HEMA Customer Registration and Intake Form

 

Open enhemalogo2014rollment for medical insurance for 2017 ended on January 31, 2017. We are now in the “Special Enrollment” Period for 2017.  Only applicants with “qualified events” can apply successfully during the remainder of the year.  During this period, most insurers in Ohio pay NO commissions or service fees. We have instituted a reasonable fee schedule for this purpose.  Our two Step Process will allow us to assist you in the choice and enrollment of a health plan and represent you in service issues with your new insurer. This includes processing healthcare.gov transactions necessary to SEP enrollees.

1) Complete and sign our HEMA Fee Agreement 3-2017  ( Fax to 614.635.2621,  or email to john@nubgroup.com, then…..

2) Complete our on-line Intake Form by clicking the link below. (we use this form for enrollment “on or off” the federal marketplace. “off” means direct enrollment with insurer)

3) ALERT:  HHS Market Stabilization requires “pre-enrollment” proof of loss of coverage as of June 1, 2017. This extends to other qualified events as of August 1, 2017.  This means you need to obtain a letter fro your prior employer to document the loss of coverage date and reason, job loss.  We will upload this document for you, but the coverage issue is now delayed until receipt and approval.

(You do not need to complete section on household income UNLESS you are interested in a federal premium subsidy for 2017. ( See Premium Subsidy section below)

Click here for the intake form

Please note, this is not an application for insurance.

Are you eligible for a Premium Subsidy?If you would like to see if you qualify for a premium subsidy please note the following key points when you complete the form, otherwise you may skip the income questions:

  1.  Include all family members who will appear on your 2017 tax return, whether or not they need coverage.  The question will be asked if each person is applying for coverage, answer accordingly.
  2.  All questions regarding income should be your best estimate for 2017.  Not 2016, as the form states.
  3.  2017 estimated household income should include all income from all family members who will appear on your 2017 income tax return.  Indicate the source of all income as asked on the form. MUST HAVE EMPLOYER PHONE NUMBERS to complete application transfeBe sure to use “Add Income” button to include additional sources of 2017 Income INCLUDING Social Security, and estimated 401K withdrawals, etc.