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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