Seattle, Washingtn 98101 MICRO GROUP EMPLOYER DOCUMENTATION REQUIREMENTS D nt cancel any existing plicies until yu receive cnfirmatin f final rates and/r acceptance f the grup by Regence BlueShield (Regence). Submissin f an applicatin des nt cnstitute acceptance nr guarantee an ffer f cverage. We hpe the fllwing will help yu thrugh the enrllment prcess. DUE DATE FOR APPLICATIONS N later than 5:00 pm (Pacific Time) n the 20 th f the mnth prir t the intended effective date f cverage, all required enrllment material and tax dcumentatin must be received by Regence. If it becmes necessary fr Regence t btain additinal infrmatin, the requested effective date may be delayed r denied. CERTIFICATION OF ENROLLMENT Fr cnsideratin f cverage as a small grup, Regence acts in accrdance with the established Revised Cde f Washingtn (RCW) 48.43.005 (33): Small emplyer r small grup means any persn, firm, crpratin, partnership, assciatin, plitical subdivisin, sle prprietr, r self-emplyed individual that is actively engaged in business that emplyed an average f at least ne, but nt mre than fifty emplyees, during the previus calendar year and emplyed at least ne emplyee n the first day f the plan year, is nt frmed primarily fr purpses f buying health insurance, and in which a bna fide emplyer-emplyee relatinship exists. In determining the number f emplyees, cmpanies that are affiliated cmpanies, r that are eligible t file a cmbined tax return fr purpses f taxatin by this state, shall be cnsidered an emplyer. Subsequent t the issuance f a health plan t a small emplyer and fr the purpse f determining eligibility, the size f a small emplyer shall be determined annually. Except as therwise specifically prvided, a small emplyer shall cntinue t be cnsidered a small emplyer until the plan anniversary fllwing the date the small emplyer n lnger meets the requirements f this definitin. A self-emplyed individual r sle prprietr wh is cvered as a grup f ne must als: (a) Have been emplyed by the same small emplyer r small grup fr at least twelve mnths prir t applicatin fr small grup cverage, and (b) verify that he r she derived at least seventy-five percent f his r her incme frm a trade r business thrugh which the individual r sle prprietr has attempted t earn taxable incme and fr which he r she has filed the apprpriate internal revenue service frm 1040, schedule C r F, fr the previus taxable year, except a self-emplyed individual r sle prprietr in an agricultural trade r business, must have derived at least fifty-ne percent f his r her incme frm the trade r business thrugh which the individual r sle prprietr has attempted t earn taxable incme and fr which he r she has filed the apprpriate internal revenue service frm 1040, fr the previus taxable year. ELIGIBILITY REQUIREMENTS Grup Eligibility is based n grup size which is determined by the average cunt f the ttal number f emplyees wh were n the grup s payrll and thse individuals that were emplyed by an affiliated cmpany during the previus calendar year. The term emplyee means any individual emplyed by an emplyer excluding cntracted 1099 individuals. The grup must cntinuusly satisfy the requirements f the Grup Master Applicatin and Cntract in rder t becme enrlled and remain enrlled. Emplyee Eligibility is based n the minimum hurs wrked per week as specified by their emplyer s Grup Cntract. Emplyers cannt set their minimum hurly requirement at less than 20 hurs per week. Emplyees must cntinuusly satisfy the requirements f Grup Master Applicatin and Cntract in rder t becme enrlled and remained enrlled. March 2014 Page 1 f 9
