1. No category

TO:
STL Employees
FROM:
Paul Doucette
IBG Benefits Management Co., Inc.
DATE:
December 12, 2011
RE:
eHOPE Enrollment Procedure
In order to enroll in the eHOPE Plan, employees will need to complete the eHOPE Enrollment Document
Packet consisting of five forms. If you are electing to remain on the current PPO Plan these documents
do not need to be completed and no further action is required on your part. These documents are only
required if you are electing the eHOPE Plan. The required documents are found in order below and
instructions for completing them are as follows:
eHOPE Member Enrollment Form - This form should be completed and returned together with ALL
OTHER FORMS in one of the methods indicated at the top of the form. The preferred method for
receipt is via secure fax to (404) 506-9164.
eHOPE HIPPA Privacy Statement – This form sets forth IBG’s commitment to the privacy of your
protected health information. Please read and sign it.
Data Collection Form for Allstate Gap - Complete the “Employee Information” and “Dependent
Information” sections only. Sign and Date. We will complete the remainder of the form for you.
DirectPay HRA Enrollment Form - This form is required to have your HRA Debit Card issued and your
family’s HRA account established. Please complete the entire form using the following specific
information:
Plan Type:
Initial Date of Coverage:
Name of Insurance Carrier:
Direct HRA
1-1-12
BCBS-IL
Blue Cross/ Blue Shield Application – Only complete Sections A, B & I. (other sections omitted for your convenience)
Blue Cross/Blue Shield Benefit Highlights – This form describes the underlying medical insurance used
in the eHOPE Plan. This does not need to be signed and is provided for your information only.
You should retain a copy of all documents for your records. If you have any questions please contact
one of the following individuals:
Nicole Watson, Account Manager (630) 433-7670 – cell
Camron Howell, IBG Principal
(480) 326-8665 – cell
Paul Doucette, IBG Principal
(770) 876-3553 – cell
[email protected]
[email protected]
[email protected]
Send Completed Form
Mail or Hand Delivery:
Your Employer’s Benefits Administrator
Via Secure Fax to:
(404) 506-9164
For Secure e-Mail Protocols call: (877) 424-2366, ext 750
eHOPE Member Enrollment
Employer
Employee Information
Employee Name
Occupation
Mailing Address
City
State
E-Mail
Home Phone
Cell Phone
Zip
Family Members
(include children under age 26)
Date of Birth
Name
Age
Gender
(M/F)
SSN
Occupation
Spouse
Child
Child
Child
Child
Child
Child
Child
Child
Specify any Voluntary
Benefits You have elected
□ EE Life
□ STD
□ Dependent Life
□ Pre-Paid Legal
□ Cancer
□ LTD
□ Critical Illness □ Accident
□ Long Term Care □ Vision
□ Gap
□ Dental
Acknowledgment
I hereby enroll myself and my dependents in the Health Option Plan for Employees (eHOPE). I acknowledge that while a member of the eHOPE Plan I cannot
make contributions to a Health Savings Account (HSA).
Signature:
Date:
P.O B ox 2925 • Frederik sted • VI 00841
770 Old Rosw ell Plac e • S uite A500 • Ro swell • GA 00876
501 S. Tow anda Barnes Rd. • Suit e 3 • Bloomington • IL 617 05
Tel (877) 424-2366 • Fax (404) 506-9164
NOTE: Keep one copy of this
Notice for your records and
Return one signed copy with
your enrollment documents.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT
YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN
GET ACCESS TO THIS INFORMATION
_______________________
PLEASE REVIEW CAREFULLY
IBG Benefits Management Company, Inc. (IBG) values you as a participant in the Health Option Plan for Employees (eHOPE), and
protection of your privacy is very important to us. As an eHOPE member you and your family will have access to services provided by
your group major medical insurance company, Allstate Workplace Division, US Preventive Medicine, Inc., The Karis Group, Inc., Teladoc,
and Total Administrative Services Corporation (TASC). These firms are Business Associates of IBG. A “Business Associates” a business
associate is a person or organization, other than a member of IBG’s workforce, that performs certain functions or activities on behalf of,
or provides certain services to, a covered entity that involve the use or disclosure of individually identifiable health information. Business
associate functions or activities on behalf of a covered entity include claims processing, data analysis, utilization review, and billing.
These business associates provide services designed to assist you and your families in maintaining and improving your health and
reducing health care costs.
