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You may have the right to some continued coverage for a
certain period of time after a qualifying event that makes you,
your spouse, or dependents no longer eligible for FlexAbility
benefits. Contact your local Human Resources department as soon
as possible.
Any employee, employee's spouse, or dependent children covered
by the group health plan on the day before the qualifying event
may be eligible for continued benefits. Exactly who is eligible
for continuation and how long they may continue their coverage
depends on the type of qualifying event, and whether you are
covered under another group plan.
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- Voluntary or involuntary termination of employment for
reasons other than "gross misconduct"
- Reduction in the number of hours of employment (no longer
eligible for benefits)
- Termination of the employee's employment for reasons
other than "gross misconduct"
- Reduction in the number of hours worked by the employee
(no longer eligible for benefits)
- Divorce or legal separation of the covered employee
- Death of the covered employee
- Loss of "dependent" status under the plan
This table shows the continuation coverage period for the
different qualifying events.
| Qualifying
Event
|
Beneficiary |
Coverage |
Termination
Reduction in hours |
Employee, spouse dependent child |
18 months (see note) |
Employee entitled to Medicare
Divorce or legal separation
Death of a covered employee |
Spouse,
Dependent child |
36 months |
| Loss of "dependent status" |
dependent child |
36 months |
Note: A disabled beneficiary may extend benefits to 29
months if disabled at the time of the qualifying event, or if
disability occurs at any time during the first 60 days of
Continuation of Coverage, and he or she has been determined to be
disabled by Title II or XVI of the Social Security Act.
If you have a child or adopt a child during the period of
Continuation of Coverage, you may elect to cover that child.
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Participants who are covered under another group plan are not
eligible to continue coverage under the Peace Health Plan. (There
may be an exception if a pre-existing condition exclusion applies
on your other coverage.)
If you are on strike, you have certain rights to continuation
of coverage. Your union is responsible for collecting your share
of the premium charges, and can answer your questions regarding
coverage.
If you are receiving Workers' Compensation payments and are
not actively working the number of hours required to maintain
your eligibility, you may qualify for continuation coverage on a
self-pay basis.
Your local Human Resources department will send you, your
spouse, or your dependent continuation notices within 14 days
after they receive information that a qualifying event has
occurred.
If a qualifying event occurs that your local Human
Resources department would not otherwise know about, you or a
family member must notify the Human Resources Department within
60 days after the event has occurred.
You have 60 days from the date that the qualifying event
occurs, or from the date that your employer sent the continuation
notice, whichever is later, to notify your local Human Resources
department that you would like to elect to continue coverage.
You, your spouse, or a legal guardian may elect continuation for
a minor child.
Coverage begins on the date that your coverage would have
otherwise ended.
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With continuation coverage, you are responsible for the
premium payments. The first payment must be received by your
employer within 45 days after the date you elect to continue
coverage. The first payment must cover the period from the date
of the qualifying event to the date you elected to continue
coverage.
All subsequent premium payments are due on the first of each
month for which you want continuation of coverage. There is a
30-day grace period for premium payments.
Continuation premiums are calculated as 102 percent of the
active health plan rate for the same coverage. Premium for a
disabled beneficiary increases to 150 percent of the active
health plan rate after the 18th month of coverage. If your
premium changes, you will be notified 30 days before the change
goes into effect.
During your continuation coverage, you will be able to have
the same coverage you had when the event occurred that qualified
you for continuation.
Example: If your coverage before the qualifying event
included medical, dental, vision, and a health care spending
account, then you are eligible for these same coverage during
your continuation period.
The same rules that applied to your coverage before
continuation went into effect apply to your continuation
coverage.
Example: A dependent who is over the age of 23 is choosing
continuation and will be moving out of the service area. The
dependent may change medical options--for example, from HMO to
Catastrophic. The dependent cannot choose medical coverage if he
or she was not covered under the medical plan before the
qualifying event.
You may elect to change options at three times: the time you
choose continuation coverage, during the open enrollment period,
or if a change in family status occurs. You may not elect to
change options at any other time during your continuation period.
