New Group Submission Checklist HARVARD PILGRIM HEALTH CARE Best Buy HSA PPO Plans

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1 hsainsurance.com New Group Submission Checklist HARVARD PILGRIM HEALTH CARE Best Buy HSA PPO Plans To ensure your application is processed as quickly and accurately as possible, follow these steps: 1. The employer completes and signs the HSA Membership Application 2. The employer completes and signs the Intermediary Group Application 3. The employer must provide a copy of the present carrier s current premium statement 4. Provide a copy of the following information: If a sole Proprietorship Wage Detail Report from DUA QUEST System/WR-1 Mass. Quarterly Payroll (if filed) 1040 Schedule C If a Corporation or Partnership Wage Detail Report from DUA QUEST System/WR-1 Mass. Quarterly Payroll (most recent) If a New Business If tax information is not available, owner must provide copies of DBA Certificate, Business License, Articles of Incorporation or other proof deemed appropriate by HPHC 5. Each eligible employee completes a HPHC PPO Plan Enrollment Form 6. The employer completes and signs the Pediatric Dental Attestation only if enrolling in a plan without pediatric dental coverage. 7. Each eligible employee applying for a waiver completes a Waiver of Coverage Form. 8. Enclose copy of Proposal/Quote showing rates for desired effective date 9. Pay your first premium: Enclose your premium, payable to Health Services Administrators (HSA). -or- Pay online at or scan QR code with smartphone. If you pay online or through smartphone, please note the confirmation number from your online payment to Unibank: 10. (Receipt of payment does not guarantee coverage. HSA must receive completed enrollment materials by the carrier deadline) Enclose your Annual Membership Fee of $125 (payable to HSA), or pay online (see step 8). -or- If enrolling through an Association or Chamber of Commerce, please note the name: (If not already a member of a participating Association or Chamber of Commerce, additional requirements may apply, such as completing a membership application and paying dues.) 11. Send all required documents (including this checklist) to: Corporate Office 135 Wood Road Braintree, MA or- Regional Office 574 Boston Road Billerica, MA Sales Rep: Contact Info: PLEASE NOTE: Complete applications and premium payment for new business must be received by HSA at least 10 calendar days prior to the requested effective date. All coverage will be effective on the 1st day of the month. Once your enrollment has been approved and processed, you will receive a member confirmation by mail with your account number. Your permanent ID cards will be issued to you directly by the carrier. Permanent ID cards generally take 7-10 business days from date your enrollment was approved and processed. Corporate Office: 135 Wood Rd, Braintree, MA (781) (877) (781) fax 2013

2 Membership Application Please complete each section of this application. Failure to do so could delay enrollment. hsainsurance.com Employer information Employer name Date business established (Mo./Yr.) / Employer address City State Zip Owner/principal contact name (first and last) Title Business Phone Cell phone Fax Website Billing address City State Zip Type of business Corporation Partnership Proprietorship LLC Other: Nature of business: Employer tax ID# SIC code Do you regularly employ at least one individual that is not an owner and/or the spouse of an owner? Yes Number of full-time employees (30 hours or more per week; including owner) Number of part-time employees (less than 30 hours per week) Quote # (from Group Proposal) No Certification 1. The company named above is a bona fide business and not in operation for the sole purpose of obtaining health insurance. 2. All enrollees are actively working for financial compensation and are covered by Worker s Compensation as required by law. 3. Premium payments are due on the 25 th of each month for coverage effective the 1 st of the next month. 4. Insurance coverage is subject to cancellation if payments are not received by the 1 st of the month. 5. Payments not received by the 10 th of the month are subject to a late fee, currently $ Payments not received by the 20 th of the month are subject to a pending termination fee, currently $ Reinstatement of coverage terminated due to non-payment of premium is at the sole discretion of the carrier. 8. Checks returned for insufficient funds or other reasons will be charged a bad check fee, currently $ Member firms must maintain good standing in their respective Business Association or Chamber of Commerce to participate in the group insurance programs offered through HSA. 10. HSA Insurance is a billing and enrollment agent and is not responsible for payment of claims on your behalf. I certify that the information on this form is true and complete, that I understand and agree to the above administrative requirements, and that I have the legal authority to sign on the company s behalf. Signature Title Date Broker name (if applicable) Address City State ZIP For office use only Account representative Corporate Office: 135 Wood Rd, Braintree, MA (781) (877) (781) fax 2014

