Date Received by BCBSNC PO Box 30016 Durham, NC 27702-3016 New Enrollment Application must be completed in full by applicant(s). Section 1: New Enrollment Request Your effective date will be determined by the date your application is submitted. Please note that if you are applying for coverage through the Federal Health Insurance Marketplace, the Marketplace will determine your effective date. Please note that if you are applying for coverage outside of the Annual Enrollment Period (AEP), changes can only be made if due to a Qualified Life Event (QLE). Please call your local agent. Complete all applicable sections of this application. Section 2: Applicant Information Please fill in all information for each person who is applying for coverage. Name (First, Middle Initial, Last) Primary Applicant Spouse / Domestic Partner Relationship Status Social Security Number Birthdate Month Day Year This application is designed to accommodate up to 3 dependent children. For options on how to apply for coverage with 4 or more dependent children, call your local agent. Section 3: Primary Applicant s Contact Information Required telephone numbers (where you can best be reached) Evening number with area code: Single Married Single Married Domestic Partnership Separated Domestic Partnership Separated To enroll one child only, you may list that child as the Primary Applicant above. Please note: ren under age 18 are not eligible for a Health Savings Account unless applying as a dependent under their parent s health policy. Dependent ren Status Social Security Number Birthdate Sex Handicapped Under 26 or Handicapped (First, Middle Initial, Last) Month Day Year Dependent 1 Biological Adopted M F Step Foster Legal Custody Dependent 2 Dependent 3 Biological Step Foster Legal Custody Biological Adopted Adopted Step Foster Legal Custody Primary applicant s street address (Please check box if this is a temporary address ) Daytime number with area code: M M F F Sex M M F F Street Address: Apt. or suite: City and State: Zip code: NC county of residence: I d like to receive my monthly premium bills at this email address. If bank draft or Email address: recurring credit card is chosen as a payment option, no bill or notice is sent. Primary applicant s billing address (if different from street address ONLY bills will be sent to this address) Street Address: City and State: Apt. or suite: Zip code: An independent licensee of the Blue Cross and Blue Shield Association., SM Marks of the Blue Cross and Blue Shield Association. SM1 Mark of Blue Cross and Blue Shield of rth Carolina. D161OffExchange, 8/14 PAGE 1 of 8
Section 4: Plan Coverage Selection I am applying for coverage. In the grid below, check the box that matches both the coinsurance and the deductible that you want (please check only one box). In-Network Deductible $0 $500 $1,000 $2,700* $2,800 $3,000 $3,500 $5,000 $5,500* $6,600** 0% Coinsurance 20% 30% 50% * Plans are eligible for a Health Savings Account ** This is the Blue Advantage Catastrophic plan. I understand that I must be under the age of 30 or qualify for a hardship exemption as defined by the Federal Health Insurance Marketplace. I understand that I need to include a copy of my hardship exemption notice that I receive from the Federal Health Insurance Marketplace with this completed application. I understand that BCBSNC will confirm my eligibility with the Federal Health Insurance Marketplace. I am applying for coverage. In the grid, check the box that matches both the coinsurance and the deductible that you want (please check only one box). Coinsurance In-Network Deductible $1,000 $3,500 $5,500 0% I am applying for coverage. In the grid below, check the box that matches both the coinsurance and the deductible that you want (please check only one box). In-Network Deductible $0 $500 $1,000 $2,700* $2,800 $3,000 $3,500 $5,000 $5,500* $6,600** 0% Coinsurance 20% 30% 50% * Plans are eligible for a Health Savings Account ** This is the Blue Value Catastrophic plan. I understand that I must be under the age of 30 or qualify for a hardship exemption as defined by the Federal Health Insurance Marketplace. I understand that I need to include a copy of my hardship exemption notice that I receive from the Federal Health Insurance Marketplace with this completed application. I understand that BCBSNC will confirm my eligibility with the Federal Health Insurance Marketplace. NOTE: Blue Value has a smaller provider network than other BCBSNC plans. Visit bcbsnc.com and click Find a Doctor to confirm your doctor participates with our plan. I am applying for coverage. In the grid below, check the box that matches both the coinsurance and the deductible that you want (please check only one box). In-Network Deductible $500 $1,000 $3,000 $3,500 $5,000 $5,500* 0% Coinsurance 20% 20% 30% 30% * Plans are eligible for a Health Savings Account NOTE: BlueLocal with Carolinas HealthCare System has a smaller provider network than other BCBSNC plans. Visit bcbsnc.com and click Find