HIP Healthy NY Small Businesses App

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					                                    Healthy NY Case Submission

                                  Small Businesses (2-50 Employees)


        Eligibility Requirements:
       • Business is located in New York State and has 50 employees or fewer
       • Business did not provide health insurance to its employees in the last 12
       months
       • Employees work 20 or more hours per week
       • Thirty percent of the employees earn $40,000 or less in annual wages
       • Fifty percent of the employees must be enrolled in the Healthy New York
       plan; or, they must have coverage through another source
       • Fifty percent of the Healthy New York plan premium is paid by the
       employer


Along with your signed and dated application, be sure to include the following documents listed below.

    Completed Small Group Application and Employee Enrollment Application
    Quarterly Combined, Withholding, Wage Reporting and Unemployment
     Insurance Return (NYS 45)
    If you do not have an NYS-45, you may provide a letter from a C.P.A. or
     attorney. The letter must include the company name, tax identification
     number, a list of all employees, the number of hours/week each employee
     works and their salary. Also please submit a copy of filed certificate of
     organization.
    A completed Health Benefits Waiver for all waiving employees
    A business check for the first month's premium payable to Health Insurance
     Plan of Greater New York

Make sure to:
    Sign all forms where indicated
    Furnish and sign the BOR letter included with this application
Mail application forms along with the above to:
                                     Vista Health Solutions, Inc.
                                          Enrollment Dep’t.
                                            PO Box 337
                                         Suffern, NY 10901

31 Park Ave., Suffern, NY 10901         Tel. 8457532320 Fax. 8455101940           info@nyhealthinsurer.com
 
                                    Healthy NY Application for Small Businesses
 
 
    Healthy NY Application Instructions
    Individuals and sole proprietors looking to purchase Healthy NY must complete a different application.

    Confidentiality Statement: The information provided on this application will remain confidential and will only
    be disclosed to the staff at health plans and state agencies operating this program.
 
 
    Section A: Small Business Information                        • Your business has a class of employees that you have
                                                                   not offered health insurance to during the last 12
    In this section, we ask how to contact you. Your               months but would now like to cover. The class must
    business must be located in New York State in order            pertain to geographic location or employees’ earnings,
    to participate.                                                method of payment, hours, or job duties.
                                                                  
 
                                                                 Section D: Eligibility Requirements
    Section B: Coverage Options                                   
                                                                 The business must be able to answer “Yes” to each
    1. Benefits                                                  question in Section D to be eligible.
    Healthy NY offers a standardized benefits package,            
    with an optional prescription benefit. Choose if you         Section E: Participation Requirements
    want Healthy NY with a prescription drug benefit              
    or without a prescription drug benefit.                      In order to be eligible, your business must meet the
    Once you choose the benefit option, you will not be able     participation rules concerning employees who will
    to change your selection until your annual recertification   purchase Healthy NY.
    or at the time of a premium rate change.                      
 
                                                                  
                                                                 Section F: Employee Information
    2 . Deductible                                                
                                                                 Please answer the questions in Section F about your
    All plans are subject to an annual deductible. The
                                                                 employees who will be enrolling in Healthy NY.
    deductible amount is the amount you must spend out-of-
                                                                 You do not need to include information about their
    pocket before services are covered. Preventive care can
                                                                 dependents. If necessary, photocopy the chart and
    be accessed prior to meeting the deductible. For 2012,
                                                                 attach additional sheets.
    the deductible is $1,200 for individuals and $2,400 for       
    families. The deductible amount may change annually           
    and we encourage you to visit our website at                 Section G: Certification
    www.healthyny.com for more information.                       
                                                                 The certification must be completed by a duly
                                                                 authorized officer of the business.
                                                                  
    Section C: Insurance Information                              
                                                                  
    Healthy NY is available to small business employers who      Submitting Your Application
    have not provided comprehensive health insurance to their     
    employees or a class of their employees during the last 12   Detach and send your completed application your broker,
    months. If you provided health benefits within the last 12   the HMO or participating insurer selected by your
    months, your business may still qualify if:                  business. To submit this application, please mail it to: Vista
                                                                 Health Solutions, PO Box 337, Suffern, NY 10901.
    • Your business provided only “limited” health
                                                                 Additional documents may be required by the carrier if necessary
      insurance benefits.
                                                                 to complete the application process. If you have any
    • Your business did not contribute more than $50 per         questions, please contact our office at 1-888-215-4045 or
      employee per month towards the premium (or $75 if          845-753-2320. You call also visit www.nyhealthinsurer.com to
      the business is located in Bronx, Kings, Nassau, New       chat with a representative or Email info@nyhealthinsurer.com.
      York, Orange, Putnam, Queens, Richmond, Rockland,
                                                                  
