INDIVIDUAL POLICY CHANGE APPLICATION

Transcription

1 INDIVIDUAL POLICY CHANGE APPLICATION Instructions: Please complete all applicable areas of this application. Please print using black ink. WPS/Delta Dental of Wisconsin/WPS Health Plan, Inc. d/b/a Arise Health Plan ( Insurer ) does NOT guarantee approval of this application for any person, or issuance of a policy. If you do not understand any questions on this application, please contact your Agent or Individual Sales Representative. When complete, please mail this application to the appropriate company shown on Page 6. Note: Only complete this change application if you are making a change to your current policy. If you would like to apply for the currently marketed plan, please complete the Individual Application. Customer Name Customer Number Social Security Number Are you a WPS or Arise Health Plan member? WPS Arise Health Plan 1. Information Changes A. CHANGE NAME From: To: Effective Date of Change: (Check one:) Primary Applicant Spouse Dependent Child B. CHANGE ADDRESS Current Address: Number and Street City County State Zip New Address: Number and Street City County State Zip Effective Date of Change: New Phone Number (if applicable) If you have moved to a different county, your Preferred Provider Plan network and rates, if applicable, may be affected. Please contact your agent, or Sales Representative. C. CHANGE PREFERRED PROVIDER PLAN NETWORK WPS Only Change To: Statewide Western Healthy U Aspirus Southern The effective date of the network change for you and all your covered dependents shall be the first day of the calendar month following the receipt of this completed application by WPS. Your rates may be affected if your new network is in a different rating zone. Please contact your agent, or WPS Sales Representative. D. Change Benefits For benefit options please see page Dental Change: Add Delta Dental Plan underwritten by Delta Dental of Wisconsin dental coverage is only available if you have selected medical coverage If any person applying for coverage has other dental coverage that is not canceling and will not be replaced, you are not eligible for the dental plan coverage. Cancel Dental Plan. 2. Primary Care Physician (PCP) Change - Arise Health Plan Only (Or call (920) or toll free )

2 1. Information Changes (cont.) E. Types of Coverage and Benefits Plan - Please refer to your policy for any non-participating provider benefits. Please choose a plan offered by the Insurer you are currently enrolled with. To change between Insurers, please complete the Individual Application. 1. Preferred Plan Deductibles and out-of-pocket maximums listed below are for individuals. Family deductibles and out-of-pocket maximum are two times the individual. Selection Metal Tier Deductible Coinsurance Out-of- Pocket Limit Convenient Care Clinic Copay PCP Copay Specialist Copay ER Copay Free PCP Visits Prescription Plan Generic/Formulary/Non- Formulary/Specialty Platinum 1 $ % $1,250 $10 $20 $40 $150 0 $10/$35/$60/25% to $500 Platinum 2 $0 90% $6,600 D/C D/C D/C D/C 3 $10/$35/$60/25% to $500 Platinum 3 $500 80% $1,250 D/C D/C D/C D/C 3 $10/$35/$60/25% to $500 Gold 1 $2, % $3,000 $10 $25 $50 $150 0 $15/$40/$65/25% to $500 Gold 2 $1,000 80% $2,500 $10 $25 $50 $150 0 $15/$40/$65/25% to $500 Gold 3 $1, % $2,500 D/C D/C D/C D/C 3 $15/$40/$65/25% to $500 Silver 1 $3,000 90% $6,600 $10 $30 $60 $200 0 $20/$50/$75/25% to $500 Silver 2 $3,000 70% $6,600 $10 $30 $60 $200 0 $20/$50/$75/25% to $500 Silver 3 $2,000 80% $6,600 $10 $30 $60 $200 0 $20/$50/$75/25% to $500 Silver 4 $4,000 70% $6,600 $10 $30 $60 $200 0 $20/$50/$75/25% to $500 Silver 5 $4, % $6,600 $10 $30 $60 $200 0 $20/$50/$75/25% to $500 Silver 6 $2,500 80% $5,000 $10 $30 $60 $200 0 $20/$50/$75/25% to $500 Silver 7 $2,000 80% $5,000 D/C D/C D/C D/C 3 $20/$50/$75/25% to $500 Silver 8 $1,500 70% $6,600 D/C D/C D/C D/C 3 $20/$50/$75/25% to $500 Silver 9 $2,500 70% $5,000 D/C D/C D/C D/C 3 $20/$50/$75/25% to $500 Silver 10 $2,000 80% $6,600 D/C D/C D/C D/C 3 $20/$50/$75/25% to $500 Bronze 1 $6, % $6,600 D/C D/C D/C D/C 3 D/C Bronze 2 $5,000 80% $6,600 D/C D/C D/C D/C 3 D/C Bronze 3 $4,500 70% $6,600 D/C D/C D/C D/C 3 D/C Catastrophic* $6, % $6,600 D/C D/C D/C D/C 3 D/C 2. HSA Qualified HDHP Plans Deductibles and out-of-pocket maximums listed below are for individual coverage. Family deductibles and out-of-pocket maximums are two times the individual. If you are applying for family coverage, the family deductible must be met before any benefits are paid. Selection Metal Tier Deductible Coinsurance Out-of- Pocket Limit Convenient Care Clinic Copay PCP Copay Specialist Copay ER Copay Free PCP Visits Prescription Plan Generic/Formulary/Non- Formulary/Specialty Gold 4 $2, % $2,000 D/C D/C D/C D/C 0 D/C Silver 11 $3, % $3,500 D/C D/C D/C D/C 0 D/C Silver 12 $3, % $3,000 D/C D/C D/C D/C 0 D/C Silver 13 $3,000 90% $4,000 D/C D/C D/C D/C 0 D/C Silver 14 $2,500 80% $4,500 D/C D/C D/C D/C 0 D/C Silver 15 $2,000 80% $4,000 D/C D/C D/C D/C 0 D/C

