CALIFORNIA - Pacificare Health Systems

Generally, Medicare beneficiaries cannot
make any other changes during 2006
unless they meet the following special
exceptions: the Medicare Advantage Plan in
which the enrollee is enrolled is discontinued
in the Service Area in which the enrollee lives;
the enrollee moves out of the Service Area of
the Medicare Advantage Plan; the Medicare
Advantage Organization offering the plan
violated a material provision of its contract
with the enrollee; or the enrollee meets
such other material conditions as CMS may
provide.
For Medicare beneficiaries who are newly
eligible for Medicare coverage:
These Medicare beneficiaries may elect to
enroll in a Medicare Advantage Plan when
they first become entitled to both Part A and
Part B of Medicare. Their enrollment period
begins on the first day of the third month
before the date on which they are entitled
to both Part A and Part B, and ends on the
last day of the third month after the date on
which they become eligible for both Parts
of Medicare. For example: If a beneficiary
is eligible for both Part A and Part B on
September 1, he may enroll in a Medicare
Advantage Plan as early as June 1, but not
later than August 31, for a September 1
effective date.
University of California Eligibility
Provisions
Who is Eligible
You may participate in the Plan if you are
an eligible Retiree and enrolled in both the
Hospital (Part A) and the Medical (Part B)
parts of Medicare. The same applies to your
Dependents. Dependents who are covered
by the PacifiCare plan, but not by both parts
of Medicare, may continue in that Plan until
they cease to be eligible. Anyone enrolled in a
non-University Medicare Advantage Managed
Care contract or enrolled in a non-University
Medicare Part D Prescription Drug Plan will
be disenrolled from this health plan.
Section 2 – Eligibility, Enrollment
Periods and Effective Date
Eligible Retirees (Including Survivors):
You may continue University medical plan
coverage when you retire (Retiree) or start
collecting disability or survivor benefits
(Survivor) from the University of California
retirement plan, or any defined benefit plan
to which the University contributes, provided:
1. you meet the University’s service credit
requirements for Retiree medical
eligibility;
2. the Effective Date of your Retiree status
is within 120 calendar days of the date
employment ends (or the date of the
Employee/Retiree’s death in the case of a
Survivor);
3. you elect to continue coverage at the time
of retirement.
A Survivor – a deceased Retiree’s Family
Member receiving monthly benefits from a
University-sponsored defined benefit plan –
may be eligible to continue coverage as set
forth in the University’s Group Insurance
Regulations. For more information, see the
UC Group Insurance Eligibility Factsheet for
Retirees and Eligible Family Members.
If you are eligible for Medicare, you must
follow UC’s Medicare Rules.
The following are the University of
California’s eligibility criteria for Dependent
coverage. In order for Dependents to be
enrolled in the Secure Horizons Group
Retiree MA Plan, they must also meet the
Secure Horizons MA Plan eligibility criteria
set forth in this section. Dependents who
meet the University of California’s eligibility
criteria set forth below but do not meet the
Secure Horizons’ MA Plan eligibility criteria
may be eligible for coverage through the
PacifiCare Health Plan described in Part A of
this Combined Evidence of Coverage and
Disclosure Form.
Eligible Dependents:
SPOUSE: Your legal spouse, except if you
are a Survivor you may not enroll your legal
spouse.
Questions? Call the Customer Service Department at 1-800-228-2144,
(TDHI) 1-800-685-9355, Monday through Friday, 7:00 a.m. to 9:00 p.m.
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PART B