Small Business Subscriber Change Request Blue Shield of California and Blue Shield of California Life & Health Insurance Company

Transcription

1 Small Business Subsriber Change Request Blue Shield of California and Blue Shield of California Life & Health Insurane Company All hange requests must be reeived within 31 days of the effetive date of the hange. This form is used to request hanges in personal information, add/anel dependent overage, or hange plans during open enrollment. For employees requesting a new Personal Physiian (HMO plans), visit blueshielda.om or all Blue Shield at the number on the bak of your Blue Shield member ID ard. Subsriber information All information requested in this setion is required for all hanges. Enrolled employee (subsriber) name Blue Shield subsriber ID number Soial Seurity number (required per CMS) Employment status Full time (30 hrs) Part time (20-29 hrs) COBRA/Cal-COBRA benefiiary Group/employer name Blue Shield Group ID (from ID ard) Requested effetive date Member information update Address hange Please omplete this setion to update your address. Inlude both your full previous and full new address. HMO plans: If you have moved outside your Personal Physiian s servie area, you will need to hange Personal Physiians. Visit blueshielda.om, or all Blue Shield at the number on your ID ard for more information. Old address City State ZIP ode County address City State ZIP ode County Dependent name (if address hange is appliable for dependent only): Phone/ address hange Please omplete this setion to update your phone or address information with Blue Shield. Old phone number Work Old address Home phone number Work Home address Employee name hange doumentation may be required Note: Doumentation is required, suh as opy of ourt order, marriage liense, driver s liense, or ID ard. Old name name Reason for hange: Marriage Divore Other Doumentation attahed? (please speify): Yes No orretion doumentation required Note: Doumentation may be required suh as a opy of the driver s liense, ID ard, or birth ertifiate. Member s name Doumentation attahed? Yes No Soial Seurity number orretion/hange doumentation required A opy of the Soial Seurity ard, letter of verifiation from the Soial Seurity Offie, and a written statement explaining the reason for the hange are required. Old Soial Seurity number Soial Seurity number Doumentation attahed? Yes No Blue Shield of California is an independent member of the Blue Shield Assoiation C675-1 (1/15) C675-1 (1/15) 1 of 5

2 Subsriber name Subsriber ID number Employer name Member eligibility hanges Dependent addition of overage Please omplete this setion to add a spouse, domesti partner, or dependent hild to the employee s overage. Please opy and attah additional pages as needed if adding multiple dependents. The request must be reeived within the time frame allowed per the qualifying event, or during the group s open enrollment period. Doumentation is required to verify the date of the qualifying event, inluding for loss of overage, adoption, or ourt-ordered overage. A ompleted Refusal of Coverage (C19927) is required for any dependent that is refusing overage under the plan. Note: Soial Seurity number is required per CMS. Dependent 1 Dependent hild Spouse/domesti partner Dependent hild: legal guardianship Reason for addition born Adoption Court order Marriage Domesti partnership Loss of overage Open enrollment / / Soial Seurity number Gender: Male Female Address (if different from employee) City State ZIP ode Was the dependent overed under another health insurane plan within the past 12 months? Yes No If yes, please speify arrier and plan name, start and end dates of overage: Carrier and plan name: / / to HMO provider name HMO provider number IPA/MG name Yes No Dental HMO provider name Dental HMO provider number Yes No Enrolling in same produts seleted by subsriber? Yes No If no, is Refusal of Coverage form for those plans being delined attahed? Yes No Dependent 2 Reason for addition Dependent hild Spouse/domesti partner Dependent hild: legal guardianship born Adoption Court order Marriage Domesti partnership Loss of overage Open enrollment Soial Seurity number Gender: Male Female Address (if different from employee) City State ZIP ode Was the dependent overed under another health insurane plan within the past 12 months? Yes No If yes, please speify arrier and plan name, start and end dates of overage: Carrier and plan name: / / to HMO provider name HMO provider number IPA/MG name Yes No Dental HMO provider name Dental HMO provider number Yes No Enrolling in same produts seleted by subsriber? Yes No If no, is Refusal of Coverage form for those plans being delined attahed? Yes No Dependent anellation of overage Please omplete this setion to anel all Blue Shield overage for a dependent spouse, domesti partner, or hild due to loss of eligibility. If any dependents being anelled remain eligible for overage, or if overage is being partially anelled (not all plans), a ompleted Refusal of Coverage form is required for those plans being delined/anelled. Dependent hild Spouse/domesti partner Reason for anellation Divore Death Military deployment Other insurane overage Termination of domesti partnership Soial Seurity number Gender: Male Female Address (if different from employee) City State ZIP ode Canel overage for all Blue Shield plans? Yes No If no, please attah ompleted Refusal of Coverage form. C675-1 (1/15) 2 of 5

