Guide t Yung Adult Dependent Cverage The New Yrk State Legislature passed a law in 2009 which extends the availability f health insurance cverage t yung adults thrugh the age f 29. As a result, Freelancers Insurance Cmpany (FIC) will nw extend health insurance cverage t eligible yung adult dependents f FIC enrllees. Eligibility In rder t be eligible fr cverage, yur yung adult dependent des nt need t live with yu, be financially supprted by yu, r be a full-time student. Hwever, he r she must: Be unmarried; Be between the ages f 26 and 29; Nt be insured by r eligible fr cmprehensive (i.e., medical and hspital) health insurance thrugh his r her wn emplyer; Live, wrk, r reside in New Yrk State; and Nt be cvered under Medicare. Yur yung adult dependent will nt be included under yur cverage. Yur dependent will have his r her wn cverage and must meet any applicable deductibles and cinsurance maximums. Eligibility Dcuments Yur yung adult dependent must prve his r her eligibility by submitting specific dcuments with his r her insurance applicatin: Residency Submit cpies f tw f the fllwing: Drivers license Current utility bill Apartment lease r hme deed W-2 frms r mst recent tax return Current phne bill r cable bill Ineligibility fr current emplyer s health plan Submit cpies f bth f the fllwing: Current Emplyment Frm (included with enrllment frm) Recent pay stub (if emplyed) Relatinship with parent If yur yung adult dependent has never been cvered under yur FIC health insurance plan, please submit a cpy f ne f the fllwing: Birth certificate Legal guardian papers Adptin papers Cst The cst fr yur yung adult dependent s cverage is the member premium rate n yur current health insurance plan. When t Enrll Yu can a add yung adult dependent at the time yu enrll in a plan, during the annual pen enrllment perid, and within 60 days f a qualifying event. Qualifying events include:
Lss r terminatin f ther cverage (due t terminatin f emplyment, terminatin f the plan r cntract, lss f eligibility as a child under yur plan, r lss f eligibility fr a gvernment spnsred plan) Change f circumstances that results in the dependent becming eligible Hw t Enrll Freelancers Unin handles all billing and enrllment fr FIC plans. T enrll in cverage, ask yur dependent t dwnlad and cmplete the attached enrllment frm. The frm and the eligibility dcuments mentined abve must be returned t Freelancers Unin Member Services with a check fr payment fr the first mnth f cverage. Please see the guidelines belw fr when these frms must be returned. If yu are enrlling in cverage fr the first time and als wish t enrll yur yung adult dependent, please return the frm, dcuments, and check within 30 days f the date yu cmplete yur nline enrllment fr health insurance. Yur yung adult dependent s cverage will be retractive t the date yur cverage began. If yur child is currently cvered by yur health insurance plan and will be turning 26, yu must return the frm, dcuments, and check within 60 days f the last day f the mnth in which they turn 26. Cverage will be retractive t their cverage end date. (T avid a gap in cverage, we recmmend sending the frms, dcuments, and check t Freelancers Unin Member Services befre the end f the mnth in which they turn 26.) If yu are enrlling yur dependent due t any ther qualifying event, yu must return the frm, dcuments, and check within 60 days f the qualifying event. The frm, dcuments, and check must be received by the 22nd f the mnth befre the mnth yu d like cverage t start. If yu are enrlling yur dependent due t pen enrllment, the frm, dcuments, and check must be received during the annual pen enrllment perid, which usually takes place in Nvember. Yur dependent s cverage wuld begin n January 1st f the fllwing year. Billing and Payment Yur yung adult dependent will receive his r her invices by mail at the address listed n their enrllment frm and payment is due n the 15th f the mnth prir t the cverage mnth. Yur dependent s mnthly premium will nt appear n yur mnthly invice nline. Yur dependent cannt view invices r billing infrmatin nline, hwever he r she can get billing infrmatin ver the phne by calling Freelancers Unin Member Services at 800.856.9981. Yur dependent will be billed directly fr this cverage. He r she will receive his r her wn bill and must send payments t a different address than yu d. Mnthly premium payments must be made by paper check and mailed t: Freelancers Unin ATTN: YAD Cverage 20 Jay Street, Suite 700 Brklyn, NY 11201 Please make the checks payable t Freelancers Unin and include the dependent s full name and yur Freelancers Unin Member ID n the check.
