Common use of Liability Calculation Method Per Claim Clause in Contracts

Liability Calculation Method Per Claim. In General Member Liability Calculation Unless subject to a fixed dollar copayment, the calculation of the member liability on claims for covered healthcare services will be based on the lower of the participating provider's billed covered charges or the negotiated price made available to Florida Blue by the Host Blue. Employer Liability Calculation The calculation of Employer liability on claims for covered healthcare services processed through the BlueCard Program will be based on the negotiated price made available to Florida Blue by the Host Blue (under the contract between the Host Blue and the provider). Sometimes, this negotiated price may be greater for a given service or services than the billed charge in accordance with how the Host Blue has negotiated with its participating healthcare provider(s) for specific healthcare services. In cases where the negotiated price exceeds the billed charge, Employer may be liable for the excess amount even when the member’s deductible has not been satisfied. This excess amount reflects an amount that may be necessary to secure (a) the provider’s participation in the network and/or (b) the overall discount negotiated by the Host Blue. In such a case, the entire contracted price is paid to the provider, even when the contracted price is greater than the billed charge. Claims Pricing Host Blues determine a negotiated price, which is reflected in the terms of each Host Blue’s provider contracts. The negotiated price made available to Florida Blue by the Host Blue may be represented by one of the following: • An actual price. An actual price is a negotiated rate of payment in effect at the time a claim is processed without any other increases or decreases; or • An estimated price. An estimated price is a negotiated rate of payment in effect at the time a claim is processed, reduced or increased by a percentage to take into account certain payments negotiated with the provider and other claim- and non-claim-related transactions. Such transactions may include, but are not limited to, anti-fraud and abuse recoveries, provider refunds not applied on a claim-specific basis, retrospective settlements and performance related bonuses or incentives; or • An average price. An average price is a percentage of billed covered charges in effect at the time a claim is processed representing the aggregate payments negotiated by the Host Blue with all of its healthcare providers or a similar classification of its providers and other claim- and non-claim- related transactions. Such transactions may include the same ones as noted above for an estimated price. The Host Blue determines whether it will use an actual, estimated or average price. The use of estimated or average pricing may result in a difference (positive or negative) between the price Employer pays on a specific claim and the actual amount the Host Blue pays to the provider. However, the BlueCard Program requires that the amount paid by the member and Employer is a final price; no future price adjustment will result in increases or decreases to the pricing of past claims. Any positive or negative differences in estimated or average pricing are accounted for through variance accounts maintained by the Host Blue and are incorporated into future claim prices. As a result, the amounts charged to Employer will be adjusted in a following year, as necessary, to account for over- or underestimation of the past years’ prices. The Host Blue will not receive compensation from how the estimated price or average price methods, described above, are calculated. Because all amounts paid are final, neither positive variance account amounts (funds available to be paid in the following year), nor negative variance amounts (the funds needed to be received in the following year), are due to or from Employer. If Employer terminates, you will not receive a refund or charge from the variance account. Variance account balances are small amounts relative to the overall paid claims amounts and will be liquidated over time. The timeframe for their liquidation depends on variables, including, but not limited to, overall volume/number of claims processed and variance account balance. Variance account balances may earn interest at the federal funds or similar rate. Host Blues may retain interest earned on funds held in variance accounts. BlueCard Program Fees and Compensation Employer understands and agrees to reimburse Florida Blue for certain fees and compensation which Florida Blue is obligated under the BlueCard Program to pay to the Host Blues, to the Association and/or to vendors of BlueCard Program related services. The specific BlueCard Program fees and compensation that are charged to Employer are set forth in Exhibit B. BlueCard Program Fees and compensation may be revised from time to time. Only the BlueCard Program access fee may be charged separately each time a claim is processed through the BlueCard Program. All other BlueCard Program related fees are included in the Administrative Fee. The access fee is charged by the Host Blue to Florida Blue for making its applicable provider network available to Employer’s. The access fee will not apply to non-participating provider claims. The access fee is charged on a per claim basis and is charged as a percentage of the discount/differential Florida Blue receives from the applicable Host Blue subject to a maximum of $2,000 per claim. When charged, Florida Blue passes the access fee directly on to Employer. Instances may occur in which the claim payment is zero or Florida Blue pays only a small amount because the amounts eligible for payment were applied to patient cost sharing (such as a deductible or coinsurance). In these instances, Florida Blue will pay the Host Blue’s access fee and pass it along directly to Employer as stated above even Employer paid little or had no claim liability. An Administrative Fee encompasses fees Florida Blue charges to Employer for administering Employer’s benefit plan. They may include both local (within Florida Blue’s service area) and Inter-Plan fees. For purposes of this Agreement, they include the following BlueCard Program related fees other than the BlueCard Program access fee: namely, administrative expense allowance (AEA) fee, central financial agency fee, ITS transaction fee, toll free number fee, PPO provider directory fee and Blue Cross Blue Shield Global® Core Program Fees, if applicable. Special Cases: Value-Based Programs Value-Based Programs Definitions Accountable Care Organization (ACO): A group of healthcare providers who agree to deliver coordinated care and meet performance benchmarks for quality and affordability in order to manage the total cost of care for their member populations. Global Payment/Total Cost of Care: A payment methodology that is defined at the patient level and accounts for either all patient care or for a specific group of services delivered to the patient such as outpatient, physician, ancillary, hospital services and prescription drugs. Patient-Centered Medical Home (PCMH): A model of care in which each patient has an ongoing relationship with a primary care physician who coordinates a team to take collective responsibility for patient care and, when appropriate, arranges for care with other qualified physicians.

