Cover Colorado

Welcome to CoverColorado.  We look forward to helping you with your insurance needs.  This packet contains frequently asked questions about the CoverColorado program and specific PPO benefits.  We suggest that you read this information prior to calling the CoverColorado office. Once you have read the entire packet, call us for additional information, clarification or questions regarding your specific situation.

What or who is CoverColorado?

·   CoverColorado is a non-profit entity created by the Colorado Legislature to provide medical insurance for eligible Colorado residents who, because of a pre-existing medical condition, are unable to get coverage from private insurers.

·   CoverColorado also serves as the state’s plan for individuals who are eligible under the Health Insurance Portability and Accountability Act, otherwise known as HIPAA HCTC for Trade Act or Pension Benefit Guarantee Corp.

Who is eligible:

· You must have resided in Colorado as a legal resident for at least six months prior to applying for coverage, unless you are HIPAA eligible or transferring from another state’s high risk insurance pool;

· You cannot be eligible for Medicaid, Medicare or any other health insurance;

· If you have health insurance coverage and you have exceeded the amount allowed for a particular benefit or you have coverage that does not include a particular benefit (ex: prescription drug coverage) you are not eligible for CoverColorado. CoverColorado is not a supplemental to other health plans.

· You cannot have been terminated from CoverColorado in the 12 months prior to your application or have received $1,000,000 in benefits from the CoverColorado program;

· Inmates or residents of public institutions are not eligible for CoverColorado.

What types of health insurance plans are available?

CoverColorado offers a statewide major medical plan, with eight  deductible levels to choose from, using the PacifiCare PPO Network.  Refer to the plan design.

What if I have a pre-existing condition?

· If you have not been insured within the past  90 days prior to applying for CoverColorado, expenses related to any pre-existing medical condition will not be covered for the first 6 months that you are enrolled.

· A pre-existing condition is defined as a sickness or pregnancy for which you have seen a health care professional, received medical treatment or advice, been billed, taken a prescription or received diagnostic testing within 6 months prior to your CoverColorado effective date.

· If you have been insured, for at least six continuous months, within 90 days of application to CoverColorado, you will not be subject to the 6-month pre-existing waiting period.

What is a Certificate of Creditable Coverage (CCC)?

Group health plans and health insurance issuers are required to furnish a certificate of coverage to an individual.  This is documentation of the individual’s prior creditable coverage. You will need to request this from your last insurance carrier.

Which documents may establish creditable coverage in the absence of a Certificate of Coverage?

· Pay stubs showing a payroll deduction for health coverage.

· Bank statements showing deductions made for health coverage.

· Records from medical care providers indicating health coverage.

· Explanation of benefits (EOB’s) or other correspondence indicating coverage for the past 6 months.

· Third party written statements verifying periods of coverage.

· Any other relevant documents that evidence periods of health coverage in force for the past six months or 18 months for HIPAA.

What is involuntary termination?

· An insurance carrier ceasing business operations in Colorado.  For example: leaving the state, no longer offering a group or individual product, or filing for bankruptcy.

· An employer no longer offering insurance coverage. For example:  insurance benefits no longer offered to employees or an employer filing for bankruptcy.

· Involuntary termination is NOT the exhaustion of benefits such as COBRA, State Continuation, and in some cases no longer being an eligible dependent.

· Involuntary termination is NOT the recision of a health insurance policy.

Is out of state coverage available?

Yes, there is a wrap network available if benefits are utilized

while out of state.

Is group coverage available?

No, all policies are issued on an individual basis.

Can my employer pay my premium?

No, employers cannot pay premium as this is not a group or employer sponsored plan. 

I am self employed, can I pay with a business or DBA account?

· No, checks from business or DBA accounts will not be accepted and will be returned.

· Personal checks only.

If I am self-employed, am I covered on the job?

· No, work related injuries are not covered.

· This exclusion applies to expenses resulting from occupational accidents or sickness covered under: occupational disease laws, employer’s liability, municipal/state/federal law or Workers’ Compensation Act.

· Benefits for medical services and supplies resulting from a work-related illness or injury will not be paid if a self-employed individual has chosen not to purchase Workers’ Compensation

Is family/dependent coverage available?

· There are no family rates; each family member who is enrolled will be charged the rate applicable to them.

· Eligible dependents may be enrolled, under separate policies and will be charged an individual rate based on their age, gender, smoking status and geographic location.

· A separate application is required for each family member. However, dependents who can obtain health insurance in the commercial market or through an employer may find it less expensive than paying the CoverColorado rate.

Terminations

Coverage is terminated under certain circumstances:

1. When you are no longer a Colorado resident

2. If you do not reply to residency inquiries within 30 days              

3. When you become eligible for a substantially equivalent coverage under health insurance or other plan.

4. When you request termination. (30 day notification required)

Can I re-enter the program after termination?

If you fail to pay the premium or you voluntarily leave the CoverColorado program, you will not be eligible to re-apply until 12 months after termination date, unless you are HIPAA eligible.

Will being on CoverColorado mean I can never get “regular” insurance?

