Document:

Addendum to Agreement Form for Operation of Medicare Advantage Plan

 Exhibit 10.5 
  
 MA-ONLY EMPLOYER/ UNION-ONLY GROUP CONTRACT ADDENDUM 
  
 EMPLOYER/UNION-ONLY GROUP PART C ADDENDUM TO CONTRACT 
 WITH APPROVED ENTITY PURSUANT TO SECTIONS 1851 THROUGH 1859 
 OF THE SOCIAL SECURITY ACT FOR THE OPERATION OF A MEDICARE 
 ADVANTAGE PLAN 
  
 The Centers for Medicare & Medicaid Services (hereinafter referred to as
“CMS”) and (See Chart), a Medicare Advantage Organization (hereinafter referred to as the “MA Organization”) agree to amend the contract (See Chart) (INSERT “H” OR “R” NUMBER) governing
the MA Organization’s operation of a Medicare Advantage plan described in section 1851(a)(2)(A) or section 1851(a)(2)(C) of the Social Security Act (hereinafter referred to as “the Act”), including all attachments, addenda, and
amendments thereto, to include the provisions contained in this Addendum (collectively hereinafter referred to as the “contract”), under which the MA Organization shall offer Employer/Union-Only Group MA-Only Plans (hereinafter referred to
as “employer/union-only group health plans”) in accordance with the waivers granted by CMS under section 1857(i) of the Act. The terms of this Addendum shall only apply to MA-only health plans offered exclusively to employers/unions.

  
 This Addendum is made pursuant to Subpart K of 42 CFR Part 422. 
  

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 MA-ONLY EMPLOYER/ UNION-ONLY GROUP CONTRACT ADDENDUM 
  

 Article I 
 Employer/Union-Only Group Medicare Advantage Health Plan 
  

	A.	MA Organization agrees to operate one or more employer/union-only group health plans in accordance with the terms of this Addendum, the Medicare Advantage contract (except for
requirements contained therein that are expressly waived or modified by this Addendum), all provisions of Federal statutes, regulations, and policies applicable to MA organizations or MA plans (except to the extent any such provisions are expressly
waived or modified by this Addendum), and any employer/union-only group waiver guidance. 

  

	B.	This Addendum is deemed to incorporate any changes that are required by statute to be implemented during the term of the contract, and any regulations and policies implementing or
interpreting such statutory provisions. 

  

	C.	In the event of any conflict between the employer/union-only group waiver guidance issued prior to the execution of the contract and this Addendum, the provisions of this Addendum
shall control. In the event of any conflict between the employer/union-only group waiver guidance issued after the execution of the contract and this Addendum, the provisions of the employer/union-only group guidance shall control.

  

	D.	This Addendum is in no way intended to supersede or modify 42 CFR Part 422 or sections 1851 through 1859 of the Act, except as specifically provided in applicable
employer/union-only group waiver guidance and/or in this Addendum. Failure to reference a statutory or regulatory requirement in this Addendum does not affect the applicability of such requirement to the MA Organization and CMS.

  

	E.	The provisions of this Addendum apply to all employer/union-only group health plans offered by MA Organization. In the event of any conflict between the provisions of this Addendum
and any other provision of the contract, the terms of this Addendum shall control. 

  
 Article II 
 Functions to be Performed by the Medicare Advantage Organization

  

	A.	PROVISION OF BENEFITS 

  

	 	1.	MA Organization agrees to provide enrollees in each of its employer/union-only group health plans the basic benefits (hereinafter referred to as “basic benefits”) as
required under 42 CFR §422.101 and, to the extent applicable, supplemental benefits under 42 CFR §422.102 and as established in the MA Organization’s final benefit and price bid proposal as approved by CMS. 

 

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 MA-ONLY EMPLOYER/ UNION-ONLY GROUP CONTRACT ADDENDUM 
  

	 	2.	MA Organization may swap different types of mandatory supplemental benefits and optional supplemental benefits (as defined in 42 CFR §422.2) (hereinafter referred to as
“supplemental benefits”) of equal actuarial value in employer/union-only group health plans. 

  

	 	3.	MA Organization may modify the cost sharing (e.g., coinsurance, copayments, deductibles) of basic and supplemental benefits offered in employer/union-only group health plans by
providing a higher benefit level and/or a modified premium to employer/union-only groups contracting with MA Organization. The uniformity of premium, benefits, and cost-sharing requirement of 42 CFR §422.100(d)(2) shall not apply to such
modifications. The overall value of each modified benefit offered to employer/union-only groups must be actuarially equivalent to the basic and/or supplemental benefit offered in the employer/union-only group health plan and the modification must
not have the effect of denying or discouraging access to covered medically-necessary health care items and services as set forth in 42 CFR §422.100(f)(2). 

  

	 	4.	The requirements in section 1852 of the Act and 42 CFR §422.100(c)(1) pertaining to the offering of benefits covered under Medicare Part A and in section 1851 of the Act and 42
CFR §422.50(a)(1) pertaining to who may enroll in an MA plan are waived for employer/union-only group health plan enrollees who are not entitled to Medicare Part A. 

