2015 Small group new business application

2015 Small group new business application PLEASE COMPLETE AND RETURN ALL PAGES IN THIS APPLICATION OR PROCESSING COULD BE DELAYED. 1-50 eligible employees

New group checklist Use this checklist to expedite the processing of your submission. Send all materials to Priority Health in accordance with required 30-day processing lead time to PH-SalesSBD@priorityhealth.com or 616.957.2529. If you have questions or need additional information, please call your independent insurance agent or the Priority Health Small Business department at 616.942.1820, or 800.471.2504. New group application return all pages. If common control, each subgroup MUST complete an application page. MESC 1017 (Quarterly Wage Detail Report) required of all groups regardless of size. For groups with 1 or 2 eligible employees please submit additional required business proofs (see next page). Enrollment form for all enrolling employees ensure that dates of hire, employer and employee signature, and PCP selection (if an HMO or POS) are listed on each form. The COBRA Continuation portion of the enrollment form is also required for any COBRA participant. Employee Waiver Form (if applicable). Copy of Final Proposal and Census from PriorityQuote 2.0. If electing voluntary dental coverage, a dental invoice is needed from the prior carrier to waive dental waiting periods (optional). 2

Application 1-50 employees Group information Group name (must be full legal name) Tax ID Group address City State ZIP County Phone number that we may use to contact you: ( ) Landline (home phone) Cell phone Billing address Fax Email City State ZIP County Group administration contact Phone number that we may use to contact you: ( ) Landline (home phone) Cell phone Group billing contact Fax Email Phone number that we may use to contact you: ( ) Landline (home phone) Cell phone Effective date Fax Email Renewal date 2015 Small business plan (e.g. HMO 100 Platinum 250) 2015 Dental plan (e.g. Dental Plan-A 1500 Voluntary) If PriorityHRA SM plan name of the HRA administrator: Total number of employees Total full time/full time equivalent Number eligible Number enrolling Number waiving CEO/Decision maker name Title 3

Business information For groups claiming religious exempt status, Priority Health reserves the right to request additional information for verification from the group regarding business activities and proper SIC code placement. Final SIC determination will be made by Priority Health. Priority Health reserves the right to re-rate at any time if discrepancies are found. SIC code (only needed for religious organizations): Specific nature of business: Is your group eligible to file taxes as common control with another company? Yes; All companies must be enrolled as one group Is this a PEO/leasing company? Yes; All companies must be enrolled as one group Eligibility requirements The group's extension of coverage policy for lay-off or disability may not exceed six months. If a group has no written policy for laid-off employees, the group's standard terminations or end of month applies. If a group has no written policy for employees on a disability leave, the term of coverage shall not exceed six months from the date of disability. Full-time eligibility hours (hours worked per week to be considered eligible for benefits cannot be less than 17.5): New hire waiting period If there is more than one class of employee, please give the waiting period for each different class. Date of hire 30 days 60 days 90 days 1st of the month following: Date of hire 30 days 60 days Term policy Date of termination Layoff policy Last day worked End of month End of month 30 days 60 days 90 days 6 months Disability policy Last day worked End of month 30 days 60 days 90 days 6 months Dependent eligibility End of the month dependent turns 26 End of the calendar year dependent turns 26 Domestic partner Yes; If yes, same gender only? Yes No No No No Early retiree option Yes No All employers who had 20 or more employees on 50% of its typical business days during the preceding calendar year must comply with COBRA. Qualified beneficiaries, as defined by COBRA, are eligible for coverage unless in an excluded class (i.e. retiree, part-time and temporary employees). Is your company required to offer COBRA? Yes No Would you like an Infinisource 1 packet? Yes No 4 1 COBRA administration through Infinisource is a free, value-added service to Priority Health employers

Insurance information Has your business ever had coverage with Priority Health? Yes; If yes, please provide date of coverage: / / and group number: No Name of most recent carrier: Type of most recent health care coverage? (DIFS required information check one) Non-profit health care corporation Uninsured PPO Self-insured Traditional insurance Worker's compensation carrier: Policy number: Section 111 Based on today s date, did you have 20 or more employees for 20 or more calendar weeks (this includes full-time, part-time, intermittent, leased and/or seasonal employees excluding self-employed individuals) during the previous or current calendar year? Yes; If you met this threshold during the previous year or current calendar year, please provide the date that this threshold was reached No; Please enter today's date date: / / Did you have 100 or more employees during 50 percent of your business days (full-time, part-time, intermittent, leased and/or seasonal employees excluding self-employed individuals) during the previous calendar year? Yes; Enter 1/1 of the previous calendar year No; Please enter today's date date: / / Pediatric dental Small groups who are not purchasing coverage on the Health Insurance Marketplace must purchase pediatric dental benefits as part of Essential Health Benefits under health care reform. Even if you don t have children under the age of 19, you re required to purchase pediatric dental. Yes I already have purchased pediatric dental coverage through a certified stand-alone dental carrier. No I do not currently have pediatric dental coverage, but understand this is a requirement and certify my intent to purchase this coverage Agent signature (optional) Date Employer signature (required) Date 5

