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000 Xxxx 00xx Xxxxxx, 00xx Xxxxx
Xxx Xxxx, Xxx Xxxx 00000
REINSURANCE AGREEMENT
between
PREFERRED LIFE INSURANCE COMPANY OF NEW YORK New York, New York
(hereinafter referred to as "Preferred Life")
and
WELLCARE XX XXX XXXX - XXXXXXXX Xxxxxxxx, Xxx Xxxx
(hereinafter referred to as "Plan")
November 1, 1996
REINSURANCE POLICY NUMBER 17055-044
Tax I.D. #___________________
TABLE OF CONTENTS
TITLE ARTICLE
Reinsurance Coverage
Definitions I
Schedule of Reinsurance II
Premium Payment III
Notice of Claims and Reimbursement IV
Reports, Records and Audits V
Arbitration VI
Insolvency/Cessation of Operations VII
Limitations of Reinsurance Coverage VIII
Effective Date, Duration and Termination IX
General Provisions X
Document Execution
Endorsements:
Continuation of Benefits 1
Out of Area Conversion Provision 2
Reinsurance Coverage
It is hereby agreed that in consideration of the promises, terms, and conditions
contained in this Reinsurance Agreement, Plan shall cede to, and Preferred Life
shall reinsure, the portion specified herein of the Membership Service
Agreements issued by the Plan.
ARTICLE I
Definitions
A. "Member Services Agreement" shall mean those contractual agreements to
provide services to Members of the Plan which are approved by the
State of New York and are for those Members for whom Plan has
requested reinsurance coverage from Preferred Life. Applicable
Membership Service Agreements shall be appended to this Reinsurance
Agreement as Exhibit A.
B. "Service Area" shall mean the Service Area defined in the Member
Services Agreement.
C. "Member" shall mean any person or family dependent enrolled and
eligible to receive services under a Member Services Agreement.
D. "Reasonable and Customary" shall mean expenses generally incurred for
cases of comparable nature and severity in the geographical area
involved.
E. "Contract Year" shall mean the twelve (12) month period which begins
on the Effective Date of this Reinsurance Agreement, or any
anniversary of the Effective Date.
F. "Acute Care Services" shall mean those services which are necessary to
the care and treatment of an unstable medical condition caused by the
onset of a severe illness or injury which places the patient's health
in severe jeopardy and requires immediate medical attention. Acute
Care Services do not include health care or other services which are
for custodial care, or services which assist in or are intended to
improve the usual activities of daily living.
G. "Approved Fixed Procedural Fee Hospital" shall mean a hospital with
fixed per diems or fixed case rates which have been reviewed and
approved by Preferred Life prior to any service being rendered. This
does not include any discounted fee-for-service arrangements, nor does
it include per diems or case rates which revert to a discount off
actual charges for fee-for-service once an outlier or stoploss
threshold has been reached.
H. "Prior Approved Transplant Reimbursement Schedule" shall mean a
reimbursement schedule for a specific transplant procedure that is
approved, in writing, by Preferred Life prior to the transplant
admission. Instructions for obtaining prior approval are available
from Preferred Life upon request.
I. "Deductible" shall mean the Deductible amount shown in the Schedule of
Reinsurance. The Deductible will be applied to any Loss as follows:
1. If the Loss consists of Eligible Hospital Services incurred
during a period of continuous, uninterrupted confinement at one
or more facilities, charges from each facility will be applied to
the Deductible in an amount equal to the proportion of that
facility's Services to total Eligible Hospital Services.
ARTICLE I
(Continued)
2. If the Loss consists of Eligible Hospital Services incurred
during two or more periods of noncontinuous confinement, Services
will be applied to the Deductible based on the date incurred
beginning with charges incurred earliest in the Contract Year and
continuing in incurred date order until the Deductible is
satisfied.
