Benefit Schedule for Employer Groups SIGNATURE SHEET Anniversary Group No.: AE: Benefit & Premium Modification Broker: This Agreement, consisting of the Benefit Schedule(s) and other related documents, as supplemented by this Signature Sheet and attachments, has been entered into between. (Colorado Choice) and the Subscriber Group named below, in order to provide eligible Subscribers and eligible Dependents electing to enroll hereunder with health care benefits as specified in the Benefit Schedule(s) and related documents. This Agreement may be amended pursuant to the Benefit Schedule(s) and related documents of at any time by mutual written consent between the Subscriber Group and Colorado Choice. 1. Name and Address of Subscriber Group: Employer Tax I.D. No.: Administrator: 2. Eligibility: Employees and/or Dependents must meet the following requirements in addition to those specified in Article III: Full time employees must work at least hours per week (must be at least 24 hours per week). Employer contribution*: Employee Dependents *To avoid discrimination an employer that pays 100% of eligible employee &/or 100% of eligible dependent health care coverage cannot exclude any eligible employees &/or dependent from participation in the healthcare plan: 3. Monthly Prepayment Schedule (premium): The rates are in effect for coverage through: See attached for Subscriber Group rates. It is the Subscriber Group s responsibility to prepay for healthcare coverage prior to the month of coverage (for example, payment for February coverage must be received by Colorado Choice in January) to maintain coverage. Colorado Choice has no responsibility to extend coverage beyond the month for which premiums have been received or to send Subscriber Group billings or statements for any period of coverage. 4. Contract Type Rate Tier Structure: Employer groups of 1-9 employees: Employer groups of 10-50 employees: Employer groups of 51+ employees: Eligible employees are rated with an age-banded rate structure. Please make a choice between agebanded and composite rates for your group. Age-Banded Composite 5. Type of Benefit Plan: Benefit Plan: Riders: 6. Special Instructions & Other Attachments: 7. Open Enrollment Periods: Applications for membership are accepted from through to provide coverage beginning Composite Tier Executed at: Subscriber Grp: Print Name & Effective Cynthia Palmer, CEO Ver2010 Page 1 of 7
700 Main Street, Suite 100, Alamosa, CO 81101 * 719-589-3696 or 1-800-475-8466 SIGNATURE SHEET 1. We wish to enroll our firm as a group account with Colorado Choice. 2. We understand the eligibility rules applicable to employee enrollment and the prepayment requirements of Colorado Choice. 3. Participating requirements for specific coverage(s) have been explained in detail, and we fully understand that they must be met and maintained in order for the group to remain eligible for coverage. 4. The group herewith tenders the amount of $ ; and in consideration of approval of the application by the Plan, it promises to pay the Plan, as appropriate, any balance necessary to constitute the full initial payment for group benefits herein identified in the application. It is understood that the Plan has the right to accept or reject this application, and coverage will not commence until the application has been accepted. This Agreement, consisting of the attached Group Medical and Hospital Service Agreement and Benefit Schedule(s), as supplemented by this Group Application and Signature Sheet, has been entered into between Colorado Choice and the Subscriber Group named above, in order to provide eligible Subscribers and eligible Dependents electing to enroll here under with health care benefits as specified in the Benefit Schedule(s). This Agreement may be amended with mutual written consent between the Subscriber Group and Colorado Choice at any time. Executed at: Subscriber Grp: Effective Print Name: Print Name: Cynthia Palmer Authorized Representative CEO Authorized Representative PRODUCER STATEMENT Name: Production Split: Address: Make Check Payable to: Telephone: Fax #: Federal Tax I.D. #: Producer #: I certify that all the information contained in this application is correct to the best of my knowledge. I also certify that: 1. This firm is a bona fide business establishment. 2. All participation requirements have been met. 3. Coverage s, enrollment provisions, eligibility requirements, limitations, exclusions, the effect of misrepresentations and termination provisions have been fully explained and understood by the employer. I know of no reason why the Plan coverage should not be offered, and I recommend that such coverage be coverage. Dated this day of Print Name of Producer: Producer Any change to this Producer statement does not constitute an amendment to the Group Application and Signature Sheet. Ver2010 Page 2 of 7
