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Admin America

COBRA_SPM Renewal

1Company and Contact Details
2Renewal Details
3Plans with Rate Changes Only
4Medical Insurance
5Dental Insurance
6Vision Insurance
7ICHRA
8FSA
9HRA
10Additional Plan Types
11COBRA OE Assistance
12SPM/Retiree/Direct Billing
13SPM Medical Insurance
14SPM Dental Insurance
15SPM Vision Insurance
16SPM Other Insurance
17SPM Rate Changes
18Renewal Confirmation

Company Name and Contact Details

Does the Employer use a DBA Name?
Have there been any Employer or Broker Contact Changes?
Broker Contact
Name
Email
Add as Renewal Contact? (Y/N)
 
Employer Contact
Name
Email
Add as Renewal Contact? (Y/N)
 
A Benefit Specific Contact is an employer or broker contact whom participants should contact with any benefit-specific questions.

Any broker contacts must hold a current license. Admin America cannot advise on benefit information, and we will refer employees to this contact if they have questions.

Benefit Specific Contact Info
Contact Name
Email
Phone Number
 
Please select your Renewal Options
Does the company currently have more than 20 employees?
Was the company's total employee count over 20 employees for at least half of the prior calendar year?
COBRA coverage is only required for groups with over 20 employees. However, this count is based on a calendar year. If the company drops under 20 after July 1st, they might still be subject to COBRA through December of the following year.

State Continuation Determination

COBRA coverage is only required for groups with over 20 employees. However, this count is based on a calendar year. If the company drops under 20 after July 1st, they might still be subject to COBRA through December of the following year.
State Continuation Notice
Certain states require their own version of continuation coverage even if the company is no longer COBRA eligible. If your company becomes subject to State Continuation as a result of dropping below the COBRA employee count, Admin America will not be able to continue assisting with the Continuation Coverage. We will assist for one year after the company drops below the COBRA threshold, but if the company doesn't become COBRA eligible again during this period, we will require the group find .

SPM/Retiree/Direct Bill Rules

How long after due date will SPM Participants have to pay their premiums before termination?

Premiums are due at the start of the month. This will determine the grace period of time they are allowed to make their payment after the due date. After which, if still unpaid, we will report to the employer to terminate the member.
There is a 2% fee added to all SPM Premiums. Should that 2% be billed to the Participant or to the Employer?
This fee is a pass-through fee added automatically by the payment system. If Employer option is selected, the 2% will be deducted from the remittance sent to the employer.
Do your SPMS Include Retirees?
How long can retirees remain on the benefits?

Admin America Broker & Employer Resources

COBRA Renewal Details

Please select the Insurance Products that are being renewed with us:
If you have any of these benefits administered elsewhere, they do not need to be marked here. Plans not marked will be terminated, so you won't need to worry about reporting all product terminations to us. If you have multiple plans under each category, you will be able to add the details in under the sections.
Please pick the renewal type that best applies to your medical plans.
Please pick the renewal type that best applies to your dental plans.
Please pick the renewal type that best applies to your vision plans.
Please pick the renewal type that best applies to your "Other" plans.
Do any of your plans allow for Domestic Partner Coverage?
Domestic Partners are not considered tax dependents and are automatically excluded from some plans. If they are not covered under any of the above listed plans either, this section can be left blank.
Are there guidelines limiting participant enrollment options?
Please do not include the following: Full-time Only, Part-Time not eligible, Children over 26 removed; Examples to include may be:. in or out-of-area plan eligibility restrictions, division restrictions, etc.
If this only affects some plans, please describe the plan(s) and the restrictions, or let us know if this applies to all plans.