Liability Calculation Method Per Claim. In General Member Liability Calculation Unless subject to a fixed dollar copayment, the The calculation of the member Member liability on claims for covered healthcare services Covered Services processed through the BlueCard Program will be based on the lower of the participating providerProvider's billed covered charges or the negotiated price made available to Florida Blue Us by the Host Blue. Employer Liability Calculation The calculation of Employer liability on claims for covered healthcare services processed through the BlueCard Program will be based on the negotiated price made available to Florida Blue by the Host Blue (under the contract between the Host Blue and the provider). Sometimes, this negotiated price may be greater for a given service or services than the billed charge in accordance with how the Host Blue has negotiated with its participating healthcare provider(s) for specific healthcare services. In cases where the negotiated price exceeds the billed charge, Employer may be liable for the excess amount even when the member’s deductible has not been satisfied. This excess amount reflects an amount that may be necessary to secure (a) the provider’s participation in the network and/or (b) the overall discount negotiated by the Host Blue. In such a case, the entire contracted price is paid to the provider, even when the contracted price is greater than the billed charge. Claims Pricing Host Blues may use various methods to determine a negotiated price, which is reflected in depending on the terms of each Host Blue’s provider health care Provider contracts. The negotiated price made available to Florida Blue Us by the Host Blue may be represented represent a payment negotiated by a Host Blue with a health care Provider that is one of the following: • An actual price. An actual price is a negotiated rate of payment in effect at the time a claim is processed without any other increases or decreases; , or • An estimated price. An estimated price is a negotiated rate of payment in effect at the time a claim is processed, reduced or increased by a percentage to take into account certain payments negotiated with the provider Provider and other claim- and non-claim-related transactions. Such transactions may include, but are not limited to, anti-fraud and abuse recoveries, provider Provider refunds not applied on a claim-specific basis, retrospective settlements settlements, and performance performance-related bonuses or incentives; or • An average price. An average price is a percentage of billed covered charges in effect at the time a claim is processed representing the aggregate payments negotiated by the Host Blue with all of its healthcare providers health care Providers or a similar classification of its providers Providers and other claim- and non-claim- claim-related transactions. Such transactions may include the same ones as noted above for an estimated price. The Host Blue determines whether it will use Blues using either an actualestimated price or an average price may, estimated in accordance with Inter-Plan Programs policies, prospectively increase or average price. The use reduce such prices to correct for over- or underestimation of estimated past prices (i.e., prospective adjustments may mean that a current price reflects additional amounts or average pricing may result in a difference (positive credits for claims already paid to Providers or negative) between the price Employer pays on a specific claim and the actual amount the Host Blue pays anticipated to the providerbe paid to or received from Providers). However, the BlueCard Program requires that the amount paid by the member and Employer Member is a final price; no future price adjustment will result in increases or decreases to the pricing of past claims. Any positive or negative differences in The BlueCard Program requires that the price submitted by a Host Blue to Us is a final price irrespective of any future adjustments based on the use of estimated or average pricing pricing. In some instances federal law or the laws of a small number of states may require Host Blues either (i) to use a basis for determining Member liability for covered medical expenses that does not reflect the entire savings realized, or expected to be realized, on a particular claim or (ii) to add a surcharge. Should either federal law or the law of the state in which health care services are accounted for through variance accounts maintained by accessed mandate liability calculation methods that differ from the negotiated price methodology or require a surcharge, We would then calculate Member liability in accordance with applicable law. Return of Overpayments Under the BlueCard Program, recoveries from a Host Blue and are incorporated into future claim prices. As a result, the amounts charged to Employer will be adjusted