Eligibility.
An employer can designate any “class” of employees as eligible for coverage and may require completion of a waiting period prior to coverage becoming effective. All eligible employees must be actively at work performing all of the duties of their job for the employer.

Employees’ dependents (legal spouse and children under age 26) are also eligible provided that the employee is eligible and becomes insured under the plan. Eligible dependents must be actively at work for their employer or, if not employed, able to engage in substantially all of the usual activities of a person in good health who is the same age and sex and not confined in a hospital or other facility.

The plan is guaranteed issue for all eligible employees and their eligible dependents. There are no medical questions to answer and no physical examination is required.

Enrollment Process.
Once the employee has met the eligibility requirements, the employee will be provided with information about the plan and allowed the opportunity to enroll by completing an enrollment form. Note: enrollment forms are not required if the employer is paying the entire premium.

Coverage Effective Date.
Coverage will be effective the 1st of the month following receipt of the enrollment form provided that the full premium is also received.

Coverage Termination Date.
Coverage will remain in effect until the first of the following occurs: the employee is no longer eligible; the end of the period for which premium has been paid; the date employment ends; the date the employer ceases to participate in the plan; the date the group policy terminates.

Dependent coverage terminates concurrently with that of the employee or earlier if they no longer qualify as a dependent.

Premium Payment.
Premiums are collected through payroll deduction for any amounts payable by each participating employee and, for blanket plans, from the employer. The employer will receive a monthly billing statement and must pay as billed. Changes and adjustments should be noted on the remittance and will be reflected on the next billing statement. Each modal billing will include an administrative fee of up to $9 depending on group size.

Claim Process.
All claims are paid directly to the provider of service when benefits have been assigned by the employee. If benefits are not assigned, payment is made directly to the employee.

Limitations / Exclusions.
For voluntary plans only, benefits are subject to a 6 month pre-existing conditions limitation. (See Exclusions & Limitations section for definition of a pre-existing condition.)

The pre-existing condition limitation is not applicable to blanket plans.