KEYSTONE 65 HMO GROUP MEDICARE …

1 KS65 HMOgrpMActrt_031011 KEYSTONE 65 HMO GROUP MEDICARE advantage contract effective as of EFF. DATE by and between GROUP NAME (Called the GROUP ) GROUP Number: GROUP # and KEYSTONE HEALTH PLAN EAST (Called the Plan) a Pennsylvania corporation whose address is 1901 Market Street, Philadelphia, PA 19103 KS65 HMOgrpMActrt_031011 KEYSTONE 65 HMO GROUP MEDICARE advantage contract TABLE OF CONTENTS SECTION TITLE PAGE NUMBERS GA GROUP APPLICATION 3 AC ACCEPTANCE 4 SE SCHEDULE OF ELIGIBILITY 5 EN ENROLLMENT AND DISENROLLMENT 5 TE TERMINATIONS 7 PR PREMIUM RATES AND BILLING 9 PD MEDICARE PRESCRIPTION DRUG COVERAGE 11 GP GENERAL PROVISIONS 11 EV MEMBER EVIDENCE OF COVERAGE 14 3 KS65 HMOgrpMActrt_031011 SECTION GA GROUP APPLICATION is hereby made to KEYSTONE HEALTHPLAN EAST (Called the Plan) whose main office address is 1901 Market Street, Philadelphia, PA l9l03 By GROUP NAME (Called the GROUP )

2 Whose main office address is GROUP ADDRESS For the coverage afforded by GROUP contract Number(s) in Section SE, the terms of which are hereby approved and accepted by the GROUP to take effect on the contract Date specified in this GROUP contract . It is agreed that this Application supersedes any previous Application for this contract . 4 KS65 HMOgrpMActrt_031011 SECTION AC ACCEPTANCE IN CONSIDERATION OF the GROUP Application and the payment of premiums when due and subject to all terms of this contract . KEYSTONE HEALTH PLAN EAST (Called the Plan) hereby agrees to provide each Enrollee of GROUP NAME (Called the GROUP ) GROUP contract NUMBER GROUP # The benefits of this contract as set forth in the attached KEYSTONE 65 HMO Member Evidence of Coverage beginning on each Enrollee's Effective Date. The GROUP 's contract Date is EFF.

3 DATE and the contract will continue until December 31, when, unless terminated as provided by this contract , it will renew for a further period of twelve (12) consecutive months and thereafter, from year to year. The Plan accepts the Application of the GROUP at its Home Office in Philadelphia, Pennsylvania (which is the State of Issue). The GROUP may accept this contract by making required payments to the Carrier. Such acceptance renders all terms and conditions hereof binding on the Carrier and the GROUP . Date: CURRENT DATE 5 KS65 HMOgrpMActrt_031011 SECTION SE SCHEDULE OF ELIGIBILITY A. SUBSIDIARY OR AFFILIATED UNITS OF THE GROUP The subsidiary or affiliated unit included under this contract is GROUP number: GROUP #. B. ELIGIBLE ENROLLEE 1. Eligible Enrollee is a GROUP retiree or employee of a GROUP under twenty (20) who (a) is eligible for the GROUP s benefit plan, (b) is entitled to MEDICARE benefits under MEDICARE Part A and enrolled in MEDICARE Part B, (c) lives in Plan s service area, (d) has not been medically determined to have end-stage renal disease unless the Enrollee meets the allowed exceptions under CMS guidance or federal law, and (e) who is listed on the completed Application provided by the Plan.

4 2. Eligible Enrollee may also be a dependent of an Enrollee described above, provided that the dependent (a) is eligible for the GROUP s benefit plan, (b) is entitled to MEDICARE benefits under MEDICARE Part A and enrolled in MEDICARE Part B, (c) lives in Plan s service area, and (d) has not been medically determined to have end-stage renal disease (unless an exception under 42 (a)(2)(i) (iii) applies). 3. Eligible Enrollees who are converting to MEDICARE Parts A and B (also known as out-of-area age-ins ) may enroll in KEYSTONE 65 HMO during their Initial Coverage Election Period, even if they reside outside the service and continuation area, provided that the Eligible Enrollee is converting from KEYSTONE commercial coverage and CMS access requirements are met under 42 SECTION EN- ENROLLMENT AND DISENROLLMENT A. ENROLLMENT The GROUP acknowledges that its eligible enrollees are enrolling in a MEDICARE advantage or MEDICARE advantage -Prescription Drug Plan and that an enrollment application form must be completed by each enrollee.

