Common use of Liability Calculation Method Per Claim Clause in Contracts

Liability Calculation Method Per Claim. The calculation of Member liability on claims for covered health care services processed through the Blue Card Program will be based on the lower of the participating Provider's billed covered charges or the negotiated price made available to BCBSNC by the Host Blue. The methods employed by a Host Blue to determine a negotiated price may vary among Host Blues based on the terms of each Host Blue’s Provider contracts. The negotiated price made available to BCBSNC by a Host Blue may represent a payment that is one of the following: (i) an actual price. An actual price is a negotiated payment without any other increases or decreases (“Actual Price”), or (ii) an estimated price. An estimated price is a negotiated payment increased or reduced by a percentage to take into account certain payments negotiated with the Provider and other claim- and non-claim- related transactions. Such transactions may include, but are not limited to, anti-fraud and abuse recoveries, Provider refunds not applied on a claim-specific basis, retrospective settlements, and performance-related bonuses or incentives (“Estimated Price”), or (iii) an average price. An average price is a percentage of billed covered charges, representing the aggregate payments negotiated by the Host Blue with all of its Providers or a similar classification of its Providers and other claim- and non-claim-related transactions (“Average Price”). Such transactions may include the same ones as noted above for an estimated price. Host Blues using either the Estimated Price or Average Price may, in accordance with Inter-Plan Programs policies, prospectively increase or reduce the Estimated Price or Average Price to correct for over- or underestimation of past prices. However, the amount paid by the Member is a final price; no future price adjustment will be applied to claims already paid. A small number of states may require a Host Blue to either (i) use a basis for determining Member liability for covered healthcare services that does not reflect the entire amount of realized or expected savings on a particular claim, or (ii) add a surcharge. Should any state enact a law that mandates liability calculation methods that differ from the negotiated price methodology or require a surcharge, BCBSNC would then calculate Member liability in accordance with applicable law.

Liability Calculation Method Per Claim. The calculation of the Member liability on claims for covered health care services Covered Services processed through the Blue Card BlueCard Program will be based on the lower of the participating Provider's billed covered charges or the negotiated price made available to BCBSNC Us by the Host Blue. The Host Blues may use various methods employed by a Host Blue to determine a negotiated price may vary among Host Blues based price, depending on the terms of each Host Blue’s health care Provider contracts. The negotiated price made available to BCBSNC Us by a the Host Blue may represent a payment negotiated by a Host Blue with a health care Provider that is one of the following: (i) an : An actual price. An actual price is a negotiated payment without any other increases or decreases (“Actual Price”)decreases, or (ii) an or An estimated price. An estimated price is a negotiated payment reduced or increased or reduced by a percentage to take into account certain payments negotiated with the Provider and other claim- and non-claim- claim-related transactions. Such transactions may include, but are not limited to, anti-fraud and abuse recoveries, Provider refunds not applied on a claim-specific basis, retrospective settlements, and performance-related bonuses or incentives (“Estimated Price”), or (iii) an incentives; or An average price. An average price is a percentage of billed covered charges, charges representing the aggregate payments negotiated by the Host Blue with all of its health care Providers or a similar classification of its Providers and other claim- and non-claim-related transactions (“Average Price”)transactions. Such transactions may include the same ones as noted above for an estimated price. Host Blues using either the Estimated Price an estimated price or Average Price an average price may, in accordance with Inter-Inter- Plan Programs policies, prospectively increase or reduce the Estimated Price or Average Price such prices to correct for over- or underestimation of past pricesprices (i.e., prospective adjustments may mean that a current price reflects additional amounts or credits for claims already paid to Providers or anticipated to be paid to or received from Providers). However, the amount paid by the Member is a final price; no future price adjustment will be applied result in increases or decreases to claims already paidthe pricing of past claims. The BlueCard Program requires that the price submitted by a Host Blue to Us is a final price irrespective of any future adjustments based on the use of estimated or average pricing. A small number of states may require a Host Blue to either (i) to use a basis for determining Member liability for covered healthcare services Covered Services that does not reflect the entire amount of realized savings realized, or expected savings to be realized, on a particular claim, claim or (ii) to add a surcharge. Should any the state enact a law that mandates in which health care services are accessed mandate liability calculation methods that differ from the negotiated price methodology or require a surcharge, BCBSNC We would then calculate Member liability in accordance with applicable law. Under the BlueCard