Oregon Small Group Application Health Net Health Plan of Oregon, Inc. (1 50 employees) Subscriber group information Full legal name of employer (include punctuation and abbreviations) hereafter known as Subscriber Group: DBA: Group number(s): Phone: Fax: Federal tax ID/EIN: Physical address (street address, city, state, ZIP): Billing address (if different from the above address): Group benefits administrator name and title: Workers compensation carrier name: Effective date: Anniversary date: Administrator email address: Workers compensation policy number: Type of organization Corporation Partnership Sole proprietorship Nature of business: Other (describe): Date of business inception: SIC code: Is the group subject to COBRA? Generally, COBRA applies to any non-church group that employed 20 or more employees on at least 50% of its working days in the preceding calendar year. The Subscriber Group must notify Health Net Health Plan of Oregon, Inc. as changes in COBRA status occur. Yes No, due to size No, other reason (please specify): Is the group subject to ERISA? Generally, ERISA applies to employer health plans. Sole proprietors or partnerships that do not have any employees may not be subject to ERISA. The Subscriber Group must notify Health Net Health Plan of Oregon, Inc. as changes in ERISA status occur. Yes, ERISA plan year begins in the month of: No, government or public plan or church plan No, other reason (please specify): Eligibility information This provision may only be changed at the time of the group contract renewal each year. Employees: Regular, active full-time employees scheduled to work at least hours/week (must be at least 17.5 hours). Include non-registered Domestic Partners as dependents: Yes No Dependents: Legal spouse, Registered Domestic Partner and child(ren), from birth to age 26, of employee spouse or Registered Domestic Partner. Local government retiree: Local government means any city, county, school district, or other special district in this state. Retired employee means a former officer or employee of a local government who is retired for service or disability, and who received or is receiving retirement benefits under the Public Employees Retirement System or any other retirement system or plan applicable to officers and employees of the local government. Health Net Health Plan of Oregon, Inc. is a subsidiary of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All rights reserved. HNOR Sm Grp App 4/2015 Page 1 of 6
Employers probationary period Will there be eligibility conditions that will apply prior to the probationary period? Yes No (e.g., being in an eligible job classification, achieving job-related licensure requirements or satisfying a reasonable and bona fide employment-based orientation period ). Newly hired employees must enroll the first day of the month on or following: 30 days from date of hire 60 days from date of hire Date of hire Waive eligibility probationary period (for new groups only): Do you want to waive the eligibility probationary period for all current employees? Yes, all current employees will be eligible for benefits as of the effective date. No, current employees who have not completed the probationary period must finish serving the probationary period. Newly eligible employees first day of the month following date of eligibility. Definition of newly eligible employee : Part-time employee who has been employed for the length of the probationary period and is moving to regular, full-time employee. Transfer who has been employed for the length of the probationary period. Laid off employee rehired within 9 months. Other (must be pre-approved by Underwriting): Definition of newly eligible dependents : For child: date of birth or placement for adoption. For spouse, Registered Domestic Partner and stepchild(ren): first day of the month on or following the date of marriage or certification of Registered Domestic Partnership. Employer contribution The employer must contribute at least 50% of the cost of employee coverage. Employee medical: % of monthly rate OR $ toward monthly rate Dependent medical: % of monthly rate OR $ toward monthly rate Employee dental: % of monthly rate OR $ toward monthly rate Dependent dental: % of monthly rate OR $ toward monthly rate Participation requirements: 1. The Subscriber Group must employ at least one eligible employee for enrollment and must be an Oregon small employer as defined by Oregon and/or federal regulations. Eligibility rules must be the same for medical and dental enrollment. 2. All enrolled employees must have a bona fide partnership, independent contractor or employer-employee relationship with the Subscriber Group. If the Subscriber Group includes leased employees and independent contractors under the health plan, all leased employees and independent contractors must be covered. 