Anthem Blue Cross and Blue Shield HealthKeepers, Inc. Group Size: 51-99 mid-size Acct. Code: Group Number(s): Company Name ( the Applicant ): Year Operational: Street Address: For Internal Use Only City: Zip: City/County: Billing Address: (if different from above) City: Zip: Group Administrator: Title: Phone Number: ( ) E-mail Address: Fax Number: ( ) Company Executive: Title: Group Tax ID# A. BENEFIT SELECTION Effective Date: Health Benefits: Month Day Year Indicate how often you would like to be billed: once every 1 month 2 months 3 months 6 months 12 months PPO Health Benefits Available for Groups with 51-99 Employees: Offered by Anthem Blue Cross and Blue Shield KeyCare 10 Plus KeyCare 15 Plus KeyCare 20 Plus KeyCare 25 Plus KeyCare 10 KeyCare 15 KeyCare 20 KeyCare 25 KeyCare 30 KeyCare 30/2000 KeyCare 30/4000* 20% 20% 20% 20% 30% 30% 30% 30% KeyCare 30/5000* KeyCare 500 20% 30% KeyCare 1000 KeyCare 2000 20% 20% Other (specify) 30% 30% *only available with $15/40/75/20% pharmacy option Lumenos HRA 1500/80%/500 3000/100%/1000* 1500/80%/750 1500/100%/500* 5000/100%/1000* 1500/100%/750* 3000/100%/1500* HRA Balance Transfer? Yes No Lumenos HSA 1500/80% 3000/100%* Other (specify) 1500/100%* 5000/100%* Do you want us to facilitate opening a Health Savings Account Financial Custodian (bank) account? Yes** No * These Lumenos HSA/HRA 100% plans include $10/30/50/20% drug plan as part of embedded benefits ** Checking Yes requires completion of HSA Companion Document Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. are independent licensees of the Blue Cross Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 51-99 GRP HMO PPO (1/15)
Point of Service (POS) Health and Rx Benefits Available for Groups with 51-99 Employees: Offered by HealthKeepers, Inc. (Check all that apply; POS = Point of Service) Copay and Coinsurance Products o Product 10 POS o Product 15 POS o Product 20 POS o Product 25 POS Deductible Products o Value Advantage 25/500 o Value Advantage 25/500/30 o Value Advantage 30/1000 o Value Advantage 30/1000/30 o Other (specify) o Product 20/20 POS o $500 Ded o $1000 Ded o Product 25/30 POS o $1000 Ded o $2000 Ded o Other (specify) o Healthy Support plans*** o Product 15 POS o Product 25 POS o Value Advantage 25/500 o Product 25/30 POS All Deductible and Lumenos Products Include Both Open Access and Point of Service Features o Value Advantage 30/2000 o Value Advantage 30/2000/30 o Value Advantage 30/4000* o Value Advantage 30/4000/30* o Value Advantage 30/5000* o Value Advantage 30/5000/30* Lumenos Products Lumenos HSA o 2800/100%** o 3000/100%** o 5000/100%** o 1500/80% o 2800/80% o 3000/80% Lumenos HRA o 2500/100%/1000** o 3000/100%/1000** o 5000/100%/1000** o 2500/80%/1000 o 3000/80%/1000 o 4000/80%/1500 o 5000/80%/2500 o Other (specify) * These Value Advantage plans are only available with the $15/40/75/20% pharmacy option **These Lumenos HSA/HRA 100% plans include $10/30/50/20% drug plan as part of embedded benefits ***Healthy Support plans are only available with Generic Premium $15/40/75 or 20% w/$500 deductible pharmacy option Do you want Anthem to facilitate opening a Health Savings Account Financial Custodian (bank) account? o Yes**** o No ****Checking Yes requires completion of HSA Companion Document Benefit Administration (will apply to all plans administered): o Calendar Year (Standard) o Plan Year Product Design (check all that apply) Value Added (Association _ 3 Digit Code) Blue Advantage Prescription Drug RX (indicate corresponding health benefit selected under each Rx plan - the Rx plans listed are not available to Healthy Support or Lumenos HSA or HRA plans except as noted) $10/20/35/20% $10/30/50/20% $10/30/50/20% w/ $150 Ded $15/40/75/20% Other (specify)
Options/Riders: Anthem Health Rewards Anthem Basic EAP Anthem Enhanced EAP 4 6 Morbid Obesity Domestic Partner and Children HSA account fees paid by group Other (specify) Value Added Association Name Blue View Vision Riders: Whole Group o Voluntary BVV130 BVV130/$15 BVV130/$25 12/12 12/24 12/12 12/24 12/12 12/24 Other (specify) B. COVERAGE HISTORY. 1. COVERAGE Name of present HISTORY carrier: 2. Is your group currently enrolled with Anthem Blue Cross and Blue Shield or HealthKeepers, Inc., or has it been enrolled within the past 12 months? No Yes If yes, give group number and cancellation date. 3. Are your employees covered by Workers Compensation? No Yes If yes, give name of insurer. C. GROUP INFORMATION 1. Type of Organization: Proprietorship Partnership Corporation Other 2. SIC Code: (if known, otherwise check the appropriate box below and briefly describe the nature of your business) Agriculture, Forestry, Fishing Finance Public Administration Retail Trade Construction Mining Transportation, Communications, Services Education Manufacturing Electric, Gas or Sanitation Service Wholesale Trade Nature of your