Exhibit 10.1
BLUE CROSS LICENSE AGREEMENT
(Includes revisions, if any, adopted by Member Plans through
their September 22, 2000 meeting)
This agreement by and between Blue Cross and Blue Shield
Association ("BCBSA") and The Blue Cross Plan, known as
RightCHOICE Managed Care, Inc. (the "Plan").
Preamble
WHEREAS, the Plan and/or its predecessor(s) in interest
(collectively the "Plan") had the right to use the BLUE CROSS
and BLUE CROSS Design service marks (collectively the "Licensed
Marks") for health care plans in its service area, which was
essentially local in nature;
WHEREAS, the Plan was desirous of assuring nationwide
protection of the Licensed Marks, maintaining uniform quality
controls among Plans, facilitating the provision of cost
effective health care services to the public and otherwise
benefiting the public;
WHEREAS, to better attain such ends, the Plan and the
predecessor of BCBSA in 1972 simultaneously executed the BCA
License Agreement (s) and the Ownership Agreement; and
WHEREAS, BCBSA and the Plan desire to supercede said
Agreement(s) to reflect their current practices and to assure
the continued integrity of the Licensed Marks and of the BLUE
CROSS system;
NOW, THEREFORE, in consideration of the foregoing and the
mutual agreements hereinafter set forth and for other good and
valuable consideration, the receipt and sufficiency of which are
hereby acknowledged, the parties agree as follows:
Agreement
1. BCBSA hereby grants to the Plan, upon the terms and
conditions of this License Agreement, the right to use BLUE
CROSS in its trade and/or corporate name (the "Licensed Name"),
and the right to use the Licensed Marks, in the sale, marketing
and administration of health care plans and related services in
the Service Area set forth and defined in paragraph 5 below. As
used herein, health care plans and related services shall
include acting as a nonprofit health care plan, a for-profit
health care plan, or mutual health insurer operating on a
not-for-profit or for-profit basis, under state law; financing
access to health care services; providing health care management
and administration; administering, but not underwriting, non-
health portions of Worker's Compensation insurance; and
delivering health care services, except hospital services (as
defined in the Guidelines to Membership Standards Applicable to
Regular Members).
2. The Plan may use the Licensed Marks and Name in
connection with the offering of: a) health care plans and
related services in the Service Area through Controlled
Affiliates, provided that each such Controlled Affiliate is
separately licensed to use the Licensed Marks and Name under the
terms and conditions contained in the Agreement attached as
Exhibit 1 hereto (the "Controlled Affiliate License Agreement");
and: b) insurance coverages offered by life insurers under the
applicable law in the Service Area, other than those which the
Plan may offer in its own name, provided through Controlled
Affiliates, provided that each such Controlled Affiliate is
separately licensed to use the Licensed Marks and Name under the
terms and conditions contained in the Agreement attached as
Exhibit 1A hereto (the "Controlled Affiliate License Agreement
Applicable to Life Insurance Companies") and further provided
that the offering of such services does not and will not dilute
or tarnish the unique value of the Licensed Marks and Name; and
c) administration and underwriting of Workers' Compensation
Insurance Controlled Affiliates, provided that each such
Controlled Affiliate is separately licensed to use the Licensed
Marks and Name under the terms and conditions contained in the
Agreement attached as Exhibit 1 hereto (the "Controlled
Affiliate License."). As used herein, a Controlled Affiliate is
defined as an entity organized and operated in such a manner
that it is subject to the bona fide control of a Plan or Plans
and, if the entity meets the standards of subparagraph B but not
subparagraph A of this paragraph, the entity, its owners, and
persons with authority to select or appoint members or board
members, other than a Plan or Plans, have received written
approval of BCBSA. Absent written approval by BCBSA of an
alternative method of control, bona fide control shall mean that
a Plan or Plans authorized to use the Licensed Marks in the
Service Area of the Controlled Affiliate pursuant to this
License Agreement(s) with BCBSA, other than such Controlled
Affiliate's License Agreement(s), (the "Controlling Plan(s)"),
must have:
A. The legal authority, directly or
indirectly through wholly-owned subsidiaries: (a) to
select members of the Controlled Affiliate's
governing body having more than 50% voting control
thereof; (b) to exercise control over the policy and
operations of the Controlled Affiliate; (c) to
prevent any change in the articles of incorporation,
bylaws or other establishing or governing documents
of the Controlled Affiliate with which the
Controlling Plan(s) do(es) not concur. In addition,
a Plan or Plans directly or indirectly through wholly-
owned subsidiaries shall own more than 50% of any
for-profit Controlled Affiliate; or
Amended as of March 11, 1999
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B. The legal authority directly or
indirectly through wholly-owned subsidiaries (a) to
select members of the Controlled Affiliate's
governing body having not less than 50% voting
control thereof; (b) to prevent any change in the
articles of incorporation, bylaws or other
establishing or governing documents of the Controlled
Affiliate with which the Controlling Plan(s) do(es)
not concur; (c) to exercise control over the policy
and operations of the Controlled Affiliate at least
equal to that exercised by persons or entities
(jointly or individually) other than the Controlling
Plan(s). Notwithstanding anything to the contrary in
(a) through (c) hereof, the Controlled Affiliate's
establishing or governing documents must also require
written approval by the Controlling Plan(s) before
the Controlled Affiliate can:
1. Change its legal and/or trade name;
2. Change the geographic area in which it
operates;
3. Change any of the types of businesses in
which it engages;
4. Create, or become liable for by way of
guarantee, any indebtedness, other than
indebtedness arising in the ordinary course of
business;
5. Sell any assets, except for sales in the
ordinary course of business or sales of
equipment no longer useful or being replaced;
6. Make any loans or advances except in the
ordinary course of business;
7. Enter into any arrangement or agreement
with any party directly or indirectly affiliated
with any of the owners of the Controlled
Affiliate or persons or entities with the
authority to select or appoint members or board
members of the Controlled Affiliate, other than
the Plan or Plans (excluding owners of stock
holdings of under 5% in a publicly traded
Controlled Affiliate);
8. Conduct any business other than under the
Licensed Marks and Name;
9. Take any action that any Controlling Plan or
BCBSA reasonably believes will adversely
affect the Licensed Marks or Names.
In addition, a Plan or Plans directly or indirectly
through wholly owned subsidiaries shall own at least
50% of any for-profit Controlled Affiliate.
Amended as of June 11,
1998
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(The next page is page 3)
3. The Plan may engage in activities not required by
BCBSA to be directly licensed through Controlled Affiliates and
may indicate its relationship thereto by use of the Licensed
Name as a tag line, provided that the engaging in such
activities does not and will not dilute or tarnish the unique
value of the Licensed Marks and Name and further provided that
such tag line use is not in a manner likely to cause confusion
or mistake. Consistent with the avoidance of confusion or
mistake, each tag line use of the Plan's Licensed Name: (a)
shall be in the style and manner specified by BCBSA from
time-to-time; (b) shall not include the design service marks;
(c) shall not be in a manner to import more than the Plan's mere
ownership of the Controlled Affiliate; and (d) shall be
restricted to the Service Area. No rights are hereby created in
any Controlled Affiliate to use the Licensed Name in its own
name or otherwise. At least annually, the Plan shall provide
BCBSA with representative samples of each such use of its
Licensed Name pursuant to the foregoing conditions.
4. The Plan recognizes the importance of a comprehensive
national network of independent BCBSA licensees which are
committed to strengthening the Licensed Marks and Name. The
Plan further recognizes that its actions within its Service Area
may affect the value of the Licensed Marks and Name nationwide.
The Plan agrees (a) to maintain in good standing its membership
in BCBSA; (b) promptly to pay its dues to BCBSA, said dues to
represent the royalties for this License Agreement; (c)
materially to comply with all applicable laws; (d) to comply
with the Membership Standards Applicable to Regular Members of
BCBSA, a current copy of which is attached as Exhibit 2 hereto;
and (e) reasonably to permit BCBSA, upon a written, good faith
request and during reasonable business hours, to inspect the
Plan's books and records necessary to ascertain compliance
herewith. As to other Plans and third parties, BCBSA shall
maintain the confidentiality of all documents and information
furnished by the Plan pursuant hereto, or pursuant to the
Membership Standards, and clearly designated by the Plan as
containing proprietary information of the Plan.
5. The rights hereby granted are exclusive to the Plan
within the geographical area(s) served by the Plan on June 30,
1972, and/or as to which the Plan has been granted a subsequent
license, which is hereby defined as the "Service Area," except
that BCBSA reserves the right to use the Licensed Marks in said
Service Area, and except to the extent that said Service Area
may overlap areas served by one or more other licensed Blue
Cross Plans as of said date or subsequent license, as to which
overlapping areas the rights hereby granted are nonexclusive as
to such other Plan or Plans only.
Amended as of November 20, 1997
-3-
6. Except as expressly provided by BCBSA with respect to
National Accounts, Government Programs and certain other
necessary and collateral uses, the current rules and regulations
governing which are attached as Exhibit 3 and Exhibit 4 hereto,
or as expressly provided herein, the Plan may not use the
Licensed Marks and Name outside the Service Area or in
connection with other goods and services, nor may the Plan use
the Licensed Marks or Name in a manner which is intended to
transfer in the Service Area the goodwill associated therewith
to another xxxx or name. Nothing herein shall be construed to
prevent the Plan from engaging in lawful activity anywhere under
other marks and names not confusingly similar to the Licensed
Marks and Name, provided that engaging in such activity does and
will not dilute or tarnish the unique value of the Licensed
Marks and Name.
7. The Plan agrees that it will display the Licensed
Marks and Name only in such form, style and manner as shall be
specifically prescribed by BCBSA from time-to-time in
regulations of general application in order to prevent
impairment of the distinctiveness of the Licensed Marks and Name
and the goodwill pertaining thereto. The Plan shall cause to
appear on all materials on or in connection with which the
Licensed Marks or Name are used such legends, markings and
notices as BCBSA may reasonably request in order to give
appropriate notice of service xxxx or other proprietary rights
therein or pertaining thereto.
8. BCBSA agrees that: (a) it will not grant any other
license effective during the term of this License Agreement for
the use of the Licensed Marks or Name which is inconsistent with
the rights granted to the Plan hereunder; and (b) it will not
itself use the Licensed Marks in derogation of the rights of the
Plan or in a manner to deprive the Plan of the full benefits of
this License Agreement. The Plan agrees that it will not attack
the title of BCBSA in and to the Licensed Marks or Name or
attack the validity of the Licensed Marks or of this License
Agreement. The Plan further agrees that all use by it of the
Licensed Marks and Name or any similar xxxx or name shall inure
to the benefit of BCBSA, and the Plan shall cooperate with BCBSA
in effectuating the assignment to BCBSA of any service xxxx or
trademark registrations of the Licensed Marks or any similar
xxxx or name held by the Plan or a Controlled Affiliate of the
Plan, all or any portion of which registration consists of the
Licensed Marks.
-4-
9. (a). Should the Plan fail to comply with the
provisions of paragraphs 2-4, 6, 7 and/or 12, and not cure such
failure within thirty (30) days of receiving written notice
thereof (or commence curing such failure within such thirty day
period and continue diligent efforts to complete the curing of
such failure if such curing cannot reasonably be completed
within such thirty day period), BCBSA shall have the right to
issue a notice that the Plan is in a state of noncompliance.
Except as to the termination of a Plan's License Agreement or
the merger of two or more Plans, disputes as to noncompliance,
and all other disputes between or among BCBSA, the Plan, other
Plans and/or Controlled Affiliates, shall be submitted promptly
to mediation and mandatory dispute resolution pursuant to the
rules and regulations of BCBSA, a current copy of which is
attached as Exhibit 5 hereto, and shall be timely presented and
resolved. The mandatory dispute resolution panel shall have
authority to issue orders for specific performance and assess
monetary penalties. If a state of noncompliance as aforesaid is
undisputed by the Plan or is found to exist by a mandatory
dispute resolution panel and is uncured as provided above, BCBSA
shall have the right to seek judicial enforcement of the License
Agreement. Except, however, as provided in paragraphs 9(d)(iii)
and 15(a)(i)-(viii) below, no Plan's license to use the Licensed
Marks and Name may be finally terminated for any reason without
the affirmative vote of three-fourths of the Plans and
three-fourths of the total then current weighted vote of all the
Plans.
(b). Notwithstanding any other provision of this
License Agreement, a Plan's license to use the Licensed Marks
and Name may be forthwith terminated by the affirmative vote of
three-fourths of the Plans and three-fourths of the total then
current weighted vote of all the Plans at a special meeting
expressly called by BCBSA for the purpose on ten (10) days
written notice to the Plan advising of the specific matters at
issue and granting the Plan an opportunity to be heard and to
present its response to Member Plans for: (i) failure to comply
with any minimum capital or liquidity requirement under the
Membership Standard on Financial Responsibility; or (ii)
impending financial insolvency; or (iii) the pendency of any
action instituted against the Plan seeking its dissolution or
liquidation or its assets or seeking appointment of a trustee,
interim trustee, receiver or other custodian for any of its
property or business or seeking the declaration or establishment
of a trust for any of its property of business, unless this
License Agreement has been earlier terminated under paragraph
15(a); or (iv) such other reason as is determined in good faith
immediately and irreparably to threaten the integrity and
reputation of BCBSA, the Plans and/or the Licensed Marks.
(c). To the extent not otherwise provided therein,
neither: (i) the Membership Standards Applicable to Regular
Members of BCBSA; nor (ii) the rules and regulations governing
National Accounts, Government Programs and certain other uses;
nor (iii) the rules and regulations governing mediation and
mandatory dispute resolution, may be amended unless and until
each such amendment is first adopted by the affirmative vote of
three-fourths of the Plans and of three-fourths of the total
then current weighted vote of all the Plans.
Amended as of March 11, 1999
-5-
9. (d). The Plan may operate as a for-profit company
on the following conditions:
(i) The Plan shall discharge all responsibilities which
it has to the Association and to other Plans by virtue of this Agreement
and the Plan's membership in BCBSA.
(ii) The Plan shall not use the licensed Marks and
Name, or any derivative thereof, as part of its legal name or
any symbol used to identify the Plan in any securities market.
The Plan shall use the licensed Marks and Name as part of its
trade name within its service area for the sale, marketing and
administration of health care and related services in the
service area.
(iii) The Plan's license to use the Licensed Marks and
Name shall automatically terminate effective: (a) thirty days
after the Plan knows, or there is an SEC filing indicating that,
any Institutional Investor, has become the Beneficial Owner of
securities representing 10% or more of the voting power of the
Plan ("Excess Institutional Voter"), unless such Excess
Institutional Voter shall cease to be an Excess Institutional
Voter prior to such automatic termination becoming effective;
(b) thirty days after the Plan knows, or there is an SEC filing
indicating that, any Noninstitutional Investor has become the
Beneficial Owner of securities representing 5% or more of the
voting power of the Plan ("Excess Noninstitutional Voter")
unless such Excess Noninstitutional Voter shall cease to be an
Excess Noninstitutional Voter prior to such automatic
termination becoming effective; (c) thirty days after the Plan
knows, or there is an SEC filing indicating that, any Person has
become the Beneficial Owner of 20% or more of the Plan's then
outstanding common stock or other equity securities which
(either by themselves or in combination) represent an ownership
interest of 20% or more pursuant to determinations made under
paragraph 9(d)(iv) below ("Excess Owner"), unless such Excess
Owner shall cease to be an Excess Owner prior to such automatic
termination becoming effective; (d) ten business days after
individuals who at the time the Plan went public constituted the
Board of Directors of the Plan (together with any new directors
whose election to the Board was approved by a vote of 2/3 of the
directors then still in office who were directors at the time
the Plan went public or whose election or nomination was
previously so approved) (the "Continuing Directors") cease for
any reason to constitute a majority of the Board of Directors;
or (e) ten business days after the Plan consolidates with or
merges with or into any person or conveys, assigns, transfers or
sells all or substantially all of its assets to any person other
than a merger in which the Plan is the surviving entity and
immediately after which merger, no person is an Excess
Institutional Voter, an Excess Noninstitutional Voter or an
Excess Owner: provided that, if requested by the affected Plan
in a writing received by BCBSA prior to such automatic
termination becoming effective, the provisions of this paragraph
9(d)(iii) may be waived, in whole or in part,
Amended as of September 17, 1997
-5a-
upon the affirmative vote of a majority of the disinterested
Plans and a majority of the total then current weighted vote of
the disinterested Plans. Any waiver so granted may be
conditioned upon such additional requirements (including but not
limited to imposing new and independent grounds for termination
of this License) as shall be approved by the affirmative vote of
a majority of the disinterested Plans and a majority of the
total then current weighted vote of the disinterested Plans. If
a timely waiver request is received, no automatic termination
shall become effective until the later of: (1) the conclusion of
the applicable time period specified in paragraphs 9(d)(iii)(a)-
(d) above, or (2) the conclusion of the first Member Plan
meeting after receipt of such a waiver request.
In the event that the Plan's license to use the Licensed Marks
and Name is terminated pursuant to this Paragraph 9(d)(iii), the
license may be reinstated in BCBSA's sole discretion if, within
30 days of the date of such termination, the Plan demonstrates
that the Person referred to in clause (a), (b) or (c) of the
preceding paragraph is no longer an Excess Institutional Voter,
an Excess Noninstitutional Voter or an Excess Owner.
(iv) The Plan shall not issue any class or series of
security other than (i) shares of common stock having identical
terms or options or derivatives of such common stock, (ii) non-
voting, non-convertible debt securities or (iii) such other
securities as the Plan may approve, provided that BCBSA receives
notice at least thirty days prior to the issuance of such
securities, including a description of the terms for such
securities, and BCBSA shall have the authority to determine how
such other securities will be counted in determining whether any
Person is an Excess Institutional Voter, Excess Noninstitutional
Voter or an Excess Owner.
