Special Enrollment Period Form - Highmark

[Pages:8]SPECIAL ENROLLMENT PERIOD FORM

A Special Enrollment Period (SEP) is defined as a period during which you and your family have a right to sign up for new or make changes to existing health insurance coverage. SEP qualifying life events include, but are not limited to, certain permanent moves, changes in your family size (such as marriage, birth or adoption) or loss of minimum essential coverage. In most instances, consumers have 60 days from the occurrence of the qualifying life event to sign up for or make changes to existing coverage.

This SEP form CANNOT be used to make changes to coverage purchased from the Health Insurance Marketplace or to purchase new coverage from the Health Insurance Marketplace. To make such changes or purchases, you must contact the Health Insurance Marketplace directly.

If you would like to enroll or change plans due to a qualifying life event, you must complete this form and return it with a completed application and any necessary supporting documents within the required time frame.

The receipt of a completed SEP form, along with a completed application and supporting documentation is the only form of notification that will be accepted. Failure to provide all required materials may delay your coverage effective date or cause you to be denied coverage. The effective date of coverage will be determined by the receipt date of completed information as specified above. The coverage effective date cannot be prior to the occurrence of the event. Applications received outside of the required SEP time frame for the specified qualifying life event will be denied. For more information on SEP submission deadlines, please visit .

Select the appropriate qualifying life event below and sign the form. The listing of qualifying events is subject to change. If you do not see the qualifying event that describes your situation, please contact the Health Insurance Marketplace at 1-800-318-2596.

LAST NAME

FIRST NAME

POLICY HOLDER INFORMATION

M.I.

SOCIAL SECURITY NUMBER

DATE OF EVENT

STREET ADDRESS

CITY

STATE

PA

ZIP CODE

SELECT QUALIFYING LIFE EVENT

COVERAGE EFFECTIVE DATE*

TYPES OF SUPPORTING DOCUMENTS

You may qualify for a Special

Date of birth, adoption, placement for

- Birth Certificate

Enrollment Period if you or anyone in your household, in the past 60 days, had a baby, adopted a

adoption or foster care OR the first day of the month following the event date or as described below. For court order, date

- Existing Highmark member with proof of claims for birth

child, placed a child for foster care or are under court order to provide coverage for someone

the order is effective or if plan selection is between 1st and 15th of the month, coverage will start on the 1st day of the following

- Legal papers for Adoption or Foster Care

else. You may also qualify for a

month. If the plan selection is between the - Court Order

Special Enrollment period if you need to enroll in coverage due to domestic abuse or spousal abandonment.

16th and end of the month, coverage will start the 1st day of the second month.

NOTE: Documentation of prior coverage ending is not required if you are seeking

Effective date requested:_______________ coverage due to domestic abuse or spousal

abandonment. When applying for coverage

in this instance, please sign as the policy-

holder on page three of this form.

You may qualify for a Special Enrollment Period if you, in the past 60 days, got married or created a new Domestic Partnership.

First day of the month following plan selection.

- Marriage certificate - Domestic partnership certification

* Coverage effective date cannot be prior to the occurrence of the event.

Page 1 of 6

CC-053B (R2-17)

SELECT QUALIFYING LIFE EVENT

COVERAGE EFFECTIVE DATE*

TYPES OF SUPPORTING DOCUMENTS

You may qualify for a Special

If plan selection is on or before the date of Documentation showing loss

Enrollment Period if you or anyone loss of coverage the effective date is the of medically needy coverage or

in your household lost qualifying health coverage in the past 60 days OR expects to lose coverage in the next 60 days.

first day of the month following the loss of Minimum Essential Coverage,

coverage. If plan selection is after the loss including:

of coverage the effective date is the first day of the month following the receipt

? Termination Date

of this form along with a completed

? People covered by the plan

Coverage losses that may qualify you for application and any supporting

a Special Enrollment Period:

documentation.

Loss of job-based coverage

Expiration of COBRA coverage or

non-calendar year policy

Losing individual health coverage for

- Letter of termination from carrier/ insurance company (includes dependent age max reached)

- Notice of termination of government sponsored coverage

a plan or policy you bought yourself Losing eligibility for Medicaid or

CHIP Losing eligibility for Medicare Losing coverage through a family

member Group plan employee/policy

holder becomes Medicare entitled and is no longer eligible

- Letter/notice of termination of benefits from the employer (includes divorce from policy holder, death of policy holder or policy holder becomes Medicare entitled)

- COBRA eligibility notice or documentation showing that

for group coverage

COBRA coverage or non-calendar

Death of policy holder

year policy is ending

Child loses dependent status Legal separation/divorce from

policy holder

NOTE: Voluntarily quitting other health insurance coverage, being terminated for not paying premiums or losing health insurance

NOTE: Documentation of prior coverage ending is not required if a Highmark plan is being replaced and is indicated on the application for individual/family plan health insurance.

coverage that does not qualify as minimum

essential coverage are not considered a loss of

minimum essential coverage.