J. "Eligible Hospital Services" shall mean those Acute Care Services for
Members who require Acute Care while registered bed patients, which
are generally and customarily provided by the Plan's participating
hospitals or other specialized institutions within the Service Area of
the Plan and which are prescribed, directed, or authorized by or on
behalf of the Plan. Eligible Hospital Services shall mean the lesser
of:
1. The amount of the Plan's negotiated hospital rate; or
2. The amount of the Reasonable and Customary charges; but in any
event, Eligible Hospital Services shall be limited to an average
of $2,000 per day of each period of continuous hospital
confinement. Operating room charges are excluded from the
calculation of the average daily limit. Eligible Hospital
Services shall also include Referral Services, and the hospital
portion of Emergency Out of Area Services, but shall not include
physician or surgeon charges.
K. "Referral Services" shall mean those Acute Care Services provided to a
Member by a non-participating hospital which, due to the specialized
nature of the service or facility required, cannot be provided by the
Plan's participating hospitals. Referral Services shall be considered
Eligible Hospital Services if such services are specifically
authorized by the Plan. Referral Services shall mean the lesser of:
1. The amount of the negotiated charges; or
2. The amount of the Reasonable and Customary charges; but in any
event Referral Services, to the extent they are Eligible Hospital
Services, shall be limited to an average of $2,000 per day of
each period of continuous hospital confinement. Operating room
charges are excluded from the calculation of the average daily
limit. Referral Services shall not include physician or surgeon
charges, other professional fees, or charges for take-home items
or durable medical devices.
L. "Emergency Out of Area Services" shall mean those services provided to
a Member by a hospital, physician, or surgeon and which due to an
emergency are provided outside the Service Area covered by the
Membership Service Agreement. An emergency exists when there is a
sudden onset of illness or accidental injury requiring such immediate
treatment that the life or health of the Member might be jeopardized
if taken to a hospital, physician, or surgeon within the service area
covered by the Membership Service Agreement; or when the Member is
incapable of making the decision on treatment. Emergency Out of Area
Services shall be limited to the lesser of:
1. The amount of the negotiated charges; or
2. The amount of the Reasonable and Customary charges;
ARTICLE I
(Continued)
but in any event Emergency Out of Area Services, to the extent they
are Eligible Hospital Services, shall be limited to an average of
$2,000 per day of each period of continuous hospital confinement, not
including operating room charges.
L. "Loss" shall mean only such eligible amounts as are incurred during
the Contract Year, or under the previous year's "carry forward"
provision, as defined in Article II, D. for treatment and services
rendered to a Member while this Reinsurance Agreement is in effect and
provided such treatment and services are covered by the Member
Services Agreement. The word "Loss" shall not include:
1. Compensation paid to salaried officers or employees of the Plan
or any other overhead expenses;
2. Any amount paid by the Plan for punitive or exemplary damages, or
compensatory damages awarded to any Member arising out of the
conduct of the Plan in the investigation, trial, or settlement of
any claims or failure to pay or delay in payment of benefits
under its Member Services Agreement;
3. Any Statutory penalty imposed upon the Plan on account of any
unfair trade practice or any unfair claims practice.
ARTICLE II
Schedule of Reinsurance
A. The Effective Date for this Reinsurance Agreement shall be November 1,
1996.
B. The monthly premium for the Reinsurance Coverage defined in paragraph
C. below shall be $0.27 per Member. This amount shall be guaranteed
for a period of 3 years following the effective date of this
Reinsurance Agreement, provided, however, that Preferred Life shall
have the authority to review and revise rates at the beginning of each
contract year.
C. The Reinsurance Coverage to be provided under this Reinsurance
Agreement shall be defined as follows:
1. For Eligible Hospital Services, the Deductible amount for such
Reinsurance Coverage shall be $200,000 of the Loss for each
Member for each Contract Year. Once the Deductible has been
satisfied, Preferred Life shall indemnify the Plan for:
a. The excess Loss for Eligible Hospital Services in that
Contract Year for any Member at the start of the Contract
Year shall be reimbursed as follows:
1) 90% if services are performed in a "per diem", DRG or
approved fixed procedural fee hospital.
