Annual Open Enrollment
Dunkin’ Donuts Franchisee & Distribution Center Health Plans (the “NDCP Health Plan”)
October 2016
Dear Participating Member of the NDCP Health Plan:
NDCP remains committed to offering its members and their employees access to comprehensive
medical and dental benefits at a competitive price, and is pleased to announce there will be no
increase to Health Plan premiums for the 2017 Plan Year. We will continue to offer the same
medical and dental Plan options under the NDCP Health Plan and continue our affiliation with
CBA Blue VT and the Blue Cross Blue Shield National coverage network in 2017.
The NDCP Medical Plans, with the exception of the Minimum Essential Coverage (MEC) Plan,
meet the coverage requirements of the Patient Protection and Affordable Care Act (PPACA).
Provided participating franchisees set individual employee premium contribution levels according
to the allowable limits outlined in PPACA, the NDCP Plan permit you to also meet the PPACA
affordability requirements.
The annual Open Enrollment period for 2017 Plan Year will run from October 31, 2016 –
December 2, 2016. During this time, participating franchisees and their eligible employees
may enroll in, cancel or change their medical and dental elections.
Additionally, a Waiver of Coverage Form is required if the employee declines coverage. This
form should be completed by the employee and maintained on file by the employing Franchise.
This documentation is important for ACA compliance and will reduce the ACA play or pay fees
the Franchise may be subjected to. The waiver of coverage must be updated every year during
Open Enrollment.
Information on the below items, related to the 2017 NDCP Health Plans, is enclosed in your
package:





Franchisee Group Enrollment Application and Agreements should you wish to make
changes to your 2017 elections
Benefits at a Glance (summarizing the coverage available under each Plan)
Summaries of the Premium, Quality, Value / Health Savings Account (HSA), Minimum
Essential Coverage (MEC) Medical Plans and our Premium and Quality Dental Plans
Information on Health Savings Accounts
Monthly Premium Rates for 2017
The above documents, along with the Summary of Benefits and Coverage (SBC) documents for
each medical and dental plan, are posted on the Healthcare page of the member portal at
www.nationaldcp.com. ACTION REQUIRED: As a Participating Employer, you are legally
National DCP | 3805 Crestwood Parkway | Suite 400 | Duluth, GA 30096
p: 770.369.8600 | w: NationalDCP.com
required to distribute the SBCs to your employees participating in an NDCP Health Plan no
later than December 31, 2016.
As a reminder, employees who enroll their spouse and/or dependent child(ren) in an NDCP Health
Plan will need to provide verification of eligibility documents for each enrolled dependent.
Participating Franchises must keep the dependent verification documents on file for any future
audits. Examples of acceptable dependent verification documents include:
 Spouse: Marriage certificate or front page of prior year’s filed tax return showing marital
status and spouse’s name and date of birth
 Dependent Child(ren)* up to age 26: Birth certificate, legal guardianship, custody or
court order requiring coverage for a child.
* A dependent child is defined as your natural biological child, stepchild, legally adopted child or
child placed with you or your spouse for adoption, a child for whom you or your spouse has been
appointed the legal guardian, or a child for whom you are required to provide health insurance by
a Qualified Medical Child Support Order.
Employee’s Enrollment / Change Forms for 2017 must be submitted to the NDCP Benefits
Enrollment team ([email protected]) or faxed to CBA Blue @ 802-862-7661
no later than December 2, 2016. Enrollment Forms received after December 3, 2016 may only
be processed if an employee experiences a qualifying IRS Life Event.
Changes in 2017 coverage elections, if elected, and premiums associated with such changes, will
become effective with the start of the new Plan year, January 1, 2017, and remain in effect through
December 31, 2017, unless an IRS qualifying work or life event occurs during the Plan Year.
If you and/or your employees do not wish to make any changes to current coverage elections
during the annual Open Enrollment no action is required; existing Plan elections will remain in
effect for the 2017 Plan year. Provided no changes are made to Plan elections, participants will
continue to use the same insurance cards (CBA Blue for medical / dental coverage and ExpressScripts for prescription card services).
If you have questions regarding Open Enrollment or the NDCP Health Plan benefits, please contact
Sherry McNeill, Senior Benefits Specialist, [email protected], 1 (888) 365-4327, option
4.
Sincerely,
Regina D. Bryant
Chief Human Resources Officer
National DCP | 3805 Crestwood Parkway | Suite 400 | Duluth, GA 30096
p: 770.369.8600 | w: NationalDCP.com
All CBA Blue PPO Medical Plan Options utilize the National BlueCard® PPO Network.
Questions: Please call CBA Blue at 1.800.222.9206 or visit www.cbabluevt.com .
2017 BluePrintsm – PPO Plan Options “Benefits at a Glance”
Plan Options 
Benefit
Annual Deductible
Premium Plan
PPO
Out-of-Network
Quality Plan
PPO
Out-of-Network
Value HSA Plan
MEC Plan
PPO
Out-of-Network
PPO*
None
$500 Single
$1000 Family
$500 Single
$1000 Family
$1500 Single
$3000 Family
$2000 Single
$4000 Family
$4000
$8000
N/A
$4000 Single
$8000 Family
$6000 Single
$12000 Family
$4000 Single
$8000 Family
$6000 Single
$12000 Family
$4000 Single
$8000 Family
$6000
$12000
N/A
100%
Deductible, then 70%
100%
Deductible, then 70%
100%
Deductible, then 60%
100%
$25 copay
Deductible, then 70%
$35 copay
Deductible, then 70%
Deductible, then
$25 copay
Deductible, then 60%
Not Covered
$35 copay
Deductible, then 70%
$45 copay
Deductible, then 70%
Deductible, then
$25 copay
Deductible, then 60%
Not Covered
$35 copay
Deductible, then 70%
$45 copay
Deductible, then 70%
Deductible, then
$25 copay
Deductible, then 60%
Not Covered
$35 copay
Deductible, then 70%
$45 copay
Deductible, then 70%
Deductible, then
$25 copay
Deductible, then 60%
Not Covered
100%
Deductible, then 70%
Deductible, then 90%
Deductible, then 70%
Deductible, then 80%
Deductible, then 60%
Not Covered
$75 copay
Deductible, then 70%
Deductible, then
$150 copay
Deductible, then 70%
Deductible, then 80%
Deductible, then 60%
Not Covered
$250 copay
Deductible, then 70%
Deductible, then 90%
Deductible, then 70%
Deductible, then 80%
Deductible, then 60%
Not Covered
$150 copay
Deductible, then 70%
Deductible, then 90%
Deductible, then 70%
Deductible, then 80%
Deductible, then 60%
Not Covered
Copay waived if admitted
$150 copay
$150 copay
$200 copay
$200 copay
Deductible, then $250
copay
In-network Deductible,
then
$250 copay
Not Covered
Mental Health/Substance Abuse Outpatient
Services
$25 copay
Deductible, then 70%
$35 copay
Deductible, then 70%
Deductible, then
$25 copay
Deductible, then 60%
Not Covered
$35 copay
Not Covered
$45 copay
Not Covered
Deductible, then
$25 copay
Not Covered
Not Covered
Annual Out-of-Pocket Expense Limit
The Out-of-Pocket includes medical and prescription copays.
