California HIPAA (when COBRA expires)

This page is HISTORICAL. 
Click here for ACA Quotes.

HIPAA for Non Grandfathered Plans ends 12.31.2013 per AB 1180.  or try this link.

HIPAA might come back, some of Donald Care’s proposals mention it like Senator Rand Paul’s  Obama Care Replacement Act S 222.   HIPAA eligibility rules.

Even if it’s not Open Enrollment, loss of COBRA Coverage triggers Special Enrollment for a 60 day period.  Covered CA Agent Appointment Form.

The brochures and information are for

Historical Purposes only….

 Anthem – Blue Cross

6.1.2013
Rate Regulation

Health Net

PPO   HMO

Blue Shield
Blue Shield Logo HIPAA Link
7.2013  Application

Email us for 7.2014 Grand Fathered Rates

Provider Finders, Rx Formularies, Full Policies (EOC’s), etc.

Steve can help you navigate and compare rates and benefits from several companies that offer HIPAA  guaranteed issue medical coverage, no questions asked about pre-existing conditions, when your COBRA and / or Cal COBRA end.   Steve will answer your questions and get you a policy that will cover any pre-existing conditions that you might have.    300gg-41, The Health Insurance Portability and Accountability Act of 1996)

What about Health Reform & the Exchanges, with Guaranteed Issue?

Do not wait for your Certificate of Coverage to send us your enrollment forms.  Do it this week to make sure you have NO LAPSE IN COVERAGE. The Insurance Companies have become very sticky on effective dates.    Blue Cross Request for Info. honoring initial application submission Blue Shield Documentation Required

Steve is paid by the Insurance Companies to help you send your application to the Insurance Company.  There is no charge to you for his expertise and service.  Steve’s HIPAA prices, benefits, etc. are the same as any other legally authorized agent or direct with  the Insurance Company.  The official Company brochures, with the application and rates on file with the Department of Insurance or Managed Health Care are one mouse click away, on THIS website for your review and comparison.  The posted rates are for anyone who has exhausted COBRA and qualifies for HIPAA.  There are no medical questions asked, so there is no surcharge if your health is really bad.

Steve will also help you qualify for preferred underwritten rates, as your pre-existing conditions, might not be considered that bad, by Insurance Underwriting Guidelines.   Just send us a Pre-Application Form.

Did you start a business with 2 or more employees, which can even include your spouse?

Do you have a 401k or Retirement Plan to rolloverGroup Life Insurance that needs to be continued?

Kaiser Foundation 1.2013 Pre ACA/Obamacare  Guaranteed Issue

Where can I get more detail on HIPAA (after COBRA) Guarantees & Procedures?

This page is HISTORICAL.
Get ACA quotes here.

Find your Evidence of Coverage, from your Employer Group Health Plan SAMPLE,  and you can get TONS of detail on HIPAA, COBRA & Cal COBRA
Search .pdf forms

Federal  Center for Medicare & Medicaid  Site -General Info

CA Department of Managed Health Care
Dept. of Managed Health Care

CA Insurance Code
INDIVIDUAL ACCESS TO CONTRACTS FOR HEALTH CARE SERVICES §10900-10902.6

COVERAGE FOR FEDERALLY ELIGIBLE DEFINED INDIVIDUALS    10785   SB 265 (2000)

Protecting your Health Coverage HCFA

See Consumer Links, below.

 

Who regulates HIPAA?

Appeals & Grievances

HIPAA is for Privacy, not guaranteed medical coverage, isn’t it?  (top)

I guess the medical portion was tacked on somewhere.  All the information you need is on this webpage and this website.

To learn about privacy, click here.

Consumer Links

DOL 30 Page Explanation of HIPAA
DOL HIPAA Overview Brochure

Department of Labor
FAQ’s  More Info – Job Loss

Disability Benefits 101.org
HIPAA and CA Protections
FAQ’s

CMS.Gov  Health Reform for Consumers

Similarly Situated Individuals – Protections
How to determine Similarly Situated Employees

Testimonials

Kaiser Individuals & Families  HIPAA   (top)
Kaiser only does their HIPAA plans direct and not thru brokers, this link is simply here as a public service (Leviticus 19:9
If you want to hire us as consultants that would be $150.

Rates for other Insurance Companies Posted on CA Department of Managed Care Website

CIGNA is committed to delivering affordable, quality health plans in the markets we serve. Provisions of the  recently enacted Patient Protection and Affordable Care Act (PPACA) have necessitated changes in order for  CIGNA to remain cost competitive. As a result, effective October 1, 2010, commissions will no longer be paid on any Individual & Family Plan policy containing one or more Guaranteed Issue customers.

Effective October 1, 2010, this change will impact:

  •          Existing policies covering one or more persons on a Guaranteed Issue basis
  •           New policies covering one or more persons on a Guaranteed Issue basis

For questions or more information, call CIGNA Sales Support at 1-877-CIGNA-15, 8 a.m. ? 8 p.m. Eastern Time.

  • Guaranteed Issue is defined as a case that covers any customer under age 19 who would have been declined coverage prior to the passing of PPACA or a HIPAA case.
  • All of HIPAA Technical & Research Links
    Techinical ALL of HIPAA Law and Research

    Internet and Electronic Transactions

     Uniform Electronic Transactions Act California Civil Code §1633.1.

    (g) “Electronic record” means a record created, generated, sent, communicated, received, or stored by electronic means.
    (h) “Electronic signature” means an electronic sound, symbol, or process attached to or logically associated with an electronic record and executed or adopted by a person with the intent to sign the electronic record.

    1633.7. (a) A record or signature may not be denied legal effect or enforceability solely because it is in electronic form.
    (b) A contract may not be denied legal effect or enforceability solely because an electronic record was used in its formation.
    (c) If a law requires a record to be in writing, an electronic record satisfies the law.
    (d) If a law requires a signature, an electronic signature satisfies the law.

    The new Obama’s Affordable Health Care Plan REQUIRES Web Portals

    Ehow.com Explanation

 

FAQ’s

what will happen to my son’s coverage when his Cal Cobra expires on March 31, 2014.

1) My son is diagnosed with bipolar mixed, PTSD and substance abuse. He is 24 years old, but since my spouse and I are on Medicare, we have no plan under which he can be covered until age 26.

*****He can get his own plan guaranteed issue don’t worry about the March 31 deadline to enroll because since he’s losing coverage that gives him a qualifying event which think it’s him another 60 days to enroll I can send you the citation for that if you like>

2) Currently, his plan is an HSA [Health Savings Account] (which he doesn’t need since he has no income) with Anthem Blue Cross. His current address is in the LA side of 91361.

****I’ll send you quotes when I get back to my office or click here >

3) He is in appeals for SSI (at the Council level since he has been denied three times); he is not on Medical and that would absolutely be our last choice for him because of his illness. His most recent hospitalization was May 17 of this year; we need to keep his coverage at the highest level possible.

***[Voice to text – please excuse the poor English]  If he’s not working if you’re not taking him as a deduction he can then go into covered California and that would qualify him for Medi-Cal CAL not Medicare I few want to have better coverage than if you pay the premiums I have full price no no tax advantages then that’s fine and I’ll send you those quotes I get back to my office>

So, what would be the best choice to continue his coverage? I would really prefer that UCLA be one of the providers because their psychiatric services are probably the best in the greater LA area. In addition, his current psychiatrist is an Anthem Blue Cross provider.

