Fillable Application for Coverage Individuals and Families (Blue Cross Blue Shield of Michigan)

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Application for Coverage Individuals and Families (Blue Cross Blue Shield of Michigan)

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Application for Coverage
Individuals and Families
(Off Marketplace Only)
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. 1
WF 13271 SEP 19
This application may be used for 2020 individual and family coverage through either Blue Cross Blue Shield of Michigan (BCBSM) or
Blue Care Network of Michigan (BCN), depending on which medical plan you choose. Dental plans, dental with vision, and adult
vision plans are only offered through BCBSM, but can be paired with BCBSM or BCN medical plans.
Print in black or blue ink. Complete all fields unless otherwise noted. Review your application for accuracy, then sign and date. Your
information will be used and disclosed only as permitted by our Notice of Privacy Practices. You can find a copy of our Notice of
Privacy Practices on our website at bcbsm.com/index/common/important-information/privacy-practices.html#Privacy.
If you’d like to apply for a subsidy or tax credit, are age 30 or older and would like to check your eligibility for a hardship exemption
to enroll in a Value Plan or are Native American and eligible for additional cost-sharing benefits, contact a health plan advisor at
1-888-899-3012 or your Blue Cross or BCN Agent.
To get individual medical, dental, dental with vision, or adult vision coverage, you must be a Michigan resident when your
coverage starts and continue to live in Michigan for at least 180 days each year. If you're eligible for Medicare, you’re not eligible
for individual medical coverage.
Section I: Coverage and Enrollment
Who will be covered by this plan?
One adult (individual plan)
Multiple people (family plan)
One child only (be sure to complete the “child only
coverage” section on Page 3)
Why are you applying?
Open enrollment (November 1 - December 15, 2019)
I have a qualifying event, loss of coverage, or am planning to move to Michigan
Adult only vision coverage (doesn’t require a qualifying event)
Dental or Dental with Vision (doesn’t require a qualifying event)
Have you had individual or employer-sponsored medical coverage in the past 60 days? Yes No
If you had BCBSM or BCN coverage, indicate the 9-digit enrollee ID found on your BCBSM/BCN member ID card. If you don't have
your enrollee ID, please enter 000000000: .
Note: The availability of continuous coverage depends on your event, event date and application date. Proof of employer coverage
is required if you are or were an employer-sponsored member seeking continuous coverage due to loss of employer-sponsored
coverage or death of the primary policy holder.
Date of qualifying life event:
. Your coverage start date will be assigned after we receive your application.
Internal use only:
Original effective date requested Application ID
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. 2
WF 13271 JAN 2020 W000688
The below list of qualifying events applies to 2020 plan year coverage. If seeking coverage for the 2019 plan year based on a
qualifying life event, contact a health plan adviser at 1-888-899-3012 or your Blue Cross or BCN agent. For a list of supporting proof
by event, please visit bcbsm.com/index/health-insurance-help/faqs/topics/buying-insurance/qualifying-events-special-
enrollment/documents.html. Your event must have taken place within 60 days of your application date to be considered for
coverage.
Please select the event that applies to you.
Birth, adoption
Legal guardianship
Gaining or becoming a dependent due to a child support order or other court order
Marriage
Loss of employer-sponsored group coverage. Examples: Job loss, employer ended health coverage or terminated
contributions toward health coverage or reduced work hours (below the minimum necessary to maintain coverage).
Divorce or legal separation
Death of policy holder
Turning age 26 and aging off parent's plan
Involuntary Loss from Medicaid or Children’s Health Insurance Program (CHIP)
Policy holder became eligible for and enrolled in Medicare
Exhaustion of COBRA benefits
Moved out of plan coverage area with loss of coverage
Gained access to a new plan as a result of a permanent move
Other event:
You must submit supporting proof of the event you selected above to obtain coverage.
Include supporting documentation with your application, or promptly send to:
Email: IBUenrollment@bcbsm.com
Fax: 1-877-486-2172
Individual Membership and Billing
Blue Cross Blue Shield of Michigan
600 E. Lafayette Blvd., Mail Code 610B
Detroit, MI 48226-2998
Put “QLE Supporting Documents” in the subject line of your email. Your supporting documentation must include the primary
applicant's first name, last name, date of birth, phone number, and application submission date.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. 3
WF 13271 JAN 2020 W000688
Please tell us about the main person applying for this plan. All of your information will be kept confidential and only used for this application.
Last name
First name
M.I.
Suffix
tax ID number
Are you a U.S. citizen or
legally present in the U.S.?
Yes No
Residential address (can’t be a P.O. Box)
City
State
ZIP code
County
Billing address (if different than above)
City
State
ZIP code
County
Email
Primary phone number
Type: Fax
Home Cell
Work Other
Alternate phone number
Type: Fax
Home Cell
Work Other
Gender
Male
Female
Date of birth (if child only coverage, parent or legal
guardian must provide signature).
Number of months you live in
Michigan each year
During the past six months, have you used
tobacco or nicotine in any form four or more
times per week? Yes No
*BCBSM/BCN reserves the right to verify tobacco or nicotine use and to adjust your premium accordingly.
