cdphp administration manual...cdphp administration manual 14-0375 | 08.04.14 product guide the cdphp...

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 CO

NCERNDEPARTMEN

T AND NUMBER

ϐ Adding or deleting dep

endents

ϐ Enrollment application

questions

ϐ Eligibility issues

Group Services Unit

1-866-258-1785 or (518)

641-3900

ϐ Calls placed on behalf o

f 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 S

pecialist Unit

(518) 641-3747

Broker_Employer@cdph

p .com

ϐ Commission questions

ϐ To become a CDPHP bro

ker

Broker Commission Specia

list

(518) 641-5131

Health Funding questions

on behalf of a

member, including:

ϐ Debit card inquiries

ϐ Account balances

ϐ Status of submitted FS

A and HRA claims

Health Funding Departme

nt

1-877-793-3960 or (518)

641-3770

ϐ Secure site inquiries

ϐ Account management o

f group and broker

secure site users

Automation Specialist

(518) 641-4167

mbsecuresite@cdphp .co

m


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.comhttps://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-Cornerwww.caremark.comhttp://www.cdphp.com/Brokers/Get-Your-Job-Done/Medicare-Resources/Medicare-Creditable-Coveragehttp://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.ashxhttp://www.cdphp.com/~/media/Files/Employers/Pediatric-Dental-Group-Attestation-Form.ashxhttp://www.cdphp.com/en/Health-Care-Reform/brokers/pediatric-dentalhttp://www.cdphp.com/en/Health-Care-Reform/brokers/pediatric-dentalhttp://www.cdphp.com/~/media/Files/Employers/Secure_Site_Brochure_for_Employers_Brokers.ashxhttp://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 BeSMwww .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® InMotionSMinmotion .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 .

CafeWellTMwww .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.aspxhttp://inmotion.cdphp.comhttp://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.ashxhttp://www.cdphp.com/~/media/Files/brokers/SampleBor2.ashxhttp://www.cdphp.com/~/media/Files/brokers/02-0010-Member-Application-OffExchange-2014.ashxhttp://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 corr

espondence:NYS-45-MN (7/06)

Quarterly Combined Withholding, Wage R

eporting,

And Unemployment Insurance Return

Postmark

Received date

UI SK

AI SIWT SK

Number of employees

Enter the number of full-time a

nd part-time covered

employees who worked during

or received pay for

the week that includes the 12th

day of each month.

Part A - Unemployment insuran

ce (UI) information

Part B - Withholding tax (WT)

information

20b. Credit to next quarter

withholding tax ....... or

21. Total payment due (add line

s 9 and 19; make one

remittance payable to NYS

Employment Taxes) ...........

* An overpayment of either tax can

not be used to offset the amo

unt due on the other tax.

Complete Parts D and E on b

ack of form, if required. This is

a scannable form; please file

the original.

Part C – Employee wage and

withholding information

Quarterly employee/payee wag

e reporting information (if more

than five employees or if

reporting other wages, do not m

ake entries in this section; comp

lete Form NYS-45-ATT. Do not

use negative numbers; see instr

uctions)

Annual wage and withholding to

tals

If this return is for the 4th quarter

or the last return you will be filing

for the calendar year, complete co

lumns d and e.

a Social security number

b Last name, first name, midd

le initialc

UI total remuneration/gross

wages paid this quarter

d Gross wages o

r distribution

(see instructions)

e Total tax withheld

Taxpayer’s signature

Signer’s name (please print)

Title

DateTelephone num

ber

a. First monthb. Second mon

thc. 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 differenc

e) ......

20. Total WT overpaid (if line 18


e

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

20a. Apply to outstanding

liabilities and/or refund ......

UI Employerregistration num

ber

Withholdingidentification nu

mber

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 t

he information on this return a

nd any attachments is to the be

st of my knowledge and belief t

rue, 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


e) ......

10. Total UI overpaid (if line 8

is greater than line 7, enter differ

ence

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

11. Apply to outstanding liabilities

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

Totals (column c must equal remu

neration on line 1; see instructions

for exceptions)

Taxyear

Mark an X in only one box to ind

icate the

quarter (a separate return mus

t 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

Schedule C (Form 1040) 2006

OMB No. 1545-0074

SCHEDULE C

(Form 1040)

Profit or Loss From Busi

ness

(Sole Proprietorship)

� Partnerships

, joint ventures, etc., mus

t file Form 1065 or 1065-

B.

Department of the Treasu

ry

Internal Revenue Service

Attachment

Sequence No. 09

� Attach to Form 1040, 104

0NR, or 1041. � See In

structions for Schedule C

(Form 1040).

Name of proprietor

Social security number (

SSN)

A Principal business

or profession, including

product or service (see p

age C-2 of the instruction

s)

B Enter code from pages

C-8, 9, & 10

� D Employer

ID number (EIN), if any

Business name. If no sepa

rate business name, leave

blank.

