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Home My WebLink About20223550.tiffRESOLUTION RE: APPROVE STOP LOSS APPLICATION AND SCHEDULE OF INSURANCE, AND AUTHORIZE CHAIR TO SIGN AND SUBMIT ELECTRONICALLY - AETNA LIFE INSURANCE COMPANY WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with a Stop Loss Application and Schedule of Insurance between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Resources, and Aetna Life Insurance Company, commencing January 1, 2023, and ending December 31, 2023, with further terms and conditions being as stated in said application and schedule, and WHEREAS, after review, the Board deems it advisable to approve said application and schedule, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Stop Loss Application and Schedule of Insurance between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Resources, and Aetna Life Insurance Company, be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to electronically sign and submit said application and schedule. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 21st day of December, A.D., 2022. BOARD OF COUNTY COMMISSIONERS WEL[ COUNTY, COLORADO ATTEST: ditAmjjeka, Weld County Clerk to the Board BY: Cou Attorney W/6.- ..: Date of signature: of /03 /23 Scot K. James, Chair Mike Freeman, Pro-Tem Perry L. Buck teve Moreno Lori Same Cc : PE (sDF/5s) of /I9 /23 2022-3550 PE0033 PASS -AROUND TITLE: DEPARTMENT: BOARD OF COUNTY COMMISSIONERS PASS -AROUND REVIEW Aetna Life Insurance Company Stop Loss Application Human Resources DATE: 12/00/2022 PERSON REQUESTING: Staci Datteri-Frey / Jill Scott Brief description of the problem/issue: This is to update our individual and aggregate stop loss policy coverage amounts with Aetna for medical claims. This amount is reviewed and renewed annually as part of our renewal process. What options exist for the Board? (include consequences, impacts, costs, etc. of options): Approve - claims processing will continue and Weld County will reduce risk of high cost claims. Disapprove - negotiate new terms with Aetna and subject to any high claims as of 1/1/2023. Recommendation: Approve contract as stated and reduce risk on high cost claims. Perry L. Buck Mike Freeman, Pro-Tem Scott K. James, Chair Steve Moreno Lori Saine Approve Recommendation bra &via4 „Fri --itAS-- Schedule Work Session Other/Comments: 2022-3550 it/li PE 0053 Karla Ford From: Sent: To: Subject: Approve Mike Freeman Tuesday, December 6, 2022 3:46 PM Karla Ford Re: Please Reply - Pass Around - Aetna Stop Loss Renewal Sent from my iPhone On Dec 6, 2022, at 2:07 PM, Karla Ford <kford@weldgov.com>wrote: Please advise if you approve recommendation. Thank you! Karla Ford V Office Manager, Board of Weld County Commissioners 1150 O Street, P.O. Box 758, Greeley, Colorado 80632 :: 970.336-7204 :: kfordhaweldgov.com :: www.weldgov.com **Please note my working hours are Monday -Thursday 7:00a.m.-5:00p.m.** <image002. jpg> Confidentiality Notice: This electronic transmission and any attached documents or other writings ore intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error. please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Staci Datteri-Frey <sfrey@weldgov.com> Sent: Tuesday, December 6, 2022 12:01 PM To: Karla Ford <kford@weldgov.com> Cc: Jill Scott <jscott@weldgov.com>; Esther Gesick <egesick@weldgov.com> Subject: Pass Around - Aetna Stop Loss Renewal Karla: Will you please circulate with BOCC and advise of next steps? We have an electronic version for final signature and Esther has copy of the email that contains document for signature. Let me know if you have any questions. Thank you! Staci I Datteri-Frey, MPH Benefits Manager Weld County Human Resources 1150 O Street Greeley, CO 80631 tel: 970-400-4235 Direct: 970-400-4265 Aetna Life Insurance Company Stop Loss Application and Schedule of Insurance 151 Farmington Avenue Hartford, CT06156 Policyholder Information Policyholder name (full legal name of entity): WELD COUNTY GOVERNEMENT Street: 1150 O STREET City: GREELEY State: CO Zip Code: 80631 Email: sfrey@weldgov.com Phone: (970) 400-4235 Policy period start: 01/01/2023 Policy period end: 12/31/2023 Total number of employees/covered units covered under the policy: 1,402 Pre -65 Retirees: ❑ Included 0 Excluded I Retirees 65+: ❑ Included 0 Excluded Medical paid claims basis: 0 Issued ❑ Cleared ❑ N/A Business Type: ❑ Corporation 0 Government ❑ Association ❑ Union ❑ Other Affiliates or subsidiaries included? 0 No ❑ Yes If yes, list name(s) and address state of the primary location(s) below. Affiliate full legal name(s): Address state of Primary location(s): Affiliate full legal name(s): Address state of Primary location(s): Affiliate full legal name(s): Address state of Primary location(s): Affiliate full legal name(s): Address state of Primary location(s): Affiliate full legal name(s): Address state of Primary location(s): Affiliate full legal name(s): Address state of Primary location(s): Affiliate full legal name(s): Address state of Primary location(s): Affiliate full legal name(s): Address state of Primary location(s): Affiliate full legal name(s): Address state of Primary location(s): Affiliate full legal name(s): Address state of Primary location(s): Third Party Administrator? 0 No ❑ Yes If yes, complete for each administrator or vendor. Medical: Prescription drug: Other: Individual Stop Loss Coverage (ISL) Individual Stop Loss coverage? El No E Yes I Individual Stop Loss amount: $300,000 Does individual Stop Loss amount differ by plan or class? 0 No ❑ Yes If yes, please include the plans)/class(es) and amounts below. Plan/class: Individual Stop Loss amount: $ Plan/class: Individual Stop Loss amount: $ Plan/class: Individual Stop Loss amount: $ AL HPol-App-SOI-SL 02 1 CO ad1 - 3550 Plan/class: Individual Stop Loss amount: $ Plan/class: Individual Stop Loss amount: $ High risk individual Stop Loss amount(s). included? ❑ N/A Q No ❑ Yes *See Coverage Limitations identified below. Covered benefits: 0 Medical 0 Prescription drug E Other Contract type: Claims incurred from through or Q paid basis Claims paid from 01/01/2023 through 12/31/2023 Maximum run-in claims: Q N/A or $ ❑ per covered person ❑ in total Individual coinsurance percentage reimbursable: 100% IOE transplant Stop Loss amount: ❑ N/A Q No or $ Family individual Stop Loss amount: ❑ N/A Q No or $ Aggregating Specific Stop loss amount: ❑ N/A Q No or $ Maximum lifetime individual Stop Loss payment amount: II Unlimited or $ Experience Refund Option included? ❑ N/A Q No ❑ Yes Experience refund period: Start date through Loss ratio threshold: % Refund share: % Maximum refund: % Large claim adjustment: 0 No or Adjustment is: Large claim identifier: Date of birth: Large claim identifier: Date of birth: Large claim identifier: Date of birth: Large claim identifier: Date of birth: Large claim identifier: Date of birth: Premier product included? ❑ N/A 0 No ❑ Yes Renewal risk cap included? E N/A ❑ No Q Yes Cap: 50% Other rate cap included? Q N/A ❑ No ❑ Yes Cap: % Terminal run -out coverage for claims incurred prior to policy termination and paid after termination? ❑ No Q Yes Terminal reserve or liability period: months Reimbursement types: Immediate reimbursement (Aetna as claims administrator): E N/A ❑ No Q Yes Individual accelerated claim reimbursement (TPA as claims administrator): ❑ N/A 0 No E Yes Other conditions or provisions: Aggregate Stop Loss Coverage (ASL) Aggregate Stop Loss coverage? ❑ No CO Yes I Aggregate Stop Loss percentage: 120% Covered benefits: Q Medical Q Prescription Drug ❑ Dental ❑ Vision ❑ Other Contract type: Claims incurred from through or Q paid basis Claims paid from 01/01/2023 through 12/31/2023 Maximum run-in claims: 0 N/A or $ E per covered person ❑ in total Individual Stop Loss insurer: 0 Aetna or AL HPoI-App-SOI-SL 02 2 CO Minimum aggregate Stop Loss amount: ❑ N/A $ 32,395,788 Individual internal limit: ❑ N/A Q No ❑ Yes If yes, amount: $ Maximum annual aggregate Stop Loss payment amount? ❑ N/A ❑ No Q Yes If yes, amount: $1,000,000 Deficit recoup provision? ❑ N/A Q No ❑ Yes If yes, deficit cap: Termination provision? ❑ N/A 0 No ❑ Yes Terminal run -out coverage for claims incurred prior to policy termination and paid after termination? ❑ No RI Yes Terminal reserve or liability period: months Reimbursement types: Monthly budget feature (Aetna as claims administrator): ❑ N/A ❑ No 0 Yes Aggregate accelerated claim reimbursement (TPA as claims administrator): ❑ N/A Q No ❑ Yes Other conditions or provisions: Coverage Limitations Mental Health claim expenses are Q Included ❑ Excluded Transplant coverage is 0 Included ❑ Excluded Is the policyholder a hospital or hospital group? Q No ❑ Yes If yes, are drafts suppressed for domestic claims? 0 N/A ❑ No ❑ Yes If yes, domestic claims are reimbursed at? Q N/A ❑ 100% ❑ 0% ❑ Other I I Are any of these limitations included under this Stop Loss policy? Pre-existing conditions exclusion? Q No ❑ Yes Dependent non -confinement? Q No ❑ Yes Actively at Work? Q No ❑ Yes High Risk Individual Stop Loss amounts: Member Identifier Date of Birth Description Premium Rates and Factors Premium rate: *Composite: $133.35 per employee per month (PEPM) *If individual and aggregate Stop Loss coverage is included, the premium rate is combined. Terminal liability premium rate: *Composite: $133.35 per employee per month (PEPM) or ❑ N/A *If individual and aggregate Stop Loss coverage is included, the premium rate is combined. AL HPol-App-S0I-SL 02 3 CO Aggregate Stop Loss factor: Composite: $1,925.57 per employee per month (PEPM) or ❑ N/A Terminal Liability Stop Loss factor: Composite: $1,925.57 per employee per month (PEPM) or ❑ N/A Certification and Signature You hereby represent that the information contained in this Stop Loss Application and Schedule of Insurance, any Disclosure statement, and all other information and documents provided by you to us, is true and complete to the best of your knowledge and belief. Printed name of authorized representative: Scott K. James Official Title: Chair, Weld Board of County Commissioners Signature of authorized representative: Scott /, 7aier s�oc� n ;ame,:oK ii, zozz za oe n�s1� Date: Dec 21, 2022 Agent of Record Agent's name: on file Agent's firm: on file Tax ID #: on file (If countersignature laws require commission sharing with a duly licensed resident agent in another jurisdiction, the above designation will be modified to the extent required by law.) AL HPol-App-SOI-SL 02 4 oto -- 3662" CO Fraud Notice WARNING: 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 subjects such person to criminal and civil penalties. State -specific notices: AL: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. AR: 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. CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. DC: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. FL: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. KY: 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 material fact thereto, commits a fraudulent insurance act, which is a crime. LA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. ME: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. MD: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. NM: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. NY: 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 material fact thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a'civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. OH: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. OK: WARNING - Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim AL HPol-App-S01-SL 02 5 CO for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. OR: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to civil fines and criminal