Member/Applicant: Local REALTOR Assoc. Name: Member Address: Requested effective date of coverage: 1 st of, 20

Transcription

1 Kaiser Permanente Enrollment / Instructions The Benefits Store California Local Realtor Association Benefits MEMBER / APPLICANT INFORMATION: Complete Section SELECT YOUR PLAN PLEASE CHOOSE ONE PLAN ONLY Special Benefits Member/Applicant: Local REALTOR Assoc. Name: Member Address: Requested effective date of coverage: 1 st of, 20 New Enrollee [ ] Current Benefits Store Member Changing Plans [ ] The applicant must be a member/affiliate member of a Local REALTOR Association. MOST AFFORDABLE PLANS [ ] $0/$2,000 Deductible Plan with HSA Option [ ] $0/$2,700 Deductible Plan with HSA Option [ ] $30/$3,000 Deductible Plan with HSA Option [ ] $30/$1,500 Deductible Plan with HRA Option [ ] $30/$2,500 Deductible Plan with HRA Option [ ] Bronze 6300/75 [ ] Bronze HSA 4800/40 BEST BALANCE/VALUE PLANS [ ] $50 Copayment Plan [ ] $30/$1,000 Deductible Plan [ ] $30/$1,500 Deductible Plan [ ] $40/$2,000 Deductible Plan [ ] Silver 1000/50 [ ] Silver HSA 2000/20 [ ] Silver 2000/45 [ ] Gold 0/25 [ ] Gold 500/30 [ ] Gold HRA 2250/35 Choose Your Plan BEST BENEFITS PLANS [ ] $5 Copayment Plan [ ] $15 Copayment Plan [ ] $20 Copayment Plan [ ] $30 Copayment Plan [ ] Platinum 0/10 [ ] Platinum 0/15 Signatures are required on the Kaiser Enrollment Form and on the Kaiser Enrollment Review and Information Page (the last page of the Enrollment package) to complete the Enrollment Process. Your Kaiser Plan through the Benefits Store, Inc. includes a Limited Benefit Dental Plan and a $10,000 Life Insurance Policy with an Accidental Death and Dismemberment benefit. APPLICATION INSTRUCTIONS Please Type or Print Clearly using only Black Ink, DO NOT USE Felt Tip Pens. SECTION A SECTION AB SECTION C SECTION D DO NOT Complete -Company Name, Group Account Number, Enrollment Unit, Plan Description, Employee Classification, Date of Hire or Enrollment Reason The Benefits Store will complete this information. Complete all of the Personal Information questions. Complete Family Information. The subscriber must complete all fields for any dependents being enrolled. Social Security numbers are required for coverage for all dependents. Sign and Date - Signature Required for Terms and Conditions and Arbitration Disclosure Read Carefully: Applications CAN NOT be processed without a signature and date Kaiser Enrollment Instructions CA Insurance License No.: Enrollment / Billing Department: (888) Fax: (925)

