APPLICATION FOR HIGHMARK BLUE SHIELD HEALTH INSURANCE

Transcription

1 APPLICATION FOR HIGHMARK BLUE SHIELD HEALTH INSURANCE WHO CAN ENROLL IN THE PRODUCTS LISTED ON THIS APPLICATION? You can enroll in one of these products if you reside within the Highmark Blue Shield service area and meet the eligibility guidelines set forth in the Notification and Authorization section of this Application. We are committed to providing outstanding service for our applicants and members. If you need special assistance due to limited English proficiency or because you have a disability, call us at , call TTY at 711, or visit one of our retail locations to receive assistance free of charge. WHEN SHOULD THIS APPLICATION BE USED? Use this Application for enrolling directly through Highmark Blue Shield: 1. Enrolling for new coverage (other than for Conversion or HIPAA). If you wish to enroll in an individual plan that you purchase directly from Highmark Health Services and NOT through the Health Insurance Marketplace. The Highmark Blue Shield health plans available through this Application do not apply federal premium tax credits or cost sharing reductions available under the new health care law.* *If you are unsure if you qualify for federal premium tax credits or cost sharing reductions, go to the Health Insurance Marketplace 2. Converting from group coverage to individual coverage. If you wish to enroll because you lost your Highmark Blue Shield group coverage and you are eligible for an individual Conversion policy that covers you beginning on the date you are terminated from Highmark Blue Shield group coverage. Depending upon your selection of a coverage Effective Date, your first premium payment will include a pro-rated amount for the days remaining in the month you are terminated from group coverage. The amount is based on the number of family members who were active on the Highmark Blue Shield group policy as of your termination date. The amount of your first premium payment will also include the following full month of coverage. Your Application and first premium are due by the date noted in Step 3 of this Application. 3. Enrolling in Health Insurance Portability & Accountability Act (HIPAA) coverage. If you wish to apply for HIPAA-eligible coverage due to the termination of your employer group, governmental or church plan coverage, please indicate the date you lost coverage in Step 3 of this Application. Note that you must provide proof of prior creditable coverage for HIPAA eligibility and you must return your Application within 63 days from the date that your prior employer group, governmental or church coverage ended. Parents of HIPAA-eligible children who do not elect HIPAA coverage for themselves may still enroll their HIPAA-eligible children in the program. APP-DP-HBS ENR-200 (9-13)

2 GET HELP WITH THIS APPLICATION CLICK TO CHAT: PHONE: Call our Help Center at IN PERSON: Visit your insurance agent or, for a list of retail locations near you, visit our website. THIS APPLICATION CAN BE OBTAINED FROM: KEEP THIS PAGE FOR YOUR RECORDS. Date: Check Number: Amount Paid: Deductible Amount Applied For: WHAT HAPPENS NEXT? You can download and fill out the appropriate gray box fields on your computer, or you can print and complete the appropriate box fields with an ink pen. If you complete your application using your computer, be sure to save the file to your computer or make a printed copy for your records. If you complete your application using a public computer, be sure to delete any personal information, temporary internet files and browsing history when done. You can send your application via US Mail, fax or . Print and Mail: Include your completed, signed Application along with your first premium payment to Highmark Blue Shield, P.O. Box , Pittsburgh, PA Print and Fax: Fax your completed, signed Application to Mail your first premium payment to Highmark Blue Shield, P.O. Box , Pittsburgh, PA along with the Payment and Billing Information section below. Save and your completed, signed Application to DP_Applications@highmark.com. Mail your first premium payment to Highmark Blue Shield, P.O. Box , Pittsburgh, PA along with the Payment and Billing Information section below. Note: If you are applying for a Conversion Policy with no lapse in coverage from the termination date of your Highmark Blue Shield Group policy or a HIPAA Policy with no lapse in coverage from the termination date of your last employer coverage, the first premium payment that must be paid will include a pro-rated amount for the remaining days in the month your coverage was terminated plus the following month s coverage. PAYMENT AND BILLING INFORMATION Return this portion with your check or money order to: Highmark Blue Shield, P.O. Box , Pittsburgh, PA NAME PLEASE CUT HERE ADDRESS Please indicate the Payment Enclosed for your coverage and fill in your Social Security Number in the boxes below. This Agreement renews on a month-to-month basis. The premium is payable in advance to Highmark Blue Shield on a monthly basis. Members may, for their convenience, submit amounts in excess of the specific monthly amount. However, such excess amounts will be applied on a monthly basis by Highmark Blue Shield and will be subject to premium increases on the date the increase becomes effective. Note that we must receive your premium payment before we can reimburse for any eligible services you receive. Claims for eligible services will not be processed unless your current premium has been paid in full. If your premium payment is not received within the policy grace period, your policy will be terminated as of the last month for which payment of the required premium was received. Make your check or money order payable to Highmark Blue Shield for your first full premium due. Payment Enclosed Group Number Applicant s Social Security Number $

