Individual Health Insurance Coverage Enrollment Application

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1 Individual Health Insurance Coverage Enrollment Application Issued By: Capital BlueCross and Capital Advantage Insurance Company (Capital) 2500 Elmerton Avenue Harrisburg, PA Dear Applicant, Thank you for your interest in our Individual health insurance coverage. We appreciate the opportunity to become your health insurer of choice. Enclosed are materials that will help you choose the coverage that is best suited to your needs. Individual health insurance medically underwritten products are also available to you. If interested, go to Our policy allows current members to continue health insurance coverage as an Individual member when coverage has been discontinued or are transferring coverage from another Blue Cross or Blue Shield Plan. This process is called conversion. You may convert your coverage to one of the programs offered to Individual members by Capital. If this applies to you, complete Section 4. Be sure to read all instructions and the enclosed materials carefully before you start. You may use this form to: Apply for Capital coverage (If you are eligible for Medicare, do not complete this application. Contact Capital s Medicare Sales Unit at for information about one of our Medicare Supplemental Plans or our Medicare Advantage Plans). Change enrollment information Add or remove dependents Change your coverage Cancel your coverage IMPORTANT INSTRUCTIONS REMEMBER TO SIGN, DATE, AND RETURN THE APPLICATION IN THE ENVELOPE PROVIDED. OR, YOU MAY FAX THE APPLICATION TO Incomplete applications will be returned to you. The effective date of your coverage will be determined once we receive a completed application. Please allow approximately two weeks for your application to be processed. DO NOT SEND YOUR PAYMENT WITH THIS APPLICATION. If your application is approved, you will be billed for your first month s premium. Your identification cards will be mailed separately. If you are interested in our income-based programs, Special Care SM, or the Children s Health Insurance Program (CHIP), please refer to the Individual Account Product brochure for more information on these programs. Capital strictly maintains the privacy of its applicants and insureds. Any personal information you provide to us will be carefully protected according to federal and state law. If you have any questions about this application or the benefit programs offered by Capital, contact a Customer Service Representative at Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

2 INSTRUCTIONS PAGE PLEASE READ: Please complete all sections that apply to you. If the application is incomplete, we may either call you for the missing information or return the form to you for completion. If you leave a section blank, this will delay the processing of your application. Indicate not applicable where appropriate. When you have completed the application/change form, tear off these pages. Send us only the completed application. Print clearly in blue or black ink to avoid processing delays. You may choose to make a copy for your records. Mail to: CAPITAL BLUE CROSS PO BOX HARRISBURG, PA ELIGIBILITY REQUIREMENTS List Spouse and Eligible Dependents. Eligible Dependents permitted to enroll with a subscriber/applicant include: Spouse of applicant Dependent children under age 26 Wards Plan-approved handicapped dependents regardless of dependent s age A spouse and/or child(ren) are also permitted to be added to an Individual contract as a result of a valid Qualified Medical Child Support Order (QMCSO). DIRECTIONS FOR COMPLETING THE APPLICATION A material misrepresentation of facts may lead to cancellation or voidance of coverage. If you are a new applicant, complete Sections 1, 2, 3, 5, 6, 7, 8, 9, and 12 where applicable. If you are a current member and need to make changes to your contract, complete Sections 1, 2, 3, 5, 6, 7, 8, 9, 10, and 12 where applicable. If you are transferring from another Blue Cross or Blue Shield plan, complete Sections 1, 2, 3, 4, 5, 6, 7, 8, 9, and 12 where applicable. If you are cancelling coverage, complete Sections 2, 3, 11, and 12 where applicable. 1. Medicare Statement. Do not include anyone on this application who is eligible for Medicare. Contact Capital s Medicare Sales Unit at for our Medicare Supplemental Plans or our Medicare Advantage Plans. 2. Application Category. If you are not currently covered or enrolled in an Individual health insurance product, check New Application. If you want to notify us of a change or to request a change, check I am a current member making changes to an existing contract or requesting a new contract. Record your Subscriber identification number from your current identification card (be sure to include the three character alpha prefix this is an important part of your identification number). Indicate the type of change you wish to report check all the boxes that apply under the Reason for Change in Contract: block. 3. Applicant Information. Fill in all the information requested. It is especially important that you complete the phone number fields as they are required in the event Capital needs to notify the Subscriber of benefit information. 4. Transfer/Conversion Information. If this section applies to you, please answer the applicable questions. 5. Dependent Information. Fill in all information requested. Include every individual for whom you are requesting coverage. If you are adding coverage for a dependent child, make sure you are reporting this addition within 31 days of the life status event causing the addition (i.e., birth, placement or adoption) to ensure continuous coverage. If the spouse or dependent s address is different from the Subscriber s due to a Qualified Medical Child Support Order, a copy of the court order is required (along with the alternate address) to process the address change. Submit this information with this application. If the address is different due to Act 150 (The Spousal and Child Medical Support Act 150 of PA), contact Customer Service at so the appropriate forms may be mailed to you. Be sure to have the form notarized before returning it to us. 6. Employment Information. Complete the applicable information on employment for you and your spouse. 7. Other Coverage/Replacement. If you and/or any of your family members applying for coverage currently have or are eligible for other health insurance coverage, provide the requested information. If you and/or any of your family members applying for coverage intend to terminate your current coverage, provide the requested information and carefully read the paragraph at the end of this section. Also, please complete and submit the Notice to Applicant Regarding Replacement of Accident and Sickness Insurance NF Other Eligibility. The Health Insurance Portability and Accountability Act (HIPAA) makes it easier for you to continue health coverage without preexisting condition limitations when you or a family member changes or loses a job, if you have 18 months of prior health care coverage. If you are HIPAA eligible, your coverage options are HIPAA/HCTC Comprehensive 1000 or HIPAA/HCTC Comprehensive 2500 with no preexisting condition requirements. Any eligible subscriber/applicant (including dependent children) may enroll in HIPAA Comprehensive programs regardless of age. You may waive your HIPAA eligibility and enroll in one of the other products listed, but your coverage will be subject to preexisting condition requirements. Refer to the Individual Account Product brochure for more information. The Health Coverage Tax Credit (HCTC) Program is a federal tax credit used to help pay for private health insurance for displaced workers certified to receive certain Trade Adjustment Assistance benefits and for individuals who are receiving benefits from the Pension Benefit Guarantee Corporation. If you are HCTC eligible, your coverage options are HIPAA/HCTC Comprehensive 1000 or HIPAA/HCTC Comprehensive Refer to the Individual Account Product brochure for more about HCTC eligibility, preexisting conditions, and required documentation. The federal Consolidated Omnibus Budget Reconciliation Act (COBRA) and Pennsylvania Mini-COBRA Act are statutes that require employers who provide group health care coverage to allow previously covered employees, spouses, and dependents, who might otherwise lose group health care benefits, to elect to continue their benefits.

