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Eligibility and enrollment guidelines for medical groups with 2-50 and 51+ employees

Moda Health is dedicated to providing superior customer service to its customers. A part of superior customer service is making sure that group administrators, like you, have the tools needed to effectively address the needs of employees. This guide is intended to help you do just that. If you do not find the answers you need within the guide, please give us a call.

Who can apply

Employees

All present and future, regular full-time employees are eligible for this medical care program in accordance with the requirements set forth in the policy. Each employee must satisfy any required probationary period and must work the minimum number of hours per week required by the employer.

Spouses

If an employee is married, his/her legal spouse is eligible for insurance. In Oregon, registered domestic partners are also eligible for insurance under the Oregon Family Fairness Act. For employees living outside of Oregon, domestic partners will be covered if the Plan  covers domestic partners.

Dependent children

Children are eligible up to age 26. Children over age 25 may be eligible for coverage if they are incapable of self-support because of a physical handicap or mental retardation. The following are considered children:

Newly acquired dependents

Newly acquired dependents are eligible for the plan as follows:

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Enrolling eligible employees and dependents

When should employees apply for coverage?

Employees and/or their eligible dependents must apply for coverage within 31 days of their eligibility. When an employee is eligible for coverage, give him/her an enrollment packet and walk through the information with the employee. If an employee and/or their eligible dependents do not enroll within 31 days of their eligibility, they will be considered late enrollees.

Submitting applications

Have the employee complete an enrollment application and return it to you for review. After reviewing the enrollment application, add the employee's name to the group billing change form which is included with your monthly bill. Attach the completed enrollment application with the group billing change form and submit these items with your next monthly premium. You will see the addition reflected on the following month's bill.

Identification cards

We will issue two identification cards for each employee that is enrolled in the plan. One card is for the employee and the second is for any covered dependents. If additional cards are needed, please contact your Moda Health Billing & Eligibility Specialist. Your group Billing & Eligibility Specialist is the individual specifically assigned to work your group's billing statement and is responsible for the addition and deletion of members and the generation of ID cards. Each identification card is double sided. One side reflects the prescription drug copay, and the opposite side reflects the office visit copay and each covered member's primary care physician selection (primary care physicians will be listed only on point of service, managed care with swing out, and managed care identification cards.)

"No PCP selection"

If an identification card reads "No PCP selected", it means that the employee either did not list a primary care physician on the enrollment form, the physician's name was not legible, the physician is not accepting new patients, or the physician is not a participating primary care physician in the network. Please have the employee select a new primary care physician and contact the Moda Health Customer Service department. This will ensure the appropriate level of benefits are paid for the member.

Declining coverage

Employees can waive this coverage only if they are covered under another health benefit plan. Employees waiving coverage for any other reason will count against the participation requirement stated in the Policy. Declination forms are available online.

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Late enrollment/open enrollment

What if an employee and/or dependent does not elect coverage at the time they are eligible?

If an employee does not enroll themselves and eligible dependents within 31 days of first becoming eligible, they will be considered a "late enrollee" and will have to wait for the next open enrollment period to enroll. Open enrollment occurs once a year at renewal. However, an eligible individual shall not be considered a late enrollee if they are entitled to enroll in accordance with the “When are employees not considered late enrollees” described below.

When are employees not considered late enrollees?

Employees and/or their eligible dependents are not considered late enrollees if:

Dropping employees and dependents

To drop an employee or dependent from coverage, list them on the group billing change form which is included with your monthly bill. Submit the form reflecting the appropriate changes with your monthly premium. The deletion will be reflected on the following month's bill.

When the employee elects to terminate coverage

An employee may terminate their insurance or insurance for any insured dependent by giving Moda Health written notice through the group. Insurance will end on the last day of the monthly period through which premiums are paid. If an employee terminates their own insurance, insurance for their dependents also ends.

Please note: An employee can decline coverage only if he/she is covered under another health benefit plan. Employees waiving coverage for any other reason will count against the participation requirement stated in the Policy.

Termination of employment

If employment terminates, the insurance will ordinarily end for the employee and all insured dependents on the last day of the month following termination. It is your responsibility to notify the terminated employee of their rights to continue coverage through continuation of coverage or through portability plans (COBRA).

Death

If an employee dies, insurance for their insured dependents ends on the last day of the month in which the employee's death occurred. However, surviving dependents may extend their insurance for up to three years if they meet certain requirements. Remember to notify the surviving dependents of their rights to continue coverage and then to notify the Plan if the survivors elect to do so.

Divorce

Insurance will normally end on the last day of the month in which the divorce decree is final. Remember to notify the spouse losing coverage of his/her rights to continue coverage.

Remember to terminate any covered dependenst from the Plan when they lose eligibility and to notify terminated dependents of their rights to continue coverage through Continuation of Coverage or through Portability plans.

Continuation of coverage

In some instances, employees and/or their covered dependents may be eligible to continue their coverage through federal or state plans.

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Making changes

Name changes

Please have the employee complete and sign a new enrollment application and then follow the instructions for submitting enrollment applications already discussed. A new identification card will be issued for the employee and mailed directly to their home.

Address changes

To make simple address changes, you can:

Please remind the employee to specify when the change is to be made effective.

Primary Care Physician (PCP) changes

Employees and their covered dependents can change their primary care physicians up to two times per year. To make a PCP change, have the employee:

The change will be made effective the first of the month following the request and new identification cards will be issued for the employee and mailed directly to their home.

Policy changes

All changes to the Policy must be requested in writing and submitted to your Moda Health Sales & Account Service Representative. Some policy changes may be made effective immediately, others may be made upon the renewal of the Policy. Contact your Sales & Account Service Representative for details.

Premium payment

Premium is due on the first day of each month. If premium is not received within the grace period stated in the Policy, the Policy is delinquent and coverage may be terminated back to the last day of the month for which premium was received. See a sample bill.

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