Seattle, Washingtn 98101 MICRO GROUP CHECKLIST The fllwing infrmatin must be prvided when submitting a new grup fr pssible enrllment: Washingtn State Business License a current cpy. Washingtn State Master Business Applicatin a cpy nly required fr a new business that has nt yet been required t file an IRS business tax return such as Frm 1065, 1120, 1120S, Schedule C r Schedule F. Tax Dcumentatin cpies fr the previus tax year alng with currently filed extensin if applicable. Nte: fr further infrmatin please see Micr Grup - Tax Dcumentatin. Grup Master Applicatin - all sectins require cmpletin (even if grup cnsists f nly an wner) with apprpriate signatures. Nte: any change t the applicatin must be dated and initialed. Applicatin Fr Enrllment/Change Frm all sectins require cmpletin by each enrlling emplyee with their signature and the date f signage. Nte: any change t the frm must be dated and initialed. Waiver Frm all sectins require cmpletin by each eligible emplyee that is waiving cverage under the grup plan. Nte: any change t the frm must be dated and initialed. If the reasn fr waiving cverage is due t ther cverage, please include evidence f cverage which may include a cpy f the previus mnth s billing, insurance ID card r a current Explanatin f Benefits (EOB). It is nt necessary t submit the first mnth s premium payment with the Grup Master Applicatin as Micr Grups must qualify fr cverage befre being billed. March 2014 Page 2 f 9
Seattle, Washingtn 98101 MICRO GROUP TAX DOCUMENTATION A cpy f the current Washingtn State Business License and cpies f apprpriate tax dcuments must accmpany the Grup Master Applicatin, Applicatin fr Enrllment/Change and Waiver Frm. Fr a new business that has nt yet been required t file an IRS business tax return such as Frm 1040, 1120 r 1120S r Schedule C r F, please submit a cpy f the grup s Washingtn State Master Business Applicatin. Based n hw the grup files with the IRS, please supply a cpy f each f the necessary frms as listed belw fr the previus tax year r a cpy f the prir year s tax frms alng with a cpy f the currently filed extensin. Sle Prprietrship: The mst recently filed IRS Frm 1040 (its entirety). The crrespnding Schedule C. W-2(s) fr any incme reprted n line 7 f the 1040. The tw mst recently filed State f Washingtn Quarterly Tax Reprts & Wage Detail Reprts (Frms 5208A & B) filed with the Washingtn State Emplyment Security Department (where required) and equivalent fr any ut f state emplyees. Please indicate any terminated r new emplyees n the mst recent quarter filed. Verificatin f Emplyment (VOE) frm plus 2 quarters f Business & Occupatin (B&O) Tax Returns fr the perid prir t the effective date f cverage and 3 mnths f payrll fr the perid prir t the effective date f cverage fr emplyees whse hurs are nt reprted r whse hurs are reprted at zer (0) n Frm 5208B (r equivalent fr any ut f state emplyees). Fr grups f ne, we require 4 quarters f B&O Tax Returns fr the perid prir t the cverage effective date. Imprtant ntes abut Sle Prprietrship: An eligible emplyee must be enrlled as an emplyee and nt as a dependent. The spuse f a sle prprietr can be cnsidered an emplyee if he/she is: deriving W-2 incme frm the business r is listed n the Schedule C as a jint wner r paid n a regular, peridic basis thrugh the Grup s payrll system He/she must cntinuusly satisfy the requirements f the Grup Master Applicatin and Cntract in rder t becme enrlled and remained enrlled. If the wner is nt enrlling then he/she: is exempt frm submitting IRS Frm 1040 and Schedule C must prvide a Waiver Frm The Grup must cntinuusly satisfy the participatin requirements f the Grup Master Applicatin and Cntract. If incme is reprted n line 15b f IRS Frm 1040, please indicate n the frm whether the incme is derived frm a distributin f an IRA r a rllver t a ROTH IRA (applicable nly t grups f ne emplyee). LLC s (Limited Liability Cmpany) may file as a sle prprietr, a partnership r a crpratin. March 2014 Page 3 f 9
