Master Group Application (for 1 to 50 eligible employees) Blue Shield of California

Transcription

1 Master Group Application (for 1 to 50 eligible employees) Blue Shield of California Effective January 1, 2014 Section 1 Company Information Please type or print clearly in black ink. 1 Full legal business name Effective date DBA/doing business as (if applicable) 2 Billing address: number, street, city, state, ZIP (if P.O. Box, complete No. 3 below) 3 Physical address of business (if different from above) County 4 Group contact name only designated contacts can access group information Title Phone number ( ) Fax number ( ) address: c Check here to register the above individual/entity for online account access. Note: Online account access may be established to view and/or manage your group account. Once registered, account access may be delegated to your broker or other individuals within your organization. For more information, please visit blueshieldca.com/employer. Secondary group contact name address: Phone number ( ) 5 Legal entity: c S-Corporation c C-Corporation c Partnership c Sole proprietor c LLC n-profit c Other (specify) If LLC or other was selected, please indicate the Federal Income Tax Classification of the business: Federal Tax Identification number Do you have multiple tax ID numbers? If Yes, provide the Federal Employer Tax ID number for the plan sponsor: List the major industries and products/services of your business Title Standard industry classification code(s) (SIC Code) Prior group health carrier Start/end date Coverage still in force? 6 Has the company been insured previously by Blue Shield of California? If yes, please provide Group ID and termination date: Group ID Termination date 7 Are you offering Blue Shield alongside another carrier s plan? Open enrollment dates Carrier name No. of employees: From: To: Does the company have any subsidiary or affiliated companies? Subsidiary or affiliated company name(s) Are all employees covered by workers compensation to the extent required by law? Include in coverage? Blue Shield of California is an independent member of the Blue Shield Association C15385-NC (7/13) C15385 (7/13) Master Group Application 1 of 5

2 Section 2 Eligibility 8 Total Employee Count Total No. of Enrolling Employees Total No. of Active Employees (Including Eligible Employees and Ineligible Employees, Full-Time and Part-Time) Total No. of Eligible Employees Total Number of Enrolling Medical Coverage Total No. of Employees Declining Blue Shield Coverage Total No. of Eligible Full-Time Employees Total Number of Employees Declining Enrollment Medical Coverage Total No. of Eligible Part-Time Employees 9 9a. New-Employee Waiting Period The group may select from one of the following three options for the new-employee waiting period. Eligible Employees are effective following completion of the waiting period on the day specified. c Effective first bill date following date of hire c Effective first bill due date following 30 days from date of hire c Effective on 60th day following date of hire 9b. Will the waiting period be waived for current, actively at work employees? 9c. Number of eligible employees in the waiting period? 9d. Are all full-time eligible employees being offered health coverage? 9e. If no, please describe the specific class/group of employees to whom coverage is being offered. 9f. Are all of the full-time eligible employees to whom you are offering coverage actively working an average of 30 hours per week? 9g. Do you wish to offer coverage for your permanent employees who work an average of hours per week? 9h. Are there any out-of-state employees? 9i. If yes, how many out-of-state employees are eligible for coverage? 9j. Do you wish to offer coverage for opposite-sex domestic partners under the age of 62 years (Broad coverage)? Note: Coverage for registered same-sex domestic partners and opposite-sex domestic partners where at least one parter is 62 or older (Narrow coverage) is included. Section 3 COBRA/Cal-COBRA information 10 10a. Is your group currently subject to Cal-COBRA? (Employed 2-19 eligible employees on at least 50% of its working days in the previous calendar year; or if not in business during any part of the previous calendar year, employed 2-19 eligible employees on at least 50% of its working days during the previous calendar quarter; and not subject to COBRA) 10b. Is your group currently subject to Federal COBRA and Cal-COBRA? (Employed 20 or more total employees on at least 50% of the working days in the previous calendar year) 10c. Number of current Cal-COBRA enrollees? 10d. How many employees and/or family members are in the Cal-COBRA election period? 10e. Number of current COBRA enrollees? 10f. How many employees and/or family members are in the COBRA election period? 10g. Are enrollment forms attached for all enrolling COBRA/Cal-COBRA participants? C15385 (7/13) Master Group Application 2 of 5

