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Summary Material Modifications (SMM) include a change in carriers, eligibility requirements, or participant contributions.

Provide name of the component benefit plan(s); e.g. Guardian Group Dental Plan.

"Services Provided" is the entity that administers claims.

*DEFAULT: Full-Time Employees working 30+ hours/week and Variable Hour Employees who work at least the specified hours during the testing period

*DEFAULT: Employees who are not considered Full-Time or Seasonal and Variable Hour Employees who do not work at least the specified hours during the testing period.

Please provide us with description of changes.

A material reduction in covered services generally includes increases in premiums, deductibles, coinsurance amounts, and copayment amounts.

Please provide us with a description of changes.

If DBA applies, please include DBA Name.

List Subsidiary Information

The Plan number for ERISA Form 5500 purposes, e.g., 501, 502, 503, etc. (Note—each ERISA Plan should be assigned a unique number that is not used more than once.)

ERISA § 11 02( a). The trustee or trustees must either be named in the trust instrument or in the plan instrument or appointed by a person who is a named fiduciary. ... This is unremarkable given that the trustee is the person responsible for holding and managing the plan's assets.

The effective date of the notice may not be earlier than the date on which the Notice is printed or otherwise published.

Website address in which the participant can obtain a copy of the Privacy Notice.

Some health plans may require a participant to select a primary care physician (PCP).

Are There Any Employees That Are Not Offered A Health Plan? e.g. Part-Time Employees

"Passing Plan" is a plan that meets PPACA standards, if applicable. If multiple employee classes/health plans, provide name of lowest cost passing plan for each EE class.

Please provide the cost to the employee (employee contribution only) per year; e.g. $50.00 monthly employee contribution X 12 (months) = $600.00 If multiple employee classes/health plans, provide lowest cost for each EE class.

Covered entities which have a health program or activity, part of which receives funding from HHS (such as hospitals that accept Medicare or doctors who accept Medicaid), are required to post notices of nondiscrimination and taglines that alert individuals with limited English proficiency to the availability of language assistance services. Section 1557 of the Affordable Care Act (ACA), prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in any health program or activity that receives federal financial assistance.

Name of HSA Bank

Wellness programs that allow the company to provide limited incentives that make disability-related inquiries or require medical examinations are considered programs that collect employee health information. Incentives may be financial or in-kind (e.g., time-off awards, prizes, and other items of value). This rule does not apply to wellness programs that do not obtain medical information but simply require employees to engage in a certain activity (such as attending a nutrition or weight loss class or walking a certain amount every week) in order to earn an incentive.

In Example: Incentives such as gift cards and/or premium incentives. No such rewards are considered to be outcome based.

The information from a health assessment and/or the results from your bio-metric screening will be used to provide participants with information to help them understand their current health and potential risks, and may also be used to offer them services through the wellness program.

Indicate who will receive information such as "a registered nurse," "a doctor," or "a health coach"

The ACA defines an employee as variable hour if, based on the facts and circumstances on the employee’s start date, an employer cannot determine whether the employee is reasonably expected to work an average of at least 30 hours per week during the initial measurement period because the employee’s hours are variable or uncertain.

(Initial Measurement Period may not exceed 13 months)

In Example: 1st of Month Following Date of Hire

1-90 days (Initial Measurement Period and Administrative Period may not exceed 13 months)

In Example: 1st of Month Following End of Administrative Period.

In Example: 12 Months

In Example: 12 Months

3-12 months

1-90 days

6-12 months