TIPS. for Submitting New Regulated Small Groups. I. Qualifying the candidate. (groups with 2 50 eligible employees)

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1 TIPS for Submitting New Regulated Small Groups (groups with 2 50 eligible employees) I. Qualifying the candidate 1. Is the business a candidate for small employer health and BlueCare Dental group coverage? Count the total number of employees on the payroll + New hires not yet on payroll (even if serving a waiting period) Part-time employees working fewer than 24 hours per week or other part-time staff to whom the employer is not offering coverage Seasonal and temporary employees Terminated employees = Result If the result is between two and 50, the employer is a candidate for small group coverage. Example 1: 75 Total employees on payroll + 2 New hires not yet on payroll (even if serving a waiting period) 30 Part-time employees working fewer than 24 hours per week or other part-time staff to whom the employer is not offering coverage 0 Seasonal and temporary employees 0 Terminated employees = 47 The result of 47 is between two and 50, so the business is a candidate for small employer group coverage. 2. Will the required number of eligible employees enroll in the small group health and BlueCare Dental coverage plan? At least 75 percent of eligible employees must enroll in the small group coverage plan. Use the following formula to determine if the participation requirement will be met: Count the total number of employees on the payroll + New hires not yet on payroll Part-time employees working fewer than 24 hours per week or other part-time staff to whom the employer is not offering coverage Seasonal and temporary employees Employees declining because they have other coverage (including individual, coverage, a tribal policy, Medicare, Medicaid, etc.) Terminated employees Employees serving an eligibility waiting period Others (for example, independent contractors if they are not offered coverage) = Result (Eligible Employees) Multiply the result by 0.75 to determine the minimum number of enrollees required for the group to have 75 percent participation. Report this as a whole number and round down. Example 2: 75 Total employees on payroll + 2 New hires not yet on payroll 30 Part-time employees working fewer than 24 hours per week or other part-time staff to whom the employer is not offering coverage 0 Seasonal and temporary employees 1 Employees declining because they have other coverage (including individual coverage, a tribal policy, Medicare, Medicaid, etc.) 5 Employees serving an eligibility waiting period 0 Others (for example, independent contractors if they are not offered coverage) = multiplied by.75 = The minimum number of employees who must enroll in the small employer group health plan is 30.

2 There are some exceptions to the 75 percent rule: A. Groups with only one enrollee are acceptable, as long as there are at least two eligible employees and the other eligible employee(s) are declining because they have other coverage. B. COBRA and continuation of coverage participants should not be included in calculations for qualifying the candidate. C. Workforce Blue groups require 100 percent participation. (Workforce Blue includes the Central Oklahoma Manufacturers Association - COMA; Oklahoma Independent Petroleum Association - OIPA; Central Oklahoma Clearing House Association - COCHA). D. Voluntary Group Dental has different eligibility requirements. For eligibility details, please refer to the BlueSelect Dental Voluntary Group Plan brochure at bcbsok.com/producer under Products and Forms then select Downloadable Forms on the right hand side of the page. E. BlueSelect Vision benefits are offered to Non-Chamber PPO plans with 10+ enrolling. II. Non-Chamber Groups: Required Documents 1. Small Employer Benefit Program Application (BPA): The employer should complete the group employer application. A. Each field must be completed. B. If the group has selected yes to utilizing Insure Oklahoma subsidies, the group s effective date must be the first of the month. Make certain that at least one plan chosen by the group has been approved by Insure Oklahoma. C. The employer and producer must sign the medical questionnaire acknowledging that accurate medical condition information has been provided when applicable. D. Use the Small Group proposal to obtain the plan ID when completing the plan and product options page. 2. Individual Health Statements: For groups with two or more eligible employees with only one employee enrolling in health coverage (i.e. one contract), each employee must complete the Enrollment Application/Change Form and the enrolling employee must complete the Uniform Health Questionnaire Form. 3. Employee Applications: These are required for all eligible employees. All fields should be completed, and the applications must be signed and dated by the employee. In particular: Types of Employee Enrollment Applications: A. Enrollment Application/Change Form: This document is for groups with 2-50 eligible employees. Each field in the Enrollment Application/Change Form must be completed. Agents should review employee applications and obtain any missing information before submitting them to BCBSOK. Validate the following sections for consistency: Select your Coverage, Coverage Options and Declination of Health Coverage. All fields in the Previous Coverage Information section must be completed in order for employees to receive credit for prior coverage. When completing the Declination of Health Coverage section, ensure that the reason for declining coverage is selected when appropriate. B. Other forms sometimes required include: i. Request for Continuation Coverage: Required for all COBRA or state continuation of coverage enrollees. ii. Common-Law Marriage Affidavit: Required for any enrollees wishing to cover a common-law spouse. 2

