Zoe Center for Pediatric and Adolescent Health, LLC
Proposal Terms & Conditions: Level Funding Q3P2 Triple Option
A.
General Terms of this Proposal Cigna Healthcare is pleased to present this Proposal for an Administrative Services Only group Medical, Pharmacy, Behavioral Health benefit plan (the ""Plan"") sponsored by Zoe Center for Pediatric and Adolescent Health, LLC. This proposal is valid for 60 days from its original date of release, 03/26/2025. Any revisions or updates to this proposal will not renew this valid timeframe unless expressly communicated by Cigna Healthcare.
Proposal Caveats Cigna Healthcare may revise or withdraw this Proposal if: 1. there is a change to the effective date and/or duration of the period covered by the quote. 2. the policy will not be sitused in GA. 3. the group size differs from what was presumed at the time of quote based upon confirmation of employer group status on a State definition of small or large employer group, as applicable. 4. enrollment in the Cigna Healthcare administered plan is less than 50% of the total eligible population identified as 186. 5. the final enrollment deviates from the quoted enrollment, by product or for total account, such that it results in a needed change in rates. Rates are based on final enrollment factors, including total number of enrollees, their age, sex, demographics, location and the distribution of enrollees by product or by customer tier. 6. requires you to notify us within 30 days if any of the information upon which these rates or benefits were based (including Medical History Information) changes or is inaccurate. 7. it is not the exclusive provider of Medical , Pharmacy, Vision or like products for all of Zoe Center for Pediatric and Adolescent Health, LLC's employees in all worksites. 8. benefit advisor fees/commissions are requested to be different than $40.00 PEPM. 9. By way of illustration, such legislation or executive actions which impose controls or requirements that affect: our ability to determine rates; covered medical expenses or service benefits; providers' delivery of care or the fees they charge; or our contracts with providers, may be deemed to so affect our contractual obligations. Should this happen, Cigna Healthcare will make a good faith effort to work to reach a new agreement that equitably reflects the circumstances as altered by government action. 10. there is any reimbursement arrangement ("gap" cards, etc.) that subsidizes or reduces the out-of-pocket obligation of covered persons under the policy. 11. This proposal made by Cigna Healthcare is contingent upon: ● Cigna Healthcare's receipt of the following information: -Completed medical history questionnaire 30 days prior to the policy effective date. ● Cigna reserves the right to revise or withdraw this proposal if the required medical questionnaire is not received 30 days prior to the policy effective date. B. Scope and Application of this Proposal Unless otherwise indicated, the coverage reflected in this Proposal: 1. assumes that any insurance policy, certificate/booklet, or summary plan description material will be made available to the policyholder electronically. 2. supersedes and renders null and void any prior Cigna Healthcare offer or proposal with respect to the Plan. 3. reflects the claims and administrative savings realized by packaging the following specialty coverage with Medical: Pharmacy, Cigna Total Behavioral Advantage. 4. includes Cigna's One Guide digital and customer guidance solution. 5. does not apply to part-time or seasonal employees for any plan. 6. does not apply to Medicare eligible retirees for any plan. 7. includes Cigna's Network Savings Program (NSP) and other Cost Containment programs designed to contain costs with respect to charges for out-of- network health care services/supplies that are covered by the Plan and reduce the member's balance billing exposure. For administering these programs, Cigna retains a portion of the savings or recoveries generated. 8. includes a maximum reimbursable charge (MRC) for out-of-network coverage equal to 110.0% of a fee schedule developed by Cigna Healthcare based upon a methodology similar to that used by Medicare to determine the allowable fee for similar services in the geographic market OR, where that fee schedule does not provide a value, Cigna may determine the MRC based on a rate for the same or similar service or supply by applying a Medicare-based methodology that Cigna deems appropriate. 9. does not include administration of "run out" claims incurred prior to the effective date. 10. Notwithstanding the foregoing guarantee, Cigna may revise any charges at any time if Cigna is (i) required to pay any tax or assessment, or (ii) incur additional costs in administering the contract as a result of any state or federal law. 11. assumes that Cigna is selected as the carrier for both Aggregate and Individual Stop Loss for a 12 month policy period. 12. includes Rx claims for the Aggregate Stop Loss coverage and includes RX claims for the Individual Stop Loss coverage. 13. reflects that the ISL Maximum mirrors the underlying medical plan maximum. 14. assumes 136 covered employees on the Stop Loss quote. 15. assumes that the Stop Loss contract covers claims incurred since policy inception and are paid during the current policy year. The paid period will be extended in the year of termination to include the 15 months immediately following. 16. assumes Cigna Healthcare's standard Services Agreement will be used and executed before the effective date of Cigna Healthcare providing administrative services. 17. assumes that administrative fee (excluding Incentive Programs) will be paid from the Plan Bank Account. 18. assumes that Incentive Program debit/gift card rewards will be funded by the client and will be direct billed or withdrawn from the bank account (as applicable). 19. includes charges made by either a specialty vendor or an affiliate, such as eviCore for care management programs to contain the cost of specific health services/items and/or improve adherence to evidence-based guidelines to promote patient safety and efficient care (i.e., charges for management of diagnostic cardiology, radiation therapy, musculoskeletal procedures, medical oncology, gastroenterology, sleep management and home health/DME/HIT and appropriate setting of care/service) when applicable, and medical necessity review (i.e chiropractic services). 20. includes Cigna Pathwell Specialty, a network solution for medical specialty drugs. 21. Includes Cigna Pathwell Bone & Joint℠, a clinical navigation, benefit, and network solution for musculoskeletal care.
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