FORMS & PUBLICATIONS

Enrollment Forms            Other Documents and Forms           Notices

All forms are provided in PDF format unless otherwise noted. The free Adobe® Reader® software is required.

ENROLLMENT FORMS

MACoHCT Enrollment Form
Use this form to enroll new participants and their dependents in health, dental, and/or vision coverage, and to designate beneficiaries for the Basic life insurance included with the MACoHCT medical benefit.

Life Insurance Enrollment and Beneficiary Form
The Option 1 portion of the form is required for all participants in groups that offer Option 1 (employer-paid) life insurance. The Option 2 portion of the form is used only for participants who elect Option 2 (employee-paid) life insurance. Beneficiaries for Option 1 and Option 2 coverage are also designated or changed on this form.

MACoHCT Change Form
Use this form to report changes in name, address, or marital status; to terminate a dependent’s coverage; report a change from active to retiree status; or to change beneficiaries for the Basic life insurance included with the MACoHCT medical benefit.

MACoHCT Termination Form
Use this form to terminate coverage for employees/trustees. (To terminate a dependent’s coverage, use the MACoHCT Change Form.)

Dependent Child Verification Form and Cover Letter December 27, 2007

Effective January 1, 2008, the terms of Amendment #4 (Senate Bill 419) became effective with respect to each Member Group’s effective date or the next annual renewal date concurrent with or after January 1, 2008. (See the Cover Letter mailed to all MACoHCT members dated December 27, 2007 for additional information.)

• For Member Groups effective or renewing January 1, 2008 a parent/employee may add an IRS Section 152 non-qualified dependent child to the Plan January 1, 2008 through January 31, 2008.  
• For Member Groups effective or renewing after January 1, 2008 a parent/employee may add an IRS Section 152 non-qualified dependent child during the regular open enrollment period.

Dependent Child Verifications will continued to be required for children between the ages of 19 and 25 until the Member Group’s next annual renewal date concurrent with or after January 1, 2008.

SB419 Guidance Information and Worksheet

If a parent/employee keeps or adds an IRS Section 152 non-qualified dependent child to the Plan, the “fair market amount” of the benefit (whether or not there is any increase in premium) may be included as income for the parent/employee on their W-2’s.

We strongly encourage parents/employees to contact a qualified tax consultant with any questions about SB419 and related tax consequences.

Declaration of Adult Dependent Form
This form must be notarized and submitted to MACoHCT to establish eligibility for a common-law spouse or adult partner. This form replaced the Common Law Marriage Affidavit effective July 1, 2006. (NOTE - Use the Dependent Child Verification Form for eligible adult-age children.)

Basic Plan Acknowledgement Form

Participants who have elected to enroll in the MACoHCT Basic plan will be asked to sign this affidavit acknowledging that they understand the Basic plan's limitations.

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.

Medical History Statement (Standard Life Insurance)
Use this form for life insurance late enrollees and for participants who wish to apply for life insurance amounts above the guaranteed-issue amount.

Group Health Statement Form
These forms are used for participants in new groups, or for late enrollees in existing groups.

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OTHER DOCUMENTS and FORMS

MACoHCT Domestic & International Claim Form

You can use this form to submit a claim to MACoHCT if you paid a provider up front for medical or preventive services.

County Health Department Claim Form

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

Health Fair Claim Form

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.

Caremark 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 by the participant 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.

County Quote Data Form (for MACoHCT Representatives)
This document is used for groups who are not currently insured through MACoHCT and are seeking a quote.

NOTICES

HIPAA Notice
This notice is provided to newly enrolled participants to describe the privacy protections provided under HIPAA laws.

Women’s Health and Cancer Rights Notice

This notice is provided annually to participants to discuss certain benefits that are guaranteed under HIPAA laws.

COBRA Continuation Rights Notice

This notice is mailed 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. They can mail you a letter that explains the requirements.

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Links to documents available elsewhere on this site:

MACoHCT Summary Plan Description document

MACoHCT Benefit Summary

MACoHCT ‘Frequently Needed Numbers’ list

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