David Fluker Insurance Services
Gilroy, CA - Serving California Residents Since 1995
CA License # 0B58920
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HIPAA Guaranteed Issue Health Insurance Coverage Plans For California Residents Exhausting COBRA
HIPAA Health Plan Effective Dates and Enrollment Processing Time
Submission of HIPAA applications in the manner(s) described below (per insurer's requirements) allows applicants to "lock-in" a plan start date as is available with the carrier chosen (1st, or 1st/15th after COBRA expiration). The length of the enrollment process does not alter the effective date of the plan so long as the applicant has met the submission timeliness requirements of the carrier.
The actual completion of the enrollment and final verification by the isurance company's HIPAA Enrollment Unit of satisfactory eligibility may and often does run past the requested effective date. Carriers can take 30 or more days to complete HIPAA enrollments and activate coverage. The enrollment process DOES NOT affect the requested start date of the plan so long as the applicant has met the application submission requirements. Because of required documents (some of which are not even issued until after expiration of COBRA) to prove eligibility, very few HIPAA applications are approved and enrolled by the requested effective date. In all cases where the process exceeds the effective date, so long as the applicant has met the application submission requirements to preserve the effective date, the coverage will be enrolled and activated RETROACTIVE to the requested effective date.
Submission of HIPAA applications in the manner(s) described below (per insurer's requirements) allows applicants to "lock-in" a plan start date as is available with the carrier chosen (1st, or 1st/15th after COBRA expiration). The length of the enrollment process does not alter the effective date of the plan so long as the applicant has met the submission timeliness requirements of the carrier.
The actual completion of the enrollment and final verification by the isurance company's HIPAA Enrollment Unit of satisfactory eligibility may and often does run past the requested effective date. Carriers can take 30 or more days to complete HIPAA enrollments and activate coverage. The enrollment process DOES NOT affect the requested start date of the plan so long as the applicant has met the application submission requirements. Because of required documents (some of which are not even issued until after expiration of COBRA) to prove eligibility, very few HIPAA applications are approved and enrolled by the requested effective date. In all cases where the process exceeds the effective date, so long as the applicant has met the application submission requirements to preserve the effective date, the coverage will be enrolled and activated RETROACTIVE to the requested effective date.
| Insurance Company | Plan Benefits Summary (with rate guide) |
HIPAA Application | Online App for HIPAA Only? |
| 2012 HIPAA Rate Guide (03/12) Savings 4000 PPO (HSA) Spectrum 5000 PPO Spectrum 5500 PPO Access+ HMO Access+Value HMO |
HIPAA Requirements List Application 1-3 people Application 4-6 people |
Yes (click here for instructions) |
|
HIPAA Brochure (04/2011) w/HMO Rates July 1 2011 PPO Rate Guide (07/2011) NEW |
HIPAA Application (with Premium Payment Form) |
NO |
|
HIPAA HMO Brochure (01/2012) HIPAA PPO Brochure (2011) |
HIPAA HMO Application HIPAA PPO Application |
NO |
|
HIPAA Plans & Rates (04/2011) |
Aetna HIPAA Application |
NO |
|
2012 Unified Brochure, Application and Rate Guide |
Contact Kaiser Direct at 1-800-634-4579 Kaiser only sells HIPAA plans direct |
NO |
The plan option grid and all subsequent plan information material for California HIPAA plans represents those plans which I sell and service. Other health carriers may offer HIPAA plans in California (with or without a California Contract). This page is not intended as a summary of all guaranteed-issue health plans available.
HIPAA information on this site is intended to be as accurate as possible. Be advised that insurance carriers can and do make changes to HIPAA plans, pricing and benefits without notifying agents of these changes. Because they prefer we not sell or solicit these products, carriers often don't feel it necessary to advise us of changes to HIPAA plans.
HIPAA information on this site is intended to be as accurate as possible. Be advised that insurance carriers can and do make changes to HIPAA plans, pricing and benefits without notifying agents of these changes. Because they prefer we not sell or solicit these products, carriers often don't feel it necessary to advise us of changes to HIPAA plans.
