ERISA Wrap SMM Application

Admin America SMM & ACA Health Notices Application

Questionnaire for the preparation of the Company's ERISA Compliance Services

Once the Questionnaire has been fully completed, hit the "Submit" button on the last tab for Admin America to begin working on your compliance documents.

1LEVEL OF SERVICE

2ACCOUNT INFORMATION

3PLAN INFORMATION

4SMM INFORMATION

5FEDERAL HEALTH NOTICES

6ADA

7COBRA

8HEALTH INSURANCE EXCHANGE

9MEDICARE PART D

10MHPAEA

11MICHELLE

12NEWBORN

13NO SURPRISE BILLING

14PRIVACY PRACTICES

15SPECIAL ENROLLMENT RIGHTS

16WHCRA

17DELIVERY INSTRUCTIONS

18ACKNOWLEDGEMENT & SIGNATURE

19BILLING & PAYMENT

Select Level of Service
- This is the first time that Admin America is writing our ERISA Wrap Plan Document
- Renew and prepare the Full Plan Document
- SMM + ACA Notices
- SMM Only
-Initial Wrap Document written through Admin America Pricing: $600
-Preparation of renewal Plan Document: $500
-SMM Pricing: $350
CLICK THE "SUBMIT" BUTTON TO REDIRECT TO THE ERISA WRAP APPLICATION FOR COMPLETION

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BASIC ACCOUNT INFORMATION
Legal company name*
# of employees*
Industry
SIC Code
Website Address

Federal EIN*
Type Of Business

C Corp

S Corp

LLC

Government

Governing State
State

Brokerage/Agency name
LOCATION INFORMATION
Company address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Company contact name
First Last
Website

Job title*
Primary Company contact phone#*
Primary Company Contact Email

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PLAN INFORMATION
Did Admin America, Inc. Write Your Plan Within the Past 5 Years?*
General plan
Plan name
in example: ABC Company Benefit Plan
Plan number
Welfare plan numbers begin with 501 and proceed consecutively. So, the second welfare plan of an employer would be 502, followed by 503, etc. A plan number can never be used more than once. If this is an ongoing plan, refer to the prior document or SPD, or if applicable, the most recently filed Form 5500.
Effective date of plan*
MM slash DD slash YYYY

In the case of an amended and restated plan, the effective date would be the date on which changes to specific plan provisions or benefit plans become effective. If this information is not available or this is a new plan, then the date which may be used is the date the wrap plan document is created.
Describe your plan*

A short plan year followed by the 12 month regular period

A single regular 12 month period
Generally, a plan year can be any twelve-month period selected by the plan sponsor. However, a plan can have a short plan year when there is a legitimate business purpose. This would include a short year for: the first plan year; a plan termination; or a merger of two plans that have conflicting plan years.
Short plan year start date*
MM slash DD slash YYYY

Short plan year end date*
MM slash DD slash YYYY

Plan start date*
MM slash DD slash YYYY

The Plan Year can be any twelve-month period. The Plan Year does not have to match any insurance contract year, open enrollment period, or the employer’s fiscal year. Generally, however, most employers select a January 1 calendar year which matches the date of their open enrollment selections. The Wrap Plan Year does not have to match the Wrap Effective Date.
Plan end date*
MM slash DD slash YYYY

Plan administrator
Who administrates the plan?*

Employer

Other
Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*
Phone extension
Website

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SUMMARY OF MATERIAL MODIFICATION/REDUCTION INFORMATION
Have you made a material reduction in covered services or benefits to your health plan within the last 60 days?

No

Yes
In general, the material reduction in covered services or benefits must be provided to group health plan participants within 60 days of adoption of a material reduction in covered services or benefits..
Date material reduction made
MM slash DD slash YYYY

Date material reduction effective
MM slash DD slash YYYY

Services or benefits materially reduced:
Select All
Medical plan
Adoption assistance
Dental plan
Dependent care reimbursement account (DCRA) plan
Health flexible spending arrangement (FSA)
Health reimbursement arrangement (HRA)
Health savings account (HSA)
Life insurance plan
Long-term disability plan
Prescription drug plan
Short-term disability plan
Vision plan
Premium Conversion Plan / Pre-tax contributions
Other
List Others
Explain all of the material reductions in covered services or benefits made to the health plan:
Have you made a material modification in covered services or benefits to your health plan within the last 60 days?

