Group Master Application Multiple Employer Plans

LifeWise Health Plan of Washington
P.O. Box 91060
Seattle, WA 98111-9160

GROUP MASTER APPLICATION — MULTIPLE EMPLOYER PLANS

Application is made to LifeWise Health Plan of Washington (hereafter referred to as “we,” “us,” or “our”) for a new Health Care Contract, the provisions of which shall be made available to all eligible classes of employees of participating employers. The multiple employer group shall be called "the group" in this application.
New multiple employer groups cannot be enrolled prior to our receipt date of this completed and signed application, which must be accompanied by the initial subscription charge payment. This application and subscription charge payment must be received no less than 10 days prior to the requested effective date.

GROUP ID

(Completed by LifeWise Health Plan of Washington)
1. /

PURPOSE

New Group: Complete this application and submit with enrollment forms, and the first month’s payment prior to the effective date of coverage.
Renewal: Complete this application in its entirety.
Other
Effective Date: / From / To / Annual Contract Renewal Month
2. /

GROUP INFORMATION

Note: Please provide a copy of your by-laws, employer eligibility rules, and a sample participation agreement with this application.
A. / Legal Name
Common Name Note: Required if Legal Name exceeds 50 characters and spaces, otherwise, optional.
Physical Address
City / State / ZIP / County
B. / Mailing Address / Same as Physical Address / Separate Address, complete the following:
Street/ P.O.
City / State / ZIP / County
C. / Billing Address / Same as Mailing Address / Same as Physical Address / Separate Address, complete the following:
Street/ P.O.
City / State / ZIP / County
Billing Contact Person Mr. Mrs. Ms. / Title
Phone No. ()- / Fax No. ()- / E-mail Address
D. / Tax ID Number
E. / Group Contact Person Mr. Mrs. Ms. / Title
Phone No. ()- / Fax No. ()- / E-mail Address
F. / Do you use a COBRA Administrator? No Yes, complete the following: / Same as Billing Address and Contact Person
COBRA Administrator Billing Address
City / State / ZIP / County
COBRA Administrator Contact Person Mr. Mrs. Ms. / Title
Phone No. ()- / Fax No. ()- / E-mail Address
G. / Is the group a subsidiary of or affiliated with another company or headquartered outside the State of Washington? No Yes, complete the following:
Legal Name
Physical Address
City / State / ZIP / County
H. / In the past 36 months have any participating employers in the group filed for protection or operated under Federal/State Bankruptcy laws? No Yes
In the past 36 months has any creditor filed or threatened to file a petition requesting any participating employers in the group to be put into bankruptcy? No Yes
I. / Is the group a union group? / No / Yes
Is the group a trade association? / No / Yes / Trade or other purpose of association
Number of employers in association
Is the association a HIPAA “bona fide” association? / No / Yes / Helpful Hint: "Bona fide" is defined in HIPAA regulations at 45 CFR §144.103.
3. / EMPLOYEE ELIGIBILITY REQUIREMENTS(REQUIRED OF ALL PARTICIPATING EMPLOYERS)
A. / Minimum Work Hours
Minimum work-hours for full-time employees? / hours per
Minimum work-hours for part-time employees? /

hours per

/

(not less than 20 hrs./wk.)

