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~ HEALTH PLAN Choose It and Use It.

Wpsl HEALTH • INSURANCE

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Agency Manual

2 | WPS Health Insurance and Arise Health Plan Agency Manual

03

TABLE OF CONTENTS

SECTION 1: Introduction

SECTION 2: Product Teams and Contact Information

SECTION 3: Products Overview

SECTION 4: Website Resources for Medicare Products

SECTION 5: WPS and Arise Agent Appointment Process

SECTION 6: WPS and Arise Commissions

SECTION 7: Tips for Using the Agent Portal

SECTION 8: Enrollment and Billing Processes

SECTION 9: WPS Health Insurance/Arise Health Plan Field Guide

APPENDICES 65

This document is provided for educational purposes and is not intended to provide legal advice.

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WPS Health Insurance and Arise Health Plan Agency Manual | 3

SECTION 1:

Introduction

Agency Manual

Dear Agency Partner,

In today’s busy world, we understand there are times you need information and you need it fast. With that in mind, we created this agency manual to provide you with the information you may need, right now, and right at your fngertips!

You will fnd information for a variety of WPS Health Insurance and Arise Health Plan products, including individual and family health insurance, Medicare supplement insurance, Medicare Part D (PDP), and small, large, and self-funded group health plans. There's also a reference section.

We hope you fnd this manual useful! If you can’t fnd what you need, please contact your WPS or Arise sales representative for assistance. Thank you for being a valued agency partner!

Best of health,

WPS and Arise Agency Sales Team

About WPS Health Insurance Founded in 1946, WPS is a nationally regarded government contractor and a leading Wisconsin not-for-proft health insurer. WPS provides a complete line of health insurance for businesses and individuals throughout Wisconsin. WPS Health Solutions, our parent company, is a 10-time World’s Most Ethical Companies® award winner.* Ethical behavior builds trust with our customers and the communities we serve, and is expected from every member of the WPS team.

As a local, Wisconsin-based company, our Customer Service is provided by Wisconsin residents—when you call with questions, you talk to a real person. We have many regional offces throughout the state to assist you. There are many great reasons to choose WPS, and we’re proud to have you on our team as one of those reasons.

About Arise Health Plan WPS Health Plan, Inc., doing business as Arise Health Plan, is a fresh choice in a crowd of national health insurance giants. Throughout northeast and eastern Wisconsin, Arise offers comprehensive, affordable individual, small group, and large group health plans. Value and security, health and wellness, plus service without compromise are the foundation of our health plans. Arise offers comprehensive and affordable individual, small group and large group, and self-funded health plans.

Arise's commitment is to be easy to work with and as transparent as possible, so our customers can always understand their benefts. Arise continues its tradition of Wisconsin-based service and is always looking for ways to make owning and using health insurance easier.

*2010-2019 World's Most Ethical Companies®, Ethisphere® Institute, worldsmostethicalcompanies.ethisphere.com/past-honorees.

https://www.worldsmostethicalcompanies.com/past-honorees/


SECTION 2:

Product Teams and Contact Information

INDIVIDUAL AND GROUP HEALTH PLANS

Our team is focused on selling and servicing WPS Health Insurance and Arise Health Plan individual and group health plans off the Health Insurance Marketplace along with on-Marketplace Arise individual plans.

To make your sales efforts more effcient, we offer online quoting tools and online applications you can use to improve the buying experience for your clients. By working together, we can help grow your business and spread the word about the variety of products we offer.

Contact Information ALL TERRITORIES Business hours: Monday–Friday, 8 a.m.–4:30 p.m.

Leadership Sales-related inquiries and quotes

Jeremy Ott Small Group new business email: [email protected] Vice President Individual new business phone: 800-332-0894 [email protected]

Roger Ebert WPS small group: Customer Service/Billing and Enrollment Senior Director, Group Sales Phone: 800-332-6451 920-490-6953

Fax: 608-223-3639 [email protected] Billing and Enrollment Email: [email protected]

Teresa Maas WPS individual: Customer Service/Billing and Enrollment Director, Product Development/ Phone: 800-332-6421 Account Management Fax: 920-490-6942 608-977-5783

[email protected] Billing and Enrollment Email: [email protected]

Small Group ACA and Individual Arise small group: Customer Service/Billing and Enrollment Plan Sales and Renewals Phone: 800-332-6285

Fax: 608-223-3639 Matt Mayville Billing and Enrollment Email: [email protected] Senior Agency Sales Representative

608-977-5707 [email protected] Arise individual: Customer Service/Billing and Enrollment

Phone: 800-332-6249 Tom Ingram Fax: 920-490-6942 Individual Sales Representative Billing and Enrollment Email: [email protected] 608-977-5706

[email protected]

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LARGE GROUP HEALTH PLANS Contact Information Business hours: Monday–Friday, 8 a.m.–5 p.m.

You can rely on our Sales staff to assist you with sales of WPS Sales-related inquiries and quotes Health Insurance and Arise Health Plan group health plans for

Large Group new business email: Contact your local groups of 51 or more as well as ASO groups of 10 or more, offce; see list for details which includes all Freedom Essentials groups. You get: Large Group Billing and Enrollment: • Streamlined operations to make it easier to do

business with WPS and Arise WPS/Arise Phone: 888-915-5618 • A product-focused team to improve the expertise of Fax: 608-223-3639

our staff Email: [email protected] (or assigned Focus Rep) • Better responsiveness through a dedicated customer

Large Group Customer Service:

WPS Phone: 800-223-6048

Arise Phone: 800-223-6029

support team

ALL TERRITORIES

Leadership Jeremy Ott Vice President [email protected] Roger Ebert Senior Director, Group Sales 920-490-6953 [email protected] Teresa Maas Director, Product Development/ Account Management 608-977-5783 [email protected]

ALL TERRITORIES

Account Management

Fully insured groups with 2–50 enrolled (including small group ACA), Freedom Flex self-funded groups with 25–50 enrolled, and all Freedom Essentials level-funded groups with 10–99 enrolled Team Email: [email protected] Saundra Courchane Account Manager 920-617-6375 [email protected] Rhoda Schuster Coordinator, Sales Operations 608-977-5708 [email protected]

Fully insured groups and Freedom Flex self-funded groups with 51+ enrolled (group accounts by assignment)

Courtney Loos Senior Account Manager 608-977-5817 [email protected] Carrie Helms Senior Account Manager 920-490-6262 [email protected] Carri Moberg Senior Account Manager 920-490-6974 [email protected]

NORTHEAST/FOX VALLEY

Large Group and Self-Funded Plan Sales

Green Bay Sales: [email protected] Victoria Faust Account Executive 920-490-6982 [email protected] Angela Romenesko Agency Sales Representative 920-617-6348 [email protected]

NORTHWEST/NORTH-CENTRAL


Eau Claire Sales: [email protected] Angela Smith Account Executive 715-835-9988 [email protected] Ellie Brown Coordinator, Sales Operations 715-835-7821 [email protected]

SOUTHEAST/MILWAUKEE METRO


Waukesha Sales: [email protected] Patty Jehn Account Executive 262-717-3256 [email protected] Lynn Horn Senior Agency Sales Representative 262-717-3280 [email protected] Kathy Bergquist Coordinator, Sales Operations 262-717-3257 [email protected]

SOUTHWEST WISCONSIN/ NORTHERN ILLINOIS


Madison Sales: [email protected] Bart Pukowiec Account Executive 608-977-5709 [email protected] Becky Schumal Agency Sales Representative 608-977-5813 [email protected]

























MEDICARE MARKET SOLUTIONS

You can rely on our Medicare Market Solutions team to assist you with sales of Medicare supplement and Medicare Part D plans. By working together, we can help grow your business and spread the word about the highly popular products WPS Health Insurance offers to seniors.

If you have questions, please ask your agency manager or representative. Thank you for supporting WPS Health Insurance.

Contact Information Agent Sales Support Sales-related inquiries, plan information, and enrollment 800-748-0582

Regular business hours Monday–Friday, 7:30 a.m.–5 p.m. Saturday, 9 a.m.–5 p.m.

Extended hours during PDP enrollment Monday–Friday, 7:30 a.m.–8 p.m. Saturday–Sunday, 8 a.m.–8 p.m.

Agent Services Customer Service, billing, and claims questions

Medicare supplements 888-253-2694 or [email protected]

Medicare Part D plans 800-944-2656 or [email protected]

Agent services hours Monday–Friday, 7:30 a.m.–5 p.m.

TEAM LEADERSHIP ALL TERRITORIES Keenan Jones Director of Medicare Market Sales Direct: 608-977-5631 [email protected] 1717 W. Broadway, Madison, WI 53713

SOUTH Alisa Allen Senior Agency Manager Direct: 414-255-5126 [email protected] 1717 W. Broadway, Madison, WI 53713 20800 Swenson Dr., Suite 450, Waukesha, WI 53186

Michelle Heinrich Senior Agency Representative Direct: 414-758-4939 [email protected] 1717 W. Broadway, Madison, WI 53713 20800 Swenson Dr., Suite 450, Waukesha, WI 53186

Susan Knutson Agency Representative Direct: 608-977-5621 | 608-572-4814 [email protected] 1717 W. Broadway, Madison, WI 53713

NORTH Kerri Zastrow Senior Agency Manager Direct: 715-828-1760 [email protected] 1400 Lombardi Ave., Suite 50, Green Bay, WI 54304

Tracy Balthazor Agency Representative Direct: 920-617-6373 [email protected] 1400 Lombardi Ave., Suite 50, Green Bay, WI 54304

Carmen Pankratz Agency Representative Direct: 920-490-6956 [email protected] 421 Lawrence Dr., De Pere, WI 54115

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SECTION 3:

Products Overview

INDIVIDUAL AND SMALL GROUP PLANS WPS Health Insurance

Selling Points for WPS Health Insurance Individual and Small Group (Not Self-Funded) Products

PPO and HSA-qualifed HDHP Plans

• WPS Statewide Network has every major clinic system in Wisconsin, as well as several hundred more, and includes the "wraparound" First Health/PreferredOne network, which allows in-network access in all 50 states.

• Teladoc® services: Customers have 24/7 access to U.S. board-certifed physicians, including psychologists and dermatologists, via phone or online video for nonemergency illnesses.

• $0 copay maintenance medications included: More than 30 medications for conditions such as high blood pressure, diabetes, cholesterol, and asthma.

• ExerciseRewards™ offers customers a $30 reward each month for visiting a ftness club 10 or more times that month.

• Active&Fit™ Direct works in tandem with ExerciseRewards or as a stand-alone program to offer a membership to a participating ftness center for $25 per month for 2020, and $29.99 per month beginning in 2021.

Arise Health Plan

Selling Points for Arise Health Plan Individual and Small Group Products

HMO, POS, and HSA-qualifed HDHP Plans

• Arise Network includes major clinic systems in Wisconsin and offers “wraparound” First Health network coverage, which allows in-network access in all 50 states.

• Teladoc® services: Customers have 24/7 access to U.S. board-certifed physicians, including psychologists and dermatologists, via phone or online video for nonemergency illnesses.

• $0 copay maintenance medications included: More than 30 medications for conditions such as high blood pressure, diabetes, cholesterol, and asthma.

• ExerciseRewards™ offers customers a $30 reward each month for visiting a ftness club 10 or more times that month.

• Active&Fit™ Direct works in tandem with ExerciseRewards or as a stand-alone program to offer a membership to a

participating ftness center for $25 per month for 2020, and $25 per month beginning in 2021.

LARGE GROUP AND SELF-FUNDED PLANS WPS Health Insurance

Selling Points for WPS Health Insurance Large Group Products PPO and HSA-qualifed HDHP Plans

• Statewide Network has every major clinic system in Wisconsin, as well as several hundred more.

• Statewide Network has “wraparound” First Health/PreferredOne included, which allows in-network access in all 50 states.

• As your local partner in health care, we take the time to understand your business and your employees, and then deliver a customized plan that’s the right ft for you.

• Choose from a wide range of deductible, coinsurance, and copay options that offer optimal health benefts and cost savings.

• Health management options encourage employees to live healthier lives and help reduce costs.

• WPS is also available to large group employers in Illinois.


Selling Points for WPS Health Insurance Self-Funded Group Products PPO and HSA-qualifed HDHP Plans

• Statewide Network has every major clinic system in Wisconsin, as well as several hundred more.

• Statewide Network has “wraparound” First Health/PreferredOne included, which allows in-network access in all 50 states.

• As your local partner in health care, we take the time to understand your business and your employees, and then deliver a customized plan that’s the right ft for you.

• Choose from a wide range of deductible, coinsurance, and copay options that offer optimal health benefts and cost savings.

• Health management options encourage employees to live healthier lives and help reduce costs.

Arise Health Plan

Selling Points for Arise Health Plan Large Group Products HMO and POS Plans

• Arise Network has thousands of top health care providers in Wisconsin.

• Wraparound First Health Network included, which allows in-network access in all 50 states.

• High-value group health plans can be tailored to ft your business and your employees.

• Choose from a range of deductible, coinsurance, and copay options that offer optimal health benefts and cost savings.

• Wellness options encourage healthy lifestyles and help keep employees healthier.

Selling Points for Arise Health Plan Self-Funded Group Products HMO and POS Plans

• Arise Network has thousands of top health care providers in Wisconsin.

• Wraparound First Health Network included, which allows in-network access in all 50 states.

• Variety of self-funded options available to maximize your health care dollars.

• Choose from a range of deductible, coinsurance, and copay options that offer optimal health benefts and cost savings.

• Wellness options encourage healthy lifestyles and help keep employees healthier.

MEDICARE MARKET SOLUTIONS WPS Health Insurance

Selling Points for WPS Health Insurance Medicare Products Medicare Supplement Insurance Plans

• Unlimited preventive care: Applies to Medicare Part B preventive services with no maximum beneft amount (Wisconsin only).

• No network! Customers have access to all doctors and hospitals that accept Medicare without prior authorizations or referrals.

• Silver&Fit® health club membership at no extra cost (not available with cost-sharing plans, called Plans K and L outside of Wisconsin): Fitness discount programs are not part of the insurance policy and are offered at no additional charge. Services that call for an added fee are not part of the Silver&Fit® program. The Silver&Fit program is provided by American Specialty Health Fitness, Inc., a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit is a federally registered trademark of ASH.

• Customers' coverage can’t be taken away as long as they pay their premium.

• Discounts on eyewear and hearing aids—vision and hearing discount programs are not part of the insurance policy and are offered at no additional charge.


Medicare Part D Prescription Drug Plans (PDP)—WPS MedicareRx Plan • High-quality plan offers an extensive list of covered medications. • Plan is accepted at thousands of independent and chain pharmacies across the country—Aurora, Costco, Kroger,

Jewel-Osco, Shopko, Rite-Aid, Walgreens, Walmart, and many more. • Convenient mail-order delivery of medications. • PDP is available to Wisconsin residents only.

WPS Medicare Supplement Insurance Plans As an agent, you have access to other carriers and other Medicare plan options. We appreciate every time you recommend WPS to your senior clients. Here are just a few reasons why our WPS Medicare supplement insurance plan is the right choice for your clients:

• No provider networks plus plan portability. Freedom to choose providers that accept Medicare anywhere in the U.S. And if a customer moves, their WPS plan moves with them—anywhere in the U.S.

• Additional premium discounts. A 7% household discount1 applies when a second individual from the same household enrolls in a WPS Medicare supplement insurance plan. A 2% discount also applies for automatic bank withdrawal for new business.

• No billing fees. No direct bill fee for our senior plans.

• 12-month rate guarantee. WPS plans are guaranteed for the frst 12 months a customer has the policy, unless the customer moves to a new rating area or changes benefts.

• WPS Medicare cost-sharing plans (Plans K and L). Our 25% and 50% cost-sharing plans are a great alternative for those who want to retain the freedom to choose any provider while keeping their premium affordable. Cost-sharing plans are eligible for the Additional Home Health Care rider only.

• Fitness program.2 Silver&Fit Fitness Program is included with all plans, except 25% and 50% cost-sharing plans (Plans K and L). Benefts include health club membership, home ftness kits, a resource library, ftness challenges, and more.

• No-cost vision and hearing discount programs.2 Additional discounts are available through EyeMed and Hear in America.

• Unlimited preventive benefts. For Wisconsin residents only, we help pay for preventive health services beyond standard Medicare coverage for routine vision (including refractions) and hearing exams, as well as other preventive services not covered 100% by Medicare. Includes up to $100 per calendar year for other immunizations not covered by Medicare.

• $100,000 optional foreign travel rider. For Wisconsin residents, our plans offer a maximum beneft on the Foreign Travel rider of $100,000.

• Key partnerships. WPS is endorsed by the Wisconsin Retired Educators’ Association (WREA), a nearly 12,000-customer statewide organization. We are also the offcial Medicare Supplement Partner of the Wisconsin Alumni Association.

• Available in 15 states. WPS Medicare supplement insurance plans are currently sold in Arizona, Colorado, Florida, Iowa, Illinois, Indiana, Kansas, Michigan, Nebraska, Ohio, Oklahoma, Pennsylvania, Tennessee, Texas, and Wisconsin. Plans and benefts offered vary by state, so please check with your WPS representative if you have questions.

1Household: Two or more individuals who reside together in the same dwelling. Dwelling is defned as a single home, condominium unit, or apartment unit within an apartment complex. 2Fitness, vision, hearing, and wellness programs are not part of the insurance policy, are offered at no additional charge and can be canceled by us at any time.


WPS Medicare Supplement Insurance Plans

Type of Enrollment When to Apply Effective Date Supporting Documentation

WPS Medicare Supplement Insurance Plan Open Enrollment Period

Customers have a six-month open enrollment period beginning with the month of their 65th birthday or enrollment in Medicare Part B.

Coverage begins the first of the month after we accept the application and premium, or with a requested effective date up to three months in the future.

Complete the WPS Medicare Supplement Enrollment Application

Can submit application up to three calendar months before the open enrollment period.

