P. O. Bx 1460 Little Rck, AR 72203 Applicatin fr Cverage Under the Pre-Existing Cnditin Insurance Plan administered by the Arkansas Cmprehensive Health Insurance Pl (CHIP) This Applicatin fr cverage thrugh the Pre-Existing Cnditin Insurance Plan ( PCIP ) cntains an Eligibility Wrksheet and an Enrllment Frm. The Eligibility Wrksheet explains wh may be eligible fr PCIP and asks questins t help yu figure ut if yu are eligible fr cverage. Please cntact lcal PCIP Custmer Service at 1-800-285-6477 if yu have questins abut the Applicatin. Please send yur cmpleted Eligibility Wrksheet and Enrllment Frm t: PCIP, c/ CHIP, P.O. Bx 1460, Little Rck, AR 72203. Send payment with yur Applicatin. Yur first premium payment is due with this Applicatin. Please review the Rate Sheet t determine the amunt f yur mnthly premium. Failure t send yur first premium payment alng with the submissin f yur Applicatin will delay prcessing. Premium payments may be mnthly r quarterly, at yur ptin. SPECIAL NOTIFICATION 1. PCIP is a temprary federal high risk pl anticipated t prvide cverage frm 9/1/10 thrugh 12/31/13. The PCIP is funded slely by the federal gvernment and enrllee premiums. Funds are limited. 2. PCIP is nt funded by CHIP r the State f Arkansas. 3. Enrllment fr PCIP in Arkansas will be capped at 2,500. 4. Individuals whse cmplete Applicatins are received after the cap f 2,500 has been reached will be placed n a waiting list and premiums will be returned. 5. Applicatins may nly be submitted via U.S. Mail. 6. Applicatins will be prcessed n a first cme, first serve basis based n date f receipt by CHIP. Applicatins received n a particular day will be prcessed in the rder f pstmark date. T be eligible fr PCIP cverage in Arkansas yu must: ELIGIBILITY WORKSHEET 1. Be a resident f Arkansas; 2. Be a citizen r natinal f the United States r an alien lawfully present in the United States; 3. Have nt been cvered under Creditable Cverage * at any pint during the 6-mnth perid prir t the date f this Applicatin; AND 4. Have a pre-existing cnditin as evidenced by at least ne f the fllwing: During the past 6 mnths, yu have been: Declined individual health cverage in Arkansas because f a pre-existing cnditin; r Offered individual health cverage in Arkansas with a rider excluding a pre-existing medical cnditin which yu did nt accept. If yu are under age 19, yu may als demnstrate a pre-existing cnditin by prviding evidence that: During the past 6 mnths yu have been ffered (but did nt accept) individual health cverage in Arkansas at a price that is at least twice as expensive as cmparable cverage ffered under the PCIP prgram; r During the past 5 years, yu have been treated, had treatment recmmended r have therwise received medical advice regarding cnditins listed in Exhibit A t this Applicatin. Eligibility questins begin n the next page. * Questin 3 n the fllwing page describes the varius frms f health cverage that are Creditable Cverage under federal law. Frm N. 102-APP-PCIP (1/11) PCIP Applicatin fr Cverage Page 1 f 5
GENERAL ELIGIBILITY QUESTIONS 1. Residency: Are yu a resident f the State f Arkansas? Yes N If yu answered YES, yu MUST attach prf f residency, then cntinue with questin 2. Prf f residency includes written evidence such as a cpy f yur current driver s license, yur mst recent Arkansas tax return r yur utility bill. If yu answered NO, STOP. Yu are nt eligible fr PCIP cverage. 2. Citizenship r Immigratin Status. Are yu a citizen r natinal f the United States r an alien lawfully present in the United States? Yes N If yu answered YES, yu MUST attach prf f yur status, then cntinue with questin 3. If a U.S. citizen, prvide yur Scial Security Number n the applicatin frm that fllws this Eligibility Wrksheet. If a U.S. natinal, prvide a cpy f a dcument that cnfirms yur status as a nncitizen natinal, such as a cpy f yur U.S. passprt. If a lawfully present alien, yu must prvide a cpy f yur immigratin dcument, including a dcument that has yur Alien Registratin Number r I-94 Number. Acceptable dcuments include a cpy f the fllwing: I-327 (Reentry Permit) I-551 (Permanent Resident Card) I-571 (Refuge Travel Dcument) I-766 (Emplyment Authrizatin Dcument) Machine Readable Immigrant Visa (with Temprary I- 551 language) affixed t Unexpired Freign Passprt Unexpired Freign Passprt fr Visa Waiver Prgram travelers DS2019 (Certificate f Eligibility fr Exchange Visitr (J- 1) Status), plus I-94 and an Unexpired Freign Passprt I-94 (Arrival/Departure Recrd) with unexpired Freign Passprt I-20 (Certificate f Eligibility fr Nnimmigrant (F-1) Student Status), plus I-94 and an Unexpired Freign Passprt Other dcument with an I-94 r Alien Number 3. Uninsured by Creditable Cverage within the last 6 mnths. At any pint in the last 6 mnths prir t the date yu submit this applicatin, have yu had any f the fllwing types f cverage? Yu must answer each