Information about your spouse who is applying for this plan
Last name
First name
M.I.
Suffix
tax ID number
Are you a U.S. citizen or
legally present in the U.S.?
Yes No
Gender
Male
Female
Date of birth
Number of months you live
in Michigan each year
During the past six months, have you used tobacco or nicotine in any
form four or more times per week?
Yes No
*BCBSM/BCN reserves the right to verify tobacco or nicotine use and to adjust your premium accordingly.
Information about your dependent children (under age 26 on the policy effective date) who are applying for this plan
Last name First name M.I. Date of birth
No. of
months you
live in MI
each year
Social Security or
personal tax ID number
(age one and older
required, or under
age one if available)
Gender Relationship*
U.S. citizen
or legally
present in
the U.S.?
Male
Female
Yes
No
Male
Female
Yes
No
Male
Female
Yes
No
Male
Female
Yes
No
Male
Female
Yes
No
During the past six months, have you used tobacco or nicotine in any form four or more times per week?
Yes No If yes, who?
*Dependent relationship codes (we reserve the right to audit documentation for all codes except “N”)
N – Child (by birth or adoption) P – Principally supported child A – Child adoption in progress S - Stepchild
C – Court ordered coverage L – Legal guardianship D – Disabled child
Child only coverage
Please complete this section if applying for child only coverage. Child only coverage is available for persons under age 21 on the policy effective
date. A separate application is necessary for each child.
Child’s last name
Child’s first name
M.I.
Suffix
Child’s Social Security or personal
tax ID number (age one and
older required, or under age one
if available)
Child’s date
of birth
Male
Female
U.S. citizen or
legally present
in the U.S.?
Yes
No
Child’s residential address
City
State
ZIP code
County
Legal guardian’s name
Legal guardian’s
primary phone number
Legal guardian’s email
Legal guardian's SSN (optional – used
to create member online account)
Legal guardian’s address
City
State
ZIP code
During the past six months, have you used tobacco or nicotine in any form four or more times per week? Yes No
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. 4
WF 13271 JAN 2020 W000688
Section II: Medical Plan Selection
Your network of affiliated doctors and hospitals may be different based on the product you choose. Please visit bcbsm.com/networks,
or consult your coverage documents, or a Blue Cross and BCN agent for specific network details. The BCN HMO medical plans are
managed-care plans; your care will be coordinated by a primary care physician that you select upon enrollment.
Pediatric vision benefits are included in all medical plans.
To view the BCBSM and BCN prescription drug formularies, visit bcbsm.com/2020selectdruglist.
Premiums are charged for the subscriber, spouse and all adult children age 21 and older, and for the three oldest dependent
children under age 21. Child only policies are available on all plans below.
Please select your medical plan from the list below. For plan details and availability, visit bcbsm.com/myblue.
Metro Detroit HMO (BCN Plans)
Silver
Blue Cross
®
Metro Detroit HMO Silver Extra
Blue Cross
®
Metro Detroit HMO Silver
Blue Cross
®
Metro Detroit HMO Silver Saver
Blue Cross
®
Metro Detroit HMO Silver Off Marketplace
Bronze
Blue Cross
®
Metro Detroit HMO Bronze
Blue Cross
®
Metro Detroit HMO Bronze Saver HSA
To learn about the Metro Detroit HMO network, and to see if your doctor is in network, visit bcbsm.com/index/find-a-doctor/metro-
detroit-hmo.html.
Select HMO (BCN Plans)
Preferred HMO (BCN Plans)
Silver
Blue Cross
®
Select HMO Silver Extra
Blue Cross
®
Select HMO Silver
Blue Cross
®
Select HMO Silver Saver
Blue Cross
®
Select HMO Silver Off Marketplace
Bronze
Blue Cross
®
Select HMO Bronze
Blue Cross
®
Select HMO Bronze Saver HSA
Catastrophic
Blue Cross
®
Select HMO Value
(under age 30 before the plan effective date)
Gold
Blue Cross
®
Preferred HMO Gold
Silver
Blue Cross
®
Preferred HMO Silver Extra
Blue Cross
®
Preferred HMO Silver
Blue Cross
®
Preferred HMO Silver Saver
Blue Cross
®
Preferred HMO Silver Off Marketplace
Bronze
Blue Cross
®
Preferred HMO Bronze Saver HSA
To learn about the Select HMO network, and to see if your
doctor is in network, visit bcbsm.com/index/find-a-
doctor/select.html.
To learn about the Preferred HMO network, and to see if your
doctor is in network, visit bcbsm.com/index/find-a-
doctor/preferred.html.
