Small Business Application

Transcription

1 Medical and Life/AD&D plans are provided by Health Net of Arizona, Inc. and/or Health Net Life Insurance Company (together, Health Net ). In Arizona, Health Net of Arizona, Inc. underwrites benefits for HMO plans, and Health Net Life Insurance Company underwrites benefits for indemnity plans and life insurance coverage. Health Net Life Insurance Company s Dental PPO and dental indemnity insurance plans are provided by Unimerica Life Insurance Company and administered by Dental Benefit Providers, Inc. (together, the DBP Entities ). Health Net Life Insurance Company s Vision plans are provided by Fidelity Security Life Insurance Company and serviced by EyeMed Vision Care, LLC (together, the Fidelity Entities ). Neither the DBP Entities nor the Fidelity Entities are affiliated with Health Net. Obligations under dental and vision plans are neither obligations of, nor guaranteed by, Health Net Life Insurance Company. Application is hereby made for a Group Enrollment Agreement/Group Policy provided by Health Net, Unimerica Life Insurance Company and/or the Fidelity Entities, the provisions of which are to be made available to all eligible employees, as defined, and their eligible dependents, as defined, desiring coverage hereunder. The following information regarding employee data is being submitted to allow Health Net, the DBP Entities and/or the Fidelity Entities to determine the eligibility of employees seeking enrollment. Welcome to Health Net Simple steps for completing the form: 1. Review the materials enclosed in your enrollment packet. Be sure that you understand the coverage options that are available to you by your employer. 2. Carefully review and select the plan option(s) that are best for you and your covered family members. The Affordable Care Act (ACA) requires Health Net to provide to the IRS confirmation of health care coverage for yourself, as the subscriber, and your covered dependents. The IRS uses this information to confirm each member has essential coverage and is not subject to the ACA s individual shared responsibility payment provision. Please ensure that the Social Security number (SSN) is accurate for yourself and each dependent you are enrolling. For more information on the individual shared responsibility payment provision, go to Answers-on-the-Individual-Shared-Responsibility-Provision. 3. You are not required to select a primary care physician to enroll. Be sure to fill in the names and numbers as they appear in Health Net s online ProviderSearch tool, or call the Customer Contact Center, Monday through Friday, 8:00 a.m. to 6:00 p.m., for assistance. Medical: Dental: Life: Vision: Make a copy of the completed application for your records. Small Business Application for Group Enrollment and Change Notice of Privacy Practices: Health Net knows that personal information in your medical records is private. Health Net provides members with a Notice of Privacy Practices that describes how it uses and discloses protected health information; the individual s rights to access and to request amendments, restrictions and an accounting of disclosures of protected health information; and the procedures for filing complaints. Members receive the Notice of Privacy Practices in the new member Welcome Packet. However, you may also obtain a copy of Health Net s Notice of Privacy Practices on the website at or through Health Net s Customer Contact Center at the number listed on the back of your Health Net ID card. Existing Business/Group az_non_urgent@healthnet.com Fax: New Business/Group Please send all completed paperwork to your designated account executive or broker. HNM AZ (1/15)

2 To be completed by employer Employer name: Requested effective date: Employer group number (medical): (For enrollment, sections 1, 3 and 8 are required. For waivers, only section 7 is required.) Employee eligibility date (new hire only): Same as hired date Other: Important: Please print all sections in black ink. You are entitled to see a Summary of Benefits and Coverage (SBC) before you choose a plan. Please contact your employer if you do not have the SBC for the plan you have selected. 1. Health plan information (Select coverage.) Pediatric vision is included in all medical plans. Health Net Life Insurance Company: PPO Platinum: $15/$30/$350 $15/$30/$500 $15/$30/$750 Gold: $20/$40/$500 $20/$40/$1,000 $20/$40/$2,000 Silver: 20%/20%/$1,500 20%/20%/$2,000 30%/30%/$1,500 30%/30%/$2,000 30%/30%/$2,000 (HSA) 20%/20%/$2,000/$5,000 (HSA) 20%/20%/$2,000/$6,350 (HSA) Bronze: 50%/50%/$5,500 Health Net of Arizona, Inc.: HMO Platinum: $15/$30/$350 $15/$30/$500 $15/$30/$750 Gold: $20/$40/$500 $20/$40/$1,000 $20/$40/$2,000 Silver: $30/$50/$1,500 $30/$50/$2,000/$5,000 $30/$50/$2,000/$6,350 Health Net of Arizona, Inc.: CommunityCare HMO Platinum: $15/$30/$3,000 $20/$40/$2,000 $20/$40/$4,000 Gold: $25/$50/$5,000/$600 $30/$60/$6,000/$500 $30/$60/$6,000/$750 Silver: $30/$50/$2,000 $45/$65/$1,500 20%/20%/$2,000 Bronze: 40%/40%/$3,500 (HSA) 40%/40%/$5,000 (HSA) Buy Up Dental (Health Net Life Insurance Company: DPPO) Adult Vision (Health Net Life Insurance Company: PPO) Green 2 Green 5 White 6 Elite Supreme Supreme Notice: The health care reform law requires pediatric dental services to be covered as one of the 10 required essential health benefits. Pediatric dental benefits must be available either as part of your Health Net plan or with another qualified plan offered by your employer. 2. change change: Plan change Change address/name Delete dependent(s) (list names below) Other: 3. Employee personal information application: New hire Date of hire: / / Open Enrollment Loss of prior coverage date: / / COBRA effective date: / / Qualifying event date: / / Add dependent: Qualifying event: Qualifying event date: / / Male Female Residence address: City: State: ZIP: Mailing address (if different from residence): City: State: ZIP: Date of birth Marital status: Single Married Domestic partner 1 Job title: Salary Hourly Date of hire: / / Class: Dept. #: Home telephone #: ( ) Work telephone #: ( ) address: Physician name (first, last): Primary care physician/pcp # 2 : current physician? If available, I would prefer to receive communication and plan information in Spanish. Yes No 1 HNM AZ (1/15)