penalties. RI: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. TN: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. VA: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law. WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. WV: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. AL HPol-App-S0l-SL 02 6 CO STOP LOSS APPLICATION AND SCHEDULE OF INSURANCE - AETNA LIFE INSURANCE COMPANY APPROVED AS TO SUBSTANCE: Ele ted • s '•%! r� p "rtment Head, or Deputy Department Head APPROVED AS TO FUNDING: 0.4 Chief Financial Officer APPROVED AS TO FORM: County Attorney Aetna Life Insurance Company 151 Farmington Avenue Hartford, CT 06156 Stop Loss insurance policy This policy is made by and between Aetna Life Insurance Company (Aetna) and WELD COUNTY GOVERNEMENT (policyholder) Policy number: 109724 Policy effective date: 01/01/2023 State of issuance: COLORADO Date of issuance: November 12, 2022 Welcome to Aetna. This is your Stop Loss policy, including the Stop Loss Application and Schedule of Insurance. This policy replaces any Stop Loss policies previously provided and may have riders or amendments added that alter the coverage. Throughout the policy: • "You" and "your" mean the policyholder • "Us," "we," and "our" mean Aetna • Words in bold are defined in the Glossary section This policy is underwritten by Aetna and governed by applicable federal law and the laws of the state of issuance shown above. The policy is issued based on the policyholder's signed Stop Loss Application and Schedule of Insurance, the Disclosure statement, if required, and premium payments made in compliance with the terms stated in this policy. In return, Aetna agrees to pay the policyholder for eligible claim expenses for benefits covered by the self -insured plan(s) and exceeding the Stop Loss coverage amounts, in accordance with the Stop Loss Application and Schedule of Insurance, terms, and conditions of the policy. All periods of coverage begin at 12:00 a.m. and end at 11:59 p.m. local time for the principal location of the policyholder. Signed at Aetna's home office, 151 Farmington Ave, Hartford, CT 06156. Daniel Finke President, Aetna Life Insurance Company Angela Woodard Director, Insurance and Risk Management AL HPoI-SL 01 1 CO GE -01 Table of Contents Page The policy 4 The entire policy 4 Your Stop Loss Application and Schedule of Insurance 4 Effective date 4 Conformity with law 4 Severability l ity 5 Incontestability 5 Policy changes 5 Right to recalculate 5 Changes to the plan 6 Fraud, deception, or misrepresentation 6 Bankruptcy 7 What is covered 8 Individual Stop Loss 8 Individual coinsurance percentage 8 Aggregating specific amount 8 Aggregate Stop Loss 9 Stop Loss reimbursements 9 Immediate reimbursement 9 Monthly budget feature 10 Terminal liability option 11 What is not covered — exclusions and limitations 13 Premium 16 Premium — rates 16 Premium due — calculation 16 Premium due — how billed and paid 16 Premium — when due 16 Premium — insufficient funds and overdue amounts 16 Termination 18 Automatic termination 18 Termination by the policyholder 18 Termination by Aetna 18 Non -renewal for failure to respond 19 Effective time of termination 19 Effect of termination 19 Reinstatement 19 AL HPol-SL 01 2 CO GE -01 Optional policy renewal 20 Responsibility and conduct 21 Responsibility for our employees 21 Appeals process 21 Arbitration 21 Indemnification — in general 22 Indemnification — liability 22 No Employee Retirement Income Security Act (ERISA) of 1974 liability 22 General provisions 23 Recovery of overpayments 23 Reports 23 Assignment and delegation 23 IRO overturn of claim denials 23 Correcting clerical errors 24 Legal action 24 Cost containment 25 Notice of legal actions 25 Taxes 25 Workers' compensation or state disability insurance 25 Subrogation - right to recovery 26 Aetna's additional responsibilities 27 When Aetna is not your claims administrator 28 Third party administrator (TPA) responsibilities 28 Proof of eligible claim expenses 28 Required reporting 29 Inspection and audit 30 Glossary 32 Stop Loss Application and Schedule of Insurance Issued independently AL HPoI-SL 01 3 CO GE -01 The policy The entire policy This Stop Loss policy is non -participating. It consists of the following documents: • Your signed Stop Loss Application and Schedule of Insurance • A signed Disclosure, if required • This policy • Any riders or amendments to the policy • A copy of the self -insured plan document(s) for each benefit plan covered by this policy A non -participating policy is one that you do not share (do not participate) in any surplus earnings or profit made by us. A participating policy is one that you share (participate) in any surplus earnings or profit made by us. Your Stop Loss Application and Schedule of Insurance We relied on your answers to all questions in the process to request coverage when we issued the policy to you. It is your responsibility to make sure the Stop Loss Application and Schedule of Insurance is accurate and complete. It is important that you notify us immediately of any mistakes that you find in your Stop Loss Application and Schedule of Insurance. By applying for coverage under this policy and accepting its benefits, you (or the person acting for you): • Represent that all information in your Stop Loss Application and Schedule of Insurance and statements given to us as part of your process to request coverage under this policy are true, correct and complete, to the best of your knowledge and belief • Agree to all terms, conditions and provisions of the policy If we learn that you, your agent, or a covered person defrauded us or misrepresented or omitted material facts when providing us information in the Stop Loss Application and Schedule of Insurance, Disclosure, application process, or submission requesting coverage, we may cancel the policy. We may also report fraud to criminal authorities. See the Fraud, deception, or misrepresentation section of this policy for more information. Effective date Coverage under this policy is not effective until: We have received, examined, and accepted your plan document(s) and all other information relevant to underwriting or premium rating, whether or not specifically requested • We have received, examined, and accepted your signed Disclosure statement, if applicable • We have received the signed Stop Loss Application and Schedule of Insurance We have received your first premium payment Conformity with law In the event of a conflict or apparent conflict between or among the terms and provisions of this policy and applicable laws of the state of issuance or federal law, the provisions in this policy will be given their broadest interpretation in order to reconcile the conflict or apparent conflict. If an interpretation is not possible and any provision in this policy conflicts with any applicable law of AL HPol-SL 01 4 CO GE -01 the state of issuance or federal law, the provision is amended to conform to the minimum requirements of the law. Severability Any provision or condition of this policy deemed void, voidable, invalid, or otherwise unenforceable does not make any of the remaining provisions of this policy invalid. Incontestability We can take legal or other action, using statements made in signed applications, disclosures, or other documents by you, your agent, or any covered person, during the first 2 years after the policy effective date. However, in the event of fraud, we may take legal or other action at any time as permitted by applicable law. The validity of this policy will not be contested, except for non-payment of premium, after it has been in force for 2 years from the policy effective date. Policy changes Modifications This policy may be changed in whole or in part. Any change will be valid upon approval, in writing, by an officer of Aetna. The approved change must be endorsed and made part of this policy. No other person or entity has the authority to alter this policy in any manner. When your consent is needed, payment of premium by the effective date of any change will be considered as your consent. Waiver Only an officer of Aetna may waive a requirement of the policy. No waiver will be valid unless it is endorsed and made a part of the policy. We may fail to implement or enforce compliance with a provision of the policy at any given time or under any circumstance. Our failure to do so is not a waiver of our right to implement or enforce compliance with that provision at any other time or under the same or different circumstances. Right to recalculate Aetna has the right to recalculate premium rates and Stop Loss factors for each policy renewal date. Aetna also reserves the right to change the premium rate or any aggregate Stop Loss factor as of the date of any change to the underlying assumptions or information that impacts the risk assumed for the insurance we are providing under the policy or if the change affects the initial underlying assumptions made, as of the effective date of coverage. Changes include, but are not limited to: • Any change of +/- 15% in employees or covered units • Any change to the plan document(s) that will change the risk assumed under this policy • Any change to this policy • Any addition or deletion of a unit, division, subsidiary, affiliated or associated company from this policy AL HPol-SL 01 5 CO GE -01 Any change in federal or state law or regulation that impacts this policy or the coverage provided Any change impacting the risk we have assumed, including but not limited to: age, gender, geography, occupation, incorrect or incomplete information provided in Disclosure statements, etc., that we determine impacts the nature of the risk by more than 15% Any change in claims administrator, provider network or cost containment vendor, provided we have consented to the change in writing Any change in the claims administrator's claim payment system or payment practices that causes a variation of +/- 5% versus the most recent 12 month average of claims processing time Any failure by Aetna to adjust any premium rate or Stop Loss factor during a policy period will not prohibit us from making an adjustment during any subsequent policy period. Changes to the plan This section is applicable if Aetna is not your claims administrator, network provider, or cost containment vendor for any covered benefit. Aetna has the right to approve any change to the plan if the change impacts the eligible claim expenses or assumptions under this policy. You must notify us promptly, in writing, at least 30 days before the effective date of any plan change or change in claims administrator, provider network, or cost containment vendor. Aetna's prior written agreement is required before the coverage under the policy will apply to the changes. Otherwise, benefits under the policy will be paid based on the plan as it existed when last approved by Aetna, and Aetna reserves the right to terminate the policy upon discovery of such change. Fraud, deception, or misrepresentation Aetna pursues all appropriate and available legal remedies in the event of insurance fraud. The decision to issue this policy to you, as well as the premium rates and any Stop Loss factors associated with it, are based on information provided by you, a covered person, your agent, or claims administrator. If we learn that you or anyone acting on your behalf defrauded us or misrepresented or omitted material facts that we relied upon in the decision to issue this policy at the coverage levels and premium rates identified in this policy, we reserve the right to take actions that can have serious consequences for your coverage. Any behaviors on your part include, but are not limited to: • Filing a false claim, • Providing false, incomplete, or misleading information during the underwriting process Potential serious consequences include, but are not limited to: • Denial of