Form Health1 "Application for Coverage - State and School Employees' Health Insurance Plan" - Mississippi

What Is Form Health1?

This is a legal form that was released by the Mississippi Department of Finance and Administration - a government authority operating within Mississippi. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2017;
  • The latest edition provided by the Mississippi Department of Finance and Administration;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form Health1 by clicking the link below or browse more documents and templates provided by the Mississippi Department of Finance and Administration.

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Download Form Health1 "Application for Coverage - State and School Employees' Health Insurance Plan" - Mississippi

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STATE OF MISSISSIPPI
STATE AND SCHOOL EMPLOYEES’ HEALTH INSURANCE PLAN
APPLICATION FOR COVERAGE
Employer Name
PLEASE PRINT
Section A: Enrollee Information (all fields are required)
Social Security Number
First Name
MI
Last Name
Home Address
City
State
ZIP
Primary Telephone Number
Secondary Telephone Number
Personal Email Address
Marital Status
Gender
Date of Birth
Date of Employment/Retirement
(mm/dd/yyyy)
Single
Married
Male
Female
Were you ever a full-time employee of a covered entity under the Plan prior to 1/1/2006?
No (Horizon)
Yes (Legacy)
If yes, please list your most recent (pre-1/1/06) employer and dates of employment: ________________________________________________________
_________________________________________________________________________________________________________________________________________
If married, is your spouse a Plan participant?
Yes
No If yes, Spouse Name and SSN: ________________________________________________
Section B: Health Insurance Membership Agreement Authorization (CHECK ONLY ONE BOX, SIGN AND DATE)
I hereby apply to ADD, CONTINUE AND/OR CHANGE COVERAGE for myself and/or my dependents named on this Application For
Coverage form through the State and School Employees' Health Insurance Plan (PLAN). I certify that all information provided by me on this
application is complete and accurate, and is the basis for providing coverage herein. I understand that any misrepresentation by me or my
dependents may result in the cancellation of my/our coverage under the PLAN. I understand that the coverage applied for is subject to all
exclusions, provisions, and limitations set forth by the Plan Document. I agree to be bound by all terms and conditions of the PLAN. I understand
and agree that if my application for coverage is approved, any requested coverage changes will be effective the date fixed by the PLAN or
its Administrator. I understand that if the requested coverage is approved, I am responsible for payment of the appropriate premiums and
hereby authorize for such payments to be payroll deducted, or as appropriate, withheld from my State of Mississippi retirement benefits.
I hereby WAIVE COVERAGE in the State and School Employees’ Health Insurance Plan. I have been offered coverage (or am eligible for
continuation of coverage) through the PLAN, but I elect not to be covered. I understand that by waiving coverage at this time, I may only
request coverage for myself or myself and eligible dependents at an Open Enrollment Period or during a Special Enrollment Period. I understand
that if I am a retiree and I waive coverage, I will not be allowed to re-enroll or have my coverage reinstated at a later date. If you are waiving
coverage because you are currently covered under another health insurance policy, please complete Section D.
Enrollee Signature: _________________________________________________________
Date: ______________________________________
Section C: Coverage
Do you have Medicare?
Yes
No
Enrollee Type:
Coverage Type:
Coverage Option:
Medicare Number: ___________________________
(Choose Only One)
Employee - Legacy
Enrollee Only
“A” Effective Date: _________________________
Employee - Horizon
Enrollee + Spouse
Select
“B” Effective Date: _________________________
Retiree
Enrollee + Child
Reason for Entitlement:
COBRA
Enrollee + Children
Base
(HIGH DEDUCTIBLE)
Age
ESRD
Disability
Surviving Spouse
Enrollee + Spouse & Child(ren)
Are you a tobacco user?
Yes
No
If yes, are you interested in participating in the Plan’s free cessation program?
