Priority Health Small Group Renewal Decision Form Instructions

Check this box when the dependent's eligibility should end at the end of the month in which the dependent turns 26.

Check this box when the dependent's eligibility should end at the end of the calendar year in which the dependent turns 26.

Enter any additional details about dependent eligibility (for example a specific effective date, other eligibility condition, or brief explanation) as a short text string.

Enter the disability policy waiting period or any additional details to specify a custom timing or notes for the group's disability policy (e.g., number of days or other clarifying text).

Check this box if the disability policy terminates (or coverage ends) on the employee's last day worked.

Check this box if the disability policy continues through the end of the month in which the employee's employment ends.

Check this box if the disability policy continues for 30 days after the employee's termination date.

Check this box if the disability policy continues for 60 days after the employee's termination date.

Check this box if the disability policy continues for 90 days after the employee's termination date.

Provide the details for limited same-gender domestic partner coverage, such as applicable plan name, coverage level, eligibility conditions, or any notes required to describe the offering. Fill only if 'Limited (same gender)' is 'Yes'.

Check this box if you offer domestic partner coverage only for same-gender partners (limited domestic partner coverage).

Enter the details for enhanced domestic partner coverage (same and/or opposite gender), for example the plan or benefit levels, eligibility criteria, effective dates, or any explanatory notes. Fill only if 'Enhanced (same and/or opposite gender)' is 'Yes'.

Check this box if you offer enhanced domestic partner coverage that applies to same- and/or opposite-gender partners.

If you are not offering domestic partner coverage, provide any required explanation or additional comments about exclusions or future plans for offering coverage.

Check this box if you do not offer domestic partner coverage.

Enter any details about the early retiree coverage being offered (for example: whether coverage is available, plan name(s), eligibility rules, effective dates, or other relevant notes). Fill only if 'Early retiree coverage: Yes' is 'Yes'.

Check this box if your plan is offering early retiree coverage.

Check this box if your plan is not offering early retiree coverage.

Enter the total headcount of all employees in the group (includes full- and part-time employees).

Enter the total number of full-time employees and full-time-equivalent (FTE) employees combined.

Enter the number of employees who are eligible for the benefits or plan.

Enter the number of employees who will enroll in the plan at renewal.

Enter the number of employees who are eligible but are choosing to waive coverage.

Enter the full name of the company’s CEO or primary decision maker for this account.

Enter the job title or official role of the CEO/decision maker (for example, President or HR Director).

Enter the primary phone number for the CEO/decision maker, including area code and any extension if applicable.

Enter the email address for the CEO/decision maker.

Enter the full name of the primary group administration contact responsible for this employer account.

Provide the phone number for the group administration contact, including area code and any extension if applicable.

Enter the email address for the group administration contact where communications about the account should be sent.

Enter the full name of the group's billing contact person who will receive invoices and billing communications.

Enter the primary phone number to reach the group's billing contact, including area code and any extension if applicable.

Enter the email address for the group's billing contact where billing notices and electronic statements should be sent.

Enter the number of hours per week an employee must work to be considered eligible for full-time benefits.

Provide any additional details, exceptions, waiting‑period clarifications, or other comments related to full-time eligibility and how it is applied.

Enter the group's full legal name exactly as shown on the group's W-9 or official tax documents.

Enter the employer or plan group identification number assigned by Priority Health or your organization.

Enter the plan's renewal date.

Enter any additional information or notes required when adding the HealthEquity Flexible Spending Account (for example, instructions to include the HealthEquity FSA checklist or other enrollment details). Fill only if 'Add HealthEquity Flexible Spending Account — Yes' is 'Yes'.

Check this box if you want to add a HealthEquity Flexible Spending Account (FSA) to the plan.

Check this box if you do not want to add a HealthEquity Flexible Spending Account (FSA) to the plan.

Check this box if you want HealthEquity added as the banking partner for the HSA plan.

Check this box if you do not want HealthEquity added as the banking partner for the HSA plan.

Enter the layoff policy details or specify the applicable option (for example a number of days, 'Last day worked', 'End of month', or any other custom instruction) to clarify how layoffs are handled.

Check this box if employee benefits continue through the end of the termination month.

Check this box if employee benefits terminate on the employee's last day worked (no continued coverage beyond that date).

Check this box if employee benefits continue for 30 days after the employee's last day worked.

Check this box if employee benefits continue for 60 days after the employee's last day worked.

Check this box if employee benefits continue for 90 days after the employee's last day worked.

Enter the waiting period (in days) that a new employee must satisfy before becoming eligible for benefits for this class of employees.

