Underwriting Change Form | Individual/Family Health Insurance

UndCF (R01-24) Page 1 of 13

Underwriting change form | Individual/Family health insurance

Read all instructions before completing this change form. The change form must be

completed in its entirety and all pages must be submitted in order to be processed.

¡ This form is a legal document. If you are approved for coverage, it will become a part of your contract.

Therefore, all information provided must be accurate and legible.

¡ This form must be completed in dark blue or black ink. Forms completed in pencil will not be accepted.

¡ If you make a mistake, mark through the incorrect information, initial it, date it, and provide the correct

information.

¡ Do not use liquid paper, correction tape, or “white out” to correct any mistakes on this form.

Instructions

When you are completing this form, please refer to your Arkansas Blue Cross and Blue Shield identiﬁcation card

for your Member ID and Group Number. This information must be entered correctly under Section 1 in order to

process your request.

Effective Date: Approved changes become effective on the 1st of the month. The effective date for any changes

will be the next available effective date following approval, unless otherwise requested.

00127.05.02-0423

UndCF (R01-24) Page 2 of 13

Changes to your policy can only be made during the annual open enrollment period (October 1-December 15), unless the

change is a result of a qualifying life event such as birth of a child, adoption, loss of other coverage, marriage, etc.

Section 1

Current policyholder information

When you are completing this form, please refer to your Arkansas Blue Cross and Blue Shield identiﬁcation card for your

Member ID and Group #. This information must be entered correctly under Section 1 in order to process your request.

Member ID Group number Date of birth

First name M.I. Last name Social Security No.

Residential Street City State ZIP

Section 2

Contact information*

Primary phone number Alternate phone number Email address

How do you prefer we communicate with you?

Phone

*Arkansas Blue Cross and Blue Shield may contact you, either directly or through a business associate, using your postal or email addresses,

telephone numbers or other personal information, regarding your health insurance plan, healthcare providers participating in our networks,

disease management, health education and health promotion, preventive care options, wellness programs, treatment or care coordination or

case management activities of Arkansas Blue Cross and Blue Shield or Health Advantage.

Section 3

U.S. citizenship status

¡ For any applicant who is not a U.S. citizen, a copy of his/her Permanent Resident VISA or Green Card issued by the U.S.

Citizenship and Immigration Services may be required with the application.

¡ Applicants must reside in the U.S. at least one year and must have a primary care physician in the U.S. prior to being

eligible to apply for coverage.

Yes No

Are all applicants U.S. citizens? If “No”, please provide the name(s) of the applicant(s) who are

not U.S. citizens.

Name

Type of Permanent Visa or Permanent Green Card

USCIS Category Registration No. Issue Date (Mo. Day Yr.) Expiration Date (Mo. Day Yr.)

Yes No Have all applicants applying for coverage resided in the U.S. for at least 12 continuous months? If

“No”, please provide the name(s) of the applicant(s) who have not resided in the U.S. for at least 12

continuous months.

Name:

Yes No Do all applicants applying for coverage have a Primary Care Physician established in the U.S.? If “No”,

please provide the name(s) of the applicant(s) who do not have a Primary Care Physician established

in the U.S.

Name:

UndCF (R01-24) Page 3 of 13

Changes to be made.

Please review all sections and answer all applicable questions.

Section 4

Policy change eligibility

Check all applicable boxes below that support your eligibility and provide date of qualifying life event.

Date Date

1–Annual Open Enrollment Period: 10/1 – 12/15

2–Birth

8–Loss of employer-sponsored health coverage*

3–Adoption

9–Involuntary loss of other health coverage*

4–Death

10–Military Leave

5–Marriage

11–Military Reinstatement

6–Divorce or Legal Separation

12–Eligible for other coverage*

7–New Guardianship/Legal

Custody/ Court Order to Add Child

13–Other (Give speciﬁc details and date)

NOTE: If application is not received during the Open Enrollment Period, we must receive appropriate documentation with this application to

conﬁrm qualifying life event/special election period (i.e. copy of marriage license, Certiﬁcate of Creditable Coverage from previous insurance

company, legal guardianship/custody documentation, etc.).