No

Yes
The Summary Material Modification must be provided to group health plan participants no later than 210 days after the end of the plan year in which the change is adopted, for material changes to the plan that do not result in a material reduction in covered services or benefits.
Date material modification made
MM slash DD slash YYYY

Date material modification effective
MM slash DD slash YYYY

Type of Material Modification Changes(check all that apply)*
Select All
Changes to the Types of Benefits Provided
Carrier Changes
TPA Changes
Insurance Contract Number Changes
Participating Employer Changes
Changes to Eligibility Rules
Changes to Participant Contributions
Changes to the Types of Benefits Provided
If your Plan has changed carriers, include the name of the new carrier, contract number, address, and claims administration phone number. Be sure all of the required benefit plan component information that explains the new carrier information has been distributed to Plan participants.
Carrier Changes
Include the name of the new carrier, contract number, address, and claims administration phone number.
TPA Changes
Include the name of the new TPA, address, and administration phone number.
Insurance Contract Number Changes
Include Name of Carrier, Type of Coverage, and Contract Number(s)
Participating Employer Changes
Include Name of new Employer Sponsor, EIN#, address, and phone number
Changes in Eligibility Rules
If a specific eligibility rule has changed, be sure to include the amended rule if a specific class of employees is impacted, and the date on which the rule becomes effective. It may also be helpful to create a small chart that shows the class of participants, the current eligibility rule, the new eligibility rule, and the date the new rule becomes effective.
Changes to Participant Contributions
Include the details of the specific contributions and whether enrollment materials or benefit summaries will include this information.

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The following Section is a Questionnaire to determine which Federal Health Notices your plan is required to disclose to benefit participants. To Continue with this Section check the "CONTINUE WITH QUESTIONNAIRE" box.
ACA Notices
How many employees do you have?

1 - 19

20 - 49

50 - 99

100 - 249

250 or more
Are you an applicable large employer (ALE) under the Affordable Care Act (ACA)?

Yes

No
Is your group health plan subject to COBRA?

Yes

No
Does your plan have an open enrollment period?

Yes

No
How is your health plan funded?

Fully insured, benefits are paid exclusively through insurance contracts or policies

Self-insured, benefits are paid from the employer’s general assets

Self-insured, benefits are paid through a separate trust or a separately maintained fund
Is your plan required to file an annual Form 5500 for Welfare Benefits?

Yes

No
Does your health plan cover residents in a state that offers premium assistance under a Medicaid or CHIP program?

Yes

No
Does your health plan include coverage for prescription drugs?

Yes

No
Does your health plan have grandfathered status under the ACA?

Yes

No
Do you offer a wellness program with your group health plan that conditions a reward or incentive on participants meeting a health-related standard?

Yes

No
If you offer any type of wellness program, does it involve health-related questions (for example, a health risk assessment) or medical examinations?

Yes

No

Not applicable
Include Spanish version of Notices?

Yes

No

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ADA Notice Regarding Wellness Program
Does your wellness program ask employees to complete a voluntary health risk assessment or similar assessment that asks a series of questions about their health-related activities and behaviors, and whether they have or have had certain medical conditions (e.g. cancer, diabetes, or heart disease)?

Yes

.No
Will the information from an employee’s health risk assessment be used to provide him/her with services through the wellness program?

Yes

.No
What services may be offered through the wellness program as a result of an employee’s health risk assessment? (Do not capitalize or place a period after your response.) (optional)
As part of the wellness program, will employees be asked to complete a biometric screening that includes a blood test?

Yes

.No
In the biometric screening blood test, what are the conditions for which blood will be tested? (Do not capitalize or place a period after your response.) (optional)
Will the information from an employee’s biometric screening be used to provide him/her with services through the wellness program?

Yes

.No
What services may be offered through the wellness program as a result of an employee's biometric screening? (Do not capitalize or place a period after your response.) (optional)
Will employees who choose to participate in the wellness program receive an incentive?

Yes

No
What incentive will employees who choose to participate in the wellness program receive? (Do not capitalize or place a period after your response.) (optional)
Are employees required to complete a health risk assessment to receive an incentive?

Yes

No
Are employees required to participate in a biometric screening to receive an incentive?

Yes

No
What are the criteria to achieve a participation incentive under the wellness program? (optional)
Are additional incentives made available to employees who participate in certain health-related activities?

