ERISA Wrap Application

Admin America ERISA Compliance & ACA Notices Intake Application

Questionnaire for the preparation of the Company's ERISA Plan Document & Federal Notices 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.

Thank you for allowing Admin America to provide your company with quality compliance services.

1ACCOUNT INFORMATION

2PLAN INFORMATION

3ELIGIBILITY

4BENEFITS OFFERED

5MEDICAL

6PRESCRIPTION DRUG

7DENTAL

8VISION

9LIFE INSURANCE PLAN(S)

10SHORT TERM DISABILITY

11LONG TERM DISABILITY

12FSA

13HRA

14QSEHRA

15HSA

16ADOPTION ASSISTANCE

17OTHER COMPONENT BENEFITS

18FEDERAL NOTICES

19ADA WELLNESS

20COBRA

21HEALTH INSURANCE EXCHANGE

22MEDICARE PART D

23MHPAEA

24MICHELLE

25NEWBORNS

26NO SURPRISE BILLING

27NOTICE OF PATIENT PROTECTIONS

28PRIVACY PRACTICES

29SPECIAL ENROLLMENT RIGHTS

30SMM

31WHCRA

32DELIVERY INSTRUCTIONS

33AUTHORIZED SIGNERS

34PAYMENT

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 you have both creditable and non creditable coverage, please add details here:
Is this an Employer/Union sponsored group plan?*

Yes

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

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
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 Patient Protections
Does your group health plan require or allow for the designation of primary care providers by participants or beneficiaries?*

No

Yes
Your group health plan:*

Requires the designation of a primary care provider

Allows for the designation of a primary care provider
Does your group health plan designate a primary care provider automatically?*

Yes

No
Does your group health plan require or allow for the designation of a primary care provider for a child?*

Yes

No
Does your group health plan provide coverage for obstetric or gynecological care (OB/GYN care) and require the designation by a participant or beneficiary of a primary care provider?*

Yes

No

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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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Summary of Material Modifications Or No Material Modifications
Have you made a material reduction in covered services or benefits to your health plan within the last 60 days?

Yes

No
Date material reduction made:
Date material reduction effective:
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 not listed:
Explain all of the material reductions in covered services or benefits made to the health plan:
Have you made a material modification to your health plan that did not result in a material reduction in covered services or benefits?

Yes

No
Date material modification made:
Date material modification effective:

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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/coinsurance amount applicable to mastectomy benefits:*
Please provide the In-Network deductible and coinsurance amounts applicable to mastectomy benefits, along with the plan name if multiple plans are available.
Is an out-of-network deductible amount and coinsurance percentage applicable to mastectomy benefits?*

Yes

No
Out-of-network deductible/coinsurance amount applicable to mastectomy benefits:*
Please provide the Out-of-Network deductible and coinsurance amounts applicable to mastectomy benefits, along with the plan name if multiple plans are available.
List If there are additional Health Plans that provide coverage for medical and surgical benefits related to a mastectomy (provide both in and out of network related deductibles and co-insurance for each plan.

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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
Payment Method*

Credit Card

Online Payment Center
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Coupon

ERISA Plan Document & Health Notices
Price:
Total
$0.00

Billing Contact Name*
First Last
Billing Contact Email*

Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Billing Contact Phone*

CAPTCHA

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6529
Δ

Primary HRA Plan Name	2nd HRA Plan Name	3rd HRA Plan Name

Questions

8:30 am – 5 pm EDT

Admin America, Inc.

770-992-5959 800-366-2961

Admin America ERISA Compliance & ACA Notices Intake Application

APPLICANT INFORMATION

BASIC ACCOUNT INFORMATION

LOCATION INFORMATION

PLAN INFORMATION

General plan

Plan administrator

Agent of service

Wellness program

Other participating employers

Eligibility

Eligibility Requirements

Benefits

Medical Benefit

Medical plan carrier information

Grandfathered plan

Medical plan pre-tax contribution

Medical plan eligibility

Medical plan eligibility requirements

Medical plan accompanying benefit documents

Prescription Drug Benefit

Prescription Drug plan information

Prescription Drug plan pre-tax contributions

Prescription Drug plan eligibility

Prescription plan eligibility requirements

Prescription Drug accompanying benefit documents

Dental Benefit

Dental plan carrier information

Dental plan pre-tax contributions

Dental plan eligibility

Dental plan eligibility requirements

Dental plan accompanying benefit documents

Vision Benefit

Vision plan carrier information

Vision plan pre-tax contributions

Vision plan eligibility

Vision plan eligibility requirements

Vision plan accompanying benefit documents

Life Benefit

Life plan carrier information

Life plan pre-tax contribution

Life Plan eligibility

Life plan eligibility requirements

Life plan accompanying benefit documents

Short Term Disability Benefit

Short Term Disability plan carrier information

Short Term Disability plan pre-tax contribution

Short Term Disability plan eligibility

Short Term Disability plan eligibility requirements

Short Term Disability plan accompanying benefit documents

Long Term Disability Benefit

Long Term Disability plan carrier information

Long Term Disability plan pre-tax contribution

Long Term Disability plan eligibility

Long Term Disability plan eligibility requirements

Long Term Disability plan accompanying benefit documents

Flexible Spending Account ("FSA") Benefit

FSA plan administration information

FSA account eligibility

FSA account eligibility requirements

Additional FSA information

FSA plan accompanying benefit documents

Health Reimbursement Account ("HRA") Benefit

HRA plan administration information

HRA eligibility

HRA eligibility requirements

Additional HRA information

HRA plan accompanying benefit documents

Qualified Small Employer HRA ("QSEHRA") Benefit

QSEHRA plan administration information

QSEHRA plan dates

QSEHRA eligibility

QSEHRA eligibility requirements

QSEHRA plan accompanying benefit documents

Health Savings Account ("HSA") Benefit

HSA plan administration information