a Doctor to confirm your doctor participates with our plans. I am eligible for a Cost Share Reduction (CSR). I understand that BCBSNC will confirm my eligibility with the Health Insurance Marketplace prior to enrollment. I am eligible for American Indian/Alaska Native benefit enhancements. I understand BCBSNC will confirm my eligibility with the Health Insurance Marketplace prior to enrollment. Section 5: Conversion Coverage Only complete this section if you qualify for coverage due to exhausting continuation coverage under a group or student policy. To ensure continuation of coverage, payment must be received within 31 days of your continuation coverage end date. When did the continuation When did the continuation coverage begin? coverage end? PAGE 2 of 8
Section 6: Special Enrollment Period Outside of the Annual Enrollment Period, you must experience one of the following qualifying life events (QLE) in order to apply for coverage. This application must be completed within 60 days of the QLE. If you are applying for coverage through the Health Insurance Marketplace, the Marketplace will determine your effective date. If you are applying for coverage outside of the Health Insurance Marketplace, you will be given the first available effective date, unless otherwise noted below. Choose One Qualifying Life Event Lost Eligibility to Minimum Essential Coverage t Through an Employer 1. Date of Loss of Eligibility or Coverage: 2. Indicate who lost eligibility or coverage: Self Spouse / Domestic Partner Dependent Other: 3. Lost eligibility or coverage with: Medicaid ren s Health Insurance Program (CHIP) Military Coverage Medicare Other: 4. Reason for loss of eligibility or coverage: Death Divorce Over Age Dependent Other: Lost Eligibility to Minimum Essential Coverage Through an Employer 1. Date of Loss of Eligibility or Coverage: 2. Indicate who lost eligibility or coverage: Self Spouse / Domestic Partner 3. Reason for loss of eligibility or coverage: Dependent Other: Termination of Employment Reduction of Hours Other: 4. Provide name and contact information of employer: Employer Name: Phone Number: Gained a dependent or became a dependent through birth, adoption, placement for adoption, placement as a foster child or other legal custody arrangement 1. Date of birth/event: 2. Reason: Birth Adoption Placement for Adoption Placement as Foster Legal Custody Your effective date will be the day the child was born, adopted, or placed for adoption, foster care or legal custody. Gained a dependent or became a dependent through marriage or the establishment of a domestic partnership 1. Date of Marriage/Establishment of Domestic Partnership: You or your dependent gained US citizen status 1. Date of Citizenship: 2. Indicate who gained citizenship: Self Spouse/Domestic Partner Dependent Other: You or your dependents gained access as a result of a permanent move to rth Carolina (NC) or as a result of a move to a new county within NC 1. Date of move: 2. Previous address (including county): 3. How long did you or your dependents reside at the previous address? 4. Reason for move: Work School Release from Incarceration Other: 5. Is the address in Section 3 you or your dependents new address? If no, what is your new address (including county)? You or your dependents enrollment or non-enrollment in another health benefit plan was made as a result of an error by the Health Insurance Marketplace. 2. Explanation 1. Date of error: of error: You or your dependents demonstrate that the health benefit plan you were previously enrolled in substantially violated material provisions of the contract. 2. Previous Health 1. Date of Violation: Insurance Carrier: 3. Explanation of Violation: PAGE 3 of 8
You or your dependents are determined newly eligible or ineligible for advance payments of the premium tax credit (APTC) / subsidy or have a change in eligibility for cost-sharing reductions. 1. Date of determination: 2. Reason for change: Income level Family size Employment status Other: You or your dependents have demonstrated to the Health Insurance Marketplace that due to misconduct by an entity that provided enrollment assistance or enrollment activities, you were not enrolled in coverage, enrolled in coverage not selected by you, and/or are eligible for but are not receiving APTC or cost-sharing reductions. 1. Date of misconduct: 2. Please explain: You or your dependents have demonstrated to BCBSNC that you meet other exceptional circumstances. 2. Please 1. Date of Event: explain: You removed maternity coverage from your existing BCBSNC grandfathered or transitional policy. 1. Date of Removal: Lost eligibility to pregnancy related coverage or medically needy coverage (such as Medicaid). 