Application Agreement and Certification

I certify that I am a resident of Iowa or South Dakota, and I am legally authorized to apply for coverage for myself and on behalf of all other persons named in this application. I understand that I am applying for the Health Plan Options indicated on this application which are underwritten either by Wellmark, Inc., doing business as Wellmark Blue Cross and Blue Shield of Iowa, or Wellmark Blue Cross and Blue Shield of South Dakota, or Wellmark Health Plan of Iowa, Inc., Wellmark Synergy Health, Inc., or Wellmark Value Health Plan, Inc. (collectively "Wellmark"). I further understand that coverage applied for will not start until this application and the appropriate premium amount is received and accepted by Wellmark, an effective date of coverage is established, and Wellmark reviews and approves this application and notifies me of approval of coverage.

If I am electing Health Plan Options offered by Wellmark Health Plan of Iowa, Inc., Wellmark Synergy Health, Inc., or Wellmark Value Health Plan, Inc., and am an Iowa resident, I understand that as a condition of eligibility for benefits under the coverage specified in this application, each person named in this application must maintain his/her residency in an Iowa county where the plan I’ve selected is offered by Wellmark. I understand that some of Wellmark’s plans are not available in all counties. Failure to maintain such residency by any person named in this application will give Wellmark the right to terminate the coverage specified in this application by giving that person not less than thirty (30) days' notice in advance of termination of coverage and benefits will be denied unless the medical services are related to emergency services or an accidental injury.

The statements and answers set forth in this application are full, true, and correct. I have consulted with each other person named in this application to confirm that information about them is full, true, and correct. I understand that Wellmark will rely on the completeness and truthfulness of the information given in the statements made in this application or by telephone or in writing to Wellmark, and that if I performed an act, practice, or omission that constitutes fraud or I have made an intentional misrepresentation of material fact in this application, Wellmark will be entitled to declare coverage applied for void and to refuse allowance of benefits to any person thereunder.

Coverage effective date

For Open Enrollment, effective dates are based on Wellmark receipt date as follows:

For special Enrollment Events, effective dates are based on Wellmark receipt date as follows:

Applications received between the 1st and the 15th of the month will have an effective date of the first of the month following receipt date. Applications received between the 16th and the end of the month will have an effective date of the first of the second month following receipt date. Exceptions are birth, adoption/foster care, legal guardianship, or court ordered coverage, and foster placement. For these events, coverage effective date is the date of the event. Some effective dates may result in a period of time where you don’t have health insurance coverage. If you experience a gap in coverage, your annual deductible and out of pocket maximum amounts will not be carried over to your new plan. If you want continuous coverage, please call Wellmark within 60 days of enrollment, and Wellmark will coordinate your effective dates to offer continuous coverage. Standard documentation and notification timelines apply.

Tobacco user status

If I answered "No" to the Tobacco Declaration for any person age 18 and over listed on this application, that person is eligible for a special tobacco non-user rate. If this status changes, I must notify Wellmark immediately. Wellmark may require me to recertify this status in the future. If Wellmark determines within the initial two years that this status is incorrect, Wellmark will retroactively collect historical differences in premiums before claims will be paid and the tobacco user rate will be applied on the first of the month following receipt of this information.

Eligibility

If I become enrolled in Medicare during the term of this benefits policy, I understand that this benefits policy will provide benefits secondary to Medicare unless application of federal law determines this benefit policy must provide benefits primary to Medicare.

Dental exclusion periods (Iowa only)

In the event I have selected Blue DentalSM coverage on this application, which is underwritten by Wellmark, Inc., doing business as Wellmark Blue Cross and Blue Shield of Iowa, I certify that I have been informed that there will be a six-month exclusion period before benefits are available for basic restorative services including, but not limited to, fillings, extractions, and oral surgery, and a 12-month exclusion period before benefits are available for major restorative services including, but not limited to, endodontics, periodontics, crowns, onlays, and inlays. I understand these dental coverage exclusion periods may not be waived or reduced even if I or any other person named in this application have qualifying existing coverage or qualifying previous coverage.

myBlue HSA℠

In the event I have selected myBlue HSA℠ coverage on this application, I understand that enrolling in myBlue HSA℠ coverage does not guarantee that I am or will be eligible to make contributions to a health savings account or that contributions can be made to a health savings account on my behalf. I understand that child-only contracts are not eligible for health savings accounts.