Program, recoveries from a Host Blue or its participating Providers can arise in several ways, including, but not limited to, anti-fraud and abuse recoveries, health care Provider/Hospital audits, credit balance audits, utilization review refunds, and unsolicited refunds. In some cases, the Host Blue will engage a third party to assist in identification or collection of recovery amounts. The fees of such a third party may be netted against the recovery. Recovery amounts determined in this way will be applied in accordance with applicable Inter-Plan Programs policies, which generally require correction on a claim-by-claim or prospective basis. As an alternative to the BlueCard Program, the Member’s claim for Covered Services may be processed through a negotiated national account arrangement with a Host Blue. If We have arranged for (a) Host Blue(s) to make available (a) custom health care Provider network(s) in connection with this Contract, then the terms and conditions set forth in Our negotiated national account arrangements with such Host Blue(s) shall apply. Member liability calculation will be based on the lower of either billed covered charges or negotiated price (refer to the description of negotiated price above) made available to Us by the Host Blue that allows Members access to negotiated participation agreement networks of specified Participating Providers outside of Our service area.

Liability Calculation Method Per Claim. The calculation of Member the Member’s liability on claims for covered health care healthcare services processed through the Blue Card BlueCard Program will be based on the lower of the participating Providerhealthcare provider's billed covered charges or the negotiated price made available to BCBSNC BCN by the Host Blue. The methods employed calculation of the Group’s liability on claims for covered healthcare services processed through the BlueCard Program will be based on the negotiated price made available to BCN by a the Host Blue. Sometimes, this negotiated price may be greater than billed charges if the Host Blue has negotiated with its participating healthcare provider(s) an inclusive allowance (e.g., per case or per day amount) for specific healthcare services. Host Blues may use various methods to determine a negotiated price may vary among Host Blues based price, depending on the terms of each Host Blue’s Provider healthcare provider contracts. The negotiated price made available to BCBSNC BCN by a the Host Blue may represent a payment negotiated by a Host Blue with a healthcare provider that is one of the following: (ia) an actual price. An actual price is a negotiated payment without any other increases or decreases (“Actual Price”)decreases, or (iib) an estimated price. An estimated price is a negotiated payment reduced or increased or reduced by a percentage to take into account certain payments negotiated with the Provider provider and other claim- and non-claim- claim-related transactions. Such transactions may include, but are not limited to, anti-fraud and abuse recoveries, Provider provider refunds not applied on a claim-specific basis, retrospective settlements, and performance-related bonuses or incentives (“Estimated Price”), incentives; or (iiic) an average price. An average price is a percentage of billed covered charges, charges representing the aggregate payments negotiated by the Host Blue with all of its Providers healthcare providers or a similar classification of its Providers providers and other claim- and non-claim-related transactions (“Average Price”)transactions. Such transactions may include the same ones as noted above for an estimated price. Host Blues using either the Estimated Price an estimated price or Average Price an average price may, in accordance with Inter-Plan Programs policies, prospectively increase or reduce the Estimated Price or Average Price such prices to correct for over- or underestimation of past pricesprices (i.e., prospective adjustments may mean that a current price reflects additional amounts or credits for claims already paid to providers or anticipated to be paid to or received from providers). However, the amount paid by the Member is a final price; no future price adjustment will result in increases or decreases to the pricing of past claims. The BlueCard Program requires that the price submitted by a Host Blue to BCN is a final price irrespective of any future adjustments based on the use of estimated or average pricing. If a Host Blue uses either an estimated price or an average price on a claim, it may also hold some portion of the amount that Group pay in a variance account, pending settlement with its participating healthcare providers. Because all amounts paid are final, neither variance account funds held to be applied paid, nor the funds expected to claims already paidbe received, are due to or from Group. Such payable or receivable would be eventually exhausted by healthcare provider settlements and/or through prospective adjustment to the negotiated prices. Some Host Blues may retain interest earned, if any, on funds held in variance accounts. A small number of states may require a Host Blue to either (i) to use a basis for determining Member liability for covered healthcare services that does not reflect the entire amount of realized savings realized, or expected savings to be realized, on a particular claim, claim or (ii) to add a surcharge. Should any the state enact a law that mandates in which healthcare services are accessed mandate liability calculation methods that differ from the negotiated price methodology or require a surcharge, BCBSNC BCN would then calculate Member liability in accordance with applicable law.

