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HB2557

2017-18 Enrollment Materials


2016-17 Enrollment Materials

Forms

2016-17 HB2557 Mid-Year Change Form - Use this form to request changes to your enrollments if you experience a Qualified Status Change event on or before September 30, 2017.

2017-18 HB2557 Mid-Year Change Form - Use this form to request changes to your enrollments if you experience a Qualified Status Change event October 1, 2017 or later.

ACH Debit Authorization Form - Use this form to authorize payment if you are newly enrolling in coverage, or if you wish to change your bank account during the plan year.

Note: If you are continuing coverage from 2016-17 and wish to continue using the same bank account, you do not need to submit another ACH Debit Authorization Form. Your previous authorization will automatically continue.

HB2557 Frequently Asked Questions

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