Oxford Health Plans Metro/Direct/HSA

Transcription

1 Oxford Health Plans Metro/Direct/HSA SUBMISSION REQUIREMENTS FOR OXFORD THROUGH FIRST NATIONAL ADMINISTRATORS (Sole Proprietor) Required Documentation for New York Sole Proprietor Business 1 st of Month effective ONLY Oxford Health Plans underwriting process requires that sole proprietors verify their status by submitting current tax documents. Oxford will not be able to process sole proprietor applications without the following information: Sole Proprietor Application Form A binder check (first months premium) Member Enrollment form Form 1040 (most recent) Oxford requires W-2's for all cases that have W-2 income reported on the 1040 including the spouse's income if any*. Signed Oxford Health Plans Sole Proprietor Attestation At least one of the following: Schedule C Profit & Loss From Business (sole proprietorship) Schedule F Profit & Loss From Farming For Sole Proprietors Filed as S-Corporations 1) All of the following Schedule 1120-S Income Tax Form for S Corporations o Gross Income on Schedule 1120-S must amount to at least $25,000. Schedule K-1 o Schedule K-1 must show 100% stock ownership of the business in question 2) Current Signed Copy of first two pages of U.S. Individual Tax Return Form 1040 Any applicable W-2 forms must be submitted. 3) Signed Oxford Health Plans Sole Proprietor Attestation For Sole Proprietors in Business less than 12 months 1) One of the following: New York State Business License Copy of Business Bank Statement Certificate of Incorporation 2) Signed Oxford Health Plans Sole Proprietor Attestation *Oxford requires the first two pages of the most recent 1040 (Individual Return). Also, if there is income on Line 7 of the 1040, we will need the W-2's for that income, even if it is the spouse's income. If it is the sole props income from a previous job, then we will also need proof from that employer(s) that they are no longer working there Jericho Turnpike, New Hyde Park NY *(516) * Fax (516)

2 Required Documentation for New York Sole Proprietor and Groups of One Business Oxford will accept applications from sole proprietors and S-Corporations with one eligible employee who are able to submit the following documentation and meet the standards outlined below: For Sole Proprietors Business Organizations in Operation More than 12 Months 1) At least one of the following from the most recent tax year: Schedule C Profit & Loss from Business (Sole Proprietorship) Schedule C-EZ Net Profit from Business (Sole Proprietorship) Schedule F Profit & Loss from Farming o The Gross Income on applicable Schedule (Schedules C, C-EZ, or F) must equal or exceed $25,000 2) A current signed copy of the first two pages of U.S. Individual Tax Return Form 1040 Any W-2 forms received by the sole proprietor must be submitted. 3) Sign Oxford s Sole Proprietor and Group of One Attestation Form For Corporations that have elected to be taxed as S-Corporations: 1) IRS Form 1120-S Income Tax Form for S-Corporations Gross receipts or sales must equal or exceed $25,000 2) Schedule K-1 Schedule K-1 must show 100% ownership (i.e., sole S-Corporation shareholder) for prospective insured 3) W-2 Received by the shareholder-employee from the S-Corporation under which group coverage with Oxford is sought. In addition, if applicable, S-Corporation shareholder must provide any other W-2s received from other business organizations. 4) Current signed copy of the first two pages of the U.S. Individual Tax Return Form 1040 and Schedule E (if applicable) for the S-Corporation shareholder who seeks coverage. 5) Sign Oxford s Sole Proprietor and Group of One Attestation Form Business Organizations in Operation Less than 12 Months NY

3 1) You must provide the following: Certificate of Incorporation (for S-Corporations only) New York State Business License (if applicable) Copy of Business Bank Statement (for sole proprietors only) 2) Signed Oxford Health Plans Sole Proprietor and Group of One Attestation Form Oxford reserves the right to modify the above eligibility requirements and required documentation. NY

4 New York Sole Proprietor Application Oxford Health Insurance Inc. Mailing Address: Group Enrollment Department, 14 Central Park Drive, Hooksett, NH I. G E N E R A L I N F O R M A T I O N 1. Full Legal Name of Group: 2. Primary Address of Group: (Street Address City, State, ZIP Code) *No P.O. Box 3. Plan Administrator/Contact: Liberty Plan SM Direct Oxford Exclusive Plan SM Metro Oxford HSA Direct SM Oxford HSA Exclusive SM a. Name b. Title c. Address (If different from primary) City, State, ZIP Code d. Phone Number Ext. e. Fax Number f. Address g. Add l Contact & Number 4. Name and title of person to receive billing statements: a. Name b. Title c. Address (If different from primary) City, State, ZIP Code d. Phone Number Ext. e. Fax Number 5. Nature of Business: 6. SIC Code: 7. Tax Identification Number: OHINY GA SP 1007 Page Rev 8

5 I I. A D M I N I S T R A T I V E I N F O R M A T I O N The term coverage means the benefits provided by Oxford, pursuant to the group Certificate of Coverage. 1. Effective date: We request that this coverage be effective:. (Month / Day 1st / Year) 2. Age of Business: Please indicate if your business has been in operation:. Less than 12 months More than 12 months 3. Other group health or HMO coverage: Indicate below other group health coverage which is still in force or which terminated within the past three years. Type of coverage Name of carrier Effective date If terminated, date terminated 4. Integration with Medicare Benefits: Health benefits covered by Medicare Part A and B are carved out for retired employees age 65 and over and their dependents age 65 and over if the group offers retiree coverage. I I I. P R O D U C T A N D P L A N D E S I G N S A. Oxford Sole Proprietor Plan Instructions: Please select a plan option and check off any variable items as provided below. Liberty Network Freedom Network Benefit Package Plan 1 Plan 2 Plan 3 Plan 4 Product Direct EPO Direct HSA EPO HSA PCP Copayment 30/50 25/50 N/A N/A In-Network Coinsurance % 80% 90% 90% 100% Out-of-Network Coinsurance % 60% N/A 70% N/A In-Network Single Deductible $2,000 $2,000 $2,850 $2,000 Out-of-Network Single Deductible $2,000 N/A $2,850 N/A Family Multiplier 2x 2x 2x 2x Emergency Room Copayment $100 $75 Deductible and Coinsurance Inpatient Facility Deductible and Deductible and Deductible and Coinsurance Coinsurance Coinsurance Outpatient Surgical Deductible and $300 per incident Deductible and Coinsurance Coinsurance Prescription Benefit 15/50% with $100 Deductible 15/50% with 15/50% with $2,850 Ded $2,000 Ded Domestic Partner Same and Opposite Same and Opposite Deductibles and out-of-pocket accumulations are on a calendar year basis contract year basis (Plans 1-4 only). B. Other Riders Coverage for Biologically Based Mental Illness and Children with Serious Emotional Disturbances OHINY GA SP 1007 Page Rev 8

