Anthem CA Lumenos HSA 1500 Complete ... - Medicoverage

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Questions? Visit www.Medicoverage.com or call 800-930-7956ENDORSEMENT TO THE FOLLOWING INDIVIDUAL LUMENOS POLICIESPPO Lumenos HSA Compatible 1500/100 – DX26, DX27, DX28PPO Lumenos HSA Compatible 2500/100 – DX32, DX33, DX34PPO Lumenos HSA Compatible 3000/100 – DX38, DX39, DX40PPO Lumenos HSA Compatible 5000/100 – DX44, DX45, DX46PPO Lumenos HSA Compatible 1500/70 – Z126, Z127, Z128PPO Lumenos HSA Compatible 3000/100 – Z132, Z133, Z134PPO Lumenos HSA Compatible 5000/100 – Z129, Z130, Z131PPO Lumenos HIA+ 2500/100 – DX47, DX48, DX49PPO Lumenos HIA+ 3000/100 – DX53, DX54, DX55PPO Lumenos HIA+ 5000/100 – DX59, DX60, DX61PPO Lumenos HIA+ 1500/70 – Z135, Z136, Z137PPO Lumenos HIA+ 3000/70 – Z141, Z142, Z143PPO Lumenos HIA+ 5000/100 – Z138, Z139, Z140PPO Lumenos HIA 1500/100 – DX62, DX63, DX64PPO Lumenos HIA 2500/100 – DX68, DX69, DX70PPO Lumenos HIA 3000/100 – DX74, DX75, DX76PPO Lumenos HIA 5000/100 – DX80, DX81, DX82PPO Lumenos HIA 1500/70 – Z144, Z145, Z146PPO Lumenos HIA 3000/70 – Z150, Z151, Z152PPO Lumenos HIA 5000/100 – Z147, Z148, Z149Issued byANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANYEffective March 1, 2010, the following revisions have been made to your Individual Lumenos Policyissued to you by Anthem Blue Cross Life and Health Insurance Company.PLEASE NOTE: STRIKETHROUGH INDICATES TEXT THAT HAS BEEN REMOVED;UNDERLINE INDICATES TEXT THAT HAS BEEN ADDED.I. Under part entitled ELIGIBILITY, the following changes have been made:Under the section entitled ‘Dependents,’ the 1 st bullet has changed read as follows:• The Policyholder’s lawful spouse of the opposite sex.Under the section entitled ‘Newborns and Adopted Children,’ language has changed to read asfollows:• Newborns of the Policyholder, the Policyholder’s enrolled spouse or enrolled Domestic Partner areautomatically enrolled for the first thirty-one (31) days of life. TO CONTINUE COVERAGE FOR A, THENEWBORN BEYOND THE FIRST THIRTY ONE (31) DAYS OF LIFE, YOU MUST BE ENROLLED ASA DEPENDENT BY NOTIFYING USANTHEM IN WRITING WITHIN SIXTY (60)THIRTY-ONE (31)DAYS OF BIRTH. AND THE POLICYHOLDER WILL BE RESPONSIBLE FOR ANY ADDITIONALPREMIUMS DUE EFFECTIVE FROM THE DATE OF BIRTH.NEWBORNS OF THE POLICYHOLDER’S DEPENDENT CHILDREN ARE NOT COVERED UNDERTHIS POLICY.• A child being adopted by the Policyholder will be automatically enrolled for coverage for have coveragefor up to thirty-one (31) days from the date on which the adoptive child’s birth parent or appropriate legalauthority signs a written document granting the Policyholder, enrolled spouse or enrolled DomesticPartner the right to control health care for the adoptive child, or absent this document, the date on whichother evidence exists of this right. TO CONTINUE COVERAGE FOR AN, THE ADOPTED CHILD YOUMUST BE ENROLLED AS A DEPENDENT BY NOTIFYING US IN WRITING WITHIN SIXTY(60)THIRTY-ONE (31) DAYS OF THE DATE THE POLICYHOLDER’S AUTHORITY TO CONTROLTHE CHILD’S HEALTH CARE IS GRANTED. AND THE POLICYHOLDER WILL BE RESPONSIBLEFOR ANY ADDITIONAL PREMIUMS DUE EFFECTIVE FROM THE DATE THE POLICYHOLDER’SAUTHORITY TO CONTROL THE CHILD’S HEALTH CARE IS GRANTED.CDHP 3.1.10 - END 1