No health questions.

WPS Medicare Supplement Customers may be eligible Coverage begins the first of Complete the WPS Medicare Insurance Plan Special for guaranteed acceptance if the month after we accept Supplement Enrollment Enrollment Period (SEP) they have other coverage that

is involuntarily terminating or significantly changing.

They must apply within 63 days of receiving final coverage termination notice or within 63 days of the date current coverage ends.

If their employer retiree plan premium increased more than 25%, they may also be eligible for guaranteed acceptance. These situations are subject to WPS review.

the application and premium. Application


WPS MedicareRx Plan (PDP) (Only available to Wisconsin residents)

Outstanding Medicare Part D coverage from Wisconsin’s very own not-for-proft health insurance company. WPS MedicareRx Plan is the top-rated stand-alone prescription drug plan in Wisconsin, earning four-and-a-half stars out of fve from the Centers for Medicare & Medicaid Services.*

*For 2019. Star Ratings are assessed each year and may change from one year to the next.


WPS MedicareRx Plan If currently entitled to Determined by federal law. Complete the WPS Annual Enrollment Period Medicare Part A and/or

enrolled in Medicare Part B, and a legal resident of WI, can sign up during the Annual Enrollment Period determined by federal law. Typically Oct. 15 through Dec. 7.

WPS coverage effective Jan. 1.

MedicareRx Plan (PDP) Individual Enrollment Form

WPS MedicareRx Plan Initial The Medicare Initial Effective date is: Complete the WPS Enrollment Period (IEP) Enrollment Period may

be triggered at age 65 or Medicare Disability benefit eligibility.

Turning age 65: Sign up during the three months before birthday, the month of birthday, and three months after 65th birthday.

IEP due to being newly eligible for Medicare due to disability (under age 65): Sign up during the three months before birthday, the month of birthday, and three months after 65th birthday.

First of the month following receipt of application OR Medicare Part A effective date, whichever is later.

MedicareRx Plan (PDP) Individual Enrollment Form

WPS MedicareRx Plan Special Enrollment Period (SEP)

Other circumstances may allow enrollment at another time. Includes the following: • Lose or terminate

creditable prescription drug coverage through employer or union

• Get Medicare due to disability

• Receive full Medicaid coverage

Time frames for SEPs vary by situation but typically last for two full months after the month coverage ends.

Effective date is: First of the month following receipt of application.

Complete the WPS MedicareRx Plan (PDP) Individual Enrollment Form


SECTION 4:

Website Resources for Medicare Products

Medicare Coverage Links MedicareInteractive.org

MedicareInteractive.org—trusted resources

MedicareRights.org—Medicare and current employer benefts

MedicareRights.org—Medicare Part B enrollment

ADRC Brown County—Medicare supplement or Medicare Advantage: Which is best for you?

Wisconsin Medicare savings programs

Medicare.gov publications: • Medicare & You

• Enrolling in Medicare Part A and Part B

• Welcome to Medicare

• Understanding the “Notice of Medicare Premium Payment Due” form (CMS-500)

• Understanding Medicare Part C & D enrollment periods

• Guide to Medicare’s preventive services

• What is a Medicare Advantage Plan?

Prescription Drug Links Things to think about when you compare Medicare drug coverage: • Medicare plan fnder—price Part D drugs

• Prescription drug—pill splitting

• Part D—extra help

• Consumer Guide to Health Care—prescription drug assistance programs

• Wisconsin SeniorCare Drug Program

• WPS Medicare Prescription Drug Plans

Please be advised that WPS Health Insurance, when providing links to other websites, includes links to websites operated by government agencies, nonproft organizations, and/or private businesses. When you elect to link to another site, you are not using WPS’ website. Therefore, the terms on the WPS Website Privacy Statement will not apply. When you link to another website, you are subject to the privacy policy of that site and WPS is not responsible nor is it liable for any disclosures thereunder.

http://www.medicareinteractive.org/

https://www.medicareinteractive.org/resources

http://www.medicarerights.org/PartB-Enrollment-Toolkit/Part-2-QA-Current-Employer-Insurance.pdf?utm_source=dm-national&utm_medium=e-mail&utm_campaign=DM_7.16.2012+National




https://www.medicare.gov/Publications/Search/Results.asp

http://www.medicare.gov/pubs/pdf/10050.pdf

http://www.medicare.gov/Pubs/pdf/11036.pdf







https://medicare.gov/find-a-plan/questions/home.aspx

http://consumerhealthchoices.org/wp-content/uploads/2012/01/PillSplitting-FINAL.pdf

http://pharma.about.com/od/BigPharma/a/Which-Popular-Drugs-Are-Going-Off-Patent-In-2013-2016.htm

http://www.medicare.gov/your-medicare-costs/help-paying-costs/save-on-drug-costs/save-on-drug-costs.html

https://www.dhs.wisconsin.gov/guide/freeprescr.htm

https://www.dhs.wisconsin.gov/seniorcare/factsheets/p10078.htm

http://www.wpsic.com/partd/2016-medicare-prescription-drug-plan.shtml


SECTION 5:

WPS and Arise Agent Appointment Process

All paperwork should be submitted directly to [email protected] for review.

WPS Agent-Level Listing Process Paperwork Needed

• WPS Individual Agent Listing Application

• Copy of agent's license(s) for every state in which you will conduct your business on behalf of WPS Health Insurance

Arise Agent-Level Listing Process Paperwork Needed

• Arise Individual Listing Application

• Copy of Wisconsin Health Insurance License

SECTION 6:

WPS and Arise Commissions

Commission statements and checks are mailed mid-month. Direct deposits are made mid-month directly to the agencies that elected direct deposit.

Checks/deposits are made payable to the agency. If you have any questions pertaining to your specifc payment, you will need to discuss these within your agency with the people that handle the commission distribution.

Commission inquiries: Contact Jeremy Dolfn at 608-977-6572 or [email protected]

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SECTION 7:

Tips for Using the Agent Portal

MARKETING MATERIALS ORDERING PROCESS

Log in to your account via the Agents page on wpshealth.com or arisehealthplan.com (not shown).

Click on the Marketing Materials tab in the top ribbon of the agent portal home page.

Click the Order Marketing Materials button from the drop-down menu.

You will be directed to the Place Order tab. Under Form Selection, click the drop-down arrow from the Description-Form Number box. The list is organized alphabetically and uses keywords to make fnding what you need easier. Select the marketing item you want to order from the list, preview (if desired), and select the quantity.

Click the Add to Cart button. Note: Double check that your item and quantity are correct!

Click Continue at the bottom of the screen.

You will be directed to the Shipping Information tab (not shown). Fill out the Shipping Destination where you want the materials delivered, if other than your regular mailing address.

Under Your Agency, enter your agency tax ID.

Click on the Submit Order button. You will then go to the Order Confrmation tab where you can view your completed order.

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HOW TO ACCESS AND GENERATE YOUR REPORTS Generating your reports is easy! You can access your reports via wpshealth.com or arisehealthplan.com. Follow the steps below for navigating to, generating, and exporting reports. For information on limitations, please refer to the document titled SharePoint Reporting Awareness Issues.

1. Log in to your account via the Employers or Agents tab on wpshealth.com or arisehealthplan.com.

2. Click on the Reporting link located in the top right of the Group Leader or Agent home page, shown below. Your browser will automatically log you in to the Data Dashboard.

Group Leader Home Page (WPS shown) Agent Home Page

3. Reports available for the group(s) you have access to are listed on the Reporting home page, shown at right.

Note: Agents with multiple groups—If you have access to more than one group, the groups will be categorized for you on the Reporting home page as well.

4. Clicking on one of the available reports shown on the Re-porting home page will take you to the Specify Param-eter Values page, shown at right. Under Parameters on the right side, under Grp ID, you can select which group you would like to generate reports for. Parameters allow you to select multiple options to create the report you want. Once you have selected the parameters you want, click on Apply to run your report. Your report will appear when it is fnished.

Note: If you are an Agent, you will have the ability to select a specifc group from the drop-down list. If you are a Group Leader, you will only have one group available in your drop-down list.






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5. The Report Action Area allows you to perform actions on the report after it has been generated. You can export your report, refresh the page, page through results, search results, and zoom in or out.

Note: Use your browser’s back button or hold down the Alt and left arrow keys (Alt-left) to return to the previous page.

Click on Actions, arrow down to Export, and then select PDF. (Exporting to PDF is the recommended option to print your report.)

6. If you would like to view more of the Report Display Area, you can collapse the Parameters section on the right side. If you would like to change the report parameters and rerun the report, simply expand the Parameters by clicking on the same arrow.

7. To exit your reporting session and leave wpshealth.com: a. Close the Reporting Services tab by clicking on the

“X” icon on your browser. b. Close the wpshealth.com tab by clicking Log Off

in the upper right corner of the screen (pictured).


https://wpshealth.com


SECTION 8:

Enrollment and Billing Processes

INDIVIDUAL HEALTH PLANS

Enrollment Process

WPS Off-Marketplace Individual Sold in the following counties: Ashland, Barron, Bayfeld, Buffalo, Burnett, Chippewa, Douglas, Dunn, Eau Claire, Jackson, La Crosse, Monroe, Pepin, Pierce, Polk, Rusk, Sawyer, St. Croix, Trempealeau, and Washburn.

• Mail: WPS Health Insurance P.O. Box 8190 Madison, WI 53707

• Fax: 608-223-3639 • Online: WPS Individual ACA—Online Enrollment

Note: Due to volume, please allow extra processing time for any application submitted during the ACA Open Enrollment Period. We appreciate your patience.

Billing Process • Fax: 608-223-3639 (WPS and Arise) • Email: [email protected] (WPS and Arise) • Mail:

WPS Health Insurance Arise Health Plan P.O. Box 21341 P.O. Box 21341 Eagan, MN 55121 Eagan, MN 55121

WPS and Arise plans

Arise Off-Marketplace Individual Sold in the following counties: Brown, Calumet, Dodge, Door, Fond du Lac, Green Lake, Kenosha, Kewaunee, Manitowoc, Marinette, Marquette, Milwaukee, Oconto, Outagamie, Ozaukee, Racine, Sheboygan, Washington, Waukesha, Waupaca, Waushara, and Winnebago.

• Mail: Arise Health Plan P.O. Box 11625 Green Bay, WI 54307

• Fax: 608-223-3639 Arise Off Marketplace—Paper Application

• Online: Arise Off Marketplace—Online Enrollment

Arise On-Marketplace Individual Sold in the following counties: Dodge, Calumet, Fond du Lac, Outagamie, Sheboygan, Waupaca, Waushara, and Winnebago.

• Online: Arise On Marketplace—Online Enrollment

The frst month’s premium is NOT required at time of initial enrollment. A billing statement will be mailed to the customer.

Electronic Funds Transfer: An easy-to-use service available at no additional cost. Checking or Savings Account • Money will be pulled each month from a customer-designated checking or savings account. • Pick a day your client chooses (frst of the month or the 20th of prior month).

° If date chosen is the 20th, the frst pull may be for two months of premium. • If the frst or 20th falls on a weekend or holiday, the money will pull on the next business day. • Medicare supplement plans offer a 2% discount for customers who use automatic withdrawal. Credit Card/Debit Card • Money will be pulled each month from a customer-designated credit card or debit card. • Pick a day your client chooses (frst of the month or the 20th of prior month).

° If date chosen is the 20th, the frst pull may be for two months of premium. Direct Billing: No business checks will be accepted. • WPS/Arise: No fees. • Bills are created and mailed on the third of the month and are due by the frst of the following month.

Payment in the form of a check, money order, or ACH is required by the premium due date.

https://my.wpshealth.com/en/Individual/healthplanhome?WebsiteId=b5bgurh&state=pjn2yxr&producttype=tvewa9w

mailto:billing%40wpsic.com?subject=

https://secure.wpsic.com/sales-materials/files/25062_2015_individual_enrollment_app.pdf

https://secure.wpsic.com/sales-materials/files/25062_2015_individual_enrollment_app.pdf

https://connect.wpsic.com/prodGateway/commercialGateway/unauth/beginIndividualEnrollment.do

https://connect.wpsic.com/prodGateway/commercialGateway/unauth/beginIndividualEnrollment.do


The First Premium Notice The frst premium notice is generated before applying your client’s frst month’s premium. As a result, the frst bill may show past due even though the previous month’s premium has already been paid. If your client’s frst bill shows a past due amount, they can calculate the amount they need to pay by simply subtracting the amount already paid from the Total Premium Due.

Unpaid Premium Late payment: A delinquent letter is sent out to customer and agent once payment is past due and still in the grace period. Once the grace period ends, the policy will be terminated for non-payment. Delinquent letters are not mailed for PDP.

Credits and Adjustments on Billing Statements Credits and adjustments will show on the next bill, depending on when the credit was applied and compared to when the bills are created. Retroactive billing credits and adjustments must be approved by WPS/Arise.

Plan Changes Changes for WPS/Arise Individual On- and Off-Marketplace Plans Beneft or plan changes can only take place during open enrollment for Jan. 1. If the customer has a Special Enrollment Period, please see Section 6 for details.

Renewals WPS Individual ACA Plans

• Customer and agency will receive a renewal letter 60 days prior to the effective date of the renewal. Age band increas-es go into effect at time of renewal, not beforehand. All ACA plans renew Jan. 1.

• During the annual open enrollment period, the customer has the option to: ° Do nothing and stay with updated plan and/or premium effective Jan. 1. ° Change benefts prior to Jan. 1 by calling WPS Customer Service at: 888-527-0586. ° Fill out a change form and fax to WPS Customer Service at: 608-223-3639 prior to Jan. 1.

WPS/Arise Individual Policy Change application (19348-200-2001)

WPS Non-ACA Extended Rate Guarantee (ERG) Plans • Customer and agency will receive a renewal letter 60 days prior to Jan. 1. Age band increases go into effect at time of

renewal, not beforehand. • This renewal constitutes a Special Enrollment Period for involuntary loss of coverage, where the customer has the

option to: ° Do nothing and stay with updated plan and/or premium effective Jan. 1. ° Move to an ACA-compliant plan either on- or off-Marketplace.

Arise Individual ACA Plans • Customer and agency will receive a renewal letter 60 days prior to the effective date of the renewal. Age band increas-

es go into effect at the time of renewal, not before. All ACA plans renew Jan. 1. • During the annual open enrollment period, the customer has the option to either:

° Do nothing and stay with updated plan and/or premium effective Jan. 1. ° Change benefts prior to Jan. 1 by faxing the change form specifed below to Arise Billing and Enrollment at

608-223-3639. WPS/Arise Individual Policy Change application (19348-200-2001)

https://secure.wpsic.com/sales-materials/files/19348-2001_ind-policy-change-application.pdf

https://secure.wpsic.com/sales-materials/files/19348-2001_ind-policy-change-application.pdf


Special Enrollment Period (SEP) Requirements and Documentation

Individual Eligibility and Effective Dates—Based on Policy Language


Annual Enrollment Period. Each year there is an enrollment period that will be determined by federal law to allow enrollment. Individuals must apply during this enrollment period or wait until the next annual enrollment period, unless they qualify for a special enrollment.

Determined by federal law.

Special Enrollment Periods

A policyholder or a dependent loses minimum essential coverage, including group continuation coverage required by any state or federal law. This does not include a loss of coverage due to rescission, failure to pay premiums on a timely basis, or voluntary loss of coverage. Note: Loss of a short-term health plan does not qualify for a Special Enrollment Period (SEP) for an individual health plan.

A policyholder or a dependent loses government-sponsored pregnancy-related coverage (i.e., coverage through state Medicaid or CHIP) or a dependent under the age of 18 loses government-sponsored medically needy coverage (i.e., coverage through State Medicaid). This does not include a loss of coverage due to rescission, failure to pay premiums on a timely basis, or voluntary loss of coverage.

Enrollment must be requested within 60 days of the event. If he/she does not request enrollment within this time period, the policyholder and any dependents must wait until the next Annual Enrollment Period.


Effective date of coverage is: First day of the month following plan selection. The Health Insurance Marketplace can also authorize a different effective date.

Effective date of coverage is: First day of the month following plan selection. The Health Insurance Marketplace can also authorize a different effective date.

Certificate of creditable coverage.



A policyholder gains a dependent through marriage, birth, adoption or placement for adoption, placement in foster care, or by court order.

For marriage, enrollment must be requested within 60 days of the event. The policyholder or his/her spouse must have had minimum essential coverage for one or more days in the 60 days prior to the event, unless he/she is moving from a foreign country or a United States territory, or is an American Indian as defined by section 4 of the Indian Health Care Improvement Act. For a change from single to family due to birth, we must receive enrollment within 60 days of birth or within one year. For adoption or foster care, application must be received within 60 days. For court order, must apply after the court order is issued. If he/she does not request enrollment within the time periods stated above, the policyholder and any dependents must wait until the next Annual Enrollment Period.

For marriage, effective date of coverage is: first day of the month following plan selection.

Effective date is date of birth.

Effective date is either the date the court makes a final order granting adoption or the date the child is placed for adoption or foster care.

Date of court order or date stated within court order.

The Health Insurance Marketplace can also authorize a different effective date.

Marriage—Copy of marriage certificate; proof of coverage (i.e., creditable coverage letter)

Birth—No documentation required.

Adoption, placement for adoption, or foster care—Legal documentation of adoption or proof of placement, which includes placement date, child’s name, and adoptive parent’s name OR legal documentation from a court or social service agency showing legal rights to make medical decisions for foster child.


The effective date is as follows: (1) if enrollment is received between the first and 15th of any month, the effective date is the first day of the following month; (2) if the request for enrollment is received between the 16th and the last day of the month, the effective date is the first day of the second following month.

The Health Insurance Marketplace can also authorize a different effective date.

Letter explaining the violation of the material provision of the contract, including a date and signature.

