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Primary Applicant’s Name:
Medica Individual and Family Plans
2015 MINNESOTA CHANGE FORM
This form may be used to complete the following changes to your current Medica plan.
•
Name or address change
•
Member termination
•
Newborn or adoption addition
•
Change in marital status
•
Qualified dependent addition
•
Qualified plan change
Thank you for being a Medica Member!
General information:
• Address or name change (Section B and C) or terming individuals from the policy (Section E) can be completed at
any time using this form.
•
Changes to your current health plan benefits can only be made within 60 calendar days of a qualifying event with the
exception of birth or adoption. For a list of qualifying events, see Section D. If you’d like to change your current health
plan, please make your new selection there.
•
You may be able to receive a cost sharing subsidy and/or premium tax credit, which could lower your costs. To see if
you’re eligible, please visit MNsure.org.
Effective date of coverage:
•
Coverage may begin on the first day of any month within your special enrollment period with the exception of birth or
adoption. Coverage for new dependents from birth or adoption must begin on the date of birth/adoption.
SECTION
Contact us if you have questions
Please contact a Health Plan Specialist by calling the number on the back of your ID card.
A
MEMBER INFORMATION
Note: This section must be completed.
Subscriber
Last Name:
First Name:
SECTION
Current member I.D. number:
B
M.I.:
Preferred telephone number:
Change address from
Street:
Change address to
Street:
City:
City:
Zip Code:
State:
Email:
SECTION
Alternative phone number:
ADDRESS CHANGE* (if applicable)
State:
C
Social Security Number:
Zip Code:
Email:
NAME CHANGE* (if applicable)
Change name from
Last Name:
First Name:
M.I.:
Change name to
Last Name:
First Name:
M.I.:
* A qualifying event is not needed to report these changes.
IFB9589-5-00614
Medica Individual and Family Plans Change Form
Page 1 of 5
SECTION
D
QUALIFYING EVENT CRITERIA (if applicable)
1). Please select the applicable qualifying event below.
Birth of child
Permanent move outside of Medica service area
Adoption or placement for adoption
Loss of other coverage (e.g. divorce)
Marriage
Other _________________________________________
For any qualifying event, please provide the event date: ___________________________________________
Note: Please provide supporting documentation of your qualifying event with this change form.
2). Would you like to keep your current Medica plan?
�Yes
�No - Please select your new preferred plan below.
Valid January 2015-December 2015
Medica Solo
Medica Encore
B
B
Medica Encore
Classic
Medica Direct HSA
C
H
BRONZE
SILVER
GOLD
Choose a metal level and plan type
One-Person Coverage
$100 deductible
One-Person Coverage
$100 deductible
Family Coverage
$300 deductible
Family Coverage
$300 deductible
One-Person Coverage
$2,200 deductible
One-Person Coverage
$2,200 deductible
One-Person Coverage
$1,950 deductible
Not available at
Gold level
Family Coverage
$3,950 deductible
One-Person Coverage
$3,650 deductible
One-Person Coverage
$3,150 deductible
Family Coverage
Family Coverage
$6,600 deductible
$6,600 deductible
$5,950 deductible
One-Person Coverage
$6,350 deductible
One-Person Coverage
$6,350 deductible
One-Person Coverage
$4,800 deductible
Family Coverage
Family Coverage
$12,700 deductible
$12,700 deductible
Not available at
Bronze level
Family Coverage
Family Coverage
$8,500 deductible
SECTION
NOTE: Plans are not available in all regions at all metal levels. Visit medica.com or contact your agent for information on your plan
availability. If you’d like a health plan other than the options listed above, please visit medica.com to view additional options.
E
ADDITIONS OR TERMINATIONS (if applicable)
List each person that is being added or termed from the policy. Add additonal pages if necessary.
Type of change First name Middle initial Last name
Birthdate (MM/DD/YY) Race (optional):

1
Addition
Termination
Relationship to Applicant
Social Security No.
Sex:
M
F
Type of change

2
First name Middle initial Last name
Birthdate (MM/DD/YY) Race (optional):
Addition
Termination
Relationship to Applicant
Social Security No.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or
other Pacific Islander
White
Other
Sex:
M
F
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or
other Pacific Islander
White
Other
Ethnicity
(optional):
Hispanic or
Latino
Not Hispanic
or Latino
Ethnicity
(optional):
Hispanic or
Latino
Not Hispanic
or Latino
Continues on next page…
IFB9589-5-00614
Medica Individual and Family Plans Change Form
Page 2 of 5
SECTION
E
ADDITIONS OR TERMINATIONS CONTINUED (if applicable)
List each person that is being added or termed from the policy. Add additonal pages if necessary.
Type of change First name Middle initial Last name
Birthdate (MM/DD/YY) Race (optional):

