Eligibility for Coverage

Eligibility for Coverage

 
Eligibility for Group Coverage

Eligible Employee
An employee is eligible to enroll in this health plan as a subscriber as long as:

  • The employee meets the rules on length of service, active employment, and number of hours worked that the plan sponsor has set to determine eligibility for group coverage. For details, contact your plan sponsor.
  • The employee resides in the service area (or lives and/or works within a reasonable distance from the service area).

Eligible Spouse
The subscriber may enroll an eligible spouse for coverage in this health plan under his or her group membership. An “eligible spouse” includes the subscriber’s legal spouse. (A legal civil union spouse, where applicable, is eligible to enroll for coverage in this health plan to the extent that a legal civil union spouse is determined eligible by the plan sponsor. For more details, contact your plan sponsor.)

Former Spouse
In the event of a divorce or a legal separation, the person who was the spouse of the subscriber prior to the divorce or legal separation will remain eligible for coverage in this health plan under the subscriber’s group membership, whether or not the judgment was entered prior to the effective date of the group coverage. This health plan coverage is provided with no additional premium other than the normal cost of covering a current spouse. The former spouse will remain eligible for this coverage only until the subscriber is no longer required by the judgment to provide health insurance for the former spouse or the subscriber or former spouse remarries, whichever comes first. In these situations, Blue Cross and Blue Shield must be notified within 30 days of a change to the former spouse’s address. Otherwise, Blue Cross and Blue Shield will not be liable for any acts or omissions due to having the former spouse’s incorrect address on file.

If the subscriber remarries, the former spouse may continue coverage in this health plan under a separate membership within the subscriber’s group, provided the divorce judgment requires that the subscriber provide health insurance for the former spouse. This is true even if the subscriber’s new spouse is not enrolled for coverage in this health plan under the subscriber’s group membership.

Domestic Partner
As determined by the plan sponsor, your group health plan may include the option to enroll an eligible domestic partner (instead of an eligible spouse) for coverage under an eligible employee’s group membership. This eligibility option applies to you only when your health plan coverage includes a domestic partner rider that describes these eligibility requirements.

A “domestic partner” is a person with whom the subscriber has entered into an exclusive relationship. This means that both the subscriber and domestic partner: are 18 years of age or older and of legal age of consent in the state where they reside; are competent to enter into a legal contract; share the same residence and must intend to continue to do so; are jointly responsible for basic living costs; are in a relationship of mutual support, caring, and commitment in which they intend to remain; are not married to anyone else; and are not related to each other by adoption or blood to a degree of closeness that would otherwise bar marriage in the state in which they live. A “domestic partner” may also include a person with whom the subscriber has registered as a domestic partner with any governmental domestic registry (whether or not all of the conditions stated above have been met).

If the subscriber enrolls an eligible domestic partner under his or her group membership, the domestic partner’s dependent children are eligible for coverage to the same extent that the subscriber’s dependent children are eligible for coverage under his or her group membership.

If the subscriber subsequently terminates the domestic partnership, an enrolled former domestic partner (and any enrolled children of a former domestic partner) may have the option to continue coverage under his or her group membership to the extent that federal law would usually apply.

Eligible Dependents
The subscriber may enroll eligible dependents for coverage in this health plan under his or her group membership. “Eligible dependents” include the subscriber’s (or subscriber’s spouse’s or, if applicable, subscriber’s domestic partner’s) children who are under age 26. To be an eligible dependent, a child under age 26 is not required to live with the subscriber or the subscriber’s spouse (or domestic partner), be a dependent on the subscriber’s or spouse’s (or domestic partner’s) tax return, or be a full-time student. These eligible dependents may include:

