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(do not use these links or online applications for HIPAA-only plans)
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Need Help? Have A Question?
Call 800-509-0659
Call 800-509-0659
The David Fluker
Health Insurance Agency
Gilroy, California
CA Insurance Lic # 0B58920
Tel 408-847-6139 Fax 408-762-4450 Toll-Free 800-509-0659
CA Insurance Lic # 0B58920
Tel 408-847-6139 Fax 408-762-4450 Toll-Free 800-509-0659
HIPAA Guaranteed-Issue Health Coverage Plans For Individuals & Families in California
| Comprehensive PPO with Maternity HIPAA |
PPO Non-Maternity and/or Restricted Benefit HIPAA |
HIPAA HMO Plans | HSA Compatible PPO Plans HIPAA |
| Anthem Blue Cross HIPAA Share 5000 Blue Shield Spectrum 5500 Blue Shield Spectrum 5000 |
Anthem Blue Cross HIPAA Basic PPO 1000 Health Net PPO Simple Value 50 Aetna MCOA 3500 POS Aetna MCOA 2500 Value POS |
Health Net HMO 15 Health Net HMO 40 Anthem Blue Cross SelectHMO Anthem Blue Cross HMO Saver Blue Shield CA Access+ HMO Blue Shield CA Access+ Value HMO |
Health Net PPO SimpleChoice (non-maternity) Blue Shield Spectrum Savings 4000 (non-maternity) |
Please Read Important Enrollment & Benefit Information On The Grid At The Bottom Of This Page!
For those who are exhausting COBRA/Cal-COBRA programs or are losing group health coverage with no employer continuation offering, HIPAA regulations allow you to purchase guaranteed-issue health coverage under the following rules:
-COBRA or Cal-COBRA benefits must be exhausted or not offered;
-You must apply for HIPAA coverage within 63 days after termination of COBRA, Cal-COBRA or employment if no COBRA offered;
-You must have been covered for 18 months continuously prior to HIPAA effective date with the most recent coverage being employer-sponsored group health insurance with no gaps greater than 63 days between any prior coverage;
-Must not be enrolled in nor eligible for Medicare Part A or B, Medicaid or MediCal or covered by another group health insurance plan.
If you qualify and are not medically able to obtain a private underwritten health insurance plan (which would normally be less costly), you can choose a guaranteed issue health plan. Below are plan options and rates for California residents. Please note that you do not need to be declined for individual coverage to elect a HIPAA plan.
HIPAA California Individual & Family Plans
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ANTHEM BLUE CROSS
For 2010 Anthem is offering HMO Select, HMO Saver, 5000 Share PPO and Basic 1000 PPO.
Effective May 1, 2010, Anthem has a unified application for HIPAA enrollments. The enrollment process has changed. New: A new change effective June 1, 2010 -- you can now submit premium with the Anthem HIPAA application in order to lock in a 1st of the month start date provided the application and premium payment page are submitted prior to or within the first 15 days of the applicable month. I have added the credit card and checking account deduction forms below. One of these should accompany the HIPAA application when you send it to me.
May 1, 2010 Brochure with rate guide and application
May 1, 2010 Anthem HIPAA Application Form
Anthem Blue Cross Credit Card Authorization Form
Anthem Blue Cross Checking Account Deduction Form
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BLUE SHIELD OF CALIFORNIA &
BLUE SHIELD LIFE & HEALTH
Plans Available Starting March 2, 2010
Blue Shield CA/L&H has changed the HIPAA portfolio of plans for effective dates of 3/2/10 and after. New plan choices will include Access+ HMO, PPO 5500, Spectrum PPO 5000 and Spectrum Savings PPO 4000 (HSA-compatible). Blue Shield CA has added a 5th HIPAA plan, the Access+Value HMO, effective 5/1/2010.
Blue Shield HIPAA Rates 5/1/10
Blue Shield HIPAA Application 3/1/10
Plan Summary Access+ HMO HIPAA
Plan Summary Access+ Value HMO HIPAA
Plan Summary PPO 5500 HIPAA
Plan Summary Spectrum PPO 5000 HIPAA
Plan Summary Spectrum Savings PPO 4000 HSA HIPAA
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HEALTH NET OF CALIFORNIA
May 1, 2010 rate change for Health Net. Health Net CA offers four plans under HIPAA, 2 HMO plans and 2 PPO Plans, one of which is HSA-compatible. Health Net best value is the HMO 40 plan.
