Group. Premium Only Plan (POP) Visit us at mylifepath.com

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1 Group Premium Only Plan (POP) P R OV I D E D B Y C E R I D I A N B E N E F I T S S E RV I C E S A N D B L U E S H I E L D O F CA L I F O R N I A Visit us at mylifepath.com

2 Reduce the Cost of Group Coverage with Our Premium Only Plan Market research indicates that POPs save employees an average of 30 percent in state and federal income taxes and FICA. Today s healthcare market can be uncertain and full of surprises. Navigating your way through it means coming up with creative ways to make the most of your healthcare dollar. Blue Shield of California offers a way for you to control the cost of employee benefits and enjoy substantial savings: the Premium Only Plan (POP). POPs reduce payroll taxes on the premium contributions of participating employees. The plan saves money by converting premiums from an after-tax expense to a pre-tax expense. Market research indicates that POPs save employees an average of 30 percent in state and federal income taxes and FICA. As an employer, you save an average of 10 percent on FICA and other payroll taxes on the contributions of participating employees. Our POP is administered by Ceridian Benefits Services, the industry s leading expert in POP plans for employers with fewer than 100 employees. By providing employers with a comprehensive self-administration kit, Ceridian ensures you have all the tools necessary to properly administer your plan. POP plans are offered to all groups with one or more Blue Shield medical plans. Qualified, non-taxable insurance premiums and health plan dues that can be converted to pretax expenses include health, dental, vision, group term life (up to $50,000) and disability. How Do POPs Work? Section 125 of the Internal Revenue Code allows employees to pay certain insurance premiums with pre-tax dollars. A company s taxable payroll is reduced by the amount of employee premium contributions. Overall savings depend on total company payroll and the dollars employees contribute toward their benefits. Employees who contribute reduce their taxable income by the amount of their premium contributions, so they pay less federal income tax, Social Security tax and state tax (in most states). There s no need to be an expert in Internal Revenue Code 125 plan administration. Ceridian s Installation Kit and information hotline give you the help you need. POPs can be set up for any single employer or certain related employers, including members of a controlled group of corporations, members of a group or commonly controlled trades or businesses or members of an affiliated service group. Certain individuals are prohibited from participating in POPs, such as sole proprietors and partners within a partnership, but their employees can participate. After receiving your installation kit, Ceridian Technical Support representatives are available to answer questions and provide support Monday through Thursday, 8:30 a.m. to 6:30 p.m. EST and Friday 8:30 a.m. to 5:30 p.m. EST. CERIDIAN INFORMATION HOTLINE Phone: (800) FAX: (888) Or send to: Cyberpop@ceridian.com

3 POP Administration Made Easy The POP Installation Kit contains simple, step-by-step installation instructions and all the materials necessary to communicate the plan to employees, including: Employee announcement letter Enrollment and re-enrollment forms Answers to common employee questions Administrative guidelines and forms Personalized plan document Non-discrimination testing procedures Please detach form and complete it, following the instructions on the back of the middle panel. Technical Support Any questions will be answered promptly by Ceridian s well-informed Technical Support representatives. They are prepared to answer everything from specific questions about IRS codes to general questions about implementing POP. It s as simple as calling the information hotline at (800) , Monday through Friday regular business hours EST, or sending an to cyberpop@ceridian.com. Other Assistance Ceridian s annual renewal service provides employers with timely updates and modifications to maintain the employer s compliance with changing IRS regulations. POP at a glance PRODUCT TYPE TARGET EMPLOYER SIZE EMPLOYER TAX SAVINGS EMPLOYEE TAX SAVINGS* FEATURES SET-UP/ RENEWAL COST POP Premium Only Plan Small to midsize groups 7.65% FICA tax savings on employee premium contributions Up to 39% federal tax savings Up to 9% state tax savings 7.65% FICA tax savings Easy-toinstall kit support hotline $120/$100 * Savings on qualified premium contributions depend on state and federal tax brackets Small Cost for Big Savings GROUP S BENEFIT COVERAGES INSTALLATION FEE RENEWAL Blue Shield Groups $120 $100

4 Calculate Estimated Tax Savings with POP The charts below illustrate the potential tax savings from POP. This example uses a company with an annual payroll of $250,000 and 10 employees, each of whom contributes $100 a month toward group insurance premiums and Blue Shield health plan dues. EMPLOYER SAVINGS WITHOUT POP WITH POP Annual payroll $250,000 $250,000 Employee pre-tax premiums $0 ($12,000) Taxable payroll $250,000 $238,000 FICA tax (7.65%) $19,125 $18,207 EMPLOYER SAVINGS $0 $918 EMPLOYEE SAVINGS WITHOUT POP WITH POP Annual income $25,000 $25,000 Pre-tax contribution $0 ($1,200) Taxable income $25,000 $23,800 Estimated taxes (30%) ($7,500) ($7,140) After-tax contribution ($1,200) $0 Net take-home pay $16,300 $16,660 TAKE-HOME PAY INCREASE $0 $360 Use this worksheet to calculate your company s estimated tax savings with POP. TAX SAVINGS WORKSHEET A. Total monthly employee contributions $ B. Multiply line A by.0765 x.0765 C. This is the monthly FICA tax savings $ D. Multiply line C by 12 months x 12 Getting Started By using POP, both you and your employees can immediately start reducing taxes. To receive your POP Installation Kit, simply complete and send the attached application, along with payment when applicable, to your Blue Shield account representative. For details on how to complete the POP application, see the reverse side of this brochure. ANNUAL EMPLOYER TAX SAVINGS $

