Continuation Of Insurance Application Form printable pdf download

Group Administered Texas Nine (9) Month State

Continuation of Insurance Application Form

Who is Eligible?

Any individual who is covered under a group health plan either as the employee, the spouse of the employee, or the dependent

child of the employee is eligible for the nine (9) month state continuation coverage if they have been continuously covered

under the group coverage for at least three (3) consecutive months prior to the termination of employment, and if the loss of

coverage is not due to termination of employment for cause.

Who is not Eligible?

You or your enrolled dependents are not eligible for state continuation if:

1) The termination of coverage occurred because you failed to pay any required premium;

2) Any discontinued group coverage was replaced by similar group coverage within thirty-one (31) days of the discontinuation;

3) You are or could be covered by Medicare;

4) You are covered for similar benefits by another hospital, surgical, medical, or major medical expense insurance policy,

hospital or medical service subscriber contract, medical practice plan, or any other prepaid plan or any other group plan or

program;

5) You are eligible for similar benefits whether or not covered for similar benefits under any arrangement of coverage for

individuals in a group, whether on an insured or uninsured basis; or

6) Similar benefits are provided or available to you under the requirements of any state or federal law.

How to Apply?

The completed application must be submitted to your prior employer no later than sixty (60) days after the later of: (1) the date

the group coverage would otherwise terminate; or (2) the date you are given notice of the right to continuation of group

coverage. Payment of the first month’s premium must be submitted to your prior employer within forty-five (45) days after the

initial election of coverage. Following the initial election of coverage, the monthly premium must be received no later than thirty

(30) days after the premium due date.

Explanation of Your State Continuation Coverage

Continuation of coverage under the employee’s health benefit plan will continue for a maximum of nine (9) months. The

premium will be 102% of the group premium. At the end of the nine months, no other continuation options will be available.

The state continuation coverage will be effective on the day after termination of the group coverage. You will be given credit for

time satisfied toward preexisting waiting periods and any charges that were applied to current deductibles and coinsurance

amounts. Likewise, all amounts applied to lifetime maximums will be transferred to the state continuation coverage.

This nine (9) month state continuation coverage may not terminate until the earliest of:

1) Nine months after the date the employee, member, or dependent elects to continue the group coverage;

2) The date failure to make timely payments would terminate the group coverage;

3) The date the group coverage terminates in its entirety;

4) The date the insured is or could be covered under Medicare;

5) The date the insured is covered for similar benefits by another plan or program, including:

(a) a hospital, surgical, medical, or major medical expense insurance policy;

(b) a hospital or medical service subscriber contract; or

(c)

a medical practice or other prepayment plan;

6) The date the insured is eligible for similar benefits, whether or not covered for those benefits, under any arrangement of

coverage for individuals in a group, whether on an insured or uninsured basis; or

7) The date similar benefits are provided or available to the insured under any state or federal law.

If you have questions regarding your rights for continuation of your health insurance, contact Blue Cross and Blue



Shield of Texas

toll-free at (800) 521-2227. If you have additional questions, you may contact the Texas Department of

Insurance toll-free at (800) 252-3439.

Si usted tiene una pregunta sobre sus derechos bajo el proceso de continuar el seguro de salud, hable Blue Cross

and Blue Shield of Texas, por el numero gratis (800) 521-2227. Si usted necesita mas informacion, se puede

comunicar con el Departmento de Seguros de Tejas por el numero gratis (800) 252-3439. Se habla espanol.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,

an Independent Licensee of the Blue Cross and Blue Shield Association

Form No. TX.9month.Cont.11

53594.1011 GroupAdmin

Continuation Of Insurance Application Form

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