Seattle, Washingtn 98101 Partnership: The mst recently filed IRS Frm 1065 (in its entirety). Fr grups f ne emplyee we will als need IRS Frm 1040 (in its entirety) including the Schedule E and W-2 s fr any spusal incme reprted n line 7 f the Frm 1040. The crrespnding K-1 s fr each partner and payrll/draw recrds fr each enrlling partner. Each enrlling partner must meet emplyee eligibility requirements. The tw mst recently filed State f Washingtn Quarterly Tax Reprts & Wage Detail Reprts (Frms 5208A & B) filed with the Washingtn State Emplyment Security Department (where required) and equivalent fr any ut f state emplyees. Please indicate any terminated r new emplyees n the mst recent quarter filed. Verificatin f Emplyment (VOE) frm plus 3 mnths f draw recrds fr each partner and 3 mnths f payrll recrds fr emplyees whse hurs are nt reprted r whse hurs are reprted at zer (0) n Frm 5208B (r equivalent fr any ut f state emplyees) each, fr the perid prir t the effective date f cverage. Fr grups f ne, we require 12 mnths f draw/payrll recrds fr the perid prir t the cverage effective date. Imprtant ntes abut Partnership: An eligible emplyee must be enrlled as an emplyee and nt as a dependent. The spuse f a partner can be cnsidered an emplyee if he/she is: deriving W-2 incme frm the business and is paid n a regular, peridic basis thrugh the Grup s payrll system (dcumentatin t this effect will be required) r is a partner filing a K-1 He/she must cntinuusly satisfy the requirements f the Grup Master Applicatin and Cntract in rder t becme enrlled and remained enrlled If all partners are nt enrlling then they: are exempt frm submitting IRS Frm 1065 and K-1 s must prvide Waiver Frm The Grup must cntinuusly satisfy the participatin requirements f the Grup Master Applicatin and Cntract. If incme is reprted n line 15b f IRS Frm 1040, please indicate n the frm whether the incme is derived frm a distributin f an IRA r a rllver t a ROTH IRA (applicable nly t grups f ne emplyee). LLC s (Limited Liability Cmpany) may file as a sle prprietr, a partnership r a crpratin. March 2014 Page 4 f 9
Seattle, Washingtn 98101 Crpratin: The mst recently filed IRS Frm 1120 (in its entirety) including Frm 1125-E. Fr grups f ne emplyee we will als need IRS Frm 1040 (in its entirety) and W-2 s fr any incme reprted n line 7 f the Frm 1040. The tw mst recently filed State f Washingtn Quarterly Tax Reprts & Wage Detail Reprts (Frms 5208A & B) filed with the Washingtn State Emplyment Security Department (where required) and equivalent fr any ut f state emplyees. Fr grups f ne emplyee, we require the fur mst recently filed 5208 A & B frms. Please indicate any terminated r new emplyees n the mst recent quarter filed. Verificatin f Emplyment (VOE) frm plus 3 mnths f payrll recrds fr the perid prir t the effective date f cverage fr the wner and emplyees whse hurs are nt reprted r whse hurs are reprted at zer (0) n Frm 5208B (r equivalent fr any ut f state emplyees). Fr grups f ne emplyee, we require 12 mnths f payrll recrds fr the perid prir t the cverage effective date. Imprtant ntes abut Crpratin: An eligible emplyee must be enrlled as an emplyee and nt as a dependent. A spuse f an wner/crprate fficer can be cnsidered an emplyee if he/she is: deriving W-2 incme frm the business and is paid n a regular, peridic basis thrugh the Grup s payrll system. He/she must cntinuusly satisfy the requirements f the Grup Master Applicatin and Cntract in rder t becme enrlled and remained enrlled. If all wners are nt enrlling then they: are exempt frm submitting IRS Frm 1120 including Frm 1125-E must prvide Waiver Frm The Grup must cntinuusly satisfy the participatin requirements f the Grup Master Applicatin and Cntract. If incme is reprted n line 15b f IRS Frm 1040, please indicate n the frm whether the incme is derived frm a distributin f an IRA r a rllver t a ROTH IRA (applicable nly t grups f ne emplyee). LLC s (Limited Liability Cmpany) may file as a sle prprietr, a partnership r a crpratin. March 2014 Page 5 f 9
