List bill is a premium payment method thatallows one or more individuals who work fora common employer to have the premiums

for individual health insurance coverage deductedfrom their pay and remitted to Blue Cross and BlueShield of Illinois by that employer.

By accepting authorization to deduct and remit pre-miums to us, it is not your intent, nor is it the intentof Blue Cross and Blue Shield of Illinois, to estab-lish any type of employee benefit welfare plan asdefined by either federal or state law. In fact, list billis a billing convenience only and does not create anemployee welfare benefit plan as defined by eitherfederal or state law for any of the individuals or theircovered family members.

Each employee pays 100% of the premium. As theemployer, you can not contribute to any premiums,either directly or indirectly. This includes reimburse-ment or adjustments to compensation. You are sim-ply facilitating payment of the individual’s personalhealth insurance premiums through the deductionand list bill process.

Each individual makes an independent choice ofplan and benefits. You have made no recommenda-tion or suggestion to anyone with regard to coveragechoice.

ESTABLISHING A LIST BILL ACCOUNT

As an employer agreeing to remit premiums on a listbill basis, you have already completed and submit-ted, through your Producer, a Personal HealthInsurance Certification for Employers. ThisCertification attests to your understanding of theguidelines (including limitations) for the payrolldeduction and list bill process.

If you have any questions about Blue Cross andBlue Shield of Illinois’ list bill guidelines, pleasecontact us at 800-538-8833. Have your “PayorNumber” on hand; it is shown on the enclosed letter.We’ll be happy to assist you with any questions youmight have.

At this time, we recommend you begin to immedi-ately deduct premiums from each employee whowishes to pay premiums via list bill. That way youwill have assured the collection of sufficient premi-um in advance if and when a policy is approved.Either the employee(s) or your Producer can provideyou with the premium detail that you will need toinitiate this process.

Because all applications are for individual coverageand are medically underwritten, we have a duty ofconfidentiality to those individuals. For this reason,the only information that can be made available toyou regarding these applications is the premiumamount because this information is necessary toestablish the payroll deduction process.

The First List Bill

At the time you completed the Personal HealthInsurance Certification for Employers, you alsochose to have your company’s list bill due on eitherthe 1st or the 15th of each month. If you do notrecall which date you have chosen, please call us tollfree at 800-538-8833. We’ll be happy to assist you.

Once one or more applications for coverage havebeen approved and accepted, you will receive yourcompany’s first list bill. If and when additional appli-cations are approved, the premiums for these individ-uals will automatically be added to subsequent listbills to coincide with either the 1st or the 15th of themonth, whichever date you have selected.

Bills are mailed approximately 25 days in advanceof their due date. For example, bills due on May 1stare mailed on or about April 7th.

Your list bill will consist of two parts: a monthlyaccount summary and an invoice. The summary isyour record to keep and the invoice should be com-pleted and returned with each month’s premium pay-ments. A sample is shown on page 3 for your infor-mation.

A Billing Convenience

Guide to List Bill for Employers

® ®

BlueCross BlueShield of Illinois

DIRECT MARKETS

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

ADDING EMPLOYEES TO AN EXISTING LISTBILL ACCOUNT

It is not necessary to submit another Personal HealthInsurance Certification for Employers form if youwish to add an employee to an existing list billaccount.

Once someone has submitted an application to BlueCross and Blue Shield of Illinois for consideration,you should begin to immediately deduct premiumsfrom his or her paycheck. As before, doing so willhelp assure you have collected sufficient premiumsin advance. Either the individual applying for cover-age or your Producer can provide you with the pre-mium amount.

Once the underwriting process has been completed,and if a policy is approved and accepted, we willautomatically add the individual’s name and premi-um amount to the next available list bill to facilitatepayment of all future premiums. This will be done tocoincide with your current billing on either the 1st orthe 15th of the month.

ADJUSTMENTS TO AN EMPLOYEE’S LISTBILL PREMIUM AMOUNT

Occasionally, you may receive a notice from us indi-cating that an individual’s list bill premium amount ischanging.

If the new amount is greater than the current premi-um, and you are unable to increase the employee’sdeductions in time to pay the next list bill, theemployee should submit a check for the differencedirectly to Blue Cross and Blue Shield until suchtime as the new payroll deduction amount is in place.The employee should include his or her policy num-ber on their check. If you have any questions, pleasecall us at 800-538-8833.

If the new amount is less than the current premium,simply adjust the employee’s payroll deductionamount downward and remit the lesser premium asshown on the next list bill.

REMOVING EMPLOYEES FROM ANEXISTING LIST BILL ACCOUNTIt may be necessary from time to time to remove anemployee from an existing list bill account.

If you wish to do so, simply cross out the individual’sinformation on your current list bill invoice andreturn it to Blue Cross and Blue Shield with yourpayment for the remaining employees.

You will also need to cease making payroll deduc-tions at the appropriate time and coordinate any pre-mium issues with the employee. We will contact theindividual who has been removed from the bill toestablish either a monthly bank draft from his or herpersonal account, or we will bill the employee everytwo months.

CHANGING YOUR COMPANY’S BILLINGADDRESSIf it is necessary to notify us of a change to yourcompany’s billing address, simply write the newaddress on your next list bill invoice when you paythe premium. If there isn’t space on the invoice, youmay include a brief note on a separate sheet of paperand include it with your next premium payment.

CANCELING YOUR COMPANY’S LIST BILLACCOUNTIf you wish to cancel your company’s entire listbilling process with us, please provide 30 daysadvance written notice to all employees who areaffected and to Blue Cross and Blue Shield ofIllinois. You are responsible for coordinating anyreturns of premium that may be necessary with youremployees. They will be offered the opportunity tochange the way they pay premiums to a manner andform available at that time.

CONTACT INFORMATION

• If you have any questions, please call Blue Crossand Blue Shield of Illinois Monday through Friday,8am to 5pm toll free at 800-538-8833.

• Return completed invoices, premium payments,and all other written correspondence to:

Blue Cross and Blue Shield of IllinoisP.O. Box 2039Aurora IL 60507

2

3

This summary isfor yourrecords

This invoiceis returned

to us each monthwith thePremium

® ®

BlueCross BlueShield of Illinois

DIRECT MARKETS

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

® ®

BlueCross BlueShield of Illinois

DIRECT MARKETS

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

30293.0605 IL

BlueCross BlueShieldof Illinois

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

® ®

CONSUMER MARKETS® Registered Service Marks of the Blue Cross and Blue Shield Association,

An Association of Independent Blue Cross and Blue Shield Plans