Daparunenr and Human Services mums Mawmca ass lndusmal anuzevam Lo.-um, Kentucky 40750-0091 NEW 22, 2013 91255757 'wcarmao IERR wrmmav mm? 2&3 33-1 Apgficarkan Date' November 22, 20 23 App$ieati9n'l Gee: .-- 6-1% t.?rmk5.azi an ulna. aim iw/or - ha r' I 3 Dusk?! pm.av.d ewe flu: mom 5 W, .200. . nu. mm and Inn Sm-Ia Indi-udunl Sonnets ran lroodvvu Donvorr co aozn Fabrunry 13, znla S-DIGIT UEJDI4 352i 3 AV u.3a1. Lu mun vu Ilukm Mumhcr ID: -- Dear bcr. Thu lcucr 19 [0 confirm of paper check or on I4 authorizing Anthem Anthem Blue and Blue In Imuulc 21 one-lime ACH transfer from your account umuum of 5 2mm Your account will he debuted on or aflct oz 13 14 . will be uppneu In Ihc Member ID Imcd ubnvc Pleue nole; Hm mu) luw been made lhrough uumur Ssmur.' nur IVR Pnymunl mm nr Ivy pupt.-r nu-uk kw ]m.:1ImIn\ Hm murmur um uu cnnuncd In .m rl.| I \uu hunk nun he um um: an we mcem: yuur puymenl lur wumly rmum. \uu vull r: yum ongzxul [upcr um-x my mice convened and prricuwcd We will no on,unu1..r.u keep :1 uupy for rum recon]; you know you could set up automatlc recurring payment: through your checking nccounc Io pay your pramiurrn Payment>> ml} he dcbilcd from your checking account AND you can dinmc the day your urc No mule pupcr wnny ubum, pllurh: nails lo puy yum rryuu usually mail you paymcm, you can we on mu Iryou rm: in mm option, please call us for mun: informuuou at the number below. 11' you huu: any would likc In dlscuxx other payment uphum, p}cz|su call us at X55-748-I804. We upprcuimc your bmincsx und wan! to thank you yum conunucd membership Anmcm Blue Crn-.5 and Blue suu.--crc1y. Anthem 3 mm xsax wmuut >4 uusn xm nu mu cmmwuvunsv am ituwnmovm Anthem Blue Cross and Blue Shield and Appeals fiiniliem, 2. l'.O.Box5lE . . Norlli Haven CT 0647341518 Match 18,2014 The Slate of New Hampshire Insurance Department Aim: Barbara Anderson 21 South Fruit Street, Suile 14 Concord NH 03301 Subject Terry wetherby identification Number NAIC Number: 53759 NHl)0l FiIt:Numbcr: 120637 Dear Ms. Anderson: I am writing to you mday in response to your inquiry regarding a complaint Terry in regards to the cancellation of her health insurance coverage, You have requested adctailcd narrative and timeline explaining what has transpired with respect la this complainl. My research shows thal Ms. is suppose it: be enrolled with a Silver DirectAcs records show that on February 28, 2014 a member services representative spoke with Ms. Wetherby as she called into to member services slalirig that she had not received her identification cards yet and it was determined that when the policy was to be loaded there was a diflerence between the calculated rate and the quoted premium. so it was never effeclive. A request was sent to reach out to the Exchange to get the me updated. This has been reviewed by mnnagemenl and while Anthem is warking this with the Exchange, it has been determined that Ms. Wetherby Will be enmlled with policy at the quuled rate of $623.07 and with subsidy Ms. Wetherby is responsible for $26.07. Premium payments for February and March are due because the February payment was sent back to Ms. due to the cancelled policy. Ms. Anderson. irynu have any additional questions please contact uur uffice. Sincerely, Axilhcm Blue Cross and nine Shield is Ilia lmd: name or /inmnn Plans nfN:w nfllilyuhivl, lnu lniiepeizdcm llnensee of ill: Blue cross mil nine Shield oinntticrn Companies, inc The Blue mid Blue Shield names Mid symhulx are uftlw Blue Cross and Blue Shield Assncillion fim Stwmoww Lisa Stavropoulos Grievances and Appeals Analyst Grievance and Appeals