OneSolutionEmployer Administration Guide

Sample Company

Administered by:

National Headquarters5400 LBJ Fwy. Suite 1425Dallas, TX75420

National Service Center1350 S. Boulder Ave.3rd FloorTulsa, OK74119

Welcome!ResourceOne Administrators (ROA) is pleased to welcome you as a new client!

This medical plan you have chosen is ROA’s OneSolution product.

This Administration Guide was written to help you understand ROA, your new medical benefits and your responsibilities as an employer to ensure the proper functioning of your plan.

We know you’re busy and may find it hard to read this guide from cover to cover. However, we strongly encourage you to look over the Table of Contents so you know what information this guide obtains. Also, please read the entire section entitled Employer Responsibilities. This section will recap all you have to do to keep your plan running smoothly. Everything else in this guide can be referenced as needed on a day-to-day basis.

Again, welcome from ROA. We are glad you chose OneSolution as your new plan of benefits and ROA as your administrator.

Meet Uno!

Uno will help you by pointing out each of the must-read sections in this guide..

Please review these sections and follow any instructions or suggestions given. Doing so will ensure your OneSolution plan runs smoothly for you and your plan participants.

Who We Are

ResourceOne Administrators is a privately owned Third Party Administration firm located centrally within the United States. Through strategic alliances with other benefit professionals, ROA is able to provide our clients with virtually all of their benefit needs.

ROA is committed to the service of our employers and their employees the professional administration they deserve, in a wide variety of industries.

At ROA, our staff provides us a major advantage in reaching our goals of controlling our client’s health care dollars. We employ experienced professionals who are dedicated to helping our clients. With associates having more than 25 years in self-funded administration, our seasoned staff have backgrounds in many areas.

Our mission is to lead the health insurance industry by providing quality, cost-effective employee benefits to the organizations we serve. We achieve this by utilizing state of the art technology, providing exceptional service and developing creative plan designs. The goal of ROA and our family of companies is to build long-lasting relationships based on honesty, integrity and results.

ROA Contact ListCustomer Service

Contact point for members, clients and agents

ROA’s Customer Service Team

800-967-2077 8:00 a.m. to 5:00 p.m. Central Standard Time

MedCareOne

Phone: 800-816-1206 Fax: 855-734-6581

PPO NetworkQuestions

Member, client and agent contact point for finding in-networkproviders.

Billing & Eligibility

Contact point for clients and agents about your monthly bill and your participants’ eligibility.

Your Billing Specialist800-967-2077 ext. 2327

ROAbilling@roatpa.com

ResourceOneP.O. Box 4830

Tulsa, OK 74159

Prescription Drug Plan CVS / Caremark877-860-6415 www.caremark.com

Account ManagementContact point for clients and on any and all aspects of plan administration.

Your Account Manager918-280-7797 benefits@roatpa.com

Utlization Review &Case Management

Enrollment

Initial Enrollment

Initial enrollment was completed at the time you signed up for OneSolution. At that point, your employees and dependants were entered into our system and a Fulfillment Packet with ID card(s) were created and distributed per your instructions at implementation. Please see the Fulfillment section below for details on this packet.

Ongoing Enrollment

You have chosen to submit new enrollees, terminations and changes via paper enroll-ment forms. Please make sure you fill out all enrollment materials completely and send them to your Billing & Eligibility Specialist before the 10th of each month so they are on your next bill. Also note that retroactive changes can be only honored for 60 days.

Please keep your eligibility changes up-to-date. Doing so will ensure that your employ-ees get their Fulfillment Packets and ID cards timely and that their claims will be processed without delay. Please note that retroactive changes can only be made back 60 days.

* Process all new enrollees, terminations and changes upon receipt and remit those timely to ROA per the eligibility processes agreed upon implementation. Also note that retroactive changes can only be made back 60 days.

COBRA Administration

COBRA administration will be done by CobraOne. Whenever a participant terminates from, your plan, we will assess the reason for termination provided by you. If that reason qualifies the termed participant for COBRA, we will send a COBRA offering and handle everything on our end. If the participant elects COBRA, we will bill them directly and make sure all COBRA regulations are followed and timeframes are well met.

* Your employer responsibility to be COBRA-compliant is to send all terminated participants to CobraOne timely and always include a reason for termination. We will handle everything else once we receive the participant’s termination information.

BillingMonthly List Bill

On the 27th of each month, ROA will generate a monthly invoice for premiums and fees due for the following month. For example, a check run on January 27 would be the cost of February’s coverage.

