Minutes - April 16, 2012 Regular Meeting

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BK.00024 PG.0871 Group Name: , LoL-t A of L e.e� 14. For Health Coverage (applicable only for group of 100+): 15. Group Employer Contribution (percentage) for health coverage: Number of 3 C Number of 3 unx w Eligible Employee �J _ Enrolled Employees: Employees: % Dependents :. 16. All employer- sponsored group health plans must offer COBRA continuation coverage unless the employer is Is your group health plan required to comp exempt from COBRA. (An employer is exempt If the group O employed fewer than 20 employees (including all with federal cobra continuation coverage full -time, part -time, and seasonal employees) on at least 50% of its working days during the preceding calendar requirements for this contract year? year, or (ill is a church plan or governmental plan as defined under the Internal Revenue Code.) ❑X Yes ❑ No 17. 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 ®No R you checked yes, please identify a contact perscin for ERISA plan information. Name and Title: Add ress: Phone: 18. 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 desorption (member booklet and notices regarding internal claims and appeals). 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? []Yes ❑X No If Yes, what is the primary language (e.g., Spanish)? If Yes, what is the primary language (e.g., Spanish)? The Group ac that it agrees to pay ECSS14C 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 it fees should be included in the premium or deducted from the employee's HSA account. HRA product is not currently available to Groups 1 to 50 Blue Options'" PPO /Blue Care° HMO /Classic Blue CMM Plans Product and quote numbers will display here. P P O Ou 0' N LL m LA-A. LOB Employee Only Mr+ Q LA o Employee + Child Em lo ee + Children Employee + Family Employee + 1 Other HSA/HRA Administrator Include in Premium Deductfrom Employee S u DIL.e L f+toMS l23 539.0(4 91ki.43 1,3x 8.29 S lime 0 V ` 14D 95V4 LjoI .57 n u - 4q 9 4!0•'{-1 Blue Options HSA'"/HRA Plans ANNUAL FUND CONTRIBUTION AMOUNT (in dollars) El Quote Number LOB Employee Only Employee + Spouse Employee + Child Em lo ee + Children Employee + Family Employee + 1 Other HSA/HRA Administrator Include in Premium Deductfrom Employee S u Please write in quote information, H existing quotes do not reflect the Group's final choices. Please note that any change in the amounts you listed above could result in a chance to the rate you were aucted. 20. For groups 51+ are you selecting the Flexible Spending Account (FSA) administered by BCBSNC for your employees? ❑Yes []No If yes, check which element(s) of the FSA are being offered to your employees: FSA with medical? [ ❑No FSA dependent care? []Yes ❑ No FSA limited purpose (HSA only)? ❑Yes ❑ No 21. Certification of Compliance with Federally and/or State Mandates: Federal Social Security laws require employers to provide primary healthcare benefits under employer group health plans to certain individuals who are entitled to Medicare. The Group certifies and agreesthat individuals eligible for Medicare, who are required to receive primary health care benefits under the Group's employee group health plan pursuant to federal Social Security laws, will be enrolled in a manner consistent with such laws. The Group hereby agrees to indemnify BCBSNC, hold it harmless against and reimburse it for any and all expenses paid or insured by BCBSNC due to any actor omission of the Group or the employer inconsistent with the relevant Social Security laws, as amended. H the Group allows its employees to enroll for coverage electronically, the Group is responsible for providing its employees with the appropriate notices regarding special enrollmen and pre- existing condition limitations, If applicable. PAGE 2 of 4 ,