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
_____________________________________________________
BLUE SHIELD OF CALIFORNIA &
BLUE SHIELD LIFE & HEALTH
Blue Shield HIPAA plan choices will include Access+ HMO, Access+ Value HMO, PPO 5500, Spectrum PPO 5000 and Spectrum Savings PPO 4000 (HSA-compatible). 4/1/11: Blue Shield has changed its enrollment process for HIPAA to mirror Anthem Blue Cross in terms of start dates, submission deadlines and required documentation.
Plan summaries are in the grid at the top of the page
_____________________________________________________
ANTHEM BLUE CROSS CALIFORNIA
Anthem Blue Cross California offers two PPO plans and two HMO plans. The PPO plans are the PPO Share 5000 and the Basic PPO 1000. HMO plans include the Saver HMO and the Select HMO plans.
____________________________________________________
HEALTH NET OF CALIFORNIA
February 2011 - Health Net is currently offering 2 PPO plans (including an HSA-compatible PPO) and 2 HMO plans.
_____________________________________________________
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.
You can contact Kaiser directly 1-800-634-4579.
_____________________________________________________
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.
_____________________________________________________
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:
Blue Shield CA HMO/PPO - New! Effective 4/1/11, now same as Anthem Blue Cross. 1st of the month only depending on submission date. If application submitted 1-15 of the month, 1st of the following month. If submitted 16-end of the month, 1st of the next month (1 month gap). (Example: submitted 5 January with premium, starts 1 Feb. Submitted 20 January with premium starts 1 March).
Anthem Blue Cross HMO/PPO - 1st of month depending on submission. If application and premium submitted between 1-15, first of the next month. If submitted with premium 16-31, first of the following month. (Example: submitted 5 January with premium, starts 1 Feb. Submitted 20 January with premium starts 1 March).
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 or Certificate of Prior 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
_____________________________________________________
BLUE SHIELD OF CALIFORNIA &
BLUE SHIELD LIFE & HEALTH
Blue Shield HIPAA plan choices will include Access+ HMO, Access+ Value HMO, PPO 5500, Spectrum PPO 5000 and Spectrum Savings PPO 4000 (HSA-compatible). 4/1/11: Blue Shield has changed its enrollment process for HIPAA to mirror Anthem Blue Cross in terms of start dates, submission deadlines and required documentation.
Plan summaries are in the grid at the top of the page
_____________________________________________________
ANTHEM BLUE CROSS CALIFORNIA
Anthem Blue Cross California offers two PPO plans and two HMO plans. The PPO plans are the PPO Share 5000 and the Basic PPO 1000. HMO plans include the Saver HMO and the Select HMO plans.
____________________________________________________
HEALTH NET OF CALIFORNIA
February 2011 - Health Net is currently offering 2 PPO plans (including an HSA-compatible PPO) and 2 HMO plans.
_____________________________________________________
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.
You can contact Kaiser directly 1-800-634-4579.
_____________________________________________________
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.
_____________________________________________________
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:
Blue Shield CA HMO/PPO - New! Effective 4/1/11, now same as Anthem Blue Cross. 1st of the month only depending on submission date. If application submitted 1-15 of the month, 1st of the following month. If submitted 16-end of the month, 1st of the next month (1 month gap). (Example: submitted 5 January with premium, starts 1 Feb. Submitted 20 January with premium starts 1 March).
Anthem Blue Cross HMO/PPO - 1st of month depending on submission. If application and premium submitted between 1-15, first of the next month. If submitted with premium 16-31, first of the following month. (Example: submitted 5 January with premium, starts 1 Feb. Submitted 20 January with premium starts 1 March).
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 or Certificate of Prior 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.
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.
David J. Fluker, Licensed Life & Health Insurance Agent. California State License # 0B58920
Authorized Independent Agent Serving California Residents.
Web Site ©1999 - 2012 by David Fluker - David Fluker Insurance Services. All Rights Reserved.
Authorized Independent Agent Serving California Residents.
Web Site ©1999 - 2012 by David Fluker - David Fluker Insurance Services. All Rights Reserved.