This check will be sent to your designated representative via secure email. It will include a list of covered employees, the products they have selected and the charges for each of these products.

This bill is due before the first of the next month. So, a check run on January 18 would be due on January 31. It is important to pay aa billed on time. This allows for proper claim funding and prevents delays in claim payments There is a 30-day grace period for each invoice before the client is terminated due to non-payment. However, late payments will result in a delay in claims payment. So, always pay on time and as billed.

* See the Appendix for a sample bill. Pay before the 1st of every month. Mail check payments to ROA’s P.O. box on the contact list in this guide. Write your group number on the check so we correctly apply your payment to your bill. Bills not paid within the 30-day grace period will result in lapse of group coverage.

Lapse of Group Coverage

In the event your group terminates due to non-payment, you will need to take immediate steps to amend your OneSolution plan to terminate it. This must be done to terminate your liability on future claims incurred on your self-funded plan. Your ROA representative can explain this in detail and will help you through this process. Contact yout account manager if you ever get within five business days of your group coverage lapsing.

*Contact your ROA account manager if you get within five business days of lapsing coverage for assistance in legally terminating your self-funded benefit plan.

Benefits: An Overview

Below is a brief description of each of the products you currently have under your OneSolution plan.

* For details on these products, contact one of the account management staff on the ROA Contact List in this guide. You can also view Plan Documents on the QicLink Guide at www.roatpa.com per the instructions in this guide.

MVP

Your MVP includes a Minimum Essential Coverage Plan

that covers the 63 preventative services mandated by the Affordable

Care Act in order to avoid tax penalties. In addition, your MVP plan covers prescriptions and out-patient services such as office visits, x-rays

and emergency room.

Limited Medical Benefit Plan

You have a fully-insured LB plan which pays first-dollar coverage up to a benefit

maximum on services such as emergency room visits, office visits and prescription drugs. Having this type of plan as part of your benefit package

enhances your coverage without adding any undue cost to your employees.

PPO

(PPO Network) is the Preferred Provider Organization for OneSolution. Any covered services

incurred at a PPO provider are entitled to their discounts. This

applies whether the services are covered by your plan or not. To save money on their claims, participants

should contact their PPO per the instructions on their ID cards.

CVS / Caremark

This product is your prescription plan that offers a choice of copays and

coinsurance for generic, brand, formulary and non-formulary

prescription drugs up to a maximum limit. With this Rx benefit, employees

can get the medications they need now to get well and prevent health issues from escalationg and causing them

greater financial stress.

Fulfillment Documents: For Employees & Employer

For EmployeesAs previously mentioned in the Enrollment section, we will provide a Fulfillment Packet for each household once the initial enrollment of your employees and their dependents are completed. This packet contains the following information to help participants understand their plan and how to see it.

• Cover letter explaining the contents of the Fulfillment Packet and how to contact ROA when help is needed.

• Medical ID cards

• FAQ sheet for the Affordable Care Act’s MEC benefit plans

• Schedule of benefits

• Explanation of a participant’s Continuation of Coverage Rights under COBRA

* See the Appendix for a sample FAQ sheet and continuation of coverage rights under COBRA.

For you, the EmployerWelcome Packet: This should have been delivered to you already by your broker. We provide these to new clients so they have the following information and resources to help them during the implementation process, such as a short Contact List, temporary ID cards and Benefits Change and Enrollment forms in case you have to submit changes to your initial enrollment.

Administration Guide: Now you should use this Guide for full instructions on administering your plan. As previously noted, this guide has an expanded ROA Contact List to use from here on out. Your plan participants should have already received their ID cards in their above mentioned Fulfillment Packet. As long as you send us new enrollment and eligibility changes timely, you should no longer need the temporary ID cards. Because you’re submitting ongoing enrollment, via paper enrollment forms, you can continue to use the Benefits Change Form for terminations and changes in eligibility.

Claims

The Claim Process• Incurring a claim: To ensure a claim is submitted properly to ROA for processing and

payment, all a participant needs is a OneSolution ID card. As stated above under the Fulfillment section, ID cards are sent to the home of each covered employee upon initial enrollment. This card should be presented to a medical provider at the time a claim is incurred. It contains both electronic and manual claim filing instructions for providers. It has names and contact information for your plan’s PPO and other vendors. These cards also have information for contacting ROA’s customer service team.

• Filing a claim: Filing a claim with ROA is generally done by providers and is not a claimant’s responsibility. In fact, if a claimant’s provider is in your PPO Network, they are contractually bound to file the claim for the claimant. Non-PO providers will generally file the claim as well. In the event a non-PPO provider will not file a claim, the participant should ask for an itemized receipt and contact our customer service tea, at the number provided on their ID card for instructions on how to do this manual filing.

