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HomeMy WebLinkAboutCAG1992-0039 - Other - Group Health Cooperative - Revised Enrollment & Eligibility Schedule Section IX - 01/01/1992 Group • Health Cooperative of Puget Sound 223 Taylor Avenue North (C-19165) Seattle, WA 98109 FEBRUARY 11, 1992 MR DOUG EVANS R L EVANS COMPANY INC 1210 PLAZA 600 BLDG SEATTLE WA 98101 RE: City of Kent, #0369 Dear Mr. Evans: Enclosed are two copies of the revised Enrollment and Eligibility Schedule, Section IX., for City of Kent, #0369, effective January 1, 1992. The previous Enrollment and Eligibility Schedule should be removed from the Group Medical Coverage Agreement and replaced with this revision. Please ensure that a copy of this letter and the Enrollment and Eligibility Schedule is forwarded to the group for review and attachment to their Group Medical Coverage Agreement. If you have any questions, please call your Marketing Division Account Executive. In Seattle, call 448-4140; in Tacoma, call 383-6226; in Kitsap County, call 479-6241; or in Whatcom County, call 647-7222. Sincerely, but Cathy Str ss, Supervisor Contract Administration HEALTH PLAN AND INSURANCE SERVICES cc: MARKETING Enclosures PCN-007T/bl Section IX. Enrollment and Eligibility within sixty (60) days of the date of birth. Schedule If subsequent to enrollment it is dis- A. ENROLLMENT covered that the newborn child is not eligible or if the Group does not initiate 1. Application for Enrollment.Application for dues payments on or before sixty (60) enrollment shall be made on an application days from the date of birth, GHC shall form furnished and approved by GHC. No disenroll the child retroactive to the person shall be enrolled or dues accepted effective date of coverage. until this completed application has been Children who are born in a non-GHC received and approved by GHC.The Group Facility on a nonemergency basis will is responsible for submitting completed ap- not be automatically enrolled. In the plication forms to GHC. event there is a change in the monthly a. Newly Eligible Persons.Newly eligible dues payment as a result of the addition Subscribers may make written applica- of a newborn child,the Subscriber must tion for enrollment to the Group within make written application for enroll- thirty-one (31)days of eligibility.If the ment to the Group within sixty(60)days Subscriber wishes to enroll his/her following the date of birth. eligible Dependents, application must In the event there is a change in the be made during this same thirty-one monthly dues payment as a result of the (31)day period. addition of an adoptive child,including Written application for enrollment for newborns, the Subscriber must make a newly dependent person,other than a written application for enrollment newborn or adopted child, must be within sixty (60)days from the day that made to the Group within thirty-one the child is physically placed with the (31)days after the dependency occurs. Subscriber for the purpose of adoption and the Subscriber assumes financial A Subscriber's newborn child shall be responsibility for the medical expenses automatically enrolled when born: of the child. i. at a GHC Facility or GHC Desig- b. If the spouse of a GHC Subscriber loses nated Facility;or eligibility under a group medical plan provided by his/her employer, the ii. at a non-GHC Facility due to an spouse and any eligible Dependents Emergency, provided that all the listed on the spouse's insurance may be requirements of Section X.I. of added to the GHC Subscriber's plan. this Agreement are met,including Enrollment must be continuous be- notification of GHC by way of the tween plans and application must be GHC Notification Line within made prior to, or at the same time as, twenty-four (24) hours following termination of previous enrollment. inpatient admission, or as soon thereafter as medically possible. c. Open Enrollment. A person not en- rolled as a Subscriber or Family De- GHC shall provide notice of such en- pendent when newly eligible, as rollment to the Subscriber and the described above,may make written ap- Group. It is the Subscriber's respon- plication during the Group's Open En- sibility to complete and submit a revised rollment period. application form to the Group. If the Subscriber does not want the newborn d. Health Evaluation. If a Subscriber or child enrolled,he/she must notify GHC Family Dependent wishes to enroll out- side the periods of eligibility as set forth 3B60369.ELG in Section IX.A.1., he/she must first responsibility for the medical expenses satisfy all Health Evaluation require- of the child. ments as established by GHC and defined in Section I. of the Group b. Persons Hospitalized on Effective Medical Coverage Agreement. Date.If a person,other than a newborn, is confined in a hospital on the date 2. Limitation on Enrollment.This Agreement enrollment would otherwise become will be open for application as