Minnesota Group Application - Small Employer

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Minnesota Group Application - Small Employer Submission Information Group submissions do not begin processing until all the information in the checklist below is included. Submissions received after the 10th of the month cannot be guaranteed an effective date of the first of the following month. HealthPartners will request additional information as deemed necessary. Please complete these forms and attach the following: o Completed Small Group Employer Application. o Information regarding any NEW HIRES AND OWNERS not listed on the Minnesota Quarterly Wage Report on page 2 of this form. o Minnesota Quarterly Wage Report (from the most recent quarter which should list each employee and the hours they worked); including the following: o Indication of status of all employees; full time, part-time, union, seasonal and terminated. o Copy of most recent bill from current HEALTH insurance carrier o All completed employee enrollment forms. Enrollment forms MUST be completed in their entirety. o All eligible employees must be accounted for with an application or waiver. Revised 11/10

Employer eligibility information Today s Date: Requested Eff. Date: HealthPartners Sales Executive: Full Legal Group Name: DBA (if applicable): Address: City, State, Zip: County: Phone: Fax: Federal Tax ID#: Corporate Headquarters (City, State): Contact Person: Contact Title: Contact Email: Is contact person an eligible employee? YES NO If NO, please explain: Owners and percentage of ownership for each: Are they eligible for coverage? YES NO If NO, please explain: MINNESOTA GROUP APPLICATION SMALL GROUP YES NO 1. Is this organization in any way related to other companies (such as national corporation) as a wholly or partially owned subsidiary, or does this organization own any other companies or have wholly or partially owned subsidiaries? If YES, please provide the HealthPartners Controlled Group form, found on HealthPartners.com/employer YES NO Do you have any other locations or sites? If YES, list the State and/or Country: YES NO 2. Number of years in business Industry YES NO 3. Type of Entity: S Corporation C Corporation Sole Proprietorship Partnership Non-Profit LLC (circle one: C Corporation Sole Proprietorship Partnership) 3a. Are you a Government Group, public entity or public school? YES NO Erisa or Non-Erisa 3c. Are you a church or religious group? YES NO Erisa or Non-Erisa (If YES and Erisa, please provide DOL) For 4a and 4b exclude seasonal, temporary and union employees covered under a collective bargaining agreement. 4a. On average, how many permanent employees did this organization employ (in all locations), working a normal work week of 20 or more hours throughout the preceding calendar year (January through December)?* 4b. Currently, how many employees have a normal work week of 20 hours or more?* 4c. What is the total number of employees (full/part time for entire family of companies) for your company? Medicare Secondary Payer rules apply to employer group health plans with 20 or more employees for each working day in at least 20 weeks in either the current or the preceding calendar year. If you have questions on this rule, please contact your broker or sales representative. * Some employees who do not work a full twelve months may be covered under their employers plan. These employees must work a minimum of nine months in a calendar year. If providing coverage for these employees, the employer must complete the Small Employer Contribution Agreement for Seasonal Employees Form on healthpartners.com/employer. If you are going to cover employees working for a minimum of 9 months, how many will you be covering? 5. How many employees reside outside of Minnesota? (Submit Quarterly Wage Report for each state) YES NO 6. If you elect coverage, will you be offering a Medical Expense Reimbursement plan? (such as an HRA, 105 or any underlying plan?) YES NO 7. Does this organization currently have any leased employees? If YES, please explain: YES NO 8. Does this organization currently have, intend to have, or ever had a Professional Employer Organization (PEO) agreement? If YES, please provide a copy of the agreement Please provide the name and termination date of the PEO agreement: YES NO 9. Does this organization intend to offer domestic partner coverage? Same gender Same and opposite gender Please refer to Domestic Partner Form on healthpartners.com/employer for eligibility. PARTICIPATION / EMPLOYEE ELIGIBILITY INFORMATION Number of hours all eligible employees must work per week Classification(s) of Employees Excluded from Coverage: Union covered by a collective bargaining agreement Part-time Hourly Union not covered by a collective bargaining agreement Salaried Owners Other (explain): YES NO Are retirees eligible for coverage? If yes, define policy Waiting Period for New Employees: Date of Hire OR First of the month following: 30 days 60 days 90 days Other, explain: Total number of eligible employees and Total number of eligible employees that are applying for coverage Total number of employees that are waiving coverage Total number of employees in their waiting period (application or waiver required) Number of former employees on COBRA continuation (application required) see page 2 Employer Contribution: Minimum 50% of single coverage, or Medical: Single Family Page 1 Dental: Single Family (if applicable)

