Article Structure
The Home Care Guest Membership form is a crucial document for subscribers seeking temporary healthcare coverage for family members while they are away from the Keystone Health Plan East service area. This form is designed to capture essential information, including subscriber details, guest member information, and guardian relationships for minors. Specific requirements must be fulfilled to qualify, such as the need for applicants to have resided in certain counties and to indicate their reasons for seeking guest membership. The form outlines various membership types: Long-term Traveler, Families Apart, and Student, each catering to unique circumstances. Clear guidelines detail the necessary length of stay outside the area, the process for renewing memberships, and the importance of maintaining active coverage as a subscriber. Additionally, the form emphasizes the need for accurate contact information to ensure timely receipt of ID cards and notifications, reinforcing the importance of communication with Customer Service for any address changes. Along with providing a structured application process, it also includes an Other Insurance Questionnaire that ensures additional coverage is disclosed and appropriately managed. Subscribers must complete and sign the application, affirming the accuracy of the provided information to facilitate prompt processing and coverage approval.
Home Care Guest Membership Example
Keystone Health Plan East
Away From Home Care Guest Membership Application
Please print clearly. Application must be completed and signed by the subscriber.
Today’s date: _______________ |
Guest membership termination date: |
Subscriber information
Subscriber
Subscriber’s address: Street/Apt. #
CityState Zip code
Telephone: _________________________________
Group name:
Group ID #
Subscriber ID #
The applicant is not eligible for guest membership if the subscriber has moved outside of the Keystone service area of Bucks, Chester, Delaware, Montgomery, and Philadelphia counties.
Guest member information
Name:
Social Security number
Gender: Male |
Female |
Relationship to subscriber
Away from home address:
Street Apt #
City |
State |
Zipcode |
County |
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Phone |
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Cell phone |
Other guest members
Name |
Social Security No. |
Gender |
Relationship to subscriber |
Male
Female
Male
Female
Male
Female
Provide full address to ensure receipt of ID cards and other information. If each guest member has a separate mailing address, provide address information for each member. Please include P.O. box, dorm room number, or mail stop number.
Guardian information
Guardian name
Guardian’s relationship to guest member
When applying for guest membership for a minor under age 18, you must supply the name of guardian with whom that minor resides, and state the relationship.
KHPE is an independent licensee of the Blue Cross and Blue Shield Association
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Keystone Health Plan East
Away From Home Care Guest Membership Application
Guest membership details
Length of guest membership
How long will the member |
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be out of the area? |
(date range) |
Members must be away for a MINIMUM of 90 days to be eligible for a guest membership. The maximum time for a guest membership is:
Families Apart: 1 year (renewable)
Students: 1 year (renewable while enrolled in an accredited program until the age limitation is met).
Reason for applying for guest membership
Please select the type of guest membership that you are seeking:
Families Apart. Available to spouses or dependents only who do not reside with the subscriber; the subscriber is not eligible. This type of guest membership is typically used when divorced or separated families permanently reside outside the Keystone service area.
Student. Available to qualified dependents who are temporarily residing outside of the Keystone service area while attending an accredited education institution. The dependent may not reside with the subscriber.
Name of the
(Potential guest members must reside in the service area of another participating HMO plan in order to obtain guest membership).
Additional instructions
Preventing delays in your application. Please complete and attach the Other Insurance Questionnaire to help prevent delays in processing your application.
Confirming when guest membership starts and ends. Call Customer Services at the phone number on your member ID card to confirm the effective and termination dates of the guest membership. (The effective date of the guest membership coverage is 15 days after a correctly completed and signed application is received and
processed by the Away From Home Care Department.) Guest memberships are approved for a specified period of time that depends on the type of guest membership and the employer’s group renewal date.
Making sure your guest membership coverage is active. For coverage to remain effective, the subscriber’s coverage must remain active with the employer group. In addition:
–If the guest member is a dependent, he or she must remain an eligible dependent of the subscriber for coverage to be effective.
–For student guest membership, remember to keep up with the student verification requirements of your plan.
