Group Health Coverage Employer Application

Group Health Coverage Employer Application The easiest and most efficient method to enroll a group is to log in to the NMHC broker portal at https://s...
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Group Health Coverage Employer Application The easiest and most efficient method to enroll a group is to log in to the NMHC broker portal at https://shop.mynmhc.org/ehpportal/eapp/login and complete enrollment electronically. For non-electronic enrollment, please follow the steps below.

STEP 1: EMPLOYER GROUP INFORMATION 1. Name of Employer Group

2. Requested Effective Date

3. Address of Employer Group

4. Federal Tax ID Number

5. City

6. State

7. ZIP Code

8. County

9. Type of Organization: Copies of supporting wage/tax documentation is required. See page 3 for list of requirements.

☐ Corporation

☐ Partnership

☐ Proprietorship

☐ LLC

☐ Other__________________________________

Contact Information 1. Group Contact Name/Title

2. Group Contact Phone Number

3. Group Contact Email

4. Billing Contact Name

5. Billing Contact Phone Number

6. Billing Contact Email

Employee Information 1. Total Number of Employees

2. Total Number of Full-time Employees

3. Total Number of Part-Time/Seasonal Employees

4. Total Number of Eligible Employees, Incl. Waivers

5. Total Number of Employees in Waiting Period

6. New Hire Waiting Period (cannot exceed 90 days)

1st of month following: ☐ 0 ☐ 30 ☐ 60 days 7. Waive New-Hire Waiting Period for All Employees During Initial Open Enrollment Period?

Yes ☐ No ☐

Employer Contribution 1. Single Employee $

or

2. Dependents $

%

or

%

Current Carrier Name, if Applicable: ____________________________________________________________________________________ COBRA: Most group health plans with 20 or more employees on more than 50% of its typical business days are subject to COBRA. Both full- and parttime employees are counted to determine whether a plan is subject to COBRA. Each part-time employee counts as a fraction of an employee, with the fraction equal to the number of hours that the part-time employee worked divided by the hours an employee must work to be considered full-time. Is Employer Eligible for Federal COBRA?

Name and Address of COBRA Administrator

☐ Yes ☐ No

Broker Information First Name, Middle Name, Last Name, and Suffix

Phone Number

Email

Agency Name

Agency Address

National Producer Number

Broker Signature

Date of Signature

STEP 2: PLAN SELECTION Please choose only one plan. All employees and dependents must be enrolled on the same plan.

Choice Connect PPO Plans ☐ Platinum PPO ☐ Gold PPO ☐ Silver PPO

NMHC0028-0117

SMALL GROUP PLANS Care Connect Healthy Connect HMO Plans HMO Plans ☐ Platinum HMO ☐ Platinum HMO ☐ Gold HMO ☐ Gold HMO ☐ Silver Plus HMO ☐ Bronze HMO ☐ Silver HMO ☐ HDHP Silver HMO ☐ Bronze HMO ☐ HDHP Bronze HMO

LARGE GROUP PLANS Please write in the name of your selected plan. 1. 2. 3.

_____________________________________ _____________________________________ _____________________________________

If a custom plan, write plan name here: _________________________________________

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Employer Group Name: _____________________________________

STEP 3: PAYMENT INFORMATION Coverage will not go into effect until the first month’s payment is made. How will you pay your premium? ☐ By check: We will bill you. Your payment will be due on the first of each month. You must submit the initial premium payment with this form. ☐ Over the phone: Please call us at 1-855-7MY-NMHC (1-855-769-6642) to arrange payment. ☐ Online: Please go to www.mynmhc.org and click on Pay My Bill. You may pay with a credit or debit card, or a checking or savings account. ☐ Automated bank draft: If you wish to have your bank account drafted each month, please complete the section below. Non-payment of premium will result in termination of policy back to the paid-through date.

Automated Clearing House (ACH) Debit Authorization Employer Group Contact Name and Phone Number: __________________________________________________________________ I hereby authorize New Mexico Health Connections (NMHC) to initiate debit entries and adjustments for any credits in error to the checking or savings account indicated below and request the financial institution named below to credit and/or debit the same to such account. This information will be kept for ongoing payments and the account listed will be drafted for the monthly premium amount. I am an authorized signor on the account indicated below. Account Type: ☐ Checking ☐ Savings Month to Begin Bank Draft: _______________ (Note: Account will be drafted on the first business day of the month.) Name of Financial Institution

Address of Financial Institution

Name of Account/Name on Account

Financial Institution Transit Routing Number (9 digits)

Account Number

This authorization will remain in effect until NMHC has received written notification of its termination in such time and in such manner as to afford NMHC a reasonable opportunity to act on it. Authorized Signor on Account (please print): __________________________________________________________________________ Title: __________________________________________________________________________________________________________ Signature: _____________________________________________________________________ Date: __________________________