(v) For purposes of paragraph 9(d)(iii), the following
definitions shall apply:
(a) "Affiliate" and "Associate" shall have the respective
meanings ascribed to such terms in Rule 12b-2 of the
General Rules and Regulations under the Securities Exchange
Act of 1934, as amended and in effect on November 17, 1993
(the "Exchange Act").
(b) A Person shall be deemed the "Beneficial Owner" of
and shall be deemed to "beneficially own" any securities:
(i) which such Person or any of such Person's
Affiliates or Associates beneficially owns, directly or
indirectly;
Amended as of September 17, 1997
-5b-
(ii) which such Person or any of such Person's
Affiliates or Associates has (A) the right to acquire
(whether such right is exercisable immediately or only
after the passage of time) pursuant to any agreement,
arrangement or understanding, or upon the exercise of
conversion rights, exchange rights, warrants or options, or
otherwise; or (B) the right to vote pursuant to any
agreement, arrangement or understanding; provided, however,
that a Person shall not be deemed the Beneficial Owner of,
or to beneficially own, any security if the agreement,
arrangement or understanding to vote such security (1)
arises solely from a revocable proxy or consent given to
such Person in response to a public proxy or consent
solicitation made pursuant to, and in accordance with, the
applicable rules and regulations promulgated under the
Exchange Act and (2) is not also then reportable on
Schedule 13D under the Exchange Act (or any comparable or
successor report); or
(iii) which are beneficially owned, directly or
indirectly, by any other Person (or any Affiliate or
Associate thereof) with which such Person (or any of such
Person's Affiliates or Associates) has any agreement,
arrangement or understanding (other than customary
agreements with and between underwriters and selling group
members with respect to a bona fide public offering of
securities) relating to the acquisition, holding, voting
(except to the extent contemplated by the proviso to
(b)(ii)(B) above) or disposing of any securities of the
Plan.
Notwithstanding anything in this definition of Beneficial
Ownership to the contrary, the phrase "then outstanding,"
when used with reference to a Person's Beneficial Ownership
of securities of the Plan, shall mean the number of such
securities then issued and outstanding together with the
number of such securities not then actually issued and
outstanding which such Person would be deemed to own
beneficially hereunder.
(c) A Person shall be deemed an "Institutional Investor"
if (but only if) such Person (i) is an entity or group
identified in the SEC's Rule 13d-1(b)(1)(ii) as constituted
on June 1, 1997, and (ii) every filing made by such Person
with the SEC under Regulation 13D-G (or any successor
Regulation) with respect to such Person's Beneficial
Ownership of Plan securities shall have contained a
certification identical to the one required by item 10 of
SEC Schedule 13G as constituted on June 1, 1997.
Amended as of September 17, 1997
-5c-
(d) "Noninstitutional Investor" means any Person who is
not an Institutional Investor.
(e)"Person" shall mean any individual, firm, partnership,
corporation, trust, association, joint venture or other
entity, and shall include any successor (by merger or
otherwise) of such entity.
Amended as of September 17, 1997
-5d-
(The next page is page 6)
10. This License Agreement shall remain in effect: (a)
until terminated as provided herein; or (b) until this and all
such other License Agreements are terminated by the affirmative
vote of three-fourths of the Plans and three-fourths of the
total then current weighted vote of all the Plans; (c) until
terminated by the Plan upon six (6) months written notice to
BCBSA.
11. Except as otherwise provided in paragraph 15 below or
by the affirmative vote of three-fourths of the Plans and
three-fourths of the total then current weighted vote of all the
Plans, or unless this and all such other License Agreements are
simultaneously terminated by force of law, the termination of
this License Agreement for any reason whatsoever shall cause the
reversion to BCBSA of all rights in and to the Licensed Marks
and Name, and the Plan agrees that it will promptly discontinue
all use of the Licensed Marks and Name, will not use them
thereafter, and will promptly, upon written notice from BCBSA,
change its corporate name so as to eliminate the Licensed Name
therefrom.
12. The license hereby granted to Plan to use the Licensed
Marks and Name is and shall be personal to the Plan so licensed
and shall not be assignable by any act of the Plan, directly or
indirectly, without the written consent of BCBSA. Said license
shall not be assignable by operation of law, nor shall Plan
mortgage or part with possession or control of this license or
any right hereunder, and the Plan shall have no right to grant
any sublicense to use the Licensed Marks and Name.
13. BCBSA shall maintain appropriate service xxxx
registrations of the Licensed Marks and BCBSA shall take such
lawful steps and proceedings as may be necessary or proper to
prevent use of the Licensed Marks by any person who is not
authorized to use the same. Any actions or proceedings
undertaken by BCBSA under the provisions of this paragraph shall
be at BCBSA's sole cost and expense. BCBSA shall have the sole
right to determine whether or not any legal action shall be
taken on account of unauthorized use of the Licensed Marks, such
right not to be unreasonably exercised. The Plan shall report
any unlawful usage of the Licensed Marks to BCBSA in writing and
agrees, free of charge, to cooperate fully with BCBSA's program
of enforcing and protecting the service xxxx rights, trade name
rights and other rights in the Licensed Marks.
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14. The Plan hereby agrees to save, defend, indemnify
and hold BCBSA and any other Plan(s) harmless from and against
all claims, damages, liabilities and costs of every kind, nature
and description which may arise exclusively and directly as a
result of the activities of the Plan. BCBSA hereby agrees to
save, defend, indemnify and hold the Plan and any other Plan(s)
harmless from and against all claims, damages, liabilities and
costs of every kind, nature and description which may arise
exclusively and directly as a result of the activities of BCBSA.
15. (a). This Agreement shall automatically
terminate upon the occurrence of any of the following events:
(i) a voluntary petition shall be filed by the Plan or by BCBSA
seeking bankruptcy, reorganization, arrangement with creditors
or other relief under the bankruptcy laws of the United States
or any other law governing insolvency or debtor relief, or (ii)
an involuntary petition or proceeding shall be filed against the
Plan or BCBSA seeking bankruptcy, reorganization, arrangement
with creditors or other relief under the bankruptcy laws of the
United States or any other law governing insolvency or debtor
relief and such petition or proceeding is consented to or
acquiesced in by the Plan or BCBSA or is not dismissed within
sixty (60) days of the date upon which the petition or other
document commencing the proceeding is served upon the Plan or
BCBSA respectively, or (iii) an order for relief is entered
against the Plan or BCBSA in any case under the bankruptcy laws
of the United States, or the Plan or BCBSA is adjudged bankrupt
or insolvent (as that term is defined in the Uniform Commercial
Code as enacted in the state of Illinois) by any court of
competent jurisdiction, or (iv) the Plan or BCBSA makes a
general assignment of its assets for the benefit of creditors,
or (v) the Department of Insurance or other regulatory agency
assumes control of the Plan or delinquency proceedings
(voluntary or involuntary) are instituted, or (vi) an action is
brought by the Plan or BCBSA seeking its dissolution or
liquidation of its assets or seeking the appointment of a
trustee, interim trustee, receiver or other custodian for any of
its property or business, or (vii) an action is instituted by
any governmental entity or officer against the Plan or BCBSA
seeking its dissolution or liquidation of its assets or seeking
appointment of a trustee, interim trustee, receiver or other
custodian for any of its property or business and such action is
consented to or acquiesced in by the Plan or BCBSA or is not
dismissed within one hundred thirty (130) days of the date upon
which the pleading or other document commencing the action is
served upon the Plan or BCBSA respectively, provided that if the
action is stayed or its prosecution is enjoined, the one hundred
thirty (130) day period is tolled for the duration of the stay
or injunction, and provided further, that the Association's
Board of Directors may toll or extend the 130 day period at any
time prior to its expiration, or (viii) a trustee, interim
trustee, receiver or other custodian for any of the Plan's or
BCBSA's property or business is appointed, or the Plan or BCBSA
is ordered dissolved or liquidated, or (ix) the Plan shall fail
to pay its dues and shall not cure such failure within thirty
(30) days of receiving written notice thereof. Notwithstanding
any other provision of this Agreement, a declaration or a
request for declaration of the existence of a trust over any of
the Plan's or BCBSA's property or business shall not in itself
be deemed to constitute or seek appointment of a trustee,
interim trustee, receiver or other custodian for purposes of
subparagraphs 15(a)(vii) and (viii) of this Agreement.
Amended March 12, 1998
-7-
(b). BCBSA, or the Plans (as provided and in addition to
the rights conferred in Paragraph 10(b) above), may terminate
this Agreement immediately upon written notice upon the
occurrence of either of the following events: (a) the Plan or
BCBSA becomes insolvent (as that term is defined in the Uniform
Commercial Code enacted in the state of Illinois), or (b) any
final judgment against the Plan or BCBSA remains unsatisfied or
unbonded of record for a period of sixty (60) days or longer.
(c). If this License Agreement is terminated as to
BCBSA for any reason stated in subparagraphs 15(a) and (b)
above, the ownership of the Licensed Marks shall revert to each
of the Plans.
(d). Upon termination of this License Agreement or any
Controlled Affiliate License Agreement of a Larger Controlled
Affiliate, as defined in Exhibit 1 to this License Agreement:
(i) The terminated entity
shall send a notice through the U.S.
mails, with first class postage affixed,
to all individual and group customers,
providers, brokers and agents of products
or services sold, marketed, underwritten
or administered by the terminated entity
or its Controlled Affiliates under the
Licensed Marks and Name. The form and
content of the notice shall be specified
by BCBSA and shall, at a minimum, notify
the recipient of the termination of the
license, the consequences thereof, and
instructions for obtaining alternate
products or services licensed by BCBSA.
This notice shall be mailed within 15
days after termination or, if termination
is pursuant to paragraph 10(d) of this
Agreement, within 15 days after the
written notice to BCBSA described in
paragraph 10(d).
(ii) The terminated entity
shall deliver to BCBSA within five days
of a request by BCBSA a listing of
national accounts in which the terminated
entity is involved (in a Control,
Participating or Servicing capacity),
identifying the national account and the
terminated entity's role therein. For
those accounts where the terminated
entity is the Control Plan, the Plan must
also indicate the Participating and
Servicing Plans in the national account
syndicate.
Amended as of September 19, 1996
-8-
(iii) Unless the cause of
termination is an event stated in
paragraph 15(a) or (b) above respecting
BCBSA, the Plan and its Licensed
Controlled Affiliates shall be jointly
liable for payment to BCBSA of an amount
equal to $25 multiplied by the number of
Licensed Enrollees of the terminated
entity and its Licensed Controlled
Affiliates; provided that if any other
Plan is permitted by BCBSA to use marks
or names licensed by BCBSA in the Service
Area established by this Agreement, the
payment shall be multiplied by a
fraction, the numerator of which is the
number of Licensed Enrollees of the
terminated entity and its Licensed
Controlled Affiliates and the denominator
of which is the total number of Licensed
Enrollees in the Service Area. Licensed
Enrollee means each and every person and
covered dependent who is enrolled as an
individual or member of a group receiving
products or services sold, marketed or
administered under marks or names
licensed by BCBSA as determined at the
earlier of (a) the end of the last fiscal
year of the terminated entity which ended
prior to termination or (b) the fiscal
year which ended before any transactions
causing the termination began.
Notwithstanding the foregoing, the amount
payable pursuant to this subparagraph
(d)(iii) shall be due only to the extent
that, in BCBSA's opinion, it does not
cause the net worth of the Plan to fall
below 100% of the capital benchmark
formula or its equivalent under any
successor formula, as set forth in the
applicable financial responsibility
standards established by BCBSA (provided
such equivalent is approved for purposes
of this sub paragraph by the affirmative
vote of three-fourths of the Plans and
three-fourths of the total then current
weighted vote of all the Plans), measured
as of the date of termination and
adjusted for the value of any
transactions not made in the ordinary
course of business. This payment shall
not be due in connection with
transactions exclusively by or among Plan
or their affiliates, including
reorganizations, combinations or mergers,
where the BCBSA Board of Directors
determines that the license termination
does not result in a material diminution
in the number of Licensed Enrollees or
the extent of their coverage.
Amended as of November 19, 1998
-8a-
(iv) BCBSA shall have the right
to audit the books and records of the
terminated entity and its Licensed
Controlled Affiliates to verify
compliance with this paragraph 15(d).
(v) As to a breach of 15 (d)
(i), (ii), (iii) or (iv), the parties
agree that the obligations are
immediately enforceable in a court of
competent jurisdiction. As to a breach
of 15 (d) (i), (ii) or (iv) by the Plan,
the parties agree there is no adequate
remedy at law and BCBSA is entitled to
obtain specific performance.
(e). BCBSA shall be entitled to enjoin the Plan
or any related party in a court of competent jurisdiction from
entry into any transaction which would result in a termination
of this License Agreement unless the License Agreement has been
terminated pursuant to paragraph 10 (d) of this Agreement upon
the required six (6) month written notice.
(f). BCBSA acknowledges that it is not the owner
of assets of the Plan.
16. This Agreement supersedes any and all other
agreements between the parties with respect to the subject
matter herein, and contains all of the covenants and agreements
of the parties as to the licensing of the Licensed Marks and
Name. This Agreement may be amended only by the affirmative
vote of three-fourths of the Plans and three-fourths of the
total then current weighted vote of all the Plans as officially
recorded by the BCBSA Corporate Secretary.
17. If any provision or any part of any provision of this
Agreement is judicially declared unlawful, each and every other
provision, or any part of any provision, shall continue in full
force and effect notwithstanding such judicial declaration.
18. No waiver by BCBSA or the Plan of any breach or
default in performance on the part of BCBSA or the Plan or any
other licensee of any of the terms, covenants or conditions of
this Agreement shall constitute a waiver of any subsequent
breach or default in performance of said terms, covenants or
conditions.
19a. All notices provided for hereunder shall be in
writing and shall be sent in duplicate by regular mail to BCBSA
or the Plan at the address currently published for each by BCBSA
and shall be marked respectively to the attention of the
President and, if any, the General Counsel, of BCBSA or the
Plan.
Amended as of November 20, 1997
-8b-
19b. Except as provided in paragraphs 9(b), 9(d)(iii),
15(a), and 15(b) above, this Agreement may be terminated for a
breach only upon at least 30 days' written notice to the Plan
advising of the specific matters at issue and granting the Plan
an opportunity to be heard and to present its response to the
Member Plans.
19c. For all provisions of this Agreement referring to
voting, the term `Plans' shall mean all entities licensed under
the Blue Cross License Agreement and/or the Blue Shield License
Agreement, and in all votes of the Plans under this Agreement
the Plans shall vote together. For weighted votes of the Plans,
the Plan shall have a number of votes equal to the number of
weighted votes (if any) that it holds as a Blue Cross Plan plus
the number of weighted votes (if any) that it holds as a Blue
Shield Plan. For all other votes of the Plans, the Plan shall
have one vote. For all questions requiring an affirmative three-
fourths weighted vote of the Plans, the requirement shall be
deemed satisfied with a lesser weighted vote unless six (6) or
more Plans fail to cast weighted votes in favor of the question.
-8c-
(The next page is page 9)
Amended as of June 16, 2000
20. Nothing herein contained shall be construed to
constitute the parties hereto as partners or joint venturers, or
either as the agent of the other, and Plan shall have no right
to bind or obligate BCBSA in any way, nor shall it represent
that it has any right to do so. BCBSA shall have no liability
to third parties with respect to any aspect of the business,
activities, operations, products, or services of the Plan.
21. This Agreement shall be governed, construed and
interpreted in accordance with the laws of the State of
Illinois.
IN WITNESS WHEREOF, the parties have caused this License
Agreement to be executed, effective as of the date of last
signature written below.
Blue Cross and Blue Shield Association
By /s/ Xxxxx X. Xxxxxx
Title President and Chief Executive Officer
Date 11/30/00
RightCHOICE Managed Care, Inc.
By /s/ Xxxx X. X'Xxxxxx
Title President
Date 11/30/00
-9-
EXHIBIT 1
BLUE CROSS
CONTROLLED AFFILIATE LICENSE AGREEMENT
(Includes revisions adopted by Member Plans through their
September 22, 2000 meeting)
This Agreement by and among Blue Cross and Blue Shield
Association ("BCBSA") and _______ ("Controlled Affiliate"), a
Controlled Affiliate of the Blue Cross Plan(s), known as
_________ ("Plan"), which is also a Party signatory hereto.
WHEREAS, BCBSA is the owner of the BLUE CROSS and BLUE CROSS
Design service marks;
WHEREAS, Plan and Controlled Affiliate desire that the
latter be entitled to use the BLUE CROSS and BLUE CROSS Design
service marks (collectively the "Licensed Marks") as service
marks and be entitled to use the term BLUE CROSS in a trade name
("Licensed Name");
NOW THEREFORE, in consideration of the foregoing and the
mutual agreements hereinafter set forth and for other good and
valuable consideration, the receipt and sufficiency of which are
hereby acknowledged, the parties hereby agree as follows:
1. GRANT OF LICENSE
Subject to the terms and conditions of this Agreement, BCBSA
hereby grants to Controlled Affiliate the right to use the
Licensed Marks and Name in connection with, and only in
connection with: (i) health care plans and related services , as
defined in BCBSA's License Agreement with Plan, and administering
the non-health portion of workers' compensation insurance, and
(ii) underwriting the indemnity portion of workers' compensation
insurance, provided that Controlled Affiliate's total premium
revenue comprises less than 15 percent of the sponsoring Plan's
net subscription revenue.