This section is for COBRA plans with Rate Changes Only

If you have new plans or are adding plans, plan and rate information will be requesting within that specific insurance section. (i.e. Medical Insurance)
Plan Year Changes
Plan Name
Group #
Rates Start
Rates End
 
If any of your plans have changed plan years, or you have a rate guarantee, please list those plans and rate guarantee end dates out here.
Termination rules determine how long a benefit is active after an employee experiences a COBRA qualifying event (end of month, date of event, etc.). Even if you don't have plan changes, sometimes the carrier will change when the benefit coverage will end.
Please list changes below.
Plan Name
New Term Rule
 
Please list out any benefit term rules that have changed.
How will you supply rates?
If any rates are already on file as member specific, changes can be uploaded or sent to renewal/COBRA seperately.
Composite Rates
Plan Name
Plan Type
EE Only
EE + Spouse
EE + Child(ren)
Family
EE + 1
EE + 2
 
Click + to add additional plans. Do Not Include the 2% Admin Fee. Please include carrier name in the Plan Name.
Age Banded
Plan Name
Plan Type
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Add second Age Banded Grid?
This section will allow entry for up to 6 age banded plans.
Age Banded 2
Plan Name
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Add third Age Banded Grid?
Age Banded 3
Plan Name
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Add fourth Age Banded Grid?
Age Banded 4
Plan Name
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Add fifth Age Banded Grid?
Age Banded 5
Plan Name
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Add sixth Age Banded Grid?
Age Banded 6
Plan Name
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Max. file size: 256 MB.
Please make sure that the files are named in a way where we can match them with your company and the corresponding plan (ex. [Company Name] Aetna PPO Gold Age Banded Rates)

Medical Insurance

Do all of your new medical plans share the same carrier, renewal date, termination rules, etc.?
Medical Plan Mapping Details
Old Plan Name Participants were enrolled in
New Plan Name Participants will be enrolled in
 
Click the + to Add an Additional Plan. Click the - to Remove a Plan.
This should be the date the new rates are active, including the year. (i.e. 1/1/2020).
This should be the last date the rates are scheduled to be active. If you have a rate guarantee for longer than 12 months, please put the final date of that period here.
This will determine the date when the member will start paying for COBRA coverage.
Who should we contact to re-enroll COBRA participants with the carrier?
Name
Email (required)
Fax (optional)
 
This should be a carrier enrollment contact if Admin America is reaching out directly to the carrier, but this can be a company or broker contact otherwise. If no contact is provided, this will default to the main contact on file.
Does the carrier require monthly reports confirming the COBRA participant has paid?
Some carriers will drop participants unless they receive a report each month confirming they have paid. Admin America will send this report, but we need to know if it is required.
Are any of the plans self or level funded?
Please list all self/level funded plans.
Do you need to add a second medical carrier?
if the renewal date or termination rules are different for any plans, a second carrier can be added to capture that information as well.
This should be the date the new rates are active, including the year. (i.e. 1/1/2020).
This should be the last date the rates are scheduled to be active. If you have a rate guarantee for longer than 12 months, please put the final date of that here.
This will determine the date when the member will start paying for COBRA coverage.
Who should we contact to re-enroll COBRA participants with the medical carrier?
Name
Email
Fax (optional)
 
This should be a carrier enrollment contact if Admin America is reaching out directly to the carrier, but this can be a company or broker contact otherwise.
How will you supply medical rates?
If any rates are already on file as member specific, changes can be uploaded or sent to renewal/COBRA seperately.
Medical Plan Composite Rates
Plan
EE Only
EE + Spouse
EE + Child(ren)
Family
EE + 1
EE + 2
 
Click + to add additional plans. Do Not Include the 2% Admin Fee. Please include carrier name under Plan.
Medical Plan Age Banded Grid
Plan Name
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Add a second medical age banded grid?
Medical Plan Age Banded Grid 2
Plan Name
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Add a third medical age banded grid?
Medical Plan Age Banded Grid 3
Plan Name
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Add a fourth medical age banded grid?
Medical Plan Age Banded Grid 4
Plan Name
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Add a fifth medical age banded grid?
Medical Plan Age Banded Grid 5
Plan Name
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Add a sixth medical age banded grid?
Medical Plan Age Banded Grid 6
Plan Name
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Max. file size: 256 MB.
Please make sure that the files are named in a way where we can match them with your company and the corresponding plan.

