+.\'-
Arkansas
BlueCross BlueShield
An
Independent
Licensee
of the
Blue
Cross
and
Blue
Shield
Association
PON·r,
0
,~
TOS/9N
4Np
/14rr
ON
P49£
5
,
I
Individual/Family Health Insurance
CHANGE FORM
Gold, Silver and Bronze Plans
READ ALL INSTRUCTIONS BEFORE COMPLETING THIS CHANGE FORM. THE CHANGE FORM MUST BE
COMPLETED IN ITS ENTIRETY AND ALL PAGES MUST BE SUBMITTED IN ORDER TO BE PROCESSED.
§ This form is a legal document. If you are approved for coverage, it will become a part of your contract.
Therefore, all information provided must be accurate and legible.
§ This form must be completed in dark blue or black ink. Forms completed in pencil will not be accepted.
§ If you make a mistake, mark through the incorrect information, initial it, date it, and provide the
correct information.
§ Do not use liquid paper, correction tape, or “white out” to correct any
mistakes on this form.
§ What changes would you like to make?
• Contact information Æ Complete sections 1 and 2
• Address change Æ Complete sections 1, 2 and 3
• Name change Æ Complete sections 1, 2 and 5
• Delete person from policy Æ Complete sections 1, 2, 4 and 6
• Add person to policy Æ Complete sections 1, 2, 4, 7, 8, 9, 10 and 13
• Make someone else the primary policyholder Æ Complete
sections 1, 2, 4, 7, 8, 9, 10 and 11
• Split my policy into two or more policies Æ Complete sections 1, 2, 4, 7, 8, 9, 10 and 12
INSTRUCTIONS
Changes to your policy can only be made during the annual open enrollment period,
unless the change is a result of a special election period or a qualifying life event,
such as birth of a child, adoption, loss of other coverage, marriage, etc.
When you are completing this form, please refer to your Arkansas Blue Cross and Blue Shield identification
card for your Member ID and Group Number. This information must be entered correctly under Section 1
in order to process your request.
RETURN INSTRUCTIONS
§ Any attachments submitted with the change form must be signed and dated.
§ Do not send any money with this change form.
§ Please ensure all required parties have signed and dated the change form prior to submission.
§ We strongly recommend you make a copy of this completed change form for your records.
NOTE: Additional documentation required should be faxed to Arkansas Blue Cross at 501-378-3752 or emailed to
crmcustomerservice@arkbluecross.com immediately following the submission of the application.
MPI 7560 8/18
Form No. QHP CF (R01/19)
•
{I
Arkansas
® ~ ® BlueCross BlueShield
I
CHANGE FORM
Gold, Silver and Bronze Plans
Return To: Arkansas Blue Cross and Blue Shield OR Fax to: 501-378-3752
Attn: CRM Operations and Service E-mail: CRMCustomerService@arkbluecross.com
P.O. Box 2181
Little Rock, AR 72203-2181
SECTION 1
|
CURRENT POLICYHOLDER INFORMATION
Member ID: Group Number: Date of Birth: / /
First Name: M.I.: Last Name:
SECTION 2
|
CONTACT INFORMATION*
Primary Phone Number
( )
Alternate Phone Number
( )
E-mail Address
How do you prefer we communicate with you?
q E-mail q Phone
*Arkansas Blue Cross and Blue Shield may contact you, either directly or through a business associate, using your postal or email addresses,
telephone numbers or other personal information, regarding your health insurance plan, healthcare providers participating in our networks,
disease management, health education and health promotion, preventive care options, wellness programs, treatment or care coordination or case
management activities of Arkansas Blue Cross.
CHANGES TO BE MADE – Please skip sections that do not apply to the change(s) you are making.
SECTION 3
|
ADDRESS CHANGES
Any change to your current address information can be completed below. Only complete for addresses that are changing.
Residential – This address will be noted as your physical place of residence.
Mailing – Correspondence such as letters and Personal Health Statements (PHSs) will be mailed to this address.
Billing – All billing invoices will be mailed to this address.
A person must be lawfully present in the U.S. for the entire period of enrollment.
Residential Address: Street
City State Zip
Mailing Address: Street
City State Zip
Billing Address: Street
City State Zip
NOTE: If the only change you want to make is an address change, you are not required to submit a Change Form. You may simply call Customer Service
at 1-800-800-4298, and a representative can change your address quickly and easily.
Form No. QHP CF (R01/19) PAGE 1 (Continued on page 2)
SECTION 4
|
POLICY CHANGE ELIGIBILITY
Qualifying life event changes allow you to make changes to your policy outside of the annual open enrollment period. Please ensure all
documentation is included. Such events include, but are not limited to:
§ Divorce/Legal Separation (requires a copy of divorce decree/legal separation)
§ No longer an Arkansas resident (requires a date of move or date of notification)
§ Marriage (requires a copy of the marriage certificate and proof of loss of minimum essential coverage)
§ Becoming eligible for other coverage (requires proof of eligibility of other coverage)
§ Death (requires a copy of death certificate)
Check all applicable boxes below that support your eligibility to apply for this policy and – if applicable – provide date of qualifying life event.