3 II. Non-Chamber Groups: Required Documents continued 4. Signed Small Group Proposal: Provide a copy of the small group proposal. The employer representative should sign and date the proposal and list the group s selected plan numbers. 5. Proof of Business: Common examples are listed below. Other documents may also be acceptable. If you have questions concerning this documentation, call A. Most current Oklahoma Employment Security Commission (OESC) quarterly wage report OR B. All pages of any of the following documents filed with the state: Articles or certificate of incorporation Articles or certificate of organization Certificate of limited partnership Limited liability company organization documents 3

4 II. Non-Chamber Groups: Required Documents continued 6. Proof of Wages: Common examples are listed below. The group should list the status of all employees (full time, part time, terminated, etc.) on all the documents. A. Most current OESC quarterly wage report OR B. The following documents may also be sufficient: Company payroll reports that include the company name and payroll details for the most recent three-month period When a new hire is acquired to establish two eligible employees, 30 days of payroll is required for the new employee 1099 forms are acceptable proof of wages for contract employees Group must have 2 eligible employees prior to offering coverage to 1099 employees If the employer offers coverage to 1099 employees, these employees would follow the same eligibility requirements as W2 employees W-4 forms for new hires 7. Oklahoma Supplemental Employment Verification form: This form is required when there are owners or active employees (such as new hires) not listed on the company s payroll documents. 8. Medicare Secondary Payer form: All fields must be completed. 9. Proxy Letter: This document is located on the last page of the Small Employer Application Benefit Program Application (BPA). 4

5 III. Chamber Groups: Required Documents 1. Small Employer Benefit Program Application (BPA): Same as non-chamber requirements. Use the Market Plan ID from the applicable Chamber Choice or Oklahoma Chamber Blue brochure when completing plan section on BPA. 2. Employee Applications: The employees should complete the Enrollment Application/Change Form regardless of the group s size. Health statements are not required. 3. Proof of Business: Same as non-chamber requirements. Proof of the group s chamber membership is not sufficient as proof of business. 4. Proof of Wages: Same as non-chamber requirements. 5. Proof of Chamber Membership: In order to qualify for the Chamber Choice or the Oklahoma Chamber Blue program, both the group and the producer must be active members of the applicable chamber. For Oklahoma Chamber Blue groups, the group can be a member of its local chamber or the state chamber. A. Chamber Choice Greater Oklahoma City Chamber: BCBSOK will verify the group s and the producer s membership upon receipt of the group s enrollment documents. The group must be located in one of the following counties: Canadian Logan Oklahoma Cleveland McClain Pottawatomie B. Chamber Choice Tulsa Metro Chamber: BCBSOK will verify the group s and the producer s membership upon receipt of the group s enrollment documents. The group must be located in one of the following counties: Creek Okmulgee Pawnee Tulsa Washington Muskogee Osage Rogers Wagoner 5