****Blue Cross doesn’t have their list up in full yet but I do believe that if you look at UCLA’s website and it says that all the Blue Cross plans and Covered  California cover them>

Any advice that you can offer would be greatly appreciated.

***See above and covered California pays me for my time and expertise if you do go into Medi-Cal CAL I probably won’t get paid in that so you just have to decide if you wanted to Medi-Cal or you just want to pay the regular premiums and go into we know what if you pay the premiums you even need covered California can just go direct to the insurance companies and it’s less hassle I’ll send you the quotes when I get to my office or just click here and put in your zip code, date of birth and expected income.

COBRA & HIPPA Power Point Presentation
COBRA & HIPPA Power Point Presentation

This is an

HISTORICAL page.

Please click here for current Complementary Instant Health Care Reform Quotes.

HIPAA FAQ’s

Click on the above Navigation Links to find the answers to these questions and MORE, or email us.

  1. What’s the best HIPAA plan?
    How do I look through the brochures, it’s confusing.

  2. How does it compare to pay more premium but have less out of pocket?

    $$$ Illustration

  3. Is there ONE company that give the best coverage & service?  How does MLR (Medical Loss Ratio) affect pricing & benefits?

  4. What benefits & advantages are in HIPAA?
    What if I have a pre-existing condition?
    Will my Pre-X be covered?

  5. When are you eligible for HIPAA?

  6. What are the questions that you have to answer to qualify for HIPAA?

  7. What forms or proof do I need that my COBRA is used up or that I was not eligible for Cal COBRA?

  8. When & how should I submit my application?

  9. When does my coverage start?

  10. Are there any less expensive plans?

  11. How about if I own or Start a Small Business?

  12. Is there an EASY one page form to see if I can get a Preferred Underwritten Plan?

  13. What about a “conversion” plan?

  14. Can I get on my spouses Employer Group Plan, as I just lost coverage?  Is this a Qualifying Event

  15. What if I missed the 63 day deadline or for some other reason do not qualify?

  16. Where can I get more detail on HIPAA Guarantees & procedures?

  17. What if I don’t live in California?
    Is there a directory to find a qualified Agent/Broker in my State?  How about the Insurance Companies?

  18. Who regulates HIPAA?

  19. What does the Policy, EOC say if I make a late payment?
    State Law?

  20. I thought HIPAA was only for Medical Records Privacy.

  21. Is it safe and legal to buy insurance over the Internet?

  22. Steve, you are worth a MILLION Bucks, how much do you charge for your services?

  23. What about Dental Coverage, Life Insurance and Vision?

If there was a company that gave less service or benefits than the others, I would not represent them.

Mind you, there might be companies that do not pay agents, they are not listed here.  Check the FAQ for the DMHC site that shows all companies, albeit, it’s hard to navigate.

Aetna HIPAA after Cal COBRA…
aetna logo

Authorized Agent

Aetna will be exiting the Individual Market in January 2014 – Read More

Ref 131721356684 Application must be in by 6.25.2013 for 7.1.2013 Effective Date

MCOA – Managed Choice Open Access
$2,500 &  $3,500 HIPAA
Aetna HIPAA Brochure
Brochure, Information, & Rates
Fillable Application – Complete and email or fax to us.

Find a Provider
Aetna Provider Finder

Aetna Rx Formulary
800.238.6279

Need help paying for your Rx Prescriptions?

MORE details

Aetna Open Access® Managed Choice

3500

Value 2500

Aetna help line 1-888-438-8581

[email protected]

Aetna HIPAA information on DMHC Website

Old Aetna HIPAA Rates

July 2010 Rate increase denied?
Per email from Aetna – HIPAA rates dated 7/2010 are valid and not affected by the above ruling.

Summary of Coverage 2500 5 Pages
EOC  48 Pages

INFORMATIONAL only, 20 page brochure as Aetna’s HIPAA plans are not the same as their regular offerings

 

Aetna Fax 860.975.1253

 

This page was formerly at
http://www.steveshorr.com/
hipaa_after_cobra/HIPAA.Rates_aetna.htm

 

Historical Page

Health Net HIPAA After COBRA
Health Net   - A better decision
Authorized Agent

HIPAA Rates, Brochure & Application
PPO      HMO
Health Net HIPAA Brochure

Provider – MD Search
Provider Finder

Health Net’s Drug List

A drug list, also called a formulary, is a comprehensive set of prescription medications that a health plan has approved for use by its members. Consult your Evidence of Coverage or Certificate of Insurance (“Plan Documents”) for specific coverage and limitations. The fact that a medication is listed on a drug list does not guarantee that your physician will prescribe it for you for a particular medical condition.

  • Quantity and Age Limits List
    This list identifies drugs subject to age limits or limitations on the quantity of medication available per prescription.

EOC’s – Evidence of Coverage Health Net HIPAA

Other pages in this section

Blue Shield Logo HIPAA LinkHistorical Page

Acrobat ReaderBlue Shield HIPAA Plans Rates & Quotes 7.2013

Brochure & Rates 

COBRA & Cal COBRA Documentation Required
Paperwork to prove eligibility

 

ONLINE Application  ONLY if you want to try apply for an Underwritten Plan at the same time.
ONLINE Application for Blue Shield
Online Application

 

Blue Shield Drug Database & Formulary Rx – Prescriptions

Blue Shield – Find a Provider

 

New Rules on Effective Dates

Application Received Date Application Approval Date Example  
The 1st through the 15th of the month Application is approved the 1st of the month following the month of submission. Application is received March 7, 2011, the first available effective date is April 1, 2011.  
The 16th through the last day of the month. Application is approved the 1st of the second month following the month of submission. Application is received March 23, 201, the first available effective date is May 1, 2011
blue shield ca.com
 

Is this where such restrictive working came from?
See also Small Group AB 1672

Effective 4/1/11, application processors will issue a letter with the HIPAA Guaranteed Issue Information Request Form to the applicant and broker, if appropriate.

This form will detail the needed documentation depending on the applicant’s answers to the Statement of Eligibility in the application. The applicant will then have 90 days from the original signature date to submit the documentation.

Additionally, effective 4/1/11, Blue Shield will only assign 1st of the month effective dates; instead of the 1st or the 15th of the month.

Examples: If application receipt date is…

then?

 

 

Example

1st through the 15th of the month

it will be approved for the 1st of the following month

Application received: 3/7/11

First available effective date: 4/1/11

16th through the last day of the month

it will be approved for the 1st of the month 30 days after the receipt date

Application received: 3/23/11

First available effective date: 5/1/11
(Blue Shield)

The effective date can not be prior to the signature date of the application. For HMO plans the effective date has to be the first of the month. For PPO policies they can be the 1st or the 15th. If they do not want any lapse in coverage they may need to apply in advance. As you know we will need to proof of cobra exhaustion letter as well if it applies to them.  –  Blue Shield email dated 6/1/2010

Buy Now - ONLINE Application

The ONLINE applications allows you to apply for underwritten plan & HIPAA at the same time.  You MUST check off the boxes that you want HIPAA if you do not qualify!

