Fillable EMPLOYER APPLICATION Colorado Small Group 1 ABOUT BUSINESS (City of Oakland)

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EMPLOYER APPLICATION Colorado Small Group 1 ABOUT BUSINESS (City of Oakland)

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Page 1 of 6
KFHP-KPIC-APP-CO-2019-1
Small Group 60990509 January 2019
Colorado Small Group
EMPLOYER APPLICATION
Please complete all information.
We can’t process incomplete applications.
Requested effective date
3A
EMPLOYER ELIGIBILITY
In determining the number of employees or eligible employees, affiliated companies that are eligible to file a combined tax return for purposes of state taxation
shall be considered 1 employer and must apply as 1 employer.
Is your company affiliated with another company and eligible to file a combined tax return? Yes No If Yes, please provide below:
Company name
Affiliate Subsidiary
Address City State ZIP
Federal tax ID number Phone
( ) –
/ /
2 OTHER MEDICAL COVERAGE
Does your company or affiliated company(ies) have or has it ever had group coverage directly through Kaiser Permanente? If Yes, please provide the group
number and company name.
Yes No Group #: Company name:
Does your company currently have active group health coverage?
Yes No Name of carrier: Renewal date: / /
3B
EMPLOYEE COUNT
Please provide the total number of employees (full-time and part-time).
Total ______________ Authorized company signer’s initials ______________
Note: If the total number of employees noted above is 100 or fewer, skip the following and go to section 3C.
If your total number of employees noted above is more than 100, please provide the total number of full-time and full-time-equivalent employees on the line
below. For information on calculating the number of full-time and full-time-equivalent employees (FTE),* refer to your legal counsel. To qualify for small group
coverage, your company must have at least 1 but no more than 100 full-time and full-time-equivalent employees on at least 50% of the previous calendar
quarter or previous calendar year.
Total ______________ Authorized company signer’s initials ______________
1 ABOUT BUSINESS
Legal business name
(as stated on your local business license, quarterly wage and tax report, corporate or partnership documents)
Doing business as (DBA)
Physical street address (no P.O. boxes) City State ZIP County
Phone
( ) –
Fax
( ) –
Type of business
Corporation Sole proprietorship Partnership Limited liability company (LLC) Other:
In business since (mm/dd/yyyy)
/ /
Federal tax ID (EIN) number SIC code (4 digits) Website
All employees must be covered by workers’ compensation, unless not required to be covered by law. You’re not eligible to apply for coverage if you don’t have
workers’ compensation, unless you’re exempt. I attest that the following information is correct.
Yes, my company has workers’ compensation. Pending
If Yes or Pending, name of carrier: ______________________________________ Policy # __________________________________________
(indicate unknown or pending as applicable)
Exempt from providing workers’ compensation for the following reason: _____________________________________________________________
Page 2 of 6
KFHP-KPIC-APP-CO-2019-1
Small Group 60990509 January 2019
Colorado Small Group
EMPLOYER APPLICATION
Business name (please print):
6 ERISA STATUS
Is your company subject to ERISA?
3
Yes No If you do not select an answer, we will record your status as Yes.
3
ERISA is a federal law that sets minimum standards for employee benefit plans established by private employers and employee organizations. Many group
health plans are subject to ERISA, although government and church plans generally are not. If you’re unsure of your group health plan’s ERISA status, we
recommend that you consult with your financial or legal advisor before responding.
8 RENEWAL DELIVERY PREFERENCE
We’ll deliver your Kaiser Foundation Health Plan of Colorado (KFHPCO)/Kaiser Permanente Insurance Company (KPIC) renewal(s) online in a PDF file at
account.kp.org unless you indicate below that you’d like your renewal(s) mailed to you.
I want to receive my renewal(s) by mail.
7 EMPLOYER PREMIUM CONTRIBUTION
Your contribution to coverage can be a percentage or a fixed dollar amount.
