Group Size QuestionaireThe applicability of many state and federal requirements, including The Patient Protection and Affordable Care Act ("PPACA") (P.L. 111-148) is 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. This information will be provided to the government each calendar year and will be used (in part) to determine WPS' applicable loss ratio ("MLR"), should that regulation apply to your group. This information will also be used to determine whether you (as the policyholder) and your enrollees are entitled to any rebates under MLR. For practical purposes, an employee is typically any person for which the company issues a W-2, regardless of full-time, part-time or seasonal status or whether or not they have medical coverage. 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 2011, 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 WPS health plan. 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.Please fill in the following employer information:
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