Information about Health Savings Accounts (HSA) can be found on the next page.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. 5
WF 13271 JAN 2020 W000688
Premier PPO (BCBSM Plans)
Gold
Blue Cross
®
Premier PPO Gold
Blue Cross
®
Premier PPO Gold 70/30
Silver
Blue Cross
®
Premier PPO Silver Extra
Blue Cross
®
Premier PPO Silver
Blue Cross
®
Premier PPO Silver Saver HSA
Blue Cross
®
Premier PPO Silver Off Marketplace
Bronze
Blue Cross
®
Premier PPO Bronze Extra
Blue Cross
®
Premier PPO Bronze HSA
Blue Cross
®
Premier PPO Bronze Saver
Catastrophic
Blue Cross
®
Premier PPO Value (under age 30 before the plan effective date)
To learn about the Premier PPO network and to see if your doctor is in network, visit bcbsm.com/index/common/marketplace/ppo.html.
HealthEquity
®
HSA Option
The following plans can be paired with a Health Savings Account (HSA), powered by HealthEquity
®
:
Blue Cross
®
Premier PPO Silver Saver
Blue Cross
®
Premier PPO Bronze
Blue Cross
®
Preferred HMO Bronze Saver
Blue Cross
®
Select HMO Bronze Saver
Blue Cross
®
Metro Detroit HMO Bronze Saver
If you already have our HSA but pick a non-HSA plan, you can still use the money in your HSA account, but can’t add money to that
account once your new plan starts.
There is no charge per month for our HSA. If you’d like to learn more, visit bcbsm.com/hsa. Find more details about Health Savings
Accounts on Page 10 of this application.
I would like to elect the HealthEquity
®
HSA option
Section III: Dental, Adult Vision, and Dental with Vision plan selection
The Affordable Care Act requires that individual market plans include the 10 categories of Essential Health Benefits (EHBs), one of which
is pediatric dental benefits. However, when sold off the Exchange, the plan can exclude pediatric dental coverage as long as it is,
reasonably assured enrollees have such pediatric dental coverage elsewhere.
This plan covers all 10 of the required EHBs for adults 19 years of age and older but excludes pediatric dental benefits for enrollees
under 19 years of age. Therefore, you must attest to the one of the following:
All applicants are 19 years of age or older;
I have a separate qualified dental plan with another carrier that includes pediatric dental benefit coverage for applicants under
19 years of age
With this application, I am also purchasing a qualified dental plan that includes pediatric dental benefits for applicants under
19 years of age
By signing below, I acknowledge that the above statement about the ages of all applicants or about having or purchasing a qualified
dental plan that includes pediatric dental coverage is true, to the best of my knowledge and belief, and that BCBSM/BCN will rely on
my statement. I certify that my attestation covers all members on the contract.
Signature Date
To learn more about dental and vision plans, visit bcbsm.com/dental.
All dental plans include access to more than 280,000 dental locations. Visit mibluedentist.com to find a dental provider.
Dental plans with vision and Blue Cross
®
Vision for Adults use the VSP Choice network. Visit vsp.com to find a vision provider.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. 6
WF 13271 JAN 2020 W000688
2020 Dental Only Plans 2020 Dental with Adult Vision Plans* 2020 Adult Vision Plans*
Blue Dental
SM
PPO Plus 80/60/50 Blue Dental
SM
PPO Plus 80/60/50 with Vision Blue Cross
®
Vision for Adults –
Monthly Billing
Blue Dental
SM
PPO Extra 100/70/50 Blue Dental
SM
PPO Extra 100/70/50 with Vision
Blue Dental
SM
PPO 80/50/50 Blue Dental
SM
PPO 80/50/50 with Vision Blue Cross
®
Vision for Adults –
Annual Billing
Blue Dental
SM
EPO 80/50/50 Blue Dental
SM
EPO 80/50/50 with Vision
Blue Dental
SM
PPO 100/50/50 Blue Dental
SM
PPO 100/50/50 with Vision
Blue Dental
SM
PPO Pediatric 80/50/50
*Vision benefits are for adult members who are 19 years or older on their plan effective date. Pediatric vision benefits are included
in all BCBSM/BCN medical plans.
Members effective as of January 1, 2018 who subsequently terminate their coverage will not be able to purchase another Dental or
Vision product for three years.
If you’re applying for Blue Dental coverage and your comprehensive dental coverage from another carrier ended within the last
60 days, you may be eligible for a waiver of your Blue Dental waiting period. Please send in documentation that includes the date
your previous coverage ended so that we may review it along with your application. Send your evidence of prior comprehensive
dental coverage to:
Individual Membership and Billing
Blue Cross Blue Shield of Michigan
600 E. Lafayette Blvd., Mail Code 610B
Detroit, MI 48226-2998
Fax: 1-866-392-7528
Email: DirectBilledMembership@bcbsm.com
Section IV: Additional Information
1. If applying for a medical plan please answer:
Is anyone listed on this application eligible for Medicare? Yes No
If yes, who?
To be eligible for Medicare under age 65, you need to have one of the following:
• A disability and be receiving Social Security disability insurance for more than 24 months
• A diagnosis of end stage renal disease
• A diagnosis of amyotrophic lateral sclerosis (ALS) as defined by the Center for Medicare and Medicaid Services (CMS)
For more information, visit our Medicare page at bcbsm.com/medicare.