Questions? Visit www.Medicoverage.com or call 800-930-7956II. Under the part entitled WHEN AN INSURED BECOMES INELIGIBLE, the section titled ‘An Insuredbecomes ineligible for coverage when,’ has changed to read as follows:An Insured becomes ineligible for coverageunder this Policy and subject to termination pursuant to the part entitled “DURATION AND TERMINATIONOF YOUR POLICY AND OUR RIGHT TO MODIFY YOUR POLICY” when:Under the same section, the 4 th bullet has changed and language has been added as the 5 th bullet asfollows:• The child Dependent fails to meet the eligibility rules listed in the PART part entitled ELIGIBILITY.• An Insured moves to and lives in a place outside of California.Under the section entitled ‘Notice of Change in Eligibility,’ the paragraph has changed to read asfollows:You must notify us of all changes affecting any Insured’s eligibility under this Policy except for the first andlast bullets listed above under, ‘An Insured becomes ineligible for coverage under this Policy when.’You should address any written notice to us at Anthem Blue Cross Life and Health Insurance Company,P.O. Box 9051 Oxnard, California 93031-9051.Under the section entitled, ‘Options in the Even of Changed Circumstances,’ the 4 th paragraph haschanged to read as follows:The written application must be submitted to us within thirty-one (31) days of the loss of eligibility. We willnot need proof of good health. You should address any written notice to us at Anthem Blue Cross Life andHealth Insurance Company, P.O. Box 9051 Oxnard, California 93031-9051.III. Under the part entitled MAXIMUM COMPREHENSIVE BENEFITS, the following changes have beenmade:Under the section entitled, ‘Lifetime Maximum, the following language has been added as the 2 ndparagraph:If an Insured replaces any Anthem individual medical Policy with another Anthem individual medical Policy,any benefits applied toward the Insured’s lifetime maximum benefit of the prior policy will be applied towardthe Insured’s lifetime maximum benefit of the new Policy.Under the section entitled, ‘Deductible,’ the following language has been added as the 3 rd paragraph:The automatic enrollment of a Newborn or Adopted Children under the Eligibility section may cause theapplicable deductible to automatically change from the Individual Deductible to a Family Deductible.Under the section entitled, ‘Annual Out of Pocket Maximums,’ under the Non-Participating ProviderOut of Pocket Maximum, the following language has been added as the 4 th paragraph:The automatic enrollment of a Newborn or Adopted Children under the Eligibility section may cause theapplicable copayment/coinsurance to automatically change from the Individual YearlyCopayment/Coinsurance Maximum to a Family Yearly Copayment/Coinsurance Maximum.IV. Under the part entitled BENEFIT COPAYMENT/COINSURANCE LIST, the following changes have beenmade:Under the section entitled SKILLED NURSING FACILITY the paragraph under the title has changed toread as follows:This does not include treatment for Mental or Nervous Disorders or Substance Abuse(except for the treatment of Severe Mental Illnesses and Serious Emotional Disturbances of a Child).Under the section entitled MENTAL OR NERVOUS DISORDERS AND SUBSTANCE ABUSE theparagraph under the title has changed to read as follows:This does not include the treatment for Severe Mental Illnesses and Serious Emotional Disturbances of aChild. Preservice review required for all facility based treatment, as well as outpatient professional servicesafter the twelfth (12 th ) visit. Non Participating Provider payments for this benefit will not be applied towardthe Insured’s Non-Participating Provider Out of Pocket Maximum.CDHP 3.1.10 - END 2
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Anthem CA Lumenos HSA 1500 Complete ... - Medicoverage

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