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HIP Healthy NY Individual Application

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                                           Healthy NY Case Submission
Along with your signed and dated application, be sure to include at least ONE (1) from each section listed below.



         Proof of Residence (must match address in Section A)
                   Utility Bill less that 90 days old (electric or gas)
                   Drivers License
                   Lease Contract
                   Mortgage Statement


        Proof of Employment (must match information on Section C)
                  Latest pay stub
                  Letter from employer
                  If recently unemployed, letter from previous employer stating the last
                  day of employment


        Proof of Household Income (must match figures on Section E)
                  Self and spouse’s pay subs for the last 4 weeks
                  Most recent tax documents
                  Benefit statements (if applicable – ex. social security, unemployment,
                  disability, etc) for both self and spouse
Make sure to:
    • Sign all forms where indicated
    • Include a check made payable to HIP for the first month’s
      premium
    • Include your application processing fee of $45 made payable to Vista Health
      Solutions (If previously paid online, please provide the last 4 digits of the
      credit card used or the bank account no.: _ _ _ _)

    Mail application forms along with the above to:
                                             Vista Health Solutions, Inc.
                                                  Enrollment Dep’t.
                                                    PO Box 337
                                                 Suffern, NY 10901
31 Park Ave., Suffern, NY 10901                       Tel. 8457532320  Fax. 8455101940                          info@nyhealthinsurer.com 
                                                             HEALTHY NEW YORK APPLICATION
                                                             for INDIVIDUALS and SOLE PROPRIETORS

     Section A. Application Information                                              (please tell us who you are and how to contact you)
Name: First                                                                                    M.I.       Last


Home Telephone                                                          Work Telephone                                                         E-Mail Address:


Street Address (of person applying for health insurance)                                                                                                        Apt #


City                                                                                                             State       Zip                    County


Billing Address (if different than the street address)
                                                                       S A M E                            A S                A B O V E
City                                                                                                             State       Zip                    County


 MARITAL STATUS:                 Single               Married           IN CASE OF EMERGENCY, Name __________________________________________________
                                 Legally Separated/Divorced             PLEASE CONTACT:                          Relationship ____________________________________________
 Date of Event: (mo/date/year) ____ / ____ / ____                       Telephone No:            (Home) ____________________ (Work) ______________________________

 TYPE OF APPLICATION: Please indicate whether you are applying as an individual or as a sole proprietor (someone who is the sole owner and only
 employee of a business). Please see instructions for further information.             Individual            Sole Proprietor

 Benefit Package. The premiums are different for each benefit package.
       Healthy NY High Deductible Health Plan w/ Prescription Drug Coverage
       Healthy NY High Deductible Health Plan

 (Please note that future changes between HDHP Plans and standard Healthy NY Plans may only be made at the time of recertification. )

     Section B1. Household Members                                  (please tell us about yourself, your legal spouse (or domestic partner if you are a Sole
                                  Proprietor) if residing in the household or any dependent children eligible for coverage). No one else is to be counted. The
                                  household income limitation depends upon the number of household members that you have. For each person listed,
                                  please indicate whether that person is applying for coverage.
     LIST BELOW ALL ELIGIBLE FAMILY MEMBERS (INCLUDE SELF)                  Date of Birth      ELIGIBLE          INSURANCE          POLICY    TYPE OF         EFFECTIVE   APPLYING FOR
                                                                SEX                              FOR
          (LAST NAME, FIRST NAME & SOCIAL SECURITY #)                 Mo.      Day      Yr.    MEDICARE          COMPANY*          NUMBER*   COVERAGE*         DATES*      COVERAGE
           NAME                                                                                                                                          FROM
     S                                                                                            YES                                                                        YES
                                                                  M
     E
     L                                                                                            NO                                                     TO                  NO
                                                                  F
     F     SS NO.
           _ _ _ - _ _ - _ _ _ _
PRIMARY CARE PHYSICIAN:                                               Internal                Family Practice                 Pediatrics
Physician Name __________________________________________________                                                        Physician Number ___________________________________
 S     D P NAME                                                                                                                                          FROM
 P     OA                                                                                         YES                                                                        YES
       MR                                                         M
 O     ET
 U     S                                                                                          NO                                                     TO                  NO
 S     T N SS NO.                                                 F
 E     I E _ _ _ - _ _ - _ _ _ _
       CR
PRIMARY CARE PHYSICIAN:                                               Internal                Family Practice                 Pediatrics
Physician Name __________________________________________________                                                        Physician Number ___________________________________
           NAME                                                                                                                                          FROM
     C
                                                                                                  YES                                                                        YES
     H                                                            M
     I
                                                                                                  NO                                                     TO                  NO
     L                                                            F
           SS NO.
     D     _ _ _ - _ _ - _ _ _ _
PRIMARY CARE PHYSICIAN:                                               Internal                Family Practice                 Pediatrics
Physician Name __________________________________________________                                                        Physician Number ___________________________________
           NAME                                                                                                                                          FROM
     C
                                                                                                  YES                                                                        YES
     H                                                            M
     I
                                                                                                  NO                                                     TO                  NO
     L                                                            F
           SS NO.
     D     _ _ _ - _ _ - _ _ _ _
PRIMARY CARE PHYSICIAN:                                               Internal                Family Practice                 Pediatrics
Physician Name __________________________________________________                                                        Physician Number ___________________________________