Percentage of the premium is based on the following (select 1 only):
Lowest plan offered All plans offered Specific plan offered:
Employer contribution: % per employee % per dependent (optional)
Employer contribution (fixed $): $ per employee $ per dependent (optional)
5 CONTINUATION COVERAGE
Did your company employ 20 or more employees for at least 50% of the workdays of the preceding calendar year (January through December), making it
subject to COBRA? Yes No
4 DOMESTIC PARTNER COVERAGE
Do you wish to select Domestic Partner Coverage? Yes No
If Yes: Same Sex Domestic Partner Only
Opposite Sex Domestic Partner Only
Same and Opposite Sex Domestic Partner
Employees who are enrolling a domestic partner must submit a domestic partner affidavit along with their Colorado Uniform Application.
3C
ELIGIBLE AND ENROLLING EMPLOYEES
Please provide the total number of eligible employees. Total ______________ Authorized company signer’s initials ______________
Please provide the total number of enrolling employees. Total ______________ Authorized company signer’s initials ______________
Hours per week employees must work to be eligible for coverage:
1
______________
Employee only coverage?
2
Yes No
1
Minimum 24+ hours per week
2
If you have 50 or more full-time or full-time-equivalent employees, you must offer dependent coverage. For more information about Employer Shared
Responsibility, see section 4980(H)(C)(2) of the Internal Revenue Code.
Page 3 of 6
KFHP-KPIC-APP-CO-2019-1
Small Group 60990509 January 2019
Colorado Small Group
EMPLOYER APPLICATION
Business name (please print):
11 EMPLOYEE RATE INFORMATION
Kaiser Permanente is now offering composite premium rating in addition to member-level rating.
Composite rating uses a four-tier coverage structure: Employee Only; Employee and Spouse; Employee and Child(ren); and Employee, Spouse and Child(ren).
The total member-level premium for a group is calculated then allocated to enrolled employees, based on the employee’s family composition.
Member-level rating is based and calculated on a variety of factors, such as:
• Benefit plan(s) selected
• Member demographics
• Geographic location
Because rates are calculated at the individual member level, the individual members of a particular group’s plan may experience rate changes that differ
from the group’s overall change.
Please select the rating methodology for your group:
Composite rating
Age-banded rating
10 BILLING CONTACT INFORMATION
The billing contact is the person within your company to whom billing statements are addressed. This person will have access to group information, but isn’t
authorized to sign the group agreement or to make contractual changes to your account. Only 1 billing contact is allowed.
Check here if same as contract signer.
First name MI Last name
Street address City State ZIP
Office phone
( ) –
Ext. Fax
( ) –
Cellphone
( ) –
Email How should we correspond with this person?
(select 1 only)
Email Mail
9 CONTRACT SIGNER INFORMATION
There’s only 1 contract signer. This principal person is responsible for signing the group agreement, providing renewal information, and authorized to make
membership or contractual changes to your account. This address will become the group mailing address, if different from the business physical address.
First name MI Last name Title
Street address (mailing) City State ZIP
Office phone
( ) –
Ext. Fax
( ) –
Cellphone
( ) –
Email How should we correspond with this person?
(select 1 only)
Email Mail
Page 4 of 6
KFHP-KPIC-APP-CO-2019-1
Small Group 60990509 January 2019
Colorado Small Group
EMPLOYER APPLICATION
Business name (please print):
12 MEDICAL PLANS
PLAN INFORMATION
1
Groups with at least 3 enrolled employees can select up to 3 plans if each of those employees is on a different plan.
HMO KP CO Platinum 0/20 RX Copay
†
KP CO Gold 0/30 RX Copay
†
Deductible
HMO
KP CO Platinum 250/20
KP CO Gold 500/30 RX Copay
†
KP CO Gold 1000/30
KP CO Gold 1500/30
KP CO Silver 2500/45
KP CO Silver 3500/50 RX Copay
†
KP CO Silver 5000/10
KP CO Bronze 5750/50 RX Copay
†
KP CO Bronze 7500/50
Deductible
HMO Plus
KP CO Gold DHMO Plus 1250/35
KP CO Gold DHMO Plus 2000/40
KP CO Silver DHMO Plus 3000/45
KP CO Silver HSA Plus 3500/30%
Consumer
Directed
KP CO Gold 1500/30/HSA
KP CO Silver 2750/30/HSA
KP CO Silver 4000/30/HSA
KP CO Bronze 5250/50/HSA
KP CO Bronze 6500/100%/HSA
Will Kaiser Permanente administer
your HSA Plan?