Renewing guest membership. You must renew your guest membership for a spouse or dependent 30 days before the
Notifying us each time you move in or out of the area. Call Customer Service each time guest members move in or out of the Keystone service area so that we may ensure the guest member may receive services and is assigned the proper primary care physician. You must notify us whenever the following happens:
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When a guest member comes home for break or a short period of time.
When a guest member returns to the
If you have questions and need help, call Customer Service at the number on the back of your ID card.
KHPE is an independent licensee of the Blue Cross and Blue Shield Association
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Keystone Health Plan East
Away From Home Care Guest Membership Application
Subscriber signature
I hereby certify that all information in the guest membership application is truthful and correct to the best of my knowledge. I acknowledge that the benefits program providing coverage to me or eligible dependents as guest members of the host HMO may vary from the benefits program at my home HMO. I understand that as a guest member, the host
HMO benefits program’s scope and levels of coverage apply.
________________________________________________ |
_______________ |
Subscriber’s signature |
Date |
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AFHC coordinator’s use only
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Date received |
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Effective date |
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Approved by |
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KHPE is an independent licensee of the Blue Cross and Blue Shield Association
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Keystone Health Plan East
Other Insurance Questionnaire
Please complete the following questionnaire for all members of your household. Completion of this questionnaire, which concerns other insurance coverage, is required to process your request for guest membership.
Section 1
Do you or someone else in your household have other insurance?
No. If no, please proceed to Section 2.
Yes. If yes, please complete Section 1 before going to Section 2.
Who is the subscriber of the other insurance? (Please list all)
Name (Subscriber #1): ___________________________________ |
Date of birth:____________________ |
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Name (Subscriber #2): ___________________________________ |
Date of birth:____________________ |
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Who else is covered by the other insurance? (Please list all) |
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Subscriber #1 |
Subscriber #2 |
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Dependent #1 |
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Dependent #1 |
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Dependent #2 |
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Dependent #2 |
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Dependent #3 |
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Dependent #3 |
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Is the subscriber of the other insurance employed?
No
Yes. If YES, please complete the employer information for each applicable subscriber
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Employer information (subscriber #1) |
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Employer information (subscriber #2) |
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Employer |
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Employer |
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Employer address |
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Employer address |
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Employer phone number: _________________________ |
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Employer phone number: _________________________ |
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Please fill out the other insurance information for each applicable subscriber |
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Subscriber #1 |
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Subscriber #2 |
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Insurance company name |
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Insurance company name |
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Policy number: _________________ |
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Policy number: _________________ |
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Effective date: ______________ |
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Effective date: ______________ |
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Type of benefits (check all that apply): |
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Type of benefits (check all that apply): |
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Health/Medical |
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Health/Medical |
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Prescription drug |
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Prescription drug |
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Dental |
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Dental |
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Vision |
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Vision |
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KHPE is an independent licensee of the Blue Cross and Blue Shield Association
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Keystone Health Plan East
Other Insurance Questionnaire
Section 2
Are you or someone else in your household (spouse or dependent) covered by Medicare?
No. If no, please proceed to the Employee signature section
Yes. If yes, please complete Section 2.
Please supply the names, ID numbers, effective coverage dates, and reason for Medicare eligibility for each Medicare beneficiary.
Medicare beneficiary #1 |
Medicare beneficiary #2 |
Name
ID number:
What is the effective date of coverage for:
Part A: |
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Part B: |
Reason for Medicare eligibility (please check all that apply):
Age
Disability
Are you retired?
No
Yes, I retired on (date):
Name
ID number:
What is the effective date of coverage for:
Part A: |
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Part B: |
Reason for Medicare eligibility (please check all that apply)
Age
Disability
Are you retired?
No
Yes, I retired on (date):
Subscriber signature
I hereby certify that all information in this questionnaire is truthful and correct to the best of my knowledge.