3 Harvard Pilgrim Health Care Intermediary Group Application Business Information Legal Business Name Name of Owner/Principal Contact Business Address Mailing Address (if different from Business Address) Business Telephone Business Address Business Fax Employer's Tax ID # Business Type Corporation Partnership Sole Proprietor LLC Other # Years in Business Nature of Business SIC Insurance Selected HPHC Plan selected Pediatric Dental Yes No Effective Date Requested Anniversary Date for Intermediary Contracts is April 1 st Employee Information 1. Please enter the number of Full Time Equivalents from the previous calendar year. Please refer to IRS guidelines. on how total full time equivalents must be calculated. 2. Total Number of employees including full-time and part-time for 20 or more calendar weeks during the current and prior calendar year.. 3. Total Number of benefit eligible employees - full-time employees working a minimum of 30 hours per week; part-time employees working a minimum of 20 hours per week, living in HPHC s enrollment area.. 4. Number of Waivers: Employee is covered under another plan as spouse or dependent Employee is covered by MassHealth, Medicare or Veterans programs.. Employee is covered under another plan sponsored by a second employer.. 5. Number of employees declining to enroll in this health plan. 6. Number of COBRA participants 7. Total Number of people enrolling in this plan (HPHC requires 100% participation from groups with 1-5 employees and 75% participation from groups 6+ Final Premium Rates are based on actual enrollment forms received.). 8. Eligibility Waiting Period* Date of hire 1st of the month following date of hire 30 days following date of hire 1 st of the month following 30 days 60 days following date of hire 1 st of the month following 60 days 90 days following date of hire *Definition: the day the waiting period has been satisfied (i.e. one month from date of hire) Employer Contribution Policy Employer Contribution towards all Individual Contracts Employer Contribution towards all Family Contracts (Must indicate contribution for BOTH Individual and Family.) Insurance History Do you currently have insurance? If Yes, with whom? Has your company canceled more than 3 health plans in the last four years? Y N Authorization The foregoing statements are (1) true and correct to the best of my knowledge and belief and (2) made to induce the issuance of health coverage. SIGNATURE OF COMPANY OFFICIAL TITLE DATE Harvard Pilgrim Health Care includes Harvard Pilgrim Health Care and its affiliates, Harvard Pilgrim Health Care of New England and HPHC Insurance Company

4 Pediatric Dental Attestation Please note that the Federal Health Reform Law, also known as the Patient Protection and Affordable Care Act, requires that beginning in 2014, all medical plans must include 10 broad categories of services called Essential Health Benefits, including pediatric dental coverage. Harvard Pilgrim automatically includes most of those benefits in your plan, but provides the option to purchase pediatric dental coverage on your own. You have selected a plan which does not include pediatric dental coverage. Therefore please read the attestation below, provide the information regarding your Exchange-certified dental carrier, and return this form with your enrollment package. Your health plan coverage provided by Harvard Pilgrim or its affiliates (the Health Plan ) DOES NOT include coverage for pediatric dental services, as required by the Patient Protection and Affordable Care Act. By signing below, I am attesting that each person covered under the Health Plan, now or in the future, also has coverage under the separate employer group dental plan listed below (the Dental Plan ) for the term of the Health Plan. The Dental Plan is an appropriate Exchange-certified stand-alone dental plan. Upon request, I agree to provide Harvard Pilgrim with documentation necessary to verify that each person covered under the Health Plan is also covered by the Dental Plan. If I am not able to provide such documentation or if Harvard Pilgrim determines that any person covered under the Health Plan is not also covered by an appropriate Exchange-certified stand-alone dental plan, I agree that Harvard Pilgrim may, without further consent from the employer group, charge the employer group appropriate premium for coverage of pediatric dental services. Employer Name Employer Authorized Signature Date Exchange Certified Dental Carrier Exchange Certified Dental Plan