*If you are adding a spouse or dependent who is losing coverage of an existing insurance, please apply prior to the current policy end date to

avoid a lapse in coverage. Please refer to Section 7 for more details.

Section 5

Policy appeal

Request for reinstatement:

Remove tobacco surcharge:

Name Date quit

Remove other surcharge:

Name

Remove exclusion:

Name Excluded condition

Section 6

Add spouse or dependent(s)

Qualifying life event changes allow you to make changes to your policy outside of the annual open enrollment

period. Such events include, but are not limited to:

Obtaining guardianship, legal custody of a child, or court order requiring coverage for a dependent (requires

proof of guardianship, legal custody or court order)

Loss of Eligibility (requires a Certiﬁcate of Creditable Coverage referred to as COCC)

Marriage (requires a copy of the marriage certiﬁcate)

First name M.I. Last name Sufﬁx Relationship Sex

Date of

birth

(mm/dd/yyyy)

Social

Security

number

Height Weight

ft. in. lbs.

UndCF (R01-24) Page 4 of 13

Section 7

Current insurance coverage

Yes No a. Will the coverage applied for replace or change current hospital, medical or major medical

insurance if this coverage is approved by Arkansas Blue Cross and Blue Shield and accepted by

the applicant?

i. If “yes,” please provide name of carrier:

ii. If “yes,” does the coverage have a speciﬁed termination date? If so, please provide date:

iii. If “yes,” and the coverage does not have a speciﬁed termination date, will the coverage

terminate if approved by Arkansas Blue Cross and accepted by the applicant?

Yes No b. Have any applicants recently lost employer-sponsored health coverage?* If “yes,” please provide:

Name Carrier name Termination date

Yes No c. Have any applicants recently “involuntarily” lost other health coverage?* If “yes,” please provide

Name Carrier name Termination date

Yes No d. Will any applicants be continuing any other health insurance? If “yes,” please provide:

Name Carrier name ID #

Yes No e. Are any applicants covered by Medicaid (including AR Kids First)? If “yes,” please provide name(s)

below:

Name:

Yes No f. Are any applicants covered by or eligible for Medicare Part A or Part B or Medicare Advantage (Part

C)? If “yes,” please provide name(s) below:

Name:

*When your current policy ends, you may be given a Certiﬁcate of Creditable Coverage (COCC). A COCC is issued

by your previous health insurance company and provides proof of prior coverage. Once you receive a COCC,

please provide us a copy.

Section 8

Household information

Yes No a. Do all applicants under the age of 19 reside in the same household? If “no,” please provide reason

and his/her name and address:

Name:

Address:

Reason:

Yes No b. Are all applicants permanent, legal residents of Arkansas? If “no,” please provide reason and his/her

name and address:

Name:

Address:

Reason:

UndCF (R01-24) Page 5 of 13

Section 9

Applicant(s) employment information [applicant(s) age 18 and older]

Name Employer

Job Duties

Name Employer

Job Duties

Section 10 | Add maternity

If your product is not listed, adding maternity is not an option.

BlueCare PPO Plus*

Blue Choice**

Blue Solution PPO*

Comprehensive Blue PPO**

*Must be prior to conception – cannot be pregnant prior to the effective date of maternity coverage.

**These plans have a 12-month waiting period before the maternity beneﬁts will be covered.

Section 11 | Beneﬁt changes

¡ Section 11 reﬂects beneﬁt options available for all individual policies. Please complete only the section for

your speciﬁc policy.

¡ If you are unsure of your product name, use the product group numbers listed as a reference. Your product

group number can be found on your identiﬁcation card under Group #. It will be the ﬁrst six numbers

before the dash.

