Connecticut Small Group Application OHI Oxford Health Insurance, Inc. Mailing Address:

Transcription

1 Freedom Plan PPO Oxford HSA PPO Freedom Plan Value Option Oxford Smart HSA Connecticut Small Group Application OHI Oxford Health Insurance, Inc. Mailing Address: I. GENERAL INFORMATION 1. Full legal name of company: 2. Address of company: (Street Address City, State, ZIP Code *Please - Do not use a PO Box.) 3. Plan Administrator/Contact: a. Name and Title: b. Address: c. Phone Number: d. Fax Number: Area Code e. Address: Area Code 4. Name and title of person to receive correspondence/billing statements: a. Name: b. Title: c. Address: d. Phone Number: e. Fax Number: Area Code Area Code 5. Full legal name and address of each subsidiary and/or affiliated company, branch or satellite office whose employees are to be covered: 6. Nature of business: 7. SIC Code filed with the State of CT: Page 1

2 I. GENERAL INFORMATION (continued) 8. Type of Organization: Corporation Partnership LLC LLP Other Did you have any employees other than yourself and your spouse during the preceding calendar year? Yes No 9. Tax Identification Code or Number: Federal I.D. 10. Did your group employ at least 1 but no more than 50 employees for at least 50% of your business days during the preceding 12 months? Yes No 11. Enter the Prior Calendar Year Average Total Number of Employees 12. Enter the Prior Calendar Year Full Time Equivalent Total Number of Employees 13. Subject to ERISA? Yes No (Most private sector plans are ERISA plans) If No, please indicate appropriate category: Church (Additional information needed) Federal Government Indian Tribe Commercial Business Non-Federal Government (State, Local or Tribal Gov.) Non-ERISA Other 14. Does your group sponsor a plan that covers employees of more than one employer? Yes No If you answered Yes, then indicate which of the following most closely describes your plan: Governmental Church Taft Hartley Union Employer Association 15. Is your group a Professional Employer Organization (PEO) or Employee Leasing Company (ELC), or other such entity that is a co-employer with your client(s) or client-site employee(s)? Yes No 16. Do you currently utilize the services of a Professional Employer Organization (PEO) or Employee Leasing Company (ELC), Staff Leasing Company, HR Outsourcing Organization (HRO), or Administrative Services Organization (ASO)? Yes No 17. Do you have common ownership with any other businesses? Yes No 18. Do you continue medical coverage during a leave of absence (not including state continuation or COBRA coverage), and if so, for how long once an employee begins a leave of absence? (Please refer to the applicable state and federal rules that may require benefits to be provided for a specific length of time while an employee is on leave.) Last Day worked (following the last day worked for the minimum hours required to be eligible) 3 Months (following the last day worked for the minimum hours required to be eligible) 6 Months (following the last day worked for the minimum hours required to be eligible) No, we do not offer medical coverage during a leave of absence If the employer continues to pay required medical premiums and continues participating under the medical policy, the covered person s coverage will remain in force for: (1) No longer than 3 consecutive months if the employee is: temporarily laid-off; in part time status; or on an employer approved leave of absence. (2) No longer than 6 consecutive months if the employee is totally disabled. If this coverage terminates, the employee may exercise the rights under any applicable Continuation of Medical Coverage provision or the Conversion of Medical Benefits provision described in the Certificate of Coverage. The Employer s decision to refuse to offer coverage cannot be based upon health status related factors. Page 2

3 II. ADMINISTRATIVE INFORMATION The term coverage means the benefits provided by Oxford, pursuant to the Group Certificate. 1. Effective date: (Month/Year) 2. Anniversary date: 3. Other group health or individual coverage: be indicated on the individual Member Enrollment Forms. Please Note: Type of coverage Name of carrier Effective date If terminated, date terminated 4. Employer Contributions: 5. Eligibility and Termination: a) Employee Eligibility: Full-time Employees: Retired Employees: Covered Not Covered b) Eligibility and Termination: Indicate number of months or days, whichever is applicable, in the space provided below. Waiting period cannot exceed 90 days. In (i) below, if there is no waiting period, insert O in the space provided for the number of days or months of In (ii) below, indicate whether eligibility is first day of the calendar month coinciding with or next following the date on which the employee completes the group-specified length of CLASS I Definition of Class I i) Eligibility/Termination days/months (circle one) of ii) Eligibility/Termination completes days/months (circle one) of iii) Waiting Period for Rehires Yes No If yes, waived if rehired within months. CLASS II Definition of Class II i) Eligibility/Termination days/months (circle one) of ii) employment. Eligibility/Termination completes days/months (circle one) of iii) Waiting Period for Rehires Yes No If yes, waived if rehired within months. Page 3