Dental Insurance

Do all of your new dental plans share the same carrier, renewal date, termination rules, etc.?
Dental Plan Mapping Details
Old Plan Name Participants were enrolled in
New Plan Name Participants will be enrolled in
 
Click the + to Add an Additional Plan. Click the - to Remove a Plan.
This should be the date the new rates are active, including the year. (i.e. 1/1/2020).
This should be the last date the rates are scheduled to be active. If you have a rate guarantee for longer than 12 months, please put the final date of that period here.
This will determine the date when the member will start paying for COBRA coverage.
Who should we contact to re-enroll COBRA participants with the dental carrier?
Name
Email
Fax (optional)
 
This should be a carrier enrollment contact if Admin America is reaching out directly to the carrier, but this can be a company or broker contact otherwise.
Do you need to add a second dental carrier?
if the renewal date or termination rules are different for any plans, a second carrier can be added to capture that information as well.
This should be the date the new rates are active, including the year. (i.e. 1/1/2020).
This should be the last date the rates are scheduled to be active. If you have a rate guarantee for longer than 12 months, please put the final date of that period here.
This will determine the date when the member will start paying for COBRA coverage.
Who should we contact to re-enroll COBRA participants with the dental carrier?
Name
Email
Fax (optional)
 
This should be a carrier enrollment contact if Admin America is reaching out directly to the carrier, but this can be a company or broker contact otherwise.
Are any of the dental plans self or level funded?
Please list all self/level funded plans.
How will you supply dental rates?
If any rates are already on file as member specific, changes can be uploaded or sent to renewal/COBRA seperately.
Dental Plan Composite Rates
Plan
EE Only
EE + Spouse
EE + Child(ren)
Family
EE + 1
EE + 2
 
Click + to add additional plans. Do Not Include the 2% Admin Fee
Dental Plan Age Banded Grid
Plan Name
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Add a second dental age banded grid?
Dental Plan Age Banded Grid 2
Plan Name
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Max. file size: 256 MB.
Please make sure that the files are named in a way where we can match them with your company and the corresponding plan.

Vision Insurance

Do all of your new vision plans share the same carrier, renewal date, termination rules, etc.?
Vision Plan Mapping Details
Old Plan Name Participants were enrolled in
New Plan Name Participants will be enrolled in
 
Click the + to Add an Additional Plan. Click the - to Remove a Plan.
This should be the date the new rates are active, including the year. (i.e. 1/1/2020).
This should be the last date the rates are scheduled to be active. If you have a rate guarantee for longer than 12 months, please put the final date of that period here.
This will determine the date when the member will start paying for COBRA coverage.
Who should we contact to re-enroll COBRA participants with the vision carrier?
Name
Email
Fax (optional)
 
This should be a carrier enrollment contact if Admin America is reaching out directly to the carrier, but this can be a company or broker contact otherwise.
Do you need to add a second vision carrier?
if the renewal date or termination rules are different for any plans, a second carrier can be added to capture that information as well.
This should be the date the new rates are active, including the year. (i.e. 1/1/2020).
This should be the last date the rates are scheduled to be active. If you have a rate guarantee for longer than 12 months, please put the final date of that period here.
This will determine the date when the member will start paying for COBRA coverage.
Who should we contact to re-enroll COBRA participants with the vision carrier?
Name
Email
Fax (optional)
 
This should be a carrier enrollment contact if Admin America is reaching out directly to the carrier, but this can be a company or broker contact otherwise.
How will you supply vision rates?
If any rates are already on file as member specific, changes can be uploaded or sent to renewal/COBRA seperately.
Vision Plan Composite Rates
Plan
EE Only
EE + Spouse
EE + Child(ren)
Family
EE + 1
EE + 2
 