¡ Note: Only decreases to policy limits are allowed in the sections below. To increase policy limits, please ﬁll

out an new application.

¡ If you still have questions, call customer service at 1-800-238-8379.

¡ BLUECARE PPO PLUS

Your Group # on your ID card will be one of these:

600030-600036 (grandfathered)

Decrease my calendar-year deductible to: $500 $1,000 $1,500

Decrease my calendar-year coinsurance maximum to: $1,000 $2,000

Sample Identiﬁcation Card

Group #

Product Name

Member Name:

JOHN DOE

Member ID:

XCK900000000

Dependents

02 BILL 02/01/2012

03 JACK 03/01/2015

04 JILL 07/01/1995

Member DOB:

01/01/1987

Group #

000000-1

RxBIN: 004336

RxPCN: ADV

RxGRP: RX3850

PCP CoPay: $30

Rx: Value Formulary

COMPREHENSIVE BLUE PPO III

UndCF (R01-24) Page 6 of 13

¡ BLUE CHOICE

Your Group # on your ID card will be one of these:

771000-771123 (grandfathered)

Decrease my calendar-year deductible and beneﬁt to:

$500 Deductible options

$1,000 out-of-pocket coinsurance maximum

$2,000 out-of-pocket coinsurance maximum

$1,000 Deductible options

$1,000 out-of-pocket coinsurance maximum

$2,000 out-of-pocket coinsurance maximum

$2,500 Deductible options

No out-of-pocket coinsurance

$2,000 out-of-pocket coinsurance maximum

$5,000 Deductible options

$30/$50 copay No physician copays*

$10,000 Deductible options

$30/$50 copay No physician copays*

$25,000 Deductible options

$30/$50 copay No physician copays*

*Physician visits subject to deductible.

¡ BLUE SOLUTION PPO

Your Group # on your ID card will be one of these:

780000-780003 (grandfathered)

Decrease my calendar-year deductible to: $750 $1,500 $3,000

¡ COMPREHENSIVE BLUE PPO

Your Group # on your ID card will be one of these:

390000 – 390007 or 391000 – 398000 (non-grandfathered)

790000 – 790007 or 791000 – 798000 (grandfathered)

Decrease my calendar-year deductible to:

$500 $1,000 $2,500 $5,000 $10,000 $15,000 $20,000

¡ COMPREHENSIVE BLUE PPO III

Your Group # on your ID card will be one of these:

790008-790016 (non-grandfathered)

Decrease my calendar-year deductible to:

$1,000 $1,500 $2,500 $5,000 $7,500 $10,000 $15,000 $20,000

Section 12 | Driver’s license information [applicant(s) age 14 and older]

Name License number State

In the past 5 years, has any applicant:

Yes No a. Had his or her driver’s license suspended or revoked?

Yes No b. Had two or more moving trafﬁc violations?

Yes No c. Been convicted or charged with driving under the inﬂuence of alcohol or a controlled substance?

If you answered “yes,” to any of the above questions, you MUST provide the following

information:

Name Date Violation(s)

UndCF (R01-24) Page 7 of 13

Section 13 | Sporting or hobby information

Yes No Does any applicant intend to pilot a private aircraft; race a motor vehicle, boat or snowmobile;

or participate in sky or scuba diving, ballooning, mountain climbing, hang gliding or any other

hazardous sport, hobby or activity?

Name:

Please explain:

Name:

Please explain:

Section 14 | Travel outside the USA

Yes No Is any applicant planning to travel or work outside the USA within the next two years? If “yes,”

please provide the following:

Name (list all that apply)

Country Expected length of stay Departure date Return date

Reason for travel

Section 15 | Expectant/adoptive parent information

Yes No Is any male applying for coverage an expectant father or a potential adoptive father?

Yes No Is any female applying for coverage pregnant or a potential adoptive mother?

