COBRA Implementation Guide

Transcription

1 AL LI ANCE BENEFI T GROUP NORTH CENTRAL ST ATES, I NC. COBRA Implementation Guide Contact Us Alliance Benefit Group North Central States, Inc. Office Headquarters 201 East Clark Street PO Box 1226 Albert Lea, MN P F Metro Office 8220 Commonwealth Drive, Suite 204 Eden Prairie, MN P F

2 Welcome Welcome to Alliance Benefit Group North Central States, Inc. We appreciate the opportunity to provide COBRA continuation service for you. This is to provide with an outline of the documentation and information Necessary to implement your COBRA with Alliance Benefit Group. COBRA Implementation Timeline: 1) Complete pages 3-9 below and return to Julie Dickens at or by fax at (866) ) If you have any current COBRA participants, please fill out the COBRA Continuant Takeover Form and send with the completed pages. 3) Alliance Benefit Group will review the information and setup the group in our system. If ABG should have any questions, ABG will contact you. Once the group is setup in the system, you will receive a welcome that will include the manual and information for a demo session. 4) You will also receive an Administrative Agreement, please review the agreement and return the 4 signature pages to Julie Dickens by at jdickens@abgmn.com or by fax at (866) After we receive the signed pages, we will send you a fully executed agreement. 5) The carrier change form should be faxed to your current carriers to notify them of the change in COBRA administration (sample is included at the end of this guide). Your group will now be completely set up with Alliance Benefit Group and you can begin to process any qualifying events and/or new hire notices. Please review the Employer Responsibilities found at the end of the guide. If you have any questions when completing this implementation guide, please call our office at (952) We look forward to working with you! 1 Welcome ABG NCS

3 ABG COBRA Directory Plan Consulting Roger Jorgensen, RHU, REBC Director of Marketing Administrative Services 8220 Commonwealth Drive, Suite 204 Eden Prairie, MN (952) Visit: Implementation/Administration Julie Dickens Certified COBRA Administrator 8220 Commonwealth Drive, Suite 204 Eden Prairie, MN (952) Alliance Benefit Group Customer Service Phone: (952) Toll Free Phone: (800) (Live operators Monday-Friday) Toll Free Fax: (866) Participant website: 2 Service Directory ABG NCS

4 Implementation Form EMPLOYER INFORMATION Legal Name of Organization: Mailing Address: City: State: Zip: Administrative Contact: Administrative Title: Administrative Telephone: Administrative Daily Contact COBRA: Telephone: same as above or Billing Contact: (to receive monthly invoice) Billing Telephone: same as above or State of Incorporation: # of Employees: Federal ID #: Full-time Part-time Effective date of COBRA Administration: Daily Main Company Number: Type of Organization: C Corporation S Corporation Partnership Government Agency LLC Non-Profit Other What is the formal name of the Group Health Plan? This information can be found in the employer s Plan Documents BROKER INFORMATION Name of Broker Agency: Address: Contact Name: City, State, Zip: Special Instructions: Do you want to track your reports by Department and/or Location? No Yes *If yes, please give us the Name of the Departments and/or Locations: 3 COBRA Implementation Form ABG NCS

5 COBRA ADMINISTRATION Yes! Please sign me up for a 2-year contract with Alliance Benefit Group so my Set-Up Fee is waived! If you choose, fees will be collected via ACH Debit to the account designated on the ACH Authorization Form at the end of this document. If you would like to pay the minimum monthly fee at the start of the year in a single ACH debit please check here: Yes No You will need online access to enter Qualifying Events, New Hires and QB Information. Please grant online access to: Full Name: Full Name: Address: Address: Would you like ABG to process your New Hire Enrollees and send out the Department of Labor New Hire notice? Yes No Do you want ABG to send out the Certificate of Creditable Coverage? Yes No Do you employ fewer than 20 employees on a typical day? Yes No If your medical plan is self insured and a member has been approved for the Social Security Extension. Do you want ABG to charge the standard 2% fee or the allowed 150% fee? Do you have a Union Plan? Yes* No *If yes, please tell us on a separate piece of paper how the benefits differ from those that are Non-Union PLAN INFORMATION *Rates can be submitted on carrier letterhead Medical Plan Information - Please do not include the 2% admin fee in the rates listed below Self-Funded Fully insured Is Conversion available: Yes No Coverage ends: date of event month end Eligibility Waiting Period: Does this company allow domestic partner coverage to elect continuation? Yes* No *If yes: Opposite Gender Same Gender EE Only $ EE + 1 $ Family $ EE + Spouse $ EE + Child $ EE + Child(ren) $ Age rated table: Does age rate renew 1 st of month if birthday if prior to the 15 th or 1 st of month following date of birth? Is the spouse rate the same as the employee rates below? Yes No 0-18 $ $ $ $ $ $ $ $ $ $ 65+ $ 65+ (Medicare) $ Groups under 20 employees Child $ 2 Children $ 3+ Children $ 4 COBRA Implementation Form ABG NCS

