Special Enrollment Period. The annual Open Enrollment period for new coverage is October 15 through January 15. These dates are subject to change pursuant to changes in the law. You may change your benefit plan, sign up for health care coverage or add eligible dependents during the Open Enrollment period. Outside of this Open Enrollment period, you can only sign up for health care, change your coverage or add eligible dependents if you have experienced a qualifying life event. You must enroll within 60 days of the qualifying event in order to be eligible for a Special Enrollment Period. If 60 days pass and you do not sign up for health coverage, you will have to wait until the next open enrollment period. WHA reserves the right to ask for verification of the qualifying event. I attest that I am or my dependents are eligible to enroll under a Special Enrollment Period due to the following qualifying event: Marriage or Divorce Birth or Adoption Death Loss of Minimum Essential Coverage Under an Employer Sponsored Plan: Termination of Employment Change in Employment Status Exhaustion of COBRA Continuation Coverage Returning from United States Active Duty or California National Guard Under Title 32 of the United States Code Dependent child’s loss of dependent status such as reaching age 26 Permanent Relocation to the WHA Service Area Provider Network Changes Court Ordered Coverage for Your Spouse or Minor Child Immigration Status Change Released From Incarceration Other Note: Qualifying Events are established by state and federal law. WHA will enroll applicants consistent with the law, and this list will be deemed amended following any change to relevant laws. CONDITIONS OF ACCEPTANCE Please read the following information and sign in the space(s) provided on the following page. Please read this section carefully. This section contains important information, including the reasons WHA may terminate or rescind coverage. You must fully answer each question in this application even though you may already be a WHA member. Be sure to complete the Application/Agreement accurately. If you are unsure about the answer to any question, take the time to make sure the information is accurate before submitting your Application/Agreement. By signing this Application/Agreement, you represent that all responses are true, complete, and accurate to the best of your knowledge, and that if WHA accepts your application for coverage, the Application/Agreement, together with the Combined Evidence of Coverage and Disclosure Form (EOC/DF), will constitute the plan contract between you and WHA. If WHA accepts the Applicant or Dependent(s) for coverage, coverage will begin on the first of the month following acceptance, or the first of the following month, based on your selection under “Effective Date” in this Application/Agreement. Your Application/Agreement is effective through December 31. If you comply with all the terms of this Application/Agreement and the EOC/DF, WHA will automatically renew this Application/Agreement each year on January 1. Terms of the Application/Agreement and the EOC/DF will remain the same when we renew it unless WHA has amended the documents as described under “Amendment of Agreement” in the EOC/DF. Upon acceptance, you will be provided with an EOC/DF. By accepting benefits under a WHA Individual/Family Plan, you agree to be bound by the Application/Agreement and by the EOC/DF. The EOC/DF for the Individual Advantage Plans is available upon request from WHA or your broker prior to enrollment. WHA may adopt reasonable policies, procedures, and interpretations to promote orderly and efficient administration of this agreement. You may not assign this agreement or any of the rights, interests, claims for money due, benefits, or obligations hereunder without WHA’s prior written consent. In any dispute between you and WHA, a medical group or any participating provider, each party will bear its own attorneys’ fees and other expenses. WHA’s failure to enforce any provision of this Application/ Agreement, or of the EOC/DF, will not constitute a waiver of that or any other provision, or impair WHA’s right thereafter to require your strict performance of any provision. If covered by a WHA Individual/Family Plan, in the event you suffer injury, illness or death due to the act or omission of a third party, WHA will furnish Covered Services. In the event any recovery is obtained on your behalf, you or your representative must reimburse WHA for the value of Covered Services as set forth in the EOC/DF. By executing this Application/Agreement, you grant on your behalf and on Applicant’s behalf, a lien on any such recovery and agree to cooperate with WHA when there is any possibility that a recovery may be received. The Applicant and dependents must live within WHA’s Service Area. You may contact your broker or WHA to determine whether the Applicant lives within WHA’s Service Area, or you may view the Service Area Map on WHA’s website. When the Applicant is enrolled for coverage and at any time no longer lives within the Service Area, the Applicant is no longer eligible for coverage. When the Dependent is enrolled for coverage and at any time no longer lives within the Service Area, the Dependent is no longer eligible for coverage. Living outside the Service Area is a material fact that must be reported to WHA. If WHA accepts your application for coverage, that coverage may be terminated for fraud or intentional misrepresentation of a material fact, including but not limited to fraud or material misrepresentation or omission in providing or failing to provide material information to WHA, the use of the