General Eligibility Requirements

Transcription

1 General Eligibility Requirements Please Note - We have provided these requirements as a guide. It is only intended to help you understand some of the most common eligibility requirements for offering Excellus BlueCross BlueShield health plans. Please be aware that from time to time our policies and procedures may change. If you need to verify any information, please contact our Sales Department. They will be happy to answer any questions you may have. A small group is one with at least 1, but not more than 50 eligible employees the following criteria: and meets Company is physically Headquartered within our operating area Is engaged in a legal business with the authority necessary to contract for coverage Regularly employs at least one person on an active basis for salary or wages throughout the year. The business must be non-seasonal in nature, meaning the employer, on at least 50% of its working days during the preceding year, employed one or more eligible persons Has an employer-employee relationship with eligible personnel Files state and federal income taxes as an ongoing commercial enterprise, non-profit entity, is validly exempted from filing taxes or is a government entity Meets and maintains applicable minimum participation enrollment requirements (see below) Is financially sound and expected to be a viable ongoing concern. Maximum Number of Product Combinations Small groups who select Excellus BlueCross BlueShield coverage are limited to the following number of product combinations: Group Size 1-5 net eligible employees enrolled in plan 6-20 net eligible employees enrolled in plan net eligible employees enrolled in plan Number of Products 1 For groups with 100% participation and from 1 to 20 net eligible employees, an Excellus BlueCross Blue Shield HSA product may be selected as an additional product, as long as the group does not already have an HSA product. 2 3 Rate differential: When more than one product is selected, the rate differential least 5%, but not more than 25% in total. among products must be at Minimum Participation for Excellus Blue Cross BlueShield Health Plans HMO products are not subject to participation percents, but enrollment in the Health Plan's HMO products may contribute to the total participation percentages. The group size and participation percents are based upon net eligible employees. To obtain or maintain group coverage, the Health Plan has the following participation percent requirements: Revised 11/01/07

2 Excellus {I Net Eliqible Emplovees Total Participation 100% 75% Percentaqe Please note: Employees who waive coverage under your plan because they have coverage through a spouse or as a dependent covered under their parent's policy are subtracted from total eligible employees for purposes of calculating minimum participation requirements. Emplover contribution: If the employer contributes 100% of the premium, 100% of the employees must participate Revised 11/01/07

3 Small Group Enrollment Checklist (I-50) 1. Group Information Form- Must be completed and signed by the Employer Group 2. Tax Returns and Business Documentation- a copy of the most recent quarterly NYS45-ATT. Please make notations indicating eligible employees (those working a minimum of 20 hrs per week) and ineligible employees (part-time employees working fewer than 20 hrs per week, seasonal employees and others persons not eligible for health ins.) Note: For new businesses su bstituted. that have not filed their first NYS45-A TT, copies of the W-4 may be 3. If you are submitting enrollment applications for partners or business owners not listed on the NYS45-A TT, then please submit the following: Partnerships: a copy of the most recent K1 forms for all partners Corporations: a copy to the most recent 1120C, 1120E or 1120S Charitable organizations: IRS form 990 is required, unless exempt from filing tax returns from the IRS, a copy of the exemption is then required Note: If a 2+ business has been in operation less than one year, a copy of the DBA certificate, partnership certificate, certificate of incorporation or other similar tax documentation verifying the business is authentic. 4. Attestation Form signed for any newly hired employees, owners, partners or retirees not listed on the NYS45-A TT and all sole proprietors. 5. Subscriber Application Form- must be completed and signed by the subscriber. Group number and Employer name and signature must be filled in. 6. Waiver of Group Coverage Form-must be completed by all employees not taking coverage. 7. Handicapped Dependent Form (when applicable) 8. Completed Medicare eligible/ over 65 forms (when applicable). 9. For new groups, a copy of group's first month premium check written on the business account 10. Signed Group ContracU Rate Sheet (all pages to be returned) 11. Eligibility Policy form Mail to: Excellus BlueCrass BlueShield, Rochester Region 165 Court Street Rochester, NY Attn: Corporate Sales Small Business Unit Ph: Fax: Revised 11/01/07

