Spousal Coverage

Out of a Job?Looking for health care benefits and options?

www.insurance.state.pa.us



Spousal Coverage

• Under federal law, you and your children have 30 days to join your spouse’s group plan under his or her employer if otherwise eligible due to a ‘major event’ to include losing your own group health insurance benefits.

• This option may be less expensive than COBRA.



COBRAConsolidated Omnibus Budget Reconciliation Act

• Allows unemployed workers to maintain their health insurance for up to 18 months IF the employer is required to offer COBRA continuation coverage.*

*Employers who provide group health plans to their employees with 20 or more employees on more than 50% of its typical business days in the previous calendar year are required to offer COBRA (some exceptions apply).



COBRA can be expensive, however there are some critical advantages to enrolling:

• No lapse in coverage

• New federal subsidies available

• Eligibility for HIPAA conversion without any pre-existing condition exclusions after COBRA is exhausted

Contact the US Department of Labor:

www.dol.gov/ebsa

(215) 861-5300 or toll free at 1-866-275-7922



Federal HIPAA Conversion Rights

• Issued without pre-existing condition exclusions and is guaranteed issue if you are eligible

• Two options available: Standard and Comprehensive

• May not cover everything your group plan covered




• If your employer was required to offer COBRA coverage, you must enroll and exhaust COBRA before being considered for HIPAA conversion.

• Obtain your HIPAA conversion information and apply before COBRA ends to prevent a gap in coverage.

• You have 63 days from the end of your group or COBRA coverage for your application to be received.

• You may only obtain a HIPAA conversion policy through the Blue Cross/Blue Shield company that sells coverage in the county in which you live.



Federal HIPAA Conversion Rights - To qualify:

• You need at least 18 months of prior continuous insurance coverage.

• You will need a ‘certificate of creditable coverage’* from your last employer’s insurer when applying. (18 months of COBRA also satisfies this requirement.)

*Certificates of creditable coverage are sometimes difficult to obtain, or obtain in a timely manner. You also can prove you had 18 months of continuous coverage by submitting pay stubs showing your health care deductions from your previous employer, or by submitting your explanation of benefits forms.




When requesting an application from your Blue Cross/Blue Shield company, be sure to specifically ask for information regarding HIPAA conversion. Failure to do so may result in you being sent an application for a medically underwritten policy which might result in a denial of coverage and cause you to miss the application deadline.

Questions or concerns? Contact the US Department of Labor

www.dol.gov.ebsa OR(215) 861-5300 or toll free at 1-866-275-7922



Pennsylvania State Conversion Rights

• You may be eligible for an individual conversion policy under the Pennsylvania State conversion law. (Not all employer group plans are required to offer this.)

• Call the insurance company that provides your former employer’s group health plan and ask if it is required to offer individual conversion policies under the PA Conversion law. If so, request information and an application be sent immediately.

• You must elect and exhaust COBRA (if offered) before being considered for a conversion policy.

• If you are eligible, your application must be received and your first premium paid within 31 days of notification of your conversion option.



Pennsylvania State Conversion Rights

• The benefits of a policy under PA State conversion law is that there will be no pre-existing condition exclusions unless the pre-existing condition was excluded by your previous group policy.

• The effective date of conversion will be the day following the termination of your group or COBRA coverage, so there is no lapse in coverage.

• Any dependents covered by your group policy are also eligible for conversion.

• A conversion policy is only required to provide basic health benefits.



Time is of the essence. ACT QUICKLY!

COBRA = 60 day limit to elect to continue coverage under your old job, and 45 days to pay your first premium.

PA Conversion Rights = 31 day limit for the insurance company to receive your application.

HIPAA Conversion Coverage = 63 day limit from the end of your employer group health plan to when Blue Cross Blue Shield receives your HIPAA conversion application.



Guaranteed Issued Health Plans

• If you are not eligible for COBRA continuation coverage, Federal HIPAA conversion, or conversion under PA state law and have health issues, consider a guaranteed issued health plan provided by your Blue Cross/Blue Shield company.

• Guaranteed issued health plans will have pre-existing condition exclusions (which should expire after 12 months).

• When requesting an application from your Blue Cross/Blue Shield company, it is critical that you specifically ask for information regarding Guaranteed Issued Policies.



Low Income Health Plans

• Blue Cross/Blue Shield companies provide health plans for low-income individuals.

• The cost is subsidized by the “Blues,” and therefore, is less expensive.

• Contact your Blue Cross/Blue Shield company for eligibility information, as well as inquire about pre-existing condition exclusions.

• Low-income health plans do have limited benefits but provide good basic health care coverage.



adultBasic

• Provides basic health care coverage for adults between 19 and 65 and is provided by the Commonwealth of Pennsylvania.