If the applicant states the agent made an error, obtain a signed/ dated letter from the agent indicating what took place

A policyholder’s or dependent’s enrollment or non-enrollment in a qualified health plan is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, or inaction of an officer, employee, or agent of the Health Insurance Marketplace or the Department of Health and Human Services, or its instrumentalities as evaluated and determined by the Health Insurance Marketplace. In such cases, the Health Insurance Marketplace may take such action as may be necessary to correct or eliminate the effects of such error, misrepresentation, or inaction.



A policyholder or dependent adequately demonstrates to the Health Insurance Marketplace or the Wisconsin Office of the Commissioner of Insurance (OCI) that the qualified health plan he/she is enrolled in substantially violated a material provision of its contract in relation to him/her.


The effective date is as follows: (1) if enrollment is received between the first and 15th of any month, the effective date is the first day of the following month; (2) if the request for enrollment is received between the 16th and the last day of the month, the effective date is the first day of the second following month. The Health Insurance Marketplace can also authorize a different effective date.

A policyholder or dependent applies for coverage through the Health Insurance Marketplace either during the open enrollment period or due to a qualifying event or at the State Medicaid or CHIP agency during the open enrollment period, and is determined ineligible for Medicaid or CHIP by the State Medicaid or CHIP agency either after open enrollment has ended or more than 60 days after the qualifying event.



A policyholder or dependent gains access to new qualified health plans as a result of a permanent move. This does not include a move solely for medical treatment or vacation.

Enrollment must be requested within 60 days of the event. If he/she does not request enrollment within this time period, the policyholder and any dependents must wait until the next Annual Enrollment Period. He/she and any dependents must have had minimum essential coverage for one or more days in the 60 days prior to the move, unless he/she is moving from a foreign country or a United States territory or is an American Indian as defined by section 4 of the Indian Health Care Improvement Act, or lived in a service area where no Qualified Health Plans were available through the Health Insurance Marketplace.

The effective date is as follows: (1) if enrollment is received between the first and 15th of any month, the effective date is the first day of the following month; (2) if the request for enrollment is received between the 16th and the last day of the month, the effective date is the first day of the second following month. The Health Insurance Marketplace can also authorize a different effective date. Move is defined by an address in a different county.

Documentation of previous and current address (e.g., utility bill or rental agreement); proof of coverage (i.e., creditable coverage letter).

A policyholder’s renewal of a non-calendar year plan.



Copy of renewal letter.



The policyholder or dependent gains access to new qualified health plans due to no longer being incarcerated. Incarcerated is defined as serving a term in prison or jail. It does not mean living at home or in a residential facility under supervision of the criminal justice system, or living there voluntarily. In other words, incarceration does not include being on probation, parole, or home confinement. You are not considered incarcerated if you are in jail or prison pending disposition of charges (in other words, being held, but not convicted of a crime).



Prison release document.

The policyholder is a victim of domestic abuse or spousal abandonment, enrolled in minimum essential coverage, and seeking to enroll in coverage separate from the perpetrator of the abuse or abandonment.



The policyholder or dependent gains access to an individual coverage health reimbursement arrangement (ICHRA) or is newly provided a qualifed small employer health reimbursement arrangement (QSEHRA) by his/ her employer. The individual is eligible for this SEP regardless of whether he/she is currently enrolled in individual health coverage.

Qualifying individuals have the option to request enrollment within 60 days before or 60 days following the event. The triggering event is the first day the ICHRA or QSEHRA may take effect.

The effective date is as follows: (1) If the request for enrollment is received before the day of the triggering event, the effective date is either the first day of the month following the triggering event or, if the triggering event is on the first day of the month, the date of the triggering event. (2) If the request for enrollment is received on or after the day of the triggering event, the effective date is the first day of the month following plan selection. Note: SEP is effective Jan. 1, 2020, as employers can only begin offering these types of HRAs to employees with effective dates of Jan. 1, 2020.


-


The following special enrollments are only included on the Exchange endorsement and only apply to on Marketplace.

A policyholder or a dependent who was not previously a United States citizen, national, or individual who was lawfully present in the United States gains such status. This does not include changing from one legally present status to another.

If a policyholder is an American Indian as defned by section 4 of the Indian Health Care Improvement Act, he/she may enroll in or change from one Qualifed Health Plan to another one time per month.

A policyholder or dependent is determined newly eligible for Advance Premium Tax Credits due to a decrease in household income.

A policyholder or dependent is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions, regardless of whether such policyholder is already enrolled in a qualifed health plan.



Enrollment must be requested within 60 days of the event. If he/she does not request enrollment within this time period, the policyholder and any dependents must wait until the next Annual Enrollment Period. He/she and any dependents must have had minimum essential coverage for one or more days during the 60 days preceding the date of the household income change.






No documentation required by Arise.






A policyholder adequately demonstrates to the Health Insurance Marketplace that a material error related to plan benefts, service area, or premium infuenced the qualifed individual’s or enrollee’s decision to purchase a plan through the Health Insurance Marketplace.




A policyholder demonstrates to the Health Insurance Marketplace that he/she meets other exceptional circumstances as the Health Insurance Marketplace may provide




Any other event as determined by the Health Insurance Marketplace.




WPS and Arise applications and documentation can be submitted to:

WPS Health Insurance submissions

Fax: 608-223-3639

Email: [email protected]

Mail: Customer Service WPS Health Insurance P.O. Box 8190 Madison, WI 53708

Arise Health Plan submissions

Fax: 920-490-6948

Email: [email protected]

Mail: Arise Health Plan P.O. Box 11625 Green Bay, WI 54307

Arise on-Marketplace applications must be submitted and approved through the Marketplace.




GROUP HEALTH PLANS

Enrollment Process

WPS Large Group Health Plans • Mail: WPS Health Insurance

1717 W. Broadway

P.O. Box 8190

Madison, WI 53708-8190

• Fax: 608-223-3626 WPS Group Application—Paper Application

• Online: wpshealth.com, click on Group Health Insurance, then click on Large Groups

Arise Large Group Health Plans • Mail: Arise Health Plan

P.O. Box 11625

Green Bay, WI 54307-1625

• Fax: 920-490-6942 Arise Employer Group Application—Paper Application

• Online: arisehealthplan.com, click on Employers

Groups of 2 to 50—New Group Enrollment Required Group Enrollment Materials

Groups Subject to ACA • WPS/Arise Employer Application

• WPS/Arise Disclosure Notice with 2–50 total employees

• Employee Applications (all employees, including those employees still in their probationary period and employees who are presently on COBRA/State continuation)

• Most recent Quarterly Wage and Tax Statement (Please see the “Required Tax Documents for New Group Sales” section below for further detail)

• Copy of the sold quote

• Copy of Sold Quote Age Rate Matrix Grid

Non-ACA Groups • WPS/Arise Employer Application

• Employee Medically Underwritten Applications with appropriate Health Questions completed for each eligible employee and/or dependent(s) enrolling for coverage, as well as for those employees still in their probationary period and employees presently on COBRA/State continuation

• Employee Waiver Applications with Waiver Section completed for all eligible employees waiving coverage with WPS/Arise

• Copy of COBRA/State Continuation election forms for any terminated employee who has not elected COBRA/State Continuation, but still appears on the prior carrier billing statement

• Most recent billing statement from the group’s current carrier (if applicable)

• Most recent Quarterly Wage and Tax Statement (please see the “Required Tax Documents for New Group Sales” section below for further detail)

• Copy of the sold proposal/quote given to the agent, broker, and/or the policyholder

https://secure.wpsic.com/sales-materials/files/25656-med-comp-app.pdf

https://wps.healthinsurance-asp.com/exemplar/shopping/anonymous.html#welcome

https://secure.wpsic.com/sales-materials/files/25656-med-comp-app.pdf

https://wps.healthinsurance-asp.com/exemplar/shopping/anonymous.html#welcome



Special Enrollment Period (SEP) Requirements and Documentation

Small and Large Group Eligibility and Effective Dates—Based on Policy Language


Annual Enrollment Period Each year there is an enrollment period that will be determined by federal law to allow enrollment. Unless eligible for a Special Enrollment Period, individuals must apply during the annual enrollment period, which is the month prior to the group’s anniversary date.

Coverage will be effective on the anniversary date of the group.

Employee group enrollment application (must be completed and submitted within 31 days of becoming eligible for coverage).

New Employee Must apply within 31 days of becoming eligible (eligibility date would be the date coverage would become effective under the policy). (Also, may apply within 60 days of loss of eligibility for Medicaid and after eligibility for premium assistance determination). If the employee does not enroll as stated above, he/she must wait until the next annual enrollment period, unless he/she qualifies for a Special Enrollment Period.

Coverage will be effective on the date he/she is initially eligible.

Employee group enrollment application must be completed and submitted within 31 days of becoming eligible for coverage.

Example: If the group has a probationary period that states coverage becomes effective the first of the month following one month of

full-time employment: Date of hire: Sept. 3, 2020

Eligibility Date: Nov. 1, 2020 Application must be received by: Dec. 2, 2020 (31 days)

New Dependent Must apply within 31 days of becoming eligible, unless eligible for a Special Enrollment Period (marriage, birth, adoption, placement, court order).

Coverage will be effective on the date he/she is initially eligible.

Marriage—Employee group enrollment application.

Birth—Employee group enrollment application.

Adoption, placement for adoption or foster care— Legal documentation of adoption or proof of placement which includes placement date, child’s name, and adoptive parent’s name OR legal documentation from a court or social service agency showing legal rights to make medical decisions for foster child.



Special Enrollment Provision— Loss of Other Coverage Applies to those employees not covered under the policy, but who are otherwise eligible to apply. Note: “Loss of Other Coverage” includes loss of a short-term health plan.

If an employee waived benefits when initially eligible and states he/she has other coverage and then loses that other coverage, we must receive the enrollment form within 31 days after the loss of the other coverage.

Coverage will be effective on the first day of the month following the date the other coverage ended.

Employee group enrollment application.

Special Enrollment Provision— Adding a Newborn Natural Child to Existing Family Coverage

We request the covered employee notify us within 60 days of the date of the birth.

Coverage is effective from the moment of birth.

No documentation required.

Special Enrollment Provision— Change in Marital Status

If a covered employee marries, we must receive an enrollment form within 31 days of marriage.

Coverage is effective on the date of marriage.

No documentation required.

Special Enrollment Provision— Changing to Family Coverage Due to Birth

Coverage is provided from the moment of birth and for the next 60 days. Prior to the end of that 60-day period, the covered employee must complete an enrollment form to apply for family coverage as stated below. If he/she fails to apply, coverage ends at the end of that 60-day period. To change coverage, we must receive an enrollment form: (1) within 60 days after the birth of his/her child; or (2) within one year after the birth of the child (with this option they must pay all past due premiums). If the enrollment form is received by us after the enrollment period stated above, he/she must enroll during the Annual Enrollment Period.

Coverage is effective on the child’s date of birth.

Employee group enrollment application.

Special Enrollment Provision— Changing to Family Coverage Due to Adoption

We must receive an enrollment form within the 60-day enrollment period following the date of the adoption, placement of adoption. If we receive the enrollment form after the enrollment period ends, the new dependents may only be added during the Annual Enrollment Period.

The effective date will be one of the following: (1) the date a court makes a final order granting adoption; (2) the date the child is placed for adoption; or (3) a later date elected by the covered employee.

Adoption—legal documentation of adoption or proof of placement, which includes placement date, child’s name, and adoptive parent’s name.



Special Enrollment Provision— Changing to Family Coverage or Adding a Dependent Due to a Court Order

We must receive the following after the applicable court order is issued: (1) a completed enrollment form; (2) a copy of the court order; and (3) payment of appropriate premium.

This document is provided for educational purposes and is not intended to provide legal advice. If questions arise related to how Special Enrollment Periods (SEP) apply to specifc matters, then the Billing and Enrollment Department at 888-915-5618 should be consulted. This information is applicable to fully insured employer groups only. Self-funded employer groups may have different special enrollment periods. Self-funded employer group members should see their Summary Plan Description or call customer service to confrm their special enrollment periods.

Effective date will be either: (1) the date that court order is issued; or (2) another coverage date contained in that court order.

Court order.

All Groups—Required Tax Documents for New Group All businesses of two or more eligible employees must supply the following documentation:

• Most recent Quarterly Contribution/Wage Report or, if not required to fle a Quarterly Contribution/Wage Report, all the items listed under the group’s specifc business type (see subheadings below).

• “C” Corporations ° Articles of Incorporation ° Form 1120 ° Payroll

• “S” Corporations ° Articles of Incorporation ° Form 1120S ° Payroll

• Partnership ° Partnership Agreement ° Form 1065 ° Payroll

• Sole Proprietorship ° Business license ° Form 1040/Schedule C ° Payroll

• Church ° Form 941 ° Payroll

• Limited Liability Company (LLC)

° LLC agreement and documentation for either a “C” Corporation or a Partnership (see above), depending on how they fle with the state

• If the business has been in existence less than one year and not fled a Quarterly Contribution/Wage Report, we will accept Corporation or Partnership papers and payroll

• Farmers—If not a corporation or partnership, farmers are required to submit Schedule F, itemization of line 24, and copies of W-2 statements for all employees

Groups of 51 or More—New Group Enrollment Required Group Enrollment Materials

• Group Application • Most recent Quarterly Wage and Tax Statement with employee status indicated for all employees listed as to whom is

presently full-time, part-time, seasonal, and/or terminated • Most recent prior carrier billing statement (if applicable) • Employee’s Medically Underwritten Application for each eligible employee and dependent(s) enrolling for coverage • Employee’s Waiver Applications for each eligible employee who will be waiving the health coverage • Copy of the proposal given to the agent, broker, and/or the policyholder

Process for Full Underwriting • Large employer groups with 51+ total employees are initially reviewed by WPS/Arise Health Underwriting. • WPS/Arise Health Underwriting reviews the information for completeness of forms, eligibility requirements, and

medical history that may impact future claims. • Tele-underwriting services may be used by WPS/Arise when underwriting group policies; applicants should be made

aware that they may be contacted by telephone if necessary to obtain additional medical information.

WPS Agency Manual 29


Billing Process

Groups of 2 to 50 Initial Monthly Premium Groups that choose the direct billing option should submit their premium with their enrollment. If they choose ACH, we will withdraw the frst month’s premium from the ACH account. Standard grace period will still apply to the frst month’s premium. The policy will be terminated if payment is not made in a timely manner.

Unpaid Premium Late payment: A delinquent email is sent out to the group once payment is past due and still in the grace period. Once the grace period ends, the policy will be terminated for non-payment.

Groups of 51 or More Initial Monthly Premium Groups that choose the direct billing option should submit their premium with their enrollment. If they choose ACH, we will withdraw the frst month’s premium from the ACH account. Standard grace period will still apply to the frst month’s premium. The policy will be terminated if payment is not made in a timely manner.

Unpaid Premium Late payment: A delinquent email is sent out to the group once payment is past due and still in the grace period. Once the grace period ends, the policy could be terminated for non-payment.

All Groups—Back Billing and Credit Adjustments Clerical Errors Errors by either the group or by WPS/Arise will not invalidate coverage otherwise in force nor continue coverage otherwise

terminated. Upon discovery of an error, an equitable adjustment will be made in the premium and/or beneft payment.

All Groups—Group Changes Small Transitional groups can make a change on their existing policy or move to an ACA-compliant plan upon renewal.

• All transitional relief beneft changes on current policy should be submitted to Underwriting.

• All small group changes to metal-tier plans should be submitted to Customer Service.

Customer Network Changes Employees can change to a different network offered by the group if they request a change during open enrollment or experi-ence a special enrollment event.

• If employee does not meet the requirements to change networks, WPS/Arise will notify the group. • If employee meets requirements to change networks, but the group doesn’t offer the requested network, the group can

opt to add a network (described below). • If employee meets requirements to change networks and the group offers the network requested, WPS/Arise will

change the employee to the new network the frst of the month following receipt of the request in the WPS/Arise Customer Service Department.

Group Adding Network To add a network, the group leader should submit these forms to WPS/Arise Underwriting for fully insured groups only:

• Employer’s Group Application with the appropriate sections completed • A rate quote prepared by WPS/Arise Sales or Underwriting and signed by the group leader • A letter on company letterhead indicating which employees should be transferred to the new network (for both fully

insured and self-funded)


Acquisition of a Subsidiary or Buyout (Common Ownership or Affliation) An existing group that acquires new employees because of a subsidiary purchase or buyout may add any eligible employee from the subsidiary or buyout within 31 days of the purchase or buyout.

Employee additions due to acquisition or buyout are subject to the following requirements: • A Quote Request Form and an Employer Group Application must be submitted to WPS/Arise Underwriting for

prior approval, along with a census for the new employees, medical statement, applications, or claims experience for new subsidiary/segment of employees.

• WPS/Arise will credit any calendar-year deductibles from the prior carrier; WPS/Arise must receive the proper enrollment forms, with appropriate medical questions completed.

• The prior carrier’s most recent billing statement must be submitted. • If a change in rating size occurs, WPS/Arise Underwriting may re-rate the entire group on the effective date for the new

segment. This process does not change the group’s anniversary date. Otherwise, changes in rating size will be implemented on the group’s regular anniversary date.

° If a new business entity is formed due to a buyout or merger, employees covered by WPS/Arise under the old entity will not be subject to medical underwriting if applying for eligible WPS/Arise group coverage.

° If adding a subsidiary (common ownership or affliation), this subsidiary must meet all the eligibility requirements of a new group on its own to be eligible to apply with the existing group.

Billing and Enrollment Services and Contact Information Each group will be provided contact information for its own dedicated administrative representative. The representative will respond to the inquires of our large group leaders and be responsible for eligibility updates and accurate premium billing.

Plan Changes

All Groups—Beneft Changes Retroactive beneft changes are generally not permitted. All beneft changes must be submitted to WPS/Arise Underwriting for approval and rating before the effective date of the change. In unique situations involving union negotiations or other extenuating circumstances, WPS/Arise may allow retroactive beneft changes. WPS/Arise will, however, charge an appropriate administrative fee to cover the cost of claims processing, re-billing, etc.