Example: You terminate your employment and elect to
continue medical, dental, and vision coverage. A few months
later you decide you don't want to continue paying for the vision
and dental coverage. To drop these choices you must wait until
the next open enrollment period. If a family status change occurs
that allows you to drop coverage, however, you could do so
outside the normal open enrollment period. (Not wanting to pay
for a coverage is not considered a family status change.)
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Continuation coverage ends when any one of these conditions is
met:
- The beneficiary (you or your covered dependent) becomes
covered under another group plan (there may be an
exception if pre-existing limitations apply).
- Your payments are not made within 30 days of the due
date.
- Your employer ceases to maintain any group health plan.
- The beneficiary (you or your dependent) becomes entitled
to Medicare.
- The end of your continuation coverage period is reached.
Oregon Portability
If
you lose eligibility for group coverage or Continuation continuation coverage by the
Plan, you may be eligible for Portability coverage through the Oregon Medical
Insurance Pool (OMIP). OMIP is not sponsored or endorsed by the In-Network Plan or PeaceHealth. Rather, OMIP is authorized under Oregon law to provide
Portability coverage to certain Oregon residents who have lost coverage under a
group health benefit plan. Upon proper application and the payment of the
applicable premiums, Portability coverage with OMIP will generally become
effective as of the day following your termination of coverage under the In-Network
Plan.
To be eligible for Portability coverage
with OMIP, you must meet the following requirements:
- You must have been covered under one or more
Oregon group health benefit plans for at least 180 days and applied for
Portability coverage no later than the 63rd day after
termination of your In-Network Plan coverage; and
- You must be an Oregon resident and a
resident of the Plan’s service area.
You are NOT eligible for a Portability
Plan if:
- You are eligible for federal Medicare
coverage; or
- You remain eligible for your prior active
group coverage; or
- You are covered under another group or
individual plan, policy, contract, or agreement providing benefits for
hospital or medical care; or
- You move out of the State of Oregon
For further information regarding
Portability coverage with OMIP, and to receive an application for coverage, call
the OMIP administrator, Regence Blue Cross and Blue Shield, at 1-800-848-7280.
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Each benefit plan provides a method for appealing a claim that
has been denied.
If your claim is denied, you should appeal to your
Claims
Administrator first. Some benefits provide an additional appeal
to the FlexAbility Plan Administrator if you follow the appeal
procedures and still are not satisfied with the Claims
Administrator's decision.
Also, if you wish to appeal any decision regarding
eligibility, enrollment, or status changes, you may do so by
writing to the Plan Administrator.
Send your appeal to:
FlexAbility
Plan Administrator
PeaceHealth
15325 SE 30th Place Suite 300
Bellevue, WA 98007
State why you believe the claim should not have been denied,
and submit any information, questions, or comments you think are
appropriate.
You will receive a response to your appeal from the Plan
Administrator by mail within 90 days after the Plan Administrator
receives the appeal. If the Plan Administrator needs more than 90
days to review your appeal, you will be notified of the delay and
the reasons for it.
If this appeal is denied, you may appeal in writing to the
Employee Benefits Committee.
Send your appeal to:
Employee Benefits
Committee
PeaceHealth
15325 SE 30th Place Suite 300
Bellevue, WA 98007
The Employee Benefits Committee must respond to your appeal
within 90 days, or send you a notice of delay within that same
time period. If your appeal is denied by the Employee Benefits
Committee, no additional appeals will be considered unless
accompanied by additional supporting information.
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Each benefit type or plan has its own Claims Administrator,
and some have more than one (due to location). When a benefit
type has more than one Claims Administrator, where you work will
determine which Claims Administrator you use.
Each Claims Administrator has a Customer Service
Representative whose job it is to answer members' questions about
the plans. If you have any questions or concerns about your
benefits or your coverage, call your Claims Administrator's
Customer Service Representative, toll-free, for assistance.
The following table is a complete list of all the Claims
Administrators for the FlexAbility benefit plans. The Claims
Administrators for each benefit are also listed in the section of
this handbook that describes the benefit.
If you are an employee of the Corporate Center
office but you work at one of the other
PeaceHealth locations, your Claims Administrators are the ones at
the location where you're currently working.
