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The following date and time information will help us to assist you better: Sat Dec 14 22:32:54 GMT 2024

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About you
Coverage

Are you 65+ or Medicare eligible?*

If you have Medicare coverage, you cannot enroll in this plan. However, you can enroll other family members who aren't eligible for Medicare. Change your answer above to "No" to continue enrolling other family members, or follow this link to View Our Medicare Plans.

Do you have and are you planning to keep medical coverage with another insurer (other than Medicaid)?*

You cannot be the Subscriber/Policy holder on the selected plan, however you can enroll other family members and Subscriber/Policy holder who do not have other medical coverage. Change your answer above to "No" to continue enrolling other family members.

Have you obtained stand-alone dental coverage that provides a pediatric dental essential health benefit through a NY State of Health-certified stand-alone dental plan offered outside of the NY State of Health?*

Your selected plan includes pediatric dental coverage benefit at an additional cost. Please either revise your answer here or Select a New Plan and answer 'Yes' on the stand-alone dental coverage question.

Your selected plan does NOT include pediatric dental coverage. Please either revise your answer here or Select a New Plan and answer 'No' on the stand-alone dental coverage question.

We have provided you with coverage of the pediatric dental essential health benefit at an additional charge.
When you can enroll outside of Open Enrollment

Are you losing coverage from an Excellus BlueCross BlueShield Plan?*

The print date on the notice from your employer
advising of HRA Plan Eligibility ?
If your event date is outside of 60 days from today's date, you must wait for Open Enrollment
Event Date must be Date of Death of deceased
Event Date must be newborn's Date of Birth
Date Pregnancy Confirmed
The first date of HRA Plan Eligibility
you are applying
The date you request may change based
on the reason you are applying
A copy of Proof of loss of coverage is required before we can complete this request.
LIST OF ACCEPTABLE PROOF: Proof of loss of coverage from previous employer (term letter, pay stub of both current and previous hours, letter from employer stating no longer eligible or contributions to COBRA are ending, legal document from current health insurance plan (including exchange) advising termination date and reason to be involuntary, insurer termination notice/letter.)
A copy of D29 Annual Certification form is required before we can complete this request.
A copy of your Marriage Certificate or Proof of Domestic Partnership and Financial Interdependence is required before we can complete this request. NOTE: Date on the proof must match the event date indicated.
Please attach proof that one spouse had Minimum Essential Coverage or that they lived outside of the US or in a US territory for one or more days during the 60 days preceding the date of marriage
A copy of Death Certificate or Obituary, Proof of loss of coverage listing who was covered under old policy is required before we can complete this request.
A copy of the Birth Certificate is required before we can complete this request.
A copy of the Adoption Certificate, Proof of Custody or Proof Adoption petition is filed is required before we can complete this request.
A copy of Adoption Certificate, Proof Adoption petition is filed or Court Documents appointing Legal Guardianship is required before we can complete this request.
A copy of address change is required before we can complete this request.
LIST OF ACCEPTABLE PROOF:
  • Proof of residency (e.g. prior and current utility bill, phone bill, lease agreement etc. in applicant's name) within 60 days.
  • Proof of prior coverage OR proof that no Qualified Health Plan (QHP) options were available in the prior county must be attached.
A copy of Divorce Certificate, Divorce Decree, Annulment Court Ruling, Legal Separation Agreement or affidavit of Domestic Partnership discontinuance is required before we can complete this request.
A copy of the Confirmation of Pregnancy form or equivalent form is required before we can complete this request.
LIST OF ACCEPTABLE PROOF: The pregnancy should be documented and verified by the Provider on the Confirmation of Pregnancy form or equivalent form or letterhead signed by confirming Dr with date pregnancy confirmed.
A copy of proof of release from incarceration is required before we can complete this request.
A copy of proof of becoming a Citizen, National or Lawfully present is required before we can complete this request.
LIST OF ACCEPTABLE PROOF: www.healthcare.gov/immigrants/documentation
A copy of proof of court order is required before we can complete this request.
A copy of economic hardship-HHS Certificate of Exemption is required before we can complete this request.
Please attach proof from your employer that you have been offered a HRA
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Subscriber

You selected a 'Child-Only' plan. Please enter the youngest child as the Subscriber.




Address

Home Address

Mailing Address

Family Member(s)

To enroll family members, click the below button.

 Add Family Member

Use the 'Edit' or 'Remove' buttons to make changes to family members

Select Name Relationship Date of Birth
 Edit Family Member     Delete Family Member

Is family member 65+ or Medicare eligible?*

This family member cannot be added to the plan, however you can enroll other family members who do not have Medicare Coverage. Change your answer above to 'No' to continue enrolling other family members.

Does the family member have coverage from another insurance carrier(other than Medicaid)?*

Family member cannot be added to the selected plan, however you can enroll other Family members who do not have Other Medical Coverage. Change your answer above to "No" to continue enrolling other family members.

A copy of Disability Certificate is required before we can complete this request
X
*

Please answer below questions

Is the dependent unmarried?*

We're sorry, the plan you selected does not cover dependents age 26 to 30 (up to their 30th birthday) who are married or eligible for other coverage or live, work, reside outside New York. If you answered the questions above incorrectly then change your answers to "Yes" to continue enrolling the family member, or follow this link to Select a New Plan.