Preventive Care Adult & Child Well Care
Includes: Exams pap smears, prostate screening, labs,
immunizations, etc.
Primary Care Physician Office Visits
Specialist Physician Office Visits
Chiropractic
Chiropractic limited to 12 per calendar year.
Short Term Rehab (PT, OT, ST)
Physical, occupational, & speech therapy combined calendar
year max 60.
Diagnostic Lab and X-ray
High Tech Radiology (MRI, PET, CAT Scans)
Inpatient Hospital
Includes Mental Health and Substance Abuse Admissions.
Max two copays per member per calendar year.
Outpatient Facility Day Surgery
Emergency Room
Infertility (Outpatient)
Maximum of six attempts per lifetime.
Prescription Drug Benefit
RETAIL - Generic / Preferred Brand / Non-Preferred
MAIL – Generic / Preferred Brand / Non- Preferred
Lifetime Maximum
$10 copay/$30 copay/$50 copay
$20 copay/$60 copay/$100 copay
$15 copay/$45 copay/$60 copay
$30 copay/$90 copay/$120 copay
Deductible, then
$15 copay/$45 copay/$60 copay
$30 copay/$90 copay/$120 copay
Preventive Drugs Only
covered 100%
Unlimited
Unlimited
Unlimited
Unlimited
*The Plan will not pay for out-of-network services on the Minimum Essential Coverage Plan.
 CBA Blue, of Vermont, is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Trademarks of the Blue Cross and Blue Shield Association. These pages summarize the benefits of your plan. Your
Summary Plan Description defines the full terms and conditions in greater detail, including unique benefit maximums. Should any questions arise concerning benefits, the Summary Plan Description shall govern.
A Hassle-Free HealthEquity® HSA:
A Healthy Choice for Saving
Discover an easy, hassle-free health savings account (HSA) from HealthEquity and
discover the best way to save for health care, and a great way to save on taxes.
Individual HSA Contribution Limit
What Is an HSA?
An HSA is a tax-free savings account that works with a qualified health plan to help
you pay your insurance deductible and qualified out-of-pocket medical expenses.
$3,400 (2017)
$3,350 (2016)
You take the money you would have paid for higher health insurance premiums
and use it to pay qualified medical expenses or save it and let it grow from year
to year. What’s more:
 Your HSA—including all the money you and your employer
contribute—is yours.
- You won’t lose it if you don’t spend it, change jobs, retire,
or leave the health plan.
Family HSA Contribution Limit
 You never pay taxes on withdrawals for qualified medical expenses1.
 Your money earns interest and you don’t pay taxes on the interest earned1.
 Your contributions are tax-free and reduce your overall taxable income.
$6,750 (2017)
$6,750 (2016)
Why Choose a HealthEquity® HSA?
Your HealthEquity HSA includes:
 Easy-to-use online access to claims
and payments—access claims2,
pay bills, get reimbursements, and
more—all from a single,easy-to-use
online portal.
 Live service 24/7/365—get the
same service at 2 a.m. or 2 p.m.
from knowledgeable, US-based
HealthEquity Member
Services specialists.
 Remarkable education and
support—Rely on HealthEquity
Member Services and online
resources to get the most from your
HSA, find comparative pricing
on prescriptions and medical services,
research diseases, and more.
 Everything you get from a typical HSA
and more—including:
- FDIC-insured cash deposits that earn
competitive interest rates
- Free mutual fund investment
options with no transaction fees3
- Free HealthEquity Visa® health
account card†
Who’s Eligible for an HSA?
Anyone meeting the following
requirements is eligible for an HSA.
 Be enrolled in a qualified health plan.
 Have no other health coverage
except what’s permitted by the IRS
(see IRS Publication 969).
 Not be enrolled in Medicare.
 Not be claimed as a dependent on
someone else’s tax return.
Is an HSA Right for You?
Seventy percent of people have less than $1,000 of medical expense a year (including what both the insured and the health plan pay4).
Why not invest the money you’d pay for premiums in an interest-bearing, tax-advantaged HSA and lower-premium health plan?
Even if you have higher medical expenses, an HSA often costs less than a traditional plan when you combine what you save on
premiums and your out-of-pocket maximum. See the health plan comparison tool in the resource center at www.healthequity.com or
ask your employer for a cost comparison and see the savings for yourself.
Frequently Asked Questions
To learn even more, visit www.healthequity.com or contact HealthEquity Member Services by phone
or at [email protected].
Q. How Much Can Contributing to
AnHSASave Me on Taxes?
A. If you’re in the 25% tax bracket and
contribute $1,500, you save $375 in
taxes*! In addition your $1,500 grows
tax-free in your HSA. And when you
incur costs, you have money you can
withdraw with no tax penalty for
qualified medical expenses.
Sample Tax Savings
Your contribution: $1,500
Annual medical expenses: $500
Saving with
interest at
year’s end*
Cumulative
tax savings*
5 years
10 years 20 years
$5,101
$10,462
$22,019
$2,295
$4,670
$9,671
*Examples based on a 1% interest rate on HSA compounded
over time, a 5% state tax rate, and a 25% federal tax bracket.
Individual results will vary based on the amount contributed to
the HSA, medical expenses, and tax bracket.
Calculate your own savings at
http://healthequity135.vtoolkit.com/
apptoolkit/app/login/loginglobal.cfm.
Q. What’s A Qualified
Medical Expense?
A. Qualified medical expenses are
those that generally qualify for the
income tax deduction outlined in IRS
Publication 502. See www.irs.gov/pub/
irs-pdf/p502.pdf for a complete list
or visit the resource center on www.
healthequity.com.
Q. Who Can Put Money In My HSA?
A. Anyone can contribute to your HSA.
Only you and your employer receive
tax deductions on monies contributed.
And your contribution is tax-free.
Q. How Much Money Can I
Contribute to My HSA?
A. In 2017, the maximum contribution
set by the IRS for an individual is
$3,400 and $6,750 for family
coverage (up from $3,350 and $6,750
in 2016). People 55 and older can
make an additional $1,000 “catch-up”
contribution. Limits are the same
regardless of the source.
Q. CAN I Take The Money Out Of My
HSA Any Time I Want?
A. Yes. You can take money out anytime
tax-free and without penalty as long
as it’s to pay for qualified medical
expenses. If you take money out for
other purposes, you’ll pay income
taxes plus a 20% penalty.
Q. Can I Use The Money in My
HSA to Pay For My Children’s
Medical Expenses?
A. Yes. Your HSA can be used to pay the
qualified medical expenses of any
family member who qualifies as a
dependent on your tax return. If the
dependent isn’t on your health plan,
his/her expenses won’t apply to
your deductible.
Q. Can I Access My HSA Online?
A. Yes. Simply visit your member portal
or www.myhealthequity.com.
www.healthequity.com
866.346.5800
HealthEquity does not provide medical or tax advice. Content should not in any case replace professional medical or tax advice. If you have questions regarding a medical condition,
please consult a qualified health care professional. Please consult your tax adviser for tax questions.
