CALIFORNIA - Pacificare Health Systems

PART A
110
Member Eligibility
4. You are not eligible for coverage under a group
Health Plan, Medicare, or Medi-Cal (Medicaid);
5. You have no other health insurance coverage; and
6. You have elected and exhausted fully any
continuation coverage you were offered under
COBRA or Cal-COBRA.
There are important terms you need to understand,
important factors you need to consider, and important
choices you need to make in a very short time frame
regarding the options available to you following
termination of your group health care coverage. For
example, if you are offered, but do not elect and
exhaust COBRA or CAL-COBRA Continuation Coverage,
you are not eligible for guaranteed issuance of a HIPAA
individual contract. You should read carefully all of
the information set forth in this section. Additional
information is available from PacifiCare by calling 1-
800-624-8822.
If you believe your HIPAA rights have been violated,
you should contact the Department of Managed Health
Care at 1-888-HMO-2219 or visit the Department’s Web
site at www.dmhc.ca.gov.
Certificate of Creditable Coverage
According to the requirements of the Health Insurance
Portability and Accountability Act of 1996 (HIPAA), a
Certificate of Creditable Coverage will be provided
to the Subscriber by PacifiCare when the Subscriber
or a Dependent ceases to be eligible for benefits
under the University of California’s health benefit
plan. Certificates of Creditable Coverage will also
be provided upon request while the Subscriber or
Dependent is covered under the Health Plan and up
to 24 months after coverage under the Health Plan
ceases. A Certificate of Creditable Coverage may be
used to reduce or eliminate a Pre-Existing Condition
exclusion period imposed by a subsequent Health Plan.
Creditable coverage information for Dependents will
be included on the Subscriber’s Certificate, unless the
Dependent’s address of record or coverage information
is substantially different from the Subscriber’s. Please
contact the PacifiCare Customer Service department
if you need a duplicate Certificate of Creditable
Coverage. If you meet HIPAA-eligibility requirements,
you may be able to obtain individual coverage using
your Certificate of Creditable Coverage.
Uniformed Services Employment and
Reemployment Rights Act
Continuation of Benefits under USERRA. Continuation
coverage under this Health Plan may be available to
you through the University of California under the
Uniform Services Employment and Reemployment
Rights Act of 1994, as amended (USERRA). The
continuation coverage is equal to, and subject to the
same limitations as, the benefits provided to other
Members regularly enrolled in this Health Plan. These
benefits may be available to you if you are absent from
employment by reason of service in the United States’
uniformed services, up to the maximum 24-month
period if you meet the USERRA requirements. USERRA
benefits run concurrently with any benefits that may be
available through the Consolidated Omnibus Budget
Reconciliation Act (COBRA) of 1985, as amended. The
University of California will provide written notice
to you for USERRA continuation coverage. If you are
called to active military duty and are stationed outside
of the Service Area, you or your eligible Dependents
must still maintain a permanent address inside the
Service Area and must select a Participating Medical
Group within 30 miles of that address. To obtain
coverage, all care must be provided or arranged in the
Service Area by the designated Participating Medical
Group, except for Emergency and Urgently Needed
Services.
The Health Plan Premium for USERRA Continuation
of benefits is the same as the Health Plan Premium
for other PacifiCare Members enrolled through the
University of California plus a 2 percent additional
surcharge or administrative fee, not to exceed 102
percent of the University of California’s active group
Premium. Under arrangement with the University,
PacifiCare is responsible for billing and collecting
Health Plan Premiums from you or your Dependents
otherwise due under this Agreement. Additionally,
the University of California is responsible to maintain
accurate records regarding USERRA Continuation
Member Health Plan Premium, qualifying events,
terminating events and any other information that
may be necessary for PacifiCare to administer this
continuation benefit.