claims • Recalculation of premium rates or redetermination of the terms and conditions of this policy • Termination of this policy, including retroactively back to its effective date • Recovery of amounts we have already paid • Prosecution to the full extent under state and federal law AL HPol-SL 01 6 CO GE -01 Bankruptcy Other than the liability required by this policy, we are not liable to you, your plan, or your claims administrator for: • Bankruptcy • Insolvency • Financial impairment • Receivership • Voluntary plan of arrangement with creditors • Your dissolution or the dissolution of your designated claims administrator(s) and/or vendor(s) Your insolvency will not make Aetna liable to your creditors, including covered persons under the plan. In the event of your insolvency or bankruptcy, subject to the terms and conditions of this policy, we may pay to your receiver, trustee, liquidator or legal successor amounts otherwise payable to you under this policy. We will make payments only if you have paid all required premiums and have complied with your obligations under this policy. Nothing in this section increases our liability beyond what would have existed had you not become insolvent or bankrupt. AL HPol-SL 01 7 CO GE -01 What is covered Aetna will reimburse you for eligible claim expenses paid under the plan and according to the coverage levels and features indicated in the Stop Loss Application and Schedule of Insurance and the terms and conditions of this policy. Individual Stop Loss If the Stop Loss Application and Schedule of Insurance indicates an individual Stop Loss amount is included under this policy, we will pay you the amount that a covered person's total eligible claim expenses exceed the individual Stop Loss amount during the policy period, adjusted for any contract type, if applicable. The amount payable will also be adjusted by any applicable individual coinsurance percentage, family individual Stop Loss amount, or aggregating specific Stop Loss amount. The total amount payable is also subject to any maximum annual individual Stop Loss payment amount or individual lifetime Stop Loss payment amount, as indicated on the Stop Loss Application and Schedule of Insurance. If the Stop Loss Application and Schedule of Insurance indicates an IOE transplant Stop Loss amount is included under this policy, we will pay you the amount that a covered person's total eligible claim expenses exceed the IOE transplant Stop Loss amount during the policy period, adjusted for any contract type, if applicable. The amount payable will also be adjusted by any individual coinsurance percentage, family individual Stop Loss amount or aggregating specific Stop Loss amount. The total amount payable is also subject to any maximum annual individual Stop Loss payment amount or individual lifetime Stop Loss payment amount, as indicated on the Stop Loss Application and Schedule of Insurance. A high risk individual Stop Loss amount may be assigned to any high risk covered person during the underwriting process for any policy period, in accordance with the terms and provisions of this policy and as indicated in the Stop Loss Application and Schedule of Insurance. If individual Stop Loss coverage terminates before the end of the policy period, the individual Stop Loss amount will not be reduced. Individual coinsurance percentage Once the individual Stop Loss amount or IOE transplant Stop Loss amount is met for a covered person, we will pay you the percentage of eligible claim expenses as indicated on the Stop Loss Application and Schedule of Insurance. Aggregating specific amount As indicated on the Stop Loss Application and Schedule of Insurance, the aggregating specific amount is an optional Stop Loss feature that adds to your liability by providing a second amount (the aggregating specific amount) that must be met before eligible claim expenses are reimbursed under individual Stop Loss coverage Eligible claim expenses in excess of the individual Stop Loss amount for any covered person are added together until the cumulative total equals the aggregating specific amount. Once the aggregating specific amount is met, whether by one or multiple covered persons, it is considered satisfied for the policy period. AL HPoI-SL 01 8 CO GE -01 When you elect this feature, we will not pay an individual Stop Loss benefit until you have also met the aggregating specific Stop Loss amount. Eligible claim expenses used to satisfy the aggregating specific Stop Loss amount will apply toward the aggregate Stop Loss corridor. Aggregate Stop Loss If the Stop Loss Application and Schedule of Insurance indicates aggregate Stop Loss is included under this policy, we will pay you the amount that total eligible claim expenses exceed the aggregate Stop Loss corridor during the policy period adjusted for any contract type, if applicable. The amount payable will be reduced by any eligible claim expenses exceeding any: • Individual Stop Loss amount • IOE transplant Stop Loss amount • High risk individual Stop Loss amount • Individual internal limit • Other provision of this policy, as applicable The total amount payable is also subject to the minimum aggregate Stop Loss amount and any maximum annual aggregate Stop Loss payment amount, as indicated on the Stop Loss Application and Schedule of Insurance. Stop Loss reimbursements Aetna will make Stop Loss reimbursements due under the terms of this policy and according to the contract type indicated on the Stop Loss Application and Schedule of Insurance. If Aetna is not your claims administrator, we will reimburse you after satisfactory proof of loss is submitted by you or your claims administrator, according to the conditions and provisions of this policy. Aetna has the right to deduct any due but unpaid premium that would otherwise be payable by you from any Stop Loss reimbursement. This right will not prevent the termination of this policy for non-payment of premium in accordance with the Termination section of this policy. Any eligible claim expense that is reimbursable under this policy due to exceeding the individual, aggregate, or any other Stop Loss amounts, and that is also funded as a reimbursable eligible claim expense under another Stop Loss policy: • Is not eligible for reimbursement under this policy • Must be repaid to us if we previously reimbursed it Immediate reimbursement Benefits Immediate reimbursement is only available when Aetna is the claims administrator for your plan. If you purchase individual Stop Loss coverage, eligible claim expenses that exceed the individual Stop Loss amount under this policy may be reimbursed on an immediate funding basis. Availability of immediate funding for individual Stop Loss reimbursements is dependent upon the individual Stop Loss amount and other policy features that you select. You will be notified by us, in writing, before the effective or renewal date if the coverage you have selected is not eligible for immediate reimbursement. Immediate reimbursement is provided subject to the following terms and conditions: • Essential legal documents of the policy must be fully executed by all applicable parties and on file with us AL HPol-SL 01 9 CO GE -01 • Only covered benefits that Aetna administers are eligible • The coverage levels and policy features selected by you must be available (i.e. system - supported) for immediate reimbursement • Eligible claim expenses must exceed the individual Stop Loss amount and any other applicable Stop Loss amount available under individual coverage before any individual Stop Loss payment will be made Certain claims are not eligible for immediate reimbursement. These include, but are not limited to: • Claims paid by a third party claims administrator • Eligible claim expenses paid outside of system -supported claim processing procedures • Run-in claims and, under certain circumstances, run -out claims (i.e. coverage crossing multiple reimbursement periods and/or policy periods) Immediate reimbursement is not a guarantee of coverage. After the end of each policy period, as adjusted for any contract type, we will perform a reconciliation to verify all individual Stop Loss reimbursements were made in accordance with the terms of the policy. Monthly budget feature When Aetna is the claims administrator of your plan and you purchase aggregate Stop Loss coverage under this policy, the monthly budget feature provides protection against monthly claim fluctuations by applying a monthly cap on eligible claim expenses. The aggregate Stop Loss corridor is converted to a monthly cash flow limit, based on enrollment and the number of policy months in your policy period. If your cumulative eligible claim expenses exceed the aggregate Stop Loss corridor for the month, the monthly budget feature operates as follows: • From the monthly cash flow limit, eligible claim expenses that you paid during the month are subtracted: — If the eligible claim expenses that you paid during the month are less than the monthly cash flow limit, the unused cash flow limit is carried forward to the next month to fund future eligible claim expenses that you pay. If the eligible claim expenses that you paid during the month exceed the cumulative monthly cash flow limit, the amount over the limit is funded by Aetna and recovered in future months when eligible claim expenses are less than the monthly cash flow limit. If at any time during the policy period, the eligible claim expenses exceed the total aggregate Stop Loss corridor, we will fund any eligible claim expenses in excess of the aggregate Stop Loss corridor, up to any maximum annual aggregate Stop Loss payment amount indicated on the Stop Loss Application and Schedule of Insurance. In no event can the aggregate Stop Loss corridor be less than the minimum aggregate Stop Loss amount as indicated in the Stop Loss Application and Schedule of Insurance. This includes a mid -year plan termination. The monthly budget feature is provided subject to the following terms and conditions: • Essential legal documents must be fully executed by all applicable parties and on file with us • Only covered benefits for which Aetna is the claims administrator are eligible • The coverage levels and policy features selected by you must be available (i.e. system - supported) for the monthly budget feature to apply AL HPoI-SL 01 10 CO GE -01 Certain claims are not eligible for the monthly budget feature. These include, but are not limited to: • Claims paid by a third party claims administrator • Eligible claim expenses paid outside of system -supported claim processing procedures • Run-in claims and, under certain circumstances, run -out claims (i.e. coverage crossing multiple reimbursement periods and/or policy periods) After the end of each policy period, as adjusted for any contract type, we will perform a reconciliation to verify any Stop Loss reimbursements were made in accordance with the terms of the policy. Terminal liability option Benefits If you purchase terminal liability coverage prior to the effective date of the policy period, as indicated on the Stop Loss Application and Schedule of Insurance, you may exercise it by providing us with 30 days written notice prior to termination of the policy, unless the policy terminates for non-payment of premium. We will insure you for eligible claim expenses: • Incurred under the plan by covered persons during the policy period immediately prior to termination of the policy and in excess of the applicable aggregate and individual Stop Loss amounts. When benefits are paid during the 3 month period following termination of the policy. This period following termination when we will pay benefits is referred to as the terminal liability period. The amount of any terminal liability premium due but unpaid may be deducted from any Stop