EMPLOYER GROUP APPLICATION Segment 2: Small Group Bundled with Medical; Size 2 100

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1 The HIPAA Certification must be included with the Employer Group Application in order for this application to be considered complete. Incomplete applications may be returned. EMPLOYER GROUP APPLICATION Segment 2: Small Group Bundled with Medical; Size For Delta Dental internal use only: Group # Subgroup # 9L Legal Group Name: Physical Address: Mailing Address: Phone: Fax: Contact Name: Title: Phone: Fax: SIC Code Enter number must be completed by broker or employer. If billing is different from above, please complete below: Billing Entity Name: RMHP Billing Address: PO Box Grand Junction, CO Contact Name: Becky Watson Title: RMHP Billing Representative Phone: Fax: becky.watson@rmhp.org PARTICIPATION Total Number of Enrolled Employees Total Number of Eligible Employees Enter number Enter number NOTE: Employees eligible for medical are eligible for dental. EMPLOYER CONTRIBUTION Employer % Employee % Enter percent Enter percent If other, please describe: Delta Dental Group App RMHP Seg 2 Updated 02/08/16 Page 1

2 ENROLLMENT TYPE: Contributory or Voluntary Select One PRODUCT SELECTION: Select One Contributory open enrollment Contributory open enrollment requirements: 50% employer contribution for the single employee premium and the greater of 2 or 50% of all eligible employees must enroll. Voluntary open enrollment with waiting periods Voluntary open enrollment requirements: 0% to 49% employer contribution for the single employee premium and the greater of 2 or 20% of all eligible employees must enroll. To waive waiting periods at initial enrollment, submit copy of most recent prior dental carrier bill. Delta Dental PPO SM plus Premier High Option Plan (see options below) Delta Dental PPO (MAC) High Option Plan ($1,500 annual maximum, ortho not available) Dental Product Selection with ACA-compliant Metal Plan: All 2015 RMHP ACA-compliant medical plans include embedded child dental coverage up to age 19. Dental plans are available for employees and their spouses/partners age 19 and older. Employers with 25 or more employees enrolling in the dental plan have an orthodontic option that allows enrollment of children. Adult-Only Dental Dental Product Selection with a Non ACA-compliant Health Plan: PPO pluspremier and MAC dental plans are available to employees and their dependents, including children. Non ACA-compliant health plans do not include embedded child dental coverage. Employers with 25 or more employees enrolling in the dental plan have an orthodontic option that allows enrollment of children. Family Dental PPO PLUS PREMIER PLAN BENEFIT OPTIONS: One selection per column (do not fill this out if you have chosen the PPO MAC plan) Annual Maximum Orthodontia $1,000 Yes No $1,500 Yes No $2,000 Yes No EMPLOYEE ELIGIBILITY AND COVERAGE: Dental plan eligibility criteria must be the same as the medical plan eligibility. Rocky Mountain Health Plans determines eligibilty. *Dependent Eligibility: Children to the end of the month in which they turn 26, regardless of student status. Affordable Care Act pediatric dental to the end of the month in which they turn 19. GENERAL INFORMATION Name of previous dental carrier: Enter name If internal transfer from Delta Dental, enter prior Delta Dental group #: Enter group # ENROLLMENT METHOD, RATES AND BILLING Payment Method: ACH Initial Enrollment Method*: EE/EDI Ongoing Enrollment Method: EE/EDI Administrative COBRA: None Tier Structure RATES Grandfathered Plan Rates Tier Structure RATES Per Member Per Month Employee Child (up to age 19) Employee + Spouse Adult (19+) Employee + Children Employee + Family Delta Dental Group App RMHP Seg 2 Updated 02/08/16 Page 2

