GROUP APPLICATION HIP/NYSBG Sole Prop Plans - 2012 Enrollment … · Articles of Incorporation or...

-BE SURE TO MAINTAIN CURRENT COVERAGE UNTIL YOU RECEIVE APPROVAL FROM HIP-

Company Name:_________________________________________________________________________

Address:________________________________________________________________________________

________________________________________________________________________________________

Company Phone #:___________________________________ Type of Business:_______________________

Contact:____________________________________________ Title:_________________________________

Total Number of Employees: _________ Total Number of EE’s working 20 hours or more per week: _________Total number of eligible employees: _________Total number of subscribers enrolling: _________

Single:_________ Employee/Spouse:__________ Employee/Child:__________ Family: __________

Present Insurance Carrier:___________________________________Dates of Coverage: From:____/____/____ To:____/____/____

Requested Effective Date: _____/_____/_____

GUIDELINES FOR ALL PLANS 1. The employer must be a member in good standing of the New York State Business Group (NYSBG). 2. All payments payable to ELITE PROGRAMS, INC. as administrators for NYSBG using a business check. 3. HIP requires at least two of the following documents to verify sole proprietor status: Schedule C – Coverage will be issued in the name of the company on this schedule. Form 1120-S - U.S. Corporation Income Tax Return for S corporations with K-1(s) Form 1065 with Schedule K-1 CT-4-S - New York S Corporation Franchise Tax Return Schedule F - Profit and Loss From Farming Signed NYS-45 or NYS-45-ATT Form Articles of Incorporation or Certificate to Do Business A signed copy of the most recent Schedule SE – Self-Employment Tax Form. An EmblemHealth/HIP Letter of Certification signed by a CPA or Attorney who is not an employee or relative of an employee of the group. 5. Enrollment cannot be accepted if they are not properly completed, and accompanied by premium payment. 6. Enrollments, changes and cancellations must be submitted at least 15 days prior to effective date. 7. Your premium must be received before the 1st of the month of coverage to avoid termination of coverage.

PLAN APPLIED FOR (Check One Plan) HIP/NYSBG Association Plans: 1 SELECT PPO (30/50/Ded&Coins/150) - **NO Rx** 2 SELECT PPO (30/50/Ded&Coins/150) - with Rx ($10 Generic/No Brand/$100 Ded.) 3 SELECT PPO (30/50/Ded&Coins/150) - with Rx ($20/$30/$50/$300 Ded.)

All premiums must be made payable to “Elite Programs, Inc.” or check will be returned.The information provided above is true and correct to the best of my knowledge. I understand that

coverage and benefits may be affected by failure to provide complete and accurate information. I understandall current employees have the option of joining HIP now, or on my group’s annual anniversary date.

Signature of Owner/Partner Licensed Insurance Agent/Broker

Date Representative’s Phone Number

GROUP APPLICATIONHIP/NYSBG Sole Prop Plans - 2012

I am enrolling for coverage for myself, my spouse and any eligible children. I understand that for policies issued or renewed after September 23, 2010, dependent children may stay on or be added to a parent’s policy until age 26 (end of birthday month), regardless of student status, as part of federal health reform. The premium will be billed at the applicable coverage tier and other than the basic enrollment form, nothing else is required. Most employer groups cannot limit dependent coverage eligibility even if the qualified dependent has access to his or her own employer based coverage. Only standard GHI and HIP HMO Direct Pay, Healthy New York and GHI large groups have the possibility of restrictions for adding dependents up to age 26.

As part of New York State’s “Age 29” law, eligible young adults through age 29 (up to 30th birthday) may continue or obtain coverage through a parent’s group policy.

If I am required to contribute to the premium for my coverage, I hereby authorize my employer to deduct such contributions in advance from wages due me and to remit same to HIP.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto commits a fraudulent insurance act, which is a crime, and shall be subject to civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation.

HIP PRIME POS and HIPaccess II applicants, please note that your benefits are provided under two separate contracts: a HIP HMO contract issued by the Health Insurance Plan of Greater New York and a HIP PRIME POS and/or HIPaccess II contract issued by the HIP Insurance Company of New York. Both contracts will end simultaneously if your HIP PRIME POS or HIPaccess II coverage ends.