Loss payment otherwise owed to you. Special provisions When Aetna: • Is your claims administrator, the terminal liability option may only be exercised if Aetna continues to administer run -out claims for the plan during the terminal liability period • Is not your claims administrator, the terminal liability option may only be exercised if your current claims administrator(s) indicated in the Stop Loss Application and Schedule of Insurance continues to administer run -out claims for the plan during the terminal liability period When you choose to exercise the terminal liability option: Eligible claim expenses will continue to accrue towards the individual Stop Loss amount through the 3 month period following termination of the Stop Loss policy. The aggregate Stop Loss corridor will be increased to include an additional amount to cover the terminal liability period. The amount of this increase will be calculated of the product of three factors: - The number of employees or covered units on the first day of the last policy month, times 2, times the terminal liability Stop Loss factor indicated in the Stop Loss Application and Schedule of Insurance. - This additional amount will be added to the aggregate Stop Loss corridor, and the sum will be subject to the minimum aggregate Stop Loss amount indicated in the Stop Loss Application and Schedule of Insurance. Premium for the terminal liability period, in addition to any past due premium, is due by AL HPol-SL 01 11 CO GE -01 the date of termination of the policy. This premium will be calculated as the product of three factors: - The monthly terminal liability premium rate indicated in the Stop Loss Application and Schedule of Insurance, times the number of employees or covered units on the first day of the last policy month, times 2. Limitations • The terminal liability option may only be exercised if at least 4 policy months have elapsed in the policy period. AL HPoI-SL 01 12 CO GE -01 What is not covered — exclusions and limitations This section outlines what is not covered as an eligible claim expense under this policy. Exclusions related to eligibility and enrollment • Expenses paid for an employee, covered unit, and any associated dependents that did not enroll according to the terms of the plan until they are enrolled in accordance with the terms of the plan. Expenses incurred by any individual who is not a covered person under the plan when the expense is incurred. Expenses paid for covered persons of a unit, division, subsidiary, affiliate, or associate company added after the effective date of this policy unless approved in writing by us prior to their effective date of coverage under the plan. Expenses paid under the plan for your covered retirees and associated dependents as indicated on the Stop Loss Application and Schedule of Insurance. Expenses paid for a covered person following termination of coverage under the plan for any class, unit, or division of participants that includes the covered person and any associated dependents. Expenses incurred by a late Consolidated Omnibus Budget Reconciliation Act (COBRA) enrollee. Except for a clerical error as described in the General provisions section of this policy, the policy will exclude any claim expenses for a covered person whose eligibility for, or coverage under, COBRA is continued beyond the timeframes specified by federal law for any reason including your clerical error. This exclusion includes those individuals who: - Do not receive a valid COBRA extension offer from you, in accordance with federal law, within the 30 days immediately following a COBRA qualifying event - Fail to make a valid, signed COBRA election within the 60 days immediately following the receipt of COBRA election rights from you - Fail to make COBRA premium payments within the time period specified by federal law We may require written documentation that these requirements have been satisfied. Exclusions related to plan administration Costs related to the administration of the plan including, but not limited to: Claim payment functions Cost containment administrative fees Large case management Audit - Negotiation - PPO access fees — Premium functions — Claim review — Consultant fees Costs associated with extra -contractual damages, compensatory damages or punitive damages assessed against you. Legal expenses, court costs, or interest upon judgments. AL HPoI-SL 01 13 CO GE -01 Expenses for taxes, fees, assessments and surcharges that may be assessed on claims under the plan by any government body. This exclusion does not apply to the MA Uncompensated Care Pool, Minnesota Care Provider Tax, or New York Health Care Reform Act surcharges unless the surcharge relates to excess or punitive payments made on behalf of you to fund indigent care and graduate medical education solely as a result of your decision not to pay directly into the pool. Exclusions related to claim administration Expenses paid by you or the claims administrator that are incurred prior to the effective date of this policy unless otherwise indicated in the Stop Loss Application and Schedule of Insurance. Expenses for drugs or medications, treatment, services or supplies that are considered experimental or investigational, and any service or treatment resulting from complications of experimental or investigational treatment. Expenses paid for services, medications, or supplies that are not medically necessary, and any service or treatment resulting from related complications. Expenses resulting from treatment provided outside the United States, and any service or treatment resulting from related complications, unless approved by us in writing before the service is provided. Expenses paid at your direction but that we determine are not payable under the plan, in accordance with our current established claim practices or in excess of the reasonable and customary charge. Expenses resulting from capitation payments, defined as contractually determined, regularly -scheduled payments to certain providers based on the number of plan participants entitled to receive services from that provider. In return, the providers provide certain agreed -upon services to eligible plan participants. Incentive payments, care coordinator payments, risk share payments, and other non -fee - for -service payments paid or received in connection with an agreement with an accountable care or similar provider organization. Eligible claim expenses not submitted to us within 6 months after the -end of the policy period. If the Stop Loss Application and Schedule of Insurance indicates coverage under a terminal liability period, terminal reserve period, or run -out period associated with a specific contract type, the 6 month submission period will begin at the end of these periods. Expenses for claims not submitted to the claims administrator within 12 months of the date incurred. Expenses for benefits that are reimbursable under any under workers' compensation or a similar program under local, state, or federal law for any illness or injury related to employment or self-employment, even if the covered person fails to claim rights to those benefits. General exclusions If you have valid and collectible insurance, reinsurance, indemnity, or any reimbursement agreements covering eligible claim expenses in excess of individual, aggregate, or aggregating specific amounts also covered by this policy, this policy is in excess of and will not contribute with the other insurance, reinsurance or indemnity. Expenses paid for any benefits not indicated on the Stop Loss Application and Schedule of Insurance as covered benefits under any applicable individual Stop Loss amount or aggregate Stop Loss corridor. AL HPol-SL 01 14 CO GE -01 Expenses not incurred or paid within the contract type as indicated in the Stop Loss Application and Schedule of Insurance. Expenses paid according to changes or an amendment to the plan not agreed to in writing by us. Expenses not specifically covered under the terms of the plan. Expenses for any other benefits that you and we mutually agree will not be subject to the Stop Loss insurance as indicated in this policy. Eligible claim expenses paid or benefits that were originally denied by the claims administrator and are adjusted by the claims administrator more than 2 years after the original coverage determination date are not eligible for coverage under the policy. Expenses for a covered person if the covered person's medical conditions or claim information was not disclosed to us as part of the underwriting of this policy or upon request. Any expense that is determined to be fraudulent. AL HPoI-SL 01 15 CO GE -01 Premium Premium — rates The policy period's monthly premium rate is indicated in the Stop Loss Application and Schedule of Insurance. Premium due — calculation Premium: • Will be calculated and payable on a monthly basis or any other basis you and we mutually agree upon • Is based on the premium rate indicated in the Stop Loss Application and Schedule of Insurance and the number of employees or covered units covered at the time the invoice is prepared • May be adjusted due to factors outlined in the Right to recalculate section Premium due — how billed and paid We may bill you electronically and you may pay premium due to us electronically. If you are not billed electronically, you must send your premium to us at the address shown on the invoice on or before the premium due date. Payment occurs when we receive sufficient funds. A check does not constitute payment until it is honored by a bank. We may return a check issued against insufficient funds without making a second deposit attempt. We may accept a partial payment of premium without waiving our right to collect the entire amount due. Premium payments will be credited first to any past due and unpaid premium, in the order it is due. We may choose not to accept premium that is paid for you by someone else unless we are required to by law. If the total actual premium due (determined at the financial accounting) is less than the amount of premium paid, the difference will be paid to you at the time the accounting is provided to you. If the total actual premium due exceeds the amount paid, you must pay us the difference within 30 days of the date the accounting is provided to you. Premium — when due Premium is due on the premium due date. You will pay all premium payments in U.S. dollars no later than 15 days after the premium due date. If we have not received premium due by the due date, the policy will automatically terminate without further notice to you and all rights to benefits under this policy will end. Premiums will be due for any period the policy was in force. Refer to the Termination section of this policy. Premium — insufficient funds and overdue amounts A service charge may be assessed when there are insufficient funds to pay premium due. If you don't pay your premium on time, we may charge you interest in the amount of 12% per annum on the amount that is overdue. Overdue premium includes amounts not paid by 15 days AL HPol-SL 01 16 CO GE -01 after the premium due date. We may also recover from you the costs of collecting any unpaid premium, including reasonable attorney fees and costs of suit. Aetna will reduce any payment due to you under this policy by: • The amount of any premiums due and unpaid • Any overpayments or other reimbursements made in error if incorrect information is received • Any other amounts due to us AL HPol-SL 01 17 CO GE -01 Termination Automatic termination This policy will terminate if: • You have not paid us all premiums due. The policy and all coverage will automatically terminate on the last day of the period that premiums have been paid. • The plan terminates. This policy will automatically terminate on the same date and time that the