This grant of rights is non-exclusive and is limited to the
Service Area served by the Plan. Controlled Affiliate may not
use the Licensed Marks and Name in its legal name and may use the
Licensed Marks and Name in its Trade Name only with the prior
consent of BCBSA.
2. QUALITY CONTROL
A. Controlled Affiliate agrees to use the Licensed Marks
and Name only in connection with the licensed services and
further agrees to be bound by the conditions regarding quality
control shown in attached Exhibit A as they may be amended by
BCBSA from time-to-time.
Amended as of March 11, 1999
B. Controlled Affiliate agrees to comply with all
applicable federal, state and local laws.
C. Controlled Affiliate agrees that it will provide on an
annual basis (or more often if reasonably required by Plan or by
BCBSA) a report or reports to Plan and BCBSA demonstrating
Controlled Affiliate's compliance with the requirements of this
Agreement including but not limited to the quality control
provisions of this paragraph and the attached Exhibit A.
D. Controlled Affiliate agrees that Plan and/or BCBSA may,
from time-to-time, upon reasonable notice, review and inspect the
manner and method of Controlled Affiliate's rendering of service
and use of the Licensed Marks and Name.
E. As used herein, a Controlled Affiliate is defined as an
entity organized and operated in such a manner, that it meets the
following requirements:
(1) A Plan or Plans authorized to use the Licensed Marks in the
Service Area of the Controlled Affiliate pursuant to separate
License Agreement(s) with BCBSA, other than such Controlled
Affiliate's License Agreement(s), (the "Controlling Plan(s)"),
must have the legal authority directly or indirectly through
wholly-owned subsidiaries to select members of the Controlled
Affiliate's governing body having not less than 50% voting
control thereof and to:
(a) prevent any change in the articles of incorporation,
bylaws or other establishing or governing documents of the
Controlled Affiliate with which the Controlling Plan(s) do(es)
not concur;
(b) exercise control over the policy and operations of the
Controlled Affiliate at least equal to that exercised by persons
or entities (jointly or individually) other than the Controlling
Plan(s); and
Notwithstanding anything to the contrary in (a) through (b)
hereof, the Controlled Affiliate's establishing or governing
documents must also require written approval by the Controlling
Plan(s) before the Controlled Affiliate can:
(i) change its legal and/or trade names;
(ii) change the geographic area in which it
operates;
(iii) change any of the type(s) of businesses in
which it engages;
(iv) create, or become liable for by way of guarantee,
any indebtedness, other than indebtedness arising
in the ordinary course of business;
(v) sell any assets, except for sales in the ordinary
course of business or sales of equipment no longer
useful or being replaced;
(vi) make any loans or advances except in the ordinary
course of business;
(vii) enter into any arrangement or agreement with
any party directly or indirectly affiliated with
any of the owners or persons or entities with the
authority to select or appoint members or board
members of the Controlled Affiliate, other than
the Plan or Plans (excluding owners of stock
holdings of under 5% in a publicly traded
Controlled Affiliate);
(viii)conduct any business other than under the Licensed
Marks and Name;
(ix) take any action that any Controlling Plan or BCBSA
reasonably believes will adversely affect the Licensed Marks and
Name.
In addition, a Plan or Plans directly or indirectly through
wholly owned subsidiaries shall own at least 50% of any for-
profit Controlled Affiliate.
Or
(2) A Plan or Plans authorized to use the Licensed Marks in the
Service Area of the Controlled Affiliate pursuant to separate
License Agreement(s) with BCBSA, other than such Controlled
Affiliate's License Agreement(s), (the "Controlling Plan(s)"),
have the legal authority directly or indirectly through wholly-
owned subsidiaries to select members of the Controlled
Affiliate's governing body having more than 50% voting control
thereof and to:
(a) prevent any change in the articles of incorporation,
bylaws or other establishing or governing documents of
the Controlled Affiliate with which the Controlling
Plan(s) do(es) not concur;
(b) exercise control over the policy and operations of the
Controlled Affiliate.
In addition, a Plan or Plans directly or indirectly through
wholly-owned subsidiaries shall own at least 50% of any for-
profit Controlled Affiliate.
3. SERVICE XXXX USE
A. Controlled Affiliate recognizes the importance of a
comprehensive national network of independent BCBSA licensees
which are committed to strengthening the Licensed Marks and Name.
The Controlled Affiliate further recognizes that its actions
within its Service Area may affect the value of the Licensed
Marks and Name nationwide.
B. Controlled Affiliate shall at all times make proper
service xxxx use of the Licensed Marks and Name, including but
not limited to use of such symbols or words as BCBSA shall
specify to protect the Licensed Marks and Name and shall comply
with such rules (generally applicable to Controlled Affiliates
licensed to use the Licensed Marks and Name) relative to service
xxxx use, as are issued from time-to-time by BCBSA. Controlled
Affiliate recognizes and agrees that all use of the Licensed
Marks and Name by Controlled Affiliate shall inure to the benefit
of BCBSA.
C. Controlled Affiliate may not directly or indirectly use
the Licensed Marks and Name in a manner that transfers or is
intended to transfer in the Service Area the goodwill associated
therewith to another xxxx or name, nor may Controlled Affiliate
engage in activity that may dilute or tarnish the unique value of
the Licensed Marks and Name.
D. If Controlled Affiliate meets the standards of 2E(1)
but not 2E(2) above and any of Controlled Affiliate's
advertising or promotional material is reasonably determined by
BCBSA and/or the Plan to be in contravention of rules and
regulations governing the use of the Licensed Marks and Name,
Controlled Affiliate shall for ninety (90) days thereafter obtain
prior approval from BCBSA of advertising and promotional efforts
using the Licensed Marks and Name, approval or disapproval
thereof to be forthcoming within five (5) business days of
receipt of same by BCBSA or its designee. In all advertising and
promotional efforts, Controlled Affiliate shall observe the
Service Area limitations applicable to Plan.
E. Controlled Affiliate shall use its best efforts in the
Service Area to promote and build the value of the Licensed Marks
and Name.
4. SUBLICENSING AND ASSIGNMENT
Controlled Affiliate shall not, directly or indirectly,
sublicense, transfer, hypothecate, sell, encumber or mortgage, by
operation of law or otherwise, the rights granted hereunder and
any such act shall be voidable at the sole option of Plan or
BCBSA. This Agreement and all rights and duties hereunder are
personal to Controlled Affiliate.
5. INFRINGEMENT
Controlled Affiliate shall promptly notify Plan and Plan
shall promptly notify BCBSA of any suspected acts of
infringement, unfair competition or passing off that may occur in
relation to the Licensed Marks and Name. Controlled Affiliate
shall not be entitled to require Plan or BCBSA to take any
actions or institute any proceedings to prevent infringement,
unfair competition or passing off by third parties. Controlled
Affiliate agrees to render to Plan and BCBSA, without charge, all
reasonable assistance in connection with any matter pertaining to
the protection of the Licensed Marks and Name by BCBSA.
6. LIABILITY INDEMNIFICATION
Controlled Affiliate and Plan hereby agree to save, defend,
indemnify and hold BCBSA harmless from and against all claims,
damages, liabilities and costs of every kind, nature and
description (except those arising solely as a result of BCBSA's
negligence) that may arise as a result of or related to
Controlled Affiliate's rendering of services under the Licensed
Marks and Name.
7. LICENSE TERM
A. Except as otherwise provided herein, the license
granted by this Agreement shall remain in effect for a period of
one (1) year and shall be automatically extended for additional
one (1) year periods unless terminated pursuant to the provisions
herein.
B. This Agreement and all of Controlled Affiliate's rights
hereunder shall immediately terminate without any further action
by any party or entity in the event that Plan ceases to be
authorized to use the Licensed Marks and Name.
C. Notwithstanding any other provision of this Agreement,
this license to use the Licensed Marks and Name may be forthwith
terminated by the Plan or the affirmative vote of the majority of
the Board of Directors of BCBSA present and voting at a special
meeting expressly called by BCBSA for the purpose on ten (10)
days written notice to the Plan advising of the specific matters
at issue and granting the Plan an opportunity to be heard and to
present its response to
Member Plans for: (1) failure to comply with any applicable
minimum capital or liquidity requirement under the quality
control standards of this Agreement; or (2) failure to comply
with the "Organization and Governance" quality control standard
of this Agreement; or (3) impending financial insolvency; or (4)
for a Smaller Controlled Affiliate (as defined in Exhibit A),
failure to comply with any of the applicable requirements of
Standards 2, 3, 4, 5 or 7 of attached Exhibit A; or (5) the
pendency of any action instituted against the Controlled
Affiliate seeking its dissolution or liquidation of its assets or
seeking appointment of a trustee, interim trustee, receiver or
other custodian for any of its property or business or seeking
the declaration or establishment of a trust for any of its
property or business, unless this Controlled Affiliate License
Agreement has been earlier terminated under paragraph 7(e); or
(6) failure by a Controlled Affiliate that meets the standards of
2E(1) but not 2E(2) above to obtain BCBSA's written consent to a
change in the identity of any owner, in the extent of ownership,
or in the identity of any person or entity with the authority to
select or appoint members or board members, provided that as to
publicly traded Controlled Affiliates this provision shall apply
only if the change affects a person or entity that owns at least
5% of the Controlled Affiliate's stock before or after the
change; or (7) such other reason as is determined in good faith
immediately and irreparably to threaten the integrity and
reputation of BCBSA, the Plans, any other licensee including
Controlled Affiliate and/or the Licensed Marks and Name.
D. Except as otherwise provided in Paragraphs 7(B), 7(C)
or 7(E) herein, should Controlled Affiliate fail to comply with
the provisions of this Agreement and not cure such failure within
thirty (30) days of receiving written notice thereof (or commence
a cure within such thirty day period and continue diligent
efforts to complete the cure if such curing cannot reasonably be
completed within such thirty day period) BCBSA or the Plan shall
have the right to issue a notice that the Controlled Affiliate is
in a state of noncompliance. If a state of noncompliance as
aforesaid is undisputed by the Controlled Affiliate or is found
to exist by a mandatory dispute resolution panel and is uncured
as provided above, BCBSA shall have the right to seek judicial
enforcement of the Agreement or to issue a notice of termination
thereof. Notwithstanding any other provisions of this
Agreement, any disputes as to the termination of this License
pursuant to Paragraphs 7(B), 7(C) or 7(E) of this Agreement shall
not be subject to mediation and mandatory dispute resolution.
All other disputes between BCBSA, the Plan and/or Controlled
Affiliate shall be submitted promptly to mediation and mandatory
dispute resolution. The mandatory dispute resolution panel shall
have authority to issue orders for specific performance and
assess monetary penalties. Except, however, as provided in
Paragraphs 7(B) and 7(E) of this Agreement, this license to use
the Licensed Marks and Name may not be finally terminated for any
reason without the affirmative vote of a majority of the present
and voting members of the Board of Directors of BCBSA.
E. This Agreement and all of Controlled Affiliate's rights
hereunder shall immediately terminate without any further action
by any party or entity in the event that:
(1) Controlled Affiliate shall no longer comply with item
2(E) above;
(2) Appropriate dues, royalties and other payments for
Controlled Affiliate pursuant to paragraph 9 hereof, which are
the royalties for this License Agreement, are more than sixty
(60) days in arrears to BCBSA; or
(3) Any of the following events occur: (i) a voluntary
petition shall be filed by Controlled Affiliate seeking
bankruptcy, reorganization, arrangement with creditors or other
relief under the bankruptcy laws of the United States or any
other law governing insolvency or debtor relief, or (ii) an
involuntary petition or proceeding shall be filed against
Controlled Affiliate seeking bankruptcy, reorganization,
arrangement with creditors or other relief under the bankruptcy
laws of the United States or any other law governing insolvency
or debtor relief and such petition or proceeding is consented to
or acquiesced in by Controlled Affiliate or is not dismissed
within sixty (60) days of the date upon which the petition or
other document commencing the proceeding is served upon the
Controlled Affiliate, or (iii) an order for relief is entered
against Controlled Affiliate in any case under the bankruptcy
laws of the United States, or Controlled Affiliate is adjudged
bankrupt or insolvent as those terms are defined in the Uniform
Commercial Code as enacted in the State of Illinois by any court
of competent jurisdiction, or (iv) Controlled Affiliate makes a
general assignment of its assets for the benefit of creditors, or
(v) the Department of Insurance or other regulatory agency
assumes control of Controlled Affiliate or delinquency
proceedings (voluntary or involuntary) are instituted, or (vi) an
action is brought by Controlled Affiliate seeking its dissolution
or liquidation of its assets or seeking the appointment of a
trustee, interim trustee, receiver or other custodian for any of
its property or business, or (vii) an action is instituted by any
governmental entity or officer against Controlled Affiliate
seeking its dissolution or liquidation of its assets or seeking
the appointment of a trustee, interim trustee, receiver or other
custodian for any of its property or business and such action is
consented to or acquiesced in by Controlled Affiliate or is not
dismissed within one hundred thirty (130) days of the date upon
which the pleading or other document commencing the action is
served upon the Controlled Affiliate, provided that if the action
is stayed or its prosecution is enjoined, the one hundred thirty
(130) day period is tolled for the duration of the stay or
injunction, and provided further, that the Association's Board of
Directors may toll or extend the 130 day period at any time prior
to its expiration, or (viii) a trustee, interim trustee, receiver
or other custodian for any of Controlled Affiliate's property or
business is appointed or the Controlled Affiliate is ordered
dissolved or liquidated. Notwithstanding any other provision of
this Agreement,
a declaration or a request for declaration of the existence of a
trust over any of the Controlled Affiliate's property or business
shall not in itself be deemed to constitute or seek appointment
of a trustee, interim trustee, receiver or other custodian for
purposes of subparagraphs 7(e)(3)(vii) and (viii) of this
Agreement.
F. Upon termination of this Agreement for cause or
otherwise, Controlled Affiliate agrees that it shall immediately
discontinue all use of the Licensed Marks and Name, including any
use in its trade name.
G. Upon termination of this Agreement, Controlled
Affiliate shall immediately notify all of its customers that it
is no longer a licensee of BCBSA and, if directed by the
Association's Board of Directors, shall provide instruction on
how the customer can contact BCBSA or a designated licensee to
obtain further information on securing coverage. The
notification required by this paragraph shall be in writing and
in a form approved by BCBSA. The BCBSA shall have the right to
audit the terminated entity's books and records to verify
compliance with this paragraph.
H. In the event this Agreement terminates pursuant to 7(b)
hereof, or in the event the Controlled Affiliate is a Larger
Controlled Affiliate (as defined in Exhibit A), upon termination
of this Agreement, the provisions of Paragraph 7.G. shall not
apply and the following provisions shall apply:
(1) The Controlled Affiliate shall send a notice through
the U.S. mails, with first class postage affixed, to all
individual and group customers, providers, brokers and agents of
products or services sold, marketed, underwritten or administered
by the Controlled Affiliate under the Licensed Marks and Name.
The form and content of the notice shall be specified by BCBSA
and shall, at a minimum, notify the recipient of the termination
of the license, the consequences thereof, and instructions for
obtaining alternate products or services licensed by BCBSA. This
notice shall be mailed within 15 days after termination.
(2) The Controlled Affiliate shall deliver to BCBSA within
five days of a request by BCBSA a listing of national accounts in
which the Controlled Affiliate is involved (in a control,
participating or servicing capacity), identifying the national
account and the Controlled Affiliate's role therein.
(3) Unless the cause of termination is an event respecting
BCBSA stated in paragraph 15(a) or (b) of the Plan's license
agreement with BCBSA to use the Licensed Marks and Name, the
Controlled Affiliate, the Plan, and any other Licensed Controlled
Affiliates of the Plan shall be jointly liable for payment to
BCBSA of an amount equal to $25 multiplied by the number of
Licensed Enrollees of the Controlled Affiliate; provided that if
any other Plan is permitted by BCBSA to use marks or names
licensed by BCBSA in the Service Area
established by this Agreement, the payment shall be multiplied by
a fraction, the numerator of which is the number of Licensed
Enrollees of the Controlled Affiliate, the Plan, and any other
Licensed Controlled Affiliates and the denominator of which is
the total number of Licensed Enrollees in the Service Area.
Licensed Enrollee means each and every person and covered
dependent who is enrolled as an individual or member of a group
receiving products or services sold, marketed or administered
under marks or names licensed by BCBSA as determined at the
earlier of (i) the end of the last fiscal year of the terminated
entity which ended prior to termination or (ii) the fiscal year
which ended before any transactions causing the termination
began. Notwithstanding the foregoing, the amount payable
pursuant to this subparagraph H. (3) shall be due only to the
extent that, in BCBSA's opinion, it does not cause the net worth
of the Controlled Affiliate, the Plan or any other Licensed
Controlled Affiliates of the Plan to fall below 100% of the
capital benchmark formula, or its equivalent under any successor
formula, as set forth in the applicable financial responsibility
standards established by BCBSA (provided such equivalent is
approved for purposes of this sub paragraph by the affirmative
vote of three-fourths of the Plans and three-fourths of the total
then current weighted vote of all the Plans); measured as of the
date of termination, and adjusted for the value of any
transactions not made in the ordinary course of business. This
payment shall not be due in connection with transactions
exclusively by or among Plans or their affiliates, including
reorganizations, combinations or mergers, where the BCBSA Board
of Directors determines that the license termination does not
result in a material diminution in the number of Licensed
Enrollees or the extent of their coverage.
(4) BCBSA shall have the right to audit the books and
records of the Controlled Affiliate, the Plan, and any other
Licensed Controlled Affiliates of the Plan to verify compliance
with this paragraph 7.H.