4 Group Information Groups with 50 or fewer eliqible emplovees (Must be completed by an Employer enrolling in Excellus BlueCrass BlueShield health insurance) 1. Name and Address of Employer. 2. Name, Title and Phone # of Contact Person at Employer. Name Title } Telephone 3. Desired effective date of health insurance coverage. *We require 30 days to implement the plan. Plans may begin on the 15t or the 15th of the month 4. Enrollment Questions a) Total number of individuals actively working at company (not retirees)* b) Total number of retirees eligible for coverage (if any)* c) Number of active employees NOT eligible for coverage (less than 20 hours per week, etc.) d) Number of eligible employees NOT taking coverage due to coverage elsewhere (such as other coverage through a spouse) e) SUM TOTAL-number of employees and retirees who are eligible to select coverage through this group, excluding the number in "d" above who have coverage elsewhere (e=a+b-cd) f) Number of eligible employees and retirees selecting no coverage AT ALL g) NET number of eligible individuals taking coverage through this Employer whether the coverage is issued by Excellus BCBS or by another insurer or HMO (e=f+g) *Include employees and other individuals working a minimum of 20 hours per week (unless the employer's eligibility rules require a greater number of hours per week); retirees when the consistent policy of the business is to cover retirees; and owners of the business if actively engaged in the business but not technically an employee. 5. Attach supporting documentation. See reverse side for required documents and check which applies: groups with 2 or more employees OR sole proprietor. 6. Signature. The undersigned certifies that, to the best of my knowledge and belief and under penalty of perjury, the information listed above is true and complete, including the number of persons proposed for coverage who work at least 20 hours per week. Signature of Contact Person Date Fax Number or Address Excellus BlueCross BlueShield, Rochester Region Revised 11/01/07

5 In response to #5 on the previous page, attach the following supporting documentation that the company was not formed solely for obtaining insurance and the employees or eligible retirees were not added to the Employer solely to obtain insurance: For aroups with 2 or more emplovees. This category also includes businesses with several employees, but only one is eligible for health insurance coverage. 1. Each Employer with 2 or more employees must provide a copy of the most recent NYS 45-ATT-MN, with notations indicating eligible employees (those working a minimum of 20 hours per week) and ineligible employees (part-time employees working fewer than 20 hours per week, seasonal employees and other persons not eligible for health insurance). NOTE: If the Employer's rules require a minimum of more than 20 hours per week in order to be eligible for coverage, e.g., 30 hours, then the notations should be based on the employer's own eligibility rule. 2. If there are any persons who are proposed for health insurance WHO ARE NOT listed on the NYS-45-ATT-MN, the Employer must provide one of the following as documentation that the person works at least 20 hours per week or is otherwise eligible for coverage: (i) for partnerships, a copy of the most recent 1065K-1 with income amount stricken; OR (ii) for business owners, a copy of the most recent Schedule E to Form 1120, or Schedule K-1 to Form 1120S, or Schedule E to Form 1120F; OR (iii) the attached attestation that the individuals not listed on the NYS-45-ATT-MN, or the individuals being proposed for coverage when the business is new and has not yet filed a NYS-45-ATT-MN, work at least 20 hours per week or are otherwise eligible for coverage (e.g., retired). 3. If the Employer has been in existence for less than one year, it must provide a copy of its DBA certificate or certificate of incorporation. For persons in business alone (sole proprietors). 1. Each Employer must provide the attached attestation that the sole proprietor or employee works at least 20 hours per week in the business. 2. Each Employer must provide a copy of most recent NYS-45-ATT-MN; or if the sole proprietorship does not file the NYS-45-ATT-MN, it must provide a copy of a pay stub, estimated tax form or other documentation of active employment status. 3. If the Employer has been in operation for MORE than one year, it must provide a copy of one of the following tax forms: Schedule C, Schedule E, W-2 or 1099 with Schedule F. 4. If the Employer has been in operation LESS than one year, it must provide a cancelled check from the business, OR the DBA certificate, OR similar tax documentation that the business is authentic and in operation. Revised 11/01/07

6 ATTESTATION I,, the (Name) (Title) at (Name of Employer) do hereby attest that Check which applies OR For groups with 2 or more employees, including businesses with only one employee who is eligible for health insurance coverage. With respect to groups with 2 or more employees, the following individual(s) work at least 20 hours per week at the above-named Employer or are otherwise eligible for coverage under a group health insurance plan to be issued by Excellus BlueCross BlueShield. Other individuals eligible for coverage can include partners, owners of the business if actively engaged in the business but not technically an employee, and retirees when the consistent policy of the business is to cover retirees. Include a notation for each person indicating employee (E), partner (P), business owner (0), or retiree (R). Sole proprietors. With respect to an applicant for coverage as a sole proprietor, the following individual works at least 20 hours per week at the above-named Employer. If you are applying for coverage as a sole proprietor, only one (1) name will be listed * if a second page is required please sign and date each page (Signature) (Date) Revised 5/15/07

