Medical Plan Selection Form
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3205MPS
12/13
Medical Plan Selection Form
11/13
(To be submitted with Application Form 205INFA)
Want help with costs?
STOP! This is the wrong application for you. This application is only for Vermonters who do not get coverage through
their jobs and do not want to find out if they qualify for financial help. An individual earning up to $46,000 or a family of
four earning up to $94,200 may qualify for financial help. To see if you qualify for help, visit VermontHealthConnect.gov
or call 1-855-899-9600.
Note: Please consult Vermont Health Connect’s plan comparison brochures, the insurance companies’ Summaries of
Benefits and Coverage (SBC), and VermontHealthConnect.gov to be sure you are clear on the plan details before making
your selection. For a free copy of an SBC for one or more of the Qualified Health Plans (QHPs), please call BlueCross
BlueShield of Vermont (1-800-247-2583) or MVP (1-800-348-8515).
CONTACT PERSON
Please print the name of the adult from Step 1 of your “Application for Health Coverage.”
FIRST AND LAST NAME (PLEASE PRINT):
MARITAL STATUS:
DATE OF BIRTH (MM/DD/YYYY):
Marital status: M-Married, NM-Never Married, W-Widowed, LS-Legally Separated, SEP-Separated, D-Divorced, DP-Domestic Partner, CU-Civil Union
Step 1:
Please choose your tier by checking the circle to the left.
VT Rate Tier
VT Tier Title
Definition – Individual Medical
⃝
Tier I
Single
One person – the subscriber (may be an adult or a child)
Two persons who are married to each other or are in a civil union,
⃝
Tier II
Couple
according to the rules of Vermont
Single Head of Household
One adult subscriber and one or more dependent child(ren), up to
⃝
Tier III
(HoH) with one or more
the age of 26
children
⃝
Tier IV
Family
Couple* with one or more dependent children, up to the age of 26
* As defined in Tier II
NOTES FROM VERMONT DEPARTMENT OF FINANCIAL REGULATION (DFR):
•
Children over the age of 26 may be covered if deemed incapacitated dependents.
•
Dependent children include: biological children, adopted children, step-children, and children for whom
subscriber is legal guardian.
•
Individual market spouse and/or dependents may enroll in their own unique QHPs (e.g., dad elects BCBSVT Gold
and mom enrolls in MVP Bronze) but, if using paper application, must fill out separate applications.
205MPS
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Parent category: Medical