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Ways to Maintain Pennsylvania Health Insurance Coverage

Ways to Maintain Coverage

Conversion Policies: If you have coverage through an employer's group health plan and then lose the coverage as a result of job termination, you can buy conversion coverage. This is an individual policy from the company that insured your employer's group plan. To qualify, you must have been covered under your prior group health plan for at least three months. In addition, when you apply, you cannot be covered under or be eligible for similar benefits through a group health plan or Medicare. You must be notified of your conversion rights and must apply within 31 days of the notification. Surviving spouses, divorced spouses, and dependent children covered under the group health plan also may be eligible to purchase a conversion policy.

COBRA Continuation Coverage: A federal law known as the Consolidated Omnibus Budget Reconciliation Act (COBRA) gives a person enrolled in a group policy the right to continue in the group coverage on a temporary basis after the departure from an employer with 20 or more employees. The participant must pay the full group premium, including any part the employer had been paying, plus 2% for administrative expenses. Coverage can be continued for 18 months; 29 months if you become eligible for social security disability during the first 60 days of COBRA continuation; 36 months if you were insured through your spouse's or parent's group coverage and the spouse or parent has died, divorced, or separated. COBRA also applies to dependent children who lose coverage because they reach maximum age limits.

COBRA does not apply if the employer terminates the plan. Also, if the employer goes out of business and cancels the plan or fails to pay the premium, the coverage stops and COBRA does not apply. COBRA only applies when the group policy remains in force. This applies if the employer changes group plans, but not if the plan is completely terminated.

COBRA applies to all employers of 20 or more workers. This includes self-insured employers, but does not apply to plans sponsored by the federal government or certain church related organizations as defined by federal law.

Pre-Existing Conditions: Recent additions to Pennsylvania law help to assure continued coverage for you and your dependents when you change jobs and obtain health insurance through a group health plan. Insurance companies may impose only one 12-month waiting period for any pre-existing condition treated or diagnosed in the previous six months. Your prior health insurance coverage will be credited toward the pre-existing condition exclusion period as long as you maintained continuous coverage without a break of more than 63 days. Pregnancy is not considered a pre-existing condition. Newborns and adopted children who are covered within 30 days of birth, adoption or placement for adoption are not subject to the 12-month waiting period.

If you have had group health coverage for one year (18 months for late enrollees), and you switch jobs and go to another plan, the new health plan cannot impose another pre-existing condition exclusion period, provided there is no break in your coverage for more than 63 days.

Guaranteed Issue to Eligible Individuals: Guaranteed Issue of Health Insurance to Eligible Individuals. New Pennsylvania law also makes it easier for you to get individual insurance under certain situations, including if you left a job where you had group health insurance, or had another plan for more than 18 months without a break of more than 63 days. Specifically, if you meet certain criteria, you are considered an eligible individual and guaranteed the right to buy individual health coverage from Blue Cross and Blue Shield plans in Pennsylvania without a pre-existing condition exclusion period.

To be an eligible individual, you must:

  • have had 18 months of continuous credible coverage, at least the last day of which was under a group health plan;
  • have used up any COBRA continuation coverage for which you were eligible;
  • not be eligible for Medicare, Medicaid or a group health plan;
  • not have other health insurance.

You must apply for health insurance for which you are an eligible individual within 63 days of losing your prior coverage.

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