16-4962 (1/07)
     LIST BELOW ALL ELIGIBLE FAMILY MEMBERS (INCLUDE SELF)         MED. GROUP         Date of Birth     ELIGIBLE   INSURANCE       POLICY    TYPE OF         EFFECTIVE   APPLYING FOR
                                                             SEX    NETWORK                               FOR
          (LAST NAME, FIRST NAME & SOCIAL SECURITY #)               PHYSICIAN   Mo.      Day      Yr.   MEDICARE   COMPANY*       NUMBER*   COVERAGE*         DATES*      COVERAGE

         NAME                                                                                                                                           FROM
 C
                                                                                                           YES                                                              YES
 H                                                             M
 I
                                                                                                          NO                                            TO                  NO
 L                                                             F
         SS NO.
 D       _ _ _ - _ _ - _ _ _ _
PRIMARY CARE PHYSICIAN:                                                Internal                 Family Practice                Pediatrics
Physician Name __________________________________________________                                                      Physician Number ___________________________________
         NAME                                                                                                                                           FROM
 C
                                                                                                           YES                                                              YES
 H                                                             M
 I
                                                                                                          NO                                            TO                  NO
 L                                                             F
         SS NO.
 D       _ _ _ - _ _ - _ _ _ _
PRIMARY CARE PHYSICIAN:                                                Internal                 Family Practice                Pediatrics
Physician Name __________________________________________________                                                      Physician Number ___________________________________


                               * If your spouse and/or dependents have other Health Insurance please provide information above.
                                              Pregnant women count as two people for determining household size.
                        Are any of the household members listed above pregnant?           NO       YES (how many?) __________________________




     Section B2. Household Income
                                     Please list your current monthly gross income and the current monthly gross income of your
                                     spouse (if residing in your household). Please include wages, salary, interest and dividends, self-
                                     employment income, social security income, retirement income, alimony, unemployment benefits
                                     and workers compensation. Please do not include public assistance, supplemental security income
                                     (SSI), foster care payments or child support payments.


                                       Applicant’s Current Monthly Gross Income                                                        $


                                       Spouse’s Current Monthly Gross Income                                                           $


                    (Please Note: Sole Proprietors should deduct their monthly business expenses in calculating their monthly income.)



      Section C. Health Insurance Information
Generally, Healthy New York coverage is available to people who do not currently have and have not had health insurance for 12 months.
However, there are exceptions - such as if your other coverage provides limited benefits, if your coverage terminated due to certain reasons, or
if your other coverage is one that is eligible for transfer to Healthy New York. See the instructions for additional information.