3 Subsriber name Subsriber ID number Employer name Plan hanges Plan hange request Please indiate the requested hanges to overage through an annual or speial open enrollment period by ompleting all setions below for medial plan and speialty plan options. Medial benefit plans: Please hek with your employer to determine the benefit plans available to you. No hange to medial benefits. Blue Shield of California Off Exhange Pakage Plans Platinum Full PPO 0 OffEx Platinum Full PPO 150 OffEx Gold Full PPO 0 OffEx Gold Full PPO 750 OffEx Silver Full PPO 1250 OffEx Silver Full PPO 1700 OffEx Bronze Full PPO 4500 OffEx Silver Full PPO HSA 2000 OffEx Bronze Full PPO HSA 3500 OffEx Bronze Full PPO HSA 5500 OffEx Platinum Aess+ HMO $25 OffEx Gold Aess+ HMO $30 OffEX Silver Aess+ HMO $55 OffEx Platinum Loal Aess+ HMO $25 OffEx Gold Loal Aess+ HMO $30 OffEx Silver Loal Aess+ HMO $55 OffEx Trio ACO HMO Plans Platinum Trio ACO HMO $25 OffEx Gold Trio ACO HMO $30 OffEx Silver Trio ACO HMO $55 OffEx Blue Shield of California Mirror Pakage Plans Platinum 90 HMO Network 1 Mirror Platinum 90 HMO Network 2 Mirror Gold 80 HMO Network 1 Mirror Gold 80 HMO Network 2 Mirror Silver 70 HMO Network 1 Mirror Silver 70 HMO Network 2 Mirror Bronze 60 PPO Mirror Pediatri dental benefit plans (required if seleting Medial)* Children s Dental PPO Children s Dental HMO Family Dental PPO Family Dental HMO * Pursuant to state and federal law, the group must have pediatri dental overage. Therefore, employees enrolling in a Blue Shield medial plan must be enrolled in pediatri dental overage Speialty Benefit Plans Dental, Vision, and Life Insurane plan seletion Please omplete the attahed Speialty Benefits Employee Benefit Seletion form to indiate hanges to speialty benefit overage. Setion SB1 Dental benefits Dental HMO Plans DHMO Basi DHMO Plus DHMO Deluxe DHMO Voluntary Dental PPO Plans Ultimate Dental PPO for Small Business 50/2000 Ultimate Dental Plus PPO for Small Business 50/2000 Smile SM Deluxe /2000/No Ortho/MAC Smile SM Deluxe Plus /2000/Ortho/MAC Smile SM Deluxe 50/1500/Ortho/MAC Smile SM Deluxe Gold 50/1500/Ortho/U85 Dental In-Network Only (INO) Plans* Smile SM INO Dental Plan 50/1500/Endo-Perio 80%/Ortho Smile SM INO Dental Plan 50/1500/Endo-Perio 80%/No Ortho Smile SM INO Dental Voluntary Plan 50/1500/Endo-Perio 50%/Ortho Smile SM INO Dental Voluntary Plan 50/1500/Endo-Perio 50%/No Ortho Smile SM 50/1500/No Ortho/MAC Smile SM Plus 50/1500/Ortho/MAC Smile SM Value 50/1500/No Ortho/MAC Smile SM Plus Gold 50/1500/Ortho/U85 Smile SM Basi 75/1000/No Ortho/MAC Smile SM Basi Voluntary 75/1000/No Ortho/MAC Smile SM INO Dental Plan 50/2500/Endo-Perio 80%/Ortho Smile SM INO Dental Plan 50/2500/Endo-Perio 80%/No Ortho Smile SM INO Dental Voluntary Plan 50/2500/Endo-Perio 50%/Ortho Smile SM INO Dental Voluntary Plan 50/2500/Endo-Perio 50%/No Ortho * Underwritten by Blue Shield of California Life & Health Insurane Company (Blue Shield Life). Setion SB2 Vision Coverage Vision Coverage* Ultimate Vision for Small Business ( ) Ultimate Vision Plus 0/0/150/120 Ultimate Vision 0/0/150 Ultimate Vision Plus 15/25/150/120 Ultimate Vision 15/25/150 Ultimate Vision Voluntary 15/25/150 1 Ultimate Vision 0/0/120 Ultimate Vision 15/25/120 Preferred Vision for Small Business ( ) Preferred Vision Plus 0/0/150/120 Preferred Vision 0/0/150 Preferred Vision Plus 15/25/150/120 Preferred Vision 15/25/150 Preferred Vision 0/0/120 Preferred Vision 15/25/120 Preferred Vision Voluntary 15/25/120 1 Enhaned Vision for Small Business ( ) Enhaned Vision Plus 0/0/150/120 Enhaned Vision 0/0/150 Enhaned Vision Plus 15/25/150/120 Enhaned Vision 15/25/150 Enhaned Vision 0/0/120 Enhaned Vision 15/25/120 Enhaned Vision Voluntary 15/25/120 1 * Underwritten by Blue Shield of California Life & Health Insurane Company (Blue Shield Life). 1 Voluntary vision plans require a minimum of three enrolling, eligible employees. C675-1 (1/15) 3 of 5

