exv10w12






Exhibit 10.12




BLUE SHIELD

CONTROLLED AFFILIATE LICENSE AGREEMENT

(Includes revisions adopted by Member Plans through their November 19, 2009 meeting)




     This Agreement by and among Blue Cross and Blue Shield Association
(“BCBSA”) and Triple-S Salud, Inc. (“Controlled Affiliate”), a Controlled Affiliate of the Blue Shield Plan(s),
known as Triple-S Management Corporation (“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;





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	 	(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 more than 50% of any for-profit Controlled Affiliate.





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     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. Notwithstanding any other provision in the Plan’s License Agreement with BCBSA or in this
Agreement, Controlled Affiliate shall use its best efforts to promote and build the value of the
Licensed Marks and Name.



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     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: (i) the Plan ceases
to be authorized to use the Licensed Marks and Name; or (ii) pursuant to Paragraph 15(a)(x) of the
Blue Cross License Agreement the Plan ceases to be authorized to use the Licensed Names and Marks
in the geographic area served by the Controlled Affiliate provided, however, that if the Controlled
Affiliate is serving more than one State or portions thereof, the termination of this Agreement
shall be limited to the State(s) or portions thereof in which the Plan’s license to use the
Licensed Marks and Names is terminated. By not appealing or challenging such regulatory action
within the time prescribed by law or regulation, and in any event no later than 120 days after such
action is taken, a Plan shall be deemed to have exhausted its rights to appeal or challenge, and
automatic termination shall proceed.



Amended as of September 14, 2004




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     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 the Board
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.



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     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)
any government or any government official, office, agency, branch, or unit 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.



Amended as of March 18, 2004





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     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, except that, in the event of a partial termination of this Agreement pursuant to
Paragraph 7(B)(ii) of this Agreement, the notices, national account listing, payment, and audit
right listed below shall be applicable solely with respect to the geographic area for which the
Plan’s license to use the Licensed Names and Marks is terminated:



     (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, subject to any
conflicting state law and state regulatory requirements. 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 the Re-Establishment Fee (described below)
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 Re-Establishment Fee 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.



Amended as of June 16, 2005





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The Re-Establishment Fee shall be indexed to a base fee of $80. The Re-Establishment
Fee through December 31, 2005 shall be $80. The Re-Establishment Fee for calendar
years after December 31, 2005 shall be adjusted on January 1 of each
calendar year up to and including January 1, 2010 and shall be the base fee multiplied by 100% plus
the cumulative percentage increase or decrease in the Plans’ gross administrative expense (standard
BCBSA definition) per Licensed Enrollee since December 31, 2004. The adjustment shall end on
January 1, 2011, at which time the Re-Establishment Fee shall be fixed at the then-current amount
and no longer automatically adjusted. For example, if the Plans’ gross administrative expense per
Licensed Enrollee was $278.60, $285.00 and $290.00 for calendar year end 2004, 2005 and 2006,
respectively, the January 1, 2007 Re-Establishment Fee would be $83.27 (100% of base fee plus $1.84
for calendar year 2005 and $1.43 for calendar year 2006. 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 Health Risk-Based Capital 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. At least 50% of the Re-Establishment Fee shall be awarded to the Plan (or Plans) that
receive the new license(s) for the service area(s) at issue; provided, however, that such award
shall not become due or payable until all disputes, if any, regarding the amount of and BCBSA’s
right to such ReEstablishment Fee have been finally resolved; and provided further that the award
shall be based on the final amount actually received by BCBSA. The Board of Directors shall adopt a
resolution which it may amend from time to time that shall govern BCBSA’s use of its portion of the
award. In the event that the Controlled Affiliate’s license is reinstated by BCBSA or is deemed to
have remained in effect without interruption by a court of competent jurisdiction, BCBSA shall
reimburse the Controlled Affiliate (and/or the Plan or its other Licensed Controlled Affiliates, as
the case may be) for payments made under this subparagraph 7.H.(3) only to the extent that such
payments exceed the amounts due to BCBSA pursuant to paragraph 7.M. and any cost associated with
reestablishing the Service Area, including any payments made by BCBSA to a Plan or Plans (or their
Licensed Controlled Affiliates) for purposes of replacing the Controlled Affiliate.




Amended as June 16, 2005





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     (4) BCBSA shall have the right to examine and audit and/or hire at terminated
entity’s expense a third party auditor to examine and 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) Subsequent to termination of this Agreement, the terminated entity and its affiliates,
agents, and employees shall have an ongoing and continuing obligation to protect all BCBSA and Blue
Licensee data that was acquired or accessed during the period this Agreement was in force,
including but not limited to all confidential processes, pricing, provider, discount and other
strategic and competitively sensitive information (“Blue Information”) from disclosure, and shall
not, either alone or with another entity, disclose such Blue Information or use it in any manner to
compete without the express written permission of BCBSA.



     (6) As to a breach of 7.H.(1), (2), (3), (4) or (5) 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. This Agreement shall remain in effect until terminated by the Controlled Affiliate upon not
less than eighteen (18) months written notice to the Association or upon a shorter notice period
approved by BCBSA in writing at its sole discretion, or until terminated as otherwise provided
herein.



     J. 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.and M. hereof upon termination of the BCBSA license agreement of any Larger Controlled
Affiliate of the Plan.



     K. 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.



     L. BCBSA acknowledges that it is not the owner of assets of the Controlled Affiliate.



     M. 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.



Amended as of June 16, 2005





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     N. In the event this Agreement terminates and is subsequently reinstated by
BCBSA or is deemed to have remained in effect without interruption by a court of competent
jurisdicition, the Controlled Affiliate, the Plan, and any other Licensed Controlled Affiliates of
the Plan shall be jointly liable for reimbursing BCBSA the reasonable costs incurred by BCBSA in
connection with the termination and the reinstatement or court action, and any associated legal
proceedings, including but not limited to: outside legal fees, consulting fees, public relations
fees, advertising costs, and costs incurred to develop, lease or establish an interim provider
network. Any amount due to BCBSA under this subparagraph may be waived in whole or in part by the
BCBSA Board of Directors in its sole discretion.



