CDPHP Administration Manual€¦ · 5 CDPHP Administration Manual 14-0375 | 08.04.14 Product Guide The CDPHP Family of Companies CDPHP comprises three lines of business . ϐ Capital

C D P H P ®

Administration Manual

2CDPHP Administration Manual 14-0375 | 08.04.14

Table of ContentsWelcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Product Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Commercial Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Prescription Drug Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Substantial Savings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Cost-controlling Networks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Pediatric Dental Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

The CDPHP Advantage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Large Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Community-Rated HMO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Embrace Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Healthy Direction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

CDPHP Shared Health Underwriting Guidelines (with second year cap) . . . . . . . . . . . 18

Administrative Services Only (ASO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Group-Specific Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Delta Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Information Required For A Quote . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Information Required for a Quote . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Renewal Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Small Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Community-Rated HMO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Community-Rated PPO, HDPPO, HDEPO, Embrace Health, and Healthy Direction . . . 22

Embrace Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Healthy Direction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Delta Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

All Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Request To Change Waiting Period For New Hires . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Termination policy change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Secure Employer Web Portal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Special Open Enrollment requests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Paperwork Required To Set Up A Flexible Spending Account (FSA) . . . . . . . . . . . . . . . 28

Make Changes Online . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Paperwork Required To Set Up A Health Reimbursement Arrangement (HRA) . . . . . . 29


Paperwork Required To Set Up A Health Savings Account (HSA) . . . . . . . . . . . . . . . . 29

Submission of Funding Account Paperwork . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Group Medicare Advantage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Member Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Subscriber . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Dependents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Qualifying Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

New Dependents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Adoption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Newly Born Adopted Infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Handicapped Dependents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Continuation of Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Persons Not Eligible for Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Log in to cdphp .com . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Enrollment Periods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Rejecting Enrollment or Electing Not to Enroll During Open Enrollment . . . . . . . . . . . 38

Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Checklist for Paying Invoices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

Corporate Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Complaints, Grievances, and Appeals . . . . . . . . . . . . . . . . . . . . . 41


WelcomeWelcome to Capital District Physicians’ Health Plan, Inc. (CDPHP®). Our health plan was founded to make benefits affordable and to improve the health of our community. We also strive to make our programs simple to administer.

The CDPHP Administration Manual is an informative guide to help make CDPHP health benefits management as easy as possible. It provides general guidelines on the policies and procedures of our plans as well as links to more detailed information and commonly used forms.

The information contained in this manual may change at any time based on federal and/or state legislation, or CDPHP rulings.

For additional contact information, please visit our website at www.cdphp.com and select “Contact Us.”

Who to Call

TYPE OF QUESTION OR CONCERNDEPARTMENT AND NUMBER

ϐ Adding or deleting dependents

ϐ Enrollment application questions

ϐ Eligibility issues

Group Services Unit

1-866-258-1785 or (518) 641-3900

ϐ Calls placed on behalf of a member

ϐ Researching the status of a claim

ϐ How to access care

ϐ Plan-specific questions (e .g ., what is covered?)

Broker/Employer Group Specialist Unit

(518) 641-3747

Broker_Employer@cdphp .com

ϐ Commission questions

ϐ To become a CDPHP broker

Broker Commission Specialist

(518) 641-5131

Health Funding questions on behalf of a

member, including:

ϐ Debit card inquiries

ϐ Account balances

ϐ Status of submitted FSA and HRA claims

Health Funding Department

1-877-793-3960 or (518) 641-3770

ϐ Secure site inquiries

ϐ Account management of group and broker

secure site users

Automation Specialist

(518) 641-4167

mbsecuresite@cdphp .com


Product GuideThe CDPHP Family of CompaniesCDPHP comprises three lines of business .

ϐ Capital District Physicians’ Health Plan, Inc. (CDPHP)—HMO, Healthy New York, Medicare Advantage .

ϐ CDPHP Universal Benefits,® Inc. (CDPHP UBI)—PPO, High Deductible PPO, EPO, High Deductible EPO, and Medicare Advantage PPO products .

ϐ Capital District Physicians’ Healthcare Network, Inc. (CDPHN)—Administrative service only (ASO), self-insured plans, and funding accounts .

CDPHP Plans(All plans below are off the Marketplace)CDPHP offers a full spectrum of product choices suitable for companies of all sizes . As part of the commitment that CDPHP makes to its members, many important preventive care services are fully covered . This is a benefit that members appreciate . It is also cost-effective, as it helps members stay healthy and avoid serious illnesses .

The following services are covered in full by most of our fully insured group plans:

ϐ Routine well-child visits and annual physicals for adults

ϐ Mammograms, yearly Pap tests, prostate cancer screenings

ϐ Laboratory tests associated with annual physicals; other lab test copayments are waived at designated sites

ϐ X-rays and other imaging provided within a preferred network

ϐ Most immunizations

All plans include worldwide coverage for emergency care.


The chart below offers brief descriptions and highlights of our plans . Each can be customized to meet different business and employee needs .

Plan Description HighlightsGroup Size

Availability & Rating Options

CDPH

P U

BI

EPO The member is free to see any in-network physician without a referral . Many copayment options and can have an upfront deductible . Generally, no coinsurances .

ϐ Members may see any physician within our large, diverse national network .

ϐ Easy access to benefits with no claim forms .

ϐ No referrals needed . ϐ Predictable, affordable copayments .

ϐ Compatible with an FSA; if the plan has a deductible, it can also be combined with an HRA .

ϐ An out-of-pocket maximum protects the member from catastrophic costs, as covered care is paid at 100 percent of the allowed amount once the out-of-pocket maximum is met .

Small group – community rated

Large group – experience rated

CDPH

P U

BI

Hybrid EPO A lower-cost EPO that is generally the same as the EPO, with the addition of a deductible and coinsurance for facility-based services .


ϐ No referrals needed . ϐ Monthly premiums are lower than those for the traditional EPO .

ϐ Members pay set, affordable copayments for office visit services .


ϐ Compatible with an HRA and/or FSA .






CDPH

P U

BI

HDEPO The lowest-cost EPO plan offers national network coverage without having to pay for out-of-network access you may not need .


ϐ Once deductible is met, services may be covered in full or a coinsurance/copayment may be required .

ϐ Members assume greater responsibility and control of the expenditure of their health care dollars .

ϐ No referrals needed . ϐ An out-of-pocket maximum protects the member from catastrophic costs, as covered care is paid at 100 percent of the allowed amount once the out-of-pocket maximum is met .

ϐ Some HDEPO plans are compatible with tax-advantaged Health Savings Accounts (HSAs) .

ϐ Can also be combined with an HRA and/or FSA .



CDPH

P U

BI

PPO Offers the same national network, but includes out-of-network coverage .

ϐ Freedom to see a doctor in- or out-of-network, but pay a lower copayment or coinsurance in-network (after meeting any deductible) .

ϐ No referrals needed . ϐ Out-of-pocket costs are lower for services provided in-network .


ϐ Compatible with an HRA and/or FSA .






CDPH

P U

BI

Hybrid PPO A PPO that offers lower monthly premiums because of a blend of copayments and coinsurances .

ϐ Members retain freedom to use out-of-network providers by meeting a deductible and paying a coinsurance .

ϐ Set, affordable copayments apply to office visit services obtained in-network .


ϐ No referrals needed . ϐ Compatible with an HRA and/or FSA .

Small group– community rated

Large group– experience rated

CDPH

P U

BI

High Deductible PPO

The lowest-cost PPO option, it offers secure protection against the high costs of medical care .

ϐ The higher the deductible, the lower the premium .

ϐ Once deductible is met, services may be covered in full or a coinsurance/copayment may be required .

ϐ Members assume greater responsibility and control of the expenditure of their health care dollars .


ϐ No referrals needed . ϐ Some HDPPO plans are compatible with tax-advantaged Health Savings Accounts (HSAs) .

ϐ Can also be combined with an HRA and/or FSA .

Small group– community rated

Large group– experience rated




CDPH

P U

BI

Healthy Direction

EPO designs that directly tie healthy behaviors to the member’s out-of-pocket costs .

ϐ A plan that engages employees to actively participate in their own health by encouraging them to take five healthy steps . When steps are completed, the employees gain or maintain a lower cost share and earn enhanced benefits .

ϐ The five steps include: – Complete PHA – Submit Hixny Consent

Form – Choose a PCP – Visit PCP for annual

preventive exam – Complete a biometric

screening



CDPH

P

HMO Comprehensive, easy-to-use coverage with no deductibles .

ϐ Affordable copayments for doctor visits .

ϐ A PCP coordinates care and refers to network specialists as needed .

ϐ Women may choose an OB/GYN to visit without a referral .


Small and large groups

Community rated only

CDPH

P U

BI

Embrace Health

An EPO with an upfront deductible that offers a CDPHP-funded bonus account that can be used for any IRS-qualified health expenses .

ϐ Makes available a “bonus” account funded by CDPHP of $200 or $500 that can be used for any IRS- qualified expense and any non-covered IRS- qualified items .

ϐ Compatible with FSA .

Small group –community rated





CDPH

P an

d CD

PHP

UB

IGroup Medicare Advantage Plans

Offers a low-cost plan that makes it easy for Medicare eligibles and retirees to receive all the benefits of Medicare and more, from CDPHP .

HMO and PPO options available .

ϐ Wide variety of plan designs available .

ϐ Low copayments for primary and specialty care .

ϐ Routine eye exams and hearing tests with just a copayment, plus an allowance toward eyeglasses or contact lenses, and hearing aids .

ϐ No-cost access to the Senior Fit fitness program helps members stay healthy and active .

ϐ Optional Part D prescription drug plans are available .

Small and large groups

Risk adjusted

Community rated

CDPH

P U

BI

Group Medicare Supplement Plans

Comprehensive coverage for some or all of the expenses not covered by Medicare Parts A and B .

ϐ Freedom to go to any doctor or hospital that accepts Medicare .

ϐ No networks, referrals, or prior authorizations required .

ϐ Four plan designs available (A, B, F, and N) .

ϐ Community-rated ϐ Contact group sales for information on group size requirements

CDPH

N

ASO Administrative Services Only plans provide companies the management apparatus and network access to self-fund their health benefits programs .

ϐ Gain maximum control over design and cost of the plan .

ϐ Enhance employee satisfaction with a customized health benefit plan .

ϐ Access to a comprehensive network of hospitals, physicians, and other health care providers

ϐ Proven health care management, claims processing, and administration .

250 or more eligible employees


Commercial Service AreaRating Regions

Find-A-DocThousands of physicians participate with CDPHP . We make it easy for you to learn more by offering Find-A-Doc - a tool available via the web or via our My CDPHP Mobile app .

To access Find-A-Doc via the web, go to www.cdphp.com and click on Find-A-Doc on the home page .

You can also download the My CDPHP Mobile app, which allows you to locate participating physicians and access benefit information . Visit www .cdphp .com/mobile for installation instructions .

Both tools can be used by following three easy steps:

Step 1 . Enter your member ID or select your product from the drop-down box . Click “Search .”

Step 2 . Enter a ZIP code or city and state information, and how far out you want to search .

