R99-108 AUTHORIZING APPLICATIONS

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for Covered Services rendered to a Covered Person or the agreed upon cost for Covered Ser- � vices that the Host Plan passes to the Claim Administrator, whichever is lower. Often, the agreed upon cost is a simple discount. Sometimes, however, the agreed upon cost may represent either an estimated discount or an average discount realized or expected by the Host Plan based on separate financial arrangements or other non-claims transactions with Host Plan Providers. '�, The estimated or average discount may be adjusted in the future to correct for over or underes- I timation of the past determinations of the agreed upon cost. � In other instances, laws in a small number of states dictate the basis upon which the Covered Person's liability is calculated.When Covered Services are rendered in one of those states,the coinsurance amount, deductible, out-of-pocket maximum and/or any benefit maximum will be calculated using the state's statutory method. However,the Employer acknowledgesthat the Claim Administrator may be required to reimburse the Host Plan only for Claim Payments which have been discounted pursuant to an agreement between the Host Plan and its Host Plan Provider including the service charges thereon. In any event, the Employer shall reimburse the Claim Administrator the amount paid by the Claim Administrator to the Host Plan for Claim Payments plus any service charges payable by the Claim Administrator to the Host Plan, in addition to all applicable service charges of the Agreement hereunder. B. BlueCard Access Fees From time to time Covered Persons may receive health care services outside Illinois and from a Provider which does not have a contract with the Claim Administrator for the provision of, and . payment for, such health care services. Under such circumstances the Blue Cross and Blue Shield Plan in the particular state in which such services are received (the"Host Plan") will pro- cess the Covered Person's Claim in accordance with the Host Plan's applicable contract, if any, with the particular Provider("Host Plan Provider"). Host Plans may charge the Claim Administra- tor an access fee for making their negotiated payment rates and the resulting savings available on Claims incurred by Covered Persons under this Agreement. This BlueCard access fee may be up to 10% (but not to exceed $2,000 for any Claim) of the resulting savings. When the Claim Administrator is charged an access fee by a Host Plan for such services, such fee shall be considered and treated as a Claim Payment under this Agreement. If the Claim Administrator receives any credit relative to such access fee from the Host Plan, such amount shall be credited against Claim Payments under this Agreement. Instances may occur in which no Claim Payment or a minimal Claim Payment is made underthis Agreement because the amounts eligible for payment were applied to the deductible or Coinsu- rance. Nonetheless,if the Host Plan charges the Claim Administrator an accessfee as discussed above relative to such Claim,the Claim Administrator shall pay such fee and such amount shall be considered and treated as a Claim Payment under this Agreement. The Employer representsthat it has included the provision stated in this Section XVII.in its Plan Docu- ment. XVIII. MEDICARE SECONDARY PAYER ("MSP") PROVISIONS A. The MSP Law The Employer has certain obligations under the Medicare Secondary Payer ("MSP") statute. 1. Scope of the Statute: . The statutory requirements and rules for MSP coverage vary depending on the basis for Medicare and employer group health plan ("GHP")coverage,as well as certain otherfactors, - 11 -