Agent information (to be completed when using an agent) Agent name Broker ID Agency name Contact name Federal tax ID number Address City State ZIP Phone Fax Email Agent acknowledgement Group must be of a permanent nature and financially stable. Group must have been formed for a purpose other than to secure group insurance. Group must meet the definition of small employer and full time equivalent employee as defined in 4980H(c)(2) of the Internal Revenue Code, 26 U.S.C. 4980H(c)(2). Seasonal employees (those working less than 6 months), temporary employees, substitute employees and 1099 contractors are not eligible. Directors, corporate officers, trustees, corporate lawyers, elected officials and owners or partners are not eligible unless they are full time employees. Group must carry worker s compensation coverage unless not required by law. Priority Health will not co-exist with an employer sponsored individual plan if it causes group to not meet the participation rules. Members who are eligible for Medicare (or any governmental benefits), will be treated as if they are enrolled in Medicare parts A & B when Priority Health benefits are applied whether or not they are actually enrolled. Wrapping is only permitted if a group purchases a PriorityHRA package. I understand that Group may terminate this Agreement, without cause, at the end of any month by giving Health Plan 30 days advance written notice of termination. SUBMITTING THIS APPLICATION IS ACKNOWLEDGMENT THAT THE INFORMATION CONTAINED IN THE APPLICATION IS TRUE AND COMPLETE. GROUP UNDERSTANDS THAT HEALTH PLAN WILL RELY ON THE INFORMATION CONTAINED IN THE APPLICATION TO SET THE PREMIUM AND TO PROVIDE THE COVERED SERVICES UNDER THIS AGREEMENT. Agent signature Date 6 3

Additional requirements groups with 1-2 eligible employees Sole proprietor 1. Copy of Schedule C and 2. Copy of Federal Tax I.D. and the IRS Verification Form or Certification, e.g. Doing Business As (DBA) Certificate with County Clerk stamp Partnership 1. Copy of Schedule 1065 including Schedule K1 and 2. Copy of Federal Tax I.D. and the IRS Verification Form, or partnership papers Corporation 1. Copy of Schedule 1120 (Sub S - Schedule 1120s) including Schedule K1 and 2. Copy of any federal document with Federal I.D. number, or Articles of Incorporation Farmer Copy of schedule F Limited liability company 1. Copy of Schedule 1065 including Schedule K1 and 2. Copy of Articles of Organization Non-profit corporation If sole proprietor - Schedule C and state license or certification Non sole proprietor - Copy of Federal Tax I.D. including the IRS Verification Form and state license or certification and copy of applicable tax filing for entity Automatic bill payment plan Priority Health has developed an electronic fund transfer process for collecting monthly health insurance premiums. On the first business day of the month, the checking or savings account that you have designated below will be automatically debited for the amount on your billing statement. You will receive your premium billing statement each month approximately ten (10) days prior to the deduction from your account. Priority Health must be notified of any changes to your designated account at least five (5) business days prior to the last day of the month. Please fill out all information appropriately and return it with your application for coverage or it can be mailed directly to: Attn: Group Services MS 2279 Priority Health 1231 East Beltline NE Grand Rapids, MI 49525 You will receive a letter in the mail confirming your request for automatic monthly deductions from the account specified. This letter will also notify you in advance of the first date that your premium payment deduction will occur. If you have any additional questions on the automatic bill payment plan, please call Group Services at 800.942.0954. continued > 7

Automatic bill payment plan (continued) Enrollment form I authorize Priority Health to deduct the premium payment from the checking or savings account listed below. I understand the deduction will occur on the first business day of every month and if at any time I decide to discontinue this payment service, I will notify Priority Health in writing at least 30 days in advance. Company name Group ID Billing address City State ZIP Mailing address (if different) City State ZIP Contact person Phone ( ) Email I understand I must be authorized by the company to sign this form on its behalf. Authorized signature Date Print name To ensure the correct account number is used for this electronic payment and to obtain the ABA/Routing number, please contact your financial institution. Name of financial institution Account holder name ABA/routing number (9 digits on the bottom of check) Checking (or savings) account number There will be a $50 charge for any transfers returned for insufficient funds. - - Account type Checking Savings Important Please include either a voided check, copy of a voided check, copy of a statement or a bank letter with this application. 8

Employee waiver form This form is required for all eligible employees who are not enrolling with Priority Health at the time of initial enrollment and/or the group s open enrollment period. I understand that I am eligible for Priority Health coverage through my employer. I waive the right to enroll with Priority Health as offered to me by my employer for the following reason (please check one): I have other coverage through my spouse or other family member I have other coverage through Medicare or a pension plan I have other coverage through another source that is not employer-sponsored or employer paid I have no other coverage but choose not to enroll in my employer s plan I am waiving for other employer-paid coverage I understand that I will not be eligible for coverage through Priority Health until my employer s next open enrollment period unless I qualify for coverage due to a HIPAA qualifying event (such as marriage, birth of a child, adoption, or loss of other coverage). Employee name printed: Employee signature: Date: Group name: Priority Health group number: 9