Step 3 . Indicate the specialty (type of doctor) you want to find . If you are looking for a specific physician or group, enter the name in the field provided .

Your search results will appear sorted by the closest distance to your specified location . You may also choose to sort your results alphabetically by last name .

Tip: You can narrow your search results by choosing from one of the options shown on the left side of the results page, including gender, specialty, hospitals, and languages .

www.cdphp.com

https://findadoc.cdphp.com/

http://www.cdphp.com/Members/Use-Your-Benefits/Connect-with-CDPHP/Find-A-Doc-Mobile.aspx


National NetworkCDPHP UBI offers a comprehensive network throughout the New York metro area and across the nation . This extensive network is included as a base benefit with most EPO, PPO, and High Deductible EPO and PPO plans .*

In-network coverage is available in all 50 states as well as Puerto Rico . Members have access to more than 725,000 providers throughout the U .S . Go to Find-A-Doc to locate a provider .

Emergency CareAll CDPHP members are covered for worldwide emergency care* at the in-network level . If a member experiences an emergency so severe that immediate medical attention is needed to avoid serious health damage, a member should dial 911 or go to the nearest hospital emergency room no matter where he/she is . It is recommended that the member notify his/her physician as soon as possible .

* This benefit does not extend to members of the Federal Employees Health Benefits Plan, or

Medicare Choices PPO plans.

CDPHP UBI Regional NetworkWithin these counties, services must be received by a CDPHP UBI Regional Network provider.

CDPHP UBI National Network

24-County Service Area

More than 725,000 providers

*

ALASKAHAWAII

*

*

**

*

*

**

*

**

*

**

* *

**

**

***

*

Albany

Bennington

Berkshire

Bradford

Broome

Cayuga

Chenango

Columbia

Cortland

Delaware

Dutchess

Fulton

Greene

Madison MontgomeryNEW YORK

Oneida

Onondaga

Orange

Otsego

Putnam

Rensselaer

Saratoga

Schenectady

Schoharie

SullivanSusquehanna

Tioga

Tompkins

Ulster

PENNSYLVANIA

MASSACHUSETTS

Addison

Hamilton

Herkimer

Jefferson

Lewis

Oswego

Rutland

St. Lawrence

VERMONT

Warren

Washington

Chittenden

Clinton

Essex

Franklin

Franklin


Prescription Drug CoverageCDPHP is pleased to be affiliated with Caremark® to help us manage our members’ pharmacy benefits . This partnership provides convenient online access to detailed reliable pharmacy benefits information .

Large groups use Formulary 1, and small groups use Formulary 2 . Both small and large group plans have access to the Premier Rx network .

Employers and members are welcome to search basic details on the CDPHP drug formulary, including tier information . This feature is set up using $10/$25/$40 three-tier coverage for illustration purposes . You must click through all steps of pricing in order to view complete coverage information . Members can log onto Caremark .com using their member ID to get details specific to their benefit plan, such as: whether a particular drug is covered by CDPHP, how much they can expect to pay for the drug, and generic alternatives to the drug .

Creditable CoverageBy October 15 each year, employer groups are required to advise their employees whether or not their prescription drug coverage is deemed creditable coverage with Medicare .

Delta DentalCDPHN is proud to offer Delta Dental plans to provide comprehensive, high-quality dental coverage . Delta Dental of New York is part of the Delta Dental Plans Association, one of the largest dental benefits organizations in the nation, which covers nearly 60 million people in the U .S . With plans that cover everything from preventive care to orthodontic services, there is a plan for every business and budget .

Substantial Savings Delta Dental’s network dentists agree not to bill more than their contracted fees, helping employers and members save money . Plus, nearly 89 cents of every Delta Dental premium dollar is paid directly for dental services .

Cost-controlling NetworksDelta Dental’s fee-for-service plans provide a safety net that promises controlled costs . Members who have the Delta Dental PPOSM plan usually have the lowest costs when visiting a PPO dentist . Delta Dental PPO plus Premier plans offer a combination of the PPO and Delta Dental Premier® networks to maximize access and savings .

A Registered Mark of Delta Dental Plans Association

http://www.cdphp.com/Members/Rx-Corner

www.caremark.com

http://www.cdphp.com/Brokers/Get-Your-Job-Done/Medicare-Resources/Medicare-Creditable-Coverage

http://www.cdphp.com/Employers/Our-Health-Plans/Benefit-Options


Pediatric Dental CoveragePediatric dental coverage is required under the Affordable Care Act (ACA) . If Delta Dental isn’t in an employer’s benefit solution, CDPHP will ensure their employees and families still receive this required benefit, enrolling them in a pediatric dental plan through the attestation process on the member applications or attestation form .

However, if an employer is providing employees the essential pediatric dental coverage from another plan not offered by CDPHP, they have the option to opt out from the Delta Dental Pediatric Dental Plan through CDPHP on behalf of their employees, using the Pediatric Dental Group Attestation Form .

For more information on the process, view our pediatric dental online resource .

The CDPHP AdvantageWe’re aimed at providing you, your clients, and their employees with tools and resources that make the CDPHP experience convenient, accessible, affordable, and valuable . From 24/7 account access to money-saving programs, you’ll find our commitment to being the plan people trust in everything we do .

Secure Member, Employer, and Broker SitesThe CDPHP secure member, employer, and broker sites give you, your clients, and their employees the ability to manage an account at any time, from any place with internet access . The information is easily accessible, and always protected and secure .

ϐ Enroll, terminate, and update members

ϐ Update and change member demographic and personal information

ϐ View and print temporary PDF versions of member ID cards and order new ones

ϐ Obtain health funding reports

ϐ Access online “self-serve” billing services

ϐ View invoices online

ϐ Reconcile and download a subscriber roster

ϐ Make payments online

Find information on getting started and tips for using the site in our Secure Site Brochure .

Members benefit from their own secure site, as well, where they can track claims, find out about benefits, get copies of their ID cards, and more .

http://www.cdphp.com/en/Members/Health-Plan/Dental-And-Vision/~/media/Files/members/Pediatric-Dental-Coverage-Attestation.ashx

http://www.cdphp.com/~/media/Files/Employers/Pediatric-Dental-Group-Attestation-Form.ashx

http://www.cdphp.com/en/Health-Care-Reform/brokers/pediatric-dental

http://www.cdphp.com/en/Health-Care-Reform/brokers/pediatric-dental

http://www.cdphp.com/~/media/Files/Employers/Secure_Site_Brochure_for_Employers_Brokers.ashx

http://www.cdphp.com/~/media/Files/Employers/Secure_Site_Brochure_for_Employers_Brokers.ashx


CDPHP Shared Health*CDPHP Shared Health offers the security of a fully insured plan with the flexibility and control of a self-administered plan . Employers will never pay more than the standard premium for the year, but could pay less .

A dedicated clinical account manager will guide them through group-specific information and through the development of health improvement strategies . In addition, extensive health promotions, wellness programming, and rewards are also a part of the CDPHP Shared Health program .

CDPHP Shared Health offers a commitment to help your clients manage health care costs by improving the health and wellness of their employees and dependents . Contact your CDPHP representative for more information .

CVS ExtraCare® Health CardCDPHP partners with CVS Caremark® to offer members extra savings on commonly used health products .

Members receive a special CDPHP CVS Caremark ExtraCare® Health card, allowing them a 20 percent discount off the already low prices on CVS brand health-related products .

Subscribers receive two card key tags when they enroll in CDPHP, so others in their immediate families can cash in on the savings . Discounts are received instantly when members present their cards at the register .

There are more than 1,300 items that are discounted for CDPHP members carrying the card, including ibuprofen, decongestants, contact lens supplies, and bandages . A more comprehensive list of items that qualify can be found on the CDPHP website .

Life Points®

Life Points® provides incentives to encourage employees to take control of their health . Members are rewarded for completing a variety of healthy activities, including attending a physical exam, joining a gym, and participating in a free CDPHP wellness class . Members age 19 and older can earn up to $365 worth of points per year, per contract .

Activities are tracked on a secure website and rewards can be redeemed for gift cards or merchandise from hundreds of retailers, including CVS/Pharmacy®, L .L . Bean®, SpaFinder®, and more .

Life Points is available with selected plans . Contact your CDPHP representative for more information .

Members save 20% at over 7,200 CVS stores nationwide.

®

* Available only to large groups. See Underwriting Guidelines on page 18.

http://www.cdphp.com/~/media/Files/otherpdfs/CVS_ExtraCare_Card_Discount_Eligible.ashx


Rx for LessWith Rx for Less, members with prescription drug benefits can get deep discounts on specified generic drugs at any CVS, Walmart, or Price Chopper . Many drugs are available for a penny a pill . There’s no sign-up process or registration fee – members simply present their CDPHP ID card when purchasing their prescription to receive their discount .

Preventive Drug ListCDPHP has developed the CDPHP Preventive Drug List, a list of commonly used medications that are not subject to the deductible for most high deductible plans, which typically provide benefits after the deductible has been met . As a result, members can get their prescription benefits before they meet their deductible, saving them money .

Health Promotion and WellnessA highly trained, productive, and healthy workforce is one of the most valuable differentiators in today’s competitive market . Partnering with a health plan that focuses on improving the health of your clients’ workforce—to keep them at work, not the doctor’s office—will help you give them the best return on their investment .

Learn more about CDPHP health and wellness programs for your business .

My CDPHP Mobile AppWhen members use My CDPHP Mobile, they can access important benefit information, like their copay amounts or deductible balances . They can also view, email or fax their member ID card or locate the nearest doctor, hospital, or health care facility while on the go .

Weigh 2 BeSM

www .cdphp .com/weight-management

Weigh 2 BeSM is a free site that provides the tools and information needed to lose weight safely and effectively and offers support and resources to live and maintain a healthy lifestyle, including weight assessment tools, recipes, wellness support and classes, and more .

CDPHP® InMotionSM

inmotion .cdphp .com

CDPHP InMotion is a powerful tool that allows members to track their fitness activities and helps them achieve their health and fitness goals . It has a mobile app that uses the built-in GPS technology of a smartphone to record essential metrics, like duration, distance, pace, speed, and elevation . What’s more, InMotion can be used to establish a daily calorie and nutrition plan .

CafeWellTM

www .cafewell .com/cdphp

CafeWellTM is a Social Health Management® site that CDPHP offers to help promote the health and wellness of our members and their communities . It provides a safe, secure environment for participating in discussions, joining groups, and getting expert information .

http://www.cdphp.com/Employers/Wellness-Solutions/Worksite-Wellness.aspx

http://inmotion.cdphp.com

http://www.cafewell.com/


Large GroupsUNDERWRITING PARTICIPATION GUIDELINES

Group Size DefinitionLarge groups are defined as employer groups that employ at least 51 eligible employees nationwide, excluding from eligibility any employees eligible to participate in a Taft-Hartley Welfare Trust Benefit Plan .

Multiple OptionsCDPHP has the flexibility and expertise to accommodate clients as a sole source carrier or a slice participant . Multiple options may be offered at the discretion of CDPHP .

Product Line RequirementsCommunity-Rated HMOEmployer groups must be located in the CDPHP approved service area and have two or more active eligible employees, working 20 hours or more per week .