3
Addition
Termination
Relationship to Applicant
Social Security No.
Sex:
M
F
Type of change

4
First name Middle initial Last name
Birthdate (MM/DD/YY) Race (optional):
Addition
Termination
Relationship to Applicant
Social Security No.
Sex:
M
F
Type of change

5
First name Middle initial Last name
Social Security No.
Sex:
M
F
Type of change

6
First name Middle initial Last name
Social Security No.
Sex:
M
F
Type of change

7
First name Middle initial Last name
Social Security No.
Sex:
M
F
Type of change

8
First name Middle initial Last name
Social Security No.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or
other Pacific Islander
White
Other
Birthdate (MM/DD/YY) Race (optional):
Addition
Termination
Relationship to Applicant
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or
other Pacific Islander
White
Other
Birthdate (MM/DD/YY) Race (optional):
Addition
Termination
Relationship to Applicant
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or
other Pacific Islander
White
Other
Birthdate (MM/DD/YY) Race (optional):
Addition
Termination
Relationship to Applicant
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or
other Pacific Islander
White
Other
Birthdate (MM/DD/YY) Race (optional):
Addition
Termination
Relationship to Applicant
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or
other Pacific Islander
White
Other
Sex:
M
F
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or
other Pacific Islander
White
Other
Ethnicity
(optional):
Hispanic or
Latino
Not Hispanic
or Latino
Ethnicity
(optional):
Hispanic or
Latino
Not Hispanic
or Latino
Ethnicity
(optional):
Hispanic or
Latino
Not Hispanic
or Latino
Ethnicity
(optional):
Hispanic or
Latino
Not Hispanic
or Latino
Ethnicity
(optional):
Hispanic or
Latino
Not Hispanic
or Latino
Ethnicity
(optional):
Hispanic or
Latino
Not Hispanic
or Latino
Tobacco use
Has anyone listed on this change form used tobacco products four or more times a week on average
(other than for religious or ceremonial purposes) within the last six months? . . . . . . . . . . . . . . . . . . . . . . . . . . . �Yes
�No
If Yes, list all individuals:
IFB9589-5-00614
Medica Individual and Family Plans Change Form
Page 3 of 5
SECTION
F
AUTHORIZATION AND REPRESENTATION
TO BE SIGNED BY SUBSCRIBER
I understand and agree this change form will not alter any other limitations, conditions, provisions or exclusions that were
part of my policy or application prior to the effective date of this plan change.
I understand that my premium may be impacted by the change(s) requested on this form. I will be responsible for any
additional premium amount due from the effective date of the change(s). I understand that any reduction in premium
will be reflected on the billing invoice.
The information provided on this form is accurate and complete. I understand and agree that any omissions of incorrect
statements knowingly made by me on this form may invalidate my coverage.
By signing below, I agree that this change form amends the original and will be incorporated into and made part of the
application form and the policy.
Please provide signature below if the Subscriber is under
age 18:
Signature of Subscriber:
Date:
X
Signature of Guarantor, Parent or Legal Guardian:
Date:
X
I authorize Medica to make the changes to my policy as requested by the Subscriber and identified on this change form.
Signature of Other Members Over Age 18:
Date:
X
Date:
X
IFB9589-5-00614
Date:
X
Signature of Other Members Over Age 18:
Return completed form to:
Medica
Mail Route CW295
PO Box 9310
Minneapolis, MN 55440-9310
Signature of Other Members Over Age 18:
Signature of Other Members Over Age 18:
Date:
X
or Fax to:
952-992-2511
Medica Individual and Family Plans Change Form
Page 4 of 5
FOR OFFICE USE ONLY
Date received:
Print agent’s name:
Effective date of
change:
Reviewed by:
New plan code:
Premium change:
�Yes
�No
Agent number:
MEDICA PRIVACY NOTICE
Medica takes its responsibility of protecting your personal information seriously. Where possible, Medica de-identifies or
encrypts personal information. We use and disclose personal information only to the extent necessary to conduct treatment,
payment and health care operations, or to comply with legal, regulatory or accreditation requirements.
Medica and its business associates obtain, maintain, use and share personal information to carry out certain routine
activities. Routine activities include: (i) treatment-related activities, such as referring you to a doctor or other provider;
(ii) payment-related activities, such as paying a claim for medical services rendered; and (iii) health care operations, such
as professional peer review.
The law also gives you rights to access, copy, and amend your personal information. You have the right to requestrestrictions
on certain uses and disclosures of your personal information. You also have the right to obtain information about how and
when your personal information has been used and disclosed.
Medica’s full Privacy Notice is available upon request by calling 1-800-670-5935 or by going to www.medica.com
Mail Route CW295, PO Box 9310, Minneapolis, MN 55490-9310
© 2014 Medica. Medica® is a registered service mark of Medica Health Plans. “Medica” refers to the family of health plan
businesses that includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, Medica
Self-Insured, and Medica Health Management, LLC.
UNV1011
IFB9589-5-00614
Medica Individual and Family Plans Change Form
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