California Employee Enrollment/Change Form - 1-100 Employees ...

GR-69068-12 (4-16) 1 CA SGB V2 R-POD E

California Small Group Business Employee Enrollment/Change Form (1 - 100 employees)

TO COMPLY WITH CALIFORNIA LAW, WHEREVER THE TERM SPOUSE APPEARS IT SHALL BE CONSTRUED TO INCLUDE DOMESTIC PARTNER.

Coverage is provided by the following entities: Aetna Health of California Inc. for HMO, Aetna Dental of California Inc. for Dental (DMO only) and Aetna Life Insurance Company for all other coverages. For Vision coverage, certain claims administration services are provided by First American Administrators, Inc. and certain network administration services are provided through EyeMed Vision Care LLC (EyeMed).

Group number

Aetna member ID number (if available)

Company name

INSTRUCTIONS: You, the employee, must complete this enrollment form in full. If you do not, we will return it to you or your employer, and that can delay its processing. You alone are responsible for its accuracy and completeness. If you are enrolling, please be sure to sign and date Employee Signature on page 5. If you are declining coverage, you must complete Section F on page 5. Please use only black ink to complete this form.

Effective date

Date of hire

New hire

Rehire / reinstatement *

New group enrollment

Late enrollment

Open enrollment

Waiver

Add spouse / dependent child

Change of coverage

Name change

Other

Employee termination

Remove spouse / dependent child

Cancel coverage

* Does not apply to supplemental or dependent life insurance

COBRA Cal-COBRA 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.

Member Social Security number or tax ID number*

Last name, first name, middle initial

Home address (PO box not acceptable)

Apt. number

City, state

ZIP code

Work address (PO box not acceptable)

City, state

ZIP code

Home telephone

( ) -

Work telephone

( ) -

Primary language spoken (optional)

Number of dependents enrolling for medical coverage including spouse

Salary (if enrolling for life coverage)

$

Hourly

Monthly

Weekly

Number of hours worked a week

Check One:

Full time 1099 Seasonal Union Part time Retiree Temporary

Job title

*Social Security number is optional; tax identification number is acceptable.

B. Coverage selection Please print clearly.

1. Medical coverage selection: Select a medical plan by checking the appropriate box below. (The plan must be offered by your employer.)

Plan choices by network

HMO plans

HMO Full Network HMO Aetna Value Network (AVN) HMO Deductible Network HMO Basic Network