7 Eligibility Policy for New Employees Group Name: Group Number {If Assigned}: Our Standard new hire waiting period for eligibility for health insurance is: (type of employee: salaried, hourly, etc.) Date of Hire First of the month following date of hire First of month following 30 days of employment First of month following 60 days of employment First of month following 90 days of employment First of month following 6 months of employment First of month following 1 year of employment Other Note: If group employer makes no contribution to the member premium, waiting period should be no less than 60 days. Note: If group has multiple waiting periods per occupation, please note all waiting periods. Our Standard rehire waiting period for eligibility for health insurance is: Same guidelines as new hire Date of rehire First of the month following rehire Other Minimum hours per week that an employee must work to be eligible: 20 hours 25 hours 30 hours 40 hours Note: Employer can determine full time status as stated above but may not select under 20 hours. The above policies have been submitted for business indicated above. I understand that these policies are accepted and must remain in effect for at least one full year before they are eligible to be changed. Authorized Group Signature: Date Signed: Date Effective: Revised 5/15/07

8 Waiver of Group Coverage Company Name: Employee Name: Date of Birth: Please Check One: [] I waive my employer's group health insurance coverage for myself and my dependents (if any). [] I am enrolling in my employer's group health insurance coverage but I am waiving coverage for my dependents. Reason for Waiving Coverage - Please Check One: [] Covered through spouse's employer, or: [] Covered through a parent's employer Employer Name: Insurance Company: [] Other reason (explain): Employee Signature: Date: IMPORTANT: If you checked that you are declining coverage due to other coverage, you will be eligible to enroll in this Plan within 30 days of the date that you are no longer eligible for the other coverage. If you did not state that the reason for waiving coverage is due to other coverage, then you cannot enroll in this Plan until your employer's open enrollment period (absent acquiring a new dependent through birth, marriage or adoption.) Revised 5/15/07

9 Client Profile Please fill in all areas. If a question does not apply, write in N/A. Thank you for taking the time to fill out this questionnaire. GENERAL INFORMATION Name of Business Mailing Address BlueCross BlueShield Group No. Type of Business Owner/CEO Website Address Group Representative Telephone Number ( Address Fax Number ( Benefit Decision Maker Telephone Number ( UNION INFORMATION Total Number of Union Employees Name of Union Union Contact Person Telephone Number CONTRIBUTION STRATEGY Do you contribute to the medical coverage? DYes o No Medical Contribution Single Family Do you contribute to dental coverage? DYes o No Dental Contribution Single Family If contribution is based on a specific product or is unique, please explain briefly Revised 11/1/07

10 Excellus {I Client Profile (cont.\ OTHER PLAN OFFERINGS Do you have a Flexible Benefit/Cafeteria If yes, type of plan: Plan DYes o No o Pre-Tax Premium (POP) 0 Flexible Spending Account (FSA) o Full Cafeteria Plan Administrator of Plan Do you offer medical, dental, vision or Rx coverage through another Insurance Carrier? DYes o No If you answered yes, please provide the following information. Name of Carrier Name of Plan Plan deductible Plan coinsurance Office Visit copay Sing le Fam ily Inpatient hospitalization co pay or coinsurance Student/Dependent coverage ages Domestic Partner Benefits o Covered o Not Covered Prescription Drug Plan Rating Tier o 2 Tier o 3 Tier o 4 Tier o 5 Tier The undersigned certifies that, to the best of my knowledge and belief and under penalty of perjury, the information listed about is true and complete. Employer Representative Signature: Date: Please return questionnaire to: Excellus BlueCross BlueShield, Rochester Region 165 Court St Rochester, New York Ph: Fax: (585) Revised 11/1/07