(5) As to a breach of 7.H.(1), (2), (3) or (4), the parties
agree that the obligations are immediately enforceable in a court
of competent jurisdiction. As to a breach of 7.H.(1), (2) or (4)
by the Controlled Affiliate, the parties agree there is no
adequate remedy at law and BCBSA is entitled to obtain specific
performance.
I. In the event the Controlled Affiliate is a Smaller
Controlled Affiliate (as defined in Exhibit A), the Controlled
Affiliate agrees to be jointly liable for the amount described in
H.3. hereof upon termination of the BCBSA license agreement of
any Larger Controlled Affiliate of the Plan.
J. BCBSA shall be entitled to enjoin the Controlled
Affiliate or any related party in a court of competent
jurisdiction from entry into any transaction which would result
in a termination of this Agreement unless the Plan's license from
BCBSA to use the Licensed Marks and Names has been terminated
pursuant to 10(d) of the Plan's license agreement upon the
required 6 month written notice.
K. BCBSA acknowledges that it is not the owner of assets
of the Controlled Affiliate.
L. In the event that the Plan has more than 50 percent
voting control of the Controlled Affiliate under Paragraph
2(E)(2) above and is a Larger Controlled Affiliate (as defined in
Exhibit A), then the vote called for in Paragraphs 7(C) and 7(D)
above shall require the affirmative vote of three-fourths of the
Plans and three-fourths of the total then current weighted vote
of all the Plans.
8. DISPUTE RESOLUTION
The parties agree that any disputes between them or between
or among either of them and one or more Plans or Controlled
Affiliates of Plans that use in any manner the Blue Cross and
Blue Cross Marks and Name are subject to the Mediation and
Mandatory Dispute Resolution process attached to and made a part
of Plan's License from BCBSA to use the Licensed Marks and Name
as Exhibits 5, 5A and 5B as amended from time-to-time, which
documents are incorporated herein by reference as though fully
set forth herein.
9. LICENSE FEE
Controlled Affiliate will pay to BCBSA a fee for this
License determined pursuant to the formula(s) set forth in
Exhibit B.
10. JOINT VENTURE
Nothing contained in the Agreement shall be construed as
creating a joint venture, partnership, agency or employment
relationship between Plan and Controlled Affiliate or between
either and BCBSA.
Amended as of March 11, 1999
11. NOTICES AND CORRESPONDENCE
Notices regarding the subject matter of this Agreement or
breach or termination thereof shall be in writing and shall be
addressed in duplicate to the last known address of each other
party, marked respectively to the attention of its President and,
if any, its General Counsel.
12. COMPLETE AGREEMENT
This Agreement contains the complete understandings of the
parties in relation to the subject matter hereof. This Agreement
may only be amended by the affirmative vote of three-fourths of
the Plans and three-fourths of the total then current weighted
vote of all the Plans as officially recorded by the BCBSA
Corporate Secretary.
13. SEVERABILITY
If any term of this Agreement is held to be unlawful by a
court of competent jurisdiction, such findings shall in no way
affect the remaining obligations of the parties hereunder and the
court may substitute a lawful term or condition for any unlawful
term or condition so long as the effect of such substitution is
to provide the parties with the benefits of this Agreement.
14. NONWAIVER
No waiver by BCBSA of any breach or default in performance
on the part of Controlled Affiliate or any other licensee of any
of the terms, covenants or conditions of this Agreement shall
constitute a waiver of any subsequent breach or default in
performance of said terms, covenants or conditions.
14A. VOTING
For all provisions of this Agreement referring to voting, the
term `Plans' shall mean all entities licensed under the Blue
Cross License Agreement and/or the Blue Shield License
Agreement, and in all votes of the Plans under this Agreement
the Plans shall vote together. For weighted votes of the Plans,
the Plan shall have a number of votes equal to the number of
weighted votes (if any) that it holds as a Blue Cross Plan plus
the number of weighted votes (if any) that it holds as a Blue
Shield Plan. For all other votes of the Plans, the Plan shall
have one vote. For all questions requiring an affirmative three-
fourths weighted vote of the Plans, the requirement shall be
deemed satisfied with a lesser weighted vote unless six (6) or
more Plans fail to cast weighted votes in favor of the question.
Amended as of June 16, 2000
THIS PAGE IS INTENTIONALLY BLANK.
15. GOVERNING LAW
This Agreement shall be governed by, and construed and
interpreted in accordance with, the laws of the State of
Illinois.
16. HEADINGS
The headings inserted in this agreement are for convenience
only and shall have no bearing on the interpretation hereof.
IN WITNESS WHEREOF, the parties have caused this License
Agreement to be executed and effective as of the date of last
signature written below.
Controlled Affiliate:
By:______________________________________
Date:____________________________________
Plan:
By:______________________________________
Date:____________________________________
BLUE CROSS AND BLUE SHIELD ASSOCIATION
By:______________________________________
Date:____________________________________
EXHIBIT A
CONTROLLED AFFILIATE LICENSE STANDARDS
September 2000
PREAMBLE
The standards for licensing Controlled Affiliates are
established by BCBSA and are subject to change from time-to-
time upon the affirmative vote of three-fourths (3/4) of the
Plans and three-fourths (3/4) of the total weighted vote.
Each licensed Plan is required to use a standard Controlled
Affiliate license form provided by BCBSA and to cooperate
fully in assuring that the licensed Controlled Affiliate
maintains compliance with the license standards.
The Controlled Affiliate License provides a flexible vehicle
to accommodate the potential range of health and workers'
compensation related products and services Plan Controlled
Affiliates provide. The Controlled Affiliate License
collapses former health Controlled Affiliate licenses (HCC,
HMO, PPO, TPA, and IDS) into a single license using the
following business-based criteria to provide a framework for
license standards:
* Percent of Controlled Affiliate controlled by parent:
Greater than 50 percent or 50 percent?
* Risk assumption: yes or no?
* Medical care delivery: yes or no?
* Size of the Controlled Affiliate: If the Controlled
Affiliate has health or workers' compensation
administration business, does such business constitute 15
percent or more of the parent's and other licensed health
subsidiaries' contract enrollment?
EXHIBIT A (continued)
For purposes of definition:
* A "smaller Controlled Affiliate:" (1) comprises less
than fifteen percent (15%) of Plan's and its licensed
Controlled Affiliates' total contract enrollment (as
reported on the BCBSA Quarterly Enrollment Report,
excluding rider and freestanding coverage, and treating
an entity seeking licensure as licensed);* or (2)
underwrites the indemnity portion of workers'
compensation insurance and has total premium revenue less
than 15 percent of the sponsoring Plan's net subscription
revenue.
* A "larger Controlled Affiliate" comprises fifteen
percent (15%) or more of Plan's and its licensed
Controlled Affiliates' total contract enrollment (as
reported on the BCBSA Quarterly Enrollment Report,
excluding rider and freestanding coverage, and treating
an entity seeking licensure as licensed.)*
Changes in Controlled Affiliate status:
If any Controlled Affiliate's status changes regarding: its
Plan ownership level, its risk acceptance or direct delivery
of medical care, the Controlled Affiliate shall notify BCBSA
within thirty (30) days of such occurrence in writing and
come into compliance with the applicable standards within
six (6) months.
If a smaller Controlled Affiliate's health and workers'
compensation administration business reaches or surpasses
fifteen percent (15%) of the total contract enrollment of
the Plan and licensed Controlled Affiliates, the Controlled
Affiliate shall:
EXHIBIT A (continued)
1. Within thirty (30) days, notify BCBSA of this fact in
writing, including evidence that the Controlled Affiliate
meets the minimum liquidity and capital (BCBSA Capital
Benchmark or "Managed Care Organizations Risk-Based Capital
(MCO-RBC)" as defined by the NAIC and state-established
minimum reserve) requirements of the larger Controlled
Affiliate Financial Responsibility standard; and
2. Within six (6) months after reaching or surpassing the
fifteen percent (15%) threshold, demonstrate compliance
with all license requirements for a larger Controlled
Affiliate.
If a Controlled Affiliate that underwrites the indemnity
portion of workers' compensation insurance receives a change
in rating or proposed change in rating, the Controlled
Affiliate shall notify BCBSA within 30 days of notification
by the external rating agency.
___________
*For purposes of this calculation,
The numerator equals:
Applicant Controlled Affiliate's contract enrollment, as
defined in BCBSA's Quarterly Enrollment Report (excluding
rider and freestanding coverage).
The denominator equals:
Numerator PLUS Plan and all other licensed Controlled
Affiliates' contract enrollment, as reported in BCBSA's
Quarterly Enrollment Report (excluding rider and
freestanding coverage).
EXHIBIT A (continued)
STANDARDS FOR LICENSED CONTROLLED AFFILIATES
As described in Preamble section of Exhibit A to the Affiliate License
Agreement, each controlled affiliate seeking licensure must answer four
questions. Depending on the controlled affiliate's answers, certain
standards apply:
1.What percent of the controlled affiliate is controlled by the parent
Plan?
More than 50% 50% 100% and Primary
Business is
Government Non-Risk
Standard 1A, 4 Standard 1B, 4
Standard 4*,10A
* Applicable only if using the names and marks.
IN ADDITION,
0.Xx risk being assumed?
Yes No
--------------------------------- --------------------------------------
Controlled Controlled Controlled Controlled Controlled Controlled
Affiliate Affiliate Affiliate Affiliate Affiliate Affiliate's
underwrites comprises < comprises >= comprises < comprises >= Primary
any 15% of 15% of 15% of 15% of Business is
indemnity total total total total Government
portion of contract contract contract contract Non-Risk
workers' enrollment enrollment enrollment enrollment
compensation of Plan and of Plan and of Plan and of Plan and
insurance its its its its
licensed licensed licensed licensed
Standards affiliates, affiliates, affiliates affiliates Standard
7A-7E and does and does 10B
not not
underwrite underwrite
the the Standard 2 Standard 6H
indemnity indemnity (Guidelines
portion of portion of 1.1,1.3)
workers' workers'
compensation compensation
insurance insurance
Standard 2 Standard 6H
(Guidelines
1.1,1.2)
IN ADDITION,
0.Xx medical care being directly provided?
Yes No
Standard 3A Standard 3B
IN ADDITION,
4.If the controlled affiliate has health or workers' compensation
administration business, does such business comprise 15% or more of the
total contract enrollment of Plan and its licensed controlled affiliates?
Yes No
Standards 6A-6I Controlled Controlled Controlled
Affiliate is Affiliate Affiliate's
a former is not a Primary
primary former Business is
licensee primary Government
licensee Non-Risk
Standards Standards Standards 8,
5,8,9 5,8 10(C)
EXHIBIT A (continued)
Standard 1 - Organization and Governance
1A.) The Standard for more than 50% Plan control is:
A Controlled Affiliate shall be organized and operated in
such a manner that a licensed Plan or Plans authorized to
use the Licensed Marks in the Service Area of the Controlled
Affiliate pursuant to separate License Agreement(s) with
BCBSA, other than such Controlled Affiliate's License
Agreement(s), (the "Controlling Plan(s)"), have the legal
authority, directly or indirectly through wholly-owned
subsidiaries: 1) to select members of the Controlled
Affiliate's governing body having more than 50% voting
control thereof; and 2) to prevent any change in the
articles of incorporation, bylaws or other establishing or
governing documents of the Controlled Affiliate with which
the Controlling Plan(s) do(es) not concur; and 3) to
exercise control over the policy and operations of the
Controlled Affiliate. In addition, a Plan or Plans directly
or indirectly through wholly-owned subsidiaries shall own
more than 50% of any for-profit Controlled Affiliate.
1B.) The Standard for 50% Plan control is:
A Controlled Affiliate shall be organized and operated in
such a manner that a licensed Plan or Plans authorized to
use the Licensed Marks in the Service Area of the Controlled
Affiliate pursuant to separate License Agreement(s) with
BCBSA, other than such Controlled Affiliate's License
Agreement(s), (the "Controlling Plan(s)"), have the legal
authority, directly or indirectly through wholly-owned
subsidiaries:
1) to select members of the Controlled Affiliate's
governing body having not less than 50% voting control
thereof ; and
2) to prevent any change in the articles of incorporation,
bylaws or other establishing or governing documents of
the Controlled Affiliate with which the Controlling
Plan(s) do(es) not concur; and
3) to exercise control over the policy and operations of
the Controlled Affiliate at least equal to that
exercised by persons or entities (jointly or
individually) other than the Controlling Plan(s).
Notwithstanding anything to the contrary in 1) through 3)
hereof, the Controlled Affiliate's establishing or governing
documents must also require written approval by the
Controlling Plan(s) before the Controlled Affiliate can:
o change the geographic area in which it
operates
o change its legal and/or trade names
o change any of the types of businesses in
which it engages
o create, or become liable for by way of
guarantee, any indebtedness, other than
indebtedness arising in the ordinary course of
business
o sell any assets, except for sales in the
ordinary course of business or sales of equipment
no longer useful or being replaced
o make any loans or advances except in the
ordinary course of business
o enter into any arrangement or agreement with
any party directly or indirectly affiliated with
any of the owners or persons or entities with the
authority to select or appoint members or board
members of the Controlled Affiliate, other than
the Plan or Plans (excluding owners of stock
holdings of under 5% in a publicly traded
Controlled Affiliate)
o conduct any business other than under the
Licensed Marks and Name
o take any action that any Controlling Plan or
BCBSA reasonably believes will adversely affect
the Licensed Marks and Name.
In addition, a Plan or Plans directly or indirectly through
wholly-owned subsidiaries shall own at least 50% of any for-
profit Controlled Affiliate.
EXHIBIT A (continued)
Standard 2 - Financial Responsibility
A Controlled Affiliate shall be operated in a manner that
provides reasonable financial assurance that it can fulfill
all of its contractual obligations to its customers. If a
risk-assuming Controlled Affiliate ceases operations for any
reason, Blue Cross and/or Blue Cross Plan coverage will be
offered to all Controlled Affiliate subscribers without
exclusions, limitations or conditions based on health
status. If a nonrisk-assuming Controlled Affiliate ceases
operations for any reason, sponsoring Plan(s) will provide
for services to its (their) customers.
Standard 3 - State Licensure/Certification
3A.) The Standard for a Controlled Affiliate that employs,
owns or contracts on a substantially exclusive basis
for medical services is:
A Controlled Affiliate shall maintain unimpaired licensure
or certification for its medical care providers to operate
under applicable state laws.
3B.) The Standard for a Controlled Affiliate that does not
employ, own or contract on a substantially exclusive
basis for medical services is:
A Controlled Affiliate shall maintain unimpaired licensure
or certification to operate under applicable state laws.
Standard 4 - Certain Disclosures
A Controlled Affiliate shall make adequate disclosure in
contracting with third parties and in disseminating public
statements of 1) the structure of the Blue Cross and Blue
Shield System; and 2) the independent nature of every
licensee; and 3) the Controlled Affiliate's financial
condition.
Standard 5 - Reports and Records for Certain Smaller
Controlled Affiliates
For a smaller Controlled Affiliate that does not underwrite
the indemnity portion of workers' compensation insurance,
the Standard is:
EXHIBIT A (continued)
A Controlled Affiliate and/or its licensed Plan(s) shall
furnish, on a timely and accurate basis, reports and records
relating to these Standards and the License Agreements
between BCBSA and Controlled Affiliate.
Standard 6 - Other Standards for Larger Controlled
Affiliates
Standards 6(A) - (I) that follow apply to larger Controlled
Affiliates.
Standard 6(A): Board of Directors
A Controlled Affiliate Governing Board shall act in the
interest of its Corporation in providing cost-effective
health care services to its customers. A Controlled
Affiliate shall maintain a governing Board, which shall
control the Controlled Affiliate, composed of a majority of
persons other than providers of health care services, who
shall be known as public members. A public member shall not
be an employee of or have a financial interest in a health
care provider, nor be a member of a profession which
provides health care services.
Standard 6(B): Responsiveness to Customers
A Controlled Affiliate shall be operated in a manner
responsive to customer needs and requirements.
Standard 6(C): Participation in National Programs
A Controlled Affiliate shall effectively and efficiently
participate in each national program as from time to time
may be adopted by the Member Plans for the purposes of
providing portability of membership between the licensees
and ease of claims processing for customers receiving
benefits outside of the Controlled Affiliate's Service Area.
Such programs are applicable to licensees, and include:
1. Transfer Program;
2. BlueCard Program;
EXHIBIT A (continued)
3. Inter-Plan Teleprocessing System (ITS); and
4. Electronic Claims Routing Process.
Standard 6(D): Financial Performance Requirements
In addition to requirements under the national programs
listed in
Standard 6C: Participation in National Programs, a
Controlled Affiliate shall take such action as required to
ensure its financial performance in programs and contracts
of an inter-licensee nature or where BCBSA is a party.
Standard 6(E): Cooperation with Plan Performance Response
Process
A Controlled Affiliate shall cooperate with BCBSA's Board of
Directors and its Plan Performance and Financial Standards
Committee in the administration of the Plan Performance
Response Process and in addressing Controlled Affiliate
performance problems identified thereunder.
Standard 6(F): Independent Financial Rating
A Controlled Affiliate shall obtain a rating of its
financial strength from an independent rating agency
approved by BCBSA's Board of Directors for such purpose.
Standard 6(G): Best Efforts
During each year, a Controlled Affiliate shall use its best
efforts in the designated Service Area to promote and build
the value of the Blue Xxxxx Xxxx.
Standard 6(H): Financial Responsibility
A Controlled Affiliate shall be operated in a manner that
provides reasonable financial assurance that it can fulfill
all of its contractual obligations to its customers.