Platinum AVN HMO 15 Copay Plan Platinum Basic HMO 15 Copay Plan

Gold HMO 20 Gold AVN HMO 20 Gold Basic HMO 20

Gold AVN HMO 30 Copay Plan Gold Basic HMO 30 Copay Plan

Gold HMO 45 Gold AVN HMO 45 Gold Basic HMO 45

Gold HMO Deductible 250 Gold Basic HMO 250

Silver HMO Deductible 1500 Silver Basic HMO 1500

Silver HMO Deductible 2000 Silver Basic HMO 2000

Silver HMO Ded 2000 Copay Plan Silver Basic HMO 2000 Copay Plan

Bronze Basic HMO 6300 Plan

Bronze HMO Deductible 6500 Bronze Basic HMO 6500

GR-69068-12 (4-16) 2 CA V2 E

B. Coverage selection (Continued)

Open Access Managed Choice (MC) plans

MC Full Network MC Savings Plus Network

Platinum Savings Plus 0 Copay Plan

Gold MC 0 Copay Plan Gold Savings Plus 0 Copay Plan

Gold MC 750 80/50 Gold Savings Plus 750 80/50

Silver MC 1000 70/50 Silver Savings Plus 1000 70/50

Silver MC 2000 80/50 HDHP Plan Silver Savings Plus 2000 80/50 HDHP Plan

Silver MC 2000 60/50 Silver Savings Plus 2000 60/50

Silver MC 2000 Copay Silver Savings Plus 2000 Copay

Bronze MC 4000 Copay Bronze Savings Plus 4000 Copay

Bronze MC HDHP 4800 60/50 HSA Plan Bronze Savings Plus HDHP 4800 60/50 HSA Plan

Bronze MC 6550 100/50 HSA Bronze Savings Plus 6550 100/50 HSA

Bronze MC 6500 Copay Bronze Savings Plus 6500 Copay

Aetna Whole Health Networks

PrimeCare MemorialCare ACO

HMO plans EPO plans

Gold PrimeCare HMO 30 Copay Plan Gold MemorialCare EPO 750 80

Gold PrimeCare HMO 45

Silver PrimeCare HMO Ded 1500 Silver MemorialCare EPO 2000 Copay

Bronze PrimeCare HMO Ded 6500 Bronze MemorialCare EPO 4000 Copay

MC plans MC plans

Gold PrimeCare MC 750 80/50

Silver PrimeCare MC 2000 60/50 Silver MemorialCare MC 2000 60/50

Bronze PrimeCare MC 4000 Copay Bronze MemorialCare MC 6500 Copay

Aetna Whole Health Networks (Continued)

SCCIPA ACO

EPO plans

Gold SCCIPA EPO 750 80

Silver SCCIPA EPO 2000 Copay

Bronze SCCIPA EPO 4000 Copay

MC plans

Silver SCCIPA MC 2000 60/50

Bronze SCCIPA MC 6500 Copay

PPO Full Network Indemnity (only available if OAMC or PPO networks are not available)

Gold PPO 750 80/50 Silver Indemnity 1500 80

Control/Group number Suffix Account Plan number

2. Dental Check one (if applicable).

Non-voluntary plans: Aetna Dental Plan - Plan option: For FOC, choose: DMO or PPO

Voluntary plans: Aetna Dental Plan - Plan option: For FOC, choose: DMO or PPO

Before today, were you covered under this employers dental plan? Yes No

Creditable coverage is allowed for new members enrolling in voluntary 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 coverage? Discount dental and preventive only plans do not apply. Yes No


3. Vision Check applicable box.

Aetna VisionSM Preferred Yes No

Continued on next page

GR-69068-12 (4-16) 3 CA V2 E

B. Coverage selection (Continued)


4. Life and disability Yes No

Life / AD&D Ultra (for groups with 2-9 employees) Check applicable boxes.

Employee Basic Life / AD&D Ultra

Life / AD&D Ultra (for groups with 10-100 employees) Check applicable boxes.

Employee Basic Life / AD&D Ultra Supplemental Life / AD&D Ultra

Spouse Optional Spouse Life / AD&D Ultra

Child Optional Child Life / AD&D Ultra

Disability (Coverage for employee only) Check applicable boxes.

Short Term Disability (for groups with 51-100 employees) Yes No

Long Term Disability (for groups with 10-100 employees) Yes No

C. Individuals Covered List individuals for whom you are enrolling or adding/changing/removing coverage. Add more sheets if needed. For dependents with different last names or living at another address, complete Section D below. 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. Disabled children may be covered if they are over age 26. Please refer to your plan documents or contact your benefits administrator.

1 Employee name (Last, first, middle initial)

Sex (M/F)

Birthdate (MM/DD/YYYY)

/ /

Status

Single Married

Divorced Legally separated

Domestic partnership

Choosing coverage for:

Medical Dental

Vision STD LTD

Life / AD&D Ultra

Primary care physician (PCP) provider office ID number

Current patient

Yes

Dental office ID number (if applicable)

Current patient

Yes

2 Spouse name (Last, first, middle initial)

Sex (M/F)

Social Security number


/ /

Relationship

Spouse Domestic partner

Other


Medical Dental

Vision

Life / AD&D Ultra

PCP provider office ID number

Current patient

Yes


Current patient

Yes

3 Child name (Last, first, middle initial)

Sex (M/F)



/ /

Relationship

Child Stepchild

Other


Medical Dental

Vision

Life / AD&D Ultra


Current patient

Yes


Current patient

Yes


Sex (M/F)



/ /

Relationship

Child Stepchild

Other


Medical Dental

Vision

Life / AD&D Ultra


Current patient

Yes


Current patient

Yes


Sex (M/F)



