Instructions. Please complete the following documents. All application data and forms must be entered into the Oscar enrollment portal at business.hioscar. com.
New Jersey Application for Small Group Health Benefits Policy Instructions The attached forms should be completed with the assistance of your authorized Broker or Oscar Sales Representative. Please complete all necessary forms in their entirety. Please print in ink or type your responses. Ensure that all areas requiring a signature and date are complete. The Officer, Partner, Owner and / or Correspondent signing the application must be listed on the New Jersey Small Employer Certification. Completed enrollment application forms should be entered on the Oscar enrollment portal (business.hioscar.com) prior to your effective date. This can be completed by your Broker or an Oscar Sales Representative. Required documents Please complete the following documents. All application data and forms must be entered into the Oscar enrollment portal at business.hioscar. com. Oscar does not accept any paper forms by mail or fax. New Jersey Application for Small Group Health Benefits Policy This can be completed online in the Oscar enrollment portal and Section 5 (Signature) should be signed, scanned, and uploaded where indicated in the portal. New Jersey Small Employer certification This entire form is required to be signed, scanned, and uploaded to the portal New Jersey Employee Enrollment application One application should be completed for each employee or COBRA/continuation of benefits recipient enrolling. These applications can be completed entirely online by the employees, or completed on paper and data entered into the online portal. Small Employer Health Benefits Waiver of Coverage One form is needed for each employee waiving or refusing coverage. These can be completed online. Payroll verification through appropriate tax documentation, i.e., WR30 WR30 is required for groups, unless there are seven (7) or more eligible employees enrolling. If WR30 is not available a substitute payroll document such as a K-1, Schedule C and/or 1120 will suffice. All payroll verifications must be scanned and uploaded to the portal. Premium payment Payment of the first month's premium must be submitted with the application either by 1) ACH payment or 2) Check. ACH payments can be setup for automatic deduction on the first of every month or can be uploaded solely for an automatic first payment. ACH form can be found at https://www.hioscar.com/brokers/forms/small-group. If the group wishes to pay the first premium via check they must mail it to the address below with the Group Name and Group Number, if available. Oscar Garden State Insurance Corporation P.O. Box 419895 Boston, MA 02241 - 9895 Oscar: New Jersey Application for a Small Group Health Benefits Policy Policies effective 1/1/2019 and later 1 of 6 New Jersey Application for Small Group Health Benefits Policy Preferred effective date of coverage (mm/dd/yyyy)? Must be the 1st or 15th of a future month. (Note: The Effective Date will be on or after the date Oscar approves the application.) Section 1: Policyholder information Policy holder (full legal name of company) Employer Tax ID Policy Number: ___________ (Oscar Use Only) New policy Change in policy Main address City State ZIP Mailing address (if different than address from above) City State ZIP Telephone Facsimile Email address Contract information should be provided (check one) Electronically Hard copy Correspondent Title Type of organization Corporation Partnership Nature of business (specify): Proprietorship Other (explain): SIC code Number of full-time employees in your company* Number of full-time employees to be insured Class or classes to be excluded Insurance requested for Employees Only Employees and Dependents including Spouse Employees and Dependents excluding Spouse Should the plan provide coverage for domestic partners as permitted by P.L. 2003, c. 246? Yes If yes, should the plan provide coverage for coverage of children of a covered domestic partner? Yes Is the employer subject to the requirements of COBRA? Yes Is the employer subject to the requirements of Medicare as Secondary Payor Rules for eligibility due to age? Yes Due to disability? Yes Orientation period? Yes *Refer to the New Jersey Small Employer Certification for the definition of a full-time employee. Oscar: New Jersey Application for a Small Group Health Benefits Policy Policies effective 1/1/2019 and later No No No No No No 2 of 6 Waiting period before employees become insured (may not exceed 90 days): Present employees New or rehired employees Period for Annual Employee Open Enrollment Period No waiting period No waiting period One month One month Two months Two months 90 days 90 days What percentage of the premium will the employer pay? Deposit ($) Premium paid* Monthly Automatic checking withdrawal Affiliates, subsidiaries or branches (Must be included for purposes of participation) Legal name & location No. of full-time employees in this company No. of full-time employees to be insured Section 2: Specifications for coverage Please select up to 3 desired health benefits options: Oscar Bronze $3,000 Oscar Silver $2,500 PPO Oscar Silver $0 Oscar Silver $1,500 Oscar Gold $1000 Oscar Platinum $0 Oscar Silver $2,500 Deductibles and out-of-pocket accumulation periods are on a... *All plans include pediatric dental. Calendar year Contract year basis Section 3: All questions must be answered 1. Is there any Group Health Plan: Now in force and to be continued? Currently being applied for? If "Yes", identify the name of the Group Health Plan, give a description of the plan(s) and name of insurance carrier(s): Yes No Yes No 2. Name of present or prior group carrier (required) Effective date of prior coverage Cancellation/termination date Is the coverage applied for in this application replacing other group insurance? If "Yes", give reason: Plan being replaced: 3. Are extended benefits provided in case of termination of health benefits? *Premium will be due as of the effective date. The premium for the first month of coverage must be attached. Oscar: New Jersey Application for a Small Group Health Benefits Policy Policies effective 1/1/2019 and later Yes No Yes No 3 of 6 To the best of your knowledge are there any current or former employees or their eligible dependents whose health insurance is being continued? Yes No Please provide the following information for each current/former employee or dependent on health continuations. Name of employee / dependent Date of birth Type of continuation State/Federal/Extended Benefits Reason for termination Disability/Other Continuation dates Start End (If additional space is needed, attach a separate sheet, signed and dated.) To the best of your knowledge: Are any employees or dependents presently incapacitated? Are any dependent children incapable of self-support due to a physical or mental disability? Additional space to explain if items in this section were answered "Yes". Give details including names where appropriate. Yes No Yes No Does the employer participate in an arrangement with a Professional Employer Organization? (Refer to Advisory Bulletin 00-SEH-02 if you need information concerning what constitutes a Professional Employer Organization.) If yes, is health coverage available as a client of the PEO? Oscar: New Jersey Application for a Small Group Health Benefits Policy Policies effective 1/1/2019 and later Yes No Yes No 4 of 6 Section 4: Agent/producer information and underwriting group enrollment use 1. I am not aware of any additional information not contained within this application that may have bearing on this group or any member's eligibility. 