Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… ·...

36
Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties Blue Choice Medical, BlueChoice Plus Medical, Blue Preferred Medical, Dental, Vision 1. Signed Rate Quote (Paper rates are unacceptable.) All of the pages to the signed rate proposal are required when the group is submitted, including the disclosure. Core plans require a rate quote if selected. 2. Tax Documentation (Required for all CareFirst Submissions) Please refer to Tax Documentation summary in the most current CareFirst broker manual. Automated Payroll registers are acceptable if the payroll company’s name is printed on it. (eg., ADP, Paychex, Safeguard, etc.) NOTE: THIS CANNOT BE A PAYROLL SPREADSHEET BY THE GROUP. 3. Completed Employee Election Forms Please have each employee complete questions 1-6, sign, date, and select the benefit election and coverage level for each product. PCP name and number is required for all HMOs, including Opt Outs. 4. Group Application Blue Choice Medical - MD/CFBC/SE/HMO-BCOO/GCA (1/14) Broker Signature and Tax identification number must be on the group application. 5. Group Application Blue Choice Plus Medical – CFMI/SE/POS/GCA (1/14) Broker Signature and Tax identification number must be on the group application. 6. Group Application Blue Preferred Medical – CFMI/SE/PPO/GCA (1/14) Broker Signature and Tax identification number must be on the group application. 7. Group Application Dental or Vision CFMI/DN-VS ONLY GCA (R. 1/13) Broker Signature and Tax identification number must be on the group application. 8. Waiver of Enrollment Form Full time employees declining coverage. 9. COBRA Selection Form must be accompanied by completed Enrollment Election Form or Selection Form for Those Groups Not Eligible for COBRA 10. Check payable to: Benefit Design Group LLC *1 st of the month effective date include 1 month’s premium. *15 th of the month effective date include 1½ month’s premium. 11. Authorization Agreement for Preauthorized Payments Form For groups with 5 or less enrolled employees. First month’s premium must be paid with group submission. 12. Indicate Prior Carrier (If Applicable) _______________________________ Indicates documentation required for all cases *Please submit completed paperwork to Benefit Design Group at least one day prior to the deadline. Posted on our website, www.benefitdesigngroup.com are the specific deadline dates. Thank you.

Transcript of Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… ·...

Page 1: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

Blue Choice Medical, BlueChoice Plus Medical, Blue Preferred Medical, Dental, Vision

1. Signed Rate Quote (Paper rates are unacceptable.) All of the pages to the signed rate proposal are required when the group is submitted, including the disclosure. Core plans require a rate quote if selected. 2. Tax Documentation (Required for all CareFirst Submissions) Please refer to Tax Documentation summary in the most current CareFirst broker manual. Automated Payroll registers are acceptable if the payroll company’s name is printed on it. (eg., ADP, Paychex, Safeguard, etc.) NOTE: THIS CANNOT BE A PAYROLL SPREADSHEET BY THE GROUP.

3. Completed Employee Election Forms Please have each employee complete questions 1-6, sign, date, and select the benefit election and coverage level for each product. PCP name and number is required for all HMOs, including Opt Outs.

4. Group Application Blue Choice Medical - MD/CFBC/SE/HMO-BCOO/GCA (1/14)

Broker Signature and Tax identification number must be on the group application.

5. Group Application Blue Choice Plus Medical – CFMI/SE/POS/GCA (1/14) Broker Signature and Tax identification number must be on the group application.

6. Group Application Blue Preferred Medical – CFMI/SE/PPO/GCA (1/14) Broker Signature and Tax identification number must be on the group application.

7. Group Application Dental or Vision – CFMI/DN-VS ONLY GCA (R. 1/13) Broker Signature and Tax identification number must be on the group application. 8. Waiver of Enrollment Form Full time employees declining coverage.

9. COBRA Selection Form must be accompanied by completed Enrollment Election Form

or Selection Form for Those Groups Not Eligible for COBRA 10. Check payable to: Benefit Design Group LLC *1st of the month effective date include 1 month’s premium. *15th of the month effective date include 1½ month’s premium. 11. Authorization Agreement for Preauthorized Payments Form For groups with 5 or less enrolled employees. First month’s premium must be paid with group submission. 12. Indicate Prior Carrier (If Applicable) _______________________________ Indicates documentation required for all cases *Please submit completed paperwork to Benefit Design Group at least one day prior to the deadline. Posted on our website, www.benefitdesigngroup.com are the specific deadline dates. Thank you.

Page 2: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

54 MARYLAND GROUP ELIGIBILITY | BROKER MANUALPROVIDER MANUAL

The following information was either provided by State legislation (as in the case of a self-employed individual), or by the Maryland Office of Unemployment Insurance to determine which tax documents are available to verify eligibility of an employer group and its employees:

Tax Documentation

Type of BusinessDLLR/OUI 15/16 required if employees are:

DLLR/OUI 15/16 not required if employees are:

If no DLLR/OUI 15/16 required, submit Instead

�� Self-Employed Individuals

�� Self-Employed “Licensed Professionals” such as Attorneys, physicians (LLP “Limited Liability Partnership” excluded)

Effective 10/ 1/ 2005, self-employeds are no longer considered “small employer groups.” No open enrollment periods will be offered.

�� Signed Form 1040 or 1040EZ and any one of the following: Schedule C, C-EZ, F, SE, Form 1120, 1120-S or Form 1065 with K-1, Form 7004, and Form 4868

�� Articles of (Professional) Incorporation and “Letter of Good Standing” from licensing group

Corporation (HB 857, HB 988 or HB 1359: 2+ eligibles)

Note: In most cases, corporations will have a formal Wage & Tax (DLLR/OUI 15/16)**

Form 1120, Form 1120-S or Articles of Incorporation showing owners of business

Sole Proprietorship(HB 857, HB 988 or HB 1359: 2+ eligibles)

�� Owner’s children (over age 21)

�� Other employees

�� Owner�� Spouse�� Owner’s children (under age 21)

�� Owner’s parents

Signed Schedule C/ F Showing at least Husband and wife as Owners**

Partnership(HB 857, HB 988 or HB 1359: 2+ eligibles)

�� Spouse�� Owner’s children�� Other employees

Partners Form 1065 and signed K-1 forms for each Partner**

Note that a current Wage and Tax Statement (DLLR/OUI 15/16) is required on all accounts including those migrating between CareFirst companies. Stock certificates are not accepted as proof of ownership.* In lieu of Form 501 C 3, will accept the Charter Documents of the organization along with an Affidavit of a CPA certifying the status of the

organization pursuant to IRC 501 C 3.** If the owners are the only employees, in addition to the tax documents they must also submit a notarized letter on company letterhead listing

the name of each, the number of hours per week each works, and their eligibility status.

> >CONTENTS

Page 3: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

55 MARYLAND GROUP ELIGIBILITY | BROKER MANUALPROVIDER MANUAL

Type of BusinessDLLR/OUI 15/16 required if employees are:

DLLR/OUI 15/16 not required if employees are:

If no DLLR/OUI 15/16 required, submit Instead

Non-Profit Organization(1 sole eligible employee working 20 hrs/wk)

Any employee(s) IRS Form 501(c)(3) a.k.a. “Letter of Determination” w/notarized letter on company letter-head, listing employees, hours per week/eligibility status*

Note that a current Wage and Tax Statement (DLLR/OUI 15/16) is required on all accounts including those migrating between CareFirst companies. Stock certificates are not accepted as proof of ownership.* In lieu of Form 501 C 3, will accept the Charter Documents of the organization along with an Affidavit of a CPA certifying the status of the

organization pursuant to IRC 501 C 3.** If the owners are the only employees, in addition to the tax documents they must also submit a notarized letter on company letterhead listing

the name of each, the number of hours per week each works, and their eligibility status.

Tax Documentation

> >CONTENTS

Page 4: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

56 MARYLAND GROUP ELIGIBILITY | BROKER MANUALPROVIDER MANUAL

To be considered an eligible employee a spouse must appear on the wage and tax, appear as an owner on the tax document, or produce a W-2. In addition to the required tax documentation, the group must provide a written statement that they are both working 30+ hours per week. Refer to the following matrix for help in determining whether your small employer group should be written as a 2+ Husband/Wife under a group contract or is defined as “self-employed” and not eligible for coverage under MSGR.