Please answer the following questions regarding health insurance coverage in the space provided. Most questions can be answered with a sim-
ple ‘Yes” or “No”

1.           Do you currently have health insurance coverage which includes both medical and hospital benefits?
                     (see instructions)            Yes              No

2.           Have you had health insurance coverage during the past twelve months?                                             Yes              No

             (Note: Answer “No” if your coverage was through Medicaid, Child Health Plus, Family Health Plus or another public program or if you
             had Cobra coverage)
                      (if no, skip question number 4)

3a.          If you have had health insurance coverage during the past twelve months, did it terminate for one
             of the following reasons? (check all that apply)
                          Loss of employment
                          Death of a family member resulting in termination of coverage
                          Change to a new employer which does not provide coverage
                          Change of residence
 16-4962 (1/07)
3a. (continued)
                      Discontinuation of a group health insurance plan
                      Legal separation, divorce or annulment
                      Loss of eligibility for group health insurance coverage
                      Loss of coverage due to reaching the maximum age of dependency
                      Termination or Cancellation of COBRA/continuation coverage

3b.        Date coverage terminated or will terminate due to reason noted above. ___________________________

4a.        Are you eligible for health insurance through your employer?                        Yes                No

4b.        Does your employer contribute towards the cost of the health insurance? NA          Yes                No




    Section D. Employment
You can qualify for Healthy NY if you or your spouse worked during the past year. Please answer the following questions about employment.

           Is currently employed                 You                Spouse           Neither

           Has worked in the past year           You                Spouse           Neither

If both questions are answered “Neither”, you will not qualify for Healthy NY.



    Section E. Documentation
You need to attach 3 types of documentation. These include documentations of employment status, documentation of
                                   NYS residence and documentation of income.
                        Examples of Acceptable Documentation (You need only one for each category):




          Employment Status                                     NYS Residence                                    Income
      •   Pay Stubs                              •   Utility Bill                                    •   Pay stubs
      •   W-2s forms                             •   Postmarked Mail With Address                    •   W-2s forms
      •   Letter From Employer                   •   Letter/Lease/Rent Receipt with Home             •   Letter From Employer
      •   Documentation sufficient to                Address from Landlord                           •   Business Records
          demonstrate self-employment            •   NYS Driver’s License                            •   Award letters/benefit checks
      •   Other (please explain)                 •   Property Tax Records or Mortgage Statement      •   Other (please explain)
                                                 •   Other (please explain)




*   Income documentation must cover an entire month and should reflect current income.




                                         YOU MAY ALSO NEED TO SHOW PROOF OF OTHER ITEMS

           Individuals who are transferring from other public programs should attach proof of participation in these programs
                                              in addition to the documentation listed above.




16-4962 (1/07)
     Section F. Certification
1.     I am applying for direct payment coverage for myself, my spouse, and any eligible dependents as prescribed by
       law. I elect to enroll myself and my family members, if any, with the Medical Group/Network Physician named
       above.
2.     I understand that this application is subject to acceptance and assignment of an effective date by HIP and all infor-
       mation furnished in this application is true and complete to the best of my knowledge.


By signing this certification of eligibility, I certify under penalty of perjury that all statements contained in this certifi-
cation are true to the best of my knowledge.
I further certify that I am ineligible for health insurance provided by my employer and that all individuals to be covered
are ineligible for Medicare.
I understand that any person who knowingly and with the intent to defraud any insurance company or other person
files an application for insurance or statement of claim containing any materially false information, or conceals for the
purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is
a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim
for each such violation.




Signature _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __                           Date _ _ _ _ _ _ _ _ _ _ _ _ __
     completed application
Your      ns


1.     I understand that pre-existing conditions will not be covered during the first 12 months of the contract. A Pre-exist-
       ing Condition is a condition (whether physical or mental), regardless of the cause of the condition, for which med-
       ical advice, diagnosis, care or treatment was recommended by a duly licensed medical professional or received
       within the six (6) month period ending on the enrollment date. HIP will credit the time I/we were covered by the
       previous policy, provided that the break in coverage between the prior plan and coverage under this plan does not
       exceed Sixty-three (63) days, exclusive of any waiting periods. I agree that after enrolled, I will upon request pro-
       vide HIP and/or my medical group with information on pre-existing conditions(s) and any previous coverage I had.
       Subject to the applicable State and Federal laws pertaining to pre-existing conditions and creditable coverage, ben-
       efits for pre-existing conditions may not be payable for up to twelve months from the effective date of the contract.
Federal Trade Adjustment Act of 2002
The 12 month exclusion period mentioned above is shorter if you have been determined to be eligible under the Federal
Trade Adjustment Act of 2002.
2.     On behalf of myself and each eligible family member, I hereby authorize all health care providers who have ren-
       dered any service to any of us, to furnish to HIP and our Medical Group/Network Physician, at any time upon
       request all medical information for the purposes of processing claims or managing care.




