Agenda - 4-7-14 Reg. Meeting - Laserfiche WebLink

Home Browse Search

Group Name: County of Lee 64 3 14. For Health Coverage: 15. Group Employer Contribution (percentage) for health coverage: Number of Number of HSA 100 % /PPO80% Eligible Employees: Enrolled Employees: t Employees: % Dependents: % 16. Please provide the average number of employees at your company during the preceding calendar year. This average must include all individuals employed by your company, whether an employee was full -time, part-time, and /or seasonal. Important: The federal Fmner� government requires the total average number, regardless of whether employees were eligible to enroll, and /or participated 625 in the group insurance coverage. Only include temporary employees if they worked for your company (i.e., employees that receive a W -2). 17. All employer- sponsored group health plans must offer COBRA continuation coverage unless the employer is exempt from COBRA. (An employer is exempt if the group (i) employed fewer than 20 employees (including all full -time, part-time, and seasonal employees) on at least 50% of its working days during the preceding calendar year; or (ii) is a church plan or governmental plan as defined under the Internal Revenue Code.) Is your group health plan required to comply with federal COBRA continuation coverage requirements for this contract year? ❑■ Yes ❑ No Insured ONLY: For the group health plans selected below (medical /dental only), will the group delegate COBRA administration (as outlined in the Group Contract) to BCBSNC's designee? ❑ Yes ❑ No, the group opts out of this service and will obtain its own COBRA administrator. 18. The Employee Retirement Income Security Act of 1974 (ERISA) regulates employee health benefit plans sponsored by most employers. Governmental Plans and church- sponsored plans (as defined by federal law) are exempt. Will this coverage insure an Employee Welfare Benefit Plan that is regulated by ERISA? ❑ Yes N No If you checked yes, please identify a contact person for ERISA plan information. Name and Title: Address: Phone: 19. Under federal law, the Plan Administrator may be required to provide a notice to Plan Participants who do not read English but are literate in another language, advising them of where they can get information and assistance concerning their benefits and member rights. The notice must be in their primary language and appear in the summary plan description (member booklet). The following information is being requested to determine if such a notice will be necessary. It may also assist BCBSNC in meeting special customer service needs. For Groups 100+: Are 10% or more (or 500) of the plan For Groups 1 -99: Are 25% or more of all plan participants participants whichever is less, literate only in the same literate only in the same foreign (non - English) language? ❑Yes ❑ No foreign (non - English) language? El Yes ❑■ No If Yes, what is the primary language (e.g., Spanish)? If Yes, what is the primary language (e.g., Spanish)? 20. The Group acknowledges that it agrees to pay BCBSNC the following rates for the benefits below. Please check the benefit plan(s) you have selected for your group. If you will be contributing to an HSA during the benefit period, please verify benefit plans, annual contribution amounts, and the HSA administrator you will be contributing through. If the BCBSNC chosen HSA administrator has been selected for the HSA, please also verify if fees should be included in the premium or deducted from the employee's HSA account. Blue Options'" (PPO) / Blue Care` (HMO) /Classic Blue® (CMM) / Blue Values" (POS) / Blue Selects"' (PPO) / Dental Blue* Plans Product and quote numbers will display here. B0123 NSQ# HSA NSQ# Employee Employee /Children Family Blue Options 123 671.59 1,150.73 1,651.37 HSA 501.37 663.51 1,186.72 21. Is the selected benefit plan being paired with a Health Reimbursement Account (HRA) administered by BCBSNC? El Yes ❑■ No If yes, are the owners electing coverage? E] Yes ❑ No If yes, please provide the name of the owner(s) If the selected benefit plan is being paired with an HRA, a fully completed HRA Addendum must be attached. Blue Options HSNm GROUPS 51+ ELIGIBLE EMPLOYEES This section must be completed to ensure accurate enrollment. Please write in quote information below, if existing quotes do not reflect the Group's final choices. Any change in the amounts you listed below could result in a change to the rate you were quoted. ANNUAL FUND CONTRIRUTION AMni uuT r., a„ui Quote Number LOB Employee Only Y Employee + Spouse P Employee + Child lo Emp ee +Child Wren Employee +Family Employee y + 1 Other HSA Administrator Include in Premium Deduct from Employee's HSA Account HSA 0 0 0 0 other El PAGE 2 of 4