†
this card is issued by the Bancorp Bank pursuant to a license from Visa U.S.A. Inc. the Bancorp Bank; Member FDIC.
1
Under federal law and most state laws.
2
Requires that your health plan be integrated with HealthEquity.
3
Investment options and balance thresholds required to invest vary and are subject to change.
4
2006 claims data from insurer with more than 700,000 lives.
Copyright © 2011 HealthEquity, Inc. All rights reserved. HealthEquity and the HealthEquity logo are registered trademarks or service marks of HealthEquity, Inc.
Visa is a registered trademark of Visa U.S.A. Inc. HealthEquity, Inc. is an independent sales organization (ISo) pursuant to an agreement with the Bancorp Bank.
Building Health Savings is a service mark of HealthEquity, Inc.
HE HSA1P 20120601/1
The CBA Blue Dental Plan does not utilize a Preferred Dental Provider network
Participants may seek services from a licensed provider of their choice
Questions: Please call CBA Blue at 1.800.222.9206 or visit www.cbabluevt.com .
BluePrintsm – 2017 Dental Plan Options “Benefits at a Glance”
Plan Options 
Premium Plan
Benefit
Annual Deductible
Calendar Year Benefit Maximum
Per individual.
Lifetime Orthodontic Benefit Maximum
Maximum is per individual.
All Providers
Quality Plan
All Providers
Single $50
Family$150
Single $50
Family$150
$2000
$750
$1500
Not Covered
100%
100%
80%*
80%*
50%*
Not Covered
Preventative Services
Oral Exams
Cleanings
X-rays (Bitewing- 1 every six months, Full Mouth- 1 every 60 months)
Sealants (up to age 19)
Fluoride (up to age 19)
Basic Restorative Services**
Periodontal Services
Periodontal Cleanings
Endodontic Services
Root Canals
Pulp Capping
Sedative Fillings
Composite Fillings
Amalgam Fillings
Crown Repairs
Denture Adjustments
Dental Reline
Bridge Repairs
Dental Anesthesia
Simple Extractions
Palliative Treatment
Major Restorative Services
Inlay/Onlay Restoration
Stainless Steel Crown
Bridgework
Crowns
Dentures
Partial Dentures
Temporary Crowns
Implants
* Subject to Plan Deductible
 CBA Blue, of Vermont, is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Trademarks of the Blue Cross and Blue Shield Association. These pages summarize the benefits of your plan. Your
Summary Plan Description defines the full terms and conditions in greater detail, including unique benefit maximums. Should any questions arise concerning benefits, the Summary Plan Description shall govern.
BluePrint® - 2017 Minimum Essential Coverage Plan (MEC Plan)
1
BENEFIT CATEGORY
BlueCard®
Coinsurance
Plan
Member
2
PREVENTIVE HEALTH SERVICES ADULTS/CHILDREN
100%
0%
BlueCard® (You Pay)
•
•
Routine physical examinations
Alcohol misuse screening and counseling (primary care visits only,
beginning at age 11)
•
Cholesterol screening
•
Depression screening (adults, children ages 12-18, primary care visits
only)
•
Diet behavioral counseling (included as part of annual visit and
intensive counseling by primary care clinicians or by nutritionists and
dieticians)
•
Hemoglobin A1c
•
Hepatitis B testing
•
HIV screening and counseling
•
Immunizations, including flu shots (flu shots at age 19 and above at a
doctor’s office or pharmacy; under age 19 at a doctor’s office)³
•
Obesity screening and counseling (adults and children, in primary care
settings)
•
Sexually transmitted diseases (STDs) – screenings and counseling
(adolescents, adults and pregnant women)
•
Skin cancer behavioral counseling
•
Tobacco use screening and counseling (primary care visits only)
•
Total cholesterol tests
2
PREVENTIVE HEALTH SERVICES ADULTS ONLY
$0
BlueCard® (You Pay)
•
•
Anemia screening for pregnant women
Aspirin for the prevention of heart disease (no coverage for over‐ the‐
counter aspirin)³
•
Blood pressure screening (adults without known hypertension)
•
Colorectal cancer screening, including colonoscopy, sigmoidoscopy
and fecal occult blood test
•
Diabetes screenings
•
Vitamin D supplement for adults age 65 and older to decrease the risk
of falls and fractures
•
Lung cancer screening
•
Hepatitis C screening
2
PREVENTIVE HEALTH SERVICES WOMEN ONLY
•
•
•
•
•
•
•
Breast cancer chemoprevention (counseling only for
women at high risk for breast cancer and low risk for adverse effects of
chemoprevention)
Breast cancer screening, including mammograms and counseling for
genetic susceptibility screening
Breastfeeding primary care interventions (applicable to pregnant
women and new mothers) includes lactation classes and support at
prenatal and post-partum visits, and newborn visits; supplies
Cervical cancer screening, including pap smears
Comprehensive lactation support, counseling, and costs of renting
breastfeeding equipment
Contraceptive methods approved by the FDA, sterilization procedures
and contraceptive patient education and counseling (contraceptives
covered with no member cost sharing include generics and brand
name drugs with no generic alternative, including emergency
contraceptives)³
$0
BlueCard® (You Pay)
$0
CBA Blue is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Trademarks of the Blue Cross and Blue Shield
Association.
2
PREVENTIVE HEALTH SERVICES WOMEN ONLY
BlueCard® (You Pay)
•
Folic acid supplements (women planning or capable of pregnancy
only)³
•
Gestational diabetes screening
•
HPV (human papillomavirus) testing
•
Interpersonal and domestic violence counseling and screenings
•
Iron deficiency anemia (pregnant women at prenatal visits)
•
Microalbuminuria test (pregnant women)
•
Osteoporosis screening (screening to begin at age 50 for women at
increased risk)
•
Ovarian cancer susceptibility screening
•
Rh (D) incompatibility, screening (pregnant women)
•
Routine OB/GYN examinations
•
Routine outpatient prenatal and postpartum visits
2
PREVENTIVE HEALTH SERVICES MEN ONLY
•
Abdominal aortic aneurysm screening (for males 65‐75 one time only,
if ever smoked)
2
PREVENTIVE HEALTH SERVICES CHILDREN ONLY
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Autism screening (for children at 18 and 24 months
of age; primary care settings)
Behavioral assessments (children of all ages; developmental
surveillance, in primary care settings)
Congenital hypothyroidism (screening for newborns
only)
Dental caries prevention – oral fluoride (for children
to 6 months to 6 years of age) Note: Coverage for fluoride is only
provided if your plan includes outpatient pharmacy coverage³
Dyslipidemia screening (for children at high risk for
higher lipid levels)
Hearing screening (screening for newborn only,
primary care settings)
Iron deficiency prevention (primary care counseling for children ages 6
to 12 months only)³
Lead screening (children at risk)
Phenylketonuria screening (newborns before 7days old)
Sickle cell disease, screening (screening at birth and
first newborn visit)
Tuberculosis skin testing
Vision screening (children to age 5 only)
Gonorrhea preventive medication (newborn eye drops) for all
newborns between 0-7 days of age for the prevention of gonococcal
ophthalmia neonatorum³
$0
BlueCard® (You Pay)
$0
BlueCard® (You Pay)
$0
* These pages summarize the benefits of your health care plan. Your Summary Plan Description defines the full terms and conditions in greater detail.
