R2016-136 BlueCross BlueShield Administration of Group Health Benefit Plan 2017

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between Claim Administrator and the particular Provider. (See provisions regarding "CLAIM ADMINISTRATOR'S SEPARATE FINANCIAL ARRANGEMENTS WITH PROVIDERS" in Exhibit 2.) Claim Payment also includes Employer's pro rata share of Alternative Compensation Arrangement Payments. 24.12"Coinsurance" means a percentage of an eligible expense that a Covered Person is required to pay toward a Covered Service. 24.13"Coordinated Home Care Program" means an organized skilled patient care program in which care is provided in the home. Care may be provided by a Hospital's licensed home health department or by other licensed home health agencies. A Covered Person must be homebound (that is, unable to leave home without assistance and requiring supportive devices or special transportation) and must require Skilled Nursing Service on an intermittent basis under the direction of a Physician, a Physician assistant who has been authorized by a Physician to prescribe those services, or an advanced practice nurse with a collaborating agreement with a Physician that delegates that authority. A Coordinated Home Care Program includes physical, occupational and speech therapists, and necessary medical supplies. The program does not include and is not intended to provide benefits for Private Duty Nursing Service or Custodial Care Service. It also does not cover services for activities of daily living (personal hygiene, cleaning, cooking, etc.). 24.14"Copayment" means a specified dollar amount that a Covered Person is required to pay toward a Covered Service. 24.15"Covered Employee" shall have the same meaning as defined in Employer's Plan to the extent consistent with the BPA. 24.16"Covered Person"shall have the same meaning as defined in Employer's Plan to the extent consistent with the applicable ASO BPA. 24.17"Covered Service" means a service or supply specified in the Plan for which benefits will be provided and for which Claim Administrator has agreed to provide administrative services under this Agreement. 24.18"Custodial Care Service" means any service primarily for personal comfort or convenience that provides general maintenance, preventive, and/or protective care without any clinical likelihood of improvement of a Covered Person's condition. Custodial Care Services also means those services which do not require the technical skills, professional training and clinical assessment ability of medical and/or nursing personnel in order to be safely and effectively performed. These services can be safely provided by trained or capable non-professional personnel, are to assist with routine medical needs (including but not limited to dressings, administration of routine medications, ventilator suctioning and other care) and are to assist with activities of daily living (including but not limited to bathing, eating and dressing). Custodial Care Service also means providing care on a continuous Inpatient or Outpatient basis without any clinical improvement by the Covered Person. 24.19"Dental Maximum Allowance" means one of the following amounts in accordance with the type of dental benefits coverage elected, if any, on the most current ASO BPA: a. For a Provider who has a written agreement with Claim Administrator or the entity chosen by Claim Administrator to administer a participating provider option dental benefits program at the time Covered Services for dental benefits are rendered("Participating Dentist"),the amount such Participating Dentist has agreed to accept as payment in full for a particular Covered Service. All benefit payments for Covered Services rendered by Participating Dentists will be based on the Network schedules which these Providers have agreed to accept as payment in full. b. For a Provider who does not have a written agreement with Claim Administrator or the entity chosen by Claim Administrator to administer a participating provider option dental benefits program at the time Covered Services for dental benefits are rendered ("Non-Participating Dentist"), the amount described in i. or ii. below, in accordance with the type of dental benefits coverage elected by Employer: I. The lesser of the Non-Participating Dentist's Claim Charge or an amount that is equal to the standard contracted fee for Participating Dentists in the same geographic area.In the event such lesser amount does not equate to the Non-Participating Dentist's Claim Charge, a Covered Person will be responsible for the difference between such amount and the Claim Charge, along with any applicable Copayment, Coinsurance and deductible amount(s). ii. The lesser of the Non-Participating Dentist's Claim Charge or Maximum Allowance amount which is based on data provided by a U&C service. HCSC IL Gen ASA Med Non ERISA REG Rev.8.16 15 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.