Liability Calculation Method Per Claim. The calculation of the Member liability on claims for covered health care services Covered Services processed through the Blue Card BlueCard Program will be based on the lower of the participating Provider's billed covered charges or the negotiated price made available to BCBSNC Us by the Host Blue. The Host Blues may use various methods employed by a Host Blue to determine a negotiated price may vary among Host Blues based price, depending on the terms of each Host Blue’s health care Provider contracts. The negotiated price made available to BCBSNC Us by a the Host Blue may represent a payment negotiated by a Host Blue with a health care Provider that is one of the following: (i) an : • An actual price. An actual price is a negotiated payment without any other increases or decreases (“Actual Price”)decreases, or (ii) an or • An estimated price. An estimated price is a negotiated payment reduced or increased or reduced by a percentage to take into account certain payments negotiated with the Provider and other claim- and non-claim- claim-related transactions. Such transactions may include, but are not limited to, anti-fraud and abuse recoveries, Provider refunds not applied on a claim-specific basis, retrospective settlements, and performance-related bonuses or incentives (“Estimated Price”), or (iii) an incentives; or • An average price. An average price is a percentage of billed covered charges, charges representing the aggregate payments negotiated by the Host Blue with all of its health care Providers or a similar classification of its Providers and other claim- and non-claim-related transactions (“Average Price”)transactions. Such transactions may include the same ones as noted above for an estimated price. Host Blues using either the Estimated Price an estimated price or Average Price an average price may, in accordance with Inter-Plan Programs policies, prospectively increase or reduce the Estimated Price or Average Price such prices to correct for over- or underestimation of past pricesprices (i.e., prospective adjustments may mean that a current price reflects additional amounts or credits for claims already paid to Providers or anticipated to be paid to or received from Providers). However, the amount paid by the Member is a final price; no future price adjustment will be applied result in increases or decreases to claims already paidthe pricing of past claims. A The BlueCard Program requires that the price submitted by a Host Blue to Us is a final price irrespective of any future adjustments based on the use of estimated or average pricing. In some instances federal law or the laws of a small number of states may require a Host Blue to Blues either (i) to use a basis for determining Member liability for covered healthcare services medical expenses that does not reflect the entire amount of realized savings realized, or expected savings to be realized, on a particular claim, claim or (ii) to add a surcharge. Should any either federal law or the law of the state enact a law that mandates in which health care services are accessed mandate liability calculation methods that differ from the negotiated price methodology or require a surcharge, BCBSNC We would then calculate Member liability in accordance with applicable law. Under the BlueCard Program, recoveries from a Host Blue or its participating Providers can arise in several ways, including, but not limited to, anti-fraud and abuse recoveries, health care Provider/Hospital audits, credit balance audits, utilization review refunds, and unsolicited refunds. In some cases, the Host Blue will engage a third party to assist in identification or collection of recovery amounts. The fees of such a third party may be netted against the recovery. Recovery amounts determined in this way will be applied in accordance with applicable Inter-Plan Programs policies, which generally require correction on a claim-by-claim or prospective basis. As an alternative to the BlueCard Program, the Member’s claim for Covered Services may be processed through a negotiated national account arrangement with a Host Blue. If We have arranged for (a) Host Blue(s) to make available (a) custom health care Provider network(s) in connection with this Contract, then the terms and conditions set forth in Our negotiated national account arrangements with such Host Blue(s) shall apply. Member liability calculation will be based on the lower of either billed covered charges or negotiated price (refer to the description of negotiated price above) made available to Us by the Host Blue that allows Members access to negotiated