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Blue Cross & Blue Shield of Rhode Island (BCBSRI) Online Application

Individual and Family Medical and/or Dental Coverage

Welcome to our online application for medical and/or dental coverage. Please read the following to learn about the application process and the things you will need in order to apply.
Other Ways to Apply

1
Call (401) 459-5550, or toll free at
1-855-690-2583 and speak to a Blue Cross representative about applying.

2
Download the application forms and mail/fax them to Blue Cross.

Am I in the right place?
  • I am applying for a NEW plan
  • I will be a Rhode Island resident at the time of coverage
  • My employer does not offer medical coverage
Do you know the plan(s) you are applying for?
  • If you don't know your plan(s), you won't be able to complete an application
  • Visit Find a Plan for Me to find the right plan(s) for you
What do I need to complete this application?
  • The medical and/or dental plan that you are interested in applying for
  • Your Social Security Number
  • Your birth date and the birth dates for all family members (if they are to be covered)
  • Your prior insurance carrier, the date of termination from your last (or current) medical and/or dental insurance
How long will this application take me to complete?
  • The amount of time that it takes to complete this application on line will depend on the amount of information you need to provide.
How can I get help if I need it?

If you would like to talk to a Blue Cross representative, please dial the number at the bottom of every screen, (401) 351-5550 from Monday through Friday, from 8 am to 5:00 pm.

How do I contact Blue Cross for support with my current plan?
  • For help with EXISTING plans, please contact (401) 459-5000
1. What type of MEDICAL plan are you interested in applying for?
Select one item.





2. What type of DENTAL plan are you interested in applying for?
Select one item.






If you are ready to get started, click Next.
Getting Started
Blue Cross is able to offer health insurance to individuals and families within the guidelines of federal and state regulations. Please complete the information below to check if we are able to offer you insurance.

If you are eligible for health insurance directly or indirectly through an employer-sponsored plan, Medicare, Medicaid, or another group plan that employs two or more, then you are not eligible for insurance through any products covered by this application.

1. Are you a Rhode Island resident?



3. Did your employer offer this policy to you as a benefit or otherwise market this policy to you or other individual employees?



4. Do you, your employer, or any individual to be insured under this policy intend to treat this policy as a tax-exempt benefit under Section 162, 125, or 106 of the Internal Revenue Code?



8. What was the name of your prior medical insurance carrier?



9. What is the name of your current or prior dental insurance carrier?

Select a Plan Please take a moment to look over your different options and then select the one that interests you the most.
The Basics
* Fields marked with an asterisk are required.

About Me

First name *   
Middle initial   
Last name *   
Suffix   or example, Jr., Dr.
Date of birth *   MM/DD/YYYY
Sex *
Social security number *   000-00-0000
Current BCBSRI ID   
Marital status *
Primary Language *
Race
My primary care physician
Do you have a primary care physician?
To find a doctor, use our Find a Doctor tool
State
State
ADD MORE DEPENDENTS
Contact Information
* Fields marked with an asterisk are required.

My home address

Address 1  *   include street number
Address 2   include apartment number
City/town  *   
State  *
Zip code  *   
Is your mailing address the same as the home address above? *
State *
My phone and email

Primary phone  *   000-000-0000
Secondary phone   000-000-0000
Email address   e.g. JSmith@company.com
Communication preference

Best time to call

If you prefer to communicate by home phone or cell phone.
Premium Savings Options Blue Cross offers two ways to lower your monthly bill for medical coverage:
- You may be eligible to have part of your monthly premium paid through our AccessBlue program. The amount AccessBlue pays depends on your household income and family size, if you qualify.
- You may qualify for our preferred rate, which is a discounted rate based on your health status, age, and gender.
See below for information about how to apply for either or both of these programs
AccessBlueAbout Access Blue
Blue Cross offers a program called AccessBlue where a portion of you monthly bill for health coverage may be paid by Blue Cross. The amount you'll receive depends on your income and whether you enroll in an individual or family plan. The amount will be indicated on your bill. In order to apply you will need to submit your financial information.