5 Cont#: Blue Shield of California Representative: Premium Only Plan Application Reminder: Do not start pre-tax deductions until you have received the POP Installation Kit and Plan Document from Ceridian Benefits Services. SECTION A: GENERAL INFORMATION 1. Plan Sponsor (legal name): 2. Business Type (corporation, partnership, proprietorship): 3. State of Incorporation or Domicile: 4. Name of Plan: (Example: ABC Company Premium Only Plan) 5. Type of Plan (check one): A new plan effective as of: An amendment and restatement of an existing Section 125 Plan. Original plan effective date: Amendment and restatement date: Note: The application must be received by Blue Shield at least 20 business days prior to the requested effective date, or amendment and restatement date. SECTON B: DEFINITIONS 1. First day of POP plan year: Last day of POP plan year (must be 12-month period): 2. An employee of the company regularly performing services at least hours per week shall become a participant on the first day of the month coincidental with or next following the date the employee completes days of consecutive employment. 3. Employees rehired after a period of termination will become eligible for the plan on the first day of the month coincidental with or next following the date the employee completes days of consecutive employment. (Employess rehired within 30 days must continue with previously elected pretax contribution amounts.) SECTION C: ADMINSTRATION Plan Administrative Contact: Title: Mailing Address: City, State, Zip Street/Address (No P.O. Box): City, State, Zip: Signature: Date: Telephone: Fax: ( ) * address required for delivery of the POP quarterly newsletter SECTION D: AGENT/BROKER INFORMATION Name: Company/Agency: Address: City, State, Zip: Telephone: ( ) Fax: Agent Signature: Please direct questions regarding the POP plan or this application to your Blue Shield representative. Applications and checks must be submitted through your Blue Shield representative for processing. For internal use only: Blue Shield Representative: Telephone: Fax: Installation Kit and all documents will be forwarded to the plan sponsor (as indicated above). Call (800) with any questions about the POP plan or this application form. Please submit application and check on behalf of this group to your Blue Shield of California sales representative. Make check payable to Blue Shield of California.

6 How to Complete the POP Application To receive your POP Installation Kit, simply complete and send the attached application, along with a $120 payment when applicable, to your Blue Shield account representative. All checks should be made payable to Blue Shield of California. To ensure timely delivery of the POP Installation Kit, the completed POP application and payment must be received by Blue Shield at least 20 business days prior to your desired POP effective date. Applications received after that date will delay the effective date of the POP to the first day of the following month. The following information must be disclosed on the application: Section A: General Information 1. Plan Sponsor: Fill in complete legal name of the company (employer) sponsoring the plan. 2. Business Type: Indicate the business type of plan sponsor (corporation, partnership, proprietorship etc). 3. State: Indicate the state in which the plan s sponsor is incorporated. Non-corporate plan sponsors should indicate the state in which plan sponsor is domiciled. 4. Name of Plan: Identify complete name of POP (i.e., ABC Company POP). 5. Effective Date of Plan: Indicate desired effective date. The effective date should be the beginning of the first payroll period for which employee premium contributions will be converted to pretax. It is not necessary for the effective date to coincide with the first day of the plan year (shortened plan years are permitted in the first plan year). Per IRS regulations, all employee communication/election information must be distributed and the plan document adopted prior to the effective date. This date must be at least 20 business days from the date the application is submitted to Blue Shield of California. Section B: Definitions 1. First Day of Plan Year: The company must adopt a 12-month plan year. The start date of the plan year usually coincides with renewal date of insurance plan, calendar year or company fiscal year. Last Day of Plan Year: Must be 12 months after first day of plan year. 2. Eligibility of New and Existing Employees: Indicate number of hours per week and days of service required for eligibility. Usually coincides with eligibility in benefit plan. 3. Eligibility for Rehired Employees: Indicate required days of service for rehired employees. (Employees rehired within 30 days must continue with previously elected pre-tax contribution amounts.) Section C: Administration Indicate name and address of person within the company responsible for plan administration. Application should be signed by an authorized representative of the plan sponsor. The POP Installation Kit and supporting documents are backed by Ceridian Benefits Services, a firm specializing in the design and implementation of employee benefit programs. If you have any questions, please contact Ceridian at (800) A12138-REV (5/04)