Hometown Health

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Zip Code (Residential)

Personal Information

Date of Birth (MM/DD/YYYY) [remove]

Enrollment Period Open Enrollment Qualifying Life Event

Effective Date

Qualifying Life Event (QLE)

A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage. Examples of qualifying life events are moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry, divorce, or have a baby). (Source: HealthCare.gov)

Qualifying Life Event

Requested Effective Date

The application must be submitted either before or within 60 days after the date of the Qualifying Life Event. If the current and/or application submission date is past the 60-day window you do not qualify for the special enrollment period. Hometown Health will request documentation of the event after the application is submitted along with instructions on how and where to send this information.

An employee who is offered an Employer Individual Coverage Health Reimbursement Arrangement (ICHRA) will generally receive a written notice from the employer within 90 days prior to the effective date of coverage. However, employees who become eligible during the plan year, or later than the 90 days before the start of the plan year (newly hired employees), will receive notice no later than the date on which their coverage under the ICHRA becomes effective. The ICHRA effective date must coincide with the Hometown Health Individual and Family health plan coverage effective date. Please acknowledge: I acknowledge that I have a valid Qualifying Life Event and would like to change my effective date to the date above. I understand that Hometown Health will withhold all claim payments until I provide the necessary documentation and that if I fail to provide the required documentation I will be responsible for paying all claims, if any, incurred during that period.

You can also enroll in a health insurance plan for you and your family through the Silver State Health Insurance Exchange (Nevada's state-based health insurance exchange). The Silver State Health Insurance Exchange allows you to get quotes from different insurance companies that are available on the Exchange. You can compare different plans, get quotes and find out if you qualify for financial assistance. The Silver State Health Insurance Exchange is the only way to receive financial assistance for your health insurance. You can enroll online by visiting nevadahealthlink.com or by calling 1-800-547-2927 TTY 711.

How Premiums are Established and Changed

Premiums are the monthly charges the member must pay Hometown Health to establish and maintain coverage. Hometown Health determines and establishes the required premiums. Prior to a premium change, Hometown Health will send out written notification 60 days in advance of such change via email. If the member’s premium is paid beyond the effective date of the change, Hometown Health may require the member to pay an additional premium or accept a refund, whichever is necessary. If the age of the member is misstated, all amounts payable for the correct age shall be adjusted and billed to the member.

How and When to Pay Premiums

The first premium must be paid on or before the effective date of coverage under this certificate. Members will not be covered until Hometown Health receives that first payment. Coverage will be effective at 12:01 a.m. on the effective date as stated when subscriber accepts the rates on-line. After the first payment, the member’s entire premium shall be due on the first day of the applicant’s billing cycle. Premiums for dependents added mid-billing cycle will be prorated for the remainder of the applicant’s billing cycle. Any premiums following will be due on the first of the day of the applicant’s billing cycle. Premiums preferably should be paid through the on-line application web site. It is the subscriber’s responsibility to pay premiums to Hometown Health. Under no circumstances will premium payments be made on any member’s behalf or any member be accepted from a physician, a hospital or any other provider of the subscriber’s health care services or any federal or state agency. The receipt of a premium payment from such a provider or agency may result in cancellation of the subscriber’s coverage. The member may be responsible for an additional $50 charge for any item returned or dishonored by the bank as non-payable to Hometown Health for any reason. Note: The subscriber must notify Hometown Health of any address or email changes by signing into myhometownbenefits.com or calling Customer Service. Failure to receive a premium notice due to an unreported email change (or any other reason) does not relieve the member from the responsibility to pay required premiums by the premium due date.

Premium Not Received on Time

If the entire premium due is not paid within the 30 day grace period (with the exception of the first premium), coverage under this certificate will automatically terminate. Cancellation will be effective retroactively to the last date of the period for which premium has been paid. Hometown Health will not pay for any services provided to members on or after the date of cancellation. All claims paid after termination will be retroactively adjusted. Hometown Health will provide written notice of any intention not to renew this certificate for the period for which the premium has been accepted not less than 30 days prior to the premium due date. Hometown Health will provide the notice to the subscriber’s latest physical or email address in Hometown Health’s membership record.