Should any questions arise concerning benefits, the Summary Plan Description shall govern.
1
The CBA Blue Minimum Essential Benefit Plan utilizes the National BlueCard® PPO Network.
2
The list of preventive care services covered under this benefit plan may change periodically based upon the recommendation of
the United States Preventive Services Task Force, the Advisory Committee on Immunization Practices of the Centers for Disease
Control and Prevention, and the Health Resources and Services Administration. Information on the recommendations of these
agencies can be found at: https://www.healthcare.gov/what-are-my-preventive-care-benefits/
3
Certain covered services are made available to you through a Prescription Drug Program which provides you access to a retail
pharmacy network managed by Benecard. To locate a network pharmacy or access the prescription formulary, go to
www.benecardpbf.com.
Questions:
Please Call CBA Blue at 1-888-222-9206. To locate a participating BlueCard® PPO Network provider, or to learn
more about CBA Blue, please visit www.cbabluevt.com.
CBA Blue is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Trademarks of the Blue Cross and Blue Shield
Association.
DUNKIN' DONUTS FRANCHISEE AND
DISTRIBUTION CENTER HEALTH PLAN
MONTHLY PREMIUMS Effective 1/1/17 - 12/31/17
PLAN
PREMIUM
QUALITY
VALUE
MEC
PLAN
PREMIUM
QUALITY
MEDICAL
SINGLE
2 PERSON
$673.85
$495.48
$360.00
$43.81
$1,314.00
$966.20
$702.00
$85.44
DENTAL
SINGLE
2 PERSON
$51.22
$33.02
$97.75
$60.93
FAMILY
$1,853.10
$1,362.59
$990.00
$120.49
FAMILY
$139.79
$86.17
DUNKIN' DONUTS FRANCHISEE AND DISTRIBUTION CENTER
HEALTH PLAN PARTICIPATION ELIGIBILITY AND ADMINISTRATION REQUIREMENTS
MEDICAL AND DENTAL PLAN (the “Plan”) REQUIREMENTS FOR PARTICIPATING EMPLOYERS
PARTICIPATING EMPLOYERS
Only Participating Employers, as defined below, may participate in the Plan. Questions concerning whether or
not an entity qualifies as a "Participating Employer" should be directed to the Plan Administrator at National
DCP, LLC (“NDCP”).
A Participating Employer is any entity that has common law employees, and (i) has entered into a
franchise agreement with Dunkin' Brands, Inc.; or (ii) is part of a controlled group of corporations (as
defined in the Internal Revenue Code of 1986, as amended (IRS Code), § 414(b)) or commonly
controlled trades or businesses (as defined in IRS Code § 414(c)) that includes and provides services
to an entity that has entered into a franchise agreement with Dunkin’ Brands, Inc.; or (iii) is a
distribution center that services franchisees in agreements with Dunkin’ Brands, Inc.
ELIGIBLE EMPLOYEE PARTICIPANTS
The following Participant eligibility criteria must be met for enrollment in the Plan:
Eligible Franchise Owner:
•
Must be a current Member in good standing of the NDCP Co-Operative and be consistently paid through
the payroll of a Participating Employer.
Eligible Employee Participant:
•
•
Must be scheduled to work 30 or more hours per week, must be regularly scheduled to work more than
1,560 hours in a calendar year, and
Must be employed by and paid through a Participating Employer.
NDCP recommends Participating Employers consult their business / financial advisors to determine
employee eligibility under the requirements of the Affordable Care Act.
Eligible Employee Dependent:
•
•
•
Your lawful spouse or ex-spouse*;
Your child**up to age 26;
Your disabled child* age 26 and older who is mentally or physically handicapped and incapable of earning
his/her own living.
.
* An ex-spouse is deemed an eligible dependent if health plan coverage is mandated under a Qualified Domestic Relations
Order.
* An ex-spouse is deemed an eligible dependent if health plan coverage is mandated under a Qualified Domestic Relations
Order.
** A child is defined as your natural biological child, stepchild, legally adopted child or child placed with you or your spouse
for adoption, a child for whom you or your spouse has been appointed the legal guardian, or a child for whom you are
required to provide health insurance by a Qualified Medical Child Support Order.
Rev. 08/2016
A Participating Employer may be required to provide proof of eligibility for any or all participating employees.
Periodic audits of Participating Employer’s payroll and benefit enrollment records may be conducted by the
Plan Administrator or his / her authorized representative at any time.
PLAN ELECTIONS
Participating Employers:
•
•
•
•
Must elect the Plans they wish to offer to their franchise employees from the available Plan options
Determine enrollment waiting periods by Employee Class, not to exceed 90 days from the initial enrollment
eligibility date
Categorize their Eligible Employees into one of the following Employee Classes:
- Class I: Franchisees / Officers
- Class II: Managers / Supervisors
- Class III: Non-Managers
Offer a traditional health and/or dental plan to an entire Employee Class* of eligible employees, and must
offer all tiers of coverage (i.e., single, employee plus one and family coverage) for Plans elected.
Election Changes
Participating Employers:
Once elected, enrollment elections remain in effect until an eligible change in enrollment election is authorized
by the Plan Administrator.
Changes to a Franchise enrollment may occur for one of the following reasons:
-
Change in ownership of a participating franchise when the sale is an asset only sale or purchase
resulting in the loss or addition of Plan coverage; and/or
During the annual Plan Open Enrollment period. Should a Participating Employer terminate
coverage for his/her entire network of stores during Open Enrollment, the Participating
Employer's network shall be prohibited from rejoining the Plan for a period of one year
following the annual Open Enrollment period.
The Participating Employer must give the NDCP 30-days' notice before terminating his/her network of stores from
the Plan.
If a Participating Franchise transfers ownership, the current Franchise Owner must notify the NDCP Plan
Administrator of the change in Franchise ownership and the termination of coverage for the franchise, if
applicable. The new Franchise Owner must notify NDCP if they wish to enroll the applicable franchise(s) in
the Plan under their Participating Employer control group.
Changes in Plan elections must be made within thirty (30) days of a qualifying sale / purchase of a Franchise.
Changes made during the annual Plan Open Enrollment become effective January 1st of the year immediately
following the annual Plan Open Enrollment.
Employee Participants:
Once elected, an enrollment election remains in effect until an eligible change in enrollment election is made.
Changes to an employee’s enrollment may occur for any defined IRS Life Event.
Changes in Plan elections must be made within thirty (60) days of the qualifying Life Event. Changes made
during the annual Plan Open Enrollment become effective January 1st of the year immediately following the
annual Open Enrollment.
Rev. 08/2016
COBRA





Coverage for terminating employees ends on the last day of employment.
Termination notification must be received by NDCP within 30 days of the employee’s last day of
employment or the cancellation of coverage will occur on the date the termination notification was received.
COBRA notification, if applicable, will be initiated by the Plan’s third party COBRA administrator, EBPA, upon
receipt of a termination notice from the Participating Employer or designated Benefits Administrator.