If you're eligible for Medicare, you can't apply for individual medical coverage. Please visit bcbsm.com/medicare to learn more.
2. If applying for a dental or dental with vision plan without a medical plan, please answer:
Are you or any family members applying for medical coverage or will you or any family members be active under a medical plan
that’s effective on the same date as the dental plan? Yes No*
If yes, name of insurance company:
Contract number: Group number:
3. Have you terminated Blue Dental coverage within the last three years? Yes** No
4. Have you terminated Blue Vision coverage within the last three years? Yes*** No
* You’re not eligible to purchase a Dental or Dental with Vision plan if you’re not applying for medical coverage, or are or will be
active under a medical plan as of the effective date of the dental coverage.
** You’re not eligible if you terminated dental coverage on or after January 1, 2018 (not applicable if applying with a qualifying
life event).
*** You’re not eligible to purchase an Adult Vision Plan if you terminated Blue Vision Coverage within last three years.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. 7
WF 13271 JAN 2020 W000688
Section V: Optional Information
These questions are completely optional, but your responses will help us develop programs, products and networks that meet our
members' needs. Your responses won’t impact your health care options or costs.
1. Please pick a primary care physician (PCP) for each family member on your plan. If you’ve selected an HMO plan and don’t
choose a PCP, we’ll pick one for you and your family members.
If you don’t know your physician’s National Provider Identification (NPI) or other information, you can use our provider directory
at bcbsm.com/index/find-a-doctor.html.
Physician’s First Name Physician’s Last Name Physician’s NPI Seen in last year?
Applicant Yes No
Spouse Yes No
Child Yes No
Child Yes No
Child Yes No
Child Yes No
2. My yearly household income is:
Less than $30,000
$30,001 to $45,000
$45,001 to $70,000
$70,001 to $90,000
Greater than $90,001
3. Race (check all that apply for all family members)
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
Other
If Hispanic/Latino, ethnicity (check all that applies for all family members):
Mexican
Mexican American
Chicano/a
Puerto Rican
Cuban
Other
4 Preferred language (if other than English):
Chinese
French Creole
French
German
Gujarati
Hindi
Italian
Japanese
Korean
Polish
Portuguese
Russian
Spanish
Tagalog
Vietnamese
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. 8
WF 13271 JAN 2020 W000688
Section VI: Payment Options
Your security and privacy are important to us. We keep all your personal, medical and financial information confidential and safe
using industry-standard certifications and information privacy practices. You can view our privacy statement at
bcbsm.com/index/common/important-information/privacy-practices.
Please tell us how you’ll be paying your first monthly premium. Once you submit this application, you’ll be enrolled in your plan.
Don’t worry; all of your payment information will be secure. Acceptable payers are the subscriber, spouse or, when applicable, the
parent, blood relative, legal guardian, or other person or entity authorized under the law to pay the premium on the subscriber's
behalf.
1. Who will pay the premium for this policy?
Self Health Care Provider Legal guardian
Family member Other (please specify)
2. How do you want to pay your initial premium?
Electronic Fund Transfer (EFT); please complete section below
Bill me (coverage is contingent on payment of first premium being received within 31 days of assigned effective date)
For additional payment options, including credit card, visit bcbsm.com/payments once you receive your initial bill.
If you selected a BCBSM plan and have chosen to submit your first payment automatically, your payment will be deducted
two to three days after your application is approved. All future premium bills will be mailed directly to you.
If you selected a BCN medical plan, new auto-draft setups must be completed three business days before the due date for the
first payment to be deducted -- approximately the 25th of the month before your plan effective date.
Note: You’ll receive a monthly bill for future premium payments for all plans.
Electronic Fund Transfer (EFT) automatically deducts your premium payment from an account you designate.
Full name (First, Middle, Last)
Residential address
Email address
City
State
Zip code
Primary phone number
Name of financial institution
Type of account
Checking Savings
Bank account number
ABA/Routing number (9 digits)
Automatic payment can’t be processed without your signature. I authorize Blue Cross Blue Shield of Michigan (BCBSM) or Blue
Care Network (BCN) to deduct this one-time payment from the bank account listed above.
Signature Date
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. 9
WF 13271 JAN 2020 W000688
Section VII: Consent, Terms and Conditions
BLUE CROSS BLUE SHIELD OF MICHIGAN (BCBSM) OR BLUE CARE NETWORK OF MICHIGAN (BCN) PLANS
ELIGIBILITY
I understand that I’m eligible for this coverage if I, my spouse and my dependents listed on this application are residents of Michigan
on the effective date of the policy and live in Michigan at least 180 days each year, and that I, my spouse and my dependents listed
on this application aren’t eligible for or enrolled in Medicare. If anyone on this application is eligible for or enrolled in Medicare,
they’re eligible for a Dental, Dental with Vision, or Adult Vision Only plan. I certify that I, my spouse and my dependents listed on
this application are U.S. citizens or legally present in the U.S. I understand that I must notify BCBSM or BCN immediately if my
address changes.
