Common use of Temporary Coverage for Newborns Clause in Contracts

Temporary Coverage for Newborns. When a Subscriber or Member gives birth, their newborn child will be entitled to the benefits set forth in the Benefits section from birth through 3 weeks of age. After 3 weeks of age, no benefits are available unless the newborn child qualifies as a Dependent and is enrolled under this Agreement. All contract provisions, limitations, and exclusions will apply. ENROLLMENT‌ Application for enrollment must be made through the Washington State Health Benefit Exchange during open enrollment. Applicants will not be enrolled, and premiums will not be accepted, until the completed application information has been received and approved by CHPW. CHPW reserves the right to refuse enrollment to any person whose coverage under any contract for medical coverage issued by CHPW has been terminated for cause. A written application for enrollment of a newborn child must be made to CHPW within 60 days following the date of birth, if there is a change in the monthly premium payment as a result of the additional Dependent. A written application for enrollment of an adopted child must be made to CHPW within 60 days from the date the child is placed with the Subscriber for the purpose of adoption, or the Subscriber assumes total or partial financial support of the child, if there is a change in the monthly premium payment as a result of the additional Dependent. Subject to prior approval by the Washington State Office of the Insurance Commissioner, CHPW may limit enrollment, establish quotas or set priorities for acceptance of new applications if it determines that CHPW’s capacity, in relation to its total enrollment, is not adequate to provide services to additional persons. CHPW will allow special enrollment for persons in circumstances in which applicable federal or state law or regulation provides for special enrollment, called Qualifying Events. Following the occurrence of a Qualifying Event listed below, the individual experiencing the Qualifying Event has a 60 day special enrollment period to apply for coverage, including coverage for any Dependents. Applications for coverage must be received within 60 days of the occurrence of the Qualifying Event. We may ask you to provide reasonable proof or documentation that you have experienced a Qualifying Event. • Marriage or Domestic Partnership, including eligibility as a dependent of an individual marrying or entering into a domestic partnership; • Birth, placement for or adoption of the person for whom coverage is sought; • A permanent change in residence, work, or living situation, whether or not within the individual’s choice, where the health plan under which the individual was covered does not provide coverage in that person’s new service area or where a permanent change in the individual’s residence results in new eligibility for previously unavailable qualified health plans; • Loss of Coverage as a result of the dissolution of a marriage or termination of a domestic partnership, or for a Dependent on a group plan where such loss is due to the Dependent’s age; • Loss of Other Coverage, including: o The loss of minimum essential coverage, including employer-sponsored coverage, or the loss of coverage of a person under whose policy the applicant was enrolled, unless the loss is based on the previously covered individual’s misrepresentation of material fact affecting coverage or for fraud related to the discontinued health coverage; o Coverage by a qualified health plan is discontinued by the Washington State Health Benefits Exchange and the 3 month grace period for continuation of coverage has expired; o If the applicant has discontinued coverage under a health plan offered pursuant to Chapter 48.41 RCW; o A situation in which a plan no longer offers any benefits to the class of similarly situated individuals that includes the individual applying for coverage; o Loss of coverage due to errors by the Washington State Health Benefits Exchange staff or the U.S. Department of Health and Human Services; and o Loss of coverage under COBRA, including exhaustion of COBRA coverage due to failure of the employer to remit premium, and loss of COBRA coverage where the individual has exceeded the lifetime limit in the plan an no other COBRA coverage is available; • The loss of eligibility for Medicaid or a public program providing health benefits; • The applicant demonstrates to the Washington State Health Benefits Exchange that the qualified health plan in which they were enrolled violated a material provision of the coverage contract in relation to the applicant; • The applicant or their Dependent(s), as defined in R.C.W. 48.43.005, who were not previously a U.S. citizen, national, or lawfully present individual, gains such status; • The applicant becomes newly eligible or newly ineligible for advance payment of premium tax credits, has a change in eligibility for cost-sharing reductions, or the applicant’s Dependent, as defined in 26 C.F.R. 54.9801-2, becomes newly eligible; or • The applicant of