CBA Blue will be responsible for providing Certificate of Coverage (HIPAA Certification) to employees
terminating from the Plan.
The Plan will partner with EBPA to administer COBRA, including collection of premiums.
A Franchise Owner who leaves the NDCP Co-operative ends their status as a Participating Employers of the
Plan and they and any previously participating employees of their Participating franchises are ineligible for
continuation of coverage under COBRA.
PLAN PREMIUMS AND ADMINISTRATIVE FEES
Participating Employers:
Effective January 1, 2017, Participating Employers must contribute a minimum of:



50% of the published premium for the least expensive employee only medical plan offered by employee
class (excluding the Minimum Essential Coverage Plan (MEC)), and
20% of the monthly premium for other Plans offered, regardless of tier of coverage (i.e. employee plus
one, or family) or Employee Class, and
50% of the published rate for the least expensive employee only dental plan being offered.
A Participating Employer may elect to contribute more than this amount for all eligible employees.
NOTE: The ACA requires employees pay no more than 9.66% of their annual W2 Box 1 wages towards single
coverage under their employer’s medical plan. To avoid ACA compliance issues and penalty fees, Participating
Employers are encouraged to consult their financial advisors for assistance in complying with ACA
requirements.
The NDCP reserves the right to charge each Participating Employer a Plan administrative fee to
support ongoing Plan administration.
PLAN ADMINISTRATION
The Participating Employer is fully responsible for:



Account maintenance for qualifying events, including adding newly eligible employees, terminating
participant coverage, and submitting participant changes. Qualifying events pertaining to
participants/dependents, such as losing or becoming eligible for other coverage, require documentation
supporting the change.
Auditing all monthly bills and verifying accuracy of participants listed on the monthly billing.
Adhering to all local and federal rules, regulations and laws, as well as all state and federal filings relating
to administering health plan coverage to their employees. NDCP is not liable for Participating Employer's
failure to adhere to these laws.
Rev. 08/2016
BILLING
All Participating Employers, Profit Centers (PCs), are invoiced by the NDCP on a monthly basis for the following
month's premiums / fees. Newly enrolled employees are billed for the first full month enrolled in the Plan.
Conversely, terminated employees' coverage ends on the last day worked; however, Participating Employers are
responsible for the full monthly premium. Premiums are billed as full months; no partial monthly billing is
available.
Detailed monthly healthcare invoices are accessible through the Member’s account on the NDCP member
portal.
Online access to view invoices on the member portal and conduct Plan-related administration is given to the
designated Benefits Administrator for each Participating Employer.
ACKNOWLEDGEMENT AND UNDERSTANDING
Participating Employer hereby acknowledges that he/she has read and fully understands and agrees to the
eligibility and administration requirements detailed herein.
_________________________________________________
Legal Name of Participating Employer
_____________________________
Owner ID / PC Number
_________________________________________________
Signature of Participating Employer Owner
_____________________________
Date
_________________________________________________
Printed Name of Participating Employer Owner
_________________________________________________
Signature of Participating Employer Benefit Administrator
_________________________________________________
Printed Name of Participating Employer Benefit Administrator
Rev. 08/2016
_____________________________
Date
DUNKIN’ DONUTS FRANCHISEE & DISTRIBUTION CENTER HEALTH TRUST
PARTICIPATION AGREEMENT AND CERTIFICATE
______________________________________________________________________________
This Participation Agreement and Certificate is executed by the undersigned entity
(hereinafter, the “Participating Employer”). By executing this agreement, the Participating
Employer agrees as follows:
1.
The Participating Employer is bound by the provisions of the (i) Dunkin’ Donuts
Franchisee & Distribution Center Health Plan (the “Plan”) and (ii) the Dunkin’ Donuts
Franchisee & Distribution Center Health Plan Trust (the “Trust”), 1 each as established and
adopted effective as of February 14, 2006, and as amended and/or restated from time-to-time,
which together with all executed participation agreements constitute a multiple-employer welfare
arrangement as defined in ERISA § 3(40) (herein, the “Arrangement”).
2.
The Participating Employer will fully comply with all requirements as may be
established from time to time by the Administrative Committee and the Trustees under the
Arrangement.
3.
The Participating Employer has elected the coverage options and has complied
with the eligibility criteria set out in the “Franchise Owner Medical/Dental Application” and the
“Dunkin’ Donuts Franchisee & Distribution Center Health Plan Eligibility and Administration
Requirements” accompanying this Agreement. The Participating Employer agrees that coverage
under the Plan will become effective with respect to any employee or dependent of the
Participating Employer only once the individual seeking to be covered has fully satisfied all the
requirements of such elections, and has complied with the eligibility criteria and the
Arrangement.
4.
The Trustees have the authority to act on behalf of the Trust, and the
Administrative Committee has the authority to act on behalf of the Plan, with respect to any and
all matters relating to the establishment, maintenance and operation of the Arrangement.
5.
The Trustees and the Administrative Committee each has full power and
authority to establish from time to time rules and requirements for the administration of, and
participation in the Trust and Plan, respectively.
6.
This is a fully assessable contract. If the Trust is unable to pay its
obligations, Participating Employers will be required to contribute through an equitable
assessment the money necessary to meet any unfulfilled obligations.
7.
The undersigned hereby:
(a)
Acknowledges receipt of a copy of the Plan and the Trust;
(over)
1
Terms capitalized but not defined in this Agreement shall have the meaning assigned in the Trust.
Rev. 12/2008 v.1 (SRM/NDCP)
Acknowledges receipt of a copy of the “Franchise Owner Medical/Dental
(b)
Application” attached hereto;
(c)
Acknowledges receipt of a copy of the form “Dunkin’ Donuts Franchisee
& Distribution Center Health Plan Eligibility and Administration Requirements” attached hereto
and that he/she has read and fully understands the eligibility and administration requirements
discussed therein;
(d)
Warrants and represents that he, she or it is authorized to act on the behalf
of all employers under common ownership with the Participating Employer that together
constitute a single employer; and
(e)
Certifies that he/she is the ______________________ (Title) of the
Participating Employer, and that he/she is duly authorized to execute this agreement on behalf of
the Participating Employer.
Executed as of this _____ day of _________________, 20___.
________________________________________________
Participating Employer (please print)
________________________________________________
Duly Authorized Signature
________________________________________________
Name (please print)
________________________________________________
Title (please print)
Rev. 12/2008 v.1 (SRM/NDCP)
HIPAA BUSINESS ASSOCIATE AGREEMENT
THIS HIPAA BUSINESS ASSOCIATE AGREEMENT (the “Agreement”) between
the Dunkin’ Donuts Franchisee & Distribution Center Premium Health Plan, (“Covered Entity”)
and National DCP, LLC, a Business Associate of Covered Entity (“Business Associate”), is
effective as of the effective date of the Underlying Agreement as defined herein (the “Agreement
Effective Date”).
WITNESSETH:
WHEREAS, Covered Entity and Business Associate want to enter into an agreement
whereby Business Associate provides administrative services to the Covered Entity (the
“Underlying Agreement”).