If I am applying for coverage outside of the open enrollment period, I certify that I meet one of the qualifying events defined by the
Affordable Care Act (ACA), including but not limited to, birth, adoption, change in marital status, loss of job or involuntary loss of
group coverage, I am applying within the appropriate special enrollment period (SEP) as determined by my life event, and have
provided appropriate documentation of my life event. I understand full details on qualifying events and special enrollment periods
can be found at healthcare.gov. I am applying for health coverage through BCBSM or BCN, based on the specific plans I selected,
and understand that I’ll be subject to the terms and conditions of this application, and I agree that I’ll also be bound by all provisions
in the applicable plan certificates and riders. Approval of this application and coverage effective date will be determined by BCBSM
or BCN, as applicable. Additional information may be required of me. Coverage is contingent on payment of first premium being
received within 31 days of assigned effective date.
BCBSM or BCN, as applicable, have the right to test for tobacco usage to determine applicable rates, and BCBSM or BCN, as
applicable, can retroactively adjust premium rates back to the effective date based on results of tobacco (cotinine) testing. Regular
tobacco use is defined as four or more times per week excluding religious or ceremonial use. I know that under federal law,
discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity or disability. I
can file a complaint of discrimination by visiting hhs.gov/ocr/office/file.
This coverage isn’t an employer group health plan and isn’t intended in any way to be an employer-sponsored health insurance plan.
I certify that neither my or my spouse’s employer will contribute any part of the premium, nor will I or my spouse be reimbursed for
any part of the premium by the employer now, or in the future. Premium payments will be accepted from myself, my spouse or,
when applicable, the parent, blood relative, legal guardian, or other person or entity authorized under the law to pay the premium
on the subscriber's behalf.
I may enroll my eligible spouse and eligible dependents. An eligible spouse is the legal husband or wife of the subscriber, as
recognized as legal in the jurisdiction where the marriage occurred. An eligible dependent child is related to the subscriber by birth,
marriage, legal adoption or legal guardianship and under age 26 on the coverage effective date. I understand that coverage for my
dependent children will end on the last day of the year in which they reach age 26. These dependent children may apply for their
own individual coverage. Disabled, unmarried children may remain covered after they turn 26 if certain requirements are met (not
available for pediatric dental). A physician's certification of the dependent child's disability must be received 31 days after the end of
the year in which they turned 26 for determination of continuing coverage under my plan.
With regard to costs of hospital and medical services delivered by or paid for by BCBSM or BCN, as applicable, I agree to assign my
entire right to recovery of those costs against any person or organization as a result of accident or disease including injuries or
disease claimed under worker’s compensation laws or acts whether by redemption award or voluntary payment or otherwise to
BCBSM or BCN, as applicable.
I certify that the requirements of eligibility are met and that all of the information supplied on this application is true, correct, and
complete to the best of my knowledge. Detailed information regarding eligibility is available for viewing in the BCBSM or BCN
certificate and at bcbsm.com. I understand that the information will be used in reviewing my application and administering
coverage and that any misrepresentation or false or misleading information may result in termination or rescission of coverage.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. 10
WF 13271 JAN 2020 W000688
TERMINATION OF EXISTING BCBSM OR BCN COVERAGE OR PRIOR APPLICATIONS
In applying for coverage, I am requesting termination of any other BCBSM and BCN individual policy or prior application for BCBSM
or BCN coverage for which I’m a contract holder and lists the same covered members (if any) for which I have requested coverage
with this application. I also request that the prior policy termination be effective as of the effective date of this coverage and prior
BCBSM or BCN applications be terminated immediately. If I want to maintain my existing coverage when the coverage for which I’m
applying becomes effective, I will contact BCBSM/BCN directly in writing making such a request, and will include a copy of this
application with my written request.
RENEWABILITY - MEDICARE
Blue Cross Blue Shield of Michigan and Blue Care Network are prohibited from renewing individual market coverage for an enrollee
known to be entitled to Medicare Part A or enrolled in Medicare Part B if it would duplicate benefits to which the enrollee is
entitled, unless the renewal is effectuated under the same policy or contract of insurance.
TERMINATION OF COVERAGE
I understand that voluntary termination of my policy, including non-payment of premium, does not qualify as a life event to enroll
outside of the annual open enrollment period for myself or my dependents on the policy.
I understand BCBSM or BCN may terminate my coverage, if, including but not limited to, we no longer qualify for coverage under the
certificate, we can’t provide proof of residency in Michigan for a minimum of 180 days a year, or for misuse of coverage.
HEALTH SAVINGS ACCOUNT OFFERED THROUGH HEALTHEQUITY
®
Customers enrolled in HSA eligible plans can pair their plan with a health savings account (HSA) offered through HealthEquity
.
HealthEquity
is an independent company partnering with Blue Cross Blue Shield of Michigan and Blue Care Network to provide
health care spending account administration services. An independent and FDIC-insured bank holds the health savings account
dollars.
