group health plans - lindsey wilson college · lindsey wilson college . anthem health insurance...

FARMERS NATIONAL BANK PPO PLAN HDHP PLAN

NEW ENROLLMENT CHANGE ENROLLMENT

EMPLOYEE & FAMILY

GROUP HEALTH PLANS - EMPLOYEE APPLICATION/WAIVER

LINDSEY WILSON COLLEGE

NEW ENROLLMENT CHANGE ENROLLMENT

A. EMPLOYEE INFORMATION

LAST NAME FIRST NAME MI

PARTICIPANT SSN: - - PARTICIPANT DOB: / /

ADDRESS CITY STATE

ZIP CODE

PLAN TYPE: CORE BUY-UP

GENDER: MALE FEMALE MARITAL STATUS: MARRIED SINGLE

Effective Date:

HIRE DATE: / /

B. COVERAGE YOU ARE REQUESTING

Termination Date:

EMPLOYEE ONLY EMPLOYEE & FAMILY

IF ENROLLMENT CHANGE PROVIDE QUALIFYING EVENT:

C. FAMILY INFORMATION - ENROLLMENT SPOUSE: LAST NAME FIRST NAME MI

SPOUSE SSN: - - SPOUSE DOB: / /

GENDER: MALE FEMALE

CHILD: LAST NAME FIRST NAME MI

CHILD SSN: - - CHILD DOB: / /

GENDER: MALE FEMALE



GENDER: MALE FEMALE



GENDER: MALE FEMALE

Are you or any of

your Dependents

covered by

Medicare?

Yes

No

If yes, complete the

information on the

right

Name Reason Covered by: Dates became effective Medicare Numbers

Over 65

Disabled

End Stage Renal Disease

Part A

Part B

Part C

Part D

A. / /

B. / /

C. / /

D. / /

A.

B.

C.

D. Name Reason Covered by: Dates became effective Medicare Numbers

Over 65

Disabled

End Stage Renal Disease

Part A

Part B

Part C

Part D

A. / /

B. / /

C. / /

D. / /

A.

B.

C.

D.

Premium Payment: I authorize my employer to deduct the requested premium contribution from my earnings.

Authorization to Release Information: I hereby authorize any physician or medical practitioner, hospital, or other organization, institution or person that has any medical records or knowledge of me or my family as to diagnosis, treatment and prognosis regarding any physical, mental, drug or alcohol condition or any and all such information to be given to ARC Administrators or its authorized Administrator or legal representative (including medical review specialists). Any information obtained will not be released by the insurance company except to persons or organizations performing business or legal services in connection with my application or claim, including but not limited to pre-certification of hospital admissions, Continued Stay Review, On-Site Concurrent Review or as may be otherwise lawfully required or as I further authorize. A photocopy of this authorization shall be valid as the original and is valid for thirty (30) months from the date shown below. U.S. Resident: I understand that the coverage under this plan is available for United States Residents and benefits are not payable for medical expenses outside of the United States except while traveling.

M y Answers Are True and Correct: I have personally reviewed all of my answers to the questions on this application and represent that all of the information I have provided is

true and complete. I understand that it is my responsibility to provide truthful, complete and accurate information and I represent I have fully understood all the questions asked. W ith the exception of health related factors, I understand that my intentional material misstatements or failure to report information may be used as the basis of rescission or termination of coverage for me or my dependents, if any. I understand that under no circumstances is any agent allowed to (a) waive, alter or modify any questions; (b) permit me to inaccurately answer any questions; or (c) instruct me not to disclose any particular medical condition on the application. I understand that no agent is authorized or has authority to alter the terms of the Group Master Policy.

W AIVER OF COVERAGE. This is to certify that I have been given an opportunity to insure myself and/or my eligible dependents and I have DECLINED s uch coverage. I understand that if I am declining enrollment for myself or my dependents (including my spouse) because of other health insurance coverage, I may in the future be able to enroll myself and my dependents in this plan, provided that I request enrollment within thirty-one (31) days of my other coverage ending. In addition, if I have a new dependent as a result of marriage, birth, adoption, party in a suit in which the adoption of child by me is sought or placement for adoption, I may be able to enroll myself and my dependents, provided that I request enrollment within thirty-one (31) days after the marriage, birth, adoption, party in a suit in which the adoption of child by me is sought or placement for adoption. If I choose to enroll myself or my dependents, at a later date, for a reason other than the special reasons stated herein, I understand that I and/or my dependents may not enroll until my employer’s next enrollment period. I understand that I and/or my dependents will be subject to a twelve (12) month pre-existing conditions limitations period which may be proportionately reduced by my furnishing certification or creditable coverage for myself and/or dependents.

Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false

or deceptive statement is subject to civil and criminal penalties.

