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Resource Center

Watch videos and webinars, download and print your plan benefit summaries, return-to-work program forms, and other paperwork from our one-stop resource center.

Update on COVID-19

Does Memorial Hermann Health Plan cover the cost of COVID-19 testing for Members?

Memorial Hermann Health Plan will waive Member cost sharing including copays for all diagnostic testing for COVID-19, as well as telemedicine fees for HSA plans that have the service fee with Teladoc. This policy will cover Members who meet CDC guidelines and have been ordered by a physician to be tested at an approved laboratory location. This policy is effective for all Commercial, Medicare Advantage and Hybrid members. Self-insured plan sponsors have the ability to opt-out of this policy at their discretion. Please continue to check back to this website for more information.

Are there other resources available to patients?

The CDC (Centers for Disease Control and Prevention) are providing updated information on a regular basis on their website for patients and other stakeholders. For more information, click here.

2020 Resources

2020 Large Group Employer Application
2020 Small Group Employer Application
2020 Employee Enrollment Form | Spanish
2020 Hybrid Employee Enrollment | Spanish
2020 Hybrid Employer Application
2020 Hybrid ASO

All Employee Enrollments must also complete the following Attestation Form – if a SSN is not provided on the application for a dependent.

All Hybrid Employee Enrollments must also complete the following Attestation Form (Hybrid)– if a SSN is not provided on the application for a dependent.

2020 Large Group HMO Plans

 

2020 Select 001 HMO
2020 Select 002 HMO
2020 Select 003 HMO
2020 Select 500-80 HMO
2020 Select 1000-80 HMO
2020 Select 100-100 HMO
2020 Select 1500-80 HMO
2020 Select 2000-80 HMO
2020 Select 2000-100 HMO
2020 Select 2500-80 HMO
2020 Select 3000-80 HMO
2020 Select 3000-100 HSA HMO
2020 Select 5000-80 HMO
2020 Select 5000-100 HMO
2020 Select 5000-100 HSA HMO
2020 Select 6550-100 HSA HMO
2020 Select 6600-100 Standard HMO

2020 Large Group PPO Plans

2020 Select 002 PPO
2020 Select 1000-80 PPO
2020 Select 1000-100 PPO
2020 Select 1500-80 PPO
2020 Select 2000-80 PPO
2020 Select 3000-80 PPO
2020 Select 5000-80 PPO
2020 Select 5000-80 HSA PPO
2020 Select 6550-100 HSA PPO
2020 Select 6600-100 Standard PPO

2020 Large Group COC and EOC

2020 Certificate of Coverage - Large Group
2020 Evidence of Coverage - Large Group

2020 Small Group HMO Plans

2020 Select Gold 001 HMO
2020 Select Gold 1000 HMO
2020 Select Gold 1500 HMO
2020 Select Gold 2350 HMO
2020 Select Platinum 500 HMO

2020 Small Group PPO Plans

2020 Select Gold 2350 PPO

2020 Small Group HMO Hybrid Plans

2020 Select 001 HMO
2020 Select 002 HMO
2020 Select 500 HMO
2020 Select 1000 HMO
2020 Select 1500 HMO
2020 Select 2000 HMO
2020 Select 3000 HMO
2020 Select 3000 HSA HMO
2020 Select 4000 HSA HMO
2020 Select 5000 HMO
2020 Select 5000 HSA HMO
2020 Select 6350 HSA HMO
2020 Select 6850 HMO
2020 Select 7500 HMO

2020 Small Group PPO Hybrid Plans

2020 Select 2000 PPO
2020 Select 3000 PPO 

2020 Small Group COC and EOC

2020 Certificate of Coverage - Small Groups
2020 Evidence of Coverage - Small Groups 

2019 Resources

2019 Large Group Application
2019 Small Group Application
2019 Employee Enrollment Form | Spanish
2019 Hybrid Small Group Application
2019 Hybrid Employee Application | Spanish

Hybrid ASO

All HMO Group Applications must also complete the following Disclosure Form.

2019 Large Group HMO Plans

2019 Select 001 HMO
2019 Select 002 HMO
2019 Select 003 HMO
2019 Select 500-80 HMO
2019 Select 1000-80 HMO
2019 Select 1000-100 HMO
2019 Select 1500-80 HMO
2019 Select 2000-80 HMO
2019 Select 2000-100 HMO
2019 Select 2500-80 HMO
2019 Select 3000-80 HMO
2019 Select 3000-100 HSA HMO
2019 Select 5000-80 HMO
2019 Select 5000-100 HSA HMO
2019 Select 6550-100 HSA HMO
2019 Select 6600-100 Standard HMO

2019 Large Group PPO Plans

2019 Select 002 PPO
2019 Select 1000-80 PPO
2019 Select 1000-100 PPO
2019 Select 1500-80 PPO
2019 Select 2000-80 PPO
2019 Select 3000-80 PPO
2019 Select 3000-100 PPO
2019 Select 5000-80 PPO
2019 Select 5000-80 HSA PPO
2019 Select 6550-100 HSA PPO
2019 Select 6600-100 Standard PPO

2019 Large Group COC and EOC

2019 Certificate of Coverage - Large Group
2019 Evidence of Coverage - Large Group

2019 Small Group HMO Plans

2019 Select Gold 001 HMO
2019 Select Gold 1000 HMO
2019 Select Gold 1500 HMO
2019 Select Gold 2000 HMO
2019 Select Platinum 500 HMO

2019 Small Group PPO Plans

2019 Select Gold 2000 PPO

2019 Small Group HMO Hybrid Plans

2019 Select 001 HMO
2019 Select 002 HMO
2019 Select 500 HMO
2019 Select 1000 HMO
2019 Select 1500 HMO
2019 Select 2000 HMO
2019 Select 3000 HMO
2019 Select 3000 HSA HMO
2019 Select 4000 HSA HMO
2019 Select 5000 HMO
2019 Select 5000 HSA HMO
2019 Select 6350 HSA HMO
2019 Select 6850 HMO
2019 Select 7500 HMO

2019 Small Group PPO Hybrid Plans

2019 Select 2000 PPO
2019 Select 3000 PPO

2019 Small Group COC and EOC

2019 Certificate of Coverage - Small Group
2019 Evidence of Coverage - Small Group

Additional Submission Forms

Late Submission Form
Deductible Credit Form

Employee Termination Form
Employee Verification Form
Group Data Submission Agreement
CCHP 2019 Form
ACH Form