Large Group Application/Change Form (Medical/Vision: 101+ Full-time Equivalent Employees) (Dental: 51+ Full-time Equivalent Employees)

Transcription

1 Large Group Application/Change Form (Medical/Vision: 101+ Full-time Equivalent Employees) (Dental: 51+ Full-time Equivalent Employees) Thank you for choosing Empire BlueCross (Empire). Please fill out all items in order for us to quickly and accurately process your application. Once you ve completed this form, please sign in the space provided in Section 27. Section 1: Reason for application/change Fill in one only. New policy Requested effective date (MMDDYY) Change existing benefits Revision or renewal date (MMDDYY) Section 2: Group information Group name Group mailing street address City State ZIP code (5+4) County Phone no. Fax no. Authorized group contacts Primary group contact last name First name Title address (Benefit administrator) mandatory Secondary group contact last name First name Title Tertiary group contact last name First name Title Billing contact Billing phone no. Billing mailing street address (if different) City State ZIP code (5+4) County Federal employer identification no. Type of industry Is your group a subsidiary/division affiliated with another company? Yes No If yes, name No. of employees Do you currently have group coverage with Empire? Yes No If yes, what is the group number? For Empire use only Sales representative last name First name Representative code Group no. Sub-group no. Sub-group no. Sub-group no. Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. ENR6004B Rev. 1/ NYEENEBS Rev. 9/16 1 of 8

2 Section 3: Group eligibility Waiver of waiting periods Member and dependents initial and subsequent enrollment Member and dependents initial enrollment Member and dependents initial enrollment and member subsequent enrollment No waiver of waiting periods Other (specify): Eligibility dates Complete both A and B. A. Initial enrollment of group All employees and dependents coverage will be in effect: On group effective date After new employee eligibility is satisfied (see B) All enrollment forms must be received no later than thirty (30) days following the member s eligibility date. B. New employees (after initial enrollment of group) New employees will be eligible for coverage: Date of hire First day following: First of the month following: day(s) following date of hire day(s) following date of hire month(s) following date of hire month(s) following date of hire Other: The waiting period for new employee coverage cannot exceed 90 days. All enrollment forms must be received no later than sixty (60) days following the member s eligibility date. C. Employee reinstatement policy: Employees who are re-hired to the company are eligible for coverage. Date of hire: (MMDDYY) Other: Domestic Partnership selection Please select one. Domestic partnership coverage None Regions of residence Select all that apply. If you are choosing Direct POS please check all regions in which your enrolling employees reside. Albany: Albany, Clinton, Columbia, Delaware, Essex, Fulton, Greene, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren and Washington counties Connecticut Contiguous Counties: Fairfield, Hartford, Litchfield, Middlesex, New Haven, New London, Tolland and Windham counties Mid-Hudson: Dutchess, Putnam, Orange, Sullivan and Ulster counties New Jersey Contiguous Counties: Bergen, Hudson, Middlesex, Monmouth, Passaic, Sussex and Union counties New York: Bronx, Kings, Queens, New York, Nassau, Rockland, Westchester, Richmond and Suffolk counties If you are choosing HMO please check all regions in which your enrolling employees reside. Downstate I: Bronx, Kings, Rockland, Richmond Downstate II: New York, Queens, Suffolk, Nassau Capital: Albany, Schenectady, Rensselaer Mid-Hudson: Dutchess, Orange, Putnam, Sullivan, Ulster, Westchester Upstate I: Columbia, Delaware, Greene, Montgomery, Schoharie, Saratoga, Warren, Washington Upstate II: Clinton, Essex, Fulton Connecticut Contiguous Counties: Fairfield, Hartford, Litchfield, Middlesex, New Haven, New London, Tolland and Windham counties New Jersey Contiguous Counties: Bergen, Hudson, Middlesex, Monmouth, Passaic, Sussex and Union counties 2 of 8

