Regence BlueShield of Idaho Application Agreement
FEDERALLY ELIGIBLE INDIVIDUAL INFORMATION
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), guaranteed availability of individual coverage means that if you are HIPAA eligible, you cannot be denied the right to buy individual coverage. In addition, a preexisting condition exclusion cannot be applied to your coverage.
You are HIPAA eligible, also called an “eligible individual,” if ALL of the following are true at the time you apply for individual coverage in Idaho.
• You are not covered under another group health plan
• Your most recent coverage was not canceled because you did not pay your premiums or because you committed fraud
• You are not currently eligible for Medicare or Medicaid
If you are HIPAA eligible, you will lose your right to get individual coverage without an exclusion unless you submit an application for individual coverage within 63 days after the day your group coverage or continuation coverage ends. Act promptly to protect your rights.
AFFIRMATION
I affirm the answers in this “Idaho Individual Application” are complete and correct. I am providing these answers as part of the application procedure required by this insurance carrier to enroll in its insurance coverage. I understand that the insurance carrier will rely on each answer in making its determination to extend coverage and to determine the type of coverage offered. I understand if I have made any misstatement or omission in this application, the insurance carrier may take any action available by law, including but not limited to, retroactive adjustment of premiums or claims. Further, I understand that any fraud or intentional misrepresentation of material fact in my completion of this application is cause for retroactive termination of coverage by the insurance carrier and/or other action available by law. I will promptly inform the insurance carrier in writing if anything happens before my coverage takes effect that makes an answer on this application incomplete or incorrect. Following receipt of a fully-executed application, coverage will be in force as of the effective date determined by the insurance carrier under applicable law.
STATEMENT OF UNDERSTANDING
By signing this application, I represent that all my answers are complete and accurate to the best of my knowledge and belief and that I understand and agree to the following conditions:
• No independent producer, agent or employee of the insurance carrier can change any part of this application or waive the requirement that I answer all questions completely and accurately.
• The insurance carrier may terminate or rescind an insured’s coverage for any intentional misrepresentation, omission of fact by, concerning, or on behalf of any insured that was or would have been material to the insurance carrier’s acceptance of a risk, extension of coverage, provision of benefits or payment of any claim.
• If this application is approved, coverage for me and any eligible persons named on this application will begin on the effective date assigned by the insurance carrier.
• I understand that this application will become part of the contract between the insurance carrier and me.
• I affirm that I have reviewed all answers given on this application and, regardless of whether an independent producer or other person has filled out the answers for me, I verify that the answers are true and complete.
ACKNOWLEDGMENT
I acknowledge and understand my health plan may request or disclose health information about me or my dependents (persons who are eligible for benefits coverage and are listed on the application) for the purpose of facilitating health care treatment, payment or for the purpose of business operations necessary to administer health care benefits; or as required by law.
Health information requested or disclosed may be related to treatment or services performed by:
• A physician, dentist, pharmacist or other physical or behavioral health care practitioner;
• A clinic, hospital, long-term care or other medical facility;
• Any other institution providing care, treatment, consultation, pharmaceuticals or supplies or;
• An insurance carrier or group health plan.
Health information requested or disclosed may include, but is not limited to: claims records, correspondence, medical records, billing statements, diagnostic imaging reports, laboratory reports, dental records, or hospital records (including nursing records and progress notes).
This acknowledgment does not apply to obtaining information regarding psychotherapy notes. A separate authorization will be used for psychotherapy notes.
Tobacco Usage
You will state on the Idaho Individual Application whether you or a dependent over age 18 whom you are enrolling uses tobacco and has used tobacco (in any form, but excluding any religious or ceremonial use) on average four or more times per week within the last six months. A surcharge is applied to the regular periodic rate for each enrolled tobacco user.
If an enrollee becomes a tobacco user after you apply, you must notify Regence immediately and a surcharge will be added for that enrollee. If we receive false information about tobacco usage or if you fail to notify Regence of a change in tobacco usage, Regence can collect unpaid surcharges and take any other available action.
Acknowledgment
By signing the attached Individual application, you understand and agree to the terms and conditions set forth on this cover sheet as well as the terms and conditions set forth on the Application.
I certify that all statements contained herein are true to the best of my knowledge. I understand that any misrepresentation, omission, or inaccurate information required herein shall prevent recovery under the policy if such answer is fraudulent or materially affects the risk assumed by Regence. I understand this request will be underwritten to determine the extent of my eligibility, and that Regence will consider all medical information currently on file. I hereby expressly authorize any physician or hospital, or any other health care provider, to disclose to Regence any information obtained by having attended me or hereafter attending or examining me, and I understand that Regence will not disclose any information so obtained, except as permitted by law.
I acknowledge that I received an Outline of Coverage (OOC) in conjunction with this application.
Your privacy
For information about the use and disclosure of health information, including uses and disclosures required by law, please refer to the Regence Consumer Privacy Notice. A copy is available at regence.com or by calling 1-888-REGENCE.