Large Group Employer Application/Change Form
Section 1:
Reason for Application/Change – Fill in one only
Requested Effective Date
Section 2:
Revision or Renewal Date
Status Change
New Policy
Change Existing Benefits
Group Information
Group Name
Group Mailing Street Address
City
State
Parish
Phone Number
Fax Number
Federal Identification Number
Type of Industry
SIC Code
Billing Contact Information
Billing Contact Name
Title
Billing Mailing Address
Billing Phone Number
City
Parish
Zip Code
State
Zip Code
Billing Contact Email Address
Authorized Group Contacts
Primary Group Contact Name
Title
Primary Contact Phone #
Title
Secondary Contact Phone #
Email Address - MANDATORY
Secondary Group Contact Name
Email Address (Secondary Contact) - MANDATORY
Affiliation Information
Is your group a subsidiary/division affiliated with another company?
Yes
No
If yes, Company Name
Number Eligible Employees
Type of Business
Corporation
Sole
Partnership
Church
Sole Proprietorship
Other
If yes, what is the Group Number?
Do you currently have group coverage with Louisiana Health Cooperative?
Section 3:
Yes
No
Employer Online Services (if applicable)
I want to manage my group’s health plan information online. Please send login information to my email address.
Section 4:
Other Coverage
Has health insurance been purchased for the group from any carrier, including LAHC, during the last
twelve (12) months? (If more than one carrier in 12 months, please attach a separate page.)
If yes, insurance carrier name
Coverage type (ex: HMO, POS, PPO)
Yes
Coverage Start Date
No
Coverage End Date
For LAHC Use Only
Sales Representative Last Name
Group Number
SM-GR1017 Rev 1.4 05/2015
Representative First Name
Sub-Group Number
Sub-Group Number
Representative Code
Sub-Group Number
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Large Group Employer Application/Change Form
Section 5:
Group Eligibility
Waiver of Waiting Periods
Member and dependents initial and subsequent enrollment
Member and dependents initial enrollment
Member and dependents initial enrollment and member subsequent enrollment
No waiver of waiting periods
Other (specify)
Eligibility Dates (Complete both A & B)
A. Initial Enrollment of Group – All employees’ and dependents’ coverage will be in
effect:
All enrollment forms must be received no later than thirty (30) days following the member’s eligibility
date.
On Group effective date
After new employee eligibility is
satisfied (see B)
B. New Employees (after initial enrollment of group) – New employees will be eligible for coverage:
Date of hire
First day following:
First of the month following:
Other
day(s) following date of hire
day(s) following date of hire
month(s) following date of hire
month(s) following date of hire
All enrollment forms must be received no later than sixty (60) days following the member’s eligibility date.
Date of Hire
C. Employee Reinstatement Policy: Employees who are re-hired to the company are eligible for coverage.
Section 6:
Number of Employees
Will (or did) your group have at least 100 full-time and part-time employees for at least 26 weeks:
In the current calendar year?
Yes
No
If yes, list number of employees:
In the last calendar year?
Yes
No
If yes, list number of employees (Include owners, partners and locations.)
Section 7:
Number of Members
LAHC Insured
Members
TEFRA eligible2
(actively
employed)
Medicare eligible
retirees
Federal COBRA
due to Disability
(up to 29
months)
Federal COBRA
(up to 18
months)
Other
(not insured by
LAHC)
Total Number
Covered
Single
Family
2TEFRA stands for the Tax Equity and Fiscal Responsibility Act of 1982. Under TEFRA, when an employer has 20 or more full-time and/or part-time employees
on its payroll for 20 weeks in a calendar year, the group becomes the primary payer and Medicare becomes the secondary payer for the remainder of the calendar
year and the following calendar year for claims of working-aged employees and their spouses age 65+ even if they go below the 20/20 threshold. The 20 weeks in a
calendar year do not have to be consecutive to reach the 20/20 threshold.
Section 8:
Financial Arrangement
Positive billing
Invoice
Section 9:
% Employee Only
Payment Section – Group’s contribution, if any
% 2-Party
% Employee & Spouse
% Parent & Child(ren)
Contribution to HRA
$
Individual
Incentive credits offered (HRA Only)
Section 10:
% Family
HRA Carryover
$
Family
Yes
Unlimited
2x Annual amount
3x Annual amount
No
Rating Structure – Select One
For POS Plans:
Employee Only
Employee + Child(ren)
SM-GR1017 Rev 1.4 05/2015
For HMO Plans:
Employee + Spouse +1
Employee + Family
Employee Only
Employee + Child(ren)
Employee + Spouse +1
Employee + Family
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Large Group Employer Application/Change Form
Section 11:
Initial:
ID Card Mailing
Group
Section 12:
Subsequent:
LAHC LG-500
LAHC LG-2250
LAHC LG-1250
LAHC LG-3600
Member
Calendar Year or Plan Year (Plan Year option available for
medical plans with In-Network Deductible and/or Coinsurance)
Deductible Credits – This section does NOT apply to HRA/HSA
No
Section 14:
Group
Medical Benefits Section
Section 13:
Yes
Member
If yes, LAHC requires proof from the prior carrier that the member and/or dependents met all or part of the deductible.
