Amerigroup Agent Contract

APPOINTMENT REQUIREMENTS

Please complete, sign and date these forms; submit the following items to your Managing

General Agent:

1. Producer Appointment Data Sheet (PDS)

2. Medicare Advantage and Part D Broker Contract Addendum

3. NYS License

4. Errors & Omissions Insurance

5. AHIP Certificate

NOTE:

All documentation must be completed and signed in order to proceed with the appointment

process.

Submit your signed paperwork and all additional requirements to your Managing General

Agent… not directly to the Company.

You can mail your completed paperwork to:

Genesis Business Capital, Inc. Agent Licensing

520 White Plains Road Suite 500 Tarrytown, NY 10591

Or Tel: (914) 909-2548 Fax: (866) 548-1152

contracts@genesisbusinesscapital.net

All applications MUST be completed and submitted by 11:00 AM the day after closing

INCLUDING weekends and holidays. The enrollment department has to provide status to the member by the 7 th day of closing.

Note each application, BRC, and SOA has to be submitted under one attachment.

receipt.

You will be notified within 36-48 hours of submission ONLY if there is an issue with our

Agency

enrollment department in Virginia Beach.

I have read, understand, and agree to follow the above process flow. I have been provided

Signature

the opportunity to ask.

Print Name

Date

***Please notify Sylvia Flores once the application has been sent to confirm

APPLICATION SUBMISSION PROCESS ATTESTATION

❖ sylvia.fioresOamerigroup.org

+ Attachment should include all pages of your application and scope of appointment.

Applications must be submitted via:

+ The original application MUST be sent to the address below:

Below documents are needed along with the application.

o

the name (Ex: BROKER John Jones Application)

o Scan and Email to:

Please label the attachment as "BROKER+Enrolling Client Full Name+Application" next to

ATTN: Medicare Sales / Sylvia Flores

HealthPlus-An Amerigroup Company

Scope of Appointment

241 37th Street,

Brooklyn, NY 11232

Broker Reply Card

Floor

C-711

Amerigroup Broker Compensation Schedule Exhibit A

Recital: Medicare Health Benefits and Consultant are parties to that certain Agreement and wish to amend the Agreement as provided herein.

Agreement: In consideration of the mutual promises set forth herein, in the Agreement, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. Effective October 1, 2011 Exhibit A shall read as follows:

a. Consulting Fee:

i. Effective January 1, 2012, for each new enrollment facilitated by Consultant and effective in 2012, as confirmed by CMS, Consultant will be paid:

MHB agrees to pay an Agent:

A total of two hundred one, and no/100ths ($201.00) dollars for all initial enrollees, within thirty days of the first effective date of the member; and

Amerigroup Amendment made Effective March 29, 2012 Amendment: If a member enrolls with Amerivantage and was previously enrolled in an unlike plan (new to Medicare Advantage), the ICEP payment will be the full ICEP amount ($201.00). This shall be determined by CMS to qualify for an initial commission due to the status of such enrollee as 1) and ICEP enrollee 2) an enrollee from Medicare fee-for-service; within thirty days of MHB's receipt of such determination from CMS; and

If a member enrolls from a "like plan" MA to MA, the ICEP payment shall be calculated by dividing the ICEP amount by 12 (months) times the number of months the member is enrolled for the calendar year. For illustrative purposes: (1) in the event a member enrolls, effective Decemberl, 2011 or thereafter, and is in his/her first cycle year and coming from Like Plan (MA to MA), the ICEP rate is two hundred one, and 00/100ths ($201.00) dollars. The ICEP payment will be $16.75 dollars (1 month pro-ration). No further ICEP payment will be made for this enrollment; and (2) in the event a member enrolls effective February 1, 2012, and is in his or her first cycle year and coming from a Like Plan, the ICEP rate is two hundred one and 00/100ths ($201.00) dollars. Amerigroup will pay one hundred eighty four and 25/100ths ($184.25) dollars (11 months pro-ration). No further ICEP payment will be made for this member.

An additional two hundred one, and 00/100ths ($201.00) dollars for renewal enrollments for each of the next five (5) renewal years (2013 — 2017) shall be paid on a 12 month pro-ration ($16.75) dollars per month, or $201.00 annually.

Definitions: Initial, Renewal and ICEP • Initial — a specified amount for all enrollees within thirty days of the first effective

date of the member • ICEP — an additional amount for each enrollee determined by CMS to qualify for

an initial commission due to the status of such enrollee as 1) an ICEP enrollee; or 2) an enrollee from Medicare fee-for-service; within thirty days of Amerigroup's receipt of such determination from CMS (aka "true up payment)

• Renewal — an additional amount for renewal enrollments for each of the next five (5) renewal years (2013 — 2017).

Definitions: Initial, Renewal and ICEP • Initial — a specified amount for all enrollees within thirty days of the first effective

date of the member • ICEP — an additional amount for each enrollee determined by CMS to qualify for

an initial commission due to the status of such enrollee as 1) an ICEP enrollee; or 2) an enrollee from Medicare fee-for-service; within thirty days of Amerigroup's receipt of such determination from CMS (aka "true up payment)

• Renewal — an additional amount for renewal enrollments for each of the next five (5) renewal years (2013 — 2017).