Date Date Date
q1–Annual Open Enrollment Period: 11/1 – 12/15 q8–Loss of Minimum Essential q11–Errors, misinterpretation,
q2–Birth
Coverage in action by the Exchange,
q3–Adoption
q9–Non-calendar Year Policy expires
HHS, or their agents
q4–Death
outside OEP (This is a one-time SEP,
which will be used for those losing
q12–QHP Contract Violation
in relation to an individual
q5–Marriage
coverage due to the expiration of a
q13–Loss of eligibility for APTC
q6–Divorce or Legal Separation non-grandfathered policy.)
q14–Same sex marriage
q7–New Guardianship/ Legal
Custody/ Court Order to
q10–New coverage becoming available
as a result of a permanent move
q15–Eligible for other coverage
add child
q16–Other (Give specific
details and date)
NOTE: If application is not received during the Open Enrollment Period, we must receive appropriate documentation with this application to confirm qualifying life event/special
election period (i.e. copy of marriage license, Certificate of Creditable Coverage from previous insurance company, legal guardianship/custody documentation, etc.) no greater than
60 days before triggering event and no later than 60 days after triggering event, except in the case of birth where the application must be received no later than 90 days after birth.
Birth certificate required only if newborn (child 0-90 days old, as of received date) is not applying for coverage.
SECTION 5
|
NAME CHANGE
Documentation is required for any name change request. Please complete and attach appropriate documentation such as a copy of your
marriage license, divorce decree, adoption papers or other court papers to support the change.
From: First Name M.I. Last Name
To: First Name M.I. Last Name
SECTION 6
|
DELETE PERSON(S) FROM THE POLICY
In the event you would like to terminate coverage for a covered person, including the policyholder, you can do so by completing this section.
OR
You have the option to maintain the person’s coverage by splitting him/her off onto a new individual policy with identical coverage.
This will completely remove him/her from your coverage and create a new policy for the covered person. You can make this change by
completing Section 12 – Split Policy. A signature is required by both the current policyholder and new policyholder.
Important Note: Complete one change form for each new policy you are requesting.
First Name M.I. Last Name
Suffix
Reason
Form No. QHP CF (R01/19) PAGE 2 (Continued on page 3)
SECTION 7
|
ADDING SPOUSE OR DEPENDENT(S)
Qualifying life event changes allow you to make changes to your policy outside of the annual open enrollment period. Such events include,
but are not limited to:
§ Obtaining guardianship, legal custody of a child, or court order requiring coverage for a dependent (requires proof of guardianship, legal
custody or court order)
§ Loss of Eligibility (requires a Certificate of Creditable Coverage)
§ Marriage (requires a copy of the marriage certificate)
First Name M.I.
Last Name
Suffix
Relationship
Sex
Date of Birth
Social Security No.
Self
SECTION 8
|
U.S. CITIZENSHIP STATUS
For any applicant who is not a U.S. citizen, a copy of his/her Permanent Resident VISA or Green Card issued by the U.S. Citizenship and
Immigrant Services may be requested. A person must be lawfully present in the U.S. for the entire period of enrollment.
qYes qNo Are all applicants U.S. citizens? If “no,” please provide the name(s) of the applicant(s) who are not U.S. citizens.
Name:
Name:
Name:
SECTION 9
|
HOUSEHOLD INFORMATION
qYes qNo Are all applicants permanent, legal residents of Arkansas?
If “no,” please provide reason and his/her name and address:
Name: Address:
Reason:
Name: Address:
Reason:
Form No. QHP CF (R01/19) PAGE 3 (Continued on page 4)
SECTION 10
|
CURRENT/PREVIOUS INSURANCE COVERAGE
qYes qNo a. Will the coverage applied for replace or change current hospital, medical or major medical insurance if this coverage
is approved by Arkansas Blue Cross and Blue Shield and accepted by the applicant?
i. If “yes,” please provide name and phone number of carrier:
( )
ii. If “yes,” does the coverage have a specified termination date? If so, please provide date: / /
iii. If “yes,” and the coverage does not have a specified termination date, will the coverage terminate if approved
by Arkansas Blue Cross and accepted by the applicant?
qYes qNo b. Have any applicants recently lost employer-sponsored health coverage?* If “yes,” please provide:
Name: Carrier Name: Termination Date: / /
Name: Carrier Name: Termination Date: / /
qYes qNo c. Have any applicants recently “involuntarily” lost other health coverage?* If “yes,” please provide:
Name: Carrier Name: Termination Date: / /
Name: Carrier Name: Termination Date: / /
qYes qNo d. Will any applicants be continuing any other health insurance? If “yes,” please provide:
Name: Carrier Name: ID#
Name: Carrier Name: ID#
qYes qNo e. Are any applicants covered by Medicaid (including AR Kids First)?
