Laserfiche WebLink
For new coverage only, if a run-in contract as explained in the policy(24/12, 18112, or 15/12 coverage period) is <br /> purchased, claims paid by the Employer Group's prior claim administrator will be settled at the time of the annual <br /> stop loss settlement and must be reported by the Employer Group to the Company(Blue Cross and Blue Shield of <br /> Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company) by the end of the <br /> Employer Group's Current Policy Period or stop loss coverage for these run-in claims will be forfeited. <br /> ® (Paid Renewal Only) Claim Administrators Claims: Claims incurred on or after the Original Effective Date of <br /> Policy and paid during the Policy Period. <br /> 3. Covered Expenses: <br /> ®Medical Claims <br /> ® Claim Administrator's Provider Access Fees <br /> ® Prescription Drug Claims with: Prime(Preferred PBM) <br /> ❑ For Hospital Employer Groups only: Excludes %of Home Hospital Medical claims <br /> ❑Other(for example Dental/Vision): <br /> 4. Aggregate Claim Liability <br /> a. Attachment Factor 125%of the Average Claim Value <br /> b. Aggregate Claim Factors: <br /> Grou Number: PPO <br /> Com osite; or $2,078.63 $ $ $ <br /> For each Single Coverage Unit $ $ $ $ <br /> For each Family Coverage Unit $ $ $ $ <br /> c. Minimum Aggregate Point of Attachment: $12,369,482 <br /> 5. Terminal Liability Option(TLO)(does not apply to Employer Groups with 12115, 12/18,or 12124 contracts): <br /> ❑Yes ® No <br /> The following applies if the answer to item above is"Yes"(Terminal Liability Option): <br /> Must be elected at Policy inception or renewal. Premium cost is calculated by taking the average enrollment for the <br /> last two months multiplied by three times pre-termination Aggregate Stop Loss rate(s). Premium is due at the time <br /> of termination, payable by lump sum within 10 days of receipt of bill. <br /> The Final Settlement Point of Attachment shall equal the sum of the Employer's Aggregate Claim Liability amount <br /> for the Policy Period plus 15%of the Aggregate Claim Factor multiplied by 12, and then multiplied by the average <br /> enrollment for the last two(2)months of the Current Policy Period immediately preceding termination.Furthermore, <br /> for the Final Settlement Period,the Minimum Aggregate Point of Attachment shall be the Minimum Aggregate Point <br /> of Attachment in item C.4.c. above increased by 15%. The Settlement for the Final Accounting Period will be <br /> described in the section of the Policy entitled SETTLEMENTS. <br /> 6. Aggregate Stop Loss Premium: <br /> ❑ Monthly Premium <br /> Monthly Aggregate Stop Loss Premium shall be equal to the amounts obtained by multiplying the number <br /> of Covered Employees for a particular Month by: <br /> $ Composite;or <br /> $ for each Single Coverage Unit <br /> $,_for each Family Coverage Unit <br /> 3 <br /> IL SL-APP Rev. 3.21 <br /> A Division of Health Care Service Corporation,a Mutual Legal Reserve Company <br /> an Independent Licensee of the Blue Cross and Blue Shield Association <br />