HMO Plans are the HMO 15 and HMO 40
PPO Plans are the SimpleChoice HSA and SmartValue 50
Health Net CA HIPAA Brochure with rates and application 5/2010
Health Net CA HIPAA Application Form 5/2010
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KAISER PERMANENTE OF CALIFORNIA
Kaiser does not allow independent agents to sell or service their HIPAA plans. You must purchase a HIPAA plan direct from Kaiser.
As a courtesy, I have included the Kaiser HIPAA plan information, rates and application forms.
Be aware Kaiser requires applicants coming off of Kaiser group plans to apply for underwritten coverage and be declined before enrolling under HIPAA. Applicants coming off of any group plan that is not a Kaiser group plan can apply directly for HIPAA coverage without underwriting first.
Kaiser HIPAA 2010 Northern California
Kaiser HIPAA 2010 Southern California
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AETNA
July 1, 2010 Aetna has replaced the 2500/5000 POS plans with 2500 Value POS (no brand Rx coverage) and the 3500 MCOA POS plans. POS plans are not PPO plans. POS plans feature the open access of a PPO network with some of the usage restrictions of an HMO plan. Please note that the HIPAA MCOA plans are not related to the traditional MCOA plans from Aetna and may have usage/benefit restrictions. Please see the table at the bottom of the page for more information. Also, if you are doing a provider search for Aetna HIPAA POS plans, you need to use the "Aexcel" network for specialty providers, NOT the MCOA network. Aetna uses Aexcel now in California for specialty providers like OBGyn and so on.
Aetna HIPAA Rate Guide California (7/2010)
Aetna 2500 Value MCOA POS HIPAA Plan Summary
Aetna 2500 MCOA POS HIPAA Plan Summary
Aetna HIPAA Application Form
_____________________________________________________
Important Notes About HIPAA in California:
Be aware that in California, under HIPAA guaranteed-issue coverage, you are only permitted to make one plan election and enrollment. This means that once an insurer has enrolled you in their HIPAA plan, you cannot change carriers or even make plan changes with that carrier after the fact. It is important to be careful when electing coverage under HIPAA as it is a one-time choice as long as you remain under a HIPAA guaranteed-issue health plan.
Many have asked the reason for this rule. According to the health insurers, it is because once you have been enrolled under a HIPAA plan, you are considered to be under individual & family coverage and not group coverage. HIPAA eligibility requires that your last coverage be group coverage. Therefore, by enrolling under a HIPAA plan in California, you lose you further eligibility under HIPAA and cannot enroll in another plan since you are, technically, no longer eligible for HIPAA.
A word about HIPAA start dates
While HIPAA plans are intended to provide guaranteed-issue coverage after COBRA, it is important to bear in mind the effects of start dates in coordinating coverage, especially if your COBRA continuation terminates on an odd date (like the 12th of the month).
HIPAA HMO plans can only start on the first of the month following application. This means that if your COBRA expires on the 20th of the month, you will have a 10-11 day gap in coverage until the HIPAA HMO effective date. HMOs cannot coordinate to last COBRA date except for those whose COBRA ends on the last day of the month. Also, applications for HIPAA HMO plans really need to be received at my office by the 15th of the month prior to the requested HIPAA start date to ensure sufficient processing time.
HIPAA PPO plan start dates vary by health insurer. Currently the rules are as follows:
Anthem Blue Cross PPO & HMO - New! Effective May 1, 2010, PPO plans will enroll the same as HMO plan. No retroactive start dates and only the first of the month. Call me for details.
Blue Shield CA PPO - New! Effective 3/2/10, 1st or 15th following application approval
Health Net CA PPO - 1st or 15th following application approval
Aetna POS - 1st or 15th following application approval
Kaiser CA - 1st of the month only
Also be aware the even though HIPAA is a guaranteed-issue situation to those who qualfiy, it is not immediate enrollment. Carriers can take several weeks to complete enrollment under HIPAA, so be prepared for that. Also, in order to expedite the process of HIPAA enrollment, you should ensure that you can provide the following with your application:
- Certificate of Creditable Coverage showing expiration of benefits and at least 18 months of coverage; this is also referred to as a Certificate of Group Health Coverage
- COBRA certificate or letter from health insurer or employer (if self-funded/self-insured) showing exhaustion of all continuation benefits (usually provided 30-60 days before the end of COBRA); this is also referred to as a COBRA Termination Letter and can be a letter from the employer, health plan or administrator indicating that your continuation coverage will be or has come to an end due to maximum period allowed.
