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MACoHCT Forms & Publications


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Enrollment Forms

Enrollment & Change Form

Use this form to:

  • Enroll employees and elected officials in medical, dental, vision and Basic life insurance
  • Make Open Enrollment and mid-year Special Enrollment changes
  • Drop or add dependent coverage
  • Waive or voluntarily drop employee or elected official coverage
  • Designate Basic life insurance beneficiaries

UNUM Voluntary Life Insurance & AD&D Employee Paid Enrollment Form

Use this form to:

  • Enroll employees and elected officials in UNUM Voluntary Life Insurance AD&D Employee Paid coverage
  • Designate or change life insurance beneficiaries for UNUM Voluntary Life Insurance AD&D Employee Paid

UNUM Voluntary Life Insurance and AD&D Employee Paid Change Form

Use this form to:

  • Change beneficiaries for UNUM Employee Paid Voluntary Life Insurance AD&D coverage
  • Add a spouse and child(ren) to existing UNUM Employee Paid Voluntary Life Insurance AD&D coverage
  • Decrease or voluntarily discontinue UNUM Employee Paid Voluntary Life Insurance AD&D coverage
     

Termination of Coverage Form

Use this form to:

  • Cancel coverage for employees and elected officials that are no longer eligible to remain covered

Declaration of Adult Dependent Form

Along with an Enrollment & Change Form, this form must be completed and notarized to enroll common-law spouses, domestic partners and same-sex partners for coverage

UNUM Evidence of Insurability Form

This form is required for:

  • Any new employee or elected official requesting more than the UNUM Voluntary Life Insurance AD&D Employee Paid Guaranteed Issue amount
  • Any UNUM Voluntary Life Insurance AD&D Employee Paid "Late Enrollee" regardless of the amount of coverage requested

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Other Documents & Forms

Medical, Dental and Vision Claim Form

Use this form to submit a claim if you paid a provider at the time of service and need to request reimbursement from the MACoHCT plan.

County Health Department Claim Form

County health department staff can fill out this form and submit to MACoHCT for payment after administering CDC recommended immunizations. MACoHCT participants can also use this form along with original receipts to request reimbursement for CDC recommended immunizations.

Please contact the MACoHCT Adminstrative Office at 866-669-6428 for a customized Health Fair Claim Form. We are happy to prepare an easy-to-use claim form that will meet your county or group's specific needs. The customized form will ensure timely and accurate processing of claims associated with a health fair or similar event.

Prescription Drug Claim Form

MACoHCT participants can use this form along with original receipts to request reimbursement for prescription drugs that were paid in full at the pharmacy.

Sample Claim Explanation of Benefits (EOB) Form

This PDF document helps to explain the MACoHCT EOB form that participants receive after a claim has been processed.

Coordination of Benefits Questionnaire

Plan participants can use this form to identify other insurance coverage. MACoHCT will then coordinate benefits with other insurance carriers on behalf of our members. This information is required at the time of initial enrollment and on an annual basis.

Accident Questionnaire

This form can be printed, completed and returned to the MACoHCT Claims Department in order for plan participants to take advantage of the first dollar accident benefit.

Authorization to Release Information

This form allows participants age 18 and older to allow claims information to be released to one or more designated persons.

Group Health Statement

This form can be used by potential new member groups that would like to request a bid from MACoHCT for group coverage.

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Notices

COBRA Continuation Rights Notice

This notice is provided to participants upon initial enrollment describing their right to continue coverage under COBRA if they lose eligibility for group coverage.

Foreign Travel Letter (sample)

If you plan to travel outside the U.S., call the Claims Administration office (888-883-3233) for guidance on seeking health care from foreign providers. The Claims office will mail you a letter that explains the requirements.

HIPAA Notice

This notice is provided to newly enrolled participants to describe the privacy protections provided under HIPAA laws. It is also distributed to plan participants at least every three years.

Medicaid and the Children’s Health Insurance Program (CHIP) Notice

This notice describes special enrollment rights for eligible employees to enroll themselves and their children under the MACoHCT plan, if they lose coverage under Medicaid or a state-sponsored child health insurance program (CHIP). It is distributed to plan participants annually.

Women’s Health & Cancer Rights Notice

This notice describes certain benefits that are guaranteed under HIPAA laws. It is distributed to plan participants annually.

 

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