11 Excellus v GROUP ENROLLMENT FORM P.O. Box 22999, Rochester, NY A nonprofit irdependent licensee of the BlueCross BlueShieid Assodaton Instructions on Back. All Dates = mm/ddl a Check if name chan e a Check if new address "' CHECK DESIRED ACTION "' CHECK DESIRED MEDICAUDENTAUVISION COVERAGE o Add Subscriber(AA) Blue Healthv Choices A o PPO PN Dateof HirelEvent & 11 CoverageElf Date I I o Add Dependent(AB) Dateof Event 11 CoveraaeElf Date 1 1 o ChangeCoverage(AC) CoverageElf Date 11 o Transferto COBRA(AD) o (S)ubscriber a (M)Dependent o (D)isabled Dateof Event I a CancelSubscriber(S) a CancelDependent(M) a (M)edical o (D)ental a (V)ision ReasonCode(seeback) CancellationDate 1 a Blue Choice Select BS o Blue Choice Value BV o Blue Choice 25 BZ a BluePoint 2 SF o BCBS Comprehensive CO Blue Choice Preference o Healthy Choices HH a Family First FF a Dental (DE) 0 Vision (VI) SUBSCRIBER INFORMATION - ~uu:r~etfd I I I I Social Security # U1J LLlU Last Name; Street City Day Phone: UJ..J-UJ..J-I I I I I Child(ren) o Fit & Healthy FH a Blue DENTAL VISION MEDICAL 00 PPO BP o Healthy Family FM o Blue EPO BE Blue Healthv Choices B o Fit & Hea~hy FB o Healthy Family FC o BluePPO Savings Account Plan DC a Blue EPO Balance UE a FourFront EF o BluePPO/HSA HF a Comprehensive Plus CP o BCBS Traditional TR E-Mal Pddress: Blue Choice members must select a Medical Center or Primary Care Physician (PCP). Females may select an Ob/Gyn, Check Medical Center: a (W)ilson a (F)olsom a (G)reece 0 (P)erinton Current Patient? Primary Provider (Last), (First) a YON OB/GYN Provider (Last) (First) 0 Y a N First. State Sex: 0 M a F Self, Spouse a(d) 0aa Chid(ren) 0(C)( 0 B) Self 0 Self & (A) Birthdate Zip 11- FAMILY MEMBER INFORMATION "' Check relationshi and indicate de endent name or indicate de endent name and birth date to be cancelled. a (S)pouse a (D)ependent a Student(T) SocialSecurity# Sex Birthdate MedicalCenter PrimaryCarePhysician Currentpatient? 0 ya N o (H)disabled 0 (F)oster/GrandchiidDependent (mm/ddlyy) 0 (W)ilson Last First a Domestic(P)artner a Other a M 0 (F)olsom Last Name (if different) First Name 0 F I I 0 (G)reece o (S)pouse a (D)ependent a Student(T) a (H)disable 0 (F)oster/GrandchildDependent o Domestic(P)artner 0 Other Last Name (if different) First Name a (S)pouse 0 (D)ependent 0 Student(T) (H)disabled a (F)oster/GrandchildDependent o Domestic(P)artner 0 Other Last Name (if different) First Name o (S)pouse a (D)ependent 0 Student(T) a (H)disabled o Domestic(P)artner a Other Last Name (if different) a (F)oster/GrandchildDependent First Name SocialSecurity# SocialSecurity# SocialSecurity# (P)erinton Birthdate MedicalCenter IPrimaryCarePhysician (mm/ddlyy) a (W)ilson Last oa MF I I I 0 (F)olsom (G)reece a Perinton Birthdate MedicalCenter I PrimaryCarePhysician (mm/ddlyy) a (W)ilson Last a M I a (F)olsom o F I I 0 (G)reece (P)erinton Birthdate MedicalCenter PrimaryCarePhysician (mm/ddlyy) a (W)ilson Last o M 0 (F)olsom,, o F I I 0 (G)reece OB/GYNPhYSICian Perinton Last OTHER COVERAGE INFORMATION - Must be completed. You may be contacted for additional information. In addition, please provide a copy of your "Certificate of Coverage" from your former health insurance carrier or employer. Have you or any member of your family been enrolled in any other insurance policy in the last 63 days (including Dental, Medicare or Medicaid)? o Yes a No "' Check: 0 Medical and/or 0 Dental Are you keeping this coverage? 0 Yes a No "' Check previous insurance company from list below and indicate ID #: a (B) Excellus BlueCross BlueShield, Rochester Region, Blue Choice, o (0) Other - BlueCross BlueShield Plan (outside of Rochester), Indicate Plan Name: a (C) Other Carrier - Indicate Plan Name: RELEASE - You must sign and date this form to be eligible for insurance. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation, I have thoroughly read, understand and agree to comply with the terms of the Release on the back. Subscriber Signature Date EMPLOYERINFORMATION(Mustbecompletedby GroupAdministrator) Was the employee subject to a waiting period before enrolling in your employer health plan? If yes, what was the start date I I and end date I I Sex Sex Sex OB/GYNPhysician Last OB/GYNPhysician Last OB/GYNPhysician Last Currentpatient? a YO N First Currentpatient? a ya N First Currentpatient? 0 ya N First Currentpatient? a ya N First Currentpatient? a YO N First Currentpatient? 0 ya N First Currentpatient? a ya N First 'DeductibleAmI.,Depl.# andemployee# is optional. a Yes 0 No Coverage Medical Dental Vision APP F30 (10108) Group/SubGroup # Chk diait Pka # DeductibleAmount',, '0 o o o o o Return Original to Excel/us BlueCross BlueShield, at address above: Copy: Employer Group