2. I have not completed any of the information contained in the application except with the permission of the applicant and as noted by my initials and date on the application. 3. I have not signed any of the applications for an employer representative or individual employee's application. If after submission of this application, I request any additions or changes to any information, I will do so only with the written consent of the applicant, and I authorize Oscar to attribute such additions or changes to me. 4. I have advised the employer that a failure to provide complete and accurate information may result in a loss of coverage retroactive to the effective date of coverage and that coverage shall not be effective until Oscar reviews and approves the application and the employer receives a written notice from Oscar. 5. I am the appointed agent/broker and am receiving commissions for the submission of this client. No portion of my commission payments from Oscar shall be paid to an agent/broker/producer not appointed/approved by Oscar. 6. I have advised the client not to terminate any existing coverage until receiving written notification from Oscar that the coverage being applied for by this application is accepted. Writing payable/sub-agent/producer/broker First name Last name Second writing payable/sub-agent/producer/broker First name Last name Oscar broker ID Oscar broker ID NPN (optional) NPN (optional) Phone Phone Email Email Commission percentage (if splitting with a second broker): Commission percentage (if splitting with a second broker): Signature X Date (mm/dd/yyyy) General agent/producer/broker use only General agency name Signature X Date (mm/dd/yyyy) General agency representatives General agency representative name Email Oscar: New Jersey Application for a Small Group Health Benefits Policy Policies effective 1/1/2019 and later 5 of 6 Section 5: Signature It is understood that, except as provided under applicable regulations, no individual shall become insured while not actively at work on a full-time basis, and only full-time employees are eligible. (Refer to the definition on the New Jersey Employer Certification.) It is further understood that no agent has power on behalf of Oscar to make or modify any request or application for insurance or to bind Oscar by making any promise or representation or by giving or receiving any information. It is further understood that no insurance will be effective unless and until the application is accepted in writing by Oscar. Final rates will be based on enrollment data as of the Policy effective date. No contract of insurance is to be implied in any way on the basis of the completion and/or submission of this application. It is understood that I am responsible to provide Oscar with timely and accurate information regarding the date of hire for new employees and that the requested effective date of coverage will properly apply any orientation period and waiting period requirements applicable to my plan. It is further understood that any retroactive termination requests must be limited to those for which no premium or contribution has been paid for the termination period by the employee or dependent whose coverage is to be retroactively terminated. Please read this statement and check to confirm. I confirm that I have received the Summary of Benefits and Coverage (SBC) documents associated with the plan or plans I selected on this application. I confirm I will provide SBCs to plan participants and beneficiaries as required by federal regulations and guidance related to the distribution of the SBC, including the requiring for timing and delivery. Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Dated at: ___________________ on _____________________ Signature of employer Print name of Officer, Partner or Proprietor Witness to Signature Sign here Signature of Officer, Partner or Proprietor Sign here X X Note: If there are any modifications to the statements and answers given in this application (i.e., crossed out, whited-out, erased information), the applicant must attest to the modifications by giving a complete signature in the margin near the modification. Oscar: New Jersey Application for a Small Group Health Benefits Policy Policies effective 1/1/2019 and later 6 of 6 Non-Discrimination Notice of Non-Discrimination: Discrimination is Against the Law Oscar complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex, including sex stereotypes and gender identity. Coverage for medically necessary health services is made available on the same terms for all individuals, regardless of sex assigned at birth, gender identity, or recorded gender. Oscar will not deny or limit coverage to any health service based on the fact that an individual's sex assigned at birth, gender identity, or recorded gender is different from the one to which such health service is ordinarily available. Oscar will not deny or limit coverage for a specific health service related to gender transition if such denial or limitation results in discriminating against a transgender individual. Oscar: · Provides free aids and services to people with disabilities to communicate effectively with us, such as: · Qualified sign language interpreters · Written information in other formats (large print, audio, accessible electronic formats, other formats) · Provides free language services at all times to people whose primary language is not English, such as: · Qualified interpreters · Information written in other languages If you need these services, contact Member Services at 1-855-OSCAR-55 (TTY: 7-1-1). If you believe that Oscar has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: CA Members: Oscar Health Plan of California, Attention Grievances 9942 Culver City Blvd., PO Box 1279, Culver City, CA 90232 All other Members: Oscar Insurance, Attention: Grievances, PO Box 52146, Phoenix, AZ 85072 1-855-OSCAR-55 (TTY: 7-1-1), Mon - Fri 8 am - 8 pm/ Sat - Sun 9 am - 5 pm (EST), Fax: 1-888-977-2062, Email: help@hioscar.com. You can file a grievance in person or by mail, fax, or em ail. If you need help filing a grievance, Oscar's Grievances Department is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Language Assistance Services for the Deaf or Hard of Hearing ATTENTION: If you are deaf or hard of hearing, talk to text services, free of charge, are available to you. Call 1-855-Oscar-55 and dial 711 to receive TTY/TDD services. hioscar.com Multi-language interpreter services Multi-language interpreter services Español (Spanish): ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-OSCAR-55. (Chinese) 1-855-OSCAR-55. 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