D. SIGNATURE

Signature of Employee and Parent if Applicant is under the age eighteen (18) years Date_

Signature of Employee and Parent if Applicant is under the age eighteen (18) years Date

Email Address Phone Number

LINDSEY WILSON COLLEGE ANTHEM HEALTH INSURANCE ELECTION FORM

FOR PLAN YEAR 2018

I hereby elect the following plan for the 2018 plan year.

Single Core Plan - $45.91 Single Buy-up Plan - $105.61 Family Core Plan - $780.53 Family Buy-Up Plan - $935.76 Dual Employee Family Core Plan - $367.30 Dual Employee Family Buy-Up Plan - $522.53 I waive participation in the 2018 health insurance plan year. Print Name Signature Date

COORDINATION OF BENEFITS QUESTIONNAIRE

TURN OVER AND FINISH COMPLETING

Name:______________________________ Address:___________________________ City, State, Zip:______________________ Member ID:__________________________

ARC Administrators coordinates benefits with other payers when a member is covered by two or more group benefit plans.

THIS FORM IS REQUIRED TO BE COMPLETED ANNUALLY. In order to coordinate benefits accurately we request the following information be completed and returned to us within 10 days upon receipt of this letter. If you prefer to provide the information over the phone, you may call us at 800- 250-5735.

In addition to this medical coverage, are you or any of your covered dependents covered by another health plan?

□ NO- Please skip the rest of the questions, sign, date on the back and return.

□ YES- Please complete the entire form, sign, date on the back and return.

Other Carrier Name Other Carrier Address Other Carrier Phone Number

Policy Holder Name Policy Holder Date of Birth

Relation to You Policy Holder Employer

Subscriber ID Group Number Effective Date Termination Date

Type of Coverage

□ Single

□ Family

Is this a retiree policy? Yes No

Is this a COBRA policy? Yes No

Is this a Medicaid policy? Yes No

Type of Plan: Medical Dental Vision RX

Please list all dependents on this policy Name (first and last) Relationship to You Name (first and last) Relationship to You

1. ___________________ _________________ 3. ____________________ ____________________

2. ___________________ _________________ 4. ____________________ _____________________

Is this additional coverage court ordered No Yes (If yes, attach a copy of the Divorce Decree) Name and relationship of the person who has primary custody________________________________________________

If this additional coverage is Medicare, please indicate why you have Medicare Age Disability ESRD Please attach a copy of your card

Medicare Question Employee Policy Holder Name Effective Part A Effective Part B Effective Part D Medicare ID(HICN)

Are you Retired? Yes No Date of Retirement

If your Medicare benefits terminated, what part, and termination date

If you have Medicare due to ESRD, please answer the following questions

Date Dialysis began Where did you receive treatment Home Outpatient / Dialysis Center

If at home when did training begin?

Date of Transplant Was the Transplant successful Yes No If No, was a second Transplant done Yes No Was second Transplant successful Yes No

Did you resume dialysis after your transplant, and if so when?

Medicare Question Dependent Policy Holder Name Effective Part A Effective Part B Effective Part D Medicare ID(HICN)

Are you Retired? Yes No Date of Retirement

If your Medicare benefits terminated, what part, and termination date

If you have Medicare due to ESRD, please answer the following questions

Date Dialysis began Where did you receive treatment Home Outpatient / Dialysis Center

If at home when did training begin?

Date of Transplant Was the Transplant successful Yes No If No, was a second Transplant done Yes No Was second Transplant successful Yes No

Did you resume dialysis after your transplant, and if so when?

Medicare Advantage Question

It is very important that you disclose if you, your spouse or any dependents are covered by a Medicare Advantage Plan because enrollment in this health plan can cause you to be dis-enrolled from the Medicare Advantage Plan (often provided by the spouses’ employer as part of their retirement benefits).

A Medicare Advantage Plan is a health insurance program that serves as a substitute for “Original Medicare” Parts A and B Medicare Benefits. These traditional Medicare benefits are provided by a commercial insurance company (like Humana, Anthem, Cigna, and others) but include benefits for prescription drugs, and often include office copay and other benefits common to an insurance plan – benefits that are not typically provided by Medicare Parts A & B. Medicare Advantage plan can include prescription drug coverage as part of the plan and is subsidized by CMS (Center for Medicare Services).

Is anyone covered under your police covered by a Medicare Advantage Plan? No Yes (complete the section below)

Policy Holder Name Effective Date Medicare Advantage ID # as displayed on ID Card

Policy Holder Name Effective Date Medicare Advantage ID # as displayed on ID Card

Employee Signature: _____________________________ Date: ____________________

Return completed form to: ARC Administrators, P.O Box 12290, Lexington, KY 40582

Fax: 859-243-0381

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Life Insurance Beneficiary Designation FormTHE EMPLOYER MUST KEEP THIS FORM ON FILE.