C

Accounting method:

E

F

Yes No

G H

Did you “materially partic

ipate” in the operation of

this business during 2006

? If “No,” see page C-3 f

or limit on losses

If you started or acquired

this business during 2006

, check here

�

Income

Gross receipts or sales. C

aution. If this income was

reported to you on Form W

-2 and the “Statutory

employee” box on that fo

rm was checked, see pag

e C-3 and check here

�

1

1 2

2 Returns and allowa

nces

3

3 Subtract line 2 from

line 1

4

4 Cost of goods sold

(from line 42 on page 2)

5

Gross profit. Subtract lin

e 4 from line 3

5

6

Other income, including f

ederal and state gasoline

or fuel tax credit or refun

d (see page C-3)

6 7 Gross

income. Add lines 5 and

6

� 7

Expenses. Enter expenses

for business use of your h

ome only on line 30.

8

21

Repairs and maintenance

21

Advertising

8

22

Supplies (not included in Par

t III) 22

23

9

Taxes and licenses

23

10

Travel, meals, and entertai

nment:

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 prog

rams

(other than on line 19

)

14

25

15

Utilities

25

Insurance (other than hea

lth) 15

26

Wages (less employment cred

its) 26

Interest:

16

16a

Mortgage (paid to banks, e

tc.) a

Other expenses (from line

48 on

page 2)

27

16b

Other

b 17 Legal an

d professional

services

18

Office expense

18

19

Pension and profit-sharing

plans

19 Rent or lea

se (see page C-5):

20

20a

Vehicles, machinery, and equip

ment a

b

Other business property

20b

Total expenses before exp

enses for business use o

f home. Add lines 8 throu

gh 27 in columns

�

28

28

31

31

All investment is at risk.

32a

32

Some investment is not

at risk.

32b

Schedule C (Form 1040)

2006

For Paperwork Reduction

Act Notice, see page C-

8 of the instructions.

(1) Cash

(2) Accrual

(3) Other (specify)

�

Business address (includin

g suite or room no.)

�

City, town or post office,

state, and ZIP code

Cat. No. 11334P

29 30

Tentative profit (loss). Sub

tract line 28 from line 7

Expenses for business us

e of your home. Attach For

m 8829

29 30

�

Part I

Part II

27

Net profit or (loss). Subtr

act line 30 from line 29.

● If a profit,

enter on both Form 1040

, line 12, and Schedule S

E, line 2, or on Form 1040

NR,

line 13 (statutory employe

es, see page C-6). Estate

s and trusts, enter on Fo

rm 1041, line 3.

● If a loss, y

ou must go to line 32.

If you have a

loss, check the box that

describes your investmen

t in this activity (see page

C-6).

● If you checked 32a, ent

er the loss on both Form

1040, line 12, and Schedu

le SE, line 2, or on

Form 1040NR, line 13 (sta

tutory employees, see pag

e C-6). Estates and trusts,

enter on Form 1041,

line 3.

● If you checked 32b, yo

u 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 1-800-9

93-7299

Employer Application Form

Please Print

This application is hereby m

ade with CDPHP for enrollm

ent of eligible members in a

ccordance with the contract

of the employer named belo

w for coverage

subject to the group meetin

g group eligibility.

Group Effective Date:_____

______________________

______________ End D

ate: ___________________

______ Group ID:_____

______________

Check all that apply:

MedicalDelta Dental

CDPHN-Administered Health

Funding Arrangement(s):

Flexible Spending Account

(FSA) Health Reimbu

rsement Arrangement (HRA)

Health Savings Account (HS

A) None

EMPLOYER INFORMATION (R

equired)

1. Legal company name

__________________________

__________________________

__________________________

__________________________

__________________________

_________________

Fed Tax ID

SIC co

de

____________________________

____________________

________

_______________

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

? YN

5a. Total number of employ

ees on company payroll nat

ionwide (include full-time, p

art-time, owners), all locati

ons ___________________

_____________

5b. Total number of employ

ees eligible for health insur

ance (eligible employees m

ust work a minimum of 20

hours a week) nationwide

______________

5b. in all locations _______

________

CLASSIFICATION OF COVER

ED EMPLOYEES

The group agrees that mem

bership enrollment applicat

ions will be submitted only f

or eligible employees subje

ct to the enrollment provisio

ns set forth in the

contract and subject to the fo

llowing eligibility guidelines

. Member enrollment applica

tions should be submitted n

o later than 30 days prior to t

he effective date.

6. Eligible employee definit

ion (check one): Full-t

ime onlyFull-time and

part-time (20 hours or mor

e)

SUBGROUPS

__________________________

__________________________

__________________________

__________________________

__________________________

_________________

__________________________

__________________________

__________________________

__________________________

__________________________

_________________

ENROLLMENT CLASS

7. Class description (i.e., hour

ly and salary employees): ___

________________________

________________________

_________ Class #: ______

___________________

Waiting period for new hire:

________________________

________________________

________________________

________________________

_________________

Employer contribution % or $

Single: ________ Emplo

yee + Spouse: ________ P

arent + Child(ren): _______

_ Family: _________ Med

icare: ________

Non-Medicare retiree: ____

_____ Employees will be

terminated (check one):

End of monthDate of termin

ation

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.ashxhttp://www.cdphp.com/~/media/Files/brokers/02-0010-Member-Application-OffExchange-2014.ashxhttp://www.cdphp.com/~/media/Files/brokers/02-0010-Member-Application-OffExchange-2014.ashxhttp://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.ashxwww.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.ashxhttp://www.cdphp.com/Members/Health-Plan/Health-Accounts/hsahttp://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

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