Small Group Checklist

HRIC-2015-SGE05 ₁

Please use the checklist below for enrolling a small group with Health Republic^® Insurance. The more complete and thorough you are with these documents, the more quickly we can process your group for coverage. Blank PDF forms are attached when noted: you may fill them out electronically if you wish.

mail:

Health Republic Insurance

Attn: Sales Team

4000 Kruse Way Place

Ste 2-300

Lake Oswego, OR 97035

email:

sales@healthrepublicinsurance.org

fax: 503-345-9252

questions?

Please reach out to your broker sales support team.

We must receive fully-completed new group applications in-house by the 20th of the month in order to set up a group’s coverage to be effective on the first of the following month. New case submissions that are not received by this date and incomplete case submissions cannot be processed in time to provide member ID cards to the new members before their effective date.

Completed and signed Small Group Application (form attached)

Group Profile Form (form attached)

Employee Census: needs to include all employees working 17.5 hours or more per week, including

waiving employees and enrolling dependents (form attached)

Quote/rates used to sell the group

Enrollment and Change form : completed by both enrolling and waiving employees

Binder check: sent to the address below (Attn: Sales Team)

Small Group Checklist

required documents

additional information

20th of the month prior to group’s effective date of coverage:

HRIC-2015-SGE0101 ₁

1CMS group size: The Centers for Medicare & Medicaid Services determine group size as the current total number of nationwide full-time employees, part-time employees, seasonal employees, and partners. Do not count retirees, COBRA-qualified beneficiaries, individuals on other continuation options, or self-employed individuals who partici- pate in the employer’s group health plan. According to federal regulations, you must promptly notify Health Republic^® of any changes.

2Generally, 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 Republic of any changes to COBRA, ERISA, and/or TEFRA.

Full legal name of employer (include punctuation and abbreviations—hereafter known as Subscriber Group):

Requested effective date (mmddyy):

Business type (please select the one that applies): C-Corp

S-Corp Partnership

Non-profit Tax-exempt Corp.

Tax-exempt Trust Tax-exempt LLC

Tax-exempt Assoc. Other (describe):

dba of employer: Original business start date (mmddyy):

Federal tax ID/EIN: -

NAICS number: CMS group size¹:

Company name: Contact name (first, last):

Workers’ Compensation carrier name: Workers’ Compensation policy number:

Email address (please print clearly): Phone number: - -

Fax number:

- -

Physical address: City: State: ZIP code:

Mailing address: City: State: ZIP code:

Mailing address: City: State: ZIP code:

What type of continuation are you subject to?² State continuation COBRA

Are you subject to ERISA?

Yes No

Are you subject to TEFRA?

Yes No

Primary contact name (first, last): Title:

Email address (please print clearly): Phone number: - -

Fax number:

- -

Small Group Application

employer group information

billing information

contact information

HRIC-2015-SGE0101 ₂

1. The Subscriber Group must employ at least one eligible employee for enrollment and must be an Oregon small employer as defined by Oregon regulations or a HIPAA small employer as defined by Oregon and federal regulations.

2. All enrolled employees must have a bona fide partnership, independent contract, 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. At least 75% of all eligible employees who do not have a valid waiver must enroll in the plan. 4. A Refusal of Coverage/Waiver must be submitted for all employees and dependents declining coverage. The following section may only be changed at the time of the group contract renewal each year.

What are your weekly eligibility hours? (17.5-40 hours) .

Who would you like to cover? (employers with 50 or more employees can’t offer “Employee Only” coverage) Employees only Employees and dependent

Employee coverage (employer must contribute at least 50% of the employee coverage):

% of monthly rate OR $ . toward monthly rate Dependent coverage:

% of monthly rate OR $ . toward monthly rate What is your newly hired employee probationary period?

First day of the month following: Date of hire 30 days 60 days

Do you want to waive the eligibility period for all current employees? (for new groups only) Yes, all current employees will be eligible for benefits as

of the effective date. No, current employees who have not completed the

waiting period must finish serving the waiting period.

Include nonregistered domestic partners as dependents?

Yes No

Would you like to waive the probationary period for Rehires/employees switching from Part-time to Full-time?

Yes No

The Subscriber Group verifies that the information on the attached Oregon Standardized Group Profile Form is true and accurate:

Yes No

Total number of eligible employees: (Those 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 those who work on a temporary, seasonal, or substitute basis.)

