1. health and fitness

AWB
Producer Reference Manual
12/01/12 – 11/30/13
ProPoint Business Solutions
Helen Siggins
206-397-4615 ext 1
[email protected]
Dear Producer,
Thank you for choosing to be a part of our AWB Producer Team. You are
part of a small, select producer group representing the AWB HealthChoice
program.
The goal of this reference guide is to assist you through our processes: quoting
enrolling and renewing. This guide will provide you with our most common
forms and notes on when to use them and quick hints to direct you towards
often overlooked information.
While we encourage you to use these forms as your guide we recommend that
you frequently check our producer website, www.awbhealthchoice.com, for the
most up-to-date forms. Please share this with anyone on your staff who assists
with your AWB groups. It will be a valuable training tool for them.
How this guide works: We have divided this guide into four parts: Contact
Information, Quoting, Enrolling and Renewing. Each section is further
divided into specific parts, i.e. 2-14 and 15+ for Quoting, with tips and a list of
forms specific to that section on the bottom of each tips page. There are
duplicates of forms in this guide to make sure that the form in question is
represented in each section it is needed.
We value your input, so don’t hesitate to drop us an email to let us know what
works and how we might improve. Please direct your emails to Winn Cody at
[email protected]. Thank you for your efforts!
Sincerely,
The AWB HealthChoice Team
1
AWB/ProPoint Business Solutions Staffing with TPA included
AWB
Debra Brown
Plan Sponsor
360-357-1326
Benefit Solutions
ProPoint Business
Solutions
Jen Maurice
Account Lead
Managing General Agency
425-771-7359
Helen Siggins
Winn Cody
Agent Relations
Operations
206-397-4615 x1
206-397-4615 x3
Mary Sears
Sue Ellen Knieper
Accounting/Credentialing
Admin/Olympia Manager
206-397-4615 x2
360-357-1326
Shilah Miller
Nancy Sams
Renewals/General
Support
Large Group Quotes/
Renewals
360-357-1326
360-357-1326
Andy Summers
New Group Processing
360-357-1326
This chart shows the various individuals involved in HealthChoice and their areas of expertise. We
hope this helps you determine who to call if you have a question or problem.
2
ProPoint Business
Solutions
Benefit Solutions
Billing/Eligibility/COBRA
Managing General Agent
Premera
VSP
Premera
Willamette
Medical
Vision
Dental
Dental
LifeWise
Assurance
Lincoln Financial
Group
Mandatory Life
Voluntary Life & Disability
The above chart shows the various entities involved in the HealthChoice Program
3
Contact List
PRODUCER FORMS WEB SITE – Association of Washington Business
www.awbhealthchoice.com
DISTRIBUTING PRODUCERS – ProPoint Business Solutions
AWB HealthChoice
c/o ProPoint Business Solutions
PO Box 129
Olympia, WA 98507
AWB HealthChoice
c/o ProPoint Business Solutions
9725 3rd Ave NE, Ste 601
Seattle, WA 98115-2024
Street Address:
1414 Cherry St, SE
Olympia, WA 98501
Phone:
Fax:
•
•
•
•
•
(866) 448-9577
(360) 357-1326
(360) 357-1495
Phone: (206) 397-4615
Fax:
Underwriting:
New Group Processing:
Sue Ellen Knieper
[email protected]
Andrew Summers
[email protected]
Quoting:
Renewals:
Nancy Sams
[email protected]
Admin:
Shilah Miller
[email protected]
ADMINISTRATION – Benefit Solutions, Inc.
• Billing
• Eligibility
• Administration Kits
• COBRA
• Adds/Deletes
• LifeWise Assurance Company Claims
Phone: (425) 771-7359
Fax:
(206) 859-2633
•
•
•
(866) 379-9982
Credentialing & Accounting:
Mary Sears
[email protected]
Operations:
Winn Cody
[email protected]
Sales & Marketing,
Agent Relations:
Helen Siggins
[email protected]
AWB HealthChoice Plans
c/o Benefit Solutions, Inc.
PO Box 6
Mukilteo, WA 98275
Street Address:
12121 Harbour Reach Dr., Suite 105
Mukilteo, WA 98275
Jen Maurice
[email protected]
MEDICAL and DENTAL Claims & Customer Service – Premera Blue Cross
Customer Service & Claims:
Website:
Pharmacy Locator:
(800) 722-1471
www.premera.com
(800) 391-9701
Attn: Claims
Premera Blue Cross
PO Box 91059
Seattle, WA 98111-9159
4
Contact List
DENTAL – Willamette Dental
Appointments & Emergencies:
(800) 359-6019
Patient Relations:
(800) 360-1909
Web site:
Willamette Dental
6120 Capitol Blvd SE
Tumwater, WA 98501
www.willamettedental.com
VISION – Vision Service Plan (VSP)
Customer Service & Claims:
Web Site:
(800) 877-7195
www.vsp.com
Vision Service Plan
PO Box 997105
Sacramento, CA 95899-7105
MANDATORY LIFE – LifeWise Assurance Company
Customer Service & Claims:
Fax:
Web site:
(425) 918-4575
(425) 918-4485
LifeWise Assurance Company
P.O. Box 2272
Seattle, WA 98111-2272
www.lifewiseac.com
VOLUNTARY LIFE & DISABILITY – Lincoln National Life Insurance Company
Customer Service:
E-mail: General
Claims
Web site:
(800) 423-2765
Option 1 for Claims
Option 2 for Service
Lincoln National Life Insurance
Company
1300 South Clinton St
Fort Wayne, IN 46801
[email protected]
[email protected]
www.lincoln4benefits.com
PROGRAM SPONSOR – Association of Washington Business
Debra Brown:
(800) 521-9325
(360) 943-1600
Fax:
(360) 943-5811
E-mail:
Web site:
Association of Washington Business
P.O. Box 658
Olympia, WA 98507
[email protected]
www.awb.org
5
Groups 2-14: Age Rates
Quoting
• Producer quotes preliminary rates in field:
www.awbhealthchoice.com
• Current WAHIT/NWTECH - our parity policy is currently
under review therefore all quoting for those groups is on hold
• All other Premera business is parity rated for groups 51+ at
renewal date only (rates within a few dollars of renewal)
• AWB issues firm rate with Health Questionnaires
Health Questionnaires must be filled out completely by the employee
for themselves and anyone enrolling under them. There should only
be one Health Questionnaire per employee.
 For lowest possible rate complete the Request for Benefits
Quote form
 Make sure group name is on Health Questionnaires
 If there are any boxes checked give as much information as
possible on 2nd page
 Dates
 Treatment: past, current & future
 Medication: name, dosage, frequency
 If the EE can’t find an applicable condition, use #61 and
explain on 2nd page
• Nothing is final until enrollment
Required forms:
1. Quote Sheet
2. Individual Health Questionnaire
3. For lowest possible rate complete the Request for Benefits
Quote form
6
Health Questionnaire
Note to Employee: Due to the confidential nature of this form, you should have
been provided a confidential envelope in which to submit it. If not, please request
one from your group administrator. Please print clearly and complete all applicable
items on the front and back of this form.
Group name
1. employee information
Employee Last Name
First Name
MI
2. Enrollee INFORMATION
Note: Do not list dependents who will not be enrolled. Use a separate sheet to list additional enrollees.
Relationship
to Employee
Name (Last, First, MI)
Gender
Date of Birth
Height
Weight
Self
®M ®F
/
/
ft.
in.
lbs.
Spouse
®M ®F
/
/
ft.
in.
lbs.
Child
®M ®F
/
/
ft.
in.
lbs.
Child
®M ®F
/
/
ft.
in.
lbs.
Child
®M ®F
/
/
ft.
in.
lbs.
3. Health information for employee and all Enrolling dependents
Note: Please answer the following questions concerning yourself and any of your dependents who will be covered by this plan.
Health condition Selection
Have you or any family member to be covered on this plan ever had, been advised of, diagnosed with, received treatment for or had treatment
recommended for any of the following conditions?
Time elapsed since recovery, onset
or an operation for a condition
Not
1–2
treated <1 Year Years
1.
2.
3.
4.
Anemia
Leukemia
Alcoholism
Drug Abuse
Congenital Disorder—Mild to
5a.
Moderate
5b. Congenital Disorder—Severe
6a. IBS
6b. Colitis
6c. Ulcerative Colitis
7.
Crohn’s Disease
8.
GERD / Heartburn
9a. Diabetes—Insulin Dependent
9b. Diabetes—Oral Meds
9c. Diabetes—Controlled by Diet
10. Pituitary Disorders
11. Adrenal Disorders
12a. Brain Tumor
3–5
Years
6–10
Years
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Critical Organ Cyst / Tumor
(present)
o
o
o
o
o
Critical Organ Cyst / Tumor
12c.
(removed)
o
o
o
o
o
12b.
13a.
Cancer—Local (in the original
organ only)
o
o
o
o
o
13b.
Cancer—Regional (spread to
surrounding organs or tissues)
o
o
o
o
o
Time elapsed since recovery, onset
or an operation for a condition
Not
1–2
treated <1 Year Years
Cancer—Distant (spread
13c. directly or by metastasis to
other body parts)
14. Angina
15. Bypass Surgery
16. Chest Pain
17. Heart Attack (MI)
18. Heart Failure
19. Heart Valve Disorder
20. AIDS
21. ARC/HIV+
22. Cirrhosis / Liver Failure
23a. Hepatitis A
23b. Hepatitis B
23c. Hepatitis C
24. Anxiety
25. ADD / ADHD
26. Depression
27. Bipolar
3–5
Years
6–10
Years
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
28.
Disc Problems: Bulging,
Herniated, Slipped, Ruptured
o
o
o
o
o
29.
30.
31.
32a.
32b.
Spinal Column Disorder
Neck Disorder
Joint Disorder
Lupus (systemic)
Lupus (discoid)
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Continued on back
016400 (11-2006) / Health questionnaire Page OF 2
7
3. Health information for employee and all Enrolling dependents (continued)
Health condition Selection (Continued)
Time elapsed since recovery, onset
or an operation for a condition
Not
1–2
treated <1 Year Years
33.
34.
35a.
35b.
35c.
35d.
35e.
36.
37.
38.
39.
40.
41.
42a.
42b.
43.
44.
45.
Muscular Dystrophy
Osteoporosis / Bone Disorder
Osteo Arthritis
Rheumatoid Arthritis
Mild Arthritis
Moderate Arthritis
Severe Arthritis
Cerebral Palsy
Multiple Sclerosis
Paralysis / Hemiplegia
Paralysis / Quadriplegia
Parkinson’s Disease
Senile Dementia
Seizures—Petite Mal
Seizures—Grand Mal
Pregnant (Currently)
Multiple Birth/Complications
Allergies / Hay Fever (Not Mild
or Seasonal)
3–5
Years
6–10
Years
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Time elapsed since recovery, onset
or an operation for a condition
Not
1–2
treated <1 Year Years
3–5
Years
6–10
Years
46.
47.
48.
Asthma
COPD
Emphysema
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
49.
Organ Transplant (any except
corneal)
o
o
o
o
o
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
Kidney Failure
Polycystic Kidney
Kidney Stones
Aneurysm
High Blood Pressure
Poor Circulation / Edema
Stroke
High Cholesterol, Triglycerides
Sleep Apnea
Surgery Pending
Overweight
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
61.
Other:
o
o
o
o
o
4. health condition explanation
Note: Please provide detailed information for all items checked yes in section 3. Use a separate sheet to list additional details.
Condition
Number
from 3
Person’s Name
Further
Treatment
Needed
Treatment Dates
From:
/
/
To:
/
/
From:
/
/
To:
/
/
From:
/
/
To:
/
/
From:
/
/
To:
/
/
From:
/
/
To:
/
/
Treatment Details
® No ® Yes
® No ® Yes
® No ® Yes
® No ® Yes
® No ® Yes
5. EMPLOYEE SIGNATURE
I declare that to the best of my knowledge, all of the information on this form is true and complete, and all of the persons for whom I am requesting enrollment are eligible for coverage.
Employee Signature 016400 (11-2006) / Health questionnaire Date Signed / /
Page OF 2
8
Quoting
Groups 15+: Composite Rates
• Submit your 15+ quote request to AWB at
[email protected]
 You must use the AWB HealthChoice Request For
Benefits Quote form and it must be entirely filled out
 Preferred format for Employee Status:
EO, ES, EC, EF
 Census must be submitted via e-mail and in an Excel
document and must include birthdates, not ages
• AWB issues preliminary rates based on demographics without
Health Questionnaires
• Submit Health Questionnaires for firm rates
• Current WAHIT/NWTECH – our parity policy is currently
under review therefore all quoting for those groups is on hold
• All other Premera business is parity rated for groups 51+ at
renewal date only (rates within a few dollars of renewal)
• Nothing is final until enrollment
• No group size limit
Required Forms:
1. AWB RFQ
2. Census
9
Request for Benefits Quote
COMPANY TO BE QUOTED
Company Name Type of Business
NAICS
UBI Number
City
State
Zip
Phone
Comments
County
PRODUCER REQUESTING QUOTE
Producer
Account Manager/ Admin Assistant
Comments
CURRENT MEDICAL COVERAGE
Current Medical Carrier
Name of Product/ Assoc.
Number of Years with Current Carrier
Employer Contribution (EE) %
Medical
Deductible & Out of Pocket Maximum
Employer Contribution (Dep) %
Requested Effective Date Current Renewal Date
Comments
# of Employees:
CURRENT AND RENEWAL RATES
Medical Coverage Plan I
Current Rates
Renewal Rates
Medical Coverage Plan II
Current Rates
Renewal Rates
Employee
Emp./Spouse
Emp./Child
Emp./Family
*Please Note* - Our parity policy for WAHIT & NWTECH is currently under review therefore all quoting for those
groups is on hold.
February 2012
Please submit this form along with the appropriate
AWB Individual Health Questionnaires and an Excel Census to:
ProPoint Business Solutions
email: [email protected]
Fax: 360-357-1495
PO Box 129 Olympia, WA 98507
360-357-1326 or 866-448-9577
10
Enrollment
Master Application
• Fill in all information
 If declining a particular option the “No” must be
checked
 Group Rep/Owner & Agent must sign application
(no stamped signatures will be accepted)
 Eligibility & Enrollment must account for each
employee, even those not eligible for coverage
New Group Submission Checklist
• AWB Membership Profile Form & credit card information
or check made payable to AWB
 Check to see if group is a) already a member or b) if
they’ve been quoted membership. If either a or b is true,
then DO NOT quote the membership fee
• All payment for coverage checks must be made payable to
Forterra, Inc. and paid with a business check
Forms for ALL Enrollment:
1. Master Application
2. Individual Applications
3. Individual Health Questionnaires
4. AWB Membership Profile Form
5. Late Submission (if necessary)
6. Waiver (if necessary)
7. Deductible Credit Form (if necessary)
8. Domestic Partner Affidavit (if necessary)
11
EMPLOYER’S REQUEST FOR HEALTH CARE COVERAGE
Group Name
Requested Effective Date
Producer
Group Submission Checklist
Groups may be hand delivered, or submitted by mail, email, or fax. If emailed or faxed,
original documents do not need to be forwarded to ProPoint Business Solutions.
Stamped signatures are not permitted by the carrier.

