Arise Health Plan

Group Size Questionnaire

Please provide the number of employees at your institution. The applicability of many state and federal requirements, including the Patient Protection and Affordable Care Act ("PPACA") (P.L. 111-148) and the Medicare Secondary Payor Rules are based on the number of employees in your group. These provisions require detailed information regarding total number of employees as defined under the federal government guidelines for small and large group classification. Fill in your Group Size Questionnaire online or download the Group Size Questionnaire.

We have created the following questionnaire and table to help you determine group size for each month of the preceding calendar year, which will enable us to administer your plan appropriately.

To complete the following questionnaire, please refer to the How To Count Employees guide.

In the chart below, please enter the total number of employees for each month of 2018, regardless of whether you had coverage with us, had coverage with a previous carrier, or were in business but did not offer coverage. Include all employees including owners, board of directors, elected officials, etc., (see How to Count Employees) including those not covered under your Arise policy. Multi-employer plans should count all individuals in current active employment status. If you are a new business, enter the number of employees in the appropriate months and use a "0" (zero) for those months that you were not in business. Use the total number of employees at the end of the month. Remember to enter you name on this document and attest that the information is correct.

If you have other questions, please take a look at Group Leader FAQ for some frequently asked questions.

Please fill in the following employer information:

Please enter your Group Number

  Column A.
Total number of full-time employees
(as of the end of the month)
Column B.
Total number of part-time employees
(as of the end of the month)
Column C.
Others not reported in Column A or B
Combined total
(add total from Columns A+B+C)
January 2018
February 2018
March 2018
April 2018
May 2018
June 2018
July 2018
August 2018
September 2018
October 2018
November 2018
December 2018

Employers

Yes
No
Increased to 20 or more employees
Decreased to 19 or fewer employees
None of the above

Group Information

Employer Verification

By entering your name here, you are giving your legal signature.

Thank you for your cooperation in this important federal compliance matter.
Questions? Please contact Member Services Administration at 888-672-0062.

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