Send all required documents (including this checklist) to:

hsainsurance.com Fallon Community Health Plan Fallon Senior Plan Companion Care To ensure that your applications are processed as quickly as possible, just follow this checklist 1 Employer completes and signs the Master Application. 2 Employer provides copy of most recent Schedule C or WR-1. Check if Complete 3 Pay your first premium: Pay over the phone: (781) 228-2222. Payment Confirmation #: -or- Complete Electronic Payment Request Form -or- Enclose check payable to Health Services Administrators (HSA) (Receipt of payment does not guarantee coverage. HSA must receive completed enrollment materials by the carrier deadline) 4 Enclose Annual Membership Fee of $125 (Payable to HSA) -or- If enrolling through an Association or Chamber of Commerce, please indicate name of Association or Chamber * If not already a member of a participating Association or Chamber of Commerce, additional requirements may apply such as completing a membership application and paying dues. 5 Eligible enrollee completes and signs a Fallon Senior Plan Companion Plan Enrollment Form. 6 Eligible enrollee writes in their Medicare number and effective dates of Part A and B on Enrollment Form and includes a copy of their Medicare card or letter from the Social Security Administration. HSA Main Office 135 Wood Road Braintree, MA 02184 HSA Regional Office 574 Boston Road Billerica, MA 01821 Send all required documents (including this checklist) to: Sales Rep: Contact Info: All coverage will be effective on the 1 st day of the month. Enrollment materials should be received by the 25 th of the preceding month. Keep a copy of your application as your temporary ID. Once your enrollment have been approved and processed, you will receive a member confirmation by mail with your group number. Your permanent ID cards will be issued to you directly from the carrier. Permanent ID cards generally take 7-10 business days from date your enrollment was approved and processed. Corporate Office: 135 Wood Rd, Braintree, MA 02184 (781) 848-4950 (877) 777-4414 (781) 848-7020 fax Regional Office: 574 Boston Road, Billerica, MA 01821 Rhode Island Office: 2220 Plainfield Pike, Cranston RI 02921 (401) 942-0966 (401) 944-3586 fax

hsainsurance.com Fallon Health Companion Care The Companion Care Plan from Fallon Health offers more benefits at lower cost than most other options available to Medicare eligible recipients in Massachusetts. Members may go to any Medicare approved physician or hospital anywhere in the USA that accepts Medicare. Among the added benefits is unlimited prescription drug coverage. The monthly premium for this Medicare plan is $559 and is guaranteed through December 31, 2017. Eligibility Guidelines Eligible Companies An Eligible company is one that: Employs less than 20 total employees (includes full and part time) Is actively in business Is located in the Fallon Senior Plan service area Is a member in good standing of HSA Eligible Enrollee An eligible enrollee is one that: Is enrolled in Medicare Part A and Part B Lives in the United States Effective Dates All coverage will be effective on the 1 st day of the month Applications must be received by HSA by the 25 th of the month.

hsainsurance.com Fallon Health Senior Plan Member Application 2015 V1 Company Name Desired Effective Date Business Address (street, city, state, zip) Billing Address (if different) Principal Contact Telephone Fax Type of Business Corporation Proprietorship Partnership Other Nature of Business Email SIC code Date Established Tax ID Number Number of Full Time Employees Number of Seasonal Employees Number of Part Time Employees How many were employed 12 months ago? Information Related to Medicare Secondary Payer (MSP) Group attests that group has fewer than 20 employees as defined in the Medicare Secondary Payer regulations at 42 CFR 411.170: An employer is considered to employ 20 or more employees if the employer has 20 or more employees for each working day in each of 20 or more calendar weeks in the current calendar year or the preceding calendar year. The total number of current employees who receive wages, tips or other compensation (refer to line 1 of your most recent federal tax return form 941 or 944): Previous Year Q1 Q2 Q3 Q4 Current Year Q1 Q2 Q3 Q4 (includes FT, PT, seasonal, new hire) as of this date (mm/dd/yyyy). Are you offering this Medicare plan for retirees, active employees aged 65 or older or both? Do you offer group Commercial insurance for your under age 65 employees? If yes, current carrier(s) 781-848-4950 877-777-4414 www.hsainsurance.com