6 Medical Plan Information - Please do not include the 2% admin fee in the rates listed below Self-Funded Fully insured Is Conversion available: Yes No Coverage ends: date of event month end Eligibility Waiting Period: Does this company allow domestic partner coverage to elect continuation? Yes* No *If yes: Opposite Gender Same Gender EE Only $ EE + 1 $ Family $ EE + Spouse $ EE + Child $ EE + Child(ren) $ Age rated table: Does age rate renew 1 st of month if birthday if prior to the 15 th or 1 st of month following date of birth? Is the spouse rate the same as the employee rates below? Yes No 0-18 $ $ $ $ $ $ $ $ $ $ 65+ $ 65+ (Medicare) $ Groups under 20 employees Child $ 2 Children $ 3+ Children $ HRA Plan Information - Please do not include the 2% admin fee in the rates listed below Self-Funded Fully insured Coverage ends: date of event month end Waiting period for eligibility: Should this benefit be bundled with the Medical Plan? Yes No Can the medical plan be elected without the HRA? Yes No Can the HRA be elected without the Medical Plan? Yes No EE Only $ EE + 1 $ Family $ EE + Spouse $ EE + Child $ EE + Child(ren) $ 5 COBRA Implementation Form ABG NCS

7 Dental Plan Information - Please do not include the 2% admin fee in the rates listed below Self-Funded Fully insured Is Conversion available: Yes No Waiting period for eligibility: Does this company allow domestic partner coverage to elect continuation? Yes* No * If yes: Opposite Gender Same Gender EE Only $ EE + 1 $ Family $ EE + Spouse $ EE + Child $ EE + Child(ren) $ Dental Plan Information - Please do not include the 2% admin fee in the rates listed below Self-Funded Fully insured Is Conversion available: Yes No Waiting period for eligibility: Does this company allow domestic partner coverage to elect continuation? Yes* No * If yes: Opposite Gender Same Gender EE Only $ EE + 1 $ Family $ EE + Spouse $ EE + Child $ EE + Child(ren) $ 6 COBRA Implementation Form ABG NCS

8 Vision Plan Information - Please do not include the 2% admin fee in the rates listed below Self-Funded Fully insured Is Conversion available: Yes No Waiting period for eligibility: Does this company allow domestic partner coverage to elect continuation? Yes* No *If yes: Opposite Gender Same Gender EE Only $ EE + 1 $ Family $ EE + Spouse $ EE + Child $ EE + Child(ren) $ FSA Plan Information - Please do not include the 2% admin fee in the rates listed below Plan Administrator Name: Waiting period for eligibility: When does the Plan year begin? EAP Plan Information - Please do not include the 2% admin fee in the rates listed below Self-Funded Fully insured Is Conversion available: Yes No Waiting period for eligibility: Does this company allow domestic partner coverage to elect continuation? Yes* No *If yes: Opposite Gender Same Gender EE Only $ EE + 1 $ Family $ EE + Spouse $ EE + Child $ EE + Child(ren) $ 7 COBRA Implementation Form ABG NCS

9 If your company is not subject to State Continuation you can leave this page blank. Minnesota Statute 61A.092 states that if you have 25 or 25% of your employees residing in Minnesota, the Basic Life and Voluntary Life Plans are subject to State Continuation and should be offered. Please indicate if you wish to offer MN Life Continuation: Yes No Basic Life Plan Information - Please do not include the 2% admin fee in the rates listed below Is Conversion available: Yes No Self-Funded Fully insured State plan written in: Is this plan self-billed? Yes* No *If Yes, who should we notify of New election or termination? Carrier Client Basic Life rate: $ per $1,000 Family Basic Life rate: $ per month per $1,000 Spouse Basic Life rate: $ per month per $1,000 Child(ren) Basic Life rate: $ per month per $1,000 Must Member elect Basic Life to continue Voluntary Life? Yes No Must Basic Life be elected in order for Spouse/Child to elect Dependent life? Yes No Voluntary Life Plan Information - Please do not include the 2% admin fee in the rates below Is Conversion available: Yes No Self-Funded Fully insured State plan written in: Is this plan self-billed? Yes* No *If Yes, who should we notify of New election or termination? Carrier Client Must Member elect coverage in order for spouse / child to elect? Yes No Rate change upon new age bracket: Renewal first of month following date of birth Other: Are the Spouse Voluntary Life rates based on: Employee Age or Spouse Age 8 COBRA Implementation Form ABG NCS