If I answered "yes" to authorize WageWorks to contact me, I will receive guidelines and instruction from WageWorks for completing the opening of my HSA account. Please review enrollment materials carefully; it is the individual’s responsibility to validate eligibility for an HSA account. You may be required to disclose additional information such as a residential address to establish the HSA bank account. Questions regarding eligibility can be directed to WageWorks.

This authorization is voluntary. Wellmark will not condition my enrollment in a health plan, eligibility for benefits or payment of claims on giving this authorization. The information described above will be disclosed to an organization that is subject to federal health information privacy laws. The authorization will remain in effect until my information is submitted to WageWorks. I may revoke this authorization at any time by giving written notice to Wellmark, Inc. The revocation of this authorization will not affect any information disclosed to WageWorks before the revocation was received.

Release of medical information

I authorize any health care provider, including but not limited to; surgeon, physician, psychologist, nurse, social worker, or health care facility to release to Wellmark all health and mental health records protected by Federal or State law relating to AIDS or AIDS related complex, mental health and substance abuse, the past, present, or future treatments or conditions for myself or for my dependents eligible for health care coverage. I further agree upon request to furnish Wellmark with information required to administer the requested coverage.

I understand that I have the right to revoke this authorization in writing at any time by delivering such written notification to the requestor. I understand that a revocation is not effective until received by the requestor. I further understand that any revocation is not effective to the extent that Wellmark or the Provider have relied on it in the use or disclosure of protected health information.

This form does not authorize the redisclosure of medical information. Federal and State regulations do not allow further disclosure of mental health, substance abuse and AIDS/HIV related information. Wellmark maintains the confidentiality of all information received and it will not be released to any person or facility.

The protected health information described above may be disclosed to and/or received by persons or organizations that are not health plans, covered health care providers or health care clearinghouses subject to federal health information privacy laws. They may further disclose the protected health information, and it may no longer be protected by federal health information privacy laws.

I understand that I have the right to refuse to sign this authorization, but that Wellmark will then have the right to condition eligibility determination and enrollment on the receipt of this signed authorization.

Providing social security numbers or tax identification numbers

In order for Wellmark to report my coverage status to the federal government, I must provide to Wellmark my Social Security number or tax identification number and the Social Security numbers or tax identification numbers of all members covered under my coverage. The IRS requires that Wellmark report this information using the Social Security number or tax identification number of the plan member and each dependent. If Wellmark does not have Social Security or tax identification numbers, I understand Wellmark will be unable to report and send the information needed to complete federal tax returns. If I have not previously provided Social Security numbers or tax identification numbers to Wellmark for all members covered under my coverage, I will contact Wellmark by calling the Customer Service number on my ID card. If I do not provide the Social Security numbers or tax identification numbers to Wellmark for this purpose, I may be subject to a $50 penalty per violation imposed by the Internal Revenue Service. 

Payment arrangements

Payments for premiums and fees may be made on a calendar month, calendar quarter, semi-annual calendar year or calendar year basis. For example, a monthly payment for premiums and fees would be for the first day of a month through the last day of such month. A quarterly payment would be for any calendar quarterly period, such as January 1 through March 31. A semi-annual payment would be for the period of either January 1 through June 30 or July 1 through December 31. An annual payment would be for January 1 through December 31 of the applicable year.

In the event I choose to pay my premium and fees on a quarterly, semi-annual, or annual basis and there is a mid-year increase in the amount of premium(s) and/or fees, I will have the following responsibility with regard to an increase in premium(s) and fees:

• Quarterly Payments: For quarterly payments, I must pay the remaining quarterly premium and fee payment that includes the premium and fee increase.
• Semi-Annual Payments: For semi-annual payments, I must pay a bill for a premium and fee payment that equals the difference between the new semi-annual premium and fee amount and the previously paid first semi-annual premium and fee amount. I also will be required to pay a second semi-annual premium and fee amount that includes the premium and fee increase.
• Annual Payment: For annual payments, I must pay a bill for a premium and fee payment that equals the difference between the new annual premium and fee amount and the previously paid annual premium and fee amount.