3 Silver 16 $1,400 70% $6,450 D/C D/C D/C D/C 0 D/C Silver 17 $2,000 80% $6,450 D/C D/C D/C D/C 0 D/C Bronze 4 $6, % $6,000 D/C D/C D/C D/C 0 D/C Bronze 5 $5,500 80% $6,450 D/C D/C D/C D/C 0 D/C Bronze 6 $4,500 90% $6,450 D/C D/C D/C D/C 0 D/C Bronze 7 $3,500 70% $6,450 D/C D/C D/C D/C 0 D/C D/C = Deductible and Coinsurance PCP = Primary Care Physician * Applies only to person under age 30 or have hardship exemption from the Federally Facilitated Marketplace. 1. Information Changes (Cont.) F. CHANGE PREMIUM/PAYMENT MODE (Business checks and/or accounts cannot be used for premium payment.) Note: In an effort to comply with Small Employer Health Insurance laws we are unable to accept business checks for payment of premium. Change to: AUTOMATIC WITHDRAWAL. We electronically transfer your premium directly from your bank account at the frequency you request. (If you select this option, please complete the Automatic Withdrawal Payment Authorization Form.) MonthlyQuarterlySemiannuallyAnnually With this option your premium payment can be drafted from your bank account. DIRECT BILL. We send a premium notice directly to your home at the frequency you request. You return payment to the Insurer by the premium due date. Monthly Quarterly SemiannuallyAnnually CREDIT/DEBIT CARD. (If you select this option, please complete Credit/Debit Card Authorization Form.) MonthlyQuarterlySemiannuallyAnnually With this option your premium payment can be charged to your credit card. G. ADDING DEPENDENT TO NEW OR EXISTING FAMILY COVERAGE Type of Coverage Change: Single to Family Add dependent to existing family Family to Single Adding Newborn Child Newborn s Name Date of Birth Gender Social Security Number Adding Adopted Child Child s Name Date of Adoption Date of Birth Social Security Number Gender Dependent Child Child s Name Date of Birth Gender Social Security Number Reason for adding child Relationship to you Adding Spouse Spouse s Name Spouse's Social Security Number Date of Marriage Date of Birth Gender Within the past six months, has anyone named above who is age 18 or over used tobacco regularly (four or more times per week on average?) Yes No If yes, please indicate which applicants:

4 1. Information Changes (Cont.) H. TERMINATING A DEPENDENT S COVERAGE Dependent Name Date of Birth Relationship to You Type of Coverage Being Terminated Date of Coverage Termination Reason for Coverage Termination I. REASON FOR CHANGE Is the requested change due to a Qualifying event? No Yes If yes, choose: Involuntary loss of Minimum Essential Coverage for any reason other than fraud, intentional misrepresentation of a material fact or failure to pay premium Was previous coverage under COBRA? Yes No If yes, please indicate your COBRA start date: Marriage Birth Adoption or placement for adoption or appointment of guardianship Other Please provide the date of the qualifying event J. INFORMATION ON OTHER COVERAGE Please provide the following information for any person named on this application who has other individual or group health coverage: Name Current Health Carrier Effective Date Will coverage terminate upon approval of this policy? Yes No Name Current Health Carrier Effective Date Will coverage terminate upon approval of this policy? Yes No Is anyone named on this application eligible for Medicare? No Yes If yes, please indicate who: *Please note, anyone named on this application who is eligible for Medicare will not be covered by this policy. K. OTHER CHANGE If a requested change is other than a change listed is Subsection A. through H. above, please explain below. 2. Policy Effective Date (if this application is approved by the Insurer, the policy effective date is determined only by the Insurer) Please indicate your requested effective date. Please note, the effective date can be no later than 60 days from the date of application. / / The Policy Effective Date will be determined by the Insurer, subject to any applicable law or policy provisions

