Employer Group Annual Information Form 2025

Employer Group Annual Information Form
EMPLOYER GROUP RXDC & GAG CLAUSE ATTESTATION FORM

Please complete this form in its entirety. Group Health Cooperative of South Central Wisconsin (GHC-SCW) requires this information on an annual basis, at minimum, for various regulatory requirements. Failure to complete this form could result in non-compliance for your policy being cancelled and/or group health plan reporting requirements.

Please complete one (1) form per Tax Identification Number
SECTION 1: GENERAL GROUP INFORMATION
1. Corp ID:*
If known, can be located on renewal documents or contact GHC-SCW.
Section 1: General Group Information
2. Entity Legal Name*
3. Entity Doing Business As (DBA) Name:*
4. Tax Identification Number (EIN/TIN)*
9-digits, numbers only, no hyphen
5. Business Physical Address

Street Address

Street Address Line 2

CityState

Zip Code
6. If applicable, 3-digit plan number reported in the IRS Form 5500 filed with the Department of Labor:
If more than one, separate with a semicolon
SECTION 2: GAG CLAUSE PROHIBITION COMPLIANCE ATTESTATION INFORMATION (“GAG CLAUSE ATTESTATION”)
Do you want GHC-SCW to complete this entity’s Gag Clause Attestation on its behalf?

YesNo
If yes, complete the below information

If no, continue to Section 3. If you select no, GHC-SCW will not include your entity in its Gag Clause Prohibition Compliance Attestation submission for your entity and you are responsible for submission of the Attestation for your group health plan
Section 2: Group Size Information
1. Entity Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
2. Entity Point of Contact Name
3. Entity Point of Contact Email
example@example.com
4. Entity Point of Contact Phone Number
Please enter a valid phone number.
SECTION 3: RXDC REPORTRING INFORMATION

Use your GHC-SCW monthly invoices to help calculate the average amounts requested. INCLUDE employee premium payments for COBRA coverage, including any administrative fee.
1. Average Monthly Premium Paid by Members:*
To calculate the average monthly premium for Members for GHC-SCW coverage, take the total annual premium paid by Members (the employee contribution portion) during the prior calendar year and divide by 12.
2. Average Monthly Premium Paid by Employers:*
To calculate the average monthly premium for Employers for GHC-SCW coverage, take the total annual premium paid by the Employer on half of members (the employer contribution portion) during the prior calendar year and divide by 12.
Example:
In 2024, the total for all ABC Company premium invoices from GHC-SCW was $100,000. ABC Company’s employees (Members) paid/contributed $25,000 of the premium payments, and ABC Company (Employer) paid $75,000.

Average Monthly Premium Paid by Members = $2,083.33 ($25,000 / 12)
Average Monthly Premium Paid by Employer = $6,260.00 ($75,000 / 12)
SECTION 4: REPORTING
Section 3: Medicare Coordination of Benefits
Section 4: Contribution
Section 5: Gag Clause Prohibition Compliance Attestation Information (“Gag Clause Attestation”)
Section 6: RxDC Reporting Information
Section 7: Reporting
1. This form must be returned to GHC-SCW by April 15th.

2. This form must be completed in full, with complete and accurate information. GHC-SCW is not responsible for reporting errors that occur due to incomplete or inaccurate information provided on this form.

3. Provided all information requested on this form is completed in full, and duly executed by an authorized representative of the Employer
and returned to GHC-SCW by April 15th, GHC-SCW agrees to the following:

a. GHC-SCW shall post Employer’s machine-readable files to GHC-SCW’s public website, as required pursuant to the Transparency in Coverage Final Rule (CMS-9115-F).

b. If indicated “Yes” in Section 2, GHC-SCW shall submit Employer’s Gag Clause Attestation on its behalf, as required pursuant to the Transparency in Coverage Final Rule.

c. GHC-SCW shall submit Employer’s Prescription Drug Data Collection (RxDC) data submission, as required pursuant to Section 204 of Division BB, Title II (Section 204) of the Consolidated Appropriations Act, 2021.
The undersigned certifies that, to the best of my knowledge and belief and under penalty of perjury, the information listed above is true and complete. By signing and returning this form to GHC-SCW, the undersigned agrees to cooperate with GHC-SCW to provide updated information to GHC-SCW upon request to ensure compliance with any and all GHC-SCW reporting requirements and that incomplete or incorrect information may result in reporting errors.
Employer Authorized Representative Signature*

Clear
Date*

MonthDayYear
Date
Name*
Email Address*
example@example.com
Once you complete this form, please click submit.
Should be Empty:

Employer Group Annual Information Form

Section 1: General Group Information

Section 2: Group Size Information

Section 3: Medicare Coordination of Benefits

Section 4: Contribution

Section 5: Gag Clause Prohibition Compliance Attestation Information (“Gag Clause Attestation”)

Section 6: RxDC Reporting Information

Section 7: Reporting