Vision Service Plan (VSP) New Group Implementation Guide

Transcription

1 Visin Service Plan (VSP) New Grup Implementatin Guide Nrth Ranch Benefits Trust (NRBT) Administered by HealthSmart Benefit Slutins, Inc. Agents shuld submit the cmpleted New Grup Implementatin Guide back t Warner Pacific. Agent Presentatin by: Warner Pacific Insurance Services Agura Rad Westlake Village, CA Phne: (800) Fax: (800) Emplyers (Grup Administratrs) shuld cntact HealthSmart Benefit Slutins fr any administrative assistance including: billing, eligibility, renewal, plan changes, etc. The Emplyer Guide will be ed nce the grup is apprved unless a request is made therwise. Emplyers shuld use the Lck bx t return premium payments. ACH is als available upn request. Grup Administratin: HealthSmart Benefit Slutins, Inc E Dry Creek Rad, Suite 200 Englewd, CO Phne: (800) Fax: (303) pbdenver@healthsmart.cm Lckbx fr grup payments nly: HealthSmart Benefit Slutins, Inc. Lckbx 6054 P O Bx Denver, CO Emplyees shuld cntact Visin Service Plan directly fr assistance with benefit questins, claims, lcating a prvider r questins abut the VSP website. Emplyee Services & Claims: Visin Service Plan (VSP) P.O. Bx Sacrament, CA Phne: (800) Please call Warner Pacific Insurance Services, Inc. if yu have any questins abut submitting a new grup enrllment. Pst-enrllment eligibility questins shuld be directed t HealthSmart Benefit Slutins, Inc.

2 - Checklist: Three r mre emplyees are required t be enrlled at all times. Cmplete the Emplyer Applicatin frm and select ONE plan design fr the entire emplyer grup. Print an emplyee applicatin fr each emplyee t enrll. If the enrlling emplyee des nt elect t cver their dependents, then dependents may nt enrll later unless there is a qualifying event. Dependent children may remain n this plan t age 26. All emplyer grups will be made effective n the first f any given mnth. This plan has a Fcal Renewal January 1f every year. The first mnth s premium is required via check r bank draft (ACH) If paying by check, make Check payable t HealthSmart Benefit Slutins, Inc. Future payments by Check shuld be directed t the Lckbx: HealthSmart Benefit Slutins, Inc. Lck Bx 6054 P.O. Bx Denver, CO Phne: (800) If paying by Bank Draft (ACH), cmplete attached frm. If changing bank accunts, we require a 30 day ntificatin. Submit all cmpleted New Business frms t Warner Pacific fr prcessing: Warner Pacific Insurance Services, Inc. New Business Agura Rad Westlake Village, CA cntact@nrbt.cm Phne: (800) Once the grup is apprved all future new hire frms/qualifying event applicatins shuld be sent t HealthSmart directly fr prcessing: HealthSmart Benefit Slutins, Inc E. Dry Creek Rad, Suite 200 Englewd, CO Phne : (800) Fax : (303) pbdenver@healthsmart.cm Eligibility Guidelines: This is nt a vluntary plan. The grup must meet participatin requirements at all times. A minimum f three emplyees must be enrlled at all times. Enrllment in this plan is determined by the emplyer s participatin selectin. Current rates are guaranteed until December Next renewal is January 2015, regardless f the emplyer s riginal effective date. An eligible emplyee is defined as an emplyee wrking full-time, 30 hurs r mre per week. Part-time emplyees, wrking hurs per week, may be cvered if emplyer chses, r if matching the medical r dental participatin ptin as lng as there are three full time emplyees enrlled. All eligible emplyees and their eligible dependents must be added t the plan as sn as the new hire waiting perid has been met. There is n pen enrllment perid. All eligible emplyees and dependents must enrll at initial enrllment r within 30 days f a qualifying event. A qualifying event is defined as: adptin, marriage, r birth f newbrn. An eligible dependent is an emplyee s spuse/dmestic partner and any child f the enrlled applicant r spuse/dmestic partner wh is under age 26. It is the emplyee s respnsibility t infrm the grup administratr f any change in status f his/her dependents. These plans are nly available t grups headquartered in the fllwing states: CA, CO, GA, IA, IL, IN, KS, MI, MN, MO, NC, NJ, NV, OH, OK, SC, TN, TX and WV. Emplyees can live in any f the 50 states. 2