The chart assumes Maryland Small Group Reform eligibility is being met. In other words, both spouses are 30+ hours per week and have no other health insurance coverage.

In the event that an existing account no longer meets the minimum eligibility requirements for a 2+ Husband/Wife group, the account may remain active under HB 988.

Newly formed Husband and Wife Only groups must produce a notarized letter listing all full-time employees, the number of hours worked per week and their eligibility status AND the actual business formation documents that list both the husband and wife as owners. It must also be understood that, in the event of a future renewal audit, the proper tax documentation must be provided.

Husband/Wife Businesses

Receiving Salary?

Listed on Tax Doc/ Schedule

Owner? Type of Small Group

ASpouse 1 Yes Yes Yes

Self-employed owner w/dependent.Spouse 2 No No No

BSpouse 1 No Yes Yes

Self-employed owner w/dependent.Spouse 2 No No No

C Spouse 1 No Yes Yes2+ Small Group. May enroll as either 1 contract or 2 contracts.

Spouse 2 No Yes Yes

D Spouse 1 Yes Yes Yes2+ Small Group. May enroll as either 1 contract or 2 contracts.

Spouse 2 Yes Yes Yes

ESpouse 1 Yes Yes Yes

2+ Small Group. May enroll as either 1 contract or 2 contracts.

Spouse 2 Yes Yes No

> >CONTENTS

Page 5: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties
Page 6: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties
Page 7: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

MD/CFBC/SE/HMO-BCOO/GCA (1/14) 1 CFBC Small Group HMO

CareFirst BlueChoice, Inc. 840 First Street, NE

Washington, DC 20065 202-479-8000

An independent licensee of the Blue Cross and Blue Shield Association

GROUP CONTRACT APPLICATION

Non-Grandfathered Maryland Small Groups

For Products Offered off of the Maryland Health Benefits Exchange

If this Application is being completed for a new Group, or an existing Group selecting a new product or making a jurisdictional change, the Group is required to complete this Application in its entirety, in black ink, and sign, date and return it to the Group’s Sales Representative. If this Application is being completed for an existing Group that is amending general information or selections submitted on a prior Application, the Group is required to complete, in black ink, only the sections in which the information is changing, and sign, date and return this Application to the Group’s Sales Representative.

No retroactive effective dates for new groups or amendments will be permitted.

Do not alter this document except to fill in the blanks and check the boxes provided. This Application will not be accepted if any other changes to it are made.

GENERAL INFORMATION CareFirst BlueChoice Group Number (if available): Name of Organization: Physical Location:

Street Address:

City: State: Zip: Mailing Address (if other than above):

Street Address:

City: State: Zip: Billing Address (if other than above):

Street Address:

City: State: Zip: Group Administrator (Person to Contact):

Name: Telephone Number: Title: Email Address:

Federal Tax Identification Number:

Page 8: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

MD/CFBC/SE/HMO-BCOO/GCA (1/14) 2 CFBC Small Group HMO

GROUP ELIGIBILITY REQUIREMENTS The Group must meet the following requirements. Group Eligibility Requirements -- To be eligible for coverage and maintain its eligibility, the Group must meet all requirements for a Small Employer as provided in Section 31-101(z) of the Maryland Insurance Code: “Small Employer” means an employer that, during the preceding calendar year, employed an average of not more than:

A. Fifty (50) employees if the preceding calendar year ended on or before January 1, 2016; and

B. One-hundred (100) employees if the preceding calendar year ended after January 1, 2016. For purposes of this definition:

A. All persons treated as a single employer under § 414(b), (c), (m), or (o) of the Internal Revenue

Code shall be treated as a single employer; B. An employer and any predecessor employer shall be treated as a single employer; C. The number of employees of an employer shall be determined by adding:

1. The number of full-time employees; and 2. The number of full-time equivalent employees, which shall be calculated for a particular

month by dividing the aggregate number of hours of service of employees who are not full-time employees for the month by 120.

D. If an employer was not in existence throughout the preceding calendar year, the determination of

whether the employer is a small employer shall be based on the average number of employees that the employer is reasonably expected to employ on business days in the current calendar year.

E. An employer that makes enrollment in qualified health plans available to its employees through

the Maryland Health Benefits Exchange (the “SHOP Exchange”), and would cease to be a small employer by reason of an increase in the number of its employees, shall continue to be treated as a small employer for as long as it continuously makes enrollment through the SHOP Exchange available to its employees.

Except as provided above, if the Group’s actual enrollment varies such that the Group is not eligible for coverage as a Small Employer; the Group will be required to apply for other coverage by completing a new application and will be charged different premium rates. The Group Sales Representative or broker can help obtain additional detailed information about Maryland law requirements as it relates to Small Employers. Minimum Enrollment Requirements The following Minimum Enrollment Requirements do NOT apply to:

A. A Small Employer who submits this Application between November 15th and December 15th of any calendar year.

B. A Small Employer completing this Application for a CareFirst BlueChoice product with a

January 1, 2014 effective date of coverage. Otherwise, all other Groups have to enroll and maintain the following minimum enrollment requirements for medical coverage. The Group must enroll and maintain enrollment of at least 75% of all Eligible Employees. To determine enrollment, the Plan considers all Eligible Employees, except those who:

Page 9: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

MD/CFBC/SE/HMO-BCOO/GCA (1/14) 3 CFBC Small Group HMO

1. Are Eligible Employees who have group spousal coverage under a public or private plan of

health insurance or another employer’s health benefit arrangement, including Medicare, Medicaid, and CHAMPUS, that provides benefits similar to or exceeding the benefits provided under the Group Contract;

2. Are Eligible Employees who are under the age of 26 years who are covered under their parent’s

health benefit plan; 3. Are Eligible Employees who neither live nor work in the CareFirst BlueChoice Service Area.

If the Group offers another health benefits program through CareFirst BlueChoice and/or through another CareFirst BlueChoice affiliated or related entity, the total Group enrollment in all such plans will be combined to determine enrollment. In addition, the group must meet the following enrollment requirements: At least one full-time currently employed Eligible Employee must be enrolled under the Group’s coverage at all times. Enrolled Groups that drop to less than one full-time employee should contact their Group Sales Representative or the Maryland Health Benefits Exchange to arrange for individual direct pay coverage. If, at any time, the Group does not satisfy any minimum enrollment requirement stated in this Application for a group medical product, CareFirst BlueChoice reserves the right to rescind the proposal (if prior to the effective date of the applicable Group Contract), terminate the Group Contract for product that does not meet a minimum enrollment requirement, or refuse to renew the Group Contract product that does not meet a minimum enrollment requirement.

EMPLOYEE ELIGIBILITY REQUIREMENTS

The following individuals (and their dependents) are Eligible Employees and are eligible for coverage, as long as they meet the additional eligibility requirements stated in the Evidence of Coverage and any attachments thereto:

A. Full-time employees (including owners and partners) who work, on average, at least 30 hours per week.

Seasonal employees and independent contractors, such as subcontractors, who received a 1099, are not Eligible Employees. The IRS has issued guidance on when individuals are to be treated as either an employee or independent contractor.

B. Former employees and their dependents whose eligibility for group coverage has been extended

due to COBRA requirements or the Maryland Continuation of Coverage provisions.

C. Other Eligible Employees: Specify as many of the following additional categories of employees or retirees as the Group wishes to cover, even if the Group does not currently have such individuals in the Group.

YES NO Part-time employees with a normal workweek of at least 17.5 hours and who are

not full-time employees. (Those part-time employees working less than this required time period per normal workweek are not eligible).

DOMESTIC PARTNER ELIGIBILITY

Specify below whether Domestic Partners of Eligible Employees will be eligible to enroll.

YES NO Domestic Partners of Eligible Employees.

Page 10: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

MD/CFBC/SE/HMO-BCOO/GCA (1/14) 4 CFBC Small Group HMO

Enrollment Certification CareFirst BlueChoice reserves the right to inspect the records of the Group after sixty (60) days from the effective date of the Group coverage in order to verify the eligibility of employees and their Dependents. In addition, the Group may be required by CareFirst BlueChoice to complete and return to CareFirst BlueChoice an eligibility audit and/or census report annually.