- If you were not eligible for the CalCOBRA continuation extension to 36 months under AB 1401, proof that the plan did not qualify for that extension (out-of-state, self-funded, etc.). They will ask for written proof in these situations and will NOT take your word for it. You must be able to prove a valid reason for not getting the second 18 months under CalCOBRA in some official manner
-Loss of continuation due to company terminating health plan.You will need to provide some proof in writing that the employer has discontinued health insurance continuation coverage.
-COBRA or Cal-COBRA benefits must be exhausted or not offered;
-You must apply for HIPAA coverage within 63 days after termination of COBRA, Cal-COBRA or employment if no COBRA offered;
-You must have been covered for 18 months continuously prior to HIPAA effective date with the most recent coverage being employer-sponsored group health insurance with no gaps greater than 63 days between any prior coverage;
-Must not be enrolled in nor eligible for Medicare Part A or B, Medicaid or MediCal or covered by another group health insurance plan.
If you qualify and are not medically able to obtain a private underwritten health insurance plan (which would normally be less costly), you can choose a guaranteed issue health plan. Below are plan options and rates for California residents. Please note that you do not need to be declined for individual coverage to elect a HIPAA plan.
HIPAA California Individual & Family Plans
_____________________________________________________________
ANTHEM BLUE CROSS
For 2010 Anthem is offering HMO Select, HMO Saver, 5000 Share PPO and Basic 1000 PPO.
Effective May 1, 2010, Anthem has a unified application for HIPAA enrollments. The enrollment process has changed. New: A new change effective June 1, 2010 -- you can now submit premium with the Anthem HIPAA application in order to lock in a 1st of the month start date provided the application and premium payment page are submitted prior to or within the first 15 days of the applicable month. I have added the credit card and checking account deduction forms below. One of these should accompany the HIPAA application when you send it to me.
May 1, 2010 Brochure with rate guide and application
May 1, 2010 Anthem HIPAA Application Form
Anthem Blue Cross Credit Card Authorization Form
Anthem Blue Cross Checking Account Deduction Form
_____________________________________________________
BLUE SHIELD OF CALIFORNIA &
BLUE SHIELD LIFE & HEALTH
Plans Available Starting March 2, 2010
Blue Shield CA/L&H has changed the HIPAA portfolio of plans for effective dates of 3/2/10 and after. New plan choices will include Access+ HMO, PPO 5500, Spectrum PPO 5000 and Spectrum Savings PPO 4000 (HSA-compatible). Blue Shield CA has added a 5th HIPAA plan, the Access+Value HMO, effective 5/1/2010.
Blue Shield HIPAA Rates 5/1/10
Blue Shield HIPAA Application 3/1/10
Plan Summary Access+ HMO HIPAA
Plan Summary Access+ Value HMO HIPAA
Plan Summary PPO 5500 HIPAA
Plan Summary Spectrum PPO 5000 HIPAA
Plan Summary Spectrum Savings PPO 4000 HSA HIPAA
_____________________________________________________
HEALTH NET OF CALIFORNIA
May 1, 2010 rate change for Health Net. Health Net CA offers four plans under HIPAA, 2 HMO plans and 2 PPO Plans, one of which is HSA-compatible. Health Net best value is the HMO 40 plan.
HMO Plans are the HMO 15 and HMO 40
PPO Plans are the SimpleChoice HSA and SmartValue 50
Health Net CA HIPAA Brochure with rates and application 5/2010
Health Net CA HIPAA Application Form 5/2010
_____________________________________________________
KAISER PERMANENTE OF CALIFORNIA
Kaiser does not allow independent agents to sell or service their HIPAA plans. You must purchase a HIPAA plan direct from Kaiser.
As a courtesy, I have included the Kaiser HIPAA plan information, rates and application forms.
Be aware Kaiser requires applicants coming off of Kaiser group plans to apply for underwritten coverage and be declined before enrolling under HIPAA. Applicants coming off of any group plan that is not a Kaiser group plan can apply directly for HIPAA coverage without underwriting first.