Your use of these firms and the services they provide is completely voluntary. In order to provide services to you these firms may require
you to disclose or release protected health information (PHI). “Protected Health Information” or “PHI” is information about you,
including information about where you live, that can reasonably be used to identify you and that relates to your past, present or future
health or condition, the provision of health care to you or the payment for that care.
In order to facilitate the provision of health care services to you, you will be asked to disclose health related information on the forms
necessary to complete your enrollment in your company’s group health care plan and the eHOPE Plan. Information provided by you may
be disclosed to the firms indicated above but only to the extent such information is necessary to facilitate and coordinate your health
care needs and services and the payment for those services.
We protect your privacy by:
• limiting who may see your PHI;
• limiting how we may use or disclose your PHI;
• informing you of our legal duties with respect to your PHI;
• explaining our privacy policies; and
• adhering to the policies currently in effect.
This Notice describes our privacy practices, which include how we may use, disclose, collect, handle, and protect eHOPE members’
protected health information. We are required by certain federal and state laws to maintain the privacy of your protected health
information. We also are required by the federal Health Insurance Portability and Accountability Act (or “HIPAA”) Privacy Rule to give you
this Notice about our privacy practices, our legal duties, and your rights concerning your protected health information. This Notice takes
effect on April 24, 2003, and will remain in effect until we replace or modify it.
Copies of this Notice
You may request a copy of our Notice at any time. If you want more information about our privacy practices, or have questions or
concerns, please contact IBG Benefits Management Company, Inc., Legal/Privacy Officer, 770 Old Roswell Rd., Suite A500, Roswell, GA
30076 or calling toll free (877) 424-2366 ext. 750.
Changes to this Notice
The terms of this Notice apply to all records that are created or retained by us which contain your PHI. We reserve the right to revise or
amend the terms of this Notice. A revised or amended Notice will be effective for all of the PHI that we already have about you, as well
as for any PHI we may create or receive in the future. We are required by law to comply with whatever Privacy Notice is currently in
effect. You will be notified of any material change to our Privacy Notice before the change becomes effective. When necessary, a revised
Notice will be mailed to the address that we have on record for the contract holder of your member contract, and will also be posted on
our web site at www.insightbenefitsgroup.com.
P.O B ox 2925 • Frederik st ed • V I 0084 1
770 Ol d Roswell Plac e • S uit e A500 • Roswell • GA 30 076
501 S . T owa nda B arn es R d. • S uit e 3 • Bl oomi ngt on • IL 6 1705
Tel (877) 424-23 66 • Fa x (404) 506 -9164
How We May Use and Disclose Your Protected Health Information (PHI)
In order to administer your eHOPE health benefit programs effectively, we will collect, use and disclose PHI for certain of our activities,
including payment of covered services and health care operations. The following categories describe the different ways in which we may
use and disclose your PHI. Please note that every permitted use or disclosure of your PHI is not listed below. However, the different ways
we will, or might, use or disclose your PHI do fall within one of the permitted categories described below.
Payment: We may use and disclose your PHI for the purpose of assisting you in resolving payment and billing issues related to health care
services provided to you and your family under your group health plan. This may include coordinating benefits among other health care
programs or insurance carriers. For example, we may use and disclose your PHI to determine liability payment or claims for medical
services provided to you by doctors or hospitals which are covered by your health plan(s), or to determine if requested services are
covered under your health plan. We may also use and disclose your PHI to conduct business with other IBG affiliate companies with
whom we have a Business Associate Agreement.
Health Care Operations: We may use and disclose your PHI to conduct and support our business and management activities as a health
insurance issuer. For example, we may use and disclose your PHI to determine our premiums for your health plan, to conduct quality
assessment and improvement activities, to conduct business planning activities, to conduct fraud detection programs, to conduct or
arrange for medical review, or to engage in care coordination of health care services.
We may also use and disclose your PHI to offer you one of our value added programs like smoking cessation or discounted health related
services, or to provide you with information about one of our disease management programs or other available IBG health products or
health services.
We may also use and disclose your PHI to provide you with reminders to obtain preventive health services, and to inform you of
treatment alternatives and/or health related benefits and services that may be of interest to you.
Release of Information to Plan Sponsors: Plan sponsors are employers or other organizations that sponsor a group health plan. We may
disclose PHI to the plan sponsor of your group health plan as follows:
• We may disclose “summary health information” to your plan sponsor to use to obtain premium bids for providing
health insurance coverage or to modify, amend or terminate its group health plan. “Summary health
information” is information that summarizes claims history, claims expenses, or types of claims experience for
the group of individuals without identifying any condition, treatment or expense for a particular individual by
name.
