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  Enrollment Guide

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Enrollment Guide

Eligibility Guidelines

Full-Time employees and their dependents are eligible for coverage. Full-time is is defined as regularly scheduled to work at least 30-hours per week.

Dependents Include:

• The spouse of an eligible employee;
• Dependent children of an eligible employee;
  • Dependnet children may be covered up to age 25, regardless of student status
• Dependent children include:  (1) a natural child, (2) a step-child, (3) a court ordered dependent child, (4) an adopted child, (5) a child involved in a suit for adoption, (6) a child of any age who is medically certified as disabled, or (7) a child of the employee's child. 
• A child not identified in (1) through (7) above can be listed if the child’s primary residence is the employee’s household, to whom the employee is legal guardian or related by blood or marriage, and who is dependent upon the employee for more than one-half of his support as defined by the IRS of the United States.
• Dependent children are covered for maternity benefits.
• Automatic coverage for newborns for the first 31 days following birth. Infants not enrolled for coverage within the first 31 days after birth will not be eligible for coverage until the following open enrollment period or special enrollment event.

When Coverage Begins

• Coverage begins on the employee's date of hire.

When Coverage Ends

• Medical and Dental coverage ends on the last day of the month in which you, or your dependents, become inlegible.

Special Enrollment Rights

• Are provided for employees, their spouses and new dependents upon marriage, birth, adoption or placement for adoption.
• Are provided for individuals who lose their coverage in certain situations, including on separation, divorce, death, termination of employment and reduction in hours. Special enrollment rights also are provided if employer contributions toward the other coverage terminates.

Payments

Network providers agree to accept amounts negotiated with BCBSTX and are paid according to this BCBSTX-determined Allowable Amount.  Covered individuals are responsible for any required Deductibles, Coinsurance or Out-of-Pocket Amounts, and Copayments. 

Plan benefits paid to Out-of-Network providers are based on the BCBSTX-determined Allowable Amount. These providers may balance bill covered individuals for charges in excess of the BCBSTX Allowable Amount. The covered individual will be responsible for charges in excess of the Allowable Amount in addition to any applicable Deductibles, Coinsurance or Out-of-Pocket Amounts, and Copayments. For cost savings information, refer to the section on ParPlan Providers and the definition of Allowable Amount in the benefit booklet.

Preexisting conditions are defined in the benefit booklet and are excluded for 12 months. Appropriate credit will be given for time served under Creditable Coverage as defined under the law and shown in your benefit booklet.
Replacement of Medical Coverage: In compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Texas State law, the following provisions apply to each eligible participant who has health coverage under the employer’s plan immediately prior to the effective date of the health contract between the employer and BCBSTX (the contract date):

• Benefits for Eligible Expenses incurred for any service or supplies prior to the Contract Date, are not covered under the contract.
• Eligible Expenses for services or supplies incurred on or after the effective date will be considered for benefits subject to all applicable contract provisions.

Members residing in other states may use that state's network through the BlueCard program. To locate a participating provider in your state, please contact 1-800-810-BLUE or visit our web site at www.bcbstx.com to use our Provider Finder® tool.

• Your out-of-pocket cost will generally be the least amount because BlueCare Dentists have contracted to accept a lower Allowable Amount as payment in full for Eligible Dental Expenses
• You are not required to file claim forms
• You are not balance billed for costs exceeding the BCBSTX Allowable Amount for BlueCare Dentists

• Your out-of-pocket cost may be greater because DentaBlue Dentists have contracted to accept a higher Allowable Amount as payment in full for Eligible Dental Expenses
• You are not required to file claim forms
• You are not balance billed for costs exceeding the BCBSTX Allowable Amount for DentaBlue Dentists

• Your out-of-pocket cost may be greater because Non-Contracting Dentists have not entered into a contract with BCBSTX to accept any Allowable Amount determination as payment in full for Eligible Dental Expenses
• You are required to file claim forms
• You are balance billed for costs exceeding the BCBSTX Allowable Amount

• This is a general summary of your benefit design. Please refer to your benefit booklet for other details and for limitations and exclusions.
• The following eligibility provisions apply:
  • Dependent children are covered to age 25. (beyond age 25 if disabled).
  • Employees may enroll dependent children up to age 5 on the first of the month following application with no late enrollment penalty.
  • Open enrollment – employees and/or dependents not presently covered may enroll for dental 31 days prior to the anniversary date.
• An exclusion will apply to expenses involving the replacement of teeth that were missing prior to the effective date of the dental contract. All other benefits will begin on the first day of coverage. This exclusion will not apply to:
  • Any participant who becomes effective on the dental contract date who was covered under a previous group dental care contract by the Employer.
  • Any participant who has been continuously covered for 24 months under a group dental care contract with BCBSTX which included prosthetic benefits.
  • A partial or full denture or fixed bridge which includes replacement of a missing tooth which was extracted after coverage becomes effective.
• When the course of treatment will be in excess of $300, a predetermination request should be submitted to BCBSTX in advance of treatment.