2023 Application for Small Employer Coverage
2022 employee IBX Plan Brochure
2020 Application Small (Employee)
2020 Application Small (Employer)
2020 Blue Solutions Renewal Guide
Benefits Plan Comparison In network 2020
Keystone HMO Proactive Tiered Network Flyer
Tips on applying:
- Make sure to include the current UC2A report and eligibility form/ownership docs for the owner if owner is not on the UC2A report (See Eligibility Form for acceptable owner docs).
- On The UC2A report, please write the employee statuses next to their names– part-time, full-time, termed.
- If any full-time employees on the UC2A report are waiving, a waiver form must be completed.
- Make sure to include a signed copy of the quote with plan selection listed.
- No check needed for IBC- group, you will be invoiced for first premium
- On the new IBC BOR/Online access form, the “Producing Agent” box should be checked off on page 2
AFA Small Group New Business Checklist 2020
AFA New Business Submission Process 2020
Data Software License Agreement 2020
AFA Billing and Banking Handbook ABA-EBS 2020
Aetna AFA Customer Info Request Form- Blank
AFA Banking Consent Form (ACH)
AFA-Paperless-Process Submission Info
Springboard- AHIA-FSR User Template
SG AFA Springboard Census and Setup Template 11-17
Aetna 51-100 Savings + Brochure
For Aetna AFA medical, some of the forms are electronic, but here is the checklist (the employer app and HCRA are DocuSigned).
In addition to attached, we need (after the Sales Notification is submitted)—
- Aetna proposal – please circle selected plans, sign and date
- Copy of the group’s most recent prior carrier bill
- Group’s under 5 enrolling require the annotated UC2A report
Please note before a group can apply for Aetna AFA, they need to be medically underwritten, and then we submit a sales notice (last attachment) when they are ready to apply. We can run preliminary quotes first though.
Employer eServices Scheduled Direct Debit
Above is fully insured 2020 UHC paperwork.
- On the the direct debit form. ACH is optional for groups of 4+ enrolling and required for under 4 enrolling.
- If not paying with ACH/ 4+ enrolling, then include the first month’s premium check made payable to UnitedHealthcare®
- Need the signed rates with their plan selection
- Need current UC2A with employee statuses marked (Part-time, Termed, Full-time Waiving)
- If the owner does not appear on the UC2A we will need proof of ownership such as a K-1 or schedule C.
- Need payroll for any new hires who do not appear on the UC2A
All Savers 2020
For UHC AllSavers (Level-Funded) 2020 new group, we need the following–
- Employer medical Application
- ER Excess Loss Form
- ER vision/Dental app
- Current medical, vision and dental carrier bill
- Billing Agreement Form
- NY Forms (Level-Funded Requirement)
- Employee Medical Enrollment Form (or there is an Excel enrollment template that can be used if needed)
- Check made payable to UnitedHealthcare®
- UC2 Report – Quarterly tax and and wage statement
- A copy of sold rates (note: sold rates should be the medically underwritten rates, not the initial street quote).
- Term letter on company letterhead, signed and date (if you want us to submit to the current carrier)
- If selecting AllSavers’ HSA Bank there is additional paperwork (not included)
Before applying, the group needs to be medically underwritten with UHC.
Employer Participation & Floor Certification
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