•
We may disclose PHI of your identity to your plan sponsor to verify enrollment/disenrollment in your group
health plan or so that the plan sponsor can administer the group health plan; and
We will not disclose to your employer any information regarding any medical conditions or treatments.
Required by Law: We may disclose your PHI when required to do so by applicable law. For example, the law requires us to disclose your
PHI:
•
To You: When you ask us to, we will disclose to you your PHI that is in a “designated record set.” Generally, a
designated record set contains medical, enrollment, claims and billing records we may have about you, as well as
other records that we use to make decisions about your health care benefits. You can request the PHI from your
designated record set as described in the section below called “Your Privacy Rights Concerning Your Protected
Health Information.”
•
To Your Personal Representative: If you provide us with written instructions, we will disclose your PHI to
someone who is qualified to act as your personal representative according to any relevant state laws.
•
Parents as Personal Representatives of Minors: In most cases, we may disclose your minor child’s PHI to you.
However, we may be required to deny a parent’s access to a minor’s PHI according to applicable state law.
Right to Provide an Authorization for Other Uses and Disclosures
•
Other uses and disclosures of your PHI that are not described above will be made only with your written authorization.
•
You may give us written authorization permitting us to use your PHI or disclose it to anyone for any purpose.
•
We will obtain your written authorization for uses and disclosures of your PHI that are not identified by this Notice, or are
not otherwise permitted by applicable law.
Any authorization that you provide to us regarding the use and disclosure of your PHI may be revoked by you in writing at any time. After
you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Of course, we
P.O B ox 2925 • Frederik st ed • V I 0084 1
770 Ol d Roswell Plac e • S uit e A500 • Roswell • GA 30 076
501 S . T owa nda B arn es R d. • S uit e 3 • Bl oomi ngt on • IL 6 1705
Tel (877) 424-23 66 • Fa x (404) 506 -9164
are unable to take back any disclosures that we have already made with your authorization. We may also be required to disclose PHI as
necessary for purposes of payment for services received by you prior to the date when you revoke your authorization.
Your authorization must be in writing and contain certain elements to be considered a valid authorization.
Your Privacy Rights Concerning Your Protected Health Information (PHI)
You have the following rights regarding the PHI that we maintain about you. Requests to exercise your rights as listed below must be in
writing.
Right to Access Your PHI: You have the right to inspect or get copies of your PHI contained in a designated record set.
Generally, a “designated record set” contains medical, enrollment, claims and billing records we may have about you, as well as
other records that we may use to make decisions about your health care benefits. However, you may not inspect or copy
psychotherapy notes or certain other information that may be contained in a designated record set.
You may request that we provide copies of your PHI in a format other than photocopies. We will use the format you request
unless we cannot practicably do so. We may charge a reasonable fee for copies of PHI (based on our costs), for postage, and for
a custom summary or explanation of PHI. You will receive notification of any fee(s) to be charged before we release your PHI,
and you will have the opportunity to modify your request in order to avoid and/or reduce the fee. In certain situations we may
deny your request for access to your PHI. If we do, we will tell you our reasons in writing, and explain your right to have the
denial reviewed.
Right to Amend Your PHI: You have the right to request that we amend your PHI if you believe there is a mistake in your PHI, or
that important information is missing. Approved amendments made to your PHI will also be sent to those who need to know,
including (where appropriate) IBG’s vendors (known as "Business Associates"). We may also deny your request if, for instance,
we did not create the information you want amended. If we deny your request to amend your PHI, we will tell you our reasons
in writing, and explain your right to file a written statement of disagreement.
Right to an Accounting of Certain Disclosures: You may request, in writing, that we tell you when we or our Business Associates
have disclosed your PHI (an “Accounting”). Any accounting of disclosures will not include those we made:
• for payment, or health care operations;
• to you or individuals involved in your care;
• with your authorization;
• for national security purposes;
• to correctional institution personnel; or
• before April 14, 2003.
The first accounting in any 12-month period is without charge. We may charge you a reasonable fee (based on our cost) for
each subsequent accounting request within a 12-month period. If a subsequent request is received, we will notify you of any
fee to be charged, and we will give you an opportunity to withdraw or modify your request in order to avoid or reduce the fee.