The following paragraph pertains to small business groups only.I understand that pre-existing conditions will not be covered during the first 12 months of my enrollment under my group’s contract. For policies issued or renewed after September 23, 2010, pre-existing condition limitations will be waived for enrollees under age 19. A pre-existing condition is a condition (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended by a duly licensed medical professional or received within the six (6) month period ending on the enrollment date. Except that, pregnancy is not considered a pre-existing condition and genetic information may not be treated as a pre-existing condition in the absence of a diagno-sis of the condition related to such genetic information. HIP will credit the time I/we were covered by the previous policy, provided that the break in coverage under this plan does not exceed sixty-three (63) days, exclusive of any waiting periods. I agree that after enrolled, I will upon request provide HIP and/or my medical group with information on pre-existing con-ditions and any previous coverage I had. Subject to the applicable State and Federal laws pertaining to pre-existing conditions and creditable coverage, benefits for pre-existing conditions may not be payable for up to twelve months from my effective date under my group’s contract.

Note: No Retroactive Enrollments will be allowed. Members must be enrolled within 30 days from the Qualifying Event.Effective September 23, 2010, federal health reform may require changes to your coverage, depending on your plan. Get more information at www.emblemhealthreform.com.

Group Type (Check One)(To be completed by Benefits Administrator)

Sole Proprietorshipor One Subscriber

Group

Association ofTwo or More

Employees

Small Group —Less than 50Employees

Add Subscriber

Add SpouseAdd Dependent

Add SpouseAdd Dependent

MarriageBirthAdoption

New Hire orChange in Plan

For eligible employees who work more than 20 hours weekly provide a recent Copy of NYS45 showing this subscriber as an employee or copy of Payroll documentation reflecting the date, employee’s name and Social Security # or the employee’s current year W4 form.Marriage Certificate

Birth Certificate orFormal Adoption Papers orCourt Approved Guardianship Papers

ACTIONCheck ( )One Qualifying Event Documentation Required

SECTION A DOCUMENTATION BASED ON GROUP SIZE

Not Eligible

Loss of Coverage Certificate of Creditable Coverage

Membership is only $60 a year and is billed annually. Included in your membership is 1 FREE NYSBG Wellness Package (see page2).

The NYSBG Member Benefits apply to you, your employees, and their dependents (unless otherwise indicated) as part of your annual dues.

(NYSBG may add or remove membership programs without notice. Visit www.nysbg.com for updates).

1 Free NYSBG Wellness Package that includes a $25,000 Accidental Death & Dismemberment policy (ages 64 and under) and discount plans for Dental, Vision, Hearing, Prescriptions, and Holistic Medicine. Starter Website Package for $799.00 through VGL Marketing. A 3-section, 6-page website with stock images,

search engine submission, and keyword integration included. 12 professional themes as well as color choices. (Hosting, copy writing, digital photography, e-mail accounts, on-line control panel, site traffic reports, and domain name registration available at additional costs).

5% membership discount off insurance rates for your pets through Veterinary Pet Insurance. Endorsed by the American Humane Association. Discount applies to base plan only. No other discounts apply. For office and document support, or reliable and cost-effective shipping, NYSBG members can save up to 26%

on select FedEx® shipping and business services. There are no costs and no minimum shipping, copy or print requirements. Discounted less-than-truckload (LTL) shipping. Receive 60-70% off with FedEx Freight®; 52-75% with

