HomeMy WebLinkAbout000180.tiff APPLICATION FOR a
GROUP COVERAGE
O
00rom FBlueAdvantage
® ® MO Colorado
An Independent Licensee of the Blue Cross and Blue Shield Association
18n
•
an cc, BlueAdvantage Application For BlueAdvantage
C2:67 From HMO Colorado' INTERNAL USE ONLY
I An Indepaident Licensee of the Blue Cron
GROUP NUMBER ANNIVERSARY MONTH CONTRACT EFFECTIVE DATE
• • ® and Blue Shield Association
8278 3NuvH�Y I - 1 -9 7
PLEASE PRINT FIRMLY TO ENSURE THAT ALL COPIES ARE LEGIBLE. DO NOT TYPE—DO NOT TEAR FORM APART
Application for BlueAdvantage(Application)group coverage is hereby made for eligible Employees of the Employer. If this Application is
approved by HMO Colorado and Blue Cross and Blue Shield of Colorado(if applicable),this coverage will be issued to:
W a Lb COON T-y 6 ov -a-g-_N M.6N i
("THE EMPLOYER"—CORRECT LEGAL NAME OF ACCOUNT)
9is - toil' S-reeE , Ee-cy, Co 00 Si
(PHYSICAL ADDRESS-STREET,CITY,STATE,ZIP CODE)
(MAILING ADDRESS-IF DIFFERENT)
NOTE: "We,""Us,"and"Our"refer to HMO Colorado.For group sizes of 51 or more Employees,BlueAdvantage is federally qualified in
Adams,Arapahoe,Boulder,Clear Creek,Crowley,Denver,Douglas,El Paso,Fremont,Gilpin,Huerfano,Jefferson,Lorimer,Otero,Pueblo,
Miler and Weld counties.For groups with 51 or more employees,counties not listed are not federally qualified.For group sizes of 50 or fewer
Employees,BlueAdvantage is a not a federally qualified HMO product.When the product is not federally qualified,BlueAdvantage coverage
can differ from those required by federal HMO laws and regulations.'We', "Us", and"Our"also refers to Blue Cross and Blue Shield of
Colorado if coverage is provided for BlueAdvantage Custom Plus coverage.
IN CONSIDERATION of the submission of this Application by the Employer,approval thereof by us,and of the payment of premiums in
accordance with the Group Master Contract(Contract),we agree to provide group coverage as described in the Contract,the Benefit Booklet,
and this Application and the Addendum to the Application for BlueAdvantage(Addendum),for any eligible enrolled Employees and eligible
enrolled dependents,and the Employer agrees to abide by the terms,conditions,and limitations contained in such documents.
GENERAL AGREEMENT
1. NATURE OF BUSINESS(please be specific): e-OVNrY 6 over-N AAEad'r
2. Do you have current coverage in force? gYes O No,if"Yes"do you intend to cancel that coverage? X'Yes O No. If you are applying
for or retaining other group health coverage in addition to this coverage on some or all Employees specify coverage(s),Carrier,amounts,
and give details:
3. Do you intend to enroll retirees under this group health Plan?(Retirees may enroll for coverage if there are 51 or more Employees
•
enrolled under this coverage.) O Yes O No If"Yes,"give details:
4. CONTRIBUTION—The Employer will be required to contribute a minimum of 50%toward the Employee's single or 50%of the
Employees portion of the family-cost of membership premiums. The Employer will contribute the amount as stated on the Addendum.
5. PREMIUMS—It is understood that the premiums quoted may change based on the actual enrollment of the group.Premiums will
• be billed by us monthly,and will be reviewed in accordance with the Contract.