You may qualify for a Special Enrollment Period if you, in the past 60 days, made a permanent move to a new area that offers different health plan options. Qualifying events may include:

? Moving to a new home in a new ZIP code or county

? Moving to the U.S. from a foreign country or United States territory

? A student moving to or from the place they attend school

? A seasonal worker moving to or from the place they both live and work

? Moving to or from a shelter or other transitional housing

? Return from active military service ? Release from incarceration

If the plan selection is between the 1st and - Notice from carrier no longer

15th of the month, coverage will start as

providing health insurance

soon as the 1st day of the following month. coverage

If the plan selection is between the 16th and end of the month, coverage will start the 1st day of the second month.

- Proof of new residence such as dated rental/lease agreement, deed, purchase agreement, new driver's

Note: Moving only for medical treatment or staying license or state photo ID card

somewhere for vacation doesn't qualify you for an - A utility bill in the applicant's name

SEP. Important: You must prove you had qualifying health coverage for one or more days during the 60

and containing the new address

days before your move. You don't need to provide - Prison release form proof of prior coverage if you're moving from a foreign country or United States territory, are returning from - Supporting paperwork confirming active military service or release from incarceration. departure date from active military

service

- A stamped visa if moving from a foreign county

* Coverage effective date cannot be prior to the occurrence of the event.

Page 2 of 6

SELECT QUALIFYING LIFE EVENT

COVERAGE EFFECTIVE DATE*

A change in income, household or other status that affects eligibility for Advance Premium Tax Credits (APTC) or Cost-Sharing Reductions (CSR). Must currently be enrolled in a Qualified Health Plan.

If the plan selection is between the 1st and 15th of the month, your coverage will start as soon as the 1st day of the following month. If the plan selection is between the 16th and end of the month, your coverage will start the 1st day of the second month.

TYPES OF SUPPORTING DOCUMENTS

- You must send in the necessary supporting documentation from the Health Insurance Marketplace

Determine to be newly eligible for Advance Premium Tax Credit (APTC) due to not being eligible for coverage by an eligible employer sponsored plan

Notification can be 60 days prior to and 60 - You must send in the necessary

days after the loss of coverage. If plan

supporting documentation from

selection is before or on the date of loss of the Health Insurance Marketplace

coverage the effective date is the first day

of the month following the loss of coverage.

If plan selection is after the loss of coverage

the effective date is the first day of the

month following the plan selection.

The Health Insurance Marketplace determined that an unintentional enrollment error is the result of an action or omission by an agent of the Health Insurance Marketplace or Non-Health Insurance Marketplace entry.

The Health Insurance Marketplace determines that there has been a violation of a material provision of the health insurance plan in which you or a dependent are enrolled. Must currently be enrolled in a Qualified Health Plan.

Coverage effective date will be determined by the Health Insurance Marketplace.

Coverage effective date will be determined by the Health Insurance Marketplace.

- You must send in the necessary supporting documentation from the Health Insurance Marketplace

- You must send in the necessary supporting documentation from the Health Insurance Marketplace

To the best of my/our knowledge and belief, the information provided on this Special Enrollment Period Form is true and correct.

I also understand that any attempts to make a change to current enrollment through fraud or other intentional misrepresentation of a material fact will result in termination of such contract.

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.

POLICYHOLDER'S SIGNATURE

DATE

Notice to All Applicants: If you are applying for coverage due to a Special Enrollment Period, you must sign this Special Enrollment Period Form. If you are unmarried, under age 18 and applying for a policy that only covers yourself, your parent or guardian must sign. Note: The deductible amount and out-of-pocket maximum for your new individual coverage will reset on January 1st.

To submit you can:

? Mail to: Highmark Blue Cross Blue Shield P.O. Box 382555 Pittsburgh, PA 15250-8555

? Fax to Highmark at 1-866-224-5403

You MUST send in a completed Special Enrollment Period form along with a completed application and any supporting documentation or we will not be able to process your new coverage.