      Suffolk, or Westchester counties).
                                                                  
    • The coverage was offered through Healthy NY.                
                                                                  
                                                                  
                                                                  
                                                                  
                                                                  
                                                                  
                                                                  
                                                                                                             Updated January 2012
 
                                       Healthy NY Application for Small Businesses
 
 
 
        Section A: Small Business Information
 
        Company Name:
 
        Telephone: (          )                                 Fax: (        )
 
        Street Address of Business:
 
        City:                                     State:     Zip:                 County:
 
        Contact Person:                                              Title:
 
        Telephone: (              )                                   Today’s Date:
 
 
 
        Section B: Coverage Options
         
        Healthy NY is available with or without prescription drug coverage. Premiums are higher for the coverage with the
        drug benefit. All Healthy NY coverage options have a deductible of $1,200 for individual coverage ($2,400 for family
        coverage) for 2012. Preventive services are covered before meeting the deductible.
 
                           
 
        Please select your coverage option:
 


                                       Healthy NY            Healthy     NY
                                        with drug coverage          without drug coverage
 
 
 
        Section C: Insurance Information

        You may offer Healthy NY to all of your employees or a class of your employees if you have not offered
        health insurance to them in the last 12 months. Please answer the following questions to assist us in
        determining your eligibility to purchase Healthy NY.
 
 
        1. Within the last 12 months, has your business provided health
           insurance that included both medical and hospital benefits
           (other than Healthy NY) to the class of employees that you are
            looking to cover?                                                                Yes              No
 
 
        2. If the answer to question 1 above is “Yes,” did your business
           contribute more than $50 per employee per month towards
           the premium (or $75 if the business is located in Bronx, Kings,           NA
           Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland,
           Suffolk, or Westchester counties)?                                                Yes              No
 
        If the answer to both questions 1 and 2 above is “Yes,” then your business is not eligible for Healthy NY.
 
                                               Healthy NY Application for Small Businesses
 
 
 
                      Section D: Eligibility Requirements

                      Eligibility requirements were designed to reach those small businesses most in need. Please answer
                      the following questions about your business. Please note that you must be able to check “Yes” to
                      each question in this section in order to be eligible to purchase Healthy NY.
               
                         1. Does your business have 1-50 employees?                                    Yes            No
                         2. Do at least 30% of the employees who will be offered coverage earn
                            annual wages of $40,000* or less?                                          Yes            No
                   
                        3. Will your business contribute at least 50% of the
                           Healthy NY premium on behalf of full-time employees?                        Yes            No
 
                        4. Will your business offer Healthy NY coverage to all
                           employees working 20 hours or more per week
                           who earn annual wages of $40,000* or less?                                  Yes            No
 
 
 
                      Section E: Participation Requirements

                      Please answer these questions about who will be accepting Healthy NY coverage. Please note that you must
                      be able to check “Yes” to each question in this section in order to be eligible to purchase Healthy NY.
 
                      1. Will at least 50% of the class of employees who
                         are offered Healthy NY coverage through your
                         business actually accept enrollment or have health
                         insurance through another source?                                             Yes            No
 
                      2. Will at least one employee earning annual wages
                         of $40,000* or less enroll in Healthy NY?                                     Yes            No
 
 
 
                      Section F: Employee Information
                      1. Employers may offer Healthy NY coverage to their employees’
                         dependents, including spouses, domestic partners, and
                         children. Employers are not required to contribute towards
                         the Healthy NY premium for dependents. Will your business
                         be offering Healthy NY coverage to the dependents of
                         your employees?                                                               Yes            No
 
                      2. Employers may choose to make Healthy NY available
                         to their part-time workers (those who work less than 20
                         hours weekly). You do not have to contribute towards
                         the premiums for part-time workers. Will your business
                         be offering Healthy NY coverage to part-time workers?                         Yes            No
 
 
 
                      * Updated annually
                                Healthy NY Application for Small Businesses
    Section F: Employee Information (continued)
    Complete the following information for each employee who is applying for coverage.
    Please photocopy and attach additional sheets, if needed
 
                                                                                 
           Employee Name                   Male or       Social Security            Is this employee
                                           Female           Number                      eligible for
            (First, MI, Last)
                                                                                         Medicare?
                                                                                       (Yes or No)

                                                                                 
                                                                                         NO
                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 
                             Healthy NY Application for Small Businesses
 
 
    Section G: Certification
 
 
    By signing this certification of eligibility, I certify under penalty of perjury that all statements contained in
    this certification are true and accurate to the best of my knowledge. I further certify that I am duly
    authorized to execute this certification on behalf of the business.
 
