In consideration of the payment of managed care funds, EASTWEST undertakes to pay all eligible medical, hospitalization and clinic charges and expenses incurred in behalf of the Subscriber Company to the extent provided in the Schedule of Benefits and subject to all applicable terms and conditions as defined herein.
It is understood and agreed that EASTWEST shall pay in behalf of the Subscriber Company subject to limits of liability provided herein and draw the moneys out of the funds set up and charge or credit against the managed care funds held in trust the corresponding administration fees, management fees, and network access fees up to but not to exceed the aggregate of eighty five percent of the total annual membership fees / managed care funds charged under this agreement.
If the aggregate payment inclusive of administration fees and all related management fees made under this coverage part be less than eighty five percent of total annual membership fees/ managed care funds charged during the current policy year, the excess shall be credited and carried over for the account of the Subscriber Company as additional managed care funds deposited in the ensuing renewal program. However, in the event that the incurred eligible medical expenses inclusive of administration fees and related management fees exceeds the aggregate of eighty five percent of annual membership fees paid, all eligible excess medical expenses and other charges incurred shall be covered in full by the HMO aggregate stop loss coverage part as provided herein.
THIRD PARTY AGREEMENT
The Third Party Agreement (TPA) is recommended to companies who choose to self-insure their health care program. TPA is combination of HMO and self insurance whereby the company enjoys benefits similar to regular HMO plan under a self-funding program. In lieu of annual membership fees which are normally paid upfront to the HMO/insurance company, the company will only have to pay the nominal Network Access fee on an annual basis. A corresponding administration fee shall the be charged for every claim processed, the amount of which will be withdrawn from the Health Fund set up by the Client.