Fillable Small Group Business Application

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Small Group Business Application

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The Small Group Business Application form is 3 pages long and contains:

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  • 55 check-boxes
  • 118 other fields

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______________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
If Yes, please attach a completed Controlled Group Information form (X18207) and list ALL afliated entities that are part of the “single
employer”, by name, federal tax ID/EIN and location (city and state) including those NOT included in this Application for coverage.
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Small Group Business Application
Complete this Application in it’s entirety in blue or black ink.
Do not use pencil or highlighter.
Group Submission Status
New Business Effective Date:_____________________
Existing Business Change (Check all that apply):
Add or Change Medical Product (include Application(s) or
a list of subscribers to be transferred)
Add or Change Ancillary Product at Renewal: Dental Vision
Midyear Upsell Dental Vision
Other Changes (Check all that apply):
Group Name/Address
Ownership Client Eligibility
Complete all sections that apply and include
explanations in the Comments section on page 3.
Employer/Group Information
Legal Name DBA (if applicable) Federal Tax ID/EIN
Physical Address (No P.O. Box) City State County ZIP
Mailing Address
Same as physical address above
City State County ZIP
Authorized Representative Title
Telephone Number Email Address
( )
Nature of Business SIC Code Date Business was
Established
NOTE:
If correspondence and billing contacts are different, attach a sheet of paper with names, titles, addresses, telephone numbers.
Employer/Group Information
1. Is the headquarters of the Employer/Group in Minnesota? Yes No If No, provide the address of headquarters:
2. Does the Employer/Group have any leased, temporary, seasonal, or independent contract employees who are applying for
this group coverage? Yes No If Yes, provide names: ____________________________________________________________
3. Does the Employer/Group have an Individual Coverage Health Reimbursement Arrangement (ICHRA)? Yes No
If Yes, please provide the class(es) of employees who are eligible for the ICHRA. ______________________________________________
4. Does the Employer/Group have union employees who have coverage through a separate Union organization? Yes No
(If Yes, please attach a copy of union bargaining agreement or health carrier invoice that identies all covered union employees.)
5. Is the above Employer/Group afliated with other entities that are to be treated as a “single employer,” under the Internal
Revenue Code section 414 aggregation rules (e.g., controlled group corporations, entities under common control)?
Yes No
Please Note: A letter from the Employer/Group’s legal counsel or tax accountant may be requested. Companies that are not aggregated
must apply for separate group health plans, by completing individual Small Group Business Applications.
6. Does the Employer/Group currently have a group medical plan? Yes (Current Carrier Name _________________ ) No
7. Plan Sponsorship: Private Entity (ERISA) Government Entity Church Entity Public Schools
8. Ownership Type: Partnership Sole Proprietorship Corporation_________ Other ________________________
State of Inc.
List the name of each partner or owner below:
A.
B.
_____________________________________________________ C.
D.
______________________________________________________
_____________________________________________________ ______________________________________________________
Blue Cross
®
and Blue Shield
®
of Minnesota and Blue Plus
®
are nonprot independent licensees of the Blue Cross and Blue Shield Association.
F10538R06 (04/21) 1
Enrollment Information for All Products
1. Does the Employer/Group wish to cover domestic partners? Yes No
2. Number of hours employees must work per week to be considered eligible for coverage:______________________________________
3. New employees are eligible to enroll on (select one): Hire Date
Next Day Following : 30 Days 60 Days 90 Days
First Day of Next Month Following: Hire Date 30 Days 60 Days
4. I conrm. Check this box to conrm that neither Employer/Group nor any employee or enrollee will receive any premium
or cost-sharing assistance for this policy, directly or indirectly, from any ineligible third party described on page 4.
5. Eligibility for coverage of certain benets under this contract and enrollment in plans is subject to group participation
requirements based on the group’s size. The following information will be used to determine group eligibility for medical, dental
and/or vision plan(s). Please enter applicable employee counts below:
Number Eligible
Number Enrolling
Number Waiving
Active Employees COBRA Other (e.g., retiree)
Medical Vision Dental Medical Vision Dental Medical Vision Dental
Contribution(s)
Employer Medical Contribution(s) Employer Dental Contribution(s) Employer Vision Contribution(s)
Employee* Dependents Employee Dependents Employee Dependents
Percentage Percentage Percentage
*The Employer/Group is required to contribute at least 50 percent of the employee’s total monthly medical premium.
MSP and ACA Employee Counts
Question 1: For Medicare Secondary Payer (MSP) question, include all employees, regardless of the number of hours worked.
Question 2: For purposes of determining group size, the number of full-time employees an Employer/Group has in the previous calendar year
