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 Transaction Form for Group Accounts 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 business check for the first month's premium payable to GHI 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 firstname.lastname@example.org 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 email@example.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 firstname.lastname@example.org 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 GHI: __________________________ ((the “Group”) hereby designates the broker with BROKER CODE 599F to be listed as the Broker/Consultant(s) of Record (the”BOR”) for the Group. Further, the Group authorizes Group Health Incorporated 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. Broker/Consultant(s) Name Address Tax ID Commission % Split Vista Health Solutions, Inc. 31 Park Ave 20-4850104 100% Suffern, NY __________________________ Signature __________________________ Print Name __________________________ Title TransacTion Form For group accounTs I. SUBSCRIBER INFORMATION Last Name First Name M.I. Sex Social Security Number - - Street Address Apt. City State ZIP Code Were you ever a member of EmblemHealth? Marital Status: Birth Date: Telephone #: E-Mail Address: ______________________________________________ NO YES Single Married Mo. Day Yr. Home: (_____) ______________________ If YES, member ID ______________________ Domestic Partner Work: (_____) ______________________ “Go PaPErlESS” and save trees (see back of application)* Subscriber Employment Status: ___________________________________ Young Adult Coverage: 26 And Under — Family 26 - 29 — Single Parent ID: __________________________________________________ Applicant working at least 20 hours per week Primary Care Physician Name: (Not required for EPo/PPo members) oB/GYN Selection Name: (optional) Disabled? NO YES ____________________________________________________________________ ____________________________________________________________________ ID Number: ___________________________________________________________ ID Number: ___________________________________________________________ Prior Health Insurance Information: are you covered by any other health insurance or Medicare? Check one: Status: Transfer: Carrier Name: ______________________________ NO YES If YES, indicate: New Enrollment Add Dependent To Another Carrier Coverage Begin Date: ____ / ____ / ____ Insurance Co. Name: _________________________________________ Reinstatement Remove Dep. EmblemHealth Group Change: Insurance Co. Telephone #: (_____) _____________ Type of Coverage: ______________ Termination Address Change From: _________________ Coverage End Date: ____ / ____ / ____ Change to Ind. Name Change To: ___________________ Policy #: ____________________________________ Effective Date: ____ / ____ / ____ II. ENROLLMENT INFORMATION — If you are enrollIng your spouse/Dp anD/or chIlDren, please lIst each one below — see electIon of coverage for elIgIbIlIty last Name (if different) First Name Social Security Number Sex relationship Birth Date ✓ if Primary Care Physician oB/GYN Selection Mo. Day Yr. Disabled Name/ID Number Name/ID Number (Not required for EPo/PPo members) (optional) DEPENDENT Spouse - - DP Child Current/Prior Health Insurance Information: Carrier Name: ____________________________________________________ Coverage Begin Date: ____ / ____ / ____ Coverage End Date: ____ / ____ / ____ DEPENDENT - - Child Current/Prior Health Insurance Information: Carrier Name: ____________________________________________________ Coverage Begin Date: ____ / ____ / ____ Coverage End Date: ____ / ____ / ____ DEPENDENT - - Child Current/Prior Health Insurance Information: Carrier Name: ____________________________________________________ Coverage Begin Date: ____ / ____ / ____ Coverage End Date: ____ / ____ / ____ Note: A birth/marriage certificate or 1040 Form will be required for spouse/dependents with different last name. Your signature is required to process this form. Your signature attests that you have read the reverse side of this form. applicant must sign here: ______________________________________________________ Date: _____ / _____ / _____ III. EMPLOYER INFORMATION — thIs sectIon to be completeD by employer/contractor group Name of Group: Group Number: EmblemHealth GHI GHI HMO HIP Type of Individual Family Plan Name: ________________________________________ Coverage: Employee & Spouse/DP Employee & Child Requested Effective Date: Hire Date: Waiting Period: Date Submitted: Approved By: (Group Plan Administrator) Medical: ____ / ____ / ____ Dental: ____ / ____ / ____ Instructions to Benefit Administrators or Group Representatives: For groups with 50 employees or fewer, you MUST complete Section A on the reverse side of this form. Required documentation MUST be attached to this Transaction Form to be processed. 