3 Grup Infrmatin (all lines are required t be cmpleted): Effective Date (first f mnth nly): Cmpany Name: Mailing : Street : Cmpany Cntact Name: Type f Business: Federal Tax ID #: Cmpany Cntact Title: Cntact Telephne Number: Cntact Fax Number: Cntact Future Billing Invices: Number f Full-Time Emplyees: Number f Part-Time Emplyees: Is Cmpany subject t Federal COBRA? If yes, des yur State ffer State Cntinuatin after the 18 mnths f Federal COBRA? If n, des yur State ffer State Cntinuatin? Paper Statement Mailed Statement ed Electrnically Crpratin Partnership Sle Prprietrship Other Yes N Yes N Yes N Please nte: Because VSP is a multi-state, natinal carrier, if the emplyer is subject t state cntinuatin, it is the emplyer s respnsibility t request specific State Cntinuatin f Cverage based n that state s guidelines. The emplyer must als prvide the last knwn address f the COBRA insured. Grup Structure Requirements: HealthSmart can set up yur eligibility infrmatin by lcatin cdes t allw yur reprts, invices, etc. t be identified by subgrups. Fr example, yu may chse t grup yur members by physical lcatin, hurly/salaried, r sme ther frmat that cincides with yur internal requirements. All lcatin cdes are limited t fur (4) characters, but may be designated alphanumerically as yu see fit. Please indicate thse subgrups belw r indicate as nt applicable: Nt Applicable: Lcatin Cde Lcatin Descriptin Lcatin Cde Lcatin Descriptin (Please add additinal lines as needed r attach separate page.) Sample: Lcatin Cde Lcatin Descriptin Lcatin Cde Lcatin Descriptin 0001 Hustn, TX 0002 Dallas, TX 3

4 Grup Benefit Plan Design Electin (Chse ne plan): Signature Plan (Standard Netwrk) Plan A (12/24/24) w/$10 Deductible Plan A (12/24/24) w/$25 Deductible Enhanced Plan B (12/12/24) w/$10 Deductible Enhanced Plan B (12/12/24) w/$25 Deductible Plan C (12/12/12) w/$10 Deductible Plan C (12/12/12) w/$25 Deductible Chice Plan (Open Access Netwrk) Plan A (12/24/24) w/$0 Deductible Plan B (12/12/24) w/$0 Deductible Premium Calculatin: # f Members Rate Emplyee Only X $ = $ Emplyee + 1 dependent X $ = $ Emplyee + 2 r mre children X $ = $ Family X $ = $ Participatin Optins (Chse One): Subttal $ Mnthly Administratin Fee + $15.00 Grand Ttal = $ 1. VSP participatin and cntributin matches the Emplyer-Spnsred medical plan participatin exactly. All eligible emplyees and dependents must be enrlled cntinuusly under bth plans t remain eligible under the visin prgram. Name f the medical carrier that participatin will match. 2. VSP participatin and cntributin matches Emplyer-Spnsred dental plan participatin exactly. All eligible emplyees and dependents must be enrlled cntinuusly under bth plans t remain eligible under visin prgram. Name f the dental carrier that participatin will match. 3. VSP cntributin is 100% Emplyer-paid and all eligible emplyees and dependents must enrll (100% participatin). 4. VSP cntributin is 100% Emplyer-paid and all eligible emplyees (100% participatin) must enrll. N dependent cverage is ffered. Emplyee Eligibility (Chse One): The waiting perid fr visin benefit plan participatin fr future emplyees is first f the mnth fllwing: Date f Hire 1 mnth 2 mnths 3 mnths 4 mnths 5 mnths 6 mnths Are yu waiving the waiting perid fr new hires at initial enrllment? Yes N Are yu acquiring new medical/dental cverage at the same time? Yes N D yu have emplyees currently n COBRA r State Cntinuatin? Yes N D yu have emplyees in their COBRA r State Cntinuatin electin perid? Yes N If there are emplyee(s) within their COBRA r State Cntinuatin electin perid, please list them belw. 4