________________________________________________ |
_______________ |
Subscriber’s signature |
Date |
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KHPE is an independent licensee of the Blue Cross and Blue Shield Association
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Form Characteristics
| Fact Name | Fact Description |
|---|---|
| Eligibility Criteria | The applicant cannot receive guest membership if they have moved outside the Keystone service area, which includes Bucks, Chester, Delaware, Montgomery, and Philadelphia counties. |
| Minimum Requirement | Members must be away from their home area for a minimum of 90 days to qualify for guest membership. |
| Maximum Membership Duration | Guest memberships can last up to 6 months for long-term travelers and 1 year for families apart or students, with renewal options available. |
| Guardian Information | When applying for a minor, it's required to provide the guardian's name and their relationship to the guest member. |
| Application Processing | The effective date of guest membership coverage begins 15 days after the application is received and processed, provided all required information is completed. |
| Coverage Active Status | The subscriber’s insurance must remain active for the guest member’s coverage to stay valid. |
| Renewal Process | Renewal requests for guest memberships must be submitted at least 30 days before the current membership expires. |
| Notification Requirement | The subscriber must inform Customer Service whenever a guest member moves in or out of the service area or returns home for a break. |
| Subscriber Certification | Subscribers must certify the accuracy of the information provided in the application by signing the form. |
| Additional Documentation | To prevent delays, applicants are advised to complete and attach the Other Insurance Questionnaire with their application. |
Guidelines on Utilizing Home Care Guest Membership
Filling out the Home Care Guest Membership form is essential for obtaining guest membership in the specified Keystone Health service area. Ensure that all necessary information is clearly printed and accurately completed. You will need to provide details about the subscriber, guest members, and any additional required information.
- Fill in today’s date in the designated area.
- Indicate the guest membership termination date.
- Provide subscriber information, including the subscriber’s name, address, and telephone number.
- Enter the group name, group ID number, and subscriber ID number.
- Collect guest member information: fill in the name, Social Security number, gender, and relationship to the subscriber for each guest member.
- Complete the away-from-home address with the relevant street, apartment number, city, state, zip code, and county for each guest member.
- If applicable, list additional guest members along with their respective information.
- For minors, specify the guardian's name and relationship to the guest member residing with them.
- Indicate how long guest members will be out of the area, ensuring it meets the minimum requirement of 90 days.
- Select the type of guest membership being requested by checking the appropriate box.
- Input the name of the out-of-area host plan.
- Complete and attach the Other Insurance Questionnaire, if applicable, to prevent delays.
- Sign and date the application as the subscriber to certify that all information is accurate.
After submitting the application, ensure to follow up with Customer Services to confirm the effective and termination dates for the guest membership. Remember to keep your coverage active to avoid interruptions.
What You Should Know About This Form
What is the purpose of the Home Care Guest Membership form?
This form allows subscribers of Keystone Health Plan East to apply for guest membership for dependents or themselves when they move temporarily outside the Keystone service area. It provides coverage options for long-term travelers, families apart, or students enrolled in accredited education institutions.
Who is eligible to apply for guest membership?
Eligibility for guest membership depends on several factors. Subscribers may apply if they are temporarily residing outside the Keystone service area for a minimum of 90 days. However, subscribers cannot apply for membership if they have moved outside of the Keystone service area themselves. Additionally, dependents seeking coverage must meet specific criteria relating to their relationship to the subscriber and their current living situation.
What types of guest memberships are available?
There are three guest membership types: Long-term Traveler, Families Apart, and Student. The Long-term Traveler membership is for subscribers, their spouses, and dependents on long-term work assignments or dual residents. Families Apart is for spouses or dependents who do not live with the subscriber, usually due to separation or divorce. The Student membership is available for dependents residing outside the service area while attending an accredited school.
How long can a guest membership last?
The duration of guest membership varies by type. Long-term Traveler memberships can last up to six months and are nonrenewable. Families Apart and Student memberships may extend for one year, with the option to renew for students as long as they are enrolled in an accredited program. All memberships terminate if coverage with the subscriber's employer group is inactive.
What steps must be taken to ensure the application is processed correctly?
To prevent application delays, it is crucial to fill out the form clearly and completely. Additionally, attaching the Other Insurance Questionnaire helps streamline processing. Keeping contact information updated ensures that any correspondence, including ID cards, is received without issue. Subscribers should also confirm effective dates by contacting Customer Service.