Determine eligibility
To determine if your income level qualifies for AccessBlue, view the chart.
view income eligibility chart

If you do meet the requirements, we need copies of the following information:
  • Federal Income Tax Form 1040, 1040A, or 1040EZ, including all schedules filed
  • Statement of Social Security benefits (if applicable)
  • All W-2 forms
  • All 1099 forms.
Are you interested in applying for AccessBlue?
If you select yes, you'll be able to print a cover letter with directions on where to send the necessary forms listed above.

Preferred Rate Blue Cross offers a preferred rate for those who complete a health status questionnaire and are then approved. A preferred rate reduces the cost of your monthly premium.

Would you like to apply for a preferred rate?
My height
Height
Height
Dependent 2
Height
Weight   pounds
Dependent 3
Height
Weight   pounds
Dependent 4
Height
Weight   pounds
Dependent 5
Height
Weight   pounds
Dependent 6
Height
Weight   pounds
Dependent 7
Height
Weight   pounds
Dependent 8
Height
Weight   pounds
Dependent 9
Height
Weight   pounds
Dependent 10
Height
Weight   pounds
Dependent 11
Height
Weight   pounds
Dependent 12
Height
Weight   pounds
Dependent 13
Height
Weight   pounds
Dependent 14
Height
Weight   pounds
Dependent 15
Height
Weight   pounds
Name of individual   
State
State
State
State
State
State
State
State
State
State
State
State
State
State
State
State
State
State
State
State
State
State
State
State
State
Review My Application Please review your application below. There is a large amount of data displayed so please read as carefully as possible. If you need to make a correction, click on the blue link corresponding to the incorrect information. By clicking you will go back to the screen where you can make the correction.
Step 1: Getting StartedEdit Getting Started

Step 2: Select a PlanEdit Select a Plan

Step 3: The BasicsEdit The Basics

About me
Step 4: Contact InformationEdit Contact Information

My contact information
Step 5: Premium Savings OptionsEdit Premium Savings Options

Sign & Submit Before you sign, there is some important information we need you to review.

Other Insurance Notice

Please read before you buy this insurance.

Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help understanding your health insurance, contact your state insurance department, insurance division, or the State Senior Insurance Counseling program.

Important notice to persons on Medicare -
THIS IS NOT MEDICARE SUPPLEMENT INSURANCE.

This insurance provides limited benefits if you meet the conditions listed in this policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

This insurance duplicates Medicare benefits when it pays: The benefits stated in the policy and coverage for the same event are provided by Medicare.

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: hospitalization, physician services, hospice, other approved items, and services.

This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.

Dental Direct Disclosure Statement

  • A 12-month waiting period applies to major restorative services and surgical periodontics. If you decide to cancel or change your coverage, you must wait 12 months to re-apply.
  • If you re-apply, you must wait an additional 12 months for major restorative coverage and surgical periodontics.

Application Agreement
By signing this application electronically, I certify and agree that:
  1. I have read the above statements, or that they have been read to me; and
  2. All responses on this application are the truth, as best I know. If anyone knowingly lied or hid the truth Blue Cross will have the right to:
    • Reduce or deny a claim; and
    • Cancel the plan, back to the effective date; and
    • Recoup any monies paid, back to the effective date
  3. The applicant is the responsible person for the payment of premiums.
  4. No benefits will apply until the coverage is made effective by Blue Cross.
My signature

By checking this box, I, , am electronically signing this Application for Direct Pay Insurance and I understand that this electronic signature is the legal equivalent of an actual signature and that Blue Cross & Blue Shield of Rhode Island may rely on it as such.
  

Today's Date   MM/DD/YYYY
Thank You Your confirmation number is XXXXXXX, please reference this number if you contact BCBSRI. This number will be included in all the pages you can print below. If you don't print, please keep a record of the confirmation number.
Plan Application

View/print  a printer friendly version of your online application for insurance with Blue Cross.

* This page is listed here strictly for your convenience and records. You do not need to mail/fax it to us.
Certificate of Creditable Coverage - Cover Letter

View/print  this cover letter with directions on how to obtain and submit a Certificate of Creditable Coverage from your prior insurer.

* You may need to submit a Certificate of Creditable Coverage before we can begin processing your application.