Right to Request Restrictions: You have the right to request, in writing, that we place additional restrictions on our use or
disclosure of your PHI. We are not required to agree to your request. However, if we do agree, we will be bound by our
agreement except when required by law, in emergencies, or when information is necessary to treat you. An approved
restriction continues until you revoke it in writing, or until we tell you that we are terminating our agreement to a restriction.
Right to Request Confidential Communications: You have the right to request, in writing, that we use alternate means or an
alternative location to communicate with you in confidence about your PHI. For instance, you may ask that we contact you by
mail, rather than by telephone, or at work, rather than at home or vice versa.
Right to a Paper Copy of This Notice: You have the right to receive a paper copy of our Notice of Privacy Practices. You can
request a copy at any time, even if you have agreed to receive this Notice electronically. To request a paper copy of this Notice,
please contact IBG at the address and phone number listed below.
P.O B ox 2925 • Frederik st ed • V I 0084 1
770 Ol d Roswell Plac e • S uit e A500 • Roswell • GA 30 076
501 S . T owa nda B arn es R d. • S uit e 3 • Bl oomi ngt on • IL 6 1705
Tel (877) 424-23 66 • Fa x (404) 506 -9164
Your Right to File a Privacy Complaint
If you believe your privacy rights have been violated, or if you are dissatisfied with IBG’s privacy practices or procedures, you may file a
complaint with the IBG Privacy Office and with the Secretary of the U.S. Department of Health and Human Services. You will not be
penalized for filing a complaint. To file a privacy complaint with us, you may contact the Privacy Office as follows:
IBG Benefits Management Co., Inc.
Attn: Legal/Privacy Officer
770 Old Roswell Rd. Suite A500
Roswell, GA 30076
Fax: (404) 506-9184
Phone: 877-424-2366 (Ext 750)
Acknowledgement of Receipt & Consent to Disclosure
I, ____________________________________________, on behalf of myself and my dependents as covered under the eHOPE plan,
hereby acknowledge receipt of a copy of this Privacy Notice and consent to the limited disclosure of protected health information as set
forth in this Privacy Notice.
____________________________________
Signature
_____________________________________
Print Name
P.O B ox 2925 • Frederik st ed • V I 0084 1
770 Ol d Roswell Plac e • S uit e A500 • Roswell • GA 30 076
501 S . T owa nda B arn es R d. • S uit e 3 • Bl oomi ngt on • IL 6 1705
Tel (877) 424-23 66 • Fa x (404) 506 -9164
_______________
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DirectPay Enrollment Form
For enrollment assistance call 1-800-422-4661 for customer service. Have your enrollment form, Client number and company
name ready. Please print.
Client ID Number
Employer Name
Social Security Number*
Employee Last Name
First Name
Employee Address
Middle Initial
City
Date of Birth*
Date of Hire
Initial Date of Coverage
Name of Insurance Carrier
State
Gender
Zip Code
Plan Type
Participant E-mail Address
Participant Phone Number
For Dependent Coverage:
Married?
 Yes
No
Dependent children?
Yes
No
If yes, list your spouse and dependent children below:
Last Name
First Name
Social Security
Number
Relationship
to Employee
Date of
Birth
Gender
______________________ __________________ __________________ _______________ _______________ ______
______________________ __________________ __________________ _______________ _______________ ______
______________________ __________________ __________________ _______________ _______________ ______
______________________ __________________ __________________ _______________ _______________ ______
______________________ __________________ __________________ _______________ _______________ ______
______________________ __________________ __________________ _______________ _______________ ______
AUTHORIZATION: I certify the above information to be true to the best of my knowledge and that the children for whom I will be
claiming expenses either reside with me in a parent-child relationship or are legally dependent on me for their support. I understand that
any amounts remaining in my account(s) not used for qualified expenses incurred during the plan year will be forfeited in accordance with
current plan provisions and tax laws.
Signature ______________________________________________________ Date ________________
* Social Security and date of birth information for employees and their dependents is required for HRA reporting purposes to the Centers for Medicare and Medicaid
Services as part of the Medicare, Medicaid and SCHIP Extension Act of 2007. Enrollment Forms without this required information will be returned for completion.
Completed forms can be faxed to 608-663-2754 or mailed to DirectPay, 2302 International Lane, Madison, WI 53704.