Quote or rate sheet calculation

Master application, signed by group representative & producer

Late Submission form if submitted after the 20th of the month prior to effective
date (groups accepted up to the 10th of the effective month)




Employee enrollment forms
Employee health questionnaires
Waiver of coverage forms (if applicable)
Domestic Partner Affidavits (if applicable)

Copy of current carrier medical billing

Association of Washington Business Member Profile with check or charge
Information (if not a current member) made out to AWB
Amount enclosed $____________________

Payment for coverage check made payable to Forterra
Amount enclosed $____________________

Deductible Credit Forms (if applicable)
Inc
MAIL COMPLETED APPLICATION PACKET TO:
AWB HealthChoice
Mailing: Post Office Box 129, Olympia, WA 98507-0129
Street: 1414 Cherry Street, SE, Olympia, WA 98501-2341
Phone: (360) 357-1326
*
Fax: (360) 357-1495
12
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14
Enrollment
Individual Application
• All information must be filled out
• Any changes to Individual Application or Health Questionnaire
must be signed and dated
• Watch out for these common mistakes or omissions:
o Date of Hire (owners can put the date they bought/started
the company)
o Covered by Workers’ Compensation
o Prior coverage information: carrier, start and end date
o Life Beneficiary – found on the second page
o Dental Selection for groups 5+ with Dental option
o Signature – can only be signed by the employee
15
Employee Enrollment/Change Form
Employer Name Employer Number
Enrollment
Qualifying Event for special enrollment
Requested Effective Date: ___ / 01 / 201__
Employee Date of Hire: _______ / ______ / ________
Involuntary Loss of Coverage
 Adoption/Legal Guardian (Legal documentation required)
 Birth
Date ____/___/_____
Lincoln Financial Group Voluntary BENEFITS
Please check box below:
Name Change
 Address Change  Beneficiary Change
 Delete Employee(s) Effective date ____/___/_____
 COBRA / Continuation Coverage Start date ____ / 01 / 20_____
Marriage/Domestic Partnership (Affidavit Required)
Date of marriage/partnership ______/______/________
Please check appropriate box:
 New employee
 New employee & dependent(s)
 New dependent(s) (Please specify qualifying event at right)
 Entered Eligible Class
change
Please check box below:
 Divorce
 Death
Voluntary Life
Short Term Disability Buy-up
Dental Plan Selection
If your Employer is enrolling 5 or more
Long Term Disability Buy-Up
Employees and is choosing a Dental product
EmployeeSpouse
Dependent Child(ren)
 Yes
 No
 Yes
 No
you’re responsible for selecting the carrier of
 $25,000.00
 $10,000.00
 $10,000.00
$500 Weekly benefit,
Buy up benefit is limited to 60% of
your choice. If you have any questions your
 $50,000.00
 $20,000.00
3/6 pre-ex limitations on buy
employee salary, up to $5000
employer will gladly assist you during the
 $75,000.00
 $30,000.00
up amount only
Monthly benefit has a 3/12 pre-existing
enrollment process
 $100,000.00Spouse coverage must be 50%
limitation on base and buy-up plans.
 Premera DentalBlue
or less of the employee choice  Willamette Dental
Rates & benefit reduce by age
Buy-up only available if your employer has purchased the base coverage
details please refer to the benefit summaries. Please check with your producer or group adminstrator for your eligibility.
For more
Employee information
Last Name
First Name
Mailing Address
M.I.
Apt # Social Security Number
-
-
Home Phone (
)
Work Phone
(
 No
Marital Status
 Domestic Partnership (Affidavit or State Registration Required)
Prior Coverage
 YES
 NO
 Divorced
Insurance Carrier:
/
Date of Birth
/
City, State, Zip
Are you covered by workers’ compensation:  Yes
 Single  Married
 Exempt Gender  M  F
)
Email
Current Job Title
Start date of prior coverage : ______/______/________
End date of prior coverage: ______/______/________
dependent Information (Please check the add or delete box for each enrollee)
Relationship
DeleteLast
Name
to employee
Social Security Number
Add
 
Previous coverage- HIPAA:
Relationship
DeleteLast
Name
to employee
Social Security Number
Add
 
16
Revised 1/13
Previous coverage- HIPAA:
First Name
-
-
Gender  M
Prior carrier:
 F
Start date of prior coverage:
Date of Birth
/
/
-
Gender  M
Prior carrier:
Start date of prior coverage:
/
 F
Date of Birth
/
/
/
Prior coverage ended:
First Name
-
/
/
/
/
/
/
Prior coverage ended:
IMPORTANT: Both pages of this application must be completed
Page 1
Employee Enrollment/Change Form
Employer Name Employer Number
dependent Information continued (Please check the add or delete box for each enrollee)
Relationship
DeleteLast
Name
to employee
 
Social
Security Number
Add
Previous coverage- HIPAA:
Relationship
DeleteLast
Name
to employee
 
Social
Security Number
Add
Previous coverage- HIPAA:
Add
DeleteLast
Name
Relationship
to employee
 
Social
Security Number
Previous coverage- HIPAA:
Add
DeleteLast
Name
Relationship
to
employee
 