Groups that have left the CDPHP HMO pool to become either self-funded or experience-rated on an insurance license are not eligible to re-enter the CDPHP HMO pool if CDPHP determines that the group-specific experience is worse than the HMO pool experience .

Experience-Rated PPO, HDPPO, EPO, HDEPO, Embrace Health, and Healthy DirectionAvailable to large employer groups located in the CDPHP UBI service area .

ϐ 51 or more eligible employees who are regular full-time or part-time (20 hours or more per week) or seasonal working at least nine months per year .

ϐ 50 percent of eligible employees must live or work within the CDPHP UBI service area .

ϐ Eligible employee waivers, such as spousal or Medicaid, do not count toward participation requirements .

ϐ Minimum enrollment of 75 percent of insured eligible employees (sole carrier) .

ϐ Minimum enrollment of the greater of 10% of eligible employees or 10 enrolled subscribers (multiple carriers) .

ϐ Final enrollment must include no more than 15 percent Medicare eligible retirees and/or COBRA enrollees .

ϐ Employer contribution must be at least 50 percent of the “employee only” rate or the total overall health care cost of the group .

>50large group


Embrace Health ϐ Embrace Health cannot be coupled with Healthy Direction .

ϐ Embrace Health cannot be coupled with an HRA or HSA .

ϐ Embrace Health can be coupled with a health or dependent care FSA .

ϐ Single offering only .

Healthy Direction ϐ Total replacement .

ϐ No other product offered .

ϐ Same riders .

ϐ Employer contributions have to be the same for both plans .

ϐ No off-cycle changes .

CDPHP Shared Health Underwriting Guidelines (with second year cap)Available to large UBI employer groups located in the CDPHP UBI service area with 50 enrolled subscribers and CDPHP as the sole carrier . Rates are for a 12-month period . At renewal, enrollment must be at least 46 enrolled subscribers .

ϐ 80 percent of eligible employees must live or work within the CDPHP UBI service area . Anything less will be reviewed on a group by group basis and will not qualify if 20 percent or more are outside the states of NY, CT, MA, NJ, or VT .

ϐ Minimum enrollment of 75 percent of insured eligible employees .

ϐ Final enrollment must include no more than 15 percent Medicare and non-Medicare eligible retirees and/or COBRA enrollees .

ϐ Employer contribution must be at least 50 percent of the “employee only” rate or the total overall health care cost of the group .

ϐ Members’ plan design remains unchanged

ϐ Funding levels available are per member per year, as follows:

» $5,000 (available for all groups)

» $10,000 (available for groups with 100 or more enrolled)





Administrative Services Only (ASO)These products are offered through Capital District Physicians’ Healthcare Network, Inc . (CDPHN) . ASO provides companies the management apparatus and network access to self-fund their health benefits programs .

ϐ Offered to groups of 250 or more employees, however, CDPHN will review smaller groups on a case-by-case basis .

ϐ Stop-loss insurance quotes available .

ϐ The proposed administrative fee is based on a per-contract per-month basis .

Group-Specific ReportingAccount-specific reporting may be available, depending on the group’s level of enrollment in a CDPHP plan .

Delta Dental The following underwriting guidelines will apply:

ϐ Groups with 51-99 enrolled employees will utilize Delta Dental community rates .

ϐ Groups with 100 or more enrolled employees will utilize Delta Dental experience rates .

Please contact your CDPHP marketing representative for further details .

Waiting Period Requirements

ϐ For Delta-defined small groups (up to 99 enrollees), as long as the group previously had coverage for two of the four following benefits: major, prosthodontics, implants, or orthodontics, then they will be considered a non-waiting period group .

ϐ For Delta-defined large groups (100 or more enrollees), the waiting period will be reviewed and determined by Delta in a case-by-case manner .


GROUP PROCEDURES

New Large Group Implementation ChecklistInformation Required For A QuoteTo preserve the integrity of the community-rated pool and to determine the most appropriate product and funding mix to maximize account performance, CDPHP is asking all accounts to provide information for analysis purposes . The information needed includes, but is not limited to: census information; number of eligible subscribers; number insured; number of waivers; competitors currently offered; competitor benefits; competitor products and funding; contribution policy by plan; current rates; and subscribers by plan .

CDPHP uses this information in a variety of ways . The census and participation information allows us to confirm the number of insured subscribers in our service area and, based on current offerings, determine if a product to cover out-of-area members is necessary . By obtaining the product and benefit information, CDPHP can offer a package that provides benefit parity and consistency for the employer group and allows the carriers to compete on a level playing field where no one is disadvantaged .

To enroll a new large group, the following information must be provided .

For employers who are currently insured:

� Completed CDPHP Employer Application must be received by the 15th of the month prior to the effective date of the contract for new business with prior health insurance .

� Broker of Record Letter on group’s letterhead .

� Employee Enrollment Forms to CDPHP 10 days prior to the effective date .

� Delta Dental Plan Selection Form and a copy of prior dental coverage (if applicable) .

Note: For all new business with no prior health insurance, after the receipt of the employer application, there is an additional 30-day wait, with insurance becoming effective the first of the month after the waiting period . Example: When paperwork is received January 10, the effective date would be March 1 .

If CDPHP has terminated a group for non-payment, the group must wait 12 months from the date of termination before a new group application will be accepted .

Plan options can only be changed at the group’s renewal or when CDPHP is required to comply with state or federal guidelines.

http://www.cdphp.com/~/media/Files/brokers/13-0754-Employer-Application-Form-2014.ashx

http://www.cdphp.com/~/media/Files/brokers/SampleBor2.ashx

http://www.cdphp.com/~/media/Files/brokers/02-0010-Member-Application-OffExchange-2014.ashx

http://www.cdphp.com/~/media/files/Employers/LargeGroupDeltaDentalApplication.ashx


Large Group RenewalsInformation Required for a QuoteCDPHP asks all accounts to provide information for analysis purposes in the renewal process . This preserves the integrity of the community-rated pool and helps determine the most appropriate product and funding mix to maximize account performance . The information needed includes, but is not limited to: census information; number of eligible subscribers; number of insured; number of waivers; competitors currently offered; competitor benefits; competitor products and funding; contribution policy by plan; current rates; and subscribers by plan .

CDPHP uses this information in a variety of ways . The census and participation information allows us to confirm the number of insured subscribers in our service area and, based on current offerings, determine if a product to cover out-of-area members is necessary . By obtaining the product and benefit information, CDPHP can offer a package that provides benefit parity and consistency for the employer group and allows the carriers to compete on a level playing field where no one is disadvantaged .

Renewal ProcessIt is important to consider the current level of benefits and project any anticipated annual changes needed before the annual renewal period . Once the renewal process is completed, no changes can be made to contracts for a period of one year . Changes include the addition or deletion of any rider benefit or base plan copayment, coinsurance, or deductible .

The following changes to group coverage and eligibility criteria can be requested only at the time of the renewal:

ϐ Change to benefit plans (including Delta Dental)

ϐ Add/delete riders, i .e ., prescription drug, vision

ϐ New hire and termination period policy

ϐ Open enrollment for employees


Small GroupsUNDERWRITING PARTICIPATION GUIDELINES

Group Size DefinitionSmall groups are defined as employer groups that employ two to 50 eligible employees . Seasonal employees must work at least nine months per year .

Product Line RequirementsCommunity-Rated HMOEmployer groups must be located in the CDPHP approved service area and have two or more active eligible employees .

Community-Rated PPO, HDPPO, HDEPO, Embrace Health, and Healthy DirectionAvailable to small employer groups located in the CDPHP UBI approved service area .

ϐ 2-50 employees who are regular full-time or part-time or seasonal working at least nine months per year are eligible .

Embrace Health ϐ Embrace Health cannot be coupled with Healthy Direction .

ϐ Embrace Health cannot be coupled with an HRA or HSA .

ϐ Embrace Health can be coupled with a health or dependent care FSA .

Healthy Direction ϐ No off-cycle changes .

2-50small group


Delta Dental The following underwriting guidelines will apply .

Participation Requirements

ϐ A minimum of five employees, or 50 percent of all eligible employees, whichever is fewer, must be enrolled .

ϐ Group may select one business plan .

Waiting Period Requirement

ϐ For Delta-defined small groups (up to 99 enrollees), as long as the group previously had coverage for two of the four following benefits: major, prosthodontics, implants, or orthodontics, then they will be considered a non-waiting period group .

ϐ The pediatric dental plan does not have a waiting period .

Proof of Eligibility for a CDPHP Contract (Small Group Only)This document is only a brief summary and in no way should be considered legal advice . Employers should consult with their legal counsel for further explanation of necessary documents .

The Affordable Care Act (ACA) has adopted the Employee Retirement Income Security Act (ERISA) definition of an employer group, which requires one or more employees . Under ERISA, “employee” excludes “an individual and his or her spouse … with respect to a trade or business, whether incorporated or unincorporated, which is wholly owned by the individual or by the individual and his or her spouse” and also excludes “a partner in a partnership and his or her spouse…” (29 CFR section 2510 .3-3) .

CDPHP uses the following guidelines to verify a group’s eligibility to enroll in a CDPHP plan. These guidelines will be used for new groups and for new divisions on existing groups. They must be verified prior to a group’s enrollment. These guidelines help CDPHP ascertain if a business is a legitimate group and has two or more eligible employees actively working.

One of the following sets of documentation must be received along with each group or division application . A “set” consists of the documents under one heading, to be determined by the specific business arrangement of the group .

A. NYS 45 ϐ A NYS 45 is the New York State Quarterly Combined Withholding, Wage

Reporting and Unemployment Insurance Return form that displays the employer’s employees, their income, and their withholdings for the reported quarter .

ϐ A Certificate of Doing Business Under Assumed Name (DBA) form that was filed with the state may also be required for groups submitting a NYS 45 if the name that the business uses on its NYS 45 submission does not match the name of the customer applying for CDPHP group coverage . A copy of the DBA that was filed with New York state must also be submitted with the group paperwork for these groups .

( )

40629421

Part D - Form NYS-1 corrections/additions

Use Part D only for corrections/additions for the quarter being reported in Part B of this return. To correct original withholding information

reported on Form(s) NYS-1, complete columns a, b, c, and d. To report additional withholding information not previously submitted on

Form(s) NYS-1, complete only columns c and d. Lines 12 through 15 on the front of this return must reflect these corrections/additions.

aOriginallast payroll date reportedon Form NYS-1, line A (MMDD)

bOriginaltotal withheldreported on Form NYS-1, line 4

cCorrectlast payroll date(MMDD)

dCorrecttotal withheld

Part E - Change of business information22. Enter below the address at which you want to receive this form if different from the preprinted address. Taxpayer’s trade name

c/o: attn: (if applicable, mark either box and enter name) Number and street or PO box

City

State ZIP code23. If you permanently ceased paying wages, enter the date (MMDDYY) of the final payroll

(see Note below) ............................................................................................................................

