Small Group Renewal Checklist printable pdf download

Small Group

Renewal Checklist

6450 US Highway 1, Rockledge, Florida 32955

Group name: ______________________

Toll-free 844.522.5279

Group number: ____________________

To renew your coverage with Florida Hospital Care Advantage, please complete these four items and return to

us by the deadline shown on your Small Group Renewal Notice:

1. Participation Verification Form —or— UCT-6 form listing employees’ hours (if no UCT-6, send Participation

Verification form and Schedule C, F, or 1120S with K-1 schedules).

2. Copies of insurance ID cards for any employees with other group coverage and waiving FHCA coverage.

3. Small Group Renewal Checklist.

4. Small Group Renewal Notice.

Company information

Group legal name:

Authorized group contact(s):

Mailing/billing address:

Physical address:

Phone:

Fax:

Contact e-mail address:

Tax ID number:

Continuation of coverage

Under federal law, if your group had 20 or more employees on your payroll on at

Select one:

least 50% of your working days of the preceding calendar year, you must provide

___ COBRA

employees with COBRA continuation. If your group had fewer than 20 employees,

___ FHICCA

you must provide state continuation (FHICCA).

Under federal law, if your group had 20 or more employees during 20 or more

Select one:

calendar weeks in the preceding calendar year, coverage with HF is primary and

___ HF primary/Medicare secondary

Medicare is secondary. Otherwise, Medicare is primary and HF is secondary.

___ Medicare primary/HF secondary

HR policies

Leave of absence policy(s) (if applicable)

___ Yes, attached.

___ No leave policy.

Waiting period for coverage to become effective for new employees

___ Date of hire

___ First day of the month 90 days after date of hire

___ First day of the month after date of hire

___ 120 days after date of hire

___ 30 days after date of hire

___ First day of the month 120 days after date of hire

___ First day of the month 30 days after date of hire

___ 150 days after date of hire

___ 60 days after date of hire

___ First day of the month 150 days after date of hire

___ First day of the month 60 days after date of hire

___ 180 days after date of hire

___ 90 days after date of hire

___ First day of the month 180 days after date of hire

Employer contribution

_____ % per employee and _____ % for dependents

—or—

$_____ per month

Plan selection

+ + + Please remember to indicate your plan selection on the second page of the Renewal Notice. + + +

Signature

Officer of Company

Title

Date

Florida Hospital Care Advantage is administered by Health First Health Plans, Inc. Group HMO and POS health benefit plans are underwritten by Health

First Health Plans, Inc.

1175 (11/2014)

Small Group Renewal Checklist

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