3 APPLICATION FOR HIGHMARK BLUE SHIELD HEALTH INSURANCE STEP 1 TELL US ABOUT YOURSELF Complete this section with your information if you are applying for coverage. If you are applying for coverage on behalf of your dependent(s), you are considered the Policy Holder/Subscriber as well as the contact person for your dependent(s), and you are required to complete this section of the Application. If you are applying on behalf of a child under age 18 for his or her own coverage on an individual policy, please complete this section with YOUR information as you will be the contact for your child. Provide your child s information in STEP 2 and check this box n. SOCIAL SECURITY NUMBER SEX n Male DATE OF BIRTH (MONTH/DAY/YEAR) HOME ADDRESS APARTMENT NUMBER CITY STATE ZIP CODE COUNTY MAILING ADDRESS (IF DIFFERENT FROM HOME ADDRESS) APARTMENT NUMBER CITY STATE ZIP CODE COUNTY n Check here if you don t have a home address. You still need to give a mailing address. PRIMARY PHONE NUMBER OTHER PHONE NUMBER ( ) ( ) Indicate how you would like to receive your member materials including Welcome Book, Member Handbook, Agreement/Endorsements, Summary of Benefits and Coverage and Explanation of Benefits: n Electronically by logging into the website. n In the mail at the address noted above. If you provide your address, Highmark Blue Shield may, from time to time, provide you, via , with important information about health-related products and services that add value to your benefits plan. n Yes n No address: Text: n Yes n No Cell phone number: PREFERRED LANGUAGE SPOKEN (IF NOT ENGLISH) PREFERRED LANGUAGE READ (IF NOT ENGLISH) Answer the following if you will be covered under the policy: Check the box if you need special assistance due to limited English proficiency or because you have a disability. n Call us at , or call TTY at 711, or visit one of our retail locations to receive assistance free of charge. PAYMENT AND BILLING INFORMATION Please indicate the Payment Enclosed for your coverage and fill in your Social Security Number in the boxes below. This Agreement renews on a month-to-month basis. The premium is payable in advance to Highmark Blue Shield on a monthly basis. Members may, for their convenience, submit amounts in excess of the specific monthly amount. However, such excess amounts will be applied on a monthly basis by Highmark Blue Shield and will be subject to premium increases on the date the increase becomes effective. Note that we must receive your premium payment before we can reimburse for any eligible services you receive. Claims for eligible services will not be processed unless your current premium has been paid in full. If your premium payment is not received within the policy grace period, your policy will be terminated as of the last month for which payment of the required premium was received. Make your check or money order payable to Highmark Blue Shield for your first full premium due. Mail payment and completed Application to: Highmark Blue Shield, P.O. Box , Pittsburgh, PA Payment Enclosed Group Number Applicant s Social Security Number $ APP-DP-HBS ENR-200 (9-13)