Renewals

Groups of 2-50 Group renewals will be mailed at least 30 days prior to renewal date.

Groups of 51 or More Changes in Group Census WPS/Arise reserves the right to evaluate an entire group upon a change in census of 10% or more and apply a rate change as necessary.

All Groups—Group Renewal Renewal Premium Rates

• Premium rate guarantees are not allowed on groups with 2–50 employees. • Premium rate guarantees on groups with 51+ employees must be approved by WPS/Arise Senior Management.


Change in Group Status WPS/Arise will audit small groups prior to the anniversary date to determine whether underwriting standards and participation requirements continue to be met.

• Small groups that are below minimum participation will be terminated upon required written notice. • Upon request, small groups that do not meet minimum participation will be given an additional 60 days to meet such

requirements. If, after 60 days, the group has not met minimum participation, the group will be terminated.

Changes to Group Anniversary Date Changes to a group’s anniversary date must be pre-approved by WPS/Arise Underwriting.

• All lines of coverage must have a common anniversary date, unless special circumstances apply. • Without Underwriting’s approval, WPS/Arise cannot honor renewal rates for a date other than the group’s anniversary

date, as such a change may not allow ample time for preparation of necessary information to generate renewal rates.


MEDICARE MARKET SOLUTIONS

Enrollment Process

Note: In lieu of the below processes for senior plans, applications can be completed for any product over the phone by calling 800-748-0582. The writing agent doesn’t have to be present at the time of enrollment and will receive full credit for the sale. If you choose to apply by phone, we ask that you please work with your client to make a beneft determination before calling.

WPS Medicare Supplement • Mail: WPS Health Insurance, P.O. Box 8190, Madison, WI 53707 • Fax: 608-223-3639 WPS Medicare Supplement—Paper Application • Online: WPS Medicare Supplement—Online Enrollment

Required Medicare Supplement Enrollment Materials • WPS Medicare Supplement Insurance Plan Application

WPS Medicare Part D • Mail: WPS Health Insurance, P.O. Box 8190, Madison, WI 53707 • Fax: 608-243-6154

• Online: WPS PDP—Online Enrollment

Required Medicare Part D Enrollment Materials • WPS MedicareRx Plan (PDP) Application • Optional: Personal Drug List Summary

Billing Process

The frst month’s premium is NOT required at time of initial enrollment. A billing statement will be mailed to the customer.

Automatic Bank Withdrawal

An easy-to-use service available at no additional cost.

Checking or Savings Account • Money will be pulled each month from a customer-designated checking or savings account. • Pick a day your client chooses (frst of the coverage month or on the 20th of the month preceding coverage).

° If date chosen is the 20th of the month preceding coverage, the frst pull of premium may happen twice in one month for the frst two months of coverage.

• PDP is pulled on the 20th of each month PRIOR to the month coverage is for when selecting automatic withdrawal. • If the frst or 20th falls on a weekend or holiday, the money will pull on the next business day. • Medicare supplement plans offer a 2% discount for customers who use automatic bank withdrawal.

Credit Card/Debit Card • Money will be pulled each month from a customer-designated credit card or debit card. • You may set up credit or debit card payments by visiting pay.wpsic.com. Please note that if your client does not set up

a payment within fve business days of receipt of the application, the client will be automatically enrolled in the monthly direct bill option listed on the Medicare supplement enrollment application. Clients may also call WPS Customer Support at 1-888-253-2694 to add this payment option.

• Not available for PDP.

https://secure.wpsic.com/sales-materials/files/25656_2020-mms-app-wi.pdf

https://my.wpshealth.com/en/Individual/healthplanhome?CategoryId=&WebsiteId=b5bgurh&state=pjn2yxr&producttype=jlggj6t

https://my.wpshealth.com/en/Individual/healthplanhome?WebsiteId=b5bgurh&state=pjn2yxr&producttype=ytwei4u

https://pay.wpsic.com


Direct Billing: No business checks will be accepted. • PDP: No fee. • Medicare supplement: No fee. • Bills are created and mailed on the third of the month and are due by the frst of the following month.

Payment in the form of a check or money order is required by the premium due date/10th of the month. The premium due date for PDP is always the frst of the month.

The First Premium Notice The frst premium notice is generated before applying your client’s frst month’s premium. As a result, the frst bill may show past due even though the previous month’s premium has already been paid. If your client’s frst bill shows a past due amount, they can calculate the amount they need to pay by simply subtracting the amount already paid from the Total Premium Due.

Unpaid Premium Late payment: A delinquent letter is sent out to customer and agency once payment is past due and still in the grace period. Once the grace period ends, the policy will be terminated for non-payment. Delinquent letters are not mailed for PDP.

Credits and Adjustments on Billing Statements Credits and adjustments will show on the next bill, depending on when the credit was applied and compared to when the bills are created. Retroactive billing credits and adjustments must be approved by WPS.

Plan Changes

Changes for WPS Medicare Supplement Plans • A current WPS customer can reduce benefts or eliminate riders without having to answer health questions (i.e., remove

the excess charges rider to reduce the premium). • A customer who purchased a WPS Medicare supplement insurance plan between June 1, 2010, and Dec. 1, 2015, can

switch to the 50% Part A deductible or Base Plan 2 (copay) with no health questions. A customer who purchased the 25% cost-sharing plan between June 1, 2010, and Dec. 1, 2015, can switch to the 50% cost-sharing plan with no health questions.

• Dental can be added at any time as long as dental was available at time of original enrollment.

Changes for WPS MedicareRx Plan (PDP)

• Changes to Part D plans can be submitted during open enrollment or if a qualifed SEP occurs for the customer.

Renewals

WPS Medicare Supplement Plans • Renewals will be sent 60 days prior to customers’ original month of their effective date. Age band increases go into

effect at the time of renewal, not beforehand.

WPS MedicareRx Plan (PDP) • The WPS MedicareRx Plan (PDP) annual notice of change (ANOC) is mailed out to all existing customers at the end

of September for the next January effective date/rate change. The ANOC includes all changes to the policies and the new rates.

• Customers have an open enrollment in which to change plans from Oct. 15–Dec. 7 for the following January effective date. • They can change plans, enroll for the frst time, or terminate from our plan during the open enrollment period.


SECTION 9:

WPS Health Insurance/Arise Health Plan Field Guide

WPS Health Insurance/Arise Health Plan Field Guide: January 2020 Please note: The information in this Guide is not all inclusive. WPS/Arise Underwriting reserves the right to revise these guidelines at any time without advance notice.

ELIGIBILITY Eligible Groups Standard Groups Organizations of Employers (Controlled Groups,

Associations, etc.) Labor Unions Classing Out Employees Health and Welfare Trust Funds Eligibility Rules Eligible Employee Spouse Child(ren)

ALL FULLY INSURED GROUPS Domestic Partners 1099 Employee(s) Ineligible Person(s) Overage Dependents New Hires Waivers ACA Special Enrollment Reasons Late Enrollees

LOSS OF ELIGIBILITY

REGAINING ELIGIBILITY UNDER GROUP HEALTH PLANS Military Leave Employee Dependent Child(ren) Discharged Leave of Absence Due to Military Leave

GROUP QUOTES Census Information Effective Date Group Size 2–50 Total Employees Group Size 51+ Total Employees

(Medically Underwritten) Group Size 51+ Total Employees (Experience Rated) Guidelines for Quoting Groups with

MEDICARE SECONDARY PAYER RULES 37 Decision Tree (Group) 45 37 Medicare-Eligible Due to Age (65+) 45

Medicare Disabled (<65) Employee(s) 37 and/or Dependent(s) 46 38 End-Stage Renal Disease (ESRD) 46 38 38 REPORTING 38 Paid Claim Information 47 38 Prognosis Information 47 38 39 BACK BILLING AND CREDIT ADJUSTMENTS

Clerical Errors 47 Deductible/Out-of-Pocket Crediting 47

40 41 GROUP CHANGES 41 Beneft Changes 48 41 Customer Network Changes 48 41 Group Adding Network 48 42 Acquisition of a Subsidiary or Buyout (Common 42 Ownership or Affliation) 49 43 Groups 2–50 49

Groups 51+ 49 43

GROUP RENEWAL Renewal Premium Rates 49 Changes to Group Anniversary 49

43 43 GROUP POLICY TERMINATION 50 43 43 COVERAGE DISCONTINUANCE AND

REPLACEMENT Military Leave Continuation 50

44 COBRA 50 44 Liability of Prior and Succeeding Carriers in 44 Group Replacement Situations 50

Crediting Deductibles and Out-of-Pocket Expenses 50 44 COBRA, Wisconsin Continuation, Extension of Benefts 50 44

Out-of-State Residents 44


WPS/ARISE FIELD GUIDE—GROUPS Group Size Parameters 51 Effective Date of Quote 51 Groups of 2–50 51 Groups of 51 or More 51 Internet Quoting 51 Information Needed to Request a Quote 51 Quote Guidelines for Groups with 2–50 Total Employees 51 Age Adjustments 51 Required Group Enrollment Material 52 Initial Monthly Premium 52 Unpaid Premium 52 Required Tax Documents for New Groups 52 Medically Underwritten Groups of 51 or More 53 Process for Full Underwriting 53 Effective Dates 53 General Enrollment Issues 53 Small Groups Subject to ACA 53 Health Coverage 53 Probationary Period 53 2–50 Insureds 53 51 or More Insureds 54 Retiree Coverage 54 Dual-Option Underwriting Regulations 54 All 2–50 Insureds 54 Group Renewal and Changes 54 Premium Rates and Increase Guidelines 54

CLAIMS EXPERIENCE-RATED— WPS/ARISE GUIDE Effective Date 55 Quoting Guidelines 55 Information Needed to Request a Quote 55 Groups 51–99 Without Experience 55 Groups 51–99 With Experience 55 Groups of 100 or More 56 Freedom Essentials: New Group Quote Request 56 Groups of 10 or More Insureds 56 Freedom Flex: New Group Quote Request 58 Groups of 25 or More Insureds 58 Process for Full Underwriting 59 Required Group Enrollment Materials 59 Required Tax Documents for New Group 59 Initial Monthly Premium 59 Unpaid Premium 59

ENROLLMENT WITH EXPERIENCE 60

GENERAL UNDERWRITING ISSUES Matching/Duplicating Benefts and/or Administration 60 Negotiated Commissions 60 Retiree Segments 60 Multiple Option Underwriting Regulations 60

DUAL-CHOICE BETWEEN MULTIPLE CARRIERS 61

MEDICAL OPEN ENROLLMENT 61

GROUP RENEWAL AND CHANGES Changes in Group Census 61 Changes to Group Anniversary Date 61

WPS/ARISE FIELD GUIDE—INDIVIDUALS (ACA) Individual Eligibility Rules 62 Eligibility 62 Loss of Eligibility 62 Individual Enrollment 62 Open Enrollment Period 62 Individual Applications 62 Medicare Secondary Payer Rules 63 Effective Date 63 Changes to Policies 63 Submission Requirements for Special Enrollment 64 Out-of-Pocket Crediting—Off-Exchange Plans 64 Tobacco Rates 64

Appendix A—Controlled Group Questionnaire 65

Appendix B—Common Ownership Confrmation Form 66

Appendix C—1099 Employees 67

Appendix D—Domestic Partnership 68


ELIGIBILITY ELIGIBLE GROUPS Standard Groups Sole proprietorships, partnerships, limited liability companies, and corporations are eligible when the group policy is issued to the employer covering his/her employees. There are three distinct categories of employer groups, including large risk groups, small risk groups, and administrative services only/self-funded groups. ° Large Fully Insured Groups: Employer groups with 51+ total employees (including full-time, part-time, and seasonal) ° Small Fully Insured Groups: Employer groups with 2-50 total employees (including full-time, part-time, and seasonal) ° Self-Funded Groups: Self-insured employer groups To determine whether a group is eligible for large or small group coverage, group size must be determined based on number of total employees (including full-time, part-time, and seasonal).

Organizations of Employers (Controlled Groups, Associations, etc.) With very limited exception (see below), in order for WPS/Arise to issue a single group policy to an organization of multiple distinct employers, the organization of distinct employers must attest that it meets the defnition of a controlled group. A controlled group is a combination of two or more corporations that are under common control. The controlled group is considered a single employer even though they have different names and different Tax ID numbers. There are two common types of controlled groups. (1) Parent-subsidiary and (2) Brother-sister. A parent-subsidiary controlled group consists of one or more chains of corporations. A brother-sister controlled group consists of two or more corporations with the same fve or fewer owners (e.g., individuals, trusts, or estates).

If an employer has a unique Tax ID, it has the option to purchase coverage as a single employer even if it is part of a controlled group. An employer with a unique Tax ID who is a member of a controlled group can choose to offer employee benefts independently or in combination with the other members of the controlled group. Whichever way the employer chooses to go, it has guaranteed issue into the market it is a part of given the basis on which it chooses to provide benefts.

A collection of employers that does not meet the defnition of a controlled group is not eligible for coverage under a large group policy. This is true regardless of what the collection of employers calls itself. Common names for such collections of employers include, but are not limited to: associations, trusts, multiple employer welfare arrangements (MEWAs), purchasing alliances, purchasing cooperatives, coalitions, or collaborative. There are two possible exceptions to this:

• A collection of employers deemed an “employer” by the U.S. DOL. This is incredibly rare, and unless the collection of employers can produce documentation from the U.S. DOL verifying its designation as an “employer,” a policy cannot be issued under this exception.

• A collection of employers organized as a cooperative under ch.185. Wis. Stat. The collection of employers must (1) be legally organized and comply with all applicable statutory requirements and (2) not include any small employer groups. The Wisconsin cooperative statute is pre-empted by Federal law with respect to small employer groups.

Bona fde associations must meet the following criteria and be approved by WPS management. A “bona fde association,” with-in the meaning of Title XXVII of the PHS Act means:

42 U.S. Code § 300gg–91 - Defnitions (d)(3) Bona fde association The term “bona fde association” means, with respect to health insurance coverage offered in a state, an association which— (A) has been actively in existence for at least fve years; (B) has been formed and maintained in good faith for purposes other than obtaining insurance; (C) does not condition membership in the association on any health status-related factor relating to an individual (including an employee of an employer or a dependent of an employee);


(D) makes health insurance coverage offered through the association available to all members regardless of any health status-related factor relating to such members (or individuals eligible for coverage through a member); (E) does not make health insurance coverage offered through the association available other than in connection with a member of the association; and (F) meets such additional requirements as may be imposed under state law.

See Appendix A for the Controlled Group Questionnaire and Appendix B for the Common Ownership Confrmation Form. Both the Questionnaire and the Form must be completed and submitted to Underwriting with any application for coverage under a single group plan for an organization of multiple distinct employers.

Labor Unions A group policy may be issued in the name of a union to cover union members, employees, and offcers. Coverage will be available to union members and eligible management actively engaged in their occupation or on layoff and self-pay, as defned in the constitution, bylaws, trust agreement, and/or labor agreement. A copy of a document that defnes eligibility must be submitted to WPS/Arise along with the quote request.

Classing Out Employees Classing out employees is prohibited by federal and/or state laws.

Health and Welfare Trust Funds These groups are usually created as a result of collective bargaining agreements. Health and Welfare Funds are eligible groups when a group policy is issued to trustees of a fund established by one or more employers and/or one or more labor unions to cover employees or members of the union. Coverage will only be available to union members actively engaged in their occupation, as defned in the constitution, bylaws, trust agreement, and/or labor agreement and eligible management. A copy of the document that defnes eligibility and a description of the method to be used to maintain records and remit premium must be submitted to WPS/Arise.

ELIGIBILITY RULES Eligible Employee An employee who has met the eligibility requirements for insurance set forth in the group policy. Employees must work 30 hours per week and must be actively at work for groups with 2–50 enrolled employees and 80 hours or more per month for groups with 51 or more enrolled employees (the employee is actively at work on: each day of a paid vacation; or a regularly scheduled non-working day, provided that, in either case, he/she was at work on his/her last regular working day prior to such date), unless otherwise specifed on the employer group application.

Spouse The person to whom the customer is legally married, including status of legal separation. A legal spouse may be of the same or opposite sex. A customer who is responsible for providing health insurance to a former spouse under a court order cannot include any former spouse on his or her insurance as a dependent because he or she is not a legal spouse. However, coverage may be provided separately to a former spouse under Wisconsin and Federal (COBRA) Continuation provisions, if applicable.


Child(ren) Natural Children: The plan will provide coverage for a single covered employee’s/individual’s newborn natural child from the moment of that child’s birth and for the next 60 days of that child’s life immediately following that child’s date of birth. The covered employee/individual must change from single to family coverage to provide coverage for the newborn beyond the frst 60 days. To do this, he/she must apply for coverage using our application form and either: (a) pay the required premium within the frst 60 days after the birth of his/her natural child; or (b) pay all required past-due premium within one year after the birth of his/her natural child and in addition pay interest of such premium payments at a rate of 5.5% per year.

° WPS/Arise will provide coverage for a covered employee’s/individual’s child or stepchild who is less than 26 years of age. ° WPS/Arise will provide coverage for a covered employee's/individual’s child or stepchild who is a full-time student and

meets all of the following criteria: 1. The child was called to federal duty in the National Guard or in a reserve component of the U.S. armed

forces while the child was attending, on a full-time basis, an institution of higher education; and 2. The child was under the age of 26 when called to federal active duty; and 3. Within 12 months after returning from federal active duty, the child returned to an institution of higher

education on a full-time basis, regardless of age.

Note: This paragraph does not apply to Illinois products; please see the Illinois certifcate for eligibility requirements.

Adopted Children: Wisconsin Statutes 609.25 and 632.896 require coverage for adopted children and children placed for adoption with a customer under the same terms and conditions for other dependent children, with these exceptions:

° Coverage for an adopted child begins on the date a court makes a fnal order granting adoption, or on the date the child is placed for adoption with the customer, whichever is earlier.