set forth in effective, the effective date of enroll- Section IX.A.1. GHC may limit enrollment, ment for the person(s)hospitalized will establish quotas, or set priorities for accep- not begin until discharge from the tance of new applications if it determines facility. that its capacity,in relation to its total enroll- ment, is not adequate to provide services to 4. Effective Date of Services and Benefits.Ser- additional persons. vices provided to Enrollees, including new- borns,are subject to all terms and conditions 3. Effective Date of Enrollment. of the Group Agreement including the re- quirement that all services must be received a. Provided application is made as set at a GHC or GHC Designated Facility under forth in Section IX.A l.a. (above), en- the medical management of a GHC rollment for a newly eligible Subscriber physician unless the Enrollee has been and listed Dependents will begin on the Referred by a GHC physician or has date of hire. received Emergency services according to Section X.I. Subscribers who return to work from a leave without pay status within ninety B. ELIGIBILITY (90) days, shall be eligible for enroll- ment on the first of the month following In order to be accepted for enrollment and con- their date of return to work. tinuing coverage under the Group Agreement, individuals must meet all applicable requirements For eligible Subscribers and Family De- set forth below. The Group is responsible for pendents who have satisfied the Health determining eligibility. Evaluation requirement as set forth in Section IX.A.1., following acceptance 1. Subscribers. Elected officials, bona fide by the Cooperative, enrollment will employees and LEOFF II employees who begin on the date specified by GHC. are employed on a regularly scheduled basis of not less than twenty-one (21) hours per Enrollment for newly dependent per- week shall be eligible for enrollment. sons,other than newborns and adopted children,will begin on the first (1st)of LEOFF I employees will not be covered the month following application. under this plan. Provided newborns are enrolled as 2. Family Dependents.The Subscriber may en- specified in Section IX.A.I.a. (above), roll any of the following: enrollment is effective from the date of birth. a. The Subscriber's legal spouse; A newborn is defined as a child who is b. Unmarried dependent children who not older than four(4)weeks. are under the age of twenty-one (21), provided they reside regularly with the For adopted children,enrollment is ef- Subscriber or qualify as Dependents for fective from the date that the adopted Federal Income Tax purposes. child is physically placed with the Sub- scriber for the purpose of adoption and "Children" means the children of the the Subscriber has assumed financial Subscriber including adopted children, stepchildren, foster children, and any 3B60369.ELG other children for whom the Subscriber tion. Enrollment for such a De- is the legal guardian. pendent may be continued for the duration of the incapacity, c. Enrollment may be extended past the provided enrollment does not ter- limiting age for an unmarried person minate for any other reason. enrolled as a Family Dependent on Medical proof of incapacity and his/her twenty-first(21st)birthday if. proof of financial dependency must be furnished to the Coopera- i. the Dependent is a full-time tive upon request, but not more registered student at an accredited frequently than annually after the secondary school, college, or two (2) year period following the university and under the age of Dependent's attainment of the twenty-three(23);or limiting age. I the Dependent is incapable of d. Dependents of LEOFF I employees self-sustaining employment be- are eligible for coverage under this con- cause of a developmental dis- tract. ability or a physical handicap incurred prior to attainment of the Ineligible Persons. GHC reserves the right to limiting age as set forth in Section refuse enrollment to any person whose coverage IX.B.2.b.,or prior to attainment of under the Group Agreement or any other Medi- the student limiting age as set forth cal Coverage Agreement issued by Group Health in Section IX.B.2.c., and is chiefly Cooperative of Puget Sound has been terminated dependent upon the Subscriber for cause. for support and maintenance. A dependent child shall be con- C. CONTINUATION OF ENROLLMENT sidered chiefly dependent upon the Subscriber for support and While on a group approved leave of absence,the maintenance when, as a result of Subscriber and listed Dependents will continue to disability, one-half (1/2) or more receive services and benefits under this Agree- of the total support of the depend- ment for up to one hundred eighty (180) days, ent child is provided by the Sub- provided the employer or Group continues to scriber as determined under remit dues to GHC for the Subscriber and such Internal Revenue Service regula- Dependents. 3B60369.ELG