2 Kaiser Permanente Enrollment Review & Information EFFECTIVE DATE OF COVERAGE: The Benefits Store California Local Realtor Association Benefits Applications are accepted (must be received in our office) through the end of the current month for coverage to be effective the 1 st of the following month. To avoid confusion about the effective date of coverage, make sure to clearly show the requested effective date of coverage you are applying for on the application, your premium check and this form. TO EN ROLL: Review the application for accuracy, sign, date, and return to us with your premium. Make Checks Payable to The Benefits Store Trust Account. U.S. MAIL(1 St Class or Priority) OVERNIGHT/EXPRESS DELIVERY ONLY ATTN: ENROLLMENT - KAISER ATTN: ENROLLMENT - KAISER Benefits Store, Inc. Benefits Store, Inc. PO Box 238, Alamo, CA High Eagle Road, Alamo, CA PROCESSING REQUIREMENT: NOTE: INCOMPLETE APPLICATIONS OR APPLICATIONS WITHOUT THE CORRECT PREMIUM INCLUDED CANNOT BE PROCESSED. Applications Postmarked by the 15th Applications Postmarked after the 15th APPLICATION PROCESSING: THOSE APPLYING WITH CURRENT COVERAGE: One (1) months premium is required with your application if enrolling for coverage beginning the 1 st of the following month and postmarked by the 15 th Two (2) months premium is required with your application if enrolling for coverage beginning the 1 st of the following month and postmarked after the 15 th. Note the two (2) month premium requirement is waived with the use of the EFT/CCA monthly payment option. Allow 12 business days for the processing of your application and for you to appear in Kaiser s database. Kaiser ID Card(s) are normally generated within 15 working days from the time we receive your application. If we do not receive your application until the 20 th of the month you may not receive your ID card(s) until the 15 th of the following month. To avoid this delay we urge you to submit your application to us as soon as possible. Remember, everyone applying during the Open Enrollment or through a qualifying event will be accepted! Coverage is guaranteed! Those of you that have paid your current coverage premiums in advance need to request an effective date for your new coverage that will match the date when your current coverage ends. Those of you that are within the grace period for premium payment of your current coverage need to verify with your current insurer the length of time allowed for your coverage before cancellation. You should not cancel your current coverage until you are notified of your new coverage. For verification of your new coverage, please contact The Benefits Store. ADDITIONAL INFORMATION Premiums are based on actual age and are billed monthly. To cancel your coverage or to revoke your application, we require a written notice of your intent including your signature and your requested date of cancellation. We ask this statement be written on a copy of your billing statement and faxed to The Benefits Store at or mailed to our Membership Accounting department. Please visit our website for additional contact information. This notice must be received no later than 12 noon (M- F) BEFORE the 20th of the month in which you wish to cancel. For example, April 20th for an effective cancellation date of April 1 st. By signing your enrollment application you represent that all of the information you have included is Signature complete and accurate, and that you accept all terms of this application and supporting documentation. Acknowledgement Signature: Date: *This program is a special benefit for members/affiliate members of local REALTOR Associations within California. Refer to the Enrollment Materials and Benefit Booklet for a complete description of the plans. Be advised that your Association, Benefits Store, Inc. and their agents do not control premiums or coverage provided by these plans. Association members participating in these plans do so voluntarily. Kaiser Enrollment Review & Information (2015) CA Insurance License No.: Enrollment / Billing Department: (888) Fax: (925)

3 * * Please print in blue or black ink only. A.Company information (to be completed by administrator) Company name Customer ID* Enrollment unit ID* California Real Estate Benefit Plan Enrollment unit name/classification Association California Subscriber Enrollment/Change Form Company and Subscriber information Number of pages including this page Eligibility contact phone Plan (example: HMO 20, DHMO 500/30) Employee Number Effective date of enrollment/change* (mm/dd/yyyy) Reason for enrollment if adding subscriber and/or dependent(s) Open enrollment period Newly eligible, new hire, Birth of eligible dependent rehire, or increase in hours Special enrollment period (as described under Additional information on page 2) due to triggering event on (mm/dd/yyyy) B.What are the changes requested? (subscriber mark the box for each change you are requesting) Enroll subscriber (and dependents) Add dependent(s) to existing subscriber account C.Subscriber/employee information Remove dependent(s) from subscriber account Change name of subscriber and/or dependent(s) Update address Other Notice: California law prohibits an HIV test from being required or used by health care service plans/health insurance companies as a condition of obtaining coverage/health insurance coverage. Has this person ever received treatment at a Kaiser Permanente facility? Yes No Gender:* Male Female First name* MI* Medical record number (if known) Last name* Former name/nickname Social Security number* Date of birth (mm/dd/yyyy) Home address* (physical location, no P.O. Box) City* State* ZIP code* Phone Mailing address (if different than home) City State ZIP code D.Signature (please sign at the bottom of this page in the box below for subscriber signature) Kaiser Foundation Health Plan Arbitration Agreement. I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure or the ERISA claims procedure regulation, and any other claims that cannot be subject to binding arbitration under governing law) any dispute between myself, my heirs, relatives, or other associated parties on the one hand and Kaiser Foundation Health Plan, Inc. (KFHP), any contracted health care providers, administrators, or other associated parties on the other hand, for alleged violation of any duty arising out of or related to membership in KFHP, including any claim for medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal theory, must be decided by binding arbitration under California law and not by lawsuit or resort to court process, except as applicable law provides for judicial review of arbitration proceedings. I agree to give up our right to a jury trial and accept the use of binding arbitration. I understand that the full arbitration provision is contained in the Evidence of Coverage. Date (mm/dd/yyyy) X Subscriber signature* *Field required for all enrollments and changes. Disputes arising from the following fully insured Kaiser Permanente Insurance Company coverages are not subject to binding arbitration: 1) the Preferred Provider Organization (PPO) and the Out-of-Network portion of the Pointof-Service (POS) plans; 2) Preferred Provider Organization (PPO) plans; 3) Out-of-Area Indemnity (OOA) plans; and 4) KPIC Dental plans May 2016 Page 1 of Month 2016