  

	 	5.	For employer/union-only group health plans offering non-calendar year coverage, MA Organization may determine basic and supplemental benefits (including deductibles, out-of-pocket
limits, etc.) on a non-calendar year basis subject to the following requirements: 

  
 (a) Applications, bids, and other submissions to CMS must be submitted on a calendar year basis; and 
  
 (b) CMS payments will be determined on a calendar year basis. 
  

	 	6.	For employer/union-only group health plans that have a monthly beneficiary rebate described in 42 CFR §422.266: 

  
 (a) MA Organization may vary the form of rebate allocation so that the
rebates vary between employer/union groups within the plan benefit package for an employer/union group to whom MA Organization offers the plan, with the exception of a rebate credited toward the reduction of the Part B premium. Any reduction of the
Part B premium through crediting of the rebate must be available to all members of the plan at the same level, regardless of the enrollee’s employer/union group affiliation; and 
  

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 MA-ONLY EMPLOYER/ UNION-ONLY GROUP CONTRACT ADDENDUM 
  

 (b) MA Organization must: 
  
 (a) ensure Part B premium buy-downs are the same for all enrollees; 
  
 (b) ensure that the total monthly rebate amount for the plan total rebates
per enrollee are uniform across employer groups in the plan and that all rebates are accounted for and used only for the purposes provided in the Act; and 
  
 (c) retain documentation that supports the use of all of the rebates on a detailed basis and must provide access to this documentation in accordance with
the requirements of 42 CFR §422.501. 
  

	B.	ENROLLMENT REQUIREMENTS 

  

	 	1.	MA Organization agrees to restrict enrollment in an employer/union-only group health plan to those individuals eligible for the employer’s/union’s employment-based group
coverage. 

  

	 	2.	MA Organization will not be subject to the requirement set forth in 42 CFR §422.50 to offer the employer/union-only group health plan to all eligible beneficiaries residing in
the plan’s service area. 

  

	 	3.	If an employer/union elects to enroll individuals eligible for its employer/union-only group health plan through a group enrollment process, MA Organization will not be subject to
the individual enrollment requirements set forth in 42 CFR §422.60. MA Organization agrees that all individuals eligible for its employer/union-only group health plan will be advised that the employer/union contracting with MA Organization to
offer an employer/union-only group health plan (hereinafter referred to as “employer/union”) intends to enroll them into the plan through a group enrollment process unless the individual affirmatively opts out of such enrollment. MA
Organization agrees that all such individuals will be provided this information at least 30 days prior to the effective date of the individual’s enrollment in the employer/union-only group health plan. MA Organization agrees the information
must include a summary of benefits offered under the employer/union-only group health plan, an explanation of how to get more information on such plan, and an explanation of how to contact Medicare for information on other MA plans that might be
available to the individual. In addition, MA Organization agrees that all information necessary to effectuate enrollment must be submitted electronically to CMS, consistent with CMS instructions. 

  

	C.	BENEFICIARY PROTECTIONS 

  

	 	1.	MA Organization’s employer/union-only group health plans will not be subject to the marketing requirements set forth in 42 CFR §422.80. 

  

	 	2.	 CMS agrees that the disclosure requirements set forth in 42 CFR §§422.111 will not apply with respect to any employer/union-only group health plan when
the 

  

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 MA-ONLY EMPLOYER/ UNION-ONLY GROUP CONTRACT ADDENDUM 
  

	 	 
employer/union is subject to alternative disclosure requirements (e.g., the Employee Retirement Income Security Act of 1974 (“ERISA”)) and fully
complies with such alternative requirements. MA Organization agrees to provide beneficiary plan documents, including summary plan descriptions and all other beneficiary communications that provide descriptions of the benefit offerings, to CMS at the
time of use and to current and/or potential enrollees on a timely basis. CMS may review these documents in the event of beneficiary complaints or for other reasons and require changes if CMS determines that such changes are necessary.

  

	D.	SERVICE AREA 

  

	 	1.	CMS agrees that Local employer/union-only group health plans that provide coverage to individuals in any part of a State can offer coverage to individuals eligible for the
employer/union-only group throughout that State. 

  

	 	2.	CMS agrees that Regional employer/union-only group health plans and non-network Private Fee-for-Service employer/union-only group health plans may extend coverage beyond their
designated service areas to all enrollees of a particular employer/union-only group plan, regardless of where they reside in the nation, when the most substantial portion of the employer’s employees (or in the case of a union, the union’s
participants) reside in the service area where the MA Organization, either itself or through subcontractors or other partners, is a provider of non-group MA coverage. The MA Organization agrees to conduct an actual review of where the substantial
portion of the employer’s/union’s employees/participants reside and to maintain adequate supporting documentation of such review (including the date of such review, by whom the review was conducted, and any other relevant documentation to
substantiate the review), and to permit CMS to audit and review such documentation. 

  

	F.	PAYMENT TO MA ORGANIZATION 

  
 MA Organization acknowledges that the risk sharing, plan entry and retention bonus provisions of section 1858 of the Act and 42 CFR §422.458 shall
not apply to Regional employer/union-only group health plans. 
  
