Common use of Uniform Premium Requirements Clause in Contracts

Uniform Premium Requirements. With respect to the premiums charged to Members for Part C and/or Part D drug benefits, you may determine how much of a Member’s Part C and/or Part D monthly beneficiary premium you will subsidize, provided that: (i) if you subsidize different amounts for different classes of Members in a plan, such classes will be reasonable and based on objective business criteria, such as years of service, business location, job category and nature of compensation (for example, salaried and hourly), and different classes cannot be based on eligibility for the low-income subsidy; (ii) the premium will not vary for individuals within a given class of Members; and (iii) a Member cannot be charged more than the sum of their standard Part D beneficiary premium or the monthly beneficiary premium for basic benefits as defined in 42 CFR § 422.2 (i.e., all Medicare-covered benefits, except hospice services); and 100% of the monthly beneficiary premium for their non-Medicare Part C and/or Part D benefits (if any). You must pass through any direct subsidy payments received from CMS to reduce the amount the Member pays (or, in those instances when your employee pays premiums on behalf of their eligible spouse or covered dependent, the amount the employee pays). Low Income Subsidy (LIS). The low-income premium subsidy that CMS pays on behalf of an LIS-eligible Member must be passed through to the LIS-eligible Member. With respect to the premium contributions collected from your LIS-eligible Members, the monthly low-income premium subsidy will first be used to reduce that portion of the premium paid for by the LIS-eligible Member, with any remaining portion of the premium subsidy amount then used to reduce the employer’s premium contribution. You will be responsible for reducing up front the premium contribution amounts for your LIS-eligible Members. If you are not able to reduce an LIS-eligible Member’s premium contribution amount up front that has been previously paid by the LIS-eligible Member (or, your employee if they pay premiums on behalf of the LIS-eligible Member), you must directly refund the low-income premium subsidy amount up to the monthly premium contribution that you previously collected from the LIS-eligible Member (or, your employee, if applicable). You are required to refund the LIS-eligible Member (or, your employee, if applicable) within 45 days of the date Blue Cross and Blue Shield receives the low-income premium subsidy amount payment from CMS on behalf of your LIS-eligible Members. If the low-income premium subsidy amount for which a Member is eligible is less than the portion of the monthly premium paid by the Member, then you should communicate to your employee the financial consequences for the LIS-eligible Member enrolling in a plan that you elect to offer as described above, as compared to enrolling in another Part D plan with a monthly premium equal to or below the low-income premium subsidy amount. Grandfathered Status under Federal Law Group health plans in effect on March 23, 2010 may be eligible for grandfathered status pursuant to Section 1251 of the Patient Protection and Affordable Care Act, as modified by Section 2301 of the Health Care Reconciliation and Education Act of 2010 (PPACA), and 45 C.F.R. § 147.140. Group health plans that qualify for grandfathered status do not need to meet all of the requirements applicable to non-grandfathered health plans under PPACA. The changes to a group health plan that may affect its grandfathered status include, but are not limited to, the elimination of all or substantially all benefits to diagnose or treat a particular condition, an increase to the percentage of cost-sharing requirement applicable to benefits under the policy, an increase to a fixed amount cost- sharing requirement applicable to benefits under the plan (beyond what is permitted by law for retaining grandfathered status), or the creation or modification of an annual or lifetime limit (beyond what is permitted by law for retaining grandfathered status). There are also other factors of which Blue Cross and Blue Shield may not be aware, that may affect a group health plan’s grandfathered status. For example, changes by an employer the contribution rates for the group health plan’s subscribers may result in the loss of grandfathered status for the group health plan. You must immediately notify Blue Cross and Blue Shield if you make any change to your contribution rates during the policy year. The requirements for maintaining the grandfathered status of a group health plan are subject to change as new standards and/or new interpretations of existing requirements are issued by federal or state agencies. In the event you have 100 or more employees enrolled in Blue Cross and Blue Shield benefits plans, Blue Cross and Blue Shield will, upon receipt of necessary documentation, administer your plan design(s) as having grandfathered status. You acknowledge and agree that you are responsible for determining if your group health plan(s) qualify for grandfathered status. In the event that you inform Blue Cross and Blue Shield that you consider your group health plan(s) to be grandfathered group health plan(s), you represent and warrant that (i) the group health plan(s) were in effect on March 23, 2010 and (ii) you have determined that the group health plan(s) are eligible for grandfathered status. You must specify in writing the specific plan designs to be grandfathered. You are solely responsible for compliance with the disclosure and document retention requirements applicable to grandfathered plans under 45 C.F.R. § 147.140. Blue Cross and Blue Shield makes no representation or warranty regarding the past, present, or future grandfathered status of your group health plan(s) or that your group