Yes
No
Section D: Other Coverage Information
Do any of the persons listed on this application have other health insurance coverage? Yes
No
If yes, please provide the following:
1.____________________
2.____________________
3.______________________ 4.___________________
Name of Individual Covered:
Policyholder’s Name:
_______________________
__________________________
__________________________
_______________________
Policyholder’s Date of Birth:
_______________________
__________________________
__________________________
_______________________
Policyholder’s Insurance
Effective Date:
_______________________
__________________________
__________________________
_______________________
Policy Number:
_______________________
__________________________
__________________________
_______________________
Policyholder’s Employment
Active, Retiree or COBRA
Active, Retiree or COBRA
Active, Retiree or COBRA
Active, Retiree or COBRA
Status:
Insurance Company Name
_______________________
__________________________
__________________________
_______________________
address & phone #:
_______________________
__________________________
__________________________
_______________________
_______________________
__________________________
__________________________
_______________________
_______________________
__________________________
__________________________
_______________________
Group
Non-Group
Group
Non-Group
Group
Non-Group
Group
Non-Group
Coverage Type:
Application for Coverage
Mississippi State and School Employees’ Health Insurance Plan
Health1 (1/17)
STATE OF MISSISSIPPI
STATE AND SCHOOL EMPLOYEES’ HEALTH INSURANCE PLAN
APPLICATION FOR COVERAGE
Employer Name
PLEASE PRINT
Section A: Enrollee Information (all fields are required)
Social Security Number
First Name
MI
Last Name
Home Address
City
State
ZIP
Primary Telephone Number
Secondary Telephone Number
Personal Email Address
Marital Status
Gender
Date of Birth
Date of Employment/Retirement
(mm/dd/yyyy)
Single
Married
Male
Female
Were you ever a full-time employee of a covered entity under the Plan prior to 1/1/2006?
No (Horizon)
Yes (Legacy)
If yes, please list your most recent (pre-1/1/06) employer and dates of employment: ________________________________________________________
_________________________________________________________________________________________________________________________________________
If married, is your spouse a Plan participant?
Yes
No If yes, Spouse Name and SSN: ________________________________________________
Section B: Health Insurance Membership Agreement Authorization (CHECK ONLY ONE BOX, SIGN AND DATE)
I hereby apply to ADD, CONTINUE AND/OR CHANGE COVERAGE for myself and/or my dependents named on this Application For
Coverage form through the State and School Employees' Health Insurance Plan (PLAN). I certify that all information provided by me on this
application is complete and accurate, and is the basis for providing coverage herein. I understand that any misrepresentation by me or my
dependents may result in the cancellation of my/our coverage under the PLAN. I understand that the coverage applied for is subject to all
exclusions, provisions, and limitations set forth by the Plan Document. I agree to be bound by all terms and conditions of the PLAN. I understand
and agree that if my application for coverage is approved, any requested coverage changes will be effective the date fixed by the PLAN or
its Administrator. I understand that if the requested coverage is approved, I am responsible for payment of the appropriate premiums and
hereby authorize for such payments to be payroll deducted, or as appropriate, withheld from my State of Mississippi retirement benefits.
I hereby WAIVE COVERAGE in the State and School Employees’ Health Insurance Plan. I have been offered coverage (or am eligible for
continuation of coverage) through the PLAN, but I elect not to be covered. I understand that by waiving coverage at this time, I may only
request coverage for myself or myself and eligible dependents at an Open Enrollment Period or during a Special Enrollment Period. I understand
that if I am a retiree and I waive coverage, I will not be allowed to re-enroll or have my coverage reinstated at a later date. If you are waiving
coverage because you are currently covered under another health insurance policy, please complete Section D.
Enrollee Signature: _________________________________________________________
Date: ______________________________________
Section C: Coverage
Do you have Medicare?
Yes
No
Enrollee Type:
Coverage Type:
Coverage Option:
Medicare Number: ___________________________
(Choose Only One)
Employee - Legacy
Enrollee Only
“A” Effective Date: _________________________
Employee - Horizon
Enrollee + Spouse
Select
“B” Effective Date: _________________________
Retiree
Enrollee + Child
Reason for Entitlement:
COBRA
Enrollee + Children
Base
(HIGH DEDUCTIBLE)
Age
ESRD
Disability
Surviving Spouse
Enrollee + Spouse & Child(ren)
Are you a tobacco user?