6 I V. R A T E I N F O R M A T I O N Monthly Rates: All new groups are subject to the four-tier rate structure indicated below. Rates must be included in the spaces below for application processing. Please note: All four categories must be completed. Single Couple Parent/Children Family $ $ $ $ V. B R O K E R / A G E N T I N F O R M A T I O N 1. Name of Payee: 2. Payee s Oxford Broker Code (Required): 3. Payee s Social Security # or Federal Tax ID # : 4. Name of Writing Agent (Required if Payee is a company): 5. Writing Agent s Oxford Broker Code (Required if Payee is a company): 6. Commission Split % : 7. Sales Representative: Comments: Broker Co-Broker General Agent *Important Information Regarding Producer Compensation: We pay brokers and agents (referred to collectively as producers ) compensation for their services in connection with the sale of our insured products in compliance with applicable law. We pay base commissions based on factors such as product type, amount of premium, group size and number of employees. These commissions are reflected in the premium rate. In addition, we may pay bonuses pursuant to bonus programs established from time to time which are designed to provide incentives to achieve production targets, persistency levels, growth goals or other objectives. Bonuses are not reflected in the premium rate but are paid from our general administrative expenses. It is our policy not to pay commissions to producers with respect to a product for which the customer is also paying the producer a commission or other fee. Please note we also may make payments from time to time to producers for services other than those relating to the sale of policies (for example, compensation for services as a general agent or as a consultant). Producer compensation is subject to disclosure of Schedule A of the ERISA Form 5500 for customers governed by ERISA and subject to form 5500 filing requirements. We have also taken steps to ensure that producers properly disclose their compensation arrangements to their customers, but we cannot guarantee the producer s compliance. For general information on our producer payment arrangements, please go to For specific information about the compensation payable with respect to your particular policy, please contact your producer. V I. C O N S E N T AUTHORIZATION FOR BROKER TO ACT AS BENEFITS ADMINISTRATOR The undersigned hereby requests Oxford accept the Broker or General Agent named above as an authorized Benefits Administrator for purposes of processing any enrollment transactions for my company s health plan policy (including, but not limited to, Member enrollments, Member terminations, Member address changes, group contact changes, group address changes, plan renewal changes, and group contract terminations). This authorization shall be effective immediately and shall (check one only): Remain in place until it is expressly revoked by me in writing. Remain in place until. (Month / Day 1st / Year) Further, I agree that my company will be bound by the actions performed by the herein-named Broker or General Agent pursuant to this Consent Form. Additionally, I agree that this Consent Form does not authorize anyone to receive individually identifiable health information about any Oxford Member. I acknowledge that I must notify Oxford in writing to void this agreement in the event of a change in my company s Broker of Record. OHINY GA SP 1007 Page Rev 8

7 V I I. C O B R A & E X T E N S I O N O F B E N E F I T S D A T A 1. Do you have any individuals currently on COBRA continuation? Yes No If yes, identify the number of individuals. 2. Are there any dependents of employees who are currently disabled or in the hospital? Yes No 3. What is the length of the prior carrier s extension of benefits period for disabled employees or dependents? V I I I. A P P L I C A N T A G R E E M E N T This Application and the premium rates proposed by Oxford are subject to Home Office approval, in writing, by Oxford and may change due to differences in actual versus proposed enrollment, selection of benefits, changes in census data or underwriting criteria, or any other changes in underwriting as determined by Oxford. The Applicant hereby acknowledges that this Application does not constitute any obligation by Oxford to offer coverage to the Applicant until such Application is accepted, in writing, by the Home Office of Oxford. The Applicant hereby confirms that it will not cancel any current health coverage it may currently have in anticipation that this Application will be accepted by Oxford, and that Oxford shall have no obligation to provide coverage to the Applicant unless this Application is formally accepted, in writing, by the Oxford Home Office. Further, I hereby certify on behalf of the Applicant that the Applicant has not had a group health policy terminated within the past 12 months due to failure to pay premiums. Dated at: this day of 20. Full legal name of firm: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 dollars and the stated value of the claim for each violation. Oxford Health Insurance, Inc. X Signature of Authorized Officer of the Company Title Witness Duly Licensed Resident Agent/Broker OHINY GA SP 1007 Page Rev 8

8 Sole Proprietor and Group of One Attestation Form I. Business Organization Information: a. Name of Organization: Tax ID # or SS #: Primary Business Activity: Address: City: State: Zip: b. Contact Information for Business Organization Name: Fax: Title: Phone Number: II. Sole Proprietor Attestation: By executing this document, I hereby attest that: (i) the above described business organization is not an association, group purchasing organization or employee leasing organization and was formed for a lawful business purpose and not for the primary purpose of obtaining group insurance; (ii) I am the owner and operator of the above described business organization; (iii) I work a minimum of twenty (20) hours per week for this business organization; I derive the majority of my earned income (non-passive or non-investment) from the income generated from the above business organization; (iv) I seek health coverage only for myself and my eligible dependents through the above described business; (v) I (and my eligible dependents) am the only person eligible for health coverage through the above described business organization; (vi) I will promptly advise Oxford in the event that any of the statements made in this Attestation are no longer accurate. III. S-Corporations with One Eligible Employee Attestation: By executing this document, I hereby attest that: (i) the above described business organization is not an association, group purchasing organization or employee leasing organization and was formed for a lawful purpose and not for the primary purpose of obtaining group insurance; (ii) I am the sole shareholder of the above described business organization; (iii) I am currently employed by the above described business organization and work a minimum of twenty (20) hours per week for the business organization; (iv) I derive the majority of my earned income (non-passive or non-investment) from services provided to the above business organization; (v) I seek health coverage only for myself and my eligible dependents as listed on my enrollment form; (vi) I (and my eligible dependents) am the only person eligible for health coverage through the above described business organization; and (vi) I will promptly advise Oxford in the event that any of the statements made in this Attestation form are no longer accurate. IV. Tax Forms and other Documents (applicable to both Sole Proprietors and S-Corporations): By executing below, I agree to provide upon request appropriate tax forms to Oxford to validate the eligibility status. Before application will be considered, the applicant must execute this Attestation Form and provide the tax information and related documents indicated on the attached correspondence. Oxford reserves the right to modify these documentation and eligibility requirements in the future. NY

