Small Employer / Group Agreement

SMALL EMPLOYER / GROUP AGREEMENT

UP TO 50 EMPLOYEES /
Application is made to LifeWise Health Plan of Oregon (hereafter referred to as “we,” “us,” or “our”) for a new Master Group
Contract, the provisions of which shall be made available to all eligible classes of employees.
Your group cannot be enrolled prior to our receipt date of this completed and signed application, which must be accompanied
by enrollment forms and the initial premium payment. / /

GROUP ID

(Completed by LifeWise)
1. / REQUESTED EFFECTIVE DATE
2. /

GROUP INFORMATION

A. / Legal Name
Common Name Note: Required if Legal Name exceeds 43 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. / Employer Identification Number (EIN) / SIC # / NAICS #
Worker’s Compensation / State Industrial Carrier / Policy #
E. / Group Contact Person Mr. Mrs. Ms. / Title
Phone No. ()- / Fax No. ()- / E-mail Address
F. / If COBRA eligible, do you use a COBRA Administrator? complete the following:
No Yes, / Same as Billing Address and Contact Person
COBRA Administrator Billing Address
City / State / ZIP
COBRA Administrator Contact Person Mr. Mrs. Ms. / Title
Phone No. ()- / Fax No. ()- / E-mail Address
LWO 2014 LATAPP.SG / 014578 (Rev 01-2015) / SMALL EMPLOYER / GROUP AGREEMENT / PAGE 2 OF6
3. /

CURRENT MEDICAL PLAN INFORMATION

Is this plan intended to replace any existing group coverage?
No, go to next section
Yes, complete the following:
Name of current medical carrier / Planned termination date:
Name of current dental carrier / Planned termination date:
4. / Group Eligibility
A. / Did the group employ no more than 50 employees during the previous calendar year? / No / Yes
*Employee count should include: all full-time, part-time and seasonal employees, union employees, employees from any affiliated companies, partners, business owners, corporate officers, and employees who work outside the State of Oregon. Your employee count should NOT include contracted 1099 individuals. If you were not in business during the previous year, please base your average number of employees on the current calendar year.
B. / Is the company headquartered in the state of Oregon? / No Yes
C. / Is the group a subsidiary of or affiliated with another company? / No Yes
5. / EMPLOYEE ELIGIBILITY REQUIREMENTS
A. / Employees in One Class

Note: Class of employees must be based on bona fide employment-based classifications consistent with your usual business practice.

1. /

Choose one: All Employees Salaried Hourly Part-time Full-time Management

2. /

Minimum hours: ______

3. / Exact date of hire, OR
First of the month following: / Date of hire / 30 days / 60 days
B. / Employees Differentiated by Class

Use section above for the first class and this section for the second class.

1. /

Choose one: Salaried Hourly Part-time Full-time Management

2. /

Minimum hours: ______

3. / Exact date of hire, OR
First of the month following: / Date of hire / 30 days / 60 days
C. / Waive Eligibility Waiting Period
Do you want to waive the eligibility waiting period for all current qualifying employees for this enrollment period?
No, the eligibility waiting period will also apply to all current qualifying employees.
Yes, all current qualifying employees will be eligible for benefits as of the effective date.
LWO 2014 LATAPP.SG / 014578 (Rev 01-2015) / SMALL EMPLOYER / GROUP AGREEMENT / PAGE 3 OF6
6. / EMPLOYER CONTRIBUTION AND EMPLOYEE PARTICIAPTION REQUIREMENTS
Note: Certain HRA/HSA plan options include a mandatory contribution to the HRA or HSA funding account. See the Small Employer / Group Agreement Benefit Selections form for details.
A. / Minimum Contribution / Participation Requirements – APPLICABLE GROUPS ONLY
Group Size / Employer Contribution
for Employees / Employee Participation / Employer Contribution
for Dependents / Dependent Participation
Medical: 2-4 Employees / 50% / 100% / No required level* / 25%
Medical: 5-50 Employees / 50% / 75% / No required level* / 25%
Dental / Non-Voluntary:
5-50 Employees / 50% / Greater of 5 Enrolled Employees or 50% Enrolled Employees / No required level* / Optional
Dental / Voluntary:
5-50 Employees / 0% - 49% / Greater of 5 Enrolled Employees or 30% Enrolled Employees / No required level* / Optional
*Note: Employer contribution for dependent coverage cannot exceed the contribution for employee coverage.
B. / Coverage Selection
Employee-Only coverage
Employee and Dependent coverage
C. / Contribution Level
The employer will contribute the following percentages toward the cost of eligible employee and dependent coverage.
Contribution for Employees: / Medical Plan / $/% / Dental Plan / $/%
Contribution for Dependents: / Medical Plan / $/% / Dental Plan / $/%
Please Note: For Grandfathered plans, 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.
D. / To comply with Federal requirements regarding plan actuarial value, certain Health Reimbursement Arrangement (HRA) and Health Savings Accounts (HSA) plans require a specified annual employer contribution to a HRA or HSA funding account. By selecting these plans, the employer agrees to fund the accounts to the levels specified in the Small Employer / Group Agreement Benefit Selections form. The employer further agrees that the HRA account, if chosen, will be established through Connect Your Care and the HSA account, if chosen, will be established through UMB Bank. The employer agrees they will not establish other HRA or HSA funding arrangements.
By checking the box below, the employer attests that if HRA or HSA plans with mandatory contributions are selected, they agree to fund the HRA or HSA to the amounts stated in the Small Employer / Group Agreement Benefit Selections form and will not establish or make any contributions to any other employee’s HRA or HSA account.
I am selecting an HRA or HSA plan with required employer contributions and agree to the funding account requirements as stated in this application.
I am selecting a PPO, HRA or HSA plan with no required employer contributions. I agree not to make a contribution to any HRA or HSA account.
LWO 2014 LATAPP.SG / 014578 (Rev 01-2015) / SMALL EMPLOYER / GROUP AGREEMENT / PAGE 3 OF6
7. / EMPLOYEE ENROLLMENT
A. / Total number of:
1. /

