Checklist for Enrollment

Download and Print the Checklist

1. A voided check with banking information for an EFT (Electronic Funds Transfer)

2. One form of identification to show state residency:

• a. a current North Carolina driver's license or state ID
• b. current rent or mortgage payment receipt
• c. voter 's registration card
• d. state income tax return
• e. car registration
• f. property tax receipt
• g. utility bill

3. Proof of US Citizenship or Lawful Permanent Resident Alien:
If you are NOT a citizen of the United States, you are required to provide:

• a. a current North Carolina driver's license or state ID (can use for both NC and US Residency)
• b. naturalization/ citizenship certificate
• c. Visa
• d. green card
• e. I-94 card
• a. Employment Authorization Document (EAD) and Advance Parole (Temporary travel document)

4. Proof of Federally Eligible HIPAA individual (if you have had continuous coverage):

• a. a copy of a Certificate of Creditable Coverage showing 18 months of continuous coverage from your prior carrier
• b. if your prior carrier has not provided your with a certificate, other examples of proof of coverage may include:
• i. explanation of benefits or other correspondence from a plan or insurer indicating coverage
• ii. pay stubs showing a payroll deduction for health coverage
• iii. health insurance identification card
• iv. certificate of coverage for group health policy

5. Proof of creditable coverage to reduce pre-existing condition waiting period:

• a. a copy of a Certificate of Creditable Coverage showing 18 months of continuous coverage from your prior carrier
• b. if your prior carrier has not provided your with a certificate, other examples of proof of coverage may include:
• i. explanation of benefits or other correspondence from a plan or insurer indicating coverage
• ii. pay stubs showing a payroll deduction for health coverage
• iii. health insurance identification card
• iv. certificate of coverage for group health policy

6. Proof of Health Coverage Tax Credit (TAA or ATAA) or Pension Benefit Guaranty Corporation

• a. Copy of one of the following:
• i. TAA or ATAA Certification
• ii. health Coverage Tax Credit Certificate or letter indicating eligibility
• iii. proof of certification by Pension Benefit Guaranty Corporation

7. Proof of Eligibility:

• a. a letter from an individual health insurer that includes one of the following:
• i. denial or rejection due to a medical condition from the health insurer
• ii. a conditional rider that would exclude coverage for a medical condition
• iii. a premium statement or a letter showing a COBRA or state continuation premium rate that exceeds the rate you would be charged by Inclusive Health
• iv. a premium rate that exceeds the Inclusive Health rate.

8. Other documentation (if applicable):

• a. a disability award letter
• b. COBRA termination letter including the reason for termination
• c. Pre-existing condition waiting period letter from a health carrier indicating when pre-existing limitation no longer applies to you
• d. Healthcare Savings Account Banking set-up form, if using HSA Banking option through the Inclusive Health Plan.