4 Subscriber s last name* Subscriber s medical record (if known) Dependent information page(s) Use this page to enroll, remove, or update dependents. Multiple dependent information pages may be used, if space is needed for additional dependents. Sections A D on the Customer and Subscriber information page are required for all requests. E. Dependents 1 Enroll Remove Change name Relationship to subscriber: Spouse Domestic partner Dependent child Has this person ever received treatment at a Kaiser Permanente facility? Yes No Gender:* Male Female First name* MI* Medical record number (if known) Last name* Former name/nickname Social Security number* Date of birth (mm/dd/yyyy) 2 Enroll Remove Change name Relationship to subscriber: Spouse Domestic partner Dependent child Has this person ever received treatment at a Kaiser Permanente facility? Yes No Gender:* Male Female First name* MI* Medical record number (if known) Last name* Former name/nickname Social Security number* Date of birth (mm/dd/yyyy) Additional information Name(s) of covered dependent(s) that live at a different address than subscriber Home address* (physical location, no P.O. Box) City State ZIP code The following special enrollment information applies to coverage under a small group plan: If you decline coverage for yourself or an eligible dependent when you are first eligible to enroll, you can only enroll or change your coverage during an annual open enrollment period established by your employer, or during a special enrollment period if you have experienced a triggering event. You must request coverage within 60 days of a triggering event. Special enrollment triggering events include: Loss of health care (minimal essential) coverage, resulting from any of the following: loss of employer-sponsored coverage because you and/or your dependent no longer meet the eligibility requirements, or your employer no longer offers coverage or stops contributing premium payments; loss of eligibility for COBRA coverage (for a reason other than termination for cause or nonpayment of premium); your and/or your dependent s individual, Medi-Cal, Medicare, or other governmental coverage ends; or for any reason other than failure to pay premiums on a timely basis or situations allowing for a rescission (fraud or intentional misrepresentation of material fact); or loss of health care coverage including, but not limited to, loss of that coverage due to the circumstances described in Section (a)(3)(i) to (iii), inclusive, of Title 26 of the Code of Federal Regulations and the circumstances described in Section 1163 of Title 29 of the United States Code; Gaining or becoming a dependent due to marriage, domestic partnership, birth, adoption, placement for adoption, or assumption of a parent-child relationship; A valid state or federal court orders that you or your dependent be covered; Permanent relocation, such as moving to a new location and having a different choice of health plans, or being released from incarceration; The prior health coverage issuer substantially violated a material provision of the health coverage contract; A network provider s participation in your and/or your dependent s health plan ended when you and/or your dependent(s) were under active care for one of the following conditions: an acute condition (an acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration); a serious chronic condition (a serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration); pregnancy; terminal illness (a terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less); care of a newborn child between birth and age 36 months; or performance of a surgery or other procedure that has been recommended and documented by the provider to occur within 180 days of the contract s termination date or within 180 days of the effective date of coverage for a newly covered insured; A member of the reserve forces of the United States military returning from active duty or a member of the California National Guard returning from active duty service under Title 32 of the United States Code; An individual demonstrates to the Department of Managed Health Care or Department of Insurance, as applicable, with respect to health benefit plans offered outside the Exchange that the individual did not enroll in a health benefit plan during the immediately preceding enrollment period available because the individual was misinformed that he or she was covered under minimum essential coverage. *Field required for all enrollments and changes May 2016 Page 2 of 2

