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Enroll Your Group
The following items must be submitted to your Sales Representative to enroll a new group.
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For Small Groups (50 or fewer eligible employees)
Requirements Purpose Action Needed

1. Commercial Underwriting Package - includes the following:

New Business Group Information Form - Provides basic enrollment information and federal and state regulatory information needed for the company.

Eligibility Policy for New Employees - Establishes the company's standard coverage waiting periods for 'new hires' and 'rehires.'

Attestation Form - Identifies newly hired employees, owners, partners or retirees not listed on the NYS45-ATT, and sole proprietors.

Completed and signed by the employer representative.

2. Renewals

Provides detailed information in regards to the few situations where mid-year benefit changes would be permissible. Adherence to the policy
3. Medical Commercial Underwriting Guidelines (PDF) Summarizes the Health plans guidelines and eligibility requirements for group coverage. Adherence to the guidelines

4. Annual Group Information Form (PDF)

Provides basic enrollment information and federal and state regulatory information required annually Completed and signed by the group representative

5. Medicare

   

6. Underwriting Requirements for New Business - Checklist (PDF)

Provides a checklist of requirements for new business submission. Ensure all required documentation is provided with your submission
7. Group Contract, Benefit Summary & Rate Sheet This document, provided by the Sales Representative, identifies the specific plan(s) you are enrolling in and the premium/rate(s). Signed by the employer representative. Be sure to return all pages.
Provides information about the employee and his/her eligible family members for enrollment in medical, dental coverage or Medicare coverage. Completed and signed by the subscriber, with the group number and employer name filled out by the employer representative.

9. Renewal Change Forms:

Handicapped dependents who meet certain qualifications may be eligible for continued coverage.

Identifies members in the group who are eligible for Medicare and reason for eligibility.

Completed and signed by both the subscriber and the member's attending physician.

Completed and signed by the group representative and member.

10. First Month's Premium   Required for new groups.
Provide a check issued on the business account.
For Mid-Size Groups
(51 to 300 eligible employees)
To help you keep track of these documents, print the New Mid-Size Group Enrollment Check List (PDF) or the Existing Mid-Size Group Check List (PDF).

You can also request a Rate for a Mid-Size Group (PDF).

For Large Groups
(301+ eligible employees)
To help you keep track of these documents, print the New Large Group Enrollment Check List (PDF) or the Existing Large Group Check List (PDF).
Documents
Requirements Purpose Action Needed
1. Legal Name of Company and Contact Information Identifies the company's legal name, address (street, city, state, Zip, county), and primacy contact (name, email, phone, fax and Employer Identification Number (EIN)). Provided by employer representative.
2.Annual Group Information Form (PDF)

2a. Medicare Questionnaire (PDF)

Provides basic enrollment information and federal and state regulatory information required annually. Completed and signed by the group representative
3. New Business - Annual Group Information Form (PDF)    
4. Medical Commercial Underwriting Guidelines (PDF) Summarizes the Health plans guidelines and eligibility requirements for group coverage. Adherence to the guidelines
5. Group Contract, Benefit Summary & Rate Sheet This document, provided by the Sales Representative, identifies the specific plan(s) you are enrolling in and the premium/rate(s). Signed by the employer representative. Be sure to return all pages.
6. Eligibility Policy for New Employees (PDF) Establishes the company's standard coverage waiting periods for 'new hires' and 'rehires.' Completed and signed by the employer representative.
7. COBRA Election Form (if applicable)  Identifies the company's preference for COBRA premium collection, or designation as a church plan. Completed and signed by the employer representative.
8. Certificate of Coverage List A file of members who were covered by the previous carrier. Provided by the employer representative.
Provides information about the employee and his/her eligible family members for enrollment in medical, dental coverage or Medicare coverage. Completed and signed by the subscriber, with the group number and employer name filled out by the employer representative.

10. Renewal Change Forms

Handicapped dependents who meet certain qualifications may be eligible for continued coverage.

Identifies members in the group who are eligible for Medicare and reason for eligibility.

Completed and signed by both the subscriber and the member's attending physician.

Completed and signed by the group representative and member.

11. Name of FSA Administrator (if applicable) Either EBS-RMSCO or other third party administrator. Provided by employer representative.

 

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