STEP 4: READ AND SIGN The undersigned Employer applies for the health care coverage as set out in this Employer Application and agrees to pay the required premium and to be bound by the terms and conditions of the contract. State and federal law guarantee renewability of small groups. It is understood that the benefits and rates quoted may change based on the actual enrollment of the group. The Employer agrees that an employee participation level when applicable must be maintained according to New Mexico laws and regulations and NMHC policies. Employer acknowledges that if NMHC accepts this application and issues a Policy, NMHC may pay the Broker a commission and/or other compensation in connection with the issuance of such Policy. The undersigned further acknowledges that if additional information is needed regarding any commissions or other compensation paid the Broker by NMHC in connection with the issuance of a Policy, they should contact the Broker. Employer represents, and agrees that the information contained in this Application is true and correct and forms an essential basis for our issuance of the Contract. Even though this Application is submitted with proposed premiums or other funds, there will be no coverage until this Application is approved by NMHC. If NMHC approves this application, we will notify you and specify the effective date of group coverage. If we do not approve this Application, the submitted funds will be returned to the Employer. Employer’s Signature ________________________________________________________________

Date __________________________________

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

STEP 5: REQUIRED SUPPORTING DOCUMENTATION    

Employer Application – signed and completed; and Employee Applications – signed and completed; and First month’s premium payment; and Most recently filed quarterly State wage & tax report [a.k.a. State Unemployment Taxation Assessment (SUTA)]. o Include status of all employees listed (specify if eligible, part-time, seasonal, in waiting period, or waiving). Each applicant must be accounted for in the supporting documentation.

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If the group does not file a SUTA, or has not yet had to file a SUTA (e.g., a newly formed organization), the group must provide the following: 1. 2. 3.

A copy of the current New Mexico Business License; and A list of all employees, on company letterhead, including status of all employees listed (e.g., eligible, part-time, seasonal, in waiting period, or waiving); and ONE proof of business documentation as specified below: a. C Corporation – Form 1120, Form 941, Schedule E, Articles of Incorporation/Organization; or b. S Corporation – Form 1120S, Schedule K-1s, Form 941 (if there are employees in addition of shareholders), articles of incorporation/ organization, payroll records; or c. Partnership – Form 1065 or Schedule K-1 for each partner; or d. Limited Liability Company – Articles of Incorporation/Organization; or e. Sole Proprietorship – Form 1040, Schedule C; or f. Non-Profit Organization – Form 941, W-2s, or 990.

STEP 6: SUBMIT COMPLETED EMPLOYER APPLICATION AND REQUIRED SUPPORTING DOCUMENTATION DIRECTLY TO YOUR NMHC SALES EXECUTIVE. 

Submit completed documentation by the 15th of the month prior to the requested effective date to secure the requested coverage effective date.  You may also call the NMHC Sales line for assistance at 1-855-808-3568. Select option 4 (brokers), then select option 1 for a directory of sales executives. Submit Online https://shop.mynmhc.org/ehpportal/eapp/login The most efficient method to enroll a group is to log in to the NMHC broker portal and complete enrollment electronically.

Submit by Email*

Submit by Fax

Submit by Mail

[email protected]

1-800-734-1596

New Mexico Health Connections P.O. Box 36719 Albuquerque, NM 87176

*To protect the security of personal information, please ensure that you are sending information using secure (encrypted) email. If you cannot send secure email, please create an account in the NMHC Secure Messaging Portal at https://web1.zixmail.net/s/login?b=nmhealthconnections, and send the email from that account.

