R2024-342 Resolution Authorizing Agreement and Amendment with BlueCross BlueShield of Ilinois for Administration of the City Group Health Benefit Plan for Calendar Year 2025

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Other Provisions NO CHANGES SEE ADDITIONAL P•• • 1. Summary of Benefits&Coverage: a. Will Claim Administrator create Summary of Benefits and Coverage (SBC)? ® Yes. Please answer question b.The SBC Addendum is attached. ❑ No. If no,then skip question b and refer to the Administrative Services Agreement for further information. b. Will Claim Administrator distribute the(SBC)to Covered Persons? ® No. Claim Administrator will create SBC (only for benefits Claim Administrator administers under the Administrative Services Agreement) and provide SBC to Employer in electronic format. Employer will then distribute SBC to Covered Persons(or hire a third party to distribute)as required by law. ❑ Yes. Claim Administrator will create SBC (only for benefits Claim Administrator administers under the Administrative Services Agreement) and distribute SBC to Covered Persons via regular hardcopy mail or electronically.Distribution Fee for hardcopy mail is one dollar and fifty cents($1.50)per package. 2. Massachusetts Health Care Reform Act: Does the Employer direct Claim Administrator to provide written statements of creditable coverage to its Covered Employees who reside, or have enrolled dependents who reside, in Massachusetts and file electronic reports to the Massachusetts Department of Revenue in a manner consistent with the requirements under the Massachusetts Health Care Reform Act? ®Yes ❑ No /f no: The Employer acknowledges (1) it will provide written statements and electronic reporting to the Massachusetts Department of Revenue if required by the Massachusetts Health Care Reform Act or(2)that it does not believe it is subject to the notification and reporting requirements of the Massachusetts Health Care Reform Act. 3. Alternative Care Management Program (applicable to the purchased medical management program): ®Yes ❑ No The undersigned representative authorizes provision of alternative benefits for services rendered to Covered Persons for Utilization Management, Case Management, including but not limited to Behavioral Health, and other health care management programs. 4. Prior Authorization (applicable to the purchased medical management program): Employer acknowledges and agrees to utilize Claim Administrator's standard list of services and supplies for which Prior Authorization (also called pre-notification or preauthorization)is required. 5. Essential Health Benefits ("EHB")Election: Employer elects EHBs based on the following: 1. ® EHBs based on a Claim Administrator state benchmark: ® Illinois ❑ Montana ❑ New Mexico ❑Oklahoma ❑Texas 2. ❑ EHBs based on benchmark of a state other than IL, MT, NM,OK and TX If so, indicate the state's benchmark that Employer elects: 3. ❑ Other EHB, as determined by Employer In the absence of an affirmative selection by Employer of its EHBs,then Employer is deemed to have elected the EHBs based on the Illinois benchmark plan. 6. This ASO BPA is binding on both parties and is incorporated into and made a part of the Administrative Services Agreement between the parties with both such documents to be referred to collectively as the"Administrative Services Agreement'unless specified otherwise. 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. IL GEN ASO VBD BPA(Rev.06.24)Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association 1 i