MINNESOTA GROUP APPLICATION SMALL GROUP

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1 EMPLOYER ELIGIBILITY INFORMATION Today s Date: Requested Eff. Date: HealthPartners Sales Executive: Full Legal Group Name: DBA (if applicable): Address: City, State, Zip: County: Phone: Fax: Federal Tax ID#: Corporate Headquarters (City, State): Contact Person: Contact Title: Contact Is contact person an eligible employee? YES NO If NO, please explain: Owners and percentage of ownership for each: Are they eligible for coverage? YES NO If NO, please explain: MINNESOTA GROUP APPLICATION SMALL GROUP YES NO 1. Is this organization in any way related to other companies (such as national corporation) as a wholly or partially owned subsidiary, or does this organization own any other companies or have wholly or partially owned subsidiaries? If YES, please provide the HealthPartners Controlled Group form, found on HealthPartners.com/employer YES NO Do you have any other locations or sites? If YES, list the State and/or Country: 2. Number of years in business Industry 3. Type of Entity: S Corporation C Corporation Sole Proprietorship Partnership Non-Profit LLC (circle one: C Corporation Sole Proprietorship Partnership) 3a. Are you a Government Group, public entity or public school? YES NO Erisa or Non-Erisa 3c. Are you a church or religious group? YES NO Erisa or Non-Erisa (If YES and Non-Erisa, please provide DOL certification letter) For 4a and 4b exclude seasonal, temporary and union employees covered under a collective bargaining agreement. 4a. On average, how many permanent employees did this organization employ (in all locations), working a normal work week of 20 or more hours throughout the preceding calendar year (January through December)?* 4b. Currently, how many employees have a normal work week of 20 hours or more?* 4c. What is the total number of employees (full/part time for entire family of companies) for your company? Medicare Secondary Payer rules apply to employer group health plans with 20 or more employees for each working day in at least 20 weeks in either the current or the preceding calendar year. If you have questions on this rule, please contact your broker or sales representative. * Some employees who do not work a full twelve months may be covered under their employers plan. These employees must work a minimum of nine months in a calendar year. If providing coverage for these employees, the employer must complete the Small Employer Contribution Agreement for Seasonal Employees Form on healthpartners.com/employer. If you are going to cover employees working for a minimum of 9 months, how many will you be covering? 5. How many employees reside outside of Minnesota? (Submit Quarterly Wage Report for each state) YES NO 6. If you elect coverage, will you be offering a Medical Expense Reimbursement plan? (such as an HRA, 105 or any underlying plan?) YES NO 7. Does this organization currently have any leased employees? If YES, please explain: YES NO 8. Does this organization currently have, intend to have, or ever had a Professional Employer Organization (PEO) agreement? If YES, please provide a copy of the agreement Please provide the name and termination date of the PEO agreement: YES NO 9. Does this organization intend to offer domestic partner coverage? Same gender Same and opposite gender Please refer to Domestic Partner Form on healthpartners.com/employer for eligibility. YES NO 10. Do you have a rehire policy? If YES, please define PARTICIPATION / EMPLOYEE ELIGIBILITY INFORMATION Number of hours all eligible employees must work per week Classification(s) of Employees Excluded from Coverage: Union covered by a collective bargaining agreement Part-time Hourly Union not covered by a collective bargaining agreement Salaried Owners Other (explain): YES NO Are retirees eligible for coverage? If yes, define policy Waiting Period for New Employees: Date of Hire OR First of the month following: 30 days 60 days Other, explain (waiting period can not exceed 90 days): Total number of eligible employees and Total number of eligible employees that are applying for coverage Total number of employees that are waiving coverage Total number of employees in their waiting period (application or waiver required) Number of former employees on COBRA continuation (application required) see page 2 Page 1

2 Employer Contribution: Minimum 50% of single coverage, or Medical: Single Family Dental: Single Family (if applicable) EMPLOYEES AND OWNERS NOT ACCOUNTED FOR ON QUARTERLY WAGE AND DETAIL REPORT Please use this space to account for Employees and Owners NOT included on the Minnesota State Employer s Quarterly Wage and Detail Report (Form MDES-1D). Additional documentation may be required regarding owners. Employee/Owner Name Social Security Number Hire Date Termination Date # of Hours Worked FORMER EMPLOYEES ENROLLED WITH COBRA COVERAGE Please use this space to account for former employees covered by COBRA continuation. Indicate either the notification date if the individual is currently under COBRA or the cancellation date if an individual s COBRA coverage is terminating. Employers must also complete the Small Employer Verification of Terminated Employees form (HP490016) found on healthpartners.com. Former Employee Name Social Security Number Notification Date COBRA Termination Date CURRENT CARRIER INFORMATION Current MEDICAL Carrier: Type of coverage Group Individual Please list all medical carriers for the previous 5 years (if needed, attach additional pages) Name of Carrier Renewal Date Dates of Coverage Reason for Termination Renewal Rates: Single Family Renewal Plan (product) Name: Current DENTAL carrier: Renewal Date: AGENT/BROKER INFORMATION Agent Name: Address: City, State, Zip: Phone: Fax: Broker Number: Agent of Record Signature (if applicable) Printed Name and Company Date EMPLOYER SIGNATURE I hereby certify that the information provided in this document, and any additional information submitted to support this application, is accurate and complete. I understand that errors or omissions regarding this information may result in premium adjustments and/or termination of the contract as permitted by law. CEO/Owner/Authorized Company Representative Printed Name Date Page 2

