HomeMy WebLinkAboutBLUE CROSS BLUE SHIELD GROUP MASTER APPLICATION
10/16/2007
10:57
404-842-8660
.... "
SPECIAL ACCOUNTS PAGE 02/03
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GRO'UP MASTER APPLICATION
BlueCross Btu~sb'ield
of Georgia
'81ueCtoss 81ueShield
tteatthcare Plan or Georgia
Ind~ndent Licensees of the Blue Cross and 'Blue Shield Assodatlon
.,
',r
'the PIlTllO~C o(tlll$ rOIin b for Blue Cross Blue Shield HeftllhclIl'C Pllln of GeorgiD, Inc, (aCBSfU') and Slue Cross and Blue Shield orOeorsia.lnc. (SCBS(}^) tn eVlIlullte mtill!: (onlle
comptlil)"s request ror ~up in5Urtlllcecoveraee. Please 3lI$wcrall qllE5tions. This form must be signed ~nd deled by 8llofficcr oCthc company,
SeCTION 1- EMPLOYER INFORMATION
Lcgul Nbmc of Employer AJ!:J1 t R' hod C nty Group" TeleplKme Number 706-821-2874
' U us 8- Ie m n ou
Srrcct Addrc!l!l 530 Greene St. Room 601 County Richmond' Whllt is the nllturc llfthc bu.Qil1C1l57 Consolidated Government
City AUQusta I Slale GA Zl~ Code 30911 Number of years in business 10
Are there other locations to be included? Yes _ No _ tf yes, please provide the name ~d number of employees at each location. TIle Employer
certities thot (enter specific number) 2400 employees an: eligible: to. makc,llpplication for coverage on the date ofthi!l Oroup Application, and agree,
thot or more ohll eligible employees will have 'made application for membership bef'ore the 'EfFective Date ofCo'lreragc. Otherwise this
Ciroup Application will be deemed to have been withdrawtl.
SECTION II ~GROUP HEALTH PROFILE;
. Yes~
HIS cnyone ine\lrrcd health claims in excess ofS7,500 in the past 12 months and is thi: condition ongoing? No -
Specify: Employee, Dependellt or COBRA Age Dollar amount of o illgnosisIPrognosis Date of [.ast
Claim Treatment
See attached premiums vs. claims dala.
,.'....
SECTION 111- CURRENT COVERAGE INFORMATION
Carrier Effective Date Type Coverage Type of Fundifllt
United Healthcare ADril1,2005 HMO. POS. Dental Fully Insured
RATES ClIrrent Rate!! Renewal Rates . Current Rates Renewal Rlltes
Medical HMO, POS Medical Dental Dental
EE 305,93. 324.95 21.15
EE &: SP (EE +1 Dep.) 611.86.649.90 ~2.30
SE &: Child(rcn)
Family 917.79.974.85 63.45
Toml NUll1ber of Employce.? 240C TotlJl Number orEligible Employce~7 , ~400
Number of EmployeeJl Cl.lIrently Enrolled in the Health Plan? 180C Number of Employees in Employee Waiting Period b
Number of COBRA Particip~nlS 40
F-t6e1.990 07/00
10/16/20e7 10:57
404-842-8660
, .
SPECIAL ACCOUNTS
PAGE 03/03
IV - REQUESTED COVERAGE INFORIIfl..-iON '. _'
I A: Coverages Requested; (Enter appropriate coverage plan number and attach benefit sllmmary) Indicate Load Sales Officc Atlal1ta
BlucClllll5BlllCSllield Blue Cross Blue Shield BlueCross BlueShield :BlueCross BlueShield 81ueCross BlueShicld BlueCross BlueShield
HcolthcDte PIIIn gf Hcalthcare PllIn of ofGoorgia, Inc. of Georgia. Inc. of Gc=orgia. Inc. orGeOrgi:l..lne.
OeorgiD, Ipc. Gcorgill, Int, DenIal Plat'\ L& 7.. ~,
Troditional HCl1lth
HMO Plan 1 POS Pllln 2 PPO Plan Plan (TIfP) RephlCCmtnt? .te.S Vision Plan
RX COp4Y
Generic , s...:!.2..-
Btand S_
In FonnulDry s~
Not In Fonmllary S~
PTD $_
Generic
8m
In Fonnul;uy
Not In Fonnulary
pro
,$~
$_
S~
$~
$_
'F
Generic $_
Brand $_
rnFonnulary $_
Nor In Fonnulory$_
PTD $_
I B. Commcnl:!
Cicncric $_
Brand $_
fnfonnulary $_,
NOI In Fonnulary $_
PTD $
Blue erellll BlllC Shield
HcIllthcote Plan or
Oeorsill. Inc.
Elluc Choice Platinum
PI$n
See attached plan summary documents outlining copayments. plan deductlbles, etc.
Group N'Umb~r: 1 038131
HMO Plan is a modified HMO 601 Plan, non-standard drugs.
PQS plan is non~standard.
Group willl1ave the standard PPO Out of State Plan.
2. Maternity Coverage is included with'HMO and POS plans, iI1d witl1 "1'0 lIIld THP plllO$ fot groups with IS or more
employees, Maternity coverage is optional for groups with lesg than IS employees for PPO anel THP plans. [fyou Yes ~ No
have less than IS employees, do you wish to select maternity coverage? ({frejected, it cannot be added at (lInter dale.)
3. Mentol health/substance abuse options are listed on your group proposal or other supplemental
forms. Plca..o:e indicate the Lifetime Ma:dmum. ($10,000 Illld $25,000 choices arc only available for
Pro and THP grollI'll 2.50. HMO and POS are unlimited autom~tically.)
4. Indicate the percentage of the premium 10 be paid by lhe employer HMO PQS Employee Healfh 80, 14%
SUnlimited
X
$10,000
$25,000
Dcpcndem Health ao, 74%
Dependenl Oen'lal 80, 74%
Employee Dentl! 80,74 %
5. What period ofcolltinuous service (employee waiting period) On a full-time basis must be completed by an employcc
before becoming eligible for coverage? Will coverage be efTcc:tflie dale ofhirc7 Yes No X
Healt~
Dental
6A. Will the coverage be effective on the first day following the employee waiting period?
Ye,
NO~
6B. Or willlhe coverage be effective On the fi~t day of the month following tbe employee waiting period?
6C. Do YOu wish to wDive thc employee waiting period Ilt initial enrollment?
Yes~
Yes~
No
NO
EFFECTIVE DATE OF COVERAGE ,
~d'gpo:;ecl Elfcctivc Date of the Gl'OIlp Ma5ll:r Contract, if issued, ~ 12;0 Ill. m. (Eilstem Standard lime) On the 1 st
--~~ ,
day of April
_ (month),
'l11e first Contract anniversary date ~h:J1l be December 31 (month), 2006 (year)
whether or not thc two dates arc separatcd by twelvc (12) months. The Group Master Contract, if i!lllucd, shan remain in fOrec unless rerminll.tcd in aceordanee with the
terms of thc Group Ma!ttcr Contract. TIle dtll! date shall be the first of each month. '
Signccht Augusta, GA
0" March 9
F-1SS1.990 07100
(rncmr.h,date).2006
(ycar)
A'ugusla-Richmond County