° Coverage for a child placed for adoption is required whether or not a fnal order granting adoption occurs. When the child’s adoptive placement with the customer ends, the child’s coverage will be terminated.

° The customer is required to notify WPS/Arise that a child has been adopted or placed for adoption, and the insured (customer) must pay any premium or fees necessary to cover the child (if applicable). Application for coverage of adopted children must be submitted within 60 days of the fnal court order granting adoption, or placement in the home, whichever is earlier. If the customer fails to notify WPS/Arise or make payment within 60 days, WPS/Arise will treat the adoptive child as any other dependent who seeks coverage at other than the time when they are frst eligible.

Stepchildren: Eligible if the stepchild(ren) resides with the customer or is supported by the customer and/or is the child of the customer’s legal spouse, subject to all other dependent child eligibility requirements.

Legal Guardianship: Eligible for coverage when legal guardianship of a dependent child is obtained by the customer (includes customer and spouse). Children who are not the natural children of the customer and for whom the customer is not legally responsible are not eligible dependents. Relatives of the customer are not eligible dependents unless legal guardianship is obtained.

Foster Children: For all group plans, foster children are not eligible for dependent coverage. Note: This does not apply to IL large group plans (Natural children - IL doesn't require coverage if they pay within 1 year or for active duty).

Grandchildren: In Wisconsin, a child of a customer’s covered eligible dependent is eligible for coverage until the covered eligible dependent reaches age 18.

Overage Handicapped Children: Eligible if (1) resides with the insured (customer), (2) is solely dependent on/supported by the insured or the insured’s legal spouse, and (3) was a covered dependent on the date he/she reached the limiting age for dependent coverage under the policy. Documentation such as Social Security eligibility and recent tax documents showing the handicapped child(ren) are solely dependent on their natural or adopted parent is required.


ALL FULLY INSURED GROUPS DOMESTIC PARTNERS Domestic partners are only eligible for coverage if the group chooses to include this type of coverage upon initial enrollment. If not chosen upon initial enrollment, this coverage can be added by submitting an Employer Group Application indicating this change along with all applications for those domestic partners who are eligible. This change will become effective the frst of month following receipt of change application and will be subject to underwriting requirements. (Please note: this could result in a change to rates due to the additional risk.)

Note: The domestic partner option will no longer be available to ETF groups after Jan. 1, 2018, or local government units, such as school districts, counties, or municipalities, after April 1, 2018, or later, depending on the collective bargaining agreement.

The domestic partner must meet the following defnition in order to be eligible for coverage: Domestic partners are defned as two individuals:

° Who are in a committed relationship of mutual support, caring, and commitment with the intention to remain in such a relationship in the immediate future;

° Who are fnancially responsible for each other’s well-being and debts to third parties; ° Who are not married or legally separated in marriage, and who have not been a party to an action or proceeding for

divorce or annulment within six months of registration, or if one has been married, at least six months have elapsed since the date of the judgment terminating the marriage;

° Who are not currently registered in another designated partnership, and if one party has been in such a registered rela-tionship, at least six months have lapsed since the effective date of termination of that registered relationship before the registration of the current domestic partnership;

° Who are each 18 years of age or older and competent to contract; ° Who are not related by blood closer than would bar marriage in the state of their residence; ° Who live together in the same dwelling unit as a single non-proft housekeeping unit and have a relationship that is of a

permanent and domestic character; ° Whose relationship is not temporary, social, political, commercial, or economic in nature; ° Whose relationship has existed for at least six months; ° Who are not registered with any other domestic partnership; ° Who, for at least the six-month period immediately preceding the date of this Declaration, have either:

° Obtained a domestic partnership certifcate from the city, county, or state of residence or from any other city, county, or state offering the ability to register a domestic partnership; or

° Any three of the following with respect to the domestic partner: ° Joint lease, mortgage, or deed ° Joint ownership of a vehicle ° Joint ownership of a checking account or credit account ° Designation of the domestic partner as a benefciary of the covered employee’s will ° Designation of the domestic partner as a benefciary for the covered employee’s life insurance or retirement benefts ° Designation of the domestic partner as holding power of attorney for health care ° Shared household expenses

If eligible, the Domestic Partner Form (See Forms in Appendix A) must be completed and submitted along with each Employee Application.

Same-Sex Marriage: Because of the U.S. Supreme Court ruling effective Oct. 6, 2014, each spouse in a same-sex marriage is eligible to enroll the other as a dependent spouse on his/her health insurance plan, subject to the terms of the enrollee’s certifcate of coverage. Generally, spouses must apply at initial enrollment or within 31 days following the date of marriage, with coverage effective on the date of marriage. A same-sex spouse is not considered as a domestic partner; rather, he/she is considered a dependent spouse.

http://secure.wpsic.com/sales-materials/files/27380_domestic_partner_declaration.pdf


1099 EMPLOYEES The following guidelines apply to groups with less than 51 full-time equivalent employees.

• Groups with more than 50 full-time equivalent employees will determine eligibility of their 1099 employees in accor-dance with the Affordable Care Act Shared Responsibility requirements.

• A Wage and Tax Statement must be provided listing the average hours worked for each listed employee. • Leased employees and independent contractors are not eligible for coverage unless all of the following criteria are met:

° 1099 employees must meet the WPS/Arise defnition of a full-time employee. ° 1099 employees must work year-round and exclusively for the group. ° If offering to one eligible 1099 employee, the group must offer coverage to all eligible 1099 employees.

• Taxed employee for the purpose of this guideline refers to those employees listed on the State Quarterly Wage and Tax Statement.

• The group must meet all underwriting requirement on its own, before it can add 1099 employees. • Participation will then be measured on all eligible taxed employees and eligible 1099 employees. • Employer must contribute the same amount of money toward the 1099 employee’s premium as the taxed employees. • Employer must be eligible for coverage prior to adding the 1099 employee(s). There must be a minimum of two taxed

employees at all times. • A minimum of 50% of those insured must be taxed employees. • Employer application must indicate that 1099 employees are eligible for plan at time of enrollment. • 1099 employees must be effective at original enrollment, at open enrollment, or special enrollment or they will be

considered late entrants. • Employer must provide copies of all 1099 statements, including individuals not electing coverage. • 1099 employees that are eligible and not electing coverage must complete a waiver application. • 1099 employees will not be eligible for ancillary coverage.

1099 employees are only eligible for coverage if the group chooses to include this type of coverage upon initial enrollment. If not chosen upon initial enrollment, this coverage can be added by submitting an Employer Group Application indicating this change along with applications for all 1099 employees who are eligible. This change will become effective the frst of month following receipt of change application and will be subject to underwriting requirements. (Please note: this could result in a change in our rates due to the additional risk.)

If eligible, the 1099 form must be completed and submitted along with the enrollment or change application. (See 1099 Form in Appendix D.)

Groups with more than 50 full-time equivalent employees will determine eligibility of their 1099 employees in accordance with the Affordable Care Act Shared Responsibility requirements.

INELIGIBLE PERSON(S) Overage Dependents A dependent child or stepchild ceases to be eligible the day immediately following the last day of the calendar month in which the dependent child or stepchild reaches age 26.

New Hires • New hires and their dependent(s) are guaranteed coverage if an application is submitted in accordance with the group’s

new hire enrollment requirements. The effective date is the date eligible shown in accordance with the group’s waiting period (the waiting period may not exceed 90 days). If application is made after the group’s initial enrollment period as stated above, the new hire/dependent is considered a late enrollee and must wait until the next Open Enrollment Period unless he/she qualifes for a Special Enrollment Period.

• Any requests to waive all or part of the probationary period for a new hire who is a key employee must be submitted in writing to WPS/Arise Underwriting. A key employee is someone in an occupation critical to the specifc type of


business the employer is engaged in, generally in a management or highly specialized position. For fully insured large groups, the request must include the employee’s title, salary, and completed health questionnaire on the application. This request must be made prior to the individual’s requested effective date of coverage. Approval of any requests for such an exception is at the sole discretion of WPS/Arise Underwriting. For self-funded groups, nondiscrimination rules prevent acting in favor of highly compensated employees. Therefore, the probationary periods will not be waived.

Waivers When an employee, spouse, or dependent waives the WPS/Arise coverage because of other creditable coverage, a waiver must be signed by the eligible employee. This waiver will be secured on behalf of the spouse or dependent that declines coverage under the WPS/Arise policy during the initial enrollment period or as a new entrant or as an underwritten individual. Anyone waiving coverage because of other creditable coverage must complete the applicable section of the Employee Application identifying the type of coverage they currently have. For groups of 51 or more enrollees, the group must maintain in its fles proof of waiver for each individual choosing to waive coverage and provide WPS/Arise a list of employees waiving coverage.

ACA Special Enrollment Reasons If an individual or employee fails to make a positive election during the Open Enrollment Period, the person will be excluded from purchasing coverage until the next open enrollment in the subsequent year. The only exception to these rules occurs if there is a qualifying life event:

• Birth: The effective date of coverage will be the date of event. In Wisconsin, the application must be submitted within 60 days following the birth unless, within 12 months of the birth, the insured submits all past-due premium plus interest at a rate of 5.5% per year. In Illinois, the application must be submitted within 31 days following the birth if switching from individual to family coverage, or within 60 days if family coverage is already in effect.

° No special documentation needed. • Adoption: The effective date of coverage will be the date of event. (Submission of the application must be within 60

days following the event in Wisconsin or within 31 days in Illinois.) ° Submit legal documentation of adoption, which includes placement, date, child’s name, and adoptive parent’s name.

• Marriage: The effective date of coverage will be the frst day of the following the month in which the application was received by WPS/Arise.

° Submit a copy of applicant’s marriage certifcate. ° See Special Enrollment Period charts in Section 8 for additional information.

Customer State/Plan Must Notify WPS/Arise Effective Date

Wisconsin/Individual Within 60 days First of the month following plan selection

Wisconsin/Small Group Within 31 days Date of marriage

Wisconsin/Large Group Within 31 days Date of marriage

Illinois/All Groups Within 31 days Date of marriage

• Loss of Coverage: Submit Certifcate of Creditable Coverage or other proof of involuntary loss of coverage. For all group plan customers, the person must have waived coverage when initially eligible.

Customer State/Plan WPS/Arise Must Receive Enrollment Application

Effective Date

Wisconsin/Individual Within 60 days First of the month following the month in which the application was received

Wisconsin/Small Group Within 31 days First of the month following the date the other health coverage ended

Wisconsin/Large Group Within 31 days First day following the date the other health coverage ended

Illinois/All Groups Within 31 days First day following the date the other health coverage ended

• For all other reasons: Permanent Move, Gain U.S. Citizenship—If applying for individual coverage between the frst and 15th of the month, the effective date will be the frst of the following month. If applying for individual coverage between the 16th and end of the month, the effective date will be the frst of the second following month.


LATE ENROLLEES A late enrollee is an eligible employee or dependent who did not request coverage during a group’s initial enrollment period, did not apply within 30 days of the end of his/her probationary period, or does not qualify for the Special Enrollment Reasons listed above. A late enrollee is not eligible for enrollment until the next Open Enrollment Period.

LOSS OF ELIGIBILITY Coverage for all covered customers ends based on language in the policy issued.

REGAINING ELIGIBILITY UNDER GROUP HEALTH PLANS An employee who loses eligibility for group coverage and later regains eligibility may be reissued coverage as long as it is reasonable under the circumstances. A group can require the new hire to meet the plan’s eligibility criteria, including a maximum 90-day waiting period.

If an employee regains eligibility within 182 days of the termination date of his/her coverage, the previously held coverage will be reissued effective on the frst day of the calendar month following the date he/she regains eligible status if an application is submitted within 31 days of rehire (unless a particular group has other specifc requirements that supersede this). Benefts will not exceed those available if the employee had been continuously insured, except to the extent the employee would, if continu-ously insured, have been eligible to enroll dependents based on a special enrollment circumstance.

If an employee's return to eligible status is more than 182 days following the date coverage terminates, the employee will be considered a new hire (i.e., he/she will need to meet any applicable probationary period).

MILITARY LEAVE The following applies if a reservist is discharged from a branch of the Armed Services.

Employee • Under the federal Uniformed Services Employment and Re-Employment Rights Act (USERRA), employees and their

dependents are entitled to immediate reinstatement of their civilian insurance coverage upon return to employment, as long as the guidelines below are followed: ° For Active Duty of less than 30 days, the employee must return to work on the next regularly scheduled workday

after receiving adequate time for travel and rest. ° For Active Duty of 30 to 180 days, the employee must return to work within 14 days after completion of service. ° For Active Duty of more than 180 days, the employee must return to work within 90 days after completion of service.

• Subject to the above guidelines, group coverage would be reinstated on the date the employee returns to work. TRICARE coverage eligibility may continue between the date the Service Member is discharged from Active Duty and the date he/she returns to work; a TRICARE Benefts Counselor should be consulted for details, if applicable.

Dependent Child(ren) Discharged • When a dependent child is discharged from the service, coverage will be reinstated under the group plan, provided

he/she meets all other eligibility requirements, including limiting age and full-time student status, if applicable.

Leave of Absence Due to Military Leave Coverage shall end on the date the covered employee or covered dependent enters into military service, other than for duty of less than 30 days.


GROUP QUOTES CENSUS INFORMATION To avoid rate adjustments at the time of enrollment on either an age-rated or composite basis, the quote must be premised on an accurate census. Census information should include:

° Single/family participation (not marital status) ° Dates of birth or age (as of the requested effective date) for all employees ° Gender for all employees

EFFECTIVE DATE Group Size 2–50 Total Employees The cut-off date will be the last day of the month prior to the requested effective date.

Group Size 51+ Total Employees (Medically Underwritten) WPS/Arise will follow the on-Marketplace requirements for enrollments. The cutoff date will be the 15th of each month for an effective date beginning the frst of the following month. For enrollments received after the 15th of the month, the effective date will be the frst date of the second following month. For example, an enrollment received on Jan. 16 will have an effective date of March 1.

Group Size 51+ Total Employees (Experience Rated) An effective date within a proposal means that if WPS/Arise quotes rates for a group with an Oct. 1 effective date, the proposal becomes invalid after Oct. 1. Only Underwriting can agree to extend the effective date and/or modify the rates or terms of the contract.

Guidelines for Quoting Groups with Out-of-State Residents ° All groups to be quoted must be domiciled in Wisconsin or Illinois. ° Guidelines for groups with 51+ total employees:

° A maximum of 75% of the group can be out-of-state residents. Please contact WPS/Arise Underwriting regarding any such groups which do not meet this guideline. Only Underwriting may grant an exception to this guideline.

° No more than 25% of the group can be in any one state outside of Wisconsin. ° Special rule for Minnesota: For any size group with employees residing in Minnesota, the group may be quoted if fewer

than 25 employees are Minnesota residents and the employees who are Minnesota residents represent less than 25% of all covered employees. Please contact Underwriting regarding any groups that do not meet this guideline.

° For any groups not meeting the above guidelines, please contact WPS/Arise Underwriting prior to requesting a quote.


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MEDICARE SECONDARY PAYER RULES This information is a general summary relating to the Medicare Secondary Payer provisions of the Social Security Act and is for educational purposes only. It is not intended to be exhaustive nor should it be construed as legal advice. Employers should consult with legal counsel for legal advice and assistance in interpreting the application of the Medicare Secondary Payer pro-visions to their specifc circumstances and their respective group health plans. This general summary fully replaces and super-sedes all prior summary versions released or distributed, and no version should be relied upon or construed as legal advice.

Decision Tree (Group) Is the insurance coverage at issue an

individual plan or a group plan?

-

Group Plan What is the basis for Medicare eligibility

or entitlement?

Working Age (65+) ESRD Disability

Individual Plan— Medicare is the Primary Payer Medicare does not coordinate benefts

Revised 7/2018

Medicare-Eligible Due to Age (65+)

Is the individual (age 65+) covered by a GHP through an employer because the individual

himself is still working (i.e., has "current employment status") or his spouse is still working (the individual

is the dependent spouse on the GHP)?

No, neither the individual nor the spouse (as the employee) is actively working and therefore the eligibility

for coverage is not based on "current employment status" (i.e., the individual

is covered under retiree plan).

Medicare is the Primary Payer and the GHP (i.e., retiree coverage)

is secondary.

Yes, either the individual himself is still actively working or he is the

dependent spouse of the employee who is still actively working and therefore

eligible for the GHP coverage.

Does the employer have 20 or more employees?

Yes, employer has 20 or more employees.

No, the employer has fewer than 20 employees.

GHP is the Primary Payer. Medicare is the Primary Payer.

Special Rule—Multi-Employer GHPs:

If an employer having fewer than 20 employees participates in a multi-employer

GHP that has at least one other participating employer that employs 20 or more employees,

then the GHP would be primary unless the multi-employer GHP requested a Small

Employer Exception (SEE). Stated differently, if one of the participating employers in the

multi-employer GHP has 20 or more employees, then the requirement that the GHP be primary

applies to all employers, including the employer with fewer than 20 employees.

Revised 7/2018

46 | WP S Health Insurance and Arise Health Plan Agency Manual

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Medicare Disabled (<65) Employee(s) and/or Dependent(s)

End-Stage Renal Disease (ESRD)

Revised 7/2018

Medicare Disabled (<65) Employee(s) and/or Dependent(s)

Revised 7/2018

Is the individual (disabled) covered by a GHP through anemployer because the individual himself is still working (i.e.,

has "current employment status") or his family member is stillworking (the individual is the dependent on the GHP)?

Yes, either the individual himself is still actively working orhe is the dependent of the employee who is still activelyworking and, therefore, eligible for the GHP coverage.

No, neither the individual nor the family member (as theemployee) is actively working. Therefore, the eligibility for

coverage is not based on "current employment status"(i.e., the individual is covered under retiree plan).

Does the employer have 100or more employees?

Yes, employer has 100 ormore employees.

