Fillable Young Adult Dependent Through Age 29 Certification Form (University of Rochester)

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Young Adult Dependent Through Age 29 Certification Form (University of Rochester)

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A nonprofit independent licensee of the BlueCross BlueShield Association
Young Adult Dependent Through Age 29 Certification Form
Subscriber and Dependent Information
SUBSCRIBER'S LAST NAME
SUBSCRIBER'S FIRST NAME
INITIAL
SUBSCRIBER'S IDENTIFICATION #
DEPENDENT'S LAST NAME
DEPENDENT'S FIRST NAME
INITIAL
DEPENDENT'S DATE OF BIRTH
______/______/_______
yyyy
dd
mm
DEPENDENT'S STREET ADDRESS
DEPENDENT'S CITY, STATE, ZIP CODE
DEPENDENT'S SOCIAL SECURITY #
DEPENDENT'S PHONE #
Eligibility Information
Please answer the following:
1-Is the dependent under 30?
NO
YES
Single
Married,
Please indicate
2-What is the dependent's marital status?
Divorced,
Please indicate
___/___/___
marriage date:
___/___/___
divorce date:
mm
dd
yy
mm
dd
yy
3-Is the dependent covered by or eligible for employer-sponsored
NO
YES
health insurance, Medicare, or a self-insured employer plan?
4-What is the date which the dependent last had medical coverage? If known, please indicate:
___/___/___
mm
dd
yy
Please provide a certificate of coverage from previous insurance
carrier if the coverage terminated within the past 63 days.
5-Does the dependent live, work, or reside in New York State?
NO
YES
Acknowledgement and Signature
Please read the following acknowledgement section and sign below (Subscriber or young adult signature is acceptable).
I understand and agree that I will be fully responsible for payment of the premium due with respect to the extended dependent coverage
being requested.
I hereby certify that the above statements regarding eligibility are complete and correct to the best of my knowledge.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim
containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such
violation. I have thoroughly read, understand and agree to comply with the terms of the release.
SIGNATURE: DATE:
Please ensure that all sections are complete, signed, and dated prior to returning. Failure to supply all of the required information may result in delayed
processing and/or subsequent return or denial of this request.
P.O. Box 21146
Please return completed form to:
Eagan, MN 55121
B-3024
10/09
Young Adult eligibility certification form
New York state has passed health laws that give an opportunity to young adults to remain
covered under their parents’ group health insurance plans.
Under the young adult option of the law, unmarried young adults living, working or residing in
New York state will be able to remain covered under their parents’ group health insurance plan.
This will be possible even if the dependent reaches the age at which he/she would have
otherwise aged off the policy, often age 19 or 23, or when no longer a student. To be eligible
for this coverage, he/she does not have to be financially dependent on his/her parent.
The young adult must meet these eligibility requirements:
• Must live, work or reside in New York state
• Is age 29 or less
• Is not married
• Is not insured by or eligible for health care coverage through their own employer
• Not covered under Medicare
The law provides two distinct ways in which coverage may be extended: a “make-available”
rider and a “young adult option” Some eligible employers may choose the “make-available
rider and define dependents as being young adults through the age of 29..
Subscribers in an eligible employer group that does not choose to offer the “make-available”
rider may choose the “young adult option, themselves as a direct-bill option, allowing their
young adult the same coverage as the parent or guardian carries. The rate for this option will
be equal to a single rate policy.
When does the elected coverage take effect?
• For an election made within 60 days of “aging out,” the effective date is the date the
young adult would otherwise have lost coverage
• For an election made during the required open enrollment period, after a change in
circumstances that newly qualifies the young adult, or the “special election period,” the
effective date must be no later than 30 days after the election and payment of the first
premium
If you have any questions concerning the “make available” or “young adult” law, please contact
Customer Service at the phone number listed on your member identification card.
Notice of Nondiscrimination
Our Health Plan complies with federal civil rights laws. We do not discriminate on the basis of
race, color, national origin, age, disability, or sex. The Health Plan does not exclude people or
treat them differently because of race, color, national origin, age, disability, or sex.
The Health Plan:
x Provides free aids and services to people with disabilities to communicate effectively
with us, such as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic
formats, other formats)
x Provides free language services to people whose primary language is not English, such
as:
o Qualified interpreters
o Information written in other languages
If you need these services and are a Child Health Plus or Managed Medicaid member, please
call 1-800-650-4359. If you are an Essential Plan member, please call 1-877-626-9298. All
others please call 1-800-499-1275.
If you believe that the Health Plan has failed to provide these services or discriminated in
another way on the basis of race, color, national origin, age, disability, or sex, you can file a
grievance with:
Advocacy Department
Attn: Civil Rights Coordinator
PO Box 4717
Syracuse, NY 13221
Telephone number: 1-800-614
-6575
TTY number: 1-800-421-1220
Fax: 1-315-671-6656
You ca
n file a grievance in person or by mail or fax. If you need help filing a grievance, the
Health Plan’s Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and 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 or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 1-800-537-7697 (TDD)
Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.
Atención: Si habla español, contamos con ayuda gratuita de idiomas disponible para usted. Si
usted es un asegurado de Child Health Plus o Managed Medicaid, llame al número 1-800-650-
4359. Si usted es un asegurado de Essential Plan, llame al número 1-877-626-9298. Todos los
demás pueden llamar al número 1-800-499-1275.
注意：如果您说中文，您可免费获得语言协助服务。如果您是 Child Health Plus 或 Managed
Medicaid 会员，请拨打 1-800-650-4359。如果您是 Essential Plan 会员，请拨打 1-877-626-
9298。如非上述会员，请您拨打 1
-800-499-1275。
Внимание! Если ваш родной язык русский, вам могут быть предоставлены бесплатные
переводческие услуги. Если вы являетесь участником программы Child Health Plus или
Managed Medicaid, позвоните по телефону 1-800-650-4359. Если вы являетесь участником
программы Essential Plan, позвоните по телефону 1-877-626-9298. Всех остальных просим
звонить по телефону 1-800-499-1275.
Atansyon: Si ou pa pale Kreyòl Ayisyen, gen èd gratis nan lang ki disponib pou ou. Si ou se yon
manm Child Health Plus oswa Managed Medicaid, tanpri rele nimewo 1-800-650-4359. Si ou se
yon manm Essential Plan, tanpri rele nimewo 1-877-626-9298. Tout lòt moun yo, tanpri rele
nimewo 1-800-499-1275.
알려드립니다 : 한국어를 사용하시는 경우 , 무료 언어 지원을 받으실 수 있습니다 . Child Health
Plus 또는 Managed Medicaid 회원이신 경우 , 1-800-650-4359 번으로 전화해 주십시오 . Essential
Plan 회원이신 경우 , 1-877-626-9298 번으로 전화해 주십시오 . 기타의 경우 1-800-499
-
1275번으로 전화해 주십시오 .
Attenzione: Se la vostra lingua parlata è l’italiano, potete usufruire di assistenza linguistica
gratuita. Se siete iscritti a un programma Child Health Plus o Managed Medicaid, chiamate il
numero 1-800-650-4359. Se siete iscritti a un programma Essential Plan, chiamate il numero 1
-
877-626
-9298. In tutti gli altri casi, chiamate il numero 1-800-499-1275.
אמפיוערקםאז: איויא ב ררעיא טד ,שידיא זיזמואסטארפש עה ךלייעווא ףל לבעיא ראפךי. איו ב
יבט עור טפ.1-800-650-4359 Managed Medicaid,ממעבע ראד רעChild Health Plus אריז טנעא
ממע ,רעביבט ער .טפו1-877-626-9298 לא ענאדעריב עט עפור טEssential Plan יא ביוארזנעטאן
1-800-499-1275.
 :              Child
Health Plus  Managed Medicaid      1-800-650-4359    
Essential Plan      1-877-626-9298       ,
  1-800-499-1275   
Uwaga: jeśli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Jeśli jesteś
członkiem ubezpieczenia Health Plus lub Managed Medicaid, zadzwoń pod nr 1-800-650-4359.
Jeśli jesteś członkiem ubezpieczenia Essential Plan, zadzwoń pod nr 1-877-626-9298. Pozostałe
osoby powinny dzwonić pod nr 1-800-499-1275.
Child 

