Fillable United Healthcare - Form 592F New Jersey Nongroup Enrollment Change Request Form OHI

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United Healthcare - Form 592F New Jersey Nongroup Enrollment Change Request Form OHI

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The United Healthcare - Form 592F New Jersey Nongroup Enrollment Change Request Form OHI form is 7 pages long and contains:

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Country of origin: US
File type: PDF

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1
NJ-HINT-Individual
11/2017
OHI NJ IP HINT 01-2018
592F-O-1118
New Jersey Nongroup Enrollment/Change Request Form – OHI
Oxford Health Insurance, Inc.
Mailing Address: PO Box 31370, Salt Lake City, UT 84131-0370 1-800-657-8205
www.uhone.com
Instructions
• Except for section G, you must complete sections
A through I, and sign and date this form, as well as any
additional pages you may need to submit with it to provide
further requested information.
• Please PRINT except when a signature is requested.
• If a dependent child is disabled and you want to continue his or
her coverage beyond age 26, describe this in “Other Change” in
Section A, and attach proof of disability.
• If you are applying to add a spouse, civil union partner, domestic
partner, or child please check the applicable box in the “Add”
section in A and identify the applicable triggering event in the
reason section “Other Change” section in A.
• Eligible for Medicare means the person satises the requirements
for Medicare but has not yet enrolled for Medicare. Covered
under Medicare Parts A or B means you have Medicare and
CANNOT enroll for an individual plan.
• You can obtain the providers’ correct names and addresses from
the appropriate provider directory.
•
IF YOU HAVE ANY QUESTIONS concerning the benets and
services provided by or excluded under this policy, contact a
member services representative at 1-800-657-8205 before
signing this form.
• KEEP A COPY OF THIS COMPLETED APPLICATION!
Coverage must be veried with Oxford Health Insurance, Inc.
prior to visiting with a specialist or admission to a hospital.
• Triggering Events:
1. Loss of eligibility for minimum essential coverage but not if
lost due to non-payment of premium
2. Dependent attained age 26 or 31 and lost coverage
3. Marketplace changed your subsidy determination
4.
Marriage (at least one spouse must have had coverage for at
least 1 day within the prior 60 days)
5.
Birth, adoption or placement for adoption, placement in
foster care
6.
Gained access to New Jersey plans as a result of permanent
move to New Jersey (must have had coverage for at least 1
day within the prior 60 days)
Eligibility
A. Eligibility requirements are set forth under the Individual
Health Coverage Reform Act of 1992, P.L. 1992, c. 161
(N.J.S.A. 17B:27A-2 et seq.).
B. You MUST be a New Jersey resident which means your
primary residence is in New Jersey.
C. You must not be enrolled for Medicare Parts A or B.
D. If application is made for the Catastrophic Plan the following
additional requirements apply:
1. You must be under 30 years old; OR
2.
You must have a notice that you qualify for an
exemption with an exemption certificate number
(ECN) from the Marketplace.
The Annual Open Enrollment Period is the designated period
of time each year during which you may apply for or change
coverage for yourself and family members who are currently
uninsured or who are covered under another individual plan, or
who are covered under a group health plan, group health benefits
plan, a governmental plan, or a church plan. The Open Enrollment
Period begins November 1 and continues until December 15. Your
application must be signed, dated and mailed during the Annual
Open Enrollment Period. The effective date of coverage applied for
by December 15 will be January 1 of the immediately following
year.
A Special Enrollment Period that lasts for 60 days follows the
listed Triggering Events. The effective date of a new policy will be
no later than the first of the month following receipt of the
application. In addition, if the Triggering Event is the loss of
eligibility for minimum essential coverage, the Special
Enrollment Period includes the 60 days prior to the Triggering
Event. NOTE: If you currently have coverage, the plan for which
you are applying must REPLACE the current coverage
but you SHOULD NOT terminate it until the new coverage
is effective.
INSTRUCTIONS AND ELIGIBILITY REQUIREMENTS
7.
Child support order or other court order requiring coverage
8.
Application to NJ FamilyCare submitted during open
enrollment period or during a special enrollment period is
found ineligible
9.