9 Sole Proprietor and Group of One Attestation Form The undersigned certifies that, to the best of his or her knowledge and belief, and under penalty of perjury, the information listed above is true and complete. X. Signature of Applicant Date Oxford insurance products are underwritten by Oxford Health Insurance, Inc. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation. NY

10 NY Member Enrollment & Physician Selection Form Oxford Health Insurance, Inc. Mailing Address: P.O. Box 7085, Bridgeport, CT Corporate Address: 48 Monroe Turnpike, Trumbull CT Thank you for choosing Oxford Health Insurance, Inc., (Oxford) as the health plan for you and your family. IMPORTANT! Please print and press down firmly when completing this form. In order to process the attached Member Enrollment Form and begin coverage, all the following information must be completed accurately and in its entirety: Date of Employment Date of Marriage, if applicable Date of Birth Social Security Numbers Primary Care Physician selections Other coverage you or your spouse may have Employer and Employee signatures are required at the bottom of form. Complete the Family Health Statement when instructed by your Benefits Administrator. If a dependent is a full-time college student at an accredited school, you must attach proof of full-time student status, such as a paid bill/tuition statement, an Oxford Student Verification Form, or a letter from the registration/bursar s office confirming enrollment. Attach disability paperwork for dependents, if applicable If you have any questions, please feel free to call our Customer Service Department at Thank you again for choosing Oxford. OHINY MEF LS R4

11 NY Member Enrollment Form - Oxford Health Insurance, Inc. Mailing Address: P.O. Box 7085, Bridgeport, CT Corporate Address: 48 Monroe Turnpike, Trumbull CT TO BE COMPLETED BY EMPLOYER NAME OF GROUP (EMPLOYER} GROUP NUMBER CONTRACT SPECIFIC PACKAGE (CSP) BILLING GROUP (BG) PLEASE PRINT EMPLOYEE S EFFECTIVE DATE OF COVERAGE IS THIS INDIVIDUAL ENROLLING UNDER COBRA? IF YES, QUALIFYING EVENT DATE OF QUALIFYING EVENT IS THIS MEMBER DISABLED? / / YES NO / / YES NO PRODUCT SELECTED: HMO FREEDOM IS EMPLOYEE CURRENTLY: ACTIVELY AT WORK? ON LEAVE OF ABSENCE? RETIRED? LIBERTY LIBERTY HMO OTHER: YES NO YES NO YES NO AVERAGE NUMBER OF HOURS WORKED PER WEEK DATE OF FULL-TIME EMPLOYMENT EMPLOYEE OCCUPATION UNION/NON-UNION EMPLOYER SIGNATURE / / X / / TO BE COMPLETED BY EMPLOYEE EMPLOYEE LAST NAME FIRST NAME & MI MALE DATE OF BIRTH FEMALE / / STREET ADDRESS APT. NUMBER HOME PHONE BUSINESS PHONE DATE ( ) ( ) CITY STATE ZIP COUNTY SOCIAL SECURITY NUMBER OXFORD PRIMARY CARE PHYSICIAN OXFORD CODE IS THIS A NEW PHYSICIAN FOR YOU? YES NO OXFORD OB/GYN PROVIDER (FEMALE MEMBERS) OXFORD OB/GYN CODE IS THIS A NEW PHYSICIAN FOR YOU? YES NO TYPE OF COVERAGE: SINGLE FAMILY ANY OTHER HEALTH COVERAGE (INCLUDING MEDICARE) WHILE ENROLLED WITH OXFORD? SOCIAL SECURITY NUMBER OF POLICY HOLDER COVERAGE DATES PARENT / CHILD HUSBAND / WIFE YES NO IF YES, CARRIER NAME: / / TO / / LANGUAGE: ENGLISH SPANISH COMMUNICATION PREFERENCE (PLEASE RANK IN ORDER FROM 1-4) PREFERRED TIME/ PLACE OF CONTACT CHINESE OTHER: MAIL FAX PHONE - ADDRESS: DAY EVENING HOME OFFICE EMPLOYEE S DEPENDENT INFORMATION SPOUSE S LAST NAME FIRST NAME & MI DATE OF BIRTH SOCIAL SECURITY NUMBER MALE DATE OF MARRIAGE: / / FEMALE / / IS THIS DEPENDENT DISABLED? ANY OTHER HEALTH COVERAGE YES NO SOCIAL SECURITY NUMBER OF POLICY HOLDER COVERAGE DATES YES NO IF YES, NAME: / / TO / / SPOUSE S EMPLOYER SPOUSE S OCCUPATION DAYTIME PHONE OXFORD PRIMARY CARE PHYSICIAN OXFORD CODE IS THIS A NEW PHYSICIAN FOR YOU? YES NO OXFORD OB/GYN PROVIDER (FEMALE MEMBERS) OXFORD OB/GYN CODE IS THIS A NEW PHYSICIAN FOR YOU? YES NO ELIGIBLE CHILD S LAST NAME FIRST NAME & MI DATE OF BIRTH SOCIAL SECURITY NUMBER MALE AGE: ( ) / / FEMALE IS THIS DEPENDENT DISABLED? ANY OTHER HEALTH COVERAGE YES NO SOCIAL SECURITY NUMBER OF POLICY HOLDER COVERAGE DATES YES NO IF YES, NAME: / / TO / / OXFORD PRIMARY CARE PHYSICIAN OXFORD CODE IS THIS A NEW PHYSICIAN FOR YOU? YES NO OXFORD OB/GYN PROVIDER (FEMALE MEMBERS) OXFORD OB/GYN CODE IS THIS A NEW PHYSICIAN FOR YOU? YES NO ELIGIBLE CHILD S LAST NAME FIRST NAME & MI DATE OF BIRTH SOCIAL SECURITY NUMBER MALE AGE: / / FEMALE IS THIS DEPENDENT DISABLED? ANY OTHER HEALTH COVERAGE YES NO SOCIAL SECURITY NUMBER OF POLICY HOLDER COVERAGE DATES YES NO IF YES, NAME: / / TO / / OXFORD PRIMARY CARE PHYSICIAN OXFORD CODE IS THIS A NEW PHYSICIAN FOR YOU? YES NO OXFORD OB/GYN PROVIDER (FEMALE MEMBERS) OXFORD OB/GYN CODE IS THIS A NEW PHYSICIAN FOR YOU? YES NO ELIGIBLE CHILD S LAST NAME FIRST NAME & MI DATE OF BIRTH SOCIAL SECURITY NUMBER MALE AGE: / / FEMALE IS THIS DEPENDENT DISABLED? ANY OTHER HEALTH COVERAGE YES NO SOCIAL SECURITY NUMBER OF POLICY HOLDER COVERAGE DATES YES NO IF YES, NAME: / / TO / / OXFORD PRIMARY CARE PHYSICIAN OXFORD CODE IS THIS A NEW PHYSICIAN FOR YOU? YES NO OXFORD OB/GYN PROVIDER (FEMALE MEMBERS) OXFORD OB/GYN CODE IS THIS A NEW PHYSICIAN FOR YOU? YES NO RACE/ETHNICITY (OPTIONAL) (THIS INFORMATION IS FOR THE PURPOSE OF DATA COLLECTION AND WILL NOT BE USED FOR DETERMINING ELIGIBILITY, RATING OR CLAIM PAYMENT.) EMPLOYEE: WHITE AFRICAN AMERICAN/BLACK HISPANIC/LATINO ASIAN OTHER: SPOUSE: WHITE AFRICAN AMERICAN/BLACK HISPANIC/LATINO ASIAN OTHER: CHILD: WHITE AFRICAN AMERICAN/BLACK HISPANIC/LATINO ASIAN OTHER: CHILD:: WHITE AFRICAN AMERICAN/BLACK HISPANIC/LATINO ASIAN OTHER: CHILD: WHITE AFRICAN AMERICAN/BLACK HISPANIC/LATINO ASIAN OTHER: IN ORDER TO HELP US QUICKLY PROCESS THIS FORM AND AVOID DELAYS, PLEASE MAKE SURE ALL AREAS ARE PROPERLY FILLED OUT. IF YOU HAVE ADDITIONAL DEPENDENTS, PLEASE USE ANOTHER ENROLLMENT FORM TO PROVIDE THE NECESSARY INFORMATION. I understand that my enrollments and benefits are in accordance with those described in the Oxford Health Insurance Certificate. I understand that, in order to receive in-network benefits, I and any enrolled dependents must seek care through our Oxford affiliated primary care physician or through an Oxford-affiliated specialist physician with an authorized referral from the primary care physician if required. I further understand that if I do not adhere to these requirements, I will be eligible only for out-of-network health insurance coverage under the terms of the Certificate. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. X EMPLOYEE/APPLICANT SIGNATURE DATE OHINY MEF LS 805 WHITE COPY: OXFORD PINK COPY: OFFICE YELLOW COPY: EMPLOYER GREEN COPY: EMPLOYEE/MEMBER 4318 R4

