group plan - headcount management · would be $12.30 if the employee gets paid bi‐weekly. ......
TRANSCRIPT
Headcount Group Healthcare Plan
Our options include a choice of three major medical health plans which meet or exceed the
Affordable Care Act’s (“ACA”) Affordability and Quality standards and a Minimum Essential
Coverage plan (MEC). Enrollment in any of the major medical plans or the MEC plan allow you
to avoid tax penalties prescribed by the ACA for failure to be enrolled in a health plan.
If you enroll on one of the major medical plans a pre‐tax deductions of up to 9.56% of wages
will be made from your paycheck to cover the “employee share” cost of the base plan (the
Healthy Value 3500). If you desire one of the richer benefit plans you may pay the difference
between the costs of the base plan and the cost of the enhanced plans as described on the
accompanying charts.
We realize, however, that not all employees will be able to shoulder the employee share cost of
the major medical plans. Therefore, all full time employees who are not enrolled on valid health
plan outside of Headcount and who do not enroll on one of the major medical plans offered will
automatically be enrolled onto the MEC plan. This low cost option will also protect you from
paying the individual tax penalty and offers you valuable benefits. The employee cost share is a
pre‐tax deduction of $6.15 during every weekly payroll cycle. Please keep in mind that the cost
would be $12.30 if the employee gets paid bi‐weekly.
Affordable Care Act Summary
The “Affordable Care Act” (ACA) requires that individuals be enrolled in a health insurance plan
or pay a tax penalty. This is known as the individual mandate. If you do not participate in a
company sponsored health plan, a government plan, such as Medicaid, Medicare, or Tri‐med or
a privately purchased health plan you are subject to a tax penalty. The 2016 the penalty is the
greater of 2.5% of your annual household income or $695 per adult and $347.50 per child
under 18 to a maximum penalty of $2,085 per family.
Please note that an individual whose employer offers health plans that meet the ACA’s
affordability and quality standards (as Headcount’s plans do) is not eligible for a subsidy
through the health exchange. However, you may still be eligible for Medicaid and your family’s
eligibility for subsidies via the health exchanges or Medicaid will not be affected.
If you have any questions about the health plans please Headcount via email at
[email protected] or by phone at 212‐803‐7103. Please cc our health consultant
Matt Wade at [email protected] on the email as well.
Who is eligible?
Full‐time hourly employees (those working an average of 30 hours or more per week): 1st of the
month 1st day of the month following 60 days of service.
If you are eligible for benefits, you also may enroll these members of your family:
‐ Your Spouse
‐ Your Domestic Partner.
‐ Your Domestic Partner’s children.
‐ Biological children, adopted children and children legally placed for adoption through
age 25.
‐ Your Stepchildren, including your Spouse’s biological children, adopted children and
children legally placed with him or her for adoption through age 25.
‐ Children in Legal Guardianship, including grandchildren, siblings, nieces or nephews for
whom the court has granted you, your Spouse or Domestic Partner full and plenary
Legal Guardianship for them and their estate through age 25.
‐ Children in Legal Guardianship, including grandchildren, siblings, nieces or nephews for
whom the court has granted you, your Spouse or Domestic Partner full and plenary
Legal Guardianship for them and their estate through age 25.
‐ Mentally or physically disabled children past the normal age limit provided they meet
the federal requirements.
Next Steps
If you are eligible for benefits:
1. Select a plan on the Employee Election form or decline benefits by completing the form.
2. To enroll additional family members, select the plan rate to indicate enrollment.
3. Complete the health application.
Effective Date:
Jan 01, 2015
Key Features:
• Provides coverage for the 64 preventive and wellness services needed to provide Minimum Essential Coverage.
• First dollar coverage – no deductibles or co-insurance.
• No medical underwriting required.
• No pre-existing condition limitations.
• No waiting periods.
• 24/7/365 telephonic doctor consultation services at no cost.
• Access to additional discounted service options for lab, pharmacy, and other health related products and services.
Prepared By:
Proposal Date: Dec 17, 2014
First National Administrator
Why HealthyEssentials? The Lifestyle Health HealthyEssentials plan is designed to be a minimal essential benefit plan. Minimum Essential Coverage Plans are designed to provide 100% coverage for the 64 preventive and wellness services as designated by Centers for Medicare and Medicaid Services (CMS).
In addition, HealthyEssentials provides additional benefits to members including telephonic physician consultation services at no cost and access to discounts on other key healthcare services such as outpatient lab and pharmacy services.