If “yes,” please provide the following:

Name:

Expected delivery/Adoption date:

Section 16 | Infertility

Has any applicant or spouse of an applicant (whether applying for coverage or not):

Yes No a. Ever been diagnosed or treated for infertility?

Yes No b. Had surgical sterilization? If “yes,” please provide the following:

Name Treatment/Procedure Date

Section 17 | Tobacco usage

Yes No Has any applicant to be covered used any form of tobacco or nicotine supplements/cessation

products within the last 12 months? If “yes,” please provide the following:

Name Type/amount Date last used

UndCF (R01-24) Page 8 of 13

Section 18 | Previous insurance experience

Yes No Has any applicant ever been declined, rated, restricted or modiﬁed for the issuance of life,

accident, health or long-term care insurance? If “yes,” please provide the following:

Name Carrier name Year Details

Section 19 | Prescription questionnaire

Yes No Is any applicant currently taking any prescription medication, or has any applicant taken prescription

medication in the last 3 years?

If you answered “yes,” please provide full details below. Use separate sheet if necessary. Any attachment must

include all of the same information requested here and must be signed and dated. A printout from the pharmacy

is not acceptable.

Please provide the name that would have been used at the time of the prescription (e.g., a maiden name may

have been used).

Person treated

Name of

drug

Dosage

Speciﬁc disorder

or illness

Start date/

stop date

Degree of recovery:

Complete name and

address of prescribing

physician

None Partial Full

month year

UndCF (R01-24) Page 9 of 13

Section 20 | Medical questionnaire

All of the following questions must be answered for each person applying for coverage.

For each question checked below, give full details in the ADDITIONAL MEDICAL INFORMATION section which follows.

1. Has any applicant ever had or been told he/she had: (Each section must have at least one box checked. When

multiple medical conditions are listed, please CHECK all conditions that apply.)

A. Brain or nervous system disorders

Alzheimer’s disease or senile dementia

Amyotrophic lateral sclerosis

(Lou Gehrig’s disease)

Cerebral palsy

Concussion or brain injury

Convulsions, epilepsy or seizures

Headaches or migraines

Meningitis

Multiple sclerosis, muscular dystrophy or

myasthenia gravis

Neuritis

Paralysis or palsy

Parkinson’s disease

Polyneuritis

Vertigo, fainting or dizziness

Any other disorder of the brain or nervous

system

None of the above apply to any applicant(s)

B. Circulatory

Abnormal cholesterol/lipids

Angina, heart attack, myocardial infarction

Arteriosclerosis, atherosclerosis, coronary

artery disease, stent placement or

angioplasty

Cerebrovascular accident (stroke), including

transient ischemic attack (TIA)

Chest pain, shortness of breath, heart

murmur, palpitation of the heart, ablation

and rheumatic fever

Heart bypass surgery/pacemaker implant

Heart or vein/artery surgery

High blood pressure

Hemophilia

Valve repair/replacement

Any other disorder of the heart, blood,

blood vessels or circulatory system

None of the above apply to any applicant(s)

C. Digestive

Cirrhosis

Crohn’s disease or ulcerative colitis

Gastric bypass surgery or other weight loss

procedure

Gastric or duodenal ulcer

Hepatitis

Hernia/hemorrhoids

Irritable bowel syndrome or gastric

esophageal reﬂux disorder (GERD)

Pancreatitis

Pyloric stenosis

Any other disorder of stomach, intestines,

liver, gallbladder or rectum

None of the above apply to any applicant(s)

D. Kidney, urinary, reproductive

Abnormal pap smear

Bladder or renal stones

Cesarean section or miscarriage

Dialysis

Nephritis

Nephrotic syndrome, renal disease or

failure

Sexually transmitted disease

Sugar, blood or protein in urine

Any other disorder of the kidneys or urinary

tract

Any other disorder of the male reproductive

organs, including prostate

Any other disorder of the female

reproductive organs, including ovaries or

breasts

None of the above apply to any applicant(s)

