General Eligibility Requirements Please Note We have provided these requirements as a guide. It is only intended to help you understand some of the most common eligibility requirements for offering Excellus BlueCross BlueShield health plans. Please be aware that from time to time our policies and procedures may change. If you need to verify any information, please contact our account services department. They will be happy to answer any questions you may have. A small group is one with between 1 and 50 eligible employees and meets the following criteria: Is physically located within our operating area Is engaged in a legal business with the authority necessary to contract for coverage Regularly employs at least one person on an active basis for salary or wages throughout the year. The business must be non-seasonal in nature, meaning the employer on at least 50% of its working days during the preceding year employed one or more eligible persons Has an employer-employee relationship with eligible personnel Files state and federal income taxes as an ongoing enterprise or files appropriately as a non-profit entity If the employer contributes 100% of the premium, 100% of the employees must participate Meets and maintains applicable minimum participation enrollment requirements (see below) Is financially sound and expected to be a viable ongoing concern. Maximum Number of Product Combinations Small groups who select Excellus BlueCross BlueShield coverage are limited to the following number of product combinations: Group Size Number of Products 1-5 net eligible employees 1 6-20 net eligible employees 2 21-50 net eligible employees 3 For groups with 100% participation and more than 1 eligible employee, one additional product is allowed. This does not apply to groups of 1-5 net eligibles that are offering BluePPO HSA. Minimum Participation for Excellus Blue Cross BlueShield Health Plans For employers offering Excellus BCBS non-hmo health plans, 75% of the net eligible employees must enroll. Products with additional minimum participation requirements are noted below. 1 Revised 12/7/05
Product Specific Minimum Participation Requirements BlueEPO Balance, FourFront, Blue Healthy Choices ( EPO ) For employers who only offer 1 Excellus BCBS EPO product o 75% of the net eligible employees must enroll For employers who offer one or more EPO products and any other Excellus BCBS product o 50% of net eligible employees must enroll in the EPO product(s) (i.e., Blue Healthy Choices) o 20% of net eligible employees must enroll in each additional product offering o In total, 75% of net eligible employees must be enrolled in Excellus BCBS products. BluePPO HSA For employers with 6 or more eligible employees who only offer BluePPO HSA, 5% of net eligible employees must enroll in the first and second year of the product offering and 10% of net eligible employees must enroll in the third year of the product offering. In addition, at least 50% of eligible employees must be enrolled in a health insurance program through another carrier. For employers with 6 or more eligible employees who offer BluePPO HSA and one or more additional products, 5% of net eligible employees must enroll in the first and second year of the product offering and 20% of net eligible employees must be enrolled in each additional product offering. In year three of the product offering 10% of net eligible employees must enroll in BluePPO HSA and 20% of net eligible employees must be enrolled in each additional product offering. A total of 75% of net eligible employees must be enrolled in Excellus BCBS products. For employers with 5 or fewer eligible employees, 100% of net eligible employees must enroll in BluePPO HSA. Please note: Employees who waive coverage under your plan because they have coverage through a spouse or as a dependent covered under their parent s policy are not counted as eligible employees for purposes of calculating minimum participation requirements. 2 Revised 12/7/05
UNDERWRITING REQUIREMENTS FOR NEW BUSINESS CHECKLIST 1. Signed and dated rate quote and benefit summary document 2. Completed and Signed Group Information Form and Attestation 3. Copy of most recent NYS-45-ATT with attachments. Notations must include: Terminated employees, employees working less than the minimum required hours; seasonal of temporary employees; union employees; etc. 4. Eligibility Policy for New Hires Form 5. Tax returns and other business documentation. If self-employed, a copy of the most recent filed Schedule C or F from their federal tax return, Copy of DBA. If partnership, a copy of the most recent form 1065K-1 for all partners. Copy of certificate of partnership. If corporation, a copy of the most recent form 1120C, 1120E, or 1120S. Copy of certificate of incorporation. Copy of federal 941 quarterly report. A document which names the principals. Initial federal form SS4. If a business has been in operation less than one year, copies of estimated tax filings are required. 6. Waiver of Group Coverage (for all eligible employees declining coverage) 7. Client Profile 8. First Month s Premium Must be written on company account NOTE: Any incomplete portions of this package may result in a delay of your requested effective date. Mail to: Excellus BlueCross BlueShield Rochester Region 165 Court Street Rochester, NY 14647 Attn: Corporate Sales Small Business Unit Ph: 1-877-872-9308 3 Revised 12/7/05