participation agreement networks of specified Participating Providers outside of Our service area. • Member Liability Calculation. When Covered Services are provided outside of Our service area by nonparticipating Providers, the amount(s) a Member pays for such services will generally be based on either the Host Blue’s nonparticipating Provider local payment or the pricing arrangements required by applicable state law. In these situations, the Member may be responsible for the difference between the amount that the nonparticipating Provider bills and the payment We will make for the Covered Services as set forth in this paragraph. • Exceptions. In some exception cases, We may pay claims from nonparticipating Providers outside of Our service area based on the Provider’s billed charge, such as in situations where a Member did not have reasonable access to a participating Provider, as determined by Us or by applicable state law. In other exception cases, We may pay such a claim based on the payment We would make if We were paying a nonparticipating Provider inside of Our service area, as described elsewhere in this Contract, where the Host Blue’s corresponding payment would be more than Our in-service area nonparticipating Provider payment, or We may negotiate a payment with such a Provider on an exception basis. In any of these exception situations, the Member may be responsible for the difference between the amount that the nonparticipating Provider bills and payment We will make for the Covered Services as set forth in this paragraph. The Group agrees to the following: • Handle and distribute enrollment materials in a timely manner and promptly provide to Us the information necessary to administer this Contract. There is an understanding and agreement that the Group's failure to provide information in a timely manner may substantially delay and/or jeopardize the enrollment of eligible Members. • Restrict enrollment and payment of premiums through the Group to eligible Members. • Make payroll deductions for and verify with Us the eligibility of any Member on a temporary leave of absence. • Remit premiums for a terminating Member through the end of the monthly coverage period in which the Member terminates (except as provided under Refund of Premiums), unless otherwise agreed in advance in writing. • Delete terminations from the billing and to notify Us of terminations in a timely manner and as part of the administrative record-keeping process that occurs in the normal course of business. The Group further agrees that any refund of the number of months of premiums paid by the Group in error or for an ineligible Member shall be made only if claims have not been paid. • Provide each Member 30 days prior written notice of termination of this Contract, including any termination due to the Group's failure to pay premiums. • Notify each Member of any right(s) that may exist to continue coverage upon termination, as provided by any applicable law or as otherwise described in the Booklet, and collect and forward associated timely enrollment forms and premiums. • Provide those notices, in a timely manner, that a group health plan is required by law to provide (e.g., notices of a plan's preexisting condition exclusion or special enrollment rights provisions). The Group agrees to indemnify and hold Us harmless from any damages, loss, action, claim or suit (including court costs and attorney's fees) arising from or related to its failure to provide such legally-required notices. • Report monthly the names of new Members, cancelled Members and Members electing any statutory continuance of coverage. • Maintain workers' compensation coverage for all Members, as required by law. • Maintain Group eligibility in accordance with the minimum standards of applicable statutory continuances of coverage, unless We have agreed in advance and in writing to the Group's use of standards more generous to Members. • If We provide Our enrollment and/or change forms ("Forms") and/or any summary plan descriptions, benefit summaries and/or comparison sheets ("Documents") in an electronic medium for inclusion on the Group's internal intranet or by similar means, Group agrees that: - electronic access shall be limited to the Group's enrolling employees and covered employees and be restricted to a "read-only" or similar basis; - they will replace any hard-copy Forms that have been modified by Us; - the hard-copy documents on file with Us shall control in the event of any discrepancy; and - the Group remains solely responsible for the content of the documents and all other legal requirements pertaining to them (e.g., distribution).