Point of
Service
2
KP CO Platinum POS 0/25
KP CO Gold POS 1500/30
KP CO Silver POS 3000/45 RX Copay
†
KP CO Bronze POS 5750/60 RX Copay
†
FOR OUT-OF-AREA EMPLOYEES
3
PPO KP CO Silver PPO 2500/50 RX Copay
†
The KP CO Silver PPO 2500/50 plan doesn’t include coverage of pediatric dental services as required under the Affordable Care Act. The Colorado Division of
Insurance requires carriers to be reasonably assured that a consumer has or will purchase such coverage.
KP SELECT
1
The following plans are only available to employees living in qualified zip codes in Colorado Springs
HMO KP Select CO Platinum 0/20 RX Copay
†
KP Select CO Gold 0/30 RX Copay
†
Deductible
HMO
KP Select CO Platinum 250/20
KP Select CO Gold 500/30 RX Copay
†
KP Select CO Gold 1000/30
KP Select CO Gold 1500/30
KP Select CO Silver 2500/45
KP Select CO Silver 3500/50 RX Copay
†
KP Select CO Silver 5000/10
KP Select CO Bronze 5750/50 RX Copay
†
KP Select CO Bronze 7500/50
Consumer
Directed
KP Select CO Gold 1500/30/HSA
KP Select CO Silver 2750/30/HSA
KP Select CO Silver 4000/30/HSA
KP Select CO Bronze 5250/50/HSA
KP Select CO Bronze 6500/100%/HSA
Will Kaiser Permanente administer
your HSA Plan?
†
These plans cover all prescription drugs at copay, however many other plans also cover brand and generic drugs at copay.
On or after 9/23/2012, Employer Groups and Insurance Carriers are required to provide the SBC to plan participants and beneficiaries. Please visit account.kp.org
(Select “Plan” tab, then “Summary of Benefits” link) to download or print your Summary of Benefits and Coverage (SBC).
1 `
The Colorado Division of Insurance requires carriers to notify you of the following: This policy doesn’t provide any dental benefits to individuals age nineteen (19) or older. This
policy is being offered so the purchaser will have pediatric dental coverage as required by the Affordable Care Act. If you want adult dental benefits, you’ll need to buy a plan
that has adult dental benefits. This plan won’t pay for any adult dental care, so you’ll have to pay the full price of any care you receive.
2
Kaiser Foundation Health Plan of Colorado, Inc., underwrites the In-Network Tier and Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health
Plan, underwrites the Out-of-Network (Non-Participating Provider) Tier of the Point-or-Service (POS) Plan.
3
The PPO Plans are fully underwritten by KPIC and are only available to out-of-area employees.
Page 5 of 6
KFHP-KPIC-APP-CO-2019-1
Small Group 60990509 January 2019
Colorado Small Group
EMPLOYER APPLICATION
Business name (please print):
13 MEDICARE
Effective January 1, 2006, Medicare Part D prescription drug coverage is available to Medicare eligible retirees/employees. Small Business Group employers
have 2 options for Medicare Part D pharmacy benefits. Employers may elect to enroll Medicare eligible retirees/employees in Medicare Part D pharmacy
through Kaiser Permanente, or apply for the Group Retiree Drug Subsidy from the Centers of Medicare and Medicaid Services (CMS).
Choose one: Elect to enroll our Medicare eligible retiree/employees in Medicare Part D.
Elect to apply for the Group Retiree Drug Subsidy for our Medicare eligible retiree/employees.
Our group doesn’t currently have any Medicare eligible retiree/employees.
Some Kaiser Permanente medical plans may not meet the Medicare Part D creditable coverage requirements. Please consult your broker or
Kaiser Permanente sales representative for guidance.
14 IMPORTANT INFORMATION – PLEASE READ CAREFULLY
This is an application for coverage only. No contract for coverage will exist until Kaiser Foundation Health Plan of Colorado (KFHPCO) or Kaiser Permanente
Insurance Company (KPIC) has completed its review and communicated to the business applicant or the applicant’s broker that the application has been accepted
and a group health plan contract/group policy will be issued.