Total number of employees waiving coverage: A Refusal to Coverage/Waiver is included for eligible employees not enrolling:

Yes No

Total number of employees eligible to enroll: Total number of employees enrolling:

employer eligibility information

enrollment information

employer contribution

participation requirements

HRIC-2015-SGE0101 ₃

primarycare plans

PrimaryCare Silver PrimaryCare Gold

$6,600 Deductible/OOPM

$4,750 Deductible/OOPM

$2,400 Deductible/OOPM

foundationcare plans

FoundationCare Gold FoundationCare Platinum

$6,600 Deductible/OOPM

$2,800 Deductible/OOPM

$1,000 Deductible/OOPM

oregon standard plans

Oregon Standard Silver Oregon Standard Gold

$5,000 Deductible/$6,350 OOPM

$2,500 Deductible/$6,350 OOPM

$1,300 Deductible/$6,350 OOPM

corecare plans

CoreCare Gold CoreCare Platinum

$2,500 Deductible/$5,500 OOPM

$1,000 Deductible/$2,500 OOPM $500 Deductible/$1,000 OOPM

hsa plans

HSA Gold $3,000 Deductible/$6,000 OOPM

$1,300 Deductible/$2,250 OOPM

keycare plans

KeyCare Bronze

KeyCare Silver

$5,000 Deductible

$1,600 Deductible

$2,500 Deductible

$1,500 Deductible Medical

Pharmacy Medical Pharmacy

You may elect to offer up to three Health Republic plans to your eligible employees. You may select from any product family or metal tier.

$6,600 OOPM

$5,000 OOPM

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 of 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:

Are all eligible employees of the group covered by workers’ compensation?

Yes No

If you are offering multiple plans to your employees, which plan will be the basis of your employer contribution? (write plan name below)

choose your coverage

medical coverage

24-hour coverage

HRIC-2015-SGE0101 ₄

Is this coverage replacing a current group medical plan? If “Yes,” please list the name and policy number of the current carrier.

Yes No

Carrier name: Policy number:

Is other group medical coverage offered? If “Yes,” please list the name and policy number of the current carrier.

Yes No

Carrier name: Policy number:

Signature of Authorized Plan Representative: Date (mmddyy):

Print name: Title: Executed at:

Signature of Authorized Subscriber Group Representative: Date (mmddyy):

Print name: Title: Executed at:

other current coverage

initial premium payment

The payment for the first month’s premium (binder payment) must accompany this application in order for Health Republic to proceed with processing your group coverage. Payment should be made payable to Health Republic.

carrier signature

subscriber signature

1. We wish to enroll as a group account with Freelancers Consumer Operated and Oriented Program of Oregon, Inc dba Health Republic Insurance Company (referred to hereafter as HRIC). It is understood that the coverage will not be in effect until the application has been accepted by HRIC. We understand that payment of premium will be deemed to be assent to all terms of the employer contract, including modifications and renewals that are sent to us;

2. We understand the eligibility rules are applicable to employee enrollment and guaranteed renewability except for nonpayment and other reasons allowed by Oregon Law;

3. We understand the obligation to provide the Summary of Benefits and Coverage (SBC) to eligible employees at open enrollment and when newly eligible or newly hired, as required by the Patient Protection and Affordable Care Act and related regulations and rules, and accept responsibility for delivering this document;

4. We understand that premiums are prepaid and are due no later than the first day of each month;

5. We understand that a member’s coverage terminates on the last day of the month in which that member ceases to be eligible under the 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 understand that the final rates will be based on actual enrollment and may be different that the rates originally quoted;

8. Minimum participation requirements for specific coverage(s) have been fully explained in detail, and we understand that they must be met and maintained in order for the group to remain eligible for coverage;

9. We affirm that we have obtained pediatric dental coverage, as required by federal law;

10. We understand that it is a crime to knowingly provide false, incomplete, or misleading information to an insurance company; and such intent to defraud may be subject to criminal and civil penalties and HRIC may cancel the group account and refuse to pay claims; and 11. To the best of our knowledge and belief, the foregoing statements are true and complete and, along with the group application, shall

be the basis for the issuance of coverage under the group policy and shall become part thereof.

employer statement

HRIC-2015-SGE0101 ₅

mail:

Health Republic Insurance

Attn: Sales Team

4000 Kruse Way Place

Ste 2-300

Lake Oswego, OR 97035

questions?