4 STEP 2 TELL US ABOUT EVERYONE WHO WILL BE ON THE COVERAGE PLAN SELECTED This section should be used to list everyone who is applying for coverage. Eligible dependents include the applicant's spouse and/or the applicant's and/or spouse's children who are under age 26. Attach additional sheets of paper if you need it. n Check here only if person listed in STEP 1 is applying for coverage. STEP 2: PERSON 1 STEP 2: PERSON 2 RELATIONSHIP TO YOU? SOCIAL SECURITY NUMBER (If no SS#, write N/A) SEX n Male DATE OF BIRTH (MONTH/DAY/YEAR) Does this PERSON 2 live at the same address as you? n Yes n No / / If No, list address: n Check here if you require special assistance, including accommodations for disabilities or limited English proficiency. STEP 2: PERSON 3 RELATIONSHIP TO YOU? SOCIAL SECURITY NUMBER (If no SS#, write N/A) SEX n Male DATE OF BIRTH (MONTH/DAY/YEAR) Does this PERSON 3 live at the same address as you? n Yes n No / / If No, list address: n Check here if you require special assistance, including accommodations for disabilities or limited English proficiency. STEP 2: PERSON 4 RELATIONSHIP TO YOU? SOCIAL SECURITY NUMBER (If no SS#, write N/A) SEX n Male DATE OF BIRTH (MONTH/DAY/YEAR) Does this PERSON 4 live at the same address as you? n Yes n No / / If No, list address: n Check here if you require special assistance, including accommodations for disabilities or limited English proficiency. STEP 2: PERSON 5 RELATIONSHIP TO YOU? SOCIAL SECURITY NUMBER (If no SS#, write N/A) SEX n Male DATE OF BIRTH (MONTH/DAY/YEAR) Does this PERSON 5 live at the same address as you? n Yes n No / / If No, list address: n Check here if you require special assistance, including accommodations for disabilities or limited English proficiency. Page 2

5 STEP 3 COVERAGE SELECTION Review the product information to learn what each program covers. Based on the county in which you reside, choose only one product and deductible option on this Application by placing an X in the appropriate check box. The product and deductible option you choose will apply to everyone covered under the policy. FOR RESIDENTS OF THE FOLLOWING COUNTIES: CENTRE, COLUMBIA, JUNIATA, MIFFLIN, MONTOUR, NORTHUMBERLAND, SNYDER, UNION, SCHUYLKILL Note: You must reside in one of the following zip codes in Centre County to enroll in one of these plans 16801, 16802, 16803, 16804, 16805, 16820, 16827, 16828, 16832, 16835, 16844, 16865, or east of Highway 220 in the following zip codes , 16826, 16841, 16844, 16864, 16868, 16870, I am/we are applying for new coverage under: n Major Events Blue PPO $6,350 Annual Individual Deductible (Self-only coverage) Note: Major Events Blue PPO coverage is only offered to individuals under age 30 or who have received an exemption certificate from the Health Insurance Marketplace. Attach a copy of the certificate if you have one. n Flex Blue PPO 4000 a Community Blue Plan - $4,000 Annual Individual Deductible/$8,000 Annual Family Deductible n Flex Blue PPO 2650 a Community Blue Plan - $2,650 Annual Individual Deductible/$5,300 Annual Family Deductible n Flex Blue PPO 1200 a Community Blue Plan - $1,200 Annual Individual Deductible/$2,400 Annual Family Deductible n Health Savings Blue PPO 1700 a Community Blue Plan - $1,700 Annual Individual Deductible/$3,400 Annual Family Deductible Note: If you are applying for a Conversion Policy with no lapse in coverage from the termination date of your Highmark Blue Shield Group policy, or a Health Insurance Portability & Accountability Act (HIPAA Policy) with no lapse in coverage from the termination date of your last employer coverage, you must choose the product below: n Flex Blue PPO 4000 a Community Blue Plan - $4,000 Annual Individual Deductible/$8,000 Annual Family Deductible Note: Proposed initial premium payment amount assumes no tobacco use. Applicant agrees to pay any adjustment to the rate to reflect tobacco use. APPLICATION DUE DATE: Requested Effective Date of Coverage: n Conversion Policy: Effective from: n HIPAA Policy: Effective from: FIRST PREMIUM AMOUNT DUE: Effective to: Effective to: Monthly Premium for the product you selected, based on applicants indicated on this Application: FOR RESIDENTS OF THE FOLLOWING COUNTIES: ADAMS, BERKS, CUMBERLAND, DAUPHIN, FRANKLIN, FULTON, LANCASTER, LEBANAON, LEHIGH, NORTHAMPTON, PERRY, YORK I am/we are applying for new coverage under: n Major Events Blue PPO $6,350 Annual Individual Deductible (Self-only coverage) Note: Major Events Blue PPO coverage is only offered to individuals under age 30 or who have received an exemption certificate from the Health Insurance Marketplace. Attach a copy of the certificate if you have one. n Flex Blue PPO 4000 a Community Blue Plan - $4,000 Annual Individual Deductible/$8,000 Annual Family Deductible n Flex Blue PPO 2100 a Community Blue Plan - $2,100 Annual Individual Deductible/$4,200 Annual Family Deductible n Flex Blue PPO 1000 a Community Blue Plan - $1,000 Annual Individual Deductible/$2,000 Annual Family Deductible n Health Savings Blue PPO 1700 a Community Blue Plan - $1,700 Annual Individual Deductible/$3,400 Annual Family Deductible Note: If you are applying for a Conversion Policy with no lapse in coverage from the termination date of your Highmark Blue Shield Group policy, or a Health Insurance Portability & Accountability Act (HIPAA Policy) with no lapse in coverage from the termination date of your last employer coverage, you must choose the product below: n Flex Blue PPO 4000 a Community Blue Plan - $4,000 Annual Individual Deductible/$8,000 Annual Family Deductible Note: Proposed initial premium payment amount assumes no tobacco use. Applicant agrees to pay any adjustment to the rate to reflect tobacco use. APPLICATION DUE DATE: Requested Effective Date of Coverage: n Conversion Policy: Effective from: n HIPAA Policy: Effective from: FIRST PREMIUM AMOUNT DUE: Effective to: Effective to: Monthly Premium for the product you selected, based on applicants indicated on this Application: Page 3