or its participating Providers can arise in a following year, as necessary, to account for over- or underestimation of the past years’ prices. The Host Blue will not receive compensation from how the estimated price or average price methods, described above, are calculated. Because all amounts paid are final, neither positive variance account amounts (funds available to be paid in the following year), nor negative variance amounts (the funds needed to be received in the following year), are due to or from Employer. If Employer terminates, you will not receive a refund or charge from the variance account. Variance account balances are small amounts relative to the overall paid claims amounts and will be liquidated over time. The timeframe for their liquidation depends on variablesseveral ways, including, but not limited to, overall volumeanti-fraud and abuse recoveries, health care Provider/number Hospital audits, credit balance audits, utilization review refunds, and unsolicited refunds. In some cases, the Host Blue will engage a third party to assist in identification or collection of claims processed and variance account balancerecovery amounts. Variance account balances The fees of such a third party may earn interest at be netted against the federal funds recovery. Recovery amounts determined in this way will be applied in accordance with applicable Inter-Plan Programs policies, which generally require correction on a claim-by-claim or similar rateprospective basis. Host Blues may retain interest earned on funds held in variance accounts. BlueCard Program Fees and Compensation Employer understands and agrees Negotiated National Account Arrangements As an alternative to reimburse Florida Blue for certain fees and compensation which Florida Blue is obligated under the BlueCard Program Program, the Member’s claim for Covered Services may be processed through a negotiated national account arrangement with a Host Blue. If We have arranged for (a) Host Blue(s) to pay to make available (a) custom health care Provider network(s) in connection with this Contract, then the Host Blues, to the Association and/or to vendors of BlueCard Program related services. The specific BlueCard Program fees terms and compensation that are charged to Employer are conditions set forth in Exhibit B. BlueCard Program Fees and compensation may Our negotiated national account arrangements with such Host Blue(s) shall apply. Member liability calculation will be revised from time based on the lower of either billed covered charges or negotiated price (refer to time. Only the BlueCard Program access fee may be charged separately each time a claim is processed through the BlueCard Program. All other BlueCard Program related fees are included in the Administrative Fee. The access fee is charged description of negotiated price above) made available to Us by the Host Blue that allows Members access to Florida Blue for making its applicable provider network available to Employer’snegotiated participation agreement networks of specified Participating Providers outside of Our service area. The access fee will not apply to non-participating provider claims. The access fee is charged on a per claim basis and is charged as a percentage of the discount/differential Florida Blue receives from the applicable Host Blue subject to a maximum of $2,000 per claimNonparticipating Providers Outside Our Service Area • Member Liability Calculation. When chargedCovered Services are provided outside of Our service area by nonparticipating Providers, Florida Blue passes the access fee directly amount(s) a Member pays for such services will generally be based on to Employer. Instances may occur in which the claim payment is zero or Florida Blue pays only a small amount because the amounts eligible for payment were applied to patient cost sharing (such as a deductible or coinsurance). In these instances, Florida Blue will pay either the Host Blue’s nonparticipating Provider local payment or the pricing arrangements required by applicable state law. In these situations, the Member may be responsible for the difference between the amount that the nonparticipating Provider bills and the payment We will make for the Covered Services as set forth in this paragraph. • Exceptions. In some exception cases, We may pay claims from nonparticipating Providers outside of Our service area based on the Provider’s billed charge, such as in situations where a Member did not have reasonable access fee and pass it along directly to Employer a participating Provider, as stated above even Employer paid little determined by Us or had no by applicable state law. In other exception cases, We may pay such a claim liability. An Administrative Fee encompasses fees Florida Blue charges to Employer for administering Employer’s benefit plan. They may include both local (within Florida based on the payment We