24. Did you sell or transfer all or part of your business? Yes No If Yes, indicate if sale or transfer was in

Whole or Part

Note: Complete Form DTF-95, Business Tax Account Update, to report changes in federal identification number/withholding ID number, ownership,

business name, business activity, telephone number, owner/officer/partner/responsible person information, or changes that affect any other tax

administered by the NYS Tax Department. For questions regarding additional changes to your unemployment insurance account, call the Department

of Labor at (518) 485-8589 or 1 888 899-8810.If you are using a paid preparer or a payroll service, the section below must be completed.

Checklist for mailing:• File original return and keep a copy for your records.

• Complete lines 9 and 19 to ensure proper credit of payment.

• Enter your withholding ID number on your remittance.

• Make remittance payable to NYS Employment Taxes.

• Enter your telephone number in boxes below your signature.Need help or forms? Call 1 877 698-2910.NYS-45-MN (7/06) (back)

Mail to:NYS EMPLOYMENT TAXESPO BOX 4119BINGHAMTON NY 13902-4119

Payroll service name

Payroll service’s EIN

If the above address is for your paid preparer, mark this box and the c/o

box, and enter preparer’s name on the second line above ........................

Paidpreparer’suse

Mark an X ifself-employedPreparer’s SSN or PTIN

Preparer’s EIN

Withholdingidentification number

Preparer’s signature

Telephone number Date

Preparer’s firm name (or yours, if self-employed) Address

40629414

For office use only

Reference these numbers in all correspondence:NYS-45-MN (7/06)

Quarterly Combined Withholding, Wage Reporting,

And Unemployment Insurance Return

Postmark

Received date

UI SK

AI SIWT SK

Number of employees

Enter the number of full-time and part-time covered

employees who worked during or received pay for

the week that includes the 12th day of each month.

Part A - Unemployment insurance (UI) information Part B - Withholding tax (WT) information

20b. Credit to next quarter

withholding tax ....... or

21. Total payment due (add lines 9 and 19; make one

remittance payable to NYS Employment Taxes) ...........

* An overpayment of either tax cannot be used to offset the amount due on the other tax.

Complete Parts D and E on back of form, if required. This is a scannable form; please file the original.

Part C – Employee wage and withholding information

Quarterly employee/payee wage reporting information (if more than five employees or if

reporting other wages, do not make entries in this section; complete Form NYS-45-ATT. Do not

use negative numbers; see instructions)

Annual wage and withholding totals

If this return is for the 4th quarter or the last return you will be filing

for the calendar year, complete columns d and e.

a Social security number b Last name, first name, middle initial c UI total remuneration/gross

wages paid this quarterd Gross wages or distribution

(see instructions)e Total tax withheld

Taxpayer’s signature

Signer’s name (please print) Title

DateTelephone number

a. First monthb. Second month

c. Third month

1 2 3 4 Y Y

12. New York State

tax withheld .........................

13. New York City

tax withheld .........................

14. Yonkers tax

withheld ..............................

15. Total tax withheld

(add lines 12, 13, and 14) ...........

16. WT credit from previous

quarter’s return (see instr.) ......

17. Form NYS-1 payments made

for quarter ...........................

18. Total payments

(add lines 16 and 17) ................

19. Total WT amount due (if line 15

is greater than line 18, enter difference) ......

20. Total WT overpaid (if line 18

is greater than line 15, enter difference

here and mark an X in 20a or 20b)* ......

20a. Apply to outstanding

liabilities and/or refund ......

UI Employer

registration number

Withholdingidentification number

Employer legal name:

Jan 1 - Mar 31

Apr 1 - Jun 30

July 1 - Sep 30

Oct 1 - Dec 31

If seasonal employer, mark an X in the box .......

Sign your return: I certify that the information on this return and any attachments is to the best of my knowledge and belief true, correct, and complete.

0 0

0 0

0 0

1. Total remuneration paid this

quarter .............................

2. Remuneration paid this quarter

to each employee in excess of

$8,500 since January 1 ...........

3. Wages subject to contribution

(subtract line 2 from line 1) ........

4. UI contributions due

Enter your

Tax rate %

5. Re-employment service fund

(multiply line 3 × .00075) ..............

6. UI previously underpaid with

interest

7. Total of lines 4, 5, and 6 ...........

8. Enter UI previously overpaid .....

9. Total UI amounts due (if line 7

is greater than line 8, enter difference) ......

10. Total UI overpaid (if line 8

is greater than line 7, enter difference

and mark box 11 below)* ..............

11. Apply to outstanding liabilities

and/or refund .........................

Totals (column c must equal remuneration on line 1; see instructions for exceptions)

Taxyear

Mark an X in only one box to indicate the

quarter (a separate return must be completed

for each quarter) and enter the tax year.


B. Schedule F ϐ This is the Profit or Loss Farming tax form that would be submitted by a

farm attached to its Form 1040, Form 1041, or Form 1065 or 1065-B .

ϐ If the Schedule F is submitted along with the 1040 or 1041, it must be accompanied by a NYS 45 .

ϐ If the Schedule F is submitted along with a 1065 or 1065-B, the NYS 45 is not required .

C. Schedule C ϐ If a company does not use a payroll company for handling their payroll, the

employer’s payroll records will be accepted as long as they accompany a copy of cancelled checks issued to their employees that match the payroll records submitted .

ϐ New York state requires that a company must file an Assumed Name Certificate (DBA) form if they are operating under a name other than the proprietors or owners of the business . A copy of the DBA that was filed with New York state must be submitted with the group paperwork .

D. Form 1065These forms are used for partnerships . CDPHP requires both forms .

ϐ Form 1065, U.S. Return of Partnership Income Form, is for the business partnership information .

ϐ Form 1065-K-1 (Schedule K) Partner’s Share of Income, Credits, Deductions, etc . is for each individual partner .

ϐ An Assumed Name Certificate (DBA) form must also be submitted if the group name does not match the name of the partners of the business (as noted above in sections A and C) .

E. New Businesses or Newly Eligible BusinessFor a recently established business, or a previously established business that is now eligible as a group, because it hired additional staff .

ϐ These groups must provide either a 1065, Certificate of Incorporation, Articles of Organization, or a Certificate of Limited Partnership, along with their NYS 45, as proof that they are a legitimate business .

ϐ If a group cannot provide a NYS 45, because it has not yet filed one, it must submit professionally prepared payroll information . If a company does not use a payroll company for handling their payroll, two weeks of the employer’s most recent payroll records will be accepted as long as they accompany a copy of cancelled checks to their employees that match the payroll records submitted .

F. Certificate of Incorporation ϐ This form must be filed with the New York State Department of State for all

business corporations within New York .

ϐ A NYS 45 must also be submitted to verify that there are at least two eligible owners/employees for the company .

Page 2

Schedule C (Form 1040) 2006

Cost of Goods Sold (see page C-7)

35

Inventory at beginning of year. If different from last year’s closing inventory, attach explanation

33

36

Purchases less cost of items withdrawn for personal use

34

37

Cost of labor. Do not include any amounts paid to yourself

35

38

Materials and supplies

36

39

Other costs

37

40

Add lines 35 through 39

38

41

Inventory at end of year

39

Cost of goods sold. Subtract line 41 from line 40. Enter the result here and on page 1, line 4

40

42

Part IV

Part III

Information on Your Vehicle. Complete this part only if you are claiming car or truck expenses on

line 9 and are not required to file Form 4562 for this business. See the instructions for line 13 on page

C-4 to find out if you must file Form 4562.

41

When did you place your vehicle in service for business purposes? (month, day, year) �

42

Of the total number of miles you drove your vehicle during 2006, enter the number of miles you used your vehicle for:

a

Business

b

Commuting (see instructions)

c

Other

45

Do you (or your spouse) have another vehicle available for personal use?

46

Was your vehicle available for personal use during off-duty hours?

47a

Do you have evidence to support your deduction?

b

If “Yes,” is the evidence written?

Yes

No

Other Expenses. List below business expenses not included on lines 8–26 or line 30.

48

Total other expenses. Enter here and on page 1, line 27

/ /

Yes

No

Yes

No

Yes

No

48

Part V

Method(s) used tovalue closing inventory: Cost b

Other (attach explanation)

Was there any change in determining quantities, costs, or valuations between opening and closing inventory?

If “Yes,” attach explanation

Lower of cost or market c

a

No

Yes

43

44


OMB No. 1545-0074

SCHEDULE C

(Form 1040)

Profit or Loss From Business

(Sole Proprietorship)

� Partnerships, joint ventures, etc., must file Form 1065 or 1065-B.

Department of the Treasury

Internal Revenue Service

Attachment

Sequence No. 09

� Attach to Form 1040, 1040NR, or 1041. � See Instructions for Schedule C (Form 1040).

Name of proprietor

Social security number (SSN)

A Principal business or profession, including product or service (see page C-2 of the instructions)

B Enter code from pages C-8, 9, & 10

� D Employer ID number (EIN), if any

Business name. If no separate business name, leave blank.

C

Accounting method:

E

F

Yes No

G H

Did you “materially participate” in the operation of this business during 2006? If “No,” see page C-3 for limit on losses

If you started or acquired this business during 2006, check here

�

Income

Gross receipts or sales. Caution. If this income was reported to you on Form W-2 and the “Statutory

employee” box on that form was checked, see page C-3 and check here�

1

1 2

2 Returns and allowances

3

3 Subtract line 2 from line 1

4

4 Cost of goods sold (from line 42 on page 2)

5

Gross profit. Subtract line 4 from line 3

5

6

Other income, including federal and state gasoline or fuel tax credit or refund (see page C-3)

6 7 Gross income. Add lines 5 and 6

� 7

Expenses. Enter expenses for business use of your home only on line 30.

8

21

Repairs and maintenance 21

Advertising

8

22

Supplies (not included in Part III) 22

23

9

Taxes and licenses 23

10

Travel, meals, and entertainment:

24

Car and truck expenses (see

page C-4)

9

24a

11

Travel

a

Commissions and fees 10

12

Depletion

12

Deductible meals and

entertainment (see page C-6)

b

Depreciation and section 179

expense deduction (not

included in Part III) (see

page C-4)

13

13

14

Employee benefit programs

(other than on line 19)

14

25

15

Utilities

25

Insurance (other than health) 15

26

Wages (less employment credits) 26

Interest:

16

16a

Mortgage (paid to banks, etc.) a

Other expenses (from line 48 on

page 2)

27

16b

Other

b 17 Legal and professional

services

18

Office expense 18

19

Pension and profit-sharing plans

19 Rent or lease (see page C-5):

20

20a

Vehicles, machinery, and equipment a

b

Other business property

20b

Total expenses before expenses for business use of home. Add lines 8 through 27 in columns �

28

28

31

31

All investment is at risk. 32a

32

Some investment is not

at risk.

32b


For Paperwork Reduction Act Notice, see page C-8 of the instructions.

(1) Cash

(2) Accrual

(3) Other (specify) �

Business address (including suite or room no.) �

City, town or post office, state, and ZIP code

Cat. No. 11334P

29 30

Tentative profit (loss). Subtract line 28 from line 7

Expenses for business use of your home. Attach Form 8829

29 30

�

Part I

Part II

27

Net profit or (loss). Subtract line 30 from line 29.

● If a profit, enter on both Form 1040, line 12, and Schedule SE, line 2, or on Form 1040NR,

line 13 (statutory employees, see page C-6). Estates and trusts, enter on Form 1041, line 3.

