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BlueCross BlueShield of Western New YorkIndividual and Family Enrollment Application

Open EnrollmentDuring the annual Open Enrollment period, which runs from November 1, 2015 through January 31, 2016, you may apply for coverage, or members can change plans.· If BlueCross BlueShield receives the enrollment application on or before December 15, 2015, coverage

will begin on January 1, 2016, as long as the applicable premium payment is received by then.

· If BlueCross BlueShield receives the enrollment application between the dates of December 16, 2015 through January 15, 2016, coverage will begin February 1, 2016, as long as the applicable premium payment is received by then.

· If BlueCross BlueShield receives the enrollment application between the dates of January 16, 2016 through January 31, 2016, coverage will begin March 1, 2016, as long as the applicable premium payment is received by then.

If you do not enroll during open enrollment, or during a special enrollment period, you must wait until the next annual open enrollment period to enroll.

Outside of the annual open enrollment period, You, Your Spouse, or Child can enroll for coverage within 60 days prior to or after the occurrence of one of the following events below:1. You, Your Spouse or Child involuntarily loses minimum essential coverage including COBRA or state

continuation coverage (ex; loss of coverage from employer, aging off parents’ insurance policy, etc.);

2. You, Your Spouse or Child are determined newly eligible for advance payments of the premium tax credit because the coverage You are enrolled in will no longer be employer-sponsored minimum essential coverage, including as a result of Your employer discontinuing or changing available coverage within the next 60 days, provided that You are allowed to terminate existing coverage; or

3. You, Your Spouse or Child loses eligibility for Medicaid coverage, including Medicaid coverage for pregnancy-related services and Medicaid coverage for the medically needy, but not including other Medicaid programs that do not provide coverage for primary and specialty care.

Please provide the date of the qualifying event:

Outside of the annual open enrollment period, You, Your Spouse, or Child can enroll for coverage within60 days after the occurrence of one of the following events:1. You, Your Spouse or Child’s enrollment or non-enrollment in another health plan was unintentional,

inadvertent or erroneous and was the result of the error, misrepresentation, or inaction of an officer,employee, or agent of a health plan or the NYSOH;

2. You, Your Spouse or Child adequately demonstrate to Us that another health plan in which You wereenrolled substantially violated a material provision of its contract;

3. You, Your Spouse or Child move and become eligible for new health plans;

4. You gain a Dependent or become a Dependent through marriage, birth, adoption or placement foradoption or foster care, however, foster Children are not covered under this contract;

5. You, Your Spouse or Child are determined newly eligible or newly ineligible for advance payments ofthe premium tax credit or have a change in eligibility for cost-sharing reductions.

Please provide the date of the qualifying event:

BCBS104_062014

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PO Box 80, Buffalo, NY 14240-0080 Individual and Family Application/Change Form

1—Instructions for Individual and Family Enrollment Application Form

Thank you for your interest in becoming a member of BlueCross BlueShield of Western New York. In order to process yourmembership, we need you to supply the information requested on this form.· Using blue or black ink, please complete each section, leaving no blanks· Please return the application with a check for the first full month’s premium in the return envelope provided (check or money

order ONLY; no cash please) so we can process your application.· In the Plan Section, plans identified with ’#’ are available as child only coverage· If you need assistance completing the application, please call 1-800-888-5407. Monday — Friday, 8 am to 8 pm· Please return the completed application to:

BlueCross BlueShield of Western New YorkPO Box 80

Buffalo, NY 14240-0080

2—Plan Section

Please use blue or black ink, print one character per box. Check applicable plan(s).

Bronze Value Silver Ind align Silver Standard # Gold POS 7100 Platinum Ind align

Bronze POS 8100EX Silver POS 7100 Gold Ind align Gold Standard # Platinum Standard #

Bronze Standard # Silver POS 8100EX Gold Aqua Platinum POS 110EX

Blue Pediatric Dental & Blue Value Dental 1& Blue Value Dental 2 &

Please Note: All plans require selection of a Primary Care Physician (PCP). To find a PCP, sign into bcbswny.com/FindaDoctor.