4 Subsriber name Subsriber ID number Employer name Setion SB3 Life/AD&D insurane Group Term Life Insurane Employee information Full-time employment date Average hours worked per week Rehire date Class/oupation Earnings $ (exluding overtime, bonuses, et.) Hour Week Month Year Designation of benefiiary Primary benefiiary Blue Shield Life will pay the life insurane benefits to the primary benefiiary/benefiiaries identified. An employee may designate more than one primary benefiiary. Please show perentages for eah primary benefiiary in the % of benefits olumn to total 100% of benefits. If the perentage is not defined, the benefits will be distributed equally to those primary benefiiaries who survive the employee. To designate more than two primary benefiiaries, please provide on a separate sheet of paper, whih is signed and dated by the employee, and attah to this form. First name MI Last name Soial Seurity number Relationship % of benefits Address City State ZIP ode First name MI Last name Soial Seurity number Relationship % of benefits Address City State ZIP ode Contingent benefiiary Proeeds will be paid to a ontingent benefiiary only if no designated primary benefiiary survives the insured. First name MI Last name Soial Seurity number Relationship % of benefits Address City State ZIP ode Information on benefit amounts Please ontat your benefits administrator for more information regarding your group life insurane overage. Evidene of Insurability must be submitted for approval before an employee is eligible for overage over a ertain guaranteed amount or when enrolling outside of the initial eligibility period. Coverage granted to individuals listed in this enrollment form shall be subjet to all provisions and limitations stated in the Blue Shield of California Life & Health Insurane Company group life insurane poliy. Employee Basi Life and AD&D Insurane amount: $ Basi Dependent Life Insurane: Yes No Number of eligible dependents: Amount of overage requested for dependent(s): $ (Minimum amount of overage is $1,000; maximum is $5,000) * Pursuant to state and federal law, the group must have pediatri dental overage. Therefore, employees enrolling in a Blue Shield medial plan must be enrolled in Pediatri Dental Coverage. Underwritten by Blue Shield of California Life & Health Insurane Company. A46898 If transferring to HMO and/or Dental HMO plan(s), provide Personal Physiian/Dental Provider information below. Last name MI First name Sex Male Female Dental Yes No Last name MI First name Sex Male Female Dental Yes No Last name MI First name Sex Male Female Dental Yes No Last name MI First name Sex Male Female Dental Yes No / / Yes No Yes No Yes No Yes No C675-1 (1/15) 4 of 5

5 Subsriber name Subsriber ID number Employer name Please note: If Blue Shield is unable to assign the Personal Physiian and/or Dental HMO provider you requested, Blue Shield will designate a provider at random. HMO Personal Physiians an be hanged by visiting blueshielda.om after enrollment. Aknowledgement and signature I aknowledge and agree: All information I have provided on this form is aurate and omplete to the best of my knowledge and belief. I understand that this form, along with any prior enrollment form, the Evidene of Coverage/Certifiate of Insurane and Health Servie Agreement/Poliy, and any endorsements and attahments thereto, olletively onstitutes the entire agreement for overage. Signature of employee Date / / Print employee name If faxing this form, keep this doument for your files. Blue Shield of California protets the privay of your personal information, inluding your individually identifiable health information. We will not dislose your personal information without your authorization, exept as permitted or required by law. To obtain a opy of Blue Shield s Notie of Privay Praties, all the ustomer servie number on your Blue Shield member ID ard or visit our website at blueshielda.om/bsa/douments/about-blue-shield/privay. PLEASE BE SURE TO RETURN ALL PAGES OF THIS FORM. Missing information or pages may delay proessing. Complete your Subsriber Change Request form at blueshielda.om. C675-1 (1/15) 5 of 5