/ /

Relationship

Child Stepchild

Other


Medical Dental

Vision

Life / AD&D Ultra


Current patient

Yes


Current patient

Yes


Sex (M/F)



/ /

Relationship

Child Stepchild

Other


Medical Dental

Vision

Life / AD&D Ultra


Current patient

Yes


Current patient

Yes


GR-69068-12 (4-16) 4 CA V2 E

C. Individuals Covered (Continued)


Sex (M/F)



/ /

Relationship

Child Stepchild

Other


Medical Dental

Vision

Life / AD&D Ultra


Current patient

Yes


Current patient

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 youre applying for replace the coverage you have now? Yes No

Name of person Carrier name Name of person Carrier name

Conditions of enrollment

NOTICE: California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage.

On behalf of myself and the dependents listed, I agree to or with the following: 1. I acknowledge that by enrolling in the following plans, coverage is provided by the following entities (collectively referred to as Aetna): Aetna HMO: Aetna Health of California Inc. Aetna Dental DMO: Aetna Dental of California Inc. Aetna Vision: Aetna Life Insurance Company. Certain claims adjudication and other administrative services are provided by First American

Administrators, Inc. (an affiliate of EyeMed Vision Care, LLC) and/or its affiliates. Life, Accidental Death & Personal Loss Coverage (AD&D Ultra), Disability, Dental and all other health coverages: Aetna Life Insurance

Company. 2. I understand and agree that my employers application will determine coverage and that there is no coverage unless and until both the eligible

employee enrollment form and employer applications have been accepted and approved by Aetna. If Aetna demonstrates that I have acted fraudulently or intentionally misrepresented material facts, Aetna may rescind the policy or may increase premiums after giving me at least 60 days prior notice by certified mail. However, after 24 months following the issuance of the policy, Aetna will not rescind the policy for any reason and will not cancel the policy, limit the policy, or raise premiums due on the policy due to misrepresentation or inaccuracies in this form, whether willful or not. Aetna does not base its eligibility rules for medical, dental or vision on any of the following factors:

(A) Health status. (B) Medical condition, including physical and mental illnesses. (C) Claims experience. (D) Receipt of health care. (E) Medical history. (F) Genetic information. (G) Evidence of insurability, including conditions arising out of acts of domestic violence. (H) Disability. (I) Any other health status-related factor as determined by any federal regulations, rules, or guidance issued pursuant to Section 2705 of the

federal Public Health Service Act. For life coverage: I understand that the effective date of insurance for myself or for any of my dependents is subject to my being active at work on

that date and that the effective date of insurance for any of my dependents is also subject to the dependent health condition requirements of the benefit plan. Further, I understand that any insurance subject to evidence of good health or medical information will not become effective until Aetna gives its written consent. For Dependent Life, dependents are eligible from birth up to their 26th birthday.

For disability coverage: I understand that the effective date of my insurance is subject to my being active at work on that date. Further, I understand that any insurance subject to evidence of good health or medical information will not become effective until Aetna gives its written consent.


GR-69068-12 (4-16) 5 CA V2 E

Conditions of enrollment (Continued)

3. The plan documents will determine the rights and responsibilities of member(s) and will govern in the event they conflict with any benefits comparison, summary or other description of the plan.

4. I understand and agree that, with the exception of Aetna Rx Home Delivery, all participating providers and vendors are independent contractors and are neither agents nor employees of Aetna. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed and provider network composition is subject to change. Notice of the change shall be provided in accordance with applicable state law.

5. I understand and agree that, with certain exceptions described in the plan documents, HMO and DMO plans only provide coverage for referred benefits, and that, in order to be covered, services must be performed either by a participating primary care physician, primary care dentist, or by the participating specialist, hospital, pharmacy, dentist, or other provider as authorized by a referral from a participating primary care physician.

