Note: Please enter the [SSN] in accordance with [CMS] regulations. If it is not available (i.e. newborns/foreign nationals), you may leave the [SSN] field blank and Select Continue, but please provide this information when obtained.

Does the subscriber and/or dependent you are enrolling have current health coverage or had previous health coverage within the last 24 months with a break in coverage greater than 63 days? Please select 'No' if this is a new or renewing policy effective after 9/23/2010 and the enrollee is under the age of 19.

Use this only in cases where there is surviving spouse that will remain under the deceased's ID or power of attorney for a dependent child has been identified.

COBRA Definitions:

Select Self or Third Party Administered either when your company is collecting the monthly COBRA premium directly from the employee or COBRA is administered by an outside party.

Select UHC Administered (uhcservices.com) when your insurance carrier is administering COBRA services on your behalf and is collecting the premium or fee portion directly from the COBRA participant.

Please enter the number of hours the member works per week.

If dependent life products are available (based on your contract) the option to select these products will be provided upon submission of the enrollment.

Note:  Evidence of Insurability (EOI) may be required for the products you have selected.  Please review your Administrative Guide available from the home page of Employer eServices for additional details regarding your contract guidelines.

Part A - Is hospital insurance that helps cover inpatient care in hospitals, skilled nursing facility, hospice, and home health care.

Part B - Helps cover medically-necessary services like doctors' services, outpatient care, home health services, and other medical services. Part B also covers some preventive services. Check your Medicare card to find out if you have Part B.

Part D - Medicare prescription drug coverage is insurance run by an insurance company or other private company approved by Medicare. There are two ways to get Medicare prescription drug coverage:

Medicare Prescription Drug Plans.  These plans (sometimes called PDPs) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Medical Savings Account (MSA) Plans.

Medicare Advantage Plans (like an HMO or PPO) are other Medicare health plans that offer Medicare prescription drug coverage.  You get all of your Part A and Part B coverage, and prescription drug coverage (Part D), through these plans.  Medicare Advantage Plans with prescription drug coverage are sometimes called MA-PDs.

Type A - When this Dependent is covered under both employee and employee's spouse's insurance plan (married).

Type B - If the employee is awarded custody of this dependent and no other individual is required to pay for this dependent's medical expenses.

Type C - If this Dependent is covered by another individual (not a subscriber of the employee's household) and that individual is required to pay for this dependent's medical expenses.

Any changes or updates to the member's Medicare information, can be made on-line or can be submitted by the employee through the member portal.

Any changes or updates to the member's Other Medical Health Insurance (Non-Medicare) information cannot be completed on-line. Other Medical Health Insurance information changes or updates can be sent directly to your eligibility remit address or can be submitted by the employee through the member portal.

Any changes or updates to the member's Medicare information, can be made on-line or can be submitted by the employee through the member portal.

An ID card will be mailed to the member address on file within 5-7 business days.  If the member needs an ID card sooner, please have them visit MyUHC.com after 24-48 hrs to print a temporary ID card for immediate use.

"Enter the 1st day that the enrollee should not have coverage according to your contract guidelines.

Example: Employee's last day of employment was 5/17
        Contract stating date of event = termination date of 5/18
        Contract stating the end of the month = termination date as of 6/1"

Dependents of an Employee enrolled into COBRA will automatically be enrolled as a COBRA participant.   If a dependent wishes to continue on COBRA independent of the Employee, please enroll them as an Employee on COBRA on the plan.

Medicare Health Insurance Claim Number - The HIC is the Medicare identifier for Medicare beneficiaries.

COBRA Definitions:

Select Self or Third Party Administered either when your company is collecting the monthly COBRA premium directly from the employee or COBRA is administered by an outside party.

Select Carrier Administered when your insurance carrier is administering COBRA services on your behalf and is collecting the premium or fee portion directly from the COBRA participant.

* If you would like to add other insurance information for coordination of benefit purposes please contact 1-888-842-4571.

* If you would like to add other insurance information for coordination of benefit purposes please contact 1-800-936-6880.

Example:  Employee's last date of employment - 05/17

Date of event contract - end date should be 05/17

End of month contract - end date should be 05/31

For information regarding your eligibility contract guidelines please contact eligibility support.

An ID card will be mailed to the member address on file within 5-7 business days.  If the member needs an ID card sooner, please have them visit MyMedica.com after 24-48 hrs to print a temporary ID card for immediate use.

Does the member you are enrolling have 12 months of prior creditable coverage immediately preceding the enrollment date?  If so, please select "no" to indicate there is no Pre-X.  When answering this question, note that if the member has had any breaks in coverage of 63 days or greater, the coverage prior to the break does not count.  If the member does not have 12 months of creditable coverage, please click "yes" to indicate there is a Pre-X.  To comply with healthcare reform, always select "no" if the member is under the age of 19.