Click on your region to see your Claims Administrator
Information:
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If you are covered by two group insurance plans, FlexAbility
and your other insurer will work together to pay up to 100% of
your covered benefits. This is called "Coordination of
Benefits."
One group plan always pays first (primary plan) and the
other always pays second (secondary plan).
Your employer's plan is always your primary plan.
If your child is covered by both parents, the parent whose
birthday comes first in the year has the primary plan.
For example: Your birthday is April 4 and your spouse's
birthday is July 10, so your plan pays first.
If your child has insurance coverage through both parents, and
you are divorced, the court decree will often determine which
policy is primary. If it doesn't, the parent with custody has the
primary plan.
If your child is covered by a parent and a stepparent, the
general guidelines are: Parent with custody pays first, spouse of
the custodial parent pays second, and the natural parent without
custody pays third.
Always let us know as soon as you have a change in health
insurance coverage. We can help you determine which plan is
primary, so claims payment won't be delayed or confused.
If FlexAbility is your secondary plan, you still must follow
the rules and procedures for your claims to be paid.
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Most benefit plans will send you an Explanation of Benefits
(EOB) whenever a claim is paid or denied. The EOB tells you the
amount billed, the amount disallowed, and the amount paid by the
insurance company.
When your other company pays first, send your Claims
Administrator the itemized bill for services with the EOB you
have received from the other company. Usually, that is all your
plan will need to process your claim.
When a FlexAbility benefit plan pays first, attach the EOB
from your FlexAbility plan to the itemized bill for services and
send them both to your other insurer. If you have not received an
EOB from your FlexAbility plan, call and ask your Claims
Administrator to send you an EOB.
Third-party liability refers to claims that are the
responsibility of someone other than you or the insurers under
the FlexAbility benefit plans. In these cases, your benefit
coverage is secondary. Your Claims Administrator(s) need detailed
information from you whenever you use your plan benefits because
of a:
- Motor vehicle accident.
- Workplace accident, injury, or illness.
- Injury or illness that may result in a lawsuit, or for
which you expect to receive a settlement.
Your benefit plan may recover money from a third-party,
usually an insurance carrier, who may be responsible for paying
for your treatment for an illness or injury. The FlexAbility
benefit plans may sue in your name, if necessary.
By accepting membership in a benefit plan, you make an
agreement that if you receive a settlement for an illness or
injury, you must pay us back for the cost of your treatment.
For example: You are injured while on a weekend visit to a
coastal resort. You sue, and are awarded $7,500 plus attorney's
fees. Meanwhile, your medical plan has paid a total of $6,000 for
treatment of your injury, so you must reimburse your medical plan
for $6,000 out of your settlement.
Before you accept any settlement, tell your Claims
Administrator the terms, and tell the third-party that we have an
interest in the settlement.. If you have medical bills after you
receive a settlement, we will not pay those bills until your
settlement is exhausted.
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If you experience a delay in payment or settlement by the
third-party, or a delay in determining responsibility, your
benefit plan will pay your health claims for covered benefits if
you have followed the usual procedures.
The third-party could deny your claims months after you have
already received health care. The benefit plans would not be able
to pay those claims if you did not follow the usual procedures
for those claims.
If you are using your plan benefits for an illness or injury
you think may be the responsibility of another party, notify the
plan's Claims Administrator in writing as soon as possible. When
a Claims Administrator receives a claim that they think might be
the responsibility of a third-party, they will send you an
Accident/Injury Questionnaire to be filled out and returned.
The contractual rules for third-party liability are
complicated and specific. If you have questions or concerns about
any claims, please call the Claims Administrator's Customer
Service Department.
Your Claims Administrator's employees observe strict
confidentiality when handling or processing your claims and
records. Violation of member confidentiality is grounds for
dismissal.
However, by accepting the plan membership, you authorize the
Claims Administrator to release information in certain
circumstances:
- The Claims Administrator has the right to examine your
medical records for any condition for which you claim
benefits as a member.
- The Claims Administrator has the right to release member
information to physicians, hospitals, and other providers
unless state or federal law prevents disclosure without
your consent.
- The Claims Administrator has the right to use your
medical records in order to conduct professional review
programs for health services.
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