Assumptions and conditions (ABF) Zoe Center for Pediatric and Adolescent Health LLC
Effective June 1, 2025 through May 31, 2026
SIC Code: 8011
Anthem Balanced Funding (ABF) • If subject to regulatory approval, and the applicable regulator has not yet approved, these benefits and rates may need to be adjusted. • HSA/HDHP plan benefits are subject to IRS guidelines and may change. • This proposal assumes that Anthem will be the only Self Funded carrier offered and no fully-insured lives are covered. • The contract is administered on a 12/12 basis in the first year. In the second and subsequent years, the contract will be administered on a paid basis for claims incurred on or after the original effective date, unless quoted otherwise. • Quote expires on the earlier of the effective date or 60 days from the proposal date. • BlueCard fees will be billed as a paid claim with the exception of fees generated from utilization in Anthem states. • A minimum of 75% of net eligible employees must enroll for medical coverage • COBRA enrollees must not exceed 10% of total enrollees. • Anthem's rates as presented herein assume no self-insuring by the employer of underlying member cost shares. The benefits purchased from Anthem must be communicated to the members without modification. A member's financial responsibilities, including but not limited to deductibles, coinsurance, copays, out-of- pocket maximums or, for non-par providers, balance-billed charges must be paid solely by the member. The client may not partially pay, reimburse or otherwise reduce the member's costs of care. Any deviation will require Anthem to reevaluate the quoted rates or rescind the offer of coverage.
• Employer contributions must be a minimum of 50% of the employee's single portion of the premium. • Anthem will be sole administrator.
• Retirees are not eligible for coverage. • The contracts will be issued in Georgia. • This quote is being proposed as an all-inclusive package (Anthem Medical and Rx services). Any deviation from the funding type or benefit/product mix will require a re-evaluation of the entire quote and/or offer of coverage.
• Anthem is entitled to reimbursement of benefits paid if the member recovers damages from a legally liable third party. • The processing of claims incurred prior to the effective date is the responsibility of the prior claims administrator. • Renewal notification will be provided at least 60 days prior to the renewal effective date.
• Quote is contingent of ACH withdraws from group's bank account for claims and fixed fees. Quote is contingent upon the Employer not being delinquent under any Anthem insured or self-funded plan which was in effect at any point in the preceding 12 month period. Employer remains free to apply for any other insured plan for which it qualifies. • Standard Anthem administration, procedures and policies will be in force. • A Business Associate Agreement will need to be signed by the client in the event that this account sells. Failure to sign this document will result in suppression of the Large Claim Reports. • The application must be signed prior to the effective date. • This quote assumes that to the extent ERISA applies, Anthem will accept fiduciary responsibility for claims administration and the handling of the claims complaint and appeals. In addition, to the extent ERISA applies, the employer remains the Named Fiduciary of the plan. • Certain provider fees may be billed as a claims fee PCPM and are excluded from the administrative fee. • For detailed information regarding the plan designs and the administration of benefits, please refer to Anthem's health plan description forms and sample benefit booklets. • All expenses for services or supplies in excess of any limitation under the group's employee benefit program are excluded under the stop-loss program. • Anthem shall retain the difference, if any, between the invoiced amount and the amount paid to the pharmacy benefit manager for prescription drugs dispensed to members as a portion of Anthem's reasonable compensation for services provided. • Anthem Blue Cross relies on the information provided to determine whether a proposal will be issued. The responses are assumed to be correct. If material errors or omissions are found after the quote is issued, Anthem Blue Cross reserves the right to revise or rescind the quote.
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