Social
Security Number
Previous coverage- HIPAA:
First Name
-
-
Gender  M
Prior carrier:
 F
Start date of prior coverage:
Date of Birth
/
/
-
Gender  M
Prior carrier:
Date of Birth
/
/
-
-
Gender  M
Date of Birth
/
/
-
-
Gender  M
Prior carrier:
Start date of prior coverage:
Date of Birth
/
/
/
/
/
/
/
/
/
/
 F
/
/
Prior coverage ended:
First Name
/
/
 F
Start date of prior coverage:
Prior coverage ended:
First Name
Prior carrier:
/
 F
Start date of prior coverage:
/
Prior coverage ended:
First Name
-
/
/
Prior coverage ended:
Beneficiary for Employee’s Life INSURANCE Benefit
Beneficiary Name
Beneficiary Address
Relationship to employee
Applicant / HIPAA Acknowledgement
I am an active full-time employee or owner regularly working at least 20 hours per week. All information given by me on this form is true and complete. My signature below attests
that the prior coverage data provided above is complete and accurate to the best of my knowledge, and can be documented upon request with evidence of coverage from my, and my
dependent’s, prior plan(s). I authorize the Association of Washington Business to obtain information from third parties regarding any matters that may bear on this application.
I understand that AWB HealthChoice and the insurance carriers may collect, use and disclose protected health information about each individual enrolled under this application in order to
carry out its routine business functions, which include, but are not limited to, determining eligibility for benefits, paying claims, coordinating benefits with other insurance carriers or payers,
underwriting and conducting case management, care management and quality reviews. AWB HealthChoice and the insurance carriers may also disclose protected health information to
state and federal agencies or other third parties as required or permitted by law.
FRAUD WARNING STATEMENT
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include
imprisonment, fines, and denial of insurance benefits. Any person who knowingly and with intent to defraud a health care service contractor or any other person files a
request for benefit coverage 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 act which may result in the denial of health care coverage or insurance coverage.
This application must be signed Please return this form to your employer
Applicant Signature ________________________________________________________
Underwritten by:
17
Premera Blue Cross
7001 220th SW
Mountlake Terrace, WA 98043
LifeWise Assurance Company
7007 - 220th SW
Mountlake Terrace, WA 98043
Lincoln National Life Insurance Company
1300 South Clinton St.
Fort Wayne, IN 46801
Date ___________________________
Vision Service Plan (VSP)
600 University St Ste 2004
Seattle, WA 98101
Willamette Dental of Washington, Inc.
910 NE 82nd St.
Vancouver, WA 98665
Page 2 of 2
New Group Late Submission Form
IMPORTANT: This form is required for new groups submitted after the 20th of the month for
coverage effective the first day of the following month. Groups may be submitted until the 10th
of the month for an effective date of the first day of that month but they will be considered a late
submission. If the 10th falls on a weekend or holiday, materials must be submitted by the business
day immediately preceding the 10th of that month.
Requested Effective Date ______________ / _____________ / ________________
Company Name
Address
City, State, Zip
Phone (_________) __________________________ Fax (_________)____________________
I acknowledge that our group has submitted its materials late and understand this may cause a delay
in ID cards and eligibility for benefits. I acknowledge that eligible employees and their dependents
may be required to pay out-of-pocket for covered services until eligibility is updated. In the event an
eligible employee or eligible dependent pays out-of-pocket for covered services, I acknowledge it
is the responsibility of that employee or dependent to submit the request for reimbursement to the
carrier(s).
Name __________________________________________________ Title __________________
Signature __________________________________________Date ____ / _____ / ___________
Producer Name_________________________________________________________________
Producer Signature____________________________________Date____ / _____ / ___________
February 2012
18
Association of Washington Business
Washington State’s Chamber of Commerce
1414 Cherry Street Southeast
PO Box 658
Olympia WA 98507-0658
www.awb.org
HealthChoice contact information:
360.357.1326 / 866.448.9577 / 360.357.1495
Member Profile
Company Size (please check one):
2-9 employees
10 or more employees
AWB Membership is a prerequisite to participating in AWB HealthChoice.
Already a member? AWB member #______________. If your company is already a member of AWB, you do
not need to fill out this profile. If you do not know your AWB membership number, please call 800.521.9325.
Not yet a member? Please fill out the following information and enclose your check or VISA/MC/AMEX
authorization.
Name of organization:
dba (if applicable):
CEO/Owner
Mr./Ms.
First:
Last:
Email:
Company Contact
Website:
Mr./Ms.
First:
Last:
Title:
Email:
Street Address:
Mailing Address:
City:
State:
Zip+4:
-
County:
Telephone: (
)
Fax: (
)
Type of business:
NAICS:
SIC:
UBI:
Payment information
Attached/enclosed is a check for $__________________________
Please charge my (circle one) VISA/MC/AMEX $____________________________
Card #_____________________________________________________ Expiration date: __________________
Office Use Only
Insurance start date
Number of employees
Agent name
Pay to
Revised 8/27/2012
19
Waiver of Coverage Form
This is to confirm that I decline to participate in the medical plan offered through my employer’s group health plan as follows (please check appropriate box(es) below):  I do not wish to enroll myself. I have other health care coverage.  I do not wish to enroll myself. I do not have other health care coverage.  I do not wish to enroll my:  spouse  child(ren). They have other health care coverage.  I do not wish to enroll my:  spouse  child(ren). They do not have other health care coverage. Special Enrollment Rules If you decline enrollment, you may in the future be entitled to Special Enrollment under the following circumstances: 1) Involuntarily loss of other coverage If you decline enrollment for yourself or dependents because of other health coverage and the other coverage is lost involuntarily, you may be eligible for a special enrollment period. We must receive an enrollment application within 30 days after other coverage ended. Proof of prior coverage is required and enrollment may be pended until a prior coverage certificate is received. Examples of involuntary loss of coverage include: you or your eligible dependent lose eligibility for other coverage; COBRA coverage has been exhausted; or when employer contributions toward other health coverage are terminated. If other coverage is lost due to your non‐
payment of premiums or due to misconduct (such as filing a fraudulent claim) this enrollment opportunity does not apply. If you decline enrollment for yourself or dependents and the person declining coverage does not have other coverage, the special enrollment opportunity does not apply, and you would have to wait for your employer’s next annual renewal period to make enrollment changes. Please contact your employer for information regarding the annual renewal period. 2) Newly obtained dependents as a result of marriage, birth, adoption, or placement for adoption. You may be able to enroll yourself and new dependents provided we receive a completed enrollment application within 60 days after the marriage, birth, adoption or placement for adoption. Special Enrollment under these provisions is permitted only if one of the events has occurred. You may be required to provide additional information necessary to allow for this determination to be made. Employee Name ____________________________________________________________________________________ Employee Signature_____________________________________________________ Date _______/_______/________ Name of Employer __________________________________________________________________________________ Please give this completed form to your employer 20
Please return to:
Benefit Solutions, Inc. (BSI)
Deductible Credit Form
12121 Harbour Reach Dr., Suite 105
Please attach required proof of previous deductible.
ATTN: AWB Deductible Credit
DATE (mm/dd/yyyy)
Mukilteo, Wa 98275
GROUP EFFECTIVE DATE
GROUP NUMBER
MEMBER NUMBER
COMPANY NAME
COMPANY ADDRESS (city, state, ZIP)
MEMBER NAME (please print)
MEMBER ADDRESS (city, state, ZIP)
 A FULLY COMPLETED DEDUCTIBLE CREDIT FORM MUST BE RECEIVED WITHIN 90 DAYS OF
THE FIRST DAY OF YOUR EMPLOYER’S ORIGINAL EFFECTIVE DATE.
 Appropriate documentation is required to process your deductible credit information.
Please attach a copy of an Explanation of Benefits (EOB) from your previous carrier. This EOB
should list deductible dollars for each family member separately, illustrating previous deductible met.
Or, you may provide us with a report from your prior carrier that contains the following information:
prior carrier name, member name, member date of birth, and amount of medical and/or dental
deductible satisfied for the current calendar year for each family member.
 You and your family members will receive credit amounts that were applied toward your deductible on
your previous insurance plan toward the deductible on your new plan.
 You must list separately the dollar amount met by each member of your family.
MEDICAL
MEMBER’S NAME
(List your name and the name of each covered family member)
DATE OF BIRTH DEDUCTIBLE $ CREDITED
(mm/dd/yyyy) THIS YEAR
DENTAL
DEDUCTIBLE $ CREDITED
THIS YEAR
EMPLOYEE
$
$
$
$
$
$
$
$
$
$
SPOUSE
CHILD
CHILD
CHILD
OTHER
$
$
I certify that the expense information I have provided is true and complete. I have attached required
deductible documentation for each member listed on this form.
REQUESTOR SIGNATURE: X_______________________________________________________________________________
PLEASE SEND THIS FULLY COMPLETED FORM TO THE ADDRESS LISTED ABOVE.
Deductible Credit eligibility rules apply
21
Enrollment
New Group Processing Helpful Hints
Once we have all of the information needed to complete a group, we send the
approval letter to the producer for review and FedEx the group to Benefit
Solutions, Inc., hereinafter “BSI”, for processing. BSI will enter the data and
convert it into electronic form. BSI then transmits the data to Premera and
PremeraBlue Dental on Tuesday, Thursday and Friday nights. Premera then
loads the information in their system and assigns policy and individual ID
numbers. The policy numbers are transmitted back to BSI, with the ID
numbers following a few days later. This whole process can take 7 to 10 days.
Willamette Dental transmittals are sent once per week on Wednesday morning.
Willamette Dental eligibility takes 5 to 7 days to show active.
If the group is submitted after the 20th of the month, the delay may be longer.
This is the reason that we require the Late Submission Form when groups are
sent late in the month.
Our system does not routinely capture Premera policy numbers. You can
contact BSI approximately a week after receipt of your copy of the approval
letter to check progress and obtain a group number. In the meantime, the
group will need to pay out of pocket for any services incurred. After the group
is activated in Premera’s system, the group should submit a claim form for
reimbursement. The claim form can be found on Premera’s website.
As you can see, there are lots of steps required behind the scenes to activate
new groups. While allowing late submission is really helpful to producers and
groups who need coverage, the trade-off is that groups will have a period of
time when coverage is effective but not showing on the Premera system.
22
Enrollment
Approval Letter
• The following three pages, the Test Approval Letter and
the Frequently Asked Questions sheet, will be emailed to
the producer of record and mailed to the group
• Also mailed, but not included here, are the Rate Sheets
and the Plan Summaries. These can be found on the
website
23
March 1, 2013
«Account_Name»
«Address_1» «Address_2»
«City», «State» «Zip»
Dear «Account_Name»,
Thank you for your recent application for Association of Washington Business HealthChoice
underwritten by Premera Blue Cross. We are pleased to inform you that your application has been
approved as follows:
Effective Date
September 1, 2012
Rate Table 1
Group Benefits:
Coverage
Medical
Dental
Plan
Plan ID/Group #
AWB Plan D-2000
AWBD2000BC
N/A
N/A
N/A
N/A
N/A
N/A
Vision Plan Hardware
N/A
N/A
Supplemental Life
STD Base Benefit + Employee Buy Up LTD Base Benefit + Employee Buy Up
Attached is the rating chart that will be in effect under the conditions stated in your contract for the
next 12 months. If there are any premium or fee shortages, they will be reflected on your next bill.
Please note a few Administrative items:
1. A change of age that places an employee or owner in a new age band will be billed at
the new rate in the month following the birthday.
2. Coverage is dependent on maintaining an Association of Washington Business Membership. A
lapse in membership can result in discontinuation of coverage.
3. If not submitted at enrollment, all deductible credit requests must be submitted to Benefit
Solutions, Inc. within 90 days of your effective date. Credits submitted after 90 days will not
be honored.
In a short time you will receive your benefit booklets from Benefit Solutions Inc., the Association of
Washington Business contracted billing and eligibility administrator. You can also access your benefit
booklets and enrollment forms on our website: www.awbhealthchoice.com.
You, as the participating employer, are responsible for complying with the AWB HealthChoice
Administrative Guide. We strongly recommend you take the time to read through the guide in order to
effectively administer the plan to your employees. This guide can also be accessed at:
www.awbhealthchoice.com.
In approximately two weeks you will receive your Premera Blue Cross ID cards. Until ID cards arrive,
questions on coverage should be directed to your producer. After ID cards arrive, benefit and claim
questions can be handled by Premera Blue Cross Customer Service at 1-800-722-1471. For answers to
other questions or to confirm eligibility, please call the appropriate number listed on the reverse side of
the enclosed, “Questions about my coverage and billing” sheet.
ProPoint Business Solutions, 1414 Cherry St SE, Olympia, WA 98501-2341
24
Questions about my coverage and billing
What insurance carriers are contracted by the Association of Washington Business to
provide my coverage, and how will they appear on my bill? Your package from the
Association of Washington Business is contracted through a number of carriers, each an
expert in their area of coverage. AWB provides excellent pricing and value by including all
our members in a complete benefit package. Your medical coverage is provided through
Premera Blue Cross. LifeWise Assurance Company provides the Life and Accidental Death
and Dismemberment coverage and Vision Service Plan (VSP) provides vision exam and
hardware coverage. Coverage is quoted in terms of the total cost of the benefits from these
three carriers, yet they will appear separately on your bill. The total for each employee
should match what was quoted and if it doesn’t you should contact your producer.
Is dental coverage included in the Association of Washington Business package?
Employers of three or more may add dental to their coverage at an additional cost. Dental
coverage is not available to employers with 2 or fewer employees. When you purchase
dental coverage it will appear on your billing as a separate item. The Association of
Washington Business offers two dental programs: Premera DentalBlue and Willamette
Dental of Washington. Groups of 5 or more employees are eligible for a dual-option dental
program.
Will employees receive ID cards for all the coverage options we have purchased? No.
Your VSP vision exam coverage does not require an ID card. Simply tell the VSP provider
your employee Social Security number and they will verify your exam benefit. Additionally,
after the exam our members are entitled to 20% discount on a complete set of lens and
frames. VSP also reimburses our members up to $50 for an exam from a non-VSP provider.
Premera Blue Cross does issue ID cards that come in the mail within the first two weeks
after your effective date. ID cards are not required for coverage and Blue Cross providers
can verify eligibility through Blue Cross. Premera DentalBlue coverage will be noted on the
Premera medical ID cards, though they are also not required for employees to obtain
services. Willamette Dental ID cards are sent to employees directly from the company
within 30 days of the effective date. ID cards are not required for a member to secure
services, and appointments can be scheduled at any time after the employee’s effective date
of coverage.
Will my Group Number, once issued, ever change? When you renew or change
products carriers often issue new Group Numbers so they can accurately track the changes
in coverage.
How can I get more information or questions answered on my coverage? The
Association of Washington Business provides an employee packet for each new employee.
These are automatically mailed to new and renewing groups and are an excellent source of
information and can answer many questions. On the back of this letter is a list of contacts
for further information.
Nov-11
25
Premera Blue Cross Medical Coverage
Customer Service & Claims: (800) 722-1471
 Search for providers and download claim forms and RX Mail Order requests at
the Premera web site: www.premera.com
 Verify eligibility, get information on benefits & coverage, and answers to
claims & Explanation of Benefits (EOB) questions
 Pharmacy locator: (800) 391-9701
 24-hour NurseLine: (800) 841-8343
 BlueCard Provider Locator: (800) 810-2583
Premera Blue Cross, PO Box 91059, Seattle, WA 98111-9159
Premera DentalBlue
Same as Premera Blue Cross Medical Coverage
Vision Service Plan (VSP)
Customer Service & Claims: (800) 877-7195



