Form Wp 266 - Blue Cross Blue Shield Change Form printable pdf download

Instructions for Completing Blue Cross Blue Shield of Michigan Individual Coverage

Change of Status

This form is intended for use by current Blue Cross members to report changes to their contract during a qualifying life event. It is not an application for coverage.

If you enrolled in your Blue Cross plan through the Health Insurance Marketplace, please contact 1‐800‐318‐2596 to report all membership changes rather than fill out this form.

Dental

Under the health care reform law, every insurance plan needs to cover ten categories of essential health benefits including pediatric dental care for children up to age 19. On

this change of status form, before any changes can be made to your current plan, you must identify whether you have already purchased a Marketplace‐certified plan with

pediatric coverage or will have purchased one with pediatric dental coverage that begins on or before the date your medical plan coverage starts.

Counties where Blue Dental

(EPO) is available: All counties except Mason and Keweenaw

Membership changes

A qualifying life event allows you to enroll in a new health care plan or make changes to your current coverage, generally within 60 days of the event. To complete your change

of status request, some events require legal or specific documentation, while others require a signature to confirm the event. Use the chart below to determine what document

you might be required to submit with your change of status form.

Event

Documentation requirement

Birth, adoption, placement of foster child or children, guardianship,

court‐ordered dependent, marriage, divorce or legal separation, death of

Complete this form to request change and confirm the membership change with a signature.

single policyholder, change in dependent status due to turning age 26 or

death of dependent

Complete this form and submit a new driver's license or a rental lease or mortgage agreement.

Move to another location within Michigan

Loss of employer‐sponsored health care coverage; loss of dependent status

due to policy holder enrolling in Medicare; loss of coverage due to death of

Any loss of coverage will require you or your dependents to apply for a new health care plan

policy holder with dependents; change in full‐time employment status

rather than submit a change of status.

resulting in a loss of coverage; COBRA coverage ending; or loss of Medicaid or

Children's Health Insurance Program (CHIP)

Coverage changes

Coverage changes after the annual open enrollment period for individual plans are only allowed with a qualifying life event (for example, marriage, birth or loss of coverage).

Health savings account options

Other changes

Address change:

An address change may result in a change in premium rates. Permanent address changes will require proof of residency (documentation requirement above).

In order for an address to be considered temporary, you must live there less than six months a year. An alternate address is for routing of mail only.

Voluntary termination:

To terminate your entire contract with us, complete and sign the change of status form. Terminations must be requested and signed by the contract holder only;

unless termination is due to death.

Note: Without a qualifying event to enroll in coverage, termination of a policy may not allow you to enroll in another plan until the next open enrollment period, which starts in

the fourth quarter of each year.

Mailing and fax instructions

Mail or fax change of status form along with the required supporting documentation to:

Blue Cross Blue Shield of Michigan

P.O. Box 44407

Detroit, MI 48244‐0407

Fax: 1‐866‐392‐7528

Premium payments sent to this address could delay access to your benefits.

WP 2665 OCT 15