3 Section 4: Number of employees The following information is needed to determine OBRA 1 status. Employers may need to consult a tax expert to determine OBRA status. 1. Is your group OBRA eligible? Yes No 2. Will (or did) your group have at least 101 full-time equivalent employees for at least 26 weeks: In the current calendar year? Yes No If yes, list no. of employees: In the last calendar year? Yes No If yes, list no. of employees: (Include owners and partners. Count all locations.) 1 Under OBRA, when an employer has 100 or more full-time equivalent employees on its payroll for 26 weeks in a calendar year, the group becomes the primary payer and Medicare becomes the secondary payer for the remainder of the calendar year and the following calendar year for claims of actively working employees and their dependents under the age of 65 that are Medicare eligible because of a disability. Section 5: Number of members Empire insured members TEFRA eligible 2 (actively employed) Medicare-eligible retirees Federal COBRA (up to 18 months) Federal COBRA due to disability (up to 29 months) NY State Continuation (up to 36 months total) Total no. covered Other (not insured by Empire) Single Family 2 TEFRA stands for the Tax Equity and Fiscal Responsibility Act of Under TEFRA, when an employer has 20 or more full-time and/or part-time employees on its payroll for 20 weeks in a calendar year, the group becomes the primary payer and Medicare becomes the secondary payer for the remainder of the calendar year and the following calendar year for claims of working-aged employees and their spouses age 65+ even if they go below the 20/20 threshold. The 20 weeks in a calendar year do not have to be consecutive to reach the 20/20 threshold. Section 6: Financial arrangement Medical Administrative services only Required operating fund (hospital) Empire Balance Funding Closed end (Prospective + Retrospective) Deferred payment of premium Fully Insured Extended grace period Minimum premium arrangement Others (specify): Applies to all products Dental Administrative services only Required operating fund (hospital) Empire Balance Funding Closed end (Prospective + Retrospective) Deferred payment of premium Fully Insured Extended grace period Minimum premium arrangement Others (specify): Vision Administrative services only Required operating fund (hospital) Empire Balance Funding Closed end (Prospective + Retrospective) Deferred payment of premium Fully Insured Extended grace period Minimum premium arrangement Others (specify): Section 7: Payment section Group s contribution, if any. Medical Employee only: % 2-Party: % Employee & spouse: % Parent & child(ren): % Family: % Contribution applies to all products Contribution to HRA Individual: $ Family: $ HRA Carryover: None 1x annual amount 2x annual amount 3x annual amount 4x annual amount 5x annual amount Unlimited Incentive credits offered (HRA Only) Yes No Dental Employee only: % 2-Party: % Employee & spouse: % Parent & child(ren): % Family: % Vision Employee only: % 2-Party: % Employee & spouse: % Parent & child(ren): % Family: % Section 8: Rating structure Select one. For DPOS, PPO, Empire Prism plans and Empire Total Blue plans: Tier 2 Tier 3 Tier 4 For HMO: Tier 2 (Capital, Mid-Hudson, Upstate I, Upstate II) Tier 3 (Capital, Mid-Hudson, Upstate I, Upstate II) Tier 4 (all other rating regions) Section 9: ID card mailing Initial: Group Member Subsequent: Group Member 3 of 8

