Group Enrollment Application Change Form

Group Enrollment Application Change Form-Free PDF

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ENROLLMENT APPLICATION CHANGE FORM INSTRUCTIONS, PLEASE READ THOROUGHLY BEFORE COMPLETING ENROLLMENT APPLICATION CHANGE FORM. Use a black or blue ballpoint pen only Print neatly Do not abbreviate. SECTION 1 Check all the boxes that apply to indicate if you are a new enrollee or if you are requesting a change to your coverage Indicate the event and date if applicable Complete the. ENROLLMENT EVENTS additional sections that correspond to your selection. New Enrollee Complete all sections where applicable. Add Dependent Complete all sections where applicable. If you are applying for coverage for a disabled dependent over the age limit of your employer s plan please provide the additional information requested in Section 5. Additional documentation may be required as addressed in that section. If your employer offers coverage for children and your children are eligible your children are eligible for health and or dental coverage up to the dependent limiting age. and may not be denied coverage due to marital student or employment status before age 26 check with your employer for additional details regarding eligibility. requirements In addition eligible military personnel may not be denied coverage before age 30 under Illinois law If you are adding an eligible military personnel. dependent who is over the age limit of the employer s plan completion of a Defense Department Form DD 214 is required in addition to this application. Open Enrollment The period of time offered on a regular basis during which you can elect to enroll in a specific group health insurance plan or make changes to your. current membership, Special Enrollment Event If you qualify special enrollment is any change to your current membership such as marriage divorce adoption suit for adoption or placement for. adoption leave layoff moving out of the service area etc This change may occur outside of open enrollment. Effective Date of Benefits Field is mandatory and should reflect your requested date. Completion of Other Eligibility Requirements Check this box only if your employer has eligibility requirements that you have met completed prior to enrollment such as. measurement period or orientation period, Cancel Enrollee Cancel Dependent Cancel Coverage Complete Sections 1 2 4 skip Section 4 if declining coverage 8 and 9 In Section 4 include name social security. number and date of birth of individual s canceling. SECTION 2 Complete this section with details about yourself even if you are declining coverage. YOUR INFORMATION, SECTION 3 Complete all portions related to the coverages for which you are applying Please list the seven character plan ID for your selected benefit design example S533PPO in the. YOUR COVERAGE plan field If you are unsure of your group size or do not know your plan ID please ask for guidance from your employer. If you are enrolling for life or disability insurance enter the information requested When listing the beneficiary provide both the first and last name and the relationship to you. List all beneficiaries that apply, SECTION 4 Complete all areas that apply to you and each dependent.
COVERAGE OPTIONS,For HMO Plans Only, Those applying for HMO coverage are required to select a primary care physician practitioner PCP for each covered individual List the name of the physician practitioner and. the provider number from the provider directory or Provider Finder at bcbsil com Be sure to check the appropriate box for a new patient. If you selected HMO coverage you must select a medical group individual practice associations IPAs and a primary care physician PCP for each person to be covered. You must also select a PCP within the selected medical group IPA for each person to be covered You may choose a different medical group IPA for each person Care. received from a woman s principal health care provider WPHCP may be eligible for coverage without referrals from your PCP However your PCP and your WPHCP must. be affiliated with or employed by your medical group IPA in order for each person to be eligible for coverage Until we receive your selected medical group IPA you may not. be eligible and your claims may be denied Be sure to enter the medical group IPA number name PCP number and name. If you are adding an eligible military personnel dependent who is over the age limit of your employer s plan completion of a Defense Department Form 214 DD 214 is. required in addition to this application, Change Primary Care Physician Practitioner Complete Section 1 and check the Other Change s box then complete Sections 2 3 4 and 9 In Section 4 please include. enrollee s or dependent s name social security number date of birth name and number of the new PCP and the name and number of the new IPA. Change Address Name Complete Section 1 and check the Other Change s box then complete Sections 2 and 9. SECTION 5 A disabled dependent must be medically certified as disabled and dependent upon you or your spouse domestic partner