7$6&‡,QWHUQDWLRQDO/DQH‡0DGLVRQ:,‡‡)D[‡ZZZWDVFRQOLQHFRP
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1
DP-3470-102210
Blue Cross and Blue Shield of Illinois Cover Page to the
Illinois Standard Health Employee Application for Small Employers
(Groups sized 2 - 150)
The purpose of this document is to help you – an employee requesting coverage from Blue Cross and Blue Shield of Illinois (BCBSIL) – fill out
the new standard enrollment application created by the State of Illinois Department of Insurance.
As a result of the Illinois Insurance Fairness Act (Public Act 96-0857), the Illinois Department of Insurance created standard enrollment
applications that must be used by all insurance companies doing business in the small group and individual markets.
The attached standard application goes into effect January 1, 2011 and replaces the small group enrollment applications previously used by
insurance companies.
Although all insurance companies must use this standard enrollment application, the business needs and practices of all insurance companies are
not the same. Not all the information requested on the new standard enrollment application is required by BCBSIL. However, there is information
BCBSIL needs for the enrollment process that is not on the standard enrollment application.
The information below will help you understand how to complete each section of the standard enrollment application for enrollment with BCBSIL.
1. Employer Information
Your employer can use the Illinois Standard Health Employee Application with one or more insurance companies to request quotes for
employee health insurance. This standard enrollment application means you do not need to fill out different applications from each insurance
company. For your benefit, space is provided on the standard enrollment application so your employer can list the different insurance
companies that will receive your health information.
You will see references to "spouse/domestic partner" and "retiree" in the standard enrollment application. Domestic partners and retirees are
eligible only if your employer chooses to cover them. Check with your employer if you are not sure.
2. Section B – Coverage Requested
Choose the type of health coverage/product you want based on the option(s) your employer has offered you.
• Some employers may offer only one type of coverage such as a PPO health benefit plan.
• Others may provide different options such as a PPO, an HMO, and/or a plan that includes a Health Savings Account (HSA) and/or
a Health Care Account (HCA).
• You and your dependents (spouse/domestic partner and children) will all be enrolled in the same product. You cannot pick different
products for each person.
BCBSIL offers the following products for small group business. If you are not sure which product(s) are available to you, please ask your employer.
PPO
• BlueAdvantageSM
Entrepreneur PPO
• BluePrint PPO
HMO
HSA
HCA
• BlueAdvantageSM HMO
• BlueEdgeSM HSA
• BlueEdgeSM Direct HCA
• HMO Value Choice
• BlueEdgeSM Select HSA
• BlueEdgeSM Select
Direct HCA
• BlueChoice Select®
• PPO Value Choice
• CPO
• CPO Value Choice
22997.0111
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 1
3. Section C – Waiver of Coverage
You may enroll yourself and your dependents (spouse/domestic partner and children) in any coverage that your employer makes available
to you, and that BCBSIL offers. While the standard enrollment application may appear to suggest that you can waive enrolling yourself for
coverage but still enroll your dependents, BCBSIL’s policy requires that you (the employee) enroll in order to also enroll your dependents. If
you choose to waive any coverage, your dependents cannot enroll in that coverage. However, you can enroll yourself in a coverage and choose
to waive it for any of your dependents.
Please use this section to indicate if you do not wish to enroll yourself and/or any of your dependents in the following types of coverage:
• Medical
• Dental
• Basic Life
• Dependent Life
• Short-Term Disability (BCBSIL offers only to employees)
• Voluntary Life (BCBSIL offers only to employees)
While you may see these types of coverage on the standard application, they are not available from BCBSIL for small group business:
• Vision
• Long-Term Disability
For small group business, BCBSIL does not consider “Individual Coverage” (the second option on the standard application) as a valid
reason to decline your employer-offered coverage.
4. Section D – Individuals Requesting Coverage
• Weight and Height - BCBSIL requires the weight and height for yourself and your spouse/domestic partner. BCBSIL also requests
weight and height be provided for any dependent that is 18 or older.
• Military Veteran Dependents - If you have dependents that are military veterans, you must include their honorable discharge
documentation (Form DD-214).
• Disabled Dependents - Medical certification must be provided for disabled dependents.
• HMO Coverage - If you have elected to enroll in HMO coverage, information about your Primary Care Physician (PCP) is needed.
The standard enrollment application provides space for your PCP and his or her identification number. However, BCBSIL requires
more information about your physician. To accommodate this, a separate HMO / CPO Provider Selection Enrollment and Change
Form is also required for HMO enrollees. This form is used to collect the following information:
• Independent Practice Association (IPA) / Medical Group Number – this is required for BCBSIL to correctly identify the location
you have chosen to access care from your PCP.