6. CLASSIFICATION OF EMPLOYEES ELIGIBLE—All full-time Employees of the Employer who are regularly working the number
of hours per week as stated on the Addendum,subject to Federal,State,and FICA withholdings,and verifiable by payroll records. If
the Employer reduces the working hours of such Employees to less hours per week than stated on the Addendum,coverage will be
continued for such Employees and their dependents under the same conditions and for the same premium,if the following conditions
are met and the Employer so certifies:
(a) The covered Employee has been continuously employed as a full-time Employee of the Employer and has been insured under the
group Contract,or under any group Contract providing similar benefits which said group Contract replaces,for at least six months
immediately prior to such reduction in working hours;
(b) The Employer has imposed such reduction in working hours due to economic conditions;and
(c) The Employer intends to restore the Employee to a full work week schedule as soon as economic conditions improve.
7. ENROLLMENT PERCENTAGE REQUIREMENTS—For all size groups to apply for and retain group coverage and rates if we are
the sole carrier,the Employer agrees to maintain the following enrollment percentage requirements,based on TOTAL ELIGIBLE
EMPLOYEES under age 65 or age 65 or older if eligible due to TEFRA/DEFRA/COBRA:
• Group size 50 or fewer Employees must have 75%enrollment based on NET ELIGIBLE EMPLOYEES
• Group size 51 or more Employees must have 75%enrollment based on NET ELIGIBLE EMPLOYEES,with no less than 50%of
TOTAL ELIGIBLE EMPLOYEES.If the Employer pays 100%of Employees cost, 100%of eligible Employees must be enrolled.
Effective January 1,1996 and after,Employers with 50 or fewer Employees may also be,sole proprietor's,a single full time Employee
of a subchapter S or C corporation,limited liability company,or a partnership who has carried on significant business activity for a
period of at least one year prior to application for coverage.Type of organization O Proprietorship O Corporation El Partnership.
In all cases the Employer must meet the minimum enrollment and eligibility requirements according to HMO Colorado underwriting
• regulations and policies and Colorado State law.
If we are a dual carrier,to apply for and retain group coverage and rates,a minimum of three Employees must be enrolled at all times.
When we are a dual carrier,the enrollment percentage requirements do not apply.
BLU228M.APC
To arrive at NET ELIGIBLE EMPLOYEES,Employees covered elsewhere with the following types of group insurance may be excluded,
unless such coverage is offered through THE EMPLOYER:
• A Blue Cross and Blue Shield Plan;
• A Health Maintenance Organization; •
• The Federal Employees Programs;
• Military;or
• Through a commercial carrier.
If the number of eligible Employees enrolled does not comply with the required percentage,we reserve the right to cancel the Contract
upon thirty day advance written notice.
NOTE: In the event the group does not meet the minimum enrollment requirements,we reserve the right to accept this Application
with prior underwriting approval.
The Employer agrees and warrants that no person who is not an eligible member under this provision will be listed,named,or otherwise
represented by it in any way to be an eligible member,and that the Employer will not remit membership premiums for any such person
or participant or assist in obtaining or maintaining a Benefit Booklet for such ineligible person. The Employer agrees to maintain
complete records and to furnish to us,upon request, such information as may be requested by us for our underwriting review. The
Employer further agrees to permit a payroll audit by us or by a representative appointed by us.
8. DEPENDENT—Dependent children are covered until they attain the age as stated on the Addendum.
9. PROBATIONARY PERIOD—Probationary period selection is as stated on the Addendum.There will be one open enrollment onthe
groups Anniversary Date for the BlueAdvantage HMO Plan and/or BlueAdvantage Point of Service Plan.In addition,if Triple Option
coverage is selected by the Employer, members will be allowed to choose between the HMO Plan,Point of Service, and Indemnity
coverage.
10. GROUP HEALTH COVERAGE APPLIED FOR—Coverage selection is as stated on the Addendum.
COLORADO INSURANCE LAW REQUIRES ALL CARRIERS IN THE SMALL GROUP MARKET
TO ISSUE A BASIC OR STANDARD HEALTH BENEFIT PLAN UPON THE REQUEST OF A
SMALL EMPLOYER TO THE ENTIRE SMALL GROUP,REGARDLESS OF THE HEALTH STATUS
OF ANY OF THE INDIVIDUALS IN THE GROUP.