Liability Calculation Method Per Claim. The calculation of Member liability on claims for covered health care healthcare services processed through the Blue Card Program BlueCard Program, if not a flat dollar copayment, will be based on the lower of the participating Provider's billed covered charges or the negotiated price made available to BCBSNC by the Host Blue. The calculation of Plan Sponsor, Plan Administrator, and/or Group Health Plan liability on claims for covered healthcare services processed through the BlueCard Program will be based on the negotiated price made available to BCBSNC by the Host Blue. Sometimes, this negotiated price may be greater than billed charges if the Host Blue has negotiated with its participating healthcare provider(s) an inclusive allowance (e.g., per case or per day amount) for specific healthcare services. The methods employed by a Host Blue to determine a negotiated price may vary among Host Blues based on the terms of each Host Blue’s Provider contracts. The negotiated price made available to BCBSNC by a Host Blue may represent a payment that is one of the following: (ia) an actual price. An actual price is a negotiated payment without any other increases or decreases (“Actual Price”), or (iib) an estimated price. An estimated price is a negotiated payment increased or reduced by a percentage to take into account certain payments negotiated with the Provider and other claim- and non-claim- claim-related transactions. Such transactions may include, but are not limited to, anti-fraud and abuse recoveries, Provider refunds not applied on a claim-specific basis, retrospective settlements, and performance-related bonuses or incentives (“Estimated Price”), or (iiic) an average price. An average price is a percentage of billed covered charges, charges representing the aggregate payments negotiated by the Host Blue with all of its Providers or a similar classification of its Providers and other claim- and non-claim-claim- related transactions (“Average Price”). Such transactions may include the same ones as noted above for an estimated price. Host Blues using either the Estimated Price or Average Price may, in accordance with Inter-Plan Programs policies, prospectively increase or reduce the Estimated Price or Average Price to correct for over- over or underestimation of past prices. However, the amount paid by the Member is a final price; no future price adjustment will be applied to claims already paid. A small number of states may require a Host Blue to either (i) use a basis for determining Member liability for covered healthcare services that does not reflect the entire amount of realized or expected savings on a particular claim, or (ii) add a surcharge. Should any state enact a law that mandates liability calculation methods that differ from the negotiated price methodology or require a surcharge, BCBSNC would then calculate Member liability in accordance with applicable law.

Liability Calculation Method Per Claim. The calculation of Member the Participant liability on claims for covered health care services Covered Services processed through the Blue Card BlueCard® Program will be based on the lower of the participating Providerhealthcare provider's billed covered charges or the negotiated price made available to BCBSNC Service Provider by the Host BluePlan. The methods employed calculation of the Department’s liability on claims for Covered Services processed through the BlueCard® Program will be based on the negotiated price made available to Service Provider by a the Host Blue to determine a Plan. This negotiated price may vary among be greater than what would be the healthcare provider(s)’ billed charges in those instances where the Host Blues based on Plan has negotiated with its participating healthcare provider(s) an inclusive allowance for specific healthcare services (e.g., DRG or per case or per day amount payment methodologies). Each Host Plan’s determination of an applicable negotiated price will be consistent with the terms of each Host BluePlan’s Provider contractsapplicable healthcare provider contract. The negotiated price made available to BCBSNC Service Provider by a the Host Blue may represent a payment that Plan which will be passed through to the Department under this Contract is one of the following: (i) an actual price. An actual price is a negotiated payment without any other increases or decreases (“Actual Price”)decreases, or (ii) an estimated price. An estimated price is a negotiated payment reduced or increased or reduced by a percentage to take into account certain payments negotiated with the Provider provider and other claim- and non-claim- claim-related transactions. Such transactions may include, but are not limited to, anti-fraud and abuse recoveries, Provider provider refunds not applied on a claim-specific basis, retrospective settlements, and performance-related bonuses or incentives (“Estimated Price”)incentives, or (iii) an average price. An average price is a percentage of billed covered charges, charges representing the aggregate payments negotiated by the Host Blue Plan with all of its Providers healthcare providers or a similar classification of its Providers providers and other claim- and non-claim-related transactions (“Average Price”)transactions. Such transactions may include the same ones as examples noted above for an estimated price. Host Blues Plans using either the Estimated Price an estimated price or Average Price an average price may, in accordance with Inter-Plan Programs BlueCard® policies, prospectively increase or