General Policy Information

Enrollment Guidelines

Eligible employees

An eligible employee means a permanent full-time employee, who works at least 30 hours a week in the conduct of the group’s business. Sole proprietors and partners are also eligible to enroll if they are actively engaged on a full-time basis. An eligible employee does not include an employee who works on a part-time, temporary or substitute basis.

Eligible dependents

An eligible dependent is an eligible employee’s lawful spouse, unmarried child who has not reached 19 years of age, or unmarried child from the age of 19 to 23 who is a full-time student and fully dependent on the employee for support. A child is the employee’s or employee’s spouse’s natural child, adopted child, or stepchild. A husband and wife both employed by the same company must enroll separately. A dependent child may not be listed as a dependent for more than one employee.

Effective date

For new groups, the effective date (the date the coverage becomes effective) may be the first or fifteenth of the month. Subsequent monthly billing will be on the first of each month.

Waiting period

The employer may choose a no waiting period or a 1-, 2- or 3- or 6-month waiting period. The effective date for new employees is on the first day of the month following the waiting period.

Future employees/dependents

The effective date for a new hire will be the first of the month following the waiting period (the initial eligibility date) provided UniCare receives a fully completed application prior to the initial eligibility date. Applications will be accepted up to 30 days after the initial eligibility date. In this case, the effective date will be the first of the month following the date we approve the application. Coverage for newly acquired dependents requires application for the plan within 31 days after the dependent becomes eligible.

Late enrollees

A late enrollee is any eligible employee or dependent who submits his or her written application after the expiration of either the initial enrollment period or a special enrollment period or after the expiration of the annual open enrollment period. The late enrollee is eligible only at the group’s anniversary date. Please see your Certificate of Coverage for exceptions to late enrollees and other specific details.

Pre-existing Conditions

A pre-existing condition means a disease or condition for which medical advice, diagnosis, care, or treatment was recommended or received during the six (6) months immediately preceding the eligibility date. For the purpose of this plan, pregnancy is not a pre-existing condition.

Group replacement coverage

An individual who was covered under the employer’s group health plan immediately prior to its replacement by this plan and who becomes covered under this plan on the employer’s effective date will receive credit for time covered under the previous group plan toward satisfaction of the 9-month preexisting condition waiting period. With proper documentation, UniCare will also credit an individual’s medical and/or dental deductible previously applied by the employer’s prior group health plan.

Creditable coverage

We will credit the time an insured person was covered by creditable coverage provided there is not a lapse of coverage greater than 62 days between the creditable coverage and the effective date of coverage under this plan, excluding the waiting period. See the Certificate of Coverage for a complete list of creditable coverage.

Individual coverage

Any UniCare Individual medical coverage must be terminated if and when an applicant is approved for any UniCare Small Group medical plan.

*This is a brief description of some policy terms. Please refer to the applicable Certificate of Coverage for more complete details, including conditions, benefits, limitations and exclusions.