● If a loss, you must go to line 32.

If you have a loss, check the box that describes your investment in this activity (see page C-6).

● If you checked 32a, enter the loss on both Form 1040, line 12, and Schedule SE, line 2, or on

Form 1040NR, line 13 (statutory employees, see page C-6). Estates and trusts, enter on Form 1041,

line 3.

● If you checked 32b, you must attach Form 6198. Your loss may be limited.

�

(99)

Contract labor (see page C-4) 11

24b

17

06


G. Articles of Organization ϐ This form must be filed with the New York State Department of State for all

limited liability companies (LLCs) .

ϐ A NYS 45 must also be submitted to verify that there are at least two eligible owners/employees for the company .

H. Certificate of Limited Partnership ϐ Must be filed with the New York State Department of State for all limited

partnerships .

ϐ An Assumed Name Certificate (DBA) form may also be required with this certificate if the company is not doing business under the names of all the partners of the company . Per New York state law, a company must file a DBA with the state if it is operating under a name other than the proprietors or owners of the business . If the name that the Certificate of Limited Partnership is filed under does not match the name of the customer applying, a copy of the DBA that was filed with New York state must be submitted with the group paperwork .

GROUP PROCEDURES

New Small Group Implementation ChecklistTo enroll a new small group, the following information must be provided:

� Completed Employer Application – must be received by the 15th of the month prior to the effective date of the contract for new business with previous health insurance .

� Proof of business eligibility .*

� Signed confirmation of product and rates .

� To ensure appropriate enrollment, submit completed Employee Enrollment Forms to CDPHP 10 days prior to the effective date .

� Delta Dental Plan Selection Form

Note: If CDPHP has terminated a group for non-payment of premiums, the group must wait 12 months from the date of termination before a new group application will be accepted .

Your CDPHP representative is available to assist you in ensuring that your paperwork is accurate and completed in time for our deadline of the 15th of each month. Please call us if you need assistance.

13-0754 - 0613

Page 2 of 2

8. Class description (i.e., hourly and salary employees): ________________________________________________________________________________________________________

Waiting period for new hire: _________________________________________________________________________________________________________________

Employer contribution % or $ Single: ________ Employee + Spouse:________ Parent + Child(ren): ________ Family: ________ Medicare: ________

Non-Medicare retiree: _________ Employees will be terminated (check one): End of month Date of termination

9. Is CDPHP sole medical carrier? Y N 9b. If no, list other carriers:______________________________________ 2nd open enrollment?

____________________________________________________________________ Date: ____________________

Have you ever had coverage through CDPHP before? Y N If yes, under what legal name? __________________________________________________

INTERNAL USE ONLYRep code: ___________ Broker #: _________________________________________ Parent group ID#: ____________________________

Facets group type: Employer Group Chamber AssociationGroup size: Large Small Total replacement? Y N Send bill to: Group Subgroup Broker

Specialty products: Embrace Health Healthy Direction Shared Health (large group only)

Special Instructions (billing requirements, additional locations, reporting requirements, etc.):

___________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________

SIGNATURE AUTHORIZATIONMEDICARE: A subscriber who is eligible for Medicare and employed by an employer group with fewer than 20 employees or a retiree for an employer with

more than 20 employees, must have both Parts A and B of Medicare and attach a copy of his/her Medicare card to the enrollment application. Employers

are not required to offer coverage to retirees.Please Note: Benefits on your signed rate sheet are made a part of this application and may NOT be altered or modified until contract renewal, unless

statutorily mandated. Requests for changes to this application must be made in writing. Employers are responsible for the administration of any

continuation of coverage.Authorization: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement

of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits

a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed $5,000 and the stated value for the claim for each

such violation.

Employer’s signature: _____________________________________________________________________ Date: ____________________

Print name: ________________________________________________________________________________

Employer’s title: __________________________________________________________________________Broker’s signature: __________________________________________________________________________ Date: ____________________

Print name: ________________________________________________________________________________Account Rep’s signature: ____________________________________________________________________ Date: ____________________

Print name: ________________________________________________________________________________

Please print

Delta Dental Service Plans are underwritten and administered by Delta Dental of New York, Inc.

Delta Dental of New YorkOne Delta DriveMechanicsburg, PA 170551-800-932-0783TTY/TDD 1-888-373-3582www.deltadentalins.com

Capital District Physicians’ Healthcare Network, Inc.

Capital District Physicians’ Health Plan, Inc.

CDPHP Universal Benefits,® Inc.

500 Patroon Creek Blvd.

Albany, NY 12206-1057

(518) 641-5000 or 1-800-993-7299

Employer Application Form

Please Print

This application is hereby made with CDPHP for enrollment of eligible members in accordance with the contract of the employer named below for coverage

subject to the group meeting group eligibility.

Group Effective Date:_________________________________________ End Date: _________________________ Group ID:___________________

Check all that apply: Medical Delta Dental

CDPHN-Administered Health Funding Arrangement(s):

Flexible Spending Account (FSA) Health Reimbursement Arrangement (HRA) Health Savings Account (HSA) None

EMPLOYER INFORMATION (Required)

1. Legal company name

___________________________________________________________________________________________________________________________________________________

Fed Tax ID

SIC code

________________________________________________ _

______________________

Street address

City

State ZIP

_________________________________________________________________ ______________________________________________ _______ ________________________

2. Decision contact name

Phone

Fax

_________________________________________________________________ ___________________________________ ___________________________________

Street Address

ZIP

_________________________________________________________________ ___________________________________

City

State E-mail

___________________________________________________ _______ ___________________________________________________________________________________________

3. Billing contact name

Phone

Fax

_________________________________________________________________ ___________________________________ ___________________________________

Street Address

ZIP

_________________________________________________________________ ___________________________________

City

State E-mail

___________________________________________________ _______ ___________________________________________________________________________________________

4. Broker contact name

Broker agency

_________________________________________________________________ _________________________________________________________________________

Is this your broker of record? Y N

5a. Total number of employees on company payroll nationwide (include full-time, part-time, owners), all locations ________________________________

5b. Total number of employees eligible for health insurance (eligible employees must work a minimum of 20 hours a week) nationwide ______________

5b. in all locations _______________

CLASSIFICATION OF COVERED EMPLOYEES

The group agrees that membership enrollment applications will be submitted only for eligible employees subject to the enrollment provisions set forth in the

contract and subject to the following eligibility guidelines. Member enrollment applications should be submitted no later than 30 days prior to the effective date.

6. Eligible employee definition (check one): Full-time only Full-time and part-time (20 hours or more)

SUBGROUPS

___________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________

ENROLLMENT CLASS

7. Class description (i.e., hourly and salary employees): ____________________________________________________________ Class #: _________________________

Waiting period for new hire: _________________________________________________________________________________________________________________

Employer contribution % or $ Single: ________ Employee + Spouse: ________ Parent + Child(ren): ________ Family: _________ Medicare: ________

Non-Medicare retiree: _________ Employees will be terminated (check one): End of month Date of termination

Continued on page 2

Page 1 of 2

13-0754 - 0613

* See page 23 for a list of approved documents.

http://www.cdphp.com/~/media/Files/brokers/13-0754-Employer-Application-Form-2014.ashx



http://www.cdphp.com/~/media/Files/Employers/DeltaSmallBusinessPlanSelectionForm.ashx


Small Group RenewalsNinety days prior to a group’s anniversary date with CDPHP, the group will receive an annual renewal notification packet . For brokered groups, the broker will receive the same notification 2-3 days prior to the group . The renewal notification packet will contain the following important pieces of information:

� Renewal Checklist/Information Sheet – outlines recommended benefit options and rates, including paperwork deadline for renewal .

� Delta Dental Plan Selection Form

� Signed Renewal Notification – a completed renewal requires a signed renewal notification letter from the group administrator or a written notice from the broker .

� Recredentialing Form - In order to track health care resource allocations and meet both federal and state guidelines, CDPHP requires that all groups confirm or provide certain information regarding their number of eligible and non-eligible employees .

� Pediatric Dental Attestation Forms - if applicable .

Groups interested in looking at different health coverage options should contact their broker or CDPHP account representative prior to renewal .

CDPHP recommends that all renewals be completed 30 days prior to renewal to ensure all benefit changes are updated in a timely manner . In the event that we do not receive a renewal 30 days prior, a reminder notice will be mailed to the account . For brokered groups, the broker will receive the same notification 2-3 days prior to the group .

All current CDPHP groups must renew on an annual basis . If we do not receive notice of the intent to renew group coverage prior to the anniversary date, the group will be terminated for non-renewal . All members will be notified directly that their group coverage has been terminated as of the group’s anniversary date .

Renewal ProcessIt is important to consider the current level of benefits and project any anticipated annual changes needed before the annual renewal period . Once the renewal process is completed, no changes can be made to contracts for a period of one year . Changes include the addition or deletion of any rider benefit or base plan copayment, coinsurance, or deductible .

The following changes to group coverage and eligibility criteria can be requested only at the time of the renewal:

ϐ Change to benefit plans

ϐ Add/delete additional coverage options, i .e ., domestic partner, skilled nursing facility coverage, dependent to 29 coverage

ϐ Add or change Delta Dental plan

ϐ Plan options can only be changed at the group’s renewal or when CDPHP is required to comply with state or federal guidelines .

Plan options can only be changed at the group’s renewal or when CDPHP is required to comply with state or federal guidelines.

http://www.cdphp.com/~/media/Files/Employers/DeltaSmallBusinessPlanSelectionForm.ashx


All GroupsWaiting Periods For All Groups

Option Example

01 No wait, effective date of hire (DOH) DOH 1/26, Effective 1/26

02 2-month wait from DOH DOH 1/26, Effective 3/26

03 2-month wait, first of month DOH 1/26, Effective 4/1

04 1-month wait from DOH DOH 1/26, Effective 2/26

05 1-month wait, first of month DOH 1/26, Effective 3/1

06 First of month following DOH DOH 1/26, Effective 2/1

07 Within 30 days DOH 1/26, Effective sometime before 2/25

08 90 days from DOH DOH 1/26, Effective 4/26

Termination Policy For All Groups

1 Term end of month of termination

2 Term date of termination

Group ChangesSubmit to - [email protected], or fax to (518) 641-4008

Request To Change Waiting Period For New Hires A group can change its waiting period upon its renewal . A group is allowed an exception once a year outside its renewal to make this change .

A letter from the group is required to change the waiting period . The new waiting period will be in effect on the first of the month following 30 days from receipt of the notice of change by CDPHP .

A group is only allowed to have one waiting period unless it has a clear distinction as to why it needs more than one, such as hourly versus salary, union versus non-union, or management versus non-management .

Termination policy changeA group can change its termination policy upon renewal . If a group wants to change its termination policy at some other time, it needs to submit a written request . The effective date of the change will be subject to a 30-day wait, taking effect as of the first of the month following 30 days from receipt of the notice of change by CDPHP .

mailto:[email protected]


Special Open Enrollment requestsIf a group requests a special open enrollment (other than the group’s annual renewal), a letter with a valid reason for the request must be received from the group . Valid reasons include: group is not renewing contract with another carrier, rates with other carrier are too high and it is the other carrier’s open enrollment, or a group has merged with another company .

