Individual Health Insurance Enrollment Application You are eligible to apply if you meet ALL of the following: x You are a United States citizen or you are lawfully present in the United States x You legally reside full-time in South Dakota or Iowa according to US Citizenship and Immigration Services or Immigration and Customs Enforcement criteria. If you use a mail forwarding address we will contact you to determine your permanent home address. This address will be used to determine your eligibility for coverage. x You are not enrolled in Medicare. If you apply for the Avera 7150 plan you will also need to meet the following requirements: x Individual has not attained the age of 30 before the beginning of the plan year; or x Has a certification in effect for any plan year under this title that the individual is exempt from the requirement under section 5000A of the Internal Revenue Code of 1986 by reason of (i) section 5000A(e) (1) of such Code (relating to individuals without affordable coverage); or (ii) section 5000A (e) (5) of such Code (relating to individuals with hardships). How to apply: x Application must be completed by printing clearly so we can process all the information. Please use black or blue ink. x If the applicant is under age 18, the signature and relationship of a parent or legal guardian or proof of emancipation is required.
x
We must receive this application within 15 days of the date you sign the application.
Note: The receipt date of the application determines whether it is considered inside or outside of the annual open enrollment period. Application Checklist: Indicate who is requesting coverage (Section 4, Coverage Election) Indicate which benefit plan you are requesting (Section 7, Benefit Plan Election) If you would like to have your premium automatically deducted from a checking or savings account, enclose the Authorization for Automatic Bank Withdrawal for Premium Payment and a copy of a voided check. Note: The monthly bank withdrawal will start after receipt of the first month’s payment. If you are applying for special enrollment coverage due to a loss of other coverage, attach documentation of prior coverage. Note: If you have not received documentation, request it from your current health insurance company and submit it as soon as possible. The applicant must initial and date any changes made on this application. The applicant must sign and date this application on the back. (Section 10, Agreement and Certification) Please make a copy of the application for your file. When the application is complete, please mail to:
Avera Health Plans 3816 S. Elmwood Ave., Suite 100 Sioux Falls, SD 57105-6538 Or fax to:
605-322-4754
If you have questions, call our Service Center at 605-322-4545 or toll-free at 1-888-322-2115.
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FOR OFFICE USE ONLY Tracking # ________________
ENROLLMENT APPLICATION Individual Health Insurance
Effective Date _____________
1. ELIGIBILITY REVIEW You are eligible to apply if you meet ALL of the following: x You are a United States citizen or you are lawfully present in the United States x You legally reside full-time in South Dakota or Iowa according to US Citizenship and Immigration Services or Immigration and Customs Enforcement criteria. If you use a mail forwarding address we will contact you to determine your permanent home address. This address will be used to determine your eligibility for coverage. x You are not eligible for Medicare
2. MEMBERSHIP INFORMATION Select One: New Enrollment (complete all sections) Change in Benefits Special Enrollment — select one of the following qualifying events and indicate date of event here: Loss of Coverage – documentation of loss of coverage required. Birth Adoption – documentation of adoption placement. Marriage – documentation of marriage certificate required Divorce or legal separation – documentation of divorce decree required Death of covered individual – documentation of death certificate required Dependent ceasing to be a dependent – documentation of loss of coverage required Gained status as a citizen, national or lawfully present individual – documentation of permanent residency card Move to a new residence in a different premium rating area – documentation of prior and new residency Individual becomes entitled to benefits under XVIII of the Social Security Act (Medicare) A proceeding in a case under Title 11, United States Code, commencing on or after July 1, 1986 with respect to the employer from whose employment the covered individual retired at any time
3. APPLICANT INFORMATION If this application is for: x Child(ren) Only coverage, the applicant must be the youngest child. x Self and Spouse coverage, the applicant must be the youngest spouse. _
_
Social Security Number
Date of Birth
Social Security Number must be provided for applicant.
