Eligibility for Coverage
Who Is Eligible to Enroll
An employee is eligible to enroll as a subscriber under Dental Blue Freedom as long as he or she 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 health care benefits. For details, contact your plan sponsor.
A subscriber may enroll eligible dependents under his or her membership under Dental Blue Freedom. “Eligible dependents” include the subscriber’s:
- Legal spouse. (A legal civil union spouse, where applicable, is eligible to enroll in Dental Blue Freedom to the extent that a legal civil union spouse is determined eligible by the plan sponsor. For more details, contact your plan sponsor.)
- Unmarried dependent children under age 19. These include the subscriber’s or legal spouse’s dependent children who: live with the subscriber or the spouse on a regular basis; or qualify as dependents for federal tax purposes; or are the subjects of a court order that requires the subscriber to provide health insurance for the children. (Eligibility for membership in Dental Blue Freedom also includes the subscriber’s children who are recognized under a Qualified Medical Child Support Order as having the right to enroll for group coverage.)
- Newborn dependent children. The effective date of coverage for a newborn child will be the date of birth provided that the child is enrolled under the subscriber’s membership within 30 days of the date of birth.
- Unmarried adoptive dependent children under age 19. The effective date of coverage for an adoptive child will be the date of placement 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 adoptive parent is enrolled under a family membership as of the date he or she assumes custody of a child for the purpose of adoption, the child’s health care services will be covered from the date of custody (without a waiting period or pre-existing condition restriction). But, benefits for these services are subject to all the provisions described in this Dental Blue Freedom Benefit Description.
- Unmarried full-time student dependent children under age 25. In this case, the subscriber must give Blue Cross and Blue Shield verification that the child is a full-time student at an accredited educational institution. This coverage ends when the student turns age 25 or marries or on November 1st following the date the student discontinues full-time classes or graduates, whichever comes first.
- Unmarried disabled dependent children age 19 or older. An unmarried disabled dependent child may maintain coverage under the subscriber’s membership. But, the child must be either mentally or physically handicapped so as not to be able to earn his or her own living on the date he or she would normally lose eligibility under the subscriber’s membership. 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 under the subscriber’s 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.
- Unmarried children of enrolled dependent children.
Important Reminder: The eligibility provisions described in this section may differ from the federal tax laws that define who may qualify as a dependent.
In the event of divorce or legal separation, the person who was the spouse of the subscriber prior to the divorce or legal separation will remain eligible for coverage under the subscriber’s membership, whether or not the judgment was entered prior to the effective date of Dental Blue Freedom. This coverage is provided with no additional cost. 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. (In the event the subscriber remarries, the former spouse may continue coverage under a separate membership with 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 under the subscriber’s membership.)
You may enroll in Dental Blue Freedom on your initial eligibility date as determined by your group. To enroll, you must complete the enrollment form provided in your enrollment packet and return it to the address specified in the enrollment packet no later than 30 days after your eligibility date. If you choose not to enroll in Dental Blue Freedom within 30 days of your initial eligibility date, you may enroll only during an annual open enrollment period or after a qualifying event as provided by law. 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 to all eligible employees. To enroll in Dental Blue Freedom during this enrollment period, you must complete the enrollment form provided in yourenrollment packet and return it no later than the date specified in the enrollment packet.
Note: See Part 11 for information about continuation of coverage when you lose eligibility for membership in Dental Blue Freedom.
Making Membership Changes
Generally, you may make membership changes (for example, change from an individual membership to a family membership) only if you have a change in family status such as:
- Marriage or divorce.
- Birth, adoption or change in custody of a child.
- Death of an enrolled spouse or dependent child.
- The loss of an enrolled dependent’s eligibility under the subscriber’s membership. For example, when an unmarried dependent child turns age 19 or when a full-time student dependent turns age 25, his or her coverage ends under the subscriber’s 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 your plan sponsor. The plan sponsor will send you any special forms you may need. You must request the membership change within 30 days of the reason for the change. If you do not make the change within 30 days, you will have to wait until the group’s next open enrollment period to make the change. All membership changes or any additions are allowed only when they comply with the conditions outlined in this Dental Blue Freedom Benefit Description.