business: 3. The Health Information Portability and Accountability Act of 1996 (HIPAA) states that all entities treated as a single entity under subsections (b), (c), (m), or (o) of Section 414 of the IRS Code shall be considered as one employer. If your business is part of an organization that meets this definition, all companies in the organization, i.e., all subsidiaries and affiliated companies, must be written together as a single account. Is your business part of a multi-company organization that meets this requirement? No Yes If yes, list the name(s) of the other entities Are the other entities enrolling? No Yes If No, explain why not 4. Is there a COBRA administrator*? No Yes Name of COBRA administrator *Note: Anthem does not provide COBRA administration for groups.
D. ELIGIBILITY INFORMATION 1. Do any employees work out of state? No Yes If yes, give number of employees working out of state: 2. What is the percentage of premium your company contributes toward coverage (must be at least 50% of employee premium)? Employee Coverage % Dependent Coverage % 3. Probationary period/waiting period for new employees: Date of Hire (DOH) First of Month (FOM) following DOH 30 days from DOH FOM following 30 days from DOH 60 days from DOH FOM following 60 days from DOH 90 days from DOH 4. Termination Effective Date: End of month End of day E. ENROLLMENT INFORMATION 1. Please attach an Employee Application for each eligible employee applying for coverage and indicate the number of applications attached: ( Eligible Employee is defined below) 2. Please attach a copy of your company s most recent Virginia Employment Commission s Employer s Quarterly Tax Report (VEC- FC-20 and 21) with the following information noted on the copy. If a VEC form is not filed, contact your Anthem sales representative for alternate documents. Write the number of hours normally worked each week beside each employee s name. List any new employees not printed on the VEC with hours worked. List any other enrolling employee who does not appear on the VEC with hours worked and an explanation as to why he/she does not appear on the VEC. For each employee on the VEC form not applying for coverage, write one of the following codes to indicate why he/she is not applying for coverage: T : Terminated P : Not Eligible because they work less than the required number of hours per week N : Eligible but not enrolling because they are enrolled in Medicare, Tricare, FEP, or COBRA; they have coverage through a spouse s or former employer s group program; they are enrolled in an Anthem Personal Health Care plan; or they have not met the employer waiting period E : Eligible, but chooses to waive coverage for another reason not noted above. F. ELIGIBILITY DEFINITIONS Eligible Employee: An active employee of the Applicant who works at least 30 hours per week on a regular basis as of the effective date. Employment must be verifiable from state or federal wage or tax reports. An employee, as defined above, who enters into employment after the policy effective date and who completes the group imposed waiting period for eligibility and applies for coverage within 31 days. Any other class of persons represented by the Applicant, provided that written approval of their eligibility is obtained from Anthem Blue Cross and Blue Shield or HealthKeepers, Inc.; or Employees eligible for continuous coverage under State or Federal laws, e.g. COBRA. To become an eligible employee, a director or officer of a corporate Applicant must meet the same requirements as other employees of the Applicant. Independent contractors (those whose wages are reported on IRS form 1099) are considered to be self-employed and are not eligible for group coverage. Eligible Dependent: Employee s spouse, domestic partner, or children younger than age 26, which includes a newborn, natural child, or a child placed with the employee for adoption, a stepchild or any other child for whom the employee has legal guardianship or court ordered custody, or children of the domestic partner. Coverage for children will end on the last day of the month in which the children reach age 26. The age limit of 26 does not apply for the initial enrollment or maintaining enrollment of a child who cannot support himself or herself because of intellectual disability or physical handicap that began prior to the child reaching the age limit. Coverage may be obtained for the child who is beyond the age limit at the initial enrollment if the employee provides proof of handicap and dependence at the time of enrollment. (The employee may be asked to provide a physician s certification of the dependent s condition.) Dependents eligible for continuous coverage under State or Federal laws, e.g. COBRA. A proprietor or owner is an eligible employee if he/she meets the requirements of an active employee as defined above.
