Consolidated Omnibus Reconciliation Act (COBRA) – a federal law that requires employers to offer limited-time cash-premium health insurance to their terminating employees who by leaving work will lose their insurance. More detailed information can be found on the Texas Department of Insurance website at www.tdi.state.tx.us or with your human resources department.
State Continuation - a Texas law providing employees and dependents losing insurance benefits (because of specified events) the opportunity to continue the same health insurance benefits provided to active participants. More detailed information can be found on the Texas Department of Insurance website at www.tdi.state.tx.us or with your human resources department.
Health Insurance Portability and Accountability Act (HIPAA) - The Privacy Rule standards address the use and disclosure of individuals’ health information—called “protected health information” by organizations subject to the Privacy Rule — called “covered entities,” as well as standards for individuals’ privacy rights to understand and control how their health information is used. For more information visit www.hhs.gov/ocr/hipaa
Primary Care Physician (PCP) – when you are enrolled in an HMO plan, you must choose a primary care physician. You must see your PCP for care for your claims to be covered and referrals are needed to see a specialist.
Certificate of Creditable Coverage (COCC) – a document supplied by a insurance carrier or your prior employer that shows prior medical and/or dental coverage periods and information. This document may also be referred to as prior creditable coverage.
Senate Bill 51 (SB51) – the bill applies to all Texas contracts for HMO, PPO and Texas DMO benefit plans issued, delivered or renewed, on or after January 1, 2006. It affects Texas residents of these plans, but not residents of other states who are covered under a Texas contract. It does not affect Texas residents who are members of PPO plans that are contracted in another state. Additionally, this legislation change applies to all enrollees/insureds and dependents that are covered under fully insured business. This legislation change does not impact self-funded (ASO) accounts. The regulations were effective July 17, 2006, and have additional insight into administration of the law. Group policyholders are now liable for an enrollee’s or insured’s premium payments from the time the enrollee or insured ceases to be eligible for coverage until the end of the month in which the group policyholder notifies the HMO or insurer that the enrollee or insured is no longer part of the group eligible for coverage. Additionally, group policyholders are required to provide coverage for the enrollee or insured, under the policy, until the end of the month in which the termination notification is received by the benefit plan, carrier or insurer.
1. How do I contact member services? The number for member services is located on your ID card or may be obtained from the carrier website, usually under the member section. Back to Top
2. After applying for insurance, when can I go to the doctor or get a prescription filled? It is best to wait until you receive your ID card in the mail before making your appointment or trying to fill a prescription. Once your application is processed, delivery time is approximately 7-10 business days. Normally, the ID cards are mailed to your home address, however, in some instances, the ID cards are mailed to your employer. Some carrier websites offer member registration services where you may print a temporary ID card. Back to Top
3. How do I change my PCP? You may call the member services number on your ID card or complete a change form and submit it to your human resources department. Change forms may be obtained from our website. Back to Top
5. How do I get a replacement ID card or an additional ID card? With most carriers you can visit the carrier website and register as a member. From there you can order a replacement ID card. For an additional ID card, call the member services number on your ID card and request another card be sent. If you do not have access to a computer or are unable to complete your registration on the website, contact your human resources department. Back to Top
6. I never received my ID card, what should I do? With most carriers you can visit the carrier website and register as a member. From there you can order a replacement ID card. If you do not have access to a computer or are unable to complete your registration on the website, contact your human resource department. Back to Top
8. What is a qualifying event? A life event that allows you to make certain changes to your coverage outside the open enrollment period. Qualifying events are birth, marriage, adoption, divorce, loss of coverage, death, court order and MediCare eligibility. All changes must be submitted to the carrier within 31 days of the event date. The effective date of the change is the event date. Back to Top
9. What is Open Enrollment? The annual or open period of time prior to the policy renewal where you may make changes to your policy without a qualifying event. The open enrollment effective date is the renewal date of the policy.Back to Top
11. I have a newborn, how do I add the baby to my insurance? You must submit a completed change form within 31 days of the birth of the baby to your human resources department. The effective date of the newborn’s coverage is the date of birth. Change forms may be obtained from our website. Back to Top
12. To what age can my dependent children be covered on my insurance? Unmarried dependent children living at home or attending school may remain on your coverage to age 25. Self funded policies can specify the maximum dependent age. If you are unsure if your policy is self funded, ask your human resources department or call the member services department at the number on your ID card to verify maximum dependent age limits. Back to Top
Contact member services for assistance to try and resolve the issue. If you are unable to resolve the issue on your own, contact your agent for advise or assistance in resolving the issue. Back to Top
Contact member services for assistance or call the pharmacy management number for your plan. Most pharmacies have these numbers and may be able to supply you with that information. You may also visit the carrier website which will link you to the pharmacy program website. Back to Top
Call the member services department for the insurance carrier and request a COCC be delivered to you. You may also contact your prior employer, who is also authorized to provide you with this documentation. Back to Top
19. My invoice is wrong, what should I do? Call the billing number on your invoice to try and resolve the issue. If you are unable to resolve the issue on your own, please contact your agent for assistance. Back to Top
24. What family members are eligible to be covered under my insurance?Dependents are defined as spouse/domestic partner, children, adopted children or children with proper guardianship documentation. If you are unsure of your dependent qualification, contact member services or your human resources department. Back to Top