..................................................................................................
24/7/365
telemed
consults
included.
An Essential Foundation
Key Features of the HealthyEssentials Plan • Provides coverage for the 64 preventive and
wellness services needed to provide Minimum Essential Coverage.
• First dollar coverage – no deductibles or co-insurance.
• No medical underwriting required.
• No pre-existing condition limitations.
• No waiting periods.
• 24/7/365 telephonic doctor consultation services at no cost to members.
• Access to additional discounted service options for lab, pharmacy, and other health related products and services.
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1. Anemia screening on a routine basis for pregnant women
2. Bacteriuria urinary tract or other infection screening for pregnant women
3. BRCA counseling and genetic testing for women at higher risk
4. Breast Cancer Mammography screenings every year for women age 40 and over
5. Breast Cancer Chemoprevention counseling for women
6. Breastfeeding comprehensive support / counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women. Non-network services will be payable as network services.
7. Cervical Cancer screening
8. Chlamydia Infection screening
9. Contraception: FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs
10. Domestic and interpersonal violence screening and counseling for all women
11. Folic Acid supplements for women who may become pregnant when prescribed by a physician
12. Gestational diabetes screening
13. Gonorrhea screening for all women
14. Hepatitis B screening for pregnant women
15. Human Immunodeficiency Virus (HIV) screening and counseling
16. Human Papillomavirus (HPV) DNA Test: HPV DNA testing every three years for women with normal cytology results who are 30 or older
17. Osteoporosis screening over age 60
18. Routine prenatal visits for pregnant women
19. Rh Incompatibility screening for all pregnant women and follow-up testing
20. Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users
21. Sexually Transmitted Infections (STI) counseling
22. Syphilis screening
23. Well-woman visits to obtain recommended preventive services
HealthyEssentials offers the following covered benefits to provide the Minimum Essential Coverage critical for PPACA compliance for large employers.
15 COVERED PREVENTIVE SERVICES FOR ADULTS (AGES 18 AND OLDER)
1. Abdominal Aortic Aneurysm - one time screening for age 65-75
2. Alcohol Misuse screening and counseling
3. Aspirin use for men ages 45-79 and women ages 55-79 to prevent CVD when prescribed by a physician
4. Blood Pressure screening for all adults
5. Cholesterol screening for adults
6. Colorectal Cancer screening for adults starting at age 50 limited to one every 5 years
7. Depression screening for adults
8. Type 2 Diabetes screening for adults
9. Diet counseling for adults
10. HIV screening for adults
11. Immunizations vaccines for adults (Hepatitis A & B, Herpes Zoster, Human Papillomavirus, Influenza (flu shot), Measles, Mumps Rubella, Meningococcal, Pneumococcal, Tetanus, Diptheria, Pertussis)
12. Obesity screening and counseling for all adults
13. Sexually Transmitted Infection (STI) prevention counseling for adults
14. Tobacco Use screening for all adults and cessation interventions
15. Syphilis screening for all adults
..................................................................................................
23 COVERED PREVENTIVE SERVICES FOR WOMEN (INCLUDING PREGNANT WOMEN)
HealthyEssentials COVERED BENEFIT SUMMARY
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HealthyEssentials offers the following covered benefits to provide the Minimum Essential Coverage critical for PPACA compliance for large employers.
• Diphtheria, Tetanus, Pertussis
• Haemophilus influenzae type b
• Hepatitis A
• Hepatitis B
• Human Papillomavirus
• Inactivated Poliovirus
• Influenza (Flu Shot)
• Measles, Mumps, Rubella
• Meningococcal
• Pneumococcal
• Rotavirus
• Varicella
18. Iron supplements for children up to 12 months when prescribed by a physician
19. Lead screening for children
20. Medical History for all children throughout development Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
21. Obesity screening and counseling
22. Oral Health risk assessment for young children up to age 10
23. Phenylketonuria (PKU) screening in newborns
24. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents
25. Tuberculin testing for children
26. Vision screening for all children under the age of 5
26 COVERED SERVICES FOR CHILDREN
1. Alcohol and Drug Use assessments
2. Autism screening for children limited to two screenings up to 24 months
3. Behavioral Assessments for children (limited to 5 assessments up to age 17)
4. Blood Pressure screening
5. Cervical Dysplasia screening
6. Congenital Hypothyroidism screening for newborns
7. Depression screening for adolescents age 12 and older
8. Developmental screening for children under age 3, and surveillance throughout childhood
9. Dyslipidemia screening for children
10. Fluoride Chemoprevention supplements for children without fluoride in their water source when prescribed by a physician
11. Gonorrhea preventive medication for the eyes of all newborns
12. Hearing screening for all newborns
13. Height, Weight and Body Mass Index measurements for children.
14. Hematocrit or Hemoglobin screening for children
15. Hemoglobinopathies or sickle cell screening for newborns
16. HIV screening for adolescents
..............................................
