Common use of Eligibility, Enrollment and Effective Date Clause in Contracts

Eligibility, Enrollment and Effective Date. Eligible Individuals. An individual is eligible for coverage as a subscriber under this contract if, at the time of application, the subscriber is a resident in the service area for which this contract is issued, and has been determined by PIC to be an eligible individual. Note: Coverage will be rescinded or terminated in the event of fraud, intentional misrepresentation of material fact (including a misleading omission of material fact) or failure to pay, when due, any required premium. Eligible Dependents. A subscriber is permitted to enroll only eligible dependents. Eligible dependents of the subscriber include those individuals whom XXX has determined to be eligible individuals and who meet the requirements of any of the following: 1. Lawful spouse whose marriage to the subscriber is valid under Minnesota law. 2. Children, through end of the month in which the child reaches age 26, including: a. Natural children of a covered subscriber from birth. b. Legally adopted children or children placed with the subscriber for legal adoption (date of placement means the assumption and retention by a person of a legal obligation for total or partial support of a child in anticipation of adoption of the child. The child’s placement with a person terminates upon the termination of the legal obligation of total or partial support). c. Children for whom the subscriber or the subscriber’s covered lawful spouse has been appointed legal guardian by a court of law, up to the age stated in the court appointment if less than age 26. d. Stepchildren of the subscriber. e. Grandchildren of the subscriber or the subscriber’s covered lawful spouse who have resided in the covered grandparent’s home continuously since the date of the initial discharge from the hospital due to birth and are dependent on the covered grandparent for their financial support. 3. Dependent children who are disabled. Application for extended coverage and proof of incapacity must be furnished to PIC within 31 calendar days after the dependent child reaches age 26. After this initial proof, XXX may request proof again at any time during the two-year period following the child’s attainment of the limiting age but not more frequently than annually after such two-year period. A dependent child may be eligible for coverage if coverage has not otherwise terminated by PIC and if the dependent child meets all of the following criteria: a. Is incapable of self-sustaining employment, because of a physical disability, developmental disability, mental illness, or mental health disorder; and b. Is dependent on the subscriber for a majority of support and maintenance. The disabled dependent child shall be eligible for coverage as long as the dependent child is and continues to be disabled and dependent on the subscriber, unless coverage otherwise terminates under this contract. Note: Coverage will be rescinded or terminated in the event of fraud, intentional misrepresentation of material fact (including a misleading omission of material fact) or failure to pay, when due, any required premium. Initial Enrollment and Subsequent Enrollment. The subscriber must make written application to enroll, including any eligible dependents that the subscriber wishes to enroll, during an open enrollment period which occurs from November 1 through December 15 of each year. The subscriber may add eligible dependents to this contract at subsequent annual open enrollment periods. They may also be enrolled in connection with a limited open enrollment period as described in the “Limited Open Enrollment,” Section below. For further information regarding open enrollment, please contact PIC Customer Service. If you have subscriber only coverage and elect coverage for your eligible dependents which becomes effective, then you and your dependents become subject to the terms and conditions of family coverage. Newborn Child Enrollment Under Minnesota Law. Newborn infants, including the subscriber’s newborn grandchildren, who were born while the subscriber is covered under this contract and enrolled for coverage of two or more eligible individuals and who are otherwise eligible for coverage, will be covered immediately from the moment of birth for illness, injury, congenital malformation, or premature birth, regardless of when notice is received by PIC. If you submit an application more than 60 calendar days after the date of birth, the newborn will still be covered back to the date of birth; however, there may be claim processing delays until the application is received and any required premiums are paid in full. PIC must receive required payments, if any, from the date of birth before benefits will be paid. The subscriber must be covered under this contract and enrolled for coverage of two or more eligible individuals in order for the newborn infant to also obtain coverage under this contract.

Eligibility, Enrollment and Effective Date. Eligible Individuals. An individual is eligible for coverage as a subscriber under this contract if, at the time of application, the subscriber is a resident in the service area for which this contract is issued, and has been determined by PIC to be an eligible individual. Note: Coverage will be rescinded or terminated in the event of fraud, intentional misrepresentation of material fact (including a misleading omission of material fact) or failure to pay, when due, any required premium. Eligible Dependents. A subscriber is permitted to enroll only eligible dependents. Eligible dependents of the subscriber include those individuals whom XXX has determined to be eligible individuals and who meet the requirements of any of the following: 1. Lawful spouse whose marriage to the subscriber is valid under Minnesota law. 2. Children, through end of the month in which the child reaches age 26, including: a. Natural children of a covered subscriber from birth. b. Legally adopted children or children placed with the subscriber for legal adoption (date of placement means the assumption and retention by a person of a legal obligation for total or partial support of a child in anticipation of adoption of the child. The child’s placement with a person terminates upon the termination of the legal obligation of total or partial support). c. Children for whom the subscriber or the subscriber’s covered lawful spouse has been appointed legal guardian by a court of law, up to the age stated in the court appointment if less than age 26. d. Stepchildren of the subscriber. e. Grandchildren of the subscriber or the subscriber’s covered lawful spouse who have resided in the covered grandparent’s home continuously since the date of the initial discharge from the hospital due to birth and are dependent on the covered grandparent for their financial support. 3. Dependent children who are disabled. Application for extended coverage and proof of incapacity must be furnished to PIC within 31 calendar days after the dependent child reaches age 26. PIC may ask for an independent medical exam to determine the functional capacity of the dependent child. After this initial proof, XXX may request proof again at any time during the two-year period following the child’s attainment of the limiting age but not more frequently than annually after such two-year period. A dependent child may be eligible for coverage if coverage has not otherwise terminated by PIC and if the dependent child meets all of the following criteria: a. Became disabled before age 26; b. Was a dependent enrolled with PIC under this contract prior to reaching age 26; c. Is incapable of self-sustaining employment, because of a physical disability, developmental disability, mental illness, or mental health disorder; and b. d. Is dependent on the subscriber for a majority of support and maintenance. The disabled dependent child shall be eligible for coverage as long as the dependent child is and continues to be disabled and dependent on the subscriber, unless coverage otherwise terminates under this contract. Note: Coverage will be rescinded or terminated in the event of fraud, intentional misrepresentation of material fact (including a misleading omission of material fact) or failure to pay, when due, any required premium. Initial Enrollment and Subsequent Enrollment. The subscriber must make written application to enroll, including any eligible dependents that the subscriber wishes to enroll, during an open enrollment period which occurs from November 1 through December 15 of each year. The subscriber may add eligible dependents to this contract at subsequent annual open enrollment periods. They may also be enrolled in connection with a limited open enrollment period as described in the “Limited Open Enrollment,” Section below. For further information regarding open enrollment, please contact PIC Customer Service. If you have subscriber only coverage and elect coverage for your eligible dependents which becomes effective, then you and your dependents become subject to the terms and conditions of family coverage. Newborn Child Enrollment Under Minnesota Law. Newborn infants, including the subscriber’s newborn grandchildren, who were born while the subscriber is covered under this contract and enrolled for coverage of two or more eligible individuals and who are otherwise eligible for coverage, will be covered immediately from the moment date of birth for illness, injury, congenital malformation, or premature birth, regardless of when notice is received by PIC. If you submit an application more than 60 calendar days after the date of birth, the newborn will still be covered back to the date of birth; however, there may be claim processing delays until the application is received and any required premiums are paid in full. PIC must receive required payments, if any, from the date of birth before benefits will be paid. The subscriber must be covered under this contract and enrolled for coverage of two or more eligible individuals in order for the newborn infant to also obtain coverage under this contract.