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� �k <br /> 6. The Enrollment Period during which an Eligibie Person may apply for coverage if he/she did'not app�y priorto his/her � <br /> Eligibility Date or did not apply for Family Coverage when eligible to do so: <br /> ❑ At any time, subject to approval of Evidence of Insurability by the Claim Administrator. <br /> � During the Employer's annual open enrollment period. Specify: The 30th day after el i gi bi 1 tY date <br /> Such person's Coverage Date or Family Coverage Date: <br /> ❑ A date determined by the Claim Administrator following approval of Evidence of Insurability for such <br /> person by the Claim Administrator. <br /> � A date mutually agreed to bythe Claim Administrator and the Employer. Such date shall be subsequent <br /> to the open enrollment period. <br /> 7. Extension of benefits due to Temporary Layoff, Disability or Leave of Absence: <br /> Temporary Layoff: days Disability: days Leave of Absence: days <br /> However,benefiis shall be extended for the duration of an Eligib/e Person's leave in accordance with the Familyand <br /> Medica/Leave Act of 1993, as amended. <br /> 8. Total number of employees enrol/ed under the plan: 630 <br /> 9. Total number of employees(full-and part-time) employed by the Employer: 639 <br /> 10. Subscriber Share Methodology for Claims Processing Applies: ❑ Yes �No <br /> If no, a letter declining Subscriber Share Methodology for Claims Processing must be attached to fhis BPA. � <br /> ASO STATUS: <br /> ❑ New ASO Account � Renewing ASO Account ❑Former HCSC insured group converting to ASO <br /> 1. If this is a new group and HCSC is assuming responsibility for payment of claims that were incurred prior to the effec- <br /> tive date of the ASO Agreement(i.e.,"Run-In Claims"),such Run-In Claims will be processed for services incurred <br /> on or after through <br /> 2. Run-In Claims will be processed under Employer Group Number: <br /> 3. If a former HCSC insured group is converting to ASO, on what basis? <br /> ❑ Converting on a"paid"claim basis. <br /> ❑ Converting on an "incurred and paid"claim basis. <br /> � . <br /> 6'� %of Claim Payments or $ per employee per month <br /> �ipplies to All Coverages <br /> ❑Different percentage(s)or amount(s)for the following rypes of coverage(s). Please specify: <br /> �$ 3.05 per employee per month for administration of MSA. <br /> ❑$ per employee per month for administration of Utilization Management. <br /> GA-10-4 HCSC Rev.6/96 page 2 <br />