Use paper if you are sure you will not qualify

$5k   EOC

View FULL Policy – EOC (Evidence of Coverage)

Other Pages in this section

Broker ONLY

blue shield ca.com/guaranteed_issued_plans

and blueshieldca.comg uaranteed-issue

See Individual Plans for Producer Manual

This page was formerly at
http://www.steveshorr.com/
hipaa_after_cobra/HIPAA.Rates_blue_shield.htm

 

This is an HISTORICAL Page.
Click here for quotes under Health Care Reform.

Anthem Blue Cross
Anthem Blue Cross Logo
Authorized Agent

 

Blue Cross California HIPAA Rates, Coverage
& Paper Application
Blue Cross HIPAA Overview

 

Find a Doctor, Hospital and other Providers
Find a blue cross provider

 

Rx Formulary

Online Application
Use our pre underwriting form first.

Effective Dates from October 1, 2010 forward

Those who submit, or have postmarked, an application and payment between the 1st and 15th of any given month will be assigned an effective date of the 1st of the following month. For example, if an applicant sends in the application and payment on October 12, 2010, the earliest effective date they can have is November 1, 2010.

Those who submit or have postmarked an application and payment after the 15th of the month, will be assigned an effective date of the 1st of the second following month. For example, if an applicant has the application and payment postmarked on October 25, 2010, the earliest effective date they can have December 1, 2010.

Please note: The applicant’s option to request an effective date was removed from the application. We recommend applicants apply 30-60 days before the end of coverage to avoid a lapse in coverage.

Is this where such restrictive working came from?
See also Small Group AB 1672

Anthem has a newer rule regarding HIPAA start dates when the application is rolled over from a decline through underwriting.

The new rule is that the premium authorization for the underwritten application must be authorized verbally or in writing to be applied to the HIPAA rollover, it’s not automatic anymore.

The bigger issue is that when the app rolls over from decline to HIPAA, Anthem no longer allows the premium date of the original application to count towards the premium submission for the HIPAA rollover.  As an example, someone borderline HIPAA  with COBRA expiration of 10/31 applying 10/5 for Smart Sense and declined 10/15 the rollover would be after 10/15 so even if the premium rollover is authorized by note or letter, the open of the HIPAA app is considered after 10/15 and thus the start date is pushed to 12/1 and they gap a month.  There is no workaround for this situation.

If the COBRA expiration is closer than 60 days and they are a possible decline and HIPAA, I believe it best with Anthem at this point to write it HIPAA first then try underwriting later.

My RSM told me yesterday that this has been an unannounced procedure for well over six months.  But he also told me that you could preserve the premium submission date by adding a note in the additional comments section of the online app or with a paper application indicating that it is OK to use the same premium payment method for HIPAA.

Today, Support told me that was not true and that the HIPAA rollover application would only be considered ?received? when the HIPAA unit opens the HIPAA app (new ID #).  That is the point where the premium rollover authorization from the original IFP app gets date-credited.

It used to be lock in from the date of the IFP application including credit for premium submitted but Support told me they changed it Sept 2010.
From a friendly competitor

Effective Date Details
Click on image to enlarge
Blue Cross HIPAA Brochure

Please note that premium or authorization, sent in with a standard application, does NOT count for HIPAA!

Sample request for HIPAA payment

More detail on effective dates

To try to insure there is no lapse in coverage the client will need to obtain all required documents prior to the end date of their current coverage. Blue Cross email dated 6/1/2010

Evidence of Coverage EOC

HMO saver

select HMO 25

basic PPO 1000

ppo share 5000

PPO Share $1,500
Addendum

Blue Cross information on DMHC Website

Evidence of Coverage

effective date

Steve, you’re website is the greatest, but I don’t live in California

What if you have HIPAA, but move to another State?

 

Health Compare

Looking for a out of state agent

Survey of HIPAA options in 50 States
Survey of HIPAA Options

 

A CONSUMER’S GUIDE TO GETTING
AND KEEPING HEALTH INSURANCE

Health Insurance Info.net Brochure

 

Disability Benefits 101.org

 

Insurance Companies may be allowed to use  Mr. MIP and not offer their own plan as allowed by HIPAA law § 300gg–44  (top)

 

HIPAA and move out of State?

f client moves out of California they will have 6 months from time they move to get coverage in their new state. Conversion  would be available to client in the state where they move. Member will need to contact that state Blue Cross Blue Shield and inquire on plans and rates available for conversion.  Blue Cross Email dated 6.8.2012

 

Here’s my research so far.  I’m waiting to hear from BC.  Unfortunately, I think this is something just left out when the legislature made the law.

I feel NOT having a way to get HIPAA transferred is a violation of our Constitutional Right to travel. caselaw.lp.findlaw.com

Looking for a out of state agent
Use this tool to find an agent in your New State if it’s not CA

HIPAA does NOT limit the amount you can be charged for the policy. However, State law may set limits. Also, if your coverage is through a network plan, HIPAA does not guarantee that your policy will be renewed if you move outside the area served by providers under contract with your insurer. In addition, if your coverage is through a high-risk pool, and you move out of the State, HIPAA does not guarantee that your coverage will be renewed

If you have individual health insurance, generally, your coverage is renewable regardless of whether you are a HIPAA eligible individual. Your coverage may be discontinued or non-renewed
by your insurance company, only if you:
? Fail to pay your premiums;
? Commit fraud against the issuer;
? Terminate the policy;
? Move outside the service area (if in a network plan);
? Move outside a State (if in a State high-risk pool); or
? End your membership in an association (if the coverage is available only to members of the association).Source

WHEN AN INSURED BECOMES INELIGIBLE

 

An Insured becomes ineligible for coverage under this Policy when:

 

An Insured moves to and lives in a place outside of California.
Page 8

Who is Eligible for Coverage
A resident of the state of California who has properly applied for coverage and who is insurable according to our applicable underwriting requirements. sample policy

 

 

This is an HISTORICAL page
click icon at right for NEW Health Care Reform Guaranteed Issue Plans.

When & how should I submit my application?

DO NOT WAIT – TURN YOUR APPLICATION IN EARLY – Let the Insurance Company ask for the additional information!!!  

In general, we suggest that you send a Pre Application Form. and if the response is favorable apply ONLINE (through our website) for an Insurance Companies or HMO Standard Plan, Rates including underwriting and then fill out the HIPAA portion of the application- so that you get the BEST possible rates and coverage.

If you don’t qualify for the preferred rates, you will given the reason for a denial.  AB 356  Insurance Code 10113.9 & 10113.95

Here’s typical underwriting guidelines on the California Insurance Commissioner’s website.

If you are certain that you will not qualify, then do the Paper Application for HIPAA only.
HIPAA Paper Application

HIPAA is GUARANTEED Issue, as long as  you meet the qualifications (rules) and have your Certificate of Credible Coverage, this way you don’t have to worry* about coverage lapsing, while the Insurance Company is checking out your application.

63 day calculator
Calendar Date Calculator

Here’s research where a client applied for HIPAA on the 45th day and did NOT choose the option to get HIPAA if the underwritten plan did not go through.  We did not finish the project… as the reason for denial was minor and we are confident another company would write the coverage standard or with a surcharge, but less than HIPAA rates.

HIPAA Rates & Benefits

When does my coverage start?  Misc. FAQ’s ( top)

Be sure to double check the available start dates of coverage in each Insurance Companies Brochure, and detail pages, especially if you want an HMO and your coverage expires in the middle of the month.

