CALIFORNIA - Pacificare Health Systems

This includes those who are entitled to
Medicare benefits through their own or
their spouse’s non-University employment.
Individuals enrolled in both Medicare Parts
A and B are then eligible for the Medicare
premium applicable to this plan. Retirees
or Dependents who are eligible for, but
decline to enroll in both parts of Medicare,
will be assessed a monthly offset fee by the
University to cover the increased costs of
remaining in the non-Medicare plan. Retirees
or Dependents who are not eligible for Part A
will not be assessed an offset fee. A notarized
affidavit attesting to their ineligibility for
Medicare Part A will be required. Forms
for this purpose may be obtained from
the University of California’s Customer
Service Center at 1-800-888-8267. (Retirees/
Dependents who are not entitled to Social
Security and Medicare Part A will not be
required to enroll in Part B.)
You should contact Social Security three
months before your 65th birthday to inquire
about your eligibility and how you enroll in
the Hospital (Part A) and Medical (Part B)
parts of Medicare. If you qualify for disability
income benefits from Social Security, contact
a Social Security office for information about
when you will be eligible for Medicare
enrollment.
To enroll yourself and any eligible
Dependents, you must complete a University
of California Medicare Declaration form and
Secure Horizons Group Retiree MA Plan
Election Form. This notifies the University
that you are covered by the Hospital (Part
A) and Medical (Part B) parts of Medicare.
Medicare Declaration forms and Secure
Horizons Group Retiree MA Plan Election
Forms are available through the University
of California Customer Service Center and
completed forms should be returned to
them. Upon receipt by the University of
confirmation of Medicare enrollment, the
Retiree/Dependent will be changed from the
PacifiCare non-Medicare plan to the Secure
Horizons Group Retiree MA Plan for Medicare
enrollees. Retirees and their Dependents are
Section 2 – Eligibility, Enrollment
Periods and Effective Date
required to transfer to the plan for Medicare
enrollees.
You may also enroll yourself and any eligible
Dependents during your Period of Initial
Eligibility (PIE) which begins on:
a. the date you have an involuntary loss of
other group medical coverage; or
b. the date you move out of a University
Health Maintenance Organization (HMO)
plan’s Service Area on either a permanent
basis, or for more than two months on a
temporary basis.
If you are a Retiree enrolled as a spouse on a
University medical plan and become eligible
for both parts of Medicare in your own right,
you may enroll yourself on the earlier of:
a. the date both parts of Medicare are in
effect; or
b. the Effective Date of retirement.
In addition, you and your eligible Dependents
may enroll during a group open enrollment
period established by the University.
To enroll your newly eligible Dependents,
contact the University of California Customer
Service Center to obtain an enrollment form
and return it during the Dependent’s PIE.
You may enroll Dependents during a newly
eligible Dependent’s PIE. The PIE starts the
day the Dependent becomes eligible for
benefits. For a new spouse, eligibility begins
on the date of marriage. Survivors may not
add new spouses to their coverage.
During this PIE you may also enroll yourself
and/or any other eligible Family Member if
not enrolled during your own or their own
PIE. You must enroll yourself in order to
enroll any eligible Family Member. Family
Members are only eligible for the same plan
you are enrolled in. 21
For a newborn child, eligibility begins on
the child’s date of birth. For newly adopted
children, eligibility begins on the earlier of:
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