Fillable Blueadvantage Entrepreneur/blueprint (2-150) Producer/employer New Business Checklist printable pdf download

BlueAdvantage Entrepreneur/BluePrint (2-150) Producer/Employer New Business Checklist

We want to help ensure that your group enrollments are processed as quickly as possible. The checklist below will help start

the process out right. If you have any questions or require additional forms, please contact your General Agent or Blue Cross

and Blue Shield of Illinois (BCBSIL) sales executive. For your immediate convenience, we have enclosed the following

materials in your BlueAdvantage Entrepreneur/BluePrint producer/employer kit: a 2-150 Benefit Program Application

(BPA,) a 2-150 Benefit Plan Selection Form (BPS,) an Employer Group Information Form, Employee Application/Medical

Questionnaire/Waiver of Coverage forms (Enrollment Applications,) an Annual Medicare Secondary Payer (MSP) Employer

Acknowledgement Form and Instructions, an “Information Regarding the Medicare as Secondary Payer Statute” brochure,

HCSC/FDL Disclosure forms and HIPAA Notice of Privacy Practices forms.

NOTE: If a section in any document does not apply, “N/A” should be indicated.

2-150 Benefit Program Application (BPA)

⇒ Combined BPA applies to medical, dental and life/AD&D/short term disability coverage.

⇒ Fill out all sections.

⇒ The signed BPA will be returned to the employer group with the group policy after enrollment.

⇒ The Proxy must be filled out and signed. DO NOT DETACH from the BPA.

⇒ Please note: Enrollment could be delayed if the “Eligibility Date” section is not completed properly.

2-150 Benefit Plan Selection Form (BPS)

⇒ Combined BPS applies to medical, dental and life/AD&D/short term disability coverage.

Employer Group Information Form

Employee Application/Medical Questionnaire/Waiver of Coverage

This employee enrollment application is used to enroll in medical, dental and life/AD&D/short term disability products. If

the employee is waiving any coverage being offered, the Waiver of Coverage form should be completed and signed. Spousal

and/or other coverage information is required including the policy number and carrier name for other coverage.

If FDL is paid in full by the employer, the employee cannot waive this coverage.

⇒ The medical questionnaire should be completed, signed and dated by each employee (and spouse, if applicable)

for groups with 2-50 enrollees.

⇒ Please note: Enrollment could be delayed if the “Date of Employment”, “Family Coverage Information” (when

applicable) and “Medical Group/IPA Name and #” (for HMO) sections of the Application and the “Personal

Data/Health Questions” sections of the Medical Questionnaire (when applicable) are not completed properly.

Please have employees pay close attention to these sections.

Annual Medicare Secondary Payer (MSP) Employer Acknowledgement Form

Instructions – Completing the MSP Employer Acknowledgement Form

Information Regarding the Medicare as Secondary Payer Statute

The Annual Medicare Secondary Payer (MSP) Employer Acknowledgement Form collects employer size information

required to make MSP order of payment determination. The client must complete and return this form to BCBSIL within 90

days of the coverage effective date. If this information is not provided, the Centers for Medicare & Medicaid (CMS)

regulations require that the client’s group health plan coverage be considered primary to Medicare. “Instructions –

Completing the MSP Employer Acknowledgement Form” provides guidance in completing the Employer Acknowledgement

Form. “Information Regarding the Medicare as Secondary Payer Statute” provides general information about the MSP

statute, employer obligations and the MSP data match process.

Blueadvantage Entrepreneur/blueprint (2-150) Producer/employer New Business Checklist