with an HSA and the Internal Revenue Service were to rule that this Plan does not qualify as a high deductible health plan, the Employer and employees may not be eligible for the income tax benefits associated with an HSA. In this instance, they may have adverse income tax consequences with respect to their HSA for all years in which they were not eligible. However, if there were such a ruling, or if government requirements for a high deductible health plan change, Blue Shield intends to amend the Shield PPO Savings Plan prospectively, if necessary, to meet the requirements of a qualified plan. A change in the Planplan's Dues dues may also be required as a result of a change in the Planplan. Subscribers of this Plan may be eligible to establish a tax deductible Health Savings Account (HSA) plan in accordance with the provisions of the Internal Revenue Code, Section 223. This is a Participating Preferred Provider Plan. Its Benefits, particularly the payment for Services received from Non- Participating Non-Preferred Providers, differ from other Blue Shield plans. Benefits for Services provided by Non-Participating Preferred Providers may be substantially reduced, and certain Services are not covered. This Plan is intended to qualify as a “high deductible health plan” within the meaning of Section 223 of the Internal Revenue Code of 1986, as amended. In order to qualify, the calendar year deductible and out-of-pocket maximum amounts may increase annually. In the event that any court, agency, or administrative body with jurisdiction over the matter makes a final determination that this Plan does not qualify, Blue Shield will make efforts to amend this Plan prospectively, if necessary, to meet the requirements of a qualified plan. If Blue Shield determines that the amendment necessitates a change in the Plan provisions, Blue Shield will provide written notice of the change, and the change shall become effective on the first (1st) day of the month following the expiration of 30 days from the date the notice was sent. To learn more about Health Savings Accounts, eligibility and the law's current provisions, the Subscriber can consult with a financial advisor. (GPHSA) TABLE OF CONTENTS Page PART I. INTRODUCTION 4 C-4 PART II. DEFINITIONS 4 DEFINITIONS........................................................................................................................................................ C-4 PART III. ELIGIBILITY 5ELIGIBILITY........................................................................................................................................................ C-5 A. Employee Eligibility, Waiting Periods and Open Enrollment ................................................................................... C-5 B. Associated Employers ............................................................................................................................................... C-6 C. Termination of Benefits............................................................................................................................................. C-6 PART IV. GROUP RENEWAL PROVISIONS..................................................................................................................... C-7 PART V. DUES...................................................................................................................................................................... C-8 PART VI. INTER-PLAN PROGRAMS (BLUECARD PROGRAM AND OTHERS) ....................................................... C-9 PART VII. CANCELLATION/REINSTATEMENT/GRACE PERIOD ............................................................................. C-11 A. Cancellation Without Cause .................................................................................................................................... C-11 B. Cancellation for Non-Payment of Dues................................................................................................................... C-11 C. Cancellation/Rescission for Fraud, Intentional Misrepresentations of Material Fact or Failure to Provide RecordsC-11 X. Xxxxx Period ............................................................................................................................................................ C-11 E. Payment or Refund of Dues Upon Cancellation...................................................................................................... C-11 F. Termination of Benefits........................................................................................................................................... C-11 G. Employer to Provide Subscribers with Notice Confirming Termination of Coverage ............................................ C-11 PART VIII. GENERAL PROVISIONS ............................................................................................................................... C-12 A. Choice of Providers ................................................................................................................................................. C-12 B. Use of Masculine Pronoun ...................................................................................................................................... C-12 C. Workers' Compensation........................................................................................................................................... C-12 D. Changes: Entire Contract........................................................................................................................................ C-12 E. Statutory Requirements ........................................................................................................................................... C-13 