Hint Group Enrollment - Group Enrollment/change Request Form (Page 7 of 7) in pdf

In Section A1 and 2, the carrier may choose to put Civil Union Partner on the same line as Spouse, or insert new lines for Civil Union Partner separately.

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.

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

11. At Section B and D, references to primary, ob/gyn and dentist selections should be omitted is 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.

12. At Section B and D, reference to current patient information should be omitted if the carrier does not require it.

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

appropriate.

14. At Section D1, the carrier may elect not to reference Domestic Partner if an employer does not permit coverage of Domestic Partners.

15. At Section D1, the carrier may indicate that continuation is an option for “Spouse only” for groups subject ONLY to COBRA.

16. At Section D, requests for information about other prescription drug coverage are optional.

17. 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.

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

19. At Section [F], carriers may omit Domestic Partners if the employer does not allow coverage for domestic partners.

20. At Section [H], use the phrase “for the Over-Age Child based on his/her age-out anniversary” for defined small employer groups.

21. At Section [H], carriers may remove the option “Special May 12, 2006 through May 11, 2007 enrollment period” as of May 12, 2007.

22. At Section [L], omit “In addition, the [Employer] consents to payroll deduction for Dependent Under 30 Continuation Election:

No” if the carrier does not

Yes

offer the Integrated continuation coverage option.

23. At 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.

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

dexform\good_results\xml\nolinks\12557.xml

C:\

NJ-HINT-Group

[Internal Carrier Form Number]