To enroll in coverage outside of open-enrollment period, consumers must experience a "qualifying life event."
One or both members of the new couple can use the special enrollment period to enroll in coverage.
You have lost coverage after leaving active duty, reserve duty, or the California National Guard.
Learn more about the Qualifying Life Events
This is also a valid reason to qualify for Special Enrollment.
If You become a citizen, national, or permanent legal resident – you have an option to get health insurance during the special enrollment.
If you are a member of a federally recognized American Indian tribe, you can enroll at any time and change plans once per month.
An acute condition
A serious chronic condition
The care of a newborn child between birth and age 36 months
A surgery or other procedure that will occur within 180 days of the termination or start date.
If none of the above qualifying life events apply to you, then you can look into the alternative health plans. Now, it is very important to keep in mind that short-term insurance have been banned in certain places. As of January 1, 2019 – short term insurance plans are illegal in California.
Also, beware of other types of coverage that is not considered insurance by law. I am not saying that those polices are bad, just don’t assume that accident & sickness hospital indemnity plans are the same as major insurance. They are not and you should carefully read the fine print before you agree to get any of those plans.
For example, let’s explore the Faith Based Health Insurance Plans. These are non insurance by law, but are an alternative option that many would consider.
Dental and Vision Plans
Let’s look at what these plans cover:
1. Telemedicine. Telemedicine is included in most programs offered by Unity HealthShareSM and Aliera Healthcare as your first line of defense. Your membership provides you and your family 24/7/365 access to a U.S. Board certified medical doctor.
2. Preventive. Most programs from either Unity HealthshareSM or Aliera provide everyone with the necessities of the 63 preventive care services as outlined by the United States Preventive Task force. (Excludes CarePlus Advantage.) Preventive care includes the PCP office visit and does not require a co-expense or consult fee.
3. Labs & Diagnostics. Your labs and diagnostics are covered when visiting a PCP or urgent care facility in network when your plan includes primary and urgent care. For labs at hospitals or other facilities, your MSRA will apply and you will be required to pay a co-expense of $25.
4. Urgent Care. If your plan provides cost sharing for urgent care, you will have the added benefit of enjoying the ability to choose an urgent care facility in lieu of an emergency room. See the Appendix for any urgent care options and any limitations to plan.
5. Primary Care. Depending on your plan choice, primary care is at the core of preventing medical issues from escalating into a more catastrophic need. See Appendix for the specific plan details.
6. Specialty Care. Specialty care is included in most plans, but has limits defined by your specific plan design. Refer to the Appendix for specific details of MSRA and co-expense requirements.
7. X-rays. X-rays listed on your plan details in the Appendix are for imaging services at PCP or urgent care facilities only and requires a $25 read fee per view at time of service. Your MSRA will apply to all other X-rays. MRI, CT Scans and other diagnostics must be paid with your MSRA before cost sharing is provided.
8. Chronic Maintenance. Chronic maintenance is eligible when a member has chosen a plan with chronic maintenance specifically included and a listing of the maximum number of allowable visits.
9. Emergency Room. Emergency room services for stabilization or initiation of treatment of a medical emergency condition provided on an outpatient basis at a hospital, clinic, or urgent care facility, including when hospital admission occurs within twenty-three (23) hours of emergency room treatment.
10. Hospitalization. Hospital charges for inpatient or outpatient hospital treatment or surgery for a medically diagnosed condition.
11. Surgical Benefits.Non life-threatening surgical benefits are not available for the first 60 days of membership for Premium plans and all other plans require 6 month wait period. Please verify eligibility by calling Members Services before receiving any surgical services.
12. Prescription Drugs. The AlieraCare plan includes a service by RX Valet, which includes cost sharing for prescription drugs. See Appendix for details.
13. Physical Therapy. Up to six (6) visits per membership year for physical therapy by a licensed physical therapist.
14. Ambulance. Emergency land or air ambulance transportation to the nearest medical facility capable of providing the medically necessary care to avoid seriously jeopardizing the sharing member’s life or health.
15. Naturopathic and/or Alternative Treatments. Does not included chiropractic services
16. Prosthetics and their replacement, if medically necessary. This is not an eligible sharing expense
17. Medical Costs incurred outside the United States. Charges for the care and treatment of a medically diagnosed condition when treatment outside the United States is financially beneficial or when traveling or residing outside the United States. Eligibility of such charges are subject to all other provisions of the Guidelines. Medical billing is requested to be submitted in English and converted to U.S. currency.
18. Smoking Cessation. Members with preventive coverage who have acknowledged they smoke and made an additional contribution are provided the opportunity to obtain free smoking cessation medication and counseling.
19. Competitive Sports. Plan holders who participate in organized and/or sanctioned competitive sports are eligible for $5,000 (max) of sharing per incident at an emergency room, subject to the member-shared responsibility amount.