Research Done 12/1/2010 on effective dates

If we send the application to you  today, (12/1/2010) can she get coverage for 12/1/2010?

United Health – PacifiCare Aetna Blue Shield Blue Cross Health Net

Hi, You can request a 12/1/10 effective with the application submitted today.

Yes if you send the application today an effective date of 12/1/10 can be had please write on the top of the application that an effect date of 12/1/10 is needed

Application must be submitted  by 15th of month to get 1st of next month. (Learn more) The soonest effective date as long as everything has been received and payment is received as well is 2/1/2011
Learn More
Yes, we will need to receive the application by today for your client to receive 12.01.10 effective date.

Response from DMHC

HIPAA coverage must be obtained within 62 days of the exhaustion of Federal COBRA or Cal-COBRA.  The coverage will not be effective back to the date Federal and Cal-COBRA ends.  If HIPAA coverage is obtained and paid for before the 15th of the month it is effective the 1st of the following month.  If the coverage is obtained and paid for on or after the 15th of the month it is effective the 1st of the second following month.  Below are links to more HIPAA information.  dol.gov/  dmhc.ca.gov/

I just wrote a policy with PacifiCare, where we submitted the application prior to expiration of the Cal Cobra coverage, but the Certificate of Credible coverage was submitted say a week after and PacifiCare honored the original requested effective date of 4/1/2008, so no lapse in coverage.
I just checked with Blue Shield and they said they would do the same thing, but note that the requested date cannot be before the application was received.   Also, if there was enough documentation, like phone #’s, etc. they might not even ask for the Certificate of Credible Coverage.
See also Friendly competitor Dave Fluker has done an excellent job of research on this.

required documents
Do NOT wait…. Send in your application – Let the Insurance Company Ask for them.

This page is HISTORICAL ONLY.

HIPAA after COBRA, premium calculation

Click on icon at the right for new Health Care Reform – Guaranteed Issue Proposals.

How do I find and compare HIPAA rates, benefits and application in the brochures on this website?

And select the “best” one for my pocket book?

Select the Brochure, including Rates, Application and Benefits Summary you want to review first.
HIPAA .pdf brochure linksIf you have trouble loading the brochure, email us and we will email you the brochure.Rate Pages – Los Angeles – ALL Companies 4/2012
Let’s look at PacifiCare First.  PacifiCare is currently giving the fastest and most efficient Service in issuing policies.  Claims and long term service.
The bookmarks section should open up automatically.  Then let’s look at the coverage offered.  Click on Coverage Matrix
Coverage Matrix
A one page summary of the available coverage’s are shown.
One Page Summary
Then find what rating area you are in
Rating AreasUse Search Feature – to find the things you are most interested in learning about
Search
Rating Area
Next either shop other plans (the process is the same) Sample Comparison Matrix or complete the enrollment applicationIs there much difference in rates & benefits from one company to another?

We do not think so… 80% mandatory loss ratio.

Enrollment Application

Rate & Benefit Pages

What is the best plan?

The answer, as Tevia said in Fiddler on the Roof is, we do not know.

We feel like the Maytag Repairman, in that our clients very rarely call (310.519.1335), Skype or email us with any complaints.  We look forward to helping our clients enforce their legal, contractual & ethical rights with Insurance Companies.

wikipedia.org

Need Explicit Details and Complex Claims Questions?

Study of Claims and 10 sample policies
Coverage comparison of 10 sample policies
Georgetown University

Brochures - Applications - Rate Charts

Historical Info

Sample  Comparison(We have not updated this lately)

Check the actual brochures, above

Feature – Benefit

Blue Cross Blue Shield Health Net Aetna PacifiCare Misc.
HMO SaverSelect Access Plus $15$40
PPO Basic $1,000Share $5,000 $5,000*
$5,500
Simple Value $50 $2,500$3,500 SDHP (SDA – Self Directed Account)
$3,000
Select Plan
$3,000
HSA $4,000 Simple Choice
$4,000 ded
.
Individual
Out of Pocket Max (OOP)*
$3,000$3,000

$3,500

$7,500

$3,000$10,000

$10,000

$19,000

$3,000$3,000

$17,500

$9,000

$19.500*$20,500* $7,000$7,000
Participating Provider List
(MD & Hospital
)
Provider Finder Provider Finder Provider Finder  Provider Finder
Rx Formulary Formulary Formulary Formulary  Formulary Rx Formulary
Rates HMO & PPO HMO PPO HMO, PPO & HSA PPO PPO
Application Paper PAPER Paper Paper
One Page Pre-Application
Find out if you qualify for a underwritten Plan
*In & Out of Network &
Including Deductible
The above section on OOP  is being double checked

Actual Code –
Conversion and HIPAA Policies
Insurance Code §12670   

AB 1401 pdf Conversion Policies – Cal COBRA to 36 months

HIPAA information is HISTORICAL


GET Guaranteed Issue ObamaCare Quotes

FAQs / Ask Us a Question

 

View our COBRA Pages

COBRA – Right to Keep your Employer Group Health Coverage

The rest is
Historical
But it might come back to life if Pre X waiver is taken out of ACA Obamacare

federal Health
Insurance Portability and Accountability Act of 1996.

 group health insurance
(h) “Medicare” means  Medicare.

Medicare.

HIPAA Brochures & Applications

PART 6.1. HEALTH DISABILITY INSURANCE CONVERSION [12670 – 12692.5]

( Part 6.1 added by Stats. 1981, Ch. 1096, Sec. 2. )

 

12670.

It is the intent of the Legislature to ensure that persons covered by a group policy, who become ineligible for that coverage have access to benefits pursuant to this part by requiring employers, employee organizations, and other entities that provide that coverage to their employees or members to also make available conversion policies for those persons and to ensure that insurers as herein defined offer conversion policies. The conversion policy shall be the most popular preferred provider organization product offered to residents of this state under the provisions of the federal Health Insurance Portability and Accountability Act of 1996. In addition, it is the intent of the Legislature to encourage the continuation of group health coverage by requiring the entities herein defined to make available continuation benefits for widows, widowers, divorced spouses, and dependents who were covered by the group policy on the date of termination of coverage.

(Amended by Stats. 2002, Ch. 799, Sec. 1. Effective January 1, 2003. Operative September 1, 2003, by Sec. 5 of Ch. 799.)

12671.

As used in this part, the following terms have the following meanings:

(a) “Group policy” means a group health insurance policy providing medical, hospital, surgical, major medical, or comprehensive medical coverage issued by an insurer, a group contract issued by a hospital service corporation, or medical, hospital, surgical, major medical, or comprehensive medical coverage otherwise provided by a policyholder to its employees or members, except for self-insurance programs provided by employers that are not exempt from ERISA, as specified in subdivision (i). For the purposes of this part, a group policy not having an established annual renewal date shall be considered renewed on each anniversary of its effective date.

(b) “Conversion coverage” means health insurance benefits providing hospital, surgical, major medical, or comprehensive medical coverage issued to an individual under a converted policy.

(c) “Converted policy” means a policy or contract providing conversion coverage issued by an insurance company or by a hospital service corporation, or individual hospital, surgical, major medical, or comprehensive medical coverage otherwise provided by a policyholder to its employees or members.