No, the employer has fewerthan 100 employees.

GHP is the Primary Payer.Medicare is the Primary Payer.

Medicare is the Primary Payer and the GHP(i.e., retiree coverage) is secondary.


When an employer with fewer than 100 employeesparticipates in a multi-employer GHP that has atleast one employer participant with 100 or moreemployees, then the GHP is required to be theprimary payer. Stated differently, if an employerwith fewer than 100 employees participates in amulti-employer GHP that has another employer

with 100 or more employees participating, then allof the employers will be subject to the requirementto be primary regardless of having fewer than 100

employees. No exceptions to this rule exist.Revised 7/2018

Is the individual (disabled) covered by a GHP through an employer because the individual himself is still working (i.e.,

has "current employment status") or his family member is still working (the individual is the dependent on the GHP)?

Yes, either the individual himself is still actively working or he is the dependent of the employee who is still actively working and, therefore, eligible for the GHP coverage.

No, neither the individual nor the family member (as the employee) is actively working. Therefore, the eligibility for

coverage is not based on "current employment status" (i.e., the individual is covered under retiree plan).

Does the employer have 100 or more employees?

Yes, employer has 100 or more employees.

No, the employer has fewer than 100 employees.

GHP is the Primary Payer. Medicare is the Primary Payer.

Medicare is the Primary Payer and the GHP (i.e., retiree coverage) is secondary.


When an employer with fewer than 100 employees participates in a multi-employer GHP that has at least one employer participant with 100 or more employees, then the GHP is required to be the primary payer. Stated differently, if an employer with fewer than 100 employees participates in a multi-employer GHP that has another employer

with 100 or more employees participating, then all of the employers will be subject to the requirement to be primary regardless of having fewer than 100

employees. No exceptions to this rule exist.

End-Stage Renal Disease (ESRD)

Does the individual have ESRD and is covered by a GHP?*Note, "current employment status" is not a

consideration in this analysis.

Yes, the individual is covered by a GHP.No, coverage is provided by an individual plan.

Medicare does not coordinate benefts.

Is the individual in the frst 30 months of eligibility orentitlement to Medicare

(known as the "coordination period")?

Yes, then GHP is the Primary Payer.No, the coordination period has ended(the frst 30 months of eligibility or entitlement to

Medicare). Medicare is the Primary Payer.

Does the individual have ESRD and is covered by a GHP? *Note, "current employment status" is not a

consideration in this analysis.

Yes, the individual is covered by a GHP. No, coverage is provided by an individual plan.

Medicare does not coordinate benef ts.

Is the individual in the f rst 30 months of eligibility or entitlement to Medicare

(known as the "coordination period")?

Yes, then GHP is the Primary Payer. No, the coordination period has ended (the f rst 30 months of eligibility or entitlement to

Medicare). Medicare is the Primary Payer.

Revised 7/2018


I

I I I 11 I I

I I I I I I I

REPORTING PAID CLAIM INFORMATION

° Groups with 2–50 enrolled employ- WPS Reporting Package 2/19/20

Report Availability Planees: No paid claim information is available unless self-funded.

° Groups with 51–99 enrolled employees: Aggregate paid claim summary information is available on an annual basis from WPS/Arise with the group’s renewal rates.

° Groups with 100 or more enrolled employees and all self-funded groups have access to WPS/Arise SharePoint. Reports available online include:

Report Family Report Name Under 50 Risk

51 - 99 100+ ASO

25 - 50 51+

SMALL LARGE1 LARGE2 LARGE1

SMALL LARGE2 Enrollment Bill Detail X X X X X

Enrollment and Demographics Packet X X X X X Enrollment By Age and Employee Plan X X X X X Enrollment By Age and Member Type X X X X X Enrollment By Health Plan and Network X X X X X Enrollment By Subgroup and Class X X X X X Form 1095-B-C X X Summary Bill X X X X X

Financial Summary Charged to Paid X X X Claims and Utilization Packet X X X Claims and Utilization Packet (50-99) X Claims Matrix with Graphs X X X Loss Ratio X Paid By Claim Type by Subgroup & Class X X X Paid By Claim Type X X X

° Enrollment reports ° Financial summary reports ° Provider utilization

Health Conditions Claims By Diagnosis and MDC X X X X

High Cost Claims Claims Strata X X X Claims Strata (50-99) X High Cost Patients X X X

° Health conditions Medical Utilization High Level Health Statistics X X X High Level Health Statistics (50-99) X

° High-cost claims Provider Utilization Top Provider X X X

WPS/Arise Data Dashboard provides access to a group’s health care information at any time through our secure website. WPS/Arise will appropriately charge the group for any additional requests for paid claim information. All WPS/Arise Data Dashboard reports provided to fully insured groups include only de-identifed data.

PROGNOSIS INFORMATION Fully insured policies do not have the right to access diagnosis or prognosis information on specifc individuals. Therefore, WPS/Arise will not give claims runs to any employer that indicates the amount and diagnosis or prognosis on the same run.

BACK BILLING AND CREDIT ADJUSTMENTS CLERICAL ERRORS Errors by either the group or by WPS/Arise will not invalidate coverage otherwise in force nor continue coverage otherwise terminated. Upon discovery of an error, an equitable adjustment will be made in the premium and/or beneft payment.

DEDUCTIBLE/OUT-OF-POCKET CREDITING ° New groups to WPS/Arise—credit out-of-pocket amount (deductible, coinsurance, and copays) ° Existing groups voluntarily moving to an ACA plan—credit deductible only ° Existing groups moved to an ACA plan

° Calendar year ° January anniversary groups—no credit ° Non-January anniversary groups—credit deductible and coinsurance

° Plan year—no credit (if moved on plan year) ° Groups switching from WPS to Arise or Arise to WPS—credit out-of-pocket amount


Please submit Maximum Out-of-Pocket Credit Report from prior carrier to:

WPS Health Insurance Attn: Claims, Deductible Credit Supervisor P.O. Box 8190 Madison, WI 53708

This can also be faxed to the attention of Deductible Credit Supervisor at 608-977-9857.

The Maximum Out-of-Pocket Credit Report should also include employee last name, frst name, and the specifc time frame covered in the report.

If the group is unable to obtain a Maximum Out-of-Pocket Credit Report from the prior carrier, WPS/Arise will accept an Explanation of Benefts (EOB) from the employee. If employees are submitting EOBs, please make sure they are submitted in a timely manner in order to prevent WPS/Arise from taking deductibles on their claims.

GROUP CHANGES Small Transitional groups can make a change on their existing policy or move to an ACA compliant plan upon renewal.

° All transitional relief beneft changes on current policy should be submitted to our Billing and Enrollment Department:

WPS/Arise Billing and Enrollment P.O. Box 11625 Green Bay, WI 54307

° All small group changes to metal tier plans should be submitted to Customer Service.

BENEFIT CHANGES Retroactive beneft changes are generally not permitted. All beneft changes must be submitted to Underwriting for approval and rating before the effective date of the change. In unique situations involving union negotiations or other extenuating circum-stances, WPS/Arise may allow retroactive beneft changes. WPS/Arise will, however, charge an appropriate administrative fee to cover the cost of claims processing, re-billing, etc.

CUSTOMER NETWORK CHANGES ° Employees can change to a different network offered by the group if they request a change during open enrollment or

experience a special enrollment event. ° If an employee does not meet the requirements to change networks, WPS/Arise will notify the group. ° If employee meets requirements to change networks, but the group doesn’t offer the requested network, the group can

opt to add a network (described below). ° If employee meets requirements to change networks and the group offers the network requested, WPS/Arise will

change the employee to the new network the frst of the month following receipt of the request in the WPS/Arise Customer Service Department.

GROUP ADDING NETWORK To add a network, the group leader should submit these forms to WPS/Arise Underwriting for fully insured groups only:

° Employer Group Application with the appropriate sections completed. ° A rate quote prepared by WPS/Arise Sales or Underwriting and signed by the group leader. ° A letter on company letterhead indicating which employees should be transferred to the new network.

To add a network for a self-funded group, the group leader should submit the following to WPS/Arise Underwriting: ° A letter on company letterhead indicating which employees should be transferred to the new network.


ACQUISITION OF A SUBSIDIARY OR BUYOUT (COMMON OWNERSHIP OR AFFILIATION) Groups 2–50 Two groups can remain small if they have different FEIN numbers.

° An Employer Group Application must be submitted to WPS/Arise, along with a census for the new employees, medical statement, applications, or claims experience for new subsidiary/segment of employees.

° WPS/Arise will credit any calendar year out-of-pocket amounts and deductibles from the prior carrier. WPS/Arise must receive the proper enrollment forms.

° If a change in rating size occurs, WPS/Arise Underwriting may re-rate the entire group on the effective date for the new segment. This process would not change the group’s anniversary date. Otherwise, changes in rating size will be implemented on the group’s regular anniversary date.

° If a new business entity is formed as a result of a buyout or merger, employees covered by WPS/Arise under the old entity will not be subject to medical underwriting if applying for eligible WPS/Arise group coverage.

° If adding a subsidiary (common ownership or affliation), this subsidiary must meet all of the eligibility requirements of a new group on its own in order to be eligible to apply with the existing group.

Groups 51+ An existing group that acquires new employees because of a subsidiary purchase or buyout may add any eligible employee from the subsidiary or buyout within 31 days of the purchase or buyout. Employee additions due to acquisition or buyout are subject to the following requirements:

° A Quote Request Form and an Employer Group Application must be submitted to WPS/Arise Underwriting for prior approval, along with a census for the new employees, medical statement, applications, or claims experience for new subsidiary/segment of employees.

° WPS/Arise will credit any calendar year deductibles from the prior carrier. WPS/Arise must receive the proper enroll-ment forms, with appropriate medical questions completed.

° The prior carrier’s most recent billing statement. ° If a change in rating size occurs, WPS/Arise Underwriting may re-rate the entire group on the effective date for the

new segment. This process would not change the group’s anniversary date. Otherwise, changes in rating size will be implemented on the group’s regular anniversary date.

° If a new business entity is formed as a result of a buyout or merger, employees covered by WPS/Arise under the old entity will not be subject to medical underwriting if applying for eligible WPS/Arise group coverage.

° If adding a subsidiary (common ownership or affliation), this subsidiary must meet all of the eligibility requirements of a new group on its own in order to be eligible to apply with the existing group.

GROUP RENEWAL RENEWAL PREMIUM RATES Premium rate guarantees are not allowed on groups with 2–50 employees. Premium rate guarantees on groups with 51+ employees must be approved by WPS/Arise Senior Management.

CHANGES TO GROUP ANNIVERSARY ° Changes to a group’s anniversary date must be pre-approved by WPS/Arise. Without WPS'/Arise's approval,

WPS/Arise cannot honor renewal rates for a date other than the group’s anniversary date. Such a change may not allow ample time for preparation of necessary information to generate renewal rates.

° All lines of coverage must have a common anniversary date.


GROUP POLICY TERMINATIONS Group coverage may be discontinued because of non-payment of premium. In the event of termination:

° If coverage terminates for non-payment of premium, WPS/Arise is liable for all claims incurred prior to the end of the grace period. Note: The group is responsible for paying the premium during the grace period.

° WPS/Arise will provide the group with a notice of discontinuance before terminating coverage for non-payment of pre-mium. The premium must be submitted for the last month of coverage, including the grace period.

COVERAGE DISCONTINUANCE AND REPLACEMENT MILITARY LEAVE CONTINUATION Standard WPS/Arise group policies contain exclusions for coverage of health care services for an illness or injury caused by an atomic or thermonuclear explosion or resulting radiation, or any military action, friendly or hostile. In addition, when a covered employee is called to Active Duty for 30 days or more, most of our standard group policies state he/she and his/her depen-dents can no longer be covered under the group plan as of the frst day of Active Duty. Dependents called for Active Duty for 30 or more days are not covered as of the frst day of Active Duty; however, the employee and any other dependents may remain on the group plan. In either situation, the Service Member generally has at least one of the following coverage options.

COBRA If the group is a COBRA-eligible employer, COBRA can be elected. Standard COBRA guidelines apply: ° Uniformed Services Employment and Re-Employment Act (USERRA) Continuation: For any size group, the Service

Member can elect continuation of group coverage under USERRA for up to 24 months. If this option is chosen, USERRA states that the maximum premium that can be charged is 2% over the regular premium under the plan, to cover administrative costs. For plans that are subject to COBRA, USERRA continuation runs concurrently with COBRA.

° TRICARE coverage: TRICARE is the federal group health program available through the U.S. Department of Defense, of-fered to Service Members and their dependents. Customers entering active military service for more than 30 days are eligi-ble to enroll in TRICARE. Coverage begins for the Service Member and his/her dependents on the frst day of Active Duty. If group coverage is continued under USERRA or COBRA, the group coverage is primary and TRICARE is secondary.

LIABILITY OF PRIOR AND SUCCEEDING CARRIERS IN GROUP REPLACEMENT SITUATIONS Crediting Deductibles and Out-of-Pocket Expenses The succeeding carrier must give credit for deductibles and out-of-pocket expenses that were satisfed by the customer while he/she was covered under the prior plan.

COBRA, Wisconsin Continuation, Extension of Benefts In a replacement situation, the succeeding carrier must insure all customers covered under the previous plan, including those covered under COBRA, Wisconsin continuation, or an extension of benefts, for as long as they are eligible.


WPS/ARISE FIELD GUIDE—GROUPS GROUP SIZE PARAMETERS

° 2–50 total employees, including full-time, part-time, and seasonal, for federal and/or state compliance purposes. ° Groups of this size are subject to ACA group requirements ° Note: If a husband and wife are the only two eligible employees of a group, and there are no other employees

including full-time and/or part-time showing on the wage statement, they cannot apply for two single contracts (or one single and one limited family) for the sole purpose of qualifying as a two-person group

° 51 or more enrolled employees for rating and underwriting guidelines ° 51 or more total employees, including full-time, part-time, and seasonal employees, for federal and/or state compliance

purposes

If the actual initial enrollment differs from the group size quoted by WPS/Arise, the group will be placed in the correct group rated size with possible rate and beneft changes. This rule also applies at renewal. It will be based on a 12-month enrollment average during the most recent experience period.

EFFECTIVE DATE OF QUOTE Groups of 2–50 For these groups, available plans—including benefts, cost-sharing, and restrictions—are set on a calendar-year basis. Policies are issued for a 12-month plan year. Employer groups may not be renewed or moved to a different available plan before the expiration of their plan year, except at the option of the employer. For groups with 50 or fewer total employees, rates will be quoted for effective dates no more than 60 days in advance.

Groups of 51 or More For groups with 51 or more total employees, rates will be quoted for effective dates no more than 90 days in advance. Group quoting beyond the 90 days requires WPS'/Arise's approval.

INTERNET QUOTING Book-rate quoting capability is available using the online Rate Calculators on the Agent Resources page at wpshealth.com or arisehealthplan.com. Please contact your WPS/Arise Agency Manager for further details. If you do not currently have this internet quoting access, the information indicated below must be submitted to WPS/Arise to request a quote.

INFORMATION NEEDED TO REQUEST A QUOTE The following information is required to request a quote. Final rates will only be determined upon submission of full enrollment materials and after review of all information, including health information.

° Name of group and agent/broker (if applicable) ° Address of group: Indicate which employee works at which location (if applicable) ° Industry classifcation (SIC) of group ° Census information should include:

° Election participation, i.e., single/family (not marital status) ° Dates of birth and gender for each employee ° ZIP code ° Beneft selection, if multiple plans

° Beneft plan(s) and network(s) requested

QUOTE GUIDELINES FOR GROUPS WITH 2–50 TOTAL EMPLOYEES ACA groups—Rates are calculated by adding each customer rate of a family, including policyholder, spouse, all dependents ages 12 and up, and three oldest dependents between the ages of 0-20.

AGE ADJUSTMENTS ° ACA groups—Age-band adjustments will be adjusted at time of renewal ° Transitional renewals (non-ACA) receive age bumps the month following a birth date


arisehealthplan.com


REQUIRED GROUP ENROLLMENT MATERIAL Groups of 2–50

° WPS/Arise Employer Application ° WPS/Arise Disclosure Notice with 2–50 total employees ° Employee Applications or Spreadsheet Enrollment (those employees still in their probationary period and employees

who are presently on COBRA/State continuation) ° Most recent Quarterly Wage and Tax Statement (please see the “Required Tax Documents for New Groups” section

below for further detail) See our Small Group Enrollment Checklist ° Copy of the sold quote ° Copy of the sold quote age rate matrix grid

Groups of 51 or More ° WPS/Arise Employer Application ° Employee Medically Underwritten Applications—with appropriate health questions completed for each eligible

employee and/or dependent(s) enrolling for coverage, and also for those employees still in their probationary period and employees who are presently on COBRA/State continuation

° Employee Waiver Applications—with Waiver Section completed for all eligible employees waiving coverage with WPS/Arise

° Copy of COBRA/State Continuation election forms for any terminated employee that has not elected COBRA/State Continuation, but still appears on the prior carrier billing statement

° Most recent billing statement from the group’s current carrier (if applicable) ° Most recent Quarterly Wage and Tax Statement (please see the “Required Tax Documents for New Group Sales”

section below for further detail) ° Copy of the sold proposal/quote given to the agent, broker, and/or the policyholder

INITIAL MONTHLY PREMIUM ACA groups will be billed for the frst month's premium. Non-ACA groups that choose the direct billing option should submit their premium with their enrollment. If they choose ACH, then we will withdraw the frst month’s premium from the ACH account. Standard grace period will still apply to the frst month’s premium. The policy will be terminated if payment is not made in a timely manner.

UNPAID PREMIUM Late payment: A delinquent notifcation is sent out to customer and agency once payment is past due and still in the grace period. Once the grace period ends, the policy will be terminated for nonpayment.