All requests for special open enrollments must be received at least 30 days prior to the effective date of the open enrollment . No special open enrollments will be granted without receiving 30 days’ advance notice .

Funding Account ProceduresA health plan paired with a funding account provides many advantages for employers and employees . Please keep the following guidelines in mind when determining which funding accounts to offer:

ϐ Start planning early .

ϐ Educate employees .

ϐ Funding accounts and their paired health plan go hand-in-hand . They must be offered on the same plan year .

ϐ An HSA and HRA may not be offered on the same benefit plan .

ϐ HSAs may only be offered with federally qualified high deductible health plans .

ϐ CDPHN does not provide tax or legal advice or representation . Check with your tax advisor to determine the legal and tax status and implications of health reimbursement arrangements, flexible spending accounts, and/or health savings accounts .

Paperwork Required To Set Up A Flexible Spending Account (FSA)A flexible spending account (FSA) allows employees to pay for certain health care expenses and adult and child day care expenses with pre-tax dollars .

� Funding Account Administrative Agreement

� Business Associate Contract

� Alegeus ACH Authorization (Health FSA only)

� CDPHN ACH Authorization

� FSA Annual Election of Benefits forms

Secure Employer Web Portal Make Changes Online

Log into the secure employer portal at www .cdphp .com . Authorized users can make changes to member records .

Forms to register for the secure portal may be downloaded from our website .

http://www.cdphp.com/Employers/Our-Health-Plans/~/media/Files/Employers/FlexibleSpendingAccountsFlyer.ashx

www.cdphp.com


Paperwork Required To Set Up A Health Reimbursement Arrangement (HRA)A health reimbursement arrangement (HRA) is an account funded by the employer on behalf of the employee . It reimburses qualified medical expenses determined by the employer, such as copayments, deductibles, vision care expenses, prescriptions, and dental expenses .

� Funding Account Administrative Agreement

� Business Associate Contract

� Alegeus ACH Authorization (if applicable)

� CDPHN ACH Authorization

Paperwork Required To Set Up A Health Savings Account (HSA) Owned by the individual (employee), the health savings account (HSA) is an interest-bearing account that may be used to pay for qualified medical expenses .

� Health Savings Account Administrative Services Agreement

CDPHN partners with Benefit WalletTM to offer an integrated HSA solution . For more information about our HSA custodians and the appropriate documents, visit the Members section of the CDPHP website, under Our Health Plans .

Submission of Funding Account Paperwork ϐ Due to the nature of the setup, we ask for this paperwork 30 days prior to

the effective date .

ϐ Please work with your CDPHP representative on any submissions outside this date .

http://www.cdphp.com/Employers/Our-Health-Plans/~/media/Files/Employers/HealthReimbursementAccountsFlyer.ashx

http://www.cdphp.com/Members/Health-Plan/Health-Accounts/hsa

http://www.cdphp.com/employers/Health_Savings_Account.aspx


Group Medicare AdvantageGroup members and their covered dependents become entitled to Medicare when they reach age 65 or sustain certain disabilities . This includes retirees . All members are enrolled as individuals . There are no family contracts . Medicare eligible retirees must complete the Medicare application . Non-Medicare eligible family members of a retiree must fill out the appropriate active commercial application . Group applications should be completed with the appropriate sales representative prior to any member applications being completed .

EligibilityMember applications must be received by the 15th of the month prior to effective date (i .e ., for an effective date of August 1, the application must be received by July 15) . It is extremely important the group submits the Medicare Choices member enrollment application on a timely basis. CDPHP must submit applications to the Centers for Medicare & Medicaid Services’ (CMS) for approval. If the application is received late, this will delay the member’s enrollment. In addition, the effective date on the application CANNOT be prior to the signature date.

Employers cannot enroll Medicare retirees via the secure employer portal at www .cdphp .com .

ϐ See checklist for submitting a CDPHP Medicare Choices group plan .

Requirements for Medicare eligibility are as follows:

ϐ Members must have Medicare Parts A and B effective prior to or on the effective date of coverage .

ϐ Members must live in the CDPHP 24-county service area and be a permanent resident for at least 6 months of the year .

ϐ Centers for Medicare & Medicaid Services (CMS) must approve all applications .

Optional Employer Group Waiver for End Stage Renal Disease EnrolleesCDPHP may choose to accept members with ESRD who are enrolling in a Medicare Advantage (MA) plan through an employer or union group under the following circumstances:

1 . If an employer or union group offers an MA plan as a new option to its employees and retirees, regardless of whether it has been an option in the past, ESRD retirees may select this new MA plan option as the employer or union’s open enrollment rules allow .

2 . If an employer or union group that has been offering a variety of coverage options consolidates its employee/retiree offerings (i .e ., it drops one or more plans), current enrollees of the dropped plans may be accepted into an MA plan that is offered by the group .

http://www.cdphp.com/Members/Health-Plan/Group-Health-Insurance/Group-Medicare.aspx

http://www.cdphp.com/~/media/Files/medicare/Group-Medicare-Member-Application.ashx

http://www.cdphp.com/~/media/Files/medicare/Group-Medicare-Member-Application.ashx

www.cdphp.com

http://www.cdphp.com/~/media/Files/medicare/medicare2014/group/Checklist-Medicare-Group-Plan.ashx

http://www.cdphp.com/Brokers/Get-Your-Job-Done/Medicare-Resources/Know-About-Medicare


3 . If an employer or union group has contracted locally with an MA organization in more than one geographic area (for example, in two or more states), an ESRD retiree who relocates permanently from one geographic location to another may remain with the MA organization in the local employer or union MA plan .

Once a member is active, he/she will receive two identification cards, one for medical and one for drug (if drug coverage is being offered) .

Low Income Subsidy (LIS)A member must apply for LIS through Social Security Administration (SSA) . Premiums and drug copayments may differ based on income .

If a member qualifies, the adjustment in premium will be reflected on the group bill .

Termination PoliciesEmployer groups must provide 30 days written notice to the Medicare members and CDPHP when a group is not renewing with us.

For individual member termination, use Member Disenrollment Form.

Underwriting GuidelinesSmall employers must meet all of the following underwriting guidelines for group Medicare:

ϐ There must be at least one active employee on a CDPHP commercial plan .

ϐ A minimum enrollment of five Medicare enrollees is required to offer a prescription drug rider without a coverage gap .*

ϐ The employer must contribute 50 percent of the total premium, or there must be at least 50 percent participation in the Medicare plan .

ϐ Subscribers and dependents must be retired or ineligible for commercial group benefits to enroll in groups with 20 or more eligibles .

ϐ For more information, visit www .cdphp .com

* CDPHP still has group options available for your clients with fewer than five enrollees. Contact your representative for more information.

http://www.cdphp.com./~/Media/Files/Employers/Medicare_Group_Disenrollment_Form.ashx

http://www.cdphp.com/Brokers/Get-Your-Job-Done/Medicare-Resources/Know-About-Medicare

http://www.cdphp.com


Member ProceduresEligibilitySubmit to [email protected], or fax to (518) 641-4008

Individuals are accepted for enrollment when they meet the requirements outlined below .

Subscriber In order to be eligible to enroll, an individual must meet the eligibility requirements listed below and any other eligibility requirements agreed to by the group and CDPHP:

ϐ Be an actual member of the group entitled to participate in health care benefits .

ϐ Completed the length of service to satisfy the group’s waiting period .

ϐ Be 18 years of age or older, unless eligible under COBRA/ New York State continuation rules .

ϐ Receive payroll wages as evidenced by the group’s New York State payroll wage filing statement or have other written documentation of employment status acceptable to CDPHP .

DependentsTo be eligible to enroll as a dependent, an individual must either be:

ϐ Married to the subscriber, or

ϐ A child of the subscriber, who is under the age of 26 . Coverage lasts until the end of the month the child turns 26 years of age, or 30 in groups with the Dependent through 29 rider .

ϐ A child includes any natural child, stepchild, or legally adopted child, or a child for whom the subscriber is the proposed adoptive parent and who is dependent upon the subscriber during the waiting period prior to the adoption period .

ϐ A child who is under 26 and who is chiefly dependent upon subscriber for support and for whom subscriber has been appointed the legal guardian by court order .

ϐ Unmarried dependent child of the subscriber, regardless of age, who is incapable of self-sustaining employment because of mental retardation, mental illness, developmental disability, or physical handicap and who became so incapable prior to the attainment of the age at which dependent coverage would otherwise terminate .

ϐ See contract for full dependent eligibility details .

Qualifying EventsWhat life changes are considered qualifying events?

Qualifying events include the following situations that can either make a person eligible for an off-cycle enrollment, or cause them to become ineligible for coverage:

ϐ Change in legal marital status, including marriage, divorce, or the death of spouse .

ϐ Addition of a dependent due to birth or adoption .

ϐ Change in employment status of the employee or his or her spouse .

ϐ The employee or dependent changes his or her place of residence to reside in the service area .

ϐ Involuntary loss of coverage*

* Provide HIPAA certificate from

previous carrier

mailto:[email protected]


New DependentsMarriage and birth or adoption of a child are considered qualifying events . Dependents of a subscriber who fall into these categories may be enrolled during an eligibility period extending 31 days after the dependents first become eligible for coverage with CDPHP .

Dependents are not considered enrolled until the subscriber submits the appropriate Application/Change Form and CDPHP receives payment of additional applicable premiums .

ϐ Newborn children of a subscriber will be covered as a dependent as of their date of birth as long as they are enrolled within 31 days .

AdoptionEligibility of a newly adopted child is contingent upon the following conditions:

ϐ The subscriber must have filed a petition for adoption pursuant to Section 115-c of the New York Domestic Relations Law within 31 days of taking physical custody .

ϐ No notice of revocation of the adoption has been filed pursuant to Section 115-b of the New York Domestic Relations Law .

ϐ Consent to the adoption has not been revoked .

ϐ If CDPHP is not notified of an adoptive child on or before the 31st day from the date of birth, or the date the child is physically in the household of the member, then coverage will not begin until the group’s next Open Enrollment Period .

Newly Born Adopted InfantsInfants who are adopted by the member are covered from the moment of birth when the following steps resulting in final adoption are completed:

ϐ CDPHP is notified of the infant’s birth within 31 days of the date of birth .

ϐ The subscriber takes physical custody of the adoptive infant upon release from the hospital .

ϐ The subscriber files a petition for adoption pursuant to Section 115-c of the New York Domestic Relations Law within 31 days of birth .

ϐ No notice of revocation of the adoption is filed pursuant to Section 115-b of the New York Domestic Relations Law .

ϐ Consent to the adoption has not been revoked .

ϐ Coverage of the initial hospital stay for a newly born infant adopted by the subscriber is not provided by CDPHP if a natural parent has insurance or other coverage is available for the adoptive infant’s care .

Dependents may be enrolled during an eligibility period extending 31 days after the dependents first become eligible for coverage..


Handicapped Dependents To be eligible to enroll a handicapped dependent, an individual must be:

ϐ An unmarried child of the subscriber (including any stepchild, legally adopted child or proposed adoptive child), and age 26 or over .