health plan(s) are eligible for grandfathered status. In addition, to the extent that your group health plan(s) are eligible for grandfathered status, Blue Cross and Blue Shield makes no representation or warranty that this status will be retained during the current plan year or any future renewal period. You acknowledge and agree that Blue Cross and Blue Shield is not responsible and shall not be liable for any claims, costs, liabilities, losses, penalties, damages or other expenses of any kind that, directly or indirectly, arise from or relate to your group health plan(s)’ past, present and future grandfathered status, lack thereof, or any changes regarding the group health plan’s grandfathered status, including, but not limited to, any representation made by any employee, broker, agent, or independent contractor of Blue Cross and Blue Shield regarding the group health plan’s grandfathered status. Fees Negotiated with Non-Participating Providers Blue Cross and Blue Shield may in certain select circumstances use a vendor to negotiate fees with non-participating providers for covered health care services received by Members. In these certain select circumstances, the negotiation will be performed on a claim-by-claim basis to reduce inpatient and outpatient institutional and professional costs and to eliminate member balance billing for amounts in excess of the negotiated fee. The Account acknowledges and agrees that, because the negotiation with a non-participating provider will be performed after a claim is incurred, Blue Cross and Blue Shield or its vendor may be exercising fiduciary discretion in deciding which claims to negotiate and in the actual negotiation. The Account grants full discretionary authority to Blue Cross and Blue Shield or its vendor to negotiate on its behalf with the non-participating provider. Any such negotiation will be performed in accordance with applicable federal and state law, including but not limited to the No Surprises Act as applicable.

Uniform Premium Requirements. With respect to the premiums charged to Members for Part C and/or Part D drug benefits, you may determine how much of a Member’s Part C and/or Part D monthly beneficiary premium you will subsidize, provided that: (i) if you subsidize different amounts for different classes of Members in a plan, such classes will be reasonable and based on objective business criteria, such as years of service, business location, job category and nature of compensation (for example, salaried and hourly), and different classes cannot be based on eligibility for the low-income subsidy; (ii) the premium will not vary for individuals within a given class of Members; and (iii) a Member cannot be charged more than the sum of their standard Part D beneficiary premium or the monthly beneficiary premium for basic benefits as defined in 42 CFR § 422.2 (i.e., all Medicare-covered benefits, except hospice services); and 100% of the monthly beneficiary premium for their non-Medicare Part C and/or Part D benefits (if any). You must pass through any direct subsidy payments received from CMS to reduce the amount the Member pays (or, in those instances when your employee pays premiums on behalf of their eligible spouse or covered dependent, the amount the employee pays). Low Income Subsidy (LIS). The low-income premium subsidy that CMS pays on behalf of an LIS-eligible Member must be passed through to the LIS-eligible Member. With respect to the premium contributions collected from your LIS-eligible Members, the monthly low-income premium subsidy will first be used to reduce that portion of the premium paid for by the LIS-eligible Member, with any remaining portion of the premium subsidy amount then used to reduce the employer’s premium contribution. You will be responsible for reducing up front the premium contribution amounts for your LIS-eligible Members. If you are not able to reduce an LIS-eligible Member’s premium contribution amount up front that has been previously paid by the LIS-eligible Member (or, your employee if they pay premiums on behalf of the LIS-eligible Member), you must directly refund the low-income premium subsidy amount up to the monthly premium contribution that you previously collected from the LIS-eligible Member (or, your employee, if applicable). You are required to refund the LIS-eligible Member (or, your employee, if applicable) within 45 days of the date Blue Cross and Blue Shield receives the low-income premium subsidy amount payment from CMS on behalf of your LIS-eligible Members. If the low-income premium subsidy amount for which a Member is eligible is less than the portion of the monthly premium paid by the Member, then you should communicate to your employee the financial consequences for the LIS-eligible Member enrolling in a plan that you elect to offer as described above, as compared to enrolling in another Part D plan with a monthly premium equal to or below the low-income premium subsidy amount. Grandfathered Status under Federal Law Group health plans in effect on March 23, 2010 may be eligible for grandfathered status pursuant to Section 1251 of the Patient Protection and Affordable Care Act, as modified by Section 2301 of the Health Care Reconciliation and Education Act of 2010 (PPACA), and 45 C.F.R. § 147.140. Group health plans that qualify for grandfathered status do not need to meet all of the requirements applicable to non-grandfathered health plans under PPACA. The changes to a group health plan that may affect its grandfathered status include, but are not limited to, the elimination of all or substantially all benefits to diagnose or treat a particular condition, an increase to the percentage of cost-sharing requirement applicable to benefits under the policy, an increase to a fixed amount cost- cost-sharing requirement applicable to benefits under the plan (beyond what is