questin. Health insurance cverage, including Individual r jb-based health plan, COBRA r cnversin cverage and shrt-term limited duratin insurance? Yes N Medicare (Part A and/r Part B)? Yes N Medicaid? Yes N ARKids r anther state s Children s Health Insurance Prgram? Yes N A state high risk pl such as the state plans ffered by CHIP? Yes N TRICARE (military health insurance) Yes N Health insurance prvided by a public health plan established by a state, the U.S. gvernment such as cverage prvided by the VA t veterans, r freign cuntry? Yes N FEHBP (health insurance fr Federal emplyees r retirees), including Temprary Cntinuatin Cverage? Yes N A health benefit plan prvided t Peace Crps wrkers? Yes N Services prvided by the Indian Health Service r by a tribe r tribal rganizatin fr treating yur medical cnditin? Yes N If yu answered YES, STOP. Yu are nt eligible fr PCIP cverage. If yu answered NO, cntinue with questin 4. Frm N. 102-APP-PCIP (1/11) PCIP Applicatin fr Cverage Page 2 f 5
4. Difficulty btaining cverage because f pre-existing cnditin(s). In the last 6 mnths: Have yu been denied cverage by an Arkansas individual health insurer r HMO because f a pre-existing cnditin? Yes N Have yu been ffered cverage by an Arkansas individual insurer r HMO with a rider excluding a particular medical cnditin r cnditins which yu did nt accept? Yes N If the applicant is under age 19, has the applicant been ffered cverage (which the applicant did nt accept) by an Arkansas individual insurer r HMO with a mnthly premium that is at least twice as much as the current applicable premium fr PCIP? Yes N (Please review yur Outline f Cverage fr current PCIP premiums) If yu answered NO t all three questins abve, please answer questin 5. If yu answered YES t any f these three questins, yu MUST prvide the fllwing prf f yur difficulties btaining cverage because f a pre-existing cnditin, as applicable: Ntice f Rejectin: If yu have been rejected r refused by an insurer r HMO t issue individual health cverage in Arkansas within the last 6 mnths because f the existence r histry f a medical cnditin, please attach a cpy f the rejectin ntice frm the insurer r HMO and fill ut the Enrllment Frm beginning n the next page. Offer f Individual Cverage with Exclusinary Rider: If yu were ffered individual health cverage by an insurer r HMO in Arkansas within the last six mnths that cntained a rider excluding particular medical cnditin(s), but yu did nt accept such cverage, please attach a cpy f the ffer and fill ut the Enrllment Frm beginning n the fllwing page. Affrdability Standard fr Applicants under Age 19. If the applicant is under age 19 and was ffered individual cverage by an insurer r HMO in Arkansas within the last six mnths with mnthly premium that is at least twice as much as the applicable Pre-Existing Cnditin Insurance Plan premium, but yu did nt accept such cverage, please attach a cpy f the ffer and fill ut the Enrllment Frm beginning n the fllwing page. 5. Eligibility based n Existence f Medical Cnditins fr Applicants Under Age 19. Is the applicant under age 19? Yes N If yu answered NO, STOP. Yu are nt eligible fr PCIP cverage. If yu answered YES, has the applicant, within the five years preceding the date this applicatin is submitted, either: Received medical advice regarding any f the cnditins listed in Exhibit A t this Applicatin, r Had treatment recmmended by a physician r received frm a physician regarding any f the cnditins listed in Exhibit A t this Applicatin? Yes N If yu answered NO, STOP. Yu are nt eligible fr PCIP cverage. If yu answered YES, yu MUST prvide a physician s statement dcumenting the diagnsis r treatment f the cnditin(s) within the five years and fill ut the Enrllment Frm beginning n the next page. End f Eligibility Wrksheet. Enrllment Frm begins n next page. Frm N. 102-APP-PCIP (1/11) PCIP Applicatin fr Cverage Page 3 f 5
P.O. Bx 1460 Little Rck, AR 72203 Enrllment Frm Please Print All Infrmatin. APPLICANT INFORMATION LAST NAME FIRST NAME M.I. SEX DATE OF BIRTH SOCIAL SECURITY NO. DEDUCTIBLE $1,000 MAILING ADDRESS AND CONTACT INFORMATION Street r P.O. Bx Daytime Phne N. City State Zip Cde Cunty Other Phne N. RESIDENCE ADDRESS (If Different than Mailing Address) Street City State Zip Cde Cunty E-mail address: Wuld yu like t receive infrmatin abut yur cverage frm PCIP by e-mail? Yes N BILLING MODE (Please Check One) Mnthly Bank Draft (Mnthly payment is by bank draft nly. T sign up, yu MUST sign the authrizatin frm in yur packet and submit a vided check. If yu d nt submit these items with yur Applicatin, yu will be billed quarterly.) Quarterly (After initial billing with yur acceptance letter, yu will be billed fr three mnths premium due each January 1, April 1, July 1 and Octber 1.) PERSONAL INFORMATION Tbacc Use. If yu d nt answer the fllwing questin and are enrlled in PCIP, yu will be charged the rates f a tbacc user. Have yu used tbacc prducts in the last 12 mnths, including any type f lighted pipe, cigar, cigarette r any ther smking equipment filled with tbacc, r any type f smkeless tbacc, such as snuff r chewing tbacc? Yes N Disability D yu receive Scial Security Disability Insurance (SSDI)? Yes N If YES, list the date yur SSDI began: Have yu filed fr SSDI? Yes N If YES, list the date yu filed: IMPORTANT INFORMATION ABOUT BILLING AND PAYMENT 1. Rates. Yur premiums may vary frm ther PCIP plicyhlders, depending n yur age and whether yu have used tbacc prducts in the last 12 mnths. Premium rates change n yur 0 and 5 birthdays starting at age 30 (35, 40, 45, 50, etc.). 