Applicant First Name
Middle Initial
Street Address
Billing Address
City
State
Home Phone ( Gender
Male
Marital Status
_)
_—
Female Single
Work Phone (
_)
Last Name
ZIP _—
County
_ Email Address
Language preferred (spoken and/or written) if not English
Married
Divorced
Best time to reach you from 8 a.m. to 5 p.m. CT, Monday through Friday Any tobacco use in the last 6 months?
Yes
No*
*If you answered “No,” you are eligible for a special tobacco non-user rate. If this status changes, you must notify us immediately. We may require you to recertify this status in the future. If we determine within the initial two years that this status is incorrect, we may start applying the tobacco user rates on the first of the month following receipt of this information.
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4. COVERAGE ELECTION This request for coverage is for (please check one): Self
Self and Spouse
Self and Child(ren)
Child(ren) Only
Family
5. DEPENDENT INFORMATION A. Complete for covered dependents only. (If more space is needed, attach an additional sheet of paper, sign and date it.) Gender (Male or Female)
Relationship
02 Spouse
M F
Spouse
03 Dependent
M F
Yes No***
04 Dependent
M F
Yes No***
05 Dependent
M F
Yes No***
06 Dependent
M F
Yes No***
Legal Last Name, First Name, Middle Initial
Birth Date (Mo/Day/Yr)
Social Security Number
Any tobacco use in the past 12 months?
Yes No***
*South Dakota residents only: If the dependent is 26 through 29 years old and enrolled in and attending an accredited college, university, or trade or secondary school on a full time basis, he or she must remain a continuous full-time student through the age of 29 and not have other creditable coverage to be eligible for this plan. Proof of full-time student status must be provided for the enrollment process. Please note the name of the school your dependent attends and include a copy of their enrollment record from the school’s registrar. School Name
City
State
ZIP
**Social Security Number (SSN) must be provided for every dependent applying for coverage. ***If you answered “No,” you are eligible for a special tobacco non-user rate. If this status changes, you must notify us immediately. We may require you to recertify this status in the future. If we determine within the initial two years that this status is incorrect, we may start applying the tobacco user rates on the first of the month following receipt of this information.
B. Do all of the dependent(s) listed above reside in the same city and state as the applicant?
Yes
No
If no, list dependent(s) City
State
ZIP
C. Is anyone listed on the application disabled and eligible for Medicare?
Yes
No
If yes, list name(s)
6. OTHER INSURANCE COVERAGE A. Are you currently or have you previously been enrolled with Avera Health Plans?
Yes
No
If yes, list member number B. Is anyone named on the application eligible for Medicare / Medicaid? If yes, list name(s)
Yes
No
Medicare or Medicaid Number(s)
C. Will you or any of your family members be covered by another health policy after the effective date with Yes
Avera Health Plans?
No
If yes, you must provide the following information to coordinate benefits: Insurance Company
Insurance Company Phone Number
Covered Individual
Member Number
Type of Policy Group or Individual (If Group, List Employer)
Effective Date
Termination Date
Group, Employer Name: (_
(_
ENR-FORM-123 (10/16)
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_) _
_-
_-
_
_
_ Individual Group, Employer Name: _ Individual Page 3 of 5
7. BENEFIT PLANS Please select one and proceed to Section 8: Health Plans with Pediatric Dental Coverage As part of the Essential Health Benefits, dependents under the age of 19 must have dental coverage. The following plans offer pediatric dental as part of the health insurance plan: Avera 1500 with Pediatric Dental Coverage Avera 2500 with Pediatric Dental Coverage Avera 3000 with Pediatric Dental Coverage Avera 3500 with Pediatric Dental Coverage Avera 5000 with Pediatric Dental Coverage
Health Plans without Pediatric Dental Coverage Avera 1500 Avera 2500 Avera 3000 Avera 4000 Avera 5000 Avera 6550 Avera 7150 Requirements to choose this plan also include: x Individual has not attained the age of 30 before the beginning of the plan year; or x Has a certification in effect for any plan year under this title that the individual is exempt from the requirement under section 5000A of the Internal Revenue Code of 1986 by reason of (i) section 5000A(e) (1) of such Code (relating to individuals without affordable coverage); or (ii) section 5000A (e) (5) of such Code (relating to individuals with hardships).
