Download Individual Special Enrollment Application/Change Form

Individual Special Enrollment Application/Change Form (Off Exchange)
295 Lafayette St. 6th Floor | NY, NY 10012
Qualifying Event
Event Type (see instructions on back)
Date of event
Application Type
New Enrollment
______/______/___________
If Policy Change:
Policy Change
Choose your plan
Bronze
Bronze Edge+
Silver Edge
Gold
Platinum
(If policy change, select
new desired plan)
Bronze Edge
Silver
Silver Edge+
Gold Edge
Platinum Edge
Remove Dependent
Who are you buying
insurance for?
(If policy change, select
new tier if applicable)
Select if you’d like to purchase a rider to cover dependent(s) aged 26-29 (new enrollments only)
Add Dependent
Individual
Individual & Spouse
Parent & Child(ren)
Family
Policy Holder Information
* Required fields for changes to existing policies (For new enrollments, please fill out all fields except Oscar Member ID)
Oscar Member ID (if making change to plan) *
First Name*
MI*
Last Name*
Gender*
Male
Home Address
Telephone:
Apt #
Home (
)
Cell (
)
Social Security No.*
Date of Birth (MM/DD/YYYY)*
Female
City
County
Email Address
State
Zip Code
Marital Status:
Single
Married
Domestic Partner
Mailing address, if different from home address
Name
Apt #
Address
City
County
State
Zip Code
Dependent Information (If policy change, only list additions or removals)
First Name
MI
Disabled Dependent
(over age 26*)
Last Name
Gender
(M/F)
Date of Birth
(MM/DD/YYYY)
Social Security No.
Spouse
Child(ren)
*Please call us at 1-855-OSCAR-55 to request a disabled dependent form
GA / Broker Information (if applicable)
GA Name
GA License Number
GA Agency Name
Phone
Email
Broker’s Name
Broker License Number
Broker’s Agency Name
Phone
Email
Co-Broker’s Name
Co-Broker’s License Number
Co-Broker’s Agency Name
Phone
Email
Please Read the Following Terms & Conditions Carefully
I understand that upon review of my Contract that I may cancel it. Any request to cancel must be made in writing within 10 days from the date I receive the Contract. On behalf of myself and any covered dependents, to
the extent permitted by law, I hereby authorize all health care providers who have rendered service to any of us and any payers of claims to provide to Oscar any records pertaining to care provided, claims paid and/or
our medical history. I authorize Oscar to provide such information to network physicians for the purpose of continuity of care, medical management, etc. 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 five thousand dollars and the stated value of the claim for each
such violation. I am applying for coverage for myself, my spouse and my eligible dependent children named on this application. All statements made within this form are true and accurate to the best of my knowledge.
_____/_____/_________
Signature
Date
By typing your name, you are signing this Agreement electronically and consenting to its terms & conditions. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement.
Please send completed form to:
Special Enrollment Instructions
Outside of the open enrollment period, new
enrollments and changes to existing policies
with Oscar are limited to specific “qualifying
events”. A list of approved qualifying events is
provided below. If you’ve experienced one of
these qualifying events and would like to enroll
with Oscar or make a change to an existing policy,
please take the following steps. Please note that
all enrollment and change requests must be
received within 60 days of the qualifying event.*
Event Number
1. Indicate the qualifying event that you have experienced by
writing the corresponding number from the list below in the
Qualifying Event Type box on the front of this form. Please
also be sure to include the date of the qualifying event.
4.
a. New enrollments: Shortly after we’ve processed your
application you will receive a bill from Oscar. Please
note that you have 75 days from the date of your
qualifying event to submit payment to Oscar.
2. Select the appropriate option in the Application Type box
on the front to indicate whether you are requesting a new
enrollment or a change to an existing policy. If you are
requesting a change to an existing policy, please ensure that
you only include the person(s) you are adding to or removing
from the policy in the “Dependent Information” section.
3. Give your completed application and the supporting
documentation for your qualifying event to your broker for
submission to Oscar. The required supporting documentation
for each qualifying event is listed below.
Qualifying Event
Payment information
b. Policy changes: If your policy change resulted in a
change in premium, this will be reflected on your next
bill. Your payment must be received according to the
normal grace period schedule.
* In situations where a child dependent is being added to a policy due to birth or adoption,
Oscar must receive the special enrollment request within 60 days of the child’s birth in order
to be covered from the moment of birth. For special enrollment requests received after 60
days, coverage will start from the day Oscar receives the request.
Required Documentation
Effective Date of Coverage
Loss of essential health benefits (if you believe you have another situation that qualifies, contact us to inquire)
1
Employer dropping health coverage
HIPAA certificate and either a letter from employer indicating cessation of health benefits
or a bill from last month of coverage
2
Loss of employment with health benefits
HIPAA certificate and letter from former employer of creditable coverage or indicating person
is no longer covered
3
Current coverage discontinued by carrier
HIPAA certificate and letter from prior carrier indicating discontinuation of coverage
4
Loss of coverage due to divorce from or death of spouse
Copy of divorce decree or death certificate, and HIPAA certificate
5
Contract holder aging out (new enrollment only)
Letter from prior carrier indicating person is aging out, or a HIPAA certificate and proof that
individual is turning an age that results in aging out
6
Dependent aging out
Letter from prior carrier indicating person is aging out, or a HIPAA certificate and proof that
individual is turning an age that results in aging out
7
COBRA coverage ending
Letter from COBRA administrator or prior carrier indicating end of COBRA coverage
8
Moved into Oscar’s service area
Proof of residence from both new address and old address. Proof of residence from old
address must be dated within the past 120 days and proof of residence from new address
must be from within the previous 45 days. Acceptable forms of proof include mortgage
payment, rent payment, and utility bills (electric, gas, phone, cable, Internet)
Request received between 1st-15th of month:
1st of following month | Request received
between 16th-end of month: 1st of 2nd month
9
Addition of a spouse through marriage (policy change only)
Copy of marriage certificate
1st of month following marriage
10
Addition of domestic partner through registration of domestic partnership
(policy change only)
Copy of certificate of domestic partnership. If domestic partnership registration does not exist
in coverage area, please see Oscar’s off exchange certificate of coverage for alternative means
of establishing proof of domestic partnership
1st of month following certification of
domestic partnership
11
Gain a child dependent or become a child dependent through birth, adoption
or placement for adoption (policy change only)
Copy of birth/adoption certificate or proof of birth from hospital reflecting date of birth
If Oscar receives notice of birth/adoption
within 60 days of birth, coverage for the
newborn starts at the moment of birth;
otherwise coverage begins on the date on
which Oscar receives notice
12
Enrollment or non-enrollment in another qualified health plan was
unintentional, inadvertent or erroneous and was the result of the error,
misrepresentation, or agent of a health plan or the Exchange
Letter from Exchange / state verifying eligibility to enroll in a new plan
Request received between 1st-15th of month:
1st of following month | Request received
between 16th-end of month: 1st of 2nd month
13
Can demonstrate another qualified health plan in which prospective member
was enrolled substantially violated a material provision of its contract
Letter from Exchange / state verifying eligibility to enroll in a new plan
Request received between 1st-15th of month:
1st of following month | Request received
between 16th-end of month: 1st of 2nd month
14
Determined newly eligible or newly ineligible for advance payments of the
premium tax credit or have a change in eligibility for cost-sharing reductions
Letter from the Exchange indicating eligibility change for advanced premium tax credits or
cost-sharing reduction plans
Request received between 1st-15th of month:
1st of following month | Request received
between 16th-end of month: 1st of 2nd month
1st of month following loss of coverage
Other qualifying events