12 Bank OptumHealthBank.com Toll-free phone: H E A LT H S AV I N G S A C C O U N T ( H S A ) A P P L I C A T I O N To avoid processing delays, please complete all fields on the application starred fields (*) are required. Mail your completed application (and opening deposit, if applicable) to: OptumHealth Bank, P.O. Box 30777, Salt Lake City, UT Or fax both sides of this form to: and mail opening deposit, if applicable, separately to: OptumHealth Bank, P.O. Box , Salt Lake City, UT PART 1: PERSONAL INFORMATION ACCOUNT HOLDER * Social Security # / * Date of Birth Tax Identification # (mm/dd/yyyy) / / * First Name M iddle I nitial * Last Name * Street Address (cannot be a.p.o box) Apt # * City * State * ZIP Mailing Address (if different than street address) Apt # City State ZIP * Home phone # ( ) ) * Verification Code (such as your Mother s Maiden Name) To be Used for Security Purposes Up to 10 Letters Work phone # ( ext. Address PART 2: REQUEST FOR ADDITIONAL DEBIT CARD (OPTIONAL) SM You will receive a Health Savings Account MasterCard Prepaid Debit Card. If you wish to request a Health Savings Account Card for use by an authorized user either your spouse or another eligible dependent please complete the section below. Authorized U ser s First Name M iddle Initial Date of Birth Social Security # / (mm/dd/yyyy) Tax Identification # If Address is Same as Account Holder, check here / / Mailing Address City Last Name State ZIP PART 3: HIGH-DEDUCTIBLE HEALTH PLAN (HDHP)/MEDICAL PLAN INFORMATION * M edical Insurance Company or Carrier * M edi cal Insurance Plan or Group # HDHP Member Identification # (you may find this on your ID card) *Who is Covered? (check one): Individual Family [Individual + Dependent(s)] * HDHP Effective Date / / *Are you Enrolling in an HSA through your Employer? (check one): Yes No If Yes, Provide your Employer s Name: /07 PLEASE TURN PAGE OVER AND COMPLETE BOTH SIDES OF THIS APPLICATION >