HSA accounts will have no charge per month for administrative fees per funded account. Members with Native American cost-
sharing subsidies on any plan can’t open an HSA. Likewise, Blue Cross plans that aren’t high-deductible health plans (HDHP) aren’t
eligible to open an HSA account, this includes Blue Cross Plans with “extra” benefits, as some benefits are covered before the
deductible is met. If you’ve already established an HSA and begin to receive these cost-sharing subsidies, or if you switch to a non-
HDHP with BCBSM, BCN, or another insurer, you will continue to own the funds in your HSA and may continue to spend from your
HSA but you will no longer be able to contribute to and manage your HSA through BCBSM’s/BCN’s member portal at bcbsm.com.
BCBSM/BCN will notify HealthEquity of your ineligibility and you’ll receive information within one month of the date of ineligibility
on how to continue managing your health savings account.
Customers who have an HSA with HealthEquity through their current BCBSM or BCN HDHP and apply for another HDHP with either
BCBSM or can continue to manage their HSA through the BCBSM/BCN member portal. If you want to discontinue management of
your HSA with HealthEquity through the BCBSM/BCN member portal, you must contact BCBSM/BCN customer service directly to
decouple management of your HSA from your Blue Cross Blue Shield of Michigan or Blue Care Network plan.
CATASTROPHIC (VALUE) PLANS
Catastrophic plans including Blue Cross
®
Premier PPO Value and Blue Cross
®
Select HMO Value are available to individuals under age
30 or those who’ve received a certification of exemption from the individual mandate due to affordability or hardship from the
Health Insurance Marketplace. All members on the plan, including your spouse and dependents, must be under age 30 before the
plan effective date, to be eligible to enroll in a value plan. If you meet this eligibility requirement, you can stay in a catastrophic plan
for the duration of the calendar year in which you turn age 30.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. 11
CF 13271 MAY 19 R088970
AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI)
I understand that information collected about me as provided by this authorization will be used for the purposes noted below as
well as to determine my eligibility for health coverage. BCBSM or BCN may collect personal and protected health information (PHI)
about me to process my application for coverage. BCBSM or BCN will use and disclose this information only in accordance with their
Notice of Privacy Practices, which is available on bcbsm.com or by calling 313-225-9000.
I authorize:
• Use and disclosure of my PHI, including membership, eligibility and claims data stored on BCBSM’s and its subsidiaries’ computer
systems.
• Physicians, health care professionals, hospitals, clinics, laboratories, pharmacies or pharmacy benefit managers, or other health
care providers that have provided treatment or services to me or any of my dependents who are also applying for coverage to
disclose medical records, prescription history, medications prescribed and other PHI as requested to BCBSM or BCN.
• Health plans, governmental agencies or prescription drug profiling companies that have a previous relationship with me or who
have knowledge of my medical information or the medical information of any of my dependents who are also applying for
coverage to disclose medical records information, prescription history, medications prescribed and other PHI as requested to
BCBSM or BCN. My authorization includes disclosure of information on the diagnosis and treatment of human immunodeficiency
virus (HIV) infection and treatment of mental illness and the use of alcohol, drugs and tobacco, but excludes disclosure of
psychotherapy notes.
This PHI is to be disclosed so that BCBSM or BCN may: (1) perform case, care and disease management, (2) validate rating factors
allowable under the Patient Protection and Affordable Care Act (PPACA), (3) administer claims and determine or fulfill responsibility
for coverage and provision of benefits, and (4) for other legally permissible purposes, including but not limited to, health care
operations.
If BCBSM rediscloses this information, the recipient must obtain an additional authorization from me before it may redisclose the
information and, if I provide this authorization, information may be redisclosed by the recipient and is no longer protected. I
understand and acknowledge that if I’m applying for coverage from BCN that this restriction on redisclosure doesn’t apply, but if
BCN does redisclose my information, it may no longer be protected.
I understand that my enrollment with BCBSM or BCN is conditioned upon my authorization to release PHI for the purposes stated
above and that if I don’t provide authorization, I may not be eligible for enrollment. My signature on this form indicates my approval
for the release of PHI from BCBSM or BCN and its subsidiaries and from any of the parties listed above to BCBSM or BCN. A copy or
other reproduction of this authorization shall be valid as the original. My authorization expires upon the later of (i) rescission or
rejection of coverage by BCBSM or BCN; or (ii) I cause my coverage to terminate or it otherwise expires. I understand that I’m
entitled to receive a copy of this authorization upon request. I may revoke this authorization at any time by sending a written
request on a standard form available online at bcbsm.com or by contacting my Blue Cross or BCN agent. I understand that
revocation won’t affect actions taken before BCBSM or BCN or any of the parties identified above receive my request.
REFUND POLICY
I understand that requests to terminate coverage will be accepted by me, the card holder, and if I terminate coverage, BCBSM or
BCN will refund the unused portion of the monthly premium that was paid, if applicable. BCBSM or BCN will mail me a check within
30 days from the date of my termination. Details about terminating coverage can be found in the certificate or by contacting the
number on the back of my BCBSM or BCN card.