ϐ Incapable of self-sustaining employment by reason of mental illness, developmental disability, mental retardation as defined in the New York Mental Hygiene Law, or physical handicap, and became so prior to age 26 .

ϐ Chiefly dependent upon the subscriber for support and maintenance .

The subscriber may be requested by CDPHP to provide evidence of the handicapping conditions claimed to be in existence for the dependent child.

Continuation of CoverageIf the subscriber’s coverage under the contract ends due to termination of employment or membership in the group, he/she may continue coverage . Coverage may be continued for the subscriber and any of the subscriber’s covered dependents . Such coverage is subject to the terms of the contract . Continuation of coverage will not be available for:

ϐ Any person who becomes covered under Medicare .

ϐ Any person who becomes covered as an employee, member, or dependent by another group benefits plan, which does not contain any exclusion or limitation with respect to any pre-existing condition of employee, member, or dependent .

ϐ Under certain circumstances, a member may be entitled to a continuation of group health coverage under federal COBRA rules .

CDPHP is not the plan administrator under COBRA . COBRA continuation coverage applies to groups with 20 or more employees . If a member is not entitled to COBRA coverage, temporary continuation rights may be available under New York law . New York law requires that a member who wishes continuation of coverage must request such continuation in writing within 60 days following the later of the date of termination of employment or the date the member is given notice of the right to continuation by the group .

Continuation of coverage under New York law shall terminate on the date 36 months after the date of the subscriber’s termination from employment .

Continuation of coverage under the contract shall terminate if the member fails to make timely payment of the required premium . Monthly premium payments must be made in advance to the group . All terminations must be submitted within timeframes found in your contract .


Continuation of coverage will end at the first of the following to occur:

ϐ Termination under COBRA or New York continuation rules .

ϐ The end of the period for which premium payments were made (where premiums are not paid on time) .

ϐ The date on which the contract is terminated .

Information on any regulatory changes to COBRA will be posted in the Legislation Updates section of www .cdphp .com .

Persons Not Eligible for Coverage ϐ Persons who are in the armed forces of any government, other than for

duty of 31 days or less .

ϐ Any child born to or adopted by the subscriber’s dependent child .

ϐ An ex-spouse of the subscriber .

ϐ Foster children, unless otherwise eligible due to legal guardianship or legal custody .

ϐ Medicare eligible members over 65 years of age who are eligible for and do not enroll in Medicare Part A and Part B, and are employed in a group with less than 20 employees or a retiree of a group with more than 20 employees .

ϐ Non-Medicare eligible retirees and their spouses and/or dependents .

CDPHP reserves the right to examine the group’s records, including payroll records and an individual’s health, employment, or membership records in determining eligibility status for membership or possible benefit exclusions (such as, but not limited to, Workers’ Compensation) .

CDPHP reserves the right to request and be furnished with such proof as may be needed to determine the eligibility status of any member .

CDPHP reserves the right to examine the group’s records in determining eligibility status for membership.

http://www.cdphp.com/Employers/Get-Your-Job-Done/Health-Care-Reform-Latest-Updates


EnrollmentAn individual may enroll upon meeting the eligibility requirements imposed by the group and agreed to by CDPHP . The following additional guidelines for enrollment apply:

ϐ Subscribers may join CDPHP on the group’s anniversary date or during special Open Enrollment Periods agreed upon by both the group and CDPHP .

ϐ The group agrees to give all employees or members of the group the CDPHP Application/Change Form and descriptive literature as soon as they become eligible for coverage .

ϐ Employees, including new hires, may apply for coverage from CDPHP within 31 days of the date they become eligible for coverage . If such persons do not apply within the 31-day timeframe they must then wait until the group’s next Open Enrollment Period to become covered .

ϐ CDPHP is required to submit the member’s Social Security number to the Centers for Medicare & Medicaid Services (CMS) if they are:

» Between the ages of 45 and 64 years;

» Over age 65 and covered by a group plan because they and/or their spouse are still employed;

» Receiving kidney dialysis or received a kidney treatment;

» Under age 45 and known to be entitled to Medicare .

Coverage will begin as follows:

ϐ If the potential member files an Application/Change Form with CDPHP within 31 days after his/her date of eligibility, coverage will start on the date such person became eligible .

ϐ If a member married and filed an Application/Change Form with CDPHP within 31 days after the marriage indicating that he/she wants family coverage, coverage for such dependent starts on the date of the marriage or the first of the month following the date of marriage .

ϐ If a member gives birth to or adopts a child, coverage for the child will begin on the date the child is born or adopted, provided that the member submits an Application/Change Form to CDPHP within 31 days of the birth or adoption . If the member does not already have family coverage he/she must request family coverage on the Application Change Form .

Log in to cdphp .comThe CDPHP secure sites allow members, employers, and brokers to manage their accounts 24 hours a day .

Members can order ID cards, register a change of address, check claims statuses, determine payment responsibilities, and more .

Employers and brokers can enroll, terminate, and update members, obtain health funding reports, access important forms, view and pay invoices, and more .

Contact Automation at (518) 641-4167 for assistance .

500 Patroon Creek Blvd.Albany, NY 12206-1057(518) 641-3700 or

1-800-777-2273

Enrollment Application/Change Form

Form # 01-0019-2014

Continued on page 2

Page 1 of 3

PLEASE PRINT. For address and/or primary care physician changes call (518) 641-3700, 1-800-777-2273, or visit www.cdphp.comUSE BLACK INK ONLY.EMPLOYER USE ONLY

Date Hired (MM/DD/YY) (required) ___________________ Full-time Part-time (20 hours or less/week)

Date coverage is effective ____________________ Actively Working COBRA

________________________________________ Retiree 65 or older Retiree 55–65 Retiree Under 55

Date of status change ______________________ Employer Name___________________________________________________

Part- to full-time Union to non-union Other _______________________________________________________

Group/Subgroup #: ___________________________________ Class #: _____________________________________________

Chamber Assoc: ______________________________________ Grp Admin Initials (required) ________________________

A. EXPLANATION (CHECK ALL THAT APPLY)New Hire Open Enrollment Loss of Coverage Marriage Birth Change in Student Status Dependent through 29

Name/Address Change Court OrderCOBRA—Reason: Left Employ/Retirement Divorce/Legal Separation Death of Spouse Dependent Reached Max Age Loss of Student Status

Termination—Reason: Employment Terminated Remove Dependents Only Deceased Other_________________________________________

B. COVERAGE INFORMATION (CHECK ALL THAT APPLY)Product Type: HMO EPO HDEPO PPO HDPPO HNY

PCP Copay Amt: $ ________ Specialist Copay Amt: $ ________ % Coins: _____ Deduct. Amt: $ _________ Delta Dental Coverage

Compliance with Pediatric Essential Dental Health Benefit. (For employees of small groups [≤50] only.) For each member 18 or younger, indicate whether you

obtained stand-alone dental coverage that provides a pediatric dental essential health benefit through a New York Health Benefit Exchange-certified stand-alone

dental plan offered outside the New York Health Benefit Exchange. If you answer “yes,” please provide the name of the company providing the stand-alone dental

coverage. If you answer “no,” we will provide you coverage of the pediatric dental essential health benefit. Additional cost may apply. Ask your employer for rate

information.C. FUNDING ACCOUNT (CHECK ALL THAT APPLY)I am participating in a CDPHN-administered:Flexible Spending Account (FSA) Health Reimbursement Arrangement (HRA) Health Savings Account (HSA) Not Applicable

D. SUBSCRIBER INFO (CHECK ALL THAT APPLY)For HMOs only, you and each dependent MUST select a Primary Care Physician (PCP). Females may also choose one OB/GYN. Also indicate if a member is a current

patient and get the Physician # and Office Location from the provider directory or at www.cdphp.com. For all other products, include copy of your HIPAA certificate.

If you have Medicare Parts A and B, include a copy of your Medicare card.1. Last Name First Name M.I. 4. Telephone: Home Work Mobile

__________________________________________________ ____________________________ _______ _______________________________________________________________

2. Street Address Apt. # 5. E-mail Address

__________________________________________________________________________________________ _____________________________________________________________

3. City State ZIP 6. Employer Name

__________________________________________________ _____ __________________________ _________________________________________________________________

7. Social Security Number (Required)____________________________________________ Date of Birth ______________________________Medical

___________________________________________________________________________________ ____________________________________________ Add or Delete

Sex: M F Disabled End-Stage Renal Disease

Medicare number: ____________________________ Part A effective date: _______________________ Part B effective date: ___________________ Delta Dental

If 18 or younger, has stand-alone dental coverage been obtained through an Exchange-certified plan offered outside the Exchange?Add or Delete

Yes. Name of Company_________________________________________ No. (CDPHP will provide pediatric dental benefit)

Primary Language (optional*): Spoken: __________________________________________ Written: ________________________________________

Ethnicity (optional*): White Black American Indian/Alaska Native Asian/Pacific Islander Hispanic/Latino Other

Previous coverage: Yes Previous carrier: ___________________________________ Effective from: _______________ To: _________________

HMO only—Physician (PCP) Last First M.I. Office location Phys # Current Patient?

_____________________________________________ _____________________ ______ ________________________________ ______________________________

OB/GYN Last First M.I. Office location Phys # Current Patient?

_____________________________________________ _____________________ ______ ________________________________ ______________________________

*You are not required to answer. This information is important, however, as it helps us understand the diversity of our membership.


Enrollment PeriodsRefer to contract for full details.

CDPHP shall permit an employee who is eligible, but not enrolled, for coverage under the terms of the contract (or a dependent of employee who is eligible, but not enrolled), to enroll for coverage if the following conditions are met:

ϐ The employee or dependent was covered under a group health plan or had health insurance coverage at the time coverage was previously offered to the employee or dependent .

ϐ The employee’s or dependent’s coverage was under a COBRA continuation provision and the coverage was exhausted or was not under such a provision and either the coverage was terminated as a result of loss of eligibility for the coverage or employer contributions toward such coverage were terminated .

ϐ The employee’s request for enrollment is no later than 31 days after the date of exhaustion of coverage or termination of previous coverage or employer contribution .

If a person becomes a dependent of a member through marriage, birth, adoption, or placement for adoption, the person may be enrolled as a dependent of the individual . In the case of birth or adoption, the spouse of the individual may also be enrolled as a dependent of the individual if such spouse is otherwise eligible for coverage .

A dependent special enrollment period shall be a period of no more than 31 days and shall begin on the later of:

ϐ The date dependent coverage is made available; or

ϐ The date of the marriage, birth, or adoption or placement for adoption .

If an individual seeks to enroll a dependent during the first 31 days of such a qualifying event, the coverage of the dependent will become effective:

ϐ In the case of marriage, no later than the date of marriage or the 1st of the month following the date of the marriage;

ϐ In the case of the birth of a dependent, the dependent is eligible as of the date of birth .

ϐ In the case of a dependent’s adoption or placement for adoption, the date of such adoption or placement for adoption .