Locate providers on the VSP web site: www.vsp.com
Get information on benefits & coverage, and answers to claims & Explanation
of Benefits (EOB) questions
Submit out-of-network claims to:
Vision Service Plan, Out-of-Network Provider Claims
PO Box 997100, Sacramento, CA 95899-7100
Willamette Dental
Appointments or Emergencies: (800) 359-6019
Patient Relations: (800) 360-1909
Willamette Dental of Washington Web site: www.WillametteDental.com
Billing & Eligibility - Benefit Solutions Inc (BSI)
Billing & Customer Service: (425) 771-7359





Fax: (206) 859-2633
Questions about payment for coverage billing
Enrollment & eligibility - add & delete employees
Employee benefit kits
 COBRA & Continuation
Address & name changes
ID cards
Customer Service email: [email protected]
AWB HealthChoice c/o Benefit Solutions Inc, PO Box 6, Mukilteo, WA
98275-0006
Nov-11
26
ASSOCIATION OF WASHINGTON BUSINESS HEALTHCHOICE
c/o Benefit Solutions, Inc.
PO Box 6, Mukilteo, WA 98275-0006
phone 425-771-7359 fax 425-771-1226
email: [email protected]
Processing Billing Statements
This instruction sheet will provide guidelines in processing your monthly billing statement. If you have questions or
need assistance, please contact Benefit Solutions, Inc. (BSI). It is especially important that you review the first
billing you receive and verify that the coverage and rates match the quote you were provided by your Producer.
Please advise BSI immediately of any discrepancies. Please note that your rates may be affected during the plan
year if an employee crosses an age-band. If you have any questions regarding the plan or rates, please contact
your Producer.
The Billing Statement: Each Billing Statement is made up of at least 2 pages. The front page shows prior account
activity such as the amount billed for previous month, prior coverage adjustments, and payments received. Any
unpaid balance or credit on the account it will also be reflected on the first page. Your first payment for coverage as
a new group will be reflected on the 2nd billing statement. Note: Your new Premera Group Number will appear on
the lower right area of page 2 on subsequent billings. Your AWB account number is in the upper right hand corner
of the billing statement.
The 2nd and subsequent pages will list the current month’s billing detail. Subscribers (employees) are listed in
alphabetical order. Coverage elections and payments for coverage are listed in the appropriate columns with the
total for each employee to the right. The current month’s total is at the bottom of this column and the total owing,
which includes any unpaid balances or credits from the first page, are shown at the bottom of the page where it
states: Pay this amount.
PAYMENT IN FULL IS DUE BY THE FIRST OF THE CURRENT BILLING MONTH. If the payment for coverage
is not received by BSI by the 10th day of the coverage month, a late charge will be assessed at 1.5% of the
unpaid balance from the due date per month or $20, whichever is greater. The charge will apply to any unpaid
balance on your account. BSI offers a “Check by Fax” service - please call for more information.
How to add an employee: After a new employee has satisfied your company’s waiting period, please submit a
completed and signed enrollment application for the new employee. Faxed enrollment applications are accepted.
27
How to terminate/delete an employee: Draw a line through the employee’s name and enter the appropriate status
code and effective date in the column provided on the right side of the billing statement. The status codes are listed
at the top of this column. If an employee is eligible for benefits during the month in which they terminate, the
effective date of termination is the first of the following month. Any payment for coverage adjustment will appear on
the following month’s billing statement. No payment for coverage adjustment can be made more than 60 days
retroactive from the last day of employment.
If you are a COBRA eligible company: If a terminating employee has elected COBRA, enter “C” in status column
and indicate the termination date. For more information, please contact BSI.
Dependent changes: A request to remove a dependent from coverage must be submitted to BSI within 60 days of
termination their date on an AWB enrollment/change form signed by the employee. To add a dependent, you must
submit a completed enrollment form. Please note that after an employee has enrolled for coverage adding
dependents is only allowed when a “qualifying event” or “life change” has occurred, such as: birth of a child, legal
adoption or legal guardianship, Qualified Medical Support Order, court order, marriage or involuntary loss of
coverage. Each of these situations requires documentation to support the exception.
Please make one company check payable to: Forterra, Inc. and mail to AWB, c/o Benefit Solutions, Box 6,
Mukilteo, WA 98275 with the original billing statement. Please note your AWB account number on your check.
28
ASSOCIATION OF WASHINGTON BUSINESS
AWB Online Benefit Administration Service
We would like to invite you to register to use iBSI, the AWB Online Benefit
Administration Service.
iBSI provides Benefit Administrators the ability to manage employee enrollment for
health coverage. Functionality includes the ability to add new members, terminate
members and edit demographics.
Signing up for iBSI: If you are the person who is signatory on the AWB Master
Application you may register to use iBSI by sending an email to
[email protected]. You may also designate employees or contractors to
register. If you would like someone other than yourself to have access, please
include those email addresses in your email. An email response will be sent with
registration instructions. Note that in designating others to access iBSI, you have
agreed to ensure that your personal password is not shared and that anyone you
wish to have access completes the registration process.
Registering to access iBSI will require that you read and agree to the Employer Web
Site Terms of Use Agreement, as well as the iBSI Privacy Policy. Your registration
and agreement to the Terms of Use Agreement binds you to those Terms of Use and
confirms that you have the proper authority to be so bound.
We are confident you will find the iBSI Online Benefit Administration Service a
useful tool for enrollment and management of your account. New functionality and
enhancements are continually being developed and will be added to the Web Site as
they are completed. We will keep you apprised of upcoming enhancements.
If you have any questions regarding iBSI or the registration process please contact
us at [email protected].
29
Renewal
Renewal Form
• This is a re-certification that the group still meets all the
criteria to participate in AWB HealthChoice and that all
enrolled employees are still eligible.
• Everything must be filled out.
 All employee categories
 A waiting period must be checked
 A new plan must be checked
 Group rep must sign
• Applications for employees/dependents that were previously
eligible that are enrolling at renewal must be received by
ProPoint Business Solutions 30 days prior to renewal.
• Employees cannot waive coverage if the group contributes
100% of the employee payment for coverage; the group can
contribute any percentage from (min) 75% to less than 100%
in order to allow employees to waive coverage.
• Health Questionnaires are required for any employee joining
at renewal that had previously waived.
Required forms:
1. Renewal Form
2. Individual Application (as needed)
3. Individual Health Questionnaire (as needed)
30
Employer Renewal Summary
1. Employer Information IMPORTANT: This form must be completed and returned by whether or not your group is
making benefit changes.
Current Employer Information
Please note any changes below
Employer:
Federal Tax ID Number:
Contact Person:
Employer Address:
Phone:
Fax: #
Email Address:
Agent:
We’re updating our records so
please give us your NAICS code:
2. Employee Participation, Eligibility & Enrollment
AWB HealthChoice requires that a minimum of 75% of all eligible employees enroll in the Plan. Individuals who waive
coverage under AWB HealthChoice due to group coverage elsewhere are not included in the 75% calculation.
CAUTION: As a result of recently enacted health reform legislation, excluding certain employees from eligibility could cause
your plan to fail non-discrimination testing under federal law. To avoid potential penalties, employers should consult with their
own advisors before excluding employees from eligibility. AWB HealthChoice is not able to give employers legal advice.
A. Total number of employees on payroll regardless of hours worked
Note: For B and C, count each employee in only one category.
+
B. Employees not eligible to enroll – specify number of employees in each category
1. Working less than the (plan required) 20 hours/week
-
2. Temporary or seasonal
-
3. In a probationary period
-
4. In an excluded class, specify class __________________________________
-
5. Excluded by hours/week as determined by employer, specify hours_________
-
6. Not enrolling (waiving) who have coverage with other carriers
-
Total Section B (Lines 1 – 6)
C. Total number of employees eligible to enroll (Line A minus B)
=
Please include COBRA and continuation of coverage enrollees here
D. Eligible employees waiving enrollment without other coverage
-
E. Total eligible employees enrolling (Line C minus D)
=
F. % of participation (Line E divided by C, minimum 75% required)
=
G. Benefit eligibility waiting period for new employees: (First of month coinciding with or following)
 Date of Hire
 30 days
 60 days
 90 days
For Grandfathering Tracking:
Your current Payment Contributions
Employee: %
Dependents: %
Refer to renewal letter for more information on
grandfathering. Check your records for accuracy
 120 days
 180 days
H. Employer Payment Contribution:
Employee__________% (75% Required)
Dependents__________% (0% Required)
For recordkeeping purposes under federal health care reform: Please list average number of employees in previous
year*________
RARL:
ProPoint Business Solutions, PO Box 129 Olympia, WA 98507
31
Employee count should include all full-time, part-time, seasonal and union employees from any affiliated companies as well as partners, business
owners, corporate officers and employees who work outside of Washington state. Do NOT include contracted 1099 individuals. If you were not in
business during the previous year, base average number of employees on current calendar year. IMPORTANT: Please note that enrollment in the
HealthChoice Plan will be only for the Employer with the UBI number listed on this Employer Renewal Summary.
3. Plan Selections
Office Use Only
Renewal Date
Locator Number
Current Medical Plan
Rate Class
Current Vision Plan
Undw Approval
Dental Plan:
Undw Date
Dental Plan:
Misc. Notes
Life Plan:
Risk Level
Please check a selection box in each category:
Medical Plan Choice