Yes

No
Explain the additional incentives made available. (Do not capitalize or place a period after your response.)
Need Help?

Sentence will display as, 'Additional incentives of up to _________ may be available...'
Are specific activities required to receive the additional incentives?

Yes

No
Explain the specific activities required to receive additional incentives. (Do not capitalize or place a period after your response.)
Need Help?
For guidance in answering this question, please see the 3rd paragraph of the sample notice. Example: 'participate in the XYZ Company yoga class'
copy and paste the following link to your browser to view a copy of the Sample Notice for Wellness Programs
https://www.eeoc.gov/regulations/sample-notice-employer-sponsored-wellness-programs
Do particular health outcomes need to be achieved to receive the additional incentives?

Yes

No
Explain the particular health outcomes that need to be achieved. (Do not capitalize or place a period after your response.)
Need Help?
For guidance in answering this question, please see the 3rd paragraph of the sample notice. Example: 'losing 15 pounds'
copy and paste the following link to your browser to view a copy of the Sample Notice for Wellness Programs
https://www.eeoc.gov/regulations/sample-notice-employer-sponsored-wellness-programs
Insert the name and contact information of each individual who will receive the employee's personally identifiable health information as part of the wellness program. (Do not place a period after your response.)
Need Help?
Sentence will display as, " In order to provide you with services under the wellness program, the only individual(s) who will receive your personally identifiable health information is (are) ....If applicable, specify any other or additional confidentiality protections put in place for medical information obtained through the wellness program beyond (a) maintaining the medical information separate from personnel records, (b) encrypting the medical information if electronically stored, and (c) not making any employment decision based on information provided as part of the wellness program.\n(Answer in a complete sentence.) (optional)

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COBRA General Notice
If qualified beneficiaries elect COBRA continuation coverage, must the qualified beneficiaries pay for COBRA continuation coverage?

Must pay

Aren't required to pay
A qualified beneficiary is an employee, an employee's spouse, or an employee's dependent child who is covered by an employer-sponsored group health plan on the day before a qualifying event.
Does your plan provide retiree health coverage?

Yes

No
When must the employee notify the plan administrator of the following qualifying events: Divorce of the employee and spouse, legal separation of the employee and spouse, or a dependent child losing eligibility for coverage as a dependent child?

60 days

Other
Other:
If applicable, explain any additional plan procedures an employee must follow to notify the plan administrator of the following COBRA qualifying events: Divorce of the employee and spouse, legal separation of the employee and spouse, or a dependent child losing eligibility for coverage as a dependent child.(optional)
For example, describe any required information or documentation.
Spanish version:(optional)
The answer in this text area will merge into the Spanish version of this notice..
If applicable, explain any additional plan procedures an employee must follow to notify the plan administrator of a request for a disability extension of his/her COBRA coverage. (optional)
For example, describe any required information or documentation, the name of the appropriate party to whom notice must be sent, and the time period for giving notice.
Spanish version:(optional)
The answer in this text area will merge into the Spanish version of this notice..

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Health Insurance Exchange Notice (for companies who offer a health plan)
Is your health plan offered to all employees or just some employees?

All employees

Some employees. Eligible employees are:
Explain the employee eligibility requirements under the group health plan.
Does your health plan offer coverage to dependents?

We do not offer coverage.

We do offer coverage. Eligible dependents are:
Explain the dependent eligibility requirements under the group health plan.
Does your group health plan satisfy the minimum value and affordability standards of the Affordable Care Act?

Yes

No

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Medicare Part D Creditable Coverage Notice
Does your health plan offer prescription drug coverage to Medicare-eligible individuals (in general, people age 65 or older, younger people with disabilities, or people with End Stage Renal Disease [permanent kidney failure requiring dialysis or transplant])?

Yes

No
Does your health plan provide Medicare Part D creditable coverage?

Yes

No
If the participant decides to join a Medicare drug plan, will his or her current prescription drug coverage under your group health plan be affected?

Yes

No
Is this an Employer/Union sponsored group plan?

Yes

No
Was the previous employer-sponsored coverage creditable coverage under Medicare Part D?

Yes

No
Will the plan participant and his/her dependents be able to get prescription drug coverage back under your group health plan if they decide to enroll in Medicare Part D prescription drug coverage and drop their current prescription drug coverage under your group health plan?