REQUIRED TAX DOCUMENTS FOR NEW GROUPS All businesses of two or more eligible employees must supply the following documentation:

° Most recent Quarterly Contribution/Wage Report, or if not required to fle a Quarterly Contribution/Wage Report, we need all of the items listed under the group’s specifc business type (see table below).

“C” Corporations • Articles of Incorporation • Form 1120 • Payroll

“S” Corporations • Articles of Incorporation • Form 1120S • Payroll

Partnership • Partnership Agreement • Form 1065 • Payroll

Sole Proprietorship • Business license • Form 1040/Schedule C • Payroll

Church • Form 941 • Payroll

Limited Liability Company (LLC) • LLC agreement and documentation

for either a “C” Corporation or a Partnership (see above), depending on how company fles with the state

• Payroll

https://secure.wpsic.com/sales-materials/files/29459-community-solutions-small-group-checklist.pdf


° If the business has been in existence less than one year and not fled a Quarterly Contribution/Wage Report, we will accept Corporation or Partnership papers and payroll.

° Farmers: If not a corporation or partnership, farmers are required to submit Schedule F, itemization of line 24, and copies of W-2 documents for all employees.

MEDICALLY UNDERWRITTEN GROUPS OF 51 OR MORE Applications including the Health Information Questionnaire section are required by WPS/Arise for groups of 2–50 enrolled employees electing coverage. WPS/Arise will not require that employees and dependent(s) who waive coverage complete the Health Information Questionnaire.

PROCESS FOR FULL UNDERWRITING ° New small employer groups are initially reviewed by WPS/Arise Underwriting ° WPS/Arise Underwriting reviews the information for completeness of forms, eligibility requirements, and medical

history (for large groups only) that may impact future claims ° WPS/Arise Underwriting uses industry-wide underwriting manuals and other resources to determine a group’s risk,

including the Attending Physician Statement (APS), which may be requested for specifc information ° Tele-underwriting services may be used by WPS/Arise when underwriting group policies; applicants should be made

aware that they may be contacted by telephone, if necessary, to obtain additional medical information

EFFECTIVE DATES The following describes the method of assigning effective dates to new group business.

° The group enrollment must be submitted to WPS/Arise Underwriting on or before the requested effective date month. ° All underwriting information (including the signed rates) must be received by the 15th of the requested effective date

month or the effective date will be moved ahead. ° If the group enrollment is submitted after the frst of the requested effective date month, then the earliest effective date

a group can have is the frst of the following month.

GENERAL ENROLLMENT ISSUES Small Groups Subject to ACA Participation requirements may be applied, except for group enrollments received between Nov. 15 and Dec. 15 each year during open enrollment.

If participation requirements may be applied, WPS/Arise may terminate a policy immediately following the last day of a renewal period if it determines the number of participating employees falls below the minimum participation requirements. The group will be reviewed and audited by WPS/Arise annually to ensure it meets applicable minimum participation requirements.

Health Coverage ° WPS/Arise does not allow dual choice on any group. This means WPS/Arise will not offer coverage to employees who

are covered under another health beneft plan sponsored by the same employer. ° The minimum size of any group is two (2) enrolled employees, regardless of number of eligible employees who have

other creditable coverage.

PROBATIONARY PERIOD 2–50 Insureds There may only be one probationary period in a group with 2–50 enrolled lives. Probationary Period options are as follows:

° First day of the calendar month following one month of full-time employment ° First day of the calendar month following two months of full-time employment ° The day following 90 days of full-time employment ° The maximum probationary period may not extend beyond 90 days after an individual has satisfed all other plan

eligibility requirements


51 or More Insureds Groups can offer multiple probationary options, such as:

° First day of the calendar month following one month of full-time employment ° First day of the calendar month following two months of full-time employment ° Other—requires Underwriting’s approval ° The maximum probationary period may not exceed 90 days

Probationary periods may not be waived for any employees for ACA plans. New employees in new groups enrolling with WPS/Arise are automatically given coverage as of the group’s effective date with WPS/Arise even if they have not completed their probationary period, unless the group wants them to fnish the probationary period.

RETIREE COVERAGE No retiree coverage is available for groups with fewer than 51 enrolled active employees. Contact WPS Medicare Market Solu-tions at 800-748-0582 to review ways to help your employers support their seniors as they navigate Medicare.

DUAL-OPTION UNDERWRITING REGULATIONS Dual-option means one carrier offers multiple options.

All 2–50 Insureds ° Available to groups with enrollment of two (2) or more contracts ° Limit of four beneft plan offerings (within standard product offerings)

° The four plans can vary by product, deductible, coinsurance, out-of-pocket limit, drug coverage, and/or offce visit copays

° Employees with active coverage in the group can change between beneft offered plans during their Open Enrollment Period once per year or at any qualifying event during the year ° Application for the request to transfer to the other beneft plan must be received by WPS/Arise Customer Service

by the end of the Open Enrollment Period ° Employees not currently covered must enroll during open enrollment ° Groups may be able to select among multiple networks, subject to some restrictions on network offerings due to

contractual parameters ° Please contact your WPS/Arise Sales Representative to determine the networks that can be offered in a dual-

option situation

Except for the above, all other existing underwriting regulations apply for dual-option situations.

GROUP RENEWAL AND CHANGES Group renewals will be mailed at least 30 days prior to renewal date or 60 days prior to renewal if increase exceeds 25% or if benefts change.

PREMIUM RATES AND INCREASE GUIDELINES Rates can be changed annually upon renewal with 30 days written notice to the employer; 60 days if the increase is 25% or more.


CLAIMS EXPERIENCE-RATED—WPS/ARISE GUIDE

EFFECTIVE DATE Rates will be quoted for effective dates of no more than four months into the future for corporate groups and six months into the future for public groups, such as schools and municipalities, if claims experience is provided.

° With experience: Rates will be quoted for effective dates no more than six months beyond the most recent date of experience received. Updated loss experience will be required to extend an effective date.

° Without experience: Rates will be quoted at book rate, but only for effective dates not more than 90 days in the future.

An effective date within a proposal means that if WPS/Arise quotes a group with an Oct. 1 effective date, the proposal becomes invalid after Oct. 1. Additionally, only Underwriting can agree to extend the effective date and/or reduce/increase any quoted rate.

Exceptions to these guidelines will be reviewed by WPS/Arise Underwriting Management on a case-by-case basis.

QUOTING GUIDELINES Exceptions to the following quoting guidelines will be reviewed by WPS/Arise Underwriting Management on a case-by-case basis. Groups must make full and complete applications to the WPS/Arise Underwriting Department upon enrollment before fnal assessment of risk will be determined, resulting in approved rates (see section on New Group Enrollments).

INFORMATION NEEDED TO REQUEST A QUOTE Groups 51–99 Without Experience The following information is required to request a quote. Final rates will only be determined upon submission of full enrollment materials and after review of all information, including health information.

° Name of group and agent/broker (if applicable) ° Address of group: Indicate which employee works at which location (if applicable) ° Industry classifcation (SIC) of group ° Census information should include:

° Election participation, i.e., single/family (not marital status) ° Dates of birth or age and gender for each employee ° ZIP code ° Beneft selection if multiple plans

° Current beneft plan(s) and network(s) requested ° Preferred: beneft booklet/certifcate ° Will accept: schedule of benefts or SBC

° Desired commission level

Groups 51–99 With Experience For all experience-rated quotes, a feld-rated, system-generated quote should be run. In addition, the following information is required:

° Minimum of two years of claims experience; should be on carrier or company letterhead and specify dates and claims amounts; experience must be within six months of the effective date

° Average or monthly contracts for each experience period; if group has more than one beneft level, contracts should be segmented accordingly

° Current benefts and beneft history if there have been any changes during the experience period provided ° Current rates and rate history are required:

° Premium rates (if fully insured) ° COBRA/funding rates (if self-insured)


Groups of 100 or More ° Two years (20–24 months) loss experience to within six months of the requested effective date. Exceptions may be considered

on a case-by-case basis. Experience information must be on company letterhead, a prior carrier report, or formatted agent report. ° Preferred: Month-by-month (aggregate report if self-funded) ° Will accept: Current year-to-date or prior 12 months

° Customer counts for the loss experience periods ° Preferred: Month-by-month ° Will accept: Current year-to-date average count or prior 12-month average

° Shock loss information ° Total amount paid for the corresponding experience paid ° Diagnosis (and prognosis if self-funded) ° 50% report (if self-funded) ° Preferred: prognosis and current status: active, disabled, Wisconsin Continuation/COBRA (with effective date

and end date) ° Current beneft plan and any changes made during the loss experience periods

° Preferred: Complete booklet ° Will accept: Schedule or SBC

° Current employee contributions for single, limited family (if available), and family ° Carrier history ° Current rates and rate history

° Premium rates (if fully insured) ° Specifc rates (if self-funded) ° Aggregate factors (if self-funded) ° COBRA/funding rates (if self-funded) ° Admin fee (if self-funded)

° Base admin ° Network fees ° UR/LCM fee ° Rx fee ° Rx rebate % ° Top provider reports ° Pending claims report (if available)

FREEDOM ESSENTIALS: NEW GROUP QUOTE REQUEST Groups of 10 or More Insureds

Quoting groups with out-of-state residents: ° A maximum of 75% of the group can be out-of-state residents ° Sales sends quote request to WPS/Arise ASO mailbox

Based on the type of quote requested, the WPS/Arise Sales team will collect the following information. Quotes cannot be completed until all information is received.

1. Freedom Essentials quote with applications ° Book Quotes must have correct:

° Effective date ° Counts ° Benefts

° Census ° Election participation, i.e., single/family (not marital status) ° Dates of birth or age and gender for each employee ° ZIP code ° Beneft selection (if multiple plans)


° ASO Quote Request Form completely flled out ° Individual Medical Applications, signed and dated by group customers

2. Freedom Essentials Quote with Claims Experience ° Census

° Election participation, i.e., single/family (not marital status) ° Dates of birth or age and gender for each employee ° ZIP code ° Beneft selection (if multiple plans)

° Book Quote must have correct: ° Effective date ° Counts ° Benefts

° Self-Funded Quote Request Form completely flled out ° Claims experience month by month (aggregate report, if available), 2–3 years of experience within four months of

requested effective date ° Customer counts for the loss experience periods month by month, single/family ° Shock loss information for each loss experience period

° Total amount paid for each experience period ° Diagnosis and prognosis on each individual ° Current status of individuals (active, disabled, COBRA, and termed with end dates)

° Current beneft plan and any changes made during the loss experience periods ° Current rates (and renewal rates, if available)

° Premium rates (if fully insured) ° Specifc rates (if self-funded) ° Aggregate factors (if self-funded) ° Admin Fee (if self-funded)

3. Claims Experience with Applications ° Census

° Election participation, i.e., single/family (not marital status) ° Dates of birth or age and gender for each employee ° ZIP code ° Beneft selection (if multiple plans)

° Book Quotes must have correct ° Effective date ° Counts ° Benefts

° Self-Funded Quote Request Form completely flled out ° Claims experience month by month (aggregate report if available), 2–3 years of experience within four months of




° Premium rates (if fully insured) ° Specifc rates (if self-funded) ° Aggregate factors (if self-funded) ° Admin Fee (if self-funded) ° Individual Medical Applications, signed and dated by group customer


FREEDOM FLEX: NEW GROUP QUOTE REQUEST Groups of 25 or More Insureds

Quoting Groups with Out-of-State Residents ° A maximum of 75% of the group can be out-of-state residents. ° Sales sends quote request to WPS/Arise ASO mailbox

Based on the type of quote requested, the WPS/Arise Sales team will collect the following information. Quotes cannot be completed until all information is received.

1. Freedom Flex with Claims Experience ° Census

° Single/family participation ° DOB or age ° Gender ° ZIP code





° Premium rates (if fully insured) ° Specifc rates (if self-funded) ° Aggregate factors (if self-funded) ° Admin fee (if self-funded)

2. Freedom Flex with Claims Experience and Applications ° Census

° Election participation, i.e., Single/Family (not marital status) ° Dates of birth or age and gender for each employee ° ZIP code





° Premium rates (if fully insured) ° Specifc rates (if self-funded) ° Aggregate factors (if self-funded) ° Admin Fee (if self-funded)

° Individual Medical Applications, signed and dated by group customers


PROCESS FOR FULL UNDERWRITING ° Large employer groups with 51+ total employees are initially reviewed by WPS/Arise Health Underwriting ° WPS/Arise Health Underwriting reviews the information for completeness of forms, eligibility requirements, and

medical history that may impact future claims ° WPS/Arise Health Underwriting uses industry-wide underwriting manuals and other resources to determine a group’s

risk ° Tele-underwriting services may be used by WPS/Arise when underwriting group policies; applicants should be made

aware that they may be contacted by telephone, if necessary, to obtain additional medical information

REQUIRED GROUP ENROLLMENT MATERIALS ° Group application ° Most recent Quarterly Wage and Tax Statement with employee status indicated for all employees listed as to whom is

presently full-time, part-time, seasonal, and/or terminated ° Most recent prior carrier billing statement (if applicable) ° Employee’s Medically Underwritten Application for each eligible employee and dependent(s) enrolling for coverage ° Employee’s Waiver Applications for each eligible employee who will be waiving the health coverage ° Copy of the proposal given to the agent, broker, and/or the policyholder

REQUIRED TAX DOCUMENTS FOR NEW GROUP All businesses of two or more eligible employees must supply the following documentation: Most recent Quarterly Contribution/Wage Report or, if not required to fle a Quarterly Contribution/Wage Report, we need all the items listed under the group’s specifc business type (see table below).

“C” Corporations Articles of Incorporation Form 1120 Payroll

“S” Corporations Articles of Incorporation Form 1120S Payroll

Partnership Partnership Agreement Form 1065 Payroll

Sole Proprietorship Business license Form 1040/Schedule C Payroll

Church Form 941 Payroll

Limited Liability Company (LLC) LLC agreement and documentation for either a “C” Corporation or a Partnership (see above), depending on how company fles with the state

° If the business has been in existence less than one year and not fled a Quarterly Contribution/Wage Report, we will accept Corporation or Partnership papers and payroll

° Farmers: If not a corporation or partnership, farmers are required to submit Schedule F, itemization of line 24, and copies of W-2 for all employees

INITIAL MONTHLY PREMIUM Groups that choose the direct billing option should submit their premium with their enrollment. If they choose automatic premium withdrawal, then we will withdraw the frst month’s premium from the ACH account. Standard grace period will still apply to the frst month’s premium. The policy will be terminated if payment is not made in a timely manner.

UNPAID PREMIUM For late payment: A delinquent email is sent out to the group and agency once payment is past due and still in the grace period. Once the grace period ends, the policy could be terminated for non-payment.


ENROLLMENT WITH EXPERIENCE Quoted with claim experience:

° WPS/Arise Employer Application ° Census of employees and dependents enrolling on the health plan; this information could be received by either

completed WPS/Arise Applications, electronic spreadsheet, or an electronic feed from their current carrier ° Copy of COBRA/State Continuation election forms for any terminated employee that has not elected COBRA/State

Continuation, but still appears on the prior carrier billing statement ° Most recent billing statement from the group’s current carrier (if applicable) ° Copy of the signed sold proposal/quote given to the agent, broker, and/or the policyholder ° Copy of the completed WPS/Arise Intake Document ° Copy of the completed WPS/Arise Commission Amendment (if applicable)

GENERAL UNDERWRITING ISSUES MATCHING/DUPLICATING BENEFITS AND/OR ADMINISTRATION For groups of 100+ enrolling, WPS/Arise can match a group’s Schedule of Benefts (e.g., deductibles, coinsurance, etc.), if approved by Underwriting, and can be administered by Policyholder Services and/or WPS/Arise Claims.

WPS/Arise cannot match contractual wording from any other carrier. Administration of contract benefts will be the WPS/Arise standard administration. Exceptions will be considered only for 100+ groups on a case-by-case basis. WPS/Arise Underwriting, Claims, and/or Policyholder Services must approve all exceptions and determine if a single-case fling with OCI will be required.

WPS/Arise may consider matching benefts and other administrative exceptions for 100+ groups on a case-by-case basis, but will charge the group an appropriate additional administrative fee.

NEGOTIATED COMMISSIONS A preliminary discussion should take place between the WPS/Arise Sales Representative and the Sales Director to determine the desired agent/broker commission level (if other than standard). The fnal negotiated commission must be approved by the Sales Director prior to completing the Request for Proposal (RFP). A completed Group Commission Amendment form must accompany the enrollment refecting the fnal negotiated commission. Quoted rates may be affected.

RETIREE SEGMENTS The following underwriting rules apply to groups that offer formal age retirement programs and wish to establish a retiree group. Prior approval from WPS/Arise Underwriting is required to establish a retiree group.

WPS/Arise will consider retiree classes for groups with 51 or greater enrolled active employees on a case-by-case basis. Enrolled retirees cannot exceed 10% of the enrollment.

° The employer must cooperate fully in the administration of the group, e.g., centralized billing and payment of premiums ° The retiree must transfer into the retiree group directly from the employer-sponsored WPS/Arise non-retiree plan; if the

retiree subsequently leaves the plan, he/she is no longer eligible ° Individual changes in coverage (e.g., marriage) are allowed as described in enrollment section of the group policy ° WPS/Arise will establish a separate class ° Retirees with individual policies from a prior carrier are not eligible to transfer to the WPS/Arise retiree group

MULTIPLE OPTION UNDERWRITING REGULATIONS ° Minimum of 10% or 25 contracts (whichever is less) enrollees per plan ° Limit of four beneft plan offerings ° Groups may be able to select among multiple networks, subject to some restrictions on network offerings due to

contractual parameters, so please contact your WPS/Arise Sales Representative to determine the networks that can be offered in a dual-options situation

° Enrollees covered under any employer-sponsored WPS/Arise plan are eligible for annual choice between the plans ° Employees not currently covered must enroll based on standard enrollment requirements


DUAL-CHOICE BETWEEN MULTIPLE CARRIERS Review and approval by WPS/Arise Underwriting management is required.