11. Employer represents,agrees,and warrants that the Employer is in compliance with all applicable local,state,and federal laws,rules
and regulations,including but not limited to COBRA,the Family Medical Leave Act,TEFRA,DEFRA,and OBRA.To the extent any
part of this application is inconsistent with such laws, rules, and regulations, such provision shall not be deemed a part of this
application.However,the application shall be otherwise enforceable.If the Employer has agreed to have us perform specific billing and411
notification duties related to COBRA,such information will be stated on the Addendum.
MAsovn SHIg : ( - £ ASsoc. (q�) 3s6-SIS
BROKER TELEPHONE NUMBER
/770 - 2S"-+ AVENUE *rOZ • £Q.£ELEY, CO S0631
STREET,CITY,STATE,ZIP CODE
The Employer represents,agrees,and warrants that the information contained in this Application is true and correct and forms an essential
basis for our issuance of the Contract. EVEN THOUGH THIS APPLICATION IS SUBMITTED WITH PROPOSED PREMIUMS OR
OTHER FUNDS,THERE WILL BE NO COVERAGE UNTIL THIS APPLICATION IS APPROVED BY US. If we approve this
Application,we will send you a Contract of which this Application will become a part.Your prior coverage should not be cancelled until you
have been notified that your Application has been accepted.No agent can bind coverage,set an effective date,or waive or alter any provision
of this Application.The Contract will specify the effective date of group coverage. If we do not approve this Application,the submitted funds
will be returned to the Employer.
The Employer understands that if we approve this Application,the Employer agrees to be bound by the terms of the Contract.
Dated at (J ZQ�,I co this 24' day of AL)Vtfll hit 19 / C�
By �-/. IJ .ei�t+� � ZI C/t._ eA fFIR_I B c n0 xr in l S$,(M e,iS
SIGNAT F A T RIZED PERSON TIT
Approved and accepted by HMO Colorado and Blue Cross and Blue Shield of Colorado
By Date
PRESIDENT—HMO COLORADO
By Date
CHIEF EXECUTIVE OFFICER-BLUE CROSS AND BLUE SHIELD OF COLORADO •
BLll228M.APC
r BlueAdvantage Addendum To Application For BlueAdvantage
From HMO Colorado INTERNAL USE O�LY
illIds�Trdt^r[m.d de the 9v
• • avdlkasheNAaudden GflWPNUM ER A IVERSARV MONTH ADDENDUM EFFE TIVE DATE
027St -IANuAe-Y /-/-et 7
PLEASE PRINT FIRMLY TO ENSURE THAT ALL COPIES ARE LEGIBLE.DO NOT TYPE—DO NOT TEAR FORM APART
Complete all information on this Addendum to Application for BlueAdvantage (Addendum) if you are completing the Application for
BlueAdvantage. If you have previously submitted an Addendum, complete only information that is relevant to the change. If a change is not
indicated,the previous Addendum will remain in effect.
CHANGE—Iudieete aneor mane
o Contribution a C assifimtioa of Employees Eligible U )epend'ent Age 0 probationary Period
C Coverage Applied For O Optlanal Croup nenellt 0 COBRA Billing Neritkarion
This Addendum is issued to: V eL D Cou N TY COVER-N M EN T
("THE EMPLOYER"—CORRECT LEGAL NAME OF ACCOUNT)
This Addendum amends provisions of the Application.If we approve this Addendum,we will return the approved Addendum with the effective date
completed.The Addendum will become a part of the Contract.If we do not approve this Addendum,it will be returned.Other than specifically
amended herein,the terms and provisions of the Application and Contract shall remain in full force and effect.
CONTRIBUTION—The Employer will contribute B$ %of Employee's cost. The Employer will contribute 0 %of Employee's portion of
the family membership.