  • A newborn child. The effective date of coverage for a newborn child will be the child’s date of birth provided that the subscriber formally notifies the plan sponsor within 30 days of the date of birth. (A claim for the enrolled mother’s maternity admission may be considered by Blue Cross and Blue Shield to be this notice when the subscriber’s coverage is a family plan.) This health plan provides coverage for newborn infants for injury and sickness. This includes the necessary care and treatment of medically diagnosed congenital defects, birth abnormalities, and premature birth. The coverage for these services is subject to all of the provisions of this health plan.
  • An adopted child. The effective date of coverage for an adopted child will be the date of placement of the child with the subscriber for the purpose of adoption. The effective date of coverage for an adoptive child who has been living with the subscriber and for whom the subscriber has been getting foster care payments will be the date the petition to adopt is filed. If the subscriber is enrolled under a family plan as of the date he or she assumes custody of a child for the purpose of adoption, the child’s health care services for injury or sickness will be covered from the date of custody. (This coverage is provided without a waiting period or pre-existing condition restriction.) This includes the necessary care and treatment of medically diagnosed congenital defects, birth abnormalities, and premature birth. The coverage for these services is subject to all of the provisions of this health plan.
  • A newborn infant of an enrolled dependent child immediately from the moment of birth and continuing after, until the enrolled dependent child is no longer eligible as a dependent.

If an eligible dependent child is married, the dependent child can enroll for coverage under the subscriber’s group membership. And, as long as that enrolled child is an eligible dependent, his or her children are also eligible for coverage under the subscriber’s group membership. The dependent child’s spouse is not eligible to enroll as a dependent for coverage under the subscriber’s group membership.

An eligible dependent may also include:

  • A person under age 26 who is not the subscriber’s (or subscriber’s spouse’s or, if applicable, subscriber’s domestic partner’s) child but who qualifies as a dependent under the Internal Revenue Code.
  • A child recognized under a Qualified Medical Child Support Order as having the right to enroll for health care coverage.
  • A disabled dependent child age 26 or older. A dependent child who is mentally or physically incapable of earning his or her own living and who is enrolled under the subscriber’s group membership will continue to be covered after he or she would otherwise lose dependent eligibility under the subscriber’s group membership, so long as the child continues to be mentally or physically incapable of earning his or her own living. In this case, the subscriber must make arrangements with Blue Cross and Blue Shield through the plan sponsor not more than 30 days after the date the child would normally lose eligibility. Also, Blue Cross and Blue Shield must be given any medical or other information that it may need to determine if the child can maintain coverage in this health plan under the subscriber’s group membership. From time to time, Blue Cross and Blue Shield may conduct reviews that will require a statement from the attending physician. This is to confirm that the child is still an eligible disabled dependent child.

In all of these cases, the child must reside in the service area or, except for a full-time student, live within a reasonable distance from the service area.

Important Note: The eligibility provisions for dependents that are described in this section may differ from the federal tax laws that define who may qualify as a dependent.

Enrollment Periods for Group Coverage

Initial Enrollment
You may enroll for coverage in this health plan on your initial group eligibility date. This date is determined by your plan sponsor. The plan sponsor is responsible for providing you with details about how and when you may enroll for coverage in this health plan. To enroll, you must complete the enrollment form provided by your plan sponsor no later than 30 days after your eligibility date. (For more information, contact your plan sponsor.) If you choose not to enroll for coverage in this health plan on your initial eligibility date, you may enroll only during your group’s open enrollment period or within 30 days of a special enrollment event as provided by federal law.

Special Enrollment
If an eligible employee or an eligible dependent (including the employee’s spouse) chooses not to enroll for coverage in this health plan on his or her initial group eligibility date, federal law may allow the eligible employee and/or his or her eligible dependents to enroll for group coverage when:

  • The employee and/or his or her eligible dependents have a loss of other coverage (see “Loss of Other Qualified Coverage” below for more information); or
  • The employee gains a new eligible dependent (see “New Dependents” below for more information); or
  • The employee and/or his or her eligible dependent become eligible for assistance under a Medicaid plan or a state Children’s Health Insurance Program plan.

These rights are known as your “special enrollment rights.” There may be additional special enrollment rights as a result of changes required by federal law. For example, these changes may include special enrollment rights for: individuals who are newly eligible for coverage as a result of changes to dependent eligibility; and/or individuals who are newly eligible for coverage as a result of the elimination of a lifetime maximum.

Loss of Other Qualified Coverage
An eligible employee may choose not to enroll himself or herself or an eligible dependent (including a spouse) for coverage in this health plan on the initial group eligibility date because he or she or the eligible dependent has other health plan coverage as defined by federal law. (This is referred to as “qualified” coverage.) In this case, the employee and the eligible dependent may enroll for group coverage if the employee or the eligible dependent at a later date loses that other qualified health plan coverage due to any one of the following reasons.