Domestic abuse or spousal abandonment necessitating
coverage apart from the prepetrator
Enrollment of a new Subscriber ____/____/____ ______________________________________________________
Add Spouse ____/____/____ ______________________________________________________
Add Civil Union Partner ____/____/____ ______________________________________________________
Add Domestic Partner ____/____/____ ______________________________________________________
Add Dependent Child ____/____/____ ______________________________________________________
Remove Subscriber ____/____/____ ______________________________________________________
Remove Spouse ____/____/____ ______________________________________________________
Remove Civil Union Partner ____/____/____ ______________________________________________________
Remove Domestic Partner ____/____/____ ______________________________________________________
Remove Dependent Child ____/____/____ ______________________________________________________
Name Change ____/____/____ ______________________________________________________
Change Plan ____/____/____ ______________________________________________________
Special Enrollment Period
(due to Triggering Event*)
____/____/____
Other ____/____/____ ______________________________________________________
*See list of triggering Events in Instructions
2
NJ-HINT-Individual
11/2017
OHI NJ IP HINT 01-2018
592F-O-1118
New Jersey Nongroup Enrollment/Change Request Form – OHI
Oxford Health Insurance, Inc.
Mailing Address: PO Box 31370, Salt Lake City, UT 84131-0370 1-800-657-8205
www.uhone.com
Activity - Check all that apply Date of Event Reason
ADDREMOVEOTHER CHANGE
Name (Last, First, MI):
SSN: Birthdate (mm/dd/yyyy)
Male Email:
Female
Are you a resident of New Jersey? Yes No Do you maintain a home in any other state or country? Yes No If yes:
Name of State/Country:__________________ Number of months you live there each year: ___
Primary Residence: Other Residence:
Street/Apt.: ______________________________________________ Street/Apt.: ____________________________________________________
City: __________________________________ State:_____________ City: ______________________________________ State: _____________
ZIP Code: ____________________________ ZIP Code: __________________________________
Preferred Phone:
Home Cell Work (____) _________________ Phone: (____)__________________________
Alternate Phone:
Home Cell Work (____) _________________
Your billing address:
Primary residence Other residence PO Box or Other (specify)
Add Remove Continuation Other Change If a name change, indicate prior name:
Primary Name: ____________________________________ Provider No. Current Patient:
Yes No
Ob/Gyn Name: ____________________________________ Provider No. Current Patient:
Yes No
ADDRESS INFORMATIONACTIVITY
B. Applicant Information
Are you eligible for Medicare? Yes No
Are you covered under Medicare Parts A or B? Yes No
Please note: If you are eligible for Medicare, the individual policy will coordinate as
secondary payor to what Medicare paid or would have paid. Individual policies do
not operate as Medicare supplement policies.
Are you covered under any health coverage? Yes No
If yes, why are you applying for individual coverage?
______________________________________________________________
______________________________________________________________
A. Type of Activity - to be completed by Applicant Refer to instructions on front before completing this form. Print clearly.
D. Other Individuals Covered - Identify Individuals other than yourself for whom you are adding/changing/removing coverage.
Attach additional pages if necessary, dated and signed by you. (Attach proof of disability.)
1.
Spouse Domestic Partner
2. Child 3. Child 4. Child
Civil Union Partner
Add Remove Other Add Remove Other Add Remove Other Add Remove Other
Name (Last, First, MI) Name (Last, First, MI) Name (Last, First, MI) Name (Last, First, MI)
L: ______________________________ L: ____________________________ L: _____________________________ L: ____________________________
F: ______________________________ F: ____________________________ F: _____________________________ F: ____________________________
MI: ____________________________ MI: ___________________________ MI: ___________________________ MI: __________________________
Birthdate (mm/dd/yyyy): Birthdate (mm/dd/yyyy): Birthdate (mm/dd/yyyy): Birthdate (mm/dd/yyyy):
Male Female Disabled Male Female Disabled Male Female Disabled Male Female Disabled
Social Security Number: Social Security Number: Social Security Number: Social Security Number:
Eligible for Medicare? Yes No
Eligible for Medicare? Yes No
Covered under Medicare Parts A or B?
