Forms

Important information about the Individual product quoting process

Applications

Forms

Visit this page to learn about all the ways individual members can pay their bill. 


*Please note: Effective immediately, discontinue the use of the “Request for Premium Rate Reduction in Health Status” or “Tobacco Cessation Medical Questionnaire” for existing Medicare Supplement contracts and begin using the new process outlined below:

  • Member will complete a new Application for Medicare Supplement, to apply for a reduction in premiums for non-tobacco use.
    • Please ensure the member thoroughly completes all sections of the application, including tobacco and health questions, as it will be subject to underwriting.  
    • BCBSNE will review the member’s application and claim history. 
    • BCBSNE will communicate the results of the review 
      • If the member passes underwriting, a communication will be sent to the member advising them of the rate reduction.
      • If the member does not pass underwriting, a communication will be sent to the member advising of the denial.


    Individual product quoting process

    Starting August 1, 2017, you will need to manually calculate rates for: 
    • 2017 Individual ACA medical products
    • DentalEssentials products

    How to calculate rates for 2017 ACA medical products

    Use the 2017 Individual Product Rate book to calculate rates for individual ACA medical products.

    How to calculate rates for DentalEssentials products

    Use the DentalEssentials brochure. 

    New members must pay three months’ initial premium. Existing members switching to a different option are not required to submit a three-month premium payment. 

    There is no cap on dependents, so each dependent will be charged a monthly rate. 



    Here are the rates for individual dental:





      Option 1



    Option 2



    Option 3



    Option 4



    Adult < 55   $30.91



     $24.93



     $35.55



     $28.67



    Adult 55+



     $41.26



     $28.68



     $47.45



     $32.98 



    Dependents



     $31.29



     $30.82



     $35.99



     $35.45

    Here are some examples for how to calculate rates for a DentalEssentials quote: 



    New dental quotes:



    Example 1: Subscriber age 40, Spouse age 42, three children (any age up to 26), selecting Option 1

    Subscriber, age 40



    $30.91



    Spouse, age 42



    $30.91



    Three children ($31.29 x 3)



    $93.87



    Total monthly premium



    $155.69



      Three month premium due with application



    $467.07




    Example 2: Subscriber age 55, spouse age 53, two dependents, selecting Option 2

    Subscriber, age 55



    $28.68



    Spouse, age 53



    $24.93



    Two children ($30.82 x 2)



    $61.64



    Total monthly premium



    $115.25



      Three month premium due with application 



    $345.75




    Changing plans:



    Example 1: Subscriber age 42, one child, moving from Option 2 to Option 1
      Option 2 Rate



    Option 1 Rate 
    Subscriber, age 42



     $24.93



     $30.91



    One child ($30.82 x 1)



     $30.82



     $31.29



     Total



     $55.75



     $62.20




    Example 2: Subscriber age 60, spouse age 60, moving from Option 1 to Option 4

      Option 1 Rate



    Option 4 Rate



    Subscriber, age 60



     $41.26



     $32.98



    Spouse, age 60



     $41.26



     $32.98



    Total



     $82.52



     $65.96





    If you have any questions, please contact a member of your BCBSNE sales or account service team. 



HEALTH INSURANCE TERMS


COINSURANCE

The percentage of the bill you pay after your deductible has been met.

COPAY

A fixed amount you pay when you get a covered health service.

Tiered benefit plan

A health care plan featuring multiple levels of benefits based on the network status of a particular provider. 

DEDUCTIBLE

The annual amount you pay for covered health services before your insurance begins to pay.

emergency care services

Any covered services received in a hospital emergency room setting.

SUBSTANCE ABUSE DISORDER SERVICES

Includes behavioral health treatment, counseling, and psychotherapy


in-network provider

A provider contracted by your insurance company to accept an agreed upon payment for covered services. 

OUT-OF-network provider

A term for providers that aren’t contracting with your insurance company. (Your out-of-pocket costs will tend to be more expensive if you go to an out-of-network provider.)

out-of-pocket

Your expenses for medical care that aren’t reimbursed by insurance, including deductibles, coinsurance and co-payments.

penalty

If you can afford health insurance, but choose not to buy it, you must have a health coverage exemption or pay a tax penalty on your federal income tax return.

premium

The amount you pay to your health insurance company each month. 


Preventive services

Health care services that focus on the prevention of disease and health maintenance.

rehab SERVICES

Services and devices to help you recover if you are injured or have surgery. This includes physical, occupational and speech therapy.

special enrollment period

The time after the Open Enrollment Period when you can still purchase health insurance only if you have a qualifying life event (losing other health coverage, having a baby, getting married, moving).

specialist

A physician who has a majority of his or her practice in fields other than internal or general medicine, obstetrics/gynecology, pediatrics or family practice.