? Call a Highmark licensed representative at 1-855-329-1766

? Visit your insurance agent

? Visit a Highmark Insurance store

* Coverage effective date cannot be prior to the occurrence of the event. Page 3 of 6

PRINT PRODUCER NAME

FOR PRODUCER USE ONLY

PRODUCER SIGNATURE

DATE

By signing this Special Enrollment Period Form I do hereby attest, acknowledge and agree to the following:

? The Policyholder has designated me as their authorized representative in compliance with all applicable state and federal laws, rules, regulations and guidelines;

? I have read this Special Enrollment Period Form to the Policyholder required to sign this Form and such Policyholder ACCEPTS the terms and conditions set forth in this Form;

? I will immediately send a copy of this completed and submitted Special Enrollment Period Form to the Policyholder in a secure manner in compliance with all applicable state and federal laws, rules, regulations and guidelines; and

? I have retained a copy this completed and submitted Special Enrollment Period Form for my records.

Blue Cross Blue Shield Agency No.

Producer No.

Insurance may be provided by Highmark Blue Cross Blue Shield, Highmark Choice Company or Highmark Health Insurance Company, all of which are independent licensees of the Blue Cross and Blue Shield Association. Information regarding the Patient Protection and Affordable Care Act of 2010 (a.k.a. "PPACA", "Affordable Care Act", "ACA", and/or "Health Care Reform"), as amended, and/or any other law, does not constitute legal or tax advice and is subject to change based upon the issuance of new guidance and/or change in laws. State laws may be applicable. Any review of materials, request for information, or application does not obligate you to enroll for coverage. Please request the Outline of Coverage for details on benefits, conditions and exclusions. Providing your information is voluntary. To find more information about Highmark's benefits and operating procedures, such as accessing the drug formulary or using network providers, please go to QualityAssurance; or for a paper copy, call 1-855-873-4106.

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Discrimination is Against the Law The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex, including sex stereotypes and gender identity. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex assigned at birth, gender identity or recorded gender. Furthermore, the Claims Administrator/Insurer will not deny or limit coverage to any health service based on the fact that an individual's sex assigned at birth, gender identity, or recorded gender is different from the one to which such health service is ordinarily available. The Claims Administrator/Insurer will not deny or limit coverage for a specific health service related to gender transition if such denial or limitation results in discriminating against a transgender individual. The Claims Administrator/Insurer: ? Provides free aids and services to people with disabilities to communicate effectively with us, such as:

? Qualified sign language interpreters ? Written information in other formats (large print, audio, accessible electronic formats, other formats) ? Provides free language services to people whose primary language is not English, such as: ? Qualified interpreters ? Information written in other languages If you need these services, contact the Civil Rights Coordinator. If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, including sex stereotypes and gender identity, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at , or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at .

Si usted habla espa?ol, servicios de asistencia ling??stica, de forma gratuita, est?n disponibles para usted. Llame al 1-800-876-7639.

1-800-876-7639.

Nu qu? v n?i ting Vit, ch?ng t?i cung cp dch v h tr ng?n ng min ph? cho qu? v. Xin gi s 1-800-876-7639.

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 -, . 1-800-876-7639. Wann du Deitsch schwetzscht, kannscht du en Dolmetscher griege, un iss die Hilf Koschdefrei. Kannscht du 1-800-876-7639 uffrufe. . 1-800-876-7639 . Se parla italiano, per lei sono disponibili servizi di assistenza linguistica a titolo gratuito. Chiamare l'1-800-876-7639.

Arabic: 1-800-876-7639.

Si vous parlez fran?ais, les services d'assistance linguistique, gratuitement, sont ? votre disposition. Appelez au 1-800-876-7639.

Wenn Sie Deutsch sprechen, steht Ihnen unsere fremdsprachliche Unterst?tzung kostenlos zur Verf?gung. Rufen Sie 1-800-876-7639.

Dla os?b m?wicych po polsku dostpna jest bezplatna pomoc jzykowa. Zadzwo 1-800-876-7639. Si se Krey?l Ayisyen ou pale, gen s?vis ent?pr?t, gratis-ticheri, ki la pou ede w. Rele nan 1-800-876-7639.

Se a sua l?ngua ? o portugu?s, temos atendimento gratuito para voc? no seu idioma. Ligue para 1-800-876-7639.

Kung nagsasalita ka ng Tagalog, may makukuha kang mga libreng serbisyong tulong sa wika.Tumawag sa 1-800-876-7639.

Japanese: ? 1-800-876-7639

Din? kehgo y?n?ltigo, language assistance services, ?? t?? n??keh, bee n?k? adoowol, ?? bee n?ah??ti. Koj hod?ilnih 1-800-876-7639.

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