Standard Health Application – Fill Out and Use This PDF

The Standard Health Application form is a comprehensive document initiated by the State of Illinois Department of Insurance, designed to streamline the enrollment process for employees seeking health coverage from Blue Cross and Blue Shield of Illinois (BCBSIL) within small employer groups (sizes 2 - 150). Mandated by the Illinois Insurance Fairness Act, this form aims to simplify the process, ensuring that employees only need to fill out a single application even if their employer is requesting quotes from multiple insurance companies. For those looking to secure their health insurance benefits efficiently, clicking the button below is your first step to filling out the Standard Health Application form.

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Standard Health Application PDF Details

In a world where healthcare coverage is of paramount importance, navigating the intricacies of insurance applications can be a daunting process for employees seeking coverage. The Illinois Standard Health Employee Application for Small Employers, encompassing groups sized between 2 and 150, represents a significant stride towards simplifying this undertaking. Spearheaded by the Illinois Department of Insurance and mandated by the Illinois Insurance Fairness Act (Public Act 96-0857), this form standardizes the enrollment process across insurance companies operating in the small group and individual markets, a move that was put into effect from January 1, 2011. This initiative not only aims to eliminate the redundancy of filling out multiple forms for different insurers but also ensures that employees are informed about the types of coverage available through their employer, such as Preferred Provider Organizations (PPOs), Health Maintenance Organizations (HMOs), Health Savings Accounts (HSAs), and Health Care Accounts (HCAs), under Blue Cross and Blue Shield of Illinois (BCBSIL) offerings. Additionally, the form accommodates various familial situations by including sections for spouse/domestic partner and retiree information, contingent upon the employer's inclusion of these groups in their coverage plan. It underscores the importance of providing detailed personal information, including weight, height, and military veteran status, and emphasizes the necessity for applicants to understand the waiver of coverage implications and the specifics of enrolling dependents. Moreover, the form guides the applicant through providing previous coverage information and encourages clarity on additional coverage options, thereby fostering a comprehensive understanding of one’s healthcare benefits.

Question	Answer
Form Name	Standard Health Application
Form Length	14 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min 30 sec
Other names	abe illinois gov health insurance application, illinois standard health employee application, illinois standard application provider, illinois depart of public health application

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Blue Cross and Blue Shield of Illinois Cover Page to the

Illinois Standard Health Employee Application for Small Employers

(Groups sized 2 - 150)

The purpose of this document is to help you – an employee requesting coverage from Blue Cross and Blue Shield of Illinois (BCBSIL) – fill out the new standard enrollment application created by the State of Illinois Department of Insurance.

As a result of the Illinois Insurance Fairness Act (Public Act 96-0857), the Illinois Department of Insurance created standard enrollment applications that must be used by all insurance companies doing business in the small group and individual markets.

The attached standard application goes into effect January 1, 2011 and replaces the small group enrollment applications previously used by insurance companies.

Although all insurance companies must use this standard enrollment application, the business needs and practices of all insurance companies are not the same. Not all the information requested on the new standard enrollment application is required by BCBSIL. However, there is information BCBSIL needs for the enrollment process that is not on the standard enrollment application.

The information below will help you understand how to complete each section of the standard enrollment application for enrollment with BCBSIL.

1.Employer Information

Your employer can use the Illinois Standard Health Employee Application with one or more insurance companies to request quotes for employee health insurance. This standard enrollment application means you do not need to fill out different applications from each insurance company. For your benefit, space is provided on the standard enrollment application so your employer can list the different insurance companies that will receive your health information.

You will see references to "spouse/domestic partner" and "retiree" in the standard enrollment application. Domestic partners and retirees are eligible only if your employer chooses to cover them. Check with your employer if you are not sure.

2.Section B – Coverage Requested

Choose the type of health coverage/product you want based on the option(s) your employer has offered you.

•Some employers may offer only one type of coverage such as a PPO health benefit plan.

•Others may provide different options such as a PPO, an HMO, and/or a plan that includes a Health Savings Account (HSA) and/or a Health Care Account (HCA).

•You and your dependents (spouse/domestic partner and children) will all be enrolled in the same product. You cannot pick different products for each person.