WHEREAS, Covered Entity wishes to disclose certain information to Business Associate
pursuant to the terms of the Underlying Agreement, some of which may constitute Protected
Health Information (“PHI”);
WHEREAS, Covered Entity and Business Associate intend to protect the privacy and
provide for the security of PHI disclosed to Business Associate pursuant to the Underlying
Agreement in compliance with the Health Insurance Portability and Accountability Act of 1996,
Public Law 104-191 as amended by the Health Information Technology for Economic and Clinical
Health Act (“HITECH”) and the privacy rule and security standards promulgated thereunder by
the U.S. Department of Health and Human Services as amended from time to time (collectively,
“HIPAA”) and other applicable laws, including applicable state laws;
WHEREAS, the purpose of this Agreement is to satisfy certain standards and requirements
of HIPAA including, but not limited to, Title 45, Section 164.504(e) of the Code of Federal
Regulations (“C.F.R.”), as the same may be amended from time to time;
NOW THEREFORE, for good and valuable consideration, the receipt and sufficiency of
which are hereby acknowledged, the parties, intending to be legally bound, hereby agree as
follows:
I. Definitions
(a) “HIPAA Regulations” will refer to all regulations and guidance promulgated under the
Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) as amended by
the Health Information Technology for Economic and Clinical Health Act (“HITECH”)
and final HITECH regulations under the HIPAA Omnibus Rule.
(b) “Protected Health Information” or “PHI” as used herein will refer to PHI disclosed by
Covered Entity to Business Associate.
1
(c) Unless otherwise specified in this Agreement, all other capitalized terms will have the
meaning ascribed to them under the HIPAA Regulations.
II. Obligations of Business Associate
Business Associate agrees to:
(a) only use or disclose PHI as permitted or required for the Underlying Services or as required
by law;
(b) use appropriate safeguards, and comply with Subpart C of 45 CFR Part 164 with respect to
PHI in electronic form, to prevent use or disclosure of PHI other than as necessary for the
Underlying Services or this Agreement;
(c) immediately, but in no event more than seventy-two (72) hours following Discovery, report
to Covered Entity any use or disclosure of PHI not provided for by this Agreement of which it
becomes aware, including Breaches of Unsecured Protected Health Information as required at
45 CFR 164.410, and any Security Incident of which it becomes aware. Business Associate’s
notice will include information necessary for Covered Entity to comply with its breach
notification obligations under the HIPAA Regulations and/or state law. Business Associate
may supplement its initial report as facts become available.
Notice under this Section II (c) will be provided to:
Regina Bryant, [email protected], National DCP, LLC, Chief Human Resources
Officer
(d) in accordance with 45 CFR 164.502(e)(1)(ii) and 164.308(b)(2), if applicable, ensure that
any subcontractors that create, receive, maintain, or transmit PHI on behalf of Business
Associate agree to the same restrictions, conditions, and requirements that apply to the Business
Associate with respect to such information;
(e) make available PHI in a Designated Record Set to Covered Entity as necessary to satisfy
Covered Entity’s obligations under 45 CFR 164.524;
(f) make any amendment(s) to PHI in a Designated Record Set as directed or agreed to by the
Covered Entity pursuant to 45 CFR 164.526, or take other measures as necessary to satisfy
Covered Entity’s obligations under 45 CFR 164.526;
(g) maintain and make available the information required to provide an accounting of
disclosures to Covered Entity as necessary to satisfy Covered Entity’s obligations under 45
CFR 164.528 as amended from time to time;
(h) comply with the requirements of Subpart E of 45 CFR Part 164 to the extent required by
law and also to the extent that Business Associate is to carry out one or more of Covered Entity's
obligation(s) under Subpart E of 45 CFR Part 164; and
2
(i) make its internal practices, books, and records related to compliance with this Agreement
and the HIPAA Regulations available to Covered Entity and to the Secretary for purposes of
determining compliance with the HIPAA Regulations.
III. Permitted Uses and Disclosures by Business Associate
(a) Business Associate may only use or disclose PHI as necessary to perform the Underlying
Services.
(b) Business Associate may use or disclose PHI as required by law.
(c) Business Associate agrees to make uses and disclosures and requests for PHI consistent with
Covered Entity’s minimum necessary policies and procedures provided to Business Associate
in advance.
(d) Except for uses and disclosures set forth in Section III (e), (f) and (g) herein, Business
Associate may not use or disclose PHI in a manner that would violate Subpart E of 45 CFR Part
164 if done by Covered Entity.
(e) Business Associate may use PHI for the proper management and administration of the
Business Associate or to carry out the legal responsibilities of Business Associate.
(f) Business Associate may disclose PHI for the proper management and administration of
Business Associate or to carry out the legal responsibilities of Business Associate, provided the
disclosures are required by law, or Business Associate obtains reasonable assurances from the
person to whom the information is disclosed that the information will remain confidential and
be used or further disclosed only as required by law or for the purposes for which it was
disclosed to the person, and the person notifies Business Associate of any instances of which it
is aware in which the confidentiality of the information has been breached.
(g) Business Associate may provide data aggregation services relating to the health care
operations of Covered Entity.
IV. Indemnification
(a) Indemnification. Business Associate agrees to indemnify, defend and hold harmless
Covered Entity, its affiliates and each of their respective directors, officers, employees, agents
or assigns from and against any and all actions, causes of action, claims, suits and demands
whatsoever, and from all damages, liabilities, costs, fines, debts, and expenses (including costs
associated with investigation, required breach notifications and the mitigation of harm)
resulting from Business Associate’s Breach of Unsecured PHI, violation of HIPAA, applicable
state data security law or violation of this Agreement.
V. Provisions for Covered Entity to Inform Business Associate of Privacy Practices and
Restrictions
3
(a) Covered entity shall notify Business Associate of any limitation(s) in the Notice of Privacy
Practices of Covered Entity under 45 CFR 164.520, to the extent that such limitation may affect
Business Associate’s use or disclosure of Protected Health Information.
(b) Covered Entity shall notify Business Associate of any changes in, or revocation of, the
permission by an individual to use or disclose his or her PHI, to the extent that such changes
may affect Business Associate’s use or disclosure of PHI.
(c) Covered Entity shall notify Business Associate of any restriction on the use or disclosure of
PHI that Covered Entity has agreed to or is required to abide by under 45 CFR 164.522, to the
extent that such restriction may affect Business Associate’s use or disclosure of PHI.
VI. Permissible Requests by Covered Entity
Covered Entity shall not request Business Associate to use or disclose PHI in any manner that
would not be permissible under Subpart E of 45 CFR Part 164 if done by Covered Entity, except
for Business Associate uses and disclosures of PHI for data aggregation or management and
administration and the legal responsibilities of Business Associate.
VII. Term and Termination
(a) Term. The term of this Agreement shall commence on the Effective Date and shall terminate
upon termination of the Underlying Services or on the date Covered Entity terminates for cause
as authorized in paragraph (b) of this Section, whichever is sooner.
(b) Termination for Cause. Business Associate authorizes termination of this Agreement by
Covered Entity, if Covered Entity determines that Business Associate has violated a material
term of this Agreement and Business Associate has not cured the breach or ended the violation
within the reasonable time specified by Covered Entity. Termination of this Agreement will
suspend uses and disclosures of PHI by Business Associate pursuant to the Underlying
Services.
