CALIFORNIA - Pacificare Health Systems

PART A
94
Member Eligibility
Adding Family Members to Your Coverage
The Subscriber’s Spouse or Domestic Partner and
eligible children may apply for coverage with PacifiCare
during the University’s Open Enrollment Period. If
you are declining enrollment for yourself or your
Dependents (including your Spouse or Domestic
Partner) because of other health plan insurance or
group health plan coverage, you may be able to enroll
yourself and your Dependents in PacifiCare if you and
your Dependents lose eligibility for that other coverage
(or if the Employer Group stops contributing toward
your or your Dependent’ other coverage.) However,
you must request enrollment within 30 days after your
or your Dependents other coverage ends (or after
the Employer Group stops contributing toward your
or your Dependent’ other coverage). In addition, if
you have a new Dependent as a result of marriage,
birth, adoption or placement for adoption, you may
be able to enroll yourself and your Dependents.
However, you must request enrollment within 30 days
after the marriage, birth, adoption or placement for
adoption. (Guardianship is not a qualifying event for
other Family Members to enroll.) Under the following
circumstances, new Family Members may be added
outside the Open Enrollment Period. To obtain more
information contact our Customer Service department.
1. Getting Married. When a new Spouse or child
becomes an eligible Family Member as a result
of marriage, coverage begins on the first day of
the month following the date of marriage. An
application to enroll a Spouse or child eligible as
a result of marriage must be made within 30 days
of the marriage.
2. Domestic Partnership. When a new Domestic
partner or Domestic Partner’s child becomes an
eligible Family Member as a result of a domestic
partnership, coverage begins on the first of
the month following the date of the domestic
partnership. An application to enroll a Domestic
Partner or child eligible as a result of a domestic
partnership must be made within 30 days of the
domestic partnership.
3. Having a Baby. Newborns are covered for the
first 30 days of life. In order for coverage to
continue beyond the first 30 days of life, the
Subscriber must submit a Change Request Form
to PacifiCare prior to the expiration of the 30-day
period.
4. Adoption or Placement for Adoption.
Subscriber may enroll an adopted child if
Subscriber obtains an adoptive placement
from a recognized county or private agency, or
if the child was adopted as documented by a
health Facility minor release form, a medical
authorization form or a relinquishment form,
granting Subscriber, Subscriber’s Spouse or
Domestic Partner the right to control the health
care for the adoptive child or absent such a
document, on the date there exists evidence of
the Subscriber’s Spouse’s or Domestic Partner’s
right to control the health care of the child placed
for adoption. For adopted children, coverage is
effective on the date of adoption or placement for
adoption. An application must be received within
30 days of the adoption placement.
5. Guardianship. To enroll a Dependent child for
whom the Subscriber, Subscriber’s Spouse or
Domestic Partner has assumed legal guardianship,
the Subscriber must submit a Change Request
Form to PacifiCare along with a certified copy of
a court order granting guardianship within 30
days of when the Subscriber, Subscriber’s Spouse
or Domestic Partner assumed legal guardianship.
Coverage will be retroactively effective to the date
the Subscriber assumed legal guardianship.
Late Enrollment
You and your eligible Family Members may also enroll
during a group open enrollment period established by
the University.
If you are an Employee and opt out of medical
coverage or fail to enroll yourself during a PIE or
open enrollment period, you may enroll yourself at
any other time upon completion of a 90-consecutivecalendar-day
waiting period.
The eligible employee (on his or her own behalf, or
on behalf of any eligible Family Members) declined
in writing to enroll in PacifiCare when they were first
eligible because they had other health care coverage.
The other health care coverage is no longer available
due to:
i. The employee or eligible Family Member has
exhausted COBRA continuation coverage under
another group Health Plan; or