Please reach out to your broker sales support team.

email:

sales@healthrepublicinsurance.org

fax: 503-345-9252

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. This subscriber group is a bona fide business meeting the definition of Oregon small employer and/or a small employer as defined by

HIPAA and complies with Health Republic Insurance Company underwriting requirements for small employers; 3. All participation requirements have been explained and the minimum participation requirements have been met;

4. Coverage(s), enrollment provisions, eligibility requirements, benefits, limitations, and exclusions have been fully explained and understood by the employer;

5. Deductibles, copayments, and coinsurance have been fully explained and understood by the employer; and 6. I know of no reason why the Plan coverage should not be offered, and I recommend that such coverage be offered.

Note: If you’re currently appointed by Health Republic Insurance Company but your Oregon license has expired, we cannot pay your commission until we receive an updated copy of your license.

Signature of Producer: Date (mmddyy):

Print name: Producer Number (NPN):

Name of firm/agency: Email address:

submit your application

You may submit your completed, signed application by mail, email, or fax.

producer signature

producer statement

Oregon Standardized Group Profile Form Page 1 of 2 v. 04/09/14v2

4000 Kruse Way Place, Ste 2-300, Lake Oswego, OR 97035 | Tel: 503.922.3337 | healthrepublicinsurance.org

Oregon Standardized Group Profile Form

For group health benefit plans purchased outside of Cover Oregon, page 2 of this form must be completed for all new and renewing groups to determine whether a group qualifies as a small employer.

If a group requests coverage as a single group because it is an affiliated group of employers for the purpose of pension plans under subsection (b), (c), (m), or (o) of section 414 of the Internal Revenue Code of 1986, a carrier must treat the affiliated group as a single group, and the affiliated group must complete one group profile form. If the group is an affiliated group of employers but does not request coverage as a single group, a separate group profile form must be completed for each employer group in the affiliated group.

If, during the preceding calendar year, the employer employed an average of at least one but not more than 50 employees and more than 50% of these employees worked in Oregon and the employer employs at least one but not more than 50 eligible employees on the date coverage takes effect, the group is a small group.

An eligible employee is an employee who works on a regularly scheduled basis with a normal work week of at least 17.5 hours per week on the date coverage is to take effect. The following persons are not eligible employees:

Temporary employees;

Seasonal or substitute employees; and

Employees employed for fewer than 90 days unless otherwise allowed by the employer.

For purposes of determining whether a group is a small group, an owner is generally not considered an employee even if the owner performs services for the business for compensation; however, an owner may participate in a small group plan¹ as long as the group employs at least one eligible employee. An Owner includes:

A sole proprietor and the sole proprietor’s spouse;

A member of a single-member limited liability company and the member’s spouse; The owner of a wholly owned corporation and the owner’s spouse;

If an employer has more than 50 employees, the carrier may provide the employer a quote as a large group. However, the carrier must treat the employer as a small employer and must provide a small group quote to the employer if both of the following conditions apply:

The employer’s workforce consists of at least one but not more than 50 eligible employees as of the date coverage is to take effect; and

Coverage is limited to eligible employees.

1For businesses without eligible employees that have two or more certificate holders, see ORS 731.098 and 743.754.

Oregon Standardized Group Profile Form Page 2 of 2 v. 04/09/14v2

4000 Kruse Way Place, Ste 2-300, Lake Oswego, OR 97035 | Tel: 503.922.3337 | healthrepublicinsurance.org

Company: _________________________________________________________

Group number if applicable: _________________________________________________________

Address: _________________________________________________________

Company headquarters (state): _________________________________________________________ Co. type (LLC, sole proprietor, S-corp., etc.) _________________________________________________________ Contact name and title: _________________________________________________________

Email address and telephone number: _________________________________________________________ Producer name and telephone number: _________________________________________________________

1. Were a majority of employees employed in the preceding calendar year employed in Oregon, or if the employer was not in existence during the preceding calendar year, does the employer expect that a majority of its employees will be employed in Oregon during the current calendar year?

If yes, go to question 2.

If no, the employer is not an Oregon small group. Check this box and STOP HERE.

2. On average, how many employees did the employer employ during the preceding calendar year? ____ If 1 to 50, go to question 5.

If fewer than one or more than 50, go to question 3.

3. On average, how many employees does the employer reasonably expect to employ on business days in the current calendar year? ____

If 1 to 50, go to question 5. If more than 50, go to question 4.