CDPHP shall permit an employee and a dependent, who are eligible, but not enrolled, for coverage under the terms of the contract to enroll for coverage if the following conditions are met:

ϐ The employee or dependent lost eligibility for coverage under a State Medicaid, Family Health Plus, or Child Health Plus program, or

ϐ The employee or dependent has become eligible for State premium assistance, and


ϐ The employee or dependent submits an application form to CDPHP within 60 days of being terminated from Medicaid, Family Health Plus, or Child Health Plus coverage or within 60 days of being determined to be eligible for premium assistance .

Rejecting Enrollment or Electing Not to Enroll During Open EnrollmentRefer to contract for full details.

If an individual rejects initial enrollment or elects not to enroll during a subsequent open enrollment, they may enroll for coverage if the following conditions are met:

ϐ Individual or their dependent had coverage under another plan or contract when coverage was initially offered or at a subsequent open enrollment period; and

ϐ Coverage was provided in accordance with continuation required by state or federal law and was exhausted; or coverage under the other plan or contract was terminated because individual or their dependent lost eligibility for one or more of the following reasons

» Termination of employment

» Termination of the other plan or contract

» Death of the spouse

» Legal separation, divorce, or annulment

» Reduction in the number of hours worked

» Employer or other group ceased its contribution toward the premium for the other plan or contract

» Coverage was under an HMO, and individual no longer lives, works, or resides in the HMO service area

» Cessation of dependent child status

» Benefits are no longer offered to similarly situated individuals (e .g ., part time employees); or

» The benefit maximum under the plan or contract has been reached

ϐ Individual acquires a dependent due to birth, adoption, guardianship, placement for adoption or marriage, in which case the subscriber may enroll for coverage or for a type of coverage available to your group that will cover you and your eligible dependents; or

ϐ Individual loses eligibility for coverage under the Medicaid, Family Health Plus, or Child Health Plus, or they become eligible for state premium assistance under Medicaid, Family Health Plus, or Child Health Plus

ϐ Individual applies for coverage within 60 days of one of the above events occurring .


BillingStatementsCDPHP will send the group a monthly billing statement based on currently enrolled members . The group will receive an invoice approximately 10 days before the due date . Premiums are due on the first of the month of coverage (i .e ., June premiums are due June 1, and the group will receive the invoice around May 20) .

It is the group’s responsibility to reconcile a monthly invoice to ensure any requested changes have been made . Changes to coverage must be submitted via the Enrollment Application/Change Form and returned to:

CDPHP Attn: Membership and Billing Dept . 500 Patroon Creek Boulevard Albany, NY 12206

or email to membership@cdphp .com or fax to (518) 641-4008

Changes should not be sent with invoice payments.

Payment should include both current premiums and retroactive adjustments . If our records indicate an amount outstanding or overpaid, the group will be notified in writing .

Always include the bottom portion of the first page of the invoice with payment . Payment should be made in the envelope provided . Please write the group number on the check and be sure the CDPHP address is visible through the window on the envelope .

Mid-Month Enrollment and DisenrollmentThe group will be charged a full month’s premium for enrollments effective between the first and the 15th of the month . The group will not be charged for enrollments effective between the 16th and the end of the month .

Disenrollments effective between the first and 15th of the month will not be charged a premium for that month . Disenrollments effective between the 16th and the end of the month will be charged a full month’s premiums .

CDPHP does not prorate premiums .

Checklist for Paying Invoices

� Reconcile the invoice to be sure any additions, deletions, or changes that were previously submitted have been properly reflected on the premium statement .

� Put the group number on the check to ensure payment is posted to the correct account .

� Enclose the bottom portion of the first page of the invoice with an explanation of payment if the amount paid does not match the amount billed .

� Please DO NOT enclose Enrollment Application/Change Forms with premium payments .

� Please forward payments to: CDPHP P .O . Box 5251 Binghamton, NY 13902-5251

� Premium payments can also be made online . Please contact Automation at (518) 641-4167 for further details .

� Please call 1-866-258-1785 with questions regarding the bill .

The group will receive an invoice approximately 10 days before the due date. Premiums are due on the first of the month of coverage.



COBRA COBRA members will be billed on the existing group premium invoice . CDPHP does not bill COBRA members directly . The employer is responsible for collecting and paying CDPHP any premiums due for COBRA enrollees . Employers must notify CDPHP of the termination date when terminating COBRA enrollees .

Dependent Through 29Employers are not required to pay additional premium for dependent children electing this continuation option through the “Age 29” law . Participating dependents will be billed the single rate on the existing group premium invoice . The employer is responsible for collecting and paying CDPHP any premiums due for a participating dependent . An additional rider is available to offer dependents through age 29 coverage on the family account, at the family level, still listed as a dependent under parents .

Corporate ComplianceIn keeping with our commitment to integrity, and in response to increasingly complex state and federal regulations, CDPHP has created a formal corporate compliance program . The CDPHP Corporate Compliance and Integrity Program is both a proactive and a reactive effort designed to prevent, detect, and correct possible organization and employee behavior which may not fully comply with governmental laws and CDPHP corporate policies .

The program includes training all employees in regards to their duty and responsibility to follow governmental laws and CDPHP corporate policies, as well as to report suspected fraud or non-compliance of any employee, independent contractor, or agent of CDPHP .

As a contracted employer group with CDPHP, the group is encouraged to report any instance in which it believes CDPHP or any of its employees or agents may be violating any federal or state law or regulation governing our business activities . Contact the CDPHP Compliance Officer at (518) 641-5260 or the CDPHP Fraud/Compliance Hotline at 1-800-280-6885 to make such a report .

ConfidentialityCDPHP has established necessary safeguards to protect the confidentiality of group and member protected health information (PHI) . PHI includes information that CDPHP has created or received about a member’s past, present, or future health or medical condition that could be used to identify a member . It also includes information about a member’s medical treatment and payment for health care . CDPHP keeps PHI in strict confidence .

The group is encouraged to report any instance in which it believes CDPHP or any of its employees or agents may be violating any federal or state law or regulation governing our business activities . Contact the CDPHP Compliance Officer at (518) 641-5260 or the CDPHP Fraud/Compliance Hotline at 1-800-280-6885 to make such a report .


Member Privacy Rights ϐ Members may request access to information in their designated record sets .

Contact the CDPHP member services department at the number on the member’s identification card for further information .

ϐ Members may request that communications from CDPHP be sent to an alternative address . Contact the CDPHP member services department at the number on the member’s identification card for further information .

ϐ CDPHP is allowed to use and disclose PHI as necessary without member authorization in a number of different ways in connection with a member’s treatment, payment for health care, and CDPHP health care operations . For any other uses or disclosures, CDPHP obtains a member’s authorization, and the information is used as stated in the authorization .

ϐ The CDPHP Notice of Privacy Practices (NPP) contains a comprehensive listing of member rights and is published to CDPHP members annually .

Complaints, Grievances, and AppealsWe hope our health plan serves members well . If there is a problem, a member should talk to his/her doctor, or call or write member services . Most problems can be solved right away . Problems that are not solved right away over the phone, and any complaints or grievances that come in the mail, will be handled according to the CDPHP complaint and grievance procedures described in the Member Handbook . A brief overview of how to file a complaint or grievance is below .

CDPHP will not retaliate against any individual for bringing concerns to our attention . We will abide by the CDPHP membership certificate in any dispute over member benefits or rights .

How to File a ComplaintIf a member does not like some part of his/her CDPHP coverage that does not involve a decision we have made, a complaint may be filed by calling or writing to us . A designee (such as a lawyer, family member, or trusted friend) may file the complaint or grievance, if preferred .

1 . File a verbal complaint: To file a complaint by phone, call the member services department at (518) 641-3700 or 1-800-777-2273 Monday–Friday from 8 a .m . to 8 p .m . If we need more information to make a decision, we will tell the member .

2 . File a written complaint:

» by writing us a letter, or

» by asking us for a complaint form to fill out . To get a complaint form, call us at (518) 641-3700 or 1-800-777-2273 .

» Mail the complaint (form or letter) to: CDPHP Quality Enhancement Department, 500 Patroon Creek Boulevard, Albany, NY 12206-1057

The CDPHP Notice of Privacy Practices (NPP) contains a comprehensive listing of member rights and is published to CDPHP members annually.


All written decisions explain how to appeal if the member wishes to do so, and include any necessary forms . More information on filing a complaint can be found in the Member Handbook .

How to File a GrievanceIf a member does not like a decision CDPHP has made, other than a medical necessity decision, the member or a designee may file a grievance by calling or writing to us .

The member has 180 days after we tell him/her of our decision to file a grievance .

1 . File a grievance by phone: Call member services at (518) 641-3700 or 1-800-777-2273 Monday–Friday from 8 a .m . to 8 p .m . If we need more information to make a decision, we will tell the member .File a written grievance:


» by asking us for a grievance form to fill out . To get a grievance form, call us at (518) 641-3700 or 1-800-777-2273 .

» Mail your grievance (form or letter) to: CDPHP Appeals Department, 500 Patroon Creek Boulevard, Albany, NY 12206-1057.

All decisions will explain the specific reasons for the decision, any medical reasons for the decision, and how to appeal the decision . More information on filing a grievance can be found in the Member Handbook .

How to File an AppealIf the member is not satisfied with how we decide the complaint or grievance, he/she has 60 work days after hearing from us to file an appeal . If preferred, the member may ask a designee to file the appeal for him/her .

1 . File an appeal by phone: Call member services at (518) 641-3700 or 1-800-777-2273 Monday-Friday from 8 a .m . to 9 p .m .

2 . File and written appeal:


» by asking us for an appeal form to fill out . To get a appeal form, call us at (518) 641-3700 or 1-800-777-2273 .

» Mail your appeal (form or letter) to: CDPHP Appeals Department, 500 Patroon Creek Boulevard, Albany, NY 12206-1057.

More information on filing an appeal can be found in the Member Handbook .

The member has 180 days after we tell him/ her of our decision to file a grievance.

All decisions will explain the specific reasons for the decision, any medical reasons for the decision, and how to appeal the decision.


Claim Determinations The member or designee may file a claim for benefits by writing to CDPHP .

All decisions will explain the specific reasons for the decision, any medical reasons for the decision, and how to file a grievance . See the Member Handbook for more details .

Utilization Management DecisionsQualified health care professionals make all utilization management (UM) decisions . If a member disagrees with a UM decision, our resource coordination department (1-800-274-2332) may be able to help . See the Member Handbook for more information .

External AppealsA member may ask for an external appeal if CDPHP turned down a request for service, saying that it was not medically necessary or we believe it is experimental or investigational . External appeal requests must be in writing on a standard New York State Department of Financial Services (DFS) form, which can be found at, www .dfs .ny .gov/insurance/extapp/extappl .pdf .

We hope you found this manual useful in managing your health benefits. Please contact your broker or account representative with questions or for more information.

The terms of this manual are subject to the terms of the group contract and applicable law,

which would supercede the terms of this manual in the event of a conflict.

www.ins.state.ny.us/extapp/extappqa.htm

Capital District Physicians’ Health Plan, Inc. CDPHP Universal Benefits,® Inc.

500 Patroon Creek Boulevard, Albany, NY 12206-10 57 www.cdphp.com

14-0375 | 08.04.14

www.cdphp.com

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