(d) “Insurer” means the entity issuing a group policy, an individual or converted policy, a hospital service contract or an employer or employee organization otherwise providing medical, hospital, surgical, major medical, or comprehensive medical coverage to its employees or members.

(e) “Insurance” refers to health insurance, major medical, or comprehensive coverage paid by premium or contribution under a group policy, a hospital service contract, or as otherwise provided by a policyholder to its employees or members other than by self-insuring except in the case of a plan that is exempt from ERISA, but does include an employer plan that is exempt from ERISA as specified in subdivision (i). “Insurance” does not include any of the following:

(1) Coverage provided solely as an accrued liability or by reason of a disability extension.

(2) Medicare supplement insurance.

(3) Vision-only insurance.

(4) Dental-only insurance.

(5) CHAMPUS supplement insurance.

(6) Hospital indemnity insurance.

(7) Accident-only insurance.

(8) Short-term limited duration health insurance. “Short-term limited duration health insurance” means individual health insurance coverage that is offered by a licensed insurance company, intended to be used as transitional or interim coverage to remain in effect for not more than 185 days, that cannot be renewed or otherwise continued for more than one additional period of not more than 185 days, and that is not intended or marketed as health insurance coverage, a health care service plan, or a health maintenance organization subject to guaranteed issuance or guaranteed renewal pursuant to relevant state or federal law.

(9) Specified disease insurance that does not pay benefits on a fixed benefit, cash payment only basis.

(f) “Policyholder” means the holder of a group policy issued by an insurer, a holder of a group contract issued by a hospital service corporation or an employer, employee association, or other entity otherwise providing medical, hospital, surgical, major medical, or comprehensive medical coverage on a group basis to its employees or members.

(g) “Premium” means contribution or other consideration paid or payable for coverage under a group policy or converted policy.

(h) “Medicare” means Title XVIII of the United States Social Security Act as added by the Social Security Amendments of 1965 or as later amended or superseded.

(i) “Employer plan that is exempt from ERISA” means any employer plan that, pursuant to the provisions of Section 1003 of Title 29 of the United States Code, is not covered by or that is exempt from the provisions of Subchapter I (commencing with Section 1001) of Chapter 18 of Title 29 of the United States Code, except that, in the case of a governmental plan, it only includes a self-insured governmental plan as defined in subdivision (j).

(j) “Self-insured governmental plan” means a self-insured plan established or maintained for its employees by any public entity, as defined in Section 811.2 of the Government Code, that is a governmental plan as defined in subdivision (32) of Section 1002 of Title 29 of the United States Code.

(Amended by Stats. 2004, Ch. 183, Sec. 249. Effective January 1, 2005.)

12672.

(a) Any group policy issued, amended, or renewed in this state on or after January 1, 1983, which provides insurance for employees or members on an expense-incurred or service basis, other than for a specific disease or for accidental injuries only, shall contain a provision that an employee or member whose coverage under the group policy has been terminated for any reason except as provided in this part, shall be entitled to have a converted policy issued to him or her by the insurer under whose group policy he or she was covered, without evidence of insurability, subject to the terms and conditions of this part.

(b)

(1) This section shall be inoperative on January 1, 2014.

(2) If Section 5000A of the Internal Revenue Code, as added by Section 1501 of PPACA, is repealed or amended to no longer apply to the individual market, as defined in Section 2791 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-91), this section shall become operative on the date of that repeal or amendment.

(3) For purposes of this subdivision, “PPACA” means the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any rules, regulations, or guidance issued pursuant to that law.

(Amended by Stats. 2013, Ch. 441, Sec. 23. Effective October 1, 2013. Inoperative, by its own provisions, on January 1, 2014, subject to condition for resuming operation.)

12673.

Conversion coverage shall be required to be made available to an employee or member unless such coverage under the group policy terminates for one or more of the following reasons:

(a) The group policy or the policyholder’s participation in the group policy terminates and the insurance is replaced by similar coverage under another group policy within 60 days of the date of termination of the group coverage or the policyholder’s participation.

(b) The employee or member has failed to make any required payment of the premium or contribution when due.

(c) The employee or member had not been continuously covered during the three-month period immediately preceding the employee’s or member’s termination of coverage.

(Amended by Stats. 1982, Ch. 1186, Sec. 5.)

12674.

A converted policy shall be issued effective on the day following the termination of coverage under the group policy if written application and the first premium payment for the conversion policy are made to the insurer not later than 31 days after the termination of insurance, unless such requirements are waived in writing by the insurer.

(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)

12675.

The premium for the conversion coverage shall be determined in accordance with the insurer’s rates applicable to the age and class of risk of each person to be covered and to the type and amount of coverage provided.

(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)

12676.

The conversion coverage shall cover the employee or member and his or her dependents who were covered by the group policy on the date of termination of coverage. At the option of the insurer, a separate converted policy may be issued to cover any dependent.

(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)

12677.

The insurer shall not be required to issue a converted policy covering any person if such person is entitled to be covered by Medicare.

(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)

12678.

The insurer shall not be required to issue a converted policy covering any person if any of the following exists:

(a) The person is covered for similar benefits by another individual policy.

(b) The person is covered or is eligible to be covered for similar benefits by another group policy.

(c) The person is covered or is eligible to be covered for similar benefits under any arrangement of coverage for persons in a group whether insured or uninsured.

(Amended by Stats. 2002, Ch. 799, Sec. 3. Effective January 1, 2003. Operative September 1, 2003, by Sec. 5 of Ch. 799.)

12679.

A converted policy may provide that the insurer may at any time request information from any person covered thereunder as to whether he or she is covered for the similar benefits described in Section 12678. The converted policy shall provide that as of any premium due date the insurer may refuse to renew the policy or the coverage of any insured person for the following reasons only:

(a) Failure of the individual covered by the converted policy to provide the requested information.

(b) Fraud or material misrepresentation by the individual covered by the converted policy in applying for any benefits under the converted policy.

(c) Eligibility of the individual covered by the converted policy for coverage under Medicare or under any other state or federal law providing for benefits similar to those provided by the converted policy. As used in this section, “state or federal law” does not include Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code, or Title XIX of the United States Social Security Act.

(d) Nonpayment of premium.

(e) Coverage of the individual for similar benefits under another individual policy.

(f) Eligibility of the individual covered by the converted policy for coverage under any arrangement for coverage for persons in a group whether insured or uninsured.

(g) Other reasons approved by the Insurance Commissioner.

(Amended by Stats. 1982, Ch. 1186, Sec. 7.5.)

12680.

If conversion coverage is issued and benefits are also provided to a person under Section 12678, the insurer may limit the conversion benefits provided or available for such person so that such conversion benefits together with benefits provided or available from the sources referred to in Section 12678 shall not exceed 100 percent of the charges for covered benefits. Priority of any coverages involved shall be determined by the effective dates, the earlier one being first.

(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)

12681.

An insurer shall not be required to issue a converted policy providing benefits in excess of those provided under the group policy from which conversion is made.

(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)

12682.

The converted policy shall not exclude, as a preexisting condition, any condition covered by the group policy. The converted policy may provide for a reduction of its benefits by the amount of any such benefits payable under the group policy after the individual’s insurance terminates thereunder. The converted policy may also provide that during the first policy year the benefits payable under the converted policy, together with the benefits payable under the group policy, shall not exceed those that would have been payable had the individual’s coverage under the group policy remained in effect.