Ending Cverage Yung adult dependents may discntinue cverage at any time. Discntinuatin requests must be made in writing and sent t Freelancers Unin Member Services at the address belw. The effective cverage end date will be the last day f the mnth in which the discntinuatin is requested and cannt be made retractively. Yung adult dependents are nly eligible as lng as yu remain enrlled in an FIC plan. If yur cverage ends fr any reasn, yur yung adult dependent s cverage will als end. New Yrk State Cntinuatin Cverage If yur child begins cverage as a yung adult dependent and then becmes ineligible due t age r a change f circumstance, they will nt be eligible fr New Yrk State Cntinuatin Cverage. Questins? Please cntact Freelancers Unin Member Services: Member Services Freelancers Unin 20 Jay Street, Suite 700 Brklyn, NY 11201 membership@freelancersunin.rg 800.856.9981
ENROLLMENT FORM FOR YOUNG ADULT DEPENDENTS OF CURRENTLY ENROLLED MEMBERS APPLICANT INFORMATION Last Name Date f Birth Scial Security Number - - Street Address Are yu married? Yes N D yu wrk in New Yrk? Yes N First Name Hme Phne ( ) - Apt City E-Mail M.I. Are yu eligible fr Medicare? Yes N INSURANCE INFORMATION Plan Start Date: [Did yu have health insurance prir t the cverage yu are electing nw? Yes N If yes: Carrier Name Effective Date Gender Female Male State Zip Cde Are yu eligible fr health insurance thrugh an emplyer? Yes N Terminatin Date ] Will yu be cvered by any ther health insurance in additin t the cverage yu are electing nw? Yes N [If yes: Carrier Name Plicy Number Effective Date Carrier Address ] CURRENT FIC SUBSCRIBER (PARENT OF APPLICANT) Last Name First Name Freelancers Unin Member ID: Scial Security Number - - M.I. Gender Female Male ELIGIBILITY DOCUMENTATION If yu have nt been cvered n yur parent s Freelancers Unin health insurance plan befre, please cnfirm yu have enclsed the required dcuments t prve yur eligibility: Residency- Submit cpies f tw f the fllwing: Parental Relatinship (new dependents nly)- Submit a cpy f ne f the fllwing: Emplyment- Submit cpies f bth f the fllwing: PAYMENT INFORMATION Driver License Utility Bill Lease r Deed W2 r Incme Tax Return Birth Certificate Legal Guardian Papers Adptin Papers Current Emplyment Frm Please enclse a check fr tw mnths f cverage at the individual premium rate n yur parent s health plan. Please make the check payable t "Freelancers Unin" and include yur full name and yur parent s Freelancers Unin Member ID n the check. Recent Pay Stub (if emplyed) Check enclsed fr tw cverage mnths n: PPO 1: $1,112.00 (Mnthly Premium: $556.00) PPO 2: $852.00 (Mnthly Premium: $426.00) PPO 3: $638.00 (Mnthly Premium: $319.00) HD 5,000: $726.00 (Mnthly Premium: $363.00) HD 10,000: $440.00 (Mnthly Premium: $220.00) Phne r Cable Bill FICFORM08-09 1 f 2
ACKNOWLEDGEMENT (Read carefully befre signing.) I, the Primary Prpsed Insured, by my signature set frth thereafter: agree t the fllwing: (a) All statements and answers in this applicatin are cmplete and true t the best f my knwledge and belief. (b) Insurance will take effect nly if a certificate is issue based n this applicatin and the first premium is paid in full. (c) N agent has the authrity t waive any answer r therwise mdify this applicatin r t bind the Cmpany in any way by making any prmise r representatin which is nt set ut in writing in this applicatin Any persn wh knwingly and with intent t defraud any insurance cmpany r ther persn files an applicatin fr insurance r statement f claim cntaining any materially false infrmatin, r cnceals fr the purpse f misleading, infrmatin cncerning any fact material theret, cmmits a fraudulent insurance act, which is a crime, and shall als be subject t a civil penalty nt t exceed five thusand dllars and the stated value f the claim fr each such vilatin. Yung Adult Dependent Signature Print Name Date / / MM DD YYYY 2 f 2