20. Maternity. Maternity medical expenses are only eligible for sharing in certain Plans. Please see the Appendix for your specific plan design. Medical expenses for maternity ending in a delivery by an emergency cesarean section that is medically necessary are eligible for sharing up to $8,000 subject to the applicable Member Shared Responsibility Amount. Medical expenses for a newborn arising from complications at the time of delivery, including, but not limited to, premature birth, are treated as a separate incident and limited to $50,000 of eligible sharing, subject to the Member Shared Responsibility Amount.
Now, let’s take a look at what is not covered by these plans:
Total eligible needs shared from member contributions are limited as defined in this section and as further limited in writing to the individual member.
1. Lifetime Limits. $1,000,000: the maximum amount shared for eligible needs over the course of an individual member’s lifetime.
2. Annual Limits. The maximum amount shared for eligible needs per member per 12 month plan term.
3. Per Term. The limit for each term of a sharing plan. Generally, means annually except in the case of short-term cost sharing.
4. Per Incident. The occurrence of one particular sickness, illness, or accident.
5. Cancer Limits when applicable. Cancer is limited to a maximum per term of $500,000 when applicable
6. Member Shared Responsibility Amounts (MSRA). Eligible needs are limited to the amounts in excess of the MSRA, which are applied per individual member per the plan year.
7. MSRA(s). The eligible amount that does not qualify for sharing based on the membership type chosen by the member.
8. Office Visit/Urgent Care. Office visits, in particular, primary and urgent, have certain limits and inclusions. Please refer to the Appendix for your specific plan.
9. Non-Affiliated Practitioner. Services rendered by a non-affiliated practitioner will not be eligible for sharing nor will any amount be applied to your MRSA unless specified differently in the plan details contained herein..
10. Organ Transplant Limit. Eligible needs requiring organ transplant may be shared up to a maximum of $150,000 per member. This includes all costs in conjunction with the actual transplant procedure. Needs requiring multiple organ transplants will be considered on a case-by-case basis.
11. Cost Sharing for Pre-Existing Conditions. Cost sharing is not available for pre-exising conditions for the first two years of membership.
12. Overnight Sleep Testing Limit. All components of a polysomnogram must be completed in one session. A second overnight test will not be eligible for sharing under any circumstance. Overnight sleep testing must be medically necessary and will require pre-authorization (see item 8). Allowed charges will not exceed the Usual, Customary, and Reasonable charges for the area.
Medical Expenses not generally shared by HCSM Only needs incurred on or after the membership effective date are eligible for sharing under the membership instructions. The member (or the member’s provider) must submit a request for sharing in the manner and format specified by Unity HealthShareSM.
All participating members have a responsibility to abide by the Members’ Rights and Responsibilities published by Unity HealthShareSM and included at the end of these guidelines. Needs arising from any one of the following are not eligible for sharing under the membership clearing house instructions:
1. Any medical care outside of a hospital, except in the case of a needed surgery due to an accident. Members may be able to use out-patient facilities based upon the nature of the medical need and at the sole discretion of Unity HealthShareSM. In addition, some plans of Unity HealthShareSM include primary, urgent , and specialty care. See the Appendix for your plan specifics.
2. Treatment or referrals received or obtained from any family member including, but not limited to, father, mother, aunt, uncle, grandparent, sibling, cousin, dependent, or any in-laws.
3. Pre-existing Conditions. Pre-existing conditions may vary based on plan option. Please see Appendix for specific plan details.
4. Illness or injuries caused by member negligence or for which the member has acted negligently in obtaining treatment. This could be documented by, but is not limited to, review of medical records or treatment plans by a licensed medical physician.
5. Procedures or treatments that are not recognized and approved by the American Medical Association (AMA) or that are illegal. Includes procedures not approved by the AMA for a given application, procedures still in clinical trials, procedures that are classified as experimental, or unproven interventions and therapies.
6. Lifestyles or activities engaged in after the application date that conflicts with the Statement of Beliefs (on the membership application).
7. Transportation (e.g., ambulance, etc.) for conditions that are not life-threatening, unless failure to immediately transport the member will seriously jeopardize the member’s life; the additional expense for transportation to a facility that is not the nearest facility capable of providing medically necessary care; or charges in excess of $10,000 for transportation by air. Member Guide 15
8. Congenital birth defects.
9. Elective cosmetic surgery.
10. Breast implants (placement, replacement, or removal) and complications related to breast implants, including abnormal mammograms, unless related to an otherwise eligible need.
11. Elective abortion of a viable fetus/embryo, unless medically necessary to protect the life of the mother.
12. Infertility testing or treatment, as well as any birth control measures to prevent conception (i.e., the pill, IUDs, shots, etc.)
13. Sterilization or reversals (vasectomy and tubal ligation).
14. Hysterectomy without first obtaining two independent opinions (neither physician may be a partner or other affiliate of the other). Both doctors must examine the patient prior to surgery and both must find that a hysterectomy is medically necessary. The member is responsible to ensure that both physicians submit medical necessity to Unity HealthShareSM prior to surgery. Failure to follow these procedures will result in a finding of ineligibility for sharing by the membership.