I understand and agree that Wellmark can change my payment amount at any time and the amount of my periodic premium payment and fee payment, will change as provided in the policy being applied for and from time to time based on changes in my coverage, including but not limited to, changes in benefits, payment obligations (such as deductible, coinsurance and copayments), the number of covered family members, members’ ages, changes in tobacco user status, or other factors that require adjustments to the total premium and fees. These changes may occur at times other than an annual or other policy renewal.

If I have elected to authorize automatic premium withdrawals for payment from a deposit account, I understand that, depending upon the timing of when my application is received and processed, Wellmark reserves the right to withdraw the appropriate amount necessary (including multiple months of payments) to bring my account current with the next regularly scheduled automatic payment. Wellmark will not withdraw any amount above that which is due at the time of withdrawals. Notice may not be provided to me prior to this withdrawal. I understand and agree that I will not receive a paper billing statement but that should I want to be notified of amounts being withdrawn, I can do so by viewing my bill on Wellmark.com prior to my chosen withdrawal date. By visiting Wellmark.com, I can also choose to subscribe to an email notifying me when new billing statements are available which will include my withdrawal amount.

I further understand and agree that the automatic withdrawal will change periodically to correspond with the applicable premium and fees. My authorization for automatic withdrawals shall include authorization for automatic withdrawal of any changed amount unless I call or provide my bank with written notice not less than three (3) business days before a scheduled withdrawal to stop the payment. If I call my bank to stop payment, I may be required to provide a written request within fourteen (14) days after my call. I will be responsible for any fee assessed by my bank for stop-payment orders that I make. I may also be charged a returned payment fee of $25 for any automatic withdrawal that is not honored by my bank.

The Member may cancel automatic payment or provide the Member’s new/updated banking information any time by notifying Wellmark in writing or by calling the number on the Wellmark ID card by the 10th of the month prior to the next scheduled withdrawal. A Bank Account Holder other than the Member must provide written notification by the 10th of the month prior to the next scheduled withdrawal in order to cancel automatic payment or provide new/updated banking information. If the request is not received by the 10th of the month prior to the next scheduled withdrawal, request may not be processed before the next withdrawal. The Member or Bank Account Holder will be responsible for any fee assessed by the bank for insufficient funds or stop-payment orders made.

If at any time the Member’s account falls behind in payments, Wellmark reserves the right to withdraw any amount necessary, including fees, to bring the Member’s account current with the next regularly scheduled automatic payment. Wellmark will not withdraw any amount above that which is due at the time of withdrawal; notice may not be provided to either the Member or the Bank Account Holder prior to said withdrawal.

I also understand and agree that, if I am applying for coverage within 60 days of a premium change with an effective date prior to the premium change, Wellmark will provide notice of the new rate within a reasonable period of time after the enrollment of my application.

Coverage renewability

I understand that coverage is automatically renewed by payment of my premium and fees in advance; that a grace period of 31 days will be granted for the payment of each premium and fee due after the first premium and fees; and that, during this grace period, my policy will continue in force.

I understand that Wellmark may terminate my policy if:

• I fail to pay my premium and fees when due; or
• I fraudulently use my policy or make an intentional misrepresentation of a material fact under the terms of my policy; or
• I become ineligible for coverage under this policy; or
• Wellmark decides to terminate coverage of similar policies by giving written notice prior to termination. In the event Wellmark terminates individual policies of the same coverage, I will be allowed to transfer to the offered replacement policy.
• I change my residence from the geographic service area served by my selected plan.

Acknowledgment

I have read and understand the Summary of Benefits and Coverage and each provision of this application, including, but not limited to the sections entitled "Notice to Applicant Regarding Replacement of Accident and Sickness Insurance" and "Application Agreement and Certification."

I acknowledge I have received a Summary of Benefits and Coverage with this application if completed online through Wellmark.com. If a Wellmark appointed insurance producer or Wellmark representative assisted me with the application process, I have been advised I will receive a Summary of Benefits and Coverage within seven business days following the date the insurance producer or Wellmark representative signs this application.

I understand that I am not able to apply for coverage outside of open enrollment unless I had a qualifying event. If I am enrolling outside of the annual open enrollment period, I attest that I am eligible for coverage based upon a qualifying event. I understand that Wellmark can request additional documentation at any time to verify the special enrollment event.

