Please Check the Plan(S) That Interest You
Group Name as shown on Tax and Wage:
Employer Federal Tax ID Number (TIN):
Group Contact:
Email Address:
Physical Address:
Billing Address:
City:
State: Zip Code:
Phone Number: () - Fax Number: ) -
Section 1: ADDITIONAL GROUP INFORMATION
1. Group Size: Small Large
Group size is determined by the total number of Employees in Illinois. 2-50 Employees is a Small Group. 51+ Employees is a Large Group. In Iowa the group size is based on the number of eligible Employees. Please speak to your Broker or Account Executive for more information.
*** Once group size is determined please complete the Eligibility and Enrollment pages that accompany this application***
2. Requested Health Alliance Effective Date: /
3. Name of Current Carrier:
4. Is Health Alliance the sole source of health insurance? Yes No If No, identify other carriers:
5. Date Business Started: /
6. Do you have a Health Savings Account (HSA)? Yes No
Section 2: CREDITS FOR PPO PLANS ONLY
1. Does group wish to have In-Network Deductible Credit? Yes No
Deductible Credit is defined as the amount Health Alliance will credit for payments made toward the in-network deductible under the previous health insurance. If the new deductible is higher than the previous deductible, the additional amount needs to be met before benefits will be paid. Explanation of Benefits and/or a Deductible Credit Report from your previous carrier must be submitted for Deductible Credit to be applicable. NO CREDIT WILL BE GIVEN FOR OUT-OF-POCKET MAXIMUM
Section 4: MEDICARE SERVICES
Please contact your Broker and/or Sales Account Executive for plan options, rates and details
- Please check the plan(s) that interest you:
Which plan(s)?
- Effective Date of Medicare Plan: / Contract Type? Insured ASO Other
3. Approximately how many Medicare-eligible (primary) employees does your group have?
4. Approximately how many Medicare-eligible retirees does your group have?
5. Medicare Billing Type: (choose one) Group Level Individual
6. Medicare Plan Contact Information:
Medicare Group Contact: Email Address:
Physical Address:
City: State: Zip Code:
Billing Address:
Phone Number: Fax Number:
7. Sponsor Type: Employer Union Trustees of a Fund
8. Is your organization a: State Government Local Government Publicly Traded Corporation Non-Profit
Privately Held Corporation Sole Proprietorship Partnership Church Group Other
Section 5: THIRD PARTY ADMINISTRATIVE SERVICES
Health Alliance uses Benefit Planning Consultants (BPC) to administer third party services
- Are you currently using BPC to administer third party services such as COBRA, HRA, FLEX or HSA?
2. Would you like BPC to administer third party services? Yes No
3. Has HealthAlliance/BPC Service Agreement been signed? Yes No
4. Do you currently have an HRA?Yes No
5. Please mark which services you are interested in adding to your employee benefits:
Value Added COBRA (available for groups with 20 to 50 employees) COBRA (available for groups of 51+ employees)
FLEX FLEX with Debit Card HRA
Please ask your Sales Account Executive for a fee schedule. A signed BPC Service Agreement is required before services are effective. Return these documents with this application. Please note that these services cannot be retro active.
Section 6: BROKER INFORMATION (IF APPLICABLE)
I have advised my client not to terminate any existing coverage until receiving notice that the coverage being applied for by this application and the eligibility and enrollment information is accepted. I understand I have no right to bind this coverage, to alter terms of the Coverage Contract or Application in any manner or to adjust any claim for benefits under the Coverage Contract.
Print Broker Full Name: Agency:
Signature: ______Date: ______
Section 7: GROUP INFORMATION
I have read this application and attest to the accuracy of the above information.
Group Contact:
Signature: ______Date: ______
/ 2 TO 50 ELIGIBILITY AND ENROLLMENT QUESTIONNAIRE / (internal use only)
Group Number:
Group Name:
Group Contact
Email Address:
Address: / Phone Number:
City: / State: / Zip Code
Section 1: ELIGIBILITY AND ENROLLMENT QUESTIONNAIRE FOR GROUPS 2 TO 50
1. Effective Dates of Plan Year: From / To /
2. Plan year type (Choose one. If you do not select one Health Alliance will default to Annual):
Annual (January 1st to December 31st, regardless of renewal month)
Contract (12 months starting with the effective date)
3. Enrollment (please check Yes or No)
Open Enrollment: Not Applicable for groups 2 to 50. No employees and any eligible Dependents enrolling after the eligible grace period
expires will be treated as a “LateEntrant”. A pre-existing condition limitation period of up to 12 months could apply.
Dual Choice: Yes or No
Yes; Group shall conduct a dual choice period each year the Agreement is in effect, during which time all eligible employees and/or family Dependents who are currently enrolled as a Member in one of the Health Alliance Plans may switch to the other Health Alliance Plan. Any Member switching Plans who was previously subject to a pre-existing condition limitation period must complete the initial period when switching Plans. However, any Member switching Plans who has already met this limitation may switch Plans without a pre-existing limitation period. Dual choice period is subject to underwritingguidelines.
Annual Election:Not Applicable for groups 2 to 50. Health Alliance does not underwrite for small groups with more than one carrier.
