R2015-120 AUTHORIZING CITY MANAGER TO SIGN AGREEMENT Bluecross Blueshield of Illinois

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7. 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 exceed 91 calendar days from 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: 8. Enrollment: Special Enrollment: An Eligible Person may apply for coverage, Family coverage or add dependents within thirty-one (31) days of a qualifying event if he/she did not apply prior to his/her Eligibility Date or when eligible to do so. Such person's Coverage Date, Family Coverage Date, and/or dependenYs Coverage Date will be the effective date of the qualifying event or, in the event of Special Enrollment due to termination of previous coverage, the date of application of coverage. In the case of a qualifying event due to loss of coverage under Medicaid or a state children's health insurance program, however, this enrollment opportunity is not available unless the Eligible Person requests enrollment within sixty(60) days after such coverage ends. 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 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. Open Enrollment: �Yes ❑ No 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 eligible to do so, during the Employer's Open Enrollment Period. • Specify Open Enrollment Period: 12/1 to 12/31 Such person's Coverage Date, Family Coverage Date, and/or dependenYs 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. 9. Will extension of benefits due to temporary layoff, disability or leave of absence apply? ❑ Yes (specify number of days below) � No(skip to question 10) Temporary Layoff: days Disability: days Leave of Absence: days However, benefits shall be extended for the duration of an Eligible Person's leave in accordance with any applicable federal or state law. 10. *" 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. HCSC IL GEN ASO BPA(Rev. 5.15) page 3