plan terminates. Termination by the policyholder You may terminate coverage under this policy effective on any premium due date by providing us at least 30 days advance written notice. The policy may also be terminated on any other date you and we agree to. Termination by Aetna We may terminate the policy and all coverage it provides under the following conditions: If you, your agent, or a covered person perform any act or practice that constitutes fraud or if you, your agent, or a covered person make any misrepresentation of, or any omission of, a material fact relevant to the coverage, we may cancel the policy and all coverage it provides, either prospectively or retroactively to the date the fraudulent event occurred or back to the effective date if the event occurred prior to the effective date. See the Fraud, deception, or misrepresentation section. If a claims administrator, network provider, or vendor is added, canceled, or changed without our prior written consent, we may terminate the policy as of the date of the change in claims administrator, network provider, or vendor. If the plan is changed and we have not agreed in advance and in writing to continue the policy, we may terminate the policy as of the date and time the plan change is effective. If you fail to pay claims under the plan or make available funds to pay claims as required by the plan, we may terminate the policy as of the first day that you failed to fund claims. If you fail to meet the underwriting requirements we have established in our current underwriting guidelines, including any applicable participation or contribution requirements, or fail to have a minimum 101 employees or covered units under the plan, we may terminate the policy as of the first day of the first month when the underwriting requirement was not met. If you do not comply with or fail to meet your obligations under any material terms and conditions of the policy, including, but not limited to, providing required reports or other information we have reasonably requested from you that is related to our administration of the policy, we may terminate the policy as of the date you failed to comply. If you suspend active business operations, become insolvent, or are placed in bankruptcy or receivership, we may terminate the policy as of the date any of these occur. If there is any change in federal or state law or regulation that materially impacts this policy or the coverage provided, we may terminate the policy effective on the date the change in the law is effective. If you are an employer group and cease to be a group as defined under applicable state law, we may terminate the policy as of the date you no longer qualify as an employer group. If you are an employer group that is subject to ERISA, and you become exempt from ERISA, we may terminate the policy as of the date you are no longer subject to ERISA. AL HPol-SL 01 18 CO GE -01 Non -renewal for failure to respond We require you tell us if you intend to renew the policy. You must reply, in writing, within 2 weeks of your receipt of the request or within 15 days prior to the renewal date, whichever is later. If you do not reply, we will terminate coverage as of the renewal date. Effective time of termination The policy and its coverage end as of 11:59 p.m. local time at your principal location on the day of termination. Effect of termination Following termination, you and we continue to be responsible for duties we acquired prior to the termination of the policy. One of your duties includes payment of premium due for coverage up to the date of termination. We are required to continue paying you for coverage of eligible claim expenses incurred and paid under the plan prior to the termination date. You and we also continue to be responsible for any duties that the policy states are to occur following termination. If the policy terminates before the end of the policy period: • The contract type under this policy is limited to eligible claim expenses incurred and paid up to the termination date • The individual Stop Loss amount will not be reduced • The minimum aggregate Stop Loss amount will not be pro -rated Reinstatement You may request that we reinstate the policy and coverage after we terminate it. You must make the request within 30 days of the termination date. We are not obligated to reinstate the policy as of the termination date. If we do, we will require you to pay all amounts due in full before reinstatement and give us reasonable assurances that you can and will fulfill all of your obligations under the policy. AL HPoI-SL 01 19 CO GE -01 Optional policy renewal Unless the policy has terminated or is subject to termination in accordance with the Termination section on or before the end of the policy period, we may offer you a renewal. At that time, we have the right to revise the terms and conditions of the policy, including, but not limited to, premium rates, factors, and coverage levels by providing written notice to you. If you accept the renewal provisions, the policy will renew on the policy renewal date, subject to receipt of your acceptance in writing prior to the renewal date. If you use a separate claims administrator, a renewal offer for this policy is contingent upon receipt of any requested plan, census, or claim information for use in the underwriting process prior to the beginning of the subsequent policy period. AL HPol-SL 01 20 CO GE -01 Responsibility and conduct Responsibility for our employees We are responsible to you for what our employees and others that work on our behalf do as it pertains to Stop Loss coverage under this policy. If Aetna is also your administrator, any disputes regarding administration of the plan must be brought under the terms of the Master Services Agreement, which determines claims administration. We are not responsible to you for what is done by others, commonly referred to as "independent contractors." Appeals process You may appeal any claim determination made by us under this policy by submitting a written appeal to: Aetna, 151 Farmington Avenue, Hartford, Connecticut 06156. You must file an appeal within 60 days after the date of our determination. Your appeal must state the detailed basis of your disagreement with our determination and must include all documentation and information supporting your appeal that has not been previously provided to us. If any claim determination made by us meets one or more of the following conditions: • Not medically necessary • Cosmetic • Experimental or investigational treatment • Requires medical judgment then the appeal of the claim determination must include an Independent Review Organization (IRO) report that includes each panel member's report and the panel's consensus report. The IRO's report is to be provided at your expense. The members of the IRO must be mutually acceptable to you and us. In addition, the individual Stop Loss contract type and the aggregate Stop Loss contract type, as indicated in the Stop Loss Application and Schedule of Insurance, will be extended for a period not to exceed 3 months to cover only reversals of claim denials. See the IRO overturn of claim denials section in this policy. Any eligible claim expenses reimbursed pursuant to the terms and conditions of this policy will apply to the policy period that it was incurred and will be treated as if it had been paid on the date you sent notice of denial to the covered person. These eligible claim expenses will be excluded from any other policy period. Arbitration Any disagreement, controversy, or claim involving us that arises out of, or relates to, this policy or its breach will be settled by binding arbitration under the rules of the American Arbitration Association with the stipulation that the arbitrator(s) will abide by the terms of the policy and will apply the applicable rules of the law. A single arbitrator will decide all matters. Judgment for the award made by the arbitrator may be entered into any court having jurisdiction. This provision survives the termination of this policy. AL HPol-SL 01 21 CO GE -01 Indemnification — in general To the extent allowed by law, we agree to indemnify and hold you harmless against that portion of your liability to third parties as determined by a court of final jurisdiction or by binding arbitration caused directly by our willful misconduct, criminal conduct, or material breach of this policy. To the extent allowed by law, you agree to indemnify and hold us harmless against that portion of our liability to third parties as determined by a court of final jurisdiction or by binding arbitration caused directly by your: Negligence Breach of the policy Breach of applicable federal and state laws • Willful misconduct • Criminal conduct • Fraud Breach of a fiduciary responsibility in the case of an action related to, or arising out of, this policy or your role as employer or plan sponsor These indemnification rights and obligations apply during the term of the policy and to a claim made in writing within one year after termination of the policy. Your and our rights and duties in this section survive termination of the policy. Indemnification — liability We have neither the responsibility nor the obligation under this policy to directly pay any covered person or provider of eligible claim expenses for any benefit you have agreed to provide through the terms of the plan(s). Our only liability under this policy is to you, subject to the terms, conditions, and limitations of this policy. No Employee Retirement Income Security Act (ERISA) of 1974 liability Under no circumstances will we accept responsibility as an administrator or be deemed a plan fiduciary under your plan, as these terms are defined and used in the ERISA Act of 1974 and as amended. AL HPol-SL 01 22 CO GE -01 General provisions This section provides details on additional terms and conditions under this policy. Recovery of overpayments If eligible claim expense amounts change as a result of a coordination of benefit change, a subrogation recovery, audit, or billing or payment errors, we may have overpaid you. If we have overpaid you, you will promptly refund the overpaid amount to us. If you fail to refund the overpayment to us in a timely manner, we have the right to reduce any future payments due under this policy by the amount we overpaid until repayment is made in full. If this policy terminates, any reimbursements made for claims paid by you after the date of termination will immediately be refunded to us. Reports You will promptly provide us with any information we determine is necessary to carry out the provisions of this policy. Assignment and delegation You will not assign any right or delegate any duty under the policy unless we approve it in writing, and in advance. This includes assignment to any person or entity, including, but not limited to, any covered person, medical provider, or creditor. If you do so without our written approval, we are not bound by your assignment or delegation. If you use any claims administrator, vendor, or agent, you are responsible for authorizing the release of any information we request to underwrite, review potential claims, make claim determinations, calculate potential reimbursements, or perform other obligations under this policy. If we do not receive requested information, it may result in the delay, reduction or denial of a reimbursement request. Aetna may delegate some of our functions under this policy to third parties, (i.e. an authorized representative, subsidiary, affiliate or parent of Aetna). We may also change or end these delegations. We do not need your consent or need to give you advance notice to enter into, change, or end these arrangements. These delegations will not increase or reduce our or your rights or responsibilities under this