Seattle, Washingtn 98101 Subchapter S Crpratin: The mst recently filed IRS Frm 1120S (in its entirety). Fr grups f ne emplyee we will als need IRS Frm 1040 (in its entirety) including the Schedule E and W-2 s fr any incme reprted n line 7 f the Frm 1040. The crrespnding K-1 s fr each eligibly emplyed enrlling sharehlder. The tw mst recently filed State f Washingtn Quarterly Tax Reprts & Wage Detail Reprts (Frms 5208A & B) filed with the Washingtn State Emplyment Security Department (where required) and equivalent fr any ut f state emplyees. Fr grups f ne emplyee, we require the fur mst recently filed 5208 A & B frms. Please indicate any terminated r new emplyees n the mst recent quarter filed. Verificatin f Emplyment (VOE) frm plus 3 mnths f payrll recrds fr the perid prir t the effective date f cverage fr the wner and emplyees whse hurs are nt reprted r whse hurs are reprted at zer (0) n Frm 5208B (r equivalent fr any ut f state emplyees). Fr grups f ne emplyee, we require 12 mnths f payrll recrds fr the perid prir t the cverage effective date. Imprtant ntes abut Subchapter S Crpratin: An eligible emplyee must be enrlled as an emplyee and nt as a dependent. A spuse f an wner/crprate fficer can be cnsidered an emplyee if he/she is: deriving W-2 incme frm the business and is paid n a regular, peridic basis thrugh the Grup s payrll system He/she must cntinuusly satisfy the requirements f the Grup Master Applicatin and Cntract in rder t becme enrlled and remained enrlled If all wners are nt enrlling then they: are exempt frm submitting IRS Frm 1120S and K-1 s must prvide Waiver Frm The Grup must cntinuusly satisfy the participatin requirements f the Grup Master Applicatin and Cntract. If incme is reprted n line 15b f IRS Frm 1040, please indicate n the frm whether the incme is derived frm a distributin f an IRA r a rllver t a ROTH IRA (applicable nly t grups f ne emplyee). LLC s (Limited Liability Cmpany) may file as a sle prprietr, a partnership r a crpratin. March 2014 Page 6 f 9
Seattle, Washingtn 98101 Nn Prfit Organizatin: The tw mst recently filed State f Washingtn Quarterly Tax Reprts & Wage Detail Reprts (Frms 5208A & B) filed with the Washingtn State Emplyment Security Department (where required) and equivalent fr any ut f state emplyees. Fr grups f ne emplyee, we require the fur mst recently filed 5208 A & B frms. Please indicate any terminated r new emplyees n the mst recent quarter filed. Verificatin f Emplyment (VOE) frm plus 3 mnths f payrll recrds fr the perid prir t the effective date f cverage fr the wner and emplyees whse hurs are nt reprted r whse hurs are reprted at zer (0) n Frm 5208B (r equivalent fr any ut f state emplyees). Fr grups f ne emplyee, we require 12 mnths f draw/payrll recrds fr the perid prir t the cverage effective date. Imprtant ntes abut Nn Prfit Organizatin: An eligible emplyee must be enrlled as an emplyee and nt as a dependent. Fr spuses f the wner wh are emplyed by the business, please see requirements under the apprpriate wnership categry. LLC s (Limited Liability Cmpany) may file as a sle prprietr, a partnership r a crpratin. Religius Organizatin: The tw mst recently filed Washingtn State Emplyer's Quarterly Reprt fr Industrial Insurance (Wrker s Cmpensatin) Frm 212-055. Verificatin f Emplyment (VOE) frm listing all emplyees (whether enrlling r nt) plus 3 mnths f payrll recrds fr the perid prir t the effective date f cverage. Fr grups f ne emplyee, we require 12 mnths f draw/payrll recrds fr the perid prir t the cverage effective date. Imprtant ntes abut Religius Organizatins: An eligible emplyee must be enrlled as an emplyee and nt as a dependent. The spuse f a pastr can nly be cnsidered an emplyee if he/she is: deriving W-2 incme frm the business n the same fting as any ther emplyee He/she must cntinuusly satisfy the requirements f the Grup Master Applicatin and Cntract in rder t becme enrlled and remained enrlled. March 2014 Page 7 f 9
