IP Enrollment Process

Insure Oklahoma vs. SoonerCare IO is a limited benefit package. Applicants are responsible for a monthly premium. Premiums range from $0 - $ Applicants must pay their co-pays to receive services. IO does not cover children. Cannot be enrolled in any other state program. (Medicaid, SoonerCare, Family Planning, BCC) Coverage is not immediate. (45 – 60 days from application date)

Participation Agreement: The Participation Agreement page is required. Please be sure applicants read this carefully and fully understand what they are agreeing to, check the I Agree button and Submit.

Applicants working for a qualifying employer who does participate in Insure Oklahoma. Self-employed applicant. Applicants applying as disabled with a Ticket-to- Work. Applicants applying as unemployed and receiving/approved for unemployment benefits. Full time college students. Determine Application Type

Applicants working for a qualifying non-participating employer.

Proof of income is usually taxes, pay-stub or a W-2. Spouse may be approved for benefits if he or she: –Is not employed, –works full-time for an employer that would qualify but is not participating –part-time, employed by any size employer. All household members must be listed. All household income must be reported when applicable. Applicants working for a qualifying non- participating employer

Self-employed applicant

Self Employed Proof of income is usually the 1040 tax return that includes one or more of the following: –Schedule C, –Schedule E. (rents, royalties, etc.), –Schedule F( farming), –K1 (from S-Corp, and partnerships), Spouse may be approved for benefits if he or she: –is not employed, –works full-time for an employer that would qualify but is not participating –is part-time employed by any size employer. All household members must be listed. All household income must be reported when applicable.

Applicants applying as disabled with a Ticket-to-Work.

The applicant is applying as disabled with a Ticket-to- Work. Proof of income is usually a Pay-Stub or a W-2. Spouse cannot be approved for benefits. All household members must be listed. All household income must be reported when applicable.

Applicants applying as unemployed and receiving/approved for unemployment benefits

Proof of income is usually a “Monetary Determination of Unemployment Benefits” letter from the OESC. Use the weekly benefit amount listed on the letter. Spouse may be approved for benefits if he or she: –is not employed, –works full-time for an employer that would qualify but is not participating –is part-time employed by any size employer. All household members must be listed. All household income must be reported when applicable.

Applicants applying as an independent college student.

The applicant must be: – an undergraduate between the ages of 19 and 22 –enrolled in a minimum of 12 credit hours –the income of the applicants’ parents is not on their most recent Free Application for Federal Student Aid (FAFSA). A copy of the most recent FAFSA is required to complete the approval process. The applicant may work for any size employer, full or part-time or not work. Spouse cannot be approved for benefits. All household members must be listed. All household income must be reported when applicable.

Applicant Contact Information (page 1 of 8)

Applicant Address Information (page 2 of 8)

Applicant Citizenship Information (page 3 of 8) See the Proof of citizenship document.

Applicant Other Insurance Information (page 4 of 8)

Applicant Employment Information (page 5 of 8)

Applicant Employment Information Provide applicant’s employment information. FEIN is required. This number is found on W-2 or If self employed use their SSN. Include wages. If the applicant has more than one type of employment, click “add another employer”

Clicking add other employment button brings up the following screen.

Applicant Health Plan Information (page 6 of 8)

PCP’s The Insure Oklahoma Individual plan requires persons applying for benefits to choose 3 PCPs and list them on the application. Add PCP ID if chosen already or click “Search for Primary Care Provider”. Define your search.

You can copy and paste the ID # in to the application

After adding the PCP choices click next page

Applicant Other Income Information (page 6 of 8) If you have other types of income click add income. To see the types income to include see the “Income Fact Sheet”

Add Household Member Information (page 8 of 8) Clicking add household member brings up the following

Use this screen to add a spouse and children. Then click “finish household member”

Next, all of the information added to the application can be reviewed and edited

Click to sign. View the status page.

Individual Plan: What to Expect Next After completing application online you will see a status page: –Denied –Pre-approved If pre-approved a letter will be received. Immediately send required documents: –Taxes, all schedules/pages –Paystubs –W2’s, 1099’s –Letter from OESC (Oklahoma Employment Securities Commission) explaining unemployment benefits (monetary determination letter) –Ticket to work certificate for working disabled- Social Security documentation –College students – FAFSA A letter will be sent for citizenship and identity documentation: –See Proof of U.S. Citizenship & Identity list for acceptable documentation All documentation should be sent to: Insure Tulsa 4545 N Lincoln Blvd. Ste 124 Oklahoma City, OK 73105

Monthly Premiums –Most applicants will be responsible for a monthly premium. Invoices are mailed monthly. –The first letter will contain 2 invoices for the first two (2) months of premiums. The invoices state the due date. This is always the 5 th of the month preceding eligibility start date. –Subsequent payments will always be due by the 5 th of the month prior to the benefit month. Payments must be received by the 5 th, not post dated. Late payments are not accepted and will result in application being terminated. To resume coverage applicant must go through the application process again. Welcome Packet –ID card, Member hand book, OOP form and TPL forms will be received approximately one (1) week prior to eligibility start date. Individual Plan: What to Expect Next (cont.)

IP premiums range on a sliding scale between $0 and $ See the chart below for maximum premium amounts. Family Size Monthly IP Maximum Premium 1 $ person covered 2 $ people covered 3 $ people covered 4 $ people covered 5 $ people covered 6 $ people covered 7 $ people covered 8 $ people covered 9 $ people covered

Insure Oklahoma Income Guidelines Annual Effective: April 2009 Family Size Single or two worker family all self employed One worker self employed and one employed Single worker family not self employed Two worker family-not self employed 1 $ 21,660 $ - $ 24,540 $ - 2 $ 29,140 $ 32,020 $ 34,900 3 $ 36,620 $ 39,500 $ 42,380 4 $ 44,100 $ 46,980 $ 49,860 5 $ 51,580 $ 54,460 $ 57,340 6 $ 59,060 $ 61,940 $ 64,820 7 $ 66,540 $ 69,420 $ 72,300 8 $ 74,020 $ 76,900 $ 79,780 9 $ 81,500 $ 84,380 $ 87,260