2) 80% if services are performed in any other hospital
b. The excess Loss for Eligible Hospital Services in that
Contract Year for expenses related to organ and bone marrow
transplant therapy shall be reimbursed as follows:
1) 80% if services are performed in a hospital with a
Prior Approved Transplant Reimbursement Schedule for
that confinement.
2) 50% if services are performed in any other hospital.
3) 50% for organ and bone marrow Retransplantation
Services performed in any hospital. Retransplantation
Services shall mean retransplantation of the same
organ/bone tissue type performed within one year of the
date of the initial transplant procedure.
The acquisition cost of the "live" organ is not included as
a benefit in this Reinsurance Agreement for any organ
transplant procedure.
ARTICLE II
(Continued)
c. In the event an excess Loss could be indemnified under more than
one of the above subsections, the subsection providing the least
indemnity shall apply.
d. Non-Emergency admission into the following Philadelphia,
Pennsylvania hospitals shall have coinsurance of 50% of Loss
incurred:
1) Hospital of University Medical Center of Pennsylvania;
2) Jefferson Hospital;
3) Children's Hospital.
e. Notwithstanding the above, the lifetime maximum reinsurance
indemnity payable under this Reinsurance Agreement for Eligible
Hospital Services for each Member shall be $2,000,000.
D. Loss incurred by the Plan during the last thirty-one (31) days of a
Contract Year for which no benefits were payable under this
Reinsurance Agreement because such Loss was applied to the Deductible
for that Contract Year shall be applied toward the Deductible for the
succeeding Contract Year.
E. The preceding Schedule of Reinsurance is subject to the Limitations as
defined in Article VIII.
ARTICLE III
Premium Payment
A. The amount of premiums to be paid by the Plan to Preferred Life for
Reinsurance Coverage under this Reinsurance Agreement is set forth in
Article II herein.
B. Premiums shall be payable monthly and shall be based on the number of
Members enrolled and eligible to receive Eligible Hospital Services
during the month.
C. Premiums shall be due on the first day of the month for which
Reinsurance Coverage is provided and are payable to Preferred Life at
its office in New York, New York.
D. A grace period not to exceed one month shall be granted to the Plan
for the payment of every premium due.
E. If any premium is not paid before the expiration of the grace period,
this Reinsurance Agreement may terminate as of the expiration of the
period for which premium has been paid. Preferred Life shall give
written notification of such termination.
F. The premium payment by the Plan to Preferred Life shall be accompanied
by a statement signed by an authorized Plan official in which the
number of enrolled and eligible Members for that month is given.
G. Preferred Life shall have the right to change the premium at the end
of the third Contract Year of this Reinsurance Agreement and at any
time thereafter, provided this Reinsurance Agreement has not had the
premium changed within the preceding thirty six (36) months and
further provided that at least thirty-one (31) days written notice has
been given by Preferred Life to the Plan. The Plan must give Preferred
Life written notice of any change in coverage within thirty-one (31)
days.. Upon notice of such change of coverage, Preferred Life may
elect to exclude the modification of coverage from Reinsurance
Coverage or charge additional premium therefore. Preferred Life shall
not be liable for any modification of coverage of the Reinsured Policy
in the event that the Plan fails to properly notify Preferred Life.
Any change in premium that is solely the result of a change in
coverage shall not be considered a change in premium requiring the
thirty six (36) month period of time before another change in premium
can be made.
ARTICLE IV
Notice of Claims and Reimbursement
A. The Plan shall give Preferred Life timely written notice of any claim
or potential claim. The Plan shall use its best efforts to give
Preferred Life notice of claim or potential claim within thirty-one
(31) days from the date on which the claim or potential claim is
incurred.
