Part 12 – Individual Policy (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 107 any other documentation or statements that Blue Cross Blue Shield HMO Blue may ask that you send in order for Blue Cross Blue Shield HMO Blue to verify that you are eligible to enroll in this health plan under an individual contract. You must make sure that all of the information that you include on these forms is true, correct, and complete. Your right to coverage in this health plan under an individual contract is based on the condition that all information that you provide to Blue Cross Blue Shield HMO Blue is true, correct, and complete. During the enrollment process, Blue Cross Blue Shield HMO Blue will check and verify each person’s eligibility for coverage in this health plan under an individual contract. This means that when you apply for coverage, you may be required to provide evidence that you are a resident of Massachusetts. Examples of evidence to show that you are a resident can be a copy of your lease or rental agreement, a mortgage bill, or a utility bill. If you are not a citizen of the United States, Blue Cross Blue Shield HMO Blue may also require that you provide official U.S. immigration documentation. You will also be asked to provide information about your prior health plan(s), and you may be required to provide a copy of your certificate(s) of health plan coverage. If you fail to provide the information to Blue Cross Blue Shield HMO Blue that it needs to verify your eligibility for an individual contract, Blue Cross Blue Shield HMO Blue will deny your enrollment request. Once you are enrolled in this health plan, each year prior to your health plan renewal date, Blue Cross Blue Shield HMO Blue may check and verify that you are still eligible for coverage under an individual contract. Blue Cross Blue Shield HMO Blue may deny your enrollment for coverage, or cancel your coverage, in this health plan under an individual contract for any of the following reasons:  You fail to provide information to Blue Cross Blue Shield HMO Blue that it needs to verify your eligibility for coverage in this health plan under an individual contract.  You committed misrepresentation or fraud to Blue Cross Blue Shield HMO Blue about your eligibility for coverage in this health plan under an individual contract.  You made at least three or more late payments for your health plan(s) in a 12-month period.  You voluntarily ended your coverage in this health plan within the past 12 months on a date that is not your renewal date. But, this does not apply if you had creditable coverage (as defined by state law) continuously up to a date not more than 63 days prior to the date of your request for enrollment in this health plan under an individual contract. If your enrollment request is denied or your coverage is canceled, Blue Cross Blue Shield HMO Blue will send you a letter that will tell you the specific reason(s) for which they have denied (or canceled) your coverage in this health plan under an individual contract. This information will be made available, upon request, to the Massachusetts Commissioner of Insurance. Newly enrolled members will not have a waiting period before Blue Cross Blue Shield HMO Blue will provide access to health care services and benefits. Membership Changes Generally, the subscriber may make membership changes (for example, change from a plan that covers only one person to a family plan) only if the subscriber has a change in family status. This includes a change such as: marriage or divorce; birth, adoption or change in custody of a child; death of an enrolled spouse or dependent; or the loss of an enrolled dependent’s eligibility under the subscriber’s individual contract. If you want to ask for a membership change or you need to change your name or mailing address, you should call or write to Blue Cross Blue Shield HMO Blue. Blue Cross Blue Shield HMO Blue will send you any special forms that you may need. You must request a membership change within 30 days of the reason for the change. Or, if the newly eligible person had prior creditable coverage (as defined by state law), the change must be requested within 63 days of the termination date of the prior