RCI Forms

Legal Company Name ^*

Doing Business As/DBA

Employer Identification Number (EIN) ^*

Enter the number of full time employees as of December 31^st 2023. ^*

Enter the group health plan number or Form “5500 Plan Number" ^*

For most plans, this is 501

Plan information

Basic Info

Health Plan Name ^*

If possible please use the plan name as it appears in the RCI portal.

Plan type ^*

Time Frame

Starting month

Ending month

Year

Premium Information

In order to help your company comply with new regulations we need to know the cost breakdown of each of your medical health plans. Please provide the cost of each tier below.
If your plan doesn't use one of the tiers please just leave it blank.

Employee Share

Group Share

Total Amount

Employee Only

$0.00

Employee And Spouse

$0.00

Employee And Children

$0.00

Family

$0.00

Content collapsed

Do you offer any Wellness Services as defined by CMS? ^*

Yes

A wellness program, defined as a program of health promotion or disease prevention, can be (1)participatory or (2)health-contingent. Participatory wellness programs are wellness programs where none of the conditions for obtaining a reward under the wellness program are based on an individual satisfying a standard that is related to a health factor, or wellness programs that do not provide a reward. For additional explanation see cms.gov.

I have added all plans that are administered by RCI with Rx Benefits. ^*

Form Submitter Information

Your Name ^*

Phone Number

Email address ^*

CAA RxDC Reporting Information