15 FOOTNOTE INFORMATION
* Full Time Equivalent employees is calculated by counting the number of people who worked an average of 30 or more hours per week. Then add to this amount
the number of hours worked per week by non-full time employees divided by 30. You may exclude seasonal employees that work 120 days or fewer per year.
16 AUTHORIZED AGENT/BROKER OF RECORD FOR KAISER PERMANENTE
To the best of my knowledge and belief, employment and other information on this application is complete and accurate. I acknowledge that I represent
and am acting on behalf of my client and not for, or as, an employee of Kaiser Foundation Health Plan, or KPIC. I’ve explained the benefits and limitations
of coverage and advised my client not to terminate any existing coverage until receiving written notice that the coverage being applied for under the new
program has been approved. I understand that I have no right to bind this coverage, or to alter terms of the insurance.
Agent name License number
Phone
( ) –
Fax
( ) –
Cellphone
( ) –
Email
Firm name EIN/TIN Kaiser Permanente broker firm ID
Street address City State ZIP
Agent/broker signature
X
Date
General agency
Centerstone dba BenefitMall TIN 954-018229
Page 6 of 6
KFHP-KPIC-APP-CO-2019-1
Small Group 60990509 January 2019
Colorado Small Group
EMPLOYER APPLICATION
Business name (please print):
17 AGREEMENT AND SIGNATURE
As a company principal/corporate officer, having authority to contract with KFHPCO and KPIC, I agree that:
• Prepaid monthly premiums will be posted to Kaiser Permanente’s account by the due date on the Kaiser Permanente billing statement.
• My company will use employee enrollment application forms provided or approved by KFHPCO and KPIC for new employees.
• The eligibility data provided by my company to Kaiser Permanente will include coverage effective dates for my company’s employees that
correctly account for eligibility in compliance with the waiting period requirement in the Affordable Care Act and federal regulations, which
require that waiting periods not exceed 90 days. My company acknowledges that the effective date of coverage for new employees and their
eligible family dependents won’t exceed the waiting period established by my company.
• My company will abide by the contract provisions.
I attest that my company meets the definition of “small employer” as defined by applicable federal and state law. I have a minimum of 1 W-2
employee (excluding the owner, spouse, or legal domestic partner) and attest that the minimum participation requirement of eligible employees
are covered by group coverage. I agree to abide by the Kaiser Permanente deductible funding policy, which doesn’t permit directly funding or
reimbursing employees for any deductibles, coinsurance, or copays, except for our designated HRA plans, in accordance with the federal tax laws
for HDHP/HSA plans or PPO medical plans.
I attest that my company isn’t participating in a large group trust and agree not to participate while enrolled under Kaiser Permanente small
business coverage.
I understand that a Summary of Benefits and Coverage (SBC) for each of my medical plans is available at account.kp.org. I agree to provide my
eligible employees with SBCs for any plan(s) I have chosen or change to in the future.
I understand that the KP CO PPO medical plan doesn’t include the pediatric dental essential health benefit coverage required by the Affordable
Care Act. For any employee who’s enrolled in this plan, I have or will purchase such coverage separately.
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company
or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for
the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado Division of Insurance within the department of regulatory agencies.
Authorized company signer (please print name) Title (please print)
Signature required for all Kaiser Permanente Plans
X
Date
COLORADO INSURANCE LAW REQUIRES ALL CARRIERS IN THE SMALL GROUP MARKET TO ISSUE ANY HEALTH BENEFIT PLAN IT MARKETS
IN COLORADO TO SMALL EMPLOYERS OF 1-100 ELIGIBLE EMPLOYEES UPON THE REQUEST OF A SMALL EMPLOYER TO THE ENTIRE SMALL
GROUP, REGARDLESS OF THE CLAIMS EXPERIENCE OF OR ANY HEALTH STATUS RELATED FACTOR OF THE SMALL EMPLOYER AND ITS
EMPLOYEES AND THEIR DEPENDENTS IN THE GROUP.
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EMPLOYER APPLICATION Colorado Small Group 1 ABOUT BUSINESS (City of Oakland)

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