4 CLASS V Definition of Class V i) Eligibility/Termination days/months (circle one) of ii) CLASS III Definition of Class III i) Eligibility/Termination days/months (circle one) of ii) Eligibility/Termination completes days/months (circle one) of Eligibility/Termination completes days/months (circle one) of CLASS IV Definition of Class IV i) Eligibility/Termination days/months (circle one) of ii) CLASS VI Definition of Class VI i) Eligibility/Termination days/months (circle one) of ii) Eligibility/Termination completes days/months (circle one) of Eligibility/Termination completes days/months (circle one) of 6. Number of Total Employees on the Effective Date: Full-time employees Part-time employees Retired employees 7. Coordination of Benefits: No-Fault Auto Plan, under any other Group Plan and under any Group-Type Plan. 8. Integration with Medicare Benefits: 9. Dependent Eligibility: Page 4

5 III. PRODUCT / PLAN DESIGN PLEASE SELECT A PLAN FROM SECTION A, B, C, OR D A. Platinum Plans Option Freedom Plan PPO (02) - Platinum Freedom Plan PPO (10) - Platinum Freedom Plan PPO (11) - Platinum Network Freedom Freedom Freedom a. PCP b. Specialist $40 per visit $40 per visit $40 per visit In-network N/A In-network Maximum Out-of-Pocket In-network Coinsurance Outpatient Facility Copayment Inpatient Facility Copayment Emergency Room Out-of-network $3,000/$6,000 $4,000/$8,000 Out-of-network Maximum Out-of- Pocket $8,000/$16,000 Out-of-network Coinsurance Prescription Drug Coverage s and out-of-pocket accumulation periods are on a calendar year contract year basis. Page 5

6 III. PRODUCT / PLAN DESIGN (CONTINUED) B. Gold Plans Option Freedom Plan PPO (04) - Gold Freedom Plan PPO (05) - Gold Freedom Plan Value Option (01) Gold HSA Direct (90-01) Gold Network Freedom Freedom Freedom Freedom a. PCP $30 per visit $30 per visit b. Specialist In-network In-network Maximum Out-of- Pocket $4,000/$8,000 $4,000/$8,000 In-network Coinsurance Outpatient Facility Copayment after after after after after after Inpatient Facility Copayment after Emergency Room Out-of-network $4,000/$8,000 Out-of-network Maximum Out-of-Pocket $8,000/$16,000 Out-of-network Coinsurance Prescription Drug Coverage after Medical after Medical maximum of maximum of s and out-of-pocket accumulation periods are on a calendar year contract year basis. Page 6

7 III. PRODUCT / PLAN DESIGN (CONTINUED) B. Gold Plans (Continued) Option Freedom Plan PPO (12) - Gold Freedom Plan PPO (13) - Gold HSA Direct (06) Gold Network Freedom Freedom Freedom a. PCP $30 per Visit $30 per Visit b. Specialist In-network In-network Maximum Out-of-Pocket $4,,000/$8,000 In-network Coinsurance Outpatient Facility Copayment Inpatient Facility Copayment Emergency Room Out-of-network $3,000/$6,000 Out-of-network Maximum Out-of-Pocket $8,000/$16,000 Out-of-network Coinsurance Prescription Drug Coverage Medical Medical s and out-of-pocket accumulation periods are on a calendar year contract year basis. Page 7

8 III. PRODUCT / PLAN DESIGN (CONTINUED) C. Silver Plans Option Freedom Plan PPO (06) - Silver Freedom Plan PPO (07) - Silver Freedom Plan PPO (8) - Silver Freedom Plan PPO (14) - Silver Network Freedom Freedom Freedom Freedom a. PCP $30 per visit $30 per visit b. Specialist In-network $3,000/$6,000 $4,000/$8,000 In-network Maximum Out-of-Pocket In-network Coinsurance Outpatient Facility Copayment after after Inpatient Facility Copayment Emergency Room Out-of-network Out-of-network Maximum Outof-Pocket maximum $7,000/$14,000 Out-of-network Coinsurance Prescription Drug Coverage s and out-of-pocket accumulation periods are on a calendar year contract year basis. are accumulated separately. No individual on a multiple person contract may satisfy the individual and maximum out-of-pocket until the entire family or maximum out-of-pocket has been met. Page 8

