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HealthAmerica

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Underwriting Guidelines | Enrollment Forms | Miscellaneous Forms | Product Grids

Underwriting Guidelines

Underwriting Guidelines

02/03/12

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Enrollment Forms

Checklist	04/09/09
Employer Application	01/18/11
Employee Application	06/23/10
Employer Application (Ohio)	05/18/11
Employee Application (Ohio)	05/18/11

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Miscellaneous Forms

Sample Agent of Record	01/29/10
C3 HRA/FSA Product Selection Worksheet	06/28/11
C3 HRA/FSA Banking Account Information	06/28/11
Enrollment / Change Form	07/27/07
HSA Enrollment Form	05/18/11
HSA Beneficiary Designation Form	05/18/11

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Product Grids

Plan Summaries

WPA In Area Plans (One Pager)	11/11/11
WPA Out of Area Plans (One Pager)	11/11/11
SEPA In Area Plans (One Pager)	11/11/11
SEPA Out of Area Plans (One Pager)	11/11/11
Lehigh Plans (One Pager)	05/20/11

Choice Plans

Choice PPO $1500	11/11/11
Choice PPO $2500	11/11/11
Choice PPO $4000	11/11/11

Premier Plans

Premier PPO $5$10	11/11/11
Premier PPO $10$10	11/11/11
Premier PPO $15$30	11/11/11
Premier PPO $20$40	11/11/11
Premier PPO $250	11/11/11
Premier PPO $500	11/11/11
Premier PPO $750	11/11/11
Premier PPO $1000	11/11/11
Premier PPO $1250	11/11/11
Premier PPO $1500	11/11/11
Premier PPO $2000	11/11/11
Premier PPO $3000	11/11/11
Premier PPO $5000	11/11/11

Premier 1x Plans

Premier PPO $2500 1x	11/11/11
Premier PPO $3250 1x	11/11/11
Premier PPO $4000 1x	11/11/11
Premier PPO $5000 1x	11/11/11
Premier PPO $6000 1x	11/11/11
Premier PPO $7500 1x	11/11/11
Premier PPO $10000 1x	11/11/11

Classic Plans

Classic PPO $250	11/11/11
Classic PPO $500	11/11/11
Classic PPO $1000	11/11/11

Value Plans

Value PPO $250	11/11/11
Value PPO $500	11/11/11
Value PPO $1000	11/11/11
Value PPO $1500	11/11/11
Value PPO $2000	11/11/11

Qualified HDHP's

FlexChoice QHDHP PPO $1250	11/11/11
FlexChoice QHDHP PPO $1250 II	11/11/11
FlexChoice QHDHP PPO $1500	11/11/11
FlexChoice QHDHP PPO $2000	11/11/11
FlexChoice QHDHP PPO $2500	11/11/11
FlexChoice Value PPO $1250	11/11/11
FlexChoice Value PPO $2500	11/11/11
FlexChoice Value PPO $3750	11/11/11

Qualified 1x HDHP's

FlexChoice QHDHP PPO $2500 1X	11/11/11
FlexChoice QHDHP PPO $5000 1X	11/11/11

Out of Area - Choice Plans

Choice PPO $1500	11/11/11
Choice PPO $2500	11/11/11
Choice PPO $4000	11/11/11

Out of Area - Premier Plans

Premier PPO $10$10	11/11/11
Premier PPO $15$30	11/11/11
Premier PPO $250	11/11/11
Premier PPO $500	11/11/11
Premier PPO $1000	11/11/11
Premier PPO $1250	11/11/11
Premier PPO $2000	11/11/11
Premier PPO $3000	11/11/11

Out of Area - Premier 1x Plans

Premier PPO $2500 1X	11/11/11
Premier PPO $3250 1X	11/11/11
Premier PPO $4000 1X	11/11/11
Premier PPO $5000 1X	11/11/11
Premier PPO $6000 1X	11/11/11
Premier PPO $7500 1X	11/11/11
Premier PPO $10000 1X	11/11/11

Out of Area - Classic / Value Plans

Classic PPO $250	11/11/11
Classic PPO $500	11/11/11
Value PPO $250	11/11/11
Value PPO $500	11/11/11

Out of Area - Qualified HDHP's

FlexChoice QHDHP PPO $1250	11/11/11
FlexChoice QHDHP PPO $1250 II	11/11/11
FlexChoice QHDHP PPO $1500	11/11/11
FlexChoice QHDHP PPO $2000	11/11/11
FlexChoice QHDHP PPO $2500	11/11/11
FlexChoice Value PPO $2500	11/11/11

Out of Area - Qualified HDHP's

FlexChoice QHDHP PPO $2500 1X	11/11/11
FlexChoice QHDHP PPO $5000 1X	11/11/11

VIsion Plans

EyeMed Vision Basic Rider Insert	05/20/11
EyeMed Vision Mid Rider Insert	05/20/11
EyeMed Vision High Rider Insert	05/20/11
EyeMed Vision Discount Flyer	05/20/11
EyeMed Vision Exam Only Rider	05/20/11

Download all HealthAmerica Product Grids (ZIP)

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