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EXHIBIT 10.04    
  


 
 

BLUE SHIELD
  CONTROLLED AFFILIATE LICENSE AGREEMENT
  (Includes revisions adopted by Member Plans through their November 16, 2000, meeting)    
  


    This
Agreement by and among Blue Cross and Blue Shield Association ("BCBSA") and Blue Cross and Blue Shield of Georgia, Inc.
("Controlled Affiliate"), a Controlled Affiliate of the Blue Cross Plan(s), known as WellPoint Health Networks Inc. ("Plan"), which is also a
Party signatory hereto. 


    WHEREAS,
BCBSA is the owner of the BLUE SHIELD and BLUE SHIELD Design service marks; 


    WHEREAS,
Plan and Controlled Affiliate desire that the latter be entitled to use the BLUE SHIELD and BLUE SHIELD Design service marks (collectively the "Licensed Marks") as service
marks and be entitled to use the term BLUE SHIELD 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 use the Licensed Marks and Name in its legal name on
the following conditions: (i) the legal name must be approved in advance, in writing, by BCBSA; (ii) Controlled Affiliate shall not do business outside the Service Area under any name or
mark; and (iii) Controlled Affiliate shall not use the Licensed Marks and Name, or any derivative thereof, as part of any name or symbol used to identify itself in any securities market.
Controlled Affiliate may use the Licensed Marks and Name in its Trade Name only with the prior, written, 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 November 16, 2000 





 


    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 


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(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 MARK 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 mark 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 mark 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 mark 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 


3





 


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 


4





 


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. 


5





 


    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. 



6





 


    (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 Shield and
Blue Shield 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 


7





 

    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 


8





 
 
 

THIS PAGE IS INTENTIONALLY BLANK.    
  


9





 



    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. 



	Blue Cross and Blue Shield of Georgia, Inc.:	 	 
	

By:	
 	

/s/ HUGH J. STEDMAN   
 Hugh J. Stedman	
 	

 
	

Date:	
 	

3-15-01
	
 	

 
	


 WellPoint Health Networks Inc.:	

 	



 
	

By:	
 	

/s/ LEONARD D. SCHAEFFER   
 Leonard D. Schaeffer	
 	

 
	

Date:	
 	

3-15-01
	
 	

 
	


 BLUE CROSS AND BLUE SHIELD ASSOCIATION	

 	



 
	

By:	
 	

/s/ ROGER G. WILSON   
 Roger G. Wilson	
 	

 
	

Date:	
 	

3-15-01
	
 	

 




10







  




EXHIBIT A  


CONTROLLED AFFILIATE LICENSE STANDARDS  


    November 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? 



11





 





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: 


12





 


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 "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). 


    November 16,
2000 


13





 

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,
	2. Is risk being assumed?
	

	Yes	 	No
	
	 	

		 		 		 		 		 	
	Controlled Affiliate underwrites any indemnity portion of workers' compensation insurance	 	Controlled Affiliate comprises less than 15% of total contract enrollment of Plan and its licensed affiliates, and does not underwrite the indemnity portion of workers' compensation insurance	 	Controlled Affiliate comprises greater than or equal to 15% of total contract enrollment of Plan and its licensed affiliates, and does not underwrite the indemnity portion of workers' compensation
insurance	 	Controlled Affiliate comprises less than 15% of total contract enrollment of Plan and its licensed affiliates	 	Controlled Affiliate comprises greater than or equal to 15% of total contract enrollment of Plan and its licensed affiliates	 	Controlled Affiliate's Primary Business is 15% of total contract Government Non-Risk
		 		 		 		 		 	
	Standards 7A-7E	 	Standard 2

(Guidelines 1.1,1.2)	 	Standard 6H	 	Standard 2

(Guidelines 1.1,1.3)	 	Standard 6H	 	Standard 10B
	

	IN ADDITION,
	3. Is 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 Affiliate is a former primary licensee	 	Controlled Affiliate is not a former primary licensee	 	Controlled Affiliate's Primary Business is Government Non-Risk
	 	 	 	 	 	 	  	 	  	 	  
	 	 	 	 	 	 	Standards 5,8,9	 	Standards 5,8	 	Standards 8, 10(C)




14





 

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). 



15





 





    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: 



	•
	change
the geographic area in which it operates



	•
	change
its legal and/or trade names



	•
	change
any of the types of businesses in which it engages



	•
	create,
or become liable for by way of guarantee, any indebtedness, other than indebtedness arising in the ordinary course of business



	•
	sell
any assets, except for sales in the ordinary course of business or sales of equipment no longer useful or being replaced



	•
	make
any loans or advances except in the ordinary course of business



	•
	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)



	•
	conduct
any business other than under the Licensed Marks and Name



	•
	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. 


16





 

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: 


17





 

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; 



18





 





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 Cross Mark. 


    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 


19







   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 mark 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, Semi-annual "Managed Care Organizations Risk-Based Capital (MCO-RBC) Report" 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, Semi-Annual Benefit Cost Management Report. 


Amended
November 16, 2000 






20





 





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 mark 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 






21





 





EXHIBIT A (continued)  




Quarterly
Financial Report, Quarterly Estimated Risk-Based Capital for Property and Casualty Insurers, Insurance Department Examination Report; 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 16, 2000 


22






 

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 








23





 





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. 


24





 

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 mark 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. 



25










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 D.



	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® and BLUE SHIELD® 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. 









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EXHIBIT 10.04

BLUE SHIELD CONTROLLED AFFILIATE LICENSE AGREEMENT (Includes revisions adopted by Member Plans through their November 16, 2000, meeting)

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STANDARDS FOR LICENSED CONTROLLED AFFILIATES