12 nstructions for completing the Group Enrollment Form DESIRED ACTION Check the appropriate action and indicate the Date(s) in the space provided. An Event Date is the date of a specific occurrence, due to change in status, marriage, divorce, birth or adoption, group's anniversary date, or rate change. Your request must be received within 30 days of the Event Date. Please see your Group Administrator for events that fall outside the 30-day period. If New Add Subscriber, Add Dependent or Change Coverage, you must also check Desired Coverage and Persons covered, and Family Member Information section. Cancel Request To process a Subscriber or Member Cancellation, please use the Membership Cancellation Worksheet - OR To Cancel an Employee/Subscriber using the To Cancel a Dependent using the Group Enrollment Form: Group Enrollment Form: ~ check Subscriber (S) Box ~ check Dependent (M) box ~ check Products to be cancelled (Medical, Dental, Vision) ~ check Products to be cancelled (Medical, Dental, Vision) ~ indicate Reason Code in space provided (See codes below) ~ indicate Reason Code in space provided (see codes below) ~ indicate Cancellation Date in space provided ~ indicate Cancellation Date in space provided ~ complete Subscriber Information ~ complete Subscriber Information ~ complete Member Name and Member Birthdate Cancel Subscriber LE - Left Employer/No Longer Eligible PC - Preferred Care CP - Commercial CB - Cobra Begin Date CD - Cobra Disabled Date Ifthe only change is one of the following, pleasecall Customer Service at the number listedbelow. A Group Enrollment Form is not required. ~ Address ~ Birthdate ~ PCP ~ OB/GYN ~ Medical Center DESIRED COVERAGE PCP Information Reasons CE - Cobra End Date SR - Subscriber Request SD - Subscriber Deceased SB - Spouse's BCBSRA MC - Medicaid Cancel Dependent Reasons MA - Marriage OA - Dependent Over Age DM - Deceased MB - COBRA Begin Date MR - Subscriber Request DV - Divorce All products may not be applicable to your employer Qroup. Please check with your Group Administrator. Blue Choice members must select a Medical Center OR Primary Care Physician (PCP). Females may select an OB/GYN. FAMILY MEMBER AND DOCTOR INFORMATION Use an additional form, if more than four persons. QUALIFIED GUIDELINES: ~ A legal spouse (an ex-spouse is not a qualified member as of the divorce date) ~ Must be under the dependent age for your employer group - Unmarried child, natural, adopted or stepchild - A full time student (indicate under Relationship) - Chiefly dependent on you for support ~ Other: Please contact Customer Service for the appropriate form. These dependents have additional eligibility requirements. Dependents pending adoption, grandchild or foster dependents, foreign exchange students, dependents for whom employee/subscriber has legal custody or legal guardianship, or a dependent who is claimed on subscriber's current federal income tax return, or a handicapped dependent who is over the dependent age for your employer group. RELEASE ~ I acknowledge and agree that by signing this enrollment form and subsequently accepting services, I and everyone else who is covered under the contract or certificate you issue is bound by the terms and conditions of the contract or certificate applicable to my coverage. This includes, without limitation, the terms and conditions regarding the receipt and release of medical records and information. I make this acknowledgement and agreement on behalf of myself and each other person who now or in the future accept coverage under the terms of the contract applicable to my coverage (who may include, for example, my spouse and my eligible family dependents). ~ I hereby accept responsibility for payment of any portion of the premium. ~ I understand that any claim by me or one of my eligible family members may be denied and my coverage canceled upon one month's written notice, if I have knowingly included false information. ~ I understand that this contract is subject to a twelve (12) month waiting period for pre-existing conditions that have existed for a six (6) month period prior to my applying for this benefit, unless prior coverage affords credits for some or all of this time period. ~ BLUE CHOICE I understand that if I have elected a managed care product, all care, including hospital and physician care, must be provided or arranged by the designated primary care physician. ~ POINT OF SERVICE (POS) -Blue Choice Plus (BY) I understand that the Point of Service (POS) coverage is comprised of the HMO in-network product and the BlueCross BlueShield out-of-network product and that I have applied for coverage under both. I understand that the in-network benefit provided the highest level of coverage. ~ PREFERRED PROVIDER ORGANIZATION (PPO) I understand that the Preferred Provider Organization (PPO) coverage is comprised of and in-network benefit that is dependent on the utilization of medical providers who participate with the PPO and an out-of-network benefit which provides coverage for services of medical providers who do not participate with the PPO. I understand that the in-network benefit provides the highest level of coverage under the plan. ~ EXCLUSIVE PROVIDER ORGANIZATION (EPO) I understand that if I elect Exclusive Provider Organization (EPO) coverage, except in an emergency, all care must be provided by medical providers who participate with the EPO and I will not receive benefits for care that I receive from providers who do not participate with the EPO. EMPLOYER INFORMATION This section to be completed and signed by the Employer Group Administrator. Complete only the coverage section (Medical/DentaINision) that is applicable to the employee's request. If you have any questions, please contact Customer Service at: Excellus BlueCross BlueShield, Rochester Region (585) or Blue Choice Member Services (585) or