6 STEP 4 OTHER HEALTH INSURANCE INFORMATION Complete the information requested about your current health insurance. 1. Are you or any of your family members who are applying for this coverage enrolled in any private or governmental group or individual health plan or program at the time of this Application? n Yes n No 2. Is this coverage for which you are applying intended to replace any other accident or health insurance you or any family members applying currently have? This includes any current Highmark Health Services policy. n Yes n No If you answered Yes to any question, complete question 3. If you answered No, skip question 3 and go to the next section. 3. Please provide the following information about any other coverage you and/or your family members currently have or have applied for: Name of Insurance Carrier: Name of Policy Holder: Group Number: Effective Date: Policy Number: Policy Holder s Date of Birth: Relationship to Applicant: Policy Holder s Employment Status: ANSWER QUESTIONS 4-8 ONLY IF YOU ARE APPLYING FOR HIPAA COVERAGE. 4. If your most recent coverage offered you COBRA or similar state-required continuation of coverage benefits, did you elect that coverage? n Yes n No If YES, have you used up all your benefits under that coverage? n Yes n No 5. Including your most recent coverage, have you been continuously covered under some type of creditable health care coverage for a period of at least 18 months? * n Yes n No * In determining whether you have the required 18 months of prior creditable coverage, you may count periods of creditable coverage that occurred prior to any breaks in coverage only if the break in coverage was for a period of less than 63 days. Days during a waiting period for which you had no coverage are not to be counted as creditable coverage or used in determining whether there has been a break in coverage. 6. Did your most recent health care coverage end within the last 63 days? n Yes n No 7. Was your most recent health care coverage terminated due to your non-payment of premium (including contributions) or fraud? n Yes n No 8. Are you attaching a copy of your Certificate of Prior Creditable Coverage form? n Yes n No If you answered No to the question above you can still demonstrate prior creditable coverage in one of the following ways: a) You can submit your own signed written statement regarding your prior coverage. That statement should include the name(s) of the plan(s) that provided your last eighteen (18) months of coverage, including the beginning and end date(s) of all such coverage. You must also attach copies of any documents you may have evidencing that you had coverage during those periods such as a copy of an identification card, an explanation of benefits (EOB), premium invoices or pay stubs evidencing payroll deductions for health coverage, etc. You must also cooperate with Highmark Blue Shield efforts to verify that coverage. - OR - b) You may complete and submit a HIPAA Prior Coverage Disclosure and Authorization Form, available by calling Customer Service at , instead of a written statement. Prior creditable coverage may also be established through means other than documentation, such as telephone verification. Please be sure to provide as much information as you can and sign the form authorizing Highmark Blue Shield to contact your previous plan(s) to verify your prior coverage. Page 4