EFFECTIVE DATES

Coverage for a new Eligible Employee will be effective on the first day of the month following the date of employment or eligibility, whichever is later, unless otherwise specified below:

On the date of employment or eligibility, whichever is later. On the first day of the month following 30 days of employment or eligibility, whichever is later. On the first day of the month following 60 days of employment or eligibility, whichever is later.

TERMINATION OF COVERAGE

Coverage for enrolled Subscribers who are no longer eligible (and any enrolled Dependents) terminates on the last day of the month in which the Subscriber’s employment or eligibility terminates.

AGE LIMITS FOR DEPENDENT CHILDREN Dependent children enrolled by an Eligible Employee (other than an incapacitated Dependent Child) are covered until the last day of the month of their 26th birthday.

GROUP’S RESPONSIBILITY TO EMPLOYEES

In any case in which the employee is responsible for a portion of the monthly premiums, the Group must:

1. Advise the employee of his/her eligibility for coverage under the Group Contract; 2. Advise the employee when s/he may enroll for such coverage in accordance with the provisions

stipulated in this Application and the Group Contract including the Evidence of Coverage; 3. Advise the employee when coverage will commence based on the aforementioned provisions and

the date of completion of the enrollment form; 4. Advise the employee of the cost of such coverage to the employee and the method in which

payment is to be made; and 5. Obtain from the employee a completed enrollment form and a signed agreement by the employee

to pay the applicable portion of the monthly rates.

PREMIUM RATE CHANGES There may be a rate increase when approved by the Maryland Insurance Administration, as provided by law. CareFirst BlueChoice will not increase the Group’s premium rate during the 12-month period beginning on the effective date of the Group Contract. CareFirst BlueChoice may increase the Group’s premium more frequently if the increase is due solely to the enrollment of new Members. CareFirst BlueChoice will provide notice of any change to premium rates by giving the Group at least forty-five (45) days prior written notice. CareFirst BlueChoice will also prominently post notice of the premium rate change and justification for such on the CareFirst BlueChoice website.

GROUP STATEMENTS

The Group agrees that in submitting this Application, it is acting for and on behalf of itself and as the agent and representative of its employees and COBRA participants, if applicable. The Group is not the agent or

Page 11: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

MD/CFBC/SE/HMO-BCOO/GCA (1/14) 5 CFBC Small Group HMO

representative of CareFirst BlueChoice for any purpose of this Application or any Group agreement issued pursuant to this Application. The Group agrees to receive on behalf of its Subscribers and their Dependents and COBRA participants, if applicable, the Evidence of Coverage, the identification cards, and all relevant notices furnished by CareFirst BlueChoice and to forward such materials to these individuals at their last known address. The Group agrees that it has provided CareFirst BlueChoice with information regarding the eligibility of Eligible Employees (and their Dependents) that is accurate and consistent with the requirements and provisions of the Patient Protection and Affordable Care Act of 2010 (the “Affordable Care Act”) and applicable state law. This Group Contract Application is part of the Group Contract between the Group and CareFirst BlueChoice. Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. If you have any questions concerning the benefits and services that are provided by or excluded under the coverage for which you are applying, please contact a membership services representative before signing this Application. ACCEPTED FOR:

(Name of Organization) BY:

(Printed Name of Authorized Officer)

(Signature of Authorized Officer)

Title: Date: Broker (if applicable)

(Printed Name of Broker)

(Signature of Broker) Email Address: Broker ID#: Date:

Effective Date of Group Contract:

Page 12: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

CFMI/SE/POS/GCA (1/14) 1 CFMI Small Group Point-of-Service

CareFirst of Maryland, Inc. doing business as

CareFirst BlueCross BlueShield (CareFirst) 10455 Mill Run Circle

Owings Mills, Maryland 21117-5559 A private not-for-profit health service plan incorporated under the laws of the State of Maryland

and CareFirst BlueChoice, Inc.

840 First Street, NE Washington, DC 20065

202-479-8000

Independent licensees of the Blue Cross and Blue Shield Association

GROUP CONTRACT APPLICATION

Non-Grandfathered Maryland Small Groups For Point-of-Service Products Offered off of the Maryland Health Benefits Exchange

Point-of-Service is a jointly offered product with in-network benefits provided under separate contract by CareFirst BlueChoice, Inc. (CareFirst BlueChoice) and out-of-network benefits provided under separate contract by CareFirst (collectively referred to in this Application as CareFirst/CareFirst BlueChoice). With a point-of-service product, the Member may choose each time that services are sought to qualify for HMO benefits under the in-network plan or to receive traditional indemnity benefits under the out-of-network plan. If this Application is being completed for a new Group, or an existing Group selecting a new product or making a jurisdictional change, the Group is required to complete this Application in its entirety, in black ink, and sign, date and return it to the Group’s Sales Representative. If this Application is being completed for an existing Group that is amending general information or selections submitted on a prior Application, the Group is required to complete, in black ink, only the sections in which the information is changing, and sign, date and return this Application to the Group’s Sales Representative.

No retroactive effective dates for new groups or amendments will be permitted.

Do not alter this document except to fill in the blanks and check the boxes provided. This Application will not be accepted if any other changes to it are made.

GENERAL INFORMATION CareFirst Group Number (if available): Name of Organization: Physical Location:

Street Address:

City: State: Zip: Mailing Address (if other than above):

Street Address:

City: State: Zip:

Page 13: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

CFMI/SE/POS/GCA (1/14) 2 CFMI Small Group Point-of-Service

Billing Address (if other than above):

Street Address:

City: State: Zip: Group Administrator (Person to Contact):

Name: Telephone Number: Title: Email Address:

Federal Tax Identification Number:

GROUP ELIGIBILITY REQUIREMENTS

The Group must meet the following requirements. Group Eligibility Requirements -- To be eligible for coverage and maintain its eligibility, the Group must meet all requirements for a Small Employer as provided in Section 31-101(z) of the Maryland Insurance Code: “Small Employer” means an employer that, during the preceding calendar year, employed an average of not more than:

A. Fifty (50) employees if the preceding calendar year ended on or before January 1, 2016; and

B. One-hundred (100) employees if the preceding calendar year ended after January 1, 2016. For purposes of this definition:

A. All persons treated as a single employer under § 414(b), (c), (m), or (o) of the Internal Revenue

Code shall be treated as a single employer; B. An employer and any predecessor employer shall be treated as a single employer; C. The number of employees of an employer shall be determined by adding:

1. The number of full-time employees; and 2. The number of full-time equivalent employees, which shall be calculated for a particular

month by dividing the aggregate number of hours of service of employees who are not full-time employees for the month by 120.

D. If an employer was not in existence throughout the preceding calendar year, the determination of

whether the employer is a small employer shall be based on the average number of employees that the employer is reasonably expected to employ on business days in the current calendar year.

E. An employer that makes enrollment in qualified health plans available to its employees through

the Maryland Health Benefits Exchange (the “SHOP Exchange”), and would cease to be a small employer by reason of an increase in the number of its employees, shall continue to be treated as a small employer for as long as it continuously makes enrollment through the SHOP Exchange available to its employees.

Except as provided above, if the Group’s actual enrollment varies such that the Group is not eligible for coverage as a Small Employer; the Group will be required to apply for other coverage by completing a new application and

Page 14: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

CFMI/SE/POS/GCA (1/14) 3 CFMI Small Group Point-of-Service

will be charged different premium rates. The Group Sales Representative or broker can help obtain additional detailed information about Maryland law requirements as it relates to Small Employers. Minimum Enrollment Requirements The following Minimum Enrollment Requirements do NOT apply to:

A. A Small Employer who submits this Application between November 15th and December 15th of any calendar year.

B. A Small Employer completing this Application for a CareFirst/CareFirst BlueChoice product

with a January 1, 2014 effective date of coverage. Otherwise, all other Groups have to enroll and maintain the following minimum enrollment requirements for medical coverage. The Group must enroll and maintain enrollment of at least 75% of all Eligible Employees. To determine enrollment, the Plan considers all Eligible Employees, except those who:

1. Are Eligible Employees who have group spousal coverage under a public or private plan of health insurance or another employer’s health benefit arrangement, including Medicare, Medicaid, and CHAMPUS, that provides benefits similar to or exceeding the benefits provided under the Group Contract;

2. Are Eligible Employees who are under the age of 26 years who are covered under their parent’s

health benefit plan.