3 Section 4 Medical benefits 11 c Blue Shield of California Off Exchange Package For groups with one or more enrolling employees offering Blue Shield of California, the group may select from one of the following three options. The Blue Shield of California Off Exchange Package is the only package that may be offered alongside another carrier's HMO plan. c All PPO plans and Full HMO plans (excludes Exclusive HMO plans) c All PPO plans and Exclusive HMO plans (excludes Full HMO plans) c Selected plans The group may choose up to 13 plans from the options below. Note: Exclusive HMO plans may not be offered in conjunction with Full HMO plans. c Ultimate Full PPO 0 c Ultimate Full PPO 150 c Preferred Full PPO 0 c Preferred Full PPO 750 c Enhanced Full PPO 1250 c Enhanced Full PPO 2000 c Enhanced Full PPO for HSA 2000 c Basic Full PPO 4500 c Basic Full PPO for HSA 3500 c Basic Full PPO for HSA 5500 c Ultimate Full HMO $25 c Preferred Full HMO $30 c Enhanced Full HMO $55 c Ultimate Exclusive HMO $25 c Preferred Exclusive HMO $30 c Enhanced Exclusive HMO $55 c Blue Shield of California Mirror Package Groups with one or more enrolling employees that select this package may select any number of plans from the options below. Platinum Mirror Plans c Ultimate Exclusive HMO c Ultimate Full HMO Gold Mirror Plans c Preferred Exclusive HMO c Preferred Full HMO Silver Mirror Plans c Enhanced Exclusive HMO c Enhanced Full HMO Bronze Mirror Plans c Basic Exclusive PPO Note: Summary of Benefits and Coverage (SBC) forms are available for all medical plans. These forms summarize coverage and benefits for all plans in a uniform manner. Log in to blueshieldca.com/sbc to download SBC forms for the plan(s) you have applied for. Once your application for coverage is approved, customized SBC form(s) for your purchased plan(s) will be available for download and distribution at bscadocs.com/sbc. Optional Benefit The Infertility Rider may be offered in conjunction with either the Blue Shield of California Off Exchange Package or the Blue Shield of California Mirror Package. c Infertility Rider Pediatric Dental Coverage Pursuant to state and federal law, the group must have pediatric dental coverage. Therefore, the group must choose one of the pediatric dental plans listed below. Employees enrolling in a Blue Shield medical plan must be enrolled in pediatric dental coverage. c Preferred Dental PPO Pediatric 50/0 c Preferred Dental HMO Pediatric $0 c Enhanced Dental PPO Pediatric 60/0 c Enhanced Dental HMO Pediatric $20 Section 5 Dental benefits 12 Dental Plan Option Groups may offer Blue Shield of California dental coverage with a medical plan or as a standalone benefit. When adding dental coverage, please submit an application, refusal of coverage, or subscriber change request for all eligible employees and dependents who are electing dental coverage. The group may select from one of the following plan options: c Single Dental Plan Option c Dual Choice Dental Plan Option Please select two plans from the options below in one of the following combinations: c 1 Dental PPO plan and 1 Dental HMO plan c 2 Dental HMO plans c Triple Choice Dental Plan Option Please select three plans from the options below in one of the following combinations: c 2 Dental HMO plans and 1 Dental PPO plan c 3 Dental HMO plans Dental PPO Plans c Ultimate Dental Plus PPO 50/2000 c Ultimate Dental PPO 50/2000 c Smile SM Deluxe /2000/No Ortho/MAC c Smile SM Deluxe Plus /2000/Ortho/MAC c Smile SM Deluxe 50/1500/Ortho/MAC c Smile SM Deluxe Gold 50/1500/Ortho/U85 c Smile SM 50/1500/No Ortho/MAC c Smile SM Plus 50/1500/Ortho/MAC c Smile SM Value 50/1500/No Ortho/MAC c Smile SM Plus Gold 50/1500/Ortho/U85 c Smile SM Basic 75/1000/No Ortho/MAC c Smile SM Basic Voluntary 75/1000/No Ortho/MAC Dental HMO Plans c DHMO Deluxe c DHMO Plus c DHMO Voluntary c DHMO Basic C15385 (7/13) Master Group Application 3 of 5

4 Section 6 Employer contribution 13 Indicate medical contribution amount here: For employees % For dependents % The employer must contribute a minimum of 50% of the total employee rates. If the employer contributes 100% of employee rates, all eligible employees must enroll in coverage offered by the group from any carrier or health plan. Indicate dental contribution amount here: For employees % For dependents % For dental coverage, the employer must contribute at least 50% of the employee's dues (except voluntary). If 100% is paid, all eligible employees must enroll. Section 7 Form of member Evidence of Coverage/Certificate of Insurance booklets 14 You are responsible for the distribution of the Evidence of Coverage/Certificate of Insurance booklets to your covered employees. Electronic versions will be distributed via CD. Employer is responsible for distributing the documents using one of the following methods: 1) posting on the employer s intranet for employee access, or 2) ing these documents directly to their employees. Printed versions will only be mailed to the employer directly upon request. c I elect to receive printed, not electronic, EOC/COI booklets. I understand that I am responsible for distributing the documents to my covered employees. Authorization The following authorization section must be signed. (Blue Shield of California requires an original copy of this legal document with original signature.) 15 This is an application for coverage only. The group understands that no contract for coverage will exist until Blue Shield has completed its review and communicated to the applicant or the applicant s broker that the application has been accepted and a group health service contract/group policy will be issued. The group representative certifies that, to the best of his or her knowledge and belief, all of the responses given are true, correct, and complete. The group understands that if it has committed fraud or made an intentional misrepresentation of any material fact in conjunction with this application within the first 24 months of issuance of coverage, Blue Shield may pursue one of the following remedies: Coverage may be cancelled or the applicable dues/premiums may be adjusted, or following notice, the health service contract/insurance policy may be rescinded. Authorized signature Date Name and title (please print) C15385 (7/13) Master Group Application 4 of 5

5 Broker information (to be completed by broker or general agent) 16 Broker/Agency name Broker Phone number ( ) Broker contact/ address Fax number ( ) Broker street address (P.O. Box not acceptable) City State ZIP General agent tax ID number Broker tax ID number (commissions will be reported under this number) Department of Insurance license number Is this a split commission? If yes, define split Broker #1 % Broker #2 % Name of second writing agent Second writing agent tax ID number General agent name General agent Would prefer to be contacted by: c Fax or c Today s date (required) Broker signature (required) Print name / / X I certify that, to the best of my knowledge and belief, all responses given above are true and correct and complete. Blue Shield account executive Phone number Fax number Office number Account executive and region Account manager/service representative (if applicable) C15385 (7/13) Master Group Application 5 of 5