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
HSA Payroll Deduction Authorization for Minimum Value Plan – new enrollees
only
Employee_________________________________ Date _____/____/_____
Branch Location_________________________
I hereby authorize AccessPoint to deduct the following from my payroll check(s).
I understand this deduction is for my HSA Contribution for 2015 administered by Health Equity.
I authorize a weekly amount of $_____________ to be deducted from my pay for the entire 2015,
ending 12/31/2015. The maximum annual contribution amounts for 2015 are $3,350* for single
coverage and $6,650* for two-party/family coverage.
*Participants age 55 and older can contribute an additional $1,000 catch-up amount.
Employee Signature ___________________________________Date_______________
This election is only valid for 2015. A new form must be completed to participate in 2016.
Who is eligible to establish an HSA?
You are eligible if:
•
•
•
•
You have qualified High Deductible Health Plan (HDHP) coverage.
You are not enrolled in Medicare.
You do not have other non-HDHP coverage, such as through a spouse's plan.*
You are not claimed as a dependent on someone else’s tax return.
You are not eligible if you are currently insured by another healthcare provider.
Health Savings Account Advantages:
• Tax-deductible–Contributions to the HSA are 100% deductible (up to the legal limit).
• Tax-Free-Withdrawals to pay qualified medical expenses, including dental & vision, are
never taxed.
• Tax-deferred-Interest earnings accumulate tax-deferred, & if used to pay qualified
medical expenses, are tax free.
• HSA money is yours to keep-Unlike a flexible spending account, unused money in your
HSA isn’t forfeited at the end of the year; it continues to grow tax-deferred.
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