BCBSIL offers the following products for small group business. If you are not sure which product(s) are available to you, please ask your employer.

PPO	HMO	HSA		HCA
• BlueAdvantageSM	• BlueAdvantageSM HMO	• BlueEdgeSM	HSA	• BlueEdgeSM Direct HCA
Entrepreneur PPO	• HMO Value Choice	• BlueEdgeSM	Select HSA
• BluePrint PPO	• HMO Value Choice	• BlueEdgeSM	Select HSA
• BluePrint PPO
• BlueChoice Select®
• BlueChoice Select®
Value Choice
• PPO Value Choice
• CPO
• CPO Value Choice

22997.1211	A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Page 1

3.Section C – Waiver of Coverage

You may enroll yourself and your dependents (spouse/domestic partner and children) in any coverage that your employer makes available to you, and that BCBSIL offers. While the standard enrollment application may appear to suggest that you can waive enrolling yourself for coverage but still enroll your dependents, BCBSIL’s policy requires that you (the employee) enroll in order to also enroll your dependents. If you choose to waive any coverage, your dependents cannot enroll in that coverage. However, you can enroll yourself in a coverage and choose to waive it for any of your dependents.

Please use this section to indicate if you do not wish to enroll yourself and/or any of your dependents in the following types of coverage:

• Medical	• Dental	• Basic Life	• Dependent Life
• Short-Term Disability (BCBSIL offers only to employees)			• Voluntary Life (BCBSIL offers only to employees)

While you may see these types of coverage on the standard application, they are not available from BCBSIL for small group business:

•Vision

•Long-Term Disability

For small group business, BCBSIL does not consider “Individual Coverage” (the second option on the standard application) as a valid reason to decline your employer-offered coverage.

4.Section D – Individuals Requesting Coverage

•Weight and Height - BCBSIL requires the weight and height for yourself and your spouse/domestic partner. BCBSIL also requests weight and height be provided for any dependent that is 18 or older.

•Military Veteran Dependents - If you have dependents that are military veterans, you must include their honorable discharge documentation (Form DD-214).

•Disabled Dependents - Medical certification must be provided for disabled dependents.

•HMO Coverage - If you have elected to enroll in HMO coverage, information about your Primary Care Physician (PCP) is needed. The standard enrollment application provides space for your PCP and his or her identification number. However, BCBSIL requires more information about your physician. To accommodate this, a separate HMO / CPO Provider Selection Enrollment and Change Form is also required for HMO enrollees. This form is used to collect the following information:

•Independent Practice Association (IPA) / Medical Group Number – this is required for BCBSIL to correctly identify the location you have chosen to access care from your PCP.

•PCP name and the identification number.

•Female enrollees may also choose a Woman’s Principal Health Care Provider (WPHCP), so there is space to list this provider’s name and identification number as well.

•CPO Coverage - BCBSIL offers a Community Participating Option (CPO) health benefit plan. This is similar to a PPO health benefit plan, but the member can gain greater savings by using providers at specific hospitals in the CPO network. Therefore, if you have chosen the CPO product, please use the HMO / CPO Provider Selection Enrollment and Change Form to indicate the number of the CPO network you have selected.

5.Section E – Current / Prior Coverage Information: Medicare

For small group business,“Dual Enrollment” is not an applicable Medicare entitlement reason for BCBSIL.

6.Sections F & G – Health Statement / Additional Information

This section should be completed by employees of groups that have 2-50 enrolling employees. If you are not sure about completing this section, check with your employer.

•For health coverage, BCBSIL does not require the health statement questions to be completed by employees of groups that have more than 50 employees enrolling.

•For basic life coverage, the health statement questions must be completed by the employee if the group has two or more eligible employees AND is applying for an amount over the guarantee issue, applying for voluntary life coverage or for any late enrollment.

•Two pages are left blank so that information in these sections can be pulled out for underwriting (if applicable).

7.Section H – Additional Coverage Options

As stated in item #3, the following types of coverage are not available from BCBSIL for small group business:

•Vision

•Long-Term Disability

22997.1211	Page 2

Illinois Standard Health Employee Application for Small Employers

INSURER USE ONLY

Policy/Group No.