3 Employee name: 4. Family information (Please list all eligible family members to be enrolled. Attach a separate sheet for additional dependents.) Spouse Domestic partner 1 M F Last 4-digits of Social Security #: Date of birth Physician name (first, last): Primary care physician/pcp #2: current physician? Date of birth Disabled? Physician name (first, last): Primary care physician/pcp # 2 : current physician? Date of birth Disabled? Physician name (first, last): Primary care physician/pcp # 2 : current physician? Date of birth Disabled? Physician name (first, last): Primary care physician/pcp # 2 : current physician? 1 If offered by your employer. 2 Applicable to HMO plans only. HNM AZ (1/15)

4 Employee name: 5. Do you or your dependents have other health care coverage? If Yes, please complete this section, including Medicare. Self Medical: Dental: Vision: Spouse Domestic partner 1 Medical: Dental: Vision: Medical: Dental: Vision: Medical: Dental: Vision: Medical: Dental: Vision: 6. Group term life insurance, if applicable. (Attach separate sheet for additional or contingent beneficiaries.) Life/AD&D coverage: Last 4-digits of Social Security #: HNM AZ (1/15)

5 Employee name: Last 4-digits of Social Security #: 7. Declination of coverage (Complete this section if any coverage is being declined by you or your eligible dependents.) Declining medical coverage for: Self Spouse Domestic partner Dependent(s) Name(s): Reason: Other group coverage through this employer Individual coverage Other group coverage by another group (i.e., spouse s employer) Other: Declining dental coverage for: Self Spouse Domestic partner Dependent(s) Name(s): Declining vision coverage for: Self Spouse Domestic partner Dependent(s) Name(s): Reason: Other group coverage through this employer Individual coverage Other group coverage by another group (i.e., spouse s employer) Other: Reason: Other group coverage through this employer Individual coverage Other group coverage by another group (i.e., spouse s employer) Other: Stop and read carefully. The available coverages have been explained to me by my employer. I have been given the chance to apply for the available coverages. I have decided not to enroll myself and/or my dependent(s). By declining coverage, I acknowledge that my dependents and I may have to wait to be enrolled until the next open enrollment period, employer group anniversary date or qualifying event. Notice of special enrollment periods I understand if I am declining enrollment for myself or my dependent(s), including my spouse/domestic partner (if offered), because of other health coverage, I may in the future be able to enroll myself and/or my dependent(s) in this group health coverage policy, provided that I request enrollment within 31 days after my other coverage ends. In addition, if I have a new dependent(s) as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my dependent(s), provided that I request enrollment within 31 days after the marriage, birth, adoption, or placement of adoption. (Sign below only if declining coverage for yourself or your dependents. Note that you must sign both the acceptance of coverage and declination of coverage sections if you selected marital status as married but did not list your spouse as a dependent.) Employee signature: Date: Print employee name: Date: (If signed in error, please cross out and initial.) 8. Acceptance of coverage (The following authorization must be signed if you are APPLYING for coverage.) Group health insurance: I hereby request enrollment in the Health Plan identified above and authorize deductions from my earnings (if applicable) in an amount to cover the premium. I understand that my signature indicates my acceptance of the terms, conditions and provisions of the applicable Evidence of Coverage under which I am covered and that the information I have entered above is true and correct. I, on behalf of myself and my dependents, authorize Health Net, Unimerica Life Insurance Company and the Fidelity Entities, and their authorized employees, agents, independent contractors, and participating providers, to release to and/or obtain from said physician, practitioner, hospital, clinic, other medical or medically related facility, and/or employer who possess information about me or my eligible dependent(s) care or treatment, including information about drugs, alcoholism or mental illness, which Health Net requires or is obligated to provide pursuant to legal process or federal, state or local law, or otherwise requires to administer coverage under this plan. Notwithstanding anything else herein, this authorization shall not apply to the release of information pertaining to HIV, AIDS or ARC without a separate authorization signed by me specifically for that purpose. This authorization shall be valid for 30 months unless this authorization is used for the purpose of collecting information in connection with a claim or benefits, in which case this authorization shall remain effective for the duration of my coverage by Health Net. I, or my authorized agent, am entitled to receive a copy of this authorization. A photocopy of this authorization is as valid as the original. Group Term Life/AD&D Insurance: I request coverage under my employer s group insurance plan as noted, and also verify the accuracy of the employee section. Furthermore, I authorize my employer to deduct from my earnings any payments, if applicable, for this coverage. Employee signature: Date: Print employee name: Date: (Sign above only to accept coverage. If signed in error, please cross out and initial.) HNM AZ (1/15)

6 AZ (1/15) In Arizona, Health Net of Arizona, Inc. underwrites benefits for HMO plans, and Health Net Life Insurance Company underwrites benefits for indemnity plans and life insurance coverage. Health Net Life Insurance Company s Dental PPO and dental indemnity insurance plans are provided by Unimerica Life Insurance Company and administered by Dental Benefit Providers, Inc. (together, the DBP Entities ). Health Net Life Insurance Company s Vision plans are provided by Fidelity Security Life Insurance Company and serviced by EyeMed Vision Care, LLC (together, the Fidelity Entities ). Neither the DBP Entities nor the Fidelity Entities are affiliated with Health Net. Obligations under dental and vision plans are neither obligations of, nor guaranteed by, Health Net Life Insurance Company. Health Net of Arizona, Inc. and Health Net Life Insurance Company are subsidiaries of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All other identified trademarks/service marks remain the property of their respective companies. All rights reserved. HNM00385