YRC Worldwide; and 65-75% with UPS Freight. Discounted car rental rates and upgrade coupons through Avis®, Hertz®, and Alamo®. PEPP Network Solutions - Certified Financial Experts become your personal equity management team. More

than simple debt and credit reporting. Business Review, Real Estate Property Tax Reduction analysis, Retirement/Investment Portfolio analysis, and much more. Not just a report; monitoring and solutions from a network of financial professionals. Monthly membership for NYSBG subscribers is only $9.95 per month -a tremendous savings! TSYS (formerly First National Merchant Solutions), a top ten national processor, offers NYSBG members

special rates on a payment processing program that can help businesses retain more profit. Visa®/Master Card® discount rates and no monthly minimum transaction requirements. Use your existing equipment or take advantage of low rental and/or purchase options. Effective debt collection services with National Credit Systems, Inc. Members pay a one time flat fee per

claim form (minimum 30 @ $25 per for Level 1 services). Three levels of services and reporting to Experian, TransUnion, and Equifax upon failure to pay. OfficeMax® NYSBG members can access member-only pricing with OfficeMax® via OfficeMaxSolutions.com

and receive free shipping on purchases of $50 or more on top of discounted prices. Save up to: 20% on select printing and copying services with FedEx OfficeSM Business Services; 10% on

select signs and graphics production and on select finishing services. Plus, you may be eligible for savings up to 70% depending on specific printing quantities. Save Money. Communicate Smarter with the Member Conferencing Program from InterCall®. As the world’s

largest conferencing services provider, InterCall® is ready to help your business save time and money with world class conferencing solutions from simple audio-conferencing to cutting edge web-conferencing platforms such as WebEx® and Microsoft Live Meeting®. NYSBG members receive exclusive pricing on both audio and web conferencing, with toll-free audio conferencing at 60% off the standard InterCall pricing. There are no contracts to sign or minimum spending requirements, so sign up today! Enjoy exclusive savings! NYSBG members can enjoy special pricing and great discounts on a wide range of

HP business products you use every day, including printers, notebooks, PCs, servers, and so much more! Plus, NYSBG members receive free US ground shipping*, flexible financing and leasing options, a specially trained sales team, and award-winning service and support. *All orders must be billed and shipped to a US address. Some weight restrictions apply.

NYSBG Membership Application

NYSBG - 180 E. Main St., Ste. 205, Patchogue, New York 11772 1-800-427-5358 631-654-0600 www.nysbg.com

NYSBG Wellness PackageYou are entitled to one NYSBG Wellness Package with your annual dues.

You may add this package for additional employees or partners at the cost of $45 per person per year.Enrollment upon joining NYSBG or on the company's anniversary date is recommended.

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$25,000 Accidental Death & DismembermentCoverage offered through The United States Life InsuranceCompany in the City of New York, covers the WellnessPackage recipient (under the age of 65) and provides benefitsonly in the event of an accidental loss of life or limb.

The AMACORE Vision Program has 30,000 Eye CareProfessionals in over 13,000 locations nationwide includingOphthalmologists who discount all of their services includingLASIK. Substantial discounts available on contact lenses,frames and designer sunglasses and one FREE eye examper membership for prescription glasses.

The Health Connection: (alternative medicine) Thisprogram provides average discounts of 20-50% off HolisticHealth Physician Network Services, treatments, and selectvitamins. This is one of the most popular of the NYSBGprograms.

The Qualident7 Dental Discount Program: Obtainservices from a panel of over 3,000 dentists statewide. Noclaim forms, no copays, no waiting periods, and no restrictionson cosmetic services. Discounted fees are listed in the sched-ule of services so you know what you're going to pay and saveahead of time.

Business Owner/Individual Enrollment Section

HOW DID YOU LEARN ABOUT THE NEW YORK STATE BUSINESS GROUP? (CHECK ALL THAT APPLY)

BROKER EMPLOYER MEMBER REFERRAL MAIL NEWSPAPER RADIO T.V. INTERNET

PRIMARY ENROLLEE_________________________________________________________________________________________

PRIMARY MEMBER DATE OF BIRTH_______________________SS #______________________# OF DEPENDENTS____________

COMPANY___________________________________________________________________________________________________

ADDRESS____________________________________________________________________________________________________

CITY__________________________________________________STATE______________ZIP________________ZIP+4____________

PHONE________________________________FAX_____________________________E-MAIL_________________________________

FEDERAL TAX I.D. #___________________________________PRIMARY INDUSTRY_________________________________________

DEPENDENT INFORMATIONDEP. NAME__________________________________DATE OF BIRTH___________RELATION_______________SS#________________