17. Immunization vaccines for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
HealthyEssentials COVERED BENEFIT SUMMARY (CONT.)
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Integrated Benefits
As a Lifestyle Health Plans product, all HealthyEssentials Plans include unique, industry-leading value added benefits that further differentiate our product among the growing number of MEC plans on the market today.
LifestyleMD Telemed Consultations
All HealthyEssentials plan participants have access to licensed physicians 24/7/365 via phone or e-mail and will enjoy knowledgeable, on-demand, access to telemedicine consultations at no additional cost. A value added feature that improves access while reducing costs due to unnecessary office, urgent care or emergency room visits. Available as an integrated benefit at $0 Copay for HealthyEssentials plan participants.
..................................................................................................
DirectHealth Mall Discount Program
Integrated into our Lifestyle Health program is access to DirectHealth Mall, a unique employee discount program designed to save plan participants money. DirectHealth Mall is a unique consumer- direct website that offers discount savings in the categories of outpatient lab testing, diabetic supplies, medical supplies, prescription, elective medical services, vision, dental, diet and fitness, and more. HealthyEssentials plan participants have direct access to this discount portal as an integrated feature of the plan design!
..................................................................................................
PPO Network Discounts
Through our PPO network partnerships, HealthyEssentials plan participants have access to network discounts on major medical services. Ask a Lifestyle Health Plans sales associate for more details.
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Plan HealthyChoice 1500 Healthy 100 HealthyValue 3500 MEC Plus
Network Magnacare Magnacare MagnacareEffective Date 1/1/2015 1/1/2015 1/1/2015Deductible $1,500 Single / $3,000 Family $2,500 Single / $5,000 Family $3,500 Single / $7,000 Family
Lifestyle Deductible
$500 Single / $1,000 Family reduction of
member deductible based on Healthy Reward
$500 Single / $1,000 Family reduction of
member deductible based on Healthy Reward
$500 Single / $1,000 Family reduction of
member deductible based on Healthy Reward
Co-insurance 20% 0% 20%Co-insurance Maximum $2,500 single / $5,000 Family No Coinsurance Liability $2,500 single / $5,000 Family
Preventive Services 100% 100% 100%
Professional Office Visits
$30 Copay Primary Care
$50 Copay Specialist
$30 Copay Primary Care
$50 Copay Specialist
$30 Copay Primary Care
$50 Copay Specialist
Telephonic Physician Consultations $0 Copay $0 Copay $0 CopayOutpatient Lab
(Lab Corp is the Preferred Vendor)
100% if preferred vendor, otherwise Deductible
/ Co-insurance
100% if preferred vendor, otherwise Deductible
/ Co-insurance
100% if preferred vendor, otherwise Deductible
/ Co-insuranceMedicaid
Outpatient Radiology Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insurance Medicare
Diabetic Supplies
100% if preferred vendor, otherwise Deductible
/ Co-insurance
100% if preferred vendor, otherwise Deductible
/ Co-insurance
100% if preferred vendor, otherwise Deductible
/ Co-insurance A Veteran's Health Plan
Allergy Treatment $25 Copay, then 100% to $100 per visit $25 Copay, then 100% to $100 per visit $25 Copay, then 100% to $100 per visit My spouse's planOutpatient Rehab & Therapy Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insurance
*Chiropractic Services Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insurance My parent's planProfessional Services
(Services outside of an office setting) Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insuranceEmergency Services
*Hospital ER (Facility Charge Only)$150 Copay, then 100% to $1,000 per visit, then
Deductible / Co-insurance
$150 Copay, then 100% to $1,000 per visit, then
Deductible / Co-insurance
$250 Copay, then 100% to $1,000 per visit, then
Deductible / Co-insuranceEmployees with insurance please supply
the following:
*Urgent Care / ER Professional Services
$50 Copay, then 100% to $300 per visit, then
Deductible / Co-insurance
$50 Copay, then 100% to $300 per visit, then
Deductible / Co-insurance
$50 Copay, then 100% to $300 per visit, then
Deductible / Co-insurance*Ambulance Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insurance Name of carrier:
Outpatient Surgical & Therapeutic Procedures*Medical Facility Services Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insurance