B. / Coverage will end:
Last day of the month for which subscription charge is paid. / Other
C. / Domestic Partner Eligibility
Will domestic partners be eligible for coverage? / Never / Yes, for all employers / On a per-employer basis
Will domestic partners be eligible for COBRA? / Never / Yes, for all employers / On a per-employer basis
4. / EMPLOYEE ENROLLMENT
Total number of employees on payroll regardless of hours worked
Total number of COBRA/Continuation of Coverage subscribers
Calculated Actual % of participation (completed by LifeWise Health Plan of Washington) / %
5. / EMPLOYEE PARTICIPATION AND EMPLOYER CONTRIBUTION REQUIREMENTS—TO BE COMPLETED BY LIFEWISE
(REQUIRED FOR ALL PARTICIPATING EMPLOYERS)
A. / Minimum Employee Participation Requirement is / %
B. / Minimum Employer Contribution Requirements
Please Note: Waivers of coverage are NOT allowed for eligible employees of non-contributory groups.
1. / Effective date of Contribution: / (month / day / year)
2. / The participatingemployer will contribute the following percentage or dollar amount, at a minimum, toward the cost of eligible employeecoverage.
Please Note: If the participating employer differentiates contributions by class of employee, those classes must be represented.
Employee Medical
Employee Dental
Employee Vision
Note: If the Employer contribution towards the cost of any tier of coverage has decreased by more than 5 percentage points since
March 23, 2010, the plan ceases to be grandfathered.
Please Note: We reserve the right to review payroll records or comparable reports to ensure that eligibility and enrollment requirements are met.
6. / FEDERAL REQUIREMENTS
Helpful Hint: We strongly urge you to consult legal counsel in answering the questions below. The summaries below are not intended to be or to replace legal advice on your particular group. It is the group’s responsibility to inform LifeWise immediately if facts change which would cause the group’s answers below to change.
A. / Are all participating employers subject to the federal Medicare Secondary Payer (MSP) laws that prohibit discrimination against individuals with
group coverage based on their (or a spouse’s) current employment status who have Medicare due to age?
Yes. This plan will pay primary to Medicare for all employers as required by federal law. (If group includes potentially exempt (i.e., small) employers, underwriting approval is required for this option.)
No. (Please provide copies of the election letter and supporting materials filed on behalf of those small employers for whom an exception has been elected.) This plan will pay primary to Medicare unless we receive (1) a copy of the election letter and supporting materials for the relevant employer(s) and individual(s), or (2) a certification from the group that the group has no participating employer with 20 or more employees as defined by the MSP laws.
Helpful Hint: If a multiple employer group has one or more participating employers that do not qualify as a small employer, then the MSP "working aged" laws apply to all participating employers within that association and Medicare will pay secondary to the plan unless the group files an election letter on behalf of its small employers, as described below. A small employer is one that did not employ 20 employees or more (see below for definition) for each working day in each of 20 or more calendar weeks in either the current or preceding calendar year.
Medicare will pay primary for participating small employers if the group files an election letter (and supporting materials) on behalf of those small employers with the Medicare Part B carrier in the state in which the employer is headquartered.
"Employees" include all full-time and part-time employees as well as those employees on disability and subject to FICA taxes. Also count leased employees if they would be counted as employees under §414(n)(2) of the Internal Revenue Code (IRC), and count employees employed by an "affiliated service group" under IRC §414(m) or by employers considered to be a "single employer" under IRC §52(a) or (b).
6. / FEDERAL REQUIREMENTS(CONTINUED)
B. / Are any participating employers in the group subject to COBRA?
Yes
No. Give the legal reason for exemption:
Helpful Hint: Generally, these laws apply to any non-church employer that employed 20 or more employees on at least 50% of its working days in the preceding calendar year. In most cases, COBRA applies separately to each participating employer in an association.
"Employees" are full-time and part-time common-law employees. Self-employed workers as defined in IRC §401(c)(1), corporate directors, or independent contractors should not be counted unless they qualify as common-law employees. "Employees" may also include leased employees who qualify as common-law employees. Please see COBRA regulations at 26 CFR § 54.4980B-2 Q/A 5 for guidance on counting a part-time employee as a fraction of a full-time employee.
C. / Does the group want to offer COBRA to all participating employers?
Yes. Underwriting approval required.
No, just to employers subject to COBRA.
D. / Are all participating employers subject to the federal Medicare Secondary Payer (MSP) laws that prohibit discrimination against individuals with group coverage based on their (or a family member’s) current employment status who have Medicare due to disability?
Yes. This plan will pay primary to Medicare as required by federal law.
No. Group has no participating employers with 100+ employees.
Helpful Hint: Generally, these laws apply to any multiple employer group that includes at least one employer that employed at least 100 employees on 50% or more of its working days in the preceding calendar year. There is no exemption for individual employers from these requirements. See the helpful hint in 6A above for a definition of "employee" for this purpose.
E. / Are any participating employers in the group subject to ERISA?
Yes
No. Give the legal reason for exemption: / Government or Public Plan Church Plan
Other, please specify:
Helpful Hint: Generally, ERISA applies to all employer health plans except governmental, public or church plans and plans that do not cover any employees (such as the plan of a self-employed person or a partnership). Non-profit status alone does not exempt an employer from ERISA.
F. / Should the plan be considered a single ERISA plan (not a separate plan for each participating employer)?
Yes. Enter month the ERISA plan year ends: Month
No. Each employer has its own ERISA plan.
Helpful Hint: Most multiple employer welfare arrangements are deemed to be a separate plan for each participating employer. A very few such arrangements have obtained a ruling from the Department of Labor that they meet ERISA's commonality and control tests.
7. / CURRENT COVERAGE INFORMATION
A. / Is this plan intended to replace any existing coverage?
No, go to section 7B / Yes
Name(s) of prior Medical carrier(s) / Name(s) of prior Dental carrier(s) / Name(s) of prior Vision carrier(s)
Termination date / Termination date / Termination date
B. /