Section No.

Effective Date

New Hire Waiting Period

For assistance in completing this application, please contact your employer or insurance agent. For information about your health insurance rights under state and federal law, and other resources, please contact the Illinois Department of Insurance’s Office of Consumer Health Insurance toll free at (877) 527-9431.

This standard application is intended to simplify your health insurance application process. You will only need to complete this one application, even when your employer has requested quotes from multiple insurance companies.

The information you provide in this application will be sent to the following insurance companies: (To be completed by employer)

Insurer: _______________________________ Insurer: _______________________________ Insurer: _______________________________

TO BE COMPLETED BY EMPLOYER

Employer Name:				Phone #:

Address:

Reason for Enrollment (Mark all that apply)

New Enrollment:	 New Group  Open Enrollment		 New Hire (Date: ____________________________)  Late Enrollee

Special Enrollment:	 Adoption  Court Order  Dependent Addition  Divorce  Domestic Partner
	 Loss of Coverage	 Marriage	 Newborn  Other		Date of Event: _________/__________/__________

Employment Status:	 Active  Retiree (Retirement Date: ________/________/________)
	 Illinois Continuation	 COBRA
	 Employee  Dependent
	Qualifying Event: ________________________________
	Start Date ________/________/_________ Projected End Date ________/________/_________

A Employee Information

Name (Last)			(First)					(MI)

Job Title:				Hire Date:			Hrs/Week:

Marital Status:  Married	 Single	 Divorced  Widowed  Domestic Partner

Home Address:						Apt #:

City:				State:	Zip:

Home (or Cell) Phone: (	)			Business Phone: (	)

Email Address (optional):

B Coverage Requested

Medical

Employee:  Yes  No	Spouse/Domestic Partner:  Yes  No	Child(ren):  Yes  No
Plan Choice:	Plan Choice:	Plan Choice:

If you are waiving (declining) coverage for yourself or any member of your family, you must complete Section C below.

23071.0111

70670

ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER

Employer Name ________________________________ Employee Name __________________________________________

CWaiver of Coverage

Please complete this section only if you are waiving (declining) coverage for yourself or one or more of your family members.

I acknowledge that I have been given the opportunity to apply for group coverage available to me and my dependents through my employer.

I understand and agree:

If I am declining coverage for myself, my spouse/domestic partner, or my dependent child(ren) because of other coverage, I may in the future be able to enroll myself, my spouse/domestic partner, or my dependent child(ren) provided that I request enrollment within 31 days after the other coverage ends.

If I have a new spouse/domestic partner or child as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my new spouse/domestic partner or child provided that I request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.

If I decide to request coverage in the future, for a reason other than the termination of other coverage or the addition of a new spouse/domestic partner or child, I may be considered a late enrollee, if applicable, or I may have to wait until the plan’s next open enrollment period. I also understand that as a late enrollee, coverage for preexisting conditions may be excluded for up to a period of 18 months. This period may be offset by the time I, my spouse/domestic partner, or my dependent child(ren) was covered under a qualified health plan.

I certify that I was not pressured, forced, or unfairly induced by my employer, the agent, or the insurer(s) into waiving or declining the group coverage.

I DO NOT want, and hereby waive, coverage for (initial next to all that apply):

Medical for	[	] Myself	[	] My Spouse/Domestic Partner	[	] My Dependent Child(ren)

Dental✶ for	[	] Myself	[	] My Spouse/Domestic Partner	[	] My Dependent Child(ren)

Vision✶ for	[	] Myself	[	] My Spouse/Domestic Partner	[	] My Dependent Child(ren)

Basic Life✶ for	[	] Myself	[	] My Spouse/Domestic Partner	[	] My Dependent Child(ren)

Dependent Life✶ for	[	] Myself	[	] My Spouse/Domestic Partner	[	] My Dependent Child(ren)

Voluntary Life✶ for	[	] Myself	[	] My Spouse/Domestic Partner	[	] My Dependent Child(ren)

Short-Term Disability✶ for	[	] Myself	[	] My Spouse/Domestic Partner	[	] My Dependent Child(ren)

Long-Term Disability✶ for	[	] Myself	[	] My Spouse/Domestic Partner	[	] My Dependent Child(ren)

✶If offered.