policy. We may also assign this policy to an affiliate within our corporate family without your consent. An assignment will not increase or reduce either of our rights or responsibilities under this policy. IRO overturn of claim denials Coverage under the policy will be extended for a period not to exceed 3 months from the last paid date of the policy period to cover only reversals of claim denials related to an adverse benefit determination when the claim denials by the plan are subsequently overturned by Independent Review Organizations (IROs), subject to the following: • Your plan is subject to external review under the Affordable Care Act (ACA) and this status is communicated to us during the underwriting of the policy • Eligible claim expenses are paid, in whole or in part, for a covered person due to, and consistent with, the overturning of a claim denial by an IRO conducted pursuant to the applicable external review process established under the ACA AL HPol-SL 01 23 CO GE -01 Eligible claim expenses associated with a previously denied claim were incurred by the covered person during the policy period Eligible claim expenses paid after the last paid claims date of the policy period indicated in the Stop Loss Application and Schedule of Insurance are not eligible for payment under any other coverage, but are otherwise payable under the terms of the policy You or your claims administrator advises us that the denied claim for eligible claim expenses has been submitted to the IRO within 10 days of being submitted to the IRO You have received notice from the IRO that a decision was made to pay the denied claim and that you must pay the denied claim within 10 days of receiving the decision You or your claims administrator advises us of the IRO's decision prior to payment of the claim Satisfactory proof that you paid the denied claim and complied with all terms and conditions of the policy must be submitted to us by you or your claims administrator within 30 days of payment of the claim An eligible claim expense reimbursed pursuant to the terms and conditions above will relate back to the policy period it was incurred and will be treated as if it had been paid on the date you sent notice of claim denial to the covered person. These eligible claim expenses will be excluded from any other policy period. Correcting clerical errors A clerical error may be made by you, any claims administrator, a covered person, vendor, agent, or us in keeping records or providing required information. A clerical error alone will not determine whether there is coverage. We will determine the facts and decide if coverage is in force and its amount. We will make a fair adjustment in premium or factors if correction of the error or delay changes coverage or the risk assumed. Aetna is not required to honor a notification of a covered person's enrollment or termination of eligibility which Aetna receives more than 30 days after the qualifying event. We may correct, withdraw, or replace the policy, Stop Loss Application and Schedule of Insurance, and any other document issued with an error or issued in error. A clerical error does not include your: • Intentional acts • Intentional omissions • Failure to comply with the plan or this policy When you use a claims administrator that is not Aetna, your failure to report the existence of a covered person or claimant or your failure to report notice or proof of claim loss in a timely manner does not constitute clerical error. Legal action The time limit on legal actions related to coverage under the policy is subject to applicable law in the state where the policy was issued. We encourage you to complete the appeal process before you take any legal action against us for any disapproval of coverage. If you disagree with our coverage decision, you may not start legal or other action against us regarding your claim until 60 days after proof of eligible claim expense has been rejected by Aetna. AL HPoI-SL 01 24 CO GE -01 No legal action may be brought against us after 2 years from the time written proof of loss is required from you. Cost containment If you use a claims administrator or other vendor other than Aetna, we have the right to participate in any cost savings or cost containment program that you may have in connection with your plan. At our expense, we have the right to retain the services of a medical management vendor or other service provider to perform the following duties: • Assist us with cost containment with respect to claims under the plan • Provide services to you to reduce cost, risk, or expenses under the plan We may also request a medical management vendor or other service provider that we may have negotiated a set or discounted rate to contact you if, in our determination, the medical management vendor or other service provider described above provides a service that may reduce the risk, costs and expenses under the plan. Notice of legal actions You agree to: • Notify us immediately of any event or development that might result in an action of law or equity related to this policy • Forward promptly to us copies of any pleadings and reports of investigation that we request • Immediately provide to us a copy of any documents filed by or against you in any court in connection with any litigation under the plan You are responsible for paying all attorneys' fees, expenses of experts and investigations, and any damages (including exemplary or punitive damages) incurred by Aetna in connection with any litigation in which we will, without fault, become involved through or on account of this policy or the plan. If any time limitation in this policy is less than that permitted by the law of the state that the application was signed, the limitation is hereby extended to agree with the minimum period permitted by the law. Taxes You will hold us harmless for any taxes we are assessed that are beyond any tax payable on premium we have received. You are responsible for reimbursing us for any taxes we paid that are beyond any tax payable on premium we received. Workers' compensation or state disability insurance This policy does not replace or affect the requirements for coverage under any workers' compensation or state disability insurance. AL HPoI-SL 01 25 CO GE -01 Subrogation - right to recovery Your plan is required to include a comprehensive provision for subrogation and reimbursement in its Summary Plan Description. The plan must enforce this provision. If you fail to pursue any recovery or action against a responsible party, then you agree that Aetna will: • Be subrogated to or assigned your reimbursement rights • Will assume the plan's rights to pursue any recovery against any and all parties You will be responsible for any and all reasonable expenses incurred in the pursuit of recovery, including the fees and costs charged by any contracted subrogation vendor or attorney and any additional legal costs. We have the right to pursue any and all recoveries covered under this policy and paid by the plan, and to pursue these actions in the name of the plan. This includes both the portion of the plan benefits that the plan has been paid under this policy and the portion of the claim consisting of benefits paid by the plan but not payable under this policy. You: Must notify Aetna within 30 days of receiving any information that may lead to our subrogation rights Must cooperate fully with us and do all things necessary and required for Aetna to pursue any action to recover against a responsible party May not take any action, or neglect to take any action, that will prejudice or impair our rights to pursue recovery from any other responsible party May not, without our written consent, settle or give release for any claim to any other party if doing so would impair or prevent Aetna from exercising its rights of recovery If the plan: • Receives a recovery prior to our reimbursement of any eligible claim expenses under the policy, the plan must deduct the amount of the recovery from any reimbursement request • Receives a recovery after we have made payment to the plan for some or all of a particular claim, the plan must reimburse us to the full extent of the payment made by us We are under no obligation to reduce the amount we are due for any reason, even to help you pay for a lawyer or pay other costs you incurred to get a recovery. The plan must: • Still reimburse us regardless of whether this policy is still in force on the date of recovery • Reimburse us within 30 days of any recovery by the plan or plan sponsor • Account to us for all amounts recovered The rights and obligations of the plan in this section extend beyond the termination of the policy. AL HPol-SL 01 26 CO GE -01 Aetna's additional responsibilities We will prepare the legal documents of the policy as required by applicable federal and state laws. We will provide them to you in electronic form. We will also provide them to you in paper form if you request it. We will provide the coverage stated in the policy and Stop Loss Application and Schedule of Insurance. We will administer the coverage as required by the policy and applicable federal and state laws. We will protect personal health information, as required by federal and state laws. We will use it and share it with others only as needed to help us administer the policy. For a copy of our Notice of Privacy Practices log on to https://www.aetna.com/. Our duties in this section survive termination of the policy. AL HPol-SL 01 27 CO GE -01 When Aetna is not your claims administrator Third party administrator (TPA) responsibilities When Aetna is not your only administrator or ancillary services vendor (i.e. subrogation, case management, etc.), you are solely responsible for the actions of your designated TPA, including claims administrators, network providers, vendors, and agents. Without waiving any of our rights under this policy, and without making the TPA a party to this policy, we agree to recognize the TPA for the administration of your plan(s), subject to these conditions: Your TPA is responsible on your behalf for: Auditing, calculating, and processing all eligible claim expenses for the underlying plan within a reasonable amount of time - Preparing reports as required by us - Maintaining and making available to us, at all times, any information as we may reasonably require for proof of coverage Your TPA must perform any other duties as we may reasonably require, including, but not limited to, maintaining an accurate record of covered persons under the plan We are not responsible for, nor will this policy reimburse, any compensation or fees due to the TPA for functions performed by them on your behalf in relation to this policy Notice from us to your TPA under the provisions of this policy will be considered notice to you. Also, notice from us to you will be deemed notice to the TPA. If you engage a TPA without our prior approval, in addition to any other rights we have by law or under this policy, we may: • Terminate the policy as of the date the unapproved TPA began to administer the plan • Exclude any eligible claim expenses paid by the unapproved TPA Proof of eligible claim expenses Proof of eligible claim expense losses must be provided to us and must establish the nature and extent of the covered loss. Eligible claim expenses that are not submitted to us in accordance with the requirements of this section of the policy are not reimbursable and are not be considered eligible claim expenses under the policy. Individual Stop Loss If the Stop Loss Application and Schedule of Insurance indicates individual Stop Loss coverage under this policy, you must provide us with written proof of eligible claim expenses within 60 days after any individual Stop Loss amount, high risk individual Stop Loss amount, or IOE transplant Stop