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

9. BIAW Health Insurance Trust Eligibility and Participation Requirements

A. Company must be actively engaged in an income generating business licensed in the state of Washington.

B. Company must be a current, active member of an endorsing association or organization authorized by the BIAW to participate in the Trust. Membership Dues and Access Fees (if

applicable) must be maintained each year to continue participation in the Trust.

C. Company MUST satisfy the following Trust minimum “employee/subscriber participation” requirements or provide documentation indicating that they are compliant with Aff ordable

Care Act requirements:

• Companies of 2–5 eligible full-time employees: 100% participation is required (excluding Approved Waivers).

• Companies of 6 or more eligible full-time employees: 80% participation (excluding Approved Waivers).

Defi nition: Eligible employees are active employees or owners who satisfy the company’s “full-time” employment defi nition and have met your company’s insurance

probationary period established in Section 2 of this form. For purposes of the program, BIAW insurance carriers defi ne an employee as meeting the following criteria:

1. They must be remunerated on a regular, periodic basis through the company’s payroll; AND

2. They must appear on the company’s quarterly report of wages fi led with the State Employment Security Department.

D. Employees not enrolled when initially eligible may be denied coverage until the next BIAW Open Enrollment period.

E. Dependent participation is optional. Companies may require employees to pay for the cost of dependent coverage through payroll deductions. Dependents not enrolled when

initially eligible, may be required to wait until the next BIAW Open Enrollment period to enroll (see benefi t booklet for details).

F. Examples of INELIGIBLE participants include the following: Retirees, subcontractors, independent contractors, inactive owners, former employees, former owners, part-time

employees. Eligible employees must have a direct, employee-employer relationship with the participating company.

G. Eligibility requirements must be administered to all employees on a uniform and consistent basis. Participating companies are subject to periodic eligibility verifi cation audits by

the insurance carriers to ensure eligibility compliance.

H. Cancelled companies or companies leaving the Trust will not be eligible to reapply for participation in the Trust Program for 24-months.

I. I understand that Regence BlueShield and Group Health Options, Inc will rely on each answer in making coverage and rating determinations. If the issuer continues the Contract

with the Member Firm after untrue, incorrect or incomplete information is found to have been provided, and if as a result of correcting false information the Member Firm no longer

qualifi es for the Rate quoted, I understand that Regence BlueShield and Group Health Options, Inc will have the right to adjust the rates to the appropriate level retroactive to the date

the misrepresentation occurred, and the Member Firm will be required to pay the Rate adjustment within 30 days of the notice by the issuer.

J. Rates and benefi ts are guaranteed through 4/30/16 and are based upon employee age as of 5/1/15. Rates and benefi ts are subject to change due to regulatory actions, change in

mandated benefi ts, assessments imposed by the Aff ordable Care Act (ACA), any Federal and/or State regulatory rule changes, or any insurance carrier response to any such regulatory

result.

Booklet Distribution: Please inform your employees that they can access their benefi t booklet electronically at . Or, if preferred, you can contact EPK & Associates, Inc,

to order a small supply of booklets. Group Health participants will receive booklets directly from the carrier.

10. Accountable Offi cer’s Certifi cation

If the BIAW Trust carriers provide applications and/or change forms, or any benefi t summaries, comparison sheets, and/or group contracts or member brochures in an electronic

medium for inclusion on the Member Firm’s internal intranet or by similar means, the group agrees that: 1) electronic access shall be limited to the Member Firm’s applying

employees and covered employees and be restricted to a ‘read-only’ or similar basis; 2) the Member Firm will make timely modifi cations to the electronically available forms

corresponding to any substantive modifi cations that the BIAW Trust carriers make to the hard-copies of our forms; 3) the hard-copy documents on fi le with the BIAW Trust carriers

shall control in the event of any discrepancy; and 4) the Member Firm remains solely responsible for the content of the documents and all other legal requirements pertaining to

them (e.g. distribution).

I have provided these answers as part of the application procedure required by Regence BlueShield and Group Health Options, Inc to enroll in coverage and I certify that all informa-

tion completed on this form is true, correct, and complete. I understand that Regence BlueShield and Group Health Options, Inc will rely on each answer in making coverage and rat-

ing determinations. If Regence BlueShield and Group Health Options, Inc continues the Contract with the Group after untrue, incorrect, or incomplete information is found to have

been provided, and if as a result of correcting false information the Group no longer qualifi es for the Rate quoted, I understand that Regence BlueShield and Group Health Options,

Inc will have the right to adjust the rates to the appropriate level retroactive to the date the misrepresentation occurred, and the Group will be required to pay the Rate adjustment

within 30 days of the date of notice by Regence BlueShield and Group Health Options, Inc. It is a crime to knowingly provide false, incomplete, or misleading information to an

insurance company for the purposes of defrauding the insurer. Penalties include imprisonment, fi nes, and denial of insurance benefi ts. In addition, Regence BlueShield and Group

Health Options, Inc will have the right to collect any claims payment or other damages.

Accountable Offi cer’s Signature

Title

Date