 Article III 
 Record Retention and Reporting Requirements 
  

	A.	GENERAL REPORTING REQUIREMENTS 

  
 MA Organization is not subject to the general public reporting requirements contained in 42 CFR §422.516(a) for its employer/union-only group plans
to the extent that: (1) such information is required to be reported to enrollees and to the general public by other law (including ERISA or securities laws) or by a separate contractual agreement and (2) MA Organization fully complies with
such requirements. 
  

 Page 5 of 5Addendum to Medicare contract with approved entity

 Exhibit 10.6 
  
 ADDENDUM TO MEDICARE CONTRACT WITH APPROVED ENTITY 
 PURSUANT TO SECTIONS 1851 THROUGH 1859 OF THE SOCIAL SECURITY 
 ACT FOR THE OPERATION OF
A MEDICARE ADVANTAGE REGIONAL 
 COORDINATED CARE PLAN(S) 
  
 I. Risk Sharing Reconciliation Submission 
  
 A. A Medicare Advantage (MA) Organization offering an MA regional plan shall disclose to CMS such information as CMS determines necessary to carry out the risk sharing
reconciliation under subsection 1858(c) of the Act - including notification to CMS of actual allowed medical costs and actual allowed medical revenues and supporting data for the contract year under the plan by such date and in such
format as CMS specifies - in order to determine whether there are payment adjustments for the effective contract year in accordance with Section 1858(c)(2) of the Act. 
  
 B. Information disclosed or obtained pursuant to this requirement may be used by officers, employees, and contractors of CMS only for the
purposes of, and to the extent necessary in, carrying out this subsection. 
  
 C.
The risk sharing reconciliation submission under subsection 1858(c) must be audited by an independent Certified Public Accountant at the expense of the MA organization, and the results of the audit plus additional information to be specified at a
later date must be submitted to CMS for our approval. Further, CMS reserves the right conduct an independent audit of the information, at its own expense. 
  
 II. Organizational and Financial Requirements 
  
 A. In accordance with subsection 1858(d) of the Act, an MA organization that is offering a regional plan in a multi-state region and is not licensed in each State in
which it offers such a regional plan, may obtain a temporary waiver of state licensure from CMS for a period of time that CMS determines appropriate for the timely processing of the application by the State or States. 
  
 1. To obtain the waiver, the MA organization that is offering a multi-state regional plan
must: 
  
 (a) demonstrate to CMS that it has filed the necessary
state licensing application in each state in the multi-state region where a license is not held. 
  
 (b) notify CMS when each of the state licenses for which an application has been filed is approved or denied. 
  
 2. In the case of a denied state license application, CMS may extend the licensing waiver
through the end of the plan year or as CMS determines appropriate to provide for a transition. 
  
 B. An MA organization that is offering a multi-state regional plan, and which is licensed in more than one state of that region, and which has been granted a waiver of licensure pending approval of one or more state
license applications, must select one of the states in the region in which it is licensed in the region, and the rules for that state will apply for 

 Regional CCP Addendum 
  
 the period of the waiver to the other state or states in the region in which it is not licensed. 
  
 III. Coverage of Entire MA Region 
  
 In accordance with paragraph 1858(a)(1) of the Act, an MA organization that is offering a regional plan must cover the entire MA regional service area (as defined in
§422.)]. The MA organization offering a regional plan must not segment any of it regions as described in §422.262(c)(2). 
  
 IV. Special Cost-Sharing Rules for MA Regional Plans 
  
 In accordance with paragraph 1858 (b)(2) of the Act, MA regional plans must provide for a single deductible related to original Medicare Part A and Part B services, if
any deductible is imposed, as well as for an in-network and total catastrophic limit on beneficiary out-of-pocket expenditures for benefits under the original Medicare program. The MA regional plan must track the deductible (if any) and catastrophic
limits and notify members and health care providers when the deductible (if any) or a limit has been reached as described in §422.101(d)(4). 
  
 V. Election of Uniform Coverage Determination 
  
 A. In accordance with subsection 1858 (g) of the Act, an MA organization offering an MA regional plan may elect to have a local coverage determination for part of such
region be the local coverage determination applied for the entire MA region, as selected by the organization as described in §422.101(b). 
  
 B. An MA regional plan that applies a uniform local coverage determination for the entire MA region must make information on the selected local coverage policy readily
available, including through the Internet, to enrollees and health care providers as described at §422.101(b)(5) and §422.111. 
  
 VI. Assuring Network Adequacy and Disclosure to Enrollees 
  
 A. In accordance with subsection 1858(h) of the Act and §422.112(a)(1)(ii), an MA Organization offering an MA regional plan may meet provider access to care
requirements through methods other than written agreements that establish that access requirements have been met. The MA regional plan may rely on this exception in seeking to designate a non-contracting hospital as an “essential hospital”
following requirements described in §422.112(c). 
  
 B. In accordance with
subsection 1858(h), an MA regional plan must disclose to its enrollees the process enrollees should follow to secure in-network cost sharing when covered services are not readily available from contracted network providers, as described in
§422.111(b)(3)(ii). 
  

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