determines whether the employer is small or large for the next year.
Important note: If the Employer/Group has afliated companies that are to be treated as a “single employer,” refer to the following
information. Please aggregate all employees collectively for all related entities that are part of a controlled group of corporations in the
Employer/Group with employees of groups that are part of (a) controlled group of corporations, (b) partnership, proprietorship, etc.
under common control or (c) afliated service group. Refer to Internal Revenue Code Sections 52(a) and (b) and 414(m) for MSP
purposes (question 1) and Internal Revenue Code Section 414 for ACA market size determination (question 2).
MSP Question
1. During this calendar year, how many full-time and part-time employees have been employed with the Employer/Group
for at least 20 weeks or more?
• If 20 weeks haven’t passed this year, answer using last year’s information.
• Include owners, partners and ofcers and full-time, part-time, seasonal, temporary, and union employees.
• Do not include independent contractors (1099), retirees, and COBRA participants.
The Employer/Group employed 1–19 total employees.
The Employer/Group employed 20–99 total employees.
The Employer/Group employed 100 or more total employees.
See Centers for Medicare & Medicaid Services (CMS) guidelines for more information.
ACA Market Size Employee Count Question
2. Total number of full-time employees working 20 hours or more per week in the previous calendar year _____________
• Union employees for whom coverage is separately purchased under a collective bargaining agreement, international
employees, and seasonal employees working 120 days or fewer in a year should be excluded from the total employee count.
F10538R06 (04/21) 2
____________________________________________________________ _________________________________________
Product Information
Medical:
Select plan(s)
NETWORK and PLAN NUMBER
PLAN
BlueAccess
SM
(Aware
®
Network)
High Value
(High Value Network)
AdvanceHealth
(AdvanceHealth Network)
Bronze $8,700 Plan (not HSA compliant)
618
550
HSA Bronze $7,050 Plan
624 656
HSA Silver $6,100 Plan
628 561
HSA Silver $5,250 Plan
640 554
HSA Silver $4,250 Plan
645 660
Silver $4,000 Plan
627
552
336
Copay Silver $4,000 Plan
626 560 326
HSA Silver $3,850 Plan (non-embedded)
642
555
Silver $3,000 Plan
625 551 335
HSA
Silver $3,000 Plan
632 553
Silver $2,750 Plan
623 662 334
HSA Gold $2,500 Plan (non-embedded)
653 558
Copay Gold $2,000 Plan
652 557 329
Copay Gold $1,000 Plan
637 664 328
Copay Gold $500 Plan
635 556 327
Copay Platinum No Deductible Plan
655 559 330
Dental: Product Description _______________________________________________________________________________________
Vision: Product Description _______________________________________________________________________________________
Producer of Record
Producer must complete this section and sign below to be assigned as the Agent of Record and act on behalf of this Employer/Group.
Agency Name Agency Code
Producer Name Producer Number Producer Telephone Number
( )
Producer Email Address Blue Cross Sales Representative
I attest I have reviewed the completed Application and certify I have met the requirements described in the Blue Cross and Blue Shield of Minnesota
Agent Code of Conduct and my agent/agency agreement with Blue Cross. I further understand that I may not accept risk or pass on any eligibility
requirements, make or alter the terms of the Application or policy or waive any contractual rights or requirements. I agree to retain a copy of the
submitted Application for my records and to provide a copy of the submitted Application to Blue Cross upon request.
Producer Signature Date
Comments
Pediatric dental is an essential health benet available for purchase through a separate contract. For additional information on available
pediatric dental plans, please visit www.mnsure.org. Dental benet coverage is provided by an independent company.
Summary of Benets and Coverage
A Summary of Benets and Coverage (SBC) is available for medical only to assist the Employer/Group in understanding the details
of the plan. A Uniform Glossary of insurance-related terms is also available. The SBC and/or the Uniform Glossary are accessible
at bluecrossmn.com or available free of charge when requested by contacting your Agent or Broker, or by calling the Group Leader Line
at 1-877-293-7035.
F10538R06 (04/21) 3
_________________________________________________ _________________________________________________
_________________________________________________ __________________________________________________
Authorized Signature
I, the undersigned, hereby represent that I have the authority to bind the Employer/Group (“Employer”) and to make this Application for group
medical, dental, and/or vision coverage to Blue Cross and Blue Shield of Minnesota and Blue Plus (“Blue Cross”).
Employer understands and agrees that: (i) no coverage will become effective until the date specied by Blue Cross after this Application has been
approved by Blue Cross at its home ofce; (ii) the information provided in this Application is complete and true and is the basis for the coverage to
be issued, and that material misrepresentations of facts could result in termination of coverage; and (iii) Employer will timely provide information
as requested by Blue Cross with respect to its continued eligibility for coverage; and (iv) Applications for each eligible employee and dependent
must receive prior approval by Blue Cross before coverage becomes effective; and (v) no coverage will be effective until the rst monthly charges