If the Group offers another health benefits program through CareFirst/CareFirst BlueChoice and/or through another CareFirst/CareFirst BlueChoice affiliated or related entity, the total Group enrollment in all such plans will be combined to determine enrollment. In addition, the group must meet the following enrollment requirements: At least one full-time currently employed Eligible Employee must be enrolled under the Group’s coverage at all times. Enrolled Groups that drop to less than one full-time employee should contact their Group Sales Representative or the Maryland Health Benefits Exchange to arrange for individual direct pay coverage. If, at any time, If at any time the Group does not satisfy any minimum enrollment requirement stated in this Application for a group medical product, CareFirst/CareFirst BlueChoice reserves the right to rescind the proposal (if prior to the effective date of the applicable Group Contract), terminate the Group Contract for product that does not meet a minimum enrollment requirement, or refuse to renew the Group Contract product that does not meet a minimum enrollment requirement. Minimum Enrollment Requirements for Dental and/or Vision Coverage: When a Group selects employer-sponsored dental and/or vision benefit coverage, the Group must enroll and maintain enrollment of at least 75% of all Eligible Employees for the employer-sponsored dental and/or vision coverage. If at any time there are less than 75% enrolled in the employer-sponsored dental and/or vision products; CareFirst reserves the right to rescind the proposal(if prior to the effective date of the applicable Group Contract), terminate the dental and/or vision product that does not meet the 75% requirement, or refuse to renew the dental and/or vision product that does not meet the 75% requirement. If the Group selects Voluntary dental benefit coverage, the Group must enroll and maintain enrollment of the lesser of ten (10) eligible employees or 35% of all employees eligible for the Voluntary dental coverage. If the Group has less than ten (10) Eligible Employees, it is not eligible to select Voluntary dental benefit coverage. If at any time there are less than ten (10) eligible employees enrolled or 35% of all employees eligible for the Voluntary dental coverage enrolled, CareFirst reserves the right to rescind the proposal (if prior to the effective date of the applicable Group Contract), terminate the dental product that does not meet this requirement, or refuse

Page 15: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

CFMI/SE/POS/GCA (1/14) 4 CFMI Small Group Point-of-Service

to renew the dental product that does not meet this requirement. For Groups that select Voluntary vision benefit coverage, there are no minimum enrollment requirements for the Voluntary vision benefit coverage. The following employees are excluded from the counts in this provision relating to dental and/or vision coverage: those employees who have coverage under their spouse’s or parent’s group coverage, CHAMPUS, Medicare as primary under TEFRA, or their prior employer’s plan under COBRA.

EMPLOYER CONTRIBUTION To be eligible for CareFirst group dental and/or vision benefits coverage, the employer must identify the contribution level that applies to the dental and/or vision benefits coverage in the checkboxes below. If the employer’s contribution for enrolled employees is an amount equal to at least 50% of the premium cost of Individual Coverage for enrolled Eligible Employees, then the employer should select employer-sponsored below. If the employer’s contribution is less than 50% of premium cost of Individual Coverage for enrolled Eligible Employees, the plan will be considered Voluntary, and the employer should select Voluntary below. If the employee or participant in the Group agrees to pay the entire premium for the coverage to the Group, then the employer should select Voluntary below. If the Group selects dental benefit coverage, the Group must specify if the coverage will be:

Employer-sponsored or Voluntary

If the Group selects vision benefit coverage, the Group must specify if the coverage will be:

Employer-sponsored or Voluntary

EMPLOYEE ELIGIBILITY REQUIREMENTS

The following individuals (and their dependents) are Eligible Employees and are eligible for coverage, as long as they meet the additional eligibility requirements stated in the Evidence of Coverage and any attachments thereto:

A. Full-time employees (including owners and partners) who work, on average, at least 30 hours per week.

Seasonal employees and independent contractors, such as subcontractors, who received a 1099, are not Eligible Employees. The IRS has issued guidance on when individuals are to be treated as either an employee or independent contractor.

B. Former employees and their dependents whose eligibility for group coverage has been extended

due to COBRA requirements or the Maryland Continuation of Coverage provisions.

C. Other Eligible Employees: Specify as many of the following additional categories of employees or retirees as the Group wishes to cover, even if the Group does not currently have such individuals in the Group.

YES NO Part-time employees with a normal workweek of at least 17.5 hours and who are

not full-time employees. (Those part-time employees working less than this required time period per normal workweek are not eligible.)

DOMESTIC PARTNER ELIGIBILITY

Specify below whether Domestic Partners of Eligible Employees will be eligible to enroll.

YES NO Domestic Partners of Eligible Employees.

Page 16: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

CFMI/SE/POS/GCA (1/14) 5 CFMI Small Group Point-of-Service

Enrollment Certification CareFirst/CareFirst BlueChoice reserves the right to inspect the records of the Group after sixty (60) days from the effective date of the Group coverage in order to verify the eligibility of employees and their Dependents. In addition, the Group may be required by CareFirst/CareFirst BlueChoice to complete and return to CareFirst/CareFirst BlueChoice an eligibility audit and/or census report annually.

EFFECTIVE DATES

Coverage for a new Eligible Employee will be effective on the first day of the month following the date of employment or eligibility, whichever is later, unless otherwise specified below:

On the date of employment or eligibility, whichever is later. On the first day of the month following 30 days of employment or eligibility, whichever is later. On the first day of the month following 60 days of employment or eligibility, whichever is later.

TERMINATION OF COVERAGE

Coverage for enrolled Subscribers who are no longer eligible (and any enrolled Dependents) terminates on the last day of the month in which the Subscriber’s employment or eligibility terminates.

AGE LIMITS FOR DEPENDENT CHILDREN Dependent children enrolled by an Eligible Employee (other than an incapacitated Dependent Child) are covered until the last day of the month of their 26th birthday.

GROUP’S RESPONSIBILITY TO EMPLOYEES

In any case in which the employee is responsible for a portion of the monthly premiums, the Group must:

1. Advise the employee of his/her eligibility for coverage under the Group Contract; 2. Advise the employee when s/he may enroll for such coverage in accordance with the provisions

stipulated in this Application and the Group Contract including the Evidence of Coverage; 3. Advise the employee when coverage will commence based on the aforementioned provisions and

the date of completion of the enrollment form; 4. Advise the employee of the cost of such coverage to the employee and the method in which

payment is to be made; and 5. Obtain from the employee a completed enrollment form and a signed agreement by the employee

to pay the applicable portion of the monthly rates.

PREMIUM RATE CHANGES There may be a rate increase when approved by the Maryland Insurance Administration, as provided by law. CareFirst/CareFirst BlueChoice will not increase the Group’s premium rate during the 12-month period beginning on the effective date of the Group Contract. CareFirst/CareFirst BlueChoice may increase the Group’s premium more frequently if the increase is due solely to the enrollment of new Members. CareFirst/CareFirst BlueChoice will provide notice of any change to premium rates by giving the Group at least forty-five (45) days prior written notice. CareFirst/CareFirst BlueChoice will also prominently post notice of the premium rate change and justification for such on the CareFirst/CareFirst BlueChoice website.