16-1613 12/11 elecTion oF coverage Pre-existing conditions will not be covered during the first 12 months of enrollment in the EmblemHealth CompreHealth program or during the first 11 months of enrollment in the EmblemHealth EPo, EmblemHealth PPo, EmblemHealth ConsumerDirect PPo or EmblemHealth ConsumerDirect EPo plans. For policies issued or renewed after September 23, 2010, pre-existing condition limitations will be waived for enrollees under age 19. a pre-existing condition is a condition (whether physical or mental), regardless of the cause of the condition, for which medical advice of treatment was recommended or received during the six- month period prior to your enrollment date. EmblemHealth will credit the time you were covered by prior creditable health insurance coverage toward the 12-month or 11-month period, as long as the break in cov- erage between the prior coverage and your EmblemHealth coverage does not exceed 63 days, exclusive of any waiting periods. If requested, you or your group must provide EmblemHealth with information about your pre-existing conditions and/or previous coverage. You have the right to request a Certificate of Creditable Coverage from your prior health plan. If needed, EmblemHealth will help you get such a certificate from your prior plan. a large group (51 or more eligible employees) may elect to cover pre-existing conditions from the start of your EmblemHealth coverage. In such a case, your EmblemHealth policy will not contain a pre-existing condition limitation or it will state that the pre-existing condition limitation does not apply. Please call EmblemHealth at 1-877-842-3625 for more information about a pre-existing condition limitation. IMPorTaNT INForMaTIoN 1. The subscriber must complete sections I and II. The group plan administrator must complete section III and if for a small group (50 employees or fewer), provide all necessary documentation. 2. All transactions are subject to EmblemHealth’s retroactive policy (30 days for small groups, 90 days for large groups). 3. For policies issued or renewed after September 23, 2010, dependent children may stay on or be added to a parent’s policy until age 26 (end of birthday month), regardless of student status, as part of federal health reform. The premium will be billed at the applicable coverage tier and, other than the basic enrollment form, nothing else is required. Most employer groups cannot limit dependent coverage eligibility even if the qualified dependent has access to his or her own employer-based coverage. Only standard GHI and HIP HMO Direct Pay, Healthy New York and GHI large groups have the possibility of restrictions for adding dependents up to age 26. As part of New York State’s “age 29” law, eligible young adults through age 29 (up to 30th birthday) may continue or obtain coverage through a parent’s group policy. 4. Failure to complete any part of this form (e.g., group number, reason for submission, certificate number, signature, etc.) will require EmblemHealth to return this transaction form to the employer group plan administrator and may delay the requested effective date of coverage. Effective September 23, 2010, federal health reform may require changes to your coverage, depending on your plan. Get more information at www.emblemhealthreform.com. * By electing “Go Paperless,” you will receive claim statements and some other EmblemHealth letters by e-mail instead of paper mail. You will be able to view your Explanation of Benefits (EoBs) under the Claims section of the EmblemHealth Web site. Your enrollment in the “Go Paperless” option will continue as long as your account remains active, or until you choose to discontinue this option. SECTIoN a DOCUMENTATION BASED ON GROUP SIZE (To be completed by Benefits Administrator) Group Type (Check one) Sole Proprietorship association of Small Group — aCTIoN or one-Subscriber Two or More less than 50 Check (4)one Qualifying Event Documentation required Group Employees Employees Add Subscriber New Hire or Change in Plan For eligible employees who work more than 20 hours Not Eligible weekly, provide a recent Copy of NYS45 showing this subscriber as an employee or provide copy of payroll documentation reflecting the date, employee’s name and Social Security #, or the employee’s current-year W4 form. Add Spouse Marriage If last name is different Marriage Certificate 1040 Form Add Dependent Birth If last name is different Birth Certificate Adoption Formal Adoption Papers Court Approved Guardianship Papers Add Spouse Loss of Coverage Certificate of Creditable Coverage Add Dependent Add Domestic Partner Domestic Partnership Declaration of Cohabitation & Financial Not Eligible Not Eligible Interdependence form Note: No retroactive Enrollments will be allowed. Members must be enrolled within 30 days from the Qualifying Event/next billing date. Effective September 23, 2010, federal health reform may require changes to your coverage, depending on your plan. Get more information at www.emblemhealthreform.com. group Health incorporated (gHi), gHi Hmo select, inc. (gHi Hmo), Hip Health plan of new York (Hip), Hip insurance company of new York and emblemHealth services company, llc are emblemHealth companies. emblemHealth