their Dependent who is currently enrolled in employer sponsored coverage is determined newly eligible for advance payment of premium tax credit pursuant to the criteria established in 45 C.F.R. 155.120(d)(6)(iii). Please note that for qualified individuals who are an Indian, as defined by Section 4 of the Indian Health Care Improvement Act, enrollment in a qualified health plan, or change from one qualified health plan to another, is permitted 1 time per month without requiring an additional Qualifying Event triggering special enrollment. Provided eligibility criteria are met and applications for enrollment are made as set forth in this Enrollment section, enrollment will be effective as follows: • Enrollment for a newly eligible Subscriber and their listed Dependents enrolled during open enrollment will be effective on January 1, 2017, provided that the Subscriber’s application has been submitted to and approved by the Washington State Health Benefits Exchange and CHPW has received the Subscriber’s first premium payment, including any amounts due for Subscriber’s listed Dependents. • Enrollment for a newly eligible Subscriber and/or their listed Dependents enrolled in a Special Enrollment period will be effective the first day of the next month after all eligibility requirements are met including payment of applicable premium amounts, except where one of the following applies: o If the Subscriber enrolls after the 20th day of the month, enrollment will be effective the 1st day of the second month after the application is received and all eligibility requirements are met. o Enrollment for newborns is effective from the date of birth. o Enrollment for an adopted child is effective from the date that the adopted child is placed with the Subscriber for the purpose of adoption, or the Subscriber assumes total or partial financial support of the child.

Temporary Coverage for Newborns. When a Subscriber or Member gives birth, their the newborn child will be entitled to the benefits set forth in the Benefits section from birth through 3 three (3) weeks of age. After 3 three (3) weeks of age, no benefits are available unless the newborn child qualifies as a Dependent and is enrolled under this Agreement. All contract provisions, limitations, and exclusions will apply. ENROLLMENT‌ Application for enrollment must be made through the Washington State Health Benefit Exchange during open enrollment. Applicants will not be enrolled, and enrolled or premiums will not be accepted, accepted until the completed application information has been received and approved by CHPW. CHPW reserves the right to refuse enrollment to any person whose coverage under any contract for medical coverage issued by CHPW has been terminated for cause. A written application for enrollment of a newborn child must be made to CHPW within 60 days following the date of birth, if when there is a change in the monthly premium payment as a result of the additional Dependent. A written application for enrollment of an adopted adoptive child must be made to CHPW within 60 days from the date day the child is placed with the Subscriber for the purpose of adoption, adoption or the Subscriber assumes total or partial financial support of the child, if there is a change in the monthly premium payment as a result of the additional Dependent. Subject to prior approval by the Washington State Office of the Insurance Commissioner, CHPW may limit enrollment, establish quotas or set priorities for acceptance of new applications if it determines that CHPW’s capacity, in relation to its total enrollment, is not adequate to provide services to additional persons. CHPW will allow special enrollment for persons in circumstances the following circumstances:  Marriage/Domestic Partnership – Application for coverage must be made within 31 days of the date of the marriage or the beginning of the state‐registered domestic partnership;  Birth – Application for coverage for the Subscriber and Dependents other than the newborn child must have been made within 60 days of the date of birth;  Adoption or placement for adoption – Application for coverage for the Subscriber and Dependents other than the adopted child must be made within 60 days of the adoption, placement for adoption, or assumption of total or partial financial support in which applicable anticipation of the adoption;  Eligibility for medical assistance, provided such person is otherwise eligible for coverage under this Contract, when approved and requested in advance by the Washington State Department of Social and Health Services (DSHS). The request for special enrollment must be made within 60 days of DSHS’s determination that enrollment would be cost‐effective;  Coverage under a Medicaid or CHIP plan is terminated as a result of loss of eligibility for such coverage. Application for coverage must be made within 60 days of the date of termination under Medicaid or CHIP; and  Applicable federal or state law or regulation otherwise provides for special enrollment, called Qualifying Events. Following the occurrence of a Qualifying