CALIFORNIA - Pacificare Health Systems

PART A
Extending Your Coverage: Converting to an
Individual Conversion Plan
108
Member Eligibility
If you have been enrolled in this Health Plan for three
or more consecutive months, and you have been
terminated by your employer which terminates your
group Health Plan coverage, you and your currently
enrolled Family Members may apply for the individual
conversion plan issued by PacifiCare. The Employer
Group is solely responsible for notifying you of the
availability, terms and conditions of the individual
conversion plan within 15 days of the termination of
your group coverage.
An application for the conversion plan must be
received by PacifiCare within 63 days of the date
of termination of your group coverage. However,
if the University of California terminates its Group
Agreement with PacifiCare or replaces the PacifiCare
group coverage with another carrier within 15 days of
the date of termination of the Group coverage or the
Subscriber’s participation, transfer to the individual
conversion Health Plan is not permitted. You also
will not be permitted to transfer to the individual
conversion Health Plan under any of the following
circumstances:
1. You failed to pay any amounts due to the Health
Plan;
2. You were terminated by the Health Plan for
good cause or for fraud or misrepresentation as
described in the section “Termination for Good
Cause;”
3. You knowingly furnished incorrect information
or otherwise improperly obtained benefits of the
Health Plan;
4. You are covered or are eligible for Medicare;
5. You are covered or are eligible for hospital,
medical or surgical benefits under state or federal
law or under any arrangement of coverage for
individuals in a group, whether insured or selfinsured*;
6. The Employer Group’s hospital, medical or
surgical expense benefit program is self-insured;
or
7. You are covered for similar benefits under an
individual policy or contract.
Please note: If you were not previously eligible under
the PacifiCare group Health Plan benefit, as described
above, you may not enroll on PacifiCare’s Individual
Conversion Plan. This includes any future Dependents
not currently enrolled as a Member of your PacifiCare
group Health Plan under your former employer.
*Note also: If you elect COBRA or Cal-COBRA
Continuation Coverage, you are eligible for guaranteed
issuance of a HIPAA individual contract at the time your
COBRA or Cal-COBRA Coverage ends. However, if you
select Individual Conversion Coverage instead, you will
not be eligible for a HIPAA-guaranteed product.
Benefits or rates of an individual conversion plan
Health Plan are different from those in your group
plan.
An individual conversion Health Plan is also available
to:
1. Currently enrolled Dependents, if the Subscriber
dies;
2. Dependents who are currently enrolled and
are no longer eligible for group Health Plan
coverage due either to marriage or exceeding the
maximum age for Dependent coverage under the
group plan, as determined by the employer;
3. Dependents who are currently enrolled and lose
coverage as a result of the Subscriber entering
military service;
4. Spouse of the Subscriber who is currently an
enrolled Dependent under PacifiCare, if your
marriage has terminated due to divorce or legal
separation.
Written applications and the first Premium payment
for all conversions must be received by PacifiCare
within 63 days of the loss of group coverage. This is an
additional option to PacifiCare Members. This means
you do not need to enroll and use any benefits you
may have access to through COBRA or Cal-COBRA
to be eligible. For more details, please contact our
Customer Service department.
Individual Conversion Plan Premiums are due on the
first day of the coverage month (i.e., January 1st for
January coverage). If you fail to pay your Individual
Conversion Plan 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 PacifiCare’s