I may terminate my coverage by notifying BCBSM or BCN within 10 days of the effective date of my coverage. I will receive a full
refund of my premium. If I terminate my coverage after 10 days, I will receive a prorated refund on the unused portion of my
premium.
Refunds for Blue Cross
®
Vision for Adults will only be granted to those members that have elected to pay annually and have no
benefit utilization by anyone on the contract for the given year for which premium has been paid in advance. These refunds will be
processed by request as of the first of the following month (no partial month prorated refunds).
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. 12
WF 13271 JAN 2020 W000688
Section VIII: Sign and Date
Please review your application for completeness and accuracy, and sign and date below.
SUMMARY OF BENEFITS AND COVERAGE
I understand that a Summary of Benefits and Coverage (SBC) related to the coverage for which I’m applying is available on the web
at bcbsm.com/sbc. I understand the SBC isn’t a contract and that it provides only a general overview of coverage information and, if
there is any difference or discrepancy between the SBC and my applicable plan document (including certificates and riders), the plan
document will control. I consent to delivery of the SBC electronically via the website. I understand a paper copy is also available, free
of charge, by calling BCBSM at 1-888-288-2738 or BCN at 1-888-227-2345, as applicable.
Plan, marketing, and promotional materials
I understand that I’ll receive plan information, updates, announcements and reminders from Blue Cross Blue Shield of Michigan and
Blue Care Network. I consent to delivery of these materials electronically and understand that a paper version of these may also be
available to me free of charge. To discontinue these communications, I can unsubscribe at bcbsm.com or by calling the Customer
Service number on the back of my member ID card.
Signature of primary applicant (if child only policy, legal guardian must sign)
Date
Mail your completed application to:
Individual Membership and Billing
Blue Cross Blue Shield of Michigan
600 E. Lafayette Blvd, Mail Code 610B
Detroit, MI 48226
Or fax to: 877-486-2172
Area below for Blue Cross and BCN agent use only
Agent first name
Agent last name
5-digit agent code
GA name
GA 2-digit code
National producer number
Name of person entering enrollment information online
First name Last name
Date producing agent accepted paper enrollment form from individual
Date
(mm/dd/yyyy)
Date general agent or association received paper enrollment from agent
Date
(mm/dd/yyyy)
Agent signature
Date signed
We speak your language
If you, or someone you’re helping, needs assistance, you have the
right to get help and information in your language at no cost. To
talk to an interpreter, call the Customer Service number on the
back of your card, or 877-469-2583, TTY: 711 if you are not
already a member.
Si usted, o alguien a quien usted está ayudando, necesita
asistencia, tiene derecho a obtener ayuda e información en su
idioma sin costo alguno. Para hablar con un intérprete, llame al
número telefónico de Servicio al cliente, que aparece en la parte
trasera de su tarjeta, o 877-469-2583, TTY: 711 si usted todavía no
es un miembro.
اذإ ﺖﻨﻛ ﺖﻧأ وأ ﺺﺨﺷ ﺮﺧآ هﺪﻋﺎﺴﺗ ﺔﺟﺎﺤﺑ ةﺪﻋﺎﺴﻤﻟ، ﻚﯾﺪﻠﻓ ﻖﺤﻟا ﻲﻓ لﻮﺼﺤﻟا ﻰﻠﻋ
ةﺪﻋﺎﺴﻤﻟا تﺎﻣﻮﻠﻌﻤﻟاو ﺔﯾروﺮﻀﻟا ﻚﺘﻐﻠﺑ نود ﺔﯾأ ﺔﻔﻠﻜﺗ .ثﺪﺤﺘﻠﻟ ﻰﻟإ ﻢﺟﺮﺘﻣ ﻞﺼﺗا ﻢﻗﺮﺑ
ﺔﻣﺪﺧ ﻼﻤﻌﻟاء دﻮﺟﻮﻤﻟا ﻰﻠﻋ ﺮﮭظ ﻚﺘﻗﺎﻄﺑ، وأ ﻢﻗﺮﺑ 877-469-2583 TTY:711 ،اذإ
ﻢﻟ ﻦﻜﺗ ﺎﻛﺮﺘﺸﻣ ﻞﻌﻔﻟﺎﺑ.
如果您，或是您正在協助的對象，需要協助，您有權利免費
以您的母語得到幫助和訊息。要洽詢一位翻譯員，請撥在您
的卡背面的客戶服務電話；如果您還不是會員，請撥電話
877-469-2583, TTY: 711。

،




 ،




،











.






، 













877-469-2583 TTY:711


.
Nếu quý vị, hay người mà quý vị đang giúp đỡ, cần trợ giúp, quý vị
sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của
mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi số
Dịch vụ Khách hàng ở mặt sau thẻ của quý vị, hoặc 877-469-2583,
TTY: 711 nếu quý vị chưa phải là một thành viên.
Nëse ju, ose dikush që po ndihmoni, ka nevojë për asistencë, keni
të drejtë të merrni ndihmë dhe informacion falas në gjuhën tuaj.