13 PER THE USA PATRIOT ACT: To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account. When you open the account, we will ask for your name, street address, date of birth and other information that will allow us to identify you. We may also ask to see your driver s license or other identifying documents. Form of Identification (check one): Driver s License State ID Passport Identification # State of Issuance PART 4: BENEFICIARY INFORMATION (OPTIONAL) If you do not designate otherwise, your estate will be the beneficiary of your HSA upon your death. To designate an alternative beneficiary, please complete a Designation of Beneficiary form, available on OptumHealthBank.com or request one from customer service, toll-free at PART 5: REQUIRED SIGNATURE (Please Read Before Signing) By signing below, I acknowledge that: I wish to establish an HSA with OptumHealth Bank as custodian. I understand and agree that my HSA will be opened under and governed by OptumHealth Bank s Custodial and Deposit Agreement. Terms of this agreement will be binding on me unless I close my account within 30 days. This document will be sent to me when my account is opened, along with OptumHealth Bank s Privacy Policy and Schedule of Fees. I authorize OptumHealth Bank to provide information about my HSA, including my account number, to my employer (if applicable) and those acting on behalf of my employer or OptumHealth Bank (if applicable), in connection with the establishment and maintenance of my HSA. I acknowledge that my employer and all others acting on behalf of my employer (if applicable), may provide information on my behalf to establish and maintain my HSA. I understand my monthly account statements will be made available to me electronically. I agree to notify OptumHealth Bank if I wish to have statements mailed to my home address. If I have filled out the information to request an additional debit card, I hereby request OptumHealth Bank to issue a debit card on my account to the person indicated and I acknowledge I will be liable for the use of the debit card by the Authorized User. I certify that the information provided in this application is true and complete. X * Account Holder Signature Required IMPORTANT: We cannot process this application without your signature. Date PART 6: OPENING DEPOSIT Opening deposit enclosed with application (if applicable) (check one): Yes No Amount: $ If you are an individual mailing an opening deposit for your own HSA, please write your name and social security number on the check. page 2

14 Health Savings Account Employer Set-up Bank Notification Instructions: If the Employer Group elects to promote OptumHealthBank Health Savings Accounts, this form is to be used during implementation to (a) gather information from the Employer Group about their requirements for a Health Savings Account (HSA), and (b) inform OptumHealthBank that a case has been sold and provide information about the Employer Group s HSA requirements. A definitions list for all data requested on this form is on page 3. * denotes a required field, all required fields must be completed or the form will be rejected and sent back to the submitter. The completed form is to mailed to Oxford Health Insurance 14 Central Park Drive, Hooksett, NH * Attn: Group Enrollment Department. New Form Updated Form Date Submitted: Base Medical Policy # (Group ID):* 1 Employer Information Employer Name:* Employer Address 1:* Employer Address 2: City:* State:* Zip Code:* Broker Agency Name: Broker Agency Tax ID #: - - Broker Agency Address: Broker Agency Contact Name: Broker Agency Phone #: ( ) - Broker Agency Fax # :( ) - Broker Agency Broker Name: Broker ID/License #: - - Broker Address: Broker Phone #: ( ) - Broker Fax # :( ) - Broker Policy Information Effective Date of High Deductible Health Plan:* / / Case Sold Date: :* / / Projected Number of HSA Accounts: As of Date: / / 3 - Enrollment Information Method of Enrollment:* (must select one of the following as the primary enrollment method) Online Paper Batch File If Batch* - Standard Format Non-standard format (If Non-standard, include approved PRP in #9) If Batch* Will employer obtain OptumHealth HSA Affirmation? Yes No Open Enrollment Meeting Date: / / Enrollment Year:* Open enrollment period from: : / / to : / / Open enrollment HSA phone number: ( ) - Is the employer contract signed?: Yes No (applicable only to employers who select Batch with Affirmation enrollment method) 4 - Will Payroll deductions be transferred into the Employee s account?* Yes No 5 - Will Employer be Contributing to the Employee s HSA account?* Yes No Page 1 of R43

15 6 Contribution Method Health Savings Account Employer Set-up Bank Notification ACH Direct Deposit via payroll Combined Sum ACH Wire Check 7 - Contribution Frequency (if applicable) Weekly Semi-monthly Monthly Other 8 Will Employer Want to Receive a Listing of Employee Account Numbers? (Required * if yes to #4 &/or #5) Yes No Account Number File Recipient Name: Phone #: ( ) - Frequency: Weekly Semi-weekly Monthly 9 Approved PRP Requests (for OptumHealthBank use only) Is a PRP request associated to Employer Group?: Yes No (If PRP = Yes Please enter PRP number(s) below) PRP #: PRP #: PRP #: Brief Description: Brief Description: Brief Description: Comments: 10 - Contact Information 1. Form Submitter:* Phone #:* ( ) - 2. Primary Contact (HR Contact):* Phone #:* ( ) - 3. Enrollment/Eligibility Contact check if same as Primary Contact (#2) ( *required if batch selected): Phone #: ( ) - 4. Reporting Contact:* check if same as Primary Contact (#2) Phone #:* ( ) - Address: City: State: Zip Code: 5. Contribution Contact: check if same as Primary Contact (#2) ( *required if employer initiating contributions to an employee account) Phone #: ( ) - 6. Payroll Vendor/System Contact: check if same as Primary Contact (#2) Phone #: ( ) - 11 Additional Contacts: Contact Name: Contact Type: Phone #: ( ) - Contact Name: Contact Type: Phone #: ( ) - Page 2 of R43