B. Preferred Life shall furnish the Plan with a supply of claim forms to
be used in filing a claim.
C. The Plan shall file completed proof of Loss by sending to Preferred
Life the information requested on the claim form, along with copies of
the various bills and itemized expenses involved.
D. In accordance with the terms and conditions of this Reinsurance
Agreement, Preferred Life shall make payment to the Plan within thirty
(30) days of Preferred Life's receipt of complete written proof of
such Loss, subject to E. below.
E. Preferred Life shall not be liable with regard to any Loss for which
it has not received written notice within the twelve (12) months after
the end of the Contract Year in which the Loss was incurred, except in
the case of insolvency, as defined in Article VII.
ARTICLE V
Reports, Records and Audits
A. The Plan shall submit a monthly report to Preferred Life listing the
names and amounts for those Members who have received Eligible
Hospital Services during the Contract Year which exceed seventy-five
(75) percent of the per Member Deductible as set forth in Article II.
B. The Plan shall report to Preferred Life any changes of a material
nature in its Membership Service Agreements. Such report shall be sent
to Preferred Life at least thirty-one (31) days before the Effective
Date of the change so that Preferred Life may evaluate the need for
any changes in this Reinsurance Agreement.
C. The Plan shall report to Preferred Life any investigation or request
for information of a material nature by a State Insurance Department
regarding the conduct of the Plan. Such report must be provided in
writing by the Plan to Preferred Life within thirty-one (31) days
following the date the Plan receives notice, written or otherwise, of
such investigation or request from the State Insurance Department.
D. The Plan shall keep a record of the monthly enrollment of Members
covered by its Membership Service Agreements and the Eligible Hospital
Services received by each Member while covered under this Reinsurance
Agreement. Such record shall be kept during the time this Reinsurance
Agreement is in effect and for a one (1) year period after its
termination date.
E. The Plan's books and records, to the extent permitted by law, shall be
made available to Preferred Life for inspection and audit at any time
during normal business hours during the time this Reinsurance
Agreement is in effect and for a one (1) year period after its
termination date. Preferred Life shall give reasonable notice prior to
the date of such audit.
F. All information disclosed to Preferred Life by the Plan or to the Plan
by Preferred Life, either in the course of conducting negotiations or
as the result of complying with the terms and conditions of this
Reinsurance Agreement, shall be considered to be privileged and
confidential information by both the Plan and Preferred Life.
G. The submission of this Reinsurance Agreement to any Department of
Insurance or any State or Federal agency shall not be considered a
violation of F above.
ARTICLE VI
Arbitration
A. In the event of any dispute or difference of opinion arising out of
this Agreement which cannot be amicably resolved by the Plan and
Preferred Life, the Plan and Preferred Life agree that such dispute or
difference of opinion shall be submitted to and settled by
arbitration.
B. Except as otherwise provided herein, the arbitration shall be
conducted in accordance with the Commercial Arbitration Rules of the
American Arbitration Association (the "AAA" and the "AAA's Rules")
which shall be in effect on the date of delivery of demand for
arbitration. In the event that the AAA's Rules conflict with any
provisions of this Article, this Article shall govern.
C. The party that determines that a dispute should be resolved by
arbitration (the "Initiating Party") shall give written notice to the
other party (the "Responding Party") of its desire to compel
arbitration, which notice shall contain a statement setting forth the
nature of the dispute, the amount involved, if any, and the remedy
sought.
D. The arbitration tribunal shall consist of three arbitrators who must
be disinterested parties, unaffiliated with the Plan or Preferred
Life. The Plan shall appoint one arbitrator, and Preferred Life shall
appoint one arbitrator. The third arbitrator shall be appointed by the
previous two (2) arbitrators. If the two previous arbitrators cannot
agree on a third arbitrator, then the third arbitrator shall be
appointed by AAA.