(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)

12682.1.

This section does not apply to a policy that primarily or solely supplements Medicare. The commissioner may adopt rules consistent with federal law to govern the discontinuance and replacement of plan policies that primarily or solely supplement Medicare.

(a)

(1) Every group policy entered into, amended, or renewed on or after September 1, 2003, that provides hospital, medical, or surgical expense benefits for employees or members shall provide that an employee or member whose coverage under the group policy has been terminated by the employer shall be entitled to convert to nongroup membership, without evidence of insurability, subject to the terms and conditions of this section.

(2) If the health insurer provides coverage under an individual health insurance policy, other than conversion coverage under this part, it shall offer one of the two health insurance policies that the insurer is required to offer to a federally eligible defined individual pursuant to Section 10785. The health insurer shall provide this coverage at the same rate established under Section 10901.3 for a federally eligible defined individual.

(3) If the health insurer does not provide coverage under an individual health insurance policy, it shall offer a health benefit plan contract that is the same as a health benefit contract offered to a federally eligible defined individual pursuant to Section 1366.35. The health insurer shall offer the most popular preferred provider organization plan that has the greatest number of enrolled individuals for its type of plan as of January 1 of the prior year, as reported by plans by January 31, 2003, and annually thereafter, that provide coverage under an individual health care service plan contract to the department or the Department of Managed Health Care. A health insurer subject to this paragraph shall provide this coverage with the same cost-sharing terms and at the same premium as a health care service plan providing coverage to that individual under an individual health care service plan contract pursuant to Section 1399.805. The health insurer shall file the health benefit plan contract it will offer, including the premium it will charge and the cost-sharing terms of the contract, with the Department of Insurance.

(b) A conversion policy shall not be required to be made available to an employee or insured if termination of his or her coverage under the group policy occurred for any of the following reasons:

(1) The group policy terminated or an employer’s participation terminated and the insurance is replaced by similar coverage under another group policy within 15 days of the date of termination of the group coverage or the employer’s participation.

(2) The employee or insured failed to pay amounts due the health insurer.

(3) The employee or insured was terminated by the health insurer from the policy for good cause.

(4) The employee or insured knowingly furnished incorrect information or otherwise improperly obtained the benefits of the policy.

(5) The employer’s hospital, medical, or surgical expense benefit program is self-insured.

(c) A conversion policy is not required to be issued to any person if any of the following facts are present:

(1) The person is covered by or is eligible for benefits under Title XVIII of the United States Social Security Act.

(2) The person is covered by or is eligible for hospital, medical, or surgical benefits under any arrangement of coverage for individuals in a group, whether insured or self-insured.

(3) The person is covered for similar benefits by an individual policy or contract.

(4) The person has not been continuously covered during the three-month period immediately preceding that person’s termination of coverage.

(d) Benefits of a conversion policy shall meet the requirements for benefits under this chapter.

(e) Unless waived in writing by the insurer, written application and first premium payment for the conversion policy shall be made not later than 63 days after termination from the group. A conversion policy shall be issued by the insurer which shall be effective on the day following the termination of coverage under the group contract if the written application and the first premium payment for the conversion contract are made to the insurer not later than 63 days after the termination of coverage, unless these requirements are waived in writing by the insurer.

(f) The conversion policy shall cover the employee or insured and his or her dependents who were covered under the group policy on the date of their termination from the group.

(g) A notification of the availability of the conversion coverage shall be included in each evidence of coverage or other legally required document explaining coverage. However, it shall be the sole responsibility of the employer to notify its employees of the availability, terms, and conditions of the conversion coverage which responsibility shall be satisfied by notification within 15 days of termination of group coverage. Group coverage shall not be deemed terminated until the expiration of any continuation of the group coverage. For purposes of this subdivision, the employer shall not be deemed the agent of the insurer for purposes of notification of the availability, terms, and conditions of conversion coverage.

(h) As used in this section, “hospital, medical, or surgical benefits under state or federal law” do not include benefits under Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code, or Title XIX of the United States Social Security Act.

(i) (1) On and after January 1, 2014, and except as provided in paragraph (2), this section shall not apply to any health insurance policies.

(2) If Section 5000A of the Internal Revenue Code, as added by Section 1501 of PPACA, is repealed or amended to no longer apply to the individual market, as defined in Section 2791 of the federal Public Health Service Act (42 U.S.C. Section 300gg-91), paragraph (1) shall become inoperative on the date of that repeal or amendment and this section shall apply to health insurance policies issued, renewed, or amended on or after that date.

(3) For purposes of this subdivision, “PPACA” means the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any rules, regulations, or guidance issued pursuant to that law.

(Amended by Stats. 2013, Ch. 441, Sec. 24. Effective October 1, 2013.)

12682.2.

(a)

(1) At least 60 days prior to the policy renewal date, an insurer that does not otherwise issue individual health insurance policies shall issue the notice described in paragraph (2) to any policyholder of an individual health insurance policy issued pursuant to Section 12682.1 that is not a grandfathered health plan.

(2) The notice shall be in at least 12-point type and shall include all of the following information:

(A) Notice that, as of the renewal date, the individual policy will not be renewed.

(B) The availability of individual health coverage through Covered California, including at least all of the following:

(i) That, beginning on January 1, 2014, individuals seeking coverage may not be denied coverage based on health status.

(ii) That the premium rates for coverage offered by a health care service plan or a health insurer cannot be based on an individual’s health status.

(iii) That individuals obtaining coverage through Covered California may, depending upon income, be eligible for premium subsidies and cost-sharing subsidies.

(iv) That individuals seeking coverage must obtain this coverage during an open or special enrollment period, and describe the open and special enrollment periods that may apply.

(b) (1) At least 60 days prior to the policy renewal date, an insurer that issues individual health insurance policies shall issue the notice described in paragraph (2) to a policyholder of an individual health insurance policy issued pursuant to Section 10785 or 12682.1 that is not a grandfathered health plan.

(2) The notice shall be in at least 12-point type and shall include all of the following:

(A) Notice that, as of the renewal date, the individual policy shall not be renewed.

(B) Information regarding the individual health insurance policy that the insurer will issue as of January 1, 2014, which the insurer has reasonably concluded is the most comparable to the individual’s current policy. The notice shall include information on premiums for the possible replacement policy and instructions that the individual can continue their coverage by paying the premium stated by the due date.

(C) Notice of the availability of other individual health coverage through Covered California, including at least all of the following:

(i) That, beginning on January 1, 2014, individuals seeking coverage may not be denied coverage based on health status.

(ii) That the premium rates for coverage offered by a health care service plan or a health insurer cannot be based on an individual’s health status.

(iii) That individuals obtaining coverage through Covered California may, depending upon income, be eligible for premium subsidies and cost-sharing subsidies.

(iv) That individuals seeking coverage must obtain this coverage during an open or special enrollment period, and describe the open and special enrollment periods that may apply.

(c) No later than September 1, 2013, the commissioner, in consultation with the Department of Managed Health Care, shall adopt uniform model notices that health insurers shall use to comply with subdivisions (a) and (b) and Sections 10127.16, 10786, and 10965.13. Use of the model notices shall not require prior approval by the department. The model notices adopted for purposes of this section shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). The commissioner may modify the wording of these model notices specifically for purposes of clarity, readability, and accuracy.