would make if We were paying a nonparticipating Provider inside of Our service area, as described elsewhere in this Contract, where the Host Blue’s corresponding payment would be more than Our in-service area) area nonparticipating Provider payment, or We may negotiate a payment with such a Provider on an exception basis. In any of these exception situations, the Member may be responsible for the difference between the amount that the nonparticipating Provider bills and Interpayment We will make for the Covered Services as set forth in this paragraph. GENERAL PROVISIONS Group Responsibilities The Group agrees to the following: • Handle and distribute enrollment materials in a timely manner and promptly provide to Us the information necessary to administer this Contract. There is an understanding and agreement that the Group's failure to provide information in a timely manner may substantially delay and/or jeopardize the enrollment of eligible Members. • Restrict enrollment and payment of premiums through the Group to eligible Members. • Make payroll deductions for and verify with Us the eligibility of any Member on a temporary leave of absence. • Remit premiums for a terminating Member through the end of the monthly coverage period in which the Member terminates (except as provided under Refund of Premiums), unless otherwise agreed in advance in writing. • Delete terminations from the billing and to notify Us of terminations in a timely manner and as part of the administrative record-Plan feeskeeping process that occurs in the normal course of business. For purposes The Group further agrees that any refund of the number of months of premiums paid by the Group in error or for an ineligible Member shall be made only if claims have not been paid. • Provide each Member 30 days prior written notice of termination of this AgreementContract, they include the following BlueCard Program related fees other than the BlueCard Program access fee: namely, administrative expense allowance (AEA) fee, central financial agency fee, ITS transaction fee, toll free number fee, PPO provider directory fee and Blue Cross Blue Shield Global® Core Program Fees, if applicable. Special Cases: Value-Based Programs Value-Based Programs Definitions Accountable Care Organization (ACO): A group of healthcare providers who agree to deliver coordinated care and meet performance benchmarks for quality and affordability in order to manage the total cost of care for their member populations. Global Payment/Total Cost of Care: A payment methodology that is defined at the patient level and accounts for either all patient care or for a specific group of services delivered including any termination due to the patient Group's failure to pay premiums. • Notify each Member of any right(s) that may exist to continue coverage upon termination, as provided by any applicable law or as otherwise described in the Booklet, and collect and forward associated timely enrollment forms and premiums. • Provide those notices, in a timely manner, that a group health plan is required by law to provide (e.g., notices of a plan's preexisting condition exclusion or special enrollment rights provisions). The Group agrees to indemnify and hold Us harmless from any damages, loss, action, claim or suit (including court costs and attorney's fees) arising from or related to its failure to provide such legally-required notices. • Report monthly the names of new Members, cancelled Members and Members electing any statutory continuance of coverage. • Maintain workers' compensation coverage for all Members, as outpatientrequired by law. • Maintain Group eligibility in accordance with the minimum standards of applicable statutory continuances of coverage, physicianunless We have agreed in advance and in writing to the Group's use of standards more generous to Members. • If We provide Our enrollment and/or change forms ("Forms") and/or any summary plan descriptions, ancillarybenefit summaries and/or comparison sheets ("Documents") in an electronic medium for inclusion on the Group's internal intranet or by similar means, hospital services Group agrees that: - electronic access shall be limited to the Group's enrolling employees and prescription drugs. Patientcovered employees and be restricted to a "read-Centered Medical Home only" or similar basis; - they will replace any hard-copy Forms that have been modified by Us; - the hard-copy documents on file with Us shall control in the event of any discrepancy; and - the Group remains solely responsible for the content of the documents and all other legal requirements pertaining to them (PCMH): A model of care in which each patient has an ongoing relationship with a primary care physician who coordinates a team to take collective responsibility for patient care ande.g., when appropriate, arranges for care with other qualified physiciansdistribution).

