Kaiser Foundation Health Plan of the Mid- Atlantic States, Inc. (KFHP-MAS) 2101 East Jefferson Street Rockville, Maryland 20852 Kaiser Permanente Insurance Company (KPIC) One Kaiser Plaza, Oakland, California 94612 VIRGINIA MID/LARGE GROUP EMPLOYER APPLICATION APPLICATION is hereby made for group health coverage based upon the following statements and representations: Product* MEDICAL Service delivery options** HMO Signature Select Deductible HMO Signature Select HSA-Qualified Deductible HMO (HDHP) Signature Select CDHC Options (Available if a KP health plan is purchased): KP Administered HSA (available with HDHP only) KP Administered HRA (available with HMO, DHMO, HDHP) KP Administered FSA (available with HMO, DHMO, HDHP) KP Administered HRA/FSA (available with HMO, DHMO, HDHP) Added Choice POS Signature Select Flexible Choice POS Signature Only Out-of-Area PPO DENTALENHANCEMENTS(OPTIONAL) Employer-selected adult dental rider Dental benefits are underwritten by KFHP- MAS *The Service Delivery Options only apply to the benefits underwritten by KFHP-MAS. The Service Delivery Options do not apply to the products underwritten by KPIC. **Benefits underwritten by KFHP-MAS: Benefits underwritten by KPIC: HMO Option 2 and Option 3 of Flexible Choice POS, and Option 1 of Flexible Choice POS. Out-of Area PPO. Added Choice POS DO NOT ALTER THIS DOCUMENT EXCEPT TO FILL IN THE BLANKS AND CHECK THE BOXES PROVIDED. Due to regulatory reuirements, this Application will not be accepted if any other changes are made. Complete this Application in its entirety, in black ink, and sign and return it to your Sales Representative. If you have any uestions concerning the benefits and services that are provided by or excluded under the benefit plan selected, please contact your account manager or sales representative before signing this application. VALG/KFHP-KPIC APP 01/16
Section 1 APPLICANT S INFORMATION Purchaser's legal business name Group/Policy ID number: D/B/A (if applicable) Legal Corporation Sole Proprietorship Status Partnership Other Street address City State Zip code Executive contact person: Title Phone Fax Billing address City State Zip code Billing contact person Title Phone Fax Rate address City State Zip code Rate contact person Title Phone Fax Corporate/Home Office address City State Zip code Corporate/Home Office contact person Title Phone Fax Federal tax ID number Primary SIC code Reuested effective date Are there any affiliates or subsidiaries to be covered? If yes, please provider details below Company Name Address Yes No Affiliate Subsidiary Company Name Address Affiliate Subsidiary City, State, Zip City, State, Zip Section 2: EMPLOYEE ELIGIBILITY Live or work within the KFHP-MAS service area Live and work outside of KFHP-MAS service area Total A. Total # of full-time employees working [ ] hours or more per week B. Total # of permanent part-time employees C. Total # of employees reuesting group health coverage D. Total # of employees of all affiliates, subsidiaries and offices VALG/KFHP-KPIC APP 01/16 2
Section 3: BILLING INFORMATION Same as applicant information? Yes No If yes, skip to section 4 Billing address City State ZIP code Billing contact person Title Phone Fax For office use only Proration/Eff status F/MB H/DE D/DE SEC Jurisdiction: VA Section 4: RATES Employee Only Employer Contribution % HMO Rate POS Rate Out-of-Area PPO Rate HMO POS Two-Party Employee + Adult Employee + Child Employee + Child(ren) Family Medicare Section 5: OTHER HEALTH CARE COVERAGE INFORMATION Have you ever had prior coverage with KFHP-MAS and/or KPIC? Yes No If yes, under what name? If yes and coverage was provided, what was the Group/Policy ID number? Are you applying for this insurance to replace current or prior coverage provided by another group health carrier? Yes No Carrier's name Group/policy number Effective date Termination date Has an insurance carrier terminated your coverage in the past five years? Yes No If yes, please provide the following: Carrier's name Reason for termination How many group insurance carriers provided coverage to you within the past 3 years? Is your Company exempt from COBRA or any state continuation plan? Yes No If yes, please explain VALG/KFHP-KPIC APP 01/16 3
Section 6: BROKER INFORMATION (to be completed for brokered sales only) Broker name Broker firm name Group Number Assigned: Street address City State Zip Phone Fax E-mail address Life & Health license number Federal tax ID number General Agent name By signing this Application, Applicant authorizes the individual named above to act as a broker of record for health plan coverage, through KFHP-MAS, and/or KPIC, effective on Signed at Month Day Year City State Month Day Year YOUR BROKER IS/MAY BE PAID COMMISSIONS AND OTHER FINANCIAL INCENTIVES BY KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. AND/OR KAISER PERMANENTE INSURANCE COMPANY. Section 7: ENROLLMENT INFORMATION Annual open enrollment period: Enroll during month of for coverage effective 1 st, (year) New employee coverage becomes effective: Note: Maximum waiting period allowed is 90 days from the date of hire. Dependent Coverage Limiting Age for Dependent Children: (Such age may not be less than age 26) Coverage will not be provided to Domestic Partners Coverage will be provided to Domestic Partners VALG/KFHP-KPIC APP 01/16 4
