Mid-market group (51-99 eligible employees) enrollment and participation rules

Enrollment requirements

The group must:

• Have 51-99 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 the minimum number of hours per week

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Participation requirements

General requirements

• A minimum of 5 contracts must enroll in each Priority Health plan being offered.
• A minimum of 75% of all eligible employees must select a health plan. Employees declining coverage who are covered under another health plan count toward the 75%.
• Retirees can't exceed 15% of the entire group's enrollment.
• Employer contribution level must be either 75% of the single rate or 50% across all tiers.

Requirements for specific plans

PriorityPOS^SM

• No more than 10% of enrolled employees can live and work outside of the service area.

PriorityPPO^SM

• At least 70% of its eligible 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. The 5-contract minimum can be waived for an out-of-area segment.
• 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.

Requirements for offering multiple plans

• Groups seeking coverage from Priority Health as a total replacement may offer 2 benefit design options.
• A minimum of 5 enrolled contracts in each benefit level is required (waived for small out-of-area segments).
• Only 1 benefit design may be offered to out-of-area employees. A group may offer up to 2 benefit designs in-area and 1 benefit design out-of-area, for a total of up to 3 benefit designs.
• At renewal, segments that don't meet these participation requirements will be terminated.