I am declining group coverage for the following reason(s): (check all that apply)

 Spouse/Domestic Partner’s Employer Plan	 Individual Coverage (Non-Group Plan)
 COBRA/State Continuation	 Medicare or other Government Program

Other (please explain): _________________________________________________________

✪If you are declining ALL coverage for ALL persons, please skip to the Acknowledgement & Signature section on page 10 of this application.

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23071.0111	70670

ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER

Employer Name ________________________________ Employee Name __________________________________________

DIndividuals Requesting Coverage

List yourself and all eligible family members to be included under coverage.

Please check with your employer or insurance agent about who may qualify as an eligible family member under the policy.

Illinois’ Young Adult Dependent Coverage law allows parents to cover children up to the age of 26, and up to age 30 for military veteran dependents, regardless of whether the child may be considered a dependent for tax or other purposes. For more information, please visit the Illinois Department of Insurance website at www.insurance.illinois.gov.

Note: For purposes of this application, an “eligible military veteran” is a veteran who served in the active or reserve components of the U.S. Armed Forces, including the National Guard, and who received a release or discharge other than a dishonorable discharge.

If additional space is required, please attach a separate sheet and be sure to sign and date that sheet.

Employee Name (Last) _______________________________ (First) _______________________________ (MI) _______

Social Security Number:					Date of Birth:	/	/

Weight:	lbs.	Height:	ft.	in.	Gender:  Male	 Female

HMO only (if/when applicable): Primary Care Physician:					Physician ID:

Spouse/Domestic Partner Name (Last) ________________________ (First) ________________________ (MI) ______

Social Security Number:						Date of Birth:		/	/

Weight:	lbs.		Height:	ft.	in.	Gender:	 Male	 Female

HMO only (if/when applicable): Primary Care Physician:							Physician ID:

Dependent Name (Last) _______________________________					(First) _______________________________ (MI) _______
Social Security Number:						Date of Birth:		/	/

Weight:	lbs.		Height:	ft.	in.	Gender:	 Male	 Female

Eligible Military Veteran:  Yes		 No

HMO only (if/when applicable): Primary Care Physician:							Physician ID:

Dependent Name (Last) _______________________________					(First) _______________________________ (MI) _______
Social Security Number:						Date of Birth:		/	/

Weight:	lbs.		Height:	ft.	in.	Gender:	 Male	 Female

Eligible Military Veteran:  Yes		 No

HMO only (if/when applicable): Primary Care Physician:							Physician ID:

Dependent Name (Last) _______________________________					(First) _______________________________ (MI) _______
Social Security Number:						Date of Birth:		/	/

Weight:	lbs.		Height:	ft.	in.	Gender:	 Male	 Female

Eligible Military Veteran:  Yes		 No

HMO only (if/when applicable): Primary Care Physician:							Physician ID:

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23071.0111									70670

How to Edit Standard Health Application Online for Free

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stage 1 to completing illinois health application

Jot down the details in Special Enrollment Adoption, Loss of Coverage Marriage, Employment Status Active Retiree, Illinois Continuation COBRA, Employee Dependent, Qualifying Event, Start Date Projected End Date, Employee Information, A Name Last, Job Title, First, Hire Date, Marital Status Married Single, Home Address, and City.

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You're going to be instructed to write down the details to let the program complete the segment B Medical, Employee Yes No, SpouseDomestic Partner Yes No, Plan Choice, Plan Choice, Plan Choice, and If you are waiving declining.

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Finish by checking all these fields and filling them out accordingly: I DO NOT want and hereby waive, Medical for, Dental for, Vision for, Myself My SpouseDomestic, Myself My SpouseDomestic, Myself My SpouseDomestic, Basic Life for, Myself My SpouseDomestic, Dependent Life for, Myself My SpouseDomestic, Voluntary Life for, Myself My SpouseDomestic, ShortTerm Disability for, and Myself My SpouseDomestic.

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