5 The Benefits Store, Inc. Association Benefits CA License No Credit Card Authorization / Automated Clearing House (ACH) Electronic Funds Transfer (EFT) Authorization Insured Information Name: Payment Selection CCA [ ] EFT / ACH [ ] Credit Card Transaction Credit Card Information: Visa [ ] Mastercard [ ] Discover [ ] American Express [ ] Card Number: Exp: (MM / YY): - / - Name (as appears on the card): Authorization Code: - - Address: City: State: Zip: Monthly Recurring Charges: I authorize the Benefits Store to charge this credit card for the monthly premium on the 20th of each month. Yes [ ] No [ ] Initials: Credit Card payments will be assessed the full premium rate which includes a 2.5% administration charge. Automated Clearing House (ACH) / Electronic Funds Transfer (EFT) Transaction Name on Account: Name of Financial Institution: Routing Number (9 digits): Account Number: Account Holder Type: Personal [ ] Business [ ] Account Type: Checking [ ] Savings [ ] Determining your routing number: To determine your routing number, refer to your check. The routing number is ALWAYS 9 digits long and it is enclosed by colons. The location of the routing number and account number on you company check varies depending on your bank; for example: Bank 1 Bank 2 Bank 3 Routing # Check # Account # Routing # Account # Check # Check # Routing # Account # I authorize the Benefits Store to deduct the monthly premium from this bank account. Yes [ ] No [ ] Initials: 5th of the Month [ ] 15th of the Month [ ] Monthly Recurring Charges (EFT) Payment Authorization Authorization is given to The Benefits Store, Inc. to charge my credit card or debit the banking account listed above. I will not hold The Benefits Store, Inc. responsible for delay, loss or misapplication of funds due to incorrect or incomplete information supplied by me or my depository/credit institution. Monthly Transactions Authorization Authorization is given to The Benefits Store, Inc. to charge my credit card or initiate debits (payments) to the financial institution indicated above. This financial institution is authorized to debit the account. This authority is to remain in full force and effect until either a 30 day revocation notice is written to The Benefits Store, Inc. or upon the termination of the coverage through The Benefits Store, Inc. Should a rate change due to policy renewal, age band change or coverage tier occur, I authorize The Benefits Store, Inc. to automatically make the adjustment to my monthly deduction. Note: I understand and authorize a $25 service charge may be applied against my account for all denied transactions for any reason. Authorized Signature: Payment Amount: Date: $ The Benefits Store, Inc. - PO Box 238 Alamo, CA Membership / Accounting : CustomerService@BenefitsStore.com BENEFITS STORE, Inc. Association Benefits