Page 17: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

CFMI/SE/POS/GCA (1/14) 6 CFMI Small Group Point-of-Service

GROUP STATEMENTS

The Group agrees that in submitting this Application, it is acting for and on behalf of itself and as the agent and representative of its employees and COBRA participants, if applicable. The Group is not the agent or representative of CareFirst/CareFirst BlueChoice for any purpose of this Application or any Group agreement issued pursuant to this Application. The Group agrees to receive on behalf of its Subscribers and their Dependents and COBRA participants, if applicable, the Evidence of Coverage, the identification cards, and all relevant notices furnished by CareFirst/CareFirst BlueChoice and to forward such materials to these individuals at their last known address. The Group agrees that it has provided CareFirst/CareFirst BlueChoice with information regarding the eligibility of Eligible Employees (and their Dependents) that is accurate and consistent with the requirements and provisions of the Patient Protection and Affordable Care Act of 2010 (the “Affordable Care Act”) and applicable state law. This Group Contract Application is part of the applicable Group Contract(s) between the Group and CareFirst or CareFirst BlueChoice. Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. If you have any questions concerning the benefits and services that are provided by or excluded under the coverage for which you are applying, please contact a membership services representative before signing this Application. ACCEPTED FOR:

(Name of Organization) BY:

(Printed Name of Authorized Officer)

(Signature of Authorized Officer)

Title: Date: Broker (if applicable)

(Printed Name of Broker)

(Signature of Broker) Email Address: Broker ID#: Date:

Effective Date of Group Contract:

Page 18: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

CFMI/SE/PPO/GCA (1/14) 1 CFMI Small Group PPO

CareFirst of Maryland, Inc. doing business as

CareFirst BlueCross BlueShield (CareFirst) 10455 Mill Run Circle

Owings Mills, MD 21117-5559

A private not-for-profit health service plan incorporated under the laws of the State of Maryland

An independent licensee of the Blue Cross and Blue Shield Association

GROUP CONTRACT APPLICATION

Non-Grandfathered Maryland Small Groups For Products Offered off of the Maryland Health Benefits Exchange

If this Application is being completed for a new Group, or an existing Group selecting a new product or making a jurisdictional change, the Group is required to complete this Application in its entirety, in black ink, and sign, date and return it to the Group’s Sales Representative. If this Application is being completed for an existing Group that is amending general information or selections submitted on a prior Application, the Group is required to complete, in black ink, only the sections in which the information is changing, and sign, date and return this Application to the Group’s Sales Representative.

No retroactive effective dates for new groups or amendments will be permitted.

Do not alter this document except to fill in the blanks and check the boxes provided. This Application will not be accepted if any other changes to it are made.

GENERAL INFORMATION CareFirst Group Number (if available): Name of Organization: Physical Location:

Street Address:

City: State: Zip: Mailing Address (if other than above):

Street Address:

City: State: Zip:

Page 19: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

CFMI/SE/PPO/GCA (1/14) 2 CFMI Small Group PPO

Billing Address (if other than above):

Street Address:

City: State: Zip: Group Administrator (Person to Contact):

Name: Telephone Number: Title: Email Address:

Federal Tax Identification Number:

GROUP ELIGIBILITY REQUIREMENTS

The Group must meet the following requirements. Group Eligibility Requirements -- To be eligible for coverage and maintain its eligibility, the Group must meet all requirements for a Small Employer as provided in Section 31-101(z) of the Maryland Insurance Code: “Small Employer” means an employer that, during the preceding calendar year, employed an average of not more than:

A. Fifty (50) employees if the preceding calendar year ended on or before January 1, 2016; and

B. One-hundred (100) employees if the preceding calendar year ended after January 1, 2016. For purposes of this definition:

A. All persons treated as a single employer under § 414(b), (c), (m), or (o) of the Internal Revenue

Code shall be treated as a single employer; B. An employer and any predecessor employer shall be treated as a single employer; C. The number of employees of an employer shall be determined by adding:

1. The number of full-time employees; and 2. The number of full-time equivalent employees, which shall be calculated for a particular

month by dividing the aggregate number of hours of service of employees who are not full-time employees for the month by 120.

D. If an employer was not in existence throughout the preceding calendar year, the determination of

whether the employer is a small employer shall be based on the average number of employees that the employer is reasonably expected to employ on business days in the current calendar year.

E. An employer that makes enrollment in qualified health plans available to its employees through

the Maryland Health Benefits Exchange (the “SHOP Exchange”), and would cease to be a small employer by reason of an increase in the number of its employees, shall continue to be treated as a small employer for as long as it continuously makes enrollment through the SHOP Exchange available to its employees.

Except as provided above, if the Group’s actual enrollment varies such that the Group is not eligible for coverage as a Small Employer; the Group will be required to apply for other coverage by completing a new application and

Page 20: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

CFMI/SE/PPO/GCA (1/14) 3 CFMI Small Group PPO

will be charged different premium rates. The Group Sales Representative or broker can help obtain additional detailed information about Maryland law requirements as it relates to Small Employers. Minimum Enrollment Requirements The following Minimum Enrollment Requirements do NOT apply to:

A. A Small Employer who submits this Application between November 15th and December 15th of any calendar year.

B. A Small Employer completing this Application for a CareFirst product with a January 1, 2014

effective date of coverage. Otherwise, all other Groups have to enroll and maintain the following minimum enrollment requirements for medical coverage. The Group must enroll and maintain enrollment of at least 75% of all Eligible Employees. To determine enrollment, the Plan considers all Eligible Employees, except those who:

1. Are Eligible Employees who have group spousal coverage under a public or private plan of health insurance or another employer’s health benefit arrangement, including Medicare, Medicaid, and CHAMPUS, that provides benefits similar to or exceeding the benefits provided under the Group Contract;

2. Are Eligible Employees who are under the age of 26 years who are covered under their parent’s

health benefit plan.

If the Group offers another health benefits program through CareFirst and/or through another CareFirst affiliated or related entity, the total Group enrollment in all such plans will be combined to determine enrollment. In addition, the group must meet the following enrollment requirements: At least one full-time currently employed Eligible Employee must be enrolled under the Group’s coverage at all times. Enrolled Groups that drop to less than one full-time employee should contact their Group Sales Representative or the Maryland Health Benefits Exchange to arrange for individual direct pay coverage. If, at any time, If at any time the Group does not satisfy any minimum enrollment requirement stated in this Application for a group medical product, CareFirst reserves the right to rescind the proposal (if prior to the effective date of the applicable Group Contract), terminate the Group Contract for product that does not meet a minimum enrollment requirement, or refuse to renew the Group Contract product that does not meet a minimum enrollment requirement. Minimum Enrollment Requirements for Dental and/or Vision Coverage: When a Group selects employer-sponsored dental and/or vision benefit coverage, the Group must enroll and maintain enrollment of at least 75% of all Eligible Employees for the employer-sponsored dental and/or vision coverage. If at any time there are less than 75% enrolled in the employer-sponsored dental and/or vision products; CareFirst reserves the right to rescind the proposal(if prior to the effective date of the applicable Group Contract), terminate the dental and/or vision product that does not meet the 75% requirement, or refuse to renew the dental and/or vision product that does not meet the 75% requirement. If the Group selects Voluntary dental benefit coverage, the Group must enroll and maintain enrollment of the lesser of ten (10) eligible employees or 35% of all employees eligible for the Voluntary dental coverage. If the Group has less than ten (10) Eligible Employees, it is not eligible to select Voluntary dental benefit coverage. If at any time there are less than ten (10) eligible employees enrolled or 35% of all employees eligible for the Voluntary dental coverage enrolled, CareFirst reserves the right to rescind the proposal (if prior to the effective date of the applicable Group Contract), terminate the dental product that does not meet this requirement, or refuse to renew the dental product that does not meet this requirement.

Page 21: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

CFMI/SE/PPO/GCA (1/14) 4 CFMI Small Group PPO

For Groups that select Voluntary vision benefit coverage, there are no minimum enrollment requirements for the Voluntary vision benefit coverage. The following employees are excluded from the counts in this provision relating to dental and/or vision coverage: those employees who have coverage under their spouse’s or parent’s group coverage, CHAMPUS, Medicare as primary under TEFRA, or their prior employer’s plan under COBRA.

