HealthNow New York Individual and Family Enrollment Application

Transcription

1 Healthw New York Individual and Family Enrollment Application Open Enrollment During the annual Open Enrollment period, which runs from vember 15, 2014 through February 15, 2015, you may apply for coverage, or members can change plans. If Healthw receives the enrollment application on or before December 15, 2014, coverage will begin on January 1, 2015, as long as the applicable premium payment is received by then. If Healthw receives the enrollment application between the dates of December 16, 2014 through January 15, 2015, coverage will begin February 1, 2015, as long as the applicable premium payment is received by then. If Healthw receives the enrollment application between the dates of January 16, 2015 through February 15, 2015, coverage will begin March 1, 2015, as long as the applicable premium payment is received by then. If you do not enroll during open enrollment, or during a special enrollment period, you must wait until the next annual open enrollment period to enroll. Outside of the annual open enrollment period, You, Your Spouse, or Child can enroll for coverage within 60 days prior to or after the occurrence of one of the following events below: 1. You, Your Spouse or Child involuntarily loses minimum essential coverage including COBRA or state continuation coverage (ex; loss of coverage from employer, aging off parents insurance policy, etc.); 2. You, Your Spouse or Child are determined newly eligible for advance payments of the premium tax credit because the coverage You are enrolled in will no longer be employer-sponsored minimum essential coverage, including as a result of Your employer discontinuing or changing available coverage within the next 60 days, provided that You are allowed to terminate existing coverage; or 3. You, Your Spouse or Child loses eligibility for Medicaid coverage, including Medicaid coverage for pregnancy-related services and Medicaid coverage for the medically needy, but not including other Medicaid programs that do not provide coverage for primary and specialty care. Please provide the date of the qualifying event: Outside of the annual open enrollment period, You, Your Spouse, or Child can enroll for coverage within 60 days after the occurrence of one of the following events: 1. You, Your Spouse or Child s enrollment or non-enrollment in another health plan was unintentional, inadvertent or erroneous and was the result of the error, misrepresentation, or inaction of an officer, employee, or agent of a health plan or the NYSOH; 2. You, Your Spouse or Child adequately demonstrate to Us that another health plan in which You were enrolled substantially violated a material provision of its contract; 3. You, Your Spouse or Child move and become eligible for new health plans; 4. You gain a Dependent or become a Dependent through marriage, birth, adoption or placement for adoption or foster care, however, foster Children are not covered under this contract; 5. You, Your Spouse or Child are determined newly eligible or newly ineligible for advance payments of the premium tax credit or have a change in eligibility for cost-sharing reductions. Please provide the date of the qualifying event: HN104_062014

2 PO Box 80, Buffalo, NY Instructions for Individual and Family Enrollment Application Form 2 Plan Section Individual and Family Application/Change Form Thank you for your interest in becoming a member of Healthw New York. In order to process your membership, we need you to supply the information requested on this form. Using blue or black ink, please complete each section, leaving no blanks Please return the application with a check for the first full month s premium in the return envelope provided (check or money order ONLY; no cash please) so we can process your application. In the Plan Section, plans identified with # are available as child only coverage If you need assistance completing the application, please call Monday Friday, 8 am to 5 pm Please return the completed application to: Healthw New York PO Box 80 Buffalo, NY Please use blue or black ink, print one character per box. Check applicable plan(s). Bronze Standard # Silver Standard # Gold Standard # Platinum POS * + # Pediatric Dental (under Age 19) & Value Dental (family coverage) & Plan Section Key: * Includes out of network coverage # available as child only coverage & Meets pediatric dental essential health benefit requirement + Requires selection of a Primary Care Physician (PCP). To find a PCP, sign into healthnowny.com/find a Doctor. Payment Selection (check one): Monthly Quarterly 3 Reason for Enrollment/Change Applicant, please indicate the reason for this enrollment or change. New Coverage Change policy coverage Primary Care Physician Remove Dependent Loss of Coverage Open Enrollment Address/Phone Number Last Name Add dependent(s) to current coverage Add Dependent Please indicate reason for adding dependent: Newborn Marriage Loss of Coverage 4 Applicant Information Adoption Domestic Partner Change in Student Status Please complete ALL sides of this application. The applicant s signature is required in order to process the application. Applicant s Last Name Applicant s First Name M.I. Social Security Number Date of Birth (MMDDYY) Telephone Number (include area code) Gender: Female Male Mailing Address Apt Suite Marital Status Single Married Divorced City State Zip Code Legally Separated Widowed Marital Status Event Date (MMDDYY) HN104_ over

3 4 Applicant Information continued Are you a current patient, or if not a current patient, have you verified that the PCP will accept you as a new patient? 5 Dependent Information Please provide all information for each person to be covered. Spouse/Domestic Partner s Last Name Spouse/Domestic Partner s First Name M.I. Are you enrolling as a Domestic Partner? Are you a current patient, or if not a current patient, have you verified that the PCP will accept you as a new patient? Is your over-age dependent handicapped? Are you a current patient, or if not a current patient, have you verified that the PCP will accept you as a new patient?

4 5 Applicant Information continued Please provide all information for each person to be covered. Applicant s Last Name Applicant s First Name M.I. Social Security Number Date of Birth (MMDDYY) Is your over-age dependent handicapped? Are you a current patient, or if not a current patient, have you verified that the PCP will accept you as a new patient? Is your over-age dependent handicapped? Are you a current patient, or if not a current patient, have you verified that the PCP will accept you as a new patient? -over

5 5 Dependent Information continued Please provide all information for each person to be covered. Is your over-age dependent handicapped? Are you a current patient, or if not a current patient, have you verified that the PCP will accept you as a new patient? 6 Agent/Broker Certification To be completed by your Healthw New York appointed agent/broker: Did you see the proposed applicant and spouse/domestic partner, if applying at the time this application was executed? If NO, please explain: I certify to the best of my knowledge and belief, the responses herein are accurate. Agent/Broker Signature X Agent/Broker Name (please print) Date Agent/Broker Street Address/Suite./Personal Mail Box (PMB). Agent/Broker ID/TIN Agency ID/Parent TIN City State Zip Agent/Broker Phone Number Agent/Broker Fax. Agent/Broker Address Important tice I AUTHORIZE ANY LICENSED DOCTOR, HOSPITAL OR OTHER HEALTH CARE PROVIDER TO PROVIDE MY PLAN WITH ANY INFORMATION OR DOCUMENTS REQUESTED CONCERNING MEDICAL SERVICES I OR MEMBERS OF MY FAMILY HAVE RECEIVED, WHICH THE PLAN DETERMINES IS NECESSARY FOR THE OPERATION AND REGULATION OF THE PLAN. THIS INFORMATION WILL BE KEPT CONFIDENTIAL AND IS VALID FOR UP TO 24 MONTHS. * 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 SHALL ALSO BE SUBJECT TO CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. X Signature of Applicant Date