1. Date of Loss of Coverage: 2. Indicate who lost eligibility or coverage: Self Spouse / Domestic Partner Dependent Reason for loss of eligibility or coverage: Other: Section 7: Authorization for Bank Draft and/or Credit/Debit Card Charge Authorization for Bank Draft and/or Credit/Debit Card Charge By signing below, I certify that I am an authorized user of this bank account and/or credit card. I understand that the bank account/ credit card listed cannot be my employer s account. If I have chosen the Bank Draft Option, as a convenience to me, I hereby request and authorize BCBSNC to initiate the debit to my bank account payable to the order of BCBSNC for my first and subsequent months premiums. I understand that BCBSNC may attempt to debit my bank account up to three times for each month s premium to ensure no lapse in coverage. BCBSNC does not charge a fee for this service; however, I am aware that my bank may charge a fee if there are insufficient funds to cover the payment. I agree that BCBSNC s rights with respect to the bank draft shall be the same as if it were a check drawn on my bank account and signed by me personally. I also authorize my financial institution to reduce the balance of my bank account by the amount of each monthly draft. If I have chosen the Credit Card and Direct Billing Option, as a convenience to me, I hereby request and authorize BCBSNC to charge my credit card for my first payment. I also authorize my financial institution to charge my credit card account for the credit card charge. If I have chosen the recurring Credit Card Option, as a convenience to me, I hereby request and authorize BCBSNC to charge the indicated credit card on a monthly basis for the amount due under my contract with BCBSNC. I also authorize my financial institution to charge my credit card account for the credit card charge. These authorizations will remain in effect until I revoke them in writing at least 10 days prior to the date the account is scheduled to be charged. I agree that if such charges be dishonored, whether with or without cause and whether intentionally or inadvertently, BCBSNC shall have no liability whatsoever even though dishonor results in forfeiture of insurance. I agree that my chosen payment option shall be initiated upon this application s acceptance. Payment Option 1: Debit my bank account I request and authorize BCBSNC to use a bank draft to withdraw my initial payment and subsequent months premiums from my bank account. I understand that the account listed cannot be my employer s account. Name of bank: Bank routing transit number: This number appears in the lower left-hand corner of your check. Signature of Account Holder: Bank account number: Name of bank account holder: This number appears to the right of the transit number and is separated from the transit number by symbols/spaces. Your number may be shorter than the boxes provided above. Type of account: Checking Savings MM / DD / YY MM / DD / YY PAGE 4 of 8
Section 7: Authorization for Bank Draft and/or Credit/Debit Card Charge (continued) Payment Option 2: Charge my credit card I request and authorize Blue Cross and Blue Shield of rth Carolina to charge my credit card initially, then bill me monthly. I request and authorize Blue Cross and Blue Shield of rth Carolina to charge my credit card for my initial payment, as well as on a monthly basis. Name of credit card Type of credit card account Discover Card MasterCard Visa account holder: Address to which credit card bill is sent: STREET OR P.O. BO: APT. OR SUITE CITY AND STATE ZIP CODE Credit card number: Expiration MM / YY Signature of Account Holder: MM / DD / YY MM / DD / YY Section 8: Health Questions Within the past 6 months, have any of the following applicants used tobacco regularly (4 or more times a week on average) excluding religious or ceremonial uses and, if so, when was the last time tobacco was used regularly? (Applicable only to persons who are 18 years or older.) Date last used Primary Spouse / Domestic Partner 1 2 3 Section 9: Applicants Other Healthcare Coverage Any questions left blank, or questions only partially answered will cause your application to be returned to you for the missing information. Check ( ) only if the question can be answered for ALL applicants. Check ( ) under the applicant or applicants for whom Applicants the condition applies. Spouse / ALL Primary Domestic Partner 1 2 1. Is anyone applying for coverage currently covered by Medicare benefits Part A and/or Part B? 2. Is anyone applying for coverage currently covered by another health insurance program? 3 N Y Y Y Y Y N Y Y Y Y Y Section 10: Statement of Understanding for Medical Coverage I understand that by signing this Statement of Understanding for Medical Coverage, I am agreeing to the following conditions: 1. I certify that all statements on this application are complete and true. I understand that Blue Cross and Blue Shield of rth Carolina (BCBSNC) may rescind my policy for any of my acts or practices that constitute fraud or if I make an intentional misrepresentation of material fact. Additionally, for a period of two years from the date coverage is issued, BCBSNC may reform my coverage or deny claims for coverage if materially incorrect information has been given on this application. 2. I understand that the coverage applied for will not be issued unless the following conditions are met: i) BCBSNC must receive a completed application and, if requested by BCBSNC, any medical records or other information, permitted for use by applicable law. ii) BCBSNC finds that I am eligible for this coverage as of the date of the application according to its policy and that I am insurable for this coverage. Benefits may not be available until the entire premium has been applied to my policy. BCBSNC will issue me a health care be booklet and identification card for coverage. The deposit of premium fees by BCBSNC does not indicate an acceptance of this application. PAGE 5 of 8
