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Administrator's Manual

2011-2012 Sponsored Group Insurance
Administrator's Manual

Available to Sponsored Group Insurance administrators as downloadable PDF documents.

Part I - Introduction through Section V
Part II - Section VI through Conclusion (excluding Exhibits)

Exhibits
Exhibit A - Participation Agreement
Exhibit B - Summary of Rules Governing the Plan
Exhibit C - Participating Agency Plan Election Form
Exhibit D - Compliance Checklist
Exhibit E - Annual Participation Fees 

Exhibit 1 - Enrollment / Waiver Form
Exhibit 1-1 - Adult Dependent Eligibility Verification Form
Exhibit 1A - Domestic Partnership Benefits

Exhibit 2 - Consumers Life Insurance Company - Evidence of Insurability Form
Exhibit 3A - Initial Notice about Special Enrollment Rights
Exhibit 3B - Notice Requirement Logs
Exhibit 3F - Women's Health Act Notice to Participants

Exhibit 4 - HIPAA Special Enrollment Rights Form
Exhibit 5 - Guidelines for Administering a QMCSO
Exhibit 6 - Consumers Life Insurance Company - Claim Form for Waiver of Premium / Accelerated Death Benefit
Exhibit 7 - Employee Medical Insurance Election Form

Exhibit 8 - Spouse / Domestic Partner Medical Insurance Election Form
Exhibit 8A - Model Letter to Medicare Carrier
Exhibit 8B - Model Letter to Disabled or Former Employees (Already Enrolled)
Exhibit 8C - Model Letter to Disabled or Former Employees (Not Enrolled)
Exhibit 9 - Statement of HIPAA Portability Rights

Exhibit 10 - Certificate of Group Health Plan Coverage
Exhibit 10A - Statutory Structure
Exhibit 10B - Title II Administrative Simplification Components
Exhibit 10C - What Plans Does HIPAA Apply To?
Exhibit 10D - Why Should Employers Care - Penalties
Exhibit 10E - Enrollment Process Flow Chart
Exhibit 10F - Authorization Requirements / Release of Medical Information
Exhibit 10G - Authorized Release of Information Tracking Form for Agency Use

Exhibit 11 - Notice of COBRA Continuation Rights / General COBRA Notice
Exhibit 12 - COBRA Continuation Coverage Election Notice
Exhibit 12A - COBRA Election Form
Exhibit 12C - Notice to Health Care Provider about Individual's COBRA Status
Exhibit 12D - Conversion Information / COBRA Exhaustion
Exhibit 12E - Notice of Unavailability of Health Care Continuation Coverage
Exhibit 12F - Cancellation of COBRA Coverage for Nonpayment

Exhibit 13 - Consumers Life Insurance Co. - Application for Conversion of Group Life
Exhibit 13A - Consumers Life Insurance Co. - Application for Portability of Group Life

Exhibit 14 - Roster Billing Example
Exhibit 15 - MMO SuperMed Plus Health Insurance Claim Form
Exhibit 15A - MMO / Medco Prescription Drug Claim Form
Exhibit 16 - MMO Dental Claim Form
Exhibit 16A - MetLife Dental Expense Claim Form
Exhibit 17- MMO SuperMed Vision Care Claim Form
Exhibit 18 - Consumers Life Insurance Co. - Dealth Claim Form

Exhibit 19 - Medical Mutual Request to Extend Limiting Age for Dependent Child
Exhibit 19A - MetLife Dental Statement of Dependent Eligibility Beyond Limiting Age
Exhibit 19B - Kaiser Permanente Application for Disabled Dependent

Exhibit 20 - United Way Services Supply Requisition

 

 

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Upcoming Events

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United Way of Greater Cleveland is a leader in addressing health and human service needs through convening partnerships, funding programs, generating resources, and advocating for public policy to support our community's priorities.