5 Participatin Agreement: We, the undersigned grup understand that we are applying fr membership in the Supplemental Visin Benefit Emplyer Trust ( Trust ). Visin Service Plan ( VSP ) has issued a master plicy t the Trust which prvides visin benefits t emplyer grups and their eligible emplyees and dependents. We certify that all infrmatin prvided with respect t the cmpany and its emplyees/members is accurate and cmplete. If nt cmplete, VSP and/r HealthSmart Benefit Slutins, Inc. reserve the right t reject this applicatin. We, the undersigned grup, understand that we have an bligatin t ensure that all persns ffered benefits meet eligibility requirements and that cverage is ffered t every eligible persn. We understand that we will be liable fr any claims incurred during any perid in which we d nt meet the participatin and eligibility maintenance requirements. We understand that VSP and/r HealthSmart Benefit Slutins, Inc. will rely n the representatins cntained in this dcument and any thers, such as applicatins, which we prvide in determining whether they will accept us as an eligible grup. It is understd that cverage fr any benefits shall nt cmmence until a cmpleted Emplyer Applicatin has been apprved by VSP and/r HealthSmart Benefit Slutins, Inc., its authrized agents, r representatives; the first mnth s premium fr the visin benefit plan has been paid; all cmpleted emplyee applicatins have been submitted; and ntice f said apprval has been transmitted in writing t us. We certify that the answers n any and all applicatins are true and understand that cverage may be rescinded shuld it be determined at a future date that there are misstatements in the applicatins. Sme f the cntracts Visin Service Plan hlds with Warner Pacific Insurance Services ( Warner Pacific ) prvide fr payment f incentives, cmpensatin, excess surplus and bnuses ( cmpensatin ). In the sle and exclusive discretin f Warner Pacific, such cmpensatin may be retained by Warner Pacific r distributed t ther parties. Such cmpensatin will nt be returned t yu as the emplyer/plan spnsr. Any visin benefits claims submitted under yur plicy/certificate will be paid withut regard t such cmpensatin. Arbitratin Agreement: We understand that any dispute between us and VSP, Warner Pacific and/r HealthSmart Benefit Slutins, Inc. must be reslved thrugh binding arbitratin if the amunt in dispute exceeds the jurisdictinal limit f the Small Claims Curt and nt by lawsuit r curt prcess, except as Califrnia prvides fr judicial review f arbitratin prceedings. I certify that all f the infrmatin prvided in this dcument is accurate t the best f my knwledge as f the date signed. I als understand that the current rates are guaranteed until December 2014, regardless f the riginal effective date. Client Signature (Required) Print Name/Title (Required) Date Agent s Certificatin: I hereby certify that I am nt aware f any infrmatin that has been withheld frm this applicatin by the client and which may have bearing n this risk. I hereby certify that I have advised the client nt t terminate any existing cverage until they have received written ntificatin frm Warner Pacific Insurance Services and/r HealthSmart Benefit Slutins, Inc. that the cverage being requested by this applicatin is accepted. Writing Agent s Name: Agency Name: : Telephne Number: SSN r Tax ID Number: Agent Signature and Date: 5

6 AUTHORIZATION FOR DIRECT PAYMENT I am returning this authrizatin t HealthSmart Benefit Slutins, Inc., authrizing HealthSmart and the financial institutin named belw t initiate entries t my checking/savings accunt. This authrity will remain in effect until I ntify yu in writing t cancel it in such time as t affrd the financial institutin a reasnable pprtunity t act n it. I can stp payment f any entry by ntifying my financial institutin (7) days befre my accunt is charged. Grup Infrmatin Grup Name Grup # Cntact Phne Number Grup City State Zip Financial Institutin Infrmatin (Please enter name/address f bank and accunt yu wish payments t be withdrawn frm.) Name f Bank Branch f Bank City State Zip _ Signature (This is yur authrizatin fr HBS t withdraw funds frm yur accunt) Date Please check ne: Checking Savings Please check ne: Initial Payment Only Onging Mnthly Premium Payments Bank Ruting # Accunt # Nte: Withdrawals frm yur bank accunt will ccur n the 20th wrking day f each mnth. The premium withdrawal represents the next mnths premium payment (January 20 th draft fr February Cverage). Please return the cmpleted frm and a cpy f the vided check t: HEALTHSMART BENEFIT SOLUTIONS, INC E DRY CREEK RD STE 200 ENGLEWOOD CO r fax t (303) STAPLE VOIDED CHECK HERE (Cut here and retain fr yur recrds) On (date), I authrized HealthSmart Benefit Slutins, Inc. at East Dry Creek Rad, Suite 200, Englewd, CO t initiate electrnic entries t my checking/savings accunt and have agreed t the terms listed n the authrizatin. I may revke my authrizatin with the cmpany at any time by writing t HealthSmart at the address abve. If the payment amunt changes, we will ntify yu at least 5 days befre the regularly scheduled payment date. NRBT-VSP-HBS Eff. 6/1/13 - Rev