employees and owners not accounted for on quarterly wage and detail report Please use this space to account for Employees and Owners NOT included on the Minnesota State Employer s Quarterly Wage and Detail Report (Form MDES-1D). Additional documentation may be required regarding owners. Employee/Owner Name Social Security Number Hire Date Termination Date # of Hours Worked FORMER EMPLOYEES ENROLLED WITH COBRA COVERAGE Please use this space to account for former employees covered by COBRA continuation. Indicate either the notification date if the individual is currently under COBRA or the cancellation date if an individual s COBRA coverage is terminating. Employers must also complete the Small Employer Verification of Terminated Employees form (HP490016) found on healthpartners.com. Former Employee Name Social Security Number Notification Date COBRA Termination Date current carrier information Current MEDICAL Carrier: Type of coverage Group Individual Please list all medical carriers for the previous 5 years (if needed, attach additional pages) Name of Carrier Renewal Date Dates of Coverage Reason for Termination Renewal Rates: Single Family Renewal Plan (product) Name: Current DENTAL carrier: Renewal Date: AGENT/BROKER information Agent Name: Address: City, State, Zip: Email: Phone: Fax: Broker Number: Agent of Record Signature (if applicable) Printed Name and Company Date EMPLOYER SIGNATURE I hereby certify that the information provided in this document, and any additional information submitted to support this application, is accurate and complete. I understand that errors or omissions regarding this information may result in premium adjustments and/or termination of the contract as permitted by law. CEO/Owner/Authorized Company Representative Printed Name Date Page 2

Product selection PRODUCT SELECTION MEDICAL NETWORK: Open Access Open Access Perform Empower HSA Plans (High Deductible Health Plans) $1250/100% $3000/100% $2000/90% $1500/80% $1500/100% $5950/100% $2500/90% $2000/80% $2000/100% $1250/90% $3000/90% $2500/80% $2500/100% $1500/90% $1250/80% $3000/80% Empower HSA Embedded Deductible Plans $2500/100% $4000/100% $2500/90% $4000/90% $3000/100% $450/100% $3000/90% $2500/80% $3500/100% $5950/100% $3500/90% $3000/80% Empower HSA Embedded Deductible Plans $2500/100% $4000/100% $2500/90% $4000/90% $3000/100% $450/100% $3000/90% $2500/80% $3500/100% $5950/100% $3500/90% $3000/80% Copay Plan Options $25/100% $25/80% Products effective 7/1/2011 12/31/2011 Three for a Copay $500 75% $25 $1000 75% $25 $1500 75% $25 Compliance Plans Copayment Plan Deductible Plan Primary/Specialty Plans (Deductible / Copay) $300 25/50 $500 25/50 $1000 35/70 $1500 50/100 Deductible / Copay Plans $300 25 $750 25 $500 40 $1000 40 $2000 45 $500 25 $1000 25 $750 40 $1500 45 Three for Free Plans $500/75% $1000/75% $2000/70% $750/75% $1500/70% $2500/70% Empower HRA Embedded Deductible Plans $2000/100% $3000/100% $2000/80% $3000/80% $2500/100% $5000/100% $2500/80% Empower HSA Tiered Network Plan $2000 100%/90%/80% Distinctions SM $15 $30 $50 $20 $40 $60 Benefit Administration: Calendar Year Plan Year (If offering more than one product, benefit administration must match.) DENTAL PRODUCTS May also be purchased on a stand-alone basis. Distinctions 1 Distinctions 2 Distinctions 3 Distinctions 4 Optional orthodontics add-on 1 Open Access Preventive-only Dental Plan Other 1 Must have 10 or more employees enrolled to be eligible for orthodontic products. 2 Must have 5 or more employees enrolled to be eligible for voluntary plans. 3 Available to groups with 50 100 eligible employees Open Access Employer sponsored (select one benefit from each category) Annual maximum Deductible Coinsurance $750 None 100/50/0 $1000 $25 100/50/50 $1250 $50 100/80/50 $1500 $75 Optional orthodontics add-on 1 Voluntary Open Access Dental Plan 2 (select one benefit from each category) Annual maximum Deductible Coinsurance $500 $25 100/50/0 $750 $50 100/50/50 $1000 $75 100/80/50 $1250 Voluntary Open Access Dental Plan w/ortho 3 (select one benefit from each category) Annual maximum Deductible Coinsurance $1000 $25 100/80/50 $1250 $50 $75 HealthPartners will notify employees covered on HealthPartners plans of the special enrollment periods detailed in 29 CFR Sec. It is the responsibility of the employer to notify those employees who decline HealthPartners coverage of their special enrollment rights. PO Box 1309 Minneapolis, MN 55440-1309 Sales Metro Phone # 952-883-5200 Non-Metro Phone # 800-298-4235 The HealthPartners family of health plans are underwritten and/or administered by HealthPartners, Inc., Group Health, Inc., HealthPartners Insurance Company or HealthPartners Administrators, Inc. Fully insured Wisconsin plans are underwritten by HealthPartners Insurance Company. 401012 (4/11) 2011 HealthPartners Page 3