Name of employer/group (if applicable) Policy/certification no.

Name of insured Social security no.

Name of policyowner (if different) Social security no.

If you reside in a state with Marital or Community Property Laws, spousal consent is required if your spouse is not listed as a Primary Beneficiary for at least 50%.

PRIMARY BENEFICIARY(IES): Person or persons who will receive the life insurance proceeds upon your death.

Name Date of birth Social security no.

Address Relationship to insured % to be paid to beneficiary





Total percentages should add up to 100%. If no percentages are indicated, the proceeds will be divided equally. If no Primary beneficiary survives, proceeds will be paid to the Contingent beneficiary(ies) listed below. Space is provided at the bottom of the page if you wish to name additional Primary or Contingent beneficiaries.

CONTINGENT BENEFICIARY(IES): Person or persons who will receive the life insurance proceeds if there is no surviving primary beneficiary.







Si usted necesita ayuda en Español para entender este documento, puede solicitarlo sin ningun costo adicional llamando al número de servicio al cliente que se encuentra en este documento.

Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.14469ANEENLBS 6/10

Signature of insured or policyowner (2 officers’ signatures, with title, are required if corporate owned) Date signed (MM/DD/YYYY)

XSignature of spouse (if not designated as primary beneficiary and residence is in community property state) Date signed (MM/DD/YYYY)

X

Life Insurance Beneficiary Designation FormTHE EMPLOYER MUST KEEP THIS FORM ON FILE.

THE EMPLOYER MUST KEEP THIS FORM ON FILE.

Page 2 of 2

BENEFICIARY DESIGNATIONS

DEFINITIONS:The purpose of designating beneficiaries for this policy is to instruct Anthem Life Insurance Company (Anthem Life) exactly how you wish the proceeds of your policy/certificate to be paid upon your death. Therefore, please take a moment to read the examples below:

PRIMARY BENEFICIARY:Person or persons to receive the Life Insurance proceeds upon the death of the Insured. If multiple Primary Beneficiaries are listed, death benefits are divided equally among all the living Primary Beneficiaries, unless otherwise stated.

CONTINGENT BENEFICIARY:Person or persons to receive the Life Insurance proceeds when the Primary Beneficiary(ies) dies before the Insured. If multiple Contingent Beneficiaries are listed, death benefits are divided equally among all the living Contingent Beneficiaries, unless otherwise stated.

EXAMPLES OF CORRECT BENEFICIARY DESIGNATIONS:Joe and Jane Smith — Father and Mother George Jones — Friend William E. Brown — Spouse Donald C. White, Jane E. Smith, and Richard E. Beck — Children

If you choose the estate or a trust as beneficiary, see the following example beneficiary designation: Insured’s Estate: John Q. Smith –- trustee under the Mary R. Smith Trust dated 01/02/2006.

Full given names of each beneficiary must be clearly stated.

NOTE: INSUREDS OF GROUP INSURANCE MAY NOT DESIGNATE THEIR EMPLOYER AS BENEFICIARY. Employees should make a copy to keep for their personal record. Employers need to keep original on file. For All Voluntary benefits, a legible copy must be sent to Anthem Life.

ADDITIONAL BENEFICIARY(IES)

PRIMARY







CONTINGENT





Life Insurance Beneficiary Designation Form - continued

of 2

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI)

I hereby authorize ARC Administrators, it agents, subsidiaries, and affiliates, to disclose my medical, claim or benefit records, including my Protected Health Information (PHI) as indicated below to the persons or entities specified on this form.

All sections must be completed for this authorization to be valid.

1. Verification

Identification of Member: (This is the member whose information will be released.)

Name of Member whose information will be disclosed:____________________________________________

Date of Birth:___________________________________________________________________________

Member Address:________________________________________________________________________

Phone number where this member can be reached if we need to contact you:_________________________

2. Description of Information to be Released

Unless specifically indicated differently on the line provided below, I hereby authorize the full release of all

Claims, Eligibility and Benefit Information, Medical Records, and Care Coordination Information. I

acknowledge this information may be viewed through the online claim system as well as discussed over the

phone. I understand that these records may contain information created by other persons or entities, including

health care providers. I further understand these records may contain information diagnosis and or treatment

information for Alcoholism, Drug abuse or dependency, Mental Illness, HIV and or Aids. In addition, Genetic

testing information maybe contained within. If you want to specifically limit or restrict the information, dates,

or manner in which the information this authorization covers may be disclosed please indicate the limitations on

the following line.

Limitations on authorization:_______________________________________________________________

3. Person or Entity Authorized to Receive Information

Name of the person or entity you are giving permission for ARC Administrators to release your Protected

Health Information (PHI) to.