5 3. Certification/Understanding Notice CERTIFICATION: I represent and certify all of the following: no answer or information written by myself in this application was provided by the agent or anyone else (except for information provided by other family members); such representations are true, accurate, and complete to the best of my knowledge. UNDERSTANDING: : I understand that: no agent has the authority to waive an answer to any question, pass on insurability, make or alter any contract, or waive or alter any of the Insurer s other rights or requirements; any misrepresentation contained herein may be used to reduce or deny a claim, or to rescind and void coverage and the policy within the contestable period, if such misrepresentation materially affects the Insurer s acceptance of the risk, including approving any person for coverage; the Insurer has no liability for anything the agent said or failed to say before, during or after the application process, that s not subsequently confirmed in writing by an authorized officer of the Insurer, including, but not limited to, answers given by the agent in response to questions asked by myself, my spouse or my dependent(s); and the Insurer is not liable for any statement, representation, or other information provided to myself, my spouse or my dependent(s) that isn t expressly contained in a written document provided to them and signed by an authorized officer of the Insurer. I understand that the insurer fully complies with the regulations and orders regarding doing business with foreign countries or foreign nationals listed on the Office of Foreign Assets Control s Specially Designated Nationals and Blocked Persons (SDN) list. Therefore, the insurer may rescind and void any coverage if it determines that you, your spouse or any named dependent are either listed on the SDN list or associated with an entity listed on the SDN list. To the best of my knowledge and belief, I represent that all statements and answers I made in this application, and on the attached sheet(s), if any, are complete and true. I have read and understand this application, including the Certification/Understanding section above. SIGN HERE Applicant s Signature Date 4. Agent Statement Did an agent or sales representative assist you in the completion of this application? Yes No following: If yes, agent must complete the I asked the applicant, spouse and all child(ren) over age 18 all questions contained in this application and recorded their answers exactly as given to me. I also represent that no other person provided any of their answers, or influenced any of their answers; if any of their answers were influenced by another person, I have attached a written explanation thereof to this application. Writing Agent s Name (Print) Agent s Phone # Address Agent s Fax # City State/Zip Agency Name Writing Agent s License # Writing Agent s NPN # Agency s 9 Digit ID # Arise Health Plan 10 Digit Agent ID # Writing Agent s Signature Date Signed by Agent / /

6 For contact information, please see below. Mail to: Wisconsin Physicians Services Insurance Corporation P.O. Box 8190 Madison, WI Call: Visit: Mail to: WPS Health Plan Inc. d/b/a Arise Health Plan P.O. Box Green Bay, WI Call: Visit:

7 AUTOMATIC WITHDRAWAL PAYMENT AUTHORIZATION FORM By my signature below, I authorize the Insurer to instruct my financial institution to deduct my premium payments from the account designated below. I authorize my financial institution to debit the amount of my premium from my designated account. This authorization will remain in effect until I notify the Insurer in writing of its termination. My notification must afford the Insurer and my financial institution reasonable opportunity to act on it. A. ACCOUNT HOLDER INFORMATION Name Customer Number (if available) Address City State ZIP Social Security Number - - Payment mode Select One: Monthly Quarterly Semiannually Annually B. FINANCIAL INSTITUTION INFORMATION Institution Name Branch/Location Address City State ZIP Select One: Checking Account* Savings Account** Please select the 1 st day or the month or the 7 th through the 31 st of the month for payment pull. If a month does not contain the day you selected, the payment pull will occur on the last day of the month. Please note, if you do not choose a day, the payment pull will occur on the 20 th of the month: FINANCIAL INFORMATION Transit Number Account Number *IF USING A CHECKING ACCOUNT, PLEASE ATTACH A CHECK WITH VOID WRITTEN ACROSS IT. **IF USING A SAVINGS ACCOUNT, PLEASE ATTACH A DEPOSIT SLIP WITH VOID WRITTEN ACROSS IT. SIGN HERE Applicant s Signature Date

8 CREDIT/DEBIT CARD PAYMENT AUTHORIZATION FORM A. APPLICANT INFORMATION Last Name First Name Social Security Number - - B. BILLING INFORMATION, IF DIFFERENT THAN APPLICANT Name as it appears on Credit/Debit card Mailing Address City State ZIP County C. PREMIUM PAYMENT MODE Recurring Arise Health Plan (20 th of the Month) FINANCIAL INFORMATION Recurring WPS (Please select the 1 st day of the month or the 7 th through 31 st day of the month): Note: Recurring premium payments will be charged to your credit/debit card based on your selection above. If a month does not contain the day you selected, payment will be pulled from your credit/debit card account on the last day of that month. We will continue to charge premiums until the policyholder notifies us to discontinue charging premiums in accordance with the Insurer s policy. D. CREDIT/DEBIT CARD AUTHORIZATION Select One: Visa MasterCard Discover Card Credit/Debit Card Number Must be from a personal account Card Expiration Date I hereby authorize the Insurer or its authorized credit/debit card transaction agent(s) to bill my credit/debit card account indicated above for payment of premiums charged for the Insurer s policy for which I am applying. If the Insurer s policy is issued to me, I understand and agree that by executing this authorization, that action doesn t affect, waive, or change any of the policy s terms, conditions and provisions, including that policy s premium payment and grace period provisions. I am attesting the credit/debit card listed above is a personal account; I understand the premium may not be paid from a business account. SIGN HERE Applicant s Signature Date