If “yes,” please provide name(s) below:
Name:
Name:
qYes qNo f. Are any applicants covered by or eligible for Medicare Part A or Part B or Medicare Advantage (Part C)? If “yes,”
please provide name(s) below:
Name:
Name:
*When your current policy ends, you may be given a Certificate of Creditable Coverage (COCC). A COCC is issued by your previous health insurance
company and provides proof of prior coverage. Once you receive a COCC, please provide us a copy.
SECTION 11
|
OWNERSHIP CHANGE
If both the policyholder and spouse are retaining coverage, but you would like to change the ownership of the policy from the current
policyholder to the spouse, complete this section. Both the current policyholder and new policyholder must sign the change form.
From: First Name M.I. Last Name
To: First Name M.I. Last Name
SECTION 12
|
SPLIT POLICY
Indicate the name of the covered person(s) you want covered on a separate policy with identical coverage.
First Name M.I. Last Name Suffix Date of Event
Primary Phone Number
Alternate Phone Number E-mail Address
( )
( )
Please provide address information for new Policyholder ONLY:
Residential Address: Street
Mailing Address:
Billing Address:
City
Street
City
Street
City
State
State
State
Zip
Zip
Zip
Form No. QHP CF (R01/19) PAGE 4 (Continued on page 5)
I I
SECTION 13
|
TOBACCO USAGE
qYes qNo Does any new or existing enrollee currently use any form of tobacco?
Name(s):
SECTION 14
|
POLICYHOLDER PROXY AND MEMBER INFORMATION
As a Policyholder, you are a member of Arkansas Blue Cross and Blue Shield. By accepting this Policy you appoint the Board of
Directors (“Board”) of the Company to act on your behalf at all meetings of Members of the Company. This appointment shall
include such persons as the Board may designate by resolution to act on its behalf. This proxy gives the Board, or its designee,
full power to vote for you on all matters that may be voted upon at any meeting. The annual meeting of Members is held each
year at the home office of Arkansas Blue Cross and Blue Shield located at 601 S. Gaines Street, Little Rock, Arkansas, on the
third Monday of March, at 1:00 p.m. If the third Monday of March is a legal holiday, then the meeting will be at the same time
and place on the next day after, which is not a legal holiday. A special meeting may be called upon notice mailed not less than
ten (10) or more than sixty (60) days prior to such meeting. This proxy, unless revoked, shall remain in effect during the term of
this Policy. You may revoke this proxy in writing by advising the Company of such revocation at least five (5) days prior to any
meeting. You may also revoke its proxy by attending and voting in person at any Members’ meeting.
PLEASE READ BEFORE SIGNING
I UNDERSTAND: (1) The agent or broker involved in this insurance transaction may receive compensation from Arkansas
Blue Cross and Blue Shield (hereafter referred to as the COMPANY), or one of its affiliates, for services related to the
placement of this insurance. Any such compensation is included in the insurance premium paid by the insured. For more
information on the compensation involved in this transaction, please direct your inquiry to the agent or broker. (2) Any
coverage which may be issued to me shall be invalid if based on intentional misrepresentation of material fact provided by
me on the application. (3) The COMPANY may phone me for additional information that may help with the timely processing
of my application.
In signing below, I: (a) represent that the statements and answers given in this application and any signed and dated
addendum to this application (both front and back) are true, complete and correctly recorded; (b) understand that if
intentionally fraudulent misstatements were made, the COMPANY may take legal action at any time; (c) understand my
signature authorizes the COMPANY to coordinate benefits under this policy with other insurance I have which is subject
to coordination; (d) agree that this application shall be valid without time limit; (e) agree that a photocopy of this application
shall be as valid as the original, and I understand that a copy is available to me upon request. I certify that I signed this
application in the state of Arkansas.
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
This policy does not include pediatric dental services as required under the Federal Patient Protection and Affordable Care Act.
The coverage is available in the insurance market and can be purchased as a stand-alone product. Please contact Arkansas Blue
Cross and Blue Shield or your agent if you wish to purchase pediatric dental coverage or a stand-alone services product.
Rates are based on where you and any covered dependents live in Arkansas and tobacco use.
Arkansas Blue Cross and Blue Shield does not discriminate on the basis of race, color, national origin, disability, age, sex, gender
identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.
SIGNATURE SECTION
|
(Please sign appropriate line only)
Current Policyholder
OR
Parent Legal/Guardian
(if policy for a minor)
(Please Print)
X
Date
OFFICE USE ONLY
(Please Sign)
X
Date
New Policyholder
(Please Sign)
X
Date
THIS APPLICATION IS VALID FOR 90 DAYS ONLY WHEN COMPLETED AND SIGNED.
Form No. QHP CF (R01/19) PAGE 5
