CALIFORNIA - Pacificare Health Systems

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.
Coverage Under the Health Insurance
Portability and Accountability Act of 1996
(HIPAA)
You may be eligible for the PacifiCare HIPAA
Guaranteed Issue product, regardless of health status,
if you:
1. Have had at least 18 months of prior creditable
coverage, with the most recent prior creditable
coverage under a group Health Plan,
governmental plan or church plan, and with no
break in creditable coverage greater than 63 days;
2. Are not currently entitled to coverage under a
group Health Plan, Medicare or Medicaid*;
3. Do not currently have other health insurance
coverage;
4. Your most recent creditable coverage was not
terminated because of nonpayment of Premiums
or fraud; and
5. If you were eligible, you elected and have used all
federal COBRA continuation coverage available to
you.
*Please note: 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.
HIPAA-eligible individuals need not be under age sixtyfive
(65) or meet medically underwritten requirements,
but must qualify under the criteria for guaranteed
issuance under HIPAA. Please contact PacifiCare’s
Customer Service for more information.
Member Eligibility
Your Rights Under HIPAA Upon Termination of
This Group Contract
HIPAA is the acronym for the federal law known as the
Health Insurance Portability and Accountability Act of
1996. HIPAA protects health insurance coverage for
workers and their families when they change or lose
their jobs. California state law provides similar and
additional protections.
If you lose your group health insurance coverage and
meet certain important criteria, you are entitled to
purchase coverage under an individual contract from
any Health Plan that sells health insurance coverage
to individuals. Significant protections come with the
HIPAA individual contract: no Pre-Existing Condition
exclusions, guaranteed renewal at the option of the
enrollee so long as the Plan offers coverage in the
individual market and the enrollee pays the Premiums,
and limitations on the amount of the Premium charged
by the Health Plan.
Every Health Plan that sells health care coverage
contracts to individuals must fairly and affirmatively
offer, market, and sell HIPAA individual contracts to
all Federally Eligible Defined Individuals. The plan
may not reject an application from a Federally Eligible
Defined Individual for a HIPAA individual contract if:
1. The Federally Eligible Defined Individual agrees
to make the required Premium payments;
2. The Federally Eligible Defined Individual, and
his or her Dependents to be covered by the plan
contract, work or reside in the Service Area in
which the plan operates.
You are a Federally Eligible Defined Individual if, as of
the date you apply for coverage:
1. You have 18 or more months of creditable
coverage without a break of 63 days or more
between any of the periods of creditable coverage
or since the most recent coverage has been
terminated;
2. Your most recent prior creditable coverage was
under a group, government or church plan.
(COBRA and Cal-COBRA are considered employer
group coverage);
3. You were not terminated from your most recent
creditable coverage due to nonpayment of
Premiums or fraud;
Questions? Call the Customer Service Department at 1-800-624-8822. 109
PART A