New Employer Sponsor Membership Form

Tell us about your company's existing benefits that represents its worth for your employees, and your benefit offering, as intended to compete in the market for desired employees. This assessment will become the $dollar value sponsor amount in the aggregate and the capped average new employee benefit sponsored amount for your YEP card members, and a minimum bases of value to transfer and build upon.

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Enter the name of the organization that represents your entire system. The group attribute below will allow for segmentation of the organization, if needed.
If your organization holds separate benefit contracts for groups within your organization, you should consider creating a group name if you would like to continue tracking them in this order. The future state, once the existing cost assessment has been completed, would be a simple consolidated sponsorship transfer that would be segregated proportionally once received, to the individual member's respective accounts.
Enter your legacy group name and number to be used as an organizing reference tool only.
Company or Group Contact:
If there is more than one contact person that might exist for each group, please make note in the comments section at the bottom, and we will provide them with a form for their group to complete. In the future state, there would only be a need for a separate group and contact, if that is your preference.
This number will be provided for you. There will ultimately be only one contract number for your organization when enrolled.
Describe in your words the medical benefits plan that your system has in place current state, for the past two respective years of benefits spending. An assessment of this two-year average will be the amount that will be capped and will be the sponsored base funding that each respective employee will receive as sponsored funding from your system to utilize, with newly enhanced YEPcard aggregate purchasing power, their future spending choices. Select all the boxes below that apply to your current state typical benefit options. There may be healthcare benefit items that are not included below, but be sure to include everything in this section to assure that your members get fully sponsored:
Dental Choices
The details with premium amounts for (EMP+Children, EMP+Spouse, Family, or Single) should be upload using the attachment tool.
Vision Choices
The details with premium amounts for (EMP+Children, EMP+Spouse, Family, or Single) should be upload using the attachment tool.
Health Plans:
The details with premium amounts for (EMP+Children, EMP+Spouse, Family, or Single) should be upload using the attachment tool.
Prescription Plan Choices:
The detail with Rx plans premium amounts for should be upload using the attachment tool.
Health Savings Plans Choices
The detail of actual savings plan histories should be in the detail file you attach, but each employee would want to include a dollar amount that is representative to their historical out-of-pocket spending in order to adequately fund their new accounts starting out at comparable levels to the past two year's average spending. There won't be any deductibles, thresholds, or co-pays in the future. If members spend down their assets, the next option would be self-funding to their account or utilize the low interest financing that is a guaranteed benefit for all members.
In your words, please provide any unique or special circumstances for healthcare benefits you currently provide that we need to be aware of to bridge the respective care experience for each of your employees successfully.
Provide an email address and contact information for: 1) The person who can make arrangements to provide the information to begin your two-year current employee healthcare benefits spending assessment. 2) The person to send your YEPcard Employer Sponsor Annual Membership invoice to. Prices: Employers with <= 50 employees pay $200/employee, not to exceed $10k and Employers with >50 employees pay $200/employee, not to exceed $100k.