If you want health insurance:

Transcription

1 If you want health insurance: Complete this Anthem application and turn it in to your business manager! If you want a health savings account (and free money!) ollow the directions on page 2. Employer contributions are made directly into the savings account on the last day of each month and will begin as follows: 1. On Time Activation: Any account that is completed (which means fully open and activated) by the 15 th of the month in which you became eligible for medical insurance will begin receiving employer contributions on the last day of that same month. You must contact HR by the 15th w/your account # to be considered On Time. 2. Late Activation: Any account that is completed (which means fully open and activated) on or after the 16 th of the month in which you became eligible for medical insurance will begin receiving employer contributions on the last day of the following month. a. Back contributions will not be paid to any account that is considered a Late Activation as outlined above or to any account that which HR was not notified of by the 15th of that month. b. It is the responsibility of the employee to notify HR when you have opened your account as a late activation. Human resources is NOT notified by the HSA bank when a new account has been established. Important items to keep in mind: 1. YOUR ACCOUNT IS NOT CONSIDERED ULLY OPEN AND ACTIVATED UNTIL YOU HAVE RECEIVED YOUR ACTUAL SAVINGS ACCOUNT # RO THE HSA BANK. Your actual savings account # is different from a confirmation # you may receive when you first establish your online account. 2. If you don t receive a saving s account # from the bank, check your spam or call them at They may be waiting for you to provide additional documentation/proof of residency. 3. This is the one and only notification you will receive regarding the establishment of your account. Reminders are not sent. It is the responsibility of the employee to open their account upon receipt of this notice. Back contributions will not be paid to any employee. 4. If the account is not opened as an On Time Activation, the Archdiocese will assume that you are opting out of the health savings account program. If you have missed the On Time Activation period, you can enroll at any time thereafter but it will be considered a Late Activation as outlined above. If you are a priest or a religious sister, you don t need to open a health savings account. If you have any questions, please check with your business manager or Christa Bunch in Human Resources at cbunch@archindy.org.

2 How to Open an Elements inancial Health Savings Account Congratulations! You are ten minutes closer to financial wellness and your new HSA. That s all the time it takes to complete an application to Elements inancial. By choosing Elements inancial for your Health Savings Account (HSA), you ve made a wise choice that will generate many positive results. We promise to help you achieve financial wellness and success for a lifetime. We will assist and engage you with the solutions that best fit and support your goals. And as a credit union, Elements will always be looking out for your best interests. We have the kind of people, service and knowledge that make our financial institution unique. Our HSA is one of our most valuable product solutions and among the best in the financial industry: Generous Rates: Balances up to $24,999 earn 1.0% APY; balances of $25,000+ pay 1.25% APY. Robust Electronic Access: You ll have convenient options for accessing your HSA funds with your HSA debit card and online transfers. Your HSA portal at elements.org/hsa features account monitoring and resources to help you maximize your health care spending power. Resources: At Elements inancial, we focus on your wellness and success your life events, relationships, major purchases and savings goals. Visit elements.org soon for a wealth of information and solutions to support you. You re seeking ways to make your life easier; so are we. Our first commitment is to make this transition a smooth process for you. You can expect to hear from us during the early stages of your membership. or now, see Page 2 to get started.

3 Your HSA Application Instructions What You Need Before You Apply q Valid U.S. Driver s License, State Issued ID or Passport q US Social Security number q US citizenship or resident alien status When You Are Ready to Apply Go to elements.org/newhsa and follow the onscreen prompts to apply. You ll be asked to agree to our account disclosures. IPORTANT: HSA Rollovers & unding Although not required, we recommend that you use the online application to simplify the rollover of your existing HSA funds. NOTE: An HSA Rollover is permitted only once per 12 month period. You will need the following to complete your rollover at this time: Your existing HSA account number: Your Access Options Once enrolled, you ll want convenient access to your funds. After all, they re your funds. You can conduct your HSA transactions in several ways: Debit card payments Transfers & Bill Pay via ebranch: enroll at elements.org once you receive your welcome Paper checks available for a nominal fee. Call ember Service directly at (800) once you receive your welcome . Reorders can be made at elements.org/checking. The HSA Portal Simply visit elements.org/hsa the following business day to enroll for access to your HSA portal. Here you will find valuable information about your account, including the guidelines and benefits of your new HSA. The account balance to be moved: $ Secondary Options You may fund your account now with a debit or credit card or wait to fund your account with payroll contributions at a later date. Quick App Tips If you intend to add an authorized signer and/or beneficiary, gather all the information shown above for him/her, too. At several points, you ll have the chance to save and finish your application later. oney arket Savings is an additional service you will automatically open in addition to the HSA as it is a required account for all Elements members. Watch for Your Welcome Once you ve applied, you will receive a welcome from customerservice@elements.org. Please watch for and save this important message that will include your ember Number, oney arket Savings Account Number, and Health Savings Account Number. Contact Us for Support 24-Hour ember Service Contact Center (317) or toll-free (800) Live Chat via elements.org 8 a.m. to 5 p.m. customerservice@elements.org Questions about the HSA Product or Portal (855) 440-4HSA (4472) PO Box 7123 / Indianapolis, IN Thank you for joining us. How to Open an Elements inancial HSA Copyright 01/2015 Elements inancial

