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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❑ Utilize BCBSIL disabled dependent certification forms. ❑ Utilize custom/other disabled dependent certification forms. If Certification Review is administered by BCBSIL,please select allowed or not allowed below: A disabled dependent approved certification from a prior insurance carrier is ❑allowed ❑ not allowed. A disabled dependent approved certification from a prior BCBS policy is ❑allowed ❑ not allowed. 10. Will extension of benefits due to temporary layoff, disability or leave of absence apply? ❑ Yes(specify number of days below) ® No Temporary Layoff: days Disability: days Leave of Absence: days However, benefits shall be extended for the duration of an Eligible Persons leave in accordance with an applicable federal or state law, The Employer will notify BCBSIL of such requirements. 11. Enrollment: Special Enrollment: An Eligible Person may apply for coverage,family coverage or add dependents within thirty-one (31)days of a Special Enrollment qualifying event if he/she did not previously apply prior to his/her Eligibility Date or when otherwise eligible to do so. Such person's Coverage Date,family Coverage Date,and/or dependent's Coverage Date will be the effective date of the qualifying event or,in the event of Special Enrollment due to marriage or termination of previous coverage, then no later than the first day of the Plan Month following the date of receipt of the person's application of coverage. An Eligible Person may apply for coverage within sixty (60)days of a Special Enrollment qualifying event in the Case either of a loss of coverage under Medicaid or a state Children's Health Insurance program, or eligibility for group coverage where the Eligible Person is deemed qualified for group coverage assistance under a state Medicaid or CHIP premium assistance program. Open Enrollment: An Eligible Person may apply for coverage,family coverage or add dependents if he/she did not apply prior to his/her Eligibility Date or did not apply when otherwise eligible to do so, during the Employer's annual Open Enrollment Period.Such person's Coverage Date,family Coverage Date,and/or dependent's Coverage Date will be a date mutually agreed to by the Claim Administrator and the Employer.Such date shall be subsequent to the Open Enrollment Period, Specify Open Enrollment Period: 10124 thru 11/30 for a 01101 effective date Late Enrollment., An Eligible Person may apply for coverage, family coverage or add dependents if he/she did not apply prior to his/her Eligibility Date or did not apply when otherwise eligible to do so. Such person's Coverage Date, family Coverage Date,and/or dependent's Coverage Date will be a date mutually agreed to by the Claim Administrator and the Employer. Select one of the provisions below: ❑ Open Enrollment—Late applicants may only apply during Open Enrollment. ® Late Entrant—Late applicants may apply at any time—coverage effective date is determined by the receipt date and the rules governing off-cycle enrollments. 12. *Does COBRA Auto Cancel apply? ®Yes ❑ No Member's COBRA/Continuation of Coverage will be automatically cancelled at the end of the member's eligibility period. *Not recommended for accounts with automated eligibility. EMPLOYEECURRENT •- • Current number of eligible subscribers at onboarding and/or annual renewal 551. 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. 1L GEN ASO VBD BPA(Rev.05.24)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 5