Amended March 10, 2000
EXHIBIT A (continued)
Standard 6(I): Reports and Records
A Controlled Affiliate shall furnish to BCBSA on a timely
and accurate basis reports and records relating to
compliance with these Standards and the License Agreements
between BCBSA and Controlled Affiliate. Such reports and
records are the following:
A) BCBSA Controlled Affiliate Licensure
Information Request; and
B) Biennial trade name and service xxxx usage
material, including disclosure material; and
C) Changes in the ownership and governance of
the Controlled Affiliate, including changes in its
charter, articles of incorporation, or bylaws,
changes in a Controlled Affiliate's Board
composition, or changes in the identity of the
Controlled Affiliate's Principal Officers, and
changes in risk acceptance, contract growth, or
direct delivery of medical care; and
D) Quarterly Financial Report (current version)
through 12/31/00, Quarterly Financial Report
(revised version) starting 12/31/00 and
thereafter, Semi-annual "Managed Care
Organizations Risk-Based Capital (MCO-RBC) Report"
starting 12/31/98 and thereafter as defined by the
NAIC, Annual Certified Audit Report, Insurance
Department Examination Report, Annual Statement
filed with State Insurance Department (with all
attachments), and
E) Quarterly Enrollment Report (current version)
through 12/31/00, Quarterly Enrollment Report
(revised version) starting 12/31/00 and
thereafter, Semi-Annual Benefit Cost Management
Report starting 6/30/00 and thereafter, and NMIS
Report through June 30, 2000; and
Amended June 16, 2000
EXHIBIT A (continued)
Standard 6(J): Control by Unlicensed Entities Prohibited
No Controlled Affiliate shall cause or permit an entity
other than a Plan or a Licensed Controlled Affiliate
thereof to obtain control of the Controlled Affiliate or
to acquire a substantial portion of its assets related
to licensable services.
Standard 7 - Other Standards for Risk-Assuming Workers'
Compensation Controlled Affiliates
Standards 7(A) - (E) that follow apply to Controlled
Affiliates that underwrite the indemnity portion of workers'
compensation insurance.
Standard 7 (A): Financial Responsibility
A Controlled Affiliate shall be operated in a manner that
provides reasonable financial assurance that it can fulfill
all of its contractual obligations to its customers.
Standard 7(B): Reports and Records
A Controlled Affiliate shall furnish, on a timely and
accurate basis, reports and records relating to
compliance with these Standards and the License
Agreements between BCBSA and the Controlled Affiliate.
Such reports and records are the following:
A. BCBSA Controlled Affiliate Licensure Information
Request; and
B. Biennial trade name and service xxxx usage materials,
including disclosure materials; and
C. Annual Certified Audit Report, Annual Statement as
filed with the State Insurance Department (with all
attachments), Annual NAIC's Risk-Based Capital
Worksheets for Property and Casualty Insurers; and
Amended June 16, 2000
EXHIBIT A (continued)
C. Quarterly Financial Report (current version) through
12/31/00, Quarterly Financial Report (revised version)
starting 12/31/00 and thereafter, Quarterly Estimated Risk-
Based Capital for Property and Casualty Insurers, Insurance
Department Examination Report, and NMIS Report (for licensed
health business only) through June 30, 2000; and
D. Notification of all changes and proposed changes to
independent ratings within 30 days of receipt and submission
of a copy of all rating reports; and
E. Changes in the ownership and governance of the
Controlled Affiliate including changes in its charter,
articles of incorporation, or bylaws, changes in a
Controlled Affiliate's Board composition, Plan control,
state license status, operating area, the Controlled
Affiliate's Principal Officers or direct delivery of medical
care.
Standard 7(C): Loss Prevention
A Controlled Affiliate shall apply loss prevention
protocol to both new and existing business.
Standard 7(D): Claims Administration
A Controlled Affiliate shall maintain an effective
claims administration process that includes all the
necessary functions to assure prompt and proper
resolution of medical and indemnity claims.
Standard 7(E): Disability and Provider Management
A Controlled Affiliate shall arrange for the provision
of appropriate and necessary medical and rehabilitative
services to facilitate early intervention by medical
professionals and timely and appropriate return to work.
Amended November 19, 1999
EXHIBIT A (continued)
Standard 8 - Cooperation with Controlled Affiliate License
Performance Response Process Protocol
A Controlled Affiliate and its Sponsoring Plan(s) shall
cooperate with BCBSA's Board of Directors and its Plan
Performance and Financial Standards Committee in the
administration of the Controlled Affiliate License
Performance Response Process Protocol (ALPRPP) and in
addressing Controlled Affiliate compliance problems
identified thereunder.
Standard 9 - Participation in National Programs by Smaller
Controlled Affiliates
A smaller Controlled Affiliate for which this standard
applies pursuant to the Preamble section of Exhibit A of the
Controlled Affiliate License Agreement shall effectively
and efficiently participate in certain national programs
from time to time as may be adopted by Member Plans for the
purposes of providing ease of claims processing for
customers receiving benefits outside of the Controlled
Affiliate's service area and be subject to certain relevant
financial and reporting requirements.
A. National program requirements include:
* BlueCard Program;
* Inter-Plan Teleprocessing System (ITS);
* Transfer Program; and
* Electronic Claims Routing Process.
B. Financial Requirements include:
* Standard 6(D): Financial Performance Requirements and
Standard 6(H): Financial Responsibility; or
* A financial guarantee covering the Controlled
Affiliate's BlueCard Program obligations in a form, and from
a guarantor, acceptable to BCBSA.
C. Reporting requirements include:
* The Quarterly Capital Benchmark Worksheet.
Amended March 10, 2000
Standard 10 - Other Standards for Controlled Affiliates
Whose Primary Business is Government Non-Risk
Standards 10(A) - (C) that follow apply to Controlled
Affiliates whose primary business is government non-risk.
Standard 10(A) - Organization and Governance
A Controlled Affiliate shall be organized and operated in
such a manner that it is 1) wholly owned by a licensed Plan
or Plans and 2) the sponsoring licensed Plan or Plans have
the legal ability to prevent any change in the articles of
incorporation, bylaws or other establishing or governing
documents of the Controlled Affiliate with which it does not
concur.
EXHIBIT A (continued)
Standard 10(B) - Financial Responsibility
A Controlled Affiliate shall be operated in a manner that
provides reasonable financial assurance that it can fulfill
all of its contractual obligations to its customers.
Standard 10(C):- Reports and Records
A Controlled Affiliate shall furnish, on a timely and
accurate basis, reports and records relating to
compliance with these Standards and the License
Agreements between BCBSA and the Controlled Affiliate.
Such reports and records are the following:
A. BCBSA Affiliate Licensure Information Request;
and
B. Biennial trade name and service xxxx usage
materials, including disclosure material; and
C. Annual Certified Audit Report, Annual Statement
(if required) as filed with the State Insurance
Department (with all attachments), Annual NAIC
Risk-Based Capital Worksheets (if required) as
filed with the State Insurance Department (with
all attachments), and Insurance Department
Examination Report (if applicable)*; and
D. Changes in the ownership and governance of the
Controlled Affiliate, including changes in its
charter, articles of incorporation, or bylaws,
changes in the Controlled Affiliate's Board
composition, Plan control, state license status,
operating area, the Controlled Affiliate's
Principal Officers or direct delivery of medical
care.
EXHIBIT B
ROYALTY FORMULA FOR SECTION 9 OF THE
CONTROLLED AFFILIATE LICENSE AGREEMENT
Controlled Affiliate will pay BCBSA a fee for this license in
accordance with the following formula:
FOR RISK AND GOVERNMENT NON-RISK PRODUCTS:
For Controlled Affiliates not underwriting the indemnity
portion of workers' compensation insurance:
An amount equal to its pro rata share of each sponsoring
Plan's dues payable to BCBSA computed with the addition of
the Controlled Affiliate's subscription revenue and contracts
arising from products using the marks. The payment by each
sponsoring Plan of its dues to BCBSA, including that portion
described in this paragraph, will satisfy the requirement of
this paragraph, and no separate payment will be necessary.
For Controlled Affiliates underwriting the indemnity portion
of workers' compensation insurance:
An amount equal to 0.35 percent of the gross revenue per
annum of Controlled Affiliate arising from products using the
marks; plus, an annual fee of $5,000 per license for a
Controlled Affiliate subject to Standard 7.
For Controlled Affiliates whose primary business is
government non-risk:
An amount equal to its pro-rata share of each sponsoring
Plan's dues payable to BCBSA computed with the addition of
the Controlled Affiliate's government non-risk beneficiaries.
EXHIBIT B (continued)
FOR NONRISK PRODUCTS:
An amount equal to 0.24 percent of the gross revenue per
annum of Controlled Affiliate arising from products using the
marks; plus:
1) An annual fee of $5,000 per license for a Controlled
Affiliate subject to Standard 6.
2) An annual fee of $2,000 per license for all other
Controlled Affiliates.
The foregoing shall be reduced by one-half where both a BLUE
CROSS(R) and BLUE SHIELD(R) License are issued to the same Controlled
Affiliate. In the event that any license period is greater or
less than one (1) year, any amounts due shall be prorated.
Royalties under this formula will be calculated, billed and paid
in arrears.
EXHIBIT 1A
CONTROLLED AFFILIATE LICENSE AGREEMENT
APPLICABLE TO LIFE INSURANCE COMPANIES
(Includes revisions adopted by Member Plans through their
September 22, 2000 meeting)
This agreement by and among Blue Cross and Blue Shield
Association ("BCBSA")
_______________________________("Controlled Affiliate"), a
Controlled Affiliate of the Blue Cross Plan(s), known as
_______________________________________("Plan").
WHEREAS, BCBSA is the owner of the BLUE CROSS and BLUE CROSS
Design service marks;
WHEREAS, the Plan and the Controlled Affiliate desire that the
latter be entitled to use the BLUE CROSS and BLUE CROSS Design
service marks (collectively the "Licensed Marks") as service
marks and be entitled to use the term BLUE CROSS in a trade name
("Licensed Name");
NOW, THEREFORE, in consideration of the foregoing and the mutual
agreements hereinafter set forth and for other good and valuable
consideration, the receipt and sufficiency of which are hereby
acknowledged, the parties hereby agree as follows:
1. GRANT OF LICENSE
Subject to the terms and conditions of this Agreement,
BCBSA hereby grants to the Controlled Affiliate the exclusive
right to use the licensed Marks and Names in connection with and
only in connection with those life insurance and related
services authorized by applicable state law, other than health
care plans and related services (as defined in the Plan's
License Agreements with BCBSA) which services are not separately
licensed to Controlled Affiliate by BCBSA, in the Service Area
served by the Plan, except that BCBSA reserves the right to use
the Licensed Marks and Name in said Service Area, and except to
the extent that said Service Area may overlap the area or areas
served by one or more other licensed Blue Cross Plans as of the
date of this License as to which overlapping areas the rights
hereby granted are non-exclusive as to such other Plan or Plans
and their respective Licensed Controlled Affiliates only.
Controlled Affiliate cannot use the Licensed Marks or Name
outside the Service Area or, anything in any other license to
Controlled Affiliate notwithstanding, in its legal or trade
name.
2. QUALITY CONTROL
A. Controlled Affiliate agrees to use the Licensed
Marks and Name only in relation to the sale, marketing and
rendering of authorized products and further agrees to be bound
by the conditions regarding quality control shown in Exhibit A
as it may be amended by BCBSA from time-to-time.
Amended as of November 17, 1994
-1-
B. Controlled Affiliate agrees that Plan and/or
BCBSA may, from time-to-time, upon reasonable notice, review and
inspect the manner and method of Controlled Affiliate's
rendering of service and use of the Licensed Marks and Name.
C. Controlled Affiliate agrees that it will
provide on an annual basis (or more often if reasonably required
by Plan or by BCBSA) a report to Plan and BCBSA demonstrating
Controlled Affiliate's compliance with the requirements of this
Agreement including but not limited to the quality control
provisions of Exhibit A.
D. As used herein, a Controlled Affiliate is
defined as an entity organized and operated in such a manner
that it is subject to the bona fide control of a Plan or Plans.
Absent written approval by BCBSA of an alternative method of
control, bona fide control shall mean the legal authority,
directly or indirectly through wholly-owned subsidiaries: (a) to
select members of the Controlled Affiliate's governing body
having not less than 51% voting control thereof; (b) to exercise
operational control with respect to the governance thereof; and
(c) to prevent any change in its articles of incorporation,
bylaws or other governing documents deemed inappropriate. In
addition, a Plan or Plans shall own at least 51% of any
for-profit Controlled Affiliate. If the Controlled Affiliate is
a mutual company, the Plan or its designee(s) shall have and
maintain, in lieu of the requirements of items (a) and (c)
above, proxies representing 51% of the votes at any meeting of
the policyholders and shall demonstrate that there is no reason
to believe this such proxies shall be revoked by sufficient
policyholders to reduce such percentage below 51%.
3. SERVICE XXXX USE
Controlled Affiliate shall at all times make proper
service xxxx use of the Licensed Marks, including but not
limited to use of such symbols or words as BCBSA shall specify
to protect the Licensed Marks, and shall comply with such rules
(applicable to all Controlled Affiliates licensed to use the
Marks) relative to service xxxx use, as are issued from
time-to-time by BCBSA. If there is any public reference to the
affiliation between the Plan and the Controlled Affiliate, all
of the Controlled Affiliate's licensed services in the Service
Area of the Plan shall be rendered under the Licensed Marks.
Controlled Affiliate recognizes and agrees that all use of the
Licensed Marks by Controlled Affiliate shall inure to the
benefit of BCBSA.
4. SUBLICENSING AND ASSIGNMENT
Controlled Affiliate shall not sublicense, transfer,
hypothecate, sell, encumber or mortgage, by operation of law or
otherwise, the rights granted hereunder and any such act shall
be voidable at the option of Plan or BCBSA. This Agreement and
all rights and duties hereunder are personal to Controlled
Affiliate.
-2-
5. INFRINGEMENTS
Controlled Affiliate shall promptly notify Plan and
BCBSA of any suspected acts of infringement, unfair competition
or passing off which may occur in relation to the Licensed
Marks. Controlled Affiliate shall not be entitled to require
Plan or BCBSA to take any actions or institute any proceedings
to prevent infringement, unfair competition or passing off by
third parties. Controlled Affiliate agrees to render to Plan
and BCBSA, free of charge, all reasonable assistance in
connection with any matter pertaining to the protection of the
Licensed Marks by BCBSA.
6. LIABILITY INDEMNIFICATION
Controlled Affiliate hereby agrees to save, defend,
indemnify and hold Plan and BCBSA harmless from and against all
claims, damages, liabilities and costs of every kind, nature and
description which may arise as a result of Controlled
Affiliate's rendering of health care services under the Licensed
Marks.
7. LICENSE TERM
The license granted by this Agreement shall remain in
effect for a period of one (1) year and shall be automatically
extended for additional one (1) year periods upon evidence
satisfactory to the Plan and BCBSA that Controlled Affiliate
meets the then applicable quality control standards, unless one
of the parties hereto notifies the other party of the
termination hereof at least sixty (60) days prior to expiration
of any license period.
This Agreement may be terminated by the Plan or by
BCBSA for cause at any time provided that Controlled Affiliate
has been given a reasonable opportunity to cure and shall not
effect such a cure within thirty (30) days of receiving written
notice of the intent to terminate (or commence a cure within
such thirty day period and continue diligent efforts to complete
the cure if such curing cannot reasonably be completed within
such thirty day period). By way of example and not for purposes
of limitation, Controlled Affiliate's failure to abide by the
quality control provisions of Paragraph 2, above, shall be
considered a proper ground for cancellation of this Agreement.
This Agreement and all of Controlled Affiliate's
rights hereunder shall immediately terminate without any further
action by any party or entity in the event that:
-3-
A. Controlled Affiliate shall no longer comply with
Standard No. 1 (Organization and Governance) of Exhibit A or,
following an opportunity to cure, with the remaining quality
control provisions of Exhibit A, as it may be amended from
time-to-time; or
B. Plan ceases to be authorized to use the Licensed
Marks; or
C. Appropriate dues for Controlled Affiliate
pursuant to item 8 hereof, which are the royalties for this
License Agreement are more than sixty (60) days in arrears to
BCBSA.
Upon termination of this Agreement for cause or otherwise,
Controlled Affiliate agrees that it shall immediately
discontinue all use of the Licensed Marks including any use in
its trade name.
In the event of any disagreement between Plan and BCBSA as
to whether grounds exist for termination or as to any other term
or condition hereof, the decision of BCBSA shall control,
subject to provisions for mediation or mandatory dispute
resolution in effect between the parties.
Upon termination of this Agreement, Licensed Controlled
Affiliate shall immediately notify all of its customers that it
is no longer a licensee of the Blue Cross and Blue Shield
Association and provide instruction on how the customer can
contact the Blue Cross and Blue Shield Association or a
designated licensee to obtain further information on securing
coverage. The written notification required by this paragraph
shall be in writing and in a form approved by the Association.
The Association shall have the right to audit the terminated
entity's books and records to verify compliance with this
paragraph.
8. DUES
Controlled Affiliate will pay to BCBSA a fee for this
license in accordance with the following formula:
* An annual fee of five thousand dollars ($5,000) per
license, plus
* .05% of gross revenue per year from branded group products,
plus
* .5% of gross revenue per year from branded individual
products plus
* .14% of gross revenue per year from branded individual
annuity products.
The foregoing percentages shall be reduced by one-half
where both a BLUE CROSS(R) and BLUE SHIELD(R) license are
issued to the same entity. In the event that any License
period is greater or less than one (1) year, any amounts
due shall be prorated. Royalties under this formula will
be calculated, billed and paid in arrears.
Amended as of November 20, 1997
-4-
Plan will promptly and timely transmit to BCBSA all dues
owed by Controlled Affiliate as determined by the above formula
and if Plan shall fail to do so, Controlled Affiliate shall pay
such dues directly.
