pennsylvania small group employee enrollment/change form ... · 7000-3-sg 7000-3 (4-19) 3 sg (1-50)...

Pennsylvania Small Group Employee Enrollment/Change Form

Aetna Health Inc. Aetna HealthAssurance Pennsylvania Inc.

Aetna Health Insurance Company Aetna Life Insurance Company

INSTRUCTIONS: You must complete this enrollment form in full. If you do not, we will return it to you, and that can delay its processing. You alone are responsible for its accuracy and completeness. If you are declining coverage, you must complete Section F. Please use only black ink to complete this form.

Group number

Aetna member ID number (if available)

Company name

Effective date

Date of hire

New hire

Rehire / reinstatement

New group enrollment

Late enrollment

Waiver

Open enrollment

Loss of coverage

Add spouse

Add domestic partner

Add dependent child

Change of coverage

Name change

Employee termination date

Remove spouse

Remove domestic partner

Remove dependent child

Cancel coverage

Other

COBRA State continuation for: Employee Dependent Length of continuation: 18 months 36 months Other

Qualifying event Original qualifying event date Loss of coverage date

A. Employee information - You must complete this section. Please print clearly.

Social Security number Last name, first name, middle initial Job title

Home address Apt. number City, state ZIP code

Work address City, state ZIP code

Home telephone

( ) -

Work telephone

( ) -

Primary language spoken (optional)

Number of dependents, including spouse or domestic partner, enrolling for medical coverage

Salary

$

Hourly

Weekly

Monthly

Number of hours worked a week

Check one:

Full time 1099 Seasonal COBRA

Part time Retiree Temporary Union

B. Coverage selection – (Top boxes for employer and Aetna use only.)

Control/Group number Suffix Account Plan number

1. Medical Yes No Check one.

PA Silver HMO 6000 80% $30/75

PA Silver QPOS 6000 80/50 $30/75

PA Silver Open Access EPO 6000 80% $30/75

Aetna Health Inc. and Aetna Health Insurance Company underwrite the HMO and QPOS plans. Aetna HealthAssurance Pennsylvania, Inc. and / or Aetna Life Insurance Company underwrite the EPO plans.

Continued on next page

7000-3-SG SG (1-50) PA R-POD A 7000-3 (4-19) 1

B. Coverage selection (Continued)


2. Dental Yes No To enroll, enter the plan number and name below.

Non-voluntary plans – Plan number Plan name

If FOC, choose: DMO® or PPO

Voluntary plans – Plan number Plan name

If FOC, choose: DMO® or PPO

Before today, were you covered under this employer’s dental plan? Yes No Creditable coverage is allowed for new members enrolling in v oluntary takeover groups. New hires please see below if applicable: New Hire selecting a Voluntary plan and your Aetna plan is a takeover group: Were you covered for 12 months under a dental plan within the last 90 days that included both Preventive and Basic c overage? Discount dental and preventive only plans do not apply. Yes No

Employees in AZ, CA, GA, MA, MD, MO, NC, NJ and TX must either live or work within the approved DMO® service area to be eligible to enroll in the DMO®.

Aetna Life Insurance Company underwrites Aetna dental plans.


3. Aetna VisionSM Preferred Yes No

Aetna Life Insurance Company underwrites Aetna vision plans. First American Administrators, Inc. provides certain claims administration services. EyeMed Vision Care, LLC (“EyeMed”) provides certain network administration services.

C. Individuals covered – List individuals for whom you are enrolling or adding, changing or removing coverage. Add more sheets if needed.

NOTE FOR MEDICAL COVERAGE: While the Affordable Care Act mandates coverage of dependent children up to age 26, your plan may allow coverage beyond age 26. Please refer to your plan documents or contact your benefits administrator.

1

Add

Change

Remove

Employee name (Last, first, middle initial) Sex (M/F)

Birthdate (MM/DD/YYYY)

/ /

Status Single Married

Divorced Widowed

Legally separated

Choosing coverage for:

Medical Dental

Vision

Primary care physician (PCP) provider ID number

Current patient

Yes

2 Add

Change

Remove

Name (Last, first, middle initial)

Spouse Domestic partner

Sex (M/F) Social Security number


/ /


Medical Dental Vision

PCP provider ID number Current patient

Yes

3

Add

Change

Remove

Name (Last, first, middle initial) Child Stepchild

Other



/ /

Status

Different last name

Incapacitated


Medical Dental

Vision


Yes

4

Add

Change

Remove


Other



/ /

Status

Different last name

Incapacitated


Medical Dental

Vision


Yes

5

Add

Change

Remove


Other



/ /

Status

Different last name

Incapacitated


Medical Dental

Vision


Yes

Continued on next page 7000-3-SG

7000-3 (4-19) 2 SG (1-50) PA A

X

C. Individuals covered (Continued)

6

Add

Change

Remove


Other



/ /

Status

Different last name

Incapacitated


Medical Dental

Vision


Yes

D. Dependent information

List any dependent in Section C living at another address.

Name Address

E. Coordination of benefits

Will you have other health insurance at the same time as this coverage? Yes No

If yes, will the Aetna coverage you’re applying for replace the coverage you have now? Yes No

Name of person Carrier name Name of person Carrier name

F. Declining coverage – Check all that apply.

I understand I am eligible to apply for this coverage through my employer. However, I am declining the coverage I checked below:

Employee: Medical Dental

Vision

Spouse / domestic partner:

Medical Dental

Vision

Children: Medical Dental

Vision

Reason for declining coverage

Parental group coverage

Spouse / domestic partner group coverage

Medicare

Medicaid

Retiree coverage

COBRA coverage

Insurance through another job

TRICARE / Military c overage

Individual coverage – On Exchange

Individual coverage – Off Exchange

Another group plan provided by my employer

Do not want

Other

I certify I have the right to apply for this coverage. However, I am declining coverage as noted above. By declining this group coverage, I acknowledge that I and / or my dependents may have to wait until the plan's next anniversary date to be enrolled for group coverage.