permitted by law for retaining grandfathered status), or the creation or modification of an annual or lifetime limit (beyond what is permitted by law for retaining grandfathered status). There are also other factors of which Blue Cross and Blue Shield may not be aware, that may affect a group health plan’s grandfathered status. For example, changes by an employer the contribution rates for the group health plan’s subscribers may result in the loss of grandfathered status for the group health plan. You must immediately notify Blue Cross and Blue Shield if you make any change to your contribution rates during the policy year. The requirements for maintaining the grandfathered status of a group health plan are subject to change as new standards and/or new interpretations of existing requirements are issued by federal or state agencies. In the event you have 100 or more employees enrolled in Blue Cross and Blue Shield benefits plans, Blue Cross and Blue Shield will, upon receipt of necessary documentation, administer your plan design(s) as having grandfathered status. You acknowledge and agree that you are responsible for determining if your group health plan(s) qualify for grandfathered status. In the event that you inform Blue Cross and Blue Shield that you consider your group health plan(s) to be grandfathered group health plan(s), you represent and warrant that (i) the group health plan(s) were in effect on March 23, 2010 and (ii) you have determined that the group health plan(s) are eligible for grandfathered status. You must specify in writing the specific plan designs to be grandfathered. You are solely responsible for compliance with the disclosure and document retention requirements applicable to grandfathered plans under 45 C.F.R. § 147.140. Blue Cross and Blue Shield makes no representation or warranty regarding the past, present, or future grandfathered status of your group health plan(s) or that your group health plan(s) are eligible for grandfathered status. In addition, to the extent that your group health plan(s) are eligible for grandfathered status, Blue Cross and Blue Shield makes no representation or warranty that this status will be retained during the current plan year or any future renewal period. You acknowledge and agree that Blue Cross and Blue Shield is not responsible and shall not be liable for any claims, costs, liabilities, losses, penalties, damages or other expenses of any kind that, directly or indirectly, arise from or relate to your group health plan(s)’ past, present and future grandfathered status, lack thereof, or any changes regarding the group health plan’s grandfathered status, including, but not limited to, any representation made by any employee, broker, agent, or independent contractor of Blue Cross and Blue Shield regarding the group health plan’s grandfathered status. Fees Negotiated with Non-Participating Providers Blue Cross and Blue Shield may in certain select circumstances use a vendor to negotiate fees with non-participating providers for covered health care services received by Members. In these certain select circumstances, the negotiation will be performed on a claim-by-claim basis to reduce inpatient and outpatient institutional and professional costs and to eliminate member balance billing for amounts in excess of the negotiated fee. The Account acknowledges and agrees that, because the negotiation with a non-participating provider will be performed after a claim is incurred, Blue Cross and Blue Shield or its vendor may be exercising fiduciary discretion in deciding which claims to negotiate and in the actual negotiation. The Account grants full discretionary authority to Blue Cross and Blue Shield or its vendor to negotiate on its behalf with the non-participating provider. Any such negotiation will be performed in accordance with applicable federal and state law, including but not limited to the No Surprises Act as applicable.

Uniform Premium Requirements. With respect to the premiums charged to Members for Part C and/or Part D drug benefits, you may determine how much of a Member’s Part C and/or Part D monthly beneficiary premium you will subsidize, provided that: (i) if you subsidize different amounts for different classes of Members in a plan, such classes will be reasonable and based on objective business criteria, such as years of service, business location, job category and nature of compensation (for example, salaried and hourly), and different classes cannot be based on eligibility for the low-income subsidy; (ii) the premium will not vary for individuals within a given class of Members; and (iii) a Member cannot be charged more than the sum of their standard Part D beneficiary premium or the monthly beneficiary premium for basic benefits as defined in 42 CFR § §422.2 (i.e., all Medicare-covered benefits, except hospice services); and 100% of the monthly beneficiary premium for their non-Medicare Part C and/or Part D benefits (if any). You must pass through any direct subsidy payments received from CMS to reduce the amount the Member pays (or, in those instances when your employee pays premiums on behalf of their eligible spouse or covered dependent, the amount the employee pays). Low Income Subsidy (LIS). The low-income premium subsidy that CMS pays on behalf of an LIS-eligible Member must be passed through to the LIS-eligible Member. With respect to the premium contributions collected from your LIS-eligible Members, the monthly low-income premium subsidy will first be used to reduce that portion of the premium paid for by the LIS-eligible Member, with any remaining portion of the premium subsidy amount then used to reduce the employer’s premium contribution. You will be responsible for reducing up front the premium contribution amounts for your LIS-eligible Members. If you are not able to reduce an LIS-eligible Member’s