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F.A.Q.
Employee benefits center

Frequently asked questions

A: An HMO plan is the richest type of benefit plan with the lowest out-of-pocket cost. In a traditional HMO, a participant utilizes their Primary Care Physician (PCP) for any services to be performed. In the event that another doctor needs to be utilized, the PCP will refer the participant to an in-network doctor. Once the referring PCP doctor and the insurance carrier approves requested services, they will be paid at the network rates.
A: PCP stands for Primary Care Physician and these doctors are approved (contracted) by the insurance carrier to perform certain services. PCP’s are usually in the following fields: Family Practice, Internal Medicine, General Practice or Pediatrics. Please refer to your PCP booklet for special notations next to the doctor’s name. If you have any questions on a PCP specialty or approval, please contact your insurance carrier’s customer service department.
A: A PPO plan (or Preferred Provider Organization) has fewer restrictions than an HMO or POS plan. Please note that just because a doctor is contracted with the insurance carrier for the HMO/POS plans, does not mean that he is also contracted on the PPO plan. Consult directly with the insurance carrier to find out if the doctor is contracted or not. Most PPO plans have a deductible and co-insurance that a member is responsible to pay prior to the carrier paying for services.
A: Each employer has a specified waiting period before a participant and his/her family is eligible for benefits. For example, if you are hired on January 3rd and your company waiting period states that “an employee is eligible the first of the month following ninety (90) days”, you would be eligible for coverage on May 1st. If this information is confusing, then please consult your Benefits Administrator/HR for your company’s specific waiting period.

A: Once you become eligible, so does your family. Enrolling yourself and your dependents is easy, just fill out the form for each available coverage type and submit the originals to your Benefits Administrator/HR department.

These forms will then be submitted to the insurance carrier and once processed, you will receive ID cards for yourself and your enrolled dependents. Please note, for your own records, make a copy of the competed form. In the event that the original is lost/misplaced, or you do not receive your ID cards, you can contact your HR department, Broker or the carrier directly to discuss the problem.

These copies will also suffice as temporary ID cards in the event that your originals are lost and you need to visit the doctor. You have thirty (30) days from your effective date to get the appropriate forms to the insurance carrier. Please do not wait until the last minute to enroll your family, as it may cause a lapse in benefits or delay your ID cards. . Do not rely on your HR department to alert you when the thirty (30) days are coming to a close, it is your responsibility.

A: An eligible dependent is a person who falls in one of the following categories:

  • Spouse or Domestic Partner (if your company allows Domestic Partner coverage)
  • Under the Affordable Care Act (ACA) a dependent child who is under 26 years old is considered an eligible dependent for the medical plan.
  • An eligible dependent child is a biological child, legally adopted child, or step child under 26 years of age.

Once a dependent becomes eligible you have thirty (30) days from their effective date to alert the insurance company, failure to do so may result in delayed benefits or loss of eligibility until the company next Open Enrollment Period.

Please note that only Medical coverage has an Open Enrollment period. For questions please consult your company’s HR department.

A: At the point that you become ineligible, either by terminating your employ (voluntarily or involuntarily) or decreasing hours to below the minimum hours as stated in the contract provided between your company and the insurance carrier. In this case you will be eligible for COBRA (Cal-COBRA) coverage. Please contact your HR department for rates, rules and limitations.

An ineligible dependent is a person who falls in one of the following categories:

• Legally Separated or Divorced Spouse.
• Child who is 26 years of age. Rules may be different for your dental and/or vision plan so for further questions on this please consult your company’s HR department.

Each ineligible dependent can sign up for COBRA (or Cal-COBRA) insurance. Any questions please consult you HR Department directly. Once a dependent becomes ineligible it is the sole responsibility of the participant to alert the insurance company. Failure to due so may result in penalties to the employer, employee or failure to pay claims on the ineligible dependent.

A: A newly eligible dependent such as a newly married spouse, legally adopted child, newborn child or awkward are to be added to the coverage within thirty (30) days of their effective date. The effective date for the newly eligible dependent is as follows: your wedding date if spouse; the date of birth if newborn; or the date appointed by the courts for a legally adopted child or newly guardian child.

A: Open Enrollment (OE) is the annual period in which you can add dependents to your coverage , and no pre-existing conditions will be subject. Open Enrollment only applies to your company’s medical coverage. Your company should alert you as to when its OE period is, and at this time if dual insurance carriers or dual plans are available you and your dependents may change.

For example, if you and your family are covered through Lifeguard on a PPO plan and decide that you want to move to the Kaiser HMO plan, also offered by your company, you may do so during the month of OE. If you are on an HMO plan and want to change to a PPO or POS plan, this is the time to change. The change will be made on the effective date or anniversary date of the company’s plan. Please consult your HR department if you have any questions.

A: COBRA is a federally mandated law that states that an employee or dependent, in the event of losing Employer Sponsored Health Coverage, has the right to continue that coverage for at least 18 months at their own cost. You will receive a letter at the time you become eligible, for COBRA (or Cal-COBRA) with the appropriate forms and premium amounts. This information will have to be submitted back to the appropriate parties within 60 days from receipt.