Information about http://www.nevadacheckup.state.nv.us/Plus/NCU-0111%20NV%20Check%20Up%20Plus%20Employer%20App_1-16-07.pdf
Nevada Check Up Plus. …
Tags: address number, application section, attn, boise idaho, city state zip, company representative, employer application, employer health, fairview, health insurance, health insurance carrier, health management systems, health plan, hifa, mailing address, open enrollment, physical address, section 1, state zip code, taxpayer identification number,Pages: 3
Language: english
Created: Tue Jan 16 10:18:29 2007
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Nevada Check Up Plus. Return application
For more information call:
(775) 684-3777
NEVADA CHECK UP (See instructions) to:
Health Management Systems Holding Corp
(1-877-543-7669) In-State ATTN: Nevada HIFA
1-800-360-6044 Out-of-State PLUS 5257 Fairview Avenue Suite 195
Boise, Idaho 83706
Employer Application
SECTION 1
Company Name Company Representative's Name
Physical Address - Number and Street Unit/Suite City State Zip Code
Mailing Address - Number and Street Unit/Suite City State Zip Code
Representative's Contact Phone Number Does this business have 2-50 employees? Yes No (see NRS 689C.095)
Taxpayer Identification Number Open Enrollment Begin Date Open Enrollment End Date
SECTION 2
EMPLOYER HEALTH PLAN INFORMATION:
Nevada Check Up Plus will contact your Health Insurance Carrier:
1. to validate you are a "Small employer" as defined under NRS 689C.095;
2. to verify you provide "Creditable coverage" as defined under NRS 689C.053;
3. to verify your premium costs are as reported.
Is there a group health insurance program available to your employees? Yes No
Who can be covered under your insurance plan? (check all that apply) Employee Employee/Spouse Employee/Children Employee/Family
Total Amount of premium for: Employee $____________ Amount Paid by Employer $__________ Amount Paid by Employee $____________
Total Amount of premium for: Employee/Spouse $_____________ Amount Paid by Employer $__________ Amount Paid by Employee $____________
Total Amount of premium for: Employee/Children $___________ Amount Paid by Employer $__________ Amount Paid by Employee $____________
Total Amount of premium for: Employee/Family $___________ Amount Paid by Employer $__________ Amount Paid by Employee $____________
How often is the above discussed premium paid? Weekly Bi-Weekly Semi-Monthly Other _____________
Health Insurance Carrier's Name:
Health Insurance Carrier's Address:
Company's Health Insurance Policy Number:
Health Insurance Carrier's Contact Person's Name:
Health Insurance Contact Phone Number:
NCU-0111 (1/07)
SECTION 3
SIGNATURE AND AFFIRMATION
In signing this document, I hereby apply on behalf of the above named company for the company to be determined to be an employer that meets the criteria of qualifying employer under Nevada Check Up
Plus. This will then enable the company's employees who apply for and meet the other employee eligibility criteria to receive health care premium assistance. I certify that all information contained is true
and accurate to the best of my knowledge and that no facts have been excluded.
· I hereby release Nevada Check Up Plus from any liability resulting from the disclosure of information contained in this application.
· I authorize Nevada Check Up Plus, its contractors and/or the Department of Health and Human Services to contact the company's health care insurance carrier to obtain company size, health care
policy and premium information.
· I understand the eligibility determination process may take up to 45 days. The 45 days commences upon receipt of a completed application. Once a determination has been made, the company will be
notified by mail.
· A reproduced copy of this authorization constitutes an original copy.
· I declare under penalty of perjury under the laws of the State of Nevada that the foregoing is true and correct (NRS 53.045, NRS 199.120 thru NRS 199.200 and NRS 41.365).
Company Representative's Signature: ______ Date:
(Mandatory) If not signed, application will be rejected.
Did you remember to: Sign the application? Yes No
Answer all questions? Yes No
INCOMPLETE APPLICATIONS WILL BE AUTOMATICALLY REJECTED.
NCU-0111 (1/07)
------------------------- -------------------- --------------------------Detach here--------------------------- ----Keep for your records-- --------------------------Detach here----------------------------- --------------------------------- -------------------------
Nevada Check Up Plus Program 1-877-KIDS-NOW
Instructions and important information
(Please detach, keep for your records and future reference) 1-877-543-7669 In-State
1-800-360-6044 Out-of-State
What is Nevada Check Up Plus Program?
The program is designed for uninsured parents or legal guardians of Medicaid, Nevada Check Up children or other low-income parents who do not qualify for Medicaid, are employed by a
small employer, and whose gross annual income is less than or equal to 200% of the federal poverty level (FPL). It provides a monthly amount to participants who have enrolled in a
qualifying insurance program while employed by a qualifying employer. Once enrolled, the ongoing eligibility for the program will be updated quarterly, and an annual renewal is required
every year.
Program Guidelines - In order to be an eligible employer the company must meet the following criteria:
A. be a small employer (NRS 689C.095);
B. provide an employer sponsored insurance plan that is creditable coverage (NRS 689C.053); and
C. provide at least 50% of the monthly premium for enrolled employed individuals.
Instructions:
Section 1. Please fill in all information regarding the employing company and the employer's representative who is authorized to apply for the employer to become an eligible employer
for the Nevada Check Up Plus program.
Section 2. Fill in all the Health Plan and Health Plan Carrier's information. Note that Nevada Check Up Plus will contact your Health Plan Carrier to validate all data.
Section 3. Please sign the application. All applications with missing signatures will be returned. An incomplete application will delay processing.
Send the completed application to: HEALTH SYSTEMS MANAGEMENT HOLDING CORPORATION
ATTN: NEVADA HIFA
5257 FAIRVIEW AVENUE SUITE 195
BOISE, IDAHO 83706
Send any other correspondence not related to applications to:
NEVADA CHECK UP PLUS
1000 E WILLIAM ST STE 200
CARSON CITY NV 89701
More Questions?
Call us at (775) 684-3777 or toll free (877) KIDS-NOW (543-7669). Our fax number is (775) 684-8792. Spanish speaking staff is always available!
You may also visit us on our website: http://nevadacheckup.state.nv.us.
If you need help with your application or wish to receive applications to provide to your employees, please call Nevada Check Up at 1-877-KIDS-NOW or 1-877-543-7669 and
select the appropriate phone option.
NCU-0111 (1/07)