Please check box indicating your choice for
renewal coverage
Please refer to renewal letter and/or
Grandfathered Eligibility Matrix for more
information regarding plan changes
Life and AD&D Choice
$15K is required. You may upgrade to
$30 - $50K with evidence of insurability.
Plan A 250

Plan D 2500

Plan B 500

Plan D 750

Plan D 1000

Plan D 1500

Plan D 2000

Plan E 3000

Plan F 5000
 Plan HSA
1250
 Plan HSA
1700
 Plan HSA
2500
3+ only
Unless you upgrade, $15k Life & $15k
AD&D is included
Dental Plan Choice Please see attached instructions for enrolling in dental.
 I Decline Dental
 Increase employee
coverage to $30k/30k
 Increase employee
coverage to $50k/50k
Rates are included and no prior coverage is needed for any plan.
Groups with 5 or more Employees
Groups with 3 or 4 employees
Choose Carrier: Premera DentalBlue Willamette Dental
Choose Plan:
 Dental Plan I  Dental Plan II
 Dental Plan III
 Dental Plan IV
Choose Plan:
Employer Groups with 5+ Employees
are automatically eligible for dual  Dental Plan I
choice. The Employer chooses one  Dental Plan II
plan for BOTH carriers and the
 Dental Plan III
Employee selects the carrier. Dental
 Dental Plan IV
Renewal Enrollment required.
Vision Coverage Choice
Vision Exam Plus is included on all groups.
Base Short Term Disability 15/15/11 flat $200 of benefit per week.
3+ only
 Exam Plus Hardware I
No Pre-ex limitations on base benefit
Base Long Term Disability 90 day elimination period, 60% to $1,000 monthly benefit to SSNRA.
A 3/12 Pre-
Ex Limitation applies to the base benefit.
 Exam Plus Hardware II