in order to be considered for coverage if dependent. DISABLED DEPENDENT overage is part of your employer s plan The disabled dependent is required to be covered prior to age 26 to be eligible for coverage over the dependent child age limit of your. employer s plan A Disabled Dependent Authorization and Disabled Dependent Physician Certification document must be completed and submitted with this enrollment. application if applicable, SECTION 6 Complete this section if you or any dependent have other group or individual health and or dental coverage if applicable that will not be canceled when the coverage under this. OTHER COVERAGE application becomes effective, SECTION 7 Complete this section if you or any of your dependents are covered by Medicare Enter the start and end dates for the coverage that applies Your Medicare HIC number must be. MEDICARE COVERAGE listed it can be found on your Medicare ID card Check the reason for your Medicare coverage. SECTION 8 Complete this section if you are declining health coverage for yourself and your dependents Anyone declining coverage for any reason should complete Section 8 not just those. DECLINATION OF declining because of other coverage. IMPORTANT NOTICE If you are declining enrollment for yourself or your dependents including your spouse because of other health care coverage you may in the future be. able to enroll yourself or your dependents in the plan if you request enrollment within 31 days after your other coverage ends In addition if you have a new dependent as a result. of a marriage party to a civil union birth adoption becoming a party in a suit for adoption or placement of a foster child in your home you may be able to enroll yourself and your. dependents if you request enrollment within 31 days after the marriage birth adoption suit for adoption or placement for adoption or placement of an eligible foster child in. SECTION 9 Sign your name and date the enrollment application if you agree to the conditions set forth in this section Your enrollment application should be submitted to your employer s. COVERAGE CONDITIONS Enrollment Department which will then submit your form to BCBSIL. As used on the application unless indicated otherwise These terms may be used in a different way in other documents. The term marriage includes legal marriage and the establishment of a civil union or domestic partnership coverage subject to your employer s plan. The term divorce includes legal divorce and the comparable termination of a civil union or domestic partnership coverage subject to your employer s plan. The term spouse includes a legal spouse and a party to a civil union or domestic partnership coverage subject to your employer s plan. Changes in state or federal law or regulations or interpretations thereof may change the terms and conditions of coverage. If you are a current member and have questions you may call the Customer Service number on the back of your. member ID card,232320 0919 1,ENROLLMENT APPLICATION CHANGE FORM.
Group Section Social Security,Account Category, SECTION 1 ENROLLMENT EVENTS PLEASE CHECK ALL THAT APPLY IF YOU ARE DECLINING COVERAGE COMPLETE SECTIONS 2 8 AND 9 ONLY. New Enrollee Add Dependent Open Enrollment Other Changes Cancel Enrollee Cancel Dependent. Are you applying as a result of a Special Enrollment Event. No Yes Event Date Cancel Coverage Health Dental, Event New Hire Marriage Birth Term Life Dependent Life. Adoption Placement for Adoption or Suit for Adoption provide legal documents Short Term Disability Long Term Disability. Court Order provide court order or decree List names of those canceling in Section 4 below. Loss of Other Coverage,Event Divorce Death,Other explain. Terminated Employment Other, Effective Date of Benefits Completion of Other Eligibility Requirements. Indicate Event Date, SECTION 2 PLEASE TELL US ABOUT YOURSELF COMPLETE EVEN IF DECLINING COVERAGE.
Last Name First Name MI opt Suffix Birth Date MM DD YYYY Social Security. Mailing Address Street Apt City State ZIP code,Email Address Male Home Cell Phone. Name of Employer Job Title Business Phone Employment Date MM DD YYYY On average how many. hours a week do you work, Eligibility Status n Active Employee n Retired Employee Date of Retirement n COBRA Coverage Start Date Projected End Date. Illinois Continuation insured plans only Start Date Projected End Date. SECTION 3 SELECT YOUR COVERAGE PLEASE CHECK ALL THAT APPLY. Small Group Plans 1 50 Employees, Affordable Care Act Plans Grandfathered and Grandmothered Transitional Plans. PPO Other Blue Advantage Entrepreneur PPOSM Blue Advantage HMOSM. Blue Choice Preferred PPOSM Blue Choice Select PPOSM Blue Advantage HMO Value ChoiceSM. Blue OptionsSM BlueEdge Select HSASM Community Participation Organization CPO. Blue Precision HMOSM BlueEdge HSASM CPO Value Choice. BlueCare DirectSM BlueEdge HCA DirectSM Other,Plan required PPO Value Choice Plan required. Mid Market and Large Group Standard Plans 51 Employees Previous BCBSIL or HMO Membership. Mid Market Large Group Standard Plans 51, PPO Blue Choice OptionsSM BlueEdge Select HSASM Group.
