(800) 922-9902 dc16info@hsba.com

Enrollment is Required

Before you become eligible for benefits under this Plan, You must complete a formal Plan Enrollment Form. If you will be covering eligible Dependents, you will be asked to provide the necessary documentation to prove that the Dependents are eligible for coverage.

The Trust Fund Office will not pay any claims unless it has received a completed Enrollment Form from you.  If you do not complete and return an enrollment form to the Trust Fund Office, you and any eligible Dependents will be automatically enrolled in the Blue Cross Network (PPO).

If Your Family Situation Changes

You must notify the Trust Fund Office promptly if any change occurs in your family after your initial enrollment (for example, marriage, birth of a child, death of a dependent, or legal separation or divorce from your Spouse or dissolution of your Domestic Partnership).

If the change means you will be covering new Dependents, you must also request a Plan Enrollment Form within 31 days of the date you acquired the new Dependent if due to marriage or registration of a Domestic Partnership, or 60 days if due to birth, adoption or placement for adoption, and you must complete and submit the new Plan Enrollment Form to the Trust Fund Office as soon as possible, with a copy of the necessary dependent documentation (e.g., marriage certificate and/or birth records).

Your right to enroll new Dependents is guaranteed by a law known as HIPAA (the Health Insurance Portability and Accountability Act), provided you request enrollment within 31 days after the marriage or registration of Domestic Partnership, or 60 days of birth, adoption, or placement for adoption or within 60 days after you lose Medicaid or CHIP coverage or become eligible for premium assistance through Medicaid or CHIP.

 Address Change

Please notify the Trust Fund Office in writing promptly if you change your home address.

Changing Plans

 

Medical

You must live or work in the Kaiser service area in order to enroll in the Kaiser (HMO) or the Kaiser/Smart Choices (HMO). If you do not live or work in Kaiser’s service area, you must enroll in the Blue Cross Network (PPO) plan which has a deductible, or the Blue Cross Advantage Network (APPO) which has no deductible, if you are benefits eligible. A change in medical plan election is allowed once every 12 months or if you qualify for special enrollment. You may also change your Plan if you are continuing coverage under COBRA.

If you enroll in the Kaiser (HMO) or the Kaiser/Smart Choices (HMO) and then move out of the Kaiser service area, you may apply in writing to the Trust Fund Office for a transfer to the Blue Cross Network (PPO) or Blue Cross Advantage Network (APPO). The change shall be effective on the first day of the month following approval by the Trust Fund Office.

Please refer to the Quick Reference Chart for contact information on both of your medical plan options.

Dental

There are two fully insured dental plan options that are offered as alternatives to the Indemnity Dental Plan. These dental Plans are like an HMO for dental care. Services are “prepaid,” so many dental services are covered at no charge, but you may use only the dentists that participate in the network. A change in your dental plan election is allowed once every 12 months or if you qualify for special enrollment. You may also change your Dental Plan if you are continuing coverage under COBRA.

Important Note: If you have a choice of medical or dental Plans, your family must be enrolled in the same medical or dental plan option you select for yourself.  For instance, if you enroll in the Kaiser (HMO) or the Kaiser/Smart Choices (HMO), your eligible Dependents must be enrolled in the same HMO Plan.

Please refer to the Quick Reference Chart or information below for contact information on all of your dental options.

 

Indemnity Dental Plan

Prepaid Dental Plan #1 for California Residents only Prepaid Dental Plan #2
 

Delta Dental (Group #0308)

Toll-Free 1-800-765-6003

www.deltadentalins.org

 

DeltaCare USA (Group #6123)

Toll-Free 1-800-422-4234

www.deltadentalins.org

UHC Dental (Group #712019)

Toll-Free 1-877-816-3596

www.myuhcdental.com

 

Special Late Enrollment Rights

A federal law known as HIPAA provides for enrollment after initial eligibility as follows:

Newly Acquired Spouse, Domestic Partner and/or Dependent Child(ren)

If you, as the Employee or Retiree, acquire a Spouse by marriage, a Domestic Partner, or if you acquire any Dependent Child(ren) by birth, adoption or placement for adoption, you may request enrollment for yourself, the newly acquired Spouse, Domestic Partner and/or any Dependent Child(ren) no later than 31 days after the date of marriage or registration of a Domestic Partnership, or 60 days after the birth, adoption or placement for adoption.  You must provide the Trust Fund Office the documentation needed to demonstrate eligibility (such as a birth certificate or marriage license) as soon as practicable once it becomes available.