Kaiser HIPAA 2010 Northern California
Kaiser HIPAA 2010 Southern California
_____________________________________________________
AETNA
July 1, 2010 Aetna has replaced the 2500/5000 POS plans with 2500 Value POS (no brand Rx coverage) and the 3500 MCOA POS plans. POS plans are not PPO plans. POS plans feature the open access of a PPO network with some of the usage restrictions of an HMO plan. Please note that the HIPAA MCOA plans are not related to the traditional MCOA plans from Aetna and may have usage/benefit restrictions. Please see the table at the bottom of the page for more information. Also, if you are doing a provider search for Aetna HIPAA POS plans, you need to use the "Aexcel" network for specialty providers, NOT the MCOA network. Aetna uses Aexcel now in California for specialty providers like OBGyn and so on.
Aetna HIPAA Rate Guide California (7/2010)
Aetna 2500 Value MCOA POS HIPAA Plan Summary
Aetna 2500 MCOA POS HIPAA Plan Summary
Aetna HIPAA Application Form
_____________________________________________________
Important Notes About HIPAA in California:
Be aware that in California, under HIPAA guaranteed-issue coverage, you are only permitted to make one plan election and enrollment. This means that once an insurer has enrolled you in their HIPAA plan, you cannot change carriers or even make plan changes with that carrier after the fact. It is important to be careful when electing coverage under HIPAA as it is a one-time choice as long as you remain under a HIPAA guaranteed-issue health plan.
Many have asked the reason for this rule. According to the health insurers, it is because once you have been enrolled under a HIPAA plan, you are considered to be under individual & family coverage and not group coverage. HIPAA eligibility requires that your last coverage be group coverage. Therefore, by enrolling under a HIPAA plan in California, you lose you further eligibility under HIPAA and cannot enroll in another plan since you are, technically, no longer eligible for HIPAA.
A word about HIPAA start dates
While HIPAA plans are intended to provide guaranteed-issue coverage after COBRA, it is important to bear in mind the effects of start dates in coordinating coverage, especially if your COBRA continuation terminates on an odd date (like the 12th of the month).
HIPAA HMO plans can only start on the first of the month following application. This means that if your COBRA expires on the 20th of the month, you will have a 10-11 day gap in coverage until the HIPAA HMO effective date. HMOs cannot coordinate to last COBRA date except for those whose COBRA ends on the last day of the month. Also, applications for HIPAA HMO plans really need to be received at my office by the 15th of the month prior to the requested HIPAA start date to ensure sufficient processing time.
HIPAA PPO plan start dates vary by health insurer. Currently the rules are as follows:
Anthem Blue Cross PPO & HMO - New! Effective May 1, 2010, PPO plans will enroll the same as HMO plan. No retroactive start dates and only the first of the month. Call me for details.
Blue Shield CA PPO - New! Effective 3/2/10, 1st or 15th following application approval
Health Net CA PPO - 1st or 15th following application approval
Aetna POS - 1st or 15th following application approval
Kaiser CA - 1st of the month only
Also be aware the even though HIPAA is a guaranteed-issue situation to those who qualfiy, it is not immediate enrollment. Carriers can take several weeks to complete enrollment under HIPAA, so be prepared for that. Also, in order to expedite the process of HIPAA enrollment, you should ensure that you can provide the following with your application:
- Certificate of Creditable Coverage showing expiration of benefits and at least 18 months of coverage; this is also referred to as a Certificate of Group Health Coverage
- COBRA certificate or letter from health insurer or employer (if self-funded/self-insured) showing exhaustion of all continuation benefits (usually provided 30-60 days before the end of COBRA); this is also referred to as a COBRA Termination Letter and can be a letter from the employer, health plan or administrator indicating that your continuation coverage will be or has come to an end due to maximum period allowed.
