Frequently Asked Questions

In order to determine the feasibility of coverage for special employment situations, the following steps will apply:

1. Contact your Account Manager
2. Provide the details of the situation.
3. Upon Underwriting approval, your Account Manager will work with you to determine the most appropriate network for the employee.

If an employee is age 65 or over and covered by a group health plan because of current employment or the current employment of a spouse of any age, Medicare is the secondary payer if the employer has 20 or more employees and covers any of the same services as Medicare. This means that the group health plan is the primary payer. The group health plan pays first on your hospital and medical bills. If the group health plan did not pay the entire bill, the provider should submit the bill to Medicare for secondary payment. Medicare will review what your group health plan paid for Medicare-covered health care services and pay any additional costs up to the Medicare-approved amount. The employee will be responsible for the costs of services that Medicare or the group health plan does not cover. If the employer has less than 20 employees, Medicare is primary. 

The effective date for a returning or rehired employee will be determined by the employer’s group contract. 

The effective date of coverage for part-time employees changing to full-time status is determined by the Employer’s Group Contract. Please refer to your Application for Group Contract.

When an employee is ordered to enroll himself/herself and/or a dependent child through a QMCSO, coverage shall be effective on the date the order is determined to be a QMCSO. We must receive a copy of the QMCSO and an Enrollment Form or Change Form to enroll the employee and/or the child.

If an employee or dependent does not enroll in the plan at the time they are first eligible, they may be eligible to come on the plan other than during open enrollment if:

• A new dependent is acquired due to marriage, birth or adoption, or
• An eligible employee or dependent was covered under another health plan and involuntarily loses coverage.

Refer to the Special Enrollment section of your contract for more information pertaining to special enrollment privileges under HIPAA. 

• The Subscriber’s legal spouse;
• A child who is under 26 years of age and a United States citizen or legal resident of the United States and: 
  • A son or daughter of the Subscriber regardless of support level; or
  • A step-child, child subject to legal guardianship, grandchild or other blood relative who depends on the Subscriber for more than 50% of total support;
• Any child of the Subscriber who is recognized under a Qualified Medical Child Support Order (QMCSO) as having a right to enroll under the Contract.

PHP is not a COBRA advisor, nor do we provide advice on this subject. However, federal guidelines state the following: “All employers who had 20 or more employees on 50% of their typical business day during the preceding calendar year MUST comply with COBRA. The only exceptions to this rule are: Federal Government and Church Plans (within the meaning of Section 414 (e) of the Internal Revenue Code.)”

Open Enrollment is the period of time (usually one month prior to the group’s renewal) that is listed on the group contract that allows eligible employees who previously did not enroll, to come onto the plan and for those members enrolled to add, delete and/or make changes to their current coverage.

Credible Certificate of Coverage is required to prove prior coverage during a Qualifying Event. (Example: An employee loses coverage through his/her employer and now wants to be covered under the spouse’s plan. The CCOC will provide date coverage ended under prior carrier.)