(d) The notices required under this section are vital documents, pursuant to clause (iii) of subparagraph (B) of paragraph (1) of subdivision (b) of Section 10133.8, and shall be subject to the requirements of that section.

(e) For purposes of this section, the following definitions shall apply:

(1) “Covered California” means the California Health Benefit Exchange established pursuant to Section 100500 of the Government Code.

(2) “Grandfathered health plan” has the same meaning as that term is defined in Section 1251 of PPACA.

(3) “PPACA” means the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any rules, regulations, or guidance issued pursuant to that law.

(Added by Stats. 2013, Ch. 441, Sec. 25. Effective October 1, 2013.)

12683.

Subject to the provisions and conditions of this part, if the group policy from which conversion is made covers the employee or member for basic hospital or surgical expense, the employee or member shall be entitled to obtain a converted policy providing at least the following minimum benefits:

(a) Plan A.

(1) Hospital room and board daily expense benefits up to two hundred dollars ($200) for a duration of 70 days.

(2) Miscellaneous hospital expense benefits up to an amount of 10 times the hospital room and board daily expense benefits.

(3) Surgical expense benefits according to a surgical procedures schedule consistent with those customarily offered by the insurer under a group or individual health insurance policy and providing a maximum benefit of four thousand eight hundred dollars ($4,800).

(b) Plan B—75 percent of the dollar amounts of Plan A.

(c) Plan C—50 percent of the dollar amounts of Plan A.

(d) The maximum dollar amount for Plan A’s hospital room and board daily expense and surgical benefit may be redetermined by the Insurance Commissioner as to conversion coverage issued subsequent to that redetermination. The redetermination shall not be made more often than once in three years. The maximum dollar amount redetermined by the commissioner for hospital room and board shall not exceed 80 percent of the average semiprivate room rate then charged in the state.

(e) Covered expenses under this section shall include benefits for expense incurred by the employee, member, or spouse in connection with pregnancy, provided that:

(1) The pregnancy commenced while covered under the group policy from which conversion was made.

(2) The expense is of a type which would have been covered under such group policy.

(3) The conversion policy is in force when the expense is incurred.

(Amended by Stats. 1993, Ch. 1210, Sec. 10. Effective January 1, 1994.)

12684.

Subject to the provisions and conditions of this part, if the group policy from which conversion is made provides the employee or member with major medical or comprehensive medical insurance, the employee or member shall be entitled to obtain a converted policy providing comprehensive medical coverage providing at least the following benefits:

(a) A payment per covered person for all covered medical expenses incurred during the person’s lifetime equal to one hundred thousand dollars ($100,000); provided, however, that for treatment of mental illness payment may be limited to ten thousand dollars ($10,000) during the person’s lifetime.

(b) Payment of benefits at the rate of 75 percent of covered medical expenses; provided, however, that if coverage is provided for expenses incurred for outpatient treatment of mental illness, payment of benefits may be at the rate of 50 percent of such covered expenses, and the insurer may limit the amount of covered expense for each outpatient visit and the amount of benefits payable for expenses incurred during each calendar year for that outpatient treatment.

(c) A cash deductible for each benefit period at the option of the insured of two hundred dollars ($200), five hundred dollars ($500), or one thousand dollars ($1,000), but not less than the cash deductible which applied to the insured under the group policy which entitles him or her to a converted policy.

(d) Covered medical expenses shall include the charges for a semiprivate hospital room and board, but need not exceed the lesser of two hundred dollars ($200) per day or the hospital’s most common charge for a semiprivate room, covered expenses for intensive care shall be at least two and one-half times the covered hospital room and board charge. The maximum dollar amount for hospital room and board daily covered expense may be redetermined by the commissioner as to conversion coverage issued after the redetermination. That redetermination shall not be made more often than once in three years. The maximum dollar amount redetermined by the commissioner shall not exceed the average semiprivate room rate then charged in the state.

(e) Covered expenses under this section shall include benefits for expense incurred by the employee, member, or spouse in connection with pregnancy, provided that:

(1) The pregnancy commenced while covered under the group policy from which conversion was made.

(2) The expense is of a type which would have been covered under such group policy.

(3) The conversion policy is in force when the expense is incurred.

(f) Covered expense under this section need not include expense for dental or vision care, or other optional benefits not normally offered by the insurer under a major medical or comprehensive medical expense plan.

(Amended by Stats. 1993, Ch. 1210, Sec. 11. Effective January 1, 1994.)

12685.

The insurer may, at its option, offer alternative plans for group health conversion in addition to those required by this part.

(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)

12686.

(a) In the event coverage would be continued under a group policy on an employee or member following his or her retirement prior to the time he or she is or could be covered by Medicare, the employee or member may elect, in lieu of the continuation of group insurance, to have the same conversion rights as would apply had that coverage terminated at retirement by reason of termination of employment or membership.

(b) The converted policy may provide for reduction or termination of coverage of any person upon his or her eligibility for coverage under Medicare or under any other state or federal law providing for benefits similar to those provided by the converted policy. As used in this section, “state or federal law” does not include Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code, or Title XIX of the United States Social Security Act.

(c) Subject to the conditions set forth herein, the conversion coverage shall also be available to:

(1) A covered dependent spouse and such children whose coverage terminates under the group policy by reason of the death of the employee or member, or a covered dependent spouse in the event such person ceases to be a qualified family member by reason of the termination of the marriage.

(2) A child, solely with respect to himself or herself, whose coverage terminates because the child ceases to be a qualified family member under the group policy.

(d) If the benefit levels required in Section 12683 or Section 12684 exceed the benefit levels provided under the group policy, the converted policy may offer benefits which are substantially similar to those provided under the group policy in lieu of those required in Section 12683 or Section 12684.

(e) The insurer may elect to provide conversion coverage through a group insurance policy issued for that purpose in lieu of an individual policy.

(f) An insurer required by this part to provide conversion coverage may provide such coverage through one or more other insurers authorized to provide disability insurance coverage in this state.

(Amended by Stats. 1982, Ch. 1186, Sec. 10.5.)

12687.

Notwithstanding any other provision in this part, whenever an employee or member chooses among two or more conversion policies, such choice shall be made within 31 days from the last date when the employee or member was eligible for benefits under a group policy from which conversion is available.

(Amended by Stats. 1982, Ch. 1186, Sec. 11.)

12688.

Notwithstanding any provision in this part to the contrary, a hospital service corporation or any insurer which customarily offers individual conversion coverage on a service basis may, in lieu of the expense incurred conversion coverage provided in Sections 12683 and 12684, make available conversion coverage on a service basis which complies with the intent of this part as approved by the commissioner.

(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)

12689.

A notification of the conversion coverage shall be included in each certificate of coverage or other legally required document explaining coverage; provided, however, that it shall be the sole responsibility of the policyholder to notify its employees or members of the availability, terms and conditions of conversion coverage which responsibility shall be satisfied by notification within 15 days of termination of group coverage. Group coverage shall not be deemed terminated until the expiration of any continuation of the group coverage. For purposes of this part, the policyholder shall not be deemed to be the agent of the insurer for purposes of notification of the availability, terms and conditions of conversion coverage.

(Amended by Stats. 1984, Ch. 914, first Sec. 5.)

12690.

Nothing in this part shall prohibit insurers from establishing one or more pools from which the converted policies provided for on this part may be issued.