• You must have gone without insurance for 90 days prior to enrollment except if you or your spouse lost health coverage because you are no longer employed.

• Does not have pre-existing condition exclusions.

• Does not provide prescriptions, vision or dental treatment.

• There is a waiting list. However, if eligible and on the waiting list, you can purchase coverage at cost.

For more information contact:


1-800-462-2742



CHIP

• Pennsylvania CHIP covers all uninsured children and teens.

• There is no income eligibility requirements.

• Premiums will be charged based on a sliding scale.

www.chipcoverspakids.com

OR

1-800-986-5437



MEDICAID

Medicaid is available to those whose income and assets are insufficient to pay for health care. Information about the PA Department of Welfare’s Medicaid Program can be obtained from your county assistance office or you can visit:

www.dpw.state.pa.us

Veterans Health & Prescription Benefits

If you are a military Veteran, you may be eligible for Veteran’s Administration (VA) health and prescription benefits.

www.va.gov

1-800-827-1000



Partnership for Prescription Assistance Program

Single point of access to 475 public and private patient prescription assistance programs:

www.PPARx.org

Or call:

1-888-477-2669

Pennsylvania Patient Assistance Program

Helps those who are 55 or older or adults with disabilities access free prescriptions:

1-800-955-0989



PACE, PACENET & PACE PLUS MEDICARE

Pennsylvania’s prescription program for older adults, offering low-cost prescription medication to qualified residents 65 and older.

PACE – you must be 65 or older, a PA resident for at least 90 days before applying, and cannot be enrolled in the PA Dept of Public Welfare’s Medicaid prescription program. Income limitations may apply.

PACENET – The same eligibility requirements as PACE but with higher income limits so you may qualify if not eligible for PACE.

PACE Plus Medicare – Supplemented by Federal Medicare Part D prescription coverage, this program offers the most generous prescription plan in the United States.

For more information, contact the PA Dept of Aging at:

(717) 772-2730

www.aging.state.pa.us



Prescription Discount Cards

• Ask your local pharmacist • Be wary of buying discount cards not offered directly through a

pharmacy.

Veterans Prescription Benefits

If you are a military veteran, you may be eligible to make an application to receive VA prescription/health benefits.

1-800-827-1000 OR www.va.gov

Other

• Though not endorsed by the PA Insurance Department, you may be able to find prescriptions at bargain prices through retail chains such as Wal*Mart or Costco.

• Shop around and compare prices.



Dental Insurance or Assistance

• Consult a reputable insurance agent to discuss your dental insurance needs.

• If eligible, you may find a free or reduced-fee dentist

through the Pennsylvania Dental Association at (717) 234-5941.

• The Pennsylvania Dental Association also lists free and reduced fee dental offices on their website at:

www.padental.org



Blue Cross of Northeastern Pennsylvania

1-800-829-8599

TDD 1-866-280-0486

Counties served: Bradford, Carbon, Clinton, Lackawanna, Luzerne, Lycoming, Monroe, Pike, Sullivan, Susquehanna, Tioga, Wayne, Wyoming

Highmark Blue Cross Blue Shield

1-800-876-7639 ( Non Members)

1-800-544-6679 ( Current Members)

Counties Served: Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Centre, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington, Westmoreland



Independence Blue Cross215-569-8189 (Within the five-county Philadelphia area)1-800-556-5455 (Outside of the five-county Philadelphia area)Counties Served: Bucks, Chester, Delaware, Montgomery, Philadelphia

Highmark Blue Shield 1-888-269-8412 (Non Members)1-877-986-4571 (Current Members)Counties Served: Adams, Berks, Centre, Columbia, Cumberland, Dauphin,

Franklin, Fulton, Juniata, Lancaster, Lebanon, Lehigh, Mifflin, Montour, Northampton, Northumberland, Perry, Schuylkill, Snyder, Union, York

Capital Blue Cross1-800-962-2242Counties Served: Adams, Berks, Centre, Columbia, Cumberland, Dauphin,

Franklin, Fulton, Juniata, Lancaster, Lebanon, Lehigh, Mifflin, Montour, Northampton, Northumberland, Perry, Schuylkill, Snyder, Union, York



Pennsylvania Insurance DepartmentBureau of Consumer Services:

Automated Consumer Hotline: (877) 881-6388

Harrisburg: (717) 787-2317 TTY/TDD (717) 783-3898Philadelphia: (215) 560-2630 TTY/TDD (215) 560-2471Pittsburgh: (412) 565-5020 TTY/TDD (412) 565-2376

Or visit: www.insurance.state.pa.us

Spousal Coverage

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