5 The Harvard Pilgrim PPO PO BOX 9185 QUINCY, MA HPHC REASON FOR SUBMISSION (PLEASE CHECK ALL THAT APPLY) ENROLLMENT CHANGE TERMINATION NEW HIRE COBRA CHANGE COVERAGE TYPE NAME/ADDRESS CHANGE LEFT EMPLOYMENT NO LONGER ELIGIBLE ANNUAL OPEN ENROLLMENT ADD LISTED BELOW LOSS OF INSURANCE DATE VOLUNTARY CANCELLATION DECEASED DATE LOSS OF INSURANCE DATE TERMINATE (ATTACH DOCUMENTS MOVED FROM SERVICE AREA (ATTACH DOCUMENTS) LISTED BELOW MARRIAGE DATE P/T TO F/T DATE NEWBORN DATE H P P TO BE COMPLETED BY HPHC ONLY. GROUP / COMPANY NAME DATE OF HIRE GROUP #/DIVISION EFFECTIVE DATE EMPLOYEE NAME FIRST MIDDLE LAST ADDRESS APT. NO. STREET PO BOX CITY STATE ZIP COUNTY TELEPHONE (HOME) TELEPHONE (WORK) ( ) ( ) TYPE OF COVERAGE INDIVIDUAL 2-PERSON (ONLY WHERE OFFERED) FAMILY OTHER PLEASE USE THE CODES LISTED BELOW TO COMPLETE RELATION BLOCK 02 SPOUSE 03 CHILD UNDER CHILD TAX (MA ONLY) 03 CHILD TAX DEP/2 YR EXTN (MA ONLY) 04 STEPCHILD UNDER 19 05* FULL-TIME STUDENT 19 AND OVER 06 HANDICAPPED (VERIFICATION REQUIRED) 07 EX-SPOUSE FIRST MI LAST (IF NOT SAME AS EMPLOYEE) EMPLOYEE SPOUSE LANGUAGE DATE OF BIRTH SEX RELATION CODE MO DAY YR CODE SOCIAL SECURITY NUMBER - - M F LANGUAGE CODES (OPTIONAL) WHAT LANGUAGE DO YOU SPEAK MOST OFTEN? PLEASE LIST THE APPROPRIATE CODE AFTER EACH MEMBER S NAME. THIS INFORMATION WILL HELP US WORK TOWARD BEST MEETING YOUR NEEDS. AS CA CV EN FR HA HM IT KH LO MN PT RU SP VI OTHER American Sign Language Cantonese Cape Verdean English French Haitian Hmong Italian Khmer Laotian Mandarin Portuguese Russian Spanish Vietnamese Specify * IF YOU HAVE LISTED A FULL-TIME STUDENT(S) AGE 19 AND OVER, BUT UNDER THE MAXIMUM STUDENT AGE, PLEASE SUPPLY THE FOLLOWING INFORMATION: STUDENT(S) NAME NAME OF SCHOOL(S) STATE THIS INFORMATION MAY BE USED TO VERIFY ELIGIBILITY HAVE YOU EVER BEEN A MEMBER OF HPHC, HPHC OF NE, OR HPHC INSURANCE COMPANY? YES NO IF YOU WOULD LIKE TO RECEIVE A MENU OF ELECTRONIC WAYS TO INTERACT WITH US, LIST YOUR ADDRESS HERE. ADDRESS: (OPTIONAL) YOUR ADDRESS WILL BE STORED IN A PROTECTED DATABASE AND WILL REMAIN CONFIDENTIAL. MEMBERSHIP WILL BECOME EFFECTIVE UPON ACCEPTANCE BY THE PLAN. BENEFITS UNDER THE PLAN WILL BE EXPLAINED IN A SEPARATE DOCUMENT. FOR AN EXPLANATION OF HOW HARVARD PILGRIM MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION, PLEASE READ YOUR NOTICE OF PRIVACY PRACTICES PROVIDED TO YOU BY HARVARD PILGRIM IN YOUR ENROLLMENT KIT. MAINE MEMBERS: PLEASE NOTE THAT THE SUBROGATION PROVISION APPLICABLE TO MAINE MEMBERS, OUTLINED IN A SEPARATE DOCUMENT, PERMITS SUBROGATION PAYMENTS ON A JUST AND EQUITABLE BASIS. NEW HAMPSHIRE MEMBERS: PLEASE NOTE THAN AN ENROLLED PARTICIPANT SHALL BE ALLOWED A GRACE PERIOD OF TEN (10) DAYS FOR MAKING ANY PAYMENT DUE UNDER CONTRACT (N.H. RSA 420-B:8(IV)(b). I UNDERSTAND THAT A COPY OF THIS FORM WILL BE GIVEN TO ME, OR MY AUTHORIZED REPRESENTATIVE, UPON REQUEST. IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS. THE EMPLOYEE AND THE EMPLOYER MUST SIGN AND DATE THIS FORM FOR ENROLLMENT. EMPLOYEE SIGNATURE DATE EMPLOYER SIGNATURE DATE 10/ HP WHITE - HARVARD PILGRIM COPY YELLOW - EMPLOYER COPY PINK - EMPLOYEE COPY