E. Respiratory

Allergies, asthma or bronchitis

Chronic pulmonary disease, emphysema,

lung disease or respiratory syncytial virus

(RSV)

Obstructive or reactive airway disorder

Sleep apnea, cpap, bipap or vpap

Any other disorder of the lungs, bronchial

tubes or respiratory system

None of the above apply to any applicant(s)

F. Cancers, lymphatic system, blood or skin

disorders

Anemia

Cancer, leukemia or malignancy of any kind

Hodgkin’s or Non-Hodgkin’s disease

Melanoma, neoplasm or tumor

Any other disorder of the lymphatic system

Any disorder of the skin

None of the above apply to any applicant(s)

G. Glandular disorders

Adrenal disorders

Diabetes, abnormal glucose

Goiter or thyroid disease

Any disorder of the pancreas

None of the above apply to any

applicant(s)

H. Musculoskeletal

Arthritis, osteoarthritis, degenerative joint

or disc disease

Back pain and/or neck pain

Chronic fatigue

Connective tissue disorder

Disease or disorder of the joints: knee(s),

shoulder(s), elbow(s), wrist(s), other

H. Musculoskeletal (continued)

Fibromyalgia, bursitis or tendonitis

Fracture(s) or broken bone(s)

Exposed bone Yes No

Gout

Lupus, systemic

Temporomandibular joint disorder (TMJ/

TMD) or craniomandibular disorder

Any other disorder of the muscles, bones or

joints to include chiropractic care

None of the above apply to any applicant(s)

I. Ears/eyes/nose/throat

Cataracts or glaucoma

Meniere’s disease

Nasal septal defect

Sinusitis, tonsillitis or otitis media

Any other disorder of the eyes, ears, nose,

throat or esophagus

None of the above apply to any applicant(s)

J. Mental/emotional or substance abuse

Anxiety, insomnia, sleep disorder,

depression, emotional problems or

nervous disorder

Attempted suicide

Counseling or psychiatric treatment (in-

patient or out-patient)

Bipolar disorder, obsessive compulsive

disorder or developmental disorder

Eating disorder

Any other mental, emotional disorder or

situation, including ADD/ADHD

None of the above apply to any applicant(s)

K. Other

Current patient in a hospital or nursing

home

Pending Surgery Surgery Date:

Sarcoidosis

Breast implants

Saline Silicone

Surgery Date:

Any other implant(s), prosthetic device(s),

internal ﬁxation device(s) or retained

hardware (i.e.: pins, wires, screws, shunts,

stents)

Acquired immune deﬁciency syndrome

(AIDS), or AIDS-related complex or

immune deﬁciency disorder or HIV

Transplant recipient

Any injury, deformity, incapacitation,

disease or condition not listed elsewhere

None of the above apply to any applicant(s)

UndCF (R01-24) Page 10 of 13

Section 20 | Medical questionnaire (continued)

2. Has any applicant ever:

Yes No a. Consumed alcohol to excess, received treatment, or joined an organization for alcoholism

or drug addictions?

Yes No b. Used any addictive or non-addictive drug or substance for purposes other than recommended

by your physician?

Yes No c. Do you have a valid Medical Marijuana Card?

Yes No d. Used cannabis and/or cannabinol products(edible/topical)?

Date last used: / /

Yes No e. Been treated for, diagnosed by or consulted a physician, psychotherapist, counselor or any

other provider, or had any indication(s) of having a drug dependency/habit?

Yes No f. Required the assistance of any other individual for performances of any activities of daily

living? If “Yes,” please explain:

Yes No g. Been told that he/she has or has had hearing problems, ear disorder(s) or has need of hearing

devices due to any kind of hearing or ear impairment, or does any applicant have an existing

hearing aid device in place?