15. Weight control and management including nutritional counseling for weight loss, weight gain, or health maintenance. 16. Hospital stays exceeding 60 days per medical need or additional charges for a private hospital room if a semiprivate hospital room is available.
17. Any exams, physicals, or tests for which there are no specific medical symptoms, diagnosis in advance, or risk assessment testing.
18. Adult immunizations, HPV immunizations, and flu shots unless covered under an Aliera Healthcare part of the plan.
20. Physical therapy or occupational therapy that is not pre-authorized. Pre-authorized treatments are limited to a combined 6 visits in any calendar year.
21. Charges for emergency room visits and/or surgical removal for foreign objects placed in nose or ears by a child over five (5) years of age. Removal of foreign objects that can be done in an office setting will be reviewed under regular MSRAs or the Office Visit consult fee options.
22. Medication or procedures not requiring a prescription.
23. Purchase or rental of durable or reusable equipment or devices (e.g. oxygen, orthotics, hearing aids, prosthetics, and external braces), including associated supplies, diagnostic testing, or office visits.
24. Needs for active members submitted 9 months after the date of treatment. Needs for inactive members submitted 6 months after the date of treatment.
25. Dental services and procedures, including periodontics, orthodontics, temporomandibular joint disorder (TMJ), or orthognathic surgery. Includes hospital charges for dental work done under general anesthesiology. Dental work required during surgery from an accident shall be eligible for cost sharing when the dental work is required after an accident and while the member is still admitted to a hospital.
26. Optometry, vision services, glasses, contacts, supplies, vision therapy, refraction services, or office visits.
27. Psychiatric or psychological counseling, testing, treatment, medication, and hospitalization.
28. Mental or psychiatric health, learning disability, developmental delay, autism, behavior disorders, eating disorders, neuropsychological testing, alcohol/substance abuse counseling, attention deficit disorder, or hyperactivity.
29. Speech therapy (except for a deficit arising from stroke/trauma).
31. Self/inflicted or intentional injuries.
32. Acts of war.
33. Exposure to nuclear fuel, explosives, or waste.
34. Occupational injury resulting from an injury incurred while performing any activity for profit.
35. Consumption of a prescription drug not prescribed for the member or prescription drug prescribed for the member and taken in excess that causes an adverse reaction; illicit drug use by a member.
36. Illness or injury caused by the illegal activities of the member or the member’s family, including misdemeanors and felonies, regardless of whether or not charges are filed.
37. Treatment, care, or services that is not medically necessary.
38. Emergency room services, unless treatment at an emergency room is the only legitimate option because of the severity of the condition and lack of availability of treatment at an alternative facility.
39. Sexually transmitted diseases.
40. Diseases, including HIV/AIDS, due to tattoos, body piercing, or life-style choices. 41. Allergy testing or immunotherapy treatment.
42. Second surgeries are eligible for sharing based on member’s treatment plan and are subject to third party case management approval. Second surgeries on a previously eligible surgical need are not eligible unless the Member Guide 16 member has followed through with the treatment plan laid out for him or her by their physician or complications occur within 15 days of eligible surgery.
43. Genetic testing and counseling.
44. Handling charges, conveyance fees, stat fees, shipping/handling fees, administration fees, missed appointment fees, telephone/email consultations, or additional charges for services supplied in an after-hours setting.
45. Drug testing unless required by membership.
46. Sexual dysfunction services.
47. Cancer sharing eligibility is different based on plan option chosen. AlieraCare plans have a 12 month wait period for cancer. Sharing is available the 1st day of the 13 month of continuous membership. Any pre-existing or recurring cancer condition is not eligible for sharing. Cancer sharing will not be available for individuals who have cancer at the time of or five (5) years prior to application. If cancer existed outside of the 5-year time frame of a pre-exisitng look-back, the following must be met in the five (5) years prior to application, to be eligible for future, non-recurring cancer incidents. 1. The condition had not been treated nor was future treatment prescribed/planned; 2. The condition had not produced harmful sypmtoms (only benign symptoms); 3. The condition had not deteriorated.
48. Adenoid removal surgery eligible for sharing only at 50% if member has had a prior surgery to remove tonsils and the adenoids were not removed at the same time.
49. Personal aircraft includes hang gliders, parasails, ultra-lights, hot air balloons, sky/diving, and any other aircraft not operated by a commercially licensed public carrier.
50. Extreme sports: Sports that voluntarily put an individual in a life-threatening situation. Sports such as but not limited to “free climb” rock climbing, parachuting, fighting, matrial arts, racing, cliff diving, powerboat racing, air racing, motorcycle racing, extreme skiing, wingsuit, etc… First 60 Days of Participation. For sixty (60) days after Enrollment Date as a Sharing Member, medical expenses for any reason, other than accidents, illness or injury, are not eligible for sharing among members.
Copyright © 2023 Insurance Center Helpline, Inc. - All Rights Reserved.