If you are a current member and have questions, you may call the Customer Service number on the back of your
member ID card.
PLEASE READ THOROUGHLY BEFORE COMPLETING ENROLLMENT APPLICATION
/
CHANGE FORM
Use a black or blue ballpoint pen only. Print neatly. Do not abbreviate.
ENROLLMENT APPLICATION/CHANGE FORM INSTRUCTIONS
Changes in state or federal law or regulations, or interpretations thereof, may change the terms and conditions of coverage.
Check all the boxes that apply to indicate if you are a new enrollee or if you are requesting a change to your coverage. Indicate the event and date, if applicable. Complete the
additional sections that correspond to your selection.
New Enrollee: Complete all sections where applicable.
Add Dependent: Complete all sections where applicable.
• If you are applying for coverage for a disabled dependent over the age limit of your employer’s plan, please provide the additional information requested in Section 5.
Additional documentation may be required as addressed in that section.
• If your employer offers coverage for children and your children are eligible, your children are eligible for health and/or dental coverage up to the dependent limiting age
and may not be denied coverage due to marital, student or employment status before age 26 (check with your employer for additional details regarding eligibility
requirements). In addition, eligible military personnel may not be denied coverage before age 30 under Illinois law. If you are adding an eligible military personnel
dependent who is over the age limit of the employer’s plan, completion of a Defense Department Form (DD 214) is required in addition to this application.
Open Enrollment: The period of time offered on a regular basis during which you can elect to enroll in a specific group health insurance plan or make changes to your
current membership.
Special Enrollment Event: If you qualify, special enrollment is any change to your current membership such as marriage*, divorce**, adoption, suit for adoption or placement for
adoption, leave/layoff, moving out of the service area, etc. This change may occur outside of open enrollment.
Effective Date of Benefits: Field is mandatory and should reflect your requested date.
Completion of Other Eligibility Requirements: Check this box only if your employer has eligibility requirements that you have met/completed prior to enrollment, such as
measurement period or orientation period.
Cancel Enrollee/Cancel Dependent/Cancel Coverage: Complete Sections 1, 2, 4 (skip Section 4 if declining coverage), 8 and 9. In Section 4 include name, social security
number and date of birth of individual(s) canceling.
Complete this section with details about yourself even if you are declining coverage.
Complete all portions related to the coverages for which you are applying. Please list the seven character plan ID for your selected benefit design (example: S533PPO) in the
plan # field. If you are unsure of your group size or do not know your plan ID, please ask for guidance from your employer.
If you are enrolling with Dearborn National
®
, enter the information requested. When listing the beneficiary, provide both the first and last name and the relationship to you. List all
beneficiaries that apply.
Complete all areas that apply to you and each dependent.
For HMO Plans Only:
• Those applying for HMO coverage are required to select a primary care physician/practitioner (PCP) for each covered individual. List the name of the physician/practitioner and
the provider number from the provider directory or Provider Finder
®
at bcbsil.com. Be sure to check the appropriate box for a new patient.
• If you selected HMO coverage, you must select a medical group/individual practice associations (IPAs) and a primary care physician (PCP) for each person to be covered.
You must also select a PCP within the selected medical group/IPA for each person to be covered. You may choose a different medical group/IPA for each person. Care
received from a woman’s principal health care provider (WPHCP) may be eligible for coverage without referrals from your PCP. However, your PCP and your WPHCP must
be affiliated with or employed by your medical group/IPA in order for each person to be eligible for coverage. Until we receive your selected medical group/IPA, you may not
be eligible and your claims may be denied. Be sure to enter the medical group/IPA number, name, PCP number and name.
• If you are adding an eligible military personnel dependent who is over the age limit of your employer’s plan, completion of a Defense Department Form 214 (DD 214) is
required in addition to this application.
Change Primary Care Physician/Practitioner: Complete Section 1 and check the “Other Change(s)” box; then, complete Sections 2, 3, 4 and 9. In Section 4, please include
enrollee’s or dependent’s name, social security number, date of birth, name and number of the new PCP and the name and number of the new IPA.
Change Address/Name: Complete Section 1 and check the “Other Change(s)” box; then, complete Sections 2 and 9.
A disabled dependent must be medically certified as disabled and dependent upon you or your spouse***/domestic partner in order to be considered for coverage if dependent
coverage is part of your employer’s plan. The disabled dependent is required to be covered prior to age 26 to be eligible for coverage over the dependent child age limit of your
employer’s plan. A Disabled Dependent Certification and Disabled Dependent Physician Certification document must be completed and submitted with this enrollment
application, if applicable.
Complete this section if you or any dependent have other group or individual health and/or dental coverage (if applicable) that will not be canceled when the coverage under this
application becomes effective.
Complete this section if you or any of your dependents are covered by Medicare. Enter the start and end dates for the coverage that applies. Your Medicare HIC number must be
listed (it can be found on your Medicare ID card). Check the reason for your Medicare coverage.
Complete this section if you are declining health coverage for yourself and your dependents. Anyone declining coverage for any reason should complete Section 8, not just those
declining because of other coverage.
IMPORTANT NOTICE: If you are declining enrollment for yourself or your dependents (including your spouse) because of other health care coverage, you may, in the future, be
able to enroll yourself or your dependents in the plan if you request enrollment within 31 days after your other coverage ends. In addition, if you have a new dependent as a result
of a marriage, party to a civil union, birth, adoption, becoming a party in a suit for adoption, or placement of a foster child in your home, you may be able to enroll yourself and your
dependents if you request enrollment within 31 days after the marriage, birth, adoption, suit for adoption or placement for adoption, or placement of an eligible foster child in
your home.
Sign your name and date the enrollment application if you agree to the conditions set forth in this section. Your enrollment application should be submitted to your employer’s
Enrollment Department, which will then submit your form to BCBSIL.
As used on the application (unless indicated otherwise): These terms may be used in a different way in other documents.
* The term “marriage” includes legal marriage and the establishment of a civil union or domestic partnership (coverage subject to your employer’s plan).
** The term “divorce” includes legal divorce and the comparable termination of a civil union or domestic partnership (coverage subject to your employer’s plan).
*** The term “spouse” includes a legal spouse and a party to a civil union or domestic partnership (coverage subject to your employer’s plan).
SECTION 1
ENROLLMENT EVENTS
SECTION 2
YOUR INFORMATION
SECTION 3
YOUR COVERAGE
SECTION 4
COVERAGE OPTIONS
SECTION 5
DISABLED DEPENDENT
SECTION 6
OTHER COVERAGE
SECTION 7
MEDICARE COVERAGE
SECTION 8
DECLINATION OF
COVERAGE
SECTION 9
COVERAGE CONDITIONS
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