Event listed below, the individual experiencing the Qualifying Event has a 60 day special enrollment period to apply for coverage, including coverage for any Dependents. Applications for coverage must be received within 60 days of the occurrence of the Qualifying Event. We may ask you to provide reasonable proof or documentation that you have experienced a Qualifying Event. • Marriage or Domestic Partnership, including eligibility as a dependent of an individual marrying or entering into a domestic partnership; • Birth, placement for or adoption of the person for whom coverage is sought; • A permanent change in residence, work, or living situation, whether or not within the individual’s choice, where the health plan under which the individual was covered does not provide coverage in that person’s new service area or where a permanent change in the individual’s residence results in new eligibility for previously unavailable qualified health plans; • Loss of Coverage as a result of the dissolution of a marriage or termination of a domestic partnership, or for a Dependent on a group plan where such loss is due to the Dependent’s age; • Loss of Other Coverage, including: o The loss of minimum essential coverage, including employer-sponsored coverage, or the loss of coverage of a person under whose policy the applicant was enrolled, unless the loss is based on the previously covered individual’s misrepresentation of material fact affecting coverage or for fraud related to the discontinued health coverage; o Coverage by a qualified health plan is discontinued by the Washington State Health Benefits Exchange and the 3 month grace period for continuation of coverage has expired; o If the applicant has discontinued coverage under a health plan offered pursuant to Chapter 48.41 RCW; o A situation in which a plan no longer offers any benefits to the class of similarly situated individuals that includes the individual applying for coverage; o Loss of coverage due to errors by the Washington State Health Benefits Exchange staff or the U.S. Department of Health and Human Services; and o Loss of coverage under COBRA, including exhaustion of COBRA coverage due to failure of the employer to remit premium, and loss of COBRA coverage where the individual has exceeded the lifetime limit in the plan an no other COBRA coverage is available; • The loss of eligibility for Medicaid or a public program providing health benefits; • The applicant demonstrates to the Washington State Health Benefits Exchange that the qualified health plan in which they were enrolled violated a material provision of the coverage contract in relation to the applicant; • The applicant or their Dependent(s), as defined in R.C.W. 48.43.005, who were not previously a U.S. citizen, national, or lawfully present individual, gains such status; • The applicant becomes newly eligible or newly ineligible for advance payment of premium tax credits, has a change in eligibility for cost-sharing reductions, or the applicant’s Dependent, as defined in 26 C.F.R. 54.9801-2, becomes newly eligible; or • The applicant of their Dependent who is currently enrolled in employer sponsored coverage is determined newly eligible for advance payment of premium tax credit pursuant to the criteria established in 45 C.F.R. 155.120(d)(6)(iii). Please note that for qualified individuals who are an Indian, as defined by Section 4 of the Indian Health Care Improvement Act, enrollment in a qualified health plan, or change from one qualified health plan to another, is permitted 1 time per month without requiring an additional Qualifying Event triggering special enrollment. Provided eligibility criteria are met and applications for enrollment are made as set forth in this Enrollment section, enrollment will be effective as follows: •  Enrollment for a newly eligible Subscriber and their listed Dependents enrolled during open enrollment will be effective on January 1, 20172014, provided that the Subscriber’s application has been submitted to and approved by the Washington State Health Benefits Exchange and CHPW has received the Subscriber’s first premium payment, including any amounts due for Subscriber’s listed DependentsCHPW. •  Enrollment for a newly eligible Subscriber and/or their listed Dependents enrolled in dependent person, other than a Special Enrollment period will be newborn or adoptive child, is effective on the first day of the next month after all eligibility requirements are met including payment of applicable premium amounts, except where one of following the following applies: o If the Subscriber enrolls after the 20th day of the month, enrollment will be effective the 1st day of the second month after the application is received and all date eligibility requirements are met. o  Enrollment for newborns is effective from the date of birth. o  Enrollment for an adopted child adoptive children is effective from the date that the adopted adoptive child is placed with the Subscriber for the purpose of adoption, adoption or the Subscriber assumes total or partial financial support of the child.