Employees on payroll regardless of hours worked:

2. /

*Eligible employees:

3. /

Employees that work in Oregon:

4. /

Do you intend to cover ALL employees?

/ No Yes
B. / Based on your established hour and day requirements (as specified in Section 5), for employees to be eligible for coverage, please answer the following questions:
Medical / Dental
1. / Number of employees eligible to enroll:
2. / Number of employees enrolling:
3. / Number of employees in their eligibility waiting period:
4. / Number of employees not in a covered class (26–50 groups only):
5. / Number of employees working less than the minimum number of hours per week (as specified in Section 5):
C. / Based on your established Employee Eligibility requirements (i.e., # of hours and days) for employees to be eligible for coverage, please answer the following question:
Are any eligible employees waiving coverage for any reason other than existing coverage, defined as other group medical coverage (example: through a spouse), Medicaid, Medicare, CHAMPUS, Indian Health Services, or a publicly sponsored or subsidized health plan including, but not limited to, the Oregon Health Plan?
No Yes, complete the following:
Medical / Dental
1. / Number of employees waiving coverage due to other group coverage:
2. / Number of employees waiving coverage due to individual or no coverage:
D. / Total number of employees and/or dependents enrolled under COBRA/Continuation of Coverage:
E. / Do you have eligible employees employed outside the states of Oregon, Washington, or Alaska?
No Yes, complete the following table:
State/Country / Number of Employees (Medical) / Number of Employees (Dental)
F. / Do you have eligible dependents residing outside the states of Oregon, Washington, or Alaska?
No Yes, complete the following table:
State/Country / Number of Dependents (Medical) / Number of Dependents (Dental)
G. / Actual employee participation percentage (Completed by LifeWise): / Medical / % / Dental / %
H. / Group is eligible for (Completed by LifeWise): / 2–25 Rates / 26–50 Rates
* / An eligible employee is an employee who worked a regular schedule of 17.5 hours or more per week.
Eligible employees do not include employees who work on a temporary, seasonal or substitute basis.
LWO 2014 LATAPP.SG / 014578 (Rev 01-2015) / SMALL EMPLOYER / GROUP AGREEMENT / PAGE 5 OF6
8. / FEDERAL REQUIREMENTS
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. / Is the group 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?
1. / Yes. This plan will pay premium to Medicare as required by federal law. No, Under 20 employees
2. / Please also provide the number of employees who now meet Medicare’s definition of “employee"
Helpful Hint: These laws do not apply to any employer who did not employ 20 employees or more for each working day in each of 20 or more calendar weeks in either the current or preceding calendar year. For these small group plans, Medicare pays primary to the group plan.
"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).
B. / Is 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.
"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. / Is the group 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?
1. / Yes. This plan will pay premium to Medicare as required by federal law. / No. Under 100 employees
2. / Please also provide the number of employees who now meet Medicare’s definition of “employee"
Helpful Hint: Generally, these laws apply to any employer that employed at least 100 employees on 50% or more of its working days in the preceding calendar year. See the helpful hint in 8A above for a definition of "employee" for this purpose.
D. / Is this group subject to ERISA?
Yes, enter the month the ERISA plan year ends: / Month
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. Non-profit status alone does not exempt an employer from ERISA.
9. / GROUP MATERIALS
Electronic copies of benefit booklets are available online at www.lifewiseor.com. One copy of the benefit booklet will be sent to the Group Administrator and the Producer. If you would like additional benefit booklets to be sent to the Group Administrator, please indicate the number you wish to receive.
LWO 2014 LATAPP.SG / 014578 (Rev 01-2015) / SMALL EMPLOYER / GROUP AGREEMENT / PAGE 5 OF6
10. / 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 premium charge billing administration.
Producer Signature / Date
Producer of Record (Print Name) / Producer Number
E-mail Address / Name of Firm/Agency
Producer Phone / Producer Fax
Effective Date Producer is Appointed for this Group
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 % and Secondary %
11. / EMPLOYER / GROUP AGREEMENT TO CONTRACT

You, the group named in the Group Information section of this agreement, understand and agree to the following.