6 BENEFITS STORE, Inc. Association Benefits BENEFITS STORE, INC. CA Insurance License # IM PORTANT NOTICE NEW CUSTOMER SERVICE ACCESS FOR MEMBERSHIP ACCOUNTING AND BILLING QUESTIONS PHONE NUMBER: (888) FAX: (925) MAILING ADDRESS: BENEFITS STORE/ MEMBERSHIP ACCOUNTING PO Box 238 Alamo, CA Electronic Funds Transfer (EFT)/Automated Clearing House (ACH) You may do a one time transaction or monthly deduction. RELIABLE! EFT/ACH is a method of automatically withdrawing or depositing funds to an individual s bank account. SAFE! All EFT/ACH transactions are tracked and governed by the Federal Reserve. Only preauthorized transactions are allowed to be processed. EFT MONTHLY PAYMENTS! You will never again need to worry about late payments due to mail delays, misplaced payments or forgotten payments! Your payment will always be made on time. SIMPLE! Once you have completed and signed the EFT authorization form, all you need to do is record the payment transaction in your checkbook or savings register on the designated payment date. Monthly Invoice / Check Premiums are payable in advance of the month of coverage. You will receive your monthly Premium billing on or about the first of each month Example: Premiums for July coverage are billed on June 1 st and payable (received) on or before June 20 th. Late fees are charged for payments received after the 20 th. Your full payment must be received by the 20 th to avoid a late charge. We suggest that you mail your payment on or before the 12 th of each month Payments MUST be mailed to: The Benefits Store, Inc. P.O. Box Los Angeles, CA To assure proper credit make sure to include the top portion of the billing statement with your payment. Also enter the full Subscriber s name in the memo field of your check. On-Line Bill Payment Premiums are payable in advance of the month of coverage. To use On-Line Bill Payment, you will need to arrange for your financial institution to generate a check in payment for your coverage. As an example, the following links will connect you with major banks for establishing this service B of A - Online Banking Info Wells Fargo - Online Banking Information Your full payment must be received by the 20 th to avoid a late charge. We suggest that you initiate your on-line payment on or before the 10 th of each month. Payments MUST be mailed to: The Benefits Store, Inc. P.O. Box Los Angeles, CA Credit Card Payment Visa or MasterCard, or American Express Premiums are payable in advance of the month of coverage. We accept Visa, MasterCard for monthly premium payments, Credit Card payments will be assessed the full premium rate which includes a 2.5% administration charge. The Credit Card Authorization form may be downloaded from the Forms section on our web site To do so, click on the Forms tab located in the bar crossing our home page or select the following link Credit Card Authorization Form Your full payment must be received by the 20 th to avoid a late charge. We suggest you initiate your credit card payment on or before the 17 th of each month. For processing, Credit Card Authorization forms must be faxed to (925) Contact us at (888) with any questions about completing this form. To assure proper credit make sure to instruct your bank to show the full Subscriber s name in the memo field of your check.

7 Your Benefits Bill: Frequently Asked Questions The Benefits Store is committed to supporting you. Count on us to provide the products, expertise and support you need! How do I receive my bill? You have the option to receive a paper copy of your bill via mail, or a digital copy via . When will I receive my bill? You will receive your bill on or by the first of the month. When is my premium due? Your premium will always be due by the 20 th of each month prior to next month s coverage. When will I see my adjustments or payments? Any adjustments or payments made before your bill date will be reflected on your next invoice. All adjustments or payments made after your bill date will reflect on the following month s invoice. (Example: if your bill date is on the 26 th of the month, an adjustment/payment made on the 27 th would reflect on the following month s invoice.) How do I submit my payment? There are multiple options for submitting payments. Check Checks must be mailed to: The Benefits Store PO Box Los Angeles, CA Credit Card ACH/EFT if using a credit card, there is a 2.5% transaction fee added to each payment made If I m on autopay, will I still receive a bill? Yes, even if you are enrolled in automatic payments, an invoice will still be mailed to you. My coverage was terminated for nonpayment, can I get my coverage reinstated? A reinstatement request requires the account to be paid through the most current billing cycle and is subject to review and approval from the carrier. Benefits Store Insurance Services, Inc. (800) CA Insurance License #

8 Benefits Store, Inc. UWWW.BENEFITSSTORE.COM SPECIAL PROGRAMS INCLUDED IN YOUR KAISER PREMIUM THROUGH THE BENEFITS STORE ASSOCIATION PLANS Association Special Discount Dental Plan CREBPT Kaiser Members Special Discount Dental Plan gives you immediate, predictable and significant discounts for dental services. Because the Special Discount Dental plan is not insurance, plan members decide when to use a participating dentist, how often, and without any limit on their savings. For additional plan information and a list of providers please go to Association Special Life Insurance Plan The primary insured member will receive $10,000 Life and AD&D coverage automatically as part of your enrollment with the Benefits Store. This coverage is provided by Mutual of Omaha. You may be able to purchase additional coverage at very competitive rates without any health question for yourself and eligible family members. Benefits Store, Inc. P.O. Box 238 Alamo, CA Phone: Fax: Info@BenefitsStore.com CA INS Lic# BENEFITS STORE, Inc. Association Benefits