(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)

12691.

A converted policy which is delivered in a jurisdiction other than this state may be in a form which could be delivered in such jurisdiction as a converted policy had the group policy been issued in such jurisdiction.

(Added by Stats. 1981, Ch. 1096, Sec. 2. Operative January 1, 1983, by Sec. 5 of Ch. 1096.)

12692.

On and after January 1, 1985, every insurer and nonprofit hospital service plan issuing group disability insurance which covers hospital, medical, or surgical expenses shall offer to group policyholders a continuation benefit which, if selected, shall have a duration of at least 90 days and which shall be offered consecutively to any federal requirement for continuation benefits. The terms and conditions shall include continuation benefit coverage for widows, widowers, divorced or legally separated spouses, spouses of covered employees becoming entitled to benefits under Title XVIII of the Social Security Act, and their dependents, including dependent children who cease to be dependent children under the plan, who were covered by the group contract on the date of termination of coverage. However, any existing provisions of law regarding termination of a dependent child status shall not be affected by this section.

The continuation of coverage shall be available only under the following conditions:

(a) Those eligible remain within the State of California, although the departure of a dependent child to another state shall not invalidate the continuation provisions for any other family members.

(b) Those eligible do not marry or remarry, although the marriage of any dependent child shall not invalidate the continuation provisions for other family members.

(c) Those eligible are not eligible for any comparable state, federal, or private group medical plan, although the eligibility of any dependent child shall not invalidate the continuation provisions for other family members.

(d) Those eligible do not find employment with an employer that has a group plan of its own, even if the plan is less substantive, although the entry into such an employee plan by a dependent child shall not invalidate the continuation provisions for other family members.

(e) The group policy is not terminated or the employer’s participation in the group policy is not terminated.

(f) Those eligible do not knowingly furnish incorrect information or otherwise improperly obtain the benefits of the plan.

(g) The continuing individual shall pay the premium amount in the manner specified in the group policy for both his or her share of the premium and the group policyholder’s share, if any.

(h) Eligible persons under this section shall be notified in the same manner required for conversion notification pursuant to Section 12689. Every insurer shall communicate the availability of such coverage to all group policyholders and to all prospective group policyholders with whom they are negotiating.

(Amended by Stats. 1988, Ch. 960, Sec. 2.)

12692.5.

Notwithstanding any other provision of this part, Sections 12672, 12673, 12674, 12675, 12676, 12677, 12678, 12679, 12680, 12681, 12682, 12683, 12684, 12685, 12686, 12687, 12688, 12689, 12690, 12691, and 12692 shall not apply to a group policy that is issued, amended, or renewed on or after September 1, 2003.

(Added by Stats. 2002, Ch. 799, Sec. 4. Effective January 1, 2003. Operative September 1, 2003, by Sec. 5 of Ch. 799.)

 

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When can you get HIPAA?

wikipedia.org

When your 36 months of COBRA & CAL COBRA ends  you are guaranteed coverage through HIPAA until Medicare Kicks in.
§10128.57
300 gg

HIPAA is also there for you if you worked for an:

Please note that one can only pick a plan ONCE. There is no shopping around at renewal.
§300 GG b 1 b

Qualifying Questions

See the HIPAA Application for each Insurance Company.
Bookmarks HIPAA Application
The questions mirror Federal Law.
§ 300gg–41(b) 
 pdf

What forms or proof do I need that I exhausted my COBRA or was not eligible?

The best and simplest explanation we have found is on Blue Shield’s Website and is called:

HIPAA Guaranteed Issue Information Request Form

What does exhausted [ends] mean? top)

If you elect COBRA continuation coverage, options that may have been available to you before electing COBRA coverage may still be available after COBRA coverage is exhausted (ends).  Additionally, you and your family may qualify for individual health coverage as “HIPAA-eligible individuals” when COBRA coverage is exhausted. (COBRA coverage is exhausted when it ends for any reason other than either failure of the individual to pay premiums on a timely basis or for cause, such as making a fraudulent claim.)
cms.hhs.gov/

The main things that you need to apply for coverage is:

Certificate of Credible Coverage
Certificate of Credible Coverage

A letter (click to see sample) showing that your Cal COBRA has expired or if you were not eligible for Cal COBRA, then a letter stating   that your prior employer was either:

Sample request for more documentation (top)

What does exhausted mean?

Sample Letter – Does your former employer have to offer Cal COBRA?

Dear Target,

My COBRA with you runs out this Sunday 8/17.

Please let me know ASAP if Target offers CAL COBRA aka (also known as) California Continuation Benefits Replacement Act CA Insurance Code §§10128.50 et seq.  to former employees in California.   If not, please send a letter stating that, so that I can apply for HIPAA coverage, as HIPAA at §300gg 41 (B) (4) & (5) requires that I use my 18 months of Cal COBRA FIRST, if it is offered to me.

I already called the CA Dept of Insurance and they ask questions that I do not know the answers to.  Such as if you are self insured, or if you do not have to offer CAL COBRA as Insurance Code §10112.5(b) which reads in relevant part that the CA Insurance Code shall not apply to a policy … that covers hospital, medical, or surgical expenses and that is issued outside of California to an employer whose principle place of business and majority of employees are located outside of California.

Thanks,

Agent Dave Fluker’s HIPAA Web Page (Sometimes his material is more recent than ours)

HIPAA vs. Conversion Plans
Difference between HIPAA, Conversion & COBRA

How Does AB 1401 Change Group Individual Conversion Plans (ICP)?

Generally speaking, AB 1401 requires that all [Group] carriers offer an ICP that mirrors a HIPAA guaranteed issue plan with the same rates, effective September 1, 2003. 12670 et seq.)

Please note that this page is all pretty much just HISTORICAL.
Get Obamacare quotes here.

The intent of this provision is that all group carriers will offer a HIPAA guaranteed issue plan, not just the carriers that market individual products. (blue shield ca.com)

As far as the conversion and HIPAA rates, yes, they are usually very similar if not exactly the same for most plans. The Conversion plan is an extension of the group/COBRA plan whereas the HIPAA is an individual & family plan.  The rate is usually the prime factor in why someone would chose one versus the other.

The HIPAA is usually what the client would use after COBRA/Cal COBRA is exhausted or if the group has dissolved, and the client does not have the COBRA option.

The Conversion plan is still linked to the group or COBRA, so the group would still have to be in force in order to accept this. Usually a conversion is a plan design close to, or mirroring, the group plan, and is offered thru the same insurance carrier.

HIPAA is a Federal §300 gg- 41  law that requires all insurance carriers to  offer their top selling plans. Thus, enabling one to shop around.
(Excerpt of the answer to our emailed question to California Department of Managed Health Care (DMHC)).

Sample Conversion Plans

CA Dept. of Managed Health Care
Benefit Summaries
Pacificare
Find a Plan?

Summaries & Benefits of
CA Department of Managed Health Care

HIPAA & Conversion Plans
(DMHC Website)

FROM DMHC Website

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Other pages on HIPAA & COBRA

Guaranteed Issue - No Pre X Clause

Quote & Subsidy Calculation 
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Instant Health Insurance Quotes

Details on how to use our quote engine

Steve Shorr - Covered CA Certified Agent

Steve Shorr - Covered CA Certified Agent -
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Same price as Covered CA or Direct with Insurance Company
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