COLORADO CHOICE HEALTH PLANS Certification of Completed Group Renewal Please complete the following I hereby certify that the following required documentation has been submitted to Colorado Choice as part of this group renewal. The documentation requested below must be submitted each year at renewal. 1. REQUESTED TAX INFORMATION IS ATTACHED. (Information required to satisfy state regulatory requirements - varies with type of group) (UITR and/or Tax return information.) YES (Requested tax information must accompany signed renewal contract.) 2. WAIVER FORMS ARE ATTACHED. (A waiver form must be completed for each employee who is eligible for the Health Plan, but is not enrolled in the health plan.) YES NO (Waivers must accompany signed renewal contract. If waivers are not applicable because all eligible employees are enrolled, mark NO below.) All eligibles enrolled. 3. ACA DEPENDENT COVERAGE TO AGE 26 Employees have been notified that qualified dependents to age 26 may be added to their health plan at group s anniversary date. YES Employees have been notified Signed: Printed Name: Business Name: SSN or EIN: Ver2010 Page 3 of 7
COLORADO CHOICE HEALTH PLANS GROUP APPLICATION Full Legal Name of contract Holder (include punctuation and abbreviations): Group #: Effective Anniversary Federal Tax I.D.#: Address (Number, Street, P.O. Box, City, Zip): Telephone #: Fax #: Subsidiary or Affiliated Companies to be covered by the Plan: 1. 2. 3. 4. TYPE OF ORGANIZATION Non-Profit Sole Proprietorship Union Partnership Association Corporation Political Subdivision Trust Fund Other (Describe) Nature of Business: SIC Code: Date of Incorporation: GROUP BENEFITS ADMINISTRATOR Name: Address: Telephone: Fax #: BILLING CONTACT PERSON Name: Address: Telephone: Fax #: Is this a Multi Region Group? Yes No If yes, please list other Regions: Which Region is the main contact for the group? MULTI REGION AFFILIATION Ver2010 Page 4 of 7
EMPLOYEE INFORMATION Total Number of Employees Working Full-Time: Total Number of Dependents of Full-Time Employees: # of Eligible Dependents Total Number of Employees Working Part-Time: Total Number of Dependents of Part-Time Employees: # of Eligible Dependents Total Number of Other Eligible: Total Number of Dependents of Other Eligible: Number of Employees Eligible per Employer Guidelines to Enroll in the Plan: Number of Employees Enrolled (must be at least 75% of all Eligible Employees): Are all Employees and Partners/Sole Proprietors Covered by Worker s Compensation? Yes No If No, please explain: * Please provide a complete list of all such employees and dependents. ELIGIBILITY PROVISIONS (May only be changed at the time of the group contract renewal each year) Employees: Regular Active Full-Time Employees scheduled to work at least _ hours per week Regular Active Part-Time Employees scheduled to work at least hours per week Employees on approved Temporary Inactive status (please submit complete description with this application) Medicare Eligible Employees Retired Employees Other (Please submit complete description with this application) Dependents: Dependent children of the subscriber are covered through the last day of the month in which such dependent loses eligibility as a dependent or attains age twenty-six (26), whichever is applicable. A Dependent child who has not attained age 26, will be excluded from coverage only if that dependent is eligible to enroll in his/her own employersponsored health plan. Dependent children medically certified as disabled may be covered past age 26 with proof of disablility. Other (please submit complete description with this application) COMMENCEMENT OF COVERAGE PROVISIONS (Employees must enroll within 30 days of becoming eligible) Newly Hired Employees: First Day of the Month Following _ from Date of Hire Colorado Choice Standard Newly Eligible Employees: Definition of Newly Eligible Employees: First Day of the Month Following Date of Eligibility Colorado Choice Standard Other (Please submit complete description with application Part-Time to Regular, Full-Time Temporary to Regular, Full-Time Transfer Recalled from Layoff (within ) Rehired Former Employee (within ) Newly Eligible Dependents: Date of Birth of Child and First Day of the Month Following Date of Marriage Colorado Choice Standard TERMINATION PROVISIONS Last Day of the Month in which the Employee or Dependent Ceases to be Eligible under Group Eligibility Provisions Colorado Choice Standard Other (Please submit complete description with application, including payment and individual conversion provisions) Ver2010 Page 5 of 7
