400 Field Drive Lake Forest, IL 60045 www.starmarkinc.com Do For these quality boxes assurance, need Starmark updating? will call to verify the HRA plan design you have selected. Please indicate below whom Starmark should contact for verification (choose one): Company s Executive Contact Agent/Broker Company s Administrative Contact Managing General Agent Please select one of the following: I am a new Starmark customer. I am a current Starmark customer updating an existing Starmark-administered HRA. Starmark Group No.: I am a current Starmark customer adding a new Starmark-administered HRA. Starmark Group No.: Company Information Legal Name of Company ( Employer ) Business Address City State ZIP Street Address City State ZIP Executive Contact/Group Authorized Representative Federal Employer Identification Number (FEIN) Administrative Contact/Group Authorized Representative Telephone Administrative Contact Fax Administrative Contact Email Administrative Contact Additional Administrative Contacts/Group Authorized Representatives, If Applicable: Please list name(s) and email addresses of the Group Authorized Representative(s) who should receive weekly check registers for HRA activity: _ The preceding Group Authorized Representatives may have access to Protected Health Information (PHI). These individuals are authorized to discuss PHI that is the minimum necessary to administer the HRA. Please refer to your plan sponsor documents privacy requirements for your obligations to protecting your and your employees PHI. Eligibility and Special Ownership Rules I understand that only persons covered under the health plan are eligible as covered persons for the HRA. Employees (and their families) who are sole proprietors or partners of a partnership (including LLP and LLC members taxed as a partnership ), or more than 2% shareholders in a Subchapter S Corporation may not participate in the HRA plan. This exclusion does not apply to C-Corporations. Please list employees who do not qualify for the HRA in the spaces below. If the list changes, it is the employer s responsibility to notify Starmark of any changes. 1 B680-S669-158 (3-18)
A. What is the HRA Funding Period? Start Date: End Date: (Must match health plan deductible accumulation end date) B. Prior HRA Plan Rollover Do you wish to rollover your prior HRA into this HRA? Yes - please provide HRA rollover report from your previous HRA administrator. (Employees hired after this HRA plan effective date will receive benefit described in section 8.) o What is the time period this HRA will wait for prior HRA rollover until this HRA will begin to consider claims: 30 days 45 days 60 days 90 days No / Not Applicable C. ERISA HRAs are subject to the Employee Retirement Income Security Act of 1974 unless the plan is established and maintained for the benefit of employees of a church or the government (federal, state or local). The employer has determined that (choose one): The plan is governed by ERISA The plan is not governed by ERISA D. Medical Plan Design Selection I have selected the following health plan design to be paired with this HRA. As the employer, I understand that a covered employee and/or their dependent(s) must be covered under the health plan design I have selected in order to be eligible for the HRA: Healthy Incentives CDHP* Healthy Incentives PPO Healthy Choices HealthyEdge CDHP* HealthyEdge PPO * If an employer pays or reimburses all or part of employees medical expenses below the IRS-designated minimum HDHP deductible, the employees are not eligible to contribute to an HSA. Please consult your tax advisor. E. If your company has two or more Starmark health plan designs, which health plan design(s) should this HRA plan design be paired with? N/A (We have only one Starmark health plan design.) Plan 1 Plan 2 Plan 3 Plan 4 F. Who is eligible for reimbursement under the HRA plan (choose one)? Employees and Employees Only G. What kind of expenses should your HRA pay? Network selection (choose one): In-network only In-network and out-of-network N/A (Healthy Choices only) Health plan expenses (choose all that apply): Medical Deductible Medical Coinsurance Medical Copays and Access Fees Prescription Drug Card Deductible (if applicable) and Retail and Mail Service Copays 2 B680-S669-158 (3-18)
H. HRA Funding Method Employee Pays Upfront Deductible First (Bridge HRA) Amount Employee Must Pay First Upfront Deductible type (choose one): Aggregate: HRA benefits are payable after the entire employee + dependent upfront deductible is met. (Please note, the upfront deductible amounts for Employee + 1 Dependent and Employee + 2 or More must match.) Embedded: HRA benefits are payable for a member once either the individual deductible is met, or for the entire family once the family deductible is met. After the upfront deductible is met, the employer will reimburse % per eligible claim up to the HRA benefit limit. (Complete only if less than 100%.) If you selected your health plan benefit period to be on a calendar year basis, and the HRA starts on a date other than January 1 st, should the HRA provide the same deductible credit (up to the upfront deductible limit) as your health plan? Yes No Not applicable Employer Pays First (Advance HRA) Employer-Employee Cost Sharing (Shared HRA) Employer will reimburse % per eligible claim up to the HRA benefit limit. I. For family coverage, is the entire HRA benefit amount available to any covered person in the family? Yes (aggregate) No (embedded each covered person is limited to the employee-only HRA amount) J. Non-Standard HRA Request Requires prior approval from Starmark. Please consult your Starmark sales representative. Please provide the HRA benefit description. Attach a separate sheet, if needed. 3 B680-S669-158 (3-18)
K. Rollover of Unused Dollars If unused dollars remain in the HRA at the end of the HRA calendar year, do you wish to roll them over to the following year? No Yes (Please complete A and B.) A. Rollover % of each eligible claim up to the HRA maximum rollover amount B. In the chart below, indicate the maximum dollar amount that should be allowed for each employee/dependent tier. Employee Only Employee + 1 Dependent Maximum rollover Employee + 2 or More Please note: Rollover dollars are calculated at the end of the expiring HRA plan year, and thereafter are available to reimburse both prior HRA plan year and new HRA plan year eligible expenses for up to 365 days. L. Auto-Debit Authorization I authorize Starmark and the financial institution named below to initiate entries to my checking/savings account. This authority will remain in effect until I notify Starmark in writing to cancel it with such time as to afford the financial institution a reasonable opportunity to act on it. I can stop payment of any entry by notifying my financial institution. Any NSF charges will be the employer s responsibility. Employer Name Authorizer Signature Authorizer Title Date Authorizer Name Please Print Email Address Phone Number Name of Financial Institution Branch Address City State ZIP Bank Contact Name Bank Contact Phone Number Checking Savings Account No. Financial Institution Routing / ABA Number You will receive a Claims Activity Report, which will include a total of all claims processed for the week. This amount will be automatically debited from your account on the day specified. In the case of a holiday falling on the day the money is to be withdrawn from your account, the amount will be debited the next business day. Amount notification preference (choose one): Email Fax 4 B680-S669-158 (3-18)
M. Employer and Broker Acknowledgment Employer Signature Title Date Agent/Broker Name Please Print Agency/Company Name Agency/Broker Street Address City State ZIP Agency/Broker Phone Number Fax Number Email address Agent/Broker Signature Date MGA Name 5 B680-S669-158 (3-18)