attached to and made part of Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Preferred Blue PPO Preferred Provider Plan Subscriber Certificate R12-017 (2015 Rev.) to be attached to HMO-PPO Page 1 hppo12-017 Rider Domestic Partner Eligibility This rider modifies the terms of your health plan. Please keep this rider with your Subscriber Certificate for easy reference. The eligibility provisions described in your Subscriber Certificate have been changed. A subscriber may enroll a domestic partner for coverage under his or her membership. A “domestic partner” is a person of either sex with whom the subscriber has entered into an exclusive relationship. This means that both the subscriber and domestic partner: are 18 years of age or older and of legal age of consent; are competent to enter into a legal contract; share the same residence and must intend to continue to do so; are jointly responsible for basic living costs; are in a relationship of mutual support, caring, and commitment in which they intend to remain; are not married to anyone else; and are not related to each other by adoption or blood to a degree of closeness that would otherwise bar marriage in the state in which they live. A “domestic partner” may also include a person with whom the subscriber has registered as a domestic partner with any governmental domestic registry (whether or not all of the conditions stated above have been met). If the subscriber enrolls the domestic partner in his or her health plan, the domestic partner’s dependent children are eligible for coverage to the same extent that the subscriber’s dependent children are eligible for coverage in his or her health plan. (A domestic partner and an eligible spouse may not be enrolled under the same membership at the same time.) If the subscriber terminates the domestic partnership, the former domestic partner (and any enrolled children of the former domestic partner) may continue coverage in the subscriber’s health plan. They may do so to the extent that federal or state law would usually apply. All other provisions remain as described in your Subscriber Certificate.