Click + to add additional plans. Do Not Include the 2% Admin Fee
Vision Plan Age Banded Grid
Plan Name
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Add a second vision age banded grid?
Vision Plan Age Banded Grid 2
Plan Name
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Max. file size: 256 MB.
Please make sure that the files are named in a way where we can match them with your company and the corresponding plan.
Admin America Broker & Employer Resources

ICHRA

To administer an ICHRA plan(s), Admin America will need the following information: 1. A copy of your ICHRA 90-Day Notice. This notice explains benefits and provides employer contributions amounts to employees utilizing benefit. If an employer has multiple locations that have different contributing amounts other than the baseline location, we will need copy of those contributions. 2. Your utilization percentage will need to be provided. To determine utilization percentage, we will need the number of eligible employees that were able to partake in this benefit and the number of actual enrollees. 3. Plan details (i.e. ICHRA carrier, effective date, renewal date, enrollment contact (typically the employer) and benefit termination date (we will assume date of termination if not confirmed))
This should be the date the new rates are active, including the year. (i.e. 1/1/2020).
This should be the last date the rates are scheduled to be active. If you have a rate guarantee for longer than 12 months, please put the final date of that period here.
This will determine the date when the member will start paying for COBRA coverage.
Who should we contact to re-enroll COBRA participants with the ICHRA carrier?
Name
Email
Fax (optional)
 
This should be a carrier enrollment contact if Admin America is reaching out directly to the carrier, but this can be a company or broker contact otherwise.
Max. file size: 256 MB.
Please make sure that the files are named in a way where we can match them with your company and the corresponding plan (ex. [Company Name] ICHRA 90-day Notice & Rates)

Flexible Spending Account

Is Admin America the FSA administrator?
Who should we contact to re-enroll FSA COBRA participants with the benefit carrier?
Name
Email
Fax (optional)
 
This should be a carrier enrollment contact if Admin America is reaching out directly to the carrier, but this can be a company or broker contact otherwise.

Health Reimbursement Arrangement

Are the HRA rates included in any of the provided medical rates?
Does Admin America Administer the HRA?
If we are the administrator, we will calculate the HRA rates
This will determine the date when the member will start paying for COBRA coverage.
Who should we contact to re-enroll COBRA participants with the benefit carrier?
Name
Email
Fax (optional)
 
This should be a carrier enrollment contact if Admin America is reaching out directly to the carrier, but this can be a company or broker contact otherwise.
Is the HRA tied to any of the medical plans?
Medical Plan Name
Automatically Enrolled? (Y/N)
 
Please list any plans that are eligible for the HRA, and if employees are required to elect the HRA if they elect that particular plan.
HRA Rates
Plan
EE Only
EE + Spouse
EE + Child(ren)
Family
EE + 1
EE + 2
 
Click + to add additional plans. Do Not Include the 2% Admin Fee

Other Insurance

Please ensure that any plans added here are COBRA eligible, not all GAP, EAP or Telemed plans are considered COBRA eligible, and participants can't be reinstated.
Do all of these plans share the same carrier, renewal date, termination rules, etc.?
If there is only one plan in this category, please mark yes.
Plan Mapping Details
Old Plan Name Participants were enrolled in
New Plan Name Participants will be enrolled in
 
Click the + to Add an Additional Plan. Click the - to Remove a Plan.
This should be the date the new rates are active, including the year. (i.e. 1/1/2020).
This should be the last date the rates are scheduled to be active. If you have a rate guarantee for longer than 12 months, please put the final date of that period here.
This will determine the date when the member will start paying for COBRA coverage.
Who should we contact to re-enroll COBRA participants with the benefit carrier?
Name
Email
Fax (optional)
 
This should be a carrier enrollment contact if Admin America is reaching out directly to the carrier, but this can be a company or broker contact otherwise.
Do you need to add a second benefit carrier?
if the renewal date or termination rules are different for any plans, a second carrier can be added to capture that information as well.
This should be the date the new rates are active, including the year. (i.e. 1/1/2020).
This should be the last date the rates are scheduled to be active. If you have a rate guarantee for longer than 12 months, please put the final date of that period here.
This will determine the date when the member will start paying for COBRA coverage.
Who should we contact to re-enroll COBRA participants with the benefit carrier?
Name
Email
Fax (optional)
 