• Claim Payment & Explanation of Benefits (EOBs): Once ROA receives a claim, we will process it on all plans in place for that claimant. If payment is due, we will include the amount in our weekly check to that provider. The claimant will receive one EOB each month will all claims processed for them during that month. If a payment is due to the claimant instead of the provider, we will send the claimant a check at the time of processing and not hold it until the end of the month.

* Please see the Appendix for a sample Explanation of Benefits.

Claim FundingYour main responsibility in funding claims is to pay your bills on time each month. That’s because a portion of your bill payment is set aside to pay claims. Once your money is depleted, your reinsurance carrier will supply additional funds to pay claims for the rest of that month, as long as your premium payments are current. If you’re late paying your portion of the claim fund, there could be a delay in obtaining funds from your carrier.

The good news is that renewing clients may be eligible for a refund at the end of their contract period.

At renewal, ROA will let renewing clients know how much money remains in their claim fund at that time. You will have two options on how to use excess claims funds: use the funds to pay future bills or let them remain in your claim fund to pay claims during the six-month runout peri-od of your contract.

If you choose to use these funds to pay runout claims, and there are still excess funds remain-ing after the six-month runout period, you can either choose to be paid through these remain-ing funds directly or to apply the funds to future bills.

NOTE: If you decide to have the funds paid back to you, there are special federal requirements as to how they can be used. All this will be explained to you in writing at renewal and at the end of your contract period. Also, your ROA account manager can help you understand these op-tions so you can determine the best one for you to take.

* You can keep track of your claim fund from the Group Claim History Analysis which ROA will send you every month. See the Reports section for de-tails on the GCHA. However, always contact your account manager shown on the ROA contact list in this guide if you ever have any questions about your claim fund.

Reports & Legal Notices

Group Claim History AnalysisYou will receive one report from ROA each month. This report is your Group Claim History Analysis - GCHA. We will email it to you at the start of each month.

This GCHA gives you the following monthly and end-year-to-date information on your OneSolution plan:

• Number of billed employees

• Claim fund deposits from your bill payments

• Claims paid

• Claim fund surplus, if any

* Please see the Appendix for a sample GCHA. It is a straight forward and eay-to-understand report. However, an explanation of how to read it is also in the Appendix.

Legal NoticesThe federal government requires employer’s to send out several notices about participants’ rights regarding their medical plans. Currently they are as follows:

• Continuation Coverage Rights under COBRA

• Protected Health Information: Use & Disclosure

• Notice of Privacy Practices

• Premium Assistance under Medicaid & CHIP

• Women’s Health & Cancer Rights Act Notice

As mentioned in the Fulfillment section, we also provide the COBRA notice in each employee’s Fulfillment Packet.

Employer Responsibilities: A Recap

Throughout this guide, Uno has pointed out the instructions and information necessary for running your OneSolution plan. Below is a recap of these major points divided into a Must Do and a Must Read sections.

Please use this recap as a checklist to make sure you’re aware of your responsibilities (Must Do) and the information affecting your plan (Must Read).

We hope this Administration Guide has been easy to understand and that it serves you through the coming year. Of course, you can always call any of your ROA account managers for help. We appreciate your business and stand ready to give you whatever assistance you need.

Thank You

Must Do

• Process all enrollments, terminations and eligibility changes as soon as you receive them. Otherwise these changes will not be on your most current bill. Also, any retroactive changes can only be made back 60 days. Processing terminations timely is vital so that COBRA notices are mailed within the federally mandated timeframe.

• Call your Billing & Eligibility Specialist if you’re ever going to be late paying your bill to let them know when they can expect payment so that your coverage does not lapse.

• Call your ROA account manager immediately if you’re ever within five business days of the end of your 30-day grace period for paying your bill. If your coverage lapses due to non-payment, you must terminate your self-funded medical plan to avoid further claim liability. Your ROA account manager can help you with the amendment needed to terminate your lpan legally.

Paying your Bills• Pay all bills in full and on time

• Include any explanatory back-up information at time of payment

If paying by check…

• Write your group number on your check

• Mail your check to the P.O. Box shown on the ROA Contact List in this guide

Must Read

• Learn more about ROA by visiting our website at www.roatpa.com

• Read the sample documents noted previously in this guide listed in the Appendix to familiarize yourself with all paperwork, reports and notices that are relevant to your plan.