16 Definitions of Data Requested: Health Savings Account Employer Set-up Bank Notification Base Medical Policy # (Group ID) Employer group ID 1. Employer Information: Employer Name Name of Employer Employer Address 1 Employer s street address (1) Employer Address 2 Employer s street address (2), if applicable City Employer s city State Employer s state Zip Employer s zip Payer/ TPA Name Insurer offering the High Deductible Health Plan Broker Agency Name Name of Broker Agency Broker Agency Tax ID # Broker Agency Tax Identification Number Broker Agency Address Broker Agency address Broker Agency Contact Name Name of contact at Broker Agency Broker Agency Phone# Phone number of Broker Agency Broker Agency Fax # Fax number of Broker Agency Broker Agency address of Broker Agency Broker Name Name of Broker Broker ID/License # Broker s ID or License number Broker Address Broker s address Broker Phone # Broker s phone number Broker Fax # Broker s fax number Broker Broker s address 2. Policy Information Effective date of High Deductible Health Plan Date High Deductible Health Plan is effective Case Sold Date Date the High Deductible Health Plan was sold to the employer group Projected Number of HSA accounts Estimated number of HSA Accounts this group will have based on membership As of date: Date associated to the projected number of HSA accounts provided 3. Enrollment Information: Enrollment Method Method employer would like to enroll employees: Online = Employee will enroll in their OptumHealthBank HSA account through OptumHealthBank s online enrollment tool found at Paper = Send PDF of all enrollment materials to HSA Primary Contact - Employee will complete, sign, and mail OptumHealthBank's HSA paper application. OptumHealthBank to employer a PDF file of the enrollment kit. Paper = Send enrollment kits to HSA Primary Contact - Employee will complete, sign, and mail OptumHealthBank's HSA paper application. OptumHealthBank to mail employer requested number of enrollment kits. HSA Batch File = Batch (With Affirmation) - Employer FTPs OptumHealthBank an electronic eligibility batch enrollment file based on a defined frequency. Standard file format to be provided during implementation. Employer provides OptumHealthBank HSA Terms and Conditions, captures employees' HSA affirmation, and includes affirmation on OptumHealthBank standard batch file. A confirmation of application will be mailed to the employee requesting a signature. The employee cannot access their funds until the signature is received. Batch (Without Affirmation) - Employer FTPs OptumHealthBank an electronic eligibility batch enrollment file based on a defined frequency. Standard file format to be provided during implementation. A confirmation of application will be mailed to the employee requesting a signature. The account will not be opened (and contributions will not be accepted) until the signature is received Enrollment Year Year enrolling in HSA Open Enrollment Meeting Date Date on which employer s open enrollment meetings will be held. If more than one date indicate first one Open enrollment period from Date of employer s open enrollment period Open enrollment HSA phone number Employer s open enrollment HSA phone number (toll-free) Is the employer contract signed? Question asking if we have an Employer Agreement for HSA Affirmation 4. Will Payroll Deductions be Transferred into the Employee s HSA Account? Question asking if contributions will be made via payroll deduction 5. Will Employer be Contributing to Employee s HSA Account? Question asking if the employer will be contributing to employee s HSA Page 3 of R43

17 6. Contribution Method ACH Direct Deposit via payroll Combined Sum ACH Wire Check Health Savings Account Employer Set-up Bank Notification Automated Clearing House network transaction. This is a reliable and efficient nationwide batchoriented electronic funds transfer system governed by NACHA OPERATING RULES which provide for the interbank clearing of electronic payments for participating depository financial institutions. The Federal Reserve and Electronic Payments Network act as ACH Operators, central-clearing facilities through which financial institutions transmit or receive ACH entries. Content and format for each of these components is very specific and must follow predefined formats to be valid. SEE OPTUMHEALTHBANK CONTRIBUTION ADMISTRATIVE GUIDE FOR THE HSA PRODUCT FOR DETAILS. Electronic Combined Sum ACH contributions to an HSA account is a simple, two-part process. The first step consists of sending an electronic contribution file detailing the specific employee accounts and the dollar amounts that are to be deposited. The second step is to send an ACH to OptumHealthBank for the total amount. Content and format for each of these components is very specific and must follow predefined formats to be valid. SEE OPTUMHEALTHBANK CONTRIBUTION ADMISTRATIVE GUIDE FOR THE HSA PRODUCT FOR DETAILS. Electronic wire contributions to an HSA account is a simple, two-part process. The first step consists of sending an electronic contribution file detailing the specific employee accounts and the dollar amounts that are to be deposited. The second s tep is to send an electronic funds wire to OptumHealthBank for the total amount. Content and format for each of these components is very specific and must follow predefined formats to be valid. SEE OPTUMHEALTHBANK CONTRIBUTION ADMISTRATIVE GUIDE FOR THE HSA PRODUCT FOR DETAILS. Contributions may be made by either the employer or the account holder (i.e., employee) via a manual check that is submitted with worksheet detailing the contribution. This contribution method is for employers with less than 100 employees or Account Holders. SEE OPTUMHEALTHBANK CONTRIBUTION ADMISTRATIVE GUIDE FOR THE HSA PRODUCT FOR DETAILS. 7. Contribution Frequency: Frequency by which contributions will be made to employee accounts. Selections are weekly, semimonthly, monthly and other. 8. Will Employer Want to Receive a Listing of Employee Account Question asking if employer wants to receive listing of account Numbers? numbers. Account Number File Recipient Name a. Name of employer contact who would like to receive a listing of account numbers for their employees who have an open HSA account. The account numbers will be needed by the employer when making contributions. Phone Phone number of employer contact receiving account number file address of employer contact receiving account number file Frequency Frequency of the account number file. Selections are weekly, bi-weekly, monthly and other 9. Approved PRP Requests Is a PRP request associated to Employer Question asking if there is an approved PRP associated with this Employer Group. Group? PRP # PRP number Brief Description Brief description of PRP Comments Section for comments 10. Contact Information: Form Submitter Name of person filling in form Phone Phone number of person filling in form address of person filling in form Primary Contact Employer s Human Resources contact for HSA Account Phone Phone number of employer s Human Resources contact for HSA Account address of employer s Human Resources contact for HSA Account Enrollment/Eligibility Contact Employer s Enrollment/Eligibility contact Phone Phone number of employer s Enrollment/Eligibility contact address of employer s Enrollment/Eligibility contact Reporting Contact Employer s contact for reports Phone Phone number of employer s contact for reports address of employer s contact for reports Contribution Contact Employer s contact for contributions Phone Phone number of employer s contact for contributions address of Employer s contact for contributions Payroll Vendor/System Contact Employer s contact for payroll (this could be a vendor) Phone Phone number of employer s contact for payroll (this could be a vendor) address of employer s contact for payroll (this could be a vendor) 11. Additional Contacts Contact Name Name of additional contact for HSA Account Contact Type Contact Type of additional contact for HSA Account (reports, contributions, account number file, etc.) Phone Phone number of additional contact for HSA Account address of additional contact for HSA Account Page 4 of R43