7 STEP 5 NOTIFICATION AND AUTHORIZATION My/our signature on this Application indicates that I/we have read and fully understand the following statements: I/we hereby apply for health care plan coverage for myself and/or my eligible dependents listed on this Application. I/we understand and agree that the terms and conditions of our coverage will be controlled by the written Agreement with Highmark Blue Shield and that they may adopt reasonable policies, procedures, rules and interpretations, consistent with the language of that Agreement, to administer the program. I/we recognize that our coverage will only apply to admissions that occur and services that are provided on or after the effective date of our coverage. I acknowledge and agree that any personally identifiable health information about me or my enrolled dependents ( Protected Health Information ) is protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other privacy laws, and that, in accordance with those laws, Highmark Health Services may use and disclose Protected Health Information for payment, treatment and health care operations. A copy of Highmark Health Services Notice of Privacy Practices is available on the Highmark Health Services Web site or from the Highmark Health Services Privacy Office. I/we understand that the Agreement is available only to residents of the 21-counties of central Pennsylvania and the Lehigh Valley served by Highmark Health Services, and that this Application is subject to the provisions of the Agreement. I/we understand that the receipt of the benefits under this program is subject to Highmark Health Services s determination of medical necessity and appropriateness. Except for emergencies or delivery-related admissions, all inpatient admissions are subject to review by Highmark Health Services prior to the proposed admission. I can confirm that everyone applying for health insurance on this Application is a U.S. citizen, national or other individual lawfully present in the United States. I can confirm that no one applying for health insurance on this Application is incarcerated (detained or jailed). I know that I must tell Highmark Blue Shield if any information I supplied on this Application changes. I can call to report any changes. EFFECTIVE DATE OF COVERAGE I/we understand/agree that, subject to the conditions of enrollment on this Application, coverage will be effective for individuals listed on this Application following receipt of a completed Application and payment of the first premium in full: a) on the first day of the following month if the Application and premium payment are received between the first and 15th of the month - OR - b) on the first day of the second month if Application and premium payment are received between the 16th and the last day of the month - OR - c) in the case of HIPAA coverage or a Conversion policy, on the Effective Date indicated on this Application To the best of my/our knowledge and belief, the information provided on this Application is true and correct. I also understand that any attempts to qualify for the program chosen through fraud or other intentional misrepresentation of a material fact will result in termination of such contract. If typing your name in the signature field: I/We understand and I/We am/are creating an Electronic Signature that carries the same legal obligation as a written signature and I/We am/are agreeing to all of the terms and conditions set forth within this application. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Applicant s Signature Spouse/Parent s Signature Date Date NOTE TO ALL APPLICANTS: If you are married and applying for husband and wife or family coverage, both you and your spouse must sign this Application form. If you are unmarried, under age 18 and applying for individual coverage, a parent or guardian must sign. THIS APPLICATION IS VALID ONLY WHEN COMPLETED AND SIGNED BY THE APPLICANT. Page 5

8 FOR PRODUCER USE ONLY PRODUCER S CERTIFICATE ATTENTION PRODUCER: If you have questions concerning the completion of this application, please call the Producer Line at If this section is not fully completed, commission will not be paid. Blue Shield Agency No. Producer No. Agency Name Producer s Name Producer s Signature LAST FIRST MI Business Phone ( ) Area Code Completion of this section is required BY A PRODUCER if the producer wishes to act on the applicant s behalf. 1. Are you aware, based on the applicant s responses to your inquiries, of any factors impacting the eligibility of the applicant and each of his/her dependents applying for this coverage? n No n Yes 4. Is this applicant a current customer of Highmark Blue Shield? n No n Yes 5. Have you retained a signed copy of this application for your records? n No n Yes Producer Signature Agency Date Note: No producer may: 1. Accept risk or pass on any eligibility requirements; 2. Have you provided the applicant with all relevant marketing materials? n No n Yes 3. Have you advised the applicant of the features of the product that they have selected, including satisfying their deductible(s)? n No n Yes 2. Make or alter the terms of the application or policy; or 3. Waive any of Highmark Blue Shield s rights or requirements. Highmark Health Services d/b/a Highmark Blue Shield 120 Fifth Avenue Pittsburgh, PA Highmark Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association. Highmark is a registered mark of Highmark Health Services. Blue Shield and the Shield symbol are registered service marks of the Blue Cross and Blue Shield Association. INTERNAL USE ONLY Blue Cross Blue Shield Agency No. Producer No. Page 6