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
$40

$500/day, max $2000

 $300
Standard HMO $25 $250/day, max $1000

$150
500/80 $35 Deductible & Coinsurance Ded. & Coins.
1000/70 $45 Deductible & Coinsurance Ded. & Coins.
1500/75 $45 Deductible & Coinsurance Ded. & Coins.
2000/70 $45 Deductible & Coinsurance Ded. & Coins.

PPO Plans

Plan Name
Office Visit Copay
Deductible
Coinsurance
$40
$4000

30% to $8,000 max
$25
$1500
20% to $3,500 max
$35
$500
20% to $3000
$45
$1000
30% to $3,500
$45
$1500
25% to $3,500
$45
$2000
30% to $4,000
$45
$3000
35% to $2,000
Not covered
$1,500
25% to $3,500
$35
$500
30% to $3,000
$35
$1,000
30% to $2,000
$35
$1,500
30% to $3,000

 

HSA Plans

Plan Name
Deductible
Coinsurance
Max Out-of-Pocket
$2650/$4000
0%
$2650/$4000
$3250/$6000
0%
$3250/$6000
$5000/$10,000
0%
$5000/$10,000