VERY IMPORTANT! If you selected a health plan without pediatric dental coverage, please read the following: For applicants who have a dependent(s) under the age of 19 who are applying for an Avera policy without pediatric dental coverage. I attest that I will purchase (or currently have) pediatric dental coverage with a different provider: SIGN HERE
Applicant Signature Required __________________________________________ Date A
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8. FAILURE TO DISCLOSE I represent that all information listed on this application and any accompanying documents is/are complete and accurate to the best of my knowledge. I understand that my answers to the questions on this form will be used to determine eligibility for coverage and is the basis on which my premium rate may be determined. I further understand that if I intentionally misrepresent or conceal a fact and coverage would have been denied or I could be charged a higher premium, that action could provide the basis to refuse or rescind coverage and to refund any premiums paid as though coverage had never been in force. If an applicant intentionally misrepresents or conceals a fact and coverage would have been denied or charged a higher premium because the claim was incurred during the first two years of the policy, a review by Avera Health Plans will occur.
9. AUTHORIZATION TO RELEASE INFORMATION In order for Avera Health Plans to report your coverage status to the federal government, you must provide to us your Social Security number and the Social Security numbers of all members included under your coverage. The IRS requires that Avera Health Plans report this information. If Avera Health Plans does not have Social Security numbers, we will be unable to report and send the information needed to complete federal tax returns. If you do not provide the Social Security numbers to Avera Health Plans for this purpose, you may be subject to a $50 penalty per violation imposed by the Internal Revenue Service. I authorize Avera Health Plans, its employees and agents, to disclose and obtain records and information as permitted by law to authorized persons including other insurers or reinsurers, vendors of employee insurance or cafeteria plans. Avera Health Plans may be compensated by other insurers or vendors. A copy of this authorization is as valid as the original. Unless otherwise stated or revoked by my written revocation, this authorization terminates when enrollment in Avera Health Plans terminates. This information may be used to determine eligibility for benefits, payment responsibility and utilization review. I agree to abide by the documents describing my coverage (including but not limited to the Certificate of Coverage, Member Guide and Summary of Benefits and Coverage) and to pay any applicable premiums, co-payments, coinsurance and deductibles. I understand that my enrollment or eligibility for benefits in Avera Health Plans is conditional upon me signing this authorization and that failure to sign may result in being denied enrollment or benefits. I understand that I can revoke this authorization at any time by giving written notice to Avera Health Plans at 3816 S. Elmwood Ave., Suite 100, Sioux Falls, SD 57105-6538. I also understand that my revocation will not affect the rights of any individual who has acted in reliance on the authorization prior to receiving the notice of my revocation. I understand that there is a possibility of redisclosure of any information disclosed pursuant to this authorization and that information, once disclosed, may no longer be protected by federal rules governing privacy and confidentiality.
10. AGREEMENT AND CERTIFICATION I certify that I am legally authorized to apply for coverage for myself and on behalf of all other persons named in this application. I understand that I am applying for coverage as indicated on this application. I further understand that coverage applied for will not start until this application and the appropriate premium payment amount are received and accepted by Avera Health Plans, an effective date of coverage is established and Avera Health Plans notifies me in writing of approval of coverage. I certify that I have carefully and fully read the Agreement and Certification language. I have confirmed with all persons named in this application that my signature is binding to secure coverage. I have further confirmed with all persons named in the application that in the event I am not eligible for or removed from the coverage and/or the family coverage is divided into multiple policies, my signature is binding to secure coverage. Any payment will be held until the application process is complete. I have reviewed the checklist on the cover page and have completed all necessary sections of this application. SIGN HERE
Applicant Signature Ap
Date
Parent/Legal Guardian Signature (if applicant is a minor)
Date
NOTE: If guardian, please provide proof of guardianship. Parent/Legal Guardian Name (please print) Relationship Agent’s Signature
Date
Agent Name (please print)
Agency Name
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