3 9. Coverage Selection. Check the box for the Individual health insurance Benefit Option that best fits your needs. Comprehensive 2500 Comprehensive Major Medical benefits offered with a $2500 deductible, issued by Capital. Comprehensive 1000 and 2500 for HIPAA and/or Health Coverage Tax Credit Program eligible individuals Comprehensive Major Medical benefits offered with either a $1000 or $2500 deductible, issued by Capital. 10. Change Enrollment Information. For current members If you are using this form to report enrollment changes, check the areas pertaining to your change and complete the appropriate change information. Other applicants do not need to complete this section. 11. Cancel Coverage. Use this area if you are cancelling your coverage. Complete the areas which apply to your circumstance and your reason for cancellation. Be sure to sign the signature block in Section 12! 12. Required Signature. Read this section carefully. Sign and date the application. We will not accept this application if this section is not completed. Keep a copy of the signed application for your records. NEXT STEPS FOR NEW APPLICANTS We will review your application and send you an invoice for the coverage period listed on the invoice. Your coverage will be effective on the beginning date of the coverage period. You will receive identification cards and an outline of coverage listing your benefits in separate mailings. Please allow approximately two weeks for your application to be processed. QUESTIONS If you have any questions or need help completing this application, please contact a Customer Service representative at INSTRUCTIONS PAGE (Continued)

4 PAGE INTENTIONALLY LEFT BLANK

5 Individual Health Insurance Application/Change Form Please answer all questions. Print using blue or black ink. Instructions can be found on the previous page. MAIL APPLICATION TO: Capital BlueCross PO Box Harrisburg, PA OR, FAX TO: Medicare Statement Do not include anyone on this application who is eligible for Medicare! Contact Capital s Medicare Sales Unit at for information about one of our Medicare Supplemental Plans or our Medicare Advantage Plans. Application Category All applicants must check the appropriate box: For Plan Use Only Effective Date: I am a new applicant (If checked, do not complete the remainder of this section continue to Section 3.) I am a current member making changes to an existing contract or requesting a new contract. (Complete the remainder of this section.) Subscriber identification number (from card change only include 3 character alpha-prefix) Reason for change in contract: (This may result in a new contract and possibly new rates.) Birth/Placement/Adoption/Other New Dependent Death Divorce ress /Remove Dependent Date of Event: Increase Deductible (indicate deductible in Section 9.) Decrease Deductible (indicate deductible in Section 9.) Applicant Information All applicants must complete this section: 3. Last Name First Name Middle Initial Date of Birth Social Security Number Home Address (No PO Box) Street Apt. No. City and State ZIP Code County Applicant Gender Marital Status Daytime Phone Number Home Phone Number Male Female Single Married ( ) ( ) Cell Phone Number (Optional) Address ( )