Please sign here ONLY if you are declining coverage for yourself and / or dependents.

I am declining coverage. Employee signature:

Date (Month/Day/Year)

Please PRINT employee name:

Conditions of enrollment

I understand that the following legal entities underwrite the plans I apply for:

Aetna Health Inc. and Aetna Health Insurance Company underwrite the HMO and QPOS plans.

Aetna HealthAssurance Pennsylvania, Inc. and / or Aetna Life Insurance Company underwrite the EPO plans.

Aetna Life Insurance Company underwrites the dental and vision plans.

1. My employer’s application determines coverage. I don’t have coverage until Aetna approves my employee enrollment form and the employer application. Even if Aetna approves the employer application, any misstatements or omissions may result in denial of future claims. Aetna may rescind or reevaluate my coverage under the policy, as of the effective date, for eligibility and rating purposes. If Aetna voids or rescinds coverage, I may be entitled to a refund of any paid premiums from the effective date of coverage. Aetna will give at least 30 days advance written notice to any covered person affected by the proposed rescission. If I elect to receive electronic notifications, I will receive this notice in an electronic (email) format.

Continued on next page

7000-3-SG 7000-3 (4-19) 3 SG (1-50) PA A

Conditions of enrollment (Continued)

2. To support the coverages listed on this enrollment, Aetna may need information about medical history, services or treatment provided to anyone listed on this form. This may include information about mental health and substance use disorder. I authorize that the following entities can provide this information to Aetna or its agents:

Physicians

Other healthcare professionals

Hospitals

Other healthcare organizations (“providers”), including

Pharmacies

Pharmacy database benefit managers 3. I authorize Aetna to use and disclose such information to:

Affiliates

Providers

Other insurers

Third party administration

Vendors

Consultants

Governmental authorities with jurisdiction when necessary for:

Care or treatment

Payment for services

Operation of my health plan

Conduct related activities

4. I discussed the terms of this authorization with my competent adult dependents. They agreed to these terms. This authorization is valid for the term of the coverage and as long thereafter as the law allows. This authorization is voluntary. But if I don’t sign this form, my ability to enroll in the plan may be affected. I have the right to revoke this authorization in writing to Aetna at any time. I can’t revoke authorization for information already used or disclosed before I revoked my authorization. I am entitled to receive a copy of this authorization upon request. A photocopy is as valid as the original.

The Group Agreement / Group Policy determines the rights and responsibilities of members and will govern in the event they conflict with any:

Benefits comparison

Summary

Other description of the plan

Participating physicians, hospitals and other health care providers are independent contractors. They are not Aetna agents or employees. We cannot guarantee the availability of any particular provider. Any provider network is subject to change. We will provide a notice of the change in accordance with applicable state law.

5. I understand that, with certain exceptions described in the plan documents, HMO and DMO© plans only provide coverage for covered benefits. The plan documents also describe if I need a referral for certain procedures, and who can provide care. Covered services must be performed by:

Participating primary care physicians

Participating primary care dentists

Participating specialists

Participating hospitals

Participating pharmacies

Participating dentists

Other participating providers as authorized by a referral from a participating primary care physician

6. I authorize the substitution of generic pharmaceuticals for the brand-name products, as provided by law, for prescriptions filled under any pharmacy benefit.

I represent that all information supplied in this form is true and complete. I have read and agree to the conditions of enrollment and misrepresentation on this Employee Enrollment / Change Form.

I understand that if I don’t sign this form within 31 days or Aetna does not receive the request within a reasonable time, my eligibility may be affected.

I am employed by the employer shown on page 1. I am working full time or at least 25 hours or more a week for this employer at the regular place of business. I authorize deductions from my earnings for any contributions required for coverage. I agree to make any necessary payments required for coverage.

To receive documents online, please visit your secure member account at aetna.com.

Misrepresentation: 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 subjects such person to criminal and civil penalties.

Please sign here ONLY if you are enrolling in coverage for yourself and / or dependents.

Employee signature (required)

Employee email Date (Month/Day/Year)

7000-3-SG 7000-3 (4-19) 4 SG (1-50) PA A

http://aetna.com

Aetna language Assistance Information Attachment

Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability.

Aetna provides free aids/services to people with disabilities and to people who need language assistance.

If you need a qualified interpreter, written information in other formats, translation or other services, contact:

Civil Rights Coordinator, PO Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779), 1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705), [email protected].

If you believe we have failed to provide these services or otherwise disctiminated based on a protected class noted above, you can also ftle a grievance with Civil Rights Coordinator.

You can also ftle a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portaVlobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna).

7000-3-SG 7000-3 (4-19) 5 SG (1-50) PA A

mailto:[email protected].

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

TIY: 711

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7000-3-SG 7000-3 (4-19) 6 SG (1-50) PA A

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7000-3-SG 7000-3 (4-19) 7 SG (1-50) PA A

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8 7000-3 (4-19) 7000-3-SG

SG (1-50) PA A

pennsylvania small group employee enrollment/change form ... · 7000-3-sg 7000-3 (4-19) 3 sg (1-50)...

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