9. JOINT VENTURE
Nothing contained in this Agreement shall be construed as
creating a joint venture, partnership, agency or employment
relationship between Plan and Controlled Affiliate or between
either and BCBSA.
9A. VOTING
For all provisions of this Agreement referring to voting,
the term `Plans' shall mean all entities licensed under the Blue
Cross License Agreement and/or the Blue Shield License
Agreement, and in all votes of the Plans under this Agreement
the Plans shall vote together. For weighted votes of the Plans,
the Plan shall have a number of votes equal to the number of
weighted votes (if any) that it holds as a Blue Cross Plan plus
the number of weighted votes (if any) that it holds as a Blue
Shield Plan. For all other votes of the Plans, the Plan shall
have one vote. For all questions requiring an affirmative three-
fourths weighted vote of the Plans, the requirement shall be
deemed satisfied with a lesser weighted vote unless six (6) or
more Plans fail to cast weighted votes in favor of the question.
Amended as of June 16, 2000
-4a-
(The next page is page 5)
10. NOTICES AND CORRESPONDENCE
Notices regarding the subject matter of this Agreement or
breach or termination thereof shall be in writing and shall be
addressed in duplicate to the last known address of each other
party, marked respectively to the attention of its President
and, if any, its General Counsel.
11. COMPLETE AGREEMENT
This Agreement contains the complete understandings of the
parties in relation to the subject matter hereof. This
Agreement may only be amended by a writing executed by all
parties.
12. SEVERABILITY
If any term of this Agreement is held to be unlawful by a
court of competent jurisdiction, such finding shall in no way
effect the remaining obligations of the parties hereunder and
the court may substitute a lawful term or condition for any
unlawful term or condition so long as the effect of such
substitution is to provide the parties with the benefits of this
Agreement.
13. NONWAIVER
No waiver by BCBSA of any breach or default in performance
on the part of the Controlled Affiliate or any other licensee of
any of the terms, covenants or conditions of this Agreement
shall constitute a waiver of any subsequent breach or default in
performance of said terms, covenants or conditions.
14. GOVERNING LAW
This Agreement shall be governed by, and construed and
interpreted in accordance with, the laws of the State of
Illinois.
IN WITNESS WHEREOF, the parties have caused this License
Agreement to be executed, effective as of the date of last
signature written below.
BLUE CROSS AND BLUE SHIELD ASSOCIATION
By:
Date:
Controlled Affiliate
By:
Date:
Plan:
-5-
EXHIBIT A
CONTROLLED AFFILIATE LICENSE STANDARDS
LIFE INSURANCE COMPANIES
Page 1 of 2
PREAMBLE
The standards for licensing Life Insurance Companies (Life and
Health Insurance companies, as defined by state statute) are
established by BCBSA and are subject to change from time-to-time
upon the affirmative vote of three-fourths (3/4) of the Plans
and three-fourths (3/4) of the total weighted vote of all Plans.
Each Licensed Plan is required to use a standard controlled
affiliate license form provided by BCBSA and to cooperate fully
in assuring that the licensed Life Insurance Company maintains
compliance with the license standards.
An organization meeting the following standards shall be
eligible for a license to use the Licensed Marks within the
service area of its sponsoring Licensed Plan to the extent and
the manner authorized under the Controlled Affiliate License
applicable to Life Insurance Companies and the principal license
to the Plan.
Standard 1 - Organization and Governance
The LIC shall be organized and operated in such a manner that it
is controlled by a licensed Plan or Plans which have, directly
or indirectly: 1) not less than 51% of the voting control of the
LIC; and 2) the legal ability to prevent any change in the
articles of incorporation, bylaws or other establishing or
governing documents of the LIC with which it does not concur;
and 3) operational control of the LIC.
If the LIC is a mutual company, the Plan or its designee(s)
shall have and maintain, in lieu of the requirements of items 1
and 2 above, proxies representing at least 51% of the votes at
any policyholder meeting and shall demonstrate that there is no
reason to believe such proxies shall be revoked by sufficient
policyholders to reduce such percentage below 51%.
Standard 2 - State Licensure
The LIC must maintain unimpaired licensure or certificate of
authority to operate under applicable state laws as a life and
health insurance company in each state in which the LIC does
business.
Standard 3 - Records and Examination
The LIC and its sponsoring licensed Plan(s) shall maintain and
furnish, on a timely and accurate basis, such records and
reports regarding the LIC as may be required in order to
establish compliance with the license agreement. The LIC and
its sponsoring licensed Plan(s) shall permit BCBSA to examine
the affairs of the LIC and shall agree that BCBSA's board may
submit a written report to the chief executive officer(s) and
the board(s) of directors of the sponsoring Plan(s).
-1-
CONTROLLED AFFILIATE LICENSE STANDARDS
LIFE INSURANCE COMPANIES
Page 2 of 2
Standard 4 - Mediation
The LIC and its sponsoring Plan(s) shall agree to use the then-
current BCBSA mediation and mandatory dispute resolution
processes, in lieu of a legal action between or among another
licensed controlled affiliate, a licensed Plan or BCBSA.
Standard 5 - Financial Responsibility
The LIC shall maintain adequate financial resources to protect
its customers and meet its business obligations.
-2-
EXHIBIT 2
Membership Standards
Page 1 of 4
Preamble
The Membership Standards apply to all organizations seeking to
become or to continue as Regular Members of the Blue Cross and
Blue Shield Association. Any organization seeking to become a
Regular Member must be found to be in substantial compliance
with all Membership Standards at the time membership is granted
and the organization must be found to be in substantial
compliance with all Membership Standards for a period of two (2)
years preceding the date of its application. If Membership is
sought by an entity which controls or is controlled by one or
more Plans, such compliance shall be determined on the basis of
compliance by such Plan or Plans.
The Regular Member Plans shall have authority to interpret these
Standards. Compliance with any Membership Standard may be
excused, at the Plans' discretion, if the Plans agree that
compliance with such Standard would require the Plan to violate
a law or governmental regulation governing its operation or
activities.
A Regular Member Plan that operates as a "Shell Holding Company"
is defined as an entity that assumes no underwriting risk and has
less than 1% of the consolidated enterprise assets (excludes
investments in subsidiaries) and less than 5% of the consolidated
enterprise general and administrative expenses.
A Regular Member Plan that operates as a "Hybrid Holding Company"
is defined as an entity that assumes no underwriting risk and has
either more than 1% of the consolidated enterprise assets
(excludes investments in subsidiaries) or more than 5% of the
consolidated enterprise general and administrative expenses.
Standard 1: A Plan's Board shall not be controlled by any
special interest group, and shall act in the
interest of its Corporation in providing cost-
effective health care services to its customers.
A Plan shall maintain a governing Board, which
shall control the Plan, composed of a majority of
persons other than providers of health care
services, who shall be known as public members. A
public member shall not be an employee of or have
a financial interest in a health care provider,
nor be a member of a profession which provides
health care services.
Standard 2: A Plan shall furnish to the Association on a
timely and accurate basis reports and records
relating to compliance with these Standards and
the License Agreements between the Association and
the Plans. Such reports and records are the
following:
Amended as of November 19, 1998
EXHIBIT 2
Membership Standards
Page 2 of 4
A. BCBSA Membership Information Request;
B. Biennial trade name and service xxxx usage
material, including disclosure material under
Standard 7;
C. Changes in the governance
of the Plan, including changes in a Plan's
Charter, Articles of Incorporation, or Bylaws,
changes in a Plan's Board composition, or
changes in the identity of the Plan's
Principal Officers;
D. Quarterly Financial Report (current
version) through 12/31/00, Quarterly Financial
Report (revised version) starting 12/31/00 and
thereafter, Combined Quarterly Financial
Report starting 12/31/00 and thereafter, Semi-
annual "Managed Care Organizations Risk-Based
Capital (MCO-RBC) Report" starting 12/31/98
and thereafter as defined by the NAIC,
Combined Annual Financial Forecast, Annual
Certified Audit Report, Insurance Department
Examination Report, Annual Statement filed
with State Insurance Department (with all
attachments), Consolidating Financial
Statement; and
* Starting 12/31/98 and thereafter, Plans that are a Shell
Holding Company as defined in the Preamble hereto are
required to furnish only a calendar year-end "Managed Care
Organizations Risk-Based Capital (MCO-RBC) Report" as
defined by the NAIC.
* Starting 1/1/99 and thereafter, Plans that are a Shell
Holding Company as defined in the Preamble hereto are not
required to furnish a Quarterly Plan Capital Benchmark
Worksheet.
Amended as of June 16, 2000
EXHIBIT 2
Membership Standards
Page 3 of 4
E. Quarterly Enrollment Report
(current version) through 12/31/00, Quarterly
Enrollment Report (revised version) starting
12/31/00 and thereafter, Semi-Annual Benefit
Cost Management Report starting 6/30/00 and
thereafter, and NMIS Report up to and through
second quarter 2000 and Member Touchpoint
Measures Index (MTM) starting 12/31/00 and
semi-annually thereafter; and
* Starting 1/1/99 and thereafter, Plans that are a Shell
Holding Company as defined in the Preamble hereto are not
required to furnish any items identified in Paragraph E.
*
Standard 3: A Plan shall be operated in a manner that
provides reasonable financial assurance that it
can fulfill its contractual obligations to its
customers.
Standard 4: A Plan shall be operated in a manner responsive
to customer needs and requirements.
Standard 5: A Plan shall effectively and efficiently
participate in each national program as from
time to time may be adopted by the Member Plans
for the purposes of providing portability of
membership between the Plans and ease of claims
processing for customers receiving benefits
outside of the Plan's Service Area.
Such programs are applicable to Blue Cross and Blue Shield
Plans, and include:
A. Transfer Program;
B. Inter-Plan Teleprocessing System (ITS);
C. BlueCard Program; and
D. Electronic Claims Routing Process
Amended as of March 10, 2000
EXHIBIT 2
Membership Standards
Page 4 of 4
Standard 6: In addition to requirements under the national
programs listed in Standard 5: Participation in
National Programs, a Plan shall take such action
as required to ensure its financial performance
in programs and contracts of an inter-Plan
nature or where the Association is a party.
Standard 7: A Plan shall make adequate disclosure in
contracting with third parties and in
disseminating public statements of (i) the
structure of the Blue Cross and Blue Shield
System, (ii) the independent nature of every
Plan, and (iii) the Plan's financial condition.
Standard 8: A Plan shall cooperate with the Association's
Board of Directors and its Plan Performance and
Financial Standards Committee in the
administration of the Plan Performance Response
Process and in addressing Plan performance
problems identified thereunder.
Standard 9: A Plan shall obtain a rating of its financial
strength from an independent rating agency
approved by the Association's Board of Directors
for such purpose.
Standard 10: During each year, a Plan and its Controlled
Affiliate(s) engaged in providing licensable
services (excluding Life Insurance and
Charitable Foundation Services) shall use their
best efforts in the designated Service Area to
promote and build the value of the Blue Cross
and Blue Shield Marks.
Standard 11 Neither a Plan nor any Larger Controlled
Affiliate shall cause or permit an entity other
than a Plan or a Licensed Controlled Affiliate
thereof to obtain control of the Plan or Larger
Controlled Affiliate or to acquire a substantial
portion of its assets related to licensable
services.
Amended as of June 18, 1999
EXHIBIT 3
GUIDELINES WITH RESPECT TO USE OF
LICENSED NAME AND MARKS IN CONNECTION WITH NATIONAL ACCOUNTS
Page 1 of 3
1. The strength of the Blue Cross/Blue Cross National Accounts
mechanism, and the continued provision of cost effective,
quality health care benefits to National Accounts, are
predicated on locally managed provider networks coordinated on a
national scale in a manner consistent with effective service to
National Account customers and consistent with the preservation
of the integrity of the Blue Cross/Blue Shield system and the
Licensed Marks. These guidelines shall be interpreted in keeping
with such ends.
2. A National Account is an entity with employee and/or retiree
locations in more than one Plan's Service Area. Unless otherwise
agreed, a National Account is deemed located in the Service Area
in which the corporate headquarters of the National Account is
located. The Control Plan of a National Account is the Plan in
whose Service Area the National Account is located. A
participating ("Par") Plan is a Plan in whose Service Area the
National Account has employee and/or retiree locations, but in
which the National Account is not located.
3. The National Account Guidelines enunciated herein below shall
be applicable only with respect to the business of new National
Accounts acquired after January 1, 1991.
4. Control Plans shall utilize National Account identification
cards complying with then currently effective BCBSA graphic
standards in connection with all National Accounts business to
facilitate administration thereof, to minimize subscriber and
provider confusion, and to reflect a commitment to cooperation
among Plans.
5. Disputes among Plans and/or BCBSA as to the interpretation or
implementation of these Guidelines or as to other National
Accounts issues shall be submitted to mediation and mandatory
dispute resolution as provided in the License Agreement. For two
years from the effective date of the License Agreement, however,
such disputes shall be subject to mediation only, with the
results of such mediation to be collected and reported in order
to establish more definitive operating parameters for National
Accounts business and to serve as ground rules for future
binding dispute resolution.
EXHIBIT 3
Page 2 of 3
6. The Control Plan may use the BlueCard Program (as defined by
IPOC) to deliver benefits to employees and non-Medicare eligible
retirees in a Participating Plan's service area if an
alternative arrangement with the Participating Plan cannot be
negotiated. The Participating Plan's minimum servicing
requirement for those employees and non-Medicare retirees in its
service area is to deliver benefits using the BlueCard Program.
Account delivery is subject to the policies, provisions and
procedures of the BlueCard Program.
7. For provider payments in a Participating Plan's area (on non-
BlueCard claims), payment to the provider may be made by the
Participating Plan or the Control Plan at the Participating
Plan's option. If the Participating Plan elects to pay the
provider, it may not withhold payment of a claim verified by the
Control Plan or its designated processor, and payment must be in
conformity with service criteria established by the Board of
Directors of BCBSA (or an authorized committee thereof) to
assure prompt payment, good service and minimum confusion with
providers and subscribers. The Control Plan, at the
Participating Plan's request, will also assure that measures are
taken to protect the confidentiality of the data pertaining to
provider reimbursement levels and profiles.
8. For claim payments in a Participating Plan's area (on non-
BlueCard claims), Participating Plans are strongly encouraged,
but not required, to pass along to the Control Plan part or all
of local provider discounts and differentials for use by the
Control Plan in negotiating financial arrangements with National
Accounts. However, since the size, basis, form and use of local
differentials can vary substantially among Plans and also by
individual National Account characteristics, the degree and form
of any discount or differential passed along to the Control Plan
shall be strictly a matter of negotiated contractual agreement
between a Participating Plan and the Control Plan and may also
vary from one National Account to another. In order to
facilitate the quotation of national account pricing and the
offering of a variety of National Account delivery systems, all
Plans are strongly encouraged to periodically publish to other
Plans and the BCBSA their National Account contracting policies
with respect to the handling of differentials.
The Control Plan, in its financial agreements with a National
Account, is expected to reasonably reflect the aggregate amount
of differentials passed along to the Control Plan by all
Participating Plans in a National Account. The exact form and
substance of this may vary from one National Account to another
and shall be a matter of
Amended as of June 14, 1996
EXHIBIT 3
Page 3 of 3
explicit negotiation and contractual relationship between the
National Account and the Control Plan. The specifics in an
agreement between the Control Plan and the National Account may
vary in form (e.g., a guaranteed offset against retentions, or a
direct pass through, or a guaranteed aggregate percentage
discount, or no pass back at all, etc.), and the Control Plan
has the responsibility and the Authority to negotiate precise
arrangements. However, irrespective of the final arrangements
between the Control Plan and the National Account, a
Participating Plan's liability for passing along differentials
shall be limited to the contractual agreement the Participating
Plan has with the Control Plan on a specific National Account.
9. Other than in contracting with health care providers or
soliciting such contracts in areas contiguous to a Plan's
Service Area in order to serve its subscribers or those of its
licensed Controlled Affiliate residing or working in its Service
Area, a Control Plan may not use the Licensed Marks and/or Name,
as a tag line or otherwise, to negotiate directly with providers
outside its Service Area.
EXHIBIT 4
GOVERNMENT PROGRAMS AND CERTAIN OTHER USES
Page 1 of 2
1. A Plan and its licensed Controlled Affiliate may use the
Licensed Marks and Name in bidding on and executing a contract
to serve a Government Program, and in thereafter communicating
with the Government concerning the Program. With respect,
however, to such contracts entered into after the 1st day of
January, 1991, the Licensed Marks and Name will not be used in
communications or transactions with beneficiaries or providers
in the Government Program located outside a Plan's Service Area,
unless the Plan can demonstrate to the satisfaction of BCBSA's
governing body that such a restriction on use of the Licensed
Marks and Name will jeopardize its ability to procure the
contract for the Government Program. As to both existing and
future contracts for Government Programs, Plans will discontinue
use of the Licensed Marks and Name as to beneficiaries and
Providers outside their Service Area as expenditiously as
circumstances reasonably permit. Effective January 1, 1995,
except as provided in the first sentence above, all use by a
Plan of the Licensed Marks and Name in Government Programs
outside of the Plan's Service Area shall be discontinued.
Incidental communications outside a Plan's Service Area with
resident or former resident beneficiaries of the Plan, and other
categories of necessary incidental communications approved by
BCBSA, are not prohibited.