DEP. NAME__________________________________DATE OF BIRTH___________RELATION_______________SS#________________



BENEFICIARY DESIGNATION (FOR US LIFE $25,000 AD & D POLICY COVERING PERSONS UNDER AGE 65)

NAME___________________________________________________ RELATION___________________ SS#________________

BENEFICIARY CONTACT INFORMATION_____________________________________________________________________________

APS Prescription Program saves up to 60% on Genericand up to 25% on Brand name drugs. Choose from over 55,000participating pharmacies nationwide. Pay the discountedamount at the time the prescription is filled, and realize yoursavings immediately. No claim forms or co-pays.

Beltone Hearing Aid Program: The Beltone HearingCare Network consists of audiologists and state licensedhearing care practitioners. Receive a 15% discount on over80 models of hearing aids and a free hearing test at U.S.Beltone Hearing Centers.

EMPLOYEE 1_________________________________________________________________ $45/yearEMPLOYEE DATE OF BIRTH______________SOCIAL SECURITY #_________________________# OF DEPENDENTS________

DEP. NAME___________________________________DATE OF BIRTH___________RELATION_______________SS#________________





NAME___________________________________________________ RELATION___________________ SS#________________

BENEFICIARY CONTACT INFORMATION_______________________________________________________________________________

EMPLOYEE 2_________________________________________________________________ $45/year

EMPLOYEE DATE OF BIRTH______________SOCIAL SECURITY #_________________________# OF DEPENDENTS________






NAME___________________________________________________ RELATION___________________ SS#________________








NAME___________________________________________________ RELATION___________________ SS#________________








NAME___________________________________________________ RELATION___________________ SS#________________

BENEFICIARY CONTACT INFORMATION____________________________________________________________________________

Optional Employee/Partner Enrollment in NYSBG Wellness Package

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Thank you!Thank you!Thank you!Thank you!Thank you!Please submit this form with your annual dues and payment for anyadditional NYSBG Wellness Packages to:NYSBG Corporate Headquarters180 East Main Street, Suite 205, Patchogue, NY 11772

NYSBG Annual Dues........................................ $60Additional Wellness Packages$45 each enrollee per year ....................................

TOTAL AMOUNT DUE......................................

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Please make checks payable to the New York State Business Group

INSTRUCTIONS: All domestic partnerships seeking coverage under a HIP group product must completeand submit this Declaration of Cohabitation and Financial Interdependence Form. Please submitthis completed form with the requested proofs to HIP along with the Alternative Affidavit of DomesticPartnership or proof of registration of your domestic partnership in the jurisdiction or municipalitywhere you reside. Domestic partner benefits may have federal and state tax consequences. You should consult the applicable laws and/or a tax professional before applying to enroll your domestic partner for dependent health coverage.

DECLARATION OF COHABITATION & FINANCIAL INTERDEPENDENCE We, the undersigned domestic partners, being duly sworn, depose and declare that we have been living together on a continuous basis for at least six (6) months and we are financially interdependent. We submit the following proof evidencing our cohabitation and financial interdependence:

Cohabitation (Please check and attach proof of at least one (1) of the following): ____ Driver’s licenses showing that you both reside at the same address. ____ Tax returns showing that you both reside at the same address. ____ Other proof acceptable to your group and to HIP.

Please specify: ________________________________________________. Financial Interdependence (Please check and attach proof of at least two (2) of the following): ____ A joint bank account. ____ A joint credit or charge card. ____ A joint obligation on a loan. ____ Status as an authorized signatory on the domestic partner’s bank account, credit card or

charge card. ____ Joint ownership or holding of investments. ____ Joint ownership of a residence. ____ Joint ownership of real estate other than a residence. ____ Listing of both domestic partners as tenants on the lease of a shared residence. ____ Shared rental payments for a residence. ____ Listing of both domestic partners as tenants on a lease or shared rental payments for

property other than a residence. ____ A common household and shared household expenses, such as grocery bills, utility bills