Covered under Medicare Parts A or B?
Yes No Yes No Yes No Yes No
Covered under any health coverage?
Covered under any health coverage?
Yes No Yes No Yes No Yes No
Primary Care Provider: Primary Care Provider: Primary Care Provider: Primary Care Provider:
Name: __________________________ Name: _________________________ Name: _________________________ Name: ________________________
Provider ID No. Provider ID No. Provider ID No. Provider ID No.
_______________________________ ______________________________ ______________________________ _____________________________
Current Patient?
Yes No
Current Patient?
Yes No
Current Patient?
Yes No
Current Patient?
Yes No
Ob/Gyn Oce Ob/Gyn Oce Ob/Gyn Oce Ob/Gyn Oce
Name: __________________________ Name: _________________________ Name: _________________________ Name: ________________________
Provider ID No. Provider ID No. Provider ID No. Provider ID No.
_______________________________ ______________________________ ______________________________ _____________________________
Current Patient?
Yes No
Current Patient?
Yes No
Current Patient?
Yes No
Current Patient?
Yes No
If last name is dierent from If last name is dierent from If last name is dierent from If last name is dierent from
Applicant’s, please explain: Applicant’s, please explain: Applicant’s, please explain: Applicant’s, please explain:
_______________________________ ______________________________ ______________________________ _____________________________
Home address same as Applicant? Home address same as Applicant? Home address same as Applicant? Home address same as Applicant?
Yes No Yes No Yes No Yes No
If NO, complete Section E If NO, complete Section F If NO, complete Section F If NO, complete Section F
a. Street/Apt.: __________________________________________________ b. Please explain why the address is dierent:
City: ________________________________________________________ _____________________________________________________________
State, ZIP Code: _______________________________________________ _____________________________________________________________
3
NJ-HINT-Individual
11/2017
OHI NJ IP HINT 01-2018
592F-O-1118
C. Plan Option - Check one
Silver Copay Select 80 Silver Copay Select 70 Bronze Copay Select 50
E. Additional Spouse/Domestic Partner/Civil Union Partner Information - If not applicable, please mark as “NA.”
Eligible for Medicare? Yes No
Eligible for Medicare? Yes No
Covered under Medicare Parts A or B?
Covered under Medicare Parts A or B?
Covered under any health coverage?
Covered under any health coverage?
4
NJ-HINT-Individual
11/2017
OHI NJ IP HINT 01-2018
592F-O-1118
F. Additional Child Information - Provide information below about children listed in Section D, if they have a different address.
If multiple children are at an address, you may list them together. Attach additional pages as necessary, signed and dated.
Name(s): ______________________________________________________ Name(s): _____________________________________________________
Street/Apt: ____________________________________________________ Street/Apt: ___________________________________________________
City, State, ZIP Code: ____________________________________________ City, State, ZIP Code: ___________________________________________
Reason: _______________________________________________________ Reason: ______________________________________________________
Choose a category that most closely
American Indian or Alaskan Native Black, not of Hispanic Origin Hispanic
describes you:
Asian or Pacic Islander White, not of Hispanic Origin
Initial Payment with Application:
Check EFT Credit Card
Ongoing Payments:
Monthly: EFT Direct Bill
Quarterly: Direct Bill
I represent that all the information supplied in this application is true and complete. I hereby agree to the Conditions of Enrollment set forth in
this Enrollment/Change Request form.
Signature:________________________________________________________________________ Date: _______________________________________
Signature of Preparer: Date: NJ Producer License No.
General Agent: Agent ID No.
On behalf of myself and the dependents listed in this Enrollment/Change Request form, I acknowledge that:
1. I authorize any physician or medical professional, hospital, clinic or other medical care institution, carrier, consumer reporting agency, and any employer
to give Oxford Health Insurance, Inc., or any consumer reporting agency acting on behalf of Oxford Health Insurance, Inc., information pertaining to
employment, other health coverage, and medical advice, treatment or supplies for any physical or mental condition relevant to me or a minor dependent
applying for coverage. I agree that this authorization shall be valid for 30 months from the date I sign this Enrollment/Change Request form, unless revoked at
an earlier date.