*Physician & Surgeon Fees Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insuranceInpatient Hospitalization Your ID #:
*Medical Facility Services Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insurance*Anesthesiologist & Surgeon Fees Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insurance
Home Health, Skilled Nursing & Hospice Care Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insurance Name of policy holder:
Mental Health & Substance Abuse Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insurance
Durable Medical Equipment Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insurancePrescription Drug Benefits
*Preferred Network (Excludes CVS & Walmart) $20 or less / $50 / $75 / 50% $20 or less / $50 / $75 / 50% $20 or less / $50 / $75 / 50% Effective Date: (month and year)*Standard National Network $25 / $60 / $85 / 50% $25 / $60 / $85 / 50% $25 / $60 / $85 / 50%Dental
Preventative & Diagnostic Covered 100 % - 2 Cleanings per year. Covered 100 % - 2 Cleanings per year. Covered 100 % - 2 Cleanings per year.Minor Restorative 80% 80% 80%Major Work 50% 50% 50%Deductible / Annual Limit None / None None / None None / NoneMax Per Year $1,000 $1,000 $1,000
Vision
Eye Exam - Annual $10.00 $10.00 $10.00
Lenses / Contacts- Frequency limit 1 x 12 Months 1 x 12 Months 1 x 12 Months
Frames - No frequency limits 1 x 24 Months 1 x 24 Months 1 x 24 Months
Max Per Year $130 $130 $130
Pre-Tax Employee Contribution (Per week)
Single 9.56% of wages up to $97.47 9.56% of wages up to $93.58 9.56% of wages up to $80.17 $6.15
I elect:(Circle One)
Couples, Employee w child(ren), Family
Rate for the employee as above. Dependent premiums are 100% employee paid. Please contact Matt Wade at [email protected] for dependent
premium costs.
Print and Sign Your Name Print Name: X
Healthy Choice 1500 Healthy 100 Healthy Value 3500
Employee Election Form
Health Plan Options 2015 (Employees on Weekly Payroll Cycle)
See Attachment
I waive coverage
in the company
sponsored health plan
because I am enrolled in:
(Please circle one)
MEC Plan
I am not covered by a major medical
insurance plan and decline to enroll on
one here. I understand that I will be
placed on the MEC plan.
Plan HealthyChoice 1500 Healthy 100 HealthyValue 3500 Waiver / MEC plus
Network Magnacare Magnacare MagnacareEffective Date 4/1/2016 4/1/2016 4/1/2016Deductible $1,500 Single / $3,000 Family $2,500 Single / $5,000 Family $3,500 Single / $7,000 FamilyHealthy Rewards Program
Reduction of deductible
$500 Single / $1,000 Family reduction of member
deductible based on Healthy Reward points
$500 Single / $1,000 Family reduction of member
deductible based on Healthy Reward points
$500 Single / $1,000 Family reduction of member
deductible based on Healthy Reward points
Co-insurance 20% 0% 20%Co-insurance Maximum $2,500 single / $5,000 Family No Coinsurance Liability $2,500 single / $5,000 Family
Preventive Services 100% 100% 100% Medicaid
Professional Office Visits
$30 Copay Primary Care
$50 Copay Specialist
$30 Copay Primary Care
$50 Copay Specialist
$30 Copay Primary Care
$50 Copay SpecialistMedicare
Telephonic Physician Consultations $0 Copay $0 Copay $0 Copay A Veteran's Health PlanOutpatient Lab
(Lab Corp is the Preferred Vendor)
100% if preferred vendor, otherwise Deductible /
Co-insurance
100% if preferred vendor, otherwise Deductible /
Co-insurance
100% if preferred vendor, otherwise Deductible /
Co-insuranceMy spouse's plan
Outpatient Radiology Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insurance My parent's plan
Diabetic Supplies
100% if preferred vendor, otherwise Deductible /
Co-insurance
100% if preferred vendor, otherwise Deductible /
Co-insurance
100% if preferred vendor, otherwise Deductible /
Co-insuranceEmployees with insurance please supply
the following:
Allergy Treatment $25 Copay, then 100% to $100 per visit $25 Copay, then 100% to $100 per visit $25 Copay, then 100% to $100 per visit Name of carrier:Outpatient Rehab & Therapy Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insurance
*Chiropractic Services Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insuranceProfessional Services
(Services outside of an office setting) Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insuranceEmergency Services Your ID #:
*Hospital ER (Facility Charge Only)$150 Copay, then 100% to $1,000 per visit, then
Deductible / Co-insurance
$150 Copay, then 100% to $1,000 per visit, then
Deductible / Co-insurance
$250 Copay, then 100% to $1,000 per visit, then
Deductible / Co-insurance
*Urgent Care / ER Professional Services
$50 Copay, then 100% to $300 per visit, then
Deductible / Co-insurance
$50 Copay, then 100% to $300 per visit, then