 
    I understand that any person who knowingly and with the intent to defraud any insurance company or
    other person files an application for insurance or statement of claim containing any materially
    false information, or conceals for the purpose of misleading, information concerning any fact material
    thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty
    not to exceed five thousand dollars and the stated value of the claim for each such violation.
 
 
 
    Print name of person completing certification            Signature
 
 
 
    Title                                                    Date
 
 
    If a broker assisted you with completing this application, please include:
 
 
  Vista Health Solutions                     LB-1033148                       Vista Health Solutions
    Broker’s Name                           License #                         Company
 
 
  31 Park Avenue, Suffern, NY 10901                       845-753-2320            info@nyhealthinsurer.com
    Address                                              Phone                    E-mail
 
 
 
 



 
 
 
 
IMPORTANT INFORMATION ABOUT PRE-EXISTING CONDITIONS
 
    A pre-existing condition is any physical or mental condition for which medical advice, diagnosis, care,
    or treatment was recommended or received within the six-month period ending on the first day of your
    coverage under a new contract. Pregnancy is not a pre-existing condition in small group contracts. If
    you have employees with pre-existing conditions at the time they enroll in Healthy NY, the policy will
    exclude coverage for those conditions for up to 12 months. However, this 12-month period may be
    reduced or eliminated if those employees are enrolling in Healthy NY within 63 days of the termination
    of other health insurance coverage. There are no pre-existing condition exclusions for anyone under 19.
    Advise your employees to review their Healthy NY certificate or to contact the health plan for a full
    explanation of what constitutes a pre-existing condition and how this restriction may affect them.
 
    The 12-month exclusion period mentioned above is shorter if you have been determined to be eligible
    Under the Federal Trade Adjustment Act of 2002. Please notify your HMO.
ATTN HIP:

                                           (The      “Group”)        hereby     designates     the
broker/consultant(s) listed below at the commission percentage split indicated as the
broker/consultant(s) of record (the “BOR”) for the Group. Further, the Group authorizes HIP
(Health Insurance Plans of Greater New York) to send all quotes, policies and notices to the
BOR. The Group hereby acknowledges and agrees that notice to the BOR is notice to the Group.
        This BOR designation shall remain in effect until it is expressly terminated by the Group
in writing.

BOR Designation: Please insert broker/consultant(s) name(s), address(es), and the applicable
commission percentage split below.

  Broker/Consultant’s Name           Address     Tax ID/SSN                Commission % Split
1.Vista Health Solutions          31 Park Ave.   20-4850104                     100%
                               Suffern, NY 10901




X______________________________
Signature of GBA or Authorized Officer


_______________________________
Print Name


_______________________________
Title
X
                                       REFUSAL OF HIP INSURANCE FORM
                             FOR SMALL BUSINESSES WITH FEWER THAN 51 ELIGIBLE EMPLOYEES
                                                       (Please Print)



Group Policy Number:

Name of Employer:

Employee’s Name:
                        (Last, First, MI)

Social Security Number:

Marital Status:        Single          Married   Divorced     Widower

Number of Eligible Dependent Children:


I was given the opportunity to enroll in a group insurance plan offered by my employer and
insured by HIP Health Plan of New York (HIP) and HIP Insurance Company of New York.
I am refusing:
(Note: Benefits provided on a noncontributory basis cannot be refused.)

                       HIP/HMO:                                         Choice Plus:
            Employee & Dependents                                 Employee & Dependents
            Spouse                                                Spouse
            Child(ren)                                            Child(ren)


ANSWER IF YOU ARE REFUSING ANY COVERAGE:
Are you or your dependents now covered by any other group plan?                Yes   No

If yes,
Policyholder’s Name:

Carrier:

I understand that I may be required to furnish, at my expense, EVIDENCE OF INSURABILITY
satisfactory to HIP Health Plan of New York and HIP Insurance Company of New York if I later
wish to enroll for any of the coverages refused.



Signature of Employee                                                      Date




Signature of Witness                                                       Date

				
DOCUMENT INFO
Description: HIP Healthy NY Application for Small Businesses