Plan Selection Fallon Health Choose plan: SENIOR PLAN HMO SENIOR PLAN Companion Care Office co-pay In-network: $15 PCP $25 Specialist $0 Any doctor who accepts Medicare patients Rx Y Y Certification 1. I understand that all premiums for health/dental insurance are due on or before the 1 st day of the month of coverage 2. I understand if premiums are not received by the 1 st day of the month of coverage, HSA has the option of assessing a $25 late fee on the balance due. 3. I understand that if premiums are not received by the 1 st day of the month, HSA has the option of terminating coverage effective that date. 4. I certify that I have not misrepresented eligibility of an employee or misrepresented information needed to determine group size, group participation rate, or group premium rate. 5. I acknowledge that HSA is a sales and billing agent and is not responsible for payment of claims on our behalf. 6. I acknowledge that this company has fewer than 20 employees as defined in the Medicare Secondary Payer statute 42 U.S.C. 1395y. Group will immediately notify HSA if group s employee count according to Medicare Secondary Payer statute were to change so that it is no longer eligible for Medicare to be the primary payer. In the event of this change, group acknowledges that the group s Medicare eligible employees would no longer be eligible for this product. Signature (Authorized Employer Representative) Title Date 781-848-4950 877-777-4414 www.hsainsurance.com

Fallon Companion Care Enrollment Form To enroll, please provide the following information. Group name: Group number: Administrator signature: Effective date: Last name: First name: Middle initial: q Mr. q Mrs. q Miss q Ms. Birth date: Sex: q M q F Social Security number: (optional) Home phone number: ( ) Permanent residence street address: City/town: State: ZIP code: County: Mailing address if different from above: Street address: City/town: State: ZIP code: Please provide your Medicare insurance information. Please use your Medicare card to complete this section. Medicare information: Please fill in these blanks so they match your red, white and blue Medicare card, or; Attach a copy of your Medicare card or your letter from the Social Security Administration or Railroad Retirement Board You must have Medicare Parts A and B and continue to pay your Medicare Part B premium. MEDICARE HEALTH INSURANCE 1-800-MEDICARE (1-800-633-4227) Name of beneficiary: Sex: Medicare claim number: - - - Is entitled to: Effective date Hospital (Part A) / / Medical (Part B) / / Please provide the following information. Name(s) of prior insurance Medical coverage: Prescription drug coverage: Fallon Health & Life Assurance Company, Inc., a wholly owned subsidiary of Fallon Community Health Plan

Please read this important information and then sign below. The information on this form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that my signature (or the signature of the person authorized to act on behalf of the individual under the laws of the state where the individual resides) on this form means that I have read and understand the contents of this form. I certify that I am eligible to receive retiree health insurance coverage from the employer named on this form. I understand how to obtain and use services under my Fallon Companion Care coverage. I certify that all information is correct to the best of my knowledge. If signed by an authorized individual (as described above), this signature certifies that: 1) this person is authorized under state law to complete this enrollment and 2) documentation of this authority is available upon request by Fallon Health & Life Assurance Company, Inc. or by Medicare. X Your signature/authorized representative Date If you are the authorized representative, you must provide the following information: Name (printed) Relationship Address ( ) Phone number Need more information? To join, please call 1-866-839-8017 (TTY users, please call TRS Relay 711), Monday through Friday from 8:30 a.m. to 5:00 p.m. fallon health & life assurance company, inc. TM 10 Chestnut St., Worcester, MA 01608 FCHP USE ONLY q New enrollment q Age-in Name of staff member (if assisted in enrollment): Group number: Staff verification: Effective date of coverage: 07-720-329 Rev. 05 8/11