2. In connection with activity otherwise in furtherance of the
License Agreement, a Plan may use the Licensed Marks and Name
outside its Service Area in the following circumstances which
are deemed legitimate and necessary and not likely to cause
consumer confusion:
a. sending letterhead, envelopes, and similar items for
administrative purposes which do not solicit the sale of health
care plans and related services;
b. distributing business cards other than in marketing and selling;
c. contracting with health care providers or soliciting such
contracts in areas contiguous to a Plan's Service Area in order
to serve its subscribers or those of its licensed Controlled
Affiliate residing or working in its service area;
d. issuing a small sign containing the legal name or trade name of
the Plan or its licensed Controlled Affiliate for display by a
provider to identify the latter as a participating provider of
the Plan or Controlled Affiliate;
EXHIBIT 4
Page 2 of 2
e. advertising in publications or electronic media solely to persons
for employment;
f. advertising in print, electronic or other media which serve, as
a substantial market, the Service Area of the Plan or licensed
Controlled Affiliate, provided that no Plan may advertise outside
its Service Area on the national broadcast and cable networks
and that advertisements in national print media are limited to
the smallest regional edition encompassing the Service Area;
g. advertising by direct mail where the addressee's zip code plus 4
includes, at least in part, the Plan's Service Area or that of
a licensed Controlled Affiliate.
EXHIBIT 5
MEDIATION AND MANDATORY DISPUTE RESOLUTION (MMDR) RULES
The Blue Cross and Blue Shield Plans ("Plans") and the Blue
Cross Blue Shield Association ("BCBSA") recognize and acknowledge
that the Blue Cross and Blue Shield system is a unique nonprofit
and for-profit system offering cost effective health care
financing and services. The Plans and BCBSA desire to utilize
Mediation and Mandatory Dispute Resolution ("MMDR") to avoid
expensive and time-consuming litigation that may otherwise occur
in the federal and state judicial systems. Even MMDR should be
viewed, however, as methods of last resort, all other procedures
for dispute resolution having failed. Except as otherwise
provided in the License Agreements, the Plans, their Controlled
Affiliates and BCBSA agree to submit all disputes to MMDR
pursuant to these Rules and in lieu of litigation.
1. Initiation of Proceedings
A. Pre-MMDR Efforts
Before filing a Complaint to invoke the MMDR process, the
CEO of a complaining party, or his/her designated representative,
shall undertake good faith efforts with the other side(s) to try
to resolve any dispute.
B. Complaint
To commence a proceeding, the complaining party (or parties)
shall provide by certified mail, return receipt requested, a
written Complaint to the BCBSA Corporate Secretary (which shall
also constitute service on BCBSA if it is a respondent) and to
any Plan(s) and/or Controlled Affiliate(s) named therein. The
Complaint shall contain:
i. identification of the complaining party (or parties)
requesting the proceeding;
ii. identification of the respondent(s);
iii. identification of any other persons or entities who are
interested in a resolution of the dispute;
iv. a full statement describing the nature of the dispute;
v. identification of all of the issues that are being submitted
for resolution;
Amended as of November 21, 1996
vi. the remedy sought;
vii. a statement as to whether the complaining party (or parties)
elect(s) first to pursue Mediation;
viii. any request, if applicable, that one or more members of
the Mediation Committee be disqualified from the proceeding and
the grounds for such request;
ix. any request, if applicable, that the matter be handled on an
expedited basis and the reasons therefor; and
x. a statement signed by the CEO of the complaining party
affirming that the CEO has undertaken efforts, or has directed
efforts to be undertaken, to resolve the dispute before resorting
to the MMDR process.
The complaining party (or parties) shall file and serve with the
Complaint copies of all documents which the party (or parties)
intend(s) to offer at the Arbitration Hearing and a statement
identifying the witnesses the party (or parties) intend(s) to
present at the Hearing, along with a summary of each witness'
expected testimony.
C. Answer
Within twenty (20) days after receipt of the Complaint, each
respondent shall serve on the BCBSA and on the complaining party
(or parties) and on the Chairman of the Mediation Committee;
i. a full Answer to the aforesaid Complaint;
ii. a statement of any Counterclaims against the complaining
party (or parties), providing with respect thereto the
information specified in Paragraph 1.B., above;
iii. a statement as to whether the respondent elects to first
pursue Mediation;
iv. any request, if applicable, that one or more members of the
Mediation Committee be disqualified from the proceeding and the
grounds for such request; and
v. any request, if applicable, that the matter be handled on an
expedited basis and the reasons therefor.
The respondent(s) shall file and serve with the Answer or by the
date of the Initial Conference set forth in Paragraph 3.B.,
below, copies of all documents which the respondent(s) intend(s)
to offer at the Arbitration Hearing and a statement identifying
the witnesses the party (or parties) intend(s) to present at the
Hearing, along with a summary of each witness' expected
testimony.
D. Reply To Counterclaim
Within ten (10) days after receipt of any Counterclaim, the
complaining party (or parties) shall serve on BCBSA and on the
responding party (or parties) and on the Chairman of the
Mediation Committee, a Reply to the Counterclaim. Such Reply
must provide the same information required by Paragraph 1.C.
2. Mediation
A. Mediation Committee
To facilitate the mediation of disputes between or among
BCBSA, the Plans and/or their Controlled Affiliates, the BCBSA
Board has established a Mediation Committee. Mediation may be
pursued in lieu of or in an effort to obviate the Mandatory
Dispute Resolution process, and all parties are strongly urged to
exhaust the mediation procedure.
B. Election To Mediate
If any party elects first to pursue Mediation, and if it
appears to the Corporate Secretary that the dispute falls within
the jurisdiction of the Mediation Committee, as set forth in
Exhibit 5-A hereto, then the Corporate Secretary will promptly
furnish the Mediation Committee with copies of the Complaint,
Answer, Counterclaim and Reply to Counterclaim, and other
documents referenced in Paragraph 1, above.
C. Selection of Mediators
The parties shall promptly attempt to agree upon: (i) the
number of mediators desired, not to exceed three mediators; and
(ii) the selection of the mediator(s) who may include members of
the Mediation Committee and/or experienced mediators from an
independent entity to mediate all disputes set forth in the
Complaint and Answer (and Counterclaim and Reply, if any). In
the event the parties cannot agree upon the number of mediators
desired, that number shall default to three. In the event the
parties cannot agree upon the selection of mediator(s), the
Chairman will select the mediator(s), at least one of which shall
be an experienced mediator from an independent entity, consistent
with the provisions set forth in this Paragraph. No member of
the Mediation Committee who is a representative of any party to
the Mediation may be selected to mediate the dispute. The
Chairman shall also endeavor not to select as a mediator any
member of the Mediation Committee whom a party has requested to
be disqualified. If, after due regard for availability,
expertise, and such other considerations as may best promote an
expeditious Mediation, the Chairman
believes that he or she must consider for selection a member of
the Mediation Committee whom a party has requested to be
disqualified, the other members of the Committee eligible to be
selected to mediate the dispute shall decide the request for
disqualification. By agreeing to participate in the Mediation of
a dispute, a member of the Mediation Committee represents to the
party (or parties) thereto that he or she knows of no grounds
which would require his or her disqualification.
D. Binding Decision
Before the date of the Mediation Hearing described below,
the Corporate Secretary will contact the party (or parties) to
determine whether they wish to be bound by any recommendation of
the selected mediators for resolution of the disputes. If all
wish to be bound, the Corporate Secretary will send appropriate
documentation to them for their signatures before the Mediation
Hearing begins.
E. Mediation Procedure
The Chairman shall promptly advise the parties of a
scheduled Mediation Hearing date. Unless a party requests an
expedited procedure, or unless all parties to the proceeding
agree to one or more extensions of time, the Mediation Hearing
set forth below shall be completed within forty (40) days of
BCBSA's receipt of the Complaint. The selected mediators, unless
the parties otherwise agree, shall adhere to the following
procedure:
i. Each party must be represented by its CEO or other
representative who has been delegated full authority to resolve
the dispute. However, parties may send additional
representatives as they see fit.
ii. By no later than five (5) days prior to the date designated
for the Mediation Hearing, each party shall supply and serve a
list of all persons who will be attending the Mediation Hearing,
and indicate who will have the authority to resolve the dispute.
iii. Each party will be given one-half hour to present its case,
beginning with the complaining party (or parties), followed by
the other party or parties. The parties are free to structure
their presentations as they see fit, using oral statements or
direct examination of witnesses. However, neither cross-
examination nor questioning of opposing representatives will be
permitted. At the close of each presentation, the selected
mediators will be given an opportunity to ask questions of the
presenters and witnesses. All parties must be present throughout
the Mediation Hearing. The selected mediators may extend the
time allowed for each party's presentation at the Mediation
Hearing. The selected mediators may meet in executive session,
outside the presence of the parties, or may meet with the parties
separately, to discuss the controversy.
iv. After the close of the presentations, the parties will
attempt to negotiate a settlement of the dispute. If the parties
desire, the selected mediators, or any one or more of the
selected mediators, will sit in on the negotiations.
v. After the close of the presentations, the selected mediators
may meet privately to agree upon a recommendation for resolution
of the dispute which would be submitted to the parties for their
consideration and approval. If the parties have previously
agreed to be bound by the results of this procedure, this
recommendation shall be binding upon the parties.
vi. The purpose of the Mediation Hearing is to assist the
parties to settle their grievances short of mandatory dispute
resolution. As a result, the Mediation Hearing has been designed
to be as informal as possible. Rules of evidence shall not
apply. There will be no transcript of the proceedings, and no
party may make a tape recording of the Mediation Hearing.
vii. In order to facilitate a free and open discussion, the
Mediation proceeding shall remain confidential. A "Stipulation
to Confidentiality" which prohibits future use of settlement
offers, all position papers or other statements furnished to the
selected mediators, and decisions or recommendations in any
Mediation proceeding shall be executed by each party.
viii. Upon request of the selected mediators, or one of the
parties, BCBSA staff may also submit documentation at any time
during the proceedings.
F. Notice Of Termination Of Mediation
If the Mediation cannot be completed within the prescribed
or agreed time period due to the lack of cooperation of any
party, as determined by the selected mediators, or if the
Mediation does not result in a final resolution of all disputes
at the Mediation Hearing or within forty (40) days after the
Complaint was served, whichever comes first, any party or any one
of the selected mediators may so notify the Corporate Secretary,
who shall promptly issue a Notice of termination of mediation to
all parties, to the selected mediators, and to the MDR
Administrator, defined below. Such notice shall serve to bring
the Mediation to an end and to initiate Mandatory Dispute
Resolution. Upon agreement of all parties and the selected
mediators, the Mediation process may continue at the same time
the MDR process is invoked. The Notice described above would
serve to initiate the MDR proceeding and would not terminate the
proceedings.
3. Mandatory Dispute Resolution (MDR)
If all parties elect not to first pursue Mediation, or if a
notice of termination of Mediation is issued as set forth in
Paragraph 2.F., above, then the unresolved disputes set forth in
any Complaint and Answer (and Counterclaim and Reply, if any)
shall be subject to MDR.
A. MDR Administrator
The Administrator shall be an independent entity such as the
Center for Public Resources, Inc. or Endispute, Inc.,
specializing in alternative dispute resolution. The
Administrator shall be designated initially, and may be changed
from time to time, by the affirmative vote of a majority of the
Plans present and voting and a majority of the total then current
weighted vote of all the Plans present and voting.
B. Initial Conference
Within five (5) days after a Notice of Termination has
issued, or within five (5) days after the time for filing and
serving the Reply to any Counterclaim if the parties elect first
not to mediate, the parties shall confer with the Administrator
to discuss selecting a dispute resolution panel ("the Panel").
This Initial Conference may be by telephone. The parties are
encouraged to agree to the composition of the Panel and to
present that agreement to the Administrator at the Initial
Conference. If the parties do not agree on the composition of
the Panel by the time of the Initial Conference, or by any
extension thereof agreed to by all parties and the Administrator,
then the Panel Selection Process set forth in subparagraph C
shall be followed.
C. Panel Selection Process
The Administrator shall designate at least seven potential
arbitrators. The exact number designated shall be sufficient to
give each party at least two peremptory strikes. Each party
shall be permitted to strike any designee for cause and the
Administrator shall determine the sufficiency thereof in its sole
discretion. The Administrator will designate a replacement for
any designee so stricken. Each party shall then be permitted two
peremptory strikes. From the remaining designees, the
Administrator shall select a three member Panel. The
Administrator shall set the dates for exercising all strikes and
shall complete the Panel Selection Process within fifteen (15)
days of the Initial Conference. Each Arbitrator shall be
compensated at his or her normal hourly rate or, in the absence
of an established rate, at a reasonable hourly rate to be
promptly fixed by the Administrator for all time spent in
connection with the proceedings and shall be reimbursed for any
travel and other reasonable expenses.
Amended September 22, 2000
D. Duties Of The Arbitrators
The Panel shall promptly designate a Presiding Arbitrator
for the purposes reflected below, but shall retain the power to
review and modify any ruling or other action of said Presiding
Arbitrator. Each Arbitrator shall be an independent Arbitrator,
shall be governed by the Code of Ethics for Arbitrators in
Commercial Disputes, appended as Exhibit "5-B" hereto, and shall
at or prior to the commencement of any Arbitration Hearing take
an oath to that effect. Each Arbitrator shall promptly disclose
in writing to the Panel and to the parties any circumstances,
whenever arising, that might cause doubt as to such Arbitrator's
compliance, or ability to comply, with said Code of Ethics, and,
absent resignation by such Arbitrator, the remaining Arbitrators
shall determine in their sole discretion whether the
circumstances so disclosed constitute grounds for
disqualification and for replacement. With respect to such
circumstances arising or coming to the attention of a party after
an Arbitrator's selection, a party may likewise request the
Arbitrator's resignation or a determination as to
disqualification by the remaining Arbitrators. With respect to a
sole Arbitrator, the determination as to disqualification shall
be made by the Administrator.
There shall be no ex parte communication between the parties
or their counsel and any member of the Panel.
E. Panel's Jurisdiction And Authority
The Panel's jurisdiction and authority shall extend to all
disputes between or among the Plans, their Controlled Affiliates,
and/or BCBSA, except for those disputes excepted from these MMDR
procedures as set forth in the License Agreements.
With the exception of punitive or treble damages, the Panel
shall have full authority to award the relief it deems
appropriate to resolve the parties' disputes, including monetary
awards and injunctions, mandatory or prohibitory. The Panel has
no authority to award punitive or treble damages except that the
Panel may allocate or assess responsibility for punitive or
treble damages assessed by another tribunal. Subject to the
above limitations, the Panel may, by way of example, but not of
limitation:
i. interpret or construe the meaning of any terms, phrase or
provision in any license between BCBSA and a Plan or a
Controlled Affiliate relating to the use of the BLUE CROSS(R) or
BLUE SHIELD(R) service marks.
ii. determine whether BCBSA, a Plan or a Controlled Affiliate
has violated the terms or conditions of any license between the
BCBSA and a Plan or a Controlled Affiliate relating to the use of
the BLUE CROSS(R) or BLUE CROSS(R) service marks.
iii. decide challenges as to its own jurisdiction.
iv. issue such orders for interim relief as it deems appropriate
pending Hearing and Award in any Arbitration.
It is understood that the Panel is expected to resolve
issues based on governing principles of law, preserving to the
maximum extent legally possible the continued integrity of the
Licensed Marks and the BLUE CROSS/BLUE SHIELD system. The Panel
shall apply federal law to all issues which, if asserted in the
United States District Court, would give rise to federal question
jurisdiction, 28 U.S.C. 1331. The Panel shall apply Illinois
law to all issues involving interpretation, performance or
construction of any License Agreement or Controlled Affiliate
License Agreement unless the agreement otherwise provides. As to
other issues, the Panel shall choose the applicable law based on
conflicts of law principles of the State of Illinois.
F. Administrative Conference And Preliminary Arbitration Hearing
Within ten (10) days of the Panel being selected, the
Presiding Arbitrator will schedule an Administrative Conference
to discuss scheduling of the Arbitration Hearing and any other
matter appropriate to be considered including: any written
discovery in the form of requests for production of documents or
requests to admit facts; the identity of any witness whose
deposition a party may desire and a showing of exceptional good
cause for the taking of any such deposition; the desirability of
bifurcation or other separation of the issues; the need for and
the type of record of conferences and hearings, including the
need for transcripts; the need for expert witnesses and how
expert testimony should be presented; the appropriateness of
motions to dismiss and/or for full or partial summary judgment;
consideration of stipulations; the desirability of presenting any
direct testimony in writing; and the necessity for any on-site
inspection by the Panel.
G. Discovery
i. Requests for Production of Documents: All requests for the
production of documents must be served as of the date of the
Administrative Conference as set forth in Paragraph 3.F., above.
Within twenty (20) days after receipt of a request for documents,
a party shall produce all relevant and non-privileged documents
to the requesting party. In his or her discretion, the Presiding
Arbitrator may require the parties to provide lists in such
detail as is deemed appropriate of all documents as to which
privilege is claimed and may further require in-camera inspection
of the same.
ii. Requests for Admissions: Requests for Admissions
may be served up to 21 days prior to the Arbitration
Hearing. A party served with Requests For
Admissions must respond within twenty (20) days of
receipt of said request. The good faith use of and
response to Requests for Admissions is encouraged,
and the Panel shall have full discretion, with
reference to the Federal Rules of Civil Procedure,
in awarding appropriate sanctions with respect to
abuse of the procedure.
iii. Depositions As a general rule, the parties
will not be permitted to take deposition testimony
for discovery purposes. The Presiding Arbitrator,
in his or her sole discretion, shall have the
authority to permit a party to take such deposition
testimony upon a showing of exceptional good cause,
provided that no deposition, for discovery purposes
or otherwise, shall exceed three (3) hours,
excluding objections and colloquy of counsel.
iv. Expert witness(es): If a party intends to
present the testimony of an expert witness during
the oral hearing, it shall provide all other parties
with a written statement setting forth the
information required to be provided by Fed. R. Civ.
