Sec. 10.25.01.07. Initial Application and Enrollment

A. Initial application for the Premium Subsidy Program shall be made according to the procedures designated by the Commission and published on the Commission's official website.

B. The small employer shall complete an initial application published on the Commission's official website that includes the following:

(1) Information necessary to establish the eligibility of the small employer and the amount of the available subsidy;

(2) An agreement by the small employer that the employer will establish a Section 125 payroll deduction plan within 60 days of enrollment;

(3) An acknowledgement that:

(a) The Commission may employ an auditor to examine an enrolled employer's records to determine the accuracy of statements made on the application;

(b) Incorrect statements may be cause for exclusion from the Premium Subsidy Program; and

(c) Fraudulent applications may be referred for prosecution;

(4) An agreement to cooperate fully with the Commission and the Commission's auditor; and

(5) An affidavit signed by the small employer that the information in the initial application is correct and that the small employer meets the eligibility criteria for receipt of a premium subsidy.

C. The initial application shall include an affirmation signed by the licensed insurance producer that:

(1) The health benefit plan or plans selected by the small employer include a wellness benefit;

(2) The licensed insurance producer has examined the small employer's most recent Quarterly Wage Report, and the information in the initial application is consistent with that report; and

(3) To the best of the licensed insurance producer's knowledge, the information in the initial application is correct.

D. The initial application for each employee shall include the following:

(1) Information about any private or public health insurance program that provided coverage at any time during the preceding 3 months for the employee or any of the employee's dependents who will be insured under the health benefit plan; and

(2) For other than individual coverage:

(a) An affidavit that the employee's family adjusted gross income is less than or equal to the maximum income for other than individual coverage; and

(b) An agreement to provide copies of relevant tax return forms, if requested by the Commission.

E. The participating carrier's procedures and written participation agreement determines whether the licensed insurance producer, the subsidy administrator, or the participating carrier shall enter the information from the initial application in the Commission registry to register the small employer to receive a premium subsidy.

F. The Commission registry will generate:

(1) A registration number;

(2) The total premium subsidy that the participating carrier shall provide to the small employer in the form of a reduced total premium;

(3) The amount of premium subsidy for each employee that the small employer shall pass through in the form of reduced payroll deductions for health benefits; and

(4) Other information that the Commission may consider useful for administration of the Premium Subsidy Program.