4 Enrollment Application Anthem provides administrative claims payment services only, and does not assume any financial risk or obligation with respect to claims. Please complete in ink and send to The Archdiocese at the address below or fax to If you have any questions, please call Human Resources at All sections in red UST be completed. Location #, parish school/name and boxes 1-6 and 8. Incomplete forms cannot be processed. Archdiocese of Indianapolis, Human Resources 1400 N. eridian St., Indianapolis, IN Group # Location # Parish School, Agency Name & Address Anthem use: Plan Health Effective Date Dental Effective Date 1. Reason for Application New enrollment for a current employee Annual open enrollment Qualifying event documenation required 2. Status Change/Event Event date arriage Birth *Include legal documentation. 4. Employee Information New hire Rehire (date) Add dependent (see section 3) Event date / / Adoption* Legal guardianship* Single amily Last name irst name,.i. Home address City 3. Type of coverage plan Health Coverage - Blue Access PPO State Zip code Age Sex Dental Coverage - Anthem Dental PPO Single amily Social Security # (SS# required for Lumenos Health Savings Account) County (KY residents include unicipality) Single Divorced arried Home telephone Business telephone ( ) - ( ) - eail Address Are you: Retired? Disabled? Hospitalized? Yes Yes Yes No No No Occupation 5. amily Information and dependents to be enrolled. (Attach a separate sheet if necessary.) 1 Last name irst name,.i. ull time hire date Court ordered health care benefits? Yes 2 Last name irst name,.i. Is dependent s address different than applicant s address? Yes 3 Last name irst name,.i. Contracted Employee? No (If Yes, provide full address) Court ordered health care benefits? Court ordered health care benefits? Yes 4 Last name irst name,.i. Court ordered health care benefits? Yes 5 Last name irst name,.i. Court ordered health care benefits? Yes Yes Hours working per week Income reported by: W2 ulltime student? ulltime student? ulltime student? ulltime student? ulltime student? A-77 ADI 8/06 LG-ASO 1

5 Please check one: YES (completed below.) NO On the day your coverage begins, list family members, including yourself, who will be covered by any other health coverage. 6. Health Coverage Provide name, phone number and address of the HO or insurance company Policy/certificate number Effective date Policy/certificate holder s name Social Security number If you and/or your dependents are enrolled in edicare complete the following. Enrollee s name(s) edicare ID# edicare Part A effective date edicare Part B effective date ESRD onset date edicare Part D ID# edicare Part D Carrier edicare Part D edicare Part D effective date term date Reason for edicare entitlement: Age Disability ESRD & Disability End Stage Renal Disease (ESRD) 7. Prior Health Coverage Please check one: YES (completed below.) NO Have you been covered by Anthem within the past two (2) years? Dates policy in effect: Policy/Certificate #: Have you and / or your dependents had prior coverage with another carrier(s) Dates policy in effect: within the past two (2) years? Please check the type of prior coverage Employee Employee / Employee / Child(ren) Employee / /Child(ren) Termination reason: Divorce/legal separation Death of spouse COBRA coverage exhausted Employment terminated Group plan terminated Employer/group contribution ceased : Significant Terms, Conditions and Authorizations (TERS) Please read this section carefully before signing the application. 1. I may not assign any payment under my Anthem Blue Cross and Blue Shield administered benefit plan. 2. I authorize deduction from my wages/pension, if necessary for the required payment for the benefit for which I, or any dependents have applied. 3. I am applying for the benefit selected on this application. If I select a coverage, or combination of coverages, not available to me and / or a class for which I am not eligible, I agree that my selection(s) is hereby automatically amended to be consistent with the employer s application. 4. I understand that, to the extent permitted by law, Anthem reserves the right to accept or decline this application and that no right whatsoever is created by this application. I also understand that this coverage, if approved, may exclude coverage for pre-existing conditions. 5. I am responsible to timely notify my employer of any change that would make me or any dependent ineligible for benefits. 6. By signing this application, I agree and consent to the recording and / or monitoring of any telephone conversation between Anthem and myself. I acknowledge that I have read the Significant Terms, Conditions and Authorizations, and I accept such provisions as a condition of enrollment. I represent that the answers given to all questions on this application are true and accurate to the best of my knowledge and I understand they are being relied on by Anthem in accepting this application. I understand that any misstatements or failure to report new medical information prior to my effective date may result in a material change to benefits or rates. Any material misrepresentation or significant omission found in this application may result in denial of benefits or rescission or cancellation of my benefits. Kentucky: Any person who knowingly and with intent to defraud any insurance company, health maintenance organization, self-insured plan, or other person, files an application for insurance or other form of health care coverage 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. I give this authorization for and on behalf of any eligible dependents and myself if covered by the Plan. I am acting as their agent and representative. Your health benefit plan will be administered by one of the following companies based upon the state in which your employer is located: In Indiana: Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. In Kentucky: Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc. In issouri: Anthem Blue Cross and Blue Shield is the trade name RightCHOICE anaged Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC) and HO issouri, Inc. use to do business in most of issouri. RIT and certain affiliates administer non-ho benefits underwritten by HALIC and HO benefits underwritten by HO issouri, Inc. In Ohio: Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. In Wisconsin: Blue Cross Blue Shield of Wisconsin ( BCBSWi ) administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ( Compcare ) administers the HO and POS policies. Thank you for choosing Anthem Blue Cross and Blue Shield. 8. Read the TERS section above carefully before signing. Please review your application for errors or omissions. By signing this, I am indicating that I have read and understand the language in the TERS section of this application and agree to all of its terms. Applicant Signature Date A-77 ADI 8/06 LG-ASO 2

6 Genetic Information Nondiscrimination Act (GINA) The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. Genetic Information as defined by GINA includes an individual s family medical history, the results of an individual s or family member s genetic tests, the fact that an individual or an individual s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. 6/2015