P. 26(b)(4)(A)(i) prior to the expiration of the
discovery period.
v. Discovery cut-off: The Presiding Arbitrator shall
determine the date on which the discovery period
will end, but the discovery period shall not exceed
forty-five (45) days from its commencement, without
the agreement of all parties.
vi. Additional discovery: Any additional discovery will be at
the discretion of the Presiding Arbitrator. The Presiding
Arbitrator is authorized to resolve all discovery disputes, which
resolution will be binding on the parties unless modified by the
Arbitration Panel. If a party refuses to comply with a decision
resolving a discovery dispute, the Panel, in keeping with Fed. R.
Civ. P. 37, may refuse to allow that party to support or oppose
designated claims or defenses, prohibit that party from
introducing designated matters into evidence or, in extreme
cases, decide an issue submitted for resolution adversely to that
party.
H. Panel Suggested Settlement/Mediation
At any point during the proceedings, the Panel at the
request of any party or on its own initiative, may suggest that
the parties explore settlement and that they do so at or before
the conclusion of the Arbitration Hearing, and the Panel shall
give such assistance in settlement negotiations as the parties
may request and the Panel may deem appropriate. Alternatively,
the Panel may direct the parties to endeavor to mediate their
disputes as provided above, or to explore a mini-trial
proceeding, or to have an independent party render a neutral
evaluation of the parties' respective positions. The Panel shall
enter such sanctions as it deems appropriate with respect to any
party failing to pursue in good faith such Mediation or other
alternate dispute resolution methods.
I. Subpoenas On Third Parties
Pursuant to, and consistent with, the Federal Arbitration
Act, 9 U.S.C. 9 et seq., a party may request the issuance of a
subpoena on a third party, to compel testimony or documents, and,
if good and sufficient cause is shown, the Panel shall issue such
a subpoena.
J. Arbitration Hearing
An Arbitration Hearing will be held within thirty (30) days
after the Administrative Conference if no discovery is taken, or
within thirty (30) days after the close of discovery, unless all
parties and the Panel agree to extend the Arbitration Hearing
date, or unless the parties agree in writing to waive the
Arbitration Hearing. The parties may mutually agree on the
location of the Arbitration Hearing. If the parties fail to
agree, the Arbitration Hearing shall be held in Chicago,
Illinois, or at such other location determined by the Presiding
Arbitrator to be most convenient to the participants. The Panel
will determine the date(s) and time(s) of the Arbitration
Hearing(s) after consultation with all parties and shall provide
reasonable notice thereof to all parties or their
representatives.
K. Arbitration Hearing Memoranda
Twenty (20) days prior to the Arbitration Hearing, each
party shall submit to the other party (or parties) and to the
Panel an Arbitration Hearing Memorandum which sets forth the
applicable law and any argument as to any relevant issue. The
Arbitration Hearing Memorandum will supplement, and not repeat,
the allegations, information and documents contained in or with
the Complaint, Answer, Counterclaim and Reply, if any. Ten (10)
days prior to the Arbitration Hearing, each party may submit to
the other party (or parties) and to the Panel a Response
Arbitration Hearing Memorandum which sets forth any response to
another party's Arbitration Hearing Memorandum.
L. Notice For Testimony
Ten (10) days prior to the Arbitration Hearing, any party
may serve a Notice on any other party (or parties) requesting the
attendance at the Arbitration Hearing of any officer, employee or
director of the other party (or parties) for the purpose of
providing noncumulative testimony. If a party fails to produce
one of its officers, employees or directors whose noncumulative
testimony during the Arbitration Hearing is reasonably requested
by an adverse party, the Panel may refuse to allow that party to
support or oppose designated claims or defenses, prohibit that
party from introducing designated matters into evidence or, in
extreme cases, decide an issue submitted for mandatory dispute
resolution adversely to that party. This Rule may not be used
for the purpose of burdening or harassing any party, and the
Presiding Arbitrator may impose such orders as are appropriate so
as to prevent or remedy any such burden or harassment.
M. Arbitration Hearing Procedures
i. Attendance at Arbitration Hearing: Any person having a
direct interest in the proceeding is entitled to attend the
Arbitration Hearing. The Presiding Arbitrator shall otherwise
have the power to require the exclusion of any witness, other
than a party or other essential person, during the testimony of
any other witness. It shall be discretionary with the Presiding
Arbitrator to determine the propriety of the attendance of any
other person.
ii. Confidentiality: The Panel and all parties shall maintain
the privacy of the Arbitration Proceeding. The parties and the
Panel shall treat the Arbitration Hearing and any discovery or
other proceedings or events related thereto, including any award
resulting therefrom, as confidential except as otherwise
necessary in connection with a judicial challenge to or
enforcement of an award or unless otherwise required by law.
iii. Stenographic Record: Any party, or if the parties do not
object, the Panel, may request that a stenographic or other
record be made of any Arbitration Hearing or portion thereof.
The costs of the recording and/or of preparing the transcript
shall be borne by the requesting party and by any party who
receives a copy thereof. If the Panel requests a recording
and/or a transcript, the costs thereof shall be borne equally by
the parties.
iv. Oaths: The Panel may require witnesses to
testify under oath or affirmation administered by
any duly qualified person and, if requested by any
party, shall do so.
v. Order of Arbitration Hearing: An Arbitration
Hearing shall be opened by the recording of the
date, time, and place of the Arbitration Hearing,
and the presence of the Panel, the parties, and
their representatives, if any. The Panel may, at
the beginning of the Arbitration Hearing, ask for
statements clarifying the issues involved.
Unless otherwise agreed, the complaining party (or
parties) shall then present evidence to support
their claim(s). The respondent(s) shall then
present evidence supporting their defenses and
Counterclaims, if any. The complaining party (or
parties) shall then present evidence supporting
defenses to the Counterclaims, if any, and rebuttal.
Witnesses for each party shall submit to questions
by adverse parties and/or the Panel.
The Panel has the discretion to vary these
procedures, but shall afford a full and equal
opportunity to all parties for the presentation of
any material and relevant evidence
.
vi. Evidence: The parties may offer such evidence as
is relevant and material to the dispute and shall
produce such evidence as the Panel may deem
necessary to an understanding and resolution of the
dispute. Unless good cause is shown, as determined
by the Panel or agreed to by all other parties, no
party shall be permitted to offer evidence at the
Arbitration Hearing which was not disclosed prior to
the Arbitration Hearing by that party. The Panel
may receive and consider the evidence of witnesses
by affidavit upon such terms as the Panel deems
appropriate.
The Panel shall be the judge of the relevance and
materiality of the evidence offered, and conformity
to legal rules of evidence, other than enforcement
of the attorney-client privilege and the work
product protection, shall not be necessary. The
Federal Rules of Evidence shall be considered by the
Panel in conducting the Arbitration Hearing but
those rules shall not be controlling. All evidence
shall be taken in the presence of the Panel and all
of the parties, except where any party is in default
or has waived the right to be present.
Settlement offers by any party in connection with
Mediation or MDR proceedings, decisions or
recommendations of the selected mediators, and a
party's position papers or statements furnished to
the selected mediators shall not be admissible
evidence or considered by the Panel without the
consent of all parties.
vii. Closing of Arbitration Hearing: The Presiding
Arbitrator shall specifically inquire of all parties
whether they have any further proofs to offer or
witnesses to be heard. Upon receiving negative
replies or if he or she is satisfied that the record
is complete, the Presiding Arbitrator shall declare
the Arbitration Hearing closed with an appropriate
notation made on the record. Subject to being
reopened as provided below, the time within which
the Panel is required to make the award shall
commence to run, in the absence of contrary
agreement by the parties, upon the closing of the
Arbitration Hearing.
With respect to complex disputes, the Panel may, in
its sole discretion, defer the closing of the
Arbitration Hearing for a period of up to thirty
(30) days after the presentation of proofs in order
to permit the parties to submit post-hearing briefs
and argument, as the Panel deems appropriate, prior
to making an award.
For good cause, the Arbitration Hearing may be
reopened for up to thirty (30) days on the Panel's
initiative, or upon application of a party, at any
time before the award is made
. N. Awards
An Award must be in writing and shall be made promptly by
the Panel and, unless otherwise agreed by the parties or
specified by law, no later than thirty (30) days from the date of
closing the Arbitration Hearing. If all parties so request, the
Award shall contain findings of fact and conclusions of law. The
Award, and all other rulings and determinations by the Panel, may
be by a majority vote.
Parties shall accept as legal delivery of the Award the
placing of the Award or a true copy thereof in the mail addressed
to a party or its representative at its last known address or
personal service of the Award on a party or its representative.
Awards are binding only on the parties to the Arbitration
and are not binding on any non-parties to the Arbitration and may
not be used or cited as precedent in any other proceeding.
After the expiration of twenty (20) days from initial
delivery, the Award (with corrections, if any) shall be final and
binding on the parties, and the parties shall undertake to carry
out the Award without delay.
Proceedings to confirm, modify or vacate an Award shall be
conducted in conformity with and controlled by the Federal
Arbitration Act. 9 U.S.C. section 1, et seq.
O. Return Of Documents
Within sixty (60) days after the Award and the conclusion of
any judicial proceedings with respect thereto, each party and the
Panel shall return any documents produced by any other party,
including all copies thereof. If a party receives a discovery
request in any other proceeding which would require it to produce
any documents produced to it by any other party in a proceeding
hereunder, it shall not produce such documents without first
notifying the producing party and giving said party reasonable
time to respond, if appropriate, to the discovery request.
4. Miscellaneous
A. Expedited Procedures
Any party to a Mediation may direct a request for an
expedited Mediation Hearing to the Chairman of the Mediation
Committee, to the selected Mediators, and to all other parties at
any time. The Chairman of the Mediation Committee, or at his or
her direction, the then selected Mediators, shall grant any
request which is supported by good and sufficient reasons. If
such a request is granted, the Mediation shall be completed
within as short a period as practicable, as determined by the
Chairman of the Mediation Committee or, at his or her direction,
the then selected Mediators.
Any party to an Arbitration may direct a request for
expedited proceedings to the Administrator, to the Panel, and to
all other parties at any time. The Administrator, or the
Presiding Arbitrator if the Panel has been selected, shall grant
any such request which is supported by good and sufficient
reasons. If such a request is granted, the Arbitration shall be
completed within as short a time as practicable, as determined by
the Administrator and/or the Presiding Arbitrator.
B. Temporary Or Preliminary Injunctive Relief
Any party may seek temporary or preliminary injunctive
relief with the filing of a Complaint or at any time thereafter.
If such relief is sought prior to the time that an Arbitration
Panel has been selected, then the Administrator shall select a
single Arbitrator who is a lawyer who has no interest in the
subject matter of the dispute, and no connection to any of the
parties, to hear and determine the request for temporary or
preliminary injunction. If such relief is sought after the time
that an Arbitration Panel has been selected, then the Arbitration
Panel will hear and determine the request. The request for
temporary or preliminary injunctive relief will be determined
with reference to the temporary or preliminary injunction
standards set forth in Fed. R. Civ. P. 65.
C. Defaults And Proceedings In The Absence Of A Party
Whenever a party fails to comply with the MDR Rules in a
manner deemed material by the Panel, the Panel shall fix a
reasonable time for compliance and, if the party does not comply
within said period, the Panel may enter an Order of default or
afford such other relief as it deems appropriate. Arbitration
may proceed in the event of a default or in the absence of any
party who, after due notice, fails to be present or fails to
obtain an extension. An Award shall not be made solely on the
default or absence of a party, but the Panel shall require the
party who is present to submit such evidence as the Panel may
require for the making of findings, determinations, conclusions,
and Awards.
D. Notice
Each party shall be deemed to have consented that any
papers, notices, or process necessary or proper for the
initiation or continuation of a proceeding under these rules or
for any court action in connection therewith may be served on a
party by mail addressed to the party or its representative at its
last known address or by personal service, in or outside the
state where the MDR proceeding is to be held.
The Corporate Secretary and the parties may also use
facsimile transmission, telex, telegram, or other written forms
of electronic communication to give the notices required by these
rules.
E. Expenses
The expenses of witnesses shall be paid by the party causing
or requesting the appearance of such witnesses. All expenses of
the MDR proceeding, including compensation, required travel and
other reasonable expenses of the Panel, and the cost of any proof
produced at the direct request of the Panel, shall be borne
equally by the parties and shall be paid periodically on a timely
basis, unless they agree otherwise or unless the Panel in the
Award assesses such expenses, or any part thereof against any
party (or parties). In exceptional cases, the Panel may award
reasonable attorneys' fees as an item of expense, and the Panel
shall promptly determine the amount of such fees based on
affidavits or such other proofs as the Panel deems sufficient.
F. Disqualification Or Disability Of A Panel Member
In the event that any Arbitrator of a Panel with more than
one Arbitrator should become disqualified, resign, die, or refuse
or be unable to perform or discharge his or her duties after the
commencement of MDR but prior to the rendition of an Award, and
the parties are unable to agree upon a replacement, the remaining
Panel member(s):
i. shall designate a replacement, subject to the right of any
party to challenge such replacement for cause.
ii. shall decide the extent to which previously
held hearings shall be repeated.
If the remaining Panel members consider the proceedings to
have progressed to a stage as to make replacement impracticable,
the parties may agree, as an alternative to the recommencement of
the Mandatory Dispute Resolution process, to resolution of the
dispute by the remaining Panel members.
In the event that a single Arbitrator should become
disqualified, resign, die, or refuse or be unable to perform or
discharge his or her duties after the commencement of MDR but
prior to the rendition of an Award, and the parties are unable to
agree upon a replacement, the Administrator shall appoint a
successor, subject to the right of any party to challenge such
successor for cause, and the successor shall decide the extent to
which previously held proceedings shall be repeated.
G. Extensions of Time
Any time limit set forth in these Rules may be extended upon
agreement of the parties and approval of: (i) the Chairman of
the Mediation Committee if the proceeding is then in Mediation;
(ii) the Administrator if the proceeding is in Arbitration, but
no Arbitration Panel has been selected; or (iii) the Arbitration
Panel, if the proceeding is in Arbitration and the Arbitration
Panel has been selected.
H. Intervention
The Plans, their Controlled Affiliates, and BCBSA, to the
extent subject to MMDR pursuant to their License Agreements,
shall have the right to move to intervene in any pending
Arbitration. A written motion for intervention shall be made to:
(i) the Administrator, if the proceeding is in Arbitration, but
no Arbitration Panel has been selected; or (ii) the Arbitration
Panel, if the proceeding is in Arbitration and the Arbitration
Panel has been selected. The written motion for intervention
shall be delivered to the BCBSA Corporate Secretary (which shall
also constitute service on the BCBSA if it is a respondent) and
to any Plan(s) and/or Controlled Affiliate(s) which are parties
to the proceeding. Any party to the proceeding can submit
written objections to the motion to intervene. The motion for
intervention shall be granted upon good cause shown.
Intervention also may be allowed by stipulation of the parties to
the Arbitration proceeding. Intervention shall be allowed upon
such terms as the Arbitration Panel decides.
Amended September 22, 2000
I. BCBSA Assistance In Resolution of Disputes
The resources and personnel of the BCBSA may be requested by
any member Plan at any time to try to resolve disputes with
another Plan.
J. Neutral Evaluation
The parties can voluntarily agree at any time to have an
independent party render a neutral evaluation of the parties'
respective positions.
K. Recovery of Attorney Fees and Expenses
I. Motions to Compel
Nothwithstanding any other provisions of these Rules, any
Party subject to the License Agreements (for purposes of
this Section L and all of its sub-sections only hereinafter
referred to collectively and individually as a "Party") that
initiates a court action or administrative proceeding solely
to compel adherence to these Rules shall not be determined
to have violated these Rules by initiating such action or
proceeding.
II. Recovery of Fees, Expenses and Costs
The Arbitration Panel may, in its sole discretion, award a
Party its reasonable attorneys' fees, expenses and costs
associated with a filing to compel adherence to these Rules
and/or reasonable attorneys' fees, expenses and costs
incurred in responding to an action filed in violation of
these Rules; provided, however, that neither fees, expenses,
nor costs shall be awarded by the Arbitration Panel if the
Party from which the award is sought can demonstrate to the
Arbitration panel, in its sole discretion, that it did not
violate these Rules or that it had reasonable grounds for
believing that its action did not violate these Rules.
III. Requests for Reimbursement
For purposes of this Section L, any Party may request
reimbursement of fees, expenses and/or costs by submitting
said request in writing to the Arbitration Panel at any time
before an award is delivered pursuant to Section 3-N hereof,
with a copy to the Party from which reimbursement is sought,
explaining why it is entitled to such reimbursement. The
Party from which reimbursement is sought shall have 20 days
to submit a response to such request to the Arbitration
Panel with a copy to the Party seeking reimbursement.
Amended September 22, 2000
EXHIBIT 5-A
MEDIATION COMMITTEE
REPORTS TO: Board of Directors
CHARGE: 1. Develop and implement processes for resolving
misunderstandings or disagreements between Plans or
between Plans and the Association under the following
circumstances:
a. Matters at issue regarding relationships between Plans
or between Plans and the Association.
b. Matters at issue regarding relationships between Plans
or between Plans and the Association.
c. Matters at issue under the Inter-Plan Bank,
Reciprocity, and Transfer Programs.
d. Matters at issue regarding contractor selection or
performance under the Medicare Part A
Program.
2. Determination of equalization allowances and/or cost allowances
under FEP shall not be considered by this Committee.
MEMBERSHIP: Six to Eight
STAFF: Senior Vice President and General Counsel