  • The employee or the eligible dependents (including a spouse) cease to be eligible for the other qualified health plan. For example, this could mean that the loss of the other qualified health plan was due to: the loss of the spouse’s coverage; the death of the spouse; divorce; loss of dependent status; or involuntary termination. This includes when an employee or eligible dependent is covered under a Medicaid plan or a state Children’s Health Insurance Program plan and coverage is terminated as a result of loss of eligibility for that coverage.
  • The employer that is sponsoring the other qualified group health plan coverage ceases to make employer contributions for the other group health plan coverage.
  • The employee or the eligible dependents (including a spouse) exhaust their continuation of group coverage under the other qualified group health plan.
  • The prior qualified health plan was terminated due to the insolvency of the health plan carrier.

Important Note: You will not have this special enrollment right if the loss of other health plan coverage is a result of the eligible employee or the subscriber or the eligible dependent’s failure to pay the applicable premiums.

New Dependents
If an eligible employee gains a new spouse or other new eligible dependent(s) due to marriage, adoption, placement for adoption, or birth, the employee and the spouse and/or the new dependent(s) may enroll for coverage in this health plan. (If the new dependent is gained by birth, adoption, or placement for adoption, enrollment will be retroactive to the date of birth or the date of adoption or the date of placement for adoption, provided that the enrollment time requirements described below are met.)

Special Enrollment Time Requirement
To exercise your special enrollment rights, you must notify your plan sponsor no later than 30 days after the date when any one of the following situations occur: the date on which the loss of your other coverage occurs or the date on which the subscriber gains a new dependent; or the date on which the subscriber receives notice that a dependent child who was not previously eligible is newly eligible for coverage as a result of changes to dependent eligibility; or the date on which you receive notice that you are newly eligible for coverage as a result of the elimination of a lifetime maximum. For example, if your coverage under another health plan is terminated, you must request enrollment for coverage in this health plan within 30 days after your other health care coverage ends. Upon request, the plan sponsor will send you any special forms you may need. If you do not request enrollment within 30 days, you will have to wait until the group’s next open enrollment period to enroll for group coverage. You also have special enrollment rights related to termination of coverage under a state Children’s Health Insurance Program plan or a Medicaid plan or eligibility for assistance under a Medicaid plan or a state Children’s Health Insurance Program plan. When this situation applies, you must notify your plan sponsor to request
coverage no later than 60 days after the coverage terminates or the employee or eligible dependent is
determined to be eligible for assistance.

Qualified Medical Child Support Order
If the subscriber chooses not to enroll an eligible dependent for coverage in this health plan on the initial group eligibility date, the subscriber may be required by law to enroll the dependent if the subscriber is subject to a Qualified Medical Child Support Order (QMCSO). This QMCSO order is a state court or administrative agency order that requires an employer’s group to provide coverage to the child of an employee who is covered, or eligible to enroll for group coverage, in this health plan.

Open Enrollment Period
If you choose not to enroll for coverage in this health plan within 30 days of your initial group eligibility date, you may enroll during your group’s open enrollment period. The open enrollment period is the time each year during which eligible persons may enroll for or change coverage for the next year. The open enrollment period is announced by the group to all eligible employees. To enroll for coverage in this health plan during this enrollment period, you must complete the enrollment form provided in the group’s enrollment packet and return it to the group no later than the date specified in the group’s enrollment packet.

Other Membership Changes
Generally, the subscriber may make membership changes (for example, change from a subscriber only plan to a family plan) only if the subscriber has a change in family status. This includes a change such as: marriage or divorce; birth, adoption, or change in custody of a child; death of an enrolled spouse or dependent; or the loss of an enrolled dependent’s eligibility under the subscriber’s group membership. If you want to ask for a membership change or you need to change your name or mailing address, you should call or write to your plan sponsor. The plan sponsor will send you any special forms that you may need. You must request the change within the time period required by the subscriber’s group to make a change. If you do not make the change within the required time period, you will have to wait until the group’s next open enrollment period to make the change. All changes are allowed only when they comply with the eligibility and enrollment rules set by the plan sponsor for your group coverage and they comply with the conditions outlined in this benefit booklet.