Your Health Insurance Coverage Options
In order to avoid a gap in your health insurance coverage,
you must make a decision soon!
Dear Member [or insert members name],
Your employer has notified us that you have lost your eligibility for their group health insurance. This notice provides important information about your options to purchase ongoing health insurance coverage. Please read this letter carefully to find out more about the options that available to you.
OPTION 1-Purchase individual coverage through the Marketplace,
Oregon’s health insurance exchange
If you buy a plan through the Marketplace, you may qualify for federal premium assistance available to individuals and families.
You have only 60 days from the date your employer coverage ends to purchase coverage through the Marketplace. When you lose your coverage and you make your plan selection before your coverage ends or within the same month that your coverage ends, your new coverage will be effective the 1st day of the month following the event.
If you do not enroll within 60 days, you must wait until the next open enrollment period to buy an individual health plan. During open enrollment, if you enroll in a plan through the Marketplace between the 1st and the 15th your coverage will begin the first of the following month. If you enroll in a plan through the Marketplace between the 16th and the end of the month, your coverage will not be in effect until the first of the second month following your enrollment.
Individuals and families can find out if they are eligible for premium tax credits to help with the cost of insurance or public programs (such as the Oregon Health Plan or Healthy Kids) through an application process on the Marketplace website at healthcare.gov . To qualify for this financial help, the applicant must be an Oregon resident and U.S. citizen or legal immigrant. The type and amount of financial help received is based on household income, family size, and age.
You may also use the Marketplace’s financial help calculator to see if you qualify for federal premium assistance and, if so, it will give you an estimate of the help you may expect to receive.
If you are interested in purchasing new health insurance coverage (either from us or another insurance company) through the Marketplace, visit the website at healthcare.gov .
You may also contact the Marketplace at 1-800-318-2596 (Telecommunications Relay Service: 711 or call TTY 1-855-889-4325.)
OPTION 2-Purchase State Continuation
You must notify the insurer with a written request for state continuation no later than 10 days after the date your insurance company provided you notice of your eligibility.
Oregon state continuation allows you to continue to be covered under your employer’s insurance plan for up to nine months. It is the state’s equivalent to federal Consolidated Omnibus Budget Reconciliation Act (COBRA) for employers with fewer than 20 employees and others who are not subject to COBRA law. State continuation is available to employees and dependents following termination of group health insurance. Once you or your dependents purchase State Continuation coverage you will not be eligible to change coverage until the coverage period runs-out or the next open enrollment period, whichever comes first.
Family members can make a different decision than yours, about whether to continue their coverage under the state continuation program. For example, as explained in Option 2, your and/or children may find more affordable health insurance through Oregon’s health insurance exchange.
Please remember that if you choose state continuation, you will not qualify for federal premium assistance available to eligible individuals and families for coverage purchased through the Marketplace.
If you choose to purchase state continuation, you must pay your entire premium by the due date. [Include sufficient information to determine premium rates for continuation of coverage and instructions for paying]
[Insert instructions for notification].
For complete instructions on how to purchase state continuation, contact us at [insert phone number] or visit our website at [insert website address]. Your previous employer may also provide information about state continuation.
[If the insurer requires the covered person or qualified beneficiary to complete forms in order to continue coverage, the forms must be included with the notice and this notice must comply with ORS 743.610 (10).]
If your coverage for Oregon State Continuation is denied, you have the right to appeal the decision. You may submit an appeal by [Include instructions for filing an appeal.]
If you want to appeal a claim denial while you have state continuation coverage [an explanation of the process to appeal a denial of a claim under state continuation.]
OPTION 3-Purchase individual coverage
outside of the Marketplace
You have only 60 days from the date you lost your employer coverage to purchase coverage directly from us or another health insurance carrier. If you do not enroll within 60 days, you must wait until the next open enrollment period to buy an individual health plan.
You may purchase a plan directly from us or from another Oregon health insurance company that sells individual health insurance coverage. Contact us or another insurance company directly or use an insurance agent to help you find insurance.
Please remember that unless you buy a plan through the Marketplace, you will not qualify for federal premium assistance available to individuals and families.
OPTION 4-Enroll in Medicare
If you are disabled or age 65 or older, you may qualify for Medicare. Once you are eligible for Medicare, you will have an initial enrollment period to sign up. For most people, the initial enrollment period for Medicare starts three months before their 65th birthday and ends three months after their 65th birthday. In most cases it is to your advantage to sign up for Medicare when you are first eligible. If you can receive free Medicare Part A, you will not be able to get federal premium assistance for a the Marketplace plan. If you cannot receive free Medicare Part A, you may be able to get federal premium assistance for a plan offered through the Marketplace plan, depending upon your household income.
You can choose the Marketplace if you are eligible for Medicare but haven’t enrolled because you would have to pay a premium for Part A, or because you’re not collecting Social Security benefits. If you are paying a premium for Part A, you can drop your Part A and Part B coverage and get a plan through the Marketplace. If you do not have five years documented legal resident status to qualify for Medicare or Medicaid, you may be able to get a the Marketplace plan.
If you wait to enroll in Medicare after your initial enrollment period ends, you will have to pay a late enrollment penalty for as long as you have Medicare.
Note that individuals who get free Part A cannot drop it without dropping their retiree benefits (social security or railroad retirement) and paying back all retirement benefits received and costs incurred by the Medicare program as well.
Before making this choice, there are 2 important points for individuals to consider:
• Individuals who do not enroll in Medicare when first eligible (during their initial enrollment period) may have to pay late enrollment penalties if they later apply for both Premium Part A and Part B.
• In addition, individuals who enroll in Medicare after their initial enrollment period ends can enroll in Medicare only during the Medicare general enrollment period (from January 1 to March 31) and coverage does not begin until July of that year.
For more information about your Medicare benefits, contact the Oregon Senior Health Insurance Benefits Assistance (SHIBA) program for questions about Medicare at 800-722-4134 (toll-free) or go to http://www.oregon.gov/dcbs/insurance/SHIBA/Pages/shiba.aspx
Please contact us if you have questions about this letter or you want help enrolling in one of our plans.
Telephone: [Insert applicable toll free number and days and hours that help is available]
Email: [Insert applicable e-mail address]
Website: [Insert applicable website]
You may also contact the Oregon Insurance Division for answers and actions by calling 888-877-4894 (toll-free) or http://www.oregon.gov/DCBS/insurance/gethelp/Pages/answers-and-action.aspx