E. If either party refuses or neglects to appoint an arbitrator within
sixty (60) days after receipt of written notice from the other party
requesting it to do so, the requesting party shall instruct AAA to
appoint a neutral second arbitrator. The two appointed arbitrators can
then appoint the third.
F. For the purposes of arbitration, this Reinsurance Agreement shall be
considered an honorable engagement rather than a mere legal
obligation, and the arbitrators are not bound by judicial formalities
or strict rule of law in interpreting this Reinsurance Agreement.
G. The decision of a majority of the arbitrators shall be final and
binding on both the Plan and Preferred Life subject to the parties'
rights to appeal an arbitrator's decision under New York law.
H. The expense of arbitration shall be divided between the Plan and
Preferred Life based on a decision made by the arbitrators.
I. Any such arbitration shall take place in New York, unless some other
location is mutually agreed upon.
J. The laws of New York shall govern the arbitration process in the event
they conflict with A through I above.
ARTICLE VII
Insolvency/Cessation of Operations
A. In the event that Preferred Life should become insolvent, this
Reinsurance Agreement shall automatically terminate on the date of
Preferred Life's insolvency.
B. In the event that the Plan shall become insolvent, this Reinsurance
Agreement shall automatically terminate on the date of the Plan's
insolvency.
C. For purposes of this Reinsurance Agreement, "insolvent" or
"insolvency" shall mean that both of the following conditions occur:
1. A final determination is made by a court of competent
jurisdiction that the Plan or Preferred Life is insolvent; and
2. All operations of the Plan or Preferred Life cease.
The date of insolvency shall be determined as the date which the court
declares the Plan or Preferred Lifeinsolvent or the date on which the
Plan or Preferred Life has ceased operations, whichever date is later
in time.
Operations of the Plan will not be considered ceased so long as the
Plan is under control of a Receiver (which, as used herein, includes a
court or state appointed supervisor, receiver, or rehabilitator) until
the date the Receiver stops paying for future services, publicly
declares its intention to not make payment for future services, and
orders Plan providers to stop rendering services on behalf of the Plan
other than those services for the remaining term for which providers
have previously been paid.
D. This change to the style sheet made 4/21/95 - Rec'd letter from the
State with requested language. jvh. In the event of the Insolvency of
the Plan, benefits owed by Preferred Life shall be payable directly to
the Plan, or to its liquidator, receiver, conservator or statutory
successor without diminution because of the Insolvency of the Plan or
because the liquidator, receiver, conservator or statutory successor
has failed to pay all or a portion of any claim. It is agreed,
however, that the liquidator, receiver, conservator or statutory
successor of the Plan shall give Preferred Life written notice of the
pendency of each claim or Loss which may involve the Reinsurance
afforded by this Agreement within a reasonable time after such claim
or Loss is filed in the conservation or liquidation preceding or in
the receivership. Preferred Life shall have the right to investigate
each such claim or Loss and interpose, at its own expense, in the
preceding where the claim or Loss is to be adjudicated, any defense or
defenses that it may deem available to the Plan or its liquidator,
receiver, conservator or statutory successor. The expense thus
incurred by Preferred Life shall be chargeable, subject to court
approval, against the Plan or its successor as part of the expense of
conservation or liquidation to the extent of a pro rata share of the
benefit which may accrue to the Plan solely as a result of the defense
undertaken by Preferred Life. In the event of that this Agreement
terminates due to the Insolvency of the Plan and premiums are due to
Preferred Life, then in this event, Preferred Life may offset premiums
due against claims owed to the Plan or to its liquidator, receiver,
conservator or statutory successor.
E. Notice of the Plan's or Preferred Life's date of insolvency or date of
cessation of operations shall be communicated to the other party at
the earliest possible point in time.
ARTICLE VIII
Limitations of Reinsurance Coverage
A. Preferred Life's reimbursement of claims to the Plan shall not exceed,
in any event, the limits of coverage stated in Article II.