EMPLOYER CONTRIBUTION To be eligible for CareFirst group dental and/or vision benefits coverage, the employer must identify the contribution level that applies to the dental and/or vision benefits coverage in the checkboxes below. If the employer’s contribution for enrolled employees is an amount equal to at least 50% of the premium cost of Individual Coverage for enrolled Eligible Employees, then the employer should select employer-sponsored below. If the employer’s contribution is less than 50% of premium cost of Individual Coverage for enrolled Eligible Employees, the plan will be considered Voluntary, and the employer should select Voluntary below. If the employee or participant in the Group agrees to pay the entire premium for the coverage to the Group, then the employer should select Voluntary below. If the Group selects dental benefit coverage, the Group must specify if the coverage will be:

Employer-sponsored or Voluntary

If the Group selects vision benefit coverage, the Group must specify if the coverage will be:

Employer-sponsored or Voluntary

EMPLOYEE ELIGIBILITY REQUIREMENTS

The following individuals (and their dependents) are Eligible Employees and are eligible for coverage, as long as they meet the additional eligibility requirements stated in the Evidence of Coverage and any attachments thereto:

A. Full-time employees (including owners and partners) who work, on average, at least 30 hours per week.

Seasonal employees and independent contractors, such as subcontractors, who received a 1099, are not Eligible Employees. The IRS has issued guidance on when individuals are to be treated as either an employee or independent contractor.

B. Former employees and their dependents whose eligibility for group coverage has been extended

due to COBRA requirements or the Maryland Continuation of Coverage provisions.

C. Other Eligible Employees: Specify as many of the following additional categories of employees or retirees as the Group wishes to cover, even if the Group does not currently have such individuals in the Group.

YES NO Part-time employees with a normal workweek of at least 17.5 hours and who are

not full-time employees. (Those part-time employees working less than this required time period per normal workweek are not eligible.)

DOMESTIC PARTNER ELIGIBILITY

Specify below whether Domestic Partners of Eligible Employees will be eligible to enroll.

YES NO Domestic Partners of Eligible Employees.

Page 22: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

CFMI/SE/PPO/GCA (1/14) 5 CFMI Small Group PPO

Enrollment Certification CareFirst reserves the right to inspect the records of the Group after sixty (60) days from the effective date of the Group coverage in order to verify the eligibility of employees and their Dependents. In addition, the Group may be required by CareFirst to complete and return to CareFirst an eligibility audit and/or census report annually.

EFFECTIVE DATES

Coverage for a new Eligible Employee will be effective on the first day of the month following the date of employment or eligibility, whichever is later, unless otherwise specified below:

On the date of employment or eligibility, whichever is later. On the first day of the month following 30 days of employment or eligibility, whichever is later. On the first day of the month following 60 days of employment or eligibility, whichever is later.

TERMINATION OF COVERAGE

Coverage for enrolled Subscribers who are no longer eligible (and any enrolled Dependents) terminates on the last day of the month in which the Subscriber’s employment or eligibility terminates.

AGE LIMITS FOR DEPENDENT CHILDREN Dependent children enrolled by an Eligible Employee (other than an incapacitated Dependent Child) are covered until the last day of the month of their 26th birthday.

GROUP’S RESPONSIBILITY TO EMPLOYEES

In any case in which the employee is responsible for a portion of the monthly premiums, the Group must:

1. Advise the employee of his/her eligibility for coverage under the Group Contract; 2. Advise the employee when s/he may enroll for such coverage in accordance with the provisions

stipulated in this Application and the Group Contract including the Evidence of Coverage; 3. Advise the employee when coverage will commence based on the aforementioned provisions and

the date of completion of the enrollment form; 4. Advise the employee of the cost of such coverage to the employee and the method in which

payment is to be made; and 5. Obtain from the employee a completed enrollment form and a signed agreement by the employee

to pay the applicable portion of the monthly rates.

PREMIUM RATE CHANGES There may be a rate increase when approved by the Maryland Insurance Administration, as provided by law. CareFirst will not increase the Group’s premium rate during the 12-month period beginning on the effective date of the Group Contract. CareFirst may increase the Group’s premium more frequently if the increase is due solely to the enrollment of new Members. CareFirst will provide notice of any change to premium rates by giving the Group at least forty-five (45) days prior written notice. CareFirst will also prominently post notice of the premium rate change and justification for such on the CareFirst website.

Page 23: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

CFMI/SE/PPO/GCA (1/14) 6 CFMI Small Group PPO

GROUP STATEMENTS

The Group agrees that in submitting this Application, it is acting for and on behalf of itself and as the agent and representative of its employees and COBRA participants, if applicable. The Group is not the agent or representative of CareFirst for any purpose of this Application or any Group agreement issued pursuant to this Application. The Group agrees to receive on behalf of its Subscribers and their Dependents and COBRA participants, if applicable, the Evidence of Coverage, the identification cards, and all relevant notices furnished by CareFirst and to forward such materials to these individuals at their last known address. The Group agrees that it has provided CareFirst with information regarding the eligibility of Eligible Employees (and their Dependents) that is accurate and consistent with the requirements and provisions of the Patient Protection and Affordable Care Act of 2010 (the “Affordable Care Act”) and applicable state law. This Group Contract Application is part of the Group Contract between the Group and CareFirst. Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. If you have any questions concerning the benefits and services that are provided by or excluded under the coverage for which you are applying, please contact a membership services representative before signing this Application. ACCEPTED FOR:

(Name of Organization) BY:

(Printed Name of Authorized Officer)

(Signature of Authorized Officer)

Title: Date: Broker (if applicable)

(Printed Name of Broker)

(Signature of Broker) Email Address: Broker ID#: Date:

Effective Date of Group Contract:

Page 24: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

CFMI/DN-VS ONLY GCA (R. 1/13) 1 HCR Small Groups ONLY

CareFirst of Maryland, Inc. doing business as

CareFirst BlueCross BlueShield (CareFirst) 10455 Mill Run Circle

Owings Mills, Maryland 21117-5559

A private not-for-profit health service plan incorporated under the laws of the State of Maryland

An independent licensee of the Blue Cross and Blue Shield Association

GROUP CONTRACT APPLICATION FOR FREESTANDING DENTAL AND FREESTANDING VISION PRODUCTS

(For Maryland Groups Not Subject to Small Group Reform)

This form should be completed for a new Group, or an existing Group selecting a new dental or vision product or making a jurisdictional change, if the Group does not have a health benefits program through CareFirst or another CareFirst affiliate. The Group is required to complete this Application in its entirety, in black ink, and sign and return it to the Group's CareFirst Sales Representative. If the Group is an existing Group amending the current coverage or changing general information, the Group is required to complete, in black ink, only the sections in which the information is changing, sign and return this Application to the Group's CareFirst Sales Representative. Do not alter this document except to fill in the blanks and check the boxes provided. Due to regulatory requirements, this Application will not be accepted if any other changes are made.

GENERAL INFORMATION

CareFirst Group Number (if available): Name of Organization: Physical Location:

Street Address:

City: State: Zip: Mailing Address (if other than above):

Street Address:

City: State: Zip: Billing Address (if other than above):

Street Address:

City: State: Zip: Group Administrator (Person to Contact):

Name: Telephone Number: Title: Email Address:

Page 25: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

CFMI/DN-VS ONLY GCA (R. 1/13) 2 HCR Small Groups ONLY

Chief Executive Officer/President

Name: Telephone Number: Title:

Email Address:

Type of Organization Sole Proprietorship Partnership

Corporation Other _______________________ Nature of Business: Federal Tax Identification Number:

EMPLOYER CONTRIBUTION To be eligible for CareFirst Group dental and/or vision benefits coverage, the employer must identify the contribution level that applies to the dental and/or vision benefits coverage in the checkboxes below. If the employer’s contribution for enrolled employees is an amount equal to at least 50% of the cost of the Individual Coverage for enrolled employees, then the employer should select employer-sponsored below. If the employer’s contribution is less than 50% of the cost of the Individual Coverage, the plan will be considered Voluntary, and the employer should select Voluntary below. If the employee or participant in the Group agrees to pay the entire premium for the coverage to the Group, then the employer should select Voluntary below. If the Group selects dental benefit coverage, the Group must specify if the coverage will be:

Employer-sponsored or Voluntary

If the Group selects vision benefit coverage, the Group must specify if the coverage will be:

Employer-sponsored or Voluntary

GROUP ELIGIBILITY REQUIREMENTS

It is understood and agreed that in order to be eligible for coverage and maintain such eligibility, the Group must meet the following requirements. Annual Enrollment Certification: CareFirst reserves the right to inspect the records of the Group after sixty (60) days from the effective date of the Group coverage in order to verify the eligibility of employees and their dependents. In addition, the Group may be required to complete and return to CareFirst an eligibility audit and/or census report annually. Minimum Enrollment Requirements: The Group must enroll and maintain enrollment (unless otherwise approved by CareFirst) as stated below: Groups must enroll and maintain enrollment of 75% of all employees eligible for employer-sponsored coverage (or 100% if the employer pays the entire Individual Coverage premium). If at any time there are less than 75% enrolled, CareFirst reserves the right to rescind the proposal, revise the rates, terminate the product that does not meet the 75% requirement, or refuse to renew the product that does not meet the 75% requirement.