have been paid in full. Blue Cross cannot use the misrepresentation to cancel coverage that has been in effect for two (2) years or more. This
time limit does not apply to fraudulent misrepresentations.
Employer agrees to allow Blue Cross to review any of the Employer’s records that Blue Cross deems necessary to approve this Application.
It is also agreed that no agent or broker can approve this Application, set an effective date, or waive or alter any provision of this Application
or any contracts issued. It is agreed that Employer will remit monthly charges for all covered employees and that failure to remit the required
charges by the due date will result in termination of coverage.
Employer understands that neither the medical plan nor the dental plan includes coverage for the pediatric dental essential health benet and
that Blue Cross has made the Employer aware of pediatric dental coverage available for purchase. For additional information on available
pediatric dental plans, please visit mnsure.org.
Employer understands that any need for additional information may impact the effective date of coverage, the rates quoted, or the ability to offer
the group coverage requested. Employer acknowledges that Blue Cross has the right to adjust charges: (i) on a monthly due date for changes
in the status of the group, including changes to eligibility or enrollment; (ii) on a monthly due date for fraud or misrepresentation by the contract
holder, employees, or dependents; (iii) on an annual renewal; or (iv) on any date the provisions of the contract are changed. Written notice will
be mailed to the contract holder’s last address on our records at least 30 days prior to the date the adjustment becomes effective.
Employer understands that all medical participation and contribution guidelines of Blue Cross must be satised in order for the Employer to
be eligible for the coverage requested. Employer acknowledges that medical coverage may be nonrenewed if participation is less than 75
percent or Employer does not contribute at least 50 percent of each employee’s premium. Employer understands that all Blue Cross dental
and/or vision guidelines must be satised in order for the Employer to be eligible for the dental and/or vision coverage requested. Employer
acknowledges that dental and/or vision coverage may be nonrenewed if participation requirements are not met. Blue Cross understands that
rates for medical, dental, and/or vision are not binding unless approved by Blue Cross.
Blue Cross may, in its sole discretion and in accordance with applicable law and regulatory guidance, decline to accept premium and cost-
sharing payments made directly or indirectly by ineligible third parties. “Ineligible third parties” include any person or entity from which Blue
Cross is not required by law to accept such third-party payments. This may include, for example, commercial entities, health care providers and
suppliers, and other persons or entities with direct or indirect pecuniary interests. “Payments” include those made by any means, for example:
cash, check, money order, credit card payment, electronic fund transfer. If you have questions about this third-party payment policy or whether
Blue Cross will accept premium and/or cost-sharing payments made by a specic person or entity, please contact Blue Cross.
By providing an email address, Employer agrees to receive communications and/or marketing materials related to the plan(s) selected and
products offered by or made available from Blue Cross and its afliates. Employer may unsubscribe or change the email address at any time by
following the instructions included in each email communication.
By providing a phone number, Employer expressly consents to accept and receive communications and /or marketing materials related to the
plan(s) selected and products offered by or made available from Blue Cross and its afliates, via text message or voice call to the mobile device
and to the cellular/mobile telephone number(s) provided to Blue Cross.
Warning: Email and text messaging transmission cannot be guaranteed to be secure or error-free as information could be intercepted,
corrupted, lost, destroyed, arrive late or incomplete, or contain viruses. As the recipient of an email or text message from an unsecured email or
device, Blue Cross does not accept liability for any errors or omissions in the contents of this message, which arise as a result of email or text
message transmission.
Employer acknowledges that it is not applying for this coverage in connection with an offer from any ineligible third party to pay any premium or
cost sharing related to this plan.
Employer understands and agrees by signing below, the Employer is granting authority to to the Producer of Record designated above to sign
any of Blue Cross’s required authorization form(s) granting user access or entitlements to Blue Cross portals. Employer further understands
and acknowledges that this authorization will remain in effect until Employer noties Blue Cross to revoke authorization for the designated
Producer of Record. If this Application is completed as an electronic or online Application, both parties agree to conduct this transaction
electronically.
Authorized Representative Name Authorized Representative Title
Authorized Representative Signature Date
Include a copy of the most recent Minnesota Quarterly Wage Detail Report and a bill copy if the Employer/Group has current
group coverage.
F10538R06 (04/21) 4
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Small Group Business Application

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Completed 20 April 2022

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