Page 3 of 3

Language-Access Services and Non-Discrimination Notice

English You have the right to get help and information in your language at no cost. To request an interpreter, call the toll-free Customer Service phone number listed on your health plan ID card. TTY: 711. This form is also available in other formats like large print. To request it in another format, call the toll-free Customer Service phone number listed on your health plan ID card, Monday through Friday, 8 a.m. to 8 p.m. TTY: 711. Spanish Tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para solicitar un intérprete, llame al número de teléfono gratuito del Servicio al Cliente que aparece en su tarjeta de identificación del plan de salud. TTY: 711. Navajo ́ 'alínígóó bee baa hane'ígíí t'áá ni nizaád bee niká'e'eyeego bee ná'ahoot'i'. 'Ata' halne'í ła T'áá jíík'eh doo bą́ąh yíníkeedgo, hodíilnih dóó 0 bił 'adidíílchił. TTY 711. Vietnamese Bạn có quyền được trợ giúp và thông tin trong ngôn ngữ của bạn miễn phí. Để yêu cầu một thông dịch viên, hãy gọi đến số điện thoại dịch vụ khách hàng miễn phí liệt kê trên thẻ ID chương trình sức khỏe của bạn. TTY: 711. German Sie haben das Recht, Hilfe und Informationen in Ihrer Sprache kostenlos zu bekommen. Um einen Dolmetscher anzufordern, rufen Sie die gebührenfreie Telefonnummer des Kundendienstes an, die in Ihrem Personalausweis aufgeführt ist. TTY: 711. Chinese 您有权免费使用您的语言获取帮助和信息。 要请求翻译,请拨打您的健康计划身份证上列出的免费客户服务电 话号码. TTY:711。 Arabic ‫ اتصل بخدمة العمالء رقم الهاتف المجاني المدرجة في بطاقة الهوية‬،‫لطلب مترجم‬. ‫لديك الحق في الحصول على المساعدة والمعلومات في لغتك دون أي تكلفة‬ ‫خطة صحتك‬. TTY: 711. Korean 귀하는 귀하의 언어로 무료로 도움과 정보를 얻을 권리가 있습니다. 통역사를 요청하려면 건강 플랜 ID 카드에 나와있는 무료 고객 서비스 전화 번호로 전화하십시오. TTY : 711 입니다. Tagalog Kayo ay may karapatan na makakuha ng tulong at impormasyon sa iyong wika nang walang gastos. Upang humiling ng isang interpreter, tumawag sa toll-free Customer Service numero ng telepono na nakalista sa iyong planong pangkalusugan ID card. TTY: 711. Japanese あなたは無料であなたの言語でヘルプと情報を入手する権利があります。 通訳を希望する場合は、保健プラ ンIDカードに記載されているフリーダイヤルのカスタマーサービスの電話番号にお電話ください。 TTY:711 French Vous avez le droit d'obtenir de l'aide et des informations dans votre langue sans frais. Pour demander un interprète, appelez le numéro de téléphone sans frais du Service à la clientèle figurant sur votre carte d'identité du régime de soins de santé. TTY: 711.

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Italian Lei ha il diritto di richiedere assistenza e informazioni nella propria lingua, senza alcun costo. Per richiedere un interprete, chiamare il numero di telefono Servizio Clienti al numero verde indicato sulla carta d'identità piano sanitario. TTY: 711. Russian Вы имеете право получить помощь и информацию на вашем языке без каких-либо затрат. Для того, чтобы попросить переводчика, позвоните по бесплатному телефону обслуживания клиентов номер, указанный в вашем плане здоровья удостоверения личности. TTY: 711. Hindi आप कोई भी कीमत पर अपनी भाषा में और जानकारी प्राप्त करने का अधिकार रखते हैं । एक दु भाधषया के अनु रोि के धिए टोि फ्री ग्राहक सेवा फोन अपने स्वास्थ्य योजना आईडी काडड पर सूचीबद्ध नं बर पर कॉि। TTY: 711। Persian-Farsi ‫باشد داشته هزينه هيچ بدون را خود زبان به اطالعات و کمک که داريد حق شما‬. ‫شده ذکر تلفن شماره مشتريان خدمات رايگان از مترجم يک درخواست برای‬ ‫ کارت روی بر‬ID ‫بگيريد تماس خود بهداشتی برنامه‬. 711: TTY. Thai คุณมีสท ิ ธิทจะได ี่ ้ร ับความช่วยเหลือและข ้อมูลในภาษาของคุณไม่มค ี ่าใช ้จ่าย หากต ้องการขอล่ามโทรไปยังหมายเลขโทรศัพท ์โทรฟรีบริการลูกค ้าระบุไว ้ในบัตรประจาตัวประชาชนแผนสุขภาพของคุณ TTY: 711

Notice of Non-Discrimination and Accessibility The following is a statement describing nondiscrimination for NMHC and the services it provides to its clients and members:  We do not discriminate on the basis of race, color, national origin, age, disability, or gender in our health programs or activities.  We provide help free of charge to people with disabilities or whose primary language is not English. To ask for a document in another format such as large print, or to get language help such as a qualified interpreter, please call NMHC Customer Service at 1-855-769-6642, Monday through Friday, 8:00 a.m. to 5:00 p.m. TTY: 1-800-659-8331.  If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or gender, you can send a complaint to: NMHC Compliance Hotline 2440 Louisiana Blvd. NE, Suite 601 Albuquerque, NM 87110 Phone: 1-855-882-3904 Fax: 1-866-231-1344 You also have the right to file a complaint directly with the U.S. Dept. of Health and Human Services online, by phone, or by mail:  Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.  Phone: Toll-free: 1-800-368-1019, TDD: 1-800-537-7697  Mail: U.S. Dept. of Health & Human Services, 200 Independence Ave. SW, Room 509F, HHH Bldg., Washington, DC 20201

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