Section 8 EMPLOYER AGREEMENT The employer agrees to the following eligibility reuirements: 1)! To meet the following Minimum Participation Reuirement: If the plan is non-contributory, then 100% of the net eligible employees must be enrolled. If the plan is contributory, then 75% of the net eligible employees must be enrolled.! [Net eligible employees = Total eligible employees less employees working less than [! and employees with other health coverage.] 2)! Business Certification ] hours per week We certify that our company has a legitimate business operation, and does not exist for the sole purpose of obtaining health care coverage. In addition, we certify that our company has been actively engaged in our business for at least three months from the date of this Application. 3)! The Applicant agrees that in submitting this Application, it is acting for and on behalf of itself and as the agent and representative of its employees and COBRA participants, if applicable. The Applicant is not the agent or representative of KFHP-MAS or KPIC for any purpose of this Application or any Group Agreement that is issued pursuant to this Application, except enrollment. 4)! The Applicant agrees to offer enrollment in the KFHP-MAS and/or KPIC products to all individuals entitled to coverage on conditions no less favorable than those for any other health care plan available through the Group. 5)! The Applicant agrees that a bona fide employer/employee relationship exists with respect to each subscriber to be enrolled in the KFHP-MAS/KPIC products. This reuirement does not apply to eligible Taft-Hartley trusts and partnerships. 6)! The Applicant agrees that, unless KFHP-MAS and KPIC agree otherwise in writing, all persons to be covered, except retirees, dependents and those former employees covered under a continuation of benefits, are Eligible Employees of the Applicant, or a subsidiary or affiliate listed within this Application. Eligible Employee means an employee who works for a Group employer on a full-time basis, has a normal work week of 30 or more hours, has satisfied applicable waiting period reuirements, and is not a part-time, temporary, seasonal or substitute employee or independent contractor who receives a 1099 statement. Employee as the meaning given such term under section 3(6) or the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1002(6)). Independent contractors/1099 employees are not eligible for coverage. 7)! The Applicant agrees that it assumes responsibility for, and all liability related to, its determinations regarding the eligibility status of each Eligible Employee and his/her Dependents, and understands that KFHP-MAS and KPIC will rely on such eligibility determinations in effectuating coverage. Furthermore, the Applicant agrees it will be financially liable to KFHP-MAS and/or KPIC for any errors and/or omissions. 8)! The Applicant agrees that as reuired by state law, employer group has a worker's compensation coverage for its employees. The Group carries workers compensation insurance. The Group does not carry workers compensation insurance. If your company does not carry workers compensation coverage, please explain. 9)! The Applicant agrees to hold an open enrollment period at least once a year, during which all individuals entitled to coverage are offered a choice of enrollment in the KFHP-MAS/KPIC products. 10)!The Applicant agrees that the Group coverage applied for in this application will not become effective until: a) This application is approved by KFHP-MAS and/or KPIC; and b) An advance payment eual to an estimated one-month premium is received by KFHP-MAS and/or KPIC; and c) That if the cost of the coverage is to be contributory, the reuired percentage of the eligible employees shall have agreed to make the reuired contribution. 11) The Applicant agrees that the agent or the broker do not have the power on behalf of KFHP-MAS and/or KPIC, to make or modify any application for coverage, to make any promise or representation, or to waive any of the companies' (KFHP-MAS/KPIC) rights or reuirements. WARNING: ANY PERSON WHO, WITH THE INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY HAVE VIOLATED THE STATE LAW. VALG/KFHP-KPIC APP 01/16 5
POINT-OF-SERVICE (POS) OPTION DISCLOSURE STATEMENT FOR APPLICANTS FROM THE COMMONWEALTH OF VIRGINIA: Group Number Assigned: Under the law of the Commonwealth of Virginia, your employees may purchase a point-of-service option as an additional benefit. A point-of-service option allows your employees to obtain covered health care services from physicians and other providers outside of the KFHP-MAS HMO network. KFHP-MAS offers a POS plan (Added Choice) and, in conjunction with KPIC, Kaiser Permanente Flexible Choice to meet this statutory reuirement. You have the choice to pay the entire cost of the point-of-service options, pay a percentage of the cost of these options or reuire your employees to pay the entire cost of these options. The cost of the point-of-service options is identified in your proposal. Each eligible Employee must indicate his/her selection of the mandatory point-of-service option. Failure to do so will result in HMO coverage only. Applicant must provide KFHP-MAS with a list of those eligible Employees who have chosen the point-of-service option. By signing this Application, Applicant certifies that it has read and understands this disclosure statement. Applicant further certifies that it has provided notice of availability of these additional benefits to its eligible employees. Section 9 GROUP ACKNOWLEDGEMENT I understand and agree, on behalf of the employer, that the statements in this application and the answers to the Underwriting Questionnaire, if attached, are true and complete to the best of my knowledge and belief. I understand and agree that such statements and answers; a) will become part of any Group Agreement which may ultimately be issued by KFHP-MAS; (b) will become part of any policy or policies which may ultimately be issued by KPIC; and c) are made to induce KPIC and/or KFHP-MAS, to issue the group coverage as applied for. I have the authority to make the statements and representations contained in this Application and to execute this Application on behalf of the Group. WARNING: ANY PERSON WHO, WITH THE INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY HAVE VIOLATED THE STATE LAW. Signed at on City State Month Day Year By (full name in print) Signature Title Section 10 ADDITIONAL NOTES VALG/KFHP-KPIC APP 01/16 6
For KFHP - MAS Use Only Group Number Assigned Delivery System Signature Select OAD/OAS Average Age Initial Contract Period Begin Initial Contract Period End Jurisdiction: Plan Riders: DME P&O Infertility Hearing Aids CAM Pharmacy Carve Out Adult Dental Pediatric Dental Sales Representative (Print Name) BENEFITS HMO POS OOA Step Type Plan Type Rx Dental Copayment Coinsurance Deductible Out-of-Pocket Maximum Carve Out (Circle) Rx Chiro None STEPS Employee Two-Party Employee + Adult Employee + Child Employee + Children Family Employer Contribution % HMO POS HMO Rate POS Rate Out-of-Area PPO Rate VALG/KFHP-KPIC APP 01/16 7