Liability Calculation Method Per Claim. In General Member Liability Calculation Unless subject to a fixed dollar copayment, the The calculation of the member liability on claims for covered healthcare services will be based on the lower of the participating provider's billed covered charges or the negotiated price made available to Florida Blue by the Host Blue. Employer Liability Calculation The calculation of Employer Member liability on claims for covered healthcare services processed through the BlueCard Program Program, if not a flat dollar Copayment, will be based on the lower of: the provider’s billed covered charges for covered services; or the negotiated price made available to Florida Blue by the Host Blue (under the contract between the Host Blue and the provider). Sometimes, this negotiated price may be greater for a given service or services than the billed charge in accordance with how the Host Blue has negotiated with its participating healthcare provider(s) for specific healthcare services. In cases where the negotiated price exceeds the billed charge, Employer may be liable for the excess amount even when the member’s deductible has not been satisfied. This excess amount reflects an amount that may be necessary to secure (a) the provider’s participation in the network and/or (b) the overall discount negotiated Plan by the Host Blue. In such a case, the entire contracted price is paid to the provider, even when the contracted price is greater than the billed charge. Claims Pricing Host Blues may use various methods to determine a negotiated price, which is reflected in depending upon the terms of each Host Blue’s healthcare provider contracts. The negotiated price made available to Florida Blue the Plan by the Host Blue may be represented represent a payment negotiated by a Host Blue with a healthcare provider that is one of the following: • An an actual price. An actual price is a negotiated rate of payment in effect at the time a claim is processed without any other increases or decreases; or • An an estimated price. An estimated price is a negotiated rate of payment in effect at the time a claim is processed, reduced or increased by a percentage to take into account certain payments negotiated with the provider and other claim- and non-claimnonclaim-related transactions. Such transactions may include, but are not limited to, anti-fraud and abuse recoveries, provider refunds not applied on a claim-specific basis, retrospective settlements settlements, and performance performance-related bonuses or incentives; or • An an average price. An average price is a percentage of billed covered charges in effect at the time a claim is processed representing the aggregate payments negotiated by the Host Blue with all of its healthcare providers or a similar classification of its providers and other claim- and non-claim- claim-related transactions. Such transactions may include the same ones as noted above for an estimated price. The Host Blue determines whether it will use Blues using either an actualestimated price or an average price may, estimated in accordance with Inter-Plan Programs policies, prospectively increase or average price. The use reduce such prices to correct for over- or underestimation of estimated past prices (i.e., prospective adjustments may mean that a current price reflects additional amounts or average pricing may result in a difference (positive credits for claims already paid to providers or negative) between the price Employer pays on a specific claim and the actual amount the Host Blue pays anticipated to the providerbe paid to or received from providers). However, the BlueCard Program requires that the amount paid by the member and Employer Member is a final price; no future price adjustment will result in increases or decreases to the pricing of past claims. Any positive or negative differences in The BlueCard Program requires that the price submitted by a Host Blue to the Plan is a final price irrespective of any future adjustments based on the use of estimated or average pricing are accounted for through variance accounts maintained by the pricing. A small number of states require a Host Blue and either: to use a basis for determining Member liability for covered healthcare services that does not reflect the entire savings realized, or expected to be realized, on a particular claim; or to add a surcharge. Should the state in which healthcare services are incorporated into future claim prices. As accessed mandate liability calculation methods that differ from the negotiated price methodology or require a resultsurcharge, the amounts charged to Employer will be adjusted Plan would then calculate Member liability in a following year, as necessary, to account for over- or underestimation of the past years’ prices. The Host Blue will not receive compensation from how the estimated price or average price methods, described above, are calculated. Because all amounts paid are final, neither positive variance account amounts (funds available to be paid in the following year), nor negative variance amounts (the funds needed to be received in the following year), are due to or from Employer. If Employer terminates, you will not receive a refund or charge from the variance account. Variance account balances are small amounts relative to the overall paid claims amounts and will be liquidated over time. The timeframe for their liquidation depends on variables, including, but not limited to, overall volume/number of claims processed and variance account balance. Variance account balances may earn interest at the federal funds or similar rate. Host Blues may retain interest earned on funds held in variance accounts. BlueCard Program Fees and Compensation Employer understands and agrees to reimburse Florida Blue for certain fees and compensation which Florida Blue is obligated under the BlueCard Program to pay to the Host Blues, to the Association and/or to vendors of BlueCard Program related services. The specific BlueCard Program fees and compensation that are charged to Employer are set forth in Exhibit B. BlueCard Program Fees and compensation may be revised from time to time. Only the BlueCard Program access fee may be charged separately each time a claim is processed through the BlueCard Program. All other BlueCard Program related fees are included in the Administrative Fee. The access fee is charged by the Host Blue to Florida Blue for making its accordance with applicable provider network available to Employer’s. The access fee will not apply to non-participating provider claims. The access fee is charged on a per claim basis and is charged as a percentage of the discount/differential Florida Blue receives from the applicable Host Blue subject to a maximum of $2,000 per claim. When charged, Florida Blue passes the access fee directly on to Employer. Instances may occur in which the claim payment is zero or Florida Blue pays only a small amount because the amounts eligible for payment were applied to patient cost sharing (such as a deductible or coinsurance). In these instances, Florida Blue will pay the Host Blue’s access fee and pass it along directly to Employer as stated above even Employer paid little or had no claim liability. An Administrative Fee encompasses fees Florida Blue charges to Employer for administering Employer’s benefit plan. They may include both local (within Florida Blue’s service area) and Inter-Plan fees. For purposes of this Agreement, they include the following BlueCard Program related fees other than the BlueCard Program access fee: namely, administrative expense allowance (AEA) fee, central financial agency fee, ITS transaction fee, toll free number fee, PPO provider directory fee and Blue Cross Blue Shield Global® Core Program Fees, if applicable. Special Cases: Value-Based Programs Value-Based Programs Definitions Accountable Care Organization (ACO): A group of healthcare providers who agree to deliver coordinated care and meet performance benchmarks for quality and affordability in order to manage the total cost of care for their member populations. Global Payment/Total Cost of Care: A payment methodology that is defined at the patient level and accounts for either all patient care or for a specific group of services delivered to the patient such as outpatient, physician, ancillary, hospital services and prescription drugs. Patient-Centered Medical Home (PCMH): A model of care in which each patient has an ongoing relationship with a primary care physician who coordinates a team to take collective responsibility for patient care and, when appropriate, arranges for care with other qualified physicianslaw.