Loss amount has been exceeded by a covered person. If it is not possible to submit proof within this time period, proof must be given as soon as reasonably possible. Proof of loss may not be given later than 6 months after the end of the policy period that the claims administrator paid the loss, adjusted for any contract type, if applicable. Proof must be provided in a form and content satisfactory to us and must consist of the following: • Completed claim form(s) • Proof of the covered person's original enrollment record under the plan, and any changes and other applicable eligibility information, including the most current certification of AL HPol-SL 01 28 CO GE -01 coverage as required by state or federal law For each covered person exceeding the individual Stop Loss amount, high risk individual Stop Loss amount, or IOE transplant Stop Loss amount, proof of payment by the plan for eligible claim expenses submitted for reimbursement, including a paid claim detail report which includes for each claim: — Incurred date — Provider name and tax identification number (TIN) — Billed amount, allowed amount, and paid amount — Paid date — Relevant International Classification of Diseases (ICD-10) codes, Current Procedural Technology (CPT) codes, and National Drug Code (NDC) codes Copies of all relevant provider bills, reports and electronic data transactions Copies of relevant pre -certification forms and case management reports Proof of deductible and out-of-pocket maximums, if applicable For all accident claims, copies of the police report and any signed subrogation agreement Any other information we may need to fulfill our obligations under this policy Aggregate Stop Loss If the Stop Loss Application and Schedule of Insurance indicates aggregate Stop Loss coverage under this policy, you must give us written proof of loss within 60 days after the end of the policy period adjusted for any contract type, if applicable. If it is not possible to give proof within this time period, proof must be given as soon as reasonably possible. Proof of loss may not be given later than 6 months after the end of the policy period that the claims administrator paid the loss adjusted for any contract type, if applicable. Proof must be provided in a form and content satisfactory to us, and must consist of the following: A written request for reimbursement, including the calculation of the aggregate reimbursable amount A detailed claim history report by claimant for all eligible claim expenses incurred and paid during the policy period as adjusted for any contract type, including: - Incurred date - Provider name and tax identification number (TIN) - Billed amount, allowed amount, and paid amount - Paid date - Relevant International Classification of Diseases (ICD-10) codes, Current Procedural Technology (CPT) codes, and National Drug Code (NDC) codes A listing of all covered persons eligible for benefits under the plan at any time during the policy period If prescription drug coverage is indicated as an eligible claim expense on the Stop Loss Application and Schedule of Insurance, a detailed claim report of all prescription drug claims including: - The amounts of any rebates you received - A copy of the check register - A summary of claimants exceeding the individual Stop Loss amount - A summary of the benefit analysis - A copy of the loss ratio report - Any other information we may need to fulfill our obligations under this policy Required reporting AL HPoI-SL 01 29 CO GE -01 You and your claims administrator or other agents will maintain records as may be required by us for the administration of this policy. You will provide us with all information we determine is necessary to carry out the provisions of the policy upon our request. You must provide us with a copy of your underlying health benefit plan document(s), including any amendments or modifications. Any amendments or modifications must be submitted to us at least 60 days prior to the effective date. Reports are to be provided within 30 days after the end of each policy month, in a form and content satisfactory to us, including: Aggregate Stop Loss Total monthly paid claims for all covered persons in a format and with content that is satisfactory to us including: o The number of each type of employee or covered unit as of the first day of the policy month Total eligible claim expenses for all covered persons that you paid for the month A listing of claims for any covered person whose total eligible claim expenses on a paid basis during the month exceeds $25,000 o Any other information that may be reasonably required Individual Stop Loss Notice of any potential catastrophic claim via written submission on a form acceptable to us within 30 days of when: A covered person's eligible claim expenses exceed 50% of the individual Stop Loss amount If applicable, a family's eligible claim expenses exceed 50% of the family individual Stop Loss amount You, your claims administrator, or any other agent acting on your behalf, are notified that a covered person has been diagnosed with or treated for any injury, illness or disease that is reasonably likely to result in eligible claim expenses expected to exceed 50% of the individual Stop Loss amount during the 12 months following notification Any other information that may be reasonably required You will provide all claim information and will not withhold or delay information on a particular claim beyond 30 days. If there are special circumstances, the 30 days may be extended for a mutually agreed upon time. If you or your claims administrator do not provide the required information on a timely basis, we reserve the right to revise premium rates, monthly factors, or coverage levels retroactively to the policy effective date or renewal date, as applicable, once the information is received. Inspection and audit We are permitted to inspect your, your claims administrator's, or any other vendor's or agent's records and procedures pertaining to the plan at any reasonable time while your policy is in force and within 3 policy years after termination to the extent that the records relate to the premium basis or eligible claim expenses under this policy. AL HPol-SL 01 30 CO GE -01 We reserve the right to employ a third party, at our expense, to assist us with any audits. If you, your claims administrator, or any other agent fails to provide requested information, we will not reimburse you for eligible claim expenses under this policy. AL HPol-SL 01 31 CO GE -01 Glossary Aetna Aetna Life Insurance Company, an affiliate, or third party vendor under contract with Aetna. Agent A designated person or entity that has, or reasonably appears to have, the authority to act on behalf of the policyholder. This includes: Consultants Brokers Counsel HR Representatives Any other person or entity that the policyholder designates as an agent Aggregate Stop Loss corridor When aggregate Stop Loss coverage is elected, it is the total dollar amount of eligible claim expenses that you must pay for all covered persons during the policy period before aggregate Stop Loss benefits are payable. The amount is determined at the end of the policy period and is the greater of: • The sum of each month's number of employees or covered units multiplied by the aggregate Stop Loss factor, or • The minimum aggregate Stop Loss amount The aggregate Stop Loss corridor does not include claim payments made during a policy period for a covered person in excess of any: • Individual Stop Loss amount • IOE transplant Stop Loss amount • High risk individual Stop Loss amount • Individual internal limit • Any other provision of this policy, as applicable Aggregate Stop Loss factor When aggregate Stop Loss coverage is elected, it is determined prior to the start of the policy period. It is calculated as the expected eligible claim expenses for the policy period, multiplied by the aggregate Stop Loss percentage, divided by the expected number of employees or covered units at the beginning of the policy period, and divided by the number of months in the policy period. Aggregate Stop Loss percentage When aggregate Stop Loss coverage is elected, it is the percentage amount above expected eligible claim expenses that you are liable for under the terms and conditions of the policy as indicated on the Stop Loss Application and Schedule of Insurance. Under no circumstances will the aggregate Stop Loss percentage be less than the percentage required by state or federal law. Claims administrator A firm or person you have designated and have a written agreement with to process claims and provide administrative services for your health plan. The term claims administrator as used in this AL HPol-SL 01 32 CO GE -01 policy does not refer to the plan administrator used under ERISA, unless a participating employer has specifically appointed the administrator for that purpose. We must approve any administrator in advance and in writing, in accordance with the terms and conditions of this policy. Contract type Establishes the time periods that eligible claim expenses must first be incurred by a covered person through the plan and then paid by Aetna or the approved claims administrator. Covered benefits The benefits provided by the policyholder to covered persons included under the plan and included as reimbursable under this policy as indicated in the Stop Loss Application and Schedule of Insurance. Covered person Any person who meets the eligibility requirements of and is covered by the underlying self -insured health benefit plan. Covered unit A covered unit means the same as employee. Domestic claim expenses The medical expenses incurred for services delivered to covered persons within the healthcare facilities being insured by the Stop Loss policy. Effective date The date coverage begins under this policy in accordance with the Effective date section of this policy. Eligible claim expenses Expenses for covered benefits you paid based on the plan and that are included under the terms of this policy. Eligible claim expenses will include payments made to the MA Uncompensated Care Pool, Minnesota Care Provider Tax, or in New York, on your behalf, to fund indigent care and graduate medical education when paid directly into the pool. Employee An employee is defined in accordance with the eligibility requirements of, and is covered by, the underlying self -insured health benefit plan. For purposes of premium, terminal liability, terminal reserve, and aggregate Stop Loss calculations, employee means an enrolled contract or unit (i.e. single individual, individual + spouse, individual + child(ren), family). Also see covered unit. Experimental or investigational Any drug, device, procedure, treatment, or test not yet accepted by physicians or by insurance plans as standard treatment of a condition or illness. AL HPoI-SL 01 33 CO GE -01 They are experimental or investigational if: • There is not enough outcome data available from controlled clinical trials published in peer -reviewed literature to validate its safety and effectiveness for the illness or injury involved. The needed approval by the FDA has not been given for marketing. A national medical society or regulatory agency has stated in writing that it is experimental or investigational or suitable mainly for research purposes. It is the subject of a Phase I, Phase II, or the experimental or research arm of a Phase III clinical trial. These terms have the meanings given by regulations and other official actions and publications of the FDA and Department of Health and Human Services. Written protocols or a written consent form used by a facility or provider state that it is experimental or investigational. The plan deems a drug, device, procedure, test, or treatment as experimental or investigational. Aetna's experimental