 Short Term Disability
 Long Term Disability
4. Agreement & Signature for Renewal
A. I wish to renew coverage as indicated above. I understand that I do not need to send money at this time. I
understand that all payments for the previous contract year must be current before this renewal can be processed. I
understand that benefit plans and eligibility waiting periods can only change at renewal. Actual rates will be
determined by the attached rate chart, plan chosen and enrollment census on renewal. I understand that employees
must enroll when originally eligible or after involuntary loss of coverage, adoption, birth or divorce. The plan does not
offer annual open enrollment periods for employees that do not signup when originally eligible except as noted above.
B. Employer Representative Signature
C. Date/Month/Year
D. Employer Representative Name (please print)
E. Title
5. Cancellation Request
A.  We choose not to continue our coverage under AWB HealthChoice. Please cancel our coverage.
B. Employer Representative Signature
C. Date/Month/Year
D. Employer Representative Name (please print)
E. Title
RARL:
ProPoint Business Solutions, PO Box 129 Olympia, WA 98507
32
Dental Renewal Instructions
AWB HealthChoice continues to offer two options for dental. Groups with
3 or 4 Employees can select either Premera DentalBlue or Willamette
Dental. Groups with 5 or more Employees have a dual choice option
where the Employee selects their plan if dental is offered. In conjunction,
we have removed the requirement that Employer groups have prior dental
coverage in order to be eligible for Dental Plans II through IV.
To Enroll in Dental at Renewal:
Group Size 3 or 4:
1. Employer selects carrier: Premera DentalBlue or Willamette Dental
2. Employer selects plan: Dental Plan I, II, III or IV
Your Employees will be enrolled in whichever carrier you choose
Group Size 5+:
1. Employer selects the plan: Dental Plan I, II, III or IV
2. Employee selects carrier: Premera DentalBlue or Willamette
Dental
3. Fill out attached Census with each Employee’s Name, DOB, &
dental choice
Please Note:
1. Dental enrollment must match medical enrollment
2. This is not an open enrollment period
3. After your renewal effective date has passed changes cannot
be made until your next annual renewal
4. If you have any questions please contact your agent
RARL: «Age_Rate_Level»
ProPoint Business Solutions, PO Box 129 Olympia, WA 98507
«cfslocator_num»
33
Dental Renewal
Enrollment
Group Name: «Account_Name»
Renewal Month: «renewal_month»
Locator #: «cfslocator_num»
If your company has more than 5 Employees and is choosing dental, your employees have a choice
of dental carriers. Please have each employee review the dental material and make a carrier
selection in the space below. Please Note: this is not an open enrollment period and dental
enrollment must match medical enrollment. There can be no changes after your renewal
effective date has passed so all Employees must be fully informed before making their
dental selection.
Name
DOB
Dental Choice
1
____/____/_______
□Premera DentalBlue
□Willamette Dental Service
2
____/____/_______
□Premera DentalBlue
□Willamette Dental Service
3
____/____/_______
□Premera DentalBlue
□Willamette Dental Service
4
____/____/_______
□Premera DentalBlue
□Willamette Dental Service
5
____/____/_______
□Premera DentalBlue
□Willamette Dental Service
6
____/____/_______
□Premera DentalBlue
□Willamette Dental Service
7
____/____/_______
□Premera DentalBlue
□Willamette Dental Service
8
____/____/_______
□Premera DentalBlue
□Willamette Dental Service
9
____/____/_______
□Premera DentalBlue
□Willamette Dental Service
10
____/____/_______
□Premera DentalBlue
□Willamette Dental Service
11
____/____/_______
□Premera DentalBlue
□Willamette Dental Service
12
____/____/_______
□Premera DentalBlue
□Willamette Dental Service
13
____/____/_______
14
____/____/_______
□Premera DentalBlue
□Premera DentalBlue
□Premera DentalBlue
□Willamette Dental Service
□Willamette Dental Service
□Willamette Dental Service
15
____/____/_______
If you have more than 15 employees, please copy this form and submit with your renewal
summary.
RARL: «Age_Rate_Level»
ProPoint Business Solutions, PO Box 129 Olympia, WA 98507
«cfslocator_num»
34
12/1/2012 through 11/30/2013
Comparison of Medical Benefit Plans
Life / AD&D, per employee
Medical Benefits
$15,000 / $15,000
Plan A250
$15,000 / $15,000
Plan B500
Annual Deductible
$15,000 / $15,000 $15,000 / $15,000 $15,000 / $15,000 $15,000 / $15,000 $15,000 / $15,000
$15,000 / $15,000
Plan D750 Plan D1000 Plan D1500 Plan D2000 Plan D2500 Plan E3000
$15,000 / $15,000
Plan F5000
NonNonNonNonNonNonNonNetwork
Network
Network
Network
Network
Network
network
network
network
network
network
network
network
$750
$1,500 $1,000 $2,000 $1,500 $3,000 $2,000 $4,000 $2,500 $5,000
$3,000
$6,000
$5,000
$10,000
$2,250 $4,500 $3,000 $6,000 $4,500 $9,000 $6,000 $12,000 $7,500 $15,000
$9,000
$18,000 $15,000 $30,000
Network
$250
$750
$500
$1,500
$1,750
$5,250
$2,000
$6,000
$3,250
$9,750
$5,000
$15,000
$5,000
$15,000
$6,000
$18,000
$7,500
$22,500
$10 copay
$20 copay
$40 copay
$20/$40/$80
NonNetwork
network
$10 copay
$25 copay
$45 copay
$25/$62/$112
NonNetwork
network
$15 copay
$30 copay
$50 copay
$37/$75/$125
$10 copay
$25 copay
$45 copay
$25/$62/$112
$10 copay
$25 copay
$45 copay
$25/$62/$112
$15 copay
$30 copay
$50 copay
$37/$75/$125
$15 copay
$30 copay
$50 copay
$37/$75/$125
• Individual
• Family
Annual Out-of-Pocket Maximum
(Network Providers Only)
Includes coinsurance & deductible - not copays
• Per Person Maximum
• Per Family Maximum
$9,000
$27,000
$12,000
$36,000
Prescription Drugs incl. Diabetic Supplies**
• Generic - 30 day or less supply
• Preferred brands - 30 day or less supply
• Non-Preferred brands - 30 day or less supply
• Mail order: 90 day supply
Preventive Care
• Routine Exams
• Well Child Care
• Tobacco Cessation
• Health Education
• Immunizations
• Diabetes Education
Preventive Diagnostics & Mammograms
(deductible does not apply for network
providers)
Routine Eye Exams
E exams with
ith hardware
h d
discount
di
t through
th
h
• Eye
Vision Service Plan (VSP)
Home & Office Prof. Svcs/Urgent Care
100%
100%
Deductible
D
d tibl
does not
apply
100%
• Office and home visits - In-network home and 100% after
$20
office visits are not subject to the calendar year
copay*
deductible
Network
Not
d
covered
Constant
60%
Constant
60%
Deductible
D
d tibl
does not
apply
100%
Non-Network
100%
100%
Not
covered
d
Not Covered
Deductible does not apply
Constant
60%
$15 copay
$15 copay
$40 copay
$40 copay
$60 copay
$60 copay
$37/$100$150
$37/$100$150
NonNonNetwork
Network
network
network
100%
Constant 50%
100%
Network
Non-network
100% VSP after $10 copay
Non-VSP $50
100% after
Constant
$20
60%
copay*
100%
Not
Not
C
d D
Covered
d
Deductible
D
d tibl Covered
Deductible
d tibl C
does not
does not
apply
apply
Constant
50%
100%
Constant
50%
100% after Constant 100% after Constant
$35 copay* 50% $35 copay* 50%
100% after $30 copay*
Constant 50%
80%
Constant 50%
80%
100%
Constant 50%
100%
80%
Constant 50%
80%
• Naturopathic
p
Services
Surgical Services
80%
X-Ray and Lab (deductible does not apply for
network providers)
100%
Hospital and Facility Services
• Inpatient / Outpatient
• Skilled Nursing (60 days per calendar year)
Emergency Room
• Copay waived if admitted
• Annual deductible and coinsurance applies
80%
Constant
60%
Constant
60%
Constant
60%
$100 copay
80%
80%
100%
80%
Constant
60%
Constant
60%
Constant
60%
$100 copay
80%
$100 copay
80%
Constant
50%
Constant
50%
Constant
50%
$150 copay
80%
*Deductible waived if service is received in an office setting
**Your plan requires the use of generic drugs when available. A prescriber or member may request a brand-name drug instead of a generic, but if a generic equivalent is available, payment of the difference in price between
the brand
brand-name
name drug and the generic equivalent is required in addition to paying the applicable brand
brand-name
name drug cost share
share. Specialty Drugs must now be filled through Accredo or Walgreens
Walgreens. For more details on specialty
drugs and our designated specialty pharmacies, please visit our Web site at www.premera.com
80%
100%
80%
Constant
50%
Constant
50%
Constant
50%
$200 copay
80%
Page 1 of 2 ti d
continued
35
12/1/2012 through 11/30/2013
AWB HealthChoice
Medical Benefits, cont'd
Maternity for Subscriber or Spouse
• Physician
• Hospital
Chemical Dependency
• Inpatient
• Outpatient
Comparison of Medical Benefit Plans
Plan A250
Network
80%
Plan B500
Network
80%
Plan D750
Nonnetwork
Constant
60%
Plan D1000
Plan D1500
Plan D2000
Network
Non-network
80%
Constant 50%
80%
Constant 50%
Constant
60%
$20
copay*
Constant
60%
$20
copay*
Constant
60%
100% after $30 copay*
Constant 50%
80%
Constant
60%
80%
Constant
60%
80%
Constant 50%
100% after $30 copay*
Constant 50%
100% after Constant 100% after Constant
$35 copay* 50% $35 copay* 50%
100% after $30 copay*
Constant 50%
f
f
100% after
Constant 100% after
Constant
$35 copay* 50% $35 copay* 50%
80%
$20
copay*
Constant
60%
Alternative Services
• Acupuncture Services: 12 visits per year
• Chiropractic / Osteopathic Care: spinal and
other manipulations: 12 visits per year
Rehabilitation Therapy
$20
copay*
Constant
60%
$20
copay*
Constant
60%
80%
Constant
60%
80%
Constant
60%
$20
copay*
Constant
C
60%
$20
copay*
Constant
C
60%
100% after $30 copay*
Constant 50%
80%
Constant
60%
80%
Constant
60%
80%
Constant 50%
Constant
50%
80%
Constant
50%
100% after Constant 100% after Constant
$35 copay* 50% $35 copay* 50%
80%
Constant
60%
(Physical, occupational, speech and massage
therapy; cardiac & pulmonary rehabilitation)
Plan F5000
NonNonNetwork
Network
network
network
Constant
Constant
80%
80%
50%
50%
80%
$20
copay*
p
- Limit 45 visits p
per y
year
• Outpatient
Plan E3000
Constant
60%
• Outpatient
• Inpatient - Limit 30 days per year
Plan D2500
80%
Mental & Nervous Disorders
• Inpatient
Nonnetwork
Constant
60%
Constant 50%
80%
80%
Constant
50%
Constant
50%
80%
80%
Constant
50%
Constant
50%
100% after
f
Constant 100% after
C
f
C
Constant
$35 copay* 50% $35 copay* 50%
Miscellaneous Services
• Ambulance - one way to nearest hospital
• Durable medical equipment, prosthetics and
medical supplies, orthotics $300 per calendar
yr.
• Hospice Services up to 6 months
Respite care - Limit 240 hours per year
Inpatient - Limit 10 days per year
• Home health care - 130 agency visits
Out of Area Coverage
• Blue
Bl Card
C d areas
(Blue Cross/Blue Shield Plans)
• Foreign Travel
Waiting Period for Pre-Existing Conditions
Organ Transplants
• Inpatient
• Outpatient
Must be covered 6 consecutive months to be eligible,
waived with continuous prior coverage or if under the
age of 19
80%
Constant
50%
80%
Constant
50%
Covered Network and non
non-network
network benefits are paid as any covered network and non-network
non network benefits
80%
80%
80%
Not
covered
80%
Not
covered
$20 copay
Not
covered
$20 copay
Not
covered
80%
3 months, waived with continuous prior coverage or if under the age of 19
80%
Not covered
100% after $30 copay*
Not covered
80%
80%
Not
covered
80%
80%
Not
covered
100% after
Not
100% after
Not
$35 copay* covered $35 copay* covered
*Deductible waived if service is received in an office setting
36
The above is a summary of benefits and does not constitute a contract. Medical plans are underwritten by Premera Blue Cross. 24-hour coverage is provided for owners legally exempt from coverage under workers'
compensation. Certain cost containment provisions apply. See benefit booklet regarding coverages, eligibility, exclusions, and descriptions. All medical benetifs subject to Premera Blue Cross allowable charges. The
80% network level benefits, constant 50% and constant 60% non-network level benefits are provided after annual deductible unless otherwise noted. All benefits are provided on a calendar year basis. Group life
insurance is underwritten by LifeWise Assurance Company. Eye exam benefits are underwritten by Vision Service Plan (VSP). PLEASE NOTE: "Constant" percentages do not accrue toward out-of-pocket
maximums. This benefit summary is for newly enrolling or renewing groups with effective dates between December 1, 2012 and November 30, 2013.
Association of Washington Business
Washington state's chamber of commerce
Page 2 of 2
12/1/2012 through 11/30/2013
Comparison of Health Savings Account Plans
Life / AD&D, per employee
Medical Benefits
$15,000 / $15,000
$15,000 / $15,000
$15,000 / $15,000
HSA Plan 1250
HSA Plan 1700
HSA Plan 2500
$1,250
$1,700
$2,500
$2,500
$3,400
$5,000
$3,750
$7,500
$4,200
$8,400
$5,000
$10,000
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