2. I agree that, if I revoke this authorization before it expires, such revocation shall not aect any action that Oxford Health Insurance, Inc. has taken in reliance
on the authorization.
3. I understand I may receive a copy of this authorization if I request one.
4. I agree Oxford Health Insurance, Inc. will provide coverage in accordance with the terms of the contract for the individual plan.
5. I understand that my enrollment and the enrollment of my listed dependents in Oxford Health Insurance, Inc. individual plan is subject to acceptance by
Oxford Health Insurance, Inc.
6. I agree that the provision of coverage and benets is contingent upon payment of premiums and may be terminated in accordance with the terms of the
individual plan if premiums are not paid timely.
Any person who includes any false or misleading information on a Nongroup Enrollment/Change Request Form for a health benets plan is subject
to criminal and civil penalties.
G. Race/Ethnicity - Response is appreciated but NOT required!
H. Payment Information - Indicate how you would like to be billed and make payment.
I. Applicant’s Signature
J. Broker/General Agent Signature
CONDITIONS OF ENROLLMENT - APPLICANT ACKNOWLEDGEMENTS AND AGREEMENTS
MISREPRESENTATIONS
___/___/___
5
NJ-HINT-Individual
11/2017
OHI NJ IP HINT 01-2018
592F-O-1118
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION — ONLY IF PAYING BY EFT
I (we) hereby authorize Oxford
Health Insurance, Inc. to initiate
debit entries to the account indicated
below. I also authorize the named
nancial institution to debit the
same to such account.
I agree this authorization will
remain in effect until you actually
receive written notication of its
termination from me.
Type of Account:
Checking Savings
Financial Institution’s Name ________________________
Address _______________________________________
City, State, ZIP __________________________________
Draft On ______________________ ______________
Day Date Signed
X _____________________________________________
Authorized Account Signature
324F-O-1116
Nine-digit
Routing No.
Acct No.
Note: Some card issuers/nancial institutions charge cash advance fees on insurance payments.
325F-O-1116
CREDIT CARD AUTHORIZATION — ONLY IF PAYING BY CREDIT CARD
I authorize Oxford Health Insurance, Inc. to bill my
American Express/MasterCard/Visa account for
the Total Premium for Mode Chosen.
Type of Card: MasterCard Visa
American Express
Month Year
ZIP Code:
Card
Number:
X
______________________________________________________
Signature of Authorized User
Charge On ___________________
Day
Only select a charge date between the 1st and 28th of the month.
Exp. Date:
44177a-X-0518
CONSENT TO RECEIVE ELECTRONIC RECORDS AND
TO CONDUCT TRANSACTIONS ELECTRONICALLY
By submitting this consent form or a health insurance application or HMO enrollment form, you hereby
consent to presentation, delivery, storage retrieval and transmission of “Communications” related to “Our
Transaction” as electronic records instead of in paper form.
For the purposes of this form, “Our Transaction” means the entirety of the business relationship between you
and us. “Communications” includes, but is not limited to:
1. Your application or enrollment form, including subsequent amendments;
2. Information related to Our Transaction that we are required to provide or make available in writing such
as privacy notices or fraud warnings;
3. Documents related to Our Transaction such as policy, certificate, or evidence of coverage forms, claim
forms, explanation of benefit forms, premium notices, or other administrative forms (to the extent
permitted by applicable law);
4. Any emails, faxes, recorded telephone calls, or other electronic transmissions of information between you
and us and an insurance producer contracted with us, or between us and any third party.
Subject to our obligations to protect your privacy, we may, at our sole discretion, post Communications on a
website (in which case they will be sent or received, as the case may be, regardless of whether or not we
own, operate or control the website). Or send them in or attached to an email. Please be advised that
communication by unencrypted email presents a risk of disclosure to, or interception by, unintended third parties.
You must promptly tell us about any change to your electronic or physical mailing address, or other contact
information.
