CALIFORNIA - Pacificare Health Systems

Table of Contents
Your Billing Protection 85
Coordination of Benefits 85
Order of Benefit Determination Rules 87
Effect on the Benefits of This Plan 88
Right to Receive and Release Needed
Information 88
PacifiCare’s Right to Pay Others 88
Right of Recovery 89
Important Rules for Medicare and Medicare-
Eligible Members 89
Workers’ Compensation 89
Third-Party Liability – Expenses Incurred Due to
Liable Third Parties Are Not Covered 89
PacifiCare’s Right to the Repayment of a Debt as a
Charge Against Recoveries From Third Parties
Liable for a Member’s Health Care Expenses 90
Non-Duplication of Benefits With Automobile,
Accident or Liability Coverage 90
Section 8. Member Eligibility 91
Who is a PacifiCare Member? 91
Eligibility 91
Continuing Coverage for Certain Disabled
Dependents 92
Enrollment 93
During a Period of Initial Eligibility (PIE) 93
Late Enrollment 94
Effective Date 95
Change in Coverage 96
Effect of Medicare on Retiree Enrollment 96
Medicare Secondary Payer Law (MSP) 96
Medicare Private Contracting Provision 96
Termination of Coverage 97
Optional Continuation of Coverage 97
Plan Administration 97
Plan Year 98
Your Rights Under the Plan 98
Claims Under the Plan 98
Nondiscrimination Statement 98
What is a Service Area? 99
Notifying You of Changes in Your Plan 99
Updating Your Enrollment Information 99
About Your PacifiCare Identification Card (ID) 99
Renewal and Reinstatement (Renewal
Provisions) 99
Ending Coverage (Termination of Benefits) 99
Termination for Good Cause 100
Total Disability 101
Coverage Options Following Termination
(Individual Continuation of Benefits) 101
Federal COBRA Continuation Coverage 101
COBRA Qualifying Events for Subscribers 102
COBRA Qualifying Events for Spouses 102
COBRA Qualifying Events for Dependent
Children 102
Notification of Qualifying Events 103
COBRA Enrollment and Premium Information 103
Termination of COBRA Continuation Coverage 104
1401 Extended Continuation Coverage After
COBRA 104
1401 Extended Continuation Coverage
Enrollment and Premium Information
After COBRA 104
Termination of 1401 Extended Continuation
Coverage After COBRA 105
California Continuation Coverage After
COBRA for Certain Former Employees
and Their Spouses 105
Termination of Continuation Coverage After
COBRA for Certain Employees and Their
Spouses as Described in the Above Paragraph 106
Notification Requirements 107
Extending Your Coverage: Converting to an
Individual Conversion Plan 108
Coverage Under the Health Insurance Portability
and Accountability Act of 1996 (HIPAA) 109
Your Rights Under HIPAA Upon Termination of
This Group Contract 109
Certificate of Creditable Coverage 110