MARA

Member Annual Renewal Application (MARA)
ANNUAL MEMBER RENEWAL TERMS & REQUIREMENTS:
I understand and agree that I am an Authorized Member Representative (AMR) for my company and will provide accurate data to the Missouri Association of Manufacturers (MAM) and MAM Health Source for the annual Member renewal process.
1. A completed Member Annual Renewal Application (MARA).
2. Participation: CoxHealth Systems Insurance Company (CHSIC) requires the following participation requirements to be met initially and at all times throughout the life of the contract: 75% of all eligible employees.
3. Plan Offering: Members with 24 or fewer eligible employees may select up to 3 plans; Members with 25 or more eligible employees may select up to 5 plans. (You must select at least one non-EPO plan. An EPO cannot be selected as a standalone plan since these plans do not offer Out-of-Network benefits.)
4. Member in good standing with MAM.
5. To be provided upon request: A copy of the Member’s most recent Missouri Division of Employment Security Quarterly Contribution and Wage Report. Applicants requesting coverage must appear on the quarterly report earning the equivalent of the Federal minimum wage.(THE STATEMENT MUST BE MARKED TO INDICATE ANY AND ALL TERMINATIONS, PART-TIME EMPLOYEES, AND INELIGIBLE EMPLOYEES, ALONG WITH REASON OF INELIGIBILITY.)
  NOTE: It is the responsibility of the Member Company to provide adequate proof of valid employees for participation verification upon request. Lack of adequate proof will result in group coverage being denied or terminated.
6. Open Enrollment: Actively collect and submit documentation for any employee making changes.
7. Health Improvement Program (HIP): Annual program that effects the following plan year premium rates based on individual Member participation. (Due to COVID-19, HIP requirements have been suspended until further notice.)
8. MEMBERS WHO FAIL TO MAINTAIN MINIMUM PARTICIPATION REQUIREMENTS, OR DROPS TO ONE ENROLLEE, ARE SUBJECT TO TERMINATION.
Member Info
Full Legal Name for Organization *
Group Number*
DBA Name (If applicable)
Physical Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Mailing Address (If different than above)
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Other Locations
Authorized Member Representative (AMR)*
First NameLast Name
Email for AMR*
example@example.com
AMR Contact Phone Number*
AMR Contact Fax Number
Primary Contact (if different than above)
First NameLast Name
Email for Primary Contact
example@example.com
Primary Contact Phone Number
Primary Contact Fax Number

Employee Eligibility
To be an eligible employee for medical coverage, the employee must work full time on an annual basis, and for full pay, at the member’s place of business. Retirees are not eligible for coverage unless mandated by the State of Missouri. Based on Federal Regulation, members may not exclude classes of employees from eligibility if they meet the definition of an eligible employee. Required Number of Hours to be Eligible for Coverage: 30 hours per week or 1560 hours per year.
Number of paycheck deductions per year (only count pay periods with insurance deductions - Select Other if your organization has multiple modes of pay)*
Weekly (52)Weekly (48)Bi-Weekly (26)Bi-Weekly (24)Semi- Monthly (24)Monthly (12)Other
First Pay Date of 2021*
MonthDayYear
Date
Lowest Full Time Hourly Pay Rate*
Total Number of Eligible Employees*

Open Enrollment
As a MAM member we are here to support you during your busy open enrollment periods. Please let us know how we can best help!
Start date of your employee election period
MonthDayYear
Date
End date of your employee election period
MonthDayYear
Date
How do your employee make their benefit elections?*
Paper FormsElectronic Benefit Admin SystemOther
If you use an electronic benefit admin system, who is your provider?
Would you like to schedule a wellness consultation?
Would you like to schedule a contributions consultation?
Which Items would you like us to provide for your open enrollment?
Election Sheet (PDF Emailed)Enrollment Guide (PDF Emailed)Wellness incentive materials (PDF Emailed)Printed Employee Packets (Election sheet, Enrollment guide, Wellness)
If you would like us to provide printed employee packets, how many do you need?
Would you like a Connell representative to attend your employee open enrollment meetings?
Please share your availability for scheduling open enrollment meetings. If you have a specific time/date that is required please note that below as well.

Acknowledgement
As an authorized signer on behalf of my company, I acknowledge that I have read, understand, and agree to all of the MAM Health Source Member terms and eligibility requirements, and to the above Member Annual Renewal Application terms listed above. I certify that the representations within this document are true. Should the provided information be found to be false, I understand and acknowledge that my company may be subject to disciplinary action, including all legal fees and potential removal from the MAMHS program.
Today's Date*
MonthDayYear
Date
Authorized Member Representative*
First NameLast Name
Title*
Signature*
Should be Empty:

	Plan Name	Employee Only	Employee & Spouse	Employee & Child(ren)	Family
Plan 1
Plan 2
Plan 3
Plan 4
Plan 5

Member Annual Renewal Application (MARA)

Member Info

Employee Eligibility

Open Enrollment

2021 PLAN SELECTION

Open Enrollment Directive

2021 MONTHLY MEMBER (Employer) PREMIUM CONTRIBUTIONS

Acknowledgement