R2017-115 Agreement BlueCross BlueShield for Administration of City Group Health Benefit Plan for 2018

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2. Employee Definitions Full-Time Employee means: ® A person who is regularly scheduled to work a minimum of 30 hours per week and who is on the permanent payroll of the Employer. ❑ Other: 3. The Effective Date of termination for a person who ceases to meet the definition of Eligible Person: ® The date such person ceases to meet the definition of Eligible Person. ❑ The last day of the calendar month in which such person ceases to meet the definition of an Eligible Person. ❑ Other: 4. Select an effective date rule for a person who becomes an Eligible Person after the Effective Date of the Employer's health care plan (The effective date must not be later than the 91st calendar day after the date that a newly eligible person becomes eligible for coverage, unless otherwise permitted by applicable law). ® The date of employment. ❑ The day of employment. ❑ The day of the month following month(s)of employment. ❑ The day of the month following days of employment. ❑ The day of the month following the date of employment. ❑ Other: Is the waiting period requirement to be waived on initial group enrollment? ❑Yes ❑ No Are there multiple new hire waiting periods? ❑Yes ® No If yes, please attach eligibility and contribution details for each section. 5. Domestic Partners covered: ❑Yes ® No If yes: a Domestic Partner is eligible to enroll for coverage. If yes, are Domestic Partners eligible for continuation of coverage? ❑Yes ❑ No If yes, are dependents of Domestic Partners eligible to enroll for coverage?❑Yes ❑ No If yes, are dependents of Domestic Partners eligible for continuation of coverage?❑Yes ❑ No The Employer is responsible for providing notice of possible tax implications to those Covered Employees with coverage for Domestic Partners. 6. Civil Union Partners covered: i. ® The Employer is an Illinois county, municipality, the State of Illinois, subject to the Illinois School Code, a church plan or other non-ERISA plan. For such Employers, a Civil Union Partner and his or her dependents are automatically eligible to enroll for coverage and, once enrolled, eligible for continuation of coverage as described in the Employer's Plan. ii. For all other Employers, ❑Yes ❑ No If yes: A Civil Union Partner and his or her dependents are eligible to enroll for coverage. If yes, are Civil Union Partners and his or her dependents eligible for continuation of coverage? ❑Yes ❑ No The Employer is responsible for providing notice of possible tax implications to those Covered Employees with coverage for Civil Union Partners. 7. Limiting Age for covered Children: Twenty-six (26) years, regardless of presence or absence of a child's financial dependency, residency, student status, employment status, marital status, eligibility for other coverage, or any combination of those factors. Other: If Employer is an Illinois county, municipality, the State of Illinois, or subject to the Illinois School Code, this Limiting Age is extended to thirty(30)years, for unmarried eligible military personnel as described in the Employer's Plan. 8. Termination of coverage upon reaching the Limiting Age: ❑ The last day of coverage is the day prior to the birthday. . Proprietary and Confidential Information of Claim Administrator Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third party representatives,except with written permission of Claim Administrator. HCSC IL GEN ASO BPA(Rev.08/17) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, 2 an Independent Licensee of the Blue Cross and Blue Shield Association