3 CONTRACT INFORMATION AND SIGNATURES Group Effective Date for Dental Plan: Benefit Period for Deductibles and Maximums: Rate Guarantee Period (ex: Jan to Dec. 2015): Medical/Dental Anniversary Month: The first month s premium is estimated to be: Calendar Year Enter date (mm/dd/yy) Renewal must match medical Enter $amount It is agreed the Group Contract will not become effective unless and until this application is approved and accepted by Delta Dental of Colorado. It is understood that this application will be considered part of the Contract between Delta Dental of Colorado and the Group. RMHP Account Executive (account executive name to be chosen only if the group is a new group to RMHP). If it is an existing group, please check the Existing Group box. New Group Joe Brown Jeff Emerson Laurie Wilcox-Romero Existing Group Group Management Team } Ernestine Chapman Clara Swenson RMHP Account Manager Authorized Signature for Group Date It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the department of regulatory agencies. Producer Information Producer Name: Producer Firm: Street Address: Phone: Fax: Delta Dental Group App RMHP Seg 2 Updated 02/08/16 Page 3

4 Rocky Mountain Health Plans Information RMHP Contact Name: Western Slope Account Coordinators/Rhonda Linza Firm Name: Rocky Mountain Street Address: 2775 Crossroads Grand Junction, CO Phone: Fax: TIN #: Please send completed and signed Master Application including HIPAA Form, Employee Enrollment Forms and Prior Carrier Bill (if applicable) to: RMHP Sales and Marketing PO Box Grand Junction, CO Please Note: If you are filling this out electronically, please open in Adobe Acrobat and when you are finished, do Save As and rename your file. Delta Dental Group App RMHP Seg 2 Updated 02/08/16 Page 4

5 Delta Dental of Colorado Group Health Plan Certification The Group Health Plan (Plan) does hereby certify to the following: 1. That the Plan is a group health plan within the meaning of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 2. That the Plan documents you distribute to employees informing them about their benefits or the Plan documents you are legally required to maintain for your employee benefits plans (such as ERISA Plan documents) have been amended, as required by 45 CFR (f) and (b) HIPAA, to incorporate the following provisions and you, as the Plan Sponsor (employer) agreed to: a. Not use or further disclose (Protected Health Information (PHI)) other than as permitted by plan documents or as required by law; b. Ensure that any agents, including subcontractors, to whom the plan sponsor provides PHI agree to the same restrictions and conditions that apply to the plan sponsor with respect to such information; c. Not use or disclose PHI for employment-related actions and decisions; d. Report any inconsistent use or disclosure of PHI to the group health plan; e. Make PHI available to an individual based on HIPAA s access requirements; f. Make PHI available for amendment and incorporate any PHI amendments based on HIPAA s amendment requirements; g. Make available the information required to provide an accounting of disclosures; h. Make internal practices, books and records relating to the use and disclosure of PHI received from the Group Health Plan available to the Secretary of Health and Human Services to determine the Plan s compliance with HIPAA; i. Ensure that adequate separation between the Group Health Plan and the Plan Sponsor is established as required by HIPAA (45 CFR (f)(2)(iii)) and that such separation is supported by reasonable and appropriate security measures; j. If feasible, return or destroy all PHI received from the Plan that the Plan Sponsor still maintains in any form and retain no copies of such PHI when no longer needed for the specified disclosure purpose. If return or destruction is not feasible, Plan Sponsor will limit further uses and disclosures to those purposes that make the return or destruction infeasible; k. Implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic protected health information that it creates, receives, maintains, or transmits on behalf of the group health plan; l. Ensure that any agent, including a subcontractor, to whom it provides this information agrees to implement reasonable and appropriate security measures to protect the information; and m. Report to the group health plan any security incident of which it becomes aware. 3. The undersigned further certifies that he or she has the authority to sign on behalf of the Plan. Printed Name of Plan Representative Delta Dental Group Number Signature of Plan Representative Date Delta Dental of Colorado puts a high priority on compliance with laws and regulations under which it operates and is dedicated to protecting the information of our enrollees. GHPC 06/13

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