9 III. PRODUCT / PLAN DESIGN (CONTINUED) Silver Plans (Continued) Option Freedom Plan Value Option (02) - Silver Freedom Plan Value Option (03) - Silver Freedom Plan Smart HSA (01) - Silver Freedom Plan HSA PPO (01) - Silver Network Freedom Freedom Freedom Freedom a. PCP $40 per visit $40 per visit $30 per visit after b. Specialist In-network $4,000/$8,000 $3,000/$6,000 In-network Maximum Out-of-Pocket In-network Coinsurance Outpatient Facility Copayment after after after after Inpatient Facility Copayment per confinement after Emergency Room Out-of-network Out-of-network Maximum Outof-Pocket Out-of-network Coinsurance Prescription Drug Coverage after Medical after Medical Medical Medical after Medical after Medical Medical Medical s and out-of-pocket accumulation periods are on a calendar year contract year basis. are accumulated separately. No individual on a multiple person contract may satisfy the individual and maximum out-of-pocket until the entire family or maximum out-of-pocket has been met. Page 9

10 III. PRODUCT / PLAN DESIGN (CONTINUED) Silver Plans (Continued) Option Freedom Plan HSA PPO (05) - Silver Freedom Plan Direct (17) - Silver Freedom Plan Direct (18) - Silver Freedom Plan HSA (80-02) - Silver Network Freedom Freedom Freedom Freedom a. PCP b. Specialist In-network $3,000/$6,000 In-network Maximum Out-of-Pocket In-network Coinsurance Outpatient Facility Copayment after after after after Inpatient Facility Copayment Emergency Room Out-of-network Out-of-network Maximum Outof-Pocket Out-of-network Coinsurance Prescription Drug Coverage after Medical after Medical Medical Medical.. after Medical after Medical Medical Medical s and out-of-pocket accumulation periods are on a calendar year contract year basis. are accumulated separately. No individual on a multiple person contract may satisfy the individual and maximum out-of-pocket until the entire family or maximum out-of-pocket has been met. Page 10

11 III. PRODUCT / PLAN DESIGN (CONTINUED) D. Bronze Plans Option Freedom PPO HSA (08) Freedom Direct (20) Network Freedom Freedom a. PCP b. Specialist In-network In-network Maximum Out-of-Pocket In-network Coinsurance Outpatient Facility Copayment Inpatient Facility Copayment Emergency Room Out-of-network Out-of-network Maximum Out-of- Pocket Out-of-network Coinsurance Prescription Drug Coverage Medical Medical.. s and out-of-pocket accumulation periods are on a calendar year contract year basis. are accumulated separately. No individual on a multiple person contract may satisfy the individual and maximum out-of-pocket until the entire family or maximum out-of-pocket has been met. Page 11

12 IV. COBRA & EXTENSION OF BENEFITS DATA 1. Yes No If Yes, identify the number of individuals. Yes No V. BROKER/AGENT INFORMATION 1. Name of Payee: 2. Payee s Oxford Broker Code (Required): 3. Payee s Social Security # or Federal Tax ID #: 4. Name of Writing Agent (Required if Payee is a company): 5. Writing Agent s Oxford Broker Code (Required if Payee is a company): 6. Commission Split %: 7. Sales Representative: Comments: Broker Co-Broker General Agent Important Information Regarding Producer Compensation: please contact your producer. VI. CONSENT AUTHORIZATION FOR BROKER TO ACT AS BENEFITS ADMINISTRATOR Remain in place until. DATE information about any Member. Page 12

13 VII. UNDERWRITING GUIDELINES absolute discretion, to reflect the increased risk of such non-compliance or census variance. Name of Company VIII. APPLICANT AGREEMENT penalties. X Title of Officer of Applicant Date X Duly Licensed and Appointed Producer* Date Please note: If you are not currently appointed by Oxford in Connecticut, you must contact Oxford s Commissions Department at in advance of executing this application. Page 13 UHCCT