It Fits! Reimbursement Form Fallon Companion Care subscribers are eligible for reimbursement once per benefit year.* Fallon Companion Care members may request up to $200 per individual contract. Requests must be made no later than three months following a benefit year. For more information about other fitness discounts, visit fchp.org. Mail completed form to: Fallon Health & Life Assurance Co. Claims Department P.O. Box 15121 Worcester, MA 01615 Subscriber information (Note: The subscriber is the primary health insurance policyholder, not necessarily the person requesting reimbursement.) Subscriber s last name First name Middle initial Address City State ZIP Subscriber s ID # (located on the front of your card) ( ) Telephone number Activity for reimbursement Type of activity Program/gym name Benefit year Amount requested Information needed for reimbursement This completed form A copy of any/all applicable health club contracts, personal fitness trainer agreements or a copy of the registration form for a town activity. These must show the beginning and ending dates of membership activity and the names of enrolled members. Dated original receipts or copies of bank/credit statements showing the charge for membership or classes (original receipts will not be returned). These should reflect the dollar amount the member is requesting. Fallon Companion Care will only reimburse for the amount reflected on these receipts/statements. When paying by check, please send a copy of the front and back of the cancelled check. Also, a brochure from the health club, facility, or program may be requested. Certification and authorization (This form must be signed and dated below by the subscriber.) Reimbursement is subject to approval by Fallon Health & Life Assurance Company. Please allow 4-6 weeks from receipt for reimbursements. Reimbursement check should be made to (check one): q Subscriber q Member Agreement: I certify that the information above is correct to the best of my knowledge. I am claiming reimbursement only for eligible expenses incurred during the applicable calendar year and for eligible members. Subscriber s signature Date fallon health & life assurance company, inc. TM

Fallon Companion Care No deductibles. No referrals. No worries! Fallon Companion Care is a worry-free health care coverage solution for Medicare-eligible retirees. $0 deductibles and coinsurance Fallon Companion Care pays ALL of your deductibles and coinsurance.* We make it easy, so you don t have to figure out what percentage of the bill you owe or if you ve hit your out-of-pocket maximum. Coast-to-coast coverage See a provider by your home in Shrewsbury or one near the beach in San Diego! Since Fallon Companion Care doesn t have a provider network, you can receive services from any doctor who accepts Medicare anywhere in the nation! And, if you need to see a specialist, go ahead and make an appointment! With Fallon Companion Care, you don t need a referral to see a specialist. Complete benefits Fallon Companion Care s comprehensive coverage offers more benefits than Original Medicare alone and covers costs not paid for by Medicare, including outpatient prescription drugs. Here are some examples of services you won t have to worry about paying for: Annual routine physical exam Emergency care in, and outside of, the U.S. Hospital admissions Doctor office visits Diagnostic tests including X-rays and lab services Durable medical equipment including wheelchairs and oxygen Fallon Companion Care includes the It Fits! benefit a $200 annual fitness reimbursement that members can use for anything from memberships at the gym of their choice to aerobics classes, yoga, dance lessons, weightloss programs and so much more! To learn more about Fallon Companion Care, call 1-866-839-8017 (TRS 711). * For services charged at the Medicare allowed amount. Fallon Companion Care is offered through Fallon Health & Life Assurance Company, Inc., a wholly owned subsidiary of Fallon Community Health Plan, Inc. All Medicare group plan enrollees must be eligible for Medicare Parts A and B by the requested effective date of coverage and must continue to pay their Medicare Part B premium. Program eligibility and benefits may vary by employer, plan and product. 14-686-038 Rev. 00 4/14 fallonhealth & life assurance company, inc.

hsainsurance.com Electronic Payment Request Form New clients: Use this form if you wish to authorize HSA to deduct your initial payment and/or monthly payments directly from your checking account. Client Information: Client Name: 6 Digit HSA Member #: Select payment type: First month s payment Recurring monthly payment Both first month s payment and recurring monthly payment If requesting recurring monthly payments, select date for withdrawals to start. All outstanding balances owed, including fees, will be transferred at that time. 15 th of Current Month 24 th of Current Month 15 th of Next Month 24 th of Next Month Bank Information: Bank Name: Branch: City: State: Zip: Name on Account: Routing Number: Bank Account Number: Authorization: I (we) hereby authorize HSA to initiate debit entries for my (our) checking account and the depository named above, hereinafter called DEPOSITORY, to debit the same to such account. This authorization is to remain in full force and effect until HSA has received written notification from me (us) of its termination in such time and in such manner as to afford HSA and DEPOSITORY a reasonable opportunity to act on it. Note: all written debit authorizations must provide that the receiver may revoke the authorization only by notifying the originator in the manner specified in the authorization. Authorized Signer Authorized Signer (if more than one required) Sign Name Sign Name Print Name and Title Print Name and Title Date: Client Telephone: Return Form Please fax or secure email the completed form to: (781) 848-7020 or enrollment@hsainsurance.com For changes to existing bank information, please contact Customer Service: (781) 228-2222. Corporate Office: 135 Wood Rd, Braintree, MA 02184 (781) 848-4950 (877) 777-4414 (781) 848-7020 fax