How can someone confirm the start and end dates of their guest membership?
Subscribers can confirm the effective and termination dates of their guest membership by calling Customer Service at the number found on their member ID card. The effective date will typically be 15 days after the completed application has been processed.
What information is required about additional guest members?
The application requires personal details for each guest member, including name, Social Security number, gender, and their relationship to the subscriber. It is important to provide complete mailing addresses to ensure ID cards and other important information are received without delays.
When should membership be renewed?
Renewal for guest membership is necessary at least 30 days before the one-year guest membership period concludes. Subscribers must also consider each group’s open enrollment period to ensure renewed coverage meets all necessary requirements.
What should be done if a guest member moves?
If a guest member relocates in or out of the Keystone service area, it is essential to inform Customer Service. This notification is necessary for ensuring proper medical service coverage and the assignment of a primary care physician aligned with the guest member’s new resident area.
Common mistakes
Completing the Home Care Guest Membership form correctly is vital for ensuring that members receive the coverage they need. Below are common mistakes to avoid that can lead to delays or complications.
One frequent error is illegible handwriting. When filling out the form, it is essential to print clearly. Any unclear information can result in processing delays. Make sure that all names, addresses, and other details are easy to read.
Another common mistake involves missing signatures. The form must be signed by the subscriber. Without a signature, the application will not be considered complete. Double-check to ensure that you have signed where required.
Incomplete sections often lead to confusion. Many applicants fail to provide all necessary contact information, such as the telephone number and other relevant details. Providing this information is crucial for communication regarding the guest membership.
Some applicants overlook the eligibility criteria. The applicant must ensure they meet all conditions for guest membership. For example, if the subscriber has moved outside the eligible service area, the application will be denied.
When listing additional guest members, it’s important to remember to include full addresses. Providing partial addresses can create issues during the processing of the application. Make sure to include any P.O. boxes or dorm room numbers to ensure all members receive their ID cards.
Additionally, not specifying the type of guest membership can lead to complications. Selecting the appropriate category, whether it’s “Long-term Traveler,” “Families Apart,” or “Student,” is critical for processing your application accurately.
Renewal dates are often mismanaged. Applicants may forget to renew their guest membership before the deadline. Remember, it’s essential to renew at least 30 days before the current membership expires to avoid any gap in coverage.
Responding inaccurately to the Other Insurance Questionnaire is another mistake. Providing false information can delay processing your application. Make sure to complete the questionnaire thoroughly and accurately to prevent delays.
Finally, failing to notify the service provider when guest members move in or out of the area can result in coverage issues. It is necessary to communicate any changes immediately to avoid interruptions in service. Keeping records of any moves will help maintain consistent coverage.
Documents used along the form
When applying for guest membership through the Home Care Guest Membership form, several other documents may be necessary. These forms help ensure that applications are processed accurately and promptly. Below is a list of common forms associated with the guest membership application:
- Other Insurance Questionnaire: This form collects information about any other insurance coverage that the applicant or household members may have. Completing it is essential for determining eligibility for guest membership.
- Proof of Residency: Applicants may need to provide documentation proving their current residency outside the Keystone service area. This can include utility bills, rental agreements, or bank statements.
- Dependent Verification Form: This document validates the relationship between the subscriber and any dependents who seek guest membership. It may include birth certificates or guardianship documents for minors.
- Application for Continuation of Coverage: If a subscriber is applying to renew a guest membership, this form outlines the current situation and reasons for the renewal, ensuring compliance with eligibility requirements.
- Insurance Coordination of Benefits Form: This document may be required if the guest member has multiple insurance plans. It helps clarify which insurance is the primary and which is secondary, determining the order of coverage.
- Student Verification Form: For students applying for guest membership, this form confirms enrollment in an accredited institution. It may need to be updated each term to maintain eligibility.
- Emergency Contact Information Form: This form gathers emergency contacts for guest members, ensuring that caregivers can reach someone in case of an emergency while they are away.
- Membership Rights and Responsibilities Document: This outlines the rights and obligations of members enrolled in the guest membership program. It serves as an informational guide for what to expect.