Liability Calculation Method Per Claim. In General Member Liability Calculation Unless subject to a fixed dollar copayment, the The calculation of the member Member liability on claims for covered healthcare services Covered Services processed through the BlueCard Program will be based on the lower of the participating providerProvider's billed covered charges or the negotiated price made available to Florida Blue Us by the Host Blue. Employer Liability Calculation The calculation of Employer liability on claims for covered healthcare services processed through the BlueCard Program will be based on the negotiated price made available to Florida Blue by the Host Blue (under the contract between the Host Blue and the provider). Sometimes, this negotiated price may be greater for a given service or services than the billed charge in accordance with how the Host Blue has negotiated with its participating healthcare provider(s) for specific healthcare services. In cases where the negotiated price exceeds the billed charge, Employer may be liable for the excess amount even when the member’s deductible has not been satisfied. This excess amount reflects an amount that may be necessary to secure (a) the provider’s participation in the network and/or (b) the overall discount negotiated by the Host Blue. In such a case, the entire contracted price is paid to the provider, even when the contracted price is greater than the billed charge. Claims Pricing Host Blues may use various methods to determine a negotiated price, which is reflected in depending on the terms of each Host Blue’s provider health care Provider contracts. The negotiated price made available to Florida Blue Us by the Host Blue may be represented represent a payment negotiated by a Host Blue with a health care Provider that is one of the following: • An actual price. An actual price is a negotiated rate of payment in effect at the time a claim is processed without any other increases or decreases; , or • An estimated price. An estimated price is a negotiated rate of payment in effect at the time a claim is processed, reduced or increased by a percentage to take into account certain payments negotiated with the provider Provider and other claim- and non-claim-related transactions. Such transactions may include, but are not limited to, anti-fraud and abuse recoveries, provider Provider refunds not applied on a claim-specific basis, retrospective settlements settlements, and performance performance-related bonuses or incentives; or • An average price. An average price is a percentage of billed covered charges in effect at the time a claim is processed representing the aggregate payments negotiated by the Host Blue with all of its healthcare providers health care Providers or a similar classification of its providers Providers and other claim- and non-claim- claim-related transactions. Such transactions may include the same ones as noted above for an estimated price. The Host Blue determines whether it will use Blues using either an actualestimated price or an average price may, estimated in accordance with Inter- Plan Programs policies, prospectively increase or average price. The use reduce such prices to correct for over- or underestimation of estimated past prices (i.e., prospective adjustments may mean that a current price reflects additional amounts or average pricing may result in a difference (positive credits for claims already paid to Providers or negative) between the price Employer pays on a specific claim and the actual amount the Host Blue pays anticipated to the providerbe paid to or received from Providers). However, the BlueCard Program requires that the amount paid by the member and Employer Member is a final price; no future price adjustment will result in increases or decreases to the pricing of past claims. Any positive or negative differences in The BlueCard Program requires that the price submitted by a Host Blue to Us is a final price irrespective of any future adjustments based on the use of estimated or average pricing are accounted for through variance accounts maintained by the pricing. A small number of states require a Host Blue and either (i) to use a basis for determining Member liability for Covered Services that does not reflect the entire savings realized, or expected to be realized, on a particular claim or (ii) to add a surcharge. Should the state in which health care services are incorporated into future claim pricesaccessed mandate liability calculation methods that differ from the negotiated price methodology or require a surcharge, We would then calculate Member liability in accordance with applicable law. As Return of Overpayments Under the BlueCard Program, recoveries from a result, the amounts charged to Employer will be adjusted in a following year, as necessary, to account for over- or underestimation of the past years’ prices. The Host Blue will not receive compensation from how the estimated price or average price methods, described