services of the plan, or for knowingly permitting such fraud or material misrepresentation or omission by another. Such termination shall be effective upon the mailing of written notice by WHA to you. WHA may terminate an individual’s coverage only if allowed (or not disallowed) by federal and state laws and regulations. Before making any decision to rescind, WHA would notify you in writing of the grounds for rescission. WHA’s notice will tell you why your application is believed to be inaccurate or incomplete and will invite you to provide WHA with additional information. If, after considering your response, WHA decides to rescind, WHA will send written notice to you at least 30 days before the date we rescind your coverage, explaining the basis for the decision and how you can appeal it. All faxed and mailed correspondence must be signed and dated by the affected individual or someone legally authorized to act on his or her behalf. You must complete any applications, forms, or statements requested in WHA’s normal course of business or as specified in this Application/Agreement. WHA’s notices to you will be sent to the most recent address WHA has for you. You are responsible for notifying WHA of any change in address. Regardless of when you notify WHA that the Applicant moved, the Applicant will no longer be eligible for coverage if he or she moves out of the service area. Except as preempted by federal law, this Application/Agreement and the EOC/DF will be governed in accord with California law and any provision that is required to be in these documents by state or federal law shall bind you and WHA, whether or not set forth in these documents. You or your authorized representative may request a copy of your completed application by calling 916.563.2250.
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Samples: www.quotit.net, www.westernhealth.com, www.quotit.net
Special Enrollment Period. The annual Open Enrollment period for new coverage is October 15 through January 15. These dates are subject to change pursuant to changes in the law. You may change your benefit plan, sign up for health care coverage or add eligible dependents during the Open Enrollment period. Outside of this Open Enrollment period, you can only sign up for health care, change your coverage or add eligible dependents if you have experienced a qualifying life event. You must enroll within 60 days of the qualifying event in order to be eligible for a Special Enrollment Period. If 60 days pass and you do not sign up for health coverage, you will have to wait until the next open enrollment period. WHA reserves the right to ask for verification of the qualifying event. I attest that I am or my dependents are eligible to enroll under a Special Enrollment Period due to the following qualifying event: 🔾 Marriage or Divorce 🔾 Birth or Adoption 🔾 Death 🔾 Loss of Minimum Essential Coverage Under an Employer Sponsored Plan: 🔾 Termination of Employment 🔾 Change in Employment Status 🔾 Exhaustion of COBRA Continuation Coverage 🔾 Returning from United States Active Duty or California National Guard Under Title 32 of the United States Code 🔾 Dependent child’s loss of dependent status such as reaching age 26 🔾 Permanent Relocation to the WHA Service Area 🔾 Provider Network Changes 🔾 Court Ordered Coverage for Your Spouse or Minor Child 🔾 Immigration Status Change 🔾 Released From Incarceration 🔾 Other Note: Qualifying Events are established by state and federal law. WHA will enroll applicants consistent with the law, and this list will be deemed amended following any change to relevant laws. CONDITIONS OF ACCEPTANCE Please read the following information and sign in the space(s) provided on the following page. Please read this section carefully. This section contains important information, including the reasons WHA may terminate or rescind coverage. You must fully answer each question in this application even though you may already be a WHA member. Be sure to complete the Application/Agreement accurately. If you are unsure about the answer to any question, take the time to make sure the information is accurate before submitting your Application/Agreement. By signing this Application/Agreement, you represent that all responses are true, complete, and accurate to the best of your knowledge, and that if WHA accepts your application for coverage, the Application/Agreement, together with the Combined Evidence of Coverage and Disclosure Form (EOC/DF), will constitute the plan contract between you and WHA. If WHA accepts the Applicant or Dependent(s) for coverage, coverage will begin on the first of the month following acceptance, or the first of the following month, based on your selection under “Effective Date” in this Application/Agreement. Your Application/Agreement is effective through December 31. If you comply with all the terms of this Application/Agreement and the EOC/DF, WHA will automatically renew this Application/Agreement each year on January 1. Terms of the Application/Agreement and the EOC/DF will remain the same when we renew it unless WHA has amended the documents as described under “Amendment of Agreement” in the EOC/DF. Upon acceptance, you will be provided with an EOC/DF. By accepting benefits under a WHA Individual/Family Plan, you agree to be bound by the Application/Agreement and by the EOC/DF. The EOC/DF for the Individual Advantage Plans is available upon request from WHA or your broker prior to enrollment. WHA may adopt reasonable policies, procedures, and interpretations to promote orderly and efficient administration of this agreement. You may not assign this agreement or any of the rights, interests, claims