Deductible / Co-insurance
$50 Copay, then 100% to $300 per visit, then
Deductible / Co-insuranceName of policy holder:
*Ambulance Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insurance
Outpatient Surgical & Therapeutic Procedures
*Medical Facility Services Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insurance Effective Date: (month and year)
*Physician & Surgeon Fees Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insuranceInpatient Hospitalization
*Medical Facility Services Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insurance Mark one below and sign where *Anesthesiologist & Surgeon Fees Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insurance indicated:
Home Health, Skilled Nursing & Hospice Care Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insurance
Mental Health & Substance Abuse Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insurance
Durable Medical Equipment Deductible / Co-insurance Deductible / Co-insurance Deductible / Co-insurancePrescription Drug Benefits
*Preferred Network (Excludes CVS & Walmart) $20 or less / $50 / $75 / 50% $20 or less / $50 / $75 / 50% $20 or less / $50 / $75 / 50%*Standard National Network $25 / $60 / $85 / 50% $25 / $60 / $85 / 50% $25 / $60 / $85 / 50%Dental
Preventative & Diagnostic Covered 100 % - 2 Cleanings per year. Covered 100 % - 2 Cleanings per year. Covered 100 % - 2 Cleanings per year.Minor Restorative 80% 80% 80%Major Work 50% 50% 50%Deductible / Annual Limit None / None None / None None / NoneMax Per Year $1,000 $1,000 $1,000
Vision
Eye Exam - Annual $10.00 $10.00 $10.00
Lenses / Contacts- Frequency limit 1 x 12 Months 1 x 12 Months 1 x 12 Months
Frames - No frequency limits 1 x 24 Months 1 x 24 Months 1 x 24 Months
Max Per Year $130 $130 $130
Pre-Tax Employee Contribution (Bi Weekly)
Single 9.50% of wages up to $194.94 9.50% of wages up to $187.16 9.50% of wages up to $160.34 $12.30
Couple - Add to Single Rate $204.36 $200.65 $170.55
Employee with child(ren) - Add to Single Rate $171.43 $168.73 $143.46 Family - Add to Single Rate $407.85 $398.26 $340.73
Print and Sign Your Name Print Name: X
See "Healthy Essentials" Attachment
I elect: (Circle One)
I waive coverage
in the company
sponsored health plan
because I am enrolled in:
(Please circle one)
I am covered by a major medical plan as
indicated above and elect to waive
participation in the company plan.
Healthy Choice 1500 Healthy 100 Healthy Value 3500
Employee Election Form
Health Plan Options 2015 (Employees on Bi-Weekly Payroll Cycle)
MEC Plan
I am not covered by a major medical
insurance plan and decline to enroll on
one here. I understand that I will be
placed on the MEC plan.
Health Application Form
Section 1: Employer Information Employer Name: __________________________________________________________________ Hire Date: __________________
Employer Address: _________________________________________________________________
City: ______________________________________________ State: ____________________________ Zip: _____________________
Section 2: Employee Information Employee Name: ______________________________________________________________ Date of Birth: _______________
Last First M.I.
Address: ______________________________________________________________ ___________________________
______________________________________________________________ Job Title City State Zip
Marital Status: □ Single □ Divorced □ Married □ Widowed
Home Phone: ( _______ ) _______________________________ Cell Phone: ( _______ ) ___________________________________
E-mail Address: ____________________________________________________ Hours Worked per Week: ____________________
Spouse’s Employer: ___________________________________________ Spouse’s Business Phone: ( _____ ) __________________
Section 3: Other Insurance Coverage Are you or any dependent(s) disabled □ YES □ NO If YES, please indicate name(s): ____________________________________
Do you or your spouse have other health insurance? □ YES □ NO If YES, name of Carrier: _____________________________
Policy Holder’s Name: ___________________________________ Policy #: ___________________ Effective Date: ________________
Name of Covered Dependents: ____________________________________________________________________________________
Section 4: Prior Coverage Information To eliminate or reduce pre-existing condition waiting periods; a copy of your Certificate of Creditable Coverage from your current carrier will be required when enrollment in the program is completed. Submission of your prior coverage information does not automatically waive any pre-existing condition limitations.