Yes
No
If yes, are you interested in participating in the Plan’s free cessation program?
Yes
No
Section D: Other Coverage Information
Do any of the persons listed on this application have other health insurance coverage? Yes
No
If yes, please provide the following:
1.____________________
2.____________________
3.______________________ 4.___________________
Name of Individual Covered:
Policyholder’s Name:
_______________________
__________________________
__________________________
_______________________
Policyholder’s Date of Birth:
_______________________
__________________________
__________________________
_______________________
Policyholder’s Insurance
Effective Date:
_______________________
__________________________
__________________________
_______________________
Policy Number:
_______________________
__________________________
__________________________
_______________________
Policyholder’s Employment
Active, Retiree or COBRA
Active, Retiree or COBRA
Active, Retiree or COBRA
Active, Retiree or COBRA
Status:
Insurance Company Name
_______________________
__________________________
__________________________
_______________________
address & phone #:
_______________________
__________________________
__________________________
_______________________
_______________________
__________________________
__________________________
_______________________
_______________________
__________________________
__________________________
_______________________
Group
Non-Group
Group
Non-Group
Group
Non-Group
Group
Non-Group
Coverage Type:
Application for Coverage
Mississippi State and School Employees’ Health Insurance Plan
Health1 (1/17)
Enrollee Last Name:
First Name:
Enrollee SSN:
Section E: Dependents
Dependents to be Covered
Relation to
Social Security
Date of Birth
Address
Current Status
Enrollee
Number
(Last Name, First Name, MI)
(mm/dd/yyyy)
(if different from Enrollee)
1.
Spouse
?
Employed
Male
Yes
Female
No
2.
Son
Child under 26
Daughter
Disabled
3.
Son
Child under 26
Daughter
Disabled
4.
Son
Child under 26
Daughter
Disabled
Are any of the dependents listed above covered by Medicare Part A or Part B?
Yes
No
If yes, please provide the following:
Name
Medicare Number
Part A Effective Date
Part B Effective Date
Medicare Reason
_______________________
______________________
___________________
___________________
_____________________
_______________________
______________________
___________________
___________________
_____________________
_______________________
______________________
___________________
___________________
_____________________
Section F: Change Information
Add Enrollee:
Open Enrollment
Marriage
Birth
Adoption
Loss of Coverage due to Divorce
 Add Enrollee:
Other: _______________________________ Requested Effective Date: _________________________________
Add Dependent(s):
Open Enrollment
Marriage
Birth
Adoption
Other: ____________________________________
(List all dependents in Section E.)
Qualifying Event/ Effective Date: ___________________________
Change Coverage:
Base Coverage
Select Coverage
Drop Dependent(s):
Divorce
Deceased
Other: ________________________________________________________________
Provide information below for dependents to be dropped:
Name
Social Security Number
Requested Termination Date
___________________________________
______________________
_____________________________________
___________________________________
______________________
_____________________________________
___________________________________
______________________
_____________________________________
___________________________________
______________________
_____________________________________
Other Changes (Explain):
FOR EMPLOYER / ADMINISTRATOR USE ONLY:
GROUP NUMBER:___________________________
ENTERED BY: __________________
New Legacy Employee, Requested Effective Date: _____________________________________________
DATE: _________________________
New Horizon Employee, Requested Effective Date: _____________________________________________
Retiree, Requested Effective Date: ____________________________________________________________
VERIFIED BY: ___________________
COBRA, Requested Effective Date: ___________________________________________________________
DATE: __________________________
Surviving Spouse, Requested Effective Date: ___________________________________________________
Change(s), Requested Effective Date: _________________________________________________________
Print
Application for Coverage
Mississippi State and School Employees’ Health Insurance Plan
Health1 (1/17)
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