STERLING HEALTH SERVICES (3) - Laserfiche WebLink

Home Browse Search

MEDICAL 1' 1 We need medical plan and rate information for the entire calendar year being reported. If you have a plan that renews mid -year, please add this information for both plan years that occurred during that reporting year. Plan Name (i.e. Kaiser HMO): All CaiPERS Health Plans Is this plan offered to all EEs? 0 Yes ❑ No Date of Medical Plan Start: 1/1/2023 End: 1213112023 Plan Type: 0 Fully insured ❑ Self -funded Is coverage offered to: Spouse? • Yes El No Dependents? 0 Yes D No Is spouse coverage conditional? ❑ Yes 0 No Monthly Employee Only Contributions ($): 0.00 Does the plan have banded rates? ❑ Yes 0 No (If yes, please attach information on the plans, i.e. how the plans are banded, the grouping ages, the monthly employee only contribution pergrouping) Is the Actuarial Value of the Plan at Least 60%? 0 Yes ❑ No Does the plan provide minimum essential coverage? 0 Yes ❑ No Waiting Period for Full Time Employees # of days): 60 Plan Name (i.e. Kaiser HMO): Is this plan offered to all EEs? ❑ Yes No Date of Medical Plan Start: End: Plan Type: ❑ Fully insured ❑ Self -funded Is coverage offered to: Spouse? Yes No Dependents? ❑ Yes No Is spouse coverage conditional? Yes ❑ No Monthly Employee Only Contributions ($): Does the plan have banded rates? ❑ Yes ❑ No (If yes, please attach information on the plans, i.e. how the plans are banded, the grouping ages, the monthly employee only contribution pergrouping) Is the Actuarial Value of the Plan at Least 60%? Yes No Does the plan provide minimum essential coverage? ❑ Yes ❑ No Waiting Period for Full Time Employees (# of days): Plan Name (i.e. Kaiser HMO): Is this plan offered to all EEs? ❑ Yes ❑ No Date of Medical Plan Start: End: Plan Type: ❑ Fully insured ❑ Self -funded Is coverage offered to: Spouse? ❑ Yes No Dependents? ❑ Yes ❑ No Is spouse coverage conditional? ❑ Yes ❑ No Monthly Employee Only Contributions ($): Does the plan have banded rates? ❑ Yes ❑ No (if yes, please attach information on the plans, i.e. how the plans are banded, the groupingages, the monthly employee only contribution pergrouping) Is the Actuarial Value of the Plan at least 60%? Yes No Does the plan provide minimum essential coverage? Yes ❑ No Waiting Period for Full Time Employees # of days Do you offer an Individual Coverage HRA (ICHRA)? ❑ Yes 0 No