Large group (100+ eligible employees) enrollment and underwriting rules

Enrollment requirements

The group must:

• Have 100+ eligible employees
• Be of a permanent nature and financially stable
• Provide documentation about entity status (corporation, LLC, partnership, etc.) if Priority Health asks.
• Carry Worker's Compensation coverage unless not required by law.
• Define eligible employees as all active employees who work a minimum number of hours per week. The minimum must be set as a number that is greater than or equal to 17.5 hours per week.
• Exclude seasonal employees, directors, corporate officers, trustees, corporate lawyers, and owners or partners from coverage unless they are active employees who work a minimum of 17.5 hours per week.

Underwriting guidelines

General guidelines

• A minimum of 5 contracts must enroll in each Priority Health plan being offered.
• A minimum of 75% of all full-time employees must select a health plan. Employees declining coverage who are covered under another health plan count toward the 75%.
• HealthbyChoice wellness-based plans (except HealthbyChoice Motivations) are a full replacement policies.
• Retirees must make up less than 15% of the entire group's enrollment.
• Employer contribution level must be either 75% of the single rate or 50% across all tiers.

Guidelines for specific plans

PriorityPOS^SM

• PriorityPOS must be a stand-alone offering. We require underwriting approval to co-exist with any other plans.
• No more than 10% of enrolled employees can live and work outside of the service area.

PriorityPPO^SM

• At least 70% of its enrolled employees must live in the Priority Health service area.
• Groups may offer the PPO plan for out-of-area employees while offering another Priority Health product to in-area employees (retiree-only doesn't qualify). In-area and out-of-area benefits should match as closely as possible.
• Members in the service area will be enrolled in the PriorityPPO network. Members outside the service area must choose one of the selected networks as their primary network upon enrollment.
• Members seeking services from a provider in their primary network will receive in-network benefits.

Guidelines for offering multiple plans

• Groups seeking coverage from Priority Health as a total replacement may offer 3 benefit design options.
• They can combine any plan except HealthbyChoice plans.
• A minimum of 5 enrolled contracts in each benefit level is required unless one of the plans is a health savings account (HSA). HSAs must have a minimum of 2 enrolled contracts.
• Prescription drug coverage must be consistently included or excluded when offering more than 1 health plan.
• There must be at least 2 differences between the benefit designs in base coinsurance, deductible, office visit copay and or prescription drug copay.
• If a gatekeeper versus a non-gatekeeper plan is offered, this counts as one of the plan differences.
• Only 1 benefit design may be offered to out-of-area employees. A group may offer up to 3 benefit designs in-area and one benefit design out-of-area, for a total of up to 4 benefit designs.
• Health reimbursement arrangements (HRAs) and HSAs will be allowed as base products in any combination.
• At renewal, segments that don't meet participation requirements will be terminated.