Page 26: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

CFMI/DN-VS ONLY GCA (R. 1/13) 3 HCR Small Groups ONLY

For Groups with 50 or fewer eligible employees, when a Group selects Voluntary dental benefit coverage, the Group must enroll and maintain enrollment of the lesser of ten (10) eligible employees or 35% of all employees eligible for the Voluntary dental coverage. If at any time there are less than ten (10) eligible employees or 35% enrolled in the Voluntary dental coverage, CareFirst reserves the right to rescind the proposal, revise the rates, terminate the product that does not meet the requirements, or refuse to renew the product that does not meet the requirements. For Groups with more than 50 eligible employees, when a Group selects Voluntary dental benefit coverage, the Group must enroll and maintain enrollment of 20% of all employees eligible for the Voluntary dental coverage. If at any time there are less than 20% enrolled in the Voluntary dental coverage, CareFirst reserves the right to rescind the proposal, revise the rates, terminate the product that does not meet the 20% requirement, or refuse to renew the product that does not meet the 20% requirement. For Groups that select Voluntary vision benefit coverage, there are no minimum enrollment requirements for the Voluntary vision benefit coverage. The following employees should be excluded from the above counts: those employees who have coverage under their spouse’s or parent’s group coverage, CHAMPUS, Medicare as primary under TEFRA, or their prior employer’s plan under COBRA. At least two employees must be employed full-time and enrolled under the Group’s coverage at all times. Enrolled Groups that drop to less than two full-time employees no longer meet the minimum enrollment requirements of this Group Contract and should contact their CareFirst Sales Representative to arrange for individual direct pay coverage if available. If at any time total enrollment increases or decrease by 10% or more, CareFirst reserves the right to rescind the proposal, revise the rates, terminate this Group Contract, or refuse to renew this Group Contract. The basis for determining whether an enrollment increase or decrease has occurred will be the total enrollment:

1. on the effective date or contract renewal date versus the total enrollment proposed at the time the rates were developed; and

2. on the first day of any month during the contract period versus the total enrollment

proposed at the time the rates were developed. CareFirst will notify the Group for any rate adjustments allowed under the terms of this Group Contract no later than 45 days prior to the effective date of the rate change.

EMPLOYEE ELIGIBILITY REQUIREMENTS The following employees (and their dependents) are eligible for coverage, as long as they meet the additional eligibility requirements stated in the Evidence of Coverage and any attachments thereto. All employees (including owners and partners) who are regularly employed on a full-time basis working at least 30 hours a week. (Seasonal employees, subcontractors, consultants or other persons issued 1099’s by the Group are not eligible.) All former employees and their dependents whose eligibility for group coverage has been extended due to COBRA requirements or the Maryland Continuation of Coverage provisions. Note: No individual is eligible under the Group's coverage both as a Subscriber and as a Dependent. If the Group employs both Spouses of a family (or both Domestic Partners, if applicable), they may not both have Individual + Adult Coverage or Family Coverage.

Page 27: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

CFMI/DN-VS ONLY GCA (R. 1/13) 4 HCR Small Groups ONLY

Specify as many of the following additional categories of employees or retirees as the Group wishes to cover, even if the Group does not currently have such individuals in the Group. NOTE: These individuals cannot be included in the total number of Eligible Employees for the Group.

YES NO Part time employees working at least 17.5 hours a week for more than six months each year. (Those working less than these required time periods are not eligible).

YES NO Domestic Partners of eligible employees or retirees.

EMPLOYEE EFFECTIVE DATES Coverage for current employees, other individuals currently covered if selected above, and former employees whose eligibility for group coverage has been extended due to COBRA requirements or the Maryland Continuation of Coverage Provisions, and their eligible dependents becomes effective on the date that the Group Contract becomes effective. Coverage for new employees is effective as stated below (if different for different classes of employees, state all in Other section):

On the date of employment On the first day of the month following the date of employment On the first of the month following thirty (30) of employment On the first of the month following sixty (60) days of employment

TERMINATION OF COVERAGE

Coverage for enrolled Subscribers and their enrolled Dependents terminates on the date stated below:

On the date on which the Subscriber’s employment or eligibility terminates On the last day of the month in which the Subscriber’s employment or eligibility terminates

AGE LIMITS FOR DEPENDENT CHILDREN

Groups with 50 or fewer enrolled employees:

Dependent children are covered until: End of the month of their 26th birthday. Groups with more than 50 enrolled employees:

Dependent children are covered until:

Select One End of the month of their 26th birthday. End of the calendar year of their 26th birthday. On the date of their 26th birthday. End of the month of their 26th birthday (must be over 26). End of the calendar year of their 26th birthday (must be over 26). On the date of their 26th birthday (must be over 26). Other ____________________________________________

(Specify; approval by CareFirst required; age limit must be age 26 or over) CareFirst Approval: Initials____ Date_______

GROUP’S RESPONSIBILITY TO EMPLOYEES

In any case in which the employee is responsible for a portion of the monthly premiums, the Group must:

1. Advise the employee of his/her eligibility for coverage under the Group Contract;

Page 28: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

CFMI/DN-VS ONLY GCA (R. 1/13) 5 HCR Small Groups ONLY

2. Advise the employee when s/he may enroll for such coverage in accordance with the provisions stipulated in this Application and the Group Contract including the Evidence of Coverage;

3. Advise the employee when coverage will commence based on the aforementioned

provisions and the date of completion of the enrollment form; 4. Advise the employee of the cost of such coverage to the employee and the method in

which payment is to be made; and 5. Obtain from the employee a completed enrollment form and a signed agreement by the

employee to pay the applicable portion of the monthly rates.

GROUP STATEMENTS The Group agrees that in the making of this Application, it is acting for and on behalf of itself and as the agent representative of its employees and COBRA participants and participants enrolled through the Maryland Continuation of Coverage provisions, and their dependents; and it is agreed and understood that the Group is not the agent or representative of CareFirst for any purpose of this Application or any Group Contract issued pursuant to this Application. The Group agrees to receive on behalf of its eligible employees, COBRA participants, and participants enrolled through the Maryland Continuation of Coverage provisions, and their dependents, the Evidence of Coverage including all attachments, and all relevant notices furnished by CareFirst, and to forward such materials to these individuals. This Group Contract Application is part of the Agreement between the Group and CareFirst. IMPORTANT NOTE: The Group's rate sheet which describes the benefits and corresponding rates for the coverage selected must be signed by the Group before coverage can be made effective. CareFirst reserves the right to revise the rates if the actual enrollment varies substantially from that used in the original rating or if applicable law or regulatory authority requires such revisions. Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. If the Group has any questions concerning the benefits and services that are provided by or excluded under the coverage for which the Group is applying, please contact a customer services representative before signing this Application. ACCEPTED FOR:

(Name of Organization) BY:

(Printed Name of Authorized Officer)

(Signature of Authorized Officer) Title: Date:

Page 29: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

CFMI/DN-VS ONLY GCA (R. 1/13) 6 HCR Small Groups ONLY

Broker (if applicable)

(Printed Name of Broker)

(Signature of Broker) Email Address: Broker ID#: __ Date: Effective Date of Group Contract: __

Page 30: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties
Page 31: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties
Page 32: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

COBRA SELECTION FORMFOR CONTINUATION OF GROUP COVERAGEWITH CAREFIRST BLUECROSS BLUESHIELD

OR CAREFIRST BLUECHOICE, INC.