Check this box to indicate new hires become eligible for benefits 60 days after their date of hire.

Check this box to indicate new hires become eligible for benefits effective on their date of hire.

Check this box to indicate new hires become eligible for benefits 30 days after their date of hire.

Check this box to indicate new hires become eligible for benefits 90 days after their date of hire.

If using the '1st of the month following' option, enter the number of days after hire that will be used to determine the first-of-month eligibility start date.

Check this box to indicate new hires become eligible on the first of the month following their date of hire.

Check this box to indicate new hires become eligible on the first of the month following 30 days after their date of hire.

Check this box to indicate new hires become eligible on the first of the month following 60 days after their date of hire.

Check this box if you have already purchased pediatric dental coverage through a certified stand‑alone dental carrier.

Check this box if you do not currently have pediatric dental coverage but understand it is required and you intend to purchase the coverage.

Check this box if you are renewing a 2013 plan design that is exempt and does not require pediatric dental coverage.

Check this box when the group is electing to renew its existing non-ACA (non-Obamacare) plan without changing to an ACA-compliant plan.

Check this box when the group is electing to renew its existing ACA-compliant plan (note that benefit changes may apply per ACA guidelines).

Enter the full official name of the plan being listed for renewal (the plan name to appear on the renewal).

Check this box when the group intends to switch from its current plan to a different ACA-compliant plan and will list the new plan name(s).

Check this box if the group's selected plan type is an HMO (Health Maintenance Organization).

Check this box if the group's selected plan type is a PPO (Preferred Provider Organization).

Check this box if the group's selected plan type is a POS (Point of Service) plan.

Enter the exact plan name and selection (HMO, PPO or POS) for the group’s renewal, e.g., the plan type and official plan name as shown on your proposal.

Check this box when you have completed the renewal decision form and are including it with your renewal submission.

Check this box if you are including the final dental proposal with your renewal materials (if dental coverage applies).

Check this box when you are including the final proposal for the group (medical or primary plan proposal) with your renewal submission.

Check this box if a HealthEquity FSA applies and you are including the HealthEquity FSA checklist with your renewal materials.

Enter any additional notes, comments, or other details related to the renewal group checklist that do not fit into the preset checkboxes.

Check this box if an HRA applies and you are including the HRA Schedule of Reimbursement with your renewal submission.

Enter the month (MM) portion of the 1/1 date for the previous calendar year (used when 'Yes' is checked). Fill only if 'Section 111 — Had 100+ employees during 50% of business days: Yes' is 'Yes'.

Enter the day (DD) portion of the 1/1 date for the previous calendar year (used when 'Yes' is checked). Fill only if 'Section 111 — Had 100+ employees during 50% of business days: Yes' is 'Yes'.

Enter the year (YYYY) portion of the 1/1 date for the previous calendar year (used when 'Yes' is checked). Fill only if 'Section 111 — Had 100+ employees during 50% of business days: Yes' is 'Yes'.

Check this box if you had 100 or more employees for at least 50% of your business days during the previous calendar year; if checked, provide the 1/1 previous-calendar-year date in the fields to the right.

Enter the month (MM) portion of today's date (used when 'No' is checked). Fill only if 'Section 111 — Had 100+ employees during 50% of business days: No' is 'No'.

Enter the day (DD) portion of today's date (used when 'No' is checked). Fill only if 'Section 111 — Had 100+ employees during 50% of business days: No' is 'No'.

Enter the year (YYYY) portion of today's date (used when 'No' is checked). Fill only if 'Section 111 — Had 100+ employees during 50% of business days: No' is 'No'.

Check this box if you did not have 100 or more employees for at least 50% of your business days during the previous calendar year; if checked, provide today's date in the fields to the right.

Check this box if you had 20 or more employees for 20 or more calendar weeks during the previous or current calendar year; if checked, provide the date the threshold was reached in the adjacent date fields.

Check this box if you did not have 20 or more employees for 20 or more calendar weeks; if checked, enter today’s date in the adjacent date fields.

Enter the agent's signature or printed name to acknowledge and authorize this form.

Enter the date when the agent signed this form.

Enter the employer's signature or printed name to authorize and certify the information on this form.

Enter the date the employer signed this form.

Enter the employer's termination policy details or note which option applies (for example: 'Date of termination', 'End of termination month', or specify a number of days or other conditions).

Check this box when the employee's coverage should end on the actual date of their termination (coverage terminates on the termination date).

Check this box when the employee's coverage should continue through the end of the month in which they terminate (coverage terminates on the last day of that month).