6 MA Health Care Coverage Waiver Form Employer Company Name: Employee Name: On behalf of myself and my eligible dependents (if any), I waive the option to enroll in Harvard Pilgrim Health Care health insurance offered at this time by or through my employer for the following reason: Waiving Group Health Coverage (Please select one of the following) I am covered under another group plan as a spouse or dependent I am covered by the MassHealth, Medicare, or Veterans Program I am covered under another group plan sponsored by a second employer I am covered under another carrier s plan sponsored by this employer I am covered through a non-group, individual or private health care plan not offered through my employer I do not wish to participate in health care benefits at this time (I am declining health insurance entirely) If the reason stated above for waiving coverage is that you have coverage elsewhere, please provide the following information: Carrier Name: Subscriber Name: I affirm that the information I have provided on this form is true and complete to the best of my knowledge and belief. I understand that Harvard Pilgrim may either refuse to renew coverage or terminate coverage, retroactive to the effective date, for any material misinformation (including omissions) contained in this form. I understand that any person choosing to enroll at a time other than during my employer s open enrollment must meet Harvard Pilgrim s requirements for eligibility and the special enrollment rights summarized below. Employee Signature: Date: Notice of Special Enrollment Rights If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in this health plan, provided that you request enrollment within 30 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. Special enrollment rights may also apply if you lose coverage under Medicaid or the Children's Health Insurance Program (CHIP) or become eligible for state premium assistance under Medicaid or CHIP. An employee or Dependent who loses coverage under Medicaid or CHIP as a result of the loss of Medicaid or CHIP eligibility may be able to enroll in this Plan, if enrollment is requested within 60 days after Medicaid or CHIP coverage ends. An employee or Dependent who becomes eligible for group health plan premium assistance under Medicaid or CHIP may be able to enroll in this Plan if enrollment is requested within 60 days after the employee or Dependent is determined to be eligible for such premium assistance.

7 hsainsurance.com Authorization Agreement for Electronic Payments HSA members have the option of enrolling in our Electronic Payment (EP) Program. With the EP Program, you authorize HSA to deduct your monthly payments directly from your checking account. Simply fill out this form and include a copy of a voided check. Once Electronic Payment has been established, your billing statement will reflect the message Please Do Not Pay This Bill towards the middle/top section of your statement. This program could take 2-4 weeks to begin due to timing and processing factors. Electronic payments can be deducted from your account on either the 15 th or 24 th of each month. For example, July premium payments will be processed on June 15 th or June 24 th. All outstanding balances owed, including fees, will be transferred at that time. Please note, this form cannot be used for initial premium and/or dues payment upon enrollment with HSA. Client Name: 6 Digit HSA Member #: I (we) hereby authorize HSA, hereinafter called COMPANY, to initiate debit entries for my (our) Checking account indicated below and the depository named below, hereinafter called DEPOSITORY, to debit the same to such account. Please indicate which date you prefer withdrawals to start by checking one below: 15 th of Current Month 24 th of Current Month 15 th of Next Month 24 th of Next Month Bank Name: Branch: City: State: Zip: Name on Account: Routing Number: Bank Account Number: This authorization is to remain in full force and effect until COMPANY has received written notification from me (us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it Authorized Signer Sign Name Print Name and Title Authorized Signer (if more than one required) Sign Name Print Name and Title Date: Client Telephone: NOTE: ALL WRITTEN DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION. Attach voided check here Please fax or secure the completed form to: (781) or enrollment@hsainsurance.com *This form is for new enrollment in the EP Program ONLY. For changes to existing bank information, please contact Customer Service at (781) Corporate Office: 135 Wood Rd, Braintree, MA (781) (877) (781) fax

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