Annual Deductible
• Individual
• Family (employee & one or more dependent)
Annual Out-of-Pocket Maximum
(Network Providers Only)
Includes coinsurance & deductible - not copays
• Per Person Maximum
• Per Family Maximum
Supplies*
Prescription Drugs incl. Diabetic Supplies
• Generic - 30 day or less supply
• Preferred brands - 30 day or less supply
• Non-Preferred brands - 30 day or less supply
• Mail order - 90 day supply
Network
Preventive Care
• Routine Exams
• Well Child Care
• Immunizations
• Smoking Cessation
• Health Education
Preventive Diagnostics & Mammograms (deductible
pp y for network pproviders))
does not apply
Routine Eye Exams
• Eye exams with hardware discount through Vision
Service Plan (VSP)
Home & Office Prof. Svcs/Urgent Care
• Office and home visits subject to calendar year ded.
• Naturopathic Services
Surgical Services
X-Ray and Lab
Hospital and Facility Services
• Inpatient
• Outpatient surgery and procedures
• Skilled Nursing
g ((60 days
y pper calendar yyear))
Emergency Room
• Annual deductible applies
Non-network
100%
Not covered
deductible does not
apply
Network
Non-network
100%
Not covered
deductible does not
apply
Network
Non-network
100%
Not covered
deductible does not
apply
100%
50%
100%
50%
100%
50%
100% VSP after $10
copay
Non-VSP $50
100% VSP after $10
copay
Non-VSP $50
100% VSP after $10
copay
Non-VSP $50
80%
50%
80%
50%
80%
50%
80%
80%
50%
50%
80%
80%
50%
50%
80%
80%
50%
50%
80%
50%
80%
50%
80%
50%
80%
80%
80%
*Specialty Drugs must be filled through Accredo or Walgreens. For more details on specialty drugs and our designated specialty pharmacies, please visit our Web site at www.premera.com
Page 1 of 2
37
12/1/2012 through 11/30/2013
Comparison of Health Savings Account Plans
Medical Benefits
Benefits, cont'd
Maternity for Subscriber or Spouse
• Physician
• Hospital
Chemical Dependency
• Inpatient
• Outpatient
O t ti t
Mental & Nervous Disorders
• Inpatient
• Outpatient
Alternative Services
• Acupuncture Services: 12 visits per year
• Chiropractic / Osteopathic Care: spinal and other
manipulations: 12 visits per year
Rehabilitation Therapy
• Inpatient - Limit 30 days per year
• Outpatient - Limit 15 visits per year
HSA Plan 1250
HSA Plan 1700
HSA Plan 2500
Network
Non-Network
Network
Non-Network
Network
Non-Network
80%
50%
80%
50%
80%
50%
80%
80%
50%
50%
80%
80%
50%
50%
80%
80%
50%
50%
80%
80%
50%
50%
80%
80%
50%
50%
80%
80%
50%
50%
80%
50%
80%
50%
80%
50%
80%
80%
50%
50%
80%
80%
50%
50%
80%
80%
50%
50%
80%
50%
80%
50%
80%
50%
80%
50%
80%
50%
80%
50%
(Physical, occupational, speech and massage therapy;
cardiac & pulmonary rehabilitation)
Miscellaneous Services
• Ambulance - one way to nearest hospital
• Durable medical equipment, prosthetics and medical
supplies, orthotics $300 per calendar yr.
• Hospice services up to 6 months
Respite
esp e care
ca e - Limit 2400 hours
ou s pe
per yea
year
Inpatient - Limit 10 days per year
• Home health care - 130 agency visits
Out of Area Coverage
• Blue Card areas (Blue Cross/Blue Shield Plans)
80%
• Foreign Travel
Waiting Period for Pre-Existing
Pre Existing Conditions
Organ Transplants
Must be covered 6 consecutive months to be eligible, waived
with continuous prior coverage or if under the age of 19
80%
80%
3 months
months, waived with continuous prior coverage or if under the age of 19
Not Covered
80%
Not Covered
80%
80%
Not Covered
The above is a summary of benefits and does not constitute a contract. Medical plans are underwritten by Premera Blue Cross. 24-hour coverage is provided for owners legally exempt from coverage under workers'
compensation. Certain cost containment provisions apply. See benefit booklet regarding coverages, eligibility, exclusions, and descriptions. All medical benefits subject to Premera Blue Cross allowable charges.
The 80% network level benefits and 50% non-network level benefits are provided after annual deductible unless otherwise noted. All benefits are provided on a calendar year basis. Group life insurance is
underwritten by LifeWise Assurance Company. Eye exam benefits are underwritten by Vision Service Plan (VSP).
NOTE: This benefit comparison is for newly enrolling or renewing groups with effective dates between December 1, 2012 and November 30, 2013.
Association of Washington Business
P.O. Box 129, Olympia WA 98507, 360-357-1326
Find us on the Web at: www.awb.org
Page 2 of 2
38
December 1, 2012 - November 30, 2013
Comparison of Dental Benefit Plans
Effective
December 1, 2012
Dental Benefits & Rates
Plan I Monthly Rates
· Employee only
· Employee and Spouse
· Employee and Child(ren)
· Employee and Family
$42.99
$83.12
$104.23
$144.38
Annual Deductible
· Per Person (waived on Class I benefits)
· Per Family maximum (waived on Class I benefits)
Plan II Plan III Plan IV
$53.92
$106.06
$114.24
$166.38
$59.17
$116.64
$122.46
$179.92
$49.29
$97.23
$102.07
$149.99
$50
$150
$50
$50
$50
$150
$150
$150 $1,000
$1,000
$2,000
$1,000
Class I - Diagnostic & Preventive
Benefit %
Benefit %
Benefit %
Benefit %
· Exams
· Flouride
· Sealants
100%
100%
100%
80%
Benefit %
Benefit %
Benefit %
Benefit %
Annual Maximum
· Per Calendar Year
· Prophys
· X-rays
Class II - Restorative
· Restorations
· Periodontics
· Endodontics
· Oral Surgery
80%
Class III - Major
· Crowns
· Partials
· Implants
Benefit %
· Dentures
· Bridges
None
80% (90%*)
80% (90%*)
Benefit %
Benefit %
50%
50%
80%
Benefit %
50%
*Enhanced Benefit when you use in-network providers
This summary of benefits briefly describes the benefits of this program. Please refer to the Benefit Plan Booklet for a complete explanation of covered services and supplies, including:
exclusions, any limitations or reductions, and terms under which the program may be continued in force. Dental coverage is underwritten by Premera Blue Cross.
Minimum group size of 3 is required for all plans.
The summary of benefits does not constitute a contract.
Association of Washington Business - www.awbhealthchoice.com
39
2013 Willamette Dental Group Plans for
Association of Washington Business
Rates (12/1/12 to 11/30/13)
Plan 1
Plan 2
Plan 3
Plan 4
Employee
$39.14
Employee & Spouse
$75.66
$49.09
$53.83
$44.86
$96.51
$106.17
$88.51
Employee & Child(ren)
$94.86
$104.00
$111.43
$92.91
Employee & Family
$131.43
$151.43
$163.77
$136.51
Benefit
Copayment
Annual Maximum
No Annual Maximum*
No Annual Maximum*
No Annual Maximum*
No Annual Maximum*
No Deductible
No Deductible
No Deductible
No Deductible
General Office Visit
$25 per visit
$15 per visit
$15 per visit
$25 per visit
Specialty Office Visit
$30 per visit
$30 per visit
$30 per visit
$30 per visit
$50 per visit
$50 per visit
$50 per visit
$50 per visit
Deductible
Emergency Office Visit
Examinations
Covered at 100% Covered at 100% Covered at 100% Covered at 100%
All X-rays
Covered at 100% Covered at 100% Covered at 100% Covered at 100%
Teeth Cleaning
Covered at 100% Covered at 100% Covered at 100% Covered at 100%
Fluoride Treatment
Covered at 100% Covered at 100% Covered at 100% Covered at 100%
Sealants
Covered at 100% Covered at 100% Covered at 100% Covered at 100%
Head & Neck Cancer Screening
Covered at 100% Covered at 100% Covered at 100% Covered at 100%
Oral Hygiene Instruction
Covered at 100% Covered at 100% Covered at 100% Covered at 100%
Periodontal Charting
Covered at 100% Covered at 100% Covered at 100% Covered at 100%
Periodontal Evaluation
Covered at 100% Covered at 100% Covered at 100% Covered at 100%
Filllings (Amalgam)
Covered at 100% Covered at 100% Covered at 100% Covered at 100%
Crown (Stainless Steel)
Covered at 100% Covered at 100% Covered at 100% Covered at 100%
Crown (Porcelain-Metal)
$400
$200
$150
$200
Complete Upper or Lower Denture
$400
$350
$300
$350
Bridge (per tooth)
$400
$200
$150
$200
Root Canal Therapy - Anterior
$125
$100
$75
$200
Root Canal Therapy - Bicuspid
$175
$150
$100
$150
Root Canal Therapy - Molar
$220
$200
$150
$200
Osseous Surgery (per quadrant)
$400
$200
$150
$200
$70
$60
$60
$70
Root Planing (per quadrant)
Routine Extraction
Surgical Extraction (single tooth)
Covered at 100% Covered at 100% Covered at 100% Covered at 100%
$100
$75
$75
$75
Pre-Orthodontic Service
$150**
$150**
$150**
$150**
Comprehensive Orthodontia
$3,200
$2,500
$2,500
$2,500
Dental Lab Fees
Covered at 100% Covered at 100% Covered at 100% Covered at 100%
Local Anesthesia
Covered at 100% Covered at 100% Covered at 100% Covered at 100%
Nitrous Oxide
$40
$40
$40
$40
Out of Area Emergency Care Is Reimbursed Up to $100
*Temporomandibular Joint Disorder (TMJ) - $1,000 Annual Maximum with a $5,000 Lifetime Maximum
** **Fee credited towards the Comprehensive Orthodontic Service copayment if patient accepts treatment plan.
Willamette Dental of Washington, Inc. | 1.855.4DENTAL | www.WillametteDental.com
This document accompanies the Willamette Dental Enrollment Brochure Form Number 007-WA that states exclusions and other conditions of coverage.
40
2013 Willamette Dental Group Plans for
Association of Washington Business
The Willamette Dental Group plan provides
your employees with extensive dental coverage
and quality dental care. The Association of
Washington Business enables companies with
as few as three eligible employees to offer one
of these four large-group-benefit plans at a
reasonable cost. Each plan provides extensive
coverage of services and supplies to prevent,
diagnose and treat diseases or conditions of
the teeth.
Underwriting Guidelines
Eligible Employer
An employer of 3 or more eligible employees who
are enrolled in AWB Health Choice Medical Plan.
Participation Level
For groups of 3 or 4 employees, Willamette Dental
Group may not be offered alongside another
dental plan offered by another dental carrier. 100%
employee participation is required for groups with
3 to 4 employees who are enrolled in AWB Health
Choice Medical Plan.
For groups of 5 or more employees. Willamette
Dental Group plan must be offered on a dual choice
basis, which gives employees a choice of dental
plan providers. Groups must enroll 100% of their
eligible employees who are enrolled in the Health
Choice medical plan between plan offerings. There
is not a minimum participation requirement for
the Willamette Dental Group plan option if offered
on a dual choice basis for employer groups with 5
or more employees.
Contribution
The group must contribute at least 75% of the
employee premium. The balance is to be paid by
the employee for their coverage and any dependent
coverage not covered by the group. If the employee
participates in the premium payment, then the
group must collect the funds and include the
amount with its remittance of one company check
for premium to the billing administrator.
Form No. 013-WA (10/11)
Contract Form No. 001LZ1428C-WA(12/10)
Willamette Dental Group
Office Locations
•
•
•
•
•
•
•
•
•
•
•
•
•
Bellevue
Bellingham
Everett
Federal Way
Hazel Dell
Kennewick
Kent
Lakewood
Longview
Lynnwood
Northgate
Northgate Specialty
Olympia
•
•
•
•
•
•
•
•
•
•
•
•
Pullman
Puyallup
Renton
Richland
Seattle
Silverdale
Spokane Northpointe
Spokane - South Hill
Tacoma
Tumwater
Vancouver
Yakima
Eligible Employee
The employer must establish a minimum hourly
work requirement to be eligible for the plan. This
requirement can range between 20 to 40 hours.
An eligible employee must work a minimum of 20
hours per week. Temporary, seasonal or substitute
employees are not eligible. Eligible employees
must meet the probationary (waiting) period
established by the employer. This requirement
must be applied uniformly to all employees within
the same employee classification. Coverage for
eligible employees begins on the first day of the
month following or coinciding with the completion
of the probationary period.
Plans
There are four Willamette Dental Group plan
offerings from which to choose. For groups with 5
or more employees, the Willamette Dental Group
plan must be paired with the corresponding
indemnity plan number. Only one Willamette
Dental Group plan option can be offered to the
employee group.
Willamette Dental Group is not affiliated with Association of Washington
Business.
41
December 1, 2011 – November 30, 2014
Comparison of Vision Benefit Plans
Vision Service Plan
Vision Benefits & Rates
Hardware I
$150 Materials Allowance
Hardware II
$25 Materials Copay
Minimum group size 3 EEs
Minimum group size 3 EEs
Included in medical rating
Included in medical rating
Included in medical rating
Included in medical rating
Cost to add Hardware I
$4.85
$6.96
$7.03
$10.60
Cost to add Hardware II
$6.02
$9.57
$9.77
$15.75
Once Every 12 months
Discount
Discount
Once Every 12 months
Once Every 24 months
Once Every 24 months
Once Every 12 months
Once Every 12 months
Once Every 24 months
Exam Plus
$10 Exam Copay
Rates – 4 Tier




Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
Benefits



Exam
Lenses
Frames
Examination
The materials coverage applies to either contacts
OR one pair of spectacle lenses and a frame once
every benefit period
Covered in full, after $10 copay at a
VSP doctor.
Spectacle Lenses & Frames
(Discounts apply only to
services/supplies obtained from a
VSP doctor.)
Elective Contact Lenses
(Discounts apply only to services
obtained from a VSP doctor.)
Members receive a 20% discount off
the usual and customary charges on
complete pairs of prescription glasses.
15% discount off usual and customary
professional fees. Discount does not
apply to materials.
Covered in full, after $10 copay at a VSP
doctor.
Covered in full, after $10 copay at a
VSP doctor.
A total materials allowance of $150 is
available on this plan.
The allowance is available even if the
member does not receive a complete pair of
glasses nor the “complete pair” discount.
Members receive a 20% discount off the
usual and customary charges on complete
pairs of prescription glasses.
Necessary lenses up to 61mm are paid in
full, including single vision, lined
bifocal, lined trifocal lenses less any
applicable copay
The materials allowance applies to either
contacts, or one pair of spectacle lenses and
a frame.
42
Association of Washington Business
Frame of your choice covered up to
$130 plus 20% off any out-of-pocket
cost when a complete pair of glasses is
purchased.
The plan provides an allowance of $130
toward contact lenses and fittings. The
VSP doctor offers a 15% discount off
his/her professional services for contact
lenses.
Page 1 of 2
December 1, 2011 – November 30, 2014
Comparison of Vision Benefit Plans
Vision Benefits & Rates
Necessary Contact Lenses
Cosmetic Options
Discounts on
Additional Materials
[Plan discounts are available for
twelve (12) months following the
covered eye examination from the
VSP doctor who last provided the
covered eye examination.]
Out-of-network
Reimbursement Schedule
(Copays Apply)
Exam Plus
$10 Exam Copay
Hardware I
$150 Materials Allowance
Hardware II
$25 Materials Copay
15% discount off usual and customary
professional fees. Discount does not
apply to materials.
The materials allowance applies to either
contacts, or one pair of spectacle lenses and
a frame.
Covered in full, less any applicable
copay.
Members receive a 20% discount off
the usual and customary charges on
cosmetic options when complete pairs
of prescription glasses are purchased
from VSP doctors only. There is no
discount for out-of-network providers
Members receive a 20% discount off the
usual and customary charges on cosmetic
options when complete pairs of prescription
glasses are purchased from VSP doctors
only. There is no discount for out-ofnetwork providers.
Members receive a 20% discount off the
usual and customary charges on
cosmetic options when complete pairs of
prescription glasses are purchased from
VSP doctors only. There is no discount
for out-of-network providers.
20% discount off the VSP doctor’s
usual and customary fees for complete
pairs of prescription glasses, including
any cosmetic options selected.
15% off the VSP doctor’s professional
services (prescription contact lenses
provided at usual and customary).
Requires the eye exam to be within the
last 12 months.
The discounts do not apply to out-ofnetwork benefits.
20% discount off the VSP doctor’s usual
and customary fees for complete pairs of
prescription glasses, including any cosmetic
options selected.
15% off the VSP doctor’s professional
services (prescription contact lenses
provided at usual and customary.) Requires
the eye exam to be within the last 12
months.
The discounts do not apply to out-ofnetwork benefits.
20% discount off the VSP doctor’s usual
and customary fees for complete pairs of
prescription glasses, including any
cosmetic options selected.
15% off the VSP doctor’s professional
services (prescription contact lenses
provided at usual and customary.)
Requires the eye exam to be within the
last 12 months.
The discounts do not apply to out-ofnetwork benefits.
Exam
$50
Exam
$50
Materials Allowance
$150
Exam
Single Vision Lenses
Bifocal Lenses
Trifocal Lenses
Lenticular Lenses
Frame
Elective Contact Lenses
Necessary Contact Lenses
This summary of benefits does not constitute a contract.
43
Association of Washington Business
Page 2 of 2
$50
$50
$75
$100
$125
$70
$105
$210
Attention AWB HealthChoice Employers
Premium Only Plans (POP) available to all employers effective September 1st, 2011
The Premium Only Plan, or POP, is the most common cafeteria p lan. Section 125 of the Internal
Revenue Code allows the employee portion of group health insurance premium to be taken pretax.
The advantages to you as an employer are flexibility in controlling benefit costs, employee
retention and attraction, tax savings of 7.65% on every dollar the employee uses to pay for
benefit premiums. The advantages to your employees are federal, s tate and FICA tax savings
resulting in more money in your employees’ pocket.
Tax savings examples:
Employer Tax Savings
Employee Tax Savings
(i.e. - 10 employees each contributing
$1000/yr)
(1 employee)
FICA tax = $10,000
Employee contribution = $1000/yr.
Employer tax savings x 7.65%* = $765.00
Employee tax savings x 25%** = $250.00
Below are examples of the premiums that can be deducted pre-tax. Employers may deduct for
employer-sponsored plans for which the employer pays at least a portion of the premium.
Accident insurance
Cancer insurance
Dental insurance
Disability insurance*
Group term life i nsurance**
Group medical i nsurance
HMO insurance
Intensive care i nsurance
Vision i nsurance
*Disability i nsurance benefits are taxable when premiums are paid pre-tax.
**Term life limit: Up to $50,000 pre-tax on employee only; spouse/dependant life not available.
Inception fees for the POP are $100 due at the time of set up prior to effective date of the plan.
Renewal fees for the POP are $50 due prior to effective date of renewal. Renewal fees cover the
costs for:
•
•
•
•
Annual legal requirement updates
Plan document updates
Non-discrimination testing
Employee communication materials
For further details, p lease contact Benefit Solutions, Inc. at [email protected] or by
phone at (206) 859-2664 or contact your broker.
44
Flexible Spending Account (FSA) Administration
Available Through the Association of Washington Business (AWB)
All-inclusive price of $5.00 per participant per month (PPPM)*
*A one-time fee of $1.00 per debit card issued will be assessed if applicable. Card is valid for 3 years from date of issuance.
FSAs are valuable as a tool to save money,
enhance employer benefit packages and
lower health costs for employers and their
employees.
Our FSA solution can help employers
•
•
Significant tax savings with pre-tax contributions and tax
free reimbursements for qualified expenses
•
Easy access to funds with:
Ø
Save money with lower insurance premiums
for employees when combined with high
deductible health plans
•
Save on FICA taxes
•
Free up human resource staff by offering a
centralized on-line portal to answer
employee questions
•
Our FSA solution gives employees
Offer flexible benefit options including:
Ø Ability to stack FSA plans with HRAs
and HSAs, allowing employer
contribution and dependent care
options
Ø Customizing eligible expenses
AWB debit card used at point of sale
Ø On-line claim filing
Ø Direct deposit or check reimbursement
•
Secure access to accounts using a convenient online
portal that is available 24/7/365 days a year
•
Up-to-date balances and notifications with automated
email alerts and convenient home page messages
•
One-click answers to benefit questions
When you need to work with the best to deliver
reliable, trusted, customizable Consumer-Directed
Healthcare Plans, turn to the Association of
Washington Business.
Ø Alter plan rules for enrollees with a
loss of eligibility
•
Increase employee satisfaction by offering a
benefit that provides a significant tax
saving, lower healthcare costs (due to
increased focus on prevention and
wellness), hassle-free payment and claims
processes and customizable grace periods
of up to 75 days so that employees can
submit new claims for eligible expenses
beyond the plan year-end
For one administrative solution for Consumer-Directed Healthcare Plans
contact Benefit Solutions, Inc. at 206-859-2664 or email [email protected] for more information.
45
Voluntary and Group Benefits
1. Voluntary Life
Employee choice of $25K, $50K, $75K, or $100K
with full guaranteed issue (GI) to $100K
maximum.
Dependent Children (covers all children for one
rate) - $10K for $2.00 per family unit
Includes Beneficiary Connect – 6 visits for grief
and legal counseling, including memorial
planning assistance
Spouse choice of $10K, $20K, or $30K with
full GI to $30K maximum - must be 50% or
less of employee choice.
Includes Waiver of Premium, Accelerated
Death Benefit (75%), and Portability
Includes Travel Connect – Emergency Travel
Assistance, Medical/Dental referrals, and
Repatriation
Employee Benefit Options
EE
AGE
$25,000 $50,000 $75,000 $100,000
Spouse Benefit Options
EE
AGE
$10,000
$20,000
$30,000
< 25
$2.63
$5.25
$7.88
$10.50
< 25
$1.05
$2.10
$3.15
25 - 29
$2.63
$5.25
$7.88
$10.50
25 - 29
$1.05
$2.10
$3.15
30 - 34
$2.88
$5.75
$8.63
$11.50
30 - 34
$1.15
$2.30
$3.45
35 - 39
$3.13
$6.25
$9.38
$12.50
35 - 39
$1.25
$2.50
$3.75
40 - 44
$4.13
$8.25
$12.38
$16.50
40 - 44
$1.65
$3.30
$4.95
45 - 49
$5.38
$10.75
$16.13
$21.50
45 - 49
$2.15
$4.30
$6.45
50 - 54
$7.38
$14.75
$22.13
$29.50
50 - 54
$2.95
$5.90
$8.85
55 - 59 $12.38 $24.75
$37.13
$49.50
55 - 59
$4.95
$9.90
$14.85
60 - 64 $19.38 $38.75
$58.13
$77.50
60 - 64
$7.75
$15.50
$23.25
65 - 69 $16,250 $32,500 $48,750 $65,000
65 - 69
$6,500
$13,000
$19,500
$9.07
$18.14
$27.20
NA
NA
NA
NA
NA
NA
$22.67 $45.34
$68.01
$90.68
70 - 74 $12,500 $25,000
N/A
N/A
$34.21 $68.42
N/A
N/A
70 - 74
46
2. Short Term Disability
Base Benefit: $10 per employee per month,
paid by employer
15 day wait for accident/15 day wait for illness
Benefit amount is a flat $200 per week with
employer premium payroll deduction
Benefit Duration is up to 11 weeks total of
approved claim (doctor must confirm that
employee is unable to perform material duties
No Pre-existing condition limitations on Base
of occupation)
benefit.
$500 total weekly benefit and is paid by a postBuy up Benefit: $15 per employee per month
tax payroll deduction from the employee.
$25.00 per employee per month total when
3/6 pre-existing conditions limitations on buycombined with base
up amount only.
Includes Survivor Benefit (3x), Rehabilitation benefit (5% increase), 3/6 pre-existing condition benefit
and 8 week C-section benefit
3. Long Term Disability
Base Benefit: $4 per employee per month,
paid by employer
Buy up Benefit: $16 per employee per month
Voluntary buy up benefit amounts are tax free
$20.00 per employee per month total when
combined with base
90 day elimination period (time from
accident/injury before benefit will be paid), 60%
of salary to $1,000 monthly benefit to Age 65
(or Social Security Normal Retirement Age SSNRA)
60% of salary to $5,000 monthly benefit to
Social Security Normal Retirement Age
(SSNRA)
This benefit is paid by a post-tax payroll deduction from the employee
Includes 3/12 Pre-existing condition limitation, $100 minimum monthly benefit, Conversion, 24 month
own occupation coverage
Includes PIB Benefits (Progressive Income Benefit) – increases base plan to 70% to $6,000 if
employee has a serious disability which prevents him or her from performing two or more activities of
daily living (ADLs).
Includes Progressive Partial and Unlimited Return to Work Rider to coincide with Compwise pursuit
of vocational rehabilitation (if applicable).
Includes Employee Assistance Program (EAP) – Employee Connect with 4 visits for household
members for family, financial, and legal needs
* Please refer to the Summary of Benefits for more detailed plan descriptions.
47