Rocky Mountain Healthcare Small Group Health Insurance Forms and Documentation

Rocky Mountain Healthcare

Employer Application Package	Employee Application Package for New Group
Add Employee to Existing Group Plan	Employee Waiver
Business Group of One Complete Application	Employee Change Form
Employee Disenrollment Form	Continuation of Coverage
Common Law Form	Overage Dependent Form
Student Status Form	EFT Premium Payment Form

Employee forms can be faxed to our office at (303) 721-1085. Please confirm that application was received by calling (303) 721-1145. Please call with any questions regarding eligibility or waiting periods.

Plan Descriptions

HMO Plans

Health Plan Name	Office Visit Copay	Hospital Copay	Outpatient Copay
Basic HMO	$30	$400/day, max $1600	$150
Basic HMO w/ MPHH	$30	$400/day, max $1600	$150
Standard HMO	$20	$150/day, max $600	$50
C15K	$25	50% to $15K	50% to $15K
C1000	$15	50% to $1K, 20% next $4K	same as hospital
C5000	$20	50% to $5K	50% to $5K
C-1	$15	50% to $1K, 25% next $6K	same as hospital
C-3	$15	50% to $3K, 20% next $7500	same as hospital
C-8	$20	50% to $8K	50% to $8K
NC50	$15	50% to $500, 20% next $2500	same as hospital
Choice 500-90	$15	$500 + 10% to $30K	same as hospital
Choice 1000-90	$15	$1000 + 10% to $30K	same as hospital
Choice 1500-80	$20	$1500 + 20% to $30K	same as hospital
Choice 3000-80	$20	$3000 + 20% to $30K	same as hospital
Direct D-100	$15	$100 + $300/day, $1300 max	$300
Direct D-300	$15	$300 + $300/day, $1500 max	$500
Direct E-200	$20	$200 + $500/day, $2200 max	$450
Direct E-400	$20	$400 + $500/day, $2400 max	$650
Direct E-1200	$20	$1200 + $500/day, $3200 max	$1450
Direct E-3000	$20	$3000 + 20% to $30K	same as hospital
Direct F-300	$25	$300 + $750/day, $3300 max	$650
Direct F-600	$25	$600 + $750/day, $3600 max	$950
Direct F-1200	$25	$1200 + $750/day, $4200 max	$1550
Direct G-1800	$30	$1800 + $750/day, $4800 max	$2200
Plan A	$15	$300/day, $1200 max	$200
Plan B	$20	$500/day, $2000 max	$250
Plan C	$25	$750/day, $3000 max	$350

PPO Plans

Plan Name	Office Visit Copay	Deductible	Coinsurance
Basic PPO	$30	$3000	30% to $5,000 max
Basic PPO w/ MPHH	$30	$3000	30% to $5,000 max
Standard PPO	$30	$1000	20% to $2,000 max
Std PPO w/ alcohol/ substance abuse	$30	$1000	20% to $2,000 max
Choice 500 80-60	$15	$500	20% to $15K
Choice 500 90-70	$15	$500	10% to $30K
Choice 1000 80-60	$15	$1000	20% to $15K
Choice 1000 90-70	$15	$1000	10% to $30K
Choice 1500 80-60	$20	$1500	20% to $30K
Choice 3000 80-60	$20	$3000	20% to $30K
Choice 5K 80-50	$25	$5000	20% to $50K
Choice 10K 80-50	$25	$10,000	$20% to $50K
	Office Visit Copay	Hospital Copay	Outpatient Copay
Direct A200	$15	$300/day, $1200 max	$200
Direct A600	$15	$300/day, $1200 max	$200
Direct B400	$20	$500/day, $2000 max	$250
Direct B800	$20	$500/day, $2000 max	$250
Direct C600	$25	$750/day, $3000 max	$350
Direct C1200	$25	$750/day, $3000 max	$350
Direct D100	$15	$100 + $300/day, $1300 max	$300
Direct D300	$15	$300 + $300/day, $1500 max	$500
Direct E200	$20	$200 + $500/day, $2200 max	$450
Direct E400	$20	$400 + $500/day, $2400 max	$650
Direct E1200	$20	$1200 + $500/day, $3200 max	$1450
Direct E3000	$20	$3000 + $500/day, $5000 max	$3250
Direct F300	$25	$300 + $750/day, $3300 max	$650
Direct F600	$25	$600 + $750/day, $3600 max	$950
Direct F1200	$25	$1200 + $750/day, $4200 max	$1550
Direct G1800	$30	$1800 + $750/day, $4800 max	$2200

HSA Plans

Plan Name	Deductible	Coinsurance	Max Out-of-Pocket
HMO 1000	$1000/$2000	80/20	$4000/$8000
HMO 2500	$2500/$5000	80/20	$5000/$10,000
HMO 5000	$5000/$10,000	100/0	$5000/$10,000
PPO 1000	$1000/$2000	80/20	$4000/$8000
PPO 2500	$2500/$5000	80/20	$5000/$10,000
PPO 5000	$5000/$10,000	100/0	$5000/$10,000