(c) Obligations of Business Associate Upon Termination.
Upon termination of this Agreement for any reason, Business Associate shall return to Covered
Entity or, if agreed to by Covered Entity, destroy, all PHI received from Covered Entity, or
created, maintained, or received by Business Associate on behalf of Covered Entity, that
Business Associate still maintains in any form. Business Associate shall retain no copies of the
PHI. Upon termination of this Agreement for any reason, Business Associate, with respect to
PHI received from Covered Entity, or created, maintained, or received by Business Associate
on behalf of covered entity, shall:
1. retain only that PHI which is necessary for Business Associate to continue its proper
management and administration or to carry out its legal responsibilities;
2. return to Covered Entity or, if agreed to by Covered Entity, destroy the remaining
PHI that the Business Associate still maintains in any form;
4
3. continue to use appropriate safeguards and comply with Subpart C of 45 CFR Part
164 with respect to electronic PHI to prevent use or disclosure of the PHI, other
than as provided for in this Section, for as long as Business Associate retains the
PHI;
4. not use or disclose PHI retained by Business Associate other than for the purposes
for which such PHI was retained and subject to the same conditions set forth herein;
and
5. return to Covered Entity or, if agreed to by Covered Entity, destroy the PHI retained
by Business Associate when it is no longer needed by Business Associate for its
proper management and administration or to carry out its legal responsibilities.
The obligations of Business Associate under this Section shall survive the termination of this
Agreement.
VIII. Miscellaneous
(a) Regulatory References. A reference in this Agreement to a section in HIPAA means the
section as in effect or as amended.
(b) Automatic Amendment to Comply with Law. The parties acknowledge that state and
federal laws relating to electronic data security and privacy are rapidly evolving and that
amendment of this Agreement may be required to ensure compliance with such developments.
Specifically, HITECH, as implemented by the HIPAA Omnibus Rule (78 Fed. Reg. 5566
(January 25, 2013)), imposes new requirements on business associates and covered entities
with respect to privacy, security and breach notification. Applicable HIPAA and HITECH
provisions, together with any guidance issued by the Secretary, and any applicable
amendments to federal and state privacy law, are hereby incorporated by reference and will
become part of this Agreement as if set forth in their entirety, effective as of the applicable
effective date/s.
(c) Interpretation. Any ambiguity in this Agreement shall be interpreted to permit compliance
with HIPAA.
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed
by their respective duly authorized representatives as of the day and year above written.
GROUP HEALTH PLAN
BUSINESS ASSOCIATE
By:
Print Name:
Title:
Date:
By:_____________________________
Print Name: ______________________
Title: ___________________________
Date:____________________________
5
MEDICAL / DENTAL PLAN
FRANCHISE OWNER GROUP ENROLLMENT APPLICATION
PLEASE CHECK ONE: ☐ Initial Enrollment*
☐ Change/Add PC
☐ Other (explain):
NOTE: Franchise Owner is required to submit Payroll Register at time of Initial Plan Enrollment and may be asked to
provide future Payroll Registers, as needed, to verify enrollment compliance.
Application must be completed in its entirety and must be signed and dated by authorized franchise Owner for which the
Application applies. Indicate N/A in any section that does not apply to your group.
SECTION A
OWNER CONTACT NFORMATION AND PLAN ELECTIONS
OWNER CONTACT INFORMATION Enter Owner contact information
Complete Legal
Entity Name:
Owner ID (Internal
use only):
Owner’s Full
Name:
Federal ID Number:
Owner’s Phone
Number (w / Area
Code):
Owner’s Fax
Number (w/ Area
Code):
Owner’s Email
Address:
Mailing Address
for Benefits
Correspondence:
HUMAN RESOURCES / BENEFITS ADMINISTRATOR CONTACT INFORMATION Franchises participating in an
NDCP Health Plan must maintain a dedicated Human Resources / Benefits Administrator contact for their network to
facilitate efficient Plan administration and compliance activities. These Administrators will have access to view health plan
invoices, assist with participant enrollment, changes and coverage termination via the Benefit Focus portal.
Administrator’s Full Name
(First, Last)
Email Address
Mailing Address and Phone Number (Include
Area Code)
ELIGIBLE PROFIT CENTERS List Profit Center (PC) eligible for NDCP Franchisee & Distribution Center Health Plan
Coverage. Please include the state in which each PC is located and alternate mailing address, if applicable.
PC #
State
Alternate Address from Owner, if applicable
*Continue on additional sheet, if needed.
Rev 10/2016
CONFIDENTIAL
Page 1 of 6
ELIGIBLE PARTICIPANT CLASSES
Class I: Franchisees/Officers
• Eligible for coverage if paid through the payroll of a participating company.
Class II: Managers/Supervisors
• Eligible for coverage if working 30 or more hours per week and is regularly
scheduled to work more than 1,560 hours in a calendar year.
Class III: Team Members
• Eligible for coverage if working 30 or more hours per week and is regularly
scheduled to work more than 1,560 hours in a calendar year.
EFFECTIVE DATE OF COVERAGE
Waiting Period. ACA compliance requires enrollment waiting periods of 90 days or less. Please select only (1) waiting
period per Class.
Effective Date of Coverage. Applications for Group Coverage are due no later than 60 days prior to the desired effective
date of coverage. Effective date of coverage for first time applicants shall be the 1st day of the month requested, subject
to review of Payroll Register(s) and confirmation of satisfaction of all eligibility requirements.
Original Effective Date of Entry into the Plan:
Effective Date of Change in Plan Elections: (Must be the 1st of the month)
Termination of Coverage. The Plan Elections selected below shall apply for all eligible employees within each Class
throughout your network from the Effective Date of Coverage through the later of the end of the Plan Year or official
termination of coverage from the Plan, as approved by NDCP.
PAYROLL ADMINISTRATION
Payroll Vendor:
Class I:
Payroll Frequency by Employee Class:
Class II:
Class III:
If Payroll Frequency is ‘Other’, detail here:
PLAN ELECTIONS
Enter the NDCP benefit plans your franchise will offer each Employee Class and indicate percentage of the monthly
premium the franchise will cover for each Plan by Class. You may elect to offer up to four (4) Medical Plans and up to two
(2) Dental Plans per Employee Class. NDCP requires participating franchises contribute a minimum of 50% of the lowest
cost employee only premium (excluding MEC), and a minimum of 20% of all other coverage offered, regardless of Tier of
Coverage or Employee Class. You should be aware, however, that the coverage will not be considered “affordable” for
ACA purposes unless the employee cost for self-only coverage is less than 9.66% of his or her Box 1 Wages.
Rev 10/2016
CONFIDENTIAL
Page 2 of 6
CLASS I:
CLASS II:
CLASS III:
Owners and Executives on
Participating Franchise Payroll
Managers and Supervisors on
Participating Franchise Payroll
Team Members on Participating
Franchise Payroll
Is Coverage
Offered:
Waiting Period by
Class:
Plans Offered
and Percentage
of Premium Paid
by Franchise
(ER) by pay
period by Class:
Enter % covered
from the drop
down menu (i.e.,
20% to 100%)
for all Plans the
franchise will
offer in 2017.