F. Legal Process........................................................................................................................................................... C-13 G. Time of Commencement or Termination ................................................................................................................ C-13 H. Records and Information to be Furnished ............................................................................................................... C-13 I. Inquiries and Complaints......................................................................................................................................... C-13 J. Confidentiality......................................................................................................................................................... C-13 K. ERISA Plan Administrator ...................................................................................................................................... C-13 PART IX. CONTRACTHOLDER RESPONSIBILITY FOR DISTRIBUTION AND NOTIFICATION REQUIREMENTSC-14 A. Obtaining Declinations or Waivers of Coverage ..................................................................................................... C-14 B. Distribution of Summary of Benefits and Coverage (SBC) .................................................................................... C-14 C. Distribution of Member ID Cards and Evidence of Coverage and Disclosure Form Booklets ............................... C-14 D. Notification of Cancellation to Subscribers............................................................................................................. C-15 E. Notification of COBRA and Cal-COBRA Coverage Option and Other COBRA/Cal-COBRA Notices ................ C-15 EVIDENCE OF COVERAGE AND DISCLOSURE FORM ............................................................................................... C-17 Refer to the Table of Contents in the Evidence of Coverage and Disclosure Form The Evidence of Coverage and Disclosure Form includes the following optional Benefits/riders: Substance Abuse Condition Benefits

Important Information Regarding HSAs. The Full PPO Savings HSA Plan is not a “Health Savings Account” or an “HSA”. It is designed as a “high deductible health plan” that may allow Small Employers, if they are eligible, to take advantage of the income tax benefits available when they establish an HSA for their employees. The money put into the HSA is used to pay for qualified medical expenses subject to the deductibles under this Plan. NOTICE: Blue Shield does not provide tax advice. If Small Employers intend to purchase this Plan to use with an HSA for tax purposes, they should consult with their tax advisor about whether they are eligible and whether their HSA meets all legal requirements. The HSA is a governmental pilot program that is continued year to year at the discretion of Congress. Blue Shield has designed this Plan to meet government requirements for a high deductible health plan to be used in conjunction with establishing eligibility for HSA tax benefits. Although Blue Shield believes that this Plan meets these requirements, the Internal Revenue Service has not ruled on whether the Plan is qualified as a high deductible health plan. Should an a Small Employer purchase this Plan in order to obtain the income tax benefits associated with an HSA and the Internal Revenue Service were to rule that this Plan does not qualify as a high deductible health plan, the Employer and employees may not be eligible for the income tax benefits associated with an HSA. In this instance, they may have adverse income tax consequences with respect to their HSA for all years in which they were not eligible. However, if there were such a ruling, or if government requirements for a high deductible health plan change, Blue Shield intends to amend the Full PPO Savings HSA Plan prospectively, if necessary, to meet the requirements of a qualified plan. A change in the Plan's Dues may also be required as a result of a change in the Plan. Subscribers of this Plan may be eligible to establish a tax deductible Health Savings Account (HSA) plan in accordance with the provisions of the Internal Revenue Code, Section 223. This is a Participating Preferred Provider Plan. Its Benefits, particularly the payment for Services received from Non- Participating Non-Preferred Providers, differ from other Blue Shield plans. Benefits for Services provided by Non-Participating Preferred Providers may be substantially reduced, and certain Services are not covered. This Plan is intended to qualify as a “high deductible health plan” within the meaning of Section 223 of the Internal Revenue Code of 1986, as amended. In order to qualify, the calendar year deductible and out-of-pocket maximum amounts may increase annually. In the event that any court, agency, or administrative body with jurisdiction over the matter makes a final determination that this Plan does not qualify, Blue Shield will make efforts to amend this Plan prospectively, if necessary, to meet the requirements of a qualified plan. If Blue Shield determines that the amendment necessitates a change in the Plan provisions, Blue Shield will provide written notice of the change, and the change shall become effective on the first (1st) day of the month following the expiration of 30 days from the date the notice was sent. To learn more about Health Savings Accounts, eligibility and the law's current provisions, the Subscriber can consult with a financial advisor. (GPHSA) TABLE OF CONTENTS PART I. INTRODUCTION 4 PART II. DEFINITIONS 4 PART III. ELIGIBILITY 5