Yes

No
Insert a sentence explaining the prescription drug coverage plan provisions/options under your group health plan that Medicare-eligible individuals have available to them when they become eligible for Medicare Part D:

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Mental Health Parity and Addiction Equity Act (MHPAEA) Disclosure
Does your health plan offer medical/surgical benefits AND mental health or substance use disorder benefits?

Yes

No

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Michelle's Law Notice
Does your health plan provide dependent coverage beyond age of 26?

Yes

No
Does your health plan require a certification of student status before providing dependent coverage beyond age 26?

Yes

No
Enter any other permissible eligibility conditions a plan participant must satisfy to be eligible to continue coverage upon a medically necessary leave of absence from school in the box below.
Example: Student must be enrolled in the plan immediately prior to the first day of the medically necessary leave of absence.

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Newborns’ and Mothers’ Health Protection Act Notice
Does your health plan provide maternity or newborn infant coverage?

Yes

No
Enter any additional information regarding maternity or newborn infant coverage required by state law: (optional)

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No Surprise Billing
Emergency services - Explain any applicable state balance billing laws or requirements (in easy to understand language), including the applicable state agency website that can be visited for more information.
Services at in-network hospital or ambulatory surgical center – Explain any applicable state balance billing laws or requirements (in easy to understand language), including the applicable state agency website that can be visited for more information.

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Notice of Privacy Practices
Does your health plan create or receive protected health information?

Yes

No
Select an effective date for your Notice of Privacy Practices
The federal HIPAA Privacy Rule requires covered entities to describe any state or other laws that require greater limits on disclosures. Insert this type of information below. If no laws with greater limits apply to your health plan, no information needs to be added. For further assistance, contact the U.S. Department of Health and Human Services’ Office of Civil Rights at 1-800-368-1019.
Spanish version:(optional)
The answer in this text area will merge into the Spanish version of this notice..

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Special Enrollment Rights Notice
If the employee and/or his/her dependents lose eligibility for coverage under another health plan, or if the employer contributions toward that coverage cease, within how many days after that coverage ends must the employee request to enroll him/herself and/or his/her dependents in your group health plan?

30 days

Other:
Other:
If the employee gains a new dependent as a result of marriage, birth, adoption, or placement for adoption, within how many days must the employee request to enroll him/herself and/or his/her dependents in your group health plan?

30 days

Other:
Other:

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WHCRA Notice
Does your health plan provide coverage for medical and surgical benefits related to a mastectomy?

Yes

No
In-network deductible amount applicable to mastectomy benefits:
In-network coinsurance percentage applicable to mastectomy benefits:
Is an out-of-network deductible amount and coinsurance percentage applicable to mastectomy benefits?

Yes

No
Out-of-network deductible amount applicable to mastectomy benefits: (If Applicable)
Out-of-network coinsurance percentage applicable to mastectomy benefits: (If Applicable)
Add additional plan(s) information here. Include both in and out of network deductibles and coinsurance percentage(s)

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DELIVERY INSTRUCTIONS
Deliverables sent to

Client Contact

Broker Contact

Both

List names and emails of all client and broker contacts for delivery of documents:

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Authorized Signer
Name
First Last
Email

Signature

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Billing and Payment

Billing Contact Name*
First Last
Billing Contact Email*

Billing Contact Phone*

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90633
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Questions

8:30 am – 5 pm EDT

Admin America, Inc.

770-992-5959 800-366-2961

Admin America SMM & ACA Health Notices Application

BASIC ACCOUNT INFORMATION

LOCATION INFORMATION

PLAN INFORMATION

General plan

Plan administrator

SUMMARY OF MATERIAL MODIFICATION/REDUCTION INFORMATION

ACA Notices

ADA Notice Regarding Wellness Program

COBRA General Notice

Health Insurance Exchange Notice (for companies who offer a health plan)

Medicare Part D Creditable Coverage Notice

Mental Health Parity and Addiction Equity Act (MHPAEA) Disclosure

Michelle's Law Notice

Newborns’ and Mothers’ Health Protection Act Notice

No Surprise Billing

Notice of Privacy Practices

Special Enrollment Rights Notice

WHCRA Notice

DELIVERY INSTRUCTIONS

Authorized Signer

Billing and Payment