     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 Exhibit 5 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 June 16, 2005





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     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 the greater of: (i) 6/52 or more of the Plans (rounded
to the nearest whole number, with 0.5 or multiples thereof being rounded to the next higher whole
number) fail to cast weighted votes in favor of the question; or (ii) three (3) of the Plans fail
to cast weighted votes in favor of the question.
Notwithstanding the foregoing provision, if there are thirty-nine (39) Plans, the requirement of an
affirmative three-fourths weighted vote shall be deemed satisfied with a lesser weighted vote
unless four (4) or more Plans fail to cast weighted votes in favor of the question.




Amended as of June 16, 2005





12









 








THIS
PAGE IS INTENTIONALLY BLANK.





13









 








     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:
	 	 	 	 
	 

	 	 

	 	 






14









 





EXHIBIT A




CONTROLLED AFFILIATE LICENSE STANDARDS

November 2009

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’ member enrollment?





Amended September 19, 2002





15









 








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 member 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 member 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 member enrollment of the Plan and licensed
Controlled Affiliates, the Controlled Affiliate shall:




Amended September 19, 2002





16









 








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 “Health Risk-Based
Capital (HRBC)” 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 member 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’ member enrollment, as reported
in BCBSA’s Quarterly Enrollment Report (excluding rider and freestanding coverage).




Amended September 19, 2002





17









 







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:







18









 





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).




19









 











EXHIBIT A (continued)




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.





20









 








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. The requirements
of the preceding two sentences shall apply to all lines of business unless a line of business is
specially exempted from the requirement(s) by the BCBSA Board of Directors.




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:




Amended as of June 16, 2005





21









 








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;





22









 





EXHIBIT A (continued)





	3.	 	Inter-Plan Teleprocessing System (ITS);
	 
	4.	 	National Account Programs;
	 
	5.	 	Business Associate Agreement for Blue Cross and Blue Shield Licensees, effective April
14, 2003; and
	 
	6.	 	Inter-Plan Medicare Advantage Program.





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): Local and National Best Efforts




Notwithstanding any other provision in the Plan’s License Agreement with BCBSA or in this
License Agreement, during each year, a Controlled Affiliate shall use its best efforts to
promote and build the value of the Blue Shield 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 November 15, 2007




23









 








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 “Health Risk-Based Capital (HRBC) Report” as defined
by the NAIC, Annual Financial Forecast, Annual Certified Audit Report, Insurance Department
Examination Report, Annual Statement filed with State Insurance Department (with all
attachments), and
	 
	E)	 	Quarterly Enrollment Report.





Amended March 14, 2002





24









 








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, Annual Financial Forecast;
and
	 
	D.	 	Quarterly Financial Report, Quarterly Estimated Risk-Based Capital for Property and
Casualty Insurers, Insurance Department Examination Report, Quarterly Enrollment
Report; and





Amended September 19, 2002





25









 








EXHIBIT A (continued)





	E.	 	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
	 
	F.	 	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





26









 








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(A) — Participation in National Programs by Smaller Controlled Affiliates that were
former Primary Licensees




A smaller controlled affiliate that formerly was a Primary Licensee 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;
	 
	 	•	 	National Account Programs.






	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 Inter-Plan Programs
obligations in a form, and from a guarantor, acceptable to BCBSA.





Amended November 15, 2007





27









 








EXHIBIT A (continued)




Standard 9(A) — Participation in National Programs by Smaller Controlled Affiliates that were
former Primary Licensees





	C.	 	Reporting requirements include:






	 	•	 	The Semi-annual Health Risk-Based Capital (HRBC) Report.





Amended June 13, 2002





28









 








Exhibit A (continued)




Standard 9(B) — Participation in National Programs by Smaller Controlled Affiliates




A smaller controlled affiliate that voluntarily elects to participate in national programs in
accordance with BlueCard and other relevant Policies and Provisions shall effectively and
efficiently participate in 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);
	 
	 	•	 	National Account Programs.






	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 Inter-Plan
Programs obligations in a form, and from a guarantor, acceptable to BCBSA.





Amended November 15, 2007





29









 








EXHIBIT A (continued)




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.





30









 








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.





31









 





EXHIBIT A (continued)




Standard 11- Participation in Inter-Plan Medicare Advantage Program




A smaller controlled affiliate for which this standard applies pursuant to the
Preamble section of Exihibit 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.




National program requirements include:





	 	A.	 	Inter-Plan Medicare Advantage Program.





Amended November 15, 2007





32









 








EXIHIBIT A (continued)




Standard 12: Participation in Master Business Associate Agreement by Smaller Controlled
Affiliate Licensees




Effective April 14, 2003, all smaller controlled affiliates shall comply with the terms of
the Business Associate Agreement for Blue Cross and Blue Shield Licensees to the extent they
perform the functions of a business associate or subcontractor to a business associate, as
defined by the Business Associate Agreement.




Amended September 19, 2002





33









 








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 members using the Marks on health
care plans and related services as reported on the Quarterly Enrollment Report with BCBSA.
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.




Amended June 14, 2007




34









 








EXHIBIT B (continued)




FOR NONRISK PRODUCTS:




For third-party administrative business, 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 members using the Marks on health care plans and related services as reported on
the Quarterly Enrollment Report with BCBSA. 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 non-third party administrative business (e.g., case management, provider networks,
etc.), 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.




Amended June 14, 2007





35