3 PRODUCT SELECTION Products effective 1/1/2014-7/1/2014 MEDICAL NETWORK: Open Access Open Access Perform* The Park Nicollet and HealthPartners Achieve** * Only Perform and Achieve can be paired together and they must have separate products. **Achieve is only available for groups located in Morrison, Chisago, Meeker, McLeod and area 8. Benefit Administration: Calendar Year Plan Year (If offering more than one product, benefit administration must match.) All HealthPartners small employer plans include an ACA compliant embedded pediatric dental benefit. Copay & Copay/Deductible $30/95% *** $35/70% $500/$25 $500/$40 $1000/$25 $1000/$40 $2500/$50 Three for Free $500/75% $750/75% $1500/70% $2500/70% Three for Copay $1500/70%/$25 $5000/70%/$50 Empower HSA $2000/100% $3000/100% $2500/85% $3000/80% $4000/75% Empower HSA Embedded $3000/100% $2500/85% $3000/80% $4000/75% Empower HSA Rx Plus $1500/100% $2000/100% $3000/10% $2500/85% $3000/80% $4750/70% Empower HSA Rx Plus Embedded $3000/100% $2500/85% $3000/80% $4750/70% Empower HRA ***The $30-95% plan is only offered in area 8, Meeker, McLeod, Chisago and Morrison counties. This plan is only offered with the Achieve and Perform networks. DENTAL PRODUCTS May also be purchased on a stand-alone basis. Distinctions SM Dental Plan Distinctions 1 Distinctions 3 Distinctions 2 Distinctions 4 Dental Options Defined Contribution Plan Dental Options 1000 Dental Options 2000 Open Access Advantage (employer sponsored) Annual maximum Out-of-Network $1000 Option 1 $1500 Option2 Open Access Preventive-only Dental Plan Other Open Access Employer sponsored (select one benefit from each category) $750 None 100/50/0 $1000 $25 100/50/50 $1250 $50 100/80/50 $1500 $75 Voluntary Open Access Dental Plan 2 (select one benefit from each category) $500 $25 100/50/0 $750 $50 100/50/50 $1000 $75 100/80/50 $1250 Voluntary Open Access Dental Plan w/ortho 3 (select one benefit from each category) $1000 $25 100/80/50 $1250 $50 $75 1 Must have 10 or more employees enrolled to be eligible for orthodontic products. 2 Must have 5 or more employees enrolled to be eligible for voluntary plans. 3 Available to groups with eligible employees PO Box 1309 Minneapolis, MN Sales Metro Phone # Non-Metro Phone # HealthPartners will notify employees covered on HealthPartners plans of the special enrollment periods detailed in 29 CFR Sec. It is the responsibility of the employer to notify those employees who decline HealthPartners coverage of their special enrollment rights. The HealthPartners family of health plans is underwritten and/or administered byhealthpartners, Inc., Group Health, Inc., HealthPartners Insurance Company orhealthpartners Administrators, Inc. Fully insured Wisconsin plans are underwritten by HealthPartners Insurance Company. 1578_ (11/13) 2013 HealthPartners Page 3

4 HealthPartners Flex Law Notification HealthPartners has used the flexibility offered under Minnesota Statute 62L.056 to provide plans with benefits that vary from a typical HMO plan.* These modifications are noted below. Employers are required by law to inform eligible employees of the benefit modifications. Non-HSA Plans In-network Out-of-network Individual Family Individual Family Deductible > $,2250 > $3,000 Deductible> $4,500 > $6,000 Individual Deductible > $6,000 > $12,000 Deductible > $12, X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X HRA X X X X X X X *Effective since 7/1/2010, HealthPartners is no longer selling or renewing small employer comprehensive benefit plans.

5 HSA Plans In-network Out-of-network Individual Individual Family Benefit Variation from Standard HMO plan Benefits Administration: Maintenance of Benefits Benefit exclusions: acupuncture, infertility, bariatric surgery and orthognathic surgery Rx Exclusions: infertility, erectile dysfunction, nonsedating antihistamines, drugs for acid reflux and stomach ulcers Deductible > $5,900 Deductible > $6,000 Out-of-pocket maximum > $12,000 Deductible > $12,000 Out-of-pocket maximum > $24,000 HSA X X X X HSA X X X X X X X HSA X X X X X X X HSA X X X X X X X HSA X X X X X X X HSA X X X X X X X X HSA 3000E-100 X X X X X X X HSA 2500E-85 X X X X X X X HSA 3000E-80 X X X X X X X HSA 4000E-75 X X X X X X X HSA 6000E-70 X X X X X X X X HSA Rx X X X X X HSA Rx X X X X X HSA Rx X X X X X X X HSA Rx X X X X X X X HSA Rx X X X X X X X HSA Rx X X X X X X X HSA Rx X X X X X X X HSA 3000E-100Rx X X X X X X X HSA 2500E-85Rx X X X X X X X HSA 3000E-80Rx X X X X X X X HSA 4750E-70Rx X X X X X X X HSA 6000E-70Rx X X X X X X X X HealthPartners (08/13)