This should be a carrier enrollment contact if Admin America is reaching out directly to the carrier, but this can be a company or broker contact otherwise.
Do you need to add a third benefit carrier?
if the renewal date or termination rules are different for any plans, a second carrier can be added to capture that information as well.
This should be the date the new rates are active, including the year. (i.e. 1/1/2020).
This should be the last date the rates are scheduled to be active. If you have a rate guarantee for longer than 12 months, please put the final date of that period here.
This will determine the date when the member will start paying for COBRA coverage.
Who should we contact to re-enroll COBRA participants with the benefit carrier?
Name
Email
Fax (optional)
 
This should be a carrier enrollment contact if Admin America is reaching out directly to the carrier, but this can be a company or broker contact otherwise.
How will you supply benefit rates?
If any rates are already on file as member specific, changes can be uploaded or sent to renewal/COBRA seperately.
Benefit Composite Rates
Plan
EE Only
EE + Spouse
EE + Child(ren)
Family
EE + 1
EE + 2
 
Click + to add additional plans. Do Not Include the 2% Admin Fee
Benefit Age Banded Grid
Plan Name
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Add a second benefit age banded grid?
Benefit Age Banded Grid 2
Plan Name
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Max. file size: 256 MB.
Please make sure that the files are named in a way where we can match them with your company and the corresponding plan.

COBRA Open Enrollment Assistance

If there are pending or active members on file, our system will process a mailed change notice once the account has been updated. In addition, Admin America will open our online portal to allow members to view summaries (if provided below) and make changes or elections. If summaries are not provided, qualifed beneficiaries will be directed to the group or broker contact on file for benefit-specific questions.
Max. file size: 256 MB.
Please make sure that the files are named in a way where we can match them with your company and the corresponding plan.

SPM/Retiree/Direct Billing

You will be able to supply rates for your plans under the SPM Rates section.
Please select the Insurance Products that apply to your Retirees/SPMs:
SPMs refer to Special Plan Members. This typically refers to Retirees but can apply to any non-COBRA/QBs being direct-billed. Plans not marked will be terminated, so you won't need to worry about reporting all product terminations to us. If you have multiple plans under each category, you will be able to add the details in under the sections.
Please pick the renewal type that best applies to your SPM medical plans.
Please pick the renewal type that best applies to your SPM dental plans.
Please pick the renewal type that best applies to your SPM vision plans.
Please pick the renewal type that best applies to your SPM "Other" plans.
Are your new medical plans the same as those provided for COBRA Renewal?
Are your new dental plans the same as those provided for COBRA Renewal?
Are your new vision plans the same as those provided for COBRA Renewal?
Are your new "other" plans the same as those provided for COBRA Renewal?

SPM Medical Insurance

Do all of your new SPM medical plans share the same carrier, renewal date, etc.?
Will current SPMs need to be auto-enrolled in a new Medical Plan?
SPM Medical Plan Mapping Details
Old Plan Name Participants were enrolled in
New Plan Name Participants will be enrolled in
 
Click the + to Add an Additional Plan. Click the - to Remove a Plan.
This should be the date the new rates are active, including the year. (i.e. 1/1/2020).
Do you need to add a second SPM medical carrier?
if the renewal date or termination rules are different for any plans, a second carrier can be added to capture that information as well.
This should be the date the new rates are active, including the year. (i.e. 1/1/2020).