MEDICAL OPEN ENROLLMENT ° Open enrollment is 30 days prior to renewal unless specifed differently in Employer Policy ° WPS/Arise must receive all open enrollment applications by the end of the Open Enrollment Period ° All applications received during an open enrollment must be for the same effective date

GROUP RENEWAL AND CHANGES CHANGES IN GROUP CENSUS WPS/Arise reserves the right to evaluate an entire group upon a change in census of 10% or more and apply a rate change as necessary.

CHANGES TO GROUP ANNIVERSARY DATE ° Changes to a group’s anniversary date must be pre-approved by WPS/Arise Underwriting ° All lines of coverage must have a common anniversary date, unless special circumstances apply ° Groups with an average of 51 or more enrolled employees during the renewal period will be health underwritten ° Groups with an average of 51 or more enrolled employees during the renewal period will be experience rated (both

fully insured and self-funded groups) ° Rates can be changed with 30 days written notice to the employer; 60 days if increase is 25% or more


WPS/ARISE FIELD GUIDE—INDIVIDUALS (ACA) INDIVIDUAL ELIGIBILITY RULES Eligibility

° The policyholder must be 18 years of age or older. On-Marketplace policies do allow child only plans, please refer to healthcare.gov.

° Applicant and spouse must be permanent residents of the State of Wisconsin; residency means he/she must live in Wisconsin six or more months out of every calendar year

° All applicants must be a citizen of the United States or a resident legal alien ° The following are NOT eligible:

° Domestic partners, grandchildren when the dependent with the child is older than 18 ° Handicapped children and dependent children age 26 or older ° Any applicant enrolled in Medicare

° Wisconsin law states that if individual medical coverage is issued to three or more employees of the same employer, then this is small employer group coverage; therefore, group coverage must be obtained and those employees do not qualify for individual coverage

° Individuals who are eligible for a catastrophic plan must be between the age of 18 and 29 at time of issue ° Individuals who are over the age of 29 may be eligible under a hardship exemption ° Individuals who think they may have a hardship exemption must go to the Health Insurance Marketplace and

obtain a hardship exemption form to submit with the application

Loss of Eligibility Under WPS/Arise individual policies, when a customer is called to active military duty for more than 30 days, that customer is no longer eligible for coverage starting the frst day of active duty. If coverage is terminated for any customer of a WPS/Arise individual policy, the customer may reapply for another policy at a later date.

INDIVIDUAL ENROLLMENT Open Enrollment Period

° Nov. 1–Dec. 15 ° Check healthcare.gov/quick-guide/dates-and-deadlines/ for the latest information

Individual Applications ° To apply for the currently marketed Individual Plan, you must submit the WPS/Arise individual application. ° WPS website for online applications: wpshealth.com ° WPS Individual enrollments should be sent to Customer Service:

WPS Health Insurance P.O. Box 8190 Madison, WI 53708 Scan and send secure email to [email protected] Fax 608-223-3639

° Arise website for online applications: arisehealthplan.com ° Arise Individual enrollments should be sent to Billing & Enrollment

Arise Health Plan P.O. Box 11625 Green Bay, WI 54307 Fax 608-223-3639

° Initial premium may be submitted with individual applications ° We will not accept business checks unless the individual is a sole proprietor ° The sole proprietor form must be completed and submitted with the application

° WPS/Arise Off-Exchange Plans ° Customers who choose the direct billing option should submit their premium with their application ° If they choose automatic withdrawal or credit card, we will withdraw the frst month’s premium from the automatic

withdrawal account or credit card

https://www.healthcare.gov/

https://www.healthcare.gov/quick-guide/dates-and-deadlines/

https://arisehealthplan.com




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° Standard grace period of 10 days applies to the frst month premium; the policy will be terminated if payment is not made in a timely manner

° New individual policies written on or after Jan. 1, 2014, or existing policies renewed on an ACA plan will have their rates guaranteed until the following Jan. 1; when an insured has a birthday, the rate change will occur at the renewal of their policy

° It is allowable to coordinate benefts for insureds covered under individual policies

Medicare Secondary Payer Rules—Decision Tree (Individual)

Is the insurance coverage at issue an individ-ual plan or a group plan?

Individual Plan Can a Medicare-eligible individual be permitted to enroll in an individual plan (QHP or Off-Exchange Individual Plan)?

Group Plan—See other Decision Tree

No Yes

If an individual has an individual policy (QHP or off-Market-place) and is eligible for Medicare (regard-less of if they actually enroll), claims will be processed as if the

person has Medicare.

It should be not-ed that if someone is enrolled in both Medicare and an

individual plan, then Medicare is the Pri-mary Payer because

there is generally no coordination of benefts between

Medicare and indi-vidual plans.

If the individual is enrolled in Medicare Part A or B (or both Parts A and B), then the individual cannot enroll in an

individual QHP or Off-Exchange Individual Plan.

If the individual has ESRD and is enrolled in Medicare Part A or B (or both Parts A and B), then the individual cannot

enroll in an individual QHP or Off-Exchange Individual Plan.

If the individual is eligible for Medicare Part A and B, but has not enrolled in Medicare coverage, then the individual can

enroll in an individual QHP or Off-Exchange Individual Plan.

If the individual has ESRD and is eligible for Medicare Part A and B, but has not enrolled in either Medicare Part A or B,

then the individual can enroll in an individual QHP or Off-Exchange Individual Plan.

If the individual is currently enrolled in an individual QHP or Off-Exchange Individual Plan and later becomes eligible for Medicare, but does not subsequently also enroll in Medi-care coverage; the individual can continue his/her individual

QHP or Off-Exchange Plan.

If the individual is currently enrolled in an individual QHP or Off-Exchange Individual Plan and later becomes eligible

for Medicare, and then subsequently enrolls in Medicare coverage; the individual can continue his/her individual

QHP or Off-Exchange Plan.

Effective Date ° WPS/Arise will follow the Marketplace requirements for enrollments

° The cutoff date will be the 15th of each month for an effective date beginning the frst of the following month ° For applications received after the 15th of the month, the effective date will be the frst date of the second

following month ° For example, an application received on Jan. 16 will have an effective date of March 1

Changes to Policies ° If an individual would like to make a change, the change must be received in the WPS/Arise Sales Department by the

last day of the month prior to the effective date ° Individuals off-Marketplace (WPS and Arise) can elect to reduce their benefts on the frst of any month; the application

to switch benefts must be received by the last day of the month prior to the requested effective date ° Customers with an ACA-compliant plan can increase benefts only during open enrollment or if they have a special enrollment reason ° Dependents may enroll in an existing non-ACA policy but are subject to medical underwriting


Submission Requirements for Special Enrollment ° See tables in Section 8 of this manual or refer to the Special Enrollment Period Instructions on our website.

Out-of-Pocket Crediting—Off-Exchange Plans ° New individuals to WPS/Arise—No credit ° Existing individuals voluntarily moving from a non-ACA plan to an ACA plan—No credit ° Existing individuals WPS/Arise moved to an ACA plan—Credit deductible and coinsurance ° Individuals switching from WPS to Arise or Arise to WPS—No credit ° Individuals with existing WPS/Arise ACA plans changing plan designs to another ACA plan—No credit for individuals

making a change that improves their benefts; credit deductible for customers changing to a lesser beneft level ° SPECIAL NOTE: Credit will only apply to in-network out-of-pocket amounts.

Tobacco Rates ° The tobacco rating applies at a customer level. Each customer that uses tobacco four or more times a week will incur

an additional tobacco rate on the customer-level premium, not the entire family premium. ° A tobacco user is any individual 18 years or older who uses tobacco four or more times per week, on average,

excluding religious and ceremonial uses. E-cigarettes, nicotine gum, and/or patches are not considered a tobacco product.

° Once the customer has been tobacco-free for a full six months, he/she may send in a written request to Customer Service and ask that they change the policy to nonsmoker rates.

https://secure.wpsic.com/sales-materials/files/29862-1710_sep-individual.pdf


APPENDIX A—CONTROLLED GROUP QUESTIONNAIRE

Common Ownership Controlled Group Questionnaire

Name of Employer Group __________________________________________________

Primary Business Location _________________________________________________

Federal Tax ID #__________________________________________________________

Background A controlled group is a combination of two or more corporations that are under common control. The controlled group will be considered a single employer even though the parties have different names and different tax ID numbers. There are two common types of controlled groups that are frequently encountered: (1) Parent-Subsidiary and (2) Brother-Sister.

Parent-Subsidiary The parent-subsidiary group applies to one or more chains of corporations. It does not apply individual owners. Please indicate Yes or No in response to each of the below questions:

1. Is this a group of two or more corporations connected through stock ownership with a common parent corporation? Yes or No

2. Is 80% of the stock of each corporation (except the common parent) owned by one or more corporations in the group? Yes or No

3. Does the parent corporation own 80% of at least one of the other corporations? Yes or No

If the answer to ALL of the above is Yes, the group would likely meet the controlled group requirements as a parent-subsidiary group. However, the group should consult its tax professional to confrm.

Brother-Sister The brother-sister group applies when there are two or more corporations with the same fve or fewer owners (i.e., individuals, trusts, or estates). Please indicate Yes or No in response to each of the below questions:

1. Is this a group of two or more corporations with fve or fewer common owners? Yes or No

2. Do the common owners own a “controlling interest” of each group (“controlling interest” generally means 80% or more of the stock of each corporation)? Yes or No

3. Do the common owners have “effective control” (“effective control” generally means they own more than 50% of the stock of each corporation, taking into account the stock ownership of each person only to the extent such stock ownership is identical with respect to each corporation)? Yes or No

If the answer to ALL of the above is Yes, the group would likely meet the controlled group requirements as a brother-sister group. However, the group should consult its tax professional to confrm.


APPENDIX B—COMMON OWNERSHIP CONFIRMATION FORM

Common Ownership Confrmation Form

This form must be completed and signed by the employer’s accountant, attorney, or offcer of the company.

The Health Insurance Portability and Accountability Act of 1996 states that all persons treated as a single employer under subsection (b), (c), (m), or (o) of Section 414 of the Internal Revenue Code of 1986 shall be treated as one employer.

Name of Employer Group __________________________________________________

Primary Business Location _________________________________________________

Federal Tax ID #__________________________________________________________

Please list all companies that qualify as one employer under the above referenced sections of the Internal Revenue Code.

Business Name Federal Tax ID # # of Eligible Employees

1) ___________________________ _____________________ __________________

2) ___________________________ _____________________ __________________

3) ___________________________ _____________________ __________________

4) ___________________________ _____________________ __________________

5) ___________________________ _____________________ __________________

6) ___________________________ _____________________ __________________

I certify that the applicant is a single employer under section 414 of the Internal Revenue Code of 1986 (26 U.S.C. Section 414 (b), (c), (m), or (o)) and under any applicable state law. I further certify that there are no other affliated entities other than the ones listed above that are eligible to fle a combined state tax return. I represent that the information I provided is accurate, and any misrepresentation or fraudulent statement may result in rescission of the group policy, an increase in premiums retroactive to the policy date, or other consequences permitted by law.

Name (please print) and Title:_______________________________________________

Signature:_______________________________________________________________


~~- WPS I HEALTH fl~ . INSURANCE HEALTH PLAN

________________________________________________________________________ __________________

APPENDIX C—1099 EMPLOYEES

1099 Employees Form

SECTION 1: Number of FTE employees

Indicate the number of full-time equivalent (FTE) employees employed by the employer (federal FTE counting method, calculator available at: healthcare.gov/shop-calculators-fte/) Number of FTE employees: ______

If the number of FTE employees is greater than 50, 1099 employees may be added at the discretion of the employer. If the number of FTE employees is 50 or fewer, proceed to Section 2.

SECTION 2: 1099 Guidelines

The following criteria must be met in order for WPS/Arise to allow 1099 employees to be considered an eligible employee for small group insurance.

1. Do your 1099 employees meet the WPS/Arise defnition of a full-time employee? (One who works 30 hours per week or more.) _____ Yes _____ No

2. Do your 1099 employees work year-round and exclusively for your company? (Seasonal 1099 employees are not eligible for coverage.) _____ Yes _____ No

3. Will you be offering coverage to all eligible 1099 employees? _____ Yes _____ No

If you answered no to any of the above questions, your 1099 employees are not eligible for coverage with WPS/Arise. The following guidelines must also be met in order for your 1099 employees to be eligible for coverage.

1099 Employee Guidelines

° Participation will be measured on all eligible taxed employees and eligible 1099 employees. ° Employer must contribute the same amount of money toward the 1099 employee’s premium as the taxed employees. ° Employer must be eligible for coverage prior to adding the 1099 employee(s). There must be a minimum of two taxed

employees at all times. ° A minimum of 50% of the insured must be taxed employees. ° Employer application must indicate that 1099 employees are eligible for plan at time of enrollment. ° Groups that wish to add 1099 employees beyond the original enrollment are subject to medical underwriting. ° Employer must provide copies of all 1099 statements including individuals not electing coverage. ° 1099 employees that are eligible and not electing coverage must complete a waiver application. ° 1099 employees will not be eligible for ancillary coverage.

For the purposes of this form, taxed employees refers to those employees who appear on your group's State Quarterly Wage and Tax Statement (UCT-101).

Signature of Employer Representative Date

https://www.healthcare.gov/shop-calculators-fte/


~ WPS I HEALTH ~ . INSURANCE HEALTH PLAN

APPENDIX D— DOMESTIC PARTNERSHIP

Declaration of Domestic Partnership

Section One

I, ______________________________(name of employee), and _______________________________(name of domestic partner) attest and certify that we are each other’s sole domestic partners.

Domestic partners are defned as two individuals: ° Who are in a committed relationship of mutual support, caring, and commitment with the intention to remain in such a

relationship in the immediate future ° Who are fnancially responsible for each other’s well-being and debts to third parties ° Who are not married or legally separated in marriage, and who have not been a party to an action or proceeding for

divorce or annulment within six months of registration, or if one has been married, at least six months have elapsed since the date of the judgment terminating the marriage

° Who are not currently registered in another designated partnership, and if one party has been in such a registered relationship, at least six months have lapsed since the effective date of termination of that registered relationship before the registration of the current domestic partnership

° Who are each 18 years of age or older and competent to contract ° Who are not related by blood closer than would bar marriage in the state of their residence ° Who live together in the same dwelling unit as a single nonproft housekeeping unit and have a relationship that is of a

permanent and domestic character ° Whose relationship is not temporary, social, political, commercial, or economic in nature ° Whose relationship has existed for at least six months ° Who are not registered with any other domestic partnership ° Who, for at least the six-month period immediately preceding the date of this Declaration, have either:

(a) Obtained a domestic partnership certifcate from the city, county, or state of residence or from any other city, county, or state offering the ability to register a domestic partnership; or (b) Any three of the following with respect to the domestic partner (check those which apply): ____ joint lease, mortgage or deed ____ joint ownership of a vehicle ____ joint ownership of a checking account or credit account ____ designation of the domestic partner as a benefciary of the covered employee’s will ____ designation of the domestic partner as a benefciary for the covered employee’s life insurance

or retirement benefts ____ designation of the domestic partner as holding power of attorney for health care ____ shared household expenses

Section Two

1. I understand that coverage for my domestic partner and his/her dependents shall terminate upon the death of my domestic partner or upon a change of circumstances attested to in Section One above.

2. I understand that I am obligated to fle a Declaration of Termination of Domestic Partnership with WPS/Arise within 30 days of the death of my domestic partner, or the date on which my domestic partner and I no longer meet the criteria for domestic partners as set forth above, whichever is earlier.

________________________________________________________________________ __________________

________________________________________________________________________

________________________________________________________________________ __________________

________________________________________________________________________

3. I understand that falsely certifying eligibility for domestic partner benefts or failing to inform WPS/Arise if the domestic partnership ceases to meet the eligibility requirements in any respect may lead to disciplinary action, including discharge from employment.

4. I understand that upon submission of this Declaration, I am required to provide evidence of my domestic partnership as indicated in Section One above.

Section Three

1. The covered employee and the domestic partner (hereinafter referred to as “We”) hereby certify that we are each other’s sole domestic partners as defned above.

2. We have provided the information in this Declaration for use by WPS/Arise and its employees for the sole purpose of determining eligibility of the domestic partner and dependent children of the domestic partner under those policies, guidelines, practices, and beneft plans that provide coverage for domestic partners as from time to time established by WPS/Arise. We understand that WPS/Arise and its employees are permitted to use the information provided on this Declaration to administer the benefts outlined above.

3. We understand and agree that the employer is not legally required to extend such benefts to domestic partners and that the employer, at its sole discretion, may change or terminate these benefts, policies, guidelines, and practices at any time without consent of any employee or group of employees.

4. We understand that under federal and state law, beneft coverage of the non-employee domestic partner and his/her children may result in imputed taxable income to the employee, with possible withholding for payroll taxes (including income and Social Security taxes).

5. We understand that, in addition to this Declaration, certain beneft plans require the completion of forms to enroll or disenroll a domestic partner and any eligible dependents.

6. We understand that a civil action may be brought against one or both of us for any losses, including attorney’s fees and court costs, because of any false statement(s) contained in this Declaration or for failure to notify WPS/Arise of a change in circumstances required in Section Two. We agree that each of us is and agrees to be jointly and severally liable for such losses.

7. We understand that this Declaration may have legal implication relating, for example, to our ownership of property or to taxability of benefts provided. We understand that before signing this Declaration we should seek competent legal and tax advice concerning such matters. We acknowledge that the employer or WPS/Arise has provided us with no advice in this regard.

8. We understand that failure to provide complete, true, timely, and correct information may result in loss of beneft plan coverage.

We have read and understand the terms and conditions contained in the Declaration of Domestic Partnership. We affrm, under penalty of perjury, that the statements in this Declaration are true, complete, and correct.

Employee’s signature Date

Employee’s printed name

Domestic partner's signature Date

Domestic partner’s printed name

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Documents

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