Section 5: Subscriber / Dependents (Please complete for all participating dependents.) First Name MI Last Name
Social Security #
DOB
Age
M / F
Tobacco Use YES / NO
Section 6: Health Plan Enrollment
Coverage Level Plan Selected ___ Employee Only ___ I elect to participate ___ Employee / Spouse Options provided upon ___ I decline participation ___ Employee / Child(ren) underwriting approval ___ Family
Section 7: Health Information Please furnish us with the height and weight or you and your spouse:
Self: Height ____ feet _____ inches; _________ Weight Spouse: Height ____ feet _____ inches; _________ Weight
Ver.060614
1. Have you or any of your dependent(s) been diagnosed or treated for any of the following conditions in the past five (5) years? A. Cardiac Disorder □ Yes □ No H. Aids / Immune System Disorder □ Yes □ No
B. Cancer (any form) □ Yes □ No I. Alcohol / Drug Abuse □ Yes □ No C. Diabetes □ Yes □ No J. Mental / Nervous Disorder □ Yes □ No D. Kidney Disorder □ Yes □ No K. Neuromuscular Disorder □ Yes □ No E. Respiratory Disorder □ Yes □ No L. Stomach / Gastrointestinal □ Yes □ No F. Liver Disorder □ Yes □ No M. Arthritis, Back, Bone, Joint Disorder □ Yes □ No G. High Blood Pressure □ Yes □ No N. Seizures, convulsions, epilepsy □ Yes □ No
2. Within the past 5 years, have you or any dependent ever had an application for insurance declined, postponed, rated, or otherwise modified? …………………………………………………………………….. □ Yes □ No
3. Have you or any of your dependent(s) had any medical conditions in the past 24 months requiring medical care, prescription management, or hospitalization in the amount of $5,000 or more?................ □ Yes □ No
If Yes, please provide information on who and for what conditions in space provided below
4. Are you or any of your dependent(s) anticipating hospitalization or surgery, or had surgery or hospitalization recommended that has not been performed? If Yes please provide information below….. □ Yes □ No
5. Are you or any dependent(s) currently pregnant or suspect you / they may be pregnant? If Yes, please provide due date and detail in space provided below. ……………………………………… □ Yes □ No
Question Number
Family Member Disease / Diagnosis / Treatment Date of Onset Month / Year
Date Last Seen By Physician
Remaining Symptoms or Problems
6. Prescriptions / Medications – Please list any medications, prescriptions, or injections taken in the last 12 months.
Family Member Medication / Rx / Injection Dosage Medical Condition
Agreements
The answers and statements on this Group Enrollment Form are true and complete. I agree that they shall form a part of the contract of insurance under which I am applying for coverage. I understand and agree that the insurance applied for shall not take effect until approved by the insurance carrier at its Home Office. I have read, or have had read to me, the completed application and I realize that any false statements or misrepresentation in the application may result in loss of coverage under the contract
Medical Authorization I authorize any of the following to disclose any data it has on me, my health or on the health of my family. (1) any physician or other medical practitioner; (2) any hospital, clinic or other medical or medically related facility; (3) any insurance company; (4) The Medical Information Bureau; (5) any other organization, institution, or person that has any data on me or my health or on the health of my family. A copy of this shall be as valid as the original.
Fraud Warning
Any person who knowingly and with intent to defraud an insurer files an application or statement of claim containing false, incomplete or misleading information may be guilty of insurance fraud which is a crime.
Section 8: Signature I hereby authorize my employer to deduct contributions towards my benefits. I hereby agree to abide by the terms and conditions of all benefit plan summary documents, which contain the benefits, limitations, and exclusions applicable to my health and other benefit coverage. I hereby authorize my healthcare providers to disclose information from my medical records to Medova Healthcare and their respective carriers to the extent necessary to for underwriting, benefit eligibility, and pre-existing condition determinations. Upon request, a customer service representative can explain my benefit coverage options. I have read and understand the above conditions and declarations. Employee Signature: ________________________________________________________ Date: _________________________
Please answer the following questions regarding any medical treatment, conditions, or medical treatment for you and your family. If you answer “Yes” to any question please provide detail in space provided below.
Ver.060614