Biaw Health Insurance Trust Employer Participation Agreement (Page 3 of 4) in pdf

7. Employer Plan Selection

• Plan changes are allowed only during the annual BIAW Open Enrollment period.

• Companies with 2-4 enrolled employees may select one BIAW Medical Plan.

• Companies with 5 or more enrolled employees may select two BIAW Medical Plans (some restrictions apply).

A. Regence BlueShield Preferred Medical Plans

Underwritten by Regence BlueShield

1800 Ninth Avenue, Seattle, WA 98101

 HSA H100

 HSA H200

 HSA H300

 HSA H500

 HSA H600

HSA Plans

If you are selecting a Regence/Asuris HSA Plan, will you be using Health Equity for your HSA Bank?  Yes  No

If yes, who will pay the HSA Bank fees?  Employer  Employee

 Traditional T500

Traditional Plans

 Foundation F200

 Foundation F300

 Foundation F400

 Foundation F500

 Foundation F600

Foundation Plans

 Foundation F205

 Foundation F305

 Foundation F405

 Foundation F505

 Foundation F605

Foundation “Plus” Plans

 Market M100

 Market M200

 Market M300

 Market M400

 Market M500

Market Plans

 Market M600

 Market M105

 Market M205

 Market M305

 Market M405

 Market M505

Market “Plus” Plans

 Market M605

B. Group Health Medical Plans

Underwritten by Group Health Options, Inc

320 Westlake Ave, N # 100, Seattle, WA 98109

 Plan G100 (Access PPO)

 Plan G200 (Access PPO)

 Plan G300 (Access PPO)

 Plan G400 (Access PPO)

If you are selecting a Group Health HSA Plan, will you be using Health Equity for your HSA Bank?  Yes  No

If yes, who will pay the HSA Bank fees?  Employer  Employee

*Note: Please contact Health Equity directly to set up your HSA account.

C. Basic Life - AD&D Amount (employee only)

Underwritten by LifeMap Assurance Company

100 SW Market Street, Portland, OR 97207

 $25,000 ( Cost Included)

 $30,000 ($.95/EE/Mo)

 $50,000 ($4.75/EE/Mo - 2+ EE’s)

 $75,000

($9.50/EE/Mo - 10+ EE’s)

 $100,000 ($14.25/EE/Mo - 10+ EE’s)

 Other $___________________

 Yes Do you want to allow employees to individually purchase Additional “Term” Life coverage through payroll deduction?

D. Employee Assistance Program

Underwritten by Reliant Behavioral Health

1221 SW Yamhill, Suite 200, Portland, OR 97207

Yes

E. Regence BlueShield Dental & Vision Plans

Underwritten by Regence BlueShield

1800 Ninth Avenue, Seattle, WA 98101

 Dental D100

 Dental D200

 Dental D300

 Dental D400

 Vision V100

 Vision V200

 Vision V300

Notes:

• Dental Plan D100 requires 20+ employees; Dental Plans D200 requires 4+ employees; and Dental Plans D300 & D400 require 2+ employees

• If cancelled, dental and/or vision cannot be added until the Open Enrollment Period following 12-months after the date of cancellation.

8. BIAW Health Insurance Trust Monthly Payment Requirements

Detailed monthly billing statements for the next month’s premium are sent out to all companies before the end of each month. The Trust’s “Contractual” PAYMENT DUE DATE is the

fi rst day of the billed month.

In order to maintain CURRENT ELIGIBILITY for employees, full payment must be received by the Trust on or before the 1st day of the billed month. A company’s eligibility for the

month will be DELINQUENT if full payment is not received by the 1st. DELINQUENT ELIGIBILITY STATUS results in claim payment delays and other diffi culties involving employees,

their medical providers and carriers.

If full payment for the month is not received within 30 days of the PAYMENT DUE DATE, company will be RETROACTIVELY CANCELLED back to the last day of the month in which full

monthly payment was received. Partial payments will be refunded.

Payments returned to EPK & Associates (for non-suffi cient funds, stop payment etc.) must be replaced with guaranteed funds (i.e. Cashier’s check, money order, cash) before the

expiration of the 30-day grace period. A $20 fee will be assessed on all returned drafts.