7 Nrth Ranch Benefit Trust Grup Name: Emplyee # 1 Emplyee # 2 City State Zip Cde City State Zip Cde Emplyee First name Last name Gender Date f birth Emplyee First name Last name Gender Date f birth SP/DP First name Last name Gender Date f birth SP/DP First name Last name Gender Date f birth Child 1 First name Last name Gender Date f birth (> age 26) Child 1 First name Last name Gender Date f birth (> age 26 Child 2 First name Last name Gender Date f birth (> age 26) Child 2 First name Last name Gender Date f birth (> age 26 Child 3 First name Last name Gender Date f birth (> age 26) Child 3 First name Last name Gender Date f birth (> age 26 Child 4 First name Last name Gender Date f birth (> age 26) Child 4 First name Last name Gender Date f birth (> age 26 Emplyee # 3 Emplyee # 4 City State Zip Cde City State Zip Cde Emplyee First name Last name Gender Date f birth Emplyee First name Last name Gender Date f birth SP/DP First name Last name Gender Date f birth SP/DP First name Last name Gender Date f birth Child 1 First name Last name Gender Date f birth (> age 26) Child 1 First name Last name Gender Date f birth (> age 26 Child 2 First name Last name Gender Date f birth (> age 26) Child 2 First name Last name Gender Date f birth (> age 26 Child 3 First name Last name Gender Date f birth (> age 26) Child 3 First name Last name Gender Date f birth (> age 26 Child 4 First name Last name Gender Date f birth (> age 26) Child 4 First name Last name Gender Date f birth (> age 26 Emplyee # 5 Emplyee # 6 City State Zip Cde City State Zip Cde Emplyee First name Last name Gender Date f birth Emplyee First name Last name Gender Date f birth SP/DP First name Last name Gender Date f birth SP/DP First name Last name Gender Date f birth Child 1 First name Last name Gender Date f birth (> age 26) Child 1 First name Last name Gender Date f birth (> age 26 Child 2 First name Last name Gender Date f birth (> age 26) Child 2 First name Last name Gender Date f birth (> age 26 Child 3 First name Last name Gender Date f birth (> age 26) Child 3 First name Last name Gender Date f birth (> age 26 Child 4 First name Last name Gender Date f birth (> age 26) Child 4 First name Last name Gender Date f birth (> age 26 Emplyee # 7 Emplyee # 8 City State Zip Cde City State Zip Cde Emplyee First name Last name Gender Date f birth Emplyee First name Last name Gender Date f birth SP/DP First name Last name Gender Date f birth SP/DP First name Last name Gender Date f birth Child 1 First name Last name Gender Date f birth (> age 26) Child 1 First name Last name Gender Date f birth (> age 26 Child 2 First name Last name Gender Date f birth (> age 26) Child 2 First name Last name Gender Date f birth (> age 26 Child 3 First name Last name Gender Date f birth (> age 26) Child 3 First name Last name Gender Date f birth (> age 26 Child 4 First name Last name Gender Date f birth (> age 26) Child 4 First name Last name Gender Date f birth (> age 26 7