Seattle, Washingtn 98101 Schedule F Farmer: IRS Frm 1040 (in its entirety). The crrespnding Schedule F. W-2(s) fr any incme reprted n line 7 f the 1040. The fur mst recently filed State f Washingtn Quarterly Tax Reprts & Wage Detail Reprts (Frms 5208A & B) filed with the Washingtn State Emplyment Security Department (where required) and equivalent fr any ut f state emplyees. Fr grups f ne emplyee, we require the fur mst recently filed 5208 A & B frms. Please indicate any terminated r new emplyees n the mst recent quarter filed. Verificatin f Emplyment (VOE) frm plus 3 mnths f payrll recrds fr the perid prir t the effective date f cverage fr the wner and emplyees whse hurs are nt reprted r whse hurs are reprted at zer (0) n Frm 5208B (r equivalent fr any ut f state emplyees). Fr grups f ne emplyee, we require 12 mnths f draw recrds fr the perid prir t the cverage effective date. Imprtant ntes abut Schedule F Farmer: An eligible emplyee must be enrlled as an emplyee and nt as a dependent. The spuse f a farmer can be cnsidered an emplyee if he/she is: deriving W-2 incme frm the business r is listed n the Schedule F as a jint wner r paid n a regular, peridic basis thrugh the Grup s payrll system He/she must cntinuusly satisfy the requirements f the Grup Master Applicatin and Cntract in rder t becme enrlled and remained enrlled. If the wner is nt enrlling then he/she: are exempt frm submitting IRS Frm 1040 and Schedule F must prvide a Waiver Frm The Grup must cntinuusly satisfy the participatin requirements f the Grup Master Applicatin and Cntract. If incme is reprted n line 15b f IRS Frm 1040, please indicate n the frm whether the incme is derived frm a distributin f an IRA r a rllver t a ROTH IRA (applicable nly t grups f ne emplyee). LLC s (Limited Liability Cmpany) may file as a sle prprietr, a partnership r a crpratin. March 2014 Page 8 f 9
Seattle, Washingtn 98101 Grup f One Emplyee: A grup f ne emplyee is required t have been in business fr at least twelve mnths prir t the effective date f cverage and meet ther requirements as defined in RCW 48.43.005. Please see the apprpriate wnership categry fr applicable IRS tax dcuments. If incme is reprted n line 15b f IRS Frm 1040, please indicate n the frm whether the incme is derived frm a distributin f an IRA r a rllver t a ROTH IRA (applicable nly t grups f ne emplyee). New Business (applicable t grups f tw r mre emplyees): A new business that has nt yet filed all the dcuments as required within their apprpriate wnership categry may request special cnsideratin fr cverage by submitting all f the available dcumentatin alng with the fllwing: A grup that has nt been in business lng t have filed IRS tax frms (as defined in the apprpriate wnership categry) must submit the fur pages f the Master Business Applicatin filed with the Washingtn State Department f Licensing. A grup that has nt been in business lng t have filed State f Washingtn Quarterly Tax Reprts & Wage Detail Reprts (Frms 5208 A & B) as defined in the apprpriate wnership categry, must submit Verificatin f Emplyment (VOE) frm plus all payrll recrds that are available. Other dcumentatin that supprts that the grup is qualified fr cverage. Upn acceptance f cverage by Regence, the grup must cntinuusly satisfy the requirements within their apprpriate wnership categry. Regence reserves the right t require dcumentatin deemed necessary t verify that a grup is satisfying their cntractual bligatins n a grup f any size, at any time. Once the grup has been accepted fr cverage, n changes t the cntract can be made. The subsequent renewal (ne-year) will be the first pprtunity t make any change(s). Shuld yu have any questins regarding the abve, please cntact yur Prducer r yur Regence Sales Representative. March 2014 Page 9 f 9