Additional medical information

Give full details to questions answered afﬁrmatively (checked or answered “Yes”) to explain answers to questions

in SECTION 20. In addition to condition/illness please provide the type of treatment provided or planned – for

example, surgery, X-rays, EKG, lab tests, hospitalization, emergency room visit, nursing home conﬁnement,

doctor visits, rehabilitation services, occupational therapy, physical therapy, speech therapy or chiropractic

treatments. Please ensure you include all the treatments that apply. Please use the name that would have been

given at the time of the physician visit – e.g., a maiden name.

Question

number(s)

Person

treated

Speciﬁc disorder /

illness and type of

treatment

Date of ﬁrst

visit

Date of last

visit

Total

number

of visits

Degree of recovery:

Complete

name and

address of

physician

None Partial Full

month year month year

UndCF (R01-24) Page 11 of 13

Section 21 | Physician information (please provide for each applicant for the last ﬁve years)

Applicant’s name Complete name and address of physician

Date of last

visit*

Reason for

visit

Treatment/

results

*Please write NO VISIT in this box if the applicant has never seen the physician.

Please read before signing

I understand: (1) This application may be rejected if the applicant is age 19 or older. (2) If accepted, the insurance applied

for shall not become effective until the date shown on my schedule of beneﬁts and the adjusted premium, if applicable, is

paid in full. (3) If my application is accepted relying on my representations in this document, any coverage which may be

issued to me shall be invalid if based on intentional misrepresentations of material fact or fraud. (4) My signature authorizes

Arkansas Blue Cross and Blue Shield to coordinate beneﬁts under this policy with other insurance I have which is subject to

coordination. (5) Arkansas Blue Cross and Blue Shield may phone me for additional information that may help with the timely

processing of my application. In signing below, I represent that the statements and answers given in this application and any

signed and dated addendum to this application (both front and back) are true, complete and correctly recorded.

Any person who knowingly presents a false or fraudulent claim for payment of a loss or beneﬁt or knowingly presents false

information in an application for insurance is guilty of a crime and may be subject to ﬁnes and conﬁnement in prison.

I certify that I signed this change form in the state of Arkansas.

Signature section (please sign appropriate line only)

Current policyholder (required if policyholder is age 18 or older) OR parent/legal guardian (if policy for a minor)

Please print Please sign Date signed

Spouse (required if applying)

Please sign Date signed

Dependent age 18 or older (required if applying)

Please sign Date signed

Custodial parent section

If any applicant under age 19 (primary applicant or dependent), named on this application, does NOT reside with

the policyholder indicated in Section 1, the custodial parent’s signature is also required.

Custodial parent’s name (please print) Phone number

Custodial parent’s address (Street or PO box) City State ZIP

Custodial parent’s signature Date signed

IMPORTANT: Please be sure to also sign and return Page 12 of this document. We cannot process your

application without the signed Authorization to Disclose Protected Health Information form.

UndCF (R01-24) Page 12 of 13

The form below must be completed in order to process the application

Authorization to disclose protected health information

As a condition of coverage and of my enrollment in the policy, I authorize any medical professional, medical care institution, pharmacy

related service organization, pharmacy beneﬁts manager, or other provider of healthcare services or supplies, as well as any individual,

company or prior insurance carrier possessing relevant medical, health, treatment or payment information, to provide Arkansas Blue Cross

and Blue Shield and its afﬁliates or agents information concerning services, supplies, beneﬁts or payments provided or denied to me or to

any family member listed in my application, including but not limited to any and all protected health information related to treatments where

a restriction was requested for any healthcare item or service in relation to the healthcare provider having been paid in full out-of-pocket.

I understand that information obtained as a result of this authorization will be used for the purpose of determining eligibility for coverage.