Parties agree that compensation structures shall comply with all applicable State and Federal requirements.

The following is for Illustrative purpose only:

Consultant Agent/ConsultantAgency Compensation

STATE INITIAL ICEP (true up) RENEWAL TN, GA, NM, TX, NY

$201.00 $201.00 $201.00

b. Consultant shall not be eligible for compensation if any of the following events occur: (i) The potential member's application is rejected by CMS or (ii) Amerigroup reasonably determines that the potential member's application is incomplete; (iii) the potential member cancels the enrollment prior to official notification by CMS; (iv) the member disenrolls before accruing ninety (90) days

of continuous enrollment; (v) Consultant is not in Good Standing; (vi) Medicare Health Benefits or Amerigroup determine that the application was obtained in a manner that violates CMS guidelines; or (vii) the Consultant or the Consultant's agent has been terminated for cause by Medicare Health Benefits or Amerigroup. In the case of disenrollment within the first ninety days compensation paid for those disenrollees will be debited in full on the next invoice payment.

Future CMS Guidelines regarding compensation to Brokers shall be incorporated by reference into the Agreement as if done so by an Amendment signed by both parties

In no event shall the aforementioned fees be altered by MHB

The aforementioned Compensation is subject to change without notice to reflect any change made by CMS. Future CMS Guidelines regarding compensation to Agents shall be incorporated by reference into the Agreement as if done so by an Amendment signed by both parties.

Medicare Health Benefits Consultant

By: By: Name: Jane Wall Name: Title: Title: Date: September 28, 2011 Date: Revision: March 29, 2012

MEMORANDUM

TO: AMERIGROUP CONTRACTED AGENTS/BROKERS & GENERAL AGENCIES

FROM: HEATHER M. MCDANIEL

SUBJECT: 2011/2012 AMERIVANTAGE MARKETING

DATE: 9/7/2011

CC: AMERIGROUP MEDICARE SALES MANAGEMENT

2012 MARKETING

Please be advised that as of October 1, 2011 AMERIGROUP will begin marketing the Amerivantage 2012 products_ According to CMS guidelines, once a plan begins marketing 2012 products then they must cease marketing of their 2011 products.* In order to sell for Amerigroup after 9/30/11 you must be trained to sell the 2012 benefits.

Chapter three of the Managed Care Manual: Medicare Marketing Guidelines: 120.3 - Agent/Broker Training and Testing, Plan sponsors must ensure annually that all brokers and agents selling Medicare products are trained and tested annually on Medicare rules and regulations and on details specific to the plan products that they sell.

In order to sell Medicare products, a broker or agent must receive a passing score of at least eighty-five (85) percent on the test of Medicare rules and regulations.

AMERIGROUP is offering agents/brokers two organizations to meet the Medicare guidelines. An agent/broker can complete the training on line via the Gorman or AHIP training sites.

Link to Gorman training: http://www.medicaresalessentinel.corn/Agents/AgentRegistration.aspx?progratnguid=482e326- 6695-47dd-a455-76e3f1f59b6a

Link to AHIP Training hvtp://www.medicareonlinetraining.com/clients/Amerigroup Corporation/Amengroup Default/ Default.aspx

Each agent/broker is responsible for the cost of the training. AMERIGROUP will accept the 2012 AHIP certification if taken through another company. The agent/broker will just have to log onto the AMERIGROUP link set up with AHIP noted above. This will allow all the information regarding your training to be shared with AMERIGROUP to verify your successful completion of the training.

*There are limited circumstances when the 2011 plan can be sold while marketing the 2012 plan. Also PDP, MA, MA-PD organizations may not market to beneficiaries of non-renewing plans until after October 3, 2011.

In addition to the CMS required training, every sales agent representing Amerigroup must also complete the Amerivantage 2012 product training. To complete the 2012 Ametivanatge product training please contact your AMERIGROUP Medicare Sales Director.

If the Amerigroup required 2012 training, both the Medicare required training and the Amerivantage product training, are not successfully completed prior by October 1, 2011 then the agent/broker will be listed as INACTIVE status. Therefore the agent/broker will NOT be allowed to market the Amerivantage products until such time that the required 2012 training is successfully completed and documented by AMERIGROUP. This includes selling the Amerivantage 2011 products. If it is discovered that Marketing is being conducted on October 1, 2011 or later without successful completion of the 2012 required training then corrective action will be taken up to notification to the Department of Insurance in the state that you are licensed in and you will not be compensated for the application submitted.

Also please note: CMS allows plan sponsors to market on October 1 (if they choose to do so) however; plan sponsors may not accept enrollment requests from beneficiaries of non-renewing Medicare plans without a valid election period in effect.

Please attest to receipt of this communication by completing the following:

Agent/Broker Name

(Please Print)

Signature Date

Please e/mai/ completed attestation back to your Amerigroup Medicare Sales Director.

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