B. The Plan is solely responsible for providing all services to its
Members, for compensation of all liability to its Members, and for
payment of all expenses to its Members.
C. Preferred Life shall have no responsibility or obligation to provide
any services or payment to any Member of the Plan, directly or
indirectly.
D. To the extent the Plan receives or will receive any payment or
receives a reduction in its liability by reason of a Coordination of
Benefits provision in the Plan's Member Services Agreement or by any
right of subrogation, Preferred Life shall only indemnify the Plan in
respect of any excess beyond the amount of COB or subrogation amounts
received or applied currently or in the future as reductions in its
liability.
E. Preferred Life shall not reimburse the Plan for amounts incurred for
skilled nursing or rehabilitive services (including, but not limited
to treatments for motor function or mobility, physical therapy or
psychotherapies), unless such services are provided concurrent with
and incidental to Acute Care Services.
F. Preferred Life shall not be liable to the Plan, and the Plan shall
hold harmless and indemnify Preferred Life, for any of the following:
1. Professional liability or liability for any act or omission,
tortious or otherwise, in connection with any services rendered
to any person or group of persons by the Plan or any group,
entity, or person employed by or affiliated in any manner with
the Plan;
2. Expenses or losses for which the Plan has released any persons or
entity from its legal liability;
3. Liabilities which are non-pecuniary in nature (not having a
monetary value);
4. Liabilities, expenses, or losses which are based upon any
noncompliance or violation of any Federal or State statute, rule,
or regulation by the Plan;
5. Additional expenses or losses resulting from those services which
are billed in excess of the usual and customary charges for the
locality where same were administered;
6. Any expenses to the extent the Plan receives a reduction in
charges because of a Coordination of Benefits provision in the
Plan's Membership Service Agreements or any right of subrogation;
7. Any liability due to war or act of war;
8. Any liability for replacement of equipment, furniture, or
supplies which are not Eligible Hospital Services.
ARTICLE IX
Effective Date, Duration and Termination
A. This Reinsurance Agreement shall become effective on the date set
forth in Article II.
B. This Reinsurance Agreement shall continue in effect from the Effective
Date until it is terminated.
C. This Reinsurance Agreement shall automatically terminate for
non-payment of premium by the Plan as set forth in Article III.
D. This Reinsurance Agreement shall automatically terminate on the date
of Preferred Life's insolvency or cessation of operations or on the
date of the Plan's insolvency or cessation of operations.
E. This Reinsurance Agreement can be terminated in accordance with
paragraph A. of Article X.
F. Termination of this Reinsurance Agreement shall not terminate the
rights or liabilities of either the Plan or Preferred Life arising
during any period when this Reinsurance Agreement was in force,
provided that nothing herein shall be construed to extend Preferred
Life's liability for reimbursements under this Reinsurance Agreement
for any Loss paid by the Plan which was incurred on or after the date
of termination of this Reinsurance Agreement.
G. The Plan and Preferred Life shall each have the right to terminate
this Reinsurance Agreement by giving the other party, and the State of
New York Health and Insurance Departments, written notice of such
intention to terminate at least thirty-one (31) days prior to the end
of any Contract Year.
ARTICLE X
General Provisions
A. It is understood and agreed that if at any time while this Reinsurance
Agreement is in effect the Plan should:
1. Acquire the assets and liabilities of any other company,
corporation, or foundation; or
2. Be acquired, come under control of or be merged with any other
company, corporation, or foundation;
Preferred Life shall, at its option, have the right to charge an
additional premium to the Plan, or terminate this Reinsurance
Agreement by giving written notice by certified mail which shall set
forth the date and time of such termination, but not sooner than
thirty-one (31) days after the date of receipt of such notice.
B. The Plan shall give Preferred Life written notice in the event that
any of A. above should occur as soon as Plan is aware that such event
will occur.