3. For groups of 1 5 eligible employees, a minimum of 70% participation is required on the medical plan. For groups of 6 50 eligible employees, a minimum of 50% participation is required on the medical plan. 4. A Refusal of Coverage/Waiver must be submitted for all employees and dependents declining coverage. 5. Health Net is not required to be sole carrier as long as participation guidelines are met. 6. Eligible employees waiving coverage due to group coverage through another employer (e.g., spousal coverage) will not count against participation. 7. The employee needs to pay 50% minimum of the lowest cost medical plan. 8. The employee must participate in both medical or dental plans; however, the employee can choose which dependents will participate in dental. 9. A minimum of 2 employees must enroll in dental. 10. Failure to maintain these minimum contribution and minimum participation requirements may result in termination or non-renewal. HNOR Sm Grp App 4/2015 Page 2 of 6
Monthly rates (including riders) Oregon Small Employer Group rates are guaranteed for 12 months from the effective date, except for any government mandated benefits or tax changes. Rates are also based on actual group enrollment and may differ from quoted rates if there is a change in group composition. Attach quote output sheet for any additional plans chosen. Enrollment information Oregon regulations require a complete census of all employees for SEHI 1 groups of 1 to 50 employees. The Subscriber Group verifies that the information on the attached Oregon Standardized Group Profile Form is true and accurate: Yes No Due to Medicare secondary payor reporting requirements, indicate the total number of worldwide employees employed by the company/companies applying for coverage: Total #: Note: Federal regulations require you must promptly notify Health Net if the number of employees changes from the total number shown above. The number of employees who work a regular schedule of 17.5 hours or more per week on the date coverage is to take effect. Eligible employees do not include employees who work on a temporary, seasonal or substitute basis (SEHI 1 ): Number of employees eligible to enroll in the plan per eligibility provisions set by the Subscriber Group: Number of employees enrolling: A Refusal of Coverage/Waiver is included for all eligible employees not enrolling: Yes No Number of dependents enrolling: A Refusal of Coverage/Waiver is included for all eligible employees not enrolling: Yes No Total number of employees waiving coverage: 1Small Employer Health Insurance. HNOR Sm Grp App 4/2015 Page 3 of 6
Health plan information Check the box of the plans you are selecting. CommunityCare plans CC1T 10-100-1-1000DX CC1T 10-250-1-1500DX CC1T 15-500-2-1500DX CC1T 20-500-2-4000DX CC1T 25-1000-2-4000DX CC1T 20-1500-2-3500DX CC1T 15-2000-2-3500DX CC1T 20-1000-2-3000ES CC1T 15-1500-2-2500ES CC1T 30-3000-2-6000ES CC1T 35-4000-2-6000ES CC1T 35-5000-2-6350ES 24-hour coverage CommunityCare Choice Plus plans CC3T 10-100-1-1000DX CC3T 10-250-1-1500DX CC3T 15-500-2-1500DX CC3T 20-500-2-4000DX CC3T 25-1000-2-4000DX CC3T 20-1500-2-3500DX CC3T 15-2000-2-3500DX CC3T 20-1000-2-3000ES CC3T 15-1500-2-2500ES CC3T 30-3000-2-6000ES CC3T 35-4000-2-6000ES CC3T 35-5000-2-6350ES PPO Advantage plans LX15-100-2-1000 LX10-500-1-1500 A15-250-2-2000ES A15-500-1-2000ES A30-1000-2-4500DX A25-1500-2-3000DX A20-2000-2-3000DX A25-2000-2-4500DX A30-2500-3-6350ES A35-4000-3-6000 PPO Essential plans E30-500-2-4000 E25-1000-2-4000 E25-1500-2-4000 E45-5000-2-6000 E3000-3-5000 PPO High Deductible Health plan HD20008060/ HD80 HNOR Standard plans (PPO) HNOR Standard Plan HNOR Standard Plan HNOR Standard Bronze Plan (EPO) Optional coverage (Check no more than one from each category.) Pediatric vision is included in all medical plans. Purchasing pediatric dental coverage with Health Net? Yes No If No, I confirm that I am purchasing pediatric dental coverage with another carrier as required by ACA mandate. Dental Adult coverage D50-16-500-10 D50-185-1500V DP50-1855-1500 D50-1855-1500 Vision Adult coverage Elite 1010-1 Preferred 1025-2 Preferred 1025-3 Complementary care buy-up CAM 15/1000 CAM 15/1500 CAM 15/1000 Plus Are all eligible members of the group covered by workers compensation? Yes No 24-hour coverage is provided for sole proprietors, partners and corporate officers of the Subscriber Group who are not subject to mandatory workers compensation coverage. 24-hour coverage does not extend to any family member who is not also a sole proprietor, partner or corporate officer of the Subscriber Group. The name and title of an individual eligible for 24-hour coverage must be provided at the time of group or individual enrollment. Name: Title: Name: Title: Name: Title: Other current coverages Is this coverage replacing a current group medical plan? Yes No If Yes, please list the name and policy number of the current carrier: Is other group(s) medical coverage(s) offered? Yes No If Yes, please list the carriers and coverages offered: HNOR Sm Grp App 4/2015 Page 4 of 6