You acknowledge that you can receive or access Communications because you have the following:
•
A telephone
•
A computer and printer
•
A device or computer program for listening to audio CDs, mp3, WAV or other common computer audio files
•
An Internet browser
•
Access to the Internet
•
A valid email address
•
Adobe Acrobat Reader or other sufficient PDF reader
You can request a free copy of any Communications, or withdraw your consent to receive
electronic Communications at any time by sending a written request to:
Policy Administration
PO Box 31372
Salt Lake City, UT 84131-0372
I hereby consent to receive Communications and Transaction Documents electronically, as per the
aforementioned conditions. All of the Communications between the time you submit your consent and
withdraw your consent will remain valid and binding on both you and us notwithstanding your withdrawal.
I hereby DO NOT consent to receive Communications and Transaction Documents electronically,
as per the aforementioned conditions. If you do not consent, we will conduct all future business with
you in paper form.
X _____________________________________________
Primary Applicant (You)
X _____________________________________________
Parent/Guardian (if you are a minor) Relationship
X _____________________________________________
_____________________________________________
Primary Applicant (You) Email Address
Parent/Guardian (if you are a minor) Email Address
_____________________________________________ ______________________________________________
Date Policy ID Number
592F-O-1118
6 of 7
Sep 5 2018 09:05:12 am
45321-O-1117
This notice is for electronic delivery of Form 1095-B only.
It will stay in place until you tell us that you don’t want to
get Form 1095-B electronically.
What is Form 1095-B?
This is the IRS form that you will use when you prepare
your tax return to show you had minimum essential
coverage (MEC). Form 1095-B shows this information
about your health coverage:
• Type of coverage you had
• Period of coverage
• Who was covered (including dependents)
Electronic delivery of Form 1095-B
You agree to receive Form 1095-B electronically instead
of receiving a paper copy. If you also want a paper copy,
call the number on your health plan ID card. We will
keep sending future 1095-B forms electronically.
You may print Form 1095-B to use when preparing your
tax return.
You may have already agreed to get other
communications electronically. We need you to also
agree to get Form 1095-B electronically.
To stop getting electronic delivery of Form 1095-B
and to get a paper copy
You can stop getting electronic delivery of Form 1095-B
at any time and choose to get a paper copy. To do this:
1. Log in to myuhone.com
2.
Select Prole or under Quick Links, select Account
Settings for Document Delivery
3.
Under Email Electronic Document Preferences,
select No for Electronic Document Delivery 1095-B
and select Update
You may also send your request in writing to:
Oxford Health Insurance, Inc.
PO Box 31372
Salt Lake City, UT 84131-0372
Be sure to include the following information with your
request:
• Primary insured’s name
• Date of your request
• Primary insured’s email address
• Policy ID Number
• And make sure you sign the request
You can also ask for a free paper copy of Form 1095-B
by calling the member phone number on your health
plan ID card. We will keep sending Form 1095-B
electronically until you tell us not to.
Undeliverable Emails
We will send Form 1095-B to the email address you give
us. If we get a message that the form is undeliverable,
we will send you a paper copy of Form 1095-B.
To update your email address:
1.
Log in to myuhone.com
2.
Select Prole
3.
Under Contact Options, enter your email address
and select Update
To be sure that you can receive emails from us, add the
UnitedHealthcare “From” email address to your email
address book or safe list.
If your UnitedHealthcare Oxford health plan terminates
If you no longer have a UnitedHealthcare Oxford
health plan, we will send Form 1095-B for the months
you had coverage with us. If you need a prior year’s
form and don’t have access to the member portal, call
customer service to request the form.
Requirements to Receive and Keep Electronic
Information
To receive and keep electronic information, you must
have access to a computer or other device that can get
to the Internet and a printer. You must have an email
address. Also, you must have Adobe Acrobat Reader
®
version 6.0 or higher which lets you open Portable
Document Format or “PDF” les.
Form 1095-B is available for three years from the year
the form was issued.
UnitedHealthcare Oxford Form 1095-B Electronic Delivery Consent Notice
________________________________________ __________________________________________
Primary Applicant’s Name Primary Applicant’s Email Address
X ________________________________________ __________________________________________
Primary Applicant’s Signature Date
________________________________________
ID Number
592F-O-1118
7 of 7
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United Healthcare - Form 592F New Jersey Nongroup Enrollment Change Request Form OHI

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Completed 26 May 2020

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