4. Is coverage provided to persons other than eligible employees (employees who work a regular weekly schedule of 17.5 hours or more) or their dependents? ____

If no, go to question 5.

If yes, the group is a large group and not a small group. Check this box and STOP HERE. 5. How many eligible employees will be employed on the date that coverage is to take effect? ____

If fewer than 1, no Oregon small group exists. Check this box and STOP HERE. If 1 to 50, the group is a small group. Check this box and STOP HERE.

If more than 50, the group is a large group and not a small group. Check this box and STOP HERE. To the best of my knowledge, I certify that all the information contained herein is correct. I understand that the final rates will be based on actual enrollment and may differ from the rates originally quoted and that additional information may be required to verify eligibility of the group.

Date: _____________________________

Signature: _____________________________ Name and Title: _____________________________

HRIC-2015-SGE03 ₁

Please list all employees (even if waiving, enrolled in COBRA or State Continuation, or not eligible per the group guidelines) and their enrolling dependents. For an employee, please fill in all of the information and select “Employee.” For a dependent, please only fill in name and Date of Birth and select “Dependent.”

Please indicate each employee’s election in the Election column, using the following key:

EE=Employee only

ES=Employee and spouse or domestic partner EC=Employee and child(ren)

EF=Employee and family

Please indicate each employee’s eligibility status in the Status column, using the following key:

ENR=Enrolling NE=Not Enrolling NN=Not Eligible PT=Part-time

PP=New Employee in Probationary Period CSC=COBRA/State Continuation

OC=Other Coverage (coverage through another employer health benefit plan; a Waiver must be completed by each em- ployee waiving enrollment due to other coverage)

.

Employee Dependent

.

Employee Dependent

.

Employee Dependent

.

Employee Dependent

.

Employee Dependent

What are your weekly eligibility hours? (17.5 minimum to 40 hours maximum) .

Name of Employee or Dependent

(first, last) ^{ZIP code} Date of birth

(mmddyy) ^Election(see key)

Status (see key)

Date of hire

(mmddyy) ^Weekly hours What is your newly hired employee probationary period? First day of the month following:

Date of hire 30 days 60 days

Employer name: Date of census (mmddyy):

employee information only

employee census

Employee Census Form

HRIC-2015-SGE03 ₂

.

Employee Dependent

.

Employee Dependent

.

Employee Dependent

.

Employee Dependent

.

Employee Dependent

.

Employee Dependent

.

Employee Dependent

.

Employee Dependent

.

Employee Dependent

.

Employee Dependent

.

Employee Dependent

.

Employee Dependent

.

Employee Dependent

.

Employee Dependent

.

Employee Dependent

.

Employee Dependent

Name of Employee or Dependent

(first, last) ^{ZIP code} Date of birth

(mmddyy) ^Election(see key)

Status (see key)

Date of hire

(mmddyy) ^Weekly hours

employee information only

HRIC-2015-SGE0201 ₁

Please complete all information on this form. This information is required to process your enrollment.

enroll or waive your group coverage

Employer name: Group ID:

If COBRA, indicate number of months eligible for coverage: COBRA/State Continuation start date (mmddyy):

18 months 29 months 36 months

Continuation Qualifying Event (If State Continuation, eligible period of coverage cannot exceed 9 months):

Employee name (first, middle initial, last):

Home address: City: State: ZIP code:

Mailing address (if information is different than above): City: State: ZIP code: Email address (please print clearly): Phone number:

- -

Social Security #: - -

Date of Birth (mmddyy): Gender: Married?

Male Female Yes No

Effective date (mmddyy):

Employee’s Date of Hire (mmddyy): Weekly hours: .

Date employee became eligible: Same as hire date Other date

(mmddyy):

What is your medical plan choice? (Please complete this section if your employer is offering more then one choice of medical plan.)

For FoundationCare plans you must be a resident in one of the following counties: Benton, Clackamas, Coos, Crook, Curry, Deschutes, Hood River, Lane, Linn, Marion, Multnomah, Polk, Union, Washington, and Yamhill counties. For all other Health Republic plans, our service area covers the entire state of Oregon.