70% Coinsurance Benefit exclusions: acupuncture, infertility, bariatric surgery and orthognathic surgery Rx Exclusions: infertility, erectile dysfunction, nonsedating antihistamines, drugs for acid reflux and stomach ulcers Deductible > $,2250 Out-of-pocket maximum > $3,000 Deductible> $4,500 Out-of-pocket maximum > $6,000 Individual Deductible > $6,000 Out-of-pocket maximum > $12,000 Deductible > $12,000 HealthPartners Flex Law Notification HealthPartners has used the flexibility offered under Minnesota Statute 62L.056 to provide plans with benefits that vary from a typical HMO plan.* These modifications are noted below. Employers are required by law to inform eligible employees of the benefit modifications. Non-HSA Plans In-network Out-of-network Individual Family Individual Family 25-100 X X 25-80 X X 300-25 X X 500-25 X X 500-40 X X X 750-25 X X 750-40 X X X 1000-25 X X X 1000-40 X X X 1500-45 X X X X X X 2000-45 X X X X X X X 300-25/50 X X 500-25/50 X X 1000-35/70 X X X 1500-50/100 X X X X X X 500-75 X X 750-75 X X X 1000-75 X X X 1500-70 X X X X X X X 2000-70 X X X X X X X X 2500-70 X X X X X X X X X X 500-75-25 X X 1000-75-25 X X X 1500-75-25 X X X X X X 15-30-50 X X 20-40-60 X X COPAY X X DEDUCTIBLE X X HRA 2000E-100 X X X HRA 2500E-100 X X X X X X X X X HRA 3000E-100 X X X X X X X X X HRA 5000E-100 X X X X X X X X X HRA 2000E-80 X X X X X HRA 2500E-80 X X X X X X X X X HRA 3000E-80 X X X X X X X X X *Effective since 7/1/2010, HealthPartners is no longer selling or renewing small employer comprehensive benefit plans.

Benefits Administration: Maintenance of Benefits Benefit exclusions: acupuncture, infertility, bariatric surgery and orthognathic surgery Rx Exclusions: infertility, erectile dysfunction, nonsedating antihistamines, drugs for acid reflux and stomach ulcers Deductible > $5,900 Deductible > $6,000 Out-of-pocket maximum > $12,000 Deductible > $12,000 Out-of-pocket maximum > $24,000 HSA Plans In-network Out-of-network Individual Individual Family Benefit Variation from Standard HMO plan HSA 1250-100 X X X HSA 1500-100 X X X X X HSA 2000-100 X X X X X HSA 2500-100 X X X X X X X HSA 3000-100 X X X X X X X HSA 5950-100 X X X X X X X X HSA 1250-90 X X X HSA 1500-90 X X X X X HSA 2000-90 X X X X X HSA 2500-90 X X X X X X X HSA 3000-90 X X X X X X X HSA 1250-80 X X X HSA 1500-80 X X X X X HSA 2000-80 X X X X X HSA 2500-80 X X X X X X X HSA 3000-80 X X X X X X X HSA 2500E-100 X X X X X X X HSA 3000E-100 X X X X X X X HSA 3500E-100 X X X X X X X HSA 4000E-100 X X X X X X X HSA 4500E-100 X X X X X X X HSA 5950E-100 X X X X X X X X HSA 2500E-90 X X X X X X X HSA 3000E-90 X X X X X X X HSA 3500E-90 X X X X X X X HSA 4000E-90 X X X X X X X HSA 2500E-80 X X X X X X X HSA 3000E-80 X X X X X X X HSA 2000-100-90-80 X X X X X HealthPartners (03/11)

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