above, are calculated. Because all amounts paid are final, neither positive variance account amounts (funds available to be paid its participating Providers can arise in the following year), nor negative variance amounts (the funds needed to be received in the following year), are due to or from Employer. If Employer terminates, you will not receive a refund or charge from the variance account. Variance account balances are small amounts relative to the overall paid claims amounts and will be liquidated over time. The timeframe for their liquidation depends on variablesseveral ways, including, but not limited to, overall volumeanti-fraud and abuse recoveries, health care Provider/number Hospital audits, credit balance audits, utilization review refunds, and unsolicited refunds. In some cases, the Host Blue will engage a third party to assist in identification or collection of claims processed and variance account balancerecovery amounts. Variance account balances The fees of such a third party may earn interest at be netted against the federal funds recovery. Recovery amounts determined in this way will be applied in accordance with applicable Inter-Plan Programs policies, which generally require correction on a claim-by-claim or similar rateprospective basis. Host Blues may retain interest earned on funds held in variance accounts. BlueCard Program Fees and Compensation Employer understands and agrees Negotiated National Account Arrangements As an alternative to reimburse Florida Blue for certain fees and compensation which Florida Blue is obligated under the BlueCard Program Program, the Member’s claim for Covered Services may be processed through a negotiated national account arrangement with a Host Blue. If We have arranged for (a) Host Blue(s) to pay to make available (a) custom health care Provider network(s) in connection with this Contract, then the Host Blues, to the Association and/or to vendors of BlueCard Program related services. The specific BlueCard Program fees terms and compensation that are charged to Employer are conditions set forth in Exhibit B. BlueCard Program Fees and compensation may Our negotiated national account arrangements with such Host Blue(s) shall apply. Member liability calculation will be revised from time based on the lower of either billed covered charges or negotiated price (refer to time. Only the BlueCard Program access fee may be charged separately each time a claim is processed through the BlueCard Program. All other BlueCard Program related fees are included in the Administrative Fee. The access fee is charged description of negotiated price above) made available to Us by the Host Blue that allows Members access to Florida Blue for making its applicable provider network available to Employer’s. The access fee will not apply to non-participating provider claims. The access fee is charged on a per claim basis and is charged as a percentage negotiated participation agreement networks of the discount/differential Florida Blue receives from the applicable Host Blue subject to a maximum specified Participating Providers outside of $2,000 per claim. When charged, Florida Blue passes the access fee directly on to Employer. Instances may occur in which the claim payment is zero or Florida Blue pays only a small amount because the amounts eligible for payment were applied to patient cost sharing (such as a deductible or coinsurance). In these instances, Florida Blue will pay the Host Blue’s access fee and pass it along directly to Employer as stated above even Employer paid little or had no claim liability. An Administrative Fee encompasses fees Florida Blue charges to Employer for administering Employer’s benefit plan. They may include both local (within Florida Blue’s Our service area) and Inter-Plan fees. For purposes of this Agreement, they include the following BlueCard Program related fees other than the BlueCard Program access fee: namely, administrative expense allowance (AEA) fee, central financial agency fee, ITS transaction fee, toll free number fee, PPO provider directory fee and Blue Cross Blue Shield Global® Core Program Fees, if applicable. Special Cases: Value-Based Programs Value-Based Programs Definitions Accountable Care Organization (ACO): A group of healthcare providers who agree to deliver coordinated care and meet performance benchmarks for quality and affordability in order to manage the total cost of care for their member populations. Global Payment/Total Cost of Care: A payment methodology that is defined at the patient level and accounts for either all patient care or for a specific group of services delivered to the patient such as outpatient, physician, ancillary, hospital services and prescription drugs. Patient-Centered Medical Home (PCMH): A model of care in which each patient has an ongoing relationship with a primary care physician who coordinates a team to take collective responsibility for patient care and, when appropriate, arranges for care with other qualified physicians.