Enrollment reason(s) (please

select the one that applies): Qualifying Life Event(s)(please select the one that applies): New group enrollment

New hire Rehire

Part-Time to Full-Time

Marriage/Domestic Partnership Birth/Adoption

Loss of other coverage Court order

Open enrollment

Delete self Delete dependent

COBRA or State Continuation Other:

I would like to:

Enroll in group coverage Waive group coverage (If waiving, please skip to the last page of this form)

Qualifying Life Event date (mmddyy):

Employee Enrollment

and Change Form

enrollment information

HRIC-2015-SGE0201 ₂

If you need to add more dependents or information, please attach another sheet.

Name: (first, middle initial, last) Gender: Date of Birth (mmddyy): Social Security #: - - M

F

Name: (first, middle initial, last) Gender: Date of Birth (mmddyy): Social Security #: - - M

F

Name: (first, middle initial, last) Gender: Date of Birth (mmddyy): Social Security #: - - M

F

Name: (first, middle initial, last) Gender: Date of Birth (mmddyy): Social Security #: - - M

F

Name: (first, middle initial, last) Gender: Date of Birth (mmddyy): Social Security #: - - M

F

i want to enroll my…

spouse

dependent 1

dependent 2

dependent 3

dependent 4

If you are declining enrollment for yourself or your Dependents (including your spouse or Registered Domestic Partner) because of other health insurance coverage, you may in the future, be able to enroll yourself or your Dependents in this plan, as long as you request enrollment within 31 days of your other coverage ending. In addition, if you have a new Dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your Dependents as long as you request enrollment within 31 days of the marriage, birth, adoption, or placement for adoption. If you previously declined enrollment in this plan for yourself or your Dependents because of coverage under a Medicaid plan or CHIP plan, you can request enrollment within 31 days of losing that coverage.

Do you and or your Dependent(s) have health coverage that will remain in effect when your Health Republic coverage begins? No Yes (please attach a Coordination of Benefits Form.)

Does a Dependent have a different mailing address? If so, please list below:

Dependent address: City: State: ZIP code:

If coverage is Medicare, indicate: Effective date (mmddyy): Part A Part B

Spouse/Registered Domestic Partner Non-Registered Domestic Partner (Only eligible if allowed by the group)

HRIC-2015-SGE0201 ₃

important: the following terms are a part of this application. you must read them

carefully. do not sign the application until you understand these terms.

I, the applicant (employee) on my behalf and on behalf of every covered Dependent listed on this form or added in the future, hereby: 1. Agree that in the event any health care benefits provided to me or any covered Dependent by Health Republic Insurance and/

or its representatives are the primary responsibility of Medicare or of any coverage for work-related injuries, illness, or conditions, or of any third party on account of any injury, illness, condition or damage, I will fully inform Health Republic Insurance and/or its representatives and will execute such assignments, liens or other documents which may be necessary to enable Health Republic Insurance and/or its representatives to recover the value of services provided. I further agree that in the event I, any Dependent, or any of my family members collect benefits, damages or reimbursement from Medicare, or any other third party with respect to such injury, illness, condition or damage, I will immediately reimburse Health Republic Insurance and/or its representatives to the full extent of services provided by Health Republic Insurance and/or its representatives in accordance with the employer contract; 2. Agree to be bound by each and every provision of the employer contract (including all schedules and attachments which are a part

of the employer contract as now in effect and as may be amended in the future), and agree that all my rights are as specifically set forth in the employer contract;

3. Authorize my employer to deduct from my earnings any amount required to cover my share of the premiums or prepayment fees, if any, payable under the employer contract;

4. Acknowledge that Health Republic Insurance and/or its representatives’ benefits are only viable if obtained in compliance with all provisions of the employer contract; and

5. Acknowledge that all participating providers are independent contractors and are not agents, servants, officers, employees, partners, or joint ventures of, or with, and are not controlled by, Health Republic Insurance and/or its representatives; that the participating providers, including primary care physicians, are responsible for the delivery of or arrangement for all medical services to me and my Dependents; and Health Republic Insurance and/or its representatives are not, and will not be, responsible for the deliberate or negligent acts or omissions of any such participating provider or any non-participating provider.

In applying for enrollment as indicated on this enrollment form, I declare that, to the best of my knowledge, all of the information on this form is true and complete, and the person(s) for whom I am requesting enrollment are eligible for coverage. I have also read and understand the provisions above. The changes on this form supersede all previous forms submitted.

If waiving for myself and/or Dependents, I acknowledge that those who have declined coverage will have to wait to be enrolled until the next Open Enrollment period or qualifying event to be enrolled.

Signature of Employee: Date (mmddyy):

employee signature