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) • Please refer to our specimen Anthem Balanced Funding Agreement and Stop-Loss Agreement for complete details.
• If the group terminated medical coverage with Anthem any surplus remaining after the terminal liability is satisfied will be retained by Anthem. Employer is obligated to pay the Terminal Liability Fund for a complete Policy Period, even if Employer terminates this Policy prior to the end of the Policy Period.
• If the group terminates the Balanced Funding arrangement but remains with Anthem on a fully-insured or ASO arrangement, the group will receive their portion of any surplus available after the terminal liability is satisfied. • Since Anthem is neither a Hawaii authorized insurer nor a Hawaii Health Care Contractor, our benefits may not match the requirements of the Prepaid Health Care Act. We recommend that you obtain direct quotes for either an individual policy for employees who live and work in Hawaii or if there are several employees within an employer group to obtain group coverage from a Hawaii authorized insurer. This would ensure that all the state requirements are met. • Under final rules issued by EEOC under the Americans with Disabilities Act and the Genetic Information Nondiscrimination Act, wellness incentives are subject to certain limits in some situations. Incentive limits may also apply under the Affordable Care Act. Employers are responsible for taking steps to comply with all legally- required incentive limits. Please consult your attorneys or advisors for additional information as needed. • Anthem reserves the right to revise this proposal or modify these fees or rates under any of the following circumstances: - Change in nature of Employer's business - Should the total enrollment or enrollment distribution by membership type, product or location change by 10% or more from that assumed when preparing the pricing for this package - The total number of monthly Subscribers falls below 10 - Due to any taxes, fees and assessments prescribed by any statutory, regulatory or other legal authority, which may bear directly on the financial consequences of this quote - Stop-Loss compliancy under HC-95PC-75 • Employer recognizes and understands that its plan is self-funded and must comply with the required attachment points as defined by state law. Employer may be charged an additional amount upon termination and final settlement of the agreement, where necessary to reflect the liability for minimum attachment points required by applicable law. • Coverage may not be available in all areas. Anthem's ability to offer products and coverage available under plans offered by Anthem may vary by the county or zip code as well as where the group's membership resides. Your broker or account manager can work with you to confirm availability of products offered by Anthem and related service areas. • Anthem Balanced Funding does not allow late enrollees. Once a group has been installed as new business, only qualified events enable a member to join the plan. Any late enrollees will be postponed until renewal. Please make sure all enrollees are submitted prior to installation. • Anthem Balanced Funding Administrative Terms & Conditions: - The cost of drafting and printing standard Enrollment Forms, Claim Forms, ID Cards, drafted Benefit Booklets for soft copy availability and Brochures is included in the administrative fee. Non-standard forms or ID Cards may be subject to an additional fee depending on the complexity of the forms/ID Cards. - Standard Utilization Review services are included in the administrative fee. This includes Pre-admission Review, Second Surgical Opinion, Concurrent Review and Discharge Planning and Personal Case Management. - Electronic eligibility or tape must be in a format acceptable to Anthem systems. - Anthem has elected to reduce the administrative expenses associated with providing benefits rather than passing back the Rx rebates as cash or checks. Crediting the administrative fee allows the group to receive a guaranteed return each month, as opposed to a return that fluctuates due to utilization.
• Anthem Balanced Funding Stop Loss Terms & Conditions: - The Specific Stop-Loss level includes paid Medical and Rx claims.
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