CALIFORNIA - Pacificare Health Systems

ii. The termination of employment or reduction
in work hours of a person through whom the
employee or eligible Family Member was covered;
or
iii. The termination of the other Health Plan
coverage; or
iv. The cessation of an employer’s contribution
toward the employee or eligible Family Member
coverage; or
v. The death, divorce or legal separation of a person
through whom the employee or eligible Family
Member was covered.
The Court has ordered health care coverage be
provided for your Spouse or minor child.
If you are an Employee or Retiree and fail to enroll
your eligible Family Members during a PIE or open
enrollment period, you may enroll your eligible Family
Members at any other time upon completion of a 90consecutive-calendar-day
waiting period.
The 90-day waiting period starts on the date the
enrollment form is received by the local Accounting or
Benefits office and ends 90 consecutive calendar days
later.
If you have one or more children enrolled in the Plan,
you may add a newly eligible Child at any time. See
“Effective Date.”
If you are a Retiree, you may continue coverage for
yourself and your enrolled Family Members in the
same plan you were enrolled in immediately before
retiring. You must elect to continue enrollment for
yourself and your enrolled Family Member before the
effective date of retirement (or the date disability or
survivor benefits begin).
If you are a Survivor, you may not enroll your legal
Spouse or domestic partner.
Qualified Medical Child Support Order
A Member (or a person otherwise eligible to enroll in
PacifiCare) may enroll a child who is eligible to enroll
in PacifiCare upon presentation of a request by a
District Attorney, State Department of Health Services
or a court order to provide medical support for such
a Dependent child without regard to any enrollment
period restrictions.
A person having legal custody of a child or a custodial
parent who is not a PacifiCare Member may ask
about obtaining Dependent coverage as required by
a court or administrative order, including a Qualified
Medical Child Support Order, by calling PacifiCare’s
Customer Service department. A copy of the court
or administrative order must be included with the
enrollment application. Information including, but
not limited to, the ID card, Combined Evidence of
Coverage and Disclosure Form or other available
information, including notice of termination, will be
provided to the custodial parent, caretaker and/or
District Attorney. Coverage will begin on the first of the
month following receipt by PacifiCare of an enrollment
form with the court or administrative order attached.
Except for Emergency and Urgently Needed Services,
to receive coverage, all care must be provided
or arranged in the PacifiCare Service Area by the
designated Participating Medical Group, as selected by
the custodial parent or person having legal custody.
Effective Date
Member Eligibility
The following effective dates apply provided the
appropriate enrollment transaction (paper form or
electronic) has been completed within the applicable
enrollment period.
If you enroll during a PIE, coverage for you and your
Family Members is effective the date the PIE starts.
If you are a Retiree continuing enrollment in
conjunction with retirement, coverage for you and
your Family Members is effective on the first of the
month following the first full calendar month of
retirement income.
The effective date of coverage for enrollment during an
open enrollment period is the date announced by the
University.
For enrollees who complete a 90-day waiting period,
coverage is effective on the 91st consecutive calendar
day after the date the enrollment transaction is
completed.
An Employee or Retiree already enrolled in adult
plus child(ren) or family coverage may add additional
children, if eligible, at any time after their PIE.
Retroactive coverage is limited to the later of:
a. the date the Child becomes eligible, or
Questions? Call the Customer Service Department at 1-800-624-8822. 95
PART A