Section 10: Statement of Understanding for Medical Coverage (continued) 3. I understand rates upon issue may be higher than the original quoted rates. I understand that this application, along with the benefit booklet and the Summary of Benefits, is the entire legal contract between BCBSNC and myself. I further understand that any coverage provided according to this application will be subject to the provisions of the benefit booklet, issued to me by BCBSNC. 4. I understand that final rates cannot be determined until my application is processed and completed. I understand that I will have the opportunity to review and accept my final rate prior to being enrolled. I understand that once my application is approved and I have received my benefit booklet, I have 10 days to review my benefit booklet and ID card. If I m not completely satisfied, I will notify BCBSNC within the 10-day period to terminate coverage. 5. If purchasing a product that is marked as Health Savings Account (HSA)-eligible, I understand that the HSA fund is provided to me directly by a separate Administrator that is unaffiliated with BCBSNC. The HSA is not part of the health benefit plan administered by BCBSNC. BCBSNC is not responsible or liable for administration of the fund. Detailed information regarding my HSA will be provided by that Administrator. BCBSNC will share certain personal information about me with such Administrator to facilitate the Administrator s establishment of my fund. By signing this application, I authorize BCBSNC to share pertinent information with the Administrator, which may include my name, address, and Social Security number. HSA-eligible products are a high deductible health plan that qualifies its members to contribute to an HSA, unless its members are otherwise ineligible under applicable federal requirements. If unsure about whether ineligible, members should consult a qualified tax advisor. By signing this application, I authorize the fund Administrator to establish an HSA fund on my behalf, as of the date corresponding with the effective date of my high deductible health plan with BCBSNC. In order to activate the fund, I will need to provide additional authorization electronically or through documents that will be provided to me by the fund Administrator. If I choose to activate the fund, I will be issued a debit card in connection with my fund. I agree that although BCBSNC s name and marks may be included on the face of the debit card for my convenience, BCBSNC is not responsible or liable for administration of my debit card. The terms and conditions associated with my debit card are governed by my agreement with the bank issuing the card. 6. I understand that BCBSNC may receive or be required to submit information to the Federal Health Insurance Marketplace (also known as the Exchange ) as part of my application and enrollment and that BCBSNC will rely solely on the information that has been provided by the Federal Health Insurance Marketplace, where applicable. 7. I understand that BCBSNC may request, and I will be obligated to provide, additional information regarding my Special Enrollment eligibility. As the primary applicant, or the parent/guardian of the primary applicant, I warrant that I am authorized to agree to the above statements on behalf of all my dependents under age 18. (Applicant spouse/domestic partner and applicant dependents age 18 or older must sign below.) Signature of Primary Applicant or Signature of Parent/Guardian (if applicant is under age 18): Spouse/Domestic Partner: A copy of this authorization shall be as valid as the original. Section 11: BCBSNC/Producer Internal Use Only I hereby certify that I have truly and accurately recorded the information supplied by the applicant. Signature of Producer: Print Name: Producer s (P) Number: Producer s telephone number with area code: PAGE 6 of 8