10 Employee rates per $1,000 Spouse rates per $1,000 Non Smoking Smoking Non Smoking Smoking 0-18 $ 0-18 $ 0-18 $ 0-18 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 80 + $ 80 + $ 80 + $ 80 + $ Child Voluntary life rates: $ per $1,000 per month Additional 9 COBRA Implementation Form ABG NCS

11 COBRA CLIENT ACH AUTHORIZATION FORM On behalf of ( Client ), I hereby authorize Alliance Benefit Group ( ABG ) to pay to (to credit) Client s designated bank account the monthly COBRA premiums which were received by ABG from or on behalf of Client s former employees and their beneficiaries and/or to subtract from (to debit) Client s designated bank account, the monthly fees for ABG services. The credits and debits will settle on the date listed in an that will be provided by ABG to the contact members specified below. Credit monthly COBRA Premiums and debit monthly fees for services Credit monthly COBRA Premiums only Do not credit monthly COBRA Premiums or debit monthly fees for services. **Note: If this option is checked, ABG will send a check for collected COBRA Premiums and an invoice for monthly ABG service fees. Bank Name: Bank Routing Number: Bank Account Number: Bank Account Type: Checking Savings If you currently have an ACH filter please add ABG-BIS to your acceptable payer list. The persons authorized below are allowed to view supporting document for the above financial transactions which will include COBRA Member Name, address, current plan election and premium payment. Name: Name: Name: Name of Client Representative: Date: Signature: Title: 10 COBRA Client ACH Authorization Form ABG NCS

12 Sample Carrier Notice of Administration Date: Today s Date here To: Name of Carrier From: Client Name Here RE: Additional Eligibility Contacts for Group POLICY NUMBER HERE CLIENT NAME HERE has contract with Alliance Benefit Group to provide us with COBRA Administration Services. ABG will be communicating directly with you regarding all eligibility changes as it relates to COBRA; including COBRA elections, COBRA terminations and/or coverage changes. We ask you to cooperate fully with ABG on all eligibility issues involving our COBRA participants. The contact information for ABG is listed below: Julie Dickens Alliance Benefit Group Direct Dial jdickens@abg-mn.com - Toni Coleman Alliance Benefit Group Direct Dial tcoleman@abg-mn.com - Please contact us if you have any questions regarding this information. Thank you. Sincerely, COMPANY REPRESENTATIVE TITLE 11 Sample Carrier Notice of Administration ABG NCS

13 The Employer s Responsibilities IT IS THE EMPLOYER S RESPONSIBILITY TO TERMINATE YOUR EMPLOYEES BENEFITS WHEN THE QUALIFYING EVENT OCCURS. All Qualifying Events must be reported to Alliance Benefit Group via website by cobra@abg-mn.com, or by faxing (866) the event notification form within 14 days of the specific qualifying event or after loss of coverage. Audit your carrier premium billings each month to ensure that all members have been added to, changed within, or removed from your insurance carrier premium billing within 60 days. Alliance Benefit Group is not responsible for premium billing discrepancies beyond 60 days after premium billing date, as most carriers will not go more than 60 days to make adjustments. New Rates must be received in our office at least 10 days prior to the renewal date to assure timely implementation. Alliance Benefit Group will not back-bill qualified beneficiaries for premium rate increases when the rates are received in our office after the renewal date. Example: Rates received September 10 for a renewal date of September 1 will be effective October 1. Premium deficiencies due to late rate notices are the responsibility of the employer. Alliance Benefit Group will reinstate COBRA continuants on coverage when all forms and payments have been received. Payments for their COBRA premiums will follow within 20 business days of the previous month closing. If there are any questions or concerns regarding the termination and reinstatement processes, please contact Alliance Benefit Group immediately. 12 The Employer s Responsibilities ABG NCS