Plan Section Key: # available as child only coverage & Meets pediatric dental essential health benefit requirement

Payment Selection (check one): Monthly Quarterly

3—Reason for Enrollment/Change

Applicant, please indicate the reason for this enrollment or change.

New Coverage Change policy coverage Primary Care Physician Remove Dependent Loss of Coverage

Open Enrollment Address/Phone Number Last Name Add dependent(s) to current coverage

Add Dependent Please indicate reason for adding dependent: Newborn Marriage Loss of Coverage

4—Applicant Information Adoption Domestic Partner Change inStudent Status

Please complete ALL sides of this application. The applicant’s signature is required in order to process the application.

Applicant’s Last Name Applicant’s First Name M.I.

Social Security Number Dateof Birth (MMDDYY) Telephone Number (include area code) Gender: Female

- - - - Male

Mailing Address Apt Suite Marital Status Single

Married Divorced

City State Zip Code Legally Separated

Widowed

E-mail Address Marital Status Event Date (MMDDYY)

Medicare Eligible Please indicate reason for Medicare eligibility: Age 65+ Disability End Stage Renal Disease

Medicare Number (if applicable) Part A EffectiveDate (MMDDYY) Part B EffectiveDate (MMDDYY) Part DEffectiveDate (MMDDYY)

BCBS104_062014A division of HealthNow New York Inc. An independent licensee of the BlueCross BlueShield Association.

4—Applicant Information continued

Primary Care Physician’s Last Name Primary Care Physician’s First Name

Primary Care Physician Number: To find a PCP, sign into bcbswny.com/FindaDoctor.

Are you a current patient, or if not a current patient, have you verified that the PCP will accept you as a new patient? Yes No

A. Have you obtained stand-alone dental coverage that provides a pediatric dental essential health benefit through a NewYork State of Health, the Official Health Plan Marketplace (NYSOH)-certified stand-alone dental plan offered outside theNYSOH?

B. If you answered "yes", please provide the name of the company issuing the stand-alone dental coverage.

Yes No

If you answered "no", we will provide coverage of the pediatric dental essential health benefit. Additional premium will apply.

5—Dependent Information Please provide all information for each person to be covered.

Spouse/Domestic Partner’s Last Name Spouse/Domestic Partner’s First Name M.I.

Social Security Number Dateof Birth (MMDDYY) Gender: Female Male

- - Are you enrolling as a Domestic Partner? Yes No

E-mail Address






Dependent’s Last Name Dependent’s First Name M.I.


- - Is your over-age dependent handicapped? Yes No

E-mail Address








Yes No


5—Dependent Information continued

Please provide all information for each person to be covered.

Applicant’s Last Name Applicant’s First Name M.I.

Social Security Number Dateof Birth (MMDDYY)

- -




E-mail Address








Yes No





E-mail Address








Yes No


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5—Dependent Information continued

Please provide all information for each person to be covered.




E-mail Address








Yes No


6—Agent/Broker Certification

To be completed by your BlueCross BlueShield of Western New York appointed agent/broker:

Did you see the proposed applicant and spouse/domestic partner, if applying at the time this application was executed? Yes No

If NO, please explain:

I certify to the best of my knowledge and belief, the responses herein are accurate.

Agent/Broker Signature

XDate

Agent/Broker Name (please print) Agent/Broker Street Address/Suite No./Personal Mail Box (PMB) No.

Agent/Broker ID/TIN Agency ID/Parent TIN City State Zip

Agent/Broker Phone Number Agent/Broker Fax No. Agent/Broker Email Address

Important NoticeI AUTHORIZE ANY LICENSED DOCTOR, HOSPITAL OR OTHER HEALTH CARE PROVIDER TO PROVIDE MY PLAN WITH ANY INFORMATIONOR DOCUMENTS REQUESTED CONCERNING MEDICAL SERVICES I OR MEMBERS OF MY FAMILY HAVE RECEIVED, WHICH THE PLANDETERMINES IS NECESSARY FOR THE OPERATION AND REGULATION OF THE PLAN. THIS INFORMATION WILL BE KEPT CONFIDENTIALAND IS VALID FOR UP TO 24 MONTHS.* ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONFILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSEINFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIALTHERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO CIVILPENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCHVIOLATION.

XSignature of Applicant Date

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