Për të folur me një përkthyes, telefononi numrin e Shërbimit të
Klientit në anën e pasme të kartës tuaj, ose 877-469-2583,
TTY: 711 nëse nuk jeni ende një anëtar.
만약 귀하 또는 귀하가 돕고 있는 사람이 지원이 필요하다면,
귀하는 도움과 정보를 귀하의 언어로 비용 부담 없이 얻을 수
있는 권리가 있습니다. 통역사와 대화하려면 귀하의 카드
뒷면에 있는 고객 서비스 번호로 전화하거나, 이미 회원이
아닌 경우 877-469-2583, TTY: 711로 전화하십시오.
 ,      ,   ,
        
      ,   
       877-469-2583, TTY: 711
      
Jeśli Ty lub osoba, której pomagasz, potrzebujecie pomocy, masz
prawo do uzyskania bezpłatnej informacji i pomocy we własnym
języku. Aby porozmawiać z tłumaczem, zadzwoń pod numer
działu obsługi klienta, wskazanym na odwrocie Twojej karty lub
pod numer 877-469-2583, TTY: 711, jeżeli jeszcze nie masz
członkostwa.
Falls Sie oder jemand, dem Sie helfen, Unterstützung benötigt,
haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer
Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen,
rufen Sie bitte die Nummer des Kundendienstes auf der Rückseite
Ihrer Karte an oder 877-469-2583, TTY: 711, wenn Sie noch kein
Mitglied sind.
Se tu o qualcuno che stai aiutando avete bisogno di assistenza, hai
il diritto di ottenere aiuto e informazioni nella tua lingua
gratuitamente. Per parlare con un interprete, rivolgiti al Servizio
Assistenza al numero indicato sul retro della tua scheda o chiama
il 877-469-2583, TTY: 711 se non sei ancora membro.
ご本人様、またはお客様の身の回りの方で支援を必要とさ
れる方でご質問がございましたら、ご希望の言語でサポー
トを受けたり、情報を入手したりすることができます。料
金はかかりません。通訳とお話される場合はお持ちのカー
ドの裏面に記載されたカスタマーサービスの電話番号
(メンバーでない方は877-469-2583, TTY: 711)
までお電話ください。
Если вам или лицу, которому вы помогаете, нужна помощь, то
вы имеете право на бесплатное получение помощи и
информации на вашем языке. Для разговора с переводчиком
позвоните по номеру телефона отдела обслуживания
клиентов, указанному на обратной стороне вашей карты, или
по номеру 877-469-2583, TTY: 711, если у вас нет членства.
Ukoliko Vama ili nekome kome Vi pomažete treba pomoć, imate
pravo da besplatno dobijete pomoć i informacije na svom jeziku.
Da biste razgovarali sa prevodiocem, pozovite broj korisničke
službe sa zadnje strane kartice ili 877-469-2583, TTY: 711 ako već
niste član.
Kung ikaw, o ang iyong tinutulungan, ay nangangailangan ng
tulong, may karapatan ka na makakuha ng tulong at impormasyon
sa iyong wika ng walang gastos. Upang makausap ang isang
tagasalin, tumawag sa numero ng Customer Service sa likod ng
iyong tarheta, o 877-469-2583, TTY: 711 kung ikaw ay hindi pa
isang miyembro.
Important disclosure
Blue Cross Blue Shield of Michigan and Blue Care Network comply
with Federal civil rights laws and do not discriminate on the basis
of race, color, national origin, age, disability, or sex. Blue Cross
Blue Shield of Michigan and Blue Care Network provide free
auxiliary aids and services to people with disabilities to
communicate effectively with us, such as qualified sign language
interpreters and information in other formats. If you need these
services, call the Customer Service number on the back of your
card, or 877-469-2583, TTY: 711 if you are not already a member.
If you believe that Blue Cross Blue Shield of Michigan or Blue Care
Network has failed to provide services or discriminated in another
way on the basis of race, color, national origin, age, disability, or
sex, you can file a grievance in person, by mail, fax, or email with:
Office of Civil Rights Coordinator, 600 E. Lafayette Blvd., MC 1302,
Detroit, MI 48226, phone: 888-605-6461, TTY: 711,
fax: 866-559-0578, email:
CivilRights@bcbsm.com. If you need
help filing a grievance, the Office of Civil Rights Coordinator is
available to help you.
You can also file a civil rights complaint with the U.S. Department
of Health & Human Services Office for Civil Rights electronically
through the Office for Civil Rights Complaint Portal available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail, phone,
or email at: U.S. Department of Health & Human Services,
200 Independence Ave, S.W., Washington, D.C. 20201,
phone: 800-368-1019, TTD: 800-537-7697,
email:
OCRComplaint@hhs.gov. Complaint forms are
available at
http://www.hhs.gov/ocr/office/file/index.html.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.
WF 13271 SEP 19
13
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Application for Coverage Individuals and Families (Blue Cross Blue Shield of Michigan)

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Completed 10 February 2021

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