Changes in Eligibility July 1, 2011

CITY OF WEST HAVEN/WEST HAVEN BOARD OF EDUCATION
MEDICAL PLAN

NOTICE OF CHANGES IN ELIGIBILITY AND BENEFITS

MAY 1, 2011

IMPORTANT: PLEASE READ THIS NOTICE CAREFULLY. IF YOU HAVE ANY QUESTIONS, PLEASE CALL THE BENEFITS OFFICE AT (203) 937-4300 X 7134.

This notice provides you with information required by the federal Affordable Care Act and informs you about important changes to the eligibility rules and benefits under the City of West Haven/West Haven Board of Education Medical Plan (the “Plan”). These changes take effect on July 1, 2011. The changes require immediate action on your part if you have newly-eligible dependent children you want to enroll in the Plan or you want to take advantage of the other special enrollment opportunity discussed in this notice.

New Dependent Eligibility Rules

Effective July 1, 2011, to qualify for dependent coverage under the Plan, a child must: (1) meet the definition of “Child” below, and (2) be under age 26. Under these new rules, a Child under age 26 can qualify for coverage even if he/she is married or has his or her own employment-based health coverage. In addition, a Child under age 26 does not have to be a student to qualify for health coverage.

You or your spouse’s unmarried disabled Child age 26 or older is also eligible for coverage if: the child is incapable of sustaining employment by reason of physical or mental handicap as certified by a physician[1]; the disability occurred prior to the child reaching age 26; you (or your spouse) are chiefly responsible for the child’s support and maintenance.

Child” Defined: Your natural or adopted child (including a child placed for adoption); your stepchild (your spouse’s natural or adopted child, or child placed with your spouse for adoption); a child for whom you have been appointed a legal guardian[2]; and a child for whom you have been designated as the responsible party under a Qualified Medical Child Support Order (QMCSO).

The newborn child of an enrolled dependent Child is eligible for coverage only from birth up to 31 days immediately following the birth. Coverage for the child of a dependent Child will not be extended beyond 31 days following the birth unless the participant is appointed legal guardian.


Special Enrollment Opportunity for Newly-Eligible Dependents

 


SPECIAL ENROLLMENT OPPORTUNITY FOR DEPENDENT COVERAGE

Individuals whose coverage ended, or who were denied coverage (or were not eligible for coverage), because the availability of dependent coverage of children ended before the attainment of age 26 are now eligible to enroll in the City of West Haven/West Haven Board of Education Medical Plan. You may request enrollment for such children by completing the enclosed Enrollment Form and submitting it to the Benefits Office by June 1, 2011(i.e., the close of a 30-day enrollment period). If a completed Enrollment Form is received by the Benefits Office within this 30-day period, coverage for newly-eligible dependents will be effective on July 1, 2011.

If a completed Enrollment Form is not received by the Benefits Office by June 1, 2011, you will have to wait until the 2012 Enrollment Period (for coverage effective July 1, 2012) to enroll your Child in the Plan, unless you experience a special enrollment event that allows you to enroll the Child mid year in accordance with the Plan’s rules.

Please also note that if your dependent child accepts a job at the City or Board of Education of West Haven or is currently an employee of the City or Board of Education and is benefits-eligible, you must drop your child from your coverage and your child must enroll in his or her own coverage.

 

For more information, please contact the Benefits Office at TelephoneNumber.

 

Lifetime Dollar Limit on Essential Health Benefit Eliminated

 

ELIMINATION OF THE PLAN’S LIFETIME DOLLAR LIMIT ON ORGAN TRANSPLANTS

Effective July 1, 2011, the Plan’s current $1,000,000 lifetime dollar limit on benefits provided for organ transplants no longer applies.

 

New Internal and External Appeal Rules

 

INTERNAL AND EXTERNAL REVIEWS OF COVERAGE DETERMINATIONS

As you know, the Plan provides an extensive internal appeals procedure that allows you and your family the opportunity to request review of certain adverse determinations. The Affordable Care Act requires the Plan to follow specific claims and appeals rules. In addition, under the Act, if certain internal appeals are denied, you will have the right to appeal them to an independent external reviewer under revised external appeals rules. The new claims and appeals rules, including new rules regarding external review, are currently under development and will be available to you in a separate handout later this year.

 


 

New Preventive Coverage Rules

PREVENTIVE CARE

Effective July 1, 2011, the Affordable Care Act will require that certain preventive services be covered under the Plan. The required services include services that are highly recommended by the U.S. Preventive Services Task Force.

Your coverage for immunizations for infants, children, adolescents, and adults will also be consistent with guidelines recommended by the federal Centers for Disease Control and Prevention.

 

Pre-existing Condition Exclusion Eliminated on Children Under Age 19

 

ELIMINATION OF THE PLAN’S PRE-EXISTING CONDITION EXCLUSION ON INDIVIDUALS UNDER AGE 19

Effective July 1, 2011, the Plan’s pre-existing condition exclusion on benefits no longer applies to individuals under 19 years of age.

 

 

NOTE: This notice amends the City of West Haven/West Haven Board of Education Medical Plan effective July 1, 2011. It describes changes to the Plan with respect to dependent eligibility and to the Plan’s benefits as presented in prior benefits or Plan communications. Please read this notice carefully and keep it with your benefit materials for future reference.

 



 

[1] Proof of disability and dependency acceptable to Anthem BCBS must be received within 31 days of the child’s 26th birthday. Disability must be certified at the time of enrollment by a physician and thereafter, no more than annually.

[2]. If you are the legal guardian of a child, unless the child qualifies for tax-free employer-provided health coverage (for example, is your federal income tax dependent), the value of the child's coverage will be added to your pay and subject to payroll taxes