6 Transfer/Conversion Information Complete this section only if you are transferring from another Blue Cross or Blue Shield Plan/Product: Check One: I am transferring from another Blue Cross or Blue Shield Plan Identification Number: I am converting from other Capital BlueCross/Capital Advantage Insurance Company coverage Full Name of Blue Cross or Blue Shield Plan: What Date Will Your Current Coverage End? Provide an address if conversion information should be sent to an address other than the applicant s home address listed on the first page: Dependent Information Complete this section if you are adding or removing dependents list EVERY individual in your family who is requesting coverage (If additional space is needed, attach a separate sheet.) Dependent s Name and Relationship Social Security Check One Birth Date (Last) (First) (MI) Number Spouse Son Daughter Son Daughter Son Daughter Son Daughter Other If applicable, check for any child listed above if coverage is desired: Handicapped child Child s Name You will receive a Handicapped Dependent Certification Form to complete and return for approval. Employment Information Are You Employed? Yes No Employed Full-Time Part-Time Employer Name Employer Address If you need an alternate address for a spouse or dependent, please see the INSTRUCTIONS PAGE, No. 5 Dependent Information. Is Your Spouse Employed? Yes No Employed Full-Time Part-Time Employer Name Employer Address Telephone Number ( ) Telephone Number ( )

7 7. 8. Other Coverage/Replacement Do you or any person applying for coverage have other health insurance, including employer group coverage, or are eligible for any other health insurance coverage, Medicare, or Medicaid? Yes No If Yes, please list names and information. Note: No policy will be issued to any applicant or dependent who is Medicare eligible. Add additional names and information on a separate piece of paper, if necessary. Name: Employer and Policy Number: Effective Date: Is the insurance to be issued to replace any other accident and health insurance currently in force? Yes No If Yes, please complete and submit the Notice to Applicant Regarding Replacement of Accident and Sickness Insurance form NF-801 provided with this Application. A copy of this form is available on What is the intended termination date of your other coverage? If your application for coverage is accepted, we will send you an invoice for your first month s premium. You should not terminate coverage in which you and/or your dependents are enrolled until you receive confirmation of acceptance from Capital. It is your right and in your best interest to seriously consider all factors that may affect the health protection that will be available to you under your new coverage. Your new coverage may be subject to preexisting condition requirements. You may wish to secure the advice of your present insurer or its agent about the replacement of your policy. Other Eligibility See the Instructions Page for more information about this section. Are you HIPAA Eligible? Yes Not Applicable Are you HCTC Eligible? Yes Not Applicable If you checked Yes, your coverage options are HIPAA or HCTC Comprehensive 1000 or Note: HIPAA eligible dependents may enroll even when a parent or guardian does not enroll. Include a copy of your Certificate of Creditable Coverage verifying previous group health insurance coverage with this application. If a Certificate of Creditable Coverage is not available, the following, along with your cooperation with Capital, is acceptable to verify your coverage: Records for medical care that indicate health coverage Other relevant documents showing evidence of health coverage Name and telephone number of your previous employer or health insurer (to be used as a means to verify coverage via telephone) Do you choose to waive your HIPAA eligibility and enroll in one of the other products listed with preexisting condition requirements? Yes Not Applicable If you checked Yes, sign and date below: Signature 9. Are you, your spouse, or any dependent eligible for COBRA benefits? Yes Not Applicable Have the COBRA benefits been exhausted? Yes No Coverage Selection Date Complete this section if you are a new applicant or making a change to your current Individual health insurance coverage contract: Choose Your Coverage: HIPAA or HCTC Comprehensive 1000*** HIPAA or HCTC Comprehensive 2500*** Comprehensive 2500*** *Issued by Capital BlueCross **Issued by Capital Advantage Insurance Company ***Issued by Capital BlueCross and Capital Advantage Insurance Company

8 Change Enrollment Information 10. Complete this section if you are currently an Individual health insurance member who is making a change to his/her contract: Change Is For: Reason For Change: Change Name: Change Social Security Change Birth Date: Number: Subscriber Spouse Dependent-List Name Below: Divorce Marriage Other: From To From To From To Cancel Coverage Complete this section if you are currently an Individual health insurance member and wish to cancel your policy: Check this box if you are cancelling your current coverage. (Please also sign and complete the signature section below.) Reason For Cancellation Change to other insurance: Name of insurance company Identification/Policy Number Effective Date Active military duty or dependent of active military. Changed coverage to CHIP Program. Changed coverage to Special Care Program. Changed to a Medicaid policy Date Medicaid began Covered by Employer. Deceased date deceased Federal program. Became Medicare eligible. Moved permanent residence is outside of the Capital 21-county service area. Other Blue Cross or Blue Shield coverage. Other (please explain): Required Signature NOTIFICATION AND AUTHORIZATION I hereby apply for the coverage indicated. I understand this application is subject to approval by Capital. Any coverage will be subject to the terms of the contract issued to me. No one on this application is eligible for Medicare. If changes are indicated, Capital is authorized to make the changes requested above to my enrollment records. I understand the effective date of the changes will be determined by Capital. Note: Health conditions which you presently have (preexisting conditions) may not be immediately covered under the contract issued by Capital. This could result in the denial or delay of claims or benefits under the new contract, where a similar claim might have been payable under your present contract. Even though some of your present health conditions may be covered under the contract, these conditions may be subject to certain waiting periods before coverage is effective. After the application has been completed, and before you sign it, review it carefully to be certain all information has been properly reported. If you have questions about preexisting conditions and waiting periods, call Customer Service at I verify that the information given in this enrollment application is true and correct. Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim 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 and subjects such person to criminal and civil penalties. Applicant s Signature: Printed Name: Date: Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company IA-APP , Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. NF-800 (11/2012)

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