SPM Dental Insurance

Do all of your new SPM dental plans share the same carrier, renewal date, etc.?
Will current SPMs need to be auto-enrolled in a new Dental Plan?
SPM Dental Plan Mapping Details
Old Plan Name Participants were enrolled in
New Plan Name Participants will be enrolled in
 
Click the + to Add an Additional Plan. Click the - to Remove a Plan.
This should be the date the new rates are active, including the year. (i.e. 1/1/2020).
Do you need to add a second SPM dental carrier?
if the renewal date or termination rules are different for any plans, a second carrier can be added to capture that information as well.
This should be the date the new rates are active, including the year. (i.e. 1/1/2020).

SPM Vision Insurance

Do all of your new SPM vision plans share the same carrier, renewal date, etc.?
Will current SPMs need to be auto-enrolled in a new Vision Plan?
SPM Vision Plan Mapping Details
Old Plan Name Participants were enrolled in
New Plan Name Participants will be enrolled in
 
Click the + to Add an Additional Plan. Click the - to Remove a Plan.
This should be the date the new rates are active, including the year. (i.e. 1/1/2020).
Do you need to add a second SPM vision carrier?
if the renewal date or termination rules are different for any plans, a second carrier can be added to capture that information as well.
This should be the date the new rates are active, including the year. (i.e. 1/1/2020).

SPM Other Insurance

Do all of your new SPM "other" plans share the same carrier, renewal date, etc.?
Will current SPMs need to be auto-enrolled in a new "other" Plan?
SPM "other" Plan Mapping Details
Old Plan Name Participants were enrolled in
New Plan Name Participants will be enrolled in
 
Click the + to Add an Additional Plan. Click the - to Remove a Plan.
This should be the date the new rates are active, including the year. (i.e. 1/1/2020).
Do you need to add a second SPM "other" carrier?
if the renewal date or termination rules are different for any plans, a second carrier can be added to capture that information as well.
This should be the date the new rates are active, including the year. (i.e. 1/1/2020).

SPM Rate Changes

SPM Plan Year Changes
Plan Name
Rates Start
Rates End
 
If any of your plans have changed plan years, or you have a rate guarantee, please list those plans and rate guarantee end dates out here.
How will you supply the rates for your SPM plans?
If any rates are already on file as member specific, changes can be uploaded or sent to renewal/COBRA seperately.
SPM Composite Rates
Plan Name
Plan Type
EE Only
EE + Spouse
EE + Child(ren)
Family
EE + 1
EE + 2
 
Click + to add additional plans. Do Not Include the 2% Admin Fee. Please include carrier name in the Plan Name.
SPM Age Banded
Plan Name
Plan Type
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Add second SPM Age Banded Grid?
This section will allow entry for up to 6 age banded plans.
SPM Age Banded 2
Plan Name
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Add third SPM Age Banded Grid?
SPM Age Banded 3
Plan Name
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Add fourth SPM Age Banded Grid?
SPM Age Banded 4
Plan Name
Age
Rate
 
Plan name is only needed in row 1. Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00.


Do Not Include the 2% Admin Fee
Max. file size: 256 MB.
Please make sure that the files are named in a way where we can match them with your company and the corresponding plan.

Signature & Notices

Please ensure that all information is correct before submitting. Additional changes might be subject to reprocessing fees.
Notice regarding late submissions:
If your renewal is submitted after the renewal date, we will automatically process the renewal back to the renewal date. This might cause active COBRA participants to be back billed if the renewal rates are higher. If you don't want participants to be back billed, please let us know.
Signature
By entering your name you acknowledge that you are renewing with Admin America, Inc and the information you have submitted is accurate. You understand that additional changes received after the renewal is processed might be subject to reprocessing fees. You also acknowledge that all insurance carriers, to whom we have been asked to send reinstatements, have been informed of Admin America as your COBRA Third-Party Administrator and have listed on file that Admin America can make enrollment changes as necessary.
You will receive a copy of the renewal form to this email once submitted.

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We provide expert welfare benefit plan advice to both brokers and businesses. With 30+ years of experience, we’ll ensure that you’re always getting the best guidance from the most professional company offering both administration and compliance.

Admin America, Inc, Employee Benefit Consultants, Alpharetta, GA

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