Section 12: Authorization for Release of Protected Health Information I understand that my protected health information is individually identifiable health information, including demographic information, collected from me or created or received by a health care provider, a health plan, or a health care clearinghouse and that relates to: (i) my past, present, or future physical or mental health or condition; (ii) the provision of health care to me; or (iii) the past, present, or future payment for the provision of health care to me. I authorize any current or past medical professional, medical care institution, pharmacy benefit manager or other medical care giver that has treated me or provided medical services or supplies to me to disclose my protected health information to BCBSNC. I further authorize BCBSNC to review any applications for health care coverage that I may have submitted to BCBSNC in the past. I authorize BCBSNC to receive, use and disclose as necessary my protected health information in connection with any underwriting or eligibility determination purposes in connection with the coverage for which I have applied. The protected health information (excluding psychotherapy notes) that may be used and disclosed is as follows: Medical records or any information concerning my current or past health status or treatment received from my medical care providers or previous applications for health care coverage. I understand that BCBSNC will use my protected health information for the following purposes: To determine my premium rate in accordance with allowable rating factors. To comply, participate, or contribute to any government-facilitated program, requirement or mandate. I understand that BCBSNC will make every effort to safeguard my protected health information. I further understand that BCBSNC will not disclose my protected health information unless I request it or when state or federal privacy laws permit or require BCBSNC to disclose my protected health information. I understand that BCBSNC may disclose my protected health information to individuals or organizations that are not health care providers, health care clearinghouses, or health plans covered by the federal privacy regulations. I understand that if my protected health information is received by individuals or organizations that are not health care providers, health care clearinghouses, or health plans covered by the federal privacy regulations, my protected health information described above may be re-disclosed and no longer protected by federal privacy regulations. I understand that I may revoke this authorization at any time by sending a written notification addressed to: Individual Business Operations Blue Cross and Blue Shield of rth Carolina PO Box 30016 Durham, NC 27702-3016 and this revocation will be effective for future uses and disclosures of protected health information. However, I further understand that this revocation will not be effective: (i) for information that BCBSNC already used or disclosed, relying on this authorization or (ii) if the authorization was obtained as a condition of coverage in BCBSNC and, by law, BCBSNC has a right to contest the coverage. This authorization expires when my policy expires. Signature of Primary Applicant or Legal Personal Representative: Primary Applicant s Social Security Number: Spouse / Domestic Partner: - - Name of Legal Personal Representative (please print): Description of Legal Personal Representative s Authority: Blue Cross and Blue Shield of rth Carolina will provide a signed copy of this form. This page is part of the application. PAGE 7 of 8
Section 13 (optional): Complete this section only if you wish to apply for dental coverage. By completing and signing this section, you can enroll in a separate dental policy when we process your health application. You will be contacted by BCBSNC prior to enrolling, and you will be able to choose payment and effective date options at that time. Important Information: Dental Eligibility: Anyone who has been covered by Dental Blue for Individuals policy within the past twelve (12) months is NOT eligible to re-enroll within a twelve (12) month period and will not be considered for coverage at this time. Dental Prior Coverage Waiting Periods: After you enroll, dental waiting periods can be waived or reduced by the number of months a member had prior coverage, if the member can submit proof of coverage by submitting your certificate of creditable coverage to the enrollment address on your ID card. Dental waiting periods aren t waived or reduced if more than 63 days have passed between the prior coverage s termination date and the application date for BCBSNC coverage. Dental Billing: Although your initial payment may include your health and dental premium, this dental policy is a separate policy, and you will be billed separately and issued separate ID cards for this policy. Dental coverage is not included automatically with the health policy. Please indicate in the check boxes to the right which individuals from Section 2 are applying for dental coverage. Please answer this question: Has anyone applying for coverage on this application had Dental Blue for Individuals coverage within the last twelve (12) months? I understand that this application along with the Dental Blue for Individuals benefit booklet and the Summary of Benefits is the entire legal contract between BCBSNC and myself. I further understand that any coverage provided according to this application will be subject to the provisions of the benefit booklet, issued to me by BCBSNC. I hereby certify that the information provided is accurate to the best of my knowledge. All personal information provided on the previous pages remains the same and the signature(s) to the Statement of Understanding and Payment Authorization sections remain in force. ALL Applicants Primary Spouse / Domestic Partner 1 Primary Applicants Spouse / Domestic Partner 1 2 2 3 3 N Y Y Y Y Y or Parent/Guardian (if applicant under age 18): Spouse / Domestic Partner: Signature of Applicant Dependent Age 18 or Older: Signature of Applicant Dependent Age 18 or Older: Signature of Applicant Dependent Age 18 or Older: PAGE 8 of 8
