Loss of Other Coverage. Any individual eligible as a Subscriber or Dependent who did not enroll when initially eligible may enroll if each of the following is true, and if HMO receives completed enrollment application/change forms and applicable Premium payments within thirty-one (31) days after the date coverage ends or after a claim is denied due to reaching the lifetime limit under another Health Benefit Plan, self-funded employer Health Benefit Plan, or other health insurance coverage (collectively referred to in this subsection as “Prior Health Benefit Plan”):
(1) You or any eligible Dependent was covered under a Prior Health Benefit Plan at the time You were initially eligible to enroll;
(2) You declined enrollment, in writing, for Yourself and/or Your Dependent(s) at the time of initial eligibility, stating that coverage under a Prior Health Benefit Plan was the reason for declining enrollment; and
(3) You or any eligible Dependent lost coverage under a Prior Health Benefit Plan as a result of:
(a) termination of employment;
(b) a reduction in the number of hours of employment;
(c) termination of Your Prior Health Benefit Plan coverage;
(d) You or Your Dependent incurring a claim that would meet or exceed a lifetime limit on all benefits under Prior Health Benefit Plan coverage;
(e) the Prior Health Benefit Plan no longer offering any benefits to the class of similarly situated individuals that include You or Your Dependent(s);
(f) if coverage was through a health maintenance organization, You or Your Dependent(s) no longer residing, living, or working in the Service Area of the health maintenance organization and no other benefit option being available;
(g) termination of contribution toward the Premium made by the former employer;
(h) Dependent status ending (for example, due to death of a spouse, divorce, legal separation or reaching the maximum age to be eligible as a Dependent child under the Prior Health Benefit Plan); or
(i) expiration of the continuation of coverage period of the Prior Health Benefit Plan under Title X of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, or under the continuation provisions of the Texas Insurance Code. The Effective Date of Coverage under this subsection is the day after prior coverage terminated.
Loss of Other Coverage. A loss of coverage due to an individual’s failure to pay Premiums on a timely basis (including COBRA Premiums), or termination of coverage for cause (fraud or intentional misrepresentation of material fact), will not trigger a special enrollment period.
i. If you lose coverage due to any of the following triggering events, you and your eligible dependents can apply for coverage within 60 days after the date of the triggering event. If you apply and are enrolled by the 15th of the month, your new coverage will be effective on the first day of the following month. If you apply and are enrolled between the 16th and the last day of the month, your new coverage will be effective on the first day of the second following month.
1) termination of employment or reduction in hours of employment;
2) termination of employer Premium contributions;
3) change in dependent status due to divorce, annulment or the death of a covered employee whose employment afforded dependent coverage;
4) relocation out of an HMO service area (you must provide proof of having minimum essential coverage, as defined by the Affordable Care Act (ACA), for one or more days during the 60 days immediately preceding the date of the move);
Loss of Other Coverage i. For triggering events described in Section 4.3a.i, if we receive the required documentation by the 15th of the month, coverage will be effective on the first day of the following month. If received between the 16th and the last day of the month, coverage will be effective on the first day of the second following month.
ii. For triggering events described in Section 4.3a.ii, if we receive the required documentation before or on the date of the triggering event, coverage will be effective on the first day of the month following the event. If received after the date of the triggering event, coverage will be effective on the first day of the month following receipt of the required information.
Loss of Other Coverage i. If a loss of coverage results from any of the following triggering events an eligible individual, or an eligible individual on behalf of himself and his eligible dependents, may elect to enroll in the Plan within 60 days after the date of the triggering event:
1) termination of employment or reduction in hours of employment
2) termination of employer Premium contributions;
3) change in dependent status due to divorce, annulment or the death of a covered employee whose employment afforded dependent coverage;
4) relocation out of an HMO service area (you must provide proof of having minimum essential coverage, as defined by the Affordable Care Act (ACA), for one or more days during the 60 days immediately preceding the date of the move);
Loss of Other Coverage i. If a loss of coverage results from any of the following triggering events an eligible individual, or an eligible individual on behalf of himself and his eligible dependents, may elect to enroll in the Plan within 60 days after the date of the triggering event:
1) Termination of employment or reduction in hours of employment
2) Termination of employer Premium contributions;
3) Change in dependent status due to divorce, annulment or the death of a covered employee whose employment afforded dependent coverage;
4) Relocation out of an HMO service area (you must provide proof of having minimum essential coverage, as defined by the ACA, for one or more days during the 60 days immediately preceding the date of the move);
5) A bankruptcy filing by an employer from which a covered employee has retired at the time of the bankruptcy filing.
ii. If any of the following triggering events occur, an eligible individual, or an eligible individual on behalf of himself and his eligible dependents may elect to enroll in the Plan within 60 days before or 60 days after the date of the triggering event:
1) Loss of minimum essential coverage (as defined by the Affordable Care Act);
2) The last day of an individual’s enrollment in a non-calendar year group health plan or individual health insurance coverage, even if the individual has the option to renew;
3) Loss of pregnancy-related Medicaid coverage;
4) Loss of medically needy Medicaid coverage (no more than once a year).
iii. Loss of coverage due to an individual’s failure to pay Premiums on a timely basis (including COBRA Premiums), or termination of coverage for cause (fraud or intentional misrepresentation of material fact), will not trigger a special enrollment period.
