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Admin America, Inc.

Alpharetta, GA 30005

770-992-5959        800-366-2961

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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
    -Initial Wrap Document written through Admin America Pricing: $600
    -Preparation of renewal Plan Document: $500
    -SMM + ACA Notices Pricing: $300
    - SMM Only Pricing: $200
  • CLICK THE "SUBMIT" BUTTON TO REDIRECT TO THE ERISA WRAP APPLICATION FOR COMPLETION
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  • BASIC ACCOUNT INFORMATION

  • LOCATION INFORMATION

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  • PLAN INFORMATION

  • General plan

  • in example: ABC Company Benefit Plan
  • 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.
  • 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.
    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.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • 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.
  • MM slash DD slash YYYY
  • Plan administrator

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  • SUMMARY OF MATERIAL MODIFICATION/REDUCTION INFORMATION

    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..
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
    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.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • 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.
  • Include the name of the new carrier, contract number, address, and claims administration phone number.
  • Include the name of the new TPA, address, and administration phone number.
  • Include Name of Carrier, Type of Coverage, and Contract Number(s)
  • Include Name of new Employer Sponsor, EIN#, address, and phone number
  • 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.
  • 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

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  • ADA Notice Regarding Wellness Program

  • Need Help?

    Sentence will display as, 'Additional incentives of up to _________ may be available...'
  • 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
  • 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
  • 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) ....
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  • COBRA General Notice

    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.
  • The answer in this text area will merge into the Spanish version of this notice..
  • 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)

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  • Medicare Part D Creditable Coverage Notice

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  • Mental Health Parity and Addiction Equity Act (MHPAEA) Disclosure

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  • Michelle's Law Notice

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  • Newborns’ and Mothers’ Health Protection Act Notice

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  • No Surprise Billing

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  • Notice of Privacy Practices

  • The answer in this text area will merge into the Spanish version of this notice..
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  • Special Enrollment Rights Notice

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  • WHCRA Notice

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  • DELIVERY INSTRUCTIONS

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  • Authorized Signer

  • Reset signature Signature locked. Reset to sign again
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  • Billing and Payment








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  • HRA
  • COBRA
  • HSA
  • POP
  • ERISA Wrap
    • ERISA Wrap Application
    • ERISA Wrap SMM Application
  • Form 5500
  • ACA Employer Reporting

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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.

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