I hereby confirm the authority of Wellmark to make automatic withdrawals from my deposit account as set forth above under "Payment Information," and that this authorization supersedes and replaces any previous authorization given by me with respect to such authority.

I have confirmed with all persons named in this application that my signature is binding to secure coverage. I have further confirmed with all persons named in the application that in the event I am not eligible for or removed from the coverage and/or the family coverage is divided into multiple policies, my signature is binding to secure coverage. Any payment will be deposited immediately upon Wellmark’s receipt of this application.

The information in this application is correct to the best of my knowledge. I understand that if I intentionally provide false information in this application, I will be disenrolled from the plan.

Consent to receive marketing iInformation and solicitations via residential telephone, cellular phone, text, and email messages

By checking the box later in this application, and entering my signature on this application, I hereby provide my consent to Wellmark to contact me about Wellmark products and services that may be available to me. Wellmark may provide this information to me using residential telephone, cellular telephone or wireless device, text message, or email contact information provided to Wellmark from time to time. If I provide a telephone number for voice calls, I understand that Wellmark may contact me via live or prerecorded calls. I give Wellmark permission to use my personal data (including personally identifiable information) in accordance with Wellmark's privacy policy to determine the types of products and services that may be offered to me. I understand the telephone company or other communications carrier may impose charges for these contacts and that I am not required to give this consent to purchase any goods or service. I understand I may revoke this consent at any time by calling 800-819-0893.

Consent to electronic delivery of information

By checking the box in this application, and entering my signature on this application, I hereby provide my consent to Wellmark to deliver important notices and information about my health plan and coverage electronically. I understand I am being asked to consent to notices and documents being delivered to me electronically. My consent applies to notices and documents relating to my health insurance coverage ("Coverage") with Wellmark.

Right to Request for Paper Copies

I understand that I have a right to have a notice or document provided or made available in paper form at no cost. To obtain a paper copy of a notice or document delivered by electronic means, or to withdraw consent, please contact Wellmark at 800-819-0893.

Right to Withdraw Consent

I understand I have a right to withdraw consent to have a notice or document delivered by electronic means. Such consent will be deemed withdrawn upon receipt by Wellmark of the request to withdraw consent. Any withdrawal of consent shall not affect the legal effectiveness, validity or enforceability of a notice or document delivered by electronic means before the withdrawal of consent is effective. To withdraw consent to electronic notice of documents please contact Wellmark at 800-819-0893 or select the "unsubscribe" option located within the email message.

Scope of Consent

This consent applies to all notices and documents relating to my Coverage, including, but not limited to:

• Explanation of Benefits; 
• Disclosures and notices;
• Notices of cancelation, nonrenewal or termination;
• Policy contract, riders and endorsements;
• Responses to communications from you;
• Appeals correspondence;
• Billing and payment notices; and
• Other important information

Hardware and Software Requirements

In order to access, view, and retain documents electronically, I understand I must have, or have access to, a personal computer or other device that is capable of accessing the internet with an internet web browser, email or web service capabilities, the ability to receive and review attachments to emails, and software which permits me to receive and access Portable Document Format (PDF) files and MS Word files. Free software to view PDF files is available from: http://get. adobe. com/reader/. By providing this Consent, I confirm that I have, or have access to, the hardware and software identified above necessary to receive and review electronic records, and that I have an active email account with the ability to receive and access emails and email attachments in the formats described above.

Notice/Disclaimer

WELLMARK IS NOT RESPONSIBLE FOR ANY UNAUTHORIZED ACCESS BY THIRD PARTIES TO INFORMATION PROVIDED ELECTRONICALLY, INCLUDING, WITHOUT LIMITATION, ANY DIRECT, INDIRECT, SPECIAL, INCIDENTAL OR CONSEQUENTIAL DAMAGES RESULTING FROM SUCH UNAUTHORIZED ACCESS. WELLMARK ALSO IS NOT RESPONSIBLE FOR DELAYS IN TRANSMISSION OF NOTICES AND DOCUMENTS.

Consent

By accessing or opening the documents sent to me via the email address provided, I certify that (1) I consent and agree to receive notices and documents electronically and confirm that I will download or print them for my records; and (2) I have the ability to access the information that is provided electronically via email communications