Aetna Healthy NY Small Business 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
        • 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

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

        Completed Small Group Application and Enrollment Forms
        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
        A completed Total Average Employee Count Form
        A business check for the first month's premium payable to Aetna, Inc.

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                 
                                    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 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 to
      the business is located in Bronx, Kings, Nassau, New       chat with a representative or Email
      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)
                                                                                       (Yes or 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  
    Address                                              Phone                    E-mail

    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.
    Sample Broker of Records Letter. Please furnish a similar letter written on your company's letterhead.

Dear Aetna:

      __________________________ (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
hereby authorizes Aetna, Inc. 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

      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


Print Name

    NOTE: This form may be replicated. Please complete one for each enrolling employee
                                 Addendum to New Business Input Documents
                                 Mandatory Requirement for Health Care Reform

Aetna is collecting employee count information to comply with the health care reform law.
We are asking you to provide the average number of people you employed in the prior calendar year. We need this
information so we can accurately report your data and calculate any potential rebates to which you and your covered
subscribers may be entitled under the new medical loss ratio requirements set forth in the Affordable Care Act (ACA).

The law defines the number of employees as "the average number of employees employed by the employer's company
during the preceding calendar year." An employee is defined as any person for whom the company issues a W-2, including
full-time, part-time, and seasonal workers, and regardless of insurance eligibility (sample calculation below). We need the
average number of total employees for your company in 2011 to support the 2012 calculations and reports and the payment
of any rebates due in 2013.

How to calculate the average number of total employees*
To calculate average number of total employees for the year, determine the average number of employees for each month in
2011, add them together and then divide the total by twelve. In the example below, 253 / 12 = 21. Round up or down to the
nearest whole number.

                                Jan    Feb     Mar   Apr    May     June    July   Aug     Sept      Oct   Nov   Dec     Average
             Full Time          15     14       14    15     14      15      16     16      15       14    14     14
             Part Time          5      6        5      5     6        6       7      7       5        5     5      5
             Seasonal           0      0        0      0     0        2       3      3       2        0     0      0
             Total              20     20       19    20     20      23      26     26      22       19    19     19        21

*Subject to change based on future regulatory guidance

Please enter your calculated average number of employees in the box below.

    Average Number of Total Employees in 2011 (whole numbers only; please print legibly)

         Please check here if you are a sole proprietor (zero employees)
By signing below, I certify that:
    • I am an authorized representative of the plan(s) for which this information is being provided.
    • The information I have provided is true and correct.
    • Aetna may rely on the responses I have provided.

First Name (Please Print):                   Last Name (Please Print):                      Title:

Company Name:                                                                       Email Address (optional):

Signature:                                                                           Today’s Date:

Aetna reserves the right to audit all information provided. Providing false, incomplete, or misleading facts or information to an insurance
company for the purpose of defrauding or attempting to defraud the company, may violate applicable insurance statutes.

GR-68720 (1-12)
Healthy New York

Metro New York 2012 Rates
                              Dependent to Age 26                  Dependent to Age 30

Monthly high-          With Rx                 Without Rx     With Rx              Without Rx
deductible health
plan rates

Single                 $376                    $330           $376                 $330
Parent/Child(ren)      $696                    $611           $717                 $629

Couple                 $752                    $660           $752                 $660
Family                 $1,166                  $1,023         $1,201               $1,054

Syracuse 2012 Rates 
                             Dependent to Age 26               Dependent to Age 30

Monthly high-         With Rx                Without Rx     With Rx             Without Rx
deductible health
plan rates

Single                $376                   $330           $376                $330
Parent/Child(ren)     $696                   $611           $717                $629
Couple                $752                   $660           $752                $660
Family                $1,166                 $1,023         $1,201              $1,054

These rates are effective through December 2012. 
Plan Features                                           High-Deductible Health Plan (HDHP)
Deductible                                              $1,200 individual/$2,400 family
Out-of-Pocket Maximum                                   The maximum out-of-pocket expense for individuals is $6,050
(includes deductible and applicable copayments)         The maximum out-of-pocket expense for family coverage is $12,100

Primary Care Physician Visit
Office Hours                                            Deductible/$20 copayment
After-Hours/Home                                        Deductible/$20 copayment
Specialist Care
Office Visits                                           Deductible/$20 copayment
Diagnostic Outpatient Lab/X-ray Testing (at facility)   Deductible/$20 copayment
Diagnostic Outpatient Lab/X-ray Testing (at specialist) Deductible/$20 copayment with PCP referral
Surgical Services (including breast reconstruction      Deductible/20% or $200, whichever is less
following a mastectomy)*
Outpatient Therapy (speech and occupational)            Not covered
Outpatient Therapy (physical)**                         Deductible/$20 copayment per visit, 30 visit maximum per calendar year
Outpatient Dialysis/Chemotherapy                        Deductible/$20 copayment
Allergy Testing/Treatment                               Not covered
Preventive Care
Routine Physicals                                       No deductible or copayment
                                                        Adults age 22 and over – 1 visit every 24 months
Routine Prostate Cancer Screening                       No deductible or copayment
Well-Baby and Well-Child Care; Immunizations;           No deductible or copayment
Physical Exam                                           7 exams in the first 12 months; 3 exams in the second 12 months of life; 3 exams in the third 12 months of life;
                                                        1 exam per year thereafter through age 21.
Routine GYN Care                                        No deductible or copayment. Up to 2 annual exams for primary and preventive obstetric and gynecologic care;
                                                        and care required as a result of the annual examination or as a result of an acute gynecological condition.
Routine Mammography                                     No deductible or copayment. Upon the recommendation of a physician, a mammogram at any age if prior
                                                        history of breast cancer or if mother or sister has a prior history of breast cancer

