Employer Group Benefits Data Form Eligible Employees

Transcription

1 Employer Group Benefits Data Form Eligible Employees INSTRUCTIONS FOR COMPLETION 1. Answer all questions completely and accurately. 2. Do not cancel your existing coverage until you receive written notification of approval from Coventry Health Care. 3. Submit the current carrier billing statement, listing those currently insured and current rates. 4. Submit the most recent unemployment wage and tax report and indicate whether each employee is full time, part time, terminated or seasonal. SECTION I Employer Information * Group Number(s) Include all service areas: (Coventry Health Care Use Only) 5. Submit Enrollment Forms including the Waiver of Group Health section for all employees waiving coverage for themselves and/or their dependent(s). 6. Submit Enrollment Forms for every eligible employee, COBRA or State Continuant and any employee in his or her waiting period. 7. Attach a copy of the quoted rate sheet indicating the rates and corresponding benefits. Company (Legal name including any DBAs) Federal Tax ID # Company Address Street City State Zip # of Years in Business Billing Address (if different) Standard Industry Code (SIC) Billing Contact (BC) BC Phone # BC Fax # BC Administrative Contact (AC) AC Phone # AC Fax # AC Decision-Maker (DM) DM Phone # DM Fax # DM Number of Subsidiaries (if applicable) Subsidiary (s) Subsidiary Address(s) Number of Subsidiary Employees Subsidiary Contact (SC) SC Phone # SC Fax # SC Nature of Business (check one): Partnership Corporation SECTION II Medical Plan Options LLC Municipality Non-profit Union Group Limited Partnership Sole Proprietorship Other PLEASE REFER TO THE QUOTE, WHICH INDICATES THE BENEFIT PLAN AND PREMIUM RATES. THE APPLICANT/PRODUCER MUST ATTACH THE QUOTED RATE SHEET TO THIS FORM PRIOR TO SUBMISSION. WITHOUT A COPY OF THE QUOTED RATE SHEET ATTACHED, THIS FORM IS NOT FULLY COMPLETE. SECTION III Group Underwriting, Enrollment, Eligibility, Continuation and Participation Employer Contribution: % of Employee premium cost % of Dependent premium cost Employee Eligibility: Full-time employees working 30 hours per week (applies to all small employer groups). Coverage Begins: Date of hire 1 st day of month following 60 days 1 st day of month following date of hire 1 st day following 90 days 1 st day of month following 30 days

2 Coverage Terminates: The end of the month in which employment terminates (applies to all small employer groups). Initial Group Enrollment Questions: 1. Total number of Employees (including those waiving coverage or in the waiting period): Full-time Employees: Part-time, temporary or seasonal employees: 2. Total number of employees eligible for coverage 3. Are all employees covered by Worker s Compensation? Yes No If no, explain: 4. Number of employees terminated in the last 12 months: 5. a) Average number of employees for purposes of the minimum MLR requirements * (Please refer to the Example provided below.) *The total average number of employees employed by the company during the previous calendar year (January 1 st and continuing through December 31 st of that year), regardless of whether employees were eligible to enroll, and/or participated in the group insurance coverage. Include all employees to whom the employer issues a W-2 (any person employed by the employer: full-time, part-time, seasonal; also include employees of affiliated companies, if the employer is aggregated and treated as a single employer under subsection (b), (c), (m) or (o) of section 414 of the Internal Revenue Code). Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Average** Full-Time Employee Part-Time Employee Seasonal Employee Total **Average = the total number of employees for the preceding calendar year divided by 12 months. Example: This average must include all persons employed by the company and any affiliated companies in the preceding calendar year, whether an employee was full-time, part-time, and/or seasonal. Important: the government requires the total average number, regardless of whether employees were eligible to enroll, and/or participated in the group insurance coverage. Only include temporary employees if they are employees of the company (i.e., employees to whom the employer issues a W-2). Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Average Full-Time Employee Part-Time Employee Seasonal Employee Total Average = the total number of employees for the preceding calendar year divided by 12 months (e.g., 411 divided by 12 = 34) b) Medical Loss Ratio (MLR) Classification. Check the appropriate box below. More information about MLR can be found at ERISA Government Group - Non-Federal (A non-federal governmental plan is plan that is established or maintained by the government of any State or political subdivision thereof for its employees, or by any agency or instrumentality of any government of any State or political subdivision for its employees) Non-ERISA and not a Government Group (if you choose this option you must complete the Coventry non-erisa addendum that will be provided and check one of the boxes below) Non-ERISA - Agree to the terms in the Coventry non-erisa addendum Non-ERISA - Don't agree to the terms in the Coventry non-erisa addendum 6. Total number of Nebraska LB 551 Dependent continuants? List all Dependents on Nebraska LB 551 continuation (use separate sheet of paper if necessary):

3 7. Total number of COBRA continuants: List all Employees/Dependents on COBRA (use separate sheet of paper, if necessary): Initial COBRA or State Continuation Effective Date Anticipated COBRA or State Continuation End Date 8. List the previous group health carriers for the last five years: Type of Coverage (PPO, HMO, POS, etc. and deductible amount) 9. Are there any employees/dependents who reside outside of the state where the employer is located? i.e. if employer is located in Nebraska are there any employees who reside in Iowa or South Dakota? Yes No If yes, please list employees (use separate sheet of paper, if necessary): Location of residence (city, state, zip) SECTION IV Producer Information (Complete if producer is not Coventry Health Care employee) Broker Department of Insurance License Number/ Indicate State Broker Commission Split (if applicable) Broker Address Broker Phone # Broker Fax # Broker Broker Signature Agency of General Agent (if applicable) Payee Tax ID # Payee (who is paid commissions directly by Coventry) Broker Agency General Agent Coventry Health Care Account Executive SECTION V Important, Read Carefully The information contained in this document will be used for the purposes of providing final rates and completing the Group Master Contract. If any information is incomplete or inaccurate, it could result in a change in the terms of the Group Master Contract. Please read your Group Master Contract for accuracy and completeness prior to signing since the Group Master Contract will incorporate answers provided above. This document is not considered a formal part of your agreement with Coventry. Employer Signature: Date:

4 SMALL GROUP DEFINITION CHANGE AMENDMENT Coventry Health Care of Nebraska AMENDMENT TO THE CERTIFICATE OF COVERAGE, SCHEDULE OF BENEFITS AND ALL RELATED PLAN DOCUMENTS, INCLUDING: Employee Enrollment/Change Form(s) Employer Application(s) and Joinder Agreement(s) Member ID Cards Effective January 1, 2016, this amendment modifies the documents noted above. All references to group size in the above documents, as they relate to medical plan coverage, are hereby deleted and replaced with Except as stated herein nothing other than the specified provisions in this document shall be deemed altered. Accepted by: CHC 2015 SG DEF AMEND 1 CHNE 11593

5 SMALL GROUP DEFINITION CHANGE AMENDMENT Coventry Health and Life Insurance Company AMENDMENT TO THE CERTIFICATE OF COVERAGE, SCHEDULE OF BENEFITS AND ALL RELATED PLAN DOCUMENTS, INCLUDING: Employee Enrollment/Change Form(s) Employer Application(s) and Joinder Agreement(s) Member ID Cards Effective January 1, 2016, this amendment modifies the documents noted above. All references to group size in the above documents, as they relate to medical plan coverage, are hereby deleted and replaced with Except as stated herein nothing other than the specified provisions in this document shall be deemed altered. Accepted by: CHL 2015 SG DEF AMEND 1 CHNE 11603