R2010-233 AUTHORIZING AGREEMENT - Laserfiche WebLink

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OTHER PROVISIONS 1. Certificate of Creditable Coverage: � Yes ❑ No If yes: The Employer directs the Claim Administrator to issue to individuals, whose coverage under the Plan terminates during the terrn of the Administrative Services Agreement to which this ASO BPA is attached, a Certificate of Creditable Coverage. The Certificate of Creditable Coverage shall be based upon information required for issuance of a Certificate of Creditable Coverage to be provided to the Claim Administrator by the Employer and coverage under the Plan during the term of the Administrative Services Agreement. 2. Case Management Program/Medical Services Advisory: � Yes ❑ No If yes: The undersigned representative authorizes provision of altemative benefits for services rendered to Covered Persons in accordance with the provisions of the Administrative Services Agreement to which this ASO BPA is attached and the Employer's plan document. 3. Employer acknowledges and agrees to utilize Claim Administrator's standard list of services and supplies for which pre-certification is required: � Yes ❑ No If no, Employer authorizes Claim Administrator to post Employer's pre- certification requirements on Claim Administrator's Website: ❑Yes ❑ No 4. The Massachusetts Health Care Reform Act requires employers to provide, or contract with another entity to provide, a written statement to individuals residing in Massachusetts who had "creditable coverage" at any time during the prior calendar year through the employer's group health plan and to file a separate electronic report to the Massachusetts Department of Revenue verifying information in the individual written statements. a. The Employer directs 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. Such written statements and electronic reporting shall be based on information provided to the Claim Administrator by the Employer and coverage under the Plan during the term of the Administrative Services Agreement. The Employer hereby certifies that, to the best of its knowledge, such coverage under the Plan is"creditable coverage" in accordance with the Massachusetts Health Care Reform Act. The Employer acknowledges that the Claim Administrator is not responsible for verifying nor ensuring compliance with any tax and/or legal requirements related to this service. The Employer or its Covered Employees should seek advice from their legal or tax advisors as necessary. � Yes ❑ No b. If no: The Employer acknowledges it will provide written statements and electronic reporting to the Massachusetts Department of Revenue as required by the Massachusetts Health Care Reform Act. 5. Stop Loss Coverage purchased: � Yes ❑ No (If yes, complete a separate Exhibit to the Stop Loss Coverage Policy) 6. Fort Dearborn Life Insurance purchased: ❑ Yes � No (If yes, complete separate Life application) 7. Health Care Account (HCA) Administrative Services purchased: ❑ Yes � No (If yes, complete separate HCA I� application) �', 8. This ASO Benefit Program Application (ASO BPA) is incorporated into and made a part of the Administrative I, Services Agreement with both such documents to be referred to collectively as the "AgreemenY' unless specified ��, otherwise. ' ADDITIONAL PROVISIONS: I A. Grandfathered Health Plans: Employer shall provide Claim Administrator with written notice prior to renewal (and during the plan year, at least 60 days advance written notice)of any changes that would cause any benefit package of its group health plan(s) (each hereafter a "plan")to not qualify as a "grandfathered health plan" under the Affordable Care Act and applicable regulations.Any such changes (or failure to provide timely notice thereo� can result in retroactive and/or prospective changes by Claim Administrator to the terms and conditions of administrative services. In no event shall Claim Administrator be responsible for any legal, tax or other ramifications related to any plan's grandfathered health plan status or any representation regarding any plan's past, present and future grandfathered status. The grandfathered health plan form ("Form"), if any, shall be incorporated by reference and part of the BPA and Agreement, and Employer represents and warrants that such Form is true, complete and accurate. HCSC IL GEN ASO BPA Rev. 9.1.10(On-line Version) page 9