Fillable Medical Enrollment/termination/cobra Change Form (Page 4 of 4) in pdf

Notices

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an adopted child whom you enroll more than 31 days after the child’s birth, adoption

or placement for adoption.

General Notice of Special Enrollment Rights

This means that if you or your dependent is a late enrollee and has a medical condition

If you are declining enrollment under your group health plan for yourself and/or your

before coming to our plan, you will have to wait a certain period of time before the plan

dependents (if your plan includes coverage for dependents) because of other health

will provide coverage for that condition. This limitation only applies to a condition

insurance or other group health plan coverage, you may be able to enroll yourself and

which manifests itself during the six-month period immediately preceding your or your

those dependents in this group health plan if you or the dependents lose eligibility for

dependent’s enrollment date and for which medical advice, diagnosis, care or treatment

that other coverage (or if the other employer stops contributing toward your or your

was recommended or received during the six-month period immediately preceding that

dependents’ other coverage). However, if the other coverage was continuation coverage

date. The “enrollment date” is the effective date of your or your dependent’s coverage

under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), you

under the group health plan.

must request enrollment within 30 days after the COBRA coverage ends. If the other

All Small Employers

coverage was not COBRA continuation coverage, you must request enrollment within 90

days after your or your dependents’ other coverage ends (or after the other employer

A pre-existing conditions exclusion does not apply to pregnancy. In addition, it does not

stops contributing toward the other coverage).

apply to:

In addition, if this plan includes coverage for dependents and you acquire a new dependent

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individuals under age 19

as a result of marriage, birth, adoption or placement for adoption, you may be able to

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a child who is covered under any creditable coverage within 31 days of birth

enroll yourself and your dependents under this plan after declining its coverage.

adoption or placement of adoption as long as there is not a significant break in

However, you must request enrollment within 31 days after the child’s birth or within 30

coverage of more than 90 consecutive days prior to the child’s enrollment date;

days after the marriage, adoption or placement for adoption.

If you decline group health coverage under this plan, you will be asked to state in writing

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birth defects in a covered dependent child.

whether the declination was due to the existence of other health coverage. If you don’t

This plan will not provide benefits for preexisting conditions for 180 days, measured from

provide this statement, the above special enrollment rights may not be available to you if

the person’s enrollment date. However, the length of this period can be reduced by the

you need them.

number of days of your or your dependent’s prior “creditable coverage.” Most prior health

To request special enrollment or obtain more information about it, contact your benefits

coverage is creditable coverage and can be used to reduce the length of this exclusion,

manager, if available, or your employer.

provided that you or your dependent has not experienced a break in coverage of 90 days or

General Notice of Preexisting Conditions Exclusions

more.

NOTE: Your plan imposes a “pre-existing conditions exclusion.” As described below,

To reduce the length of this exclusion by creditable coverage, you must provide the plan

the details of the exclusion that your plan has differ depending on the number of eligible

with a copy of any certificates of creditable coverage that you have. There are also other

employees in your group. Contact your benefits manager, if available, or employer for

ways that you can prove prior creditable coverage.

this information.

If you have questions about the preexisting conditions exclusion, or if you need help

Small Employers with five or fewer eligible employees

demonstrating creditable coverage, contact your benefits manager, if available, or your

A “preexisting conditions exclusion” means that if you or a covered dependent (if your

employer.

plan includes coverage for dependents) is age 19 or older and has a medical condition

Notice on Dependent Under 31 Continuation

before coming to our plan, you might have to wait a certain period of time before the

Horizon Blue Cross Blue Shield of New Jersey will bill over- age dependents directly

plan will provide coverage for the condition. This limitation only applies to a condition

and enrollees will remit the premium directly to Horizon BCBSNJ. When Dependent

which manifests itself during the six-month period immediately preceding your or your

Under 31 Continuation is selected, the home address must be completed under Section

dependent’s enrollment date and for which medical advice, diagnosis, care or treatment

“A – Type of Activity” even when it is the same as the employee’s address.

was recommended or received during the six-month period immediately preceding that date.

Important Note:

The enrollment date means, with respect to an employee or dependent, the earlier of the

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Although the employee must continue eligibility under the dependent’s plan for

effective date of his/her coverage under the group health plan, or the first day of the

continued coverage of the dependent, in addition to the additional applicable eligibility

waiting period, if any, for such enrollment.

criteria, coverage for the dependent will be issued as stand-alone coverage. All

Small Employers with more than five eligible employees

cost-sharing requirements and limitations will apply and will not be combined with

In this case, your plan only imposes a pre-existing conditions exclusion on employees

the employee’s policy. Consequently, covered expenses incurred by the over-age

and dependents (if the plan includes coverage for dependents) age 19 or older who are

dependent will not contribute to family deductibles and out-of-pocket maximums, nor

late enrollees. A late enrollee is:

will family incurred expenses contribute to the over-age dependent’s deductibles or

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an employee or dependent (other than a newborn or an adopted child) who enrolls or

out-of-pocket maximums.

is enrolled more than 30 days after first becoming eligible; or

Medical Enrollment/termination/cobra Change Form Page 4

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