Nongroup Enrollment/change Request Form (Page 7 of 7) in pdf

MISREPRESENTATIONS

Any person who includes any false or misleading information on a Nongroup Enrollment/Change Request Form for a health benefits plan is subject to criminal and civil penalties.

Carrier instructions

(not to be included in the Nongroup Enrollment/Change Request form when printed by the carrier)

Carrier should insert its logo and name where indicated, or leave the table blank, or blacked-out.

Carrier must replace bracketed text “carrier name” with carrier’s full name throughout the document.

Replace “on back” with appropriate directions if the instructions are not provided on the reverse side.

If the carrier refers to the “Enrollee/Subscriber” using another term such as “Member” or “Applicant” or some similar term, replace the term “Enrollee/Subscriber” with

such other term throughout the document.

In Section A, carrier may choose to put Civil Union Partner on the same line as Spouse, or on a separate line.

In Section A, omit “Add/Change Office ID Numbers” options if carrier does not offer such options.

In Section A, the continuation billing options should be omitted if the carrier does not offer such options. In addition, the phrase “***Billing through the group for a

Dependent Under 30 Continuation Election requires agreement by the employer at Section [L]” if the carrier does not offer the Integrated continuation coverage option.

In Section B, references to the e-mail address should be omitted if the contact option is not offered.

At Section B and D, references to primary, ob/gyn and dentist selections, with LOC and NPI numbers should not be included if selections are not an option or a

requirement. If a carrier does not assign numbers for each office location, then carriers may indicate that LOC refers to the office location in the selection information,

and request that enrollees identify a name for the office location. However, carriers should not request complete office address locations.

10. At Section B and D, omit reference to current patient status, if the carrier does not require the information.

11. At section B and D, omit the request for the Certificate of Creditable Coverage to be submitted with the application if the carrier does not require it.

12. At Section C, insert carrier plan options and deductibles, coinsurance or copayment options, and provide directions for employee/enrollee selections of options as

appropriate. Listed options must be consistent with the requirements of N.J.A.C. 11:20-3.

13. At Section D, if the carrier does not require proof of full-time student status provided with the enrollment form and/or proof of disability, omit the directions to attach

proof.

14. If Section [E] is omitted, renumber Sections F through L accordingly.

15. At Section I, omit those payment options or modes that are unavailable (but note: carriers must permit payment on a monthly basis).

16. At Section [K], omit reference to agents if the carrier does not use them in the sale of individual policies. The text may be modified to include the specific broker/general

agent information the carrier requires. The scope of the information included is limited to information concerning the broker/general agent or agent.

17. In the Instructions, if carrier uses a term other than “Member Services,” the carrier should insert that term, and must include the appropriate contact phone number.

18. In the Instructions, carrier must insert the procedure to be followed to allow the applicant to secure coverage before the actual ID card is issued.

19. It Instructions, if you require selection of health care providers, insert appropriate information on how the to obtain correct NPI numbers. Note that indicating information

is available only through a website is not appropriate.

20. At the Footnote, if a carrier does not utilize an “Internal Carrier Form Number,” the carrier may omit the reference.

C:\dexform\good_results\xml\nolinks\43870.xml

NJ-HINT-Individual

[Internal Carrier Form Number]