GENERAL INFORMATION

A Quick Guide To Your Plan
Plan Guide (PDF, 61k)

Benefit Booklet
Each insured employee receives a Benefit Booklet with a Certificate of Coverage indicating the coverage and effective date. Benefits, exclusions and limitations can be found in the Benefit Booklet.

Claims Payment
Claims are paid directly by our group claims office to the insured or a network provider. We do not assign benefits to non network providers.

Eligible Employees
All full-time employees who have completed the required waiting period, if any, are eligible to enroll. “Full-time” means doing the normal duties of the job at least 30 hours per week on a regular basis at the place of business, or at any other place the business requires the employee to go, or at home. Employees working 20- 29 hours per week can be included at the employer's discretion.

Employees must enroll within 31 days of becoming eligible, otherwise they may be considered a late enrollee. (Special exceptions apply. See the Special Enrollment Period section).

Late Enrollees
"Late enrollees," will be enrolled and subject to a 12 month pre-existing condition limitation. Late enrollees are individuals who declined coverage when it was first offered to them and are not enrolling during a Special Enrollment Period. (See the Special Enrollment Period section for more details.) Late enrollees will be given credit for prior creditable coverage toward satisfaction of the pre-existing condition limitation. However, the period of time between when the person was eligible to enroll, and when he or she actually enrolled as a late enrollee will not be counted as a waiting period, and therefore will not run concurrently with the pre-existing condition period.

Special Enrollment Period
An employee or dependent who is eligible for coverage under the Plan, and who declines coverage during the initial enrollment will be allowed to enroll during a Special Enrollment Period if he or she meets the following conditions:

1. The employee or dependent declined this coverage initially because he or she stated in writing at the time of enrollment that he or she had other coverage AND the other coverage:
   
   

   • terminated as a result of loss of eligibility for that coverage (due to legal separation, divorce or annulment, death, termination of the other group health plan, termination of employment, or reduction in the number of hours of employment); or
   • was COBRA continuation which exhausted, or
   • terminated as a result of employer contributions towards such coverage ceasing.
     
     In these cases, enrollment must be made no later than 31 days after the date such coverage in the above terminated.
     OR


2. If an employee acquires a new dependent through marriage, birth, or adoption or placement for adoption, he or she may enroll himself/herself and the newly acquired dependent under this Special Enrollment provision no later than 31 days after the date the person is eligible for coverage. OR


3. A court has ordered coverage to be provided for a spouse or minor or dependent child under a covered employee's health benefit plan and the request for enrollment is made within 31 days after issuance of the court order.

Individuals enrolling during a Special Enrollment Period will be given credit for prior creditable coverage towards satisfaction of the pre-existing condition limitation.

Guarantee Renewability
All group medical plans are guarantee renewable. A carrier may not deny an employer continued participation or access to the same or different coverage under a plan except for the following reasons:

• Non-payment of premium
• Fraud or misrepresentation
• Violation of participation or contribution requirements
• Non-compliance with plan provisions
• For network plans, when there is no longer any member working or living in the service area
• When the carrier discontinues a particular product (subject to state and federal guidelines)
• When a carrier discontinues all coverage in either the large group or small group market, or both, in a state (subject to particular state guidelines)

Plans Available
PerfectHealth offers PPO and EPO High Deductible Health Plans.

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