Group Information Groups with 50 or fewer eligible employees (Must be completed by an Employer enrolling in Excellus BlueCross BlueShield health insurance) 1. Name and Address of Employer. 2. Name, Title and Phone # of Contact Person at Employer. ( ) - Name Title Telephone 3. Desired effective date of health insurance coverage. 4. Enrollment Questions a) Total number of individuals actively working at company (not retirees)* b) Total number of retirees eligible for coverage (if any)* c) Number of active employees NOT eligible for coverage (less than 20 hours per week, etc.) d) Number of eligible employees NOT taking coverage due to coverage elsewhere (such as other coverage through a spouse ) e) SUM TOTAL-number of employees and retirees who are eligible to select coverage through this group, excluding the number in d above who have coverage elsewhere (e=a+b-cd) f) Number of eligible employees and retirees selecting no coverage AT ALL g) NET number of eligible individuals taking coverage through this Employer whether the coverage is issued by Excellus BCBS or by another insurer or HMO (e=f+g) *Include employees and other individuals working a minimum of 20 hours per week (unless the employer s eligibility rules require a greater number of hours per week); retirees when the consistent policy of the business is to cover retirees; and owners of the business if actively engaged in the business but not technically an employee. 5. Attach supporting documentation. See reverse side for required documents and check which applies: groups with 2 or more employees OR sole proprietor. 6. Signature. The undersigned certifies that, to the best of my knowledge and belief and under penalty of perjury, the information listed above is true and complete, including the number of persons proposed for coverage who work at least 20 hours per week. Signature of Contact Person Date Fax Number or E-Mail Address Excellus BlueCross BlueShield, Rochester Region 4 Revised 12/7/05
In response to #5 on the previous page, attach the following supporting documentation that the company was not formed solely for obtaining insurance and the employees or eligible retirees were not added to the Employer solely to obtain insurance: For groups with 2 or more employees. This category also includes businesses with several employees, but only one is eligible for health insurance coverage. 1. Each Employer with 2 or more employees must provide a copy of the most recent NYS- 45-ATT-MN, with notations indicating eligible employees (those working a minimum of 20 hours per week) and ineligible employees (part-time employees working fewer than 20 hours per week, seasonal employees and other persons not eligible for health insurance). NOTE: If the Employer s rules require a minimum of more than 20 hours per week in order to be eligible for coverage, e.g., 30 hours, then the notations should be based on the employer s own eligibility rule. 2. If there are any persons who are proposed for health insurance WHO ARE NOT listed on the NYS-45-ATT-MN, the Employer must provide one of the following as documentation that the person works at least 20 hours per week or is otherwise eligible for coverage: (i) for partnerships, a copy of the most recent 1065K-1 with income amount stricken; OR (ii) for business owners, a copy of the most recent Schedule E to Form 1120, or Schedule K-1 to Form 1120S, or Schedule E to Form 1120F; OR (iii) the attached attestation that the individuals not listed on the NYS-45-ATT-MN, or the individuals being proposed for coverage when the business is new and has not yet filed a NYS-45-ATT-MN, work at least 20 hours per week or are otherwise eligible for coverage (e.g., retired). 3. If the Employer has been in existence for less than one year, it must provide a copy of its DBA certificate or certificate of incorporation. For persons in business alone (sole proprietors). 1. Each Employer must provide the attached attestation that the sole proprietor or employee works at least 20 hours per week in the business. 2. Each Employer must provide a copy of most recent NYS-45-ATT-MN; or if the sole proprietorship does not file the NYS-45-ATT-MN, it must provide a copy of a pay stub, estimated tax form or other documentation of active employment status. 3. If the Employer has been in operation for MORE than one year, it must provide a copy of one of the following tax forms: Schedule C, Schedule E, W-2 or 1099 with Schedule F. 4. If the Employer has been in operation LESS than one year, it must provide a cancelled check from the business, OR the DBA certificate, OR similar tax documentation that the business is authentic and in operation. 5 Revised 12/7/05