1-800
-650-4359 
Managed MedicaidHealth Plus


1-877-626-9298 Essential Plan
1-800-499-1275
Remarque : si vous parlez français, une assistance linguistique gratuite vous est proposée. Si
vous êtes un membre du programme Child Health Plus ou Managed Medicaid, veuillez appeler
le 1-800-650-4359. Si vous êtes un membre du programme Essential Plan, veuillez appeler le 1-
877-626-9298. Si vous êtes dans une autre situation, veuillez appeler le 1-800-499-1275.

Managed Medicaid Child Health Plus 1-800-650-4359 
Essential Plan1-  1-877-626-9298 
 800-499-1275
Paunawa: Kung nagsasalita ka ng Tagalog, may magagamit kang libreng tulong sa wika. Kung
isa kang miyembro ng Child Health Plus o Managed Medicaid, mangyaring tumawag sa 1-800-
650-4359. Kung isa kang miyembro ng Essential Plan, mangyaring tumawag sa 1-877
-626-
9298. Para sa lahat ng iba pa, mangyaring tumawag sa
1-800-499-1275.
Προσοχή: Αν μιλάτε Ελληνικά μπορούμε να σας προσφέρουμε βοήθεια στη γλώσσα σας
δωρεάν. Αν είστε μέλος των προγραμμάτων Child Health Plus ή Managed Medicaid, καλέστε στο
1-800-650-4359. Αν είστε μέλος του προγράμματος Essential Plan, καλέστε στο 1-877-626
-
9298. Διαφορετικά, καλέστε στο 1-800-499-1275.
Vini re: Nëse flisni shqip, ju ofrohet ndihmë gjuhësore falas. Nëse jeni anëtar i "Child Health
Plus" ose "Managed Medicaid", ju lutemi të telefononi numrin 1-800-650-4359. Nëse jeni anëtar
i planit bazë, ju lutemi të telefononi numrin 1-877-626-9298. Të gjithë personave të tjerë iu
lutemi që të telefonojnë numrin 1-800-499-1275.
By A11y Updated at 10:45 am, Mar 23, 2018
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Young Adult Dependent Through Age 29 Certification Form (University of Rochester)

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Completed 1 July 2022

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