C. This Reinsurance Agreement may be altered or amended at any time by
mutual consent of the Plan and Preferred Life either by written
Amendment or by correspondence signed by officers of the Plan and
Preferred Life. Any such Amendments or correspondence shall be binding
upon the Plan and Preferred Life and deemed to be an integral part of
this Reinsurance Agreement. Amendments are subject to approval by the
State of New York Health and Insurance Departments prior to
effectuation.
D. This Reinsurance Agreement shall not be assignable without the express
written consent of the other party.
E. Nothing in this Reinsurance Agreement shall create any right or legal
contractual relationship between Preferred Life and any Member under a
Member Services Agreement identified in Article I of this Reinsurance
Agreement.
F. The Plan is solely responsible for all services to Members, for all
liabilities to Members, and for payment of all claims of Members.
Preferred Life shall not have any responsibility or obligation to
provide any service or payment to any Member, directly or indirectly.
The Reinsurance Coverage provided herein is payable solely to the
Plan.
G. If any payment is made by Preferred Life under this Reinsurance
Agreement, Preferred Life shall be subrogated to all the Plan's rights
to recover such payment against any Member, person or organization,
and the Plan shall execute and deliver instruments and do whatever is
necessary to preserve and secure such rights. Any recovery made by the
Plan, net of attorney's fees charged to the Plan, shall be paid to
Preferred Life to the extent of payment made under this Reinsurance
Agreement.
ARTICLE X
(Continued)
H. This Reinsurance Agreement, including Endorsements and attached
papers, if any, constitutes the entire contract of reinsurance. No
change in this Reinsurance Agreement shall be valid until approved by
an executive officer of Preferred Life and unless such approval be
endorsed hereon or attached hereto. No agent has authority to change
this Reinsurance Agreement or to waive any of its provisions.
I. Plan agrees to give Preferred Life written notice of any change in
Chief Operating Management, any fundamental change in the Management
Service Contract, or any change in majority ownership of the Plan.
J. IN WITNESS WHEREOF, the Plan and Preferred Life have, by their
respective officers, executed and delivered this Reinsurance Agreement
in duplicate effective from the date set out in Article II hereof.
WELLCARE OF NEW YORK - MEDICARE
Dated: By: Xxxxxx X. Xxxx
----------------------- ----------------------------
Attest: /s/ Xxxxxx X. Xxxxx Title:
---------------------- -------------------------
PREFERRED LIFE INSURANCE COMPANY OF NEW YORK
Dated: By: /s/ Xxxxxx X. Xxxxx
----------------------- ----------------------------
Attest: /s/ Xxxxx Xxxxxxxxx Title:
---------------------- -------------------------
ENDORSEMENT NO. 1
Endorsement between Preferred Life Insurance Company of New York (hereinafter
referred to as "Preferred Life") and Wellcare of New York - Medicare
(hereinafter referred to as "Plan") Policy No. 17055-044.
The following provision is hereby made a part of the Reinsurance Agreement
between Preferred Life and Plan, in order to protect Members when they no longer
can receive benefits from the Plan or its Receiver because of insolvency of the
Plan. This Endorsement does not provide any benefit for creditors, owners, or
the Receiver of the Plan, although payment of Plan benefits under Sections 1.
and 2. below may be to the Receiver for transfer to appropriate provider payees.
As used herein, the term "Receiver" includes a court or state appointed
supervisor, receiver, or rehabilitator.
Continuation of Benefits Provision:
The reinsurance liability of Preferred Life under the Reinsurance Agreement
shall terminate according to its terms. However, upon the date the Plan is
insolvent as defined in Article VII of the Reinsurance Agreement, Preferred Life
will provide limited continuation of benefits for Members as described below.
There is no liability of Preferred Life under this Endorsement prior to the date
all conditions of insolvency in Article VII have been met, including the
condition that operations cease.
