How Coverage Works

How your coverage works

 

You are eligible to enroll in the plan as long as you live or work in the FCHP service area and you meet the plan’s underwriting guidelines.

In general, you may make changes to your insurance coverage only once during a year—on your “anniversary date.” During a designated “open enrollment” period prior to the anniversary date, any changes that you make become effective on the anniversary date. If you have any questions about your group’s enrollment period or anniversary date, please contact your employer or plan sponsor.

Types of coverage

The subscriber may choose between individual coverage and family coverage. If a subscriber chooses individual coverage, the contract covers only the subscriber.

If a subscriber chooses family coverage, the contract may cover:

  • The subscriber
  • The subscriber’s legal spouse
  • Dependent children under age 26
  • Dependent children who are mentally or physically incapable of earning a living.
  • A former spouse, as long as the divorce decree allows for it, and the subscriber has not remarried and added a new spouse to the family contract.

Dependent children include your or your spouse’s children by birth or adoption and children who are under your or your spouse’s legal guardianship. Adopted children are included from the date of
placement in the home or, in the case of a foster child, from the date of the filing of the petition to adopt. If your dependent child has a child, that child is included as a family member as long as your dependent child remains enrolled. (See Age limits for dependent children below.)

Adding dependents

The subscriber may always change to family coverage, or add additional dependents to family coverage, during open enrollment. Changes made during the open enrollment period will be effective on the subscriber’s anniversary date.

In addition, the subscriber may change to family coverage or add dependents to family coverage at the time of the following qualifying events:

  • The subscriber marries. The subscriber may change to family coverage, or add any additional dependents to family coverage at this time. See Changing your coverage.
  • Birth or adoption of a child. The subscriber may change to family coverage, or add any additional dependents to family coverage at this time. The effective date of coverage for a newborn child will be the date of birth. The subscriber must formally notify FHLAC within 30 days of the date of birth. (A claim for the enrolled mother’s maternity admission may be considered a notice when the ubscriber’s membership under this FHLAC contract is a familyplan.) FHLAC provides coverage for newly born infants for injury and sickness. This includes the necessary care and treatment of medically diagnosed congenital defects, birth abnormalities and premature birth. Coverage for these services is subject to all of the provisions described in the FHLAC contract. See Changing your coverage.
  • Loss of other health insurance coverage by a spouse and/or child(ren) who are not currently covered under the subscriber’s contract. The subscriber may add any additional dependents to family coverage at this time. If the previous coverage was not through FHLAC, FHLAC will require notification from the prior insurance company. See Changing your coverage.
  • A spouse and/or child(ren) who formerly lived outside the FCHP service area move into the service area. See Changing your coverage.
  • The subscriber is ordered by a court to provide coverage for a spouse, former spouse, or child(ren). See Divorce for more information about coverage of former spouses.

Hospital charges for the routine care of a newborn following delivery are covered under either individual or family coverage. Any other services for your newborn children or other new dependents
are covered only if the dependent is enrolled under your family coverage.

Changing your coverage

A change made at the time of a qualifying event will be effective on the date of the qualifying event if the premium is paid when due. You must notify your Plan Administrator of the change within 30 days
of the event. If you do not request the change within the 30-day period, you may not make a change until your next anniversary date.

Qualified medical child support order (QMCSO)

The plan will provide coverage for a child under the terms of a Qualified Medical Child Support Order (QMCSO) even if you do not have legal custody of the child, the child is not dependent on you for support, and regardless of any enrollment restriction which may exist for dependent coverage. If the plan receives a QMCSO and you do not enroll the dependent child, the plan will allow the custodial parent or state agency to enroll the child.

Special enrollment rights in case of Medicaid and Children’s Health Insurance Program

If you qualify under Public Law 111-3-Feb. 4, 2009, your plan sponsor shall permit you if you are eligible, but not enrolled, or your dependent if your dependent is eligible, but not enrolled, to enroll
under the group health plan in the following circumstances:

  • You or your dependent loses coverage under a Medicaid or CHIP program (in Massachusetts, MassHealth) due to a loss of eligibility. You have 60 days from the date of termination of coverage to request coverage under the group health plan for you or your dependent.
  • You or your dependent becomes newly eligible for a premium assistance subsidy program under Medicaid or CHIP. You have 60 days after the date you or your dependent is determined to be eligible for the premium assistance subsidy to request coverage under the group health plan.
Age limits for dependents

A dependent child is eligible for coverage until his or her 26th birthday. Coverage for the dependent under the contract ends on midnight of the day before his or her 26th birthday. Dependent children
may be eligible to remain under the family coverage indefinitely if they are disabled; see the following sections for more information.

A dependent child who is no longer eligible due to age also may be eligible for continuation of coverage. (See Options for continuing coverage for more information.) Whenever a dependent child’s coverage under the family coverage ends, the coverage for any offspring of that dependent child also ends.

Disabled dependents

A dependent child who is mentally or physically disabled when he or she reaches age 26, and is not capable of earning his or her own living, can remain on the family or adult child(ren) contract. The subscriber must apply within 30 days of the child’s 26th birthday. The plan determines eligibility for handicapped children. The subscriber must supply us with any medical or other information that may be needed to determine if the child is eligible to continue coverage under the family coverage.

The plan determines eligibility for disabled children. The subscriber must give us any medical or other information that we may need to determine if the child is eligible to continue coverage.

Continuing coverage for former dependents

A dependent child who is no longer eligible for coverage may be eligible for continuation of coverage or conversion to a consumer plan. See Options for continuing coverage for more information.

Surviving dependents

A dependent’s coverage ends if the subscriber dies. The dependent may be eligible for continuation of coverage or conversion to a consumer plan. See Options for continuing coverage for more information.

Divorce

In the event of divorce, the subscriber’s former spouse may remain covered under the family coverage. Coverage may continue, with no additional premium due, unless: (1) the divorce decree does not require (or no longer requires) the subscriber to maintain health insurance coverage for the former spouse, or (2) either the subscriber or the former spouse remarry.

If the subscriber remarries and wishes to add his or her new spouse to the family coverage, the former spouse remains eligible for coverage under the subscriber’s group. However, the former spouse must move from family coverage to individual coverage, subject to the provisions of COBRA, and additional premium will be required; the former spouse only remains eligible under the group if the divorce decree provides for such coverage. If the former spouse remarries, the former spouse’s eligibility ends.

Notice of cancellation of coverage of a former spouse will be mailed to the former spouse at his or her last known address, along with notice of any applicable right to reinstate coverage retroactively to the date of cancellation. The former spouse may be eligible for continuation of coverage or conversion to a consumer plan. See Options for continuing coverage for more information.