You are part of the CoverColorado program because you have a pre-existing condition.  CoverColorado insurance is considered prior creditable coverage and upon termination for the program you may request a Certificate of Creditable Coverage showing your effective and termination dates.  This will prove continuous coverage to a new insurance carrier and should prevent the carrier from imposing a pre-existing limitation on your new policy.

When is the deadline and what effective dates are offered?

· CoverColorado only offers 1^st of the month effective dates.

· Applications with ALL required documentation must be received in our office by the 15^th of month, for consideration of a first of the following month effective date.

· If the 15^th falls on a weekend, the deadline is the previous Friday.

Can I fax my application?

No, you may not fax your application.  Your original signature is required.

Faxed applications will not be processed.

How long will it take to activate my coverage?

It takes approximately 2-3 weeks to process an application. If you submit an incomplete application or your application arrives after the deadline, it will delay processing. You will be notified in writing regarding your application status.

What could keep my application from being approved?

Your application will be delayed or denied:

· If you do not completely fill out the application in all areas, and provide ALL requested information.

· If you do not attach required documentation: proof of residency, proof of eligibility and proof of prior insurance coverage.

· If you do not attach the first month premium.

What is the statewide PPO plan?

· You have a choice of eight plans with different deductible levels.

· You may choose any physician, hospital or other medical care provider and receive the benefits covered under your plan.

Is my doctor a network provider?

· The best way is to directly ask your physician if they are part of the PPO network.

· Network providers handle all the paperwork for you so that you have no claims to file.

· Lower rates for covered services using network providers.

What if my doctor is not a network provider?

· Medically necessary claims will most likely be covered, however your out of network claims will apply toward a higher deductible.

· The amount in excess of what the plan will pay is your responsibility and would not apply to your deductible or coinsurance requirements. 

· You are responsible for filing your own claims.

How does the plan work?

It’s as simple as 1-2-3.

1. You pay your monthly premium.

2. You pay claims for covered benefits up to the deductible amount.

3. Once the deductible amount has been met, you pay your portion of the coinsurance (20% or 30% and plan pays balance) up to the out-of-pocket maximum for the calendar year.

Are there co-pays for office visits and other services?

· No, there are no co-pays for office visits or other services.

What is a deductible?

· A deductible is an annual dollar amount that you must pay before CoverColorado begins to cover most medical services.

· There are separate deductibles for network and non-network care.

· Deductible and coinsurance are accumulated on a calendar year basis (January 1 – December 31), regardless of when your coverage becomes effective.

· The deductible is included in the out-of-pocket maximum.

What benefits apply toward the deductible?

· There are two benefits that do not apply toward the deductible nor does the deductible need to be met: pharmacy and preventive care, which are explained in detail in the Policy book.

· All other claims such as doctor visits, x-ray and lab work are applied toward the annual deductible and then subject to co-insurance.

Can I change my deductible?

· You may increase your deductible during the year for a January 1^st effective date.

· You must notify CoverColorado at least 30 days prior to January 1^st.

· Your deductible can NEVER be decreased.

What is co-insurance?

· Co-insurance is the portion of health care expenses that a member must pay after reaching the deductible.

· Co-insurance is calculated as a percentage of cost.

What is an out-of-pocket maximum?

· The maximum annual amount you pay in coinsurance before plan pays 100%.

· Out-of-pocket maximums vary depending upon deductible level and if utilizing in or out-of-network providers.

· The deductible is included in the out-of-pocket maximum.

How does the pharmacy benefit work?

· You must use a pharmacy in Rx Solutions statewide network which includes King Soopers, Safeway, and Walgreen’s.

· No benefits are available from non-network pharmacies. No benefits are available during the pre-existing period.

· Please refer to your benefit plan design summary sheet for details on your pharmacy coverage for each deductible plan.

· To access specific drugs in the Plan’s formulary call 1-877-461-3811 option # 3. To obtain network information go to  www.rxsolutions.com. Always verify if pre-authorization is required.

What is the Lifetime Maximum Benefit?

· Lifetime maximum benefit of $1,000,000.

How are rates determined?

· Rates are based on your age, gender, tobacco use, and county that you are currently a resident.

· Rates listed on the rate sheet are MONTHLY, per person.

How often will my premium increase?

· Historically rates are adjusted every January 1^st and July 1^st.

· However, rates are only guaranteed for 30 days and are subject to change with 30 days notice. 

· Other factors may apply, including moving into a higher age band.

· All members experience rate increases, regardless of effective date.

Are there any premium discounts available?

· Yes, the Premium Discount Program (PDP) represents a  reduction in the PPO rates.

· To be eligible for the program your income must be less than $50,000 per year and you must meet an asset test.

· To apply for the PDP, you must submit a completed Premium Discount Application and attach a complete copy, including all pages, of your most recently filed Federal Tax Return.

· If you do not apply with your original application, you may not apply until renewal, which is January 1^st of the following year.

· You will need to re-qualify EVERY year.

· Once you are approved for the Discount you will be credited to the discounted amount.

Copyright © 2006 Colorado Health Insurance Network