reduce the Estimated Price or Average Price such prices to correct for over- or underestimation of past pricesprices (i.e., prospective adjustments may mean that a current price reflects additional amounts or credits for claims already paid to providers or anticipated to be paid to or received from providers). However, the amount paid by the Member Participant and the Department is a final price; price for the limited purpose of pricing an applicable claim and no future price adjustment will result in increases or decreases to the pricing of past claims. The BlueCard® Program specifically requires that the price submitted by a Host Plan to Service Provider is a final price under this Contract for the limited purpose of pricing an applicable claim and irrespective of any future adjustments based on the use of estimated or average pricing. Recovery of overpayments from a Host Plan or its participating healthcare providers will in any event be applied for the benefit of the Department independent of this limited pricing rule and consistent with terms of this Contract. If a Host Plan uses either an estimated price or an average price on a claim, it may also hold some portion of the amount paid by a Home Plan in a variance account, pending settlement with its participating healthcare providers. This includes amounts paid by Service Provider as a Home Plan which are passed through to claims already the Department under this Contract. Because all such amounts paid are final for the limited purpose of pricing an applicable claim, neither variance account funds held to be paid, nor the funds expected to be received, are due to or from the Department. A Such payable or receivable funds would be eventually exhausted by healthcare provider settlements and/or through prospective adjustment to the negotiated prices. In such instances some Host Plans may retain interest earned, if any, on funds held in variance accounts. In some instances federal law or the laws of a small number of states may require a Host Blue to either Plans either (i) to use a basis for determining Member Participant liability for covered healthcare services Covered Services that does not reflect the entire amount of realized savings realized, or expected savings to be realized, on a particular claim, claim or (ii) to add a surcharge. Should any either federal law or the law of the state enact a law that mandates in which healthcare services are accessed mandate liability calculation methods that differ from the negotiated price methodology or require a surcharge, BCBSNC an applicable Host Plan would then calculate Member both Participant liability and Service Provider liability for Covered Services which are passed through to the Department under this Contract in accordance with such applicable law.

Liability Calculation Method Per Claim. The In General Member Liability Calculation Unless subject to a fixed dollar copayment, the calculation of Member the member liability on claims for covered health care healthcare services processed through the Blue Card Program will be based on the lower of the participating Providerprovider's billed covered charges or the negotiated price made available to BCBSNC Florida Blue by the Host Blue. Employer Liability Calculation The methods employed calculation of Employer liability on claims for covered healthcare services processed through the BlueCard Program will be based on the negotiated price made available to Florida Blue by a the Host Blue (under the contract between the Host Blue and the provider). Sometimes, this negotiated price may be greater for a given service or services than the billed charge in accordance with how the Host Blue has negotiated with its participating healthcare provider(s) for specific healthcare services. In cases where the negotiated price exceeds the billed charge, Employer may be liable for the excess amount even when the member’s deductible has not been satisfied. This excess amount reflects an amount that may be necessary to secure (a) the provider’s participation in the network and/or (b) the overall discount negotiated by the Host Blue. In such a case, the entire contracted price is paid to the provider, even when the contracted price is greater than the billed charge. Claims Pricing Host Blues determine a negotiated price may vary among Host Blues based on price, which is reflected in the terms of each Host Blue’s Provider provider contracts. The negotiated price made available to BCBSNC Florida Blue by a the Host Blue may represent a payment that is be represented by one of the following: (i) an : • An actual price. An actual price is a negotiated rate of payment in effect at the time a claim is processed without any other increases or decreases (“Actual Price”), or (ii) an decreases; or • An estimated price. An estimated price is a negotiated rate of payment in effect at the time a claim is processed, reduced or increased or reduced by a percentage to take into account certain payments negotiated with the Provider provider and other claim- and non-claim- claim-related transactions. Such transactions may include, but are not limited to, anti-fraud and abuse recoveries, Provider provider refunds not applied on a claim-specific basis, retrospective settlements, settlements and performance-performance related bonuses or incentives (“Estimated Price”), or (iii) an incentives; or • An average price. An average price is a percentage of billed covered charges, charges in effect at the time a claim is processed representing the aggregate payments negotiated by the Host Blue with all of its