2. Rate changes. PCIP rates may change at ther times as well. Yu will have 31 days ntice f any rate change. CERTIFICATION Please read carefully and sign n the next page at the end f this Certificatin. I hereby apply fr Pre-existing Cnditin Insurance Plan ( PCIP ) cverage, as ffered by the federal gvernment and administered by CHIP in the State f Arkansas. I understand and agree t everything listed belw: I certify that all the infrmatin I have prvided in this Applicatin (which includes the Eligibility Wrksheet and this Enrllment Frm) is true and cmplete. I understand that my cverage may be canceled r rescinded if CHIP determines that I have prvided false infrmatin. I certify that as f the date I cmplete this Applicatin, all infrmatin prvided in the Eligibility Wrksheet abut residency, citizenship r immigratin status, insurance cverage during the last six mnths and prf f pre-existing cnditins is true and crrect. I agree t cperate with CHIP and its authrized subcntractrs in verifying any and all infrmatin prvided regarding my eligibility fr this cverage. I have read and understand the Outline f Cverage prvided with this Applicatin. I understand that fr my Applicatin t be cmplete, I must submit all required dcuments necessary t verify infrmatin that has been prvided in this Eligibility Wrksheet and Enrllment Frm. Failure t d s will delay prcessing f my Applicatin and may affect enrllment int PCIP. I understand that if accepted, I will be issued a Plicy that explains my rights and respnsibilities as a PCIP enrllee and that failure t fllw the requirements f the Plicy may result in the cancelatin f my cverage. Frm N. 102-APP-PCIP (1/11) PCIP Applicatin fr Cverage Page 4 f 5
I understand that if I d nt pay premiums in full within 30 days after the due date, cverage will end as f the date payment was due. I understand that if I disenrll r my cverage is cancelled (fr nn-payment f premium, fr example), I will nt be able t reapply fr enrllment fr at least 6 mnths after my cverage ends, except when I lse cverage simply because I am mving frm Arkansas t anther state. I understand that if I btain ther health insurance, I am n lnger eligible fr PCIP and will immediately ntify CHIP that I have ther cverage. Any persn wh knwingly presents false infrmatin in an Applicatin fr insurance, r knwingly presents a false r fraudulent claim fr payment f a lss r benefit, is guilty f a crime and may be subject t fines and cnfinement in prisn. Signed at: City State ZIP Print Applicant s Signature X Date Signed If yu are a parent, legal guardian r authrized representative f the persn applying fr cverage, yu must sign abve and cmplete the infrmatin belw: LAST NAME FIRST NAME M.I. MAILING ADDRESS AND CONTACT INFORMATION (if different frm applicant) Street r P.O. Bx Daytime Phne N. City State Zip Cde Cunty Other Phne N. My relatinship t the persn applying fr cverage is: Parent Legal Guardian Other Authrized Representative (We may require dcumentatin f yur relatinship t the applicant) Effective Date: Subject t availability f plan s enrllment limitatins, an individual eligible fr enrllment wh submits a cmplete enrllment request by the 15 th day f a mnth will have an effective date f the 1 st day f the fllwing mnth. A cmplete Applicatin includes all required infrmatin and dcumentatin required t cmplete prcessing. Agent's Statement: I have a valid agent s r brker s license in the State f Arkansas fr accident and health insurance. I have assisted the applicant in cmpleting this Applicatin fr cverage in the Pre-Existing Cnditin Insurance Plan (PCIP). T the best f my knwledge and belief, the infrmatin cntained in this Applicatin and this affirmatin statement is crrect and cmplete. I certify that the applicant meets the PCIP eligibility standards. Print Agent s Name AR License N. Scial Security N. Agency Name AR License N. Phne Number Agent s Signature Date Address City St ZIP FOR OFFICE USE ONLY (D NOT write in this space.) Divisin N.: Effective Date: End f Enrllment Frm. Mail this Enrllment Frm with yur Eligibility Wrksheet t: PCIP c/ CHIP P.O. Bx 1460 Little Rck, Arkansas 72203 Frm N. 102-APP-PCIP (1/11) PCIP Applicatin fr Cverage Page 5 f 5