18 OXFORD HEALTH PLANS, INC. Page 1 of 2 Liberty Plan Direct SUMMARY OF COVERAGE NEW YORK SOLE PROPRIETORS BENEFIT IN-NETWORK OUT-OF-NETWORK FINANCIAL UCR: 70% of HIAA Deductible: Single $2,000 $2,000 Family $4,000 $4,000 Coinsurance 20% 40% Maximum Out-Of-Pocket: Single $4,000 $6,000 (Including Deductible) Family $8,000 $12,000 Maximum Lifetime Benefit Per Member Unlimited $1,000,000 PREVENTIVE CARE Adult Preventive Care No Charge In-Network Benefit Only Infant and Pediatric Preventive Care No Charge Deductible and 40% Coinsurance $300 annual maximum Immunizations No Charge Deductible and 40% Coinsurance OUTPATIENT CARE Primary Care Physician office visits $30 copay per visit Deductible and 40% Coinsurance Specialist Office Visits $50 copay per visit Deductible and 40% Coinsurance Surgery ** Deductible and 20% Coinsurance Deductible and 40% Coinsurance Laboratory services At Participating Laboratories Deductible and 40% Coinsurance Covered at 100% Radiology services including PT, CT scans, Magnetic Resonance Imaging (MRI) ** Deductible and 20% Coinsurance Deductible and 40% Coinsurance Precertification is required for Out of Network PET scans, MRAs, surgical endoscopic prodedures, MRIs Nuclear Medicine, CT Scans, and Bone Density Studies. Screening Mammograms Covered at 100% Deductible and 40% Coinsurance ALLERGY CARE Initial visit, and all subsequent referral visits $50 copay per visit Deductible and 40% Coinsurance HOSPITAL CARE Physician's and surgeon's services ** Deductible and 20% Coinsurance Deductible and 40% Coinsurance Semi-private room and board ** Deductible and 20% Coinsurance Deductible and 40% Coinsurance All drugs and medication Deductible and 20% Coinsurance Deductible and 40% Coinsurance EMERGENCY CARE Ambulance service when Medically Necessary Deductible and 20% Coinsurance Deductible and 20% Coinsurance At hospital emergency room $100 copay per visit Deductible and 20% Coinsurance (If member is admitted to the hospital through the ER, notification is required) Emergency Care in Urgi-Center $50 copay per visit Deductible and 40% Coinsurance MATERNITY CARE Prenatal and post-natal care $30 copay per visit Deductible and 40% Coinsurance Hospital services for mother and child ** Deductible and 20% Coinsurance Deductible and 40% Coinsurance SHORT TERM REHABILITATION 60 consec. inpatient days per condition / lifetime** Deductible and 20% Coinsurance Deductible and 40% Coinsurance 60 outpatient visits per condition per lifetime $50 copay per visit Deductible and 40% Coinsurance HOME HEALTH CARE 40 home care visits ** Subject to 20% Coinsurance Subject to 25% Coinsurance Physician house calls $50 copay per visit Deductible and 40% Coinsurance SKILLED NURSING FACILITY 200 days per calendar year** Deductible and 20% Coinsurance Deductible and 40% Coinsurance SUBSTANCE ABUSE 7 days of inpatient detox. per calendar year ** Deductible and 20% Coinsurance In-Network Benefit Only 30 days of inpatient rehab. per calendar year ** Deductible and 20% Coinsurance In-Network Benefit Only 60 outpatient rehab. visits per calendar year $50 copay per visit Deductible and 40% Coinsurance NYSG_DIRECT_1/1/07 (rev ) January 1, 2007

19 PRESCRIPTION DRUGS (Includes Oral Contraceptives) Generic Drugs**** Brand Name Drugs**** $100 Deductible (waived for Generic Drugs) $15 copayment 50% copayment ALTERNATIVE MEDICINE Chiropractic care HOSPICE CARE (210 days) Inpatient care** Outpatient care** OTHER COVERAGE Medical Supplies** Durable Medical Equipment** $1500 limit per Calendar Year Precertification for items $500 or more. Exercise Facility Subscriber Spouse $50 copay per visit Deductible and 10% Coinsurance Deductible and 10% Coinsurance Deductible and 10% Coinsurance Deductible and 10% Coinsurance $200 reimbursement per 6 month period $100 reimbursement per 6 month period DEPENDENT ELIGIBILITY: Eligible dependents include the employee's spouse and dependent children until the child reaches age 19, or age 23 if a full time student. Benefits discontinue at the end of the Calendar Year. Domestic Partners of the same or opposite sex are covered with proper documentation. **These services require precertification through Oxford. You must call Oxford at at least 14 days in advance of request. Mental health and substance abuse services can be precertified through Oxford's Behavioral Health Department by calling ****Prescription medication ordered through the Mail Order Drug Program are subject to 2 retail pharmacy copays for Generic and 50% copayment for Brand Name Drugs. The Prescription Drug Benefit is based on a Per Contract Year Limit for any applicable deductibles and/or maximum limits. Please Note: This sample summary of coverage is provided for informational purposes only. The applicable Summary of Benefits will be issued to eligible enrolled members as part of the Certificate of Coverage. Coverage is subject to the terms and conditions of the Certificate. Refer to your Certificate of Coverage for a more complete listing of all benefits, limitations, and exclusions which include, among other services not authorized by Oxford cosmetic surgery, routine foot care, custodial care, personal comfort or convenience items, private or special duty nursing, learning and behavioral disorders, Worker's Compensation, military service-related conditions, hearing aids, or, unless otherwise stated, dental services and vision correction services and supplies. Please be advised this quote is for informational purposes only. The information contained herein is subject to both state regulatory and Oxford home office approval as appropriate. NYSG Exclusive Plan Metro 1/1/07 (rev. 11/16/06) Oxford Exclusive Plan Metro January 1, 2007 Page 2 of 2