Rates
Product
Individual
Family
Employee
/Spouse
Parent/Child
Parent
/Children
Composite
Individual
Family
Employee
/Spouse
Parent/Child
Parent
/Children
Composite
HRA/HAS Admin Fee (PEPM) $
Medicare Carve Out Rates
Product
HRA Admin Fee (PEPM) $
Section 15:
Group Declaration
For eligible retirees, evidence of past employment and continuing financial arrangements is required.
If the enrollment forms submitted meet LAHC’s credentialing and eligibility requirements, and are in compliance with Louisiana State law, and we issue coverage,
the group agrees to the following:
To remit to LAHC the charges payable in accordance with the terms of the contract between LAHC and the Group, and if employee contributions are required, to
make necessary payroll deductions; group must also submit payment promptly, not to be received after the expiration of the grace period. (Failure to pay promptly
will result in the termination of the group’s coverage.) The group agrees to permit LAHC to audit and/or make copies of any records or information that relate(s) to
the administration of this coverage. (declaration continued on page 4)
SM-GR1017 Rev 1.4 05/2015
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Large Group Employer Application/Change Form
Section 15:
Group Declaration (continued from page 3)
The group further agrees: to ensure compliance with HIPAA (45 CFR Parts 160-164) as it relates to health plans, to ensure compliance with
TEFRA/DEFRA/COBRA/OBRA legislation as it relates to any active employee or dependent of an active employee who elects the group’s benefits as primary, to
ensure prompt conversion to Medicare-related/Carveout coverage for eligible Medicare retirees.
The group agrees to promptly submit an employee’s enrollment form for eligible members only and promptly remove members who are no longer eligible. Failure
to report removals promptly could result in the group being responsible for premiums and claims paid subsequent to the employee’s removal date. The group must
also ensure all employees enroll in accordance with their marital/domestic partner status.
If an acceptable enrollment form is received prior to or within 30 days after the eligibility date, coverage will begin on the date of eligibility; otherwise, coverage will
begin on open enrollment or the next group renewal date.
Benefits purchased and established eligibility selected may be changed at renewal only. It is understood that this agreement may be terminated by the group giving
prior written notice as required by the group contract. In the event of termination by the group, the group will be required to pay premiums to a date not less than 60
days subsequent to the written notification by the group to LAHC. LAHC may terminate this agreement for any of the reasons set forth in the group contract. This
group application is a part of the agreement between LAHC and the group for health insurance benefits.
Louisiana Insurance law requires that your employees who receive health coverage from an HMO or Direct POS health plan, be given 30 days prior notice when an
increase in the group insurance premium rates results in an increase in their premium contributions. Employers offering other types of health coverage are also
encouraged to provide this information to their employees.
Section 16:
Producer/Broker Declaration and Information
To the best of my knowledge, all the statements/responses in this application are true and complete. I have no knowledge about the Applicant, his/her employees, the
dependents of such employees or an individual who is receiving continuation of coverage under federal or state laws which is not fully stated in this application.
1st Producer or Brokerage of Record
Last Name
Commission % of Split
First Name
SSN/Tax ID No.
Company Name
Email Address
Mailing Street Address
City
State
Zip Code
.
Parish
Phone Number
Fax Number
Date (mm/dd/yyyy)
Producer/Broker Signature
X
2nd Producer or Brokerage of Record
Last Name
Commission % of Split
First Name
SSN/Tax ID No.
Company Name
Email Address
Mailing Street Address
City
State
Zip Code
.
Parish
Phone Number
2nd Producer/Broker Signature
Fax Number
Date (mm/dd/yyyy)
X
Section 17:
Insurance Fraud Statement
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any
materially false information, or conceals, for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act, which
is a crime and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation.
Section 18:
Signature of Authorized Representative
Print Name
Authorized Group Signature
Title
Date (mm/dd/yyyy)
X
SM-GR1017 Rev 1.4 05/2015
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