Group Eligibility

1. The group must be actively in business with a street address in one of the five Boroughs of NYC: Manhattan, Brooklyn, Queens, Bronx and Staten Island.
2. Eligible groups must have between 2 to 50 full time employees. Full time will be considered at least 20 hours per week. One employee group can be submitted only when accompanied by a waiver from the second eligible employee.
3. Owners, Partners and officers must meet minimum hourly requirement. An officer of the company should provide written employment verification.
4. Participation requirement for our POS is 50% participation after spousal waivers. No minimum requirements for HMO groups. Employees must submit waiver forms with case submission. NOTE: Carveouts permitted but participation requirements remain in effect.
5. Atlantis requires all enrolling subscribers to either reside or work in the contracted area: Manhattan, Queens, Brooklyn, Staten Island and Bronx.
6. Medicare recipients are eligible so long as they meet the criteria #2.
7. Eligible dependents are defined as legally married spouse or a legally dependent child up to the age 19 or to age 23 if financially dependent and enrolled as a full time student at an accredited educational institution. A rider to age 25 is available.
8. The following are excluded from eligibility and coverage:
   1. Individual compensated on 1099 basis.
   2. Domestic Partner of an eligible employee.
   3. Household help.
   4. Seasonal Workers, consultants & temporary personnel.
   5. Retirees.

9. Should Atlantis Health Plan determine that group information is materially false, we reserve the right to terminate or deny coverage.

1. All completed documents to enroll a new case must be submitted to Atlantis Health Plan no later than the 20th of the month preceding effective date, for 1st of the month effective. For 15th of the month effective all cases must be submitted by the 5th. If the 20th or the 5th of the month falls on a weekend, then the immediate following Monday will be considered the cut-off date.
2. Groups with incomplete information will not be enrolled until the proper information is supplied. In order to expedite the enrollment process; the following items must be included in the enrollment form:
   1. Social Security Number
   2. Date(s) of birth
   3. Complete Address
   4. Date of marriage (if applicable)
   5. Physician selection

   Incomplete applications will be returned and may affect the requested effective date.

3. Groups can be installed by class, two options can be selected for one group: one for management and one for staff. Same tier structure for both options required.

1. Group Agreement Form.
2. Signed check from the employer's business account.
3. Completed original employee enrollment forms or waivers for all eligible employees. (Faxes or copies are not acceptable)
4. Health History form for all enrolling subscribers of small groups
5. Applicable student verification form accompanied by original sealed document from educational institution.
6. Applicable Quarterly wage and tax statements.
7. Copy of current bill.

8. A group remittance agreement.
9. Claims experience.
10. Electronic file of enrolling members.

1. Most recent Quarterly Wage & Tax statement: NYS45
2. If not required to file Wage & Tax Statement, we will require one of the following:

   Business Type	Requirements
   If a "C" corporation	Articles of incorporation, form 1120 (line 13 is wages) and Payroll Documents
   If a Church	Form 941 (line 2 is wages) and payroll Documents
   If an LLC	LLC agreement and the appropriate documentation noted above.
   If a Partnership	Partnership agreement, Form 1065 (line 9 is wages) and payroll documents
   If an "s" corporation	Articles of incorporation, form 1120S (line 8 is wages) and payroll documents
   If a sole proprietor	Business license, form 1040/Schedule C (line 26 is wages) and Payroll Documents

3. If the business has been in existence less than 1 year and has not filed a quarterly Wage and Tax Statement. Atlantis Health Plan will accept Corporation or Partnership papers and payroll documents, signed by the accountant/CPA of the firm.

1. Effective date and termination of agreement.
2. Coverage
3. Eligibility
4. Notice
5. Premium Due date and payment
6. Premium Due date and adjustment
7. Premium Adjustments
8. Premium rate changes
9. Member effective dates of coverage.
10. Ineligible members.
11. Open enrollment periods
12. Responsibilities of group.
13. Termination.

1. Commissions credit will be recognized for broker of record changes beginning the first of the month following the processing of the completed letter.
2. You can send the BOR to your General Agent who will then forward information to AHP or you can mail it directly to:

   Atlantis Health Plan
   45 Broadway, Suite 300
   New York, NY 10006
   Att: Broker Business Unit.

3. AHP will honor the original document, faxes or copies will not be honored. The BOR must be on the Company Letterhead.
4. An authorized officer of the company must sign the letter.
5. Only new business is counted toward the brokers administrative fees program.
6. Groups taken over by a BOR will not be eligible for the administrative fee program.
7. Groups lost on BOR changes within the first year of coverage will not be considered eligible groups for the administration fee program.
8. AHP direct cases are vested for a period of 1 year. BOR submitted on AHP direct cases, will be honored beginning the first of the month following the processing of the completed letter (after the vested period).
9. All monthly commissions statements are mailed by the 15th of the month following the month in which the premium is received.
10. There are no retroactive BOR. Commissions will not be assigned on a retroactive basis, nor will commissions be paid retroactively.