|
|
Enrollment Checklist
Download the Checklist
Proof of North Carolina Residency
Copy of current drivers license or state ID plus
one of the following:
•current rent or mortgage payment receipt
•voter registration card
•state income tax return
•property tax receipt
•utility bill
If the rent/mortgage or utility bill is in a spouse's or guardian's name, a birth certificate or marriage certificate is also required.
Checkbook and banking information
Proof of U S citizenship or Lawful Permanent Resident Alien
a. One of the following:
•social security card
•birth certificate
•passport
•naturalization/citizenship certificate
•green card
b. Pending green card (supply two documents)
•Employment Authorization Document (EAD)
•Advance Parole (temporary travel document)
Proof of Federally Eligible HIPAA individual:
a. Copy of a Certificate of Creditable Coverage showing 18 months of continuous coverage from your prior carrier
b. If your prior carrier has not provided you with a certificate, other examples of proof of prior coverage can include:
•Explanation of benefits or other correspondence from a plan or issuer indicating coverage
•Pay stubs showing a payroll deduction for health coverage
•Health insurance identification card
•Certificate of coverage for group health policy
Proof of creditable coverage to reduce pre-existing waiting period:
(if applicable)
a. Copy of a Certificate of Creditable Coverage showing the number of days of
continuous coverage from your prior carrier
b. If your prior carrier has not provided you with a certificate, other
examples of proof of prior coverage can include:
•Explanation of benefits or other correspondence from a plan or issuer indicating coverage
•Pay stubs showing a payroll deduction for health coverage
•Health insurance identification card
•Certificate of coverage for group health policy
Proof of Health Coverage Tax Credit (TAA or ATAA) or Pension Benefit Guaranty Corporation
a. Completed Supplemental TAA form
b. Copy of one of the following
•TAA Certification
•Health Coverage Tax Credit Certificate
•Proof of Pension Benefit Guaranty Corporation
Proof of Eligibility:
Letter from an individual health insurer that includes one of the following:
•Denial or rejection letter due to a medical condition from health insurer
•A conditional rider that would exclude coverage for a medical condition
•A Letter from your physician confirming diagnosis date for each one of the presumptive medical conditions
a. Disability Award Letter
b. COBRA or state continuation coverage (mini-COBRA) termination letter including reason for termination
c. Pre-existing condition waiting period letter from health carrier indicating when pre-existing condition limitation no longer
applies to you
d. Health Savings Account Banking Set-up form, if using HSA Banking option through Inclusive Health Plan
|
|
|
|
|