P.O. Box 30016, Durham, NC 27702-3016 Authorization and Appointment Form AUTHORIZATION AND APPOINTMENT OF REPRESENTATIVE TO SUBMIT AN ELECTRONIC DOCUMENT AND SIGNATURE I understand that by signing this form, I am agreeing to the following: 1. I, Applicant, appoint the Blue Cross and Blue Shield of rth Carolina ( BCBSNC ) appointed producer named below to act as my representative ( Representative ) for the express purpose of submitting certain written personal information provided by me to BCBSNC in an electronic format as part of the process of applying for and/or maintaining insurance coverage. 2. I further appoint Representative to transmit/convert all personal information to electronic format ( Electronic Application ) from the following paper application ( Paper Application ): Blue Advantage Blue Advantage Saver Blue Select Blue Options HSA Blue Value Dental Blue for Seniors Blue Local with Carolinas HealthCare System The personal information submitted by Representative shall be taken from the Paper Application after I read and accurately complete the Paper Application in its entirety and sign the Paper Application. Representative shall correctly, accurately and completely transmit/convert all of the information provided by me on the Paper Application in an electronic format to BCBSNC. 3. I will provide Representative with unique personal data that will be used to create a personal electronic signature as part of this process of applying for insurance coverage with BCBSNC. 4. Representative shall be granted permission to use my electronic signature, and Representative s use of my electronic signature shall constitute my authorization and shall be considered as my legally binding signature for my Electronic Application. 5. Representative will provide me with copies of my completed Paper Application and this completed, signed authorization form. 6. BCBSNC will provide me with a copy of my Electronic Application once my Application has been approved. I agree to compare my Paper Application to my Electronic Application to check for any inaccuracies. 7. I have ten (10) days after receipt of my Electronic Application to notify BCBSNC that information on the Electronic Application is not accurate. If notice is not received by BCBSNC within the appropriate time frame, the Electronic Application shall be considered the accurate and original Application authorized and completed by me and for which I will be responsible. 8. After my Electronic Application has been submitted to BCBSNC, but prior to my Application being approved by BCBSNC, Representative may contact me to discuss my Application. If I orally notify my Representative of my decision to choose a new plan, deductible, coinsurance, or effective date, to add/remove applicants or maternity rider, or any other benefit change(s) during this application process, I further appoint and authorize my Representative to translate/convert my requested oral change into an electronic format. The above authorization will expire 90 days after the application submitted date. Authorization for Benefit Changes Beyond Initial Application I understand that by signing this form, I am agreeing to the following: If enrolled on this policy, my Representative shall continue to be authorized to make benefit changes not involving disclosure of personal or privileged information, based on my oral notification. Such authorization will remain in effect until I instruct BCBSNC to remove this Representative as the agent on my policy. Dental Blue for Individuals As the primary applicant or parent/guardian of the primary applicant, I warrant that I am authorized to agree to the above statements on behalf of myself and all my dependents under age 18. (Applicant Spouse/Domestic Partner and Applicant Dependents Age 18 or Older must sign below.) Print Applicant Names: Signature of Primary Applicant or Signature of Parent/Guardian (if applicant is under Age 18): Spouse/Domestic Partner: I hereby certify that I will truly and accurately record the information supplied by the applicant. Signature of Producer: Print Name: Producer: Please retain a signed copy of this form in your files. Producer s (P) Number: Application Number: DV-1, 8/14 A copy of these authorizations shall be as valid as the original.