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Rate Calculator 2015
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Rate Calculator 2015
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Existing Member Documents:
Important Notices For Existing Members:
Minimum Essential Coverage (MEC) Letter (Dated 11/3/2014)
Benefit Structure Letters (Dated 11/7/14):
If you currently are enrolled in the...
$500 Deductible - Click here for your letter.
$1000 Deductible - Click here for your letter.
$1300 Deductible - Click here for your letter.
$1500 Deductible - Click here for your letter.
$2000 Deductible - Click here for your letter.
$2500 Deductible - Click here for your letter.
$5000 Deductible - Click here for your letter.
$5200 Deductible - Click here for your letter.
1/1/2015 Premium Rate Tables
Benefit Structure Table
Forms for Existing Members Ongoing Eligibility Only:
Form for Active Members to terminate their CHIP coverage
- Rev 1/13
Name and Address Change Form
- Rev 9/13
Bank Service Plan (BSP) Form
Rev 7/13
Authorization Regarding Premiums Notices Form
Rev 3/13
Continued Eligibility
- Rev 9/2013
Residency Affidavit
(PDF) - Rev 9/13
Supplemental Application Regarding Possible Third Party Liability
- Rev 6/04
Blue Cross Blue Shield Claim Form
Privacy Forms:
Standard Authorization
- Rev 3/14
Confidential Communications Request
- Rev 9/04
Disclosure Accounting Request Form
- Rev 9/04
Licensed Illinois Insurance Producer Information & Authorization form
- Rev 3/13
PHI Access Request Form
- Rev 9/04
PHI Change Request Form
- Rev 9/04
Privacy Complaint Form
- Rev 9/04
Response to Denied Request to Change
-Rev 2/04
Restriction Request Form
- Rev 9/04
Tobacco Use Certification Forms:
If your tobacco use has changed, use the
Change of Tobacco Use
form. (Updated 1/2012)
Plan Information and Rates:
List of Hospital PPO Providers
-
Effective 7/14
ICHIP Premium calculator
Calculate your premiums
Grievance Procedure