Plan
Premium
ER
Premium %
Plan
Premium
Single:
Couple:
ER
Premium %
Single:
Couple:
Family:
Quality
Value
Couple:
Family:
Family:
Value
Single:
Couple:
Single:
VT –
Medical
Single:
(VT Only)
Single:
Couple:
Family:
VT –
Medical
Couple:
(VT Only)
Single:
Couple:
Family:
Single:
Couple:
Family:
Premium –
Dental
Couple:
Single:
Couple:
Single:
Couple:
Single:
Couple:
Family:
Health Savings
Account (HSA):
Family:
Minimum
Essential
Coverage
VT –
Medical
(VT Only)
Single:
Couple:
Family:
Single:
Couple:
Family:
Premium
– Dental
Family:
Quality –
Dental
Single:
Couple:
Family:
Premium
– Dental
Single:
Family:
Quality –
Dental
Family:
Value
Family:
Minimum
Essential
Coverage
Single:
Couple:
Couple:
Family:
Single:
Family:
Quality
Single:
Couple:
ER
Premium %
Couple:
Family:
Quality
Single:
Minimum
Essential
Coverage
Plan
Premium
Single:
Couple:
Family:
Quality –
Dental
Family:
Single:
Couple:
Family:
Offer a Health Savings Account?
If Yes, who is the vendor?
If YES, are all employee Classes eligible?
If Yes, how often does the Franchise contribute to
the employee’s account?
If NO, which employee Classes are eligible?
Additional
Explain coverage and vendor(s), as well as eligible Employee Classes and waiting periods.
Benefit Plans
Offered:
COMMENTS / ADDITIONAL INFORMATION: [Additional information related to franchise benefit coverage you believe we
need to be made aware of.]
SECTION B
COBRA AND INACTIVE EMPLOYEE PARTICIPATION
COBRA PARTICIPATION Identify all employees, spouses and/or children who currently have continuing coverage under
the provisions of COBRA.
Name of COBRA Participant(s)
Rev 10/2016
Coverage Type
(Individual or Family)
CONFIDENTIAL
Projected COBRA
Termination Date
Type of
Coverage
Page 3 of 6
☐ Medical ☐ Dental
☐ Medical ☐ Dental
☐ Medical ☐ Dental
COVERED INACTIVE EMPLOYEES List below the names of covered Employees not actively at work due to one of
the following reasons: 1) layoff; 2) leave of absence; 3) confinement in a health care facility; 4) maternity leave; 5)
disability; 6) worker’s compensation; 7) illness; 8) injury; 9) other (please specify).
Employee Name
Age
Reason for Absence
(1 – 9)
Last Date Worked
Family Coverage
☐Y ☐N
☐Y ☐N
☐Y ☐N
SECTION C
GROUP MEDICAL HISTORY / DISCLOSURE
MEDICAL HISTORY / DISCLOSURE. Please answer the following questions to the best of your knowledge. Your
Group shall not be denied coverage based on the responses to the following questions.
Has the Group’s medical coverage ever been cancelled, or applications for coverage been declined or
withdrawn? ☐ Y ☐ N
•
•
•
Answer ‘YES’ or “NO” to each question below by checking the appropriate box to the left of the question.
If you answer ‘YES’, indicate the number of members to which that answer applies in the ‘# of members’ column.
If you answer ‘NO’, insert the number zero (0) in the ‘# of members’ column.
QUESTION
YES
NO
1. In the past twelve (12) months, has any one person covered under your Employee
Benefit Plan incurred claims in excess of $62,500?
☐
☐
2. Are you aware of any person with the potential to exceed $62,500 in claims in a
Calendar Year?
☐
☐
3. Do you have any employees / dependents who are presently disabled or on COBRA?
☐
☐
# OF
MEMBERS
If you answered ‘Yes’ to any of the questions above, please provide details in the following section. Use additional
pages, if needed.
Question #
Name
(optional)
Employee,
Spouse or
Child
Age
Gender
Condition /
Diagnosis
Treatment /
Medications
Treatment
Date
Date of
Recovery
1
Jane Doe
Spouse
36
F
Stroke
Surgery
2/7/2016
8/3/2016
INSURANCE COMPANY HISTORY [NEW APPLICANTS ONLY] List all insurance companies, including HMOs, your
group is currently participating in or has participated in during the previous three (3) years (if applicable).
Name of Current Insurance
Carrier:
Rev 10/2016
Period Insured:
CONFIDENTIAL
to
Page 4 of 6
Name of Prior Insurance Carrier:
Current
Carrier
Premium
Rates for:
Employee
Only
Employee +
Spouse
Employee +
Children
Family
Period Insured:
to
☐ HMO
2017 Renewal
Current Premium Premium:
$
$
☐ PPO
$
$
$
$
☐ Other (Specify)
$
$
$
$
☐ HMO
$
$
$
$
☐ PPO
$
$
$
$
☐ Other (Specify)
$
$
$
$
☐ HMO
$
$
$
$
☐ PPO
$
$
$
$
☐ Other (Specify)
$
$
$
$
☐ HMO
$
$
$
$
☐ PPO
$
$
$
$
☐ Other (Specify)
$
$
$
$
Applicable Plan
Type
SECTION D
Deductible
$
Co-Insurance
$
ACKNOWLEDGEMENT AND UNDERSTANDING
Name and Title of Person Providing Information on
Behalf of Franchise
Email and Phone Number of Person Providing this
Form on Behalf of Franchise
ACKNOWLEDGMENT AND UNDERSTANDING
The undersigned hereby represents he / she is legally authorized to represent the Franchise Owner applying for
enrollment in the NDCP Health Plan and further acknowledges he / she:
•
Agrees to abide by all rules, regulations and laws relating to the confidentiality of information provided in this
Application;
Rev 10/2016
CONFIDENTIAL
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•
•
•
Elects and authorizes the above Plan Elections for franchises enrolled in the Plan under this Owner;
Agrees to ensure full compliance with the terms and conditions of participation in an NDCP Health Plan; and
Agrees to immediately notify the NDCP Health Plan Administrator of any changes in franchise ownership and/or
Benefit / HR Administrator contacts.
__________________________________________________
Signature of Owner / Authorized Owner Representative
____________________________________
Date
__________________________________________________
Printed Name
____________________________________
Title
Please contact the NDCP benefits team at [email protected] or call the healthcare
hotline at 1.888.365.4327, option 4, with any questions regarding this Application or Plan enrollment.
Please fax completed forms along with additional pages, if needed, to (770) 935-7662.
FOR NDCP USE ONLY
SAP Vendor ID:
CBA Blue Division ID:
Employee Census
Received:
Confirmation Sheet
Emailed:
Signed Confirmation Sheet
Received:
NE Franchise? ☐ Yes ☐ No
By:
Date:
By:
Date:
By:
Date:
BF Profile Verified:
By:
Date:
SPD Addendum Prepared:
By:
Date:
Rev 10/2016
CONFIDENTIAL
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