SAMPLE

PLAN ADMINISTRATION

Plan administrative assumptions with *TPA Administration

Terms and Conditions

●              This proposal is based on the information provided.  Therefore, any significant differences as of the effective date could affect the proposal.  This includes but is not limited to employee locations, group size, enrollment demographics, paid claims, large claims, diagnosis information, benefit plan(s), and PPO vendors.

●              This proposal assumes that group enrollment will be accepted in the file format via electronic download, use of our standard enrollment form, or through our interactive website.

●              Proposal assumes utilization of a prototype plan document and Administrative Services Agreement.

●              Proposal assumes all fixed costs and claim funding will be sent to the TPA via transfer.

●              If the contract administrators continue paying claims on a run-out basis after termination of the plan, the following will apply:

a)            The administration charge in effect at the time of termination will apply, but in no instance will the medical administration charge be less than $16.00 per employee, per month.

b)            The monthly administration charge will be billed for three (3) months and is payable as of the termination date.

c)            The contract administrator will process all run-out claims for six (6) months after the termination date.

d)            After the six-month run-out period, any claim presented to the TPA for payment will be processed at $35 per EOB.  If a Terminal Liability Option (TLO) is illustrated, this cost is included.

●              The TPA will not be held liable for typographical or clerical errors that may be contained in this proposal.

Stop-loss carrier assumptions

Terms and Conditions

●              Minimum attachment point: [100% of A.A.A.P.]

●              Participation requirements established by the reinsurance carriers must be met.

●              All quotes are contingent upon completion and approval of a claim disclosure statement, and all quotes are subject to revision pending receipt and approval of initial paid claims for the current plan year, including details on all claims in excess of 50% of the specific deductible, ongoing claims, and any large or potentially large claims.

●              This proposal assumes that there are no ongoing medical conditions.

●              Monthly paid claims, including monthly enrollments to the effective date, are required.

●              Diagnosis and prognosis of all large claims is required.

PPO Assumptions

Preferred Provider Organization (PPO) terms and conditions

●              Quoted terms are based on the use of the agreed Network.  An alternative network may require a revision in the terms quoted due to the variations in the discounts given by the carriers for different PPO networks.

●              The programs Web site contains many links to the PPO directories at no additional charge.

●              The PPO reserves the right to amend their access fee during the plan year.   Should this occur, the program will provide the plan with notice of the increase thirty (30) days prior to its effective date.

●          Costs reflected in this proposal do not include the cost of PPO directories, which is the responsibility of the employer.