premium contribution amount up front that has been previously paid by the LIS-eligible Member (or, your employee if they pay premiums on behalf of the LIS-eligible Member), you must directly refund the low-income premium subsidy amount up to the monthly premium contribution that you previously collected from the LIS-eligible Member (or, your employee, if applicable). You are required to refund the LIS-eligible Member (or, your employee, if applicable) within 45 days of the date Blue Cross and Blue Shield receives the low-income premium subsidy amount payment from CMS on behalf of your LIS-eligible Members. If the low-income premium subsidy amount for which a Member is eligible is less than the portion of the monthly premium paid by the Member, then you should communicate to your employee the financial consequences for the LIS-eligible Member enrolling in a plan that you elect to offer as described above, as compared to enrolling in another Part D plan with a monthly premium equal to or below the low-income premium subsidy amount. Grandfathered Status under Federal Law Group health plans in effect on March 23, 2010 may be eligible for grandfathered status pursuant to Section 1251 of the Patient Protection and Affordable Care Act, as modified by Section 2301 of the Health Care Reconciliation and Education Act of 2010 (PPACA), and 45 C.F.R. § 147.140. Group health plans that qualify for grandfathered status do not need to meet all of the requirements applicable to non-grandfathered health plans under PPACA. The changes to a group health plan that may affect its grandfathered status include, but are not limited to, the elimination of all or substantially all benefits to diagnose or treat a particular condition, an increase to the percentage of cost-sharing requirement applicable to benefits under the policy, an increase to a fixed amount cost- sharing requirement applicable to benefits under the plan (beyond what is permitted by law for retaining grandfathered status), or the creation or modification of an annual or lifetime limit (beyond what is permitted by law for retaining grandfathered status). There are also other factors of which Blue Cross and Blue Shield may not be aware, that may affect a group health plan’s grandfathered status. For example, changes by an employer the contribution rates for the group health plan’s subscribers may result in the loss of grandfathered status for the group health plan. You must immediately notify Blue Cross and Blue Shield if you make any change to your contribution rates during the policy year. The requirements for maintaining the grandfathered status of a group health plan are subject to change as new standards and/or new interpretations of existing requirements are issued by federal or state agencies. In the event you have 100 or more employees enrolled in Blue Cross and Blue Shield benefits plans, Blue Cross and Blue Shield will, upon receipt of necessary documentation, administer your plan design(s) as having grandfathered status. You acknowledge and agree that you are responsible for determining if your group health plan(s) qualify for grandfathered status. In the event that you inform Blue Cross and Blue Shield that you consider your group health plan(s) to be grandfathered group health plan(s), you represent and warrant that (i) the group health plan(s) were in effect on March 23, 2010 and (ii) you have determined that the group health plan(s) are eligible for grandfathered status. You must specify in writing the specific plan designs to be grandfathered. You are solely responsible for compliance with the disclosure and document retention requirements applicable to grandfathered plans under 45 C.F.R. § 147.140. Blue Cross and Blue Shield makes no representation or warranty regarding the past, present, or future grandfathered status of your group health plan(s) or that your group health plan(s) are eligible for grandfathered status. In addition, to the extent that your group health plan(s) are eligible for grandfathered status, Blue Cross and Blue Shield makes no representation or warranty that this status will be retained during the current plan year or any future renewal period. You acknowledge and agree that Blue Cross and Blue Shield is not responsible and shall not be liable for any claims, costs, liabilities, losses, penalties, damages or other expenses of any kind that, directly or indirectly, arise from or relate to your group health plan(s)’ past, present and future grandfathered status, lack thereof, or any changes regarding the group health plan’s grandfathered status, including, but not limited to, any representation made by any employee, broker, agent, or independent contractor of Blue Cross and Blue Shield regarding the group health plan’s grandfathered status. Fees Negotiated with Non-Participating Providers Blue Cross and Blue Shield may in certain select circumstances use a vendor to negotiate fees with non-participating providers for covered health care services received by Members. In these certain select circumstances, the negotiation will be performed on a claim-by-claim basis to reduce inpatient and outpatient institutional and professional costs and to eliminate member balance billing for amounts in excess of the negotiated fee. The Account acknowledges and agrees that, because the negotiation with a non-participating provider will be performed after a claim is incurred, Blue Cross and Blue Shield or its vendor may be exercising fiduciary discretion in deciding which claims to negotiate and in the actual negotiation. The Account grants full discretionary authority to Blue Cross and Blue Shield or its vendor to negotiate on its behalf with the non-participating provider. Any such negotiation will be performed in accordance with applicable federal and state law, including but not limited to the No Surprises Act as applicable.