6 III. Chamber Groups: Required Documents continued C. Oklahoma Chamber Blue (state chamber): The group must provide documentation that it is a member of its local chamber of commerce (such as a letter from the chamber or the most recent invoice for membership). BCBSOK will verify the producer s membership in the Oklahoma state chamber. The group must be located in one of the following counties. Adair Custer Kay Ottawa Alfalfa Delaware Kingfisher Payne Atoka Dewey Kiowa Pittsburg Beaver Ellis Latimer Pontotoc Beckham Garfield LeFlore Pushmataha Blaine Garvin Lincoln Roger Mills Bryan Grady Love Seminole Caddo Grant Major Sequoyah Carter Greer Marshall Stephens Cherokee Harmon Mayes Texas Choctaw Harper McCurtain Tillman Cimarron Haskell McIntosh Washita Coal Hughes Murray Woods Comanche Jackson Noble Woodward Cotton Jefferson Nowata Craig Johnston Okfuskee 6. Oklahoma Supplemental Employment Verification form: Same as for non-chamber groups. 7. Medicare Secondary Payer form: Same as for non-chamber groups. IV. Special Circumstances 1. Total Eligible Equals Two: For these groups, proof of wages is required for both employees. A W-4 form and/or the Oklahoma Supplemental Employment Verification form is not sufficient. A. If both are owners, then the group should provide government-filed documentation that lists both names as owners of the group. This can include any of the proof of business documents listed above as well as Schedule K-1 forms or Schedule of Profit or Loss forms for each owner. B. If one person is an owner and the other is an employee, then the group must provide government-filed proof of ownership for the owner as well as proof of wages for the employee. If the employee is newly hired, then the group must provide at least 30 days of payroll records for the new employee in addition to a W-4 form. C. When two enrolling employees are husband and wife, and profit or loss forms are submitted as proof of wages, a profit or loss form must be provided for both spouses along with their most recent tax return. NOTE: The forms must conclusively represent both spouses own the company or there is an employee/employer relationship. 6

7 IV. Special Circumstances continued 2. Multiple Company Names: Page 1 of the BPA asks for the legal name of the company applying for coverage. If a different company name or an additional company name appears anywhere within the paperwork submitted, please provide a detailed explanation of the relationship between the company applying and the other companies referenced within the paperwork. Your explanation may be provided by attaching an additional sheet. When applicable, you must include an assumed name certificate or doing business as (DBA) paperwork. When two or more companies have common ownership and the owners wish to cover multiple companies under one group policy, have the employer group complete and submit a Common Ownership Small Group Form. If commonly owned multiple companies are being combined under one group policy, then the SIC for the company with the higher number of enrolling employees will be used. 3. Identify all people whose names appear in the paperwork. Please identify all names that appear in the group s paperwork. Applications or declinations are required for all eligible employees. Please explain the status of all other people listed in the group s enrollment documents. 4. Staffing Companies: All employees who usually work a minimum of 24 hours or the required number of hours defined by the employer for full-time eligibility are considered eligible employees. This includes employees who may be sent or assigned to work for another company, regardless of whether a staffing company considers an employee eligible for health benefits. BCBSOK will determine the group s size and participation percentage in accordance with Oklahoma Department of Insurance guidelines. 5. Professional Employer Organization (PEO)/Staff Leasing: BCBSOK will accept a group that is a PEO if: The enrollees are actual employees of the PEO. The number of eligible employees does not exceed 50. The enrollees are not a client group or part of a client group of the PEO. No client groups will be added after the PEO coverage is issued (a client group uses services provided by the PEO.) NOTE: Assuming that eligibility and participation requirements are met, BCBSOK will accept a client group that is contracted with a PEO and applying for coverage independent of the PEO. 7

8 REQUIRED ITEMS FOR GROUP SUBMISSIONS Signed and completed Benefit Program Application (BPA) Employee Enrollment Forms: Enrollment Application/Change Form Uniform Health Questionnaire (2 eligible, 1 enrolling employee, resulting in 1 contract) Signed Small Group Proposal Most recent quarter of OESC report (Indicate terminated and part-time employees) Signed Supplemental Employment Verification Form listing new hires, owners, or other employees not listed on OESC Signed Medicare Secondary Payer Form MAIL REQUIRED DOCUMENTS TO: Blue Cross and Blue Shield of Oklahoma Southwest Service Center 1001 E. Lookout Drive Building B, 12th Floor Richardson, TX To obtain the paperwork needed to enroll new groups, log in to bcbsok.com/producer, click Products and Forms, then select Downloadable Forms on the right side of the page. A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association