4. Total number of employees including full-time, part-time, seasonal, owners, etc.?
5. Number of employees eligible for coverage
6. How many hours per week must the employee work in order to be eligible for coverage?
7. When are new hires eligible for coverage? First of the Month Following Days of employment or Date of Hire
8. Are there classes of employees not eligible for coverage?Yes No If yes, please list
9. Are there classes of employees with different eligibility dates (i.e. management vs. non-management)? Yes No
If Yes, please describe
10. Is Retiree Coverage offered (age 65 and older)?Yes No In order to be eligible at retirement, retirees must receive at least a 25%
contribution from their former Group toward the cost of the single premium rate or the retiree must be “Primary Medicare Eligible.”
Are early retirees (prior to age 65) offered coverage? Yes No
If Yes, at what age? Years of service? Other?
11. What is the employer’s percentage of contribution toward the Employees Premium?
(a minimum of 50% is required) % or Other
12. Are there employees who speak a primary language other than English?Yes No
If yes, how many employees? What language(s)?
13. Would you like to offer Domestic Partner Coverage? Yes No
14. Do you have a Health Savings Account (HSA)? Yes No
Section 2: HEALTH ALLIANCE MEDICAL PLANS STANDARDS FOR ELIGIBILITY AND ENROLLMENT
A. Applications: Must be submitted within 31 days for the eligibility date or a special enrollment period.
B. Effective Date of Dependent Coverage Termination:For Illinois Groups coverage may continue through the last day of the monththe
dependentturns age 26. For former military personnel, coverage may continue through age 30 with proof of honorable discharge. For Iowa Groups
coveragefora dependent child will terminate the last day of the month in which the child turns age 26.
C. Late Entrant: Not Applicable
D. Effective Date of Employee Coverage Termination:Coverage terminates the date the employee leaves employment. The group shall not be
entitled to receive a refund of any portion of a premium paid toHealth Alliance as a result of the Group’s failure to accurately notify Health
Alliancein writing within 31 days of the employee’s effective date of termination. Premiums for the month of termination are payable according
tothe 15th ofthe month rule. See “Remittance of Premiums”, Section 3.3 of the Group Enrollment Agreement.
E. Job Status Change Policy:Non-benefit eligible to benefit eligible will be treated as a new hire.
- Leave of Absence Policy:Health Alliance will allow employees on leaves of absence longer than six months to remain on the Plan if the Group resumes monthly contributions for these employees that meet or exceed the “Minimum Group Contribution” after the initial six month period. Employees on leaves of absence (medical, disability, education or personal leave) authorized by the Group will be allowed to pay 100% of their own premium for a maximum of six months. There must be a documented bona fide reason to believe that the employee will return to work upon conclusion of the leave of absence.
G. Layoff Policy:Health Alliance will allow employees on temporary layoffs longer than six months to remain on the Plan if the Group resumes monthly contributions for these employees that meet or exceed the “Minimum Group Contribution” after the initial six month period. Employees on temporary layoff authorized by the Group will be allowed to pay 100% of their own premium for a maximum of six months.
H. Medicare Eligible Policy:This policy applies to certain active employees age 65 and older, retirees age 65 and older and disabled persons eligible for Medicare primary coverage. If a “Medicare Eligible” Member does not elect Part B coverage when they are first eligible then Health Alliance shall determine payment as if the Member had elected Part B coverage. This is required for small and large Groups.
I. Pre-existing Condition Limitation Policy:A pre-existing condition limitation period of up to 12 months could apply, unless Late Entrant then a pre-existing condition limitation period of up to 18 months could apply. HMO products have50% coverage for the pre-existing condition period, all other products are $0 coverage for the pre-existing condition period. Proof of creditable coverage can reduce or eliminate this pre-existing condition period A pre-existing limitation period does not apply to person’s age 0 to 18.
J. Rehire Policy: Treat as a new hire.
K. Remittance of Premiums: Premiums must be paid by the first of each month. A 31-day grace period is allowed before automatic
termination.
L. Return from Layoff Policy: Coverage is effective immediately upon return from layoff.
M. Return from Leave of Absence Policy: Coverage is effective immediately upon return from leave of absence.
N. Special Enrollment Period:Any eligible Dependent may enroll during a special enrollment period. Applications must be submitted within 31 days from the date of the event. This period represents a time in which an individual may enroll in Health Alliance:
i) If there has been a change in family status involving a newly married spouse, newborn, newly adopted child, stepchild or a
legal guardianship change. Coverage would then be effective upon the date of the event.
ii) If other coverage was terminated as a result of loss of job/loss of coverage provisions. Loss of job/loss of coverage provisions include divorce, death of the spouse, termination of the spouse’s employment (voluntary or involuntary), termination of the plan by the spouse’s group, modification of the plan by the spouse’s group to terminate coverage for the class of employees of which the spouse is a Member or expiration of COBRA coverage with another Group. Coverage would then be effective the day after the coverage was lost.
- Transfer Policy: Coverage is effective the first of the month following the date of transfer.
Section 3: Service Area(s)
To be eligible for enrollment in the Plan, you must live or work within the Service Area. Please refer to the last page of your Description of Coverage Worksheet(s) for a complete list of service areas or refer to the Text page if applicable.
Section 4: Agreement
I agree that the information provided in Section 1 to be accurate to the best of my knowledge and that attempting to edit any content in Section 2 will nullify this document.
Group Name:
Signature: ______Date:______
Health Alliance Medical Plans, Inc.
Signature: ______Date:______
FOR HEALTH ALLIANCE INTERNAL USE ONLY
Sales AE: Service AE: Group Number:
# Members: # Subscribers: # Dependents: # Waivers:
Medical Underwriter: Date: Medical Risk Factor:
Miscellaneous:
Service Areas:
mkt-SmallEEQ&APP-1010
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