Blue Advantage HMOSM Blue Choice Select PPOSM Plan required Section. Blue Advantage HMO Value ChoiceSM BlueEdge HSASM Other Identification. Large Group Custom Plans 151 Employees, Traditional Blue Advantage HMOSM w HCA BlueEdge Select HSASM. PPO Blue Choice OptionsSM BlueEdge Select HCA DirectSM. CPO Blue Choice Select PPOSM Vision,CPO Value Choice BlueEdge HCASM Hearing. HMO Illinois BlueEdge HSASM Medicare Supplement,HMO Illinois w HCA BlueEdge HCA DirectSM Other. Blue Advantage HMOSM BlueEdge Select HCASM, BlueCare Dental PPOSM Employee and Party to a Civil Union or Domestic Partner Individual Employee. BlueCare Dental HMOSM Gender Male Female Employee Children. Dental Group if different than Medical Group policy Employee Spouse. Primary Language, Group Term Life Accidental Death and Dismemberment AD D and Disability Insurance.
I am not applying for Group Term Life AD D or Disability Insurance coverage. Employee Occupation Job Title Wage Rate per hour week month year. Group Basic Term Life and AD D I do not apply I do apply Amount. Group Dependents Life I do not apply I do apply,Group Supplemental Life I do not apply I do apply. Employee Election Spouse Election Child Election,Short Term Disability I do not apply I do apply. Long Term Disability I do not apply I do apply, Primary First Name Initial Last Name Relationship Birth Date MM DD YYYY Social Security. Beneficiary, Contingent First Name Initial Last Name Relationship Birth Date MM DD YYYY Social Security. Beneficiary, As used on the application unless indicated otherwise These terms may be used in a different way in other documents.
The term marriage includes legal marriage and the establishment of a civil union or domestic partnership coverage subject to your employer s plan. The term divorce includes legal divorce and the comparable termination of a civil union or domestic partnership coverage subject to your employer s plan. The term spouse includes a legal spouse and party to a civil union or domestic partnership coverage subject to your employer s plan. Life and Disability insurance is underwritten by Dearborn Life Insurance Company 701 E 22nd St Suite 300 Lombard IL 60148 Dearborn Life Insurance Company is an independent Blue Cross and Blue Shield licensee BLUE CROSS BLUE SHIELD. and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association an association of independent Blue Cross and Blue Shield Plans. 232320 0919 2,Last Name Social Security Group, SECTION 4 COVERAGE OPTIONS PLEASE COMPLETE ALL AREAS THAT APPLY. If you are adding an eligible military personnel dependent who is over the age limit of your. employer s plan completion of a Defense Department Form 214 DD 214 is required in. addition to this application,Employee Enrollee s Name PCP Name IPA Name. WPHCP Name New Patient HMO OB GYN Name optional HMO OB GYN. Dependent s Name Dependent s PCP Name PCP New Patient. Husband Wife Y N,Domestic Partner Party to a Civil Union. IPA Name WPHCP Name HMO OB GYN Name optional,IPA WPHCP HMO OB GYN. Dependent s Social Security Birth Date MM DD YYYY Home Address if different Street City State ZIP code. Dependent s Name Dependent s PCP Name PCP New Patient. Son Daughter Other Eligible Dependent Y N, Birth Date MM DD YYYY Home Address if different Street City State ZIP code Is this dependent a natural child stepchild foster If not your eligible natural .
Group Enrollment Application Change Form Blue Cross and Blue Shield of Illinois a Division of Health Care Service Corporation a Mutual Legal Reserve Company an Independent Licensee of the Blue Cross and Blue Shield Association Life and Disability insurance is underwritten by Dearborn Life Insurance Company 701 E 22nd St Suite 300 Lombard IL 60148 Dearborn Life Insurance Company is

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