Is the dependent under 30 and not insured by or eligible for employer sponsored health benefit plan?*

We're sorry, the plan you selected does not cover dependents age 26 to 30 (up to their 30th birthday) who are married or eligible for other coverage or live, work, reside outside New York. If you answered the questions above incorrectly then change your answers to "Yes" to continue enrolling the family member, or follow this link to Select a New Plan.

Does the dependent live, work or reside in New York state?*

We're sorry, the plan you selected does not cover dependents age 26 to 30 (up to their 30th birthday) who are married or eligible for other coverage or live, work, reside outside New York. If you answered the questions above incorrectly then change your answers to "Yes" to continue enrolling the family member, or follow this link to Select a New Plan.




NOTE: We are required to ask for your Social Security Number in order to meet reporting obligations under the Affordable Care Act

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Legal Acceptance

Pursuant to federal rules that implement the Affordable Care Act, individual health insurance policies must be written on a calendar year basis. This means that if your effective date of coverage is a date later than January 1st of a year, the initial term of coverage for your policy will be for less than a full year and will end on December 31st of the same year. Please be advised that all benefits and cost sharing under your policy, including the full annual deductible, apply to the partial year of coverage.

I acknowledge and agree that by signing this enrollment form and subsequently accepting services, I and everyone else who is covered under the contract you issue is bound by the terms and conditions of the contract applicable to my coverage. This includes, without limitation, the terms and conditions regarding the receipt and release of medical records and information. I make this acknowledgement and agreement on behalf of myself and each other person who accepts coverage under the terms of the contract applicable to my coverage (who may include, for example my spouse and my eligible family dependents).

I hereby accept responsibility for payment of any portion of the premium.

I hereby represent that all information furnished by me hereon is true and complete to the best of my knowledge.

[I understand that if I elect Exclusive Provider Organization (EPO) coverage, except in an emergency, all care must be provided by medical providers who participate with the EPO and I will not receive benefits for care that I receive from providers who do not participate with the EPO.]

I have thoroughly read, understand and agree to comply with the terms of this Release section.

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 $5,000 and the stated value of the claim for each such violation.

*
Third Party Administrators

Has a Broker Agent , Sales Representative or Marketplace Facilitated Enroller (MFE) helped you to complete the application?

Continue

Enroll in Summary

The Health Plan you selected is not available in the area where you live. Please see the field highlighted in Red below.

  • If your Zip code is wrong, please select 'Edit' to correct it, or
  • If your Zip code was entered correctly, you will need to select a different plan by returning to our Plan Comparison Tool.

Your application has either missing or incorrect information so we cannot accept it electronically.

  • See the field(s) highlighted in Red below and select 'Edit' to update the information

 Please review your information (use 'Edit' to make any changes) and select 'Submit' to send us your information

Coverage
Edit
Reason for Enrollment:
 
Event Date:
 
Requested Effective Date:
 
Documentation:
     
Subscriber
Edit
First Name:
 
Middle Initial:
 
Last Name:
 
Title:
 
Gender:
 
Gender Identity:
 
Date of Birth:
 
Social Security Number:
 
Address
Edit
Home Address
Street Address:
 
 
 
Email Address:
 
City:
 
State:
New york
Zip:
 
Daytime Phone Number:
 
Alternate Phone Number:
 
Mailing Address
In Care of:
 
Street Address:
 
 
 
Email Address:
 
City:
 
State:
 
Zip:
 
Day-time Phone Number:
 
Billing Address
In Care of:
 
Street Address:
 
 
 
Email Address:
 
City:
 
State:
 
Zip:
 
Family Member(s)

No Family Member has been entered

Dental Coverage
Please provide the name of the company issuing the stand-alone dental coverage:  
Legal Acceptance
Edit

Pursuant to federal rules that implement the Affordable Care Act, individual health insurance policies must be written on a calendar year basis. This means that if your effective date of coverage is a date later than January 1st of a year, the initial term of coverage for your policy will be for less than a full year and will end on December 31st of the same year. Please be advised that all benefits and cost sharing under your policy, including the full annual deductible, apply to the partial year of coverage.

I acknowledge and agree that by signing this enrollment form and subsequently accepting services, I and everyone else who is covered under the contract you issue is bound by the terms and conditions of the contract applicable to my coverage. This includes, without limitation, the terms and conditions regarding the receipt and release of medical records and information. I make this acknowledgement and agreement on behalf of myself and each other person who accepts coverage under the terms of the contract applicable to my coverage (who may include, for example my spouse and my eligible family dependents).

I hereby accept responsibility for payment of any portion of the premium.

I hereby represent that all information furnished by me hereon is true and complete to the best of my knowledge.

[I understand that if I elect Exclusive Provider Organization (EPO) coverage, except in an emergency, all care must be provided by medical providers who participate with the EPO and I will not receive benefits for care that I receive from providers who do not participate with the EPO.]

I have thoroughly read, understand and agree to comply with the terms of this Release section.

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 $5,000 and the stated value of the claim for each such violation.

*
Third Party Administrators
Edit

No Third Party Administrator has been entered

Name of Broker/Agent/CAC/Person Assisting
 
Agency Name (if Applicable)
 
Agency License # (if Applicable)
 
Agency TaxID (if Applicable)
 
Submit
Please Confirm

Are you sure want to proceed without adding a family member?

Please Confirm Family Members

You selected a plan, Are you sure want to proceed without adding a family member?

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