Health Insurance Portability and Accounting Act: When special enrollment rights are the result of loss of eligibility, BCBSM reserves the right to request verification of the reason for such loss in the form of a letter from the previous group or carrier. A Certificate of Creditable Coverage will not be accepted in lieu of a letter from the previous group or carrier unless it specifies the reason for the loss of eligibility. HIPAA special enrollment rights do not pre-empt a new hire waiting period; the new hire waiting period must first be satisfied. A certificate of creditable coverage cannot be used to waive a new hire waiting period. Voluntary terminations of other health care coverage do not qualify for HIPAA special enrollment rights. (Note, terminations of employment may qualify for special enrollment rights). . The BCN services area excludes Lenawee county in the lower peninsula. Residents of Lenawee county may receive non-emergent services in a BCN-covered county. Only Mackinac, Marquette and Houghton are included in the BCN service area in the upper peninsula. BCN. 610G Page 1 of 7 WF 3599 MAR 13 Select Plan SUBSCRIBER NEW ENROLLMENT (see Page 3 for instructions) BCBSM group number A nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association ✔ Division 007038475 BCBSM ___MVP ___CB12 ___CB Plan 4 BCN Members - Complete Page 4 for PCP Selection BCN group ID Subgroup Employer representative signature Class ID 0009 Subscriber information Date Social Security number (required) Subscriber first name Subscriber last name M.I. Marital status S Subscriber birth date Home street address County City Country - if other than USA Primary telephone number Last name Secondary telephone number Home Work Cell List all persons to be covered: State First name MI Gender Home Work Cell Date of birth Spouse M F Dep. 1 M F Dep. 2 M F Dep. 3 M F Dep. 4 M F If the permanent address of the spouse or dependent is different from the address above, please complete the information below: Spouse or dependent (full name) Street address Gender M M F ZIP code E-mail *Relationship code (see instructions for codes) Social Security number XXXXXX City State ZIP code Coordination of benefits information Do you, your spouse dependents maintain other coverage? Yes Person covered (full name) Employer or group name No If Yes, complete below: Policy number Check here if this applies to all members on the contract: Address Carrier I have read and understand the conditions of this form. Subscriber signature: Date: Health savings and flexible spending account options ✔ HSA HSA Opt out 1000 BCBSM Product indicator code: ✔ Employer reference ID Group name Add Change Cancel FSAMED Employer/Group use only Department ID FSADEPCA Goal amount: Benefit code Plan code Goal amount: Date of hire Effective date AP Service Company Check coverage if applicable: Check type of enrollment: ✔ Medical ✔ New Vision Dental COBRA enrollment Check reason: Loss of eligibility (prior coverage) Rehire BCBSM or BCN primary Part time Return from layoff Surviving spouse New group division/subgroup Hourly Open enrollment Divorce or legal separation Layoff Loss of dependent status Deceased subscriber No If Yes, complete: No Salary Retiree Reduction of hours Yes Loss of eligibility (prior coverge) Old group division/subgroup Termination Are any members listed enrolled in Medicare? Medicare primary ✔ Full time Transfer Yes Carrier’s name (Including BCBSM and BCN) If Yes, check reason category Medicare A effective date Working Aged Medicare B effective date Previous contract number Contract holder name Retired Disabled ESRD Medicare Part D effective date Average hours worked per week (required): Job title (required): Original qualifying date Policy number Termination date HIC number: Page 2 of 7 WF 3599 MAR 13 Enter e-mail address for member outreach (i.e. health and wellness). Enter the four digit BCBSM product indicator code. Enter employer or group name and employee reference identification or department number, if applicable. . If transfer, please indicate the old group/division/subgroup and new group division/subgroup numbers. Page 3 of 7 WF 3599 MAR 13 Branch _______________ Printed Employee Name________________________ Employee ID_______ Statement of Facts: To obtain any health insurance through AccessPoint, a one month premium will be collected in advance. In the event there is not ample time to collect a one month premium, makeup deductions will be taken over a one month period. This will also apply to weeks where insufficient payroll is available to collect your premium. If any premium is due at termination, the amount due will be taken from your final paycheck if available. In the event you have over payment, you will receive the amount refunded to you within 60 days of termination. Keeping in mind the current full month premium is due even if you requested termination, are without income, or have terminated for any reason. AUTHORIZATION FOR PAYROLL DEDUCTION: I agree with the Statement of Facts section above and agree to authorize the deduction of the amount(s) as shown below from my pay in order to satisfy the premium due. Please deduct the full amount of the unpaid premium detailed above. Please deduct from the following table the amount of the unpaid premium detailed above. 1week premium due will be collected in 1 payroll week along with your current deduction. 2 weeks premium due will be collected over 2 payroll weeks along with your current deduction. 3 weeks premium due will be collected over 3 payroll weeks along with your current deduction. 1 month premium due will be collected over 4 payroll weeks along with your current deduction. Payroll will determine table choice by amount of missing weeks at eligibility. This statement is in effect to your full employment and all future missed premium payments. Employee Signature Date • I understand and acknowledge the deduction may not be made if I have insufficient income during a pay period and I will be required to make up that deduction. • • I have received a benefit packet. I have read the entirety of this 3 page letter and understand my options, eligibility rules and premium obligations. I understand that I am responsible to notify you to cancel or continue my insurance at the end of my assignment. • I understand that I am responsible to log on to http://apteam.com/employeeresources/employee-login/ (Advance website employee login) each week to receive important updates and new enrollment times that may be update for healthcare coverage. • We are happy to assist you with your benefit plan questions and again, welcome to Access Point! Access Point Employee Benefits Team
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