This information may also be used by Arkansas Blue Cross and Blue Shield in investigating and adjudicating claims for beneﬁts. I understand

that in the course of its business operations, Arkansas Blue Cross and Blue Shield may disclose this information to others as required or

permitted by law and as set out in the Arkansas Blue Cross and Blue Shield Notice of Privacy Practices. I understand that information re-

disclosed may no longer be protected by federal privacy regulations. This authorization does not provide for the disclosure of psychotherapy

notes as deﬁned in 45 CFR §164.501. I understand that I may terminate this authorization by sending a written revocation to Arkansas Blue

Cross and Blue Shield, PO Box 2181, Little Rock, AR 72203-2181. However, if I revoke this authorization before I am enrolled in the policy(ies),

my application for coverage will be denied. Unless I revoke this authorization, it shall be valid for 30 months from the date of my signature

for information collected in connection with review of this application; it is valid for the duration of the coverage for information collected in

connection with investigation of claims. Both the federal government and the State of Arkansas have enacted electronic signature laws, which

allow the use of electronic signatures in all areas of commerce. See the Electronic Signatures in Global and National Commerce Act 15 USC

§§ 7001 et seq., the Arkansas Electronic Records and Signatures Act A.C.A. §§25-31-101 et seq. and the Uniform Electronic Transaction Act,

A.C.A. §§25-31-101 et seq. Electronic signatures are speciﬁcally authorized in the business of insurance. See 15 USC §§ 7001(i).

This authorization includes authorization to release information on the diagnosis and treatment of mental illness, alcohol, and drug use, as

well as authorization to release information on the diagnosis, treatment, and testing results related to HIV-AIDS, and sexually transmitted

diseases, unless otherwise restricted by applicable law.

Please note the following consequences if you decline to sign this authorization for release of your medical information, or if you later revoke

it: in that event, we may be unable to process your application or evaluate a claim for coverage and would then deny your application or your

claim for policy beneﬁts.

Applicants age 18 or older

This authorization must be signed by each applicant age 18 or older.

Print name(s) Signature Date

Applicants under age 18

List applicants under age 18 (print name).

Print name(s)

Parent/Legal Guardian’s signature

(if policy for a minor)

Date

Detach and keep for your records

Fair credit reporting act notice – notice to proposed insured

In connection with your application for insurance, an investigative consumer report may be prepared. Information may be obtained through

personal interviews with your family, friends, neighbors, business associates, ﬁnancial sources or others with whom you are acquainted. This

inquiry includes information as to your character and general reputation. If an investigative consumer report is prepared in connection with

your application, you may receive a copy of that report upon written request to Arkansas Blue Cross and Blue Shield.

Your written request should be forwarded to: Arkansas Blue Cross and Blue Shield

Individual Underwriting Division - P.O. Box 2181

Little Rock, Arkansas 72203-2181

UndCF (R01-24) Page 13 of 13

**Important information regarding grandfathered plans**

Your Arkansas Blue Cross and Blue Shield coverage may be a “grandfathered health plan” under the Patient

Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a

grandfathered health plan can preserve certain basic health coverage that was already in effect when that

law was enacted. Being a grandfathered health plan means that your policy may not include certain consumer

protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision

of preventive health services without any cost sharing. However, grandfathered health plans must comply with

certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on

beneﬁts.

Questions regarding which protections apply and which protections do not apply to a grandfathered health plan

and what might cause a plan to change from grandfathered health plan status can be directed to Arkansas Blue

Cross and Blue Shield Customer Service at 1-800-238-8379. You may also contact the U.S. Department of Health

and Human Services at www.healthcare.gov.

Return instructions

¡ Any attachments submitted with the change form must be signed and dated.

¡ Do not send any money with this change form.

¡ Please ensure all required parties have signed and dated the change form prior to submission.

¡ We strongly recommend you make a copy of this completed change form for your records.

Return To:

Arkansas Blue Cross and Blue Shield

Attn: CRM Operations and Service

P.O. Box 2181

Little Rock, AR 72203-2181

Fax to: 501-378-3752

E-mail: CRMCustomerService@arkbluecross.com