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

SB419 Guidance Information and Worksheet

Effective January 1, 2008, the terms of Montana 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.

 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.

Basic Plan Acknowledgement Form

Members who electe to enroll in the MACoHCT Basic Plan will be asked to sign this affidavit acknowledging that they understand the Basic Plan's limitations.

Medical History Statement (Standard Life Insurance)
Use this form for 1) ALL Option 2 late enrollees and 2) individuals who wish to apply for coverage that exceeds the Guaranteed Issue amount.

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OTHER DOCUMENTS and FORMS

MACoHCT Domestic & International 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.

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.

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 reqired at the time of inital 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 participats 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 Form

This form is used for participants in new member groups and late enrollees in existing member groups.

NOTICES

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.

Women’s Health and Cancer Rights Notice

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

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.

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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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