Loss of Other Coverage

If you declined coverage when you initially became eligible because you had health care coverage under another group health plan or health insurance policy (including COBRA Continuation Coverage, certain types of individual health insurance, Medicare,  or other public program) and you lose coverage under that other group health plan or health insurance policy; you may request enrollment for yourself and/or your Dependents within 31 days after the termination of the coverage under that other group health plan or health insurance policy if that other coverage terminated because of:

  • loss of eligibility for that coverage including loss resulting from legal separation, divorce, death, voluntary or involuntary termination of employment or reduction in hours (but does not include loss due to failure of Employee to pay premiums on a timely basis or termination of the other coverage for cause); or
  • termination of employer contributions toward that other coverage (an employer’s reduction but not cessation of contributions does not trigger a special enrollment right); or
  • the health insurance that was provided under COBRA Continuation Coverage, and such COBRA coverage was “exhausted;” or
  • moving out of an HMO service area if HMO coverage terminated for that reason and, for group coverage, no other option is available under the other plan;
  • the other plan ceasing to offer coverage to a group of similarly situated individuals;
  • the loss of dependent status under the other plan’s terms; or
  • the termination of a benefit package option under the other plan, unless substitute coverage offered.

COBRA Continuation Coverage is “exhausted” if it ceases for any reason other than either the failure of the individual to pay the applicable COBRA premium on a timely basis, or for cause (such as making a fraudulent claim or an intentional misrepresentation of material fact in connection with that COBRA Continuation Coverage).  Exhaustion of COBRA Continuation Coverage can also occur if the coverage ceases:

  • * due to the failure of the employer or other responsible entity to remit premiums on a timely basis;
  • * when the employer or other responsible entity terminates the health care Plan and there is no other COBRA Continuation Coverage available to the individual;
  • * when the individual no longer resides, lives, or works in a service area of an HMO or similar program (whether or not by the choice of the individual) and there is no other COBRA Continuation Coverage available to the individual; or
  • * because the 18-month, 29-month or 36-month period of COBRA Continuation Coverage has expired.

You and your Dependents may also enroll in this Plan if you (or your eligible Dependents):

  • have coverage through Medicaid or a State Children’s Health Insurance Program (CHIP) and you (or your Dependents) lose eligibility for that coverage. However, you must request enrollment in this Plan within 60 days after the Medicaid or CHIP coverage ends; or
  • become eligible for a premium assistance program through Medicaid or CHIP. However, you must request enrollment in this Plan within 60 days after you (or your Dependents) are determined to be eligible for such premium assistance.

Start of Coverage Following Special Enrollment:

  • Coverage of an individual enrolling because of loss of other coverage or because of marriage: If the individual requests Special Enrollment within 31 days of the date of the event that created the Special Enrollment opportunity, (except for a newborn and newly adopted child or on account of Medicaid or a State Children’s Health Insurance Program (CHIP), (discussed below) generally coverage will become effective on the first day of the month following the date the Plan receives the request for Special Enrollment.
  • If the individual requests enrollment within 60 days of the date of the Special Enrollment opportunity related to Medicaid or a State Children’s Health Insurance Program (CHIP), generally coverage will become effective on the first day of the month following the date of the event that allowed this Special Enrollment opportunity.
  • Coverage of a newborn or newly adopted newborn Dependent Child for whom enrollment is requested within 60 days after birth will become effective as of the date of the child’s birth.
  • Coverage of a newly adopted Dependent Child or Dependent Child Placed for Adoption for whom enrollment is requested more than 60 days after birth, but within 60 days after the child is adopted or placed for adoption, will become effective as of the date of the child’s adoption or placement for adoption, whichever occurs first.

Individuals enrolled during Special Enrollment have the same opportunity to select Plan benefit options (when such options exist) at the same costs and the same enrollment requirements as are available to similarly-situated Employees at initial enrollment.