for money due, benefits, or obligations hereunder without WHA’s prior written consent. In any dispute between you and WHA, a medical group or any participating provider, each party will bear its own attorneys’ fees and other expenses. WHA’s failure to enforce any provision of this Application/ Application/Agreement, or of the EOC/DF, will not constitute a waiver of that or any other provision, or impair WHA’s right thereafter to require your strict performance of any provision. If covered by a WHA Individual/Family Plan, in the event you suffer injury, illness or death due to the act or omission of a third party, WHA will furnish Covered Services. In the event any recovery is obtained on your behalf, you or your representative must reimburse WHA for the value of Covered Services as set forth in the EOC/DF. By executing this Application/Agreement, you grant on your behalf and on Applicant’s behalf, a lien on any such recovery and agree to cooperate with WHA when there is any possibility that a recovery may be received. The Applicant and dependents must live within WHA’s Service Area. You may contact your broker or WHA to determine whether the Applicant lives within WHA’s Service Area, or you may view the Service Area Map on WHA’s website. When the Applicant is enrolled for coverage and at any time no longer lives within the Service Area, the Applicant is no longer eligible for coverage. When the Dependent is enrolled for coverage and at any time no longer lives within the Service Area, the Dependent is no longer eligible for coverage. Living outside the Service Area is a material fact that must be reported to WHA. If WHA accepts your application for coverage, that coverage may be terminated for fraud or intentional misrepresentation of a material fact, including but not limited to fraud or material misrepresentation or omission in providing or failing to provide material information to WHA, the use of the services of the plan, or for knowingly permitting such fraud or material misrepresentation or omission by another. Such termination shall be effective upon the mailing of written notice by WHA to you. WHA may terminate an individual’s coverage only if allowed (or not disallowed) by federal and state laws and regulations. Before making any decision to rescind, WHA XXX would notify you in writing of the grounds for rescission. WHA’s notice will tell you why your application is believed to be inaccurate or incomplete and will invite you to provide WHA with additional information. If, after considering your response, WHA XXX decides to rescind, WHA will send written notice to you at least 30 days before the date we rescind your coverage, explaining the basis for the decision and how you can appeal it. All faxed and mailed correspondence must be signed and dated by the affected individual or someone legally authorized to act on his or her behalf. You must complete any applications, forms, or statements requested in WHA’s normal course of business or as specified in this Application/Agreement. WHA’s notices to you will be sent to the most recent address WHA has for you. You are responsible for notifying WHA of any change in address. Regardless of when you notify WHA that the Applicant moved, the Applicant will no longer be eligible for coverage if he or she moves out of the service area. Except as preempted by federal law, this Application/Agreement and the EOC/DF will be governed in accord with California law and any provision that is required to be in these documents by state or federal law shall bind you and WHA, whether or not set forth in these documents. You or your authorized representative may request a copy of your completed application by calling 916.563.2250000.000.0000.
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Samples: s3.amazonaws.com
Special Enrollment Period. The annual Open Enrollment period for new coverage is October 15 through January 15. These dates are subject to change pursuant to changes in the law. You may change your benefit plan, sign up for health care coverage or add eligible dependents during the Open Enrollment period. Outside of this Open Enrollment period, you can only sign up for health care, change your coverage or add eligible dependents if you have experienced a qualifying life event. You must enroll within 60 days of the qualifying event in order to be eligible for a Special Enrollment Period. If 60 days pass and you do not sign up for health coverage, you will have to wait until the next open enrollment period. WHA reserves the right to ask for verification of the qualifying event. I attest that I am or my dependents are eligible to enroll under a Special Enrollment Period due to the following qualifying event: Marriage or Divorce Birth or Adoption Death Loss of Minimum Essential Coverage Under an Employer Sponsored Plan: Termination of Employment Change in Employment Status Exhaustion of COBRA Continuation Coverage Returning from United States Active Duty or California National Guard Under Title 32 of the United States Code Dependent child’s loss of dependent status such as reaching age 26 Permanent Relocation to the WHA Service Area Provider Network Changes Court Ordered Coverage for Your Spouse or Minor Child Immigration Status Change Released From Incarceration Other Note: Qualifying Events are established by state and federal law. WHA will enroll applicants consistent with the law, and this list will be deemed amended following any change to relevant laws. CONDITIONS OF ACCEPTANCE Please read the following information and sign in the space(s) provided on the following page. Please read this section carefully. This section