- If you were not eligible for the CalCOBRA continuation extension to 36 months under AB 1401, proof that the plan did not qualify for that extension (out-of-state, self-funded, etc.). They will ask for written proof in these situations and will NOT take your word for it. You must be able to prove a valid reason for not getting the second 18 months under CalCOBRA in some official manner
-Loss of continuation due to company terminating health plan.You will need to provide some proof in writing that the employer has discontinued health insurance continuation coverage.
| Carrier | Anthem Blue Cross | Blue Shield CA | Health Net CA | Aetna |
| Start Date | NEW! HMO - first of the month following approval and premium payment as per the HIPAA brochure and application. Expect a minimum 60-day gap in coverage PPO - Eff. 5/1/10, PPO plans will have a new enrollment process. 1st of the month only following premium payment. First of which month will depend on when premium is paid. It's complicated so please call me. |
PPO - NEW! Effective 3/2/10, 1st or 15th of the month following application approval. HMO - 1st of month following enrollment |
HMO - First of the month only following enrollment PPO - 1st or 15th of the month after application approval, no retroactive start dates |
POS - 1st or 15th of the month only after application approval, no retroactive start dates |
| Application Deadlines /Restrictions | Must apply within 63 days of loss of group/continuation; may submit application at any time within the 63-day period | Must apply within 63 days of loss of continuation; Must submit application prior to requested start date | Must apply within 63 days of loss of continuation; Must submit application prior to requested start date | Must apply within 63 days of loss of continuation; Must submit application prior to requested start date |
| Required Documents | HIPAA Application; Group Health Certificate with end date; COBRA Expiration Notice; if no Cal-COBRA explanation letter | HIPAA Application; Group Health Certificate; Any other documents available | HIPAA Application; Group Health Certificate; Cal-COBRA Explanation Letter (if only 18 months); Any other documents available |
HIPAA Application; Group Health Certificate; Any other documents available |
| Time Frame to Apply | Must apply within the 63-day window Start date may exceed 63-day window |
Must apply within the 63-day window but can be enrolled after the 63-day period | Must apply within the 63-day window but can be enrolled after the 63-day period | Must apply within the 63-day window but can be enrolled after the 63-day period |
| Plan Usage Restrictions | PPO - All of California; National In-Network Services in all 50 States via BlueCard PPO program; Interplan Transfer Option to Guaranteed-Issue Coverage All 50 States under BCBS Assocation Interplan Transfer Rule HMO - Available service areas in California; emergency only services out of state |
PPO - All of California; National In-Network Services in all 50 States via BlueCard PPO program; Interplan Transfer Option to Guaranteed-Issue Coverage All 50 States under BCBS Assocation Interplan Transfer Rule HMO - Available service areas n California; emergency only services out of state |
HMO - Service Area Only; Not Transferable To Another State PPO - Service Area California; Uses FirstHealth (Carrington) Limited Network Out Of State For In-Network Services, All Other Services Are Out-Of-Network; Plan Not Transferable To Any Other State And Will Be Cancelled If Loss Of CA Resident Status |
POS - Limited Service Area Within CA; Plan Has No In-Network Benefits Outside of California And All Services In Any Other State Paid At Out-of-Network Benefit Levels; Plan Is Not Transferable To Any Other State May Be Maintained Upon Residency Change However All Benefits In New State Paid At Out-Of-Network Level |
| Ease Of Enrollment | Moderate; Carrier requires specific documents (referenced above) and will not initiate any outbound verification calls. | Easiest/Fastest; Carrier will make outbound verification phone calls on behalf of applicants | Moderate; Carrier requires specific documents (referenced above) and will not initiate any outbound verification calls | Moderate; Carrier requires specific documents (referenced above) and will not initiate any outbound verification calls. Aetna absolutely requires premium with application. Aetna will not process any application that does not include a premium payment |
David J. Fluker, Licensed Life & Health Insurance Agent. California State License # 0B58920
Authorized Independent Agent Serving California Residents.
Web Site ©1999 - 2010 by David Fluker - The David J. Fluker Insurance Agency. All Rights Reserved.
Authorized Independent Agent Serving California Residents.
Web Site ©1999 - 2010 by David Fluker - The David J. Fluker Insurance Agency. All Rights Reserved.
Anthem Blue Cross is an independent licensee of the Blue Cross Association (BCA). The Blue Cross name and symbol are registered service marks of the BCA.
Blue Shield of California Life & Health Insurance Company is an independent licensee of the Blue Shield Association.
Blue Shield of California Life & Health Insurance Company is an independent licensee of the Blue Shield Association.
HIPAA ENROLLMENT & BENEFIT GRID
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Anthem Blue Cross has no HIPAA plans available for start dates after 9/23/10 until the new HIPAA plans are approved and available. If your start date is 10/1 or after, stay tuned for the updated plans. All other carriers are holding changes for PPACA until 1/1/11.