To the best of my knowledge, I represent that all information supplied in this form is true and complete. I have read and agree to the conditions of enrollment on this enrollment / change form. I understand in the event I fail to sign and return this form within 31 days of my eligibility date or for any reason Aetna does not receive notice of the above transaction request within a reasonable time following the event, my eligibility and my dependents eligibility may be affected. I am employed by the employer shown on page 1, and I am working full time at least 30 hours a week (or 20-29 hours a week if elected by my employer) for this employer at the regular place of business. I authorize deductions from my earnings for any contributions required for coverage and I agree to make any necessary payments as required for coverage.

CA HMO ENROLLEES - NOTICE OF BINDING ARBITRATION: ANY DISPUTE ARISING FROM OR RELATED TO HEALTH PLAN MEMBERSHIP WILL BE DETERMINED BY SUBMISSION TO BINDING ARBITRATION, AND NOT BY A LAWSUIT OR RESORT TO COURT PROCESS EXCEPT AS CALIFORNIA LAW PROVIDES FOR JUDICIAL REVIEW OF ARBITRATION PROCEEDINGS. THE AGREEMENT TO ARBITRATE INCLUDES, BUT IS NOT LIMITED TO, DISPUTES INVOLVING ALLEGED PROFESSIONAL LIABILITY OR MEDICAL MALPRACTICE, THAT IS, WHETHER ANY MEDICAL SERVICES COVERED BY THIS AGREEMENT WERE UNNECESSARY OR WERE UNAUTHORIZED OR WERE IMPROPERLY, NEGLIGENTLY OR INCOMPETENTLY RENDERED. THE HEALTH PLAN AGREEMENT ALSO LIMITS CERTAIN REMEDIES AND MAY LIMIT THE AWARD OF PUNITIVE DAMAGES. SEE THE EVIDENCE OF COVERAGE FOR FURTHER INFORMATION.

I UNDERSTAND THAT I AM GIVING UP THE CONSTITUTIONAL RIGHT TO HAVE DISPUTES DECIDED IN A COURT OF LAW BEFORE A JURY, AND INSTEAD AM ACCEPTING THE USE OF BINDING ARBITRATION. THIS MEANS THAT MEMBERS WILL NOT BE ABLE TO TRY THEIR CASE IN COURT. I FURTHER UNDERSTAND THAT THE AGREEMENT CONTAINS LIMITATIONS ON CERTAIN REMEDIES AND THAT THERE MAY BE CERTAIN LIMITATIONS TO THE RECOVERY OF PUNITIVE DAMAGES.

If you wish to receive documents online, please visit your secure member account at http://www.aetna.com/individuals-families/aetna-navigator.html.

Please sign here ONLY if you are enrolling in coverage for yourself and/or dependent(s).

I AM ENROLLING FOR COVERAGE:

Employee signature X

Employee email

Date (Month/Day/Year)

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

Life / AD&D Ultra Vision

STD LTD

Reason for declining coverage

Spouse group coverage

Parental group coverage

Medicare

Medi-Cal

Retiree coverage

Another group plan provided by my employer

COBRA coverage

Insurance through another job

TRICARE Military coverage

Individual coverage On Exchange

Individual coverage Off Exchange

I have no other coverage

Do not want

Other

Spouse:

Medical Dental


Child(ren):

Medical Dental


I certify I have been given 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 dependent(s).

X I AM DECLINING COVERAGE: Employee signature

Date (Month/Day/Year)

http://www.aetna.com/individuals-families/aetna-navigator.html

GR-69068-12 (4-16) 6 CA V2 E

Designation of beneficiary Carefully review Conditions and instructions for designation of beneficiary below.

The Group Policy grants the member the authority to designate a beneficiary. A beneficiary is the person or entity who will receive the benefit payment. A primary beneficiary will be the first to receive the benefit. A contingent beneficiary will only receive the benefit payment if the primary beneficiary(ies) predeceases the insured or is otherwise barred by a state law and/or a legally binding document addressing benefit payments. The employee is automatically the primary beneficiary for dependent life and accidental death and personal loss coverage (AD&D Ultra) benefits.

