Required Federal Notice for Meaningful Access & Nondiscrimination: This notice must be included in all digital and print communications beginning AUGUST 26, 2016. Failure to provide this notice with ALL these communications will result in fines. Please contact your assigned Account Rep for any questions regarding this notice.
Group Application for ACA Small Business (N-5431 04/17 AN-T) – To be used only by employees of new non-grandfathered small groups size 1-50 applying for a plan from the small group ACA portfolio. This is an application for small business health, dental, and vision insurance for coverage effective 1/1/16 and after. Includes Standard Notice and Taglines for MA/ND.
Group Application for Health & Dental Insurance (N-5411 08/17 AN-T) – To be used by employees of Grandfathered and Non-Grandfathered Small Business Plans (2-50), Mid-Size Plans (51-100) or Large Group Fully Insured Plans (101+) with new hires, late enrollees, special enrollees, and changes. This application should also be used by Self-Funded Groups who offer coverage to domestic partners. Includes Standard Notice and Taglines for MA/ND.
Group Application for Health Insurance (N-5408 08/17 AN-T) To be used only by employees of groups 51+ or by current 2-50 grandfathered and non-grandfathered groups with new hires, late enrollees, special enrollees and changes. This is an application for Group Health Insurance for Wellmark Blue Cross and Blue Shield of Iowa and Wellmark Health Plan of Iowa. Use this form for groups no longer applying pre-existing waiting periods in accordance with the Affordable Care Act (ACA). Includes Standard Notice and Taglines for MA/ND.
MSP Compliance Form N-2305 (05/14 AN-T) – Includes Standard Notice and Taglines for MA/ND
Group Employer Application for ACA Small Business (N-53292 09/17 AN-T) – Producers will use this application for groups enrolling in coverage effective 1/1/16 and after.
2018 Renewal Alternatives Form (M-4334) – (anytime a group is transitioning to an ACA plan beginning after 11-15-15)
Group Membership Change Form – (N53143 10/14 AN-T) – Includes Standard Notice and Taglines for MA/ND
51 – 100 New Account Enrollment Form – M-53281 7/17
51 – 100 New Account Quote Request Form – M-53280 8/16
Group Membership Change Forms for Small Business ACA Plans(N-4314 10/16) – Used only to notify Wellmark of membership or contract changes for Small Business ACA Plans effective 1/1/16 or after.