CLASSIFICATION OF EMPLOYEES ELIGIBLE—The Employer requires that all full-time or permanent part-time Employees work on a
schedule of at least 20 hours per week(minimum of 24 hours per week).If other Eligibility,please explain
The Employer hereby certifies the following number of Employees in each category below:
'Ibtal Employees employed by the employer Enrolling for coverage
_ Ibtal eligible full-time Employees having served probationary period — Enrolled elsewhere
COBRA or Colorado State law continuation of coverage enrollees — No other coverage
Other,please explain: —
DEPENDENTS—Depende t children are covered until the end of the month in which they become age(sliest ect only on2):s
O 24(standard) Other(not available for all size Employers) anti) of T7fc MONTH - ff1e LL.,
PROBATIONARY PERIOD
❑ Employees are eligible to enroll for coverage under the Contract following month(s)of employment,coverage to be effective on the
next 1st day of the month.Six-month maximum for groups with 60 or fewe��oyees.
O Employees are eligible to enroll for coverage under the Contract on the date of employment,coverage to be effective on the next 1st day of
the month.Available for all size groups.
/" 0 Employees are eligible to enroll for coverage under the Contract on the date of employment, coverage to be effective on the date of
1\ employment.Employees enrolled from the 1st through the 15th of the month will be billed from the 1st of that month;Employees enrolled
from the 16th through the end�f the month will be billed the next 1 t of the following mmooth. Available only to group size 51 or more.
)4-Other 1 r r MOAYffit rot-t-cw,. FIRST FUL.t_ rAY react ob WOg- D
GROUP HEALTH COVERAGE APPLIED FOR(select only one):
O BlueAdvantage HMO Plan Plan No.
O BlueAdvantage Point of Service(we will allow only if we are the sole carrier) Ptlp No.
f( Triple Option—(we will allow only if we are the sole carrier): O Blended Rate or)g Split Rate
BlueAdvantage HMO Plan Plan No. (O // /S M of Employees enrollingBlueAdvantage Point of Service Plan No. to )I )10 #of Employees enrolling
BlueAdvantage Custom Plus Deductible Zoo 'insurance 80%to$5,000/$10,000 0 of Employees enrolling
Health Benefit Plan O Basic O Standard (complete coverage name)
Standard six-month pre-existing clause for the BlueAdvantage Point-of-Service,BlueAdvantage CustomPlus,Indemnity Basic Health Benefit Plan,
and Indemnity Standard Health Benefit Plan.When transferring coverage from a Commercial Carrier or HMO,the pre-existing clause is waived
for initial Employees covered by the group's prior carrier or HMO. A copy of the prior carrier's billing must be attached to document initial
Employees previously enrolled.
OPTIONAL GROUP BENEFIT INFORMATION
O Optional Chemical Dependency Rehabilitation Program(available only to group size 51 or more)
O Other
❑ A financial agreement has been negotiated between the Employer and us,and is outlined in detail by Endorsement to the Contract.
ISL$ ASL % Tbrmination
COBRA
O The Employer requests that we perform specific and limited duties for COBRA Administration,which are outlined in detail by Endorsement
to the Contract.
REMARKS
The Employer derstands that if we approve this Addendum,the employer agrees to be bound by the terms of the Contract and this Addendum.
Dated/ , OU this 0264'''- yof /(/Q V 19 .4
By 0 fa-1 a i l3d ['o (.�,47miss,,42m
SIGN OF A L PERSON TITLE
Approved and accepted by HMO Colorado and Blue Cross and Blue Shield of Colorado
By Date
PRESIDENT—HMO COLORADO
By Date
CHIEF EXECUTIVE OFFICER—BLUE CROSS AND BLUE SHIELD OF COLORADO
FORM NO.96065(REV.9-96) WHITE/Account—CANARY/Broker—PINK/HMO Colorado/Blue Cross and Blue Shield of Colorado BLU229M.APC
Hello