5 B. ENROLLMENT FOR PLAN OPTION CHANGES For GROUP Plan Option Changes the GROUP is responsible for maintaining all records in a manner that can be easily, accurately and quickly reproduced. The GROUP must ensure that the required data elements are included in the electronic Plan Change. The GROUP or the Plan, as mutually agreed upon, will provide each member with written notification at least twenty-one (21) days prior to the effective date as follows: 6 KS65 HMOgrpMActrt_031011 1. Notification that the GROUP intends to enroll the individual in KEYSTONE 65 HMO, (a MEDICARE advantage or a MEDICARE advantage Prescription Drug) plan that the GROUP is offering. 2. Notification that the individual may affirmatively opt out of the enrollment, the process to opt-out and any consequences of opting out under the GROUP s eligibility guidelines.

6 3. Information on the Schedule of Copayments and Limitations, an explanation of how to get more information on the KEYSTONE 65 HMO plan, and an explanation on how to contact MEDICARE for information on other MEDICARE health plan options that may be available to the individual. 4. Information under the heading Read & Sign Below contained in the Employer/Union GROUP Health Plan Enrollment/Election Form. C. VOLUNTARY ENROLLEE DISENROLLMENT Paper Disenrollment. The GROUP must inform members that if they wish to voluntarily disenroll from coverage, the member must complete a disenrollment form or other written request and submit the signed form or request prior to the requested effective date of disenrollment. D. INVOLUNTARY TERMINATION OF ENROLLEE COVERAGE The GROUP agrees to report to the Plan any involuntary termination of an Enrollee s coverage ( , if the GROUP determines an Enrollee is no longer eligible to participate in the plan) within thirty (30) days of termination of Enrollee s coverage.

7 The notification must be prospective (prior to the effective date of termination) and include information used to identify the correct member, the requested date of disenrollment, the designation that the disenrollment is involuntary, the reason for the disenrollment and the contact information and signature of the GROUP administrator sending the request. The GROUP or the Plan, as mutually agreed upon, will provide the Enrollee with advance notice of the termination at a minimum twenty-one (21) calendar days prior to the effective date of disenrollment. The notification must include all of the following components: 1. Notification of the Involuntary Termination. 2. Notice of other insurance options through the Plan. 3. Reason for the termination. 4. Information on other individual plan options the beneficiary may choose and how to request enrollment.

8 7 KS65 HMOgrpMActrt_031011 5. Notification that the disenrollment means that the individual, if applicable, will not have MEDICARE advantage Prescription Drug coverage and the potential for late-enrollment penalties in the future. 6. Explanation on how to contact MEDICARE for more information about other MEDICARE advantage plan options that might be available to the individual. E. TIMELY SUBMISSIONS OF ENROLLMENT/DISENROLLMENT REQUESTS The GROUP must submit enrollment and/or disenrollment requests within seven (7) days of receipt. SECTION TE TERMINATION A. PLAN INITIATED TERMINATION OF THE GROUP contract This contract is guaranteed renewable and cannot be cancelled as a result of the claims experience or health status of your GROUP . The Plan can, however, cancel or fail to renew this contract for the following reasons: 1.

9 GROUP 's nonpayment of premiums, subject to the following conditions: (a) Grace Period: This contract has a grace period of thirty (30) days. This means that if a payment is not made on or before the date it is due, it may be paid during the grace period. During the grace period the contract will stay in force unless prior to the date payment was due the GROUP gave timely written notice to the Plan that the contract is to be cancelled. (b) If the GROUP does not make payment during the grace period, the contract will be cancelled effective on the last day of the grace period and the Plan will have no liability for services which are incurred after the grace period. The GROUP will be required to reimburse the Plan for all outstanding premiums including the premium for the grace period. 2. For fraud or misrepresentation by the GROUP with respect to eligibility for coverage or any other material fact; 3.

10 When the GROUP has failed to comply with a material plan provision relating to employer contribution or GROUP participation rules; 4. Termination or non-renewal of the CMS contract . The Plan will provide at least ninety (90) days notice. CMS requires the Plan to terminate this contract upon termination or non-renewal of the CMS contract . The Plan will provide the GROUP ninety (90) days notice before the Plan non-renews the Centers for MEDICARE and Medicaid Services 8 KS65 HMOgrpMActrt_031011 (CMS) contract and thereby terminates this contract . Plan will provide the GROUP as much notice as reasonably practical of CMS s termination or non-renewal of the CMS contract . The notice will include the termination date for this contract . The GROUP or the Plan, as mutually agreed upon, will provide each member written notification at least twenty-one (21) days prior to the effective date of cancellation.