- Authorization to Release Information: This form allows the Health Plan to share necessary information with healthcare providers and facilities that may treat the guest member.
- Previous Coverage Summary: If applicable, this document summarizes the benefits that the guest member received under their previous plan. It provides important context for the new coverage application.
These additional documents streamline the application process, ensuring that all necessary information is collected upfront. Being prepared with these forms can help prevent delays in attaining timely coverage for guest members.
Similar forms
Health Insurance Application Form: Like the Home Care Guest Membership form, this document collects personal information, including subscriber details and coverage requirements. Both forms ensure that individuals are eligible for benefits under specific conditions, such as residency and duration of absence.
Dependent Enrollment Form: This form guides subscribers in adding dependents to their health insurance plan. Similar to the Guest Membership application, it requires personal information about dependents and indicates the conditions under which they can receive coverage.
Medicare Application Form: The Medicare application also necessitates personal and dependent data. Just as with the Guest Membership form, it includes questions about eligibility and coverage duration, aimed at ensuring appropriate access to benefits.
Change of Address Form: Subscribers completing this form must provide their new contact information. Like the Guest Membership application, it emphasizes the importance of accurate details for the effective delivery of services and benefits.
Insurance Policy Disclosure Document: This document explains the terms and conditions of the insurance coverage. Both it and the Guest Membership form clarify the scope of coverage and eligibility criteria, ensuring subscribers understand their rights and responsibilities.
Dos and Don'ts
When filling out the Home Care Guest Membership form, keep the following points in mind:
- DO print clearly. Ensure that every letter and number is legible to prevent errors.
- DO provide complete information, including all necessary addresses and relationships.
- DO check that the applicant meets the eligibility criteria before submitting the form.
- DO confirm that all signatures are present where required.
- DO include the Other Insurance Questionnaire to avoid processing delays.
- DO NOT leave any sections blank. Complete each part of the application to ensure it is processed.
- DO NOT submit the form without verifying that the information is accurate and up-to-date.
Misconceptions
Misconception 1: The Home Care Guest Membership form can be completed by anyone, not just the subscriber.
This is incorrect. The application must be filled out and signed by the subscriber, who is the primary member in the health insurance plan. This ensures that the information provided is accurate and that the subscriber agrees to the terms of the guest membership.
Misconception 2: Guest membership is available regardless of the subscriber’s location.
This is misleading. An applicant is not eligible for guest membership if the subscriber has moved outside of Keystone’s service area, which includes specific counties in Pennsylvania. It is important for subscribers to be aware of their location relative to the service area when applying for guest membership.
Misconception 3: There is no minimum duration of stay away from home for guest membership eligibility.
Contrary to this belief, members must be away for a minimum of 90 days to qualify for guest membership. This requirement ensures that the program is utilized for significant periods away from the home area, rather than short trips.
Misconception 4: All guest membership types offer the same duration of coverage.
This is not true. The length of guest membership varies depending on the type selected—Long-term Traveler offers a maximum of six months, while Families Apart and Students can be up to one year. Understanding these differences is crucial to ensure appropriate coverage for specific situations.
Misconception 5: Guest membership automatically renews each year.
This misconception can lead to gaps in coverage. It is essential for subscribers to renew guest memberships for spouses or dependents at least 30 days before the current membership period expires. Otherwise, they may lose the ability to secure ongoing coverage.
Key takeaways
When filling out the Home Care Guest Membership form, ensure that all requested information is provided clearly. Incomplete applications can lead to delays in processing.
Only subscribers who are currently active within the Keystone service area are eligible to apply for guest membership. Those who have moved out of the designated counties may not qualify.
The guest membership has specific eligibility requirements based on the relationship to the subscriber. Understanding these categories can help in selecting the correct guest membership type.
Be mindful of the application timelines. Guest memberships are effective 15 days after their properly completed forms are submitted, highlighting the importance of early submission.
Notify Customer Service of any changes in residence. This includes when a guest member moves in or out of the service area, ensuring continuous coverage and correct care assignment.
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