4 Section 10: Medical benefits section The following plans are available prior to 7/1/17 HMO 3 Empire Prism SM EPO Empire Prism EPO with Blue Priority network 5 Empire Prism EPO Select Empire Total Blue EPO (HSA) 4 Empire Total Blue EPO (HSA) with Blue Priority network 4, 5 Empire Total Blue EPO (HRA) Empire Total Blue EPO (HRA) with Blue Priority Network 5 PPO Empire Prism PPO Empire Total Blue PPO (HSA) 4 Empire Total Blue PPO (HRA) Direct POS 3 The following plans are available 7/1/17 7 Empire EPO (Copay Plan) Empire PPO (Copay Plan) Empire Blue Priority EPO (Copay) 5 Empire EPO (Copay + Coinsurance Plan) Empire PPO (Copay + Coinsurance Plan) Empire Blue Priority EPO (Copay + Coinsurance Plan) 5 Empire EPO (Copay + Deductible + Coinsurance Plan) Empire PPO (Copay + Deductible + Coinsurance Plan) Empire Blue Priority EPO (Copay + Deductible + Coinsurance Plan) 5 Empire EPO with HSA 6 Empire EPO with HRA 6 Empire PPO with HSA 6 Empire PPO with HRA 6 Empire Blue Priority EPO with HSA 5,6 Empire Blue Priority EPO with HRA 5,6 Empire EPO with HSA (HSA with Copay Plan) 6 Empire EPO with HRA (HRA with Copay Plan) 6 Empire Blue Priority EPO with HSA (HSA with Copay Plan) 5,6 Empire Blue Priority EPO with HRA (HRA with Copay Plan) 5,6 Empire EPO (Deductible + Coinsurance Plan) Empire PPO (Deductible + Coinsurance Plan) Empire Blue Priority EPO (Deductible + Coinsurance Plan) 5 Calendar year Plan year 3 HMO benefits provided by Empire HealthChoice HMO, Inc. 4 Requires completion of HSA addendum. 5 The Blue Priority network includes selected physicians from our networks. 6 Requires completion of CDH Questionnaire. 7 Pending DFS approval Section 11: Copayments PCP/Primary home/office/outpatient: $ Inpatient facility: $ Specialist home/office/outpatient: $ Emergency room: $ Ambulatory/Outpatient surgery: $ MRI/MRA, PET, CAT scans, Nuclear cardiology: $ Other: $ Empire Prism plans only: Durable medical equipment, prosthetics and orthotics: 50% coinsurance 20% coinsurance 0% coinsurance Section 12: Deductible In-Network Individual: $ Family $ Out-of-Network Individual: $ Family $ Combined INN & OON (Applies to Empire Total Blue PPO benefits only) Individual: $ Family $ Section 13: Coinsurance In-Network: % Maximum Out-of-Pocket 7 limit Individual: $ Out-of-Network: % Maximum Out-of-Pocket 8 limit Individual: $ Family: $ Family: $ 8 Includes deductible. Section 14: 4th quarter deductible carryover This Section does NOT apply to HRA/HSA. Yes No If yes, Empire requires proof from the prior carrier that the member and/or dependents met all or part of the deductible. Section 15: Maximum out of pocket limit credits Yes No If yes, Empire requires proof from the prior carrier that the member and/or dependents met all or part of the Maximum Out-of-Pocket Limit. Section 16: Make available benefits Empire is required by law to make these benefit options available to employer groups. Do you elect the following benefit options? Dependent age 26 coverage: Yes No Dependent coverage through age 29: Yes No Skilled nursing: unlimited visits: Yes No 4 of 8

5 Section 17: Vision coverage section Please select the vision product and coverage options you wish to purchase. Yes, complete the information below Blue View Vision SM Exam Only Benefits Exam frequency Exam copay Every 12 months $0 Every 24 months $5 $10 $15 No Blue View Vision SM Exam and Material Benefits Frequency exam/lenses/frames Copay exam/lenses Frame/contact lens allowance 12/12/12 months $5/$0 $150 12/12/24 months $10/$0 $130 12/24/24 months $10/$10 $100 24/24/24 months $10/$20 $80 $10/$25 $20/$20 Section 18: Prescription drug coverage section Check all applicable. Prescription Drug Program Tier 1: $ Tier 2: $ Tier 3: $ Deductible 9 : $ Preferred Generic Program Provision Provision to Waive Pharmacy Deductible for Tier 1 generic drugs purchased at a retail pharmacy (not applicable to HRA/HSA) Other: $10 Generic Only Drug formulary National Essential 9 Not applicable to mail order (mail service) program; not applicable to HRA/HSA. Groups exempt from contraceptive coverage must attach a signed affidavit. Section 19: Dental Benefits Section Check benefit and fill in. No Coverage Dental PPO Program (select one) Prime Complete Premium Care (PPO) XPO 10 Riders: Empire Dental Consumer Choice PPO 10 Empire Dental Essential Choice PPO 10 Empire Dental Enhanced Choice PPO 10 Managed Dental Programs 11 (select one) Essential Care Managed Care Dental Riders: Enhanced Care Managed Care Dental Riders: Comprehensive Care Managed Care Dental Riders: Other: 10 Pending DFS approval. Other: 11 Existing groups can attach member listing with PCD selection. Section 20: Gym reimbursement benefits section Annual reimbursement amount: $ 50 visit requirement for 6-month period No visit requirement Section 21: National Care Network (NCN) Applies to ASO only. Yes No NCN is an external vendor that attempts to reduce claim cost through negotiation and customized pricing for claims received from out-of-network providers. 5 of 8