• PCP name and the identification number.
• Female enrollees may also choose a Woman’s Principal Health Care Provider (WPHCP), so there is space to list this provider’s
name and identification number as well.
• CPO Coverage - BCBSIL offers a Community Participating Option (CPO) health benefit plan. This is similar to a PPO health benefit plan,
but the member can gain greater savings by using providers at specific hospitals in the CPO network. Therefore, if you have chosen the CPO
product, please use the HMO / CPO Provider Selection Enrollment and Change Form to indicate the number of the CPO network you
have selected.
5. Section E – Current / Prior Coverage Information: Medicare
For small group business, “Dual Enrollment” is not an applicable Medicare entitlement reason for BCBSIL.
6. Sections F & G – Health Statement / Additional Information
This section should be completed by employees of groups that have 2-50 enrolling employees. If you are not sure about completing this
section, check with your employer.
• For health coverage, BCBSIL does not require the health statement questions to be completed by employees of groups that have more than
50 employees enrolling.
• For basic life coverage, the health statement questions must be completed by the employee if the group has two or more eligible employees
AND is applying for an amount over the guarantee issue, applying for voluntary life coverage or for any late enrollment.
• Two pages are left blank so that information in these sections can be pulled out for underwriting (if applicable).
7. Section H – Additional Coverage Options
As stated in item #3, the following types of coverage are not available from BCBSIL for small group business:
• Vision
• Long-Term Disability
22997.0111
Page 2
Illinois Standard Health Employee Application
for Small Employers
For assistance in completing this application, please contact your employer
or insurance agent. For information about your health insurance rights under
state and federal law, and other resources, please contact the Illinois
Department of InsuranceÕs Office of Consumer Health Insurance toll free at
(877) 527-9431.
INSURER USE ONLY
Policy/Group No.
Section No.
Effective Date
New Hire Waiting Period
This standard application is intended to simplify your health insurance
application process. You will only need to complete this one application,
even when your employer has requested quotes from multiple insurance
companies.
The information you provide in this application will be sent to the following insurance companies:
(To be completed by employer)
Insurer: _______________________________ Insurer: _______________________________ Insurer: _______________________________
Insurer: _______________________________ Insurer: _______________________________ Insurer: _______________________________
TO BE COMPLETED BY EMPLOYER
Employer Name:
Phone #:
Address:
Reason for Enrollment (Mark all that apply)
New Enrollment:
! New Group
Special Enrollment:
! Adoption
! Open Enrollment
! Court Order
! Loss of Coverage
Employment Status: ! Active
! New Hire (Date: ____________________________) ! Late Enrollee
! Dependent Addition
! Marriage
! Newborn
! Divorce
! Other
! Domestic Partner
Date of Event: _________/__________/__________
! Retiree (Retirement Date: ________/________/________)
! Illinois Continuation
! Employee
! COBRA
! Dependent
Qualifying Event: ________________________________
Start Date ________/________/_________
A
Projected End Date ________/________/_________
Employee Information
Name (Last)
(First)
Job Title:
(MI)
Hire Date:
Marital Status:
!
Married
!
Single
!
Divorced
!
Widowed
!
Hrs/Week:
Domestic Partner
Home Address:
Apt #:
City:
State:
Home (or Cell) Phone: (
)
Zip:
Business Phone: (
)
Email Address (optional):
B
Coverage Requested
Medical
Employee:
! Yes
Plan Choice:
!
No
Spouse/Domestic Partner:
Plan Choice:
!
Yes
!
No
Child(ren):
!
Yes
! No
Plan Choice:
If you are waiving (declining) coverage for yourself or any member of your family, you must complete Section C
below.
23071.0111
70670
ILLINOIS STANDARD HEALTH APPLICATION Ð SMALL EMPLOYER
Employer Name ________________________________ Employee Name __________________________________________
I
Acknowledgement & Signature
I understand, agree, and represent that:
! I have read this document or it has been read to me.
! The answers provided within this entire application for coverage are, to the best of my knowledge and
belief, true and complete.
! Neither my employer nor the agent has the authority to waive a complete answer to any question,
determine coverage or insurability, alter any contract, or waive any of the insurance carrierÕs other
rights and requirements.
! I understand that if I intentionally omit or provide false information on or in relation to this application,
then this policy may be cancelled retroactively, in which case any claim I submit may not be paid by the
insurer. I understand that if I intentionally omit or provide false information on or in relation to this
application that I may face legal liability, including legal action based on fraud.