and telephone bills. ____ Shared household budget for purposes of receiving government benefits. ____ Status of one as representative payee for the other’s government benefits. ____ Joint ownership of major items of personal property, such as appliances and furniture. ____ Joint ownership of a motor vehicle. ____ Joint responsibility for child care. (This may be shown be means of school documents,

guardianship papers or similar documents.) ____ Shared child care expenses, such as baby sitting, day care and school bills. ____ Execution of wills naming each other as executor and/or beneficiary. ____ Designation of one as beneficiary under the other’s life insurance policy. ____ Designation of one as beneficiary under the other’s retirement benefits account. ____ Mutual grant of power of attorney. ____ Mutual grant of authority to make health care decisions, such as a health care power of

attorney. ____ Affidavit by a creditor or other individual able to testify to your partner’s financial

interdependence. ____ Other items of proof acceptable to HIP showing economic interdependency. Please specify _________________________________________________.

We are submitting this Declaration of Cohabitation & Financial Interdependence Form so that HIP maydetermine whether the partner named below is eligible for dependent health benefits coverage. We understand that our submission of these forms does not automatically enroll us in the HIP health benefitsprogram. We understand that, in the event that we no longer meet the criteria attested to in this Declaration of Cohabitation & Financial Interdependence Form, we will no longer be a domestic partnership as defined byHIP and the partner named below will no longer be eligible for HIP dependent coverage. _________________________________ _________________________________ Print Name of Employee/Subscriber Print Name of Partner _________________________________ _________________________________ Signature Signature STATE OF_____________________) : SS.: COUNTY OF___________________) Sworn to before me this _____ day of ___________________, 20________. ___________________________ Notary Public

CERTIFICATION OF SOLE PROPRIETOR STATUSFOR COVERAGE WITH HIP HEALTH PLAN OF NEW YORK

I ___________________________________________________ hereby affirm that Iam self-employed, on a full-time basis, working 20 or more hours a week. As proof of myemployment status, I have enclosed a copy of my most recent federal tax return (whichincludes a completed schedule C). I agree to notify HIP HealthPlan of New York (here-inafter, “HIP”) immediately if my circumstances change and I am no longer selfemployed.

I acknowledge and agree that it is a fraudulent act subject to criminal and civil penaltiesto knowingly and with intent to defraud file an application for insurance (including anysupporting certifications) containing any materially false information, or which concealsfor the purpose of misleading, information concerning any fact material thereto. I furtheracknowledge and agree that filing a false or misleading insurance application with HIPor failing to notify HIP if I am no longer self employed shall render any health insurancecontract entered into with HIP null and void.

I certify that this certification and my enclosed federal tax return are true, correct andcomplete.

Signature: _____________________________________ Date: _______________

7/09

REFUSAL OF HIP INSURANCE FORMFOR SMALL BUSINESSES WITH FEWER THAN 51 ELIGIBLE EMPLOYEES

(Please Print)

Group Policy Number:

Name of Employer:

Employee’s Name: (Last, First, MI)

Social Security Number:

Marital Status: Single Married Divorced Widower

Number of Eligible Dependent Children:

I was given the opportunity to enroll in a group insurance plan offered by my employer andinsured by HIP Health Plan of New York (HIP) and HIP Insurance Company of New York.I am refusing:(Note: Benefits provided on a noncontributory basis cannot be refused.)

HIP/HMO:

Employee & Dependents

Spouse

Child(ren)

Choice Plus:

Employee & Dependents

Spouse

Child(ren)

ANSWER IF YOU ARE REFUSING ANY COVERAGE:Are you or your dependents now covered by any other group plan? Yes No

If yes,Policyholder’s Name:

Carrier:

I understand that I may be required to furnish, at my expense, EVIDENCE OF INSURABILITYsatisfactory to HIP Health Plan of New York and HIP Insurance Company of New York if I laterwish to enroll for any of the coverages refused.

Signature of Employee Date

Signature of Witness Date

GROUP APPLICATION HIP/NYSBG Sole Prop Plans - 2012 Enrollment … · Articles of Incorporation or...

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Transcript of GROUP APPLICATION HIP/NYSBG Sole Prop Plans - 2012 Enrollment … · Articles of Incorporation or...