6 Section 22: Additional benefit riders and descriptions Must also include Drug, Dental, Vision and Gym Reimbursement riders selected above. Rider code Description of benefit Section 23: Rates Product Individual Family Employee/ Spouse Parent/Child Parent/ Children Composite HRA/HSA Admin Fee (PEPM) $ Medicare carveout rates HRA Admin Fee (PEPM) $ 6 of 8

7 Section 24: Group declaration The Personnel Record and the attached complete copy of my New York State Department of Taxation and Finance Quarterly Combined Withholding and Wage Reporting return of Wages Paid to each Employee (NYS-4/NYS-45/NYS-45ATT) as filed, signed by an officer or owner of the group, W-2 forms or any additional documentation validating enrollment of employees, owners, partners, officers or paid Board members (i.e., K-1, notarized statements, payroll records) are a complete statement of the total number of our employees, including the reasons why any individuals are not being covered, for which appropriate documentation is submitted. For eligible retirees, evidence of past employment and continuing financial arrangements is required. If the enrollment forms submitted meet Empire s credentialing and eligibility requirements, and are in compliance with New York State law, and we issue coverage, the group agrees to the following: To remit to Empire the charges payable in accordance with the terms of the contract between Empire and the group, and if employee contributions are required, to make necessary payroll deductions; group must also submit payment promptly, not to be received after the expiration of the grace period. (Failure to pay promptly will result in the termination of the group s coverage.) The group agrees to permit Empire to audit and/or make copies of any records or information that relate to the administration of this coverage. The group further agrees: to ensure compliance with HIPAA (45 CFR Parts ) as it relates to health plans, to ensure compliance with TEFRA/DEFRA/ COBRA/OBRA legislation as it relates to any active employee or dependent of an active employee who elects the group s benefits as primary, to ensure prompt conversion to Medicare-related/Carveout coverage of Medicare-eligible actively employed group members and dependents not covered by TEFRA/DEFRA/OBRA legislation; and to ensure prompt conversion to Medicare-related/Carveout coverage for eligible Medicare retirees. The group agrees to promptly submit an employee s enrollment form for eligible members only and promptly remove members who are no longer eligible. Failure to report removals promptly could result in the group being responsible for premiums or claims paid subsequent to the employee s removal date. The group must also ensure all employees enroll in accordance with their marital/domestic partner status. If an acceptable enrollment form is received prior to or within 30 days after the eligibility date, coverage will begin on the date of eligibility; otherwise, coverage will begin on open enrollment or the next group renewal date. Benefits purchased and established eligibility selected may be changed at renewal only. It is understood that this agreement may be terminated by the group by giving prior written notice as required by the group contract. In the event of termination by the group, the group will be required to pay premiums until the date of termination as specified in the contract. Empire may terminate this agreement for any of the reasons set forth in the group contract. This group application is a part of the agreement between Empire and the group for health insurance benefits. New York insurance law requires that your employees who receive health coverage from an HMO or Direct POS health plan, be given 30 days prior notice when an increase in the group insurance premium rates results in an increase to their premium contributions. Employers offering other types of health coverage are also encouraged to provide this information to their employees. For more information and to download a sample employee notification letter, visit Section 25: Agent/Broker declaration and Information To the best of my knowledge, all the statements/responses in this application are true and complete. I have no knowledge about the applicant, his/her employees, the dependents of such employees or an individual who is receiving continuation of coverage under federal or state laws which is not fully stated in this application. 1 st Broker Commission % of split Agent or Brokerage of Record last name First name SSN/Tax ID no. Company name address Mailing street address City State ZIP code (5+4) County Phone no. Fax no. 1 st Broker signature X Date (MMDDYYYY) 7 of 8

8 Section 25: Agent/Broker declaration and Information Continued. 2 nd Broker Commission % of split Agent or Brokerage of Record last name First name SSN/Tax ID no. Company name address Mailing street address City State ZIP code (5+4) County Phone no. Fax no. 2 nd Broker signature X Date (MMDDYYYY) Section 26: Insurance fraud statement Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation. SECTION 27: Signature of authorized representative I have read this entire application and the certification and fraud statement. Print name Title Authorized group signature X Date (MMDDYYYY) 8 of 8