Disclosures:

Cox HealthPlans reserves the right to accept or decline this application. No insurance coverage will become effective unless application is approved and application fee and appropriate premium are received prior to the effective date.
Applications are not accepted prior to 60 days from the requested effective date.
Coverage is only available to residents in Barry, Barton, Cedar, Christian, Dade, Dallas, Douglas, Greene, Hickory, Howell, Jasper, Laclede, Lawrence, McDonald, Newton, Ozark, Oregon, Phelps, Polk, Shannon, Stone, Taney, Texas, Vernon, Webster, and Wright counties.
Coverage available for applicants ages 1‐64 as of the effective date.
This policy may not cover preexisting conditions, including conditions you may currently have and are unaware of but are not diagnosed until the policy’s term. This policy may not cover certain essential health benefits. Before you realize benefits under this policy, you may be responsible for a deductible and/or co‐insurance. Be sure to discuss these items with your insurance broker before purchasing a short‐term medical policy.
This coverage is not required to comply with the Affordable Care Act.
Commission is paid per member per month (PMPM) based on cumulative active members by agency. Agencies with 1-99 total active members are paid $15 PMPM. Agencies with 100-299 total active members are paid $25 PMPM. Agencies with 300-499 total active members are paid $27 PMPM. Agencies with 500+ total active members are paid $30 PMPM.

Application Information:

A $25 non‐refundable application fee is required to be paid by credit card when submitting the application.
For Child-Only coverage do not place the parent’s information in Section A.
The Authorization Agreement for Short‐Term Direct Debit is required with the application. Upon approval of your application, monthly premiums will be debited at the beginning of each coverage month from your bank account.
For assistance completing the application see our Application Instructions.