1. Preferred Life will continue Plan benefits for Members who are
confined in an Acute Care hospital on the date Preferred Life becomes
liable for continuation of benefits, beginning on such date and
continuing until their discharge;
2. Added to the style sheet 9/7/95. This language was approved by HCFA on
8/3/95 and has been reviewed by the New York DOI via Preferred Care.
The insolvency language on Preferred and Allianz paper is now
consistent. jvh.. Preferred Life will continue Plan benefits for
Members who are confined in other inpatient facilities on the date
Preferred Life becomes liable for continuation of benefits, beginning
on such date, not exceeding the benefits which would be provided under
the Plan's Member Services Agreement, or one hundred twenty (120)
days, whichever is less. Other inpatient facilities means skilled
nursing facilities and rehabilitation facilities if such care is
rendered concurrent with and incidental to Acute Care Services;
3. Coverage is contingent on payment of premium. Preferred Life will
continue Plan benefits for any Member beginning on the date Preferred
Life becomes liable for continuation of benefits until the end of the
contract period for which premium has been paid to the Plan by that
Member, not including any Plan benefits which are the contractual
obligation of a hospital or health care provider to the Member for
such period; 4This provision has never been in the style sheet, but
was added 4/21/95 per the request of the New York DOI. jvh. Preferred
Life conversion coverage will be made available to all Members for a
period of thirty-one (31) days, without evidence of insurability. The
conversion coverage will be that which is customarily issued by
Preferred Life at the then current rates and of the type available for
conversion. 5Added to the style sheet 9/7/95. This language has been
approved by HCFA and has also been reviewed by the New York DOI via
Preferred Care. The Allianz and Preferred insolvency endorsements are
now consistent.. Any Title XVIII Medicare enrollees who are under an
"at risk" contract with the Health Care Financing Administration shall
not be covered under this Endorsement once the enrollee is eligible
for coverage under other Title XVIII provisions or any other federal
program, except as noted below:
a. Preferred Life will continue Plan benefits for any Title XVIII
Medicare enrollees beginning on the date Preferred Life becomes
liable for continuation of benefits until the end of the Contract
Period for which premium has been paid to the Plan by the Health
Care Financing Administration, not including any Plan benefits
which are the contractual obligation of a hospital or health care
provider to the Member for such period.
ENDORSEMENT NO. 1
(Continued)
Except as herein stated, all terms and conditions of the Reinsurance Agreement
remain unchanged.
The Effective Date of this Endorsement is November 1, 1996.
WELLCARE OF NEW YORK - MEDICARE
Dated: By: Xxxxxx X. Xxxx
----------------------- ----------------------------
Title:
-------------------------
PREFERRED LIFE INSURANCE COMPANY OF NEW YORK
Dated: By: /s/ Xxxxxx X. Xxxxx
----------------------- ----------------------------
Title:
-------------------------
ENDORSEMENT NO. 2
Endorsement between Preferred Life Insurance Company of New York (hereinafter
referred to as "Preferred Life") and Wellcare of New York - Medicare
(hereinafter referred to as "Plan") Policy No. 17055-044.
The following provision is hereby made a part of the Reinsurance Agreement
between Preferred Life and Plan.
Out of Area Conversion Provision
In the event that a Plan Member moves outside the Service Area of
the Plan, such Member, without evidence of insurability, shall
have the right of conversion for a period of thirty-one (31)
days. The Conversion Coverage will be that which is customarily
issued by Preferred Life at the then current rates and of the
type available for conversion.
Except as herein stated, all terms and conditions of the Reinsurance Agreement
remain unchanged.
The Effective Date of this Endorsement is November 1, 1996.
WELLCARE OF NEW YORK - MEDICARE
Dated: By: Xxxxxx X. Xxxx
----------------------- ----------------------------
Title:
-------------------------
PREFERRED LIFE INSURANCE COMPANY OF NEW YORK
Dated: By: /s/ Xxxxxx X. Xxxxx
----------------------- ----------------------------
Title:
-------------------------