                                                        A single baseline mammogram for women aged 35 – 39

                                                        An annual mammogram for women aged 40 and older
Routine Vision (Eye) Exam                               Not covered
Pediatric Dental                                        Not covered
Hearing Exam                                            Not covered
Hearing Aids                                            Not covered
Emergency Care                                          Deductible/$50 copayment, waived if admitted to hospital
Urgent Care Out-of-Area                                 Deductible/$50 copayment
Ambulance                                               Not covered
Outpatient Surgery (Facility)*                          Deductible/$75 facility copayment
Hospitalization (Facility)*                             Deductible/$500 facility copayment per continuous confinement
Skilled Nursing Facility Care                           Not covered
(in lieu of hospitalization for medically necessary
covered benefits)
Plan Features                                                 High-Deductible Health Plan (HDHP)
OB Visits                                                     No deductible/$10 copayment per visit for prenatal care
                                                              Deductible/$10 copayment for postnatal visit
Hospital (Includes Newborn Services)*                         Deductible/$500 facility copayment per continuous confinement
Home Health Care**                                            Deductible/$20 copayment per visit, 40 visit maximum per calendar year
Private Duty of Special Duty Nursing                          Not covered
Hospice — Inpatient                                           Not covered
Family Planning/Reproductive Services                         Not covered
Sterilization Procedures
Mental Health
Inpatient                                                     Not covered
Outpatient                                                    Not covered
Substance Abuse Detoxification
Inpatient Detoxification                                      Not covered
Outpatient Detoxification                                     Not covered
Substance Abuse Rehabilitation
Inpatient Rehabilitation                                      Not covered
Outpatient Rehabilitation                                     Not covered
Chiropractic Care                                             Not covered
Diabetic Supplies                                             Deductible/$20 copayment per visit for self-management education
(NY Mandate – effective 1/1/94)                               Deductible/$20 copayment per each item of equipment
                                                              Deductible/$20 copayment per 34-day supply of insulin, hypoglycemics and supplies
Prescription Drugs                                            Copayments: Deductible/$10 copayment per generic drug per 34-day supply; Deductible/$20 copayment
Note: The choice to have a prescription drug rider is made    per brand-name drug plan difference in cost between the brand-name drug and its generic equivalent per
at the time of the initial application. That selection will   34-day supply
be in effect for a 12-month period. Adding or removing        Mail-Order Delivery (MOD): Deductible/$20 copayment per generic drug per 90-day supply; $40 per brand-
the prescription drug rider can only be done upon             name drug per 90-day supply plus difference in cost between brand-name and its generic equivalent

 *Surgical services — (20% or $200, whichever is less) This copay/coinsurance is in addition to any inpatient
  hospitalization facility, outpatient facility and inpatient maternity facility copay. Includes breast
  reconstruction following a mastectomy.
**Only covered following an inpatient hospital stay, surgery or emergency room (ER) visit. Physical therapy/
  home health care visits must be related to injury/illness for which the member received inpatient services,
  surgery or ER services.

If you require language assistance from an Aetna representative, please call the Member Services
number located on your ID card, and you will be connected with the language line if needed; or you
may dial direct at 1-888-982-3862. (140 languages are available. You must ask for an interpreter.)
TDD 1-800-628-3323 (hearing impaired only).
Si requiere la asistencia de un representante de Aetna que hable su idioma, por favor llame al
número de Servicios al Miembro que aparece en su tarjeta de identificación y se le comunicará con
la línea de idiomas si es necesario; de lo contrario, puede llamar directamente al 1-888-982-3862
(140 idiomas disponibles. Debe pedir un intérprete). TDD 1-800-628-3323 (sólo para las personas con
impedimentos auditivos).
Health benefits and health insurance plans contain exclusions and limitations.
This material is for information only and is not an offer or invitation to contract. An application must be
completed to obtain coverage. Rates and benefits vary by location. Not all health services are covered. See
plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan
features and availability may vary by location and are subject to change. Providers are independent contractors
and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care
or guarantee access to health services. Aetna receives rebates from drug manufacturers that may be taken
into account in determining Aetna’s Preferred Drug List. Rebates do not reduce the amount a member pays
the pharmacy for covered prescriptions. Information is believed to be accurate as of the production date;
however, it is subject to change.
                                  Available in Spanish. Disponible en Español.

©2012 Aetna Inc.                                                              
14.02.319.1-NY A (1/12)

Description: Aetna Healthy NY Application for Small Businesses