Small group Eligibility and participation requirements (1-50 full-time eligible employees) Small businesses must meet these requirements to offer a Priority Health group benefits plan. Applicable to all group effective dates on or after Jan. 1, 2015. ELIGIBILITY Eligible employees include all employees who work on a full-time basis for 30 or more hours a week as well as employees who work 17.5 to 30 hours a week if elected by a group in their Group Agreement. Retirees under the age of 65 are eligible to be enrolled in a plan offered to active employees. The group must have a formal retiree plan established. Formal means the group has a document describing retiree eligibility, enrollment procedures, etc. or they are in the process of establishing a plan. The group must have a minimum of one active employee to cover early retirees. Unclear on a term? Find a list of definitions on page 12. Refer to the Priority Health small group Medicare (MAPD/EGWP) eligibility and participation guidelines for retirees that are over the age of 65. PARTICIPATION REQUIREMENTS FOR GROUPS OFFERING MULTIPLE PRIORITY HEALTH PLANS Groups with 1-9 eligible employees enrolling with Priority Health may offer (1) plan design. Group with 10-50 eligible employees enrolling with Priority Health may offer (2) plan designs with a minimum of (1) contracts enrolled in each of the plans. -- HealthbyChoice plans may only be paired with another HbC-type plan. PARTICIPATION OF EMPLOYEES OUTSIDE THE SERVICE AREA AND MICHIGAN HMO - 100% of employees enrolled in the plan must live or work in the service area. POS - 90% of employees enrolled in the plan must live and work in the service area. PPO - 70% of employees enrolled in the group must live in Michigan. 10

PARTICIPATION RULES APPLIED TO SEGMENTS If Priority Health is offered to a segment of employees (such as those who live in the service area or management or administrative employees), participation rules for the segment covered by the Priority Health plan will apply as if the segment offered by Priority Health is the entire group (e.g. in a group of 45 eligible employees, 30 of whom live outside the service area and are not covered by Priority Health, the participation rules for a group of 15 eligible employees will apply). If the entire group is comprised of 51 or more fulltime equivalent employees, the group is considered a Large Group and not subject to these Small Group Participation guidelines. OTHER REQUIREMENTS FOR SMALL GROUPS 1. The group must be of a permanent nature and financially stable. 2. The group must have been formed for a purpose other than to secure group insurance. 3. Seasonal employees (those working less than 6 months per year) and 1099 contractors are ineligible. Seasonal employees and part-time employees may count toward the fulltime employee equivalent count for purposes of determining employer size. 4. Directors, corporate officers, trustees, corporate lawyers, elected officials, and owners or partners are not eligible unless they are full-time eligible employees. 5. The group must carry Worker s Compensation coverage unless not required by law. 11

Definitions for determining group size EMPLOYEE The shared responsibility regulations look to existing common law standards to define who is an employee. Under this standard, an employment relationship exists if an employee is subject to the will and control of the employer not only as to what shall be done but how it shall be done. (See IRS Publication 15-A.) Under Section 54.4980H-1, the following are not considered to be common law employees (and should not be counted to determine group size): A leased employee A partner in a partnership A 2% S-corp shareholder Owners, spouses and immediate family members FULL-TIME EMPLOYEE Any employee who works, on average, 30 or more hours per week or 130 hours per month. FULL-TIME EQUIVALENT EMPLOYEE (FTE) A number based on the average hours that all part-time employees have worked for the year. To calculate the number of FTEs, a group needs to add the total service hours by all employees who are not full time and divide by 120 for each month of the last calendar year. Do not count more than 120 hours for any one employee. For example, disregard hours above 120 for any employee who may have worked overtime. In addition, the government has indicated that service hours rather than work hours must be used for this calculation. Therefore if an employers pays a part-time employee vacation time, those hours of service would count toward the calculation. LARGE GROUP An employer will be rated as a large group when there are 51 or more full-time and full-time equivalent employees. Add the total number of full-time employees to the full-time equivalents in order to determine your group size. The group needs to make this calculation for each month of the last calendar year. SEASONAL EMPLOYER EXCEPTION The seasonal employer exception indicates employers are not large if they exceed the 51 employee count for 120 days (or four months) or fewer during the preceding calendar year (the 120 days or four months do not have to be consecutive). SMALL EMPLOYER An employer will be rated as a small group when there are 50 or fewer full-time employees. Add the total number of full-time employees in order to determine your group size. The group needs to make this calculation for each month of the last calendar year. SUBGROUP/DIVIDING A COMPANY INTO SMALL GROUPS Subgroups fall under a common control group (also a controlled group or affiliated service group). All subgroup employees are considered employees of the parent group. A controlled group may not divide itself into smaller subgroups to be considered a small employer. See Section 414 (b), (c) or (m) of the Internal Revenue Code for details. 12

For internal use only Group name Effective date Renewal date Group number Subgroup number QHP ID Main class Hourly class COBRA class PPO network (required information for PriorityPPO plans) Domestic partner Early retiree Salary class Group services Billing Finance Date Date Date 13

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