! If this application for coverage is accepted, coverage will be effective on the date specified by the
insurance carrier on the certificate of coverage/certificate of insurance.
I hereby enroll for benefits as indicated in Section B and Section H of this application, for which I am presently eligible or
for which I may become eligible under my employerÕs group contract(s). If any deductions are required for this coverage,
I authorize such deductions from my earnings. I reserve the right to revoke this deduction authorization at any time upon
written notice.
I understand that the information I have provided in this application will be used by the insurance carrier and its affiliates
to make decisions regarding eligibility, enrollment, underwriting, and premium risk rating.
I understand that the medical information provided also includes my spouse/domestic partner and/or dependentsÕ
information.
I understand that I may be asked for authorization to disclose my medical, claim, or benefit records at a later time.
I understand that I should retain a duplicate copy of this application for my own records.
A photographic copy of this acknowledgment shall be as valid as the original.
I authorize the insurance carrier to electronically transmit the information contained herein.
If this application was taken over the phone or on the computer, I acknowledge that I, myself, have not actually signed
this application but instead hereby authorize the insurance carrier to print ÒElectronically AcknowledgedÓ on the
signature line of the application and I agree that such printing shall be treated as a valid signature for all purposes of this
form. I acknowledge that the insurance carrier has verified my identity for this purpose in accordance with any applicable
law or regulation.
By signing below, I acknowledge that I have read and understand this document and I am signing of my own free will.
Employee Signature _________________________________________________Date __________________________
" For assistance in completing this application, please contact your employer or insurance agent.
For information about your health care rights under state and federal law, and other resources, please contact the
Illinois Department of InsuranceÕs Office of Consumer Health Insurance toll free at (877) 527-9431.
10
23071.0111
70670
BlueEdge HSA 80/60
$3,500/$7,000 DEDUCTIBLE - $5,800 OPX
RPSE3A05
NPSE3A05
BENEFIT HIGHLIGHTS
PPO Network
This provides only highlights of the benefit plans(s). After enrollment, members will receive a Certificate that more fully describes the terms of coverage.
Program Basics
Lifetime Benefit Maximum
Per individual
Individual Coverage Deductible*
Family Coverage Deductible*
Entire deductible must be met.
Individual Coverage Out-of-Pocket Expense (OPX) Limit
The maximum amount of money that any individual will have to pay toward covered health care expenses during any
one calendar year, including the program deductible. The following items will not be applied to the out-of-pocket
expense limit:
•
Reductions in benefits due to non-compliance with utilization management program requirements
•
Charges that exceed the eligible charge or the Schedule of Maximum Allowances (SMA)
Family Coverage Out-of-Pocket Expense (OPX) Limit
The family OPX limit includes the family deductible amount. Please refer to Certificate for details on how the family
OPX limits works.
PPO
Non-PPO
(In-Network)
(Out-of-Network)
Unlimited
$3,500
$7,000
$7,000
$14,000
$5,800
$11,600
$11,600
$23,200
Outpatient Prescription Drugs
Covered under Other Covered Services below. Please refer to the Outpatient Prescription Drug Benefit Highlights
sheet for detailed information.
80% after deductible
Physician Services
Preventive Care
Routine annual physicals, well-baby exam, annual vision and hearing exams, immunizations, and other preventive
health services as determined by the USPSTF.
Maternity Services
Medical / Surgical Services
Hospital Services
Hospital Admission Deductible
Per admission, per individual
Inpatient Hospital Services
Coverage includes pre-admission testing and services received in a hospital, skilled nursing facility, coordinated
home care and hospice, including mental health and substance abuse services. Room allowances based on the
hospital’s most common semi-private room rates.
Outpatient Hospital Services
Coverage for services includes, but is not limited to outpatient or ambulatory surgical procedures, diagnostic x-rays,
lab tests, chemotherapy, radiation therapy, renal dialysis, and mammograms performed in a hospital or ambulatory
surgical center, including mental health and substance abuse services. For routine services such as mammograms,
lab tests and x-rays performed in an outpatient hospital setting, see Well Care benefits.
Outpatient Emergency Care (Accident or Illness)*
Each calendar year, the program deductible must be met before benefits will begin under this policy. The
coinsurance applies to both in- and out-of-network emergency room visits.