contains important information, including the reasons WHA may terminate or rescind coverage. You must fully answer each question in this application even though you may already be a WHA member. Be sure to complete the Application/Agreement accurately. If you are unsure about the answer to any question, take the time to make sure the information is accurate before submitting your Application/Agreement. By signing this Application/Agreement, you represent that all responses are true, complete, and accurate to the best of your knowledge, and that if WHA accepts your application for coverage, the Application/Agreement, together with the Combined Evidence of Coverage and Disclosure Form (EOC/DF), will constitute the plan contract between you and WHA. If WHA accepts the Applicant or Dependent(s) for coverage, coverage will begin on the first of the month following acceptance, or the first of the following month, based on your selection under “Effective Date” in this Application/Agreement. Your Application/Agreement is effective through December 31. If you comply with all the terms of this Application/Agreement and the EOC/DF, WHA will automatically renew this Application/Agreement each year on January 1. Terms of the Application/Agreement and the EOC/DF will remain the same when we renew it unless WHA has amended the documents as described under “Amendment of Agreement” in the EOC/DF. Upon acceptance, you will be provided with an EOC/DF. By accepting benefits under a WHA Individual/Family Plan, you agree to be bound by the Application/Agreement and by the EOC/DF. The EOC/DF for the Individual Advantage Plans is available upon request from WHA or your broker prior to enrollment. WHA may adopt reasonable policies, procedures, and interpretations to promote orderly and efficient administration of this agreement. You may not assign this agreement or any of the rights, interests, claims for money due, benefits, or obligations hereunder without WHA’s prior written consent. In any dispute between you and WHA, a medical group or any participating provider, each party will bear its own attorneys’ fees and other expenses. WHA’s failure to enforce any provision of this Application/ Application/Agreement, or of the EOC/DF, will not constitute a waiver of that or any other provision, or impair WHA’s right thereafter to require your strict performance of any provision. If covered by a WHA Individual/Family Plan, in the event you suffer injury, illness or death due to the act or omission of a third party, WHA will furnish Covered Services. In the event any recovery is obtained on your behalf, you or your representative must reimburse WHA for the value of Covered Services as set forth in the EOC/DF. By executing this Application/Agreement, you grant on your behalf and on Applicant’s behalf, a lien on any such recovery and agree to cooperate with WHA when there is any possibility that a recovery may be received. The Applicant and dependents must live within WHA’s Service Area. You may contact your broker or WHA to determine whether the Applicant lives within WHA’s Service Area, or you may view the Service Area Map on WHA’s website. When the Applicant is enrolled for coverage and at any time no longer lives within the Service Area, the Applicant is no longer eligible for coverage. When the Dependent is enrolled for coverage and at any time no longer lives within the Service Area, the Dependent is no longer eligible for coverage. Living outside the Service Area is a material fact that must be reported to WHA. If WHA accepts your application for coverage, that coverage may be terminated for fraud or intentional misrepresentation of a material fact, including but not limited to fraud or material misrepresentation or omission in providing or failing to provide material information to WHA, the use of the services of the plan, or for knowingly permitting such fraud or material misrepresentation or omission by another. Such termination shall be effective upon the mailing of written notice by WHA to you. WHA may terminate an individual’s coverage only if allowed (or not disallowed) by federal and state laws and regulations. Before making any decision to rescind, WHA would notify you in writing of the grounds for rescission. WHA’s notice will tell you why your application is believed to be inaccurate or incomplete and will invite you to provide WHA with additional information. If, after considering your response, WHA decides to rescind, WHA will send written notice to you at least 30 days before the date we rescind your coverage, explaining the basis for the decision and how you can appeal it. All faxed and mailed correspondence must be signed and dated by the affected individual or someone legally authorized to act on his or her behalf. You must complete any applications, forms, or statements requested in WHA’s normal course of business or as specified in this Application/Agreement. WHA’s notices to you will be sent to the most recent address WHA has for you. You are responsible for notifying WHA of any change in address. Regardless of when you notify WHA that the Applicant moved, the Applicant will no longer be eligible for coverage if he or she moves out of the service area. Except as preempted by federal law, this Application/Agreement and the EOC/DF will be governed in accord with California law and any provision that is required to be in these documents by state or federal law shall bind you and WHA, whether or not set forth in these documents. You or your authorized representative may request a copy of your completed application by calling 916.563.2250.
Appears in 1 contract
Samples: www.westernhealth.com