13 Excellus+, 165 Court Street, Rochester, New York A nonprofit independent licensee of the BlueCross BlueShield Association Dear Administrator: Please complete the following and return it to: Excellus BlueCross BlueShield, Rochester Region Membership and Billing Department 165 Court Street Rochester, New York Billing Election - Please select the option you prefer. o We would like Excellus BlueCross BlueShield, Rochester Region to administer the billing for our COBRA or New York State continuation of coverage provisions subscribers. (If you select this option, you must sign the Administrative Agreement on the back of this form.) o We would prefer to collect premiums and remit the payments on our COBRA or New York State continuation of coverage provisions group bill for our subscribers. 2. COBRA and New York State continuation of coverage provisions do not apply to us because: o We are considered a church plan. 3. Group Name: 4. Signature: Title: 5. Group Number: Telephone: PLEASE SEE REVERSE SIDE FOR ADMINISTRATIVE AGREEMENT (Rev. 04/04)

14 Administrative Agreement for Health Insurance Continuation Coverage Excellus BlueCross BlueShield, Rochester Region and the ("Employer") agree as follows: I. As agent for the Employer, Excellus BlueCross BlueShield, Rochester Region will, on a monthly basis, bill and collect premiums from those employees and other beneficiaries of the Employer's group health insurance plan who qualify for and elect to purchase continuation coverage in accordance with the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) or New York State continuation of coverage provisions. Benefits and premiums will correspond to those otherwise applicable under the plan, provided that Excellus BlueCross BlueShield, Rochester Region will add to each bill a charge for its administrative service equal to two percent (2%) of the applicable premium, which service charge the Employer is assigning to Excellus BlueCross BlueShield, Rochester Region as its agent. 2. The employer will have sole responsibility for complying with all notice requirements and election procedures under COBRA or New York State continuation of coverage provisions and for determining who is eligible for continuation coverage under its group health insurance plan. The Employer will notify Excellus BlueCross BlueShield, Rochester Region in writing with respect to the commencement, termination and other terms and conditions of continuation coverage for each eligible individual, and Excellus BlueCross BlueShield, Rochester Region will be entitled to rely upon those instructions. 3. The Employer will indemnify Excellus BlueCross BlueShield, Rochester Region from and against any and all claims, liabilities, costs or damages that arise as a result of Employer's failure to comply with the requirements of COBRA or New York State continuation of coverage provisions. The Employer's duty to indemnify will survive the termination of the Agreement." 4. Any party may terminate the Agreement by giving sixty days written notice to the other parties. Dated: Excellus BlueCross BlueShield, Rochester Region, By: Scott Ellsworth President Employer By: B-586 (Rev. 04/04)

15