100%
60% after deductible
80% after deductible
60% after deductible
80% after deductible
60% after deductible
$0
$300
80% after deductible
60% after deductible
80% after deductible
60% after deductible
90% after deductible
21899NGR.1010
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 1 of 2
BlueEdge HSA 80/60
$3,500/$7,000 DEDUCTIBLE - $5,800 OPX
RPSE3A05
NPSE3A05
BENEFIT HIGHLIGHTS
Additional Services
Muscle Manipulation Services*
Coverage for spinal and muscle manipulation services provided by a physician or chiropractor. Related office visits
are paid the same as other Physician Office Visits.
• $ 1,000 maximum per calendar year
Therapy Services – Speech, Occupational and Physical
Coverage for services provided by a physician or therapist.
Temporomandibular Joint (TMJ) Dysfunction and Related Disorders
Other Covered Services
•
Private duty nursing (Please refer to Certificate for details.)
• Ambulance services
•
Naprapathic services - $1,000 maximum per calendar year
• Medical supplies
•
Blood and blood components
See paragraph below regarding Schedule of Maximum Allowances (SMA).
PPO Network
PPO
(In-Network)
Non-PPO
(Out-of-Network)
80% after deductible
60% after deductible
80% after deductible
60% after deductible
80% after deductible
60% after deductible
80% after deductible
Durable Medical Equipment (DME) is a covered benefit. Please refer to Certificate for details.
Optometrists, Orthotic, Prosthetic, Pedorthists, Registered Surgical Assistants, Registered Nurse First Assistants and Registered Surgical Technologists are covered providers. Please refer to Certificate for
details.
Discounts on Eye Exams, Prescription Lenses and Eyewear
Members can present their ID cards to receive discounts on eye exams, prescription lenses and eyewear. To locate participating vision providers, log into Blue Access® for Members (BAM) at www.bcbsil.com/member
and click on the BlueExtras Discount Program link.
Blue Care Connection (BCC)
When members receive covered inpatient hospital services, outpatient mental health and substance abuse services (MHSA), coordinated home care, skilled nursing facility or private duty nursing from a participating
provider, the member will be responsible for contacting either the BCC or MHSA preauthorization line, as applicable. You must call one day prior to any hospital admission and/or outpatient MH/SA service or within 2
business days after an emergency medical or maternity admission. Please refer to your benefit booklet for information regarding benefit reductions based on failure to contact the applicable preauthorization line. Note:
Outpatient MHSA preauthorization is effective for services on or after January 1, 2011 or upon your group plan renewal date in 2011 and thereafter.
*More on Individual Coverage and Family Coverage Deductibles…
•
If a member has individual coverage, each calendar year he/she must satisfy an individual coverage deductible before receiving benefits under this policy. The amount of the individual deductible is
indicated above on this benefit highlight sheet. Once a member’s claims for covered services in a calendar year exceed this deductible amount, benefits will begin.
•
If a member and his/her dependents have family coverage, each calendar year they must satisfy the family coverage deductible before receiving benefits under this policy. The amount of the family
deductible is indicated above on this benefit highlight sheet. Once the family deductible has been satisfied it will not be necessary for anyone else in the family to meet a deductible in that calendar year. That
is, for the remainder of the calendar year, no other family member will be required to meet the deductible before receiving benefits. No one is eligible for benefits under family coverage until the entire family
deductible has been satisfied.
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Please note: The deductible amount may be adjusted based on the cost-of-living adjustments determined under the Internal Revenue Code and rounded to he nearest $50.
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Also note: Should the Federal Government adjust the deductible for high deductible plans as defined by the Internal Revenue Service, the deductible amount in the Certificate will be adjusted accordingly.
Schedule of Maximum Allowances (SMA)
The Schedule of Maximum Allowances (SMA) is not the same as a Usual and Customary fee (U&C). Blue Cross and Blue Shield of Illinois’ SMA is the maximum allowable charge for professional services, including but
not limited to those listed under Medical/Surgical and Other Covered Services above. The SMA is the amount that professional PPO providers have agreed to accept as payment in full. When members use PPO
providers, they avoid any balance billing other than applicable deductible, coinsurance and/or copayment. *Please refer to your certificate booklet for the definition of Eligible Charge and Maximum Allowance regarding
Providers who do not participate in the PPO Network."
To Locate a Participating Provider: Visit our Web site at www.bcbsil.com/providers and use our Provider Finder® tool.
In addition, benefits for covered individuals who live outside Illinois will meet all extraterritorial requirements of those states, if any, according to the group’s funding arrangements.
21899NGR.1010
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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