20 OXFORD HEALTH PLANS, INC. OXFORD HSA DIRECT SUMMARY OF COVERAGE FREEDOM NETWORK NEW YORK SOLE PROPRIETOR BENEFIT IN-NETWORK OUT-OF-NETWORK FINANCIAL UCR: 70% of HIAA Deductible: Single $2,850 $2,850 Family $5,700 $5,700 Coinsurance 10% 30% Maximum Out-of-Pocket: Single $3,850 $5,850 (Including Deductible) Family $7,700 $11,700 Maximum Lifetime Benefit Per Member Unlimited Unlimited PREVENTIVE CARE Adult Preventive Care No Charge In-Network Benefit Only Pediatric Preventive Care No Charge Deductible and 30% Coinsurance Infant Preventive Care No Charge Immunizations No Charge Deductible and 30% Coinsurance OUTPATIENT CARE Primary Care Physician office visits Deductible and 10% Coinsurance Deductible and 30% Coinsurance Specialist office visits Deductible and 10% Coinsurance Deductible and 30% Coinsurance Surgery ** Deductible and 10% Coinsurance Deductible and 30% Coinsurance Laboratory services Deductible and 10% Coinsurance Deductible and 30% Coinsurance Radiology services Deductible and 10% Coinsurance Deductible and 30% Coinsurance Preventive Mammograms No Charge Deductible and 30% Coinsurance ALLERGY CARE Initial visit, and all subsequent visits Deductible and 10% Coinsurance Deductible and 30% Coinsurance HOSPITAL CARE Physician's and surgeon's services ** Deductible and 10% Coinsurance Deductible and 30% Coinsurance Semi-private room and board ** Deductible and 10% Coinsurance Deductible and 30% Coinsurance All drugs and medication** Deductible and 10% Coinsurance Deductible and 30% Coinsurance EMERGENCY CARE Ambulance Service Deductible and 10% Coinsurance Deductible and 10% Coinsurance At hospital Emergency Room Deductible and 10% Coinsurance Deductible and 10% Coinsurance (If Member is admitted to the hospital through the ER, notification is required) Emergency Care in Urgi-Center** Deductible and 10% Coinsurance Deductible and 30% Coinsurance MATERNITY CARE Prenatal and Post-natal care** Deductible and 10% Coinsurance Deductible and 30% Coinsurance Hospital services for mother and child ** Deductible and 10% Coinsurance Deductible and 30% Coinsurance SHORT TERM REHABILITATION 60 consec. Inpatient days per condition per lifetime** Deductible and 10% Coinsurance Deductible and 30% Coinsurance 60 Outpatient visits per condition per lifetime Deductible and 10% Coinsurance Deductible and 30% Coinsurance HOME HEALTH CARE 40 Home care visits per Calendar Year ** Deductible and 10% Coinsurance Deductible and 25% Coinsurance Physician house calls Deductible and 10% Coinsurance Deductible and 30% Coinsurance SKILLED NURSING FACILITY 200 days per Calendar Year** Deductible and 10% Coinsurance Deductible and 30% Coinsurance SUBSTANCE ABUSE 7 days of Inpatient detox. per Calendar Year ** Deductible and 10% Coinsurance In-Network Benefit Only 30 days of Inpatient rehab. per Calendar Year ** Deductible and 10% Coinsurance In-Network Benefit Only 60 Outpt rehab. visits per Calendar Year** Deductible and 10% Coinsurance Deductible and 30% Coinsurance (combined w/office visits) 60 office visits per Calendar Year** Deductible and 10% Coinsurance Deductible and 30% Coinsurance (combined w/outpatient visits) NYSG HSA DIRECT 01/01/07 (rev 08/08/06) Oxford HSA Direct January 1, 2007 Page 1 of 2

21 BENEFIT IN-NETWORK OUT-OF-NETWORK MENTAL HEALTH CARE 30 days of Inpatient care per Calendar Year** Deductible and 10% Coinsurance In-Network Benefit Only 30 visits of Outpatient care per Calendar Year Deductible and 10% Coinsurance Deductible and 50% Coinsurance (combined w/office visits) We pay a $25 maximum per visit 30 office visits per Calendar Year Deductible and 10% Coinsurance Deductible and 50% Coinsurance (combined w/outpatient visits) We pay a $25 maximum per visit PRESCRIPTION DRUGS Includes Contraceptives Subject to plan Deductible listed above, then Generic**** $15 copayment Covered Only at Participating Pharmacies Brand Name**** 50% copayment HOSPICE CARE (210 Days) Inpatient Care** Deductible and 10% Coinsurance Deductible and 30% Coinsurance Outpatient Care** Deductible and 10% Coinsurance Deductible and 30% Coinsurance OTHER COVERAGE Medical Supplies** OUT-OF-NETWORK BENEFIT ONLY Deductible and 30% Coinsurance Durable Medical Equipment** Deductible and 10% Coinsurance Deductible and 30% Coinsurance $1500 limit per Calendar Year Precertification for items $500 or more. Exercise Reimbursement Subscriber $200 reimbursement per 6 month period $200 reimbursement per 6 month period Spouse $100 reimbursement per 6 month period $100 reimbursement per 6 month period DEPENDENT ELIGIBILITY: Eligible dependents include the employee's spouse and dependent children until the child reaches age 19, or age 23 if a full time student. Benefits discontinue at the end of the Calendar Year. Domestic Partners are covered with Proper Documentation. ** These services require precertification through Oxford. You must call Oxford at at least 14 days in advance of request of treatment to request precertification. Mental health and substance abuse services can be precertified through Oxford's Behavioral Health Department by calling Prescription medication ordered through the Mail Order Drug Program are subject to 2 retail pharmacy copays for Generic Drugs and 50% copayment for Brand Name Drugs. The Prescription Drug Benefit is based on a Per Calendar Year Limit for any applicable deductibles and/or maximum limits. Pharmacy claims are subject to the in-network deductible. Once the deductible has been satisfied, the applicable prescription drug copay will apply base on the option selected at plan inception. Please Note: This sample summary of coverage is provided for informational purposes only. The applicable Summary of Benefits will be issued to eligible enrolled members as part of the Certificate of Coverage. Coverage is subject to the terms and conditions of the Certificate. Refer to your Certificate of Coverage for a more complete listing of all benefits, limitations, and exclusions which include, among other services not authorized by Oxfor cosmetic surgery, routine foot care, custodial care, personal comfort or convenience items, private or special duty nursing, learning and behavioral disorders Worker's Compensation, military service-related conditions, hearing aids, or, unless otherwise stated, dental services and vision correction services and supplie Please be advised this quote is for informational purposes only. The information contained herein is subject to both state regulatory and Oxford home office approval as appropriate. NYSG HSA DIRECT 01/01/07 (rev 08/08/06) Oxford HSA Direct January 1, 2007 Page 2 of 2