ATTESTATION I,, the (Name) (Title) at (Name of Employer) do hereby attest that: Check which applies For groups with 2 or more employees, including businesses with only one employee who is eligible for health insurance coverage. With respect to groups with 2 or more employees, the following individual(s) work at least 20 hours per week at the above-named Employer or are otherwise eligible for coverage under a group health insurance plan to be issued by Excellus BlueCross BlueShield. Other individuals eligible for coverage can include partners, owners of the business if actively engaged in the business but not technically an employee, and retirees when the consistent policy of the business is to cover retirees. Include a notation for each person indicating employee (E), partner (P), business owner (O), or retiree (R). OR Sole proprietors. With respect to an applicant for coverage as a sole proprietor, the following individual works at least 20 hours per week at the above-named Employer. If you are applying for coverage as a sole proprietor, only one (1) name will be listed. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. (Signature) (Date) 6 Revised 7/20/05
Eligibility Policy for New Employees Group Name: Group Number {If Assigned}: Our Standard new hire waiting period for eligibility for health insurance is: (type of employee: salaried, hourly, etc.) Date of Hire First of the month following date of hire First of month following 30 days of employment First of month following 60 days of employment First of month following 90 days of employment First of month following 6 months of employment First of month following 1 year of employment Other Note: If group employer makes no contribution to the member premium, waiting period should be no less than 60 days. Note: If group has multiple waiting periods per occupation, please note all waiting periods. --------------------------------------------------------------------------------------------------------------------------------- Our Standard rehire waiting period for eligibility for health insurance is: Same guidelines as new hire Date of rehire First of the month following rehire Other Minimum hours per week that an employee must work to be eligible: 17.5 hours (minimum requirement) 20 hours 25 hours 30 hours 40 hours {Insurance is only offered to Full Time Employees} Note: Employer can determine full time status as stated above but may not select under 20 hours. The above policies have been submitted for business indicated above. I understand that these policies are accepted and must remain in effect for at least one full year before they are eligible to be changed. Authorized Group Signature: Date Signed: Date Effective: 7 Revised 7/20/05
Waiver of Group Coverage Company Name: Employee Name: Date of Birth: Please Check One: I waive my employer s group health insurance coverage for myself and my dependents (if any). I am enrolling in my employer s group health insurance coverage but I am waiving coverage for my dependents. Reason for Waiving Coverage - Please Check One: Covered through spouse s employer, or: Covered through a parent s employer Employer Name: Insurance Company: Other reason (explain): Employee Signature: Date: IMPORTANT: If you checked that you are declining coverage due to other coverage, you will be eligible to enroll in this Plan within 30 days of the date that you are no longer eligible for the other coverage. If you did not state that the reason for waiving coverage is due to other coverage, then you cannot enroll in this Plan until your employer s open enrollment period (absent acquiring a new dependent through birth, marriage or adoption.) 8 Revised 7/20/05
Client Profile Please fill in all areas. If a question does not apply, write in N/A. Thank you for taking the time to fill out this questionnaire. GENERAL INFORMATION Name of Business Type of Business BlueCross BlueShield Group No. Owner/CEO Website Address Group Representative Telephone Number ( ) Email Address Fax Number ( ) Benefit Decision Maker Telephone Number ( ) UNION INFORMATION Total Number of Union Employees Union Contact Person Name of Union Telephone Number CONTRIBUTION STRATEGY Do you contribute to the medical coverage? Yes No Medical Contribution Single Family Do you contribute to dental coverage? Yes No Dental Contribution Single Family If contribution is based on a specific product or is unique, please explain briefly OTHER PLAN OFFERINGS Do you have a Flexible Benefit/Cafeteria Plan Yes No If yes, type of plan: Pre-Tax Premium (POP) Flexible Spending Account (FSA) Full Cafeteria Plan Administrator of Plan Do you offer medical, dental, vision or Rx coverage through another Insurance Carrier? Yes No 9 Revised 9/8/05
Client Profile (cont.) If you answered yes, please provide the following information. Name of Carrier Name of Plan Plan deductible Single Family Plan coinsurance Office Visit copay Inpatient hospitalization copay or coinsurance Student/Dependent coverage ages Domestic Partner Benefits Covered Not Covered Prescription Drug Plan Rating Tier 2 Tier 3 Tier 4 Tier 5 Tier The undersigned certifies that, to the best of my knowledge and belief and under penalty of perjury, the information listed about is true and complete. Employer Representative Signature: Date: Please return questionnaire to: Excellus BlueCross BlueShield, Rochester Region Corporate Sales Small Business Unit 165 Court Street Rochester, New York 14647 10 Revised 9/8/05