Are you offering a plan from a carrier other than LifeWise?

No, go to section 8

/

Yes, more than one carrier’s plan is offered:

Name(s) of other Medical carrier(s)

/

Name(s) of other Dental carrier(s)

/

Name(s) of other Vision carrier(s)

Indicate if other plan is an HSA.

/

HSA?

No

Yes

No

Yes

No

Yes

8. / PRODUCER AGREEMENT TO CONTRACT
A. / You, the producer(s), certify that you have met with the group submitting this agreement and that you have fully explained its contents. You have discussed coverage, eligibility, the effect of misrepresentations, termination provisions and subscription charge billing administration.
Producer Signature / Date
Producer of Record (Print Name) / Producer Number
E-mail Address / Name of Firm/Agency
Effective Date Producer is Appointed for this Group
Commission: / PEPM / % / Scale
B. / Split Commission
Secondary Producer Name / Secondary Producer Number
Commissions are split between the primary and secondary producer as follows (e.g., 50% / 50%):
Primary % / Secondary %
9. / GROUP AGREEMENT TO CONTRACT

You, the group named in section 2 of this application, understand and agree to the following.

A. /

This application becomes part of the contract to provide health care coverage after:

• The application is signed by you;

• The application is received and approved by us; and
• We receive the initial month’s subscription charges.
You may not assign this contract without our written consent. Any attempt to do so will not have any binding effect on us. You agree to promptly deliver materials and notifications, including benefit booklets, received from us to all covered employees. You also agree to provide notification regarding the plan’s special enrollment rights to all eligible employees before their enrollment. You attest to have read this application, and certify that all statements are true and complete. You agree to the terms and obligations stated in this application. It is understood that provisions of the Health Care Contract, including subscription charges, may be amended or changed from time to time, upon our notice to you. All prior applications, to the extent that you have not made changes to them in this application, remain in full force and effect. The producer listed in section 8 will remain effective until written notice is given by either party. We are authorized to pay, on your behalf, commission, if any, for which you are liable to the above named producer.
B. / You may elect to allow the producer listed above to act as a group benefit administrator beginning on the group’s effective date. This means that the producer/administrator will be able to access membership and billing functions, and obtain information about group members via the Web on behalf of the group. These functions may include, but are not limited to:
• Reinstate Terminated Members / • Inquire on Invoice / • Order ID Cards for an Individual or Whole Family
• Request Invoice / • Inquire on Eligibility / • View Group Demographic Information
• Search for a Member / • Enroll a Member / • Cancel a Member
• View Benefit Detail
Do you elect and authorize LifeWise Health Plan of Washington to provide such information to the producer? / No Yes
C. / I affirm that this group has a physical location in the State of Washington, and I am authorized to sign on behalf of the group.
Signature of Group’s Representative / Date
Group’s Representative (Print Name) / Title
Please note: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
TRACKING INFORMATION—TO BE COMPLETED BY LIFEWISE HEALTH PLAN OF WASHINGTON

Date Received by Sales

/

Information Complete Yes No

/

Date Missing Information Received

Account Manager/Sales Executive / Extension / Rep. Code
Sales Support Contact / Extension / Sales Distribution
013427 (01-2015) / GROUP MASTER APPLICATION — MULTIPLE EMPLOYER PLANS / PAGE 1 OF 4