Sec. 10.25.01.09. Renewal Application

A. The enrolled employer shall complete a renewal application published on the Commission's official website. The renewal application shall include:

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

(2) An acknowledgement that the Commission may request that certain records be produced and made available;

(3) An affidavit signed by the enrolled employer that the information in the renewal application is correct and that the enrolled employer meets the eligibility criteria for receipt of a premium subsidy; and

(4) An affidavit signed by the enrolled employer that the enrolled employer has had a Section 125 payroll deduction plan in place over the 10-month period immediately preceding the planned date of premium subsidy renewal.

B. The renewal application shall include an affirmation signed by the licensed insurance producer that:

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

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

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

C. The renewal application shall include a signed form from each employee applying for the Premium Subsidy Program who was either not insured under the employer's health benefit plan during the previous policy year or who is changing coverage from individual coverage to other than individual coverage. The form shall include:

(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 covered under the enrolled employer's health benefit plan; and

(2) If the type of coverage is for other than individual coverage:

(a) An affidavit that the employee's family adjusted gross income is less than 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.

D. The Commission's 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 reduced total premium;

(3) Total premium subsidy for each enrolled 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.

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 renewal application in the Commission registry to register the enrolled employer to receive a premium subsidy.