OTHER CURRENT COVERAGES Does the company currently offer other coverage s? Yes No If yes, have all other coverage s been offered to all Eligible Employees and Dependents? Yes No Please list the carriers and coverage s offered: 1. 2. 3. 4. COVERAGE S APPLIED FOR SMALL GROUP Medical Plans (1-50 eligible employees) SMALL GROUP Optional Plan Riders MEDICAL PLAN: Prescription: OPEN ACCESS: Yes No DEDUCTIBLE: $ X2 X3 No Deductible Preventive Care is Excluded Preventive Care and Office Visits are Excluded Vision: Dental: Basic Comprehensive LARGE GROUP Medical Plans LARGE GROUP Optional Plan Riders MEDICAL PLANS: Prescription: OPEN ACCESS: Yes No Vision: Dental: Basic Comprehensive DEDUCTIBLE: $_ X2 X3 No deductible Preventive Care is Excluded Preventive Care and Office Visits are Excluded Ver2010 Page 6 of 7
MONTHLY RATES TWO-TIER RATES THREE-TIER RATES FOUR-TIER RATES SEE ATTACHED AGE BANDED RATES Employee: $ Employee: $ Employee: $ Employee + Family $ Employee + 1 Dependent $ Employee +Spouse: $ Employee + Family $ Employee +Child(ren) $ Employee +Family: $ Annual Rate Change Notification: 30 Days Prior to the Annual Renewal Date Colorado Choice: Standard Other: Days Prior to the Annual Renewal Date These rates are guaranteed up to 12 months from the Effective Date of the Coverage, or any lesser period mutually agreed upon. Colorado Choice reserves the right to change these rates in the event of government-mandated benefit or tax changes. Final rates are based on actual enrollment on the effective date of coverage. EMPLOYER CONTRIBUTION Employee Coverage: of Monthly Rate $ Monthly Rate Other (Submit complete description) Dependent Coverage: of Monthly Rate $ Monthly Rate Other (Submit complete description) PAYMENT PROVISIONS Full Premiums are due for the month in which coverage is effective. newborn children for the first 31 days. Colorado Choice Standard No Premium will be charged for If Commencement Date of Coverage for Employee or Dependents falls on the 1st Day of the Month through the 15th day of the Month, Full Premiums are Due for that Month; however, if Commencement Date of Coverage is the 16th Day of the Month through the End of the Month, No Premiums are Due for that Month. PARTICIPATION REQUIREMENTS GROUPS WITH 1 TO 50 EMPLOYEES - The Employer must employ at least one eligible employee for enrollment. A minimum of 75% of all eligible employees must enroll in the Plan, or have other coverage. A Waiver of Coverage must be submitted for all employees and dependents declining coverage. The employer must contribute at least 50% of the cost of the employee coverage. Eligible employees must be regular, full-time employees scheduled to work at least 24 hours per week. GROUPS WITH 51 OR MORE EMPLOYEES - A minimum of 75% of all eligible employees must enroll in the Plan, or have coverage. The employer must contribute at least 50% of the cost of the employee coverage. Eligible employees must be regular, full-time employees scheduled to work at least 24 hours per week. If Colorado Choice is the sole carrier, a Waiver of Coverage must be submitted for all employees and dependents declining coverage. ELIGIBILITY REQUIREMENTS - A bona fide employer/employee relationship is required. The employer must compensate the individual in the form of an annual, monthly or hourly wage. The employer must maintain an employment relationship pursuant to which the employer pays those payroll costs (FICA, FUI, and SUI) normally associated with maintaining a bona fide employer/employee relationship. RATING METHODOLOGIES Four-Tier Family Age-Banded Rates are rates which vary based on both the age of the subscriber and the four-tier contract type (i.e. single, employee/spouse, employee/child(ren), family). Under this methodology two single employees in different age bands will pay different rates. Composite rates are rates which vary only based on the four-tier contract type for each subscriber (i.e. all single employees have the same rate regardless of subscriber age). Composite rates are calculated so that the total premium of the group is the same as the total premium for the group under age banded rates. Ver2010 Page 7 of 7