services company, llc provides administrative services to the emblemHealth companies. Summary of Benefits GHI HealtHy Ny ePO HDHP This is a high deductible health plan. With the exception of (1) well-baby and well-child care (up to the age of 19) including immunizations; and (2) adult preventive services (including a physical examination once every three years, mammography, pap smear, prostate screening exam and immunizations); and (3) pre-natal care, the deductible must be satisfied before GHI will provide coverage for covered services. The individual deductible amount for 2010-2011* is $1,200; the family deductible amount for 2010-2011* is $2,400. Family coverage applies if the policy covers more than one person. The family deductible may be satisfied by one individual family member or by expenses incurred by various family members. However, the entire plan year deductible must be satisfied before services will be covered for any member of the family. The Out-of-pocket maximum amount for an individual for 2010-2011 is $5,250; the out-of-pocket maximum amount for a family for 2010-2011 is $10,500. Family coverage applies if the policy covers more than one person. Out-of-pocket expenses include the deductible and copayments paid for Healthy NY benefits covered by this plan. Once the out-of-pocket maximum for the plan year is reached, no further copayments will apply and covered ben- efits will be covered in full. For more information about high deductible plans, please see your certificate. Cost sharing Annual Plan Deductible $1,200 Individual for plan year 2010-2011* $2,400 Family for plan year 2010-2011* *Treasury guidelines indicate that each year, the deductible amounts required for a high deductible health plan may be increased to reflect a cost-of-living adjustment. In order for this plan to continue to meet Healthy NY high deductible health plan requirements, and for this plan to continue to qualify as a high deductible health plan for use with a health savings account, the deductible amounts set forth above for plan years 2012 – 2021 may automatically increase to the new deductible amounts estab- lished in the Treasury guidelines. Annual Out-of-Pocket Maximum $6,050 individual $5,250Individual $12,100 Family $10,500 family PhysiCians serviCes Diagnostic & treatment services $20 copayment per visit Consultant & referral services Anesthesia services Second surgical opinion Second opinion for cancer Physical therapy and occupational therapy Surgical services (including breast reconstruction following a mastectomy) 20% or $200, whichever is less emergenCy serviCes $50 copayment per visit (waived if hospital admission results from visit) adult Preventive health Care Mammography screening Covered in full Cervical cytology screening Prostate Screening continued on back Refer to GHI policy form number HNy Pla 90-10, et al. GHI and HIP are EmblemHealth companies Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies. 10-6937 10/10 Summary of Benefits continued from front adult Preventive health Care (Continued) Periodic physical examinations Covered in full Adult immunizations maternity Care Prenatal care $10 copayment per visit (prenatal) Postnatal care $10 copayment per visit (postnatal) Delivery 20% or $200, whichever is less Home visit No copayment Child Preventive health serviCes Preventive and primary care immunization Covered in full Scheduled well-care visits Covered in full Pre-admission testing $20 copayment per visit inPatient hosPital serviCes (inCluding inPatient maternity Care) Daily room & board $500 copayment per continuous confinement General nursing care Special diets Miscellaneous hospital services & supplies outPatient hosPital serviCes Diagnostic & treatment services $20 copayment per visit Home Health Care Outpatient surgery $75 facility copayment diabetiC equiPment & suPPlies and self-management eduCation $20 copayment per visit for self-education $20 copayment per each item of equipment $20 copayment per 34-day supply of insulin, hypoglycemics and supplies diagnostiC X-ray & lab serviCes $20 copayment per visit theraPeutiC serviCes Radiological services $20 copayment per visit Chemotherapy Renal Dialysis blood and blood ProduCts $20 copayment per visit PresCriPtion drugs (oPtional) Copayment: $10 per generic drug per 34-day supply $20 per brand name drug plus difference in cost between the brand name drug and its generic equivalent per 34-day supply Mail order program: $20 per generic drug per 90-day supply $40 per brand name drug per 90-day supply plus the difference in cost between the brand name drug and its generic equivalent Benefit Maximum: Unlimited NOT COVERED: Ambulance, Dental Care, Durable Medical Equipment, External Prosthetics, Ostomy Supplies, Mental Health Services, Advance Infertility Services, Chiropractic Care, Skilled Nursing Facility, Substance Abuse Diagnoses and Treatment Detoxification and Rehabilitation. This chart is intended to provide a general outline of GHI EPO Healthy NY HDHP/HSA benefits.
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