16-4962 (1/07)
Dear HIP:

                         (The “Group”) hereby designates the broker/consultant(s) listed
below at the commission percentage split indicated as the broker/consultant(s) of record
(the “BOR) for the Group. Further, the Group hereby authorizes HIP Health Plans of
York to send all quotes, policies and notices to the BOR. The Group hereby acknowledges
and agrees that notice to the BOR is notice to the Group.
       This BOR designation shall remain in effect until it is expressly terminated by the
Group in writing.

BOR Designation: Please insert broker/consultant(s) name(s), address (es), and the
applicable commission percentage split below.

  Broker/Consultant(s) Name          Address        Tax ID/SSN         Commission % Split
1. Vista Health Solutions         31 Park Ave.      20-4850104             100%
                              Suffern, NY 10901




x
___________________________________
Signature of GBA or authorized Officer

___________________________________
Print Name

owner
___________________________________
Title
Dear HIP,

Be advised that I no longer receive the wages listed on my most recent tax form
pertaining to the w2 enclosed.

Please contact me at the address listed above if you need any additional information

Thank you



 x
_______________________
Signature

_______________________
Print Name

owner
_______________________
Title
X
                                          HIP Healthy NY HMO
                                     High Deductible Health Plan

Cost Sharing

Annual Plan Deductible                             $1,200 Individual /
                                                   $2,400 Family for plan year 2012*

Annual Out-of-Pocket Maximum                       $6,050 Individual /
                                                   $12,100 Family for plan year 2012*



Plan Details
Inpatient Hospital Services*      In Network                             Out of Network
                                  $500 Copayment per continuous          Not Covered (except
Hospital Coverage
                                  confinement                            for emergency)
Skilled Nursing                   Not Covered                            Not Covered
Maternity and Routine Nursery     Covered in Full                        Not Covered
Care
Hospice Care                      Not covered                            Not Covered

Outpatient Hospital Services*     In Network                             Out of Network
Ambulatory Surgery                $75 Facility                           Not Covered
                                  Copayment
Home Health Care                  $20 Copayment – up to 40 post-         Not Covered
                                  hospital or post-surgical visits per
                                  year

Medical Services                  In Network                             Out of Network
Surgical Services                 20% or $200, whichever is less         Not Covered
Delivery                          20% or $200, whichever is less         Not Covered
Home and Office Visits            $20 Copayment                          Not Covered
Physical Check-up (once every 3   Covered in Full                        Not Covered
years)
Chiropractic Care                 Not Covered                            Not Covered
Physical Therapy                      $20 Copayment – up to 30 post-            Not Covered
                                      hospital or post-surgical visits per
                                      year
Speech Therapy                        Not Covered                               Not Covered
Well-baby and Well-child Care         Covered in Full                           Not Covered

Lab and Radiology Services            In Network                                Out of Network
Diagnostic Lab Tests and              $20 Copayment                             Not Covered
Radiology Procedures

Emergency Services                    In Network                                Out of Network
ER Professional Charge                Covered in Full                           Allowed charge
Emergency Facility Charge             $50 Copayment per visit                   $50 Copayment per
(Waived if Admitted)                                                            visit

Mental Health and Chemical            In Network                                Out of Network
Dependency Services*
Inpatient Mental Health               Not Covered                               Not Covered
Inpatient Chemical Dependency         Not Covered                               Not Covered
Treatment (Detoxification)
Chemical Dependency Treatment         Not Covered                               Not Covered
(Rehabilitation)
Outpatient Chemical Dependency        Not Covered                               Not Covered
Treatment
Outpatient Mental Health              Not Covered                               Not Covered

Pharmacy                              In Network                                Out of Network
Pharmacy                              $10 Generic                               Not Covered
                                      $20 Brand
                                      (Note: Member must pay difference in
                                      cost between brand
                                      and generic)


*Services may be subject to Pre-certification or Pre-authorization.

The benefits described here are only brief highlights of the coverage available. Some benefits may have
calendar year limits and/or maximums. The terms, limitations, conditions, and exclusions of the
insurance contract and certificate will govern.



                                                                                  Updated January 2012

				
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Description: HIP Healthy NY Application for Individuals