Beneficiary

for:

Full name(s) or entity (trust or estate)

Date of birth

Social Security number / tax ID number

Address (number, street, apt. number, city, state, ZIP code)

Phone

Relationship to

employee

% of benefit (must equal 100%)

Life

Primary

Life Contingent

SPOUSAL CONSENT FOR COMMUNITY PROPERTY STATES ONLY see Conditions and instructions for designation of beneficiary section below.

Please note that an employee is under no obligation to complete the spousal consent section on this form. I am aware that my spouse, the employee named above, has designated someone other than me to be the beneficiary of group life insurance under the above policy. I hereby consent to such designation and waive any rights I may have to the proceeds of such insurance under applicable community property laws. I understand that this consent and waiver supersedes any prior spousal consent or waiver under this plan.

Spouse signature Date

Conditions and instructions for designation of beneficiary

Conditions for designation of beneficiary

Please note: The Group Policy grants only the member the authority to designate a beneficiary. If you do not name a beneficiary, payment will be made to your survivors as described in the Group Policys beneficiary provision. You should execute the Designation of beneficiary section of this form to ensure payment is made to the person you want.

Unless otherwise expressly provided in the Designation of beneficiary section of this form, if any named primary beneficiary predeceases you, the life proceeds shall be paid equally to the remaining named primary beneficiary or beneficiaries. All primary beneficiaries must predecease you before the life proceeds will be paid to any contingent beneficiaries.

If this Designation of beneficiary provides for payment to a trustee under a trust agreement, Aetna Life Insurance Company (Aetna) shall not be obliged to know or be liable under the terms and conditions of the trust agreement. If your beneficiary is a minor at the time of your death, Aetna may require the court to appoint a guardian to receive the life proceeds for the minor.

Aetna will be fully discharged of its duties when payment is made. Aetna is not responsible for how the payment is used. If you live in one of the following community property states Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington or

Wisconsin your spouse may have a legal claim for a portion of the life insurance benefit under state law. If you name someone other than your spouse as beneficiary, payment of the death benefit may be delayed until your spouses claim is resolved.

Instructions for designation of beneficiary

If these instructions do not answer all your questions, please contact your plan sponsor for assistance.

If you make a mistake in completing this form, line out the erroneous information, add the correct information and initial the correction. The printed material on this form should not be deleted or altered in any way.

In all cases, the relationship of the beneficiary, the beneficiarys Social Security number, address and phone number should be included with the beneficiary designations.

Dollars and cents should not be specified.

If a minor child is named beneficiary, the child will not receive the benefits until age of majority.

If a trustee is named beneficiary, show the exact name of the trust, date of the trust agreement, and the name and address of the trustee. For example, The John J. Smith Revocable Life Insurance Trust, dated January 1, 1994. John Smith, Trustee, 123 Apple Lane, Hartford, CT 06006.

GR-69068-12 (4-16) 7 CA V2 E

DMHC written notice of availability of language assistance

HMO and DMO-based plans - IMPORTANT: Can you read this letter? If not, we can have somebody help you read it. You may also be able to get this letter written in your language. For free help, please call right away at 1-877-287-0117.

Planes basados en DMO y HMO - IMPORTANTE: Puede leer esta carta? En caso de no poder leerla, le brindamos nuestra ayuda. Tambin puede obtener esta carta escrita en su idioma. Para obtener ayuda gratuita, por favor llame de inmediato al 1-877-287-0117.

Traditional plans:

2008 Aetna Life Insurance Company

GR-69277 (10-16) 1 R-POD

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 are an existing Aetna member and need a qualified interpreter, written information in other formats, translation or other services, please call the number on your Aetna ID card. If you are a prospective Aetna member, please call 1-888-238-6201. If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting: 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]. You can also file 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/portal/lobby.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).

mailto:[email protected]://ocrportal.hhs.gov/ocr/portal/lobby.jsf

TTY: 711

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R

GR-69277 (10-16) 3 R-POD

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GR-69277 (10-16) 4 R-POD

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California Employee Enrollment/Change Form - 1-100 Employees ...

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Transcript of California Employee Enrollment/Change Form - 1-100 Employees ...