RFP Large Group Fully Insured
Benefits Questionnaire/Checklist (fully insured)A. GROUP INFORMATIONLegal Name: FORMTEXT ?????Website: FORMTEXT ?????Address: FORMTEXT ?????Industry: FORMTEXT ?????Effective Date: FORMTEXT ?????Waiting Period: FORMTEXT ?????# of Employees:ATNE:* FORMTEXT ?????Full-Time Active: FORMTEXT ?????COBRA: FORMTEXT ?????Waiting Period: FORMTEXT ?????Notes: FORMTEXT ?????B. ATTACHMENTS CHECKLIST FORMCHECKBOX 1. Employee Census listing all full-time employees, covered dependents, and COBRA eligible. Include first name, last name, gender, date of birth, home zip, work location, hire date, coverage tiers, and plan elections (if multiple). Include new hires in waiting period and employees who waived coverage. see sample FORMCHECKBOX 2. HB2015 Claims Reporting. Use this resource for forms and instructions. Minimum 2 years continuous reporting. We need commentary about large claimants including current employment and/or coverage status (active/termed). Report will contain:Monthly Claims vs. PremiumsMonthly Membership TotalsLarge Claimant Reporting (>$15,000)Pre-certification requests within preceding 30 daysCase Management Notes for Large Claimants FORMCHECKBOX 3. Additional Available Claims Reporting. Please provide all available claims reporting that is not associated with HB2015. FORMCHECKBOX 4. Official Renewal Offers on all lines of coverage. Provide current rates if not included in the renewal. FORMCHECKBOX 5. Summary of Benefits for current plan/plans for all lines of coverageC. BENEFIT PLAN DETAILS (If more than one class, identify the items below for each class. Use a separate format if necessary.)Employer Contribution % or $Quote Product Line?Existing Coverage?EmployeeDependentsComments FORMCHECKBOX Medical FORMCHECKBOX yes FORMCHECKBOX no FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Dental FORMCHECKBOX yes FORMCHECKBOX no FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Vision FORMCHECKBOX yes FORMCHECKBOX no FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Base Life/AD&D FORMCHECKBOX yes FORMCHECKBOX no FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Long Term Disability FORMCHECKBOX yes FORMCHECKBOX no FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Short Term Disability FORMCHECKBOX yes FORMCHECKBOX no FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Vol/Supp Life/AD&D FORMCHECKBOX yes FORMCHECKBOX no FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????D. GROUP MEDICAL CARRIER HISTORY – for last 5 yearsEffective DateTermed DateCarrierCoverage Type & Notes FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????E. GROUP MEDICAL PLAN QUESTIONS1.Are any classes of employees excluded from coverage? If so, describe each class and the exclusion: FORMTEXT ????? FORMCHECKBOX yes FORMCHECKBOX no2.Are retirees eligible for coverage? If so, how many under age 65? FORMTEXT ????? FORMCHECKBOX yes FORMCHECKBOX no3.In the past 24 months, has medical coverage terminated or a renewal or medical coverage been refused? If so, explain FORMTEXT ????? FORMCHECKBOX yes FORMCHECKBOX no4.In the past 24 months, have any medical benefits been partial self-funded or self-funded by you in any manner? If so, provide details and attach claims experience and enrollment figures. (See Attachments section for details.) FORMCHECKBOX yes FORMCHECKBOX no5.In the past 12 months, has there been an increase or decrease in total participation greater than 10%? FORMCHECKBOX yes FORMCHECKBOX no ................
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