G. CERTIFICATION AND GROUP SIGNATURE Certification: The Applicant certifies that the information on this form is correct to the best of his or her knowledge. If Anthem Blue Cross and Blue Shield accepts the coverage for which application is hereby made, the Applicant shall: 1. Provide every eligible employee an opportunity to enroll when he or she becomes eligible (only eligible employees as defined above may be added). 2. Acknowledge that the terms and conditions of the coverage will be as described in the group policy, and that such group policy is incorporated herein by reference as if the same were set forth in this document in full. 3. Acknowledge that Anthem and its affiliate HealthKeepers, Inc. may review necessary documentation to verify the group s eligibility. The Applicant understands that payment is due the first day of the month following receipt of the statement. I certify that I have read the certifications above and have the authority to sign this application on behalf of the group. Signature: Title: Date: H. AGENT/BROKER AGREEMENT The Group authorizes Anthem Blue Cross and Blue Shield or HealthKeepers, Inc. to recognize the following agent/broker/agency (if any) to be the Group s Agent of Record: Agent/Broker Name (print) Agency Name Address Agent/Broker/Anthem ID Number A O - Telephone Number I. ANTHEM SALES REPRESENTATIVE: I hereby certify that all information has been verified: Signature: Rep. Code #: Date: FAX#: FAX# I hereby certify that all the information in the Group Application and Employee Applications is correct to the best of my knowledge, and I know nothing unfavorable about this firm or any individual requesting coverage, except as noted on the health questionnaire, as required. I have complied with Anthem s underwriting rules and regulations and have explained in detail the coverage to the group and its employees. Agent/Broker Signature: Date: SECTION BELOW FOR ANTHEM USE ONLY New Renewal Submitted By Rep. No. Terr. Check Number Check Amount Initial Waiver: (Pre-X 10+ only) Group No. Group Effective Date Renewal Date Do you have Dental Benefits? Yes No Effective date: ADV Prime Complete Assoc. Code LOB Parent No. EAP Std.: EAP Enh.: Blue Adv.: Association Name Package No. Unit No. County Code No. of Employees Group Size Account Code Reopen Month Contract Eff Contribution: Single Other SIC Code Prefix Bill Date CMF PKG ID WC Prior Cov GS Notes
Medical Plan #1 Single Sub/Minor Children Spouse Family Cov ID Benefit Index RTG Type Effective Date Basic Health & Option Cost BC Insurer Fee BS Reinsurance Fee EM MM Medical Plan #2 Single Sub/Minor Children Spouse Family Cov ID Benefit Index RTG Type Effective Date Basic Health & Option Cost BC Insurer Fee BS Reinsurance Fee EM MM Medical Plan #3 Single Sub/Minor Children Spouse Family Cov ID Benefit Index RTG Type Effective Date Basic Health & Option Cost BC Insurer Fee BS Reinsurance Fee EM MM