Subscriber Group statement: 1. We wish to enroll as a group account with Health Net Health Plan of Oregon, Inc. (referred to herein as the Plan). It is understood that the coverage will not be in effect until the application has been accepted by the Plan. 2. We understand the eligibility rules are applicable to employee enrollment and guaranteed renewability except for nonpayment and other reasons allowed by Oregon law. Failure to maintain these minimum contribution and minimum participation requirements may result in termination or non-renewal. 3. We agree, in the event this application is accepted, to cooperate with Health Net Entities in complying fully with the requirements of section 2715 of the Public Health Service Act to disclose summary plan and benefit information to eligible and renewing plan participants and beneficiaries. Applicant acknowledges that it has received information provided by the Health Net Entities, Summary of Benefits and Coverage to Eligible and Covered Persons Instructions for Reproduction and Distribution and agrees to assume the responsibilities assigned to the Group thereunder. 4. We understand premiums are prepaid and are due no later than the first day of each month. 5. We understand a member s coverage terminates the last day of the month in which that member ceases to be eligible under group eligibility provisions. 6. We understand that there will be one open enrollment period per contract year. The period will be for 30 days prior to the renewal effective date. 7. We enclose the amount of $ as a deposit on the first month s premium (minimum deposit of 90% of premium). Upon acceptance of the application by the Plan, we promise to pay the Plan any balance necessary to constitute full initial payment for the group benefits identified in this application. 8. Applicant s signature below confirms: 1) Applicant s agreement to all the terms and conditions set out in this Application, including the Conditions of Enrollment and Underwriting Assumptions; and 2) the accuracy and completeness of the information that the Applicant has entered in this Application. The Agreement, consisting of the Plan Contract to be issued as the description of coverage and supplemented by this Group Application, has been entered into between Health Net Health Plan of Oregon, Inc. and the Subscriber Group in order to provide eligible enrolled employees and eligible enrolled dependents with the health care benefits as specified in the Plan Contract. The Agreement may be amended with the mutual written consent of the Subscriber Group and Health Net Health Plan of Oregon, Inc. at any time, subject to state and federal regulations. Subscriber Group Executed at: Oregon Date accepted: Signature of authorized Subscriber Group representative: Health Net Health Plan of Oregon, Inc. Executed at: Tigard, Oregon Date accepted: Signature of authorized Plan representative: Print name: Title: Print name: Title: HNOR Sm Grp App 4/2015 Page 5 of 6
Producer statement I certify that all information contained in this application is correct to the best of my knowledge. I also certify that: 1. This firm is a bona fide business establishment or is otherwise eligible to contract for insurance coverage in the State of Oregon. 2. All participation requirements have been explained and the minimum participation requirements have been met. 3. Coverages, enrollment provisions, eligibility requirements, benefits, limitations, and exclusions have been fully explained and understood by the applicant or employer. 4. Deductibles, copayments and coinsurance (if applicable) have been fully explained and understood by the employer. 5. I know of no reason why the Plan coverage should not be offered, and I recommend that such coverage be offered. Note: If you are not currently licensed by the State of Oregon and appointed by Health Net of Oregon, attach an executed copy of Health Net of Oregon s producer agreement and your current license. Commissions will not be paid prior to licensing and formal appointment. Producer signature: Date: Producer of record (print name): Producer number: Name of firm/agency: Email address: Split commission Secondary producer commission percentage: Secondary producer (print name): Producer number: For office use only AE AM Size Region RMC Health Net Health Plan of Oregon, Inc., 13221 SW 68th Pkwy., Ste. 200, Tigard, OR 97223 1-888-802-7001 www.healthnet.com HNOR Sm Grp App 4/2015 Page 6 of 6