or investigational determinations are documented in Aetna's Clinical policy bulletins. Family individual Stop Loss amount When indicated on the Stop Loss Application and Schedule of Insurance, it is the dollar amount of eligible claim expenses per covered family (eligible employees or covered units and their enrolled dependents) that you must pay prior to any family individual Stop Loss benefit becoming payable under this policy. High risk covered person A covered person that has eligible claim expenses under the plan expected to exceed the individual Stop Loss amount. The covered person may have a separate higher individual Stop Loss amount or may be excluded from coverage under this policy as indicated on the Stop Loss Application and Schedule of Insurance. High risk individual Stop Loss amount The dollar amount of eligible claim expenses for a high risk covered person that you must pay before any individual Stop Loss benefit is payable under this policy as indicated in the Stop Loss Application and Schedule of Insurance. Incurred The date services are rendered or supplies are received by a covered person for medical services and supplies. Inpatient facility charges with continuous facility stays that fall over two or more policy periods will be considered on a pro rata/per diem basis by dividing the total amount of eligible claim expenses by the total number of days of confinement and multiplying by the number of days of confinement per policy period. Professional visits that are billed for inpatient facility charges will be considered on the date they were provided to the covered person. Individual internal limit As indicated on the Stop Loss Application and Schedule of Insurance, it is the limit on eligible claim expenses that are paid by the claims administrator for any one covered person during the policy AL HPol-SL 01 34 CO GE -01 period that can be used to satisfy the aggregate Stop Loss corridor or included in the aggregate benefit amount calculation for the policy period. Individual lifetime Stop Loss payment amount When indicated on the Stop Loss Application and Schedule of Insurance, it is the maximum amount of eligible claim expenses that Aetna will fund as individual Stop Loss payments under the policy for any one covered person during their lifetime. If the eligible claim expenses paid by us under the individual Stop Loss coverage reach the individual lifetime Stop Loss payment amount, all subsequent eligible claim expenses for that covered person will be funded by you. Individual Stop Loss amount The dollar amount of eligible claim expenses per covered person that you must pay before any individual Stop Loss benefit is payable under this policy as indicated in the Stop Loss Application and Schedule of Insurance. Under no circumstances will the individual Stop Loss amount be less than the minimum amount allowed by state or federal law. IOE transplant Stop Loss amount When indicated on the Stop Loss Application and Schedule of Insurance, and if the covered person elects to have the transplant performed at one of Aetna's Institute of Excellence® (IOE) facilities, it is the amount of eligible claim expenses for a covered person receiving a transplant at an IOE facility during the policy period that you must pay before any individual Stop Loss benefit is payable under this policy. For transplant claims and eligible claim expenses covered in the policy period that the transplant benefit is paid by the claims administrator, the IOE transplant Stop Loss amount is applied instead of the individual Stop Loss amount. The IOE transplant Stop Loss amount may not be applicable to certain transplant types or a covered person's transplant claims as indicated in the Stop Loss Application and Schedule of Insurance. Maximum annual aggregate Stop Loss payment amount When indicated on the Stop Loss Application and Schedule of Insurance, it is the dollar limit that Aetna will pay in any policy period under the aggregate Stop Loss coverage. If the eligible claim expenses paid by us under the aggregate Stop Loss coverage reach the maximum annual aggregate Stop Loss payment amount, all subsequent eligible claim expenses in that policy period will not be eligible for reimbursement by us. Maximum annual individual Stop Loss payment amount When indicated on the Stop Loss Application and Schedule of Insurance, it is the maximum amount of eligible claim expenses that Aetna will fund as individual Stop Loss payments under the policy for any one covered person in a policy period. If the eligible claim expenses paid by us under the individual Stop Loss coverage reach the maximum annual individual Stop Loss payment amount in a policy period, all subsequent eligible claim expenses for that covered person will be funded by you. Medically necessary In addition to any medically necessary definition cited in the plan, a health care service, drug, or device that we determine a provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease AL HPoI-SL 01 35 CO GE -01 or its symptoms, and that we determine is: • In accordance with generally accepted standards of medical practice Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury or disease Not primarily for the convenience of the patient, physician, or other health care provider Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease Generally accepted standards of medical practice means: • Standards that are based on credible scientific evidence published in peer -reviewed medical literature generally recognized by the relevant medical community • Following the standards set forth in our clinical policies and applying clinical judgment Minimum aggregate Stop Loss amount The minimum aggregate Stop Loss amount applies when aggregate Stop Loss coverage is elected. It is the minimum amount of eligible claim expense liability that you must pay before any aggregate Stop Loss benefits may be payable. For any policy period, the aggregate Stop Loss corridor is subject to a minimum aggregate Stop Loss amount. This is the greater of: The minimum aggregate Stop Loss amount indicated on the Stop Loss Application and Schedule of Insurance The sum of the product of the number of employees or covered units on the first day of the first policy month, multiplied by the aggregate Stop Loss factor, multiplied by the number of months in the policy period, determined by mutual agreement between you and us at the beginning of the policy period Paid date The date the payment for eligible claim expenses is issued by Aetna or an Aetna -approved TPA, claims administrator, vendor, or ancillary provider. The payment instrument must be supported by sufficient funds to be honored upon presentation and will coincide with the claims paid date definition of the administrative services, ancillary, and vendor agreement(s). If funding is not available, the expense will not be deemed to have been paid until funding is available to cover the full amount of the draft as determined by us. In an issued basis funding arrangement, check issuing systems issue payments and transmit them to the claims reporting system. These checks are processed and immediately accumulate towards the Stop Loss policy. Any EFT payments are immediately funded and apply towards the Stop Loss policy. Plan Describes the self -insured health benefits you provide for covered persons. The plan is subject to ERISA, as applicable, and as is or as may be, amended and approved by Aetna. The health benefits are included under either individual Stop Loss, aggregate Stop Loss, or both as indicated in the Stop Loss Application and Schedule of Insurance. AL HPol-SL 01 36 CO GE -01 Policy Your Stop Loss policy consists of the following essential legal documents: • Your signed Stop Loss Application and Schedule of Insurance • Disclosure, if required • This document (the policy) • Any riders or amendments to the policy • A copy of the self -insured plan document(s) for each benefit plan covered by this policy Policyholder The insured entity as defined on the cover page of this policy. Policy month A policy month is the same as a calendar month. The first policy month begins on the effective date of this policy and the last policy month ends on termination of this policy. Policy period A policy period typically coincides with the plan's benefit period. The first policy period begins on the effective date of this policy. Any policy period after the first policy period begins on the policy renewal date. Premier product In consideration of additional premium paid, the Premier product provides a commitment of no new high risk individual Stop Loss amounts or rate -ups for covered persons' medical conditions upon policy renewal. Premium due date When premium is not funded by automatic electronic funds transfer, the premium is due as of the date shown on the invoice. Rate cap The rate cap is a commitment that upon renewal, if offered, the premium increase will be capped at a specified percentage. Reasonable and customary Reasonable and customary is the portion of a bill for a drug, device, procedure, test, or treatment that is eligible for coverage based on the geographical area of service. It is the amount of any non - preferred or non -network charge under a network based plan or all charges under a non -network plan. Reasonable and customary charge means the same as allowed amount, recognized charge, and usual and customary charge. The actual reasonable and customary amount will be determined in accordance with the underlying plan that has been reviewed and approved by Aetna. Renewal date Each anniversary of the effective date of the policy, unless changed by written agreement between the policyholder and Aetna. Renewal risk cap AL HPol-SL 01 37 CO GE -01 The renewal risk cap is a commitment that upon renewal, if offered, there will be no new lasers and the premium increase will be capped at a specified percentage. Run-in amount The maximum amount we will pay per covered person as applied towards the annual aggregate Stop Loss corridor on eligible claim expenses incurred prior to the policy effective or renewal date and paid on or after the policy effective or renewal date. Run-in period The period of time immediately prior to the policy effective or renewal date when eligible claim expenses are incurred but not paid until after the effective or renewal date of this policy. All run- in eligible claim expenses paid by us or by your claims administrator must be paid based on the plan in effect during the run-in period and our current standard claim practices. Run -out amount The maximum amount we will pay per covered person as applied towards the annual aggregate Stop Loss corridor for eligible claim expenses incurred during the policy period but paid after the policy period end date. Run -out period The period of time immediately following termination of the policy when eligible claim expenses incurred prior to the termination date are being paid by you. The run -out period will apply only if the same claims administrator administers benefits for the plan during the run -out period. Termination date The date coverage under this policy ends at 11:59 p.m., in accordance with the Termination section. Transplant The transplant of human solid organs, specifically: Heart Heart/lung Lung Double lung Liver • Pancreas • Kidney • Cornea Transplant also includes: • Bone marrow • Peripheral blood stem cell transplant • CAR -T cell therapy • Transfusion • Re -infusion A transplant occurrence is considered to begin at the point of evaluation for a transplant and end either: AL HPol-SL 01 38 CO GE -01 • 365 days from the date of the transplant • On the date the covered person is discharged from the hospital or outpatient facility for the admission or visits related to the transplant, whichever is later AL HPol-SL 01 39 CO GE -01 Hello