CALIFORNIA - Pacificare Health Systems

4. The date the former employee, Spouse or former
Spouse becomes entitled to Medicare;
5. For a Spouse or former Spouse, five (5) years
from the date the Spouse’s COBRA coverage
would end;
6. 15 days after PacifiCare mails notice to the
former employee, Spouse or former Spouse that
coverage is being cancelled for failure to pay
Premium. If Premium is received within 15 days
of PacifiCare’s cancellation notification you will
experience no break in coverage and no change
in benefits. However, if you do not pay your
Premium, enrollment will be cancelled effective
15 days after PacifiCare mailed the cancellation
notice. A termination notice will be sent to you at
that time and any Premium payments for coverage
after the effective date of cancellation received
after the 15-day notice period has expired will
be refunded to you within 20 business days.
However, you remain financially responsible
for unpaid Premium for coverage prior to the
effective date of cancellation.
For a Spouse or former Spouse that has used the
available California Continuation Coverage period of
five (5) years, qualified beneficiaries may be allowed
to enroll in a PacifiCare individual conversion Health
Plan, unless you are eligible for Medicare. Other
exclusions date the full 36 months of COBRA benefits
were scheduled to end, regardless of the age or length
of employment of the Subscriber.
If elected, this coverage will begin after your 36th
month of COBRA coverage and will be administered
under the same terms and conditions as if COBRA had
remained in force.
As your former employer’s Premium is not adjusted for
the age of the specific employee or eligible Dependent,
Premiums for this coverage will be 213 percent of the
current applicable group rate. Your Premium may be
increased or benefit package decreased each time your
former Employer Group’s benefit package renews or
changes. Payment is due at the time the Employer
Group’s payment is due.
For California Continuation Coverage, PacifiCare will
bill you directly once we have received your election
form. You are responsible for paying the Health Plan
Premium directly to PacifiCare on a monthly basis and
Member Eligibility
it must be delivered by first-class mail or other reliable
means. The first month’s California Continuation
COBRA Health Plan Premium payment is due within
45 days of the date that you submit the election form
to PacifiCare. This payment must be sufficient to
pay all Premiums due from the first month after the
qualifying event through the current month. Failure
to submit the correct Premium amount will disqualify
you from receiving California Continuation Coverage.
Please note you will not be enrolled in California
Continuation COBRA until PacifiCare receives both
your election form and your first Premium payment.
Thereafter, California Continuation Coverage Premiums
are due on the first day of the coverage month (i.e.,
January 1st for January coverage). If you fail to pay
your Premium when the Premium payment is due,
PacifiCare will send you a 15-day cancellation notice
reminding you that your Premium is overdue. If
Premium is received within 15 days of the issue date
of PacifiCare’s cancellation notification to you that
your Premium is overdue, you will experience no
break in coverage and no change in benefits. However,
if you do not pay your Premium, enrollment will be
cancelled effective 15 days after PacifiCare mailed the
cancellation notice. A termination notice will be sent to
you at this time, and any Premium payments received
after the 15-day notice period has expired for coverage
after the effective date of cancellation will be refunded
to you within 20 business days. However, you remain
financially responsible for unpaid Premium for may
apply. Please see the explanation under “Extending
Your Coverage: Converting to an Individual Plan.” You
may also have additional coverage under HIPAA. Please
see the explanation under “Coverage Under the Health
Insurance Portability and Accountability Act of 1996
(“HIPAA”).
Notification Requirements
The University of California is solely responsible for
notifying former employees or Dependent Spouses
(including former Spouses as defined above) of the
availability of the coverage at least 90 calendar days
before COBRA is scheduled to end. To elect this
coverage, the former employee or Spouse must notify
PacifiCare in writing at least 30 calendar days before
COBRA is scheduled to end.”
Questions? Call the Customer Service Department at 1-800-624-8822. 107
PART A