Providers healthcare providers or a similar classification of its Providers providers and other claim- and non-claim-claim- related transactions (“Average Price”)transactions. Such transactions may include the same ones as noted above for an estimated price. The Host Blues using either Blue determines whether it will use an actual, estimated or average price. The use of estimated or average pricing may result in a difference (positive or negative) between the Estimated Price or Average Price may, in accordance with Inter-Plan Programs policies, prospectively increase or reduce price Employer pays on a specific claim and the Estimated Price or Average Price actual amount the Host Blue pays to correct for over- or underestimation of past pricesthe provider. However, the BlueCard Program requires that the amount paid by the Member member and Employer is a final price; no future price adjustment will result in increases or decreases to the pricing of past claims. Any positive or negative differences in estimated or average pricing are accounted for through variance accounts maintained by the Host Blue and are incorporated into future claim prices. As a result, the amounts charged to Employer will be applied adjusted in a following year, as necessary, to account for over- or underestimation of the past years’ prices. The Host Blue will not receive compensation from how the estimated price or average price methods, described above, are calculated. Because all amounts paid are final, neither positive variance account amounts (funds available to be paid in the following year), nor negative variance amounts (the funds needed to be received in the following year), are due to or from Employer. If Employer terminates, you will not receive a refund or charge from the variance account. Variance account balances are small amounts relative to the overall paid claims already paidamounts and will be liquidated over time. A small The timeframe for their liquidation depends on variables, including, but not limited to, overall volume/number of states claims processed and variance account balance. Variance account balances may require earn interest at the federal funds or similar rate. Host Blues may retain interest earned on funds held in variance accounts. BlueCard Program Fees and Compensation Employer understands and agrees to reimburse Florida Blue for certain fees and compensation which Florida Blue is obligated under the BlueCard Program to pay to the Host Blues, to the Association and/or to vendors of BlueCard Program related services. The specific BlueCard Program fees and compensation that are charged to Employer are set forth in Exhibit B. BlueCard Program Fees and compensation may be revised from time to time. Only the BlueCard Program access fee may be charged separately each time a claim is processed through the BlueCard Program. All other BlueCard Program related fees are included in the Administrative Fee. The access fee is charged by the Host Blue to either (i) use a basis Florida Blue for determining Member liability for covered healthcare services that does making its applicable provider network available to Employer’s. The access fee will not reflect the entire amount of realized or expected savings apply to non-participating provider claims. The access fee is charged on a particular claim, or (ii) add per claim basis and is charged as a surcharge. Should any state enact a law that mandates liability calculation methods that differ percentage of the discount/differential Florida Blue receives from the negotiated price applicable Host Blue subject to a maximum of $2,000 per claim. When charged, Florida Blue passes the access fee directly on to Employer. Instances may occur in which the claim payment is zero or Florida Blue pays only a small amount because the amounts eligible for payment were applied to patient cost sharing (such as a deductible or coinsurance). In these instances, Florida Blue will pay the Host Blue’s access fee and pass it along directly to Employer as stated above even Employer paid little or had no claim liability. An Administrative Fee encompasses fees Florida Blue charges to Employer for administering Employer’s benefit plan. They may include both local (within Florida Blue’s service area) and Inter-Plan fees. For purposes of this Agreement, they include the following BlueCard Program related fees other than the BlueCard Program access fee: namely, administrative expense allowance (AEA) fee, central financial agency fee, ITS transaction fee, toll free number fee, PPO provider directory fee and Blue Cross Blue Shield Global® Core Program Fees, if applicable. Special Cases: Value-Based Programs Value-Based Programs Definitions Accountable Care Organization (ACO): A group of healthcare providers who agree to deliver coordinated care and meet performance benchmarks for quality and affordability in order to manage the total cost of care for their member populations. Global Payment/Total Cost of Care: A payment methodology that is defined at the patient level and accounts for either all patient care or require for a surchargespecific group of services delivered to the patient such as outpatient, BCBSNC would then calculate Member liability physician, ancillary, hospital services and prescription drugs. Patient-Centered Medical Home (PCMH): A model of care in accordance which each patient has an ongoing relationship with applicable lawa primary care physician who coordinates a team to take collective responsibility for patient care and, when appropriate, arranges for care with other qualified physicians.