8 Emplyee # Emplyee # City State Zip Cde City State Zip Cde Emplyee First name Last name Gender Date f birth Emplyee First name Last name Gender Date f birth SP/DP First name Last name Gender Date f birth SP/DP First name Last name Gender Date f birth Child 1 First name Last name Gender Date f birth (> age 26) Child 1 First name Last name Gender Date f birth (> age 26 Child 2 First name Last name Gender Date f birth (> age 26) Child 2 First name Last name Gender Date f birth (> age 26 Child 3 First name Last name Gender Date f birth (> age 26) Child 3 First name Last name Gender Date f birth (> age 26 Child 4 First name Last name Gender Date f birth (> age 26) Child 4 First name Last name Gender Date f birth (> age 26 Emplyee # Emplyee # City State Zip Cde City State Zip Cde Emplyee First name Last name Gender Date f birth Emplyee First name Last name Gender Date f birth SP/DP First name Last name Gender Date f birth SP/DP First name Last name Gender Date f birth Child 1 First name Last name Gender Date f birth (> age 26) Child 1 First name Last name Gender Date f birth (> age 26 Child 2 First name Last name Gender Date f birth (> age 26) Child 2 First name Last name Gender Date f birth (> age 26 Child 3 First name Last name Gender Date f birth (> age 26) Child 3 First name Last name Gender Date f birth (> age 26 Child 4 First name Last name Gender Date f birth (> age 26) Child 4 First name Last name Gender Date f birth (> age 26 Emplyee # Emplyee # City State Zip Cde City State Zip Cde Emplyee First name Last name Gender Date f birth Emplyee First name Last name Gender Date f birth SP/DP First name Last name Gender Date f birth SP/DP First name Last name Gender Date f birth Child 1 First name Last name Gender Date f birth (> age 26) Child 1 First name Last name Gender Date f birth (> age 26 Child 2 First name Last name Gender Date f birth (> age 26) Child 2 First name Last name Gender Date f birth (> age 26 Child 3 First name Last name Gender Date f birth (> age 26) Child 3 First name Last name Gender Date f birth (> age 26 Child 4 First name Last name Gender Date f birth (> age 26) Child 4 First name Last name Gender Date f birth (> age 26 Emplyee # Emplyee # City State Zip Cde City State Zip Cde Emplyee First name Last name Gender Date f birth Emplyee First name Last name Gender Date f birth SP/DP First name Last name Gender Date f birth SP/DP First name Last name Gender Date f birth Child 1 First name Last name Gender Date f birth (> age 26) Child 1 First name Last name Gender Date f birth (> age 26 Child 2 First name Last name Gender Date f birth (> age 26) Child 2 First name Last name Gender Date f birth (> age 26 Child 3 First name Last name Gender Date f birth (> age 26) Child 3 First name Last name Gender Date f birth (> age 26 Child 4 First name Last name Gender Date f birth (> age 26) Child 4 First name Last name Gender Date f birth (> age 26 Nrth Ranch Benefit Trust Print additinal cpies f this page if needed. Page f 8

9 AUTHORIZATION FOR DIRECT PAYMENT I am returning this authrizatin t HealthSmart Benefit Slutins, Inc., authrizing HealthSmart and the financial institutin named belw t initiate entries t my checking/savings accunt. This authrity will remain in effect until I ntify yu in writing t cancel it in such time as t affrd the financial institutin a reasnable pprtunity t act n it. I can stp payment f any entry by ntifying my financial institutin (7) days befre my accunt is charged. Any questins, cntact HealthSmart at (800) Client Infrmatin Client Name Client (Divisin) # Cntact Phne Number Client City State Zip Financial Institutin Infrmatin (Please enter name/address f bank and accunt yu wish payments t be withdrawn frm.) Name f Bank Branch f Bank City State Zip _ Signature (This is yur authrizatin fr HBS t withdraw funds frm yur accunt) Date Please check ne: Checking Savings Please check ne: Initial Payment Only Onging Mnthly Premium Payments Nte: Withdrawals frm yur bank accunt will ccur n the 1 st wrking day f each mnth fr which the premium is due. Bank Ruting # Accunt # HEALTHSMART BENEFIT SOLUTIONS, INC. Please return the cmpleted frm and a cpy f the vided check t: E DRY CREEK RD STE 200 ENGLEWOOD CO r fax t (303) STAPLE VOIDED CHECK HERE (Cut here and retain fr yur recrds) On (date), I authrized HealthSmart Benefit Slutins, Inc. at East Dry Creek Rad, Suite 200, Englewd, CO t initiate electrnic entries t my checking/savings accunt and have agreed t the terms listed n the authrizatin. I may revke my authrizatin with the cmpany at any time by writing t HealthSmart at the address abve. If the payment amunt changes, we will ntify yu at least 5 days befre the regularly scheduled payment date. NRBT-HBS - Rev