Name:__________________________________________________________________________________

4. Expiration of Authorization

I understand that I may revoke this authorization at any time by notifying ARC Administrators in writing:

of 2

ARC Administrators

PO Box 12290

Lexington, KY 40582

This authorization expires when I am no longer a plan participant, unless otherwise specified on the line below.

This authorization expires:_________________________________.

Please note:

• Information disclosed based on this authorization may be subject to redisclosure by the recipient and

may no longer be protected by federal privacy regulations.

• If the information on this form is not complete, ARC Administrators will return the form to you, and this

request will not be considered until ARC Administrators receives complete information.

• Coverage, treatment, payment, enrollment, and eligibility under the plan(s) for benefits does not depend

on whether you sign this authorization, any authorization is completely voluntary.

5. Signature of Member Authorizing the release of his/her Information

I have read and understand the information contained on this form and by signature am hereby expressly

authorizing ARC Administrators to release my information as described above.

Signature:______________________________________________ Date:____________________

Please return this completed form to:

Mail to:

ARC Administrators P.O. Box 12290 Lexington, KY 40582

Fax to:

(859) 243-0381

LINDSEY WILSON COLLEGE HEALTH BENEFIT PLAN 210 Lindsey Wilson Street, Columbia, KY 42728

270-384-7313

Employment Verification form for Spouse

**Any Spouse who is eligible for coverage through his/her own employer

is not eligible for coverage from Lindsey Wilson College’s health benefit plan.**

SECTION 1: This section to be completed by the participant (employee)

Participant (employee) name: _____________________________ Participant Social Security number: XXX-XX-_______

SECTION 2: This section to be completed and signed by the spouse

Spouse name: ______________________________________ Spouse signature: _____________________________

□ I am not employed at this time and if I become employed, I will complete a new “Employment verification form” to

terminate coverage for myself as of the date that coverage is available to me through my employer.

□ I am employed at this time and authorize my employer to complete the information on this form.

SECTION 3: This section to be completed by the spouse’s employer

Dear Employer:

Effective January 1, 2014, the Lindsey Wilson College Health Benefit Plan requires spouses to verify whether or not a spouse is

eligible for coverage from the plan. For verification purposes, the employer must complete this “Employment Verification form”

and return the completed form to the Lindsey Wilson College HR Office.

Please verify the following information:

□ We do not offer medical insurance.

□ We offer medical insurance but this employee is not eligible to enroll because: ____________________________.

□ We offer medical insurance, and this employee is eligible to enroll ___/___/______ in:

□ Medical (date)

□ Dental

□ Vision

□ We offer medical insurance, and this employee is enrolled effective ___/___/______ in:

□ Medical (date)

□ Dental

□ Vision

□ We offer medical insurance however, this employee has chosen not to enroll effective ___/___/______ in:

□ Medical (date)

□ Dental

□ Vision

Company Name: _________________________________________________________________

Company Benefits Representative: ________________________________ _____________________________________

Name Signature

________________________________ _____________________________________

Telephone Date

Please return this form to:

Lindsey Wilson College HR Office

210 Lindsey Wilson Street

Columbia, KY 42728

Or fax: 270-384-7373 Or Email: [email protected]

LINDSEY WILSON COLLEGE EMPLOYEE HEALTH PLAN

AUTHORIZATION TO VIEW DEPENDENT CLAIMS ONLINE

As a convenience to our participants ARC Administrators has established an online website

where participants of the Lindsey Wilson College Employee Benefit Plan will be able to log in

and view their individual health claims. In addition to the individual participant’s health claims,

upon written consent of the participant’s dependents, the participant will be able to view their

dependents health claims as well. This authorization only has to be completed and returned to

ARC Administrators if the participant wants to be able to view their dependents claims in the

online system.

Section 1: This section to be completed by the participant (employee))

Participant (employee) Name:__________________________________________

Participant Member ID #:_____________________________________________

Participant Signature:________________________________________________

Section 2: This section to be completed and signed by the spouse

By signing this authorization form I hereby give my spouse permission to view my health claims

in the online system.

Spouse Name: ______________________________________________________

Spouse Signature:___________________________________________________

Section 3: This section to be completed and signed by any other covered dependent over the age

of 18

By signing this authorization form I hereby give participant permission to view my health claims

in the online system.

Dependent Name:__________________________________________________

Dependent Signature:_______________________________________________

Dependent Name:__________________________________________________


Dependent Name:__________________________________________________


Completed Authorizations can be returned to ARC Administrators by the following methods:

Mail to: ARC Administrators

P.O. Box 12290

Lexington, KY 40582

Fax to:

859-243-0381 Attn: Eligibility Department

Email to:

[email protected]

Access to view participant’s dependents health claims will not be granted without this completed

authorization. If you have questions please contact us at 1-877-309-2955.

mailto:[email protected]

group health plans - lindsey wilson college · lindsey wilson college . anthem health insurance...

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