The Consolidated Omnibus Budget Reconciliation Act of 1985, also known as “COBRA”, requires that a grouphealth plan sponsored by an employer who typically employs 20 or more employees offer employees and theirfamilies the opportunity for a temporary extension of health coverage (called “continuation coverage” or “COBRAcoverage”) at group rates, in certain instances where coverage under the plan would otherwise end (“qualifyingevents”). Certain employer-maintained group health plans are exempt from COBRA, including small-employerplans, church plans (or tax-exempt organizations controlled by or affiliated with a church), and government plans(the Public Health Service Act governs governmental plans and contains parallel provisions of the federal law).Generally, if a member qualifies for continued coverage, he or she must pay the full cost of the applicablecoverage during this period, and any applicable administrative fee. If the qualifying member wishes to continuecoverage beyond this period, he or she may apply directly to CareFirst BlueCross BlueShield or CareFirstBlueChoice, Inc. for direct pay non-group conversion coverage within 31 days after his or her continued groupcoverage ends. (Dental, drug and eye care programs are not available under the direct pay non-group conversioncoverage.)

In general, an employer must notify the health plan administrator within 30 days after an employee’s “qualifyingevent” – death, job termination, reduced hours of employment, or eligibility for Medicare. In cases of divorce,legal marital separation, or a child’s loss of dependent status, it is the employee or his or her family’s responsibilityto notify the health plan administrator within 60 days of the event. Once notified, the plan administrator then has14 days to alert the employee and his or her family members about applicable rights to elect COBRA coverage.In turn, the employee, spouse, and children have 60 days to decide whether to buy COBRA coverage. Pleasenote that neither CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc., nor their representatives actas the health plan administrator. This form is not an application for insurance. This form is for datacollection purposes only. The above description of COBRA and COBRA procedures is general in nature.

NAME OF PARTICIPANT(S): _____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

IDENTIFICATION NO.: ___________________________________________________________________________

SOCIAL SECURITY NO.: _________________________________________________________________________

PARTICIPANT’S ADDRESS: ______________________________________________________________________

HOME TELEPHONE NO.: ( )_______________ WORK TELEPHONE NO.: ( )_________________

GROUP NAME: ___________________________ GROUP NUMBER:_____________________________

Page 33: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

PARTICIPANT’S STATEMENT

I understand and agree that in the event I cease to be eligible for continuation of group coverage, I willimmediately notify the employer through whom I have continued coverage.

Signature of Participant and Date ____________________________________________________

TO BE COMPLETED BY PLAN ADMINISTRATOR

CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc.CareFirst Blue Cross Blue Shield and CareFirst BlueChoice, Inc. are independent licensees of the BlueCross and BlueShield

Association. Registered trademark of the Blue Cross and Blue Shield Association.’ Registered trademark of CareFirst of Maryland, Inc.

tott1. I HEREBY CERTIFY THAT THE PARTICIPANT HAS BEEN PROPERLY NOTIFIED OF ALL RIGHTS AND

RESPONSIBILITIES AS DICTATED BY FEDERAL STATUTE.

2. TYPE OF QUALIFYING EVENT: __________________________________________________________

3. DATE CONTINUATION OF COVERAGE BECOMES EFFECTIVE FOR THE PARTICIPANT: __________

4. $ __________ IS THE AMOUNT THAT THE PARTICIPANT HAS BEEN TOLD MUST BE REMITTED EACHMONTH FOR CONTINUATION OF GROUP COVERAGE.

5. CONTINUED GROUP COVERAGE MUST END NO LATER THAN: ______________________________

Signature of Plan Administrator and Date__________________________________________________

PLEASE RETURN THIS FORM TO:

CAREFIRST BLUECROSS BLUESHIELD / CAREFIRST BLUECHOICE, INC.ENROLLMENT & BILLING10455 MILL RUN CIRCLEOWINGS MILLS, MD 21117MAIL STOP 02-330

CUT5870-1S (3/02)

Page 34: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

SELECTION FORMFOR CONTINUATION OF GROUP COVERAGEWITH CAREFIRST BLUECROSS BLUESHIELD

OR CAREFIRST BLUECHOICE, INC.FOR THOSE GROUPS NOT ELIGIBLE FOR COBRA

This selection form is for continued group coverage in accordance with Maryland statute and Insurance Departmentregulations. These regulations enable you as an employee of the group or as a family member to continue your groupcoverage (including dental, drug or eye care coverage) for up to 18 months after you cease to be an eligible memberof the group, as long as you meet certain requirements. You must pay the full cost of your coverage during thisperiod. If you wish to continue coverage beyond this period, you may apply for non-group Conversion Coveragewithin 31 days after your continued group coverage ends. (Existing practices and policies for converting terminatedgroup coverage to non-group Conversion Coverage will apply. Dental, drug and eye care programs are not availableunder the non-group Conversion Coverage). Please note that neither CareFirst BlueCross BlueShield, CareFirstBlueChoice, Inc., nor their representatives act as the health plan administrator. This form is not anapplication for insurance. This form is for data collection purposes only.

NAME OF PARTICIPANT(S): _____________________________________________________________________

IDENTIFICATION NO.: ___________________________________________________________________________

SOCIAL SECURITY NO.: _________________________________________________________________________

PARTICIPANT’S ADDRESS: ______________________________________________________________________

HOME TELEPHONE NO.: ( )_______________ WORK TELEPHONE NO.: ( )_________________

GROUP NAME: ___________________________ GROUP NUMBER:_____________________________

PARTICIPANT’S STATEMENTI certify that, to the best of my knowledge and belief, the following statements are true:1. My group coverage:

a) has been in force for at least three months;b) did/will not terminate as a result of my failure to pay subscription charges (or any applicable portion).

2. My group coverage did/will not terminate because of my:a) eligibility for or enrollment under Medicare;b) attainment of any limiting age specified in the group contract.

3. I am not covered under or eligible for coverage under:a) a health maintenance organization;b) another group policy.

I understand and agree that in the event I cease to be eligible for Continuation of Group Coverage for any of thereasons set forth in items 2 and 3 above, I must notify my former employer immediately.

Signature of Participant and Date ________________________________________________________

Page 35: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

TO BE COMPLETED BY PLAN ADMINISTRATOR

1. Date of termination of participant’s employment: __________________________________________2. $ ________ is the amount I will collect and remit each month for the continuation of group coverage for this

participant.

Signature of Plan Administrator and Date _________________________________________________

PLEASE RETURN THIS FORM TO:

CAREFIRST BLUECROSS BLUESHIELD / CAREFIRST BLUECHOICE, INC.ENROLLMENT & BILLING10455 MILL RUN CIRCLEOWINGS MILLS, MD 21117MAILSTOP 02-330

CUT5862-1S (3/02)

CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield andCareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the BlueCross and Blue Shield Association. ’ Registered trademark of CareFirst of Maryland, Inc.

Page 36: Maryland MSGR (2-50) New Case Checklist All Jurisdictions Blue Choice Blue Preferred Bro… · Maryland MSGR (2-50) New Case Checklist All Jurisdictions Except Montgomery and PG Counties

AUTHORIZATION AGREEMENT FORPREAUTHORIZED PAYMENTS

Company Name______________________________________________________

Company ID Number_________________________________________________

I (we) hereby authorize BENEFIT DESIGN GROUP, hereinafter called COMPANY, to initiatedebit entries to my (our) Checking Account indicated below at the depository named below,hereinafter called DEPOSITORY, to debit the same to such account.

Depository Name____________________________________________________

Branch_____________________________________________________________

City_____________________________State______________Zip______________

Routing Number______________________ Account Number_________________

This authorization is to remain in full force and effect until COMPANY has received writtennotification from me (or either of us) of its termination in such time and in such manner as toafford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

Name (s)_____________________________________________________________

ID Number___________________________________________________________

Signature__________________________________Date______________________

This arrangement does not change the premium due dates specified in the policy and it does notextend any of the grace or late periods for paying these premiums. The policy or policies will beplaced on withhold